Presenters: Anna Cianciolo PhD, Professor Medical Education, Southern Illinois School of
Medicine, Editor in Chief, Teaching and Learning in Medicine, Peter de Jong PhD, Senior
Adviser/Researcher, Center for Innovation in Medical Education Leiden University Medical
Center, Past Editor in Chief Medical Science Educator, President IAMSE, Subha Ramani
MBBS, PhD, MPH, Associate Professor Medicine, Harvard Medical School, President AMEE.

[The following notes were generated by Michele Haight]

Culture and Practices for Global Inclusion in Health Professions Education (HPE)
Publishing: What Can Work?

Global inequities exist in the STEM literature and likely in the HPE literature as well. The MEJ
24 is a list of 24 predominantly European and North American journals identified as the core
seed set of journals comprising the field of medical education. Only 3 of the top ten journals
listed are located in the Global South, representing 4.2% of authors. 62.8% of authors come from
the US, UK and Canada, which are in the Global North. 

85% of the world’s population lives in the Global South. There is a disconnect between global
knowledge production and global knowledge dissemination. Scholars from the Global South are
excluded from knowledge conversations. This leads to a lack of confidence in their capacity to
be included in knowledge conversations, which leads to a lack of representation for
disseminating knowledge as peer reviewers and editorial board members.

Global South is a term used by government and development organizations to describe
developing low- and middle-income countries that are typically former colonial entities.
However, this term has been challenged because it does not represent the nuances and
complexities of the countries and peoples it is proposed to describe.

HPE publishing uses the Global South delineation to promote inquiry and discussion. Doing so
can serve to interrupt entrenched thinking and practices in order to create a space for
participation and innovation. This term can also stimulate discussion about the agency of
individuals and organizations in achieving global inclusion.

For HPE publishing, applying an Inclusive Excellence Framework based on Shore’s (2011)
Inclusion Framework can mitigate some of the aforementioned challenges. Inclusive Excellence
occurs as the result of high belongingness and high value in uniqueness. Because this is most
easily achieved in small groups, publishers and editors are encouraged to create micro
communities within the larger publishing communities.

Adapting DeLuca’s (2013) Interdisciplinary Framework for Educational Inclusion to HPE
publishing is a practical model for education and inclusion. In its current practice, the HPE
publishing world is moving away from a unicentric perspective in which European and North
American principles, rules and regulations have dominated the publishing space. HPE publishing
is mostly gravitating towards a beginning and sometimes approaching an advanced multicentric
perspective. The overall goal for HPE publishing is to transform to a concentric perspective.

Strategies adapted from Danowitz & Tuitt, (2011) for creating a practical framework for
Inclusive Excellence are as follows:

• Programmatic focus on the intellectual and social development of members
• Engagement in purposeful development and utilization of all resources, especially human resources
• Celebrating of cultural differences and publishing about them
• Creating welcoming communities, small and large
• Embracing all diversity to enhance student, staff, and organizational learning.

The following are strategies that journals and authors can utilize to promote Inclusive
Excellence.

Journals:

• Make editorial boards and peer reviewers more diverse.
• Establish international advisory boards.
• Provide workshops and conferences to support publishing.
• Create internships for editorial boards.
• Provide English language support.
• Invite authors from different regions to participate in special issues.
• Waive article processing fees.
• Develop and train editorial board, reviewers and viewers.
• Introduce double-blinded peer reviews.

Authors:

• Carefully choose the target journal.
• Be attentive to instructions to the author; if unsure, connect with the journal.
• Find and collaborate with co-authors.
• Review the international literature.
• Explain the study’s context and why the manuscript is special.
• Explain the study’s relevance and implications.

Striving for inclusion in HPE publishing is not a matter of being altruistic. It is a necessary
endeavor to achieve a scholarly dialogue that will improve the practice and understanding of
HPE publishing. Promoting scholarly efforts and publishing infrastructure outside of the Global
North are also essential actions to attaining Inclusive Excellence. This is the work that is
currently being done by the International Network for Advancing Science and Policy (INASP)
and the Global Health Scholarship Community of Practice Program.

As always, IAMSE Student Members can register for the series for FREE!

Presenter: Ahmed Rashid MD, Professor of Medical Education, Vice Dean (International) of Medical Sciences, Director of Faculty Development for Medical Education Collaborations, University College of London’s Medical School (UCL)

[The following notes were generated by Michele Haight]

Global Approaches to Medical Education: Who Wins?

This presentation examines the intersection of globalization, global health, and medical school regulation. It poses the question about who wins when we move to a global regulation process for medical schools.

At UCL, disruptive thinking has been the status quo since 1826. It was the first university in London to welcome women and students of any religion or social background. This progressive, egalitarian approach continues at UCL to this day. UCL is London’s global university.

The team at the UCL Centre for Medical Education Collaborations (CIMEC) is involved in supporting the development of new medical schools across the world. This includes developing tailored medical education programs and designing contemporary administrative and learning environments. This work is mostly concentrated in the Global South.

The World Federation for Medical Education (WFME) is an organization that exemplifies the different issues, challenges, and priorities that faculty members and medical education leaders face in different parts of the world. There is a mismatch between the priority and recognition of this agency across the world. Those in the Global North are not necessarily aware of the existence of the WFME, whereas those in the Global South are preoccupied with its existence.

The WFME is a tiny organization with virtually no staff. The decision-making body of the WFME appears to be its Executive Council. The voting members on the Executive Council include the six presidents of the representative medical education groups for each continent (AMEE, AMSA, PAFAMS, SEARAME, AMEEMR, WPAME), two founding members (WHO, WMA), and three executive members (IFMSA, JDN, ECFMG). The structure of the WFME makes sense, but the inclusion of the ECFMG, which represents a single country (US), is problematic.

ECFMG is the gatekeeper for physicians who train outside the US and wish to do a residency in the US. Completion of residency training in the US is considered prestigious and highly desirable around the world. 

In 2010, ECFMG created a policy that as of 2023 (now 2024 due to the pandemic), all medical students wishing to train in the US had to graduate from a medical school accredited by an agency that uses globally accepted criteria such as those put forth by the WFME. The additional requirement that a medical school can only be certified by ECFMG if that school is accredited by an agency that is recognized by the WFME launched the WFME into the global consciousness. To be clear, WFME does not confer accreditation. Rather it recognizes certain accreditation agencies, and schools that are accredited by those agencies meet the requirement. This policy decision had a tremendous global impact that has been likened to the “butterfly effect” (Lorenz, E.N., 1972).

The predominant issue is that a single agency from the US (ECFMG) developed this policy, and another US organization (FAIMER) developed the mechanics for implementing the policy. Essentially, the US has singularly developed the conceptual framework and the technical infrastructure for a policy that has a worldwide impact. The following three articles provide a closer examination of the issues associated with this policy.

Altruism or Nationalism: Exploring Global Discourse in Medical Education (Rashid M.A., 2023) This article provides a critical discourse analysis of 250 papers. The analysis revealed two contrasting discursive positions: altruism and nationalism. Altruism is informed by endorsement and modernization discourses. Each of these discourses contributes to a policy narrative that aligns with key global principles for modernizing and improving medical education across the world.

The second position is nationalism (referring to American interests), which is informed by discourses of protection and control. Protection is described as twofold. It refers to protecting the American public\ from the threat of foreign doctors, and it also refers to protecting American citizens who train outside of the US from poor quality medical schools. Control refers to the need for the US to monitor and manage the quality of all medical training. 

The article proposes that both discourses are present in the policy, each one appealing to a different audience. The article concludes that it is important to highlight the tension between the WFME, a global facing agency and the ECFMG, a single country-facing agency.

Examining the WFME Recognition Programme at 10 years (Tackett et al., 2023)
This research paper produced the following observations. 

• Most of the countries that supply the most international medical graduates (IMGs) have agencies that have applied to the WFME program. So far, only 41 out of over 150 agencies around the world have applied to WFME.
• There is no formal or informal evaluation of the WFME program.
  
• The motivation for agencies to apply or not is unclear.
• A global market for accreditation has emerged and perhaps this is the most troubling observation. There are no rules to stop accreditation agencies from operating in multiple countries, and there are no rules for multiple accreditation agencies to operate in a single country. As a result, accreditation can become a highly political and commercial endeavor.
• There is a lack of transparency and no research.

Reconsidering a Global Agency for Medical Education: Back to the Drawing Board?
(Rashid, et al., 2023a)
This article postulates that the world deserves a different model for medical education.
The article points out that six white male presidents have helmed the model, even though the majority of medical schools are in the Global South. It further points out that the agency’s offices are mostly located in Western Europe and North America, not the Global South. The policies promoted by this agency legitimize standardization and westernization, and promote the values, priorities and policies of the Global North. Finally, there is a lack of transparency, democracy and evaluation in the current model.

Envisaging an alternative model might include the following characteristics, “…local rather than global, contextual rather than general, cooperative rather than hierarchical, supportive rather than judgmental, flexible rather than rigid, and developmental rather than a single snapshot…”(Rashid et al. 2023b).

COVID-19, cardiovascular disease, mental health, climate change, poverty, conflict, health care infrastructure and an aging population are just some of the public health concerns that affect individuals across the globe. Amidst these global health concerns, there is a pressing need for our learners to not only be competent in caring for patients within their local communities but to also be poised for patient care in differing cultures and geographies. How do we train our learners for this immense task? The Winter 2024 IAMSE Webcast Audio Seminar series will explore the intersection of medical and health professions education with global health. Themes will include the difficulties of life and medical practice in other parts of the world, to the unique challenges faced by migrant physicians, and medical education and scholarship in low-resource countries. The webinar series will help us recognize and appreciate our own biases as well as different perspectives on values and shared global challenges. Global health is the collaborative trans-national research and practice for improving health and achieving equity in health for all. This webinar series will equip the health professions educators to train globally-minded learners who will provide care for the medically underserved from pole to pole.

One World, One Health
Tackling the Global Health Crisis

Join us for each one-hour session beginning Thursday, January 4 at 12 PM EST. Sessions in the Winter 2024 series include:

• January 4, 12 PM EST – Global Health Electives: the Good, the Bad, the Ugly presented by Jenny Baenziger
• January 11, 12 PM EST – Climate Change and Human Health presented by Eugene Richardson
• January 18, 12 PM EST – Global Approaches to Medical School Regulation: Who Wins? presented by Ahmed Rashid
• January 25, 12 PM EST – Cultures and Practices for Global Inclusion in Health Professions Education Publishing: What Can Work presented by Anna Cianciolo, Peter de Jong, & Subha Ramani
• February 1, 12 PM EST – Refracting Lenses – Seeing Women of Colour in Global Health presented by Thirusha Naidu

As always, student member of IAMSE can register for hte series for FREE! Email support@iamse.org for details.