INTERNATIONAL AND TRANSNATIONAL MODELS FOR DELIVERING MEDICAL EDUCATION
The future for medical education
Internationalisation is one of the most important forces in higher education today, presenting a powerful challenge and an opportunity for medical school.
As part of a programme to support clinical communication skills development I spent time with Year 1 medical students observing doctor–patient interactions in a small local clinic on the outskirts of a large regional city in Malaysia. These were Malaysian students of the Malaysian-based medical school of an Australian university. The students were observing a consultation between a middle-aged Malaysian doctor and an elderly female Malay patient dressed in the traditional clothes of that region. The doctor I observed was quietly spoken, gentle, caring and seemed to put the patient at her ease. He took time to listen to the patient and reassure her about her concerns. As is the custom in Malaysia when addressing an older person not known to you, he addressed the patient as ‘auntie’. I was impressed with the rapport he created and care he took with the patient – a kind and caring doctor.
Driving back to the campus, I listened with increasing dismay to the students in the back seat discussing the consultation. They talked disparagingly of this doctor’s paternalistic, doctor-centred approach. They noted that he failed to adequately elicit the patient’s perspective on her medical condition or to engage her in discussion and decisions on the treatment options. They were concerned at his use of closed questions and apparent failure to provide opportunities for the patient to assert herself.
I wondered whether we had been watching the same consultation, and how we had arrived at such different interpretations of the doctor’s behaviour.
In considering the above anecdote it would be easy to dismiss the student perceptions as just ‘the arrogance of youth’ or a reflection of their dependence on theoretical learning rather than clinical experience in interpreting the events. However, they highlight one of the key challenges for international and transnational medical education programmes – how to produce graduates with both the skills and sensibilities to operate effectively across different healthcare systems and contexts, with all that that entails. While the focus of this chapter is on models for delivery, we will come back at some point to this key requirement for students in a globalised world to acquire the multiple ‘repertoires’ they need for the diverse contexts in which they will find themselves in future practice.
The case studies in this chapter offer examples of transnational delivery in practice. They highlight the fact that for international and transnational medical education there is no blueprint, but rather many different permutations and combinations designed to meet the particular and often unique circumstances which characterise teaching and learning in any one location.
Whether consciously or unconsciously, we tend to use our own experience as a reference point in commencing new ventures. This is natural and not unexpected, but in the context of international ventures can be limiting. It can close our minds to new possibilities or ways of doing. On the other hand, innovation and change are approached with some caution in medical education, given the high stakes in ensuring quality and safety. The process of development of curricula within international medical education programmes therefore often involves a balance between these two imperatives – a need to be flexible enough to accommodate new and varied contexts, and a need to maintain a strong grounding in established and proven practice. This is the tension under which curriculum development often occurs, involving a conservative approach but willingness to explore alternatives and options as they arise or become necessary. This ‘balancing act’ is one reason why relationship building and the associated trust that it entails are key factors in the process by which collaborative curriculum negotiation and development occur within international medical education programmes, as illustrated in the case studies presented below.
As early as 1986, Hofstede was warning against the imposition of curricula from one country to another and questioning the viability of such a process, and his concerns remain relevant today. Whilst Bleakley et al. (2008) acknowledge the value of international partnerships and collaborations in medical education, however, they note that these tend to be driven by institutions of the ‘modern, metropolitan West’ and make assumptions about the universal applicability of particular learning methods currently in favour in Western medical education (e.g. problem-based learning). According to Bleakley et al., the Western medical curriculum is ‘steeped in a particular set of cultural attitudes that are rarely questioned’ (2008: 267). They advocate a more critical perspective in evaluating international medical education initiatives based on post-colonial theory. Although it is not within the scope of this chapter to address this issue in any depth, it is nevertheless important to acknowledge that the risks of neo-colonialism within transnational medical education programmes are real and require careful consideration.
So it is important to acknowledge that, when we talk of international or transnational medical education, we are not talking about the imposition or transferral of curricula – by definition, to be international or transnational implies some genuine collaborative curricular development and growth, genuinely reflecting elements of all parties involved in programme development and delivery. While transnational ventures often involve considerable relationship building in the early stages, respect cannot be something which ends at the dinner table – it has to translate into how programmes are organised, how collaboration is negotiated and the ways in which staff from different schools and countries are positioned in all communications. It must be real rather than tokenistic and enable all parties to have an equal voice in the curriculum as it moves forward. This is perhaps the greatest challenge facing transnational medical education programmes, and one which most involved would acknowledge has only partly been achieved in many such ventures to date.
This chapter is organised around four case studies, and seeks to draw from these specific examples some general observations. The first two case studies involved the establishment of full overseas branch campuses, with new medical schools being set up; the latter two have involved educational and institutional partnerships, with students completing different phases of their medical studies in different locations and institutions. Key issues raised in these case studies and requiring careful consideration in seeking best-practice approaches in transnational delivery include: legal and regulatory frameworks; relationships with government; curriculum equivalency in standards and content; staffing; coordination of clinical learning; contextualisation of teaching; learning and assessment materials; and accreditation processes. The challenge for achieving best practice in transnational delivery is not only setting up a programme which successfully navigates a course through these key issues and requirements, but establishment of processes which can grow and be sustained in the longer term, and withstand the pressures and constraints which inevitably arise in such ventures.
The Newcastle University Medicine Malaysia (NUMed) and Monash University Malaysia (MUM) case studies presented below illustrate a number of the key issues in the establishment of transnational delivery of medical education. As the first UK medical school to establish a branch campus overseas, both the University of Newcastle and the UK and Malaysian accreditation bodies were travelling through uncharted waters to an extent. Similarly, the Monash University venture outlined in the second case study presented both the Australian Medical Council (AMC) and Malaysian Medical Council (MMC) with particular challenges. This is why (as noted below) regular communication with the accreditation bodies as well as government departments can be so important, helping to circumvent issues before they arise as well as to find solutions to potential ‘bureaucratic obstacles’.
Case study 20.1 Establishment of a branch campus medical school – Newcastle University Medicine Malaysia
In 2006 Newcastle University was invited by the Malaysian government to become part of the Educity development in Johor, Malaysia. The Educity concept is to provide an international student campus comprising a range of educational establishments from across the globe, each offering specific courses which together will be the equivalent of a conventional university. Newcastle University agreed to offer its MBBS degree and the NUMed campus opened in 2011.
NUMed was established as a Malaysian private company which is wholly owned by Newcastle University, UK. NUMed is registered as an independent private university and is subject to Malaysian law. As a UK organisation operating within an entirely different legal and regulatory framework, we have experienced inevitable frustrations with process. Processes that work well at home do not easily translate to another jurisdiction and having a good legal team negotiating the initial set-up was vital. It has been important to have governmental support for the project as NUMed has, on occasion, had to seek help from both Malaysian and UK governments to unlock bureaucratic obstacles. Establishing a branch campus from scratch has meant duplicating all those central university functions (e.g. human resources, finance) that many educators take for granted and which ensure smooth running of a campus. The value of the institutional memory shared amongst administrators is not recognised until it is absent.
The MBBS degree is awarded by Newcastle University and is a UK primary medical qualification. It is subject to accreditation by the MMC and the UK General Medical Council (GMC). This raised a number of issues, given that Newcastle was the first UK medical school to establish an overseas branch campus and there was no established mechanism for this process. We have had to work closely with the MMC and the GMC. The GMC’s involvement with NUMed has led to proposals for amendment to the Medical Act and to changes in GMC regulations. Students are Malaysian and international. Home and European Union students are not allowed to enrol.
A requirement of GMC accreditation is that the programme of study in Malaysia must be of an equivalent standard to that in the UK. Students in Malaysia sit the same exams at the same time as the students in the UK. Ensuring that we can offer an educational experience that will allow our students to meet the requirements of Tomorrow’s Doctors (GMC 2009) has been our top priority. Where possible, our teaching materials are contextualised to the Malaysia setting. A compare-and-contrast approach has been adopted, where UK practices are taught and then compared with current Malaysian practice. Fortunately, the Malaysian healthcare system is largely conducted in English and the MMC bases its policies largely on UK standards, so differences are minimised.
NUMed staff use IT to participate fully in all relevant UK curriculum management committees to ensure curricular harmonisation. Senior staff at NUMed are seconded from Newcastle, UK. Flying faculty help to maintain a UK feel to the course but are used sparingly. There are advantages of having a small local faculty largely focused on teaching as this ensures continuity for the students and faculty can innovate to improve the student learning experience. While the campus was under construction, the first two cohorts of students were taught in the UK and then transferred back to Malaysia. This meant that student numbers on the new campus rose rapidly, allowing the introduction of co-curricular activities to enhance the student experience.
Organisational differences in the approach to clinical education have required us to adopt a different teaching model to that used in the UK. Unlike in the UK, it is not the expectation in Malaysia that doctors within government hospitals have education as part of their remit. Thus it is not easy to use local practising clinicians as teachers. NUMed therefore employs its own clinical staff who accompany our students into the hospital and teach them at the bedside.
We have been able to deliver a UK medical degree within Malaysia at a branch campus in Johor. Maintenance of good relations with regulators and government has been vital to success. A solid legal framework is essential. Balance between UK content and local context is crucial. Equity of standards is maintained by having shared outcomes and shared assessment. Being able to teach within a healthcare system where English is widely spoken is important. Curriculum innovations in the branch campus can enhance teaching at home.
Case study 20.2 Establishment of Monash University’s Jeffrey Cheah School of Medicine and Health Sciences, Malaysia
Monash University currently has three medical programmes, including a graduate-entry programme based in rural Victoria, Australia. The other two are undergraduate-entry 5-year programmes, one based in Melbourne, Australia and the other, the Jeffrey Cheah School of Medicine and Health Sciences (JCSMHS), in Kuala Lumpur, Malaysia.
MUM was established as a full branch campus of Monash University in 1998, upon the invitation of the Malaysian government. It is a joint venture between Monash University in Australia and the Sunway Group and is now co-owned by the non-profit Jeffrey Cheah Foundation. The medical school commenced operations in 2005 with the first two cohorts starting in Melbourne, while preparations for full operation in Malaysia were being completed. In 2007, three cohorts of students started Years 1, 2 and 3 in Malaysia. This medical school caters primarily to Malaysian students studying in their own country, and to date has produced four cohorts of medical graduates.
Years 1 and 2 are conducted at the main MUM campus in Kuala Lumpur. Years 3 to 5 are based at the clinical school in Johor Bahru, adjacent to the Sultanah Aminah Hospital, a large 989-bed tertiary care centre. Students complete most of their clinical learning in Malaysian hospitals and clinics, but also complete a minimum of 12 weeks on clinical placements in their final year at several hospitals in metropolitan Melbourne.
The hospitals and clinics where the students undergo their clinical experience are government facilities which prioritise services over teaching, and consultants in these centres are usually unavailable for the teaching of medical students except after hours. As a result, most of the teaching in the clinics and wards is done by full-time or part-time academic staff employed by the university. While Monash academic staff are encouraged to be involved in providing clinical services, this is sometimes difficult due to heavy teaching commitments and the need to conduct research. In addition the cost of all teaching has to be borne by the university and there is no government subsidy for teaching apart from the use of the health centres.
The course in Malaysia was accredited by the AMC in 2008 and by the MMC in 2010. AMC accreditation was given on the basis of a single accreditation across the three Monash medical programmes.
The medical programme in Malaysia has the same entry and exit criteria, same start and end dates and same learning objectives as the Australian programme. Students get the same Monash testamur on completion. Curriculum implementation is very similar, with close liaison between academic staff at the respective campuses. Where required, content is contextualised to take account of differences in healthcare systems, cultures and disease prevalence. In general, students get access to lecture and learning materials from both campuses and have equal access to online library resources, including e-books and databases.
Assessments, including written exams and Objective Structured Clinical Examinations (OSCEs), are identical and conducted at the same time (the time difference between Australia and Malaysia is 3 hours or less and this allows examinations to be conducted simultaneously). Examination processes, including blueprinting and standard setting, are jointly conducted, and examination items are jointly contributed. In general communication and collaboration between campuses are excellent, with large numbers of staff travelling both ways. Students from all three medical schools (undergraduate and graduate-entry) are considered as a single group in result review meetings and board of examiners’ meetings. Students of JCSMHS have been performing on a par with the Australian-based students.
Although there are very few Australian academics on campus, there are active exchange visits by staff and a high degree of coordination and collaboration in teaching between the Australian- and Malaysian-based schools. Academic staff from both the Malaysian and Australian programmes liaise closely, have regular discussions and are members of the same curriculum and year-level committees.
As a single course implemented in several locations, governance of the programme has been a particular focus. Academic matters in the Malaysian programme are managed by a Director of Curriculum, with overview by a Deputy Dean (MBBS) who is based in Melbourne. Monash University educational policies and philosophies are reflected across all campuses, including MUM.
The governance structure has been designed to ensure that the quality and standards of the MBBS degree in Malaysia will be the same as that in Victoria. The committee structure, like the main course management committee and assessment committees as well as the year-level committees, serves all three medical programmes with active academic and student membership across all three programmes. Videoconferencing and teleconferencing are routinely used in all meetings.
Student exchange is a prominent feature and fairly large numbers of Australian campus-based students undertake units in Malaysia, especially in the later clinical years. Medical students are encouraged to be involved in staff research. Over the last 5 years research infrastructure and capacity have been added, with major research initiatives, including the Brain Research Institute of Monash Sunway (www.med.monash.edu.my/brims) and a community-based research platform (www.seaco.asia).
There have been a number of challenges over the years. Even though the AMC and MMC standards are similar, there are differences, and the need to satisfy both adds to the complexity of the programme. In addition there are governmental bureaucratic requirements that need to be satisfied.
The Monash medical programme in Malaysia has been very successful. Major reasons for this success have been the strong commitment of faculty; the decision to manage the Malaysian campus as a full branch campus with the same academic, quality and infrastructure standards; and the management of students as a single cohort. The need to satisfy local as well as Australian standards continues to pose challenges.
Staffing
The NUMed model employs a small local academic faculty to provide continuity while seconding senior staff from the University of Newcastle in the UK. Other academic teaching staff from the UK are flown in as required. Similar to the NUMed model, Monash University’s JCSMHS has employed a significant number of local academic staff, many of whom have had opportunities to attend training in Australia to develop their teaching skills further. Like NUMed, it also has flown in academic staff from overseas as required, particularly in the formative years while building local capacity, and to deliver in curriculum areas where local recruitment proved difficult (e.g. medical ethics). However, the Monash University approach has also involved recruiting staff from within the region, for example, from Singapore, India, Bangladesh and Indonesia. Unlike the NUMed approach, senior management are all local, although all have significant international experience as both practitioners and educators. Most have worked for extended periods in either Australia or the UK, and bring a considerable degree of cross-cultural experience to their positions, as well as familiarity with both Malaysian and overseas healthcare and educational contexts.
Clearly, achieving the right balance of academic staffing is crucial, and while local and overseas staff typically have the same roles and responsibilities, there may be some differences in how they can contribute to the programme. For example, local teaching staff are familiar with local healthcare systems and contexts, and may be particularly well equipped to communicate and engage with local students in accessible ways. In addition, they can guide students in interacting with local patients and clinicians. Overseas academic staff, particularly those recruited or seconded from the university’s main campus (in the UK and Australia in relation to the two case studies above) can help monitor and maintain curriculum equivalence, as well as provide an international perspective on teaching approaches and curriculum content.
While both the NUMed and MUM case studies highlight the importance of academic staff selection, undoubtedly transnational ventures place particular demands on administrative and support staff as well, and this should be acknowledged. Their capacity to operate effectively across cultures is crucial, as are the flexibility and versatility to cope with challenges as they arise.
Language and clinical learning
While in the Malaysian context English is relatively widely spoken, particularly within education circles, Malaysian society is highly diverse in terms of ethnicities, cultures and languages. Although English predominates within the healthcare system at the level of professional interactions, practitioner–patient interactions occur across a wide range of languages, and at government hospitals more often in the national language, Bahasa Malaysia. Therefore, as a learning space the clinical environment can present challenges that need to be considered. Interestingly, NUMed has found it necessary to employ its own clinical staff for bedside teaching, and these staff may have a role in mediating the language challenges for students in their interactions with patients.
In the case of MUM, a similar approach to managing clinical learning was adopted, involving both a dedicated clinical campus linked to a major public hospital in regional Malaysia and regular visits to a network of local clinics. Similar to NUMed, most clinical teaching at both hospitals and clinics is conducted by academic staff employed by the university, sometimes on a part-time basis, and staff are encouraged to maintain some involvement in provision of clinical care to patients.
In relation to patients’ perceptions of doctors, Manderson and Allotey point out that ‘ideas of professional competence are culturally informed’ (2003: 83), and that behaviour viewed as appropriate and professional within one cultural context may be viewed quite differently in another. This may also apply to clinicians’ perceptions and expectations of medical students, and highlights one of the challenges in addressing clinical learning within transnational programmes. That is, students are often learning within curricula derived primarily from one (usually Western) cultural context but doing much of their clinical learning within healthcare systems and cultural contexts sometimes quite different from that. As mentioned above, local teaching staff can play a key role in helping students navigate through this; to learn in ways which meet both curricula requirements and accommodate the expectations of patients and clinicians within the clinical environments in which most of their learning occurs.
Accreditation
While in theory the accreditation process for transnational medical education delivery is not markedly different from domestic accreditation processes, in fact the emphasis on ensuring quality and equivalence is often heightened. For this reason, accreditation represents not only a challenge, but an opportunity to ensure all aspects of a medical education programme meet best practice.
The MUM case study highlights the critical importance of accreditation from relevant medical councils in both the short- and longer-term viability of transnational medical education initiatives. This can significantly impact on recruitment of students, as well as on the capacity of the school to attract quality staff. It is an important ‘measure’ by which the credibility of the programme is gauged both locally and internationally.
The JCSMHS received accreditation from the AMC in 2008 and the MMC in 2010. It has been in negotiation with the governments of Singapore and Sri Lanka to initiate accreditation processes, due to regular intake of students from those two countries. In order to meet accreditation requirements for Australia and Malaysia, the medical school was required to demonstrate quality and equivalence across a wide range of elements, from the physical infrastructure of campuses, to the admissions processes, assessment, teaching content and provision of learning support for students. Quality and coverage of staffing to meet the breadth of the curriculum, not only in the commencing years but across the full 5 years of the degree, needed to be established and demonstrated, as did provision of processes for evaluation of programmes and staff development. The physical learning environment needed to be examined, as well as the electronic and virtual learning environments. Issues around adequate access to library and research support, as well as equivalent learning, language and pastoral support, needed to be addressed. In short, accreditation involved a comprehensive examination of the curriculum in the broadest sense, along with everything else that contributes to the total student experience of learning. This accreditation process is typically not a single event, but involves regular communication and meetings over an extended period, including visits to monitor sustainability and maintenance of standards.
Collaboration and ‘positioning’
A fundamental principle underpinning the Monash University transnational venture was that, following a formative period where the Australia-based school took a leadership role, JCSMHS and the Australia-based Central Medical School would become equal partners in a shared, evolving curriculum. Importantly, an organisational structure was adopted which explicitly established the equal status of the two undergraduate medical schools in terms of governance, curriculum input and decisions on teaching and learning. As stated above, although initial communication tended to involve the Australia-based school ‘mentoring’ the new school in terms of teaching, learning and curriculum delivery, a gradual shift towards genuine two-way dialogue was required, and forms a fundamental requirement for sustainable transnational medical education delivery involving multiple schools and campuses in different countries.
Equivalence
Equivalence in curriculum, programmes, opportunities and support is an important concept in transnational ventures, and is often a key requirement of accreditation processes (as mentioned above). While achieving equivalence in terms of the physical learning environment is often relatively easy to demonstrate, equivalence in other areas is more complex. In particular, assessment is a crucial area where steps are required to achieve and maintain equivalence. These steps can include, for example, shared input into examination and assignment writing, shared marking, and shared involvement in blueprinting, moderation and other assessment-related processes, as outlined in the two case studies above. Other areas where equivalence is often necessary but sometimes overlooked is in the provision of pastoral and learning support tailored to meet the needs of both local and international students.
Contextualisation
In the selection and development of teaching, learning and assessment materials for use in transnational programmes contextualisation is often required. Put simply, this is because materials need to be appropriate and relevant for the location in which they are delivered, and should not disadvantage students due to factors such as assumed knowledge, unfamiliar cultural references, or contexts which are not authentic. Where teaching, learning and assessment materials (e.g. OSCE scenarios) are adapted, this may involve changing surface information such as names, locations, times and demographic information (e.g. regarding a simulated patient). However, contextualisation must also take into account differences in areas such as patient behaviour, the role of family members, healthcare resourcing, diet, gender roles, lifestyle factors, social and familial relationships, attitudes to (dis)ability, educational systems, language use, cultural norms and disease prevalence. In short, ensuring the appropriateness and relevance of teaching, learning and assessment materials through contextualisation is a complex area, often requiring rigorous trialling and a continuous cycle of improvement.
The two case studies examined above involved the establishment of full overseas branch campuses. Students complete the bulk of their studies at these, graduating with a qualification recognised as equivalent to that of students studying at the universities’ main campuses located in the UK and Australia respectively. The intention is for students to graduate with a qualification that enables them to practise both in their country of study (in this case, Malaysia) and the country in which the core campus of their university is located. The two case studies that follow represent quite different models, in which students complete part of their degree in one country, and then relocate to a partner medical school (PMS) in another country for the second phase of their studies. Importantly, the curriculum delivered in Phase 1 has been developed to enable full credit transfer arrangements, and ensure an effective transition into the second phase. In the case of the International Medical University (IMU), this curriculum was developed deliberately to enable international collaboration, while in relation to the fourth case study, an existing curriculum from University of Queensland School of Medicine (UQSM) formed the basis for the institutional partnership developed with Ochsner Health System (OHS) in the USA.
Case study 20.3 The International Medical University, Kuala Lumpur, Malaysia
The International Medical College (IMC) in Kuala Lumpur, Malaysia, was established in 1992. From its inception the college adopted an innovative approach to international collaboration in medical education. In this unique collaboration the IMC forged links with leading medical schools in the English-speaking world and developed a model of medical education where students spent an initial five semesters (Phase 1) in Kuala Lumpur. Upon successful completion of Phase 1 the student transfers to a partner medical school (PMS). The student would spend another 2–3 years in the PMS and graduate with the degree of the PMS. Students transferring to a graduate medical school would spend an additional intercalated year of primarily research work to qualify for the Bachelor of Medical Science (Hons).
The Phase 1 curriculum was a common curriculum developed by IMC with the assistance of leading medical educationists, including Ronald Harden and Ian Hart. This curriculum was a progressive, systems-based, integrated medical sciences course with early clinical exposure. The curriculum was not only innovative and unique in its learning–teaching methodologies; it had to be designed to a standard that is acceptable to some of the best medical schools in the world under the credit transfer arrangement. The original consortium of five schools had over the years increased to nearly 30, and these medical schools are located in the UK, Ireland, New Zealand, Canada, USA and Australia.
Early clinical exposure and the use of a skills laboratory were hallmarks of the Phase 1 curriculum at IMC. The Clinical Skills Unit established at IMC was the first of its kind in the Association of Southeast Asian Nations region, and the design was based on the skills laboratories in Maastricht, the Netherlands and St Bartholomew’s in London, the two major laboratories then in existence in Europe.
John S. Beck, an Emeritus Professor of Pathology from the University of Dundee, Scotland, was appointed the Foundation Dean of the IMC and Sir Patrick Forrest, Emeritus Professor of Surgery from the University of Edinburgh, Scotland, as the Associate Dean. In 1993, the IMC admitted its pioneer batch of 75 medical students.
In 1999, IMC was granted university status by the government of Malaysia and became the IMU. With this new status, the university was able to award its own degrees and the IMU Clinical School was established in Seremban to give students the option of completing the entire medical course in Malaysia. After Phase 1, the student transfers to the Clinical School and completes another five semesters to graduate with the MBBS (IMU). The IMU Clinical School admitted its first cohort of 46 students in 1999.
IMC, and later IMU, had the benefit of experienced and renowned educationists as members of its Board of Governors, an International Consultative Committee and a Professional Advisory Education Committee. An Academic Council (AC) was formed, comprising the Deans or their representatives from all the PMS. The AC functions as an external quality assurance body and meets at least once a year. This annual interaction is very useful to IMU, as during these discussions there is much exchange of new information and sharing of experience. IMU has been able to adopt many best practices as a result of this. The partnership with the many PMS enables the IMU to have access to a wide range of expertise in medical education and visiting experts from the PMS hold regular training sessions for IMU faculty in all aspects of medical and health professional education.
The IMU model for international collaboration and partnership in medical education has been highly successful. Between 1993 and 2011, a total of 2,519 students had transferred to PMS. Information was available on 1,445 students who transferred between 1993 until 2005. Of these, 1,251 (87 per cent) graduated from the PMS within the minimum possible time. Another 158 (11 per cent) completed their medical studies but required additional time. Only 36 (2 per cent) failed to graduate from the PMS. These results would indicate that there are sufficient commonalities in medical programmes worldwide for students to complete a portion of the course in one country and continue successfully with the programme in another (Chow et al. 2012).
The IMU has since launched other health programmes, including Dentistry, Pharmacy, Nursing, Nutrition and Dietetics, Medical Biotechnology, Chinese Medicine and Chiropractic. In all these programmes the university had adopted a model similar to that in medicine. Students have the option of completing the entire course in Malaysia or transferring to a partner university to complete their studies under credit transfer arrangements. In doing so, the university ensures that all its programmes are benchmarked to internationally acceptable standards.
Case study 20.4 Transnational medical education between Australia and the United States of America
In 2008 a partnership was established between the UQSM, Australia, and the OHS in New Orleans, USA, in order to establish a joint medical degree programme. The UQSM had set itself the vision to be ‘Australia’s Global Medical School’ and in addition to a range of initiatives, including high levels of inbound and outbound student mobility, projects in developing-world settings, and a significant international medical student cohort studying in Australia, the school was keen to establish an offshore presence.
The OHS is an integrated academic health centre committed to high-quality clinical medicine, a range of teaching programmes and research. OHS was keen to develop its own medical degree, in a university partnership, building from its established affiliation agreements with local medical schools in Louisiana.
We enrolled our first students in January 2009, with a cohort of 16 students. Each cohort spends the first 2 years of the medical degree studying in Brisbane, Australia, alongside the onshore cohort of Australian and international students. The OSH cohort students then return to the USA for their clinical training. All students follow the same curriculum that is delivered in Australia, and all students sit identical exams, with quality assurance systems effective across all sites.
By 2013 the OHS cohort had grown to over 100 students entering each year, with a plan to increase the intake further to 120 each year. The first cohort has successfully graduated and all graduates have competed for, and taken up, residency programmes in the USA. These novel arrangements have been subjected to significant scrutiny by the AMC, and the arrangements are now accredited.
Students in the OHS cohort are all US citizens or permanent residents, and in addition to the normal examinations taken as part of their medical degree, they also take the United States Medical Licensing Examination (USMLE), in the same way that all US medical students do. This allows us to do some benchmarking, and to date we have seen that OHS students’ scores on the USMLE match the US average for USMLE Step 1, while they exceed USMLE Step 2 average scores.
We have successfully established a novel programme of transnational medical education between the USA and Australia. The two partner organisations have invested significant time and effort into the partnership, which contributed to its initial success. Demand for places is high, and Medical College Admissions Test (MCAT) and grade point average (GPA) entry scores have been maintained. Student performance and progress within the degree programme has been positive, and success rates are as high as those experienced with the Australian and onshore international cohorts.
This arrangement is not typical, but it is innovative and has created much interest and commitment from within partner organisations. Starting with our existing curriculum it was relatively straightforward to expand the teaching programme to another site, even one very distant from the main sites. Significant effort was put into faculty development, with bilateral exchange visits occurring frequently. Deep institutional friendships have evolved and additional academic activities, focused around biomedical research opportunities, are now emerging.
Intercultural competence
Intercultural competence is now addressed within most medical education programmes; however its broad relevance comes into particular focus with the demands of transnational delivery. Heightened demands are placed on the intercultural awareness and competence of everyone involved, whether Deans, teaching staff, administrative staff or students. Transnational delivery highlights the absolute need for intercultural competency to be addressed (both in general and in relation to the medical context) within medical education programmes, for both staff and students, and for it to continue to be regarded as a key graduate attribute expected of all graduating medical students. It is of relevance not only in providing students with the knowledge, sensibilities and ‘multiple repertoires’ needed in clinical contexts, but also in facilitating engagement and learning in terms of student interactions with staff, fellow students and the curriculum itself.
Transnational education and the ‘washback effect’
The process of curriculum development and renewal which accompanies transnational ventures can provide a measure of how effectively the internationalisation of curricula is occurring. The degree to which a curriculum is situated within a specific time, place and healthcare system, and the degree to which it embraces a broader global perspective, become clearer and more evident in the transnational development and delivery process. Transnational delivery has the capacity to provide students with the knowledge, skills, awareness and experience necessary for them to acquire the multiple ‘repertoires’ referred to at the start of this chapter. It also has the potential to impact positively on curriculum development and renewal in other ways.
The concept of ‘washback’ (Biggs 1996) has long been understood in medical education; it refers to the impact of assessment on what is taught and learnt (Cilliers et al. 2010). This impact can be positive or negative, influencing not only what is taught but also how it is taught. With transnational delivery a similar effect can occur in relation to the curriculum. Where genuine collaboration on curriculum development and renewal is occurring across schools and countries, the possibility becomes real of a positive washback effect, with innovative content and approaches developed as part of delivery within one medical school or at one campus informing curriculum development and delivery at the other. Such positive processes, akin to a ‘washback’ effect, are alluded to in both the MUM and NUMed case studies. Effectively, curriculum development and renewal at the overseas school or branch campus can positively impact on the way the curriculum is understood and delivered at other schools or campuses. Where meaningful collaborative processes have developed, this effect could be expected to occur both forward and backward. In this way transnational initiatives have the potential over time to produce richer, less static curricula, creating not only best practice, but a platform for ‘next practice’ (Hanlon 2007).
Conclusion
The four case studies presented in this chapter remind us that transnational medical education can take many different forms. However, what the ventures described in each case study have in common is a shared commitment to curriculum internationalisation and a belief in the value of transnational collaborations for both institutions and individuals. The anecdote which opens this chapter can serve one more purpose – to remind us that at the end of all the planning, implementation, contextualisation, accreditation and evaluation required in transnational delivery lies the fundamental imperative to equip graduates to meet the needs of an individual, often vulnerable, patient. Within an increasingly globalised world and increasingly diverse healthcare contexts, transnational delivery offers much potential to produce graduates with the necessary flexibility and versatility to manage the complex and varied needs of patients within and across healthcare systems, now and into the future.
Take-home message
• International or transnational curricula imply genuine collaborative curricular development and growth, reflecting elements from all parties involved.
• There is no blueprint, and curricula need to be designed to meet the particular needs and circumstances of teaching and learning in the local context.
• Particular attention needs to be paid to issues of staffing, language and clinical learning, accreditation, equivalence and contextualisation between the partner organisations.
• Transnational delivery requires intercultural competency and sensitivity at all levels for staff and students to work in a multitude of environments.
• Genuine collaboration and curriculum renewal offers the potential for positive ‘washback’ for all partner institutions in the way curricula are understood, designed and delivered.
Bibliography
Biggs, J.B. (1996) ‘Assessing learning quality: Reconciling institutional, staff and educational demands’, Assessment and Evaluation in Higher Education, 21: 5–16.
Bleakley, A., Brice, J. and Browne, J. (2008) ‘Thinking the post-colonial in medical education’, Medical Education, 42: 266–70.
Chow, J., Boohan, M., Carmichael, A., Lim, V. and Peters, S. (2012) ‘The International Medical University partnership: Lessons from a 20 year programme of international medical education and workforce development’, unpublished conference paper, Ottawa Conference, 9–13 March, Kuala Lumpur.
Cilliers, F.J., Schuwirth, L.W., Adendorff, H.J., Herman, N. and Van der Vleuten, C.P. (2010) ‘The mechanism of impact of summative assessment on medical students’ learning’, Advances in Health Sciences Education, 15: 695–715.
General Medical Council (GMC) (2009) Tomorrow’s doctors: Outcomes and standards for undergraduate medical education, London: GMC. Online. Available HTTP: www.gmc-uk.org/New_Doctor09_FINAL.pdf_27493417.pdf_39279971.pdf (accessed 10 June 2014).
Hanlon, V. (2007) ‘Next practice’ in education: A disciplined approach to innovation, London: Innovation Unit. Online. Available HTTP: http://www.innovationunit.org/sites/default/files/Next%20Practice%20in%20Education.pdf (accessed 23 March 2015).
Hofstede, G. (1986) ‘Cultural differences in teaching and learning’, International Journal of Intercultural Relations, 10: 301–20.
Manderson, L. and Allotey, P. (2003) ‘Cultural politics and clinical competence in Australian health services’, Anthropology in Medicine, 10(1): 71–85.