Dr Maria Tsouroufli, PhD, Senior Research Fellow in Education, Institute of Policy Studies in Education, Faculty of Humanities and Social Sciences, London Metropolitan University, London, UK. Email. Tel: 00442071332158.

In this post I unravel some of the risks embedded in the trade of internationalisation, including unproblematic notions of universalism and disembodiment of medical education and the implications for student access, participation and outcomes. I draw attention to the learning and professional capacities that international medical education favours within a competitive higher education market, dominated by western medical pedagogies, but marketed as valuing diversity and difference.

I propose an emancipatory framework of international medical education which can open up possibilities for equity and social justice in medical education and medicine.

‘Internationalisation of Medical Education: Hierarchies, Inequalities and Future Directions’

Within the wider higher education literature there is a diversity of perspectives on internationalisation. Some scholars have expressed concerns about the reduction of the concept and its policy implications to mobility issues and international student numbers (1, 2).  Internationalisation has been defined by OECD (3) as the integration of an international/intercultural dimension into all of the activities of a University, including the teaching, research and service functions.  Recently there has been a turn to ‘internationalisation at home’ in an attempt to enhance knowledge about intercultural communication and inform the development of pedagogic and management strategies that will promote inclusive learning and teaching within internationalised Universities (1).  Within the literature of ‘internationalisation at home’ the majority of research tends to compare the experiences of University students from one culture with those of another or to evaluate internationalisation strategies developed by institutions.

Internationalisation has become the latest imperative for medical education.  Global economic and social changes have increased the mobility of medical professionals and students and have opened up possibilities for international research and teaching collaborations in medical education. Along with opportunities have come concerns and an increasing interest in defining international standards of medical education that will facilitate the transportability of qualifications and the migration of the international medical workforce (4).

Concerns have also been expressed about the quality of the learning experience in international internships (5,6) and the challenges and coping strategies of international medical students (7).  However, these voices seem marginal within a context of glorification of internationalisation of medical education.  I do not adverse some of the benefits of internationalisation, including the advancement and communication of information and the potential improvement of patient health in digital knowledge economies.  Instead I propose we approach internationalisation with criticality in an attempt to unfold the hidden assumptions upon which the internationalisation imperative is predicated and sustained.

To my knowledge, there has been no systematic attempt to develop a coherent definition of internationalisation or international medical education and its fundamental tenets. For the purposes of this blog I discuss international medical education that encompasses the provision of undergraduate and postgraduate medical education beyond national borders (exporting higher education) and provision of undergraduate and postgraduate medical education for foreign students within the provider country (importing). In what follows I will focus on the hierarchies and inequalities that dominant discourses of internationalisation/international medical education simultaneously reproduce and are shaped by. The discussion is focused on three fundamental questions:

• Whose knowledge and whose culture translates into symbolic capital (resources and prestige) in international medical education?
• What capacities for learning and professional practice are privileged in international medical education?

• What directions do we need to consider in the development of an emancipatory framework of international medical education?

First, we need to consider the global shifts in higher education in terms of philosophy of governance, management and knowledge production.  Shifts from the welfare state to competitive state have resulted in reduced funding for higher education and the corporitization of Universities in many capitalist societies, including the UK.  Higher education is now governed by enterpreneurial ideologies and a culture of ‘corporate managerialism’ (9) with emphasis on accountability, productivity and marketable consumer satisfaction. Universities are caught up in the production of income, graduates and ‘knowledge workers’ (10).  They operate within a context of increased competition and knowledge capitalism which legitimises hunting of new markets and a new form of colonization.  Innovative forms of medical educational provision including cross-national medical schools and e-learning postgraduate medical education courses have grown as economic imperatives in the UK in an attempt to respond to wider political programmes that place higher education at the centre of their capitalist agenda and allegedly the national wealth generation.

Embedded within a global neo-liberalism environment, international medical education programmes are designed to attract and achieve maximum economic and educational capital. Giroux (11) argues that the corrosive corporate culture of Universities ignores privileges and hierarchies, and impacts on our understanding of higher education.

Face-to-face international undergraduate medical education programmes in the Mediterranean and the Middle East and online international postgraduate medical education programmes are American or British initiatives that serve a predominantly non-white and non-Anglosaxonic student population. Medical education in English in these regions and bilingual (English and Chinese) medical education in another big market, China, are very popular (12).  The marketed value of such courses is scripted in two contradictory premises; the assumed neutrality and universality of medical knowledge and professional practice, and the realisation of educational and cultural capital that will enhance graduates’ employability within the international market.

Within the social sciences there is a long tradition of problematization of knowledge production and generalizability. The political power, control and injustices intertwined with knowledge claims (e.g. Western theories used to support the assumed inferiority of certain races or medical science used to construct the ‘hysterical’ female body); the partiality of all knowledge, including the uncertainty of medical evidence (13) and the authentication of knowledge claims by powerful actors within academia (14, 15) are some examples of influential work on knowledge production and legitimization. However, such claims might seem an anathema to medical science and indeed all ‘hard’ sciences, allegedly indifferent to geography, nationality and politics.

My intention here is not to contest the validity of certain medical claims but rather to draw attention to the complex practices and processes that construct hierarchies of knowledge, credentials and professional practice and perpetuate inequalities within the international education market.

The control of medical education markets by predominantly American, British and Australian higher education is legitimised through global representations endorsing the superiority of one medical education curriculum over another (‘non-Western’).  The long history of colonialism provided the context for constructing ‘Western’ driven, but universally applied systems of knowledge and education. Neo-liberal domination on the other hand has led to redundancy of pedagogies of social justice, and a pre-occupation with educational and economic outcomes of higher education curricula.

The ascendancy of neoliberal ideology in higher education shifts attention from higher education as a public good to individual good as a civic responsibility. Under neo-liberalism, learners are faced with endless possibilities and free choices in knowledge economy. They are expected to be entrepreneurial, competitive and pre-occupied with success (16, 17).  The silencing of the pedagogical and ethical challenges posed by international medical education is legitimised within a context of learning reduced largely to economic motive (18) and individual, cognitive-technical practice.

 ‘The way that knowledge is organised both physically and epistemologically within most mainstream higher education context demands the erasure of the body’ (19).  The body is discussed here as both a physical as well as social-cultural site for reifying, re-making or resisting learning and professional meanings and practices (20). It has feelings, morals, and dilemmas lived within communities of practice (21) and shaped by personal as well as collective predispositions influenced by social constructs of gender, class, culture and ethnicity (22). The body does emotional labour, and perpetuates ideologies within a web of professional and power relations in a hospital, general practice or community setting. For example a female orthopaedic surgical trainee might manage her body (e.g. appearance, emotions, ‘technical’ skills and even reproductive choices) in ways that are acceptable within the gendered hidden curriculum of surgery. All these embodied acts are fundamental in the learning experiences of medical students/trainees and their professional identification process (23).

Western medical training has claimed to intentionally aspire to produce ‘rational’, disembodied doctors, homogenised and neutralised in terms of social difference and diversity (24).  Despite increasing interest on socio-cultural theories of learning in medical education research and teaching, the body is paradoxically obsolete, discredited and always present in medical training and work.  Embodied experiences such as power, control and assimilation, have received attention in undergraduate medical education research on gender, medical student identity (25, 26, 27, 28) and medical enculturation in postgraduate medical training and practice (29).

However, even in this pioneer medical educational literature the body remains conceptually and analytically implicit, rather than a fundamental instrument in constituting scholarly and professional habitus (30);  a set of dispositions to learning and professional practice that generate identities and shape successful participation in medicine and medical education.

Successful performance of favoured embodied acts allows medical students to fit into social relationships and knowledge paradigms in international medical education and develop educational capital. Embodied and gendered dispositions such as doing independent learning (15), not asking for help, controlling emotions and working ‘all hours’ have been viewed as positive and subtly reinforced in UK medical education.  Demonstration of these ‘qualities’ has been associated with capacity for educational achievement and professional competence (31).

Unfortunately medical education research has not so far explored the contradictions or oppositions between the learning dispositions and capacities of medical students/trainees and the formal and informal international medical curricula. What capacities are required for access and successful participation in international medical education? What sorts of habitus and capital facilitate access to international medical education?  If competence in the English language is one of the selection criteria we need to think what educational and economic capital would successful international applicants need to have, and what educational and social inequalities might be reproduced or increased within the context of international medical education.

How might local understandings of learning and doctoring influenced by the lived experiences of culture, religion and the gender order contradict valued and favoured embodied capacities in international medical schools? For example, if ‘selling’ the self in an admissions interview in a cross-national medical school is valued and assessed positively, what strategies of self-regulation might some non-Western female students have to employ in an attempt to participate and fit in international medical education?

Currently, student-centred methods originating in Western culture seem to represent an ‘international’ standard (32). For example, the application of problem-based learning in non-Western contexts raises a lot of questions about the implications for these methods for student participation and achievement in international medical education. What feelings, dilemmas and difficulties might international students have to manage to align their learning dispositions and identities with the normative expectations of international medical schools?

Medical education research is replete with examples of inequalities in educational achievement among different ethnic groups (33, 34). Recently considerable attention has been given to biographical and bio-psychosocial risk factors among underperforming factors in the UK, including cultural differences and country of qualification (35, 36).

Although this research is valuable in raising awareness about inequalities in medical education and medicine, it does not tell us much about the embodied learning and professional practices in undergraduate and postgraduate medical education that shape and are shaped by students’ different forms of capital (cultural, economic and social), nor does it throw any light on the learners’ relationships with the field (e.g. a hospital or a specific medical school); ‘a network of objective relations between positions’ (37)  functioning as an arena ‘of production, circulation and appropriation of goods, services, knowledge or status which participants struggle for power and capital’ (38).

Empirical research in international medical education needs to examine the different forms of capital that medical students bring and the implications for learning; the embodied medical habitus valued and reproduced in international medical education; as well as the costs of international students performances of fitting in (39, 40). I propose an emancipatory framework of international medical education which can open up possibilities for equity by focusing on the following future priorities:

• Embracing medical student diversity and difference (cultural, religious, ethnic etc.) as a resource for developing inclusive medical curricula for all learners and cosmopolitan identities

• Shifting attention from diversity in admissions to challenging marginalisation and racism, and the effects of racism on retention and success in international medical education.

• Conducting medical education research on belonging and inclusion of ‘international’ medical students and the personal and professional costs of embodied performances of fitting in.

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