Burdick, William P. MD, MSEd
In 2001, the Foundation for Advancement of International Medical Education and Research (FAIMER) initiated the FAIMER Institute, a fellowship program for midcareer faculty members in all health professions from around the world. Subsequently, six FAIMER Regional Institutes were created in India, China, Brazil, and South Africa, with several others in planning stages. All programs begin with a 1- to 3-week residential session, followed by an 11-month online session, another 1- to 2-week residential session, and a final 11-month online session. Over time, we have learned many lessons about successfully implementing transnational faculty development, building a network of regional centers, and creating a global community of educators. As international health professions education partnerships and global health educational experiences continue to expand and gain popularity, the lessons that have emerged from the FAIMER education initiatives may be particularly valuable in forging these transnational relationships.
Efforts to develop international health partnerships face many challenges: alignment with local needs, persistent dependency, and development of trust.1,2 Global education development efforts are particularly challenged by underestimation of personnel effort needed, and variation in academic cultures and incentives.3,4 The FAIMER faculty development program has also faced these hazards. Our work in global capacity building, however, has taught us about using projects, building community, teaching leadership across cultures, and amplifying change through development of the field. It has also taught us about the importance of “pull” from the low-resource institution to set the direction and scope of the relationship, rather than “push” from the high-resource institution, as well as the necessity for local capacity building to run faculty development, generosity, openness to bidirectional learning, and recognition of the partner as a person. The model we have created has proven to be an effective vehicle for strengthening education leadership, management, and methodology skills; developing a community of educators5,6; and overcoming many of the challenges inherent in global collaboration.
Tools for Successful International Collaborations
Projects that work
Projects can be a powerful tool for facilitating transfer of knowledge and promoting locally relevant institutional change, and they have been one of the most important educational design components7 of the FAIMER education programs. We recommend allocating substantial time to helping participants plan their projects. Our project discussions start by asking fellows to answer two questions: (1) What is the problem you are trying to address? and (2) What is your theory of change? Another early element in the process of project development is to ask fellows to answer the question, What is your project’s connection to improving health? After answering these questions, fellows loop back to the intervention itself, often modifying it to meet the now clearly articulated need or theory of change. By allocating significant time in our curriculum to addressing these questions and then reshaping the original project proposals, the connection between improving health professions education through a faculty development program and improving health in the region becomes stronger.
The role of education projects in institutional change is evident from our data—a majority of fellows report that their projects are not only incorporated into their institution’s curriculum or policies but also sustained and expanded to other institutions or regions.8 To enhance the likelihood of project success, we require institutional leadership endorsement of projects as part of the application process. We follow this by videoconference communication with the leadership before and after the residential sessions. The result is increased awareness of fellows’ projects and higher likelihood of sustained support for the innovation. Skills learned in the design and implementation of one project also are likely to be transferable to another project, creating a cadre of change agents able to respond to institutional needs.
The projects that fellows develop and implement as part of their fellowship are incorporated into the curriculum or policies at their schools in 56% of cases, and more than one-third of fellows noted improved teaching quality, faculty collaboration, education research interest, and curriculum alignment with community health needs as a result of their projects. In addition, 62% reported that their project was replicated at their institution, in another setting in their country, or in another country.8
Building community is the secret sauce
Building a community of educators is an explicit goal of our professional development program, and we intentionally design the program to foster community growth. We acknowledge the creation of a new “culture” within each new batch of fellows by discussing and establishing consensus about group norms. “Learning circles,” in which fellows share their personal stories, are scheduled during each residential session. We design sessions that involve the fellows in extensive group work while they are together, and use frequent listserv and conference call communication when they are apart during the intersession period. We conspicuously “leave titles by the door” and ask fellows to do the same, an important element in a multiprofessional group. Although many entering fellows achieved success before their FAIMER experience on individualistic, highly competitive pathways, most graduates acknowledge the value and benefits of creating a community of educators. The importance of community has also been acknowledged in faculty development research.9
Our data indicate that health professions educators value the breadth and stren gth of a transnational network for information sharing and personal and professional support. Challenges are remarkably similar across institutions, particularly those enduring relatively limited resources, and fellows from different countries or regions often offer useful strategies for overcoming them. At Poster Day, when fellows present their progress at a one-year milestone, we specifically ask about the difficulties they encountered during the year, and how the project has changed them. Their responses invariably evoke nods from others in the room, and solutions are often shared across continents.
Leadership and management can be taught across cultures
When we started teaching leadership and management skills, we were concerned that regional cultural differences would preclude effective diffusion of ideas in this domain. However, as participants have applied skills to authentic local projects, regional differences in symbolic and relational dimensions of leadership and management have been successfully integrated. Language as a manifestation of culture is particularly important in this context. Careful translation of words and phrases through consultation with knowledgeable native speakers has been very useful. At our China Regional Institute, we maintain a constantly updated glossary of leadership-related terms, such as “stakeholder,” “resilience,” and “empowerment,” in addition to other terminology, to reduce confusion and promote consistency.
Field development can amplify change
The field of health professions education is weak in many regions—scholarly materials like articles and books are neither frequently produced nor readily available. Professional associations focused on health professions education may not exist in these areas, and national or regional conference opportunities are limited. The lack of education-related criteria for promotion of faculty represents an important difference in academic culture and incentive; it discourages faculty from committing time and resources to produce publications in a field that will not “count” towards promotion.
Leadership skills like collaboration and knowledge diffusion can lead to a stronger regional health professions education field. We have witnessed dramatic field development in India within five years of initiation of three regional programs and graduation of about 300 FAIMER fellows. An annual health professions education conference now exists in India with over 80 posters presented this year, and the Indian Academy of Health Professions Educators, a professional society dedicated to improving education, has been laun ched. Local innovation projects are impor tant, but “field leadership” is needed to advocate for academic promotion based on contributions to education scholarship generated by these projects.
Lessons from global growth
Another set of lessons comes from gradual expansion of our programs to five other countries. First, the impetus for initiation of new programs has consistently come from “pull” in the region, not “push” from our end. Interested parties in the region with a strong desire to implement the new program are able to consider local stakeholder needs. Local initiatives for logistics, succession planning, curriculum adaptation, and faculty capacity building are essential.
Several factors have contributed to successful development of new regional programs. One is proactive engagement of potential FAIMER Institute applicants from “underserved” parts of the globe where a FAIMER Regional Institute could become an important local asset; another is passion from fellows for creating a local program. Selection of fellows for the FAIMER Institute in Philadelphia is based on the quality of their proposed education innovation project, experience in health professions education, institutional support, and their potential to become an agent for change. Change agent potential includes the possibility of participating in the development of a new regional program.
Gradually increasing local faculty leadership of program components in regional programs reduces the likelihood of persistent dependency. At the start of the Indian programs, for example, 50% of lead faculty were local; over a five-year period, that increased to about 80%. We have learned that a minimum of four FAIMER alumni from the Philadelphia program is an essential ingredient for launching a regional program. Capacity building for local program facilitators is another important factor for reducing dependency. We have created several working groups of regional faculty tasked with improving the way we teach elements of our curriculum. In addition, each year we convene directors and key faculty from the regional programs for a symposium on some aspect of conducting faculty development. The result is diffusion of ideas across programs, stronger regional faculty leading workshops, and decreased dependency.
Generosity has a multiplier effect
A further lesson in global development is generosity of time and resources. In Give and Take, Adam Grant10 describes the success associated with being a “giver”—the value of giving is apparent when returns are measured in breadth of impact. This is especially true in education capacity building, where each participant may reach hundreds of students. When participants’ faculty development facilitation skills are strengthened, they may influence hundreds of teachers, who in turn will reach many hundreds more students. In addition to the reputational benefit to the giver and the direct multiplier effect in education, the ripple effect of further giving by the beneficiaries is also described in Grant’s book.
Learning is bidirectional
We emphasize the importance of keeping an open mind to learning from participants. Although institutions with ample resources clearly have expertise, their focus and context is often unconsciously narrow. At FAIMER, we learn about the world beyond the headlines by asking questions. This includes learning the “real” story on economic development, social forces, migration, safety, and political pressures. In addition to education on global affairs from our partner institutions and participants, we have learned a great deal about health professions education—involvement of students in point-of-care testing in the community, patient education in the waiting room, training and practice of clinical associates in remote areas, advanced education standing for a prior health career, interprofessional education, and low-cost care units. In the echo chamber of high-resource health professions education, it is easy to lose sight of alternative models.
Partnership is personal
Partnerships are built on personal relationships, and personal relationships are built on trust. We work from the simple premise that we should do what we say we are going to do. The corollary to this kind of predictability is that we are carefully constrained on what we promise. Our partners are generally able to anticipate our actions and reactions.
We have learned that it is worthwhile to invest in face-to-face communication to begin a global relationship, with follow-up by almost any other means of communication. Free Internet-based tools like Skype have proven to be the most useful because partners with limited resources can use such tools to initiate contact as needed. In preparation for a new relationship, we often discuss potential relationships with others in our network to gain additional perspectives and better understand regional and cultural issues.
The final lesson learned is to acknowledge the participant as a person. We often hear the plea to see the patient as a person; not enough is written about the student as a person. Participants in global partnerships have stories that reveal important values, priorities, and perspectives. I recently asked one of our fellows when his family first obtained electricity at their home. “Don’t ask me about electricity,” he said, “ask me when I had my first pair of shoes” (answers: electricity—when he went to university; shoes—when he was 12 years old). This fellow now has an MHPE and is the principal of a college of nursing. Values and priorities come into sharper focus when we know the personal stories of our partners.
The lessons learned in 13 years of global professional development are to build community and to teach leadership, management, and education methods using authentic local projects. Through these efforts, we have been able to maintain alignment with local needs, avoid persistent dependency, and develop trust. Global initiatives are most successfully accomplished when the energy comes from the partner abroad, and generosity is the driving value. And personal stories, like those about electricity and shoes, are the glue that keeps us connected.
Acknowledgments: The author wishes to thank Dr. Page Morahan for her collaboration in the development of the Foundation for Advancement of International Medical Education and Research (FAIMER) Institute.