Hodges, Brian D

Canadian Medical Education Journal

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Brian D Hodges

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Health professions education and globalization: a call for reflexivity

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Canadian	Medical	Education	Journal	2016,	7(3),	Special	Issue		Correspondence:	Brian	Hodges,	Toronto	General	Hospital,	1RFE-410	190	Elizabeth	Street,	Toronto,	Ontario,	M5G	2C4;	Email:	brian.hodges@uhn.ca	 e1	Canadian	Medical	Education	Journal	Editorial	Health	professions	education	and	globalization:	a	call	for	reflexivity	Brian	Hodges1		1University	Health	Network,	University	of	Toronto	Published:	December	5,	2016	CMEJ	2016,	7(2):e1-e3		Available	at	http://www.cmej.ca	©	2016	Hodges;	licensee	Synergies	Partners	This	is	an	Open	Journal	Systems	article	distributed	under	the	terms	of	the	Creative	Commons	Attribution	License	(http://creativecommons.org/licenses/by/2.0)	which	permits	unrestricted	use,	distribution,	and	reproduction	in	any	medium,	provided	the	original	work	is	properly	cited.			We	 seem	 to	 be	 subject	 to	 an	 ever	 more	 strident	globalization	 discourse.	 Leaders,	 political	 parties,	countries,	 and	 international	 organizations	increasingly	work	to	create	an	identity	that	 is	either	strongly	aligned	with	or	against	globalization.	 In	the	context	 of	 such	 discursive	 ferment,	 health	professions	 education	 cannot	 escape	 the	conversation.	 And	 yet,	 a	 read	 of	 our	 literature	reflects	 more	 confusion	 than	 clarity.	 Only	 seven	years	ago,	my	colleagues	and	I	conducted	a	review	of	the	 literature	 on	 globalization	 in	medical	 education	and	 found	 next	 to	 nothing	 to	 report.1	 Concerns	abounded,	 of	 course:	 the	 nefarious	 effects	 of	students	 going	 abroad	 unsupervised,	 exporting	culturally	 inappropriate	 teaching,	 and	 poaching	health	 professionals	 from	 low	 income	 countries	under	the	guise	of	international	education.	But	those	concerns	 were	 largely	 imported	 from	 other	 fields	and	 sprinkled	 atop	 a	 medical	 education	 field	 that	had,	as	yet,	scarcely	engaged	with	the	issues.2	Not	 yet	 a	 decade	 later,	 medical	 educators	 are	turning	 the	 full	 force	 of	 their	 intellect	 to	 what	 it	means,	 and	what	 it	 does,	 to	 engage	 globally.	 Good	quality	 research	 on	 globalization	 is	 now	 available.	Martimianakis	and	Hafferty’s	careful	empirical	work	illustrates	how	easily	students	and	teachers	become	conflicted	 about	 the	way	 globalization	 is	 presented	in	 the	 classroom	 –	 mixing	 discourses	 of	 universal	competence,	cultural	specificity,	and	advocacy.3	Paul	et	al.	similarly	showed	up	inconsistencies	in	Canada’s	national	 policies	 and	 practices	 that	 simultaneously	convey	 to	 internationally	 trained	 health	professionals	 that	 they	 are	 welcome,	 but	 also	 that	they	 are	 potentially	 incompetent;	 that	 they	 are	 a	needed	part	 of	 the	 labour	 force,	 but	 also	 that	 they	upend	 the	 domestic	 job	 market.4	 Ho	 et	 al.	challenged	 the	generalization	of	 competencies5	 and	Frambach	 et	 al.	 questioned	 the	 transferability	 of	pedagogical	methods.6		It	is	not	a	question	of	if	health	sciences	schools,	their	faculty	 and	 students	 should	 participate	 in	globalization.	 Today’s	 questions	 are,	 rather,	 when	they	 do	 engage	 internationally,	 what	 is	 their	intention,	 how	 do	 they	 partner,	 and	 what	 are	 the	consequences?	 To	 date,	 schools,	 faculty,	 and	Canadian	Medical	Education	Journal	2016,	7(3),	Special	Issue		 e2	students	 have	 been	 passive	 with	 regard	 to	 these	 questions	 -	 perhaps	 because	 of	 naiveté	 but	 also,	 I	believe,	 because	of	 a	 failure	 to	 consider	 the	ethical	dimension	of	international	activity.		A	novel	approach	to	countering	that	passivity	comes	from	 the	 University	 of	Washington.	 In	 the	 spirit	 of	the	 “plastic	 pocket	 card”	 that	 is	 ubiquitous	 in	medical	 education,	 Mathew	 Sparke	 and	 colleagues	created	a	card	that	illustrates,	not	how	to	resuscitate	a	 patient,	 or	 how	 to	 escalate	 a	 crisis,	 but	 how	 to	reflect	 on	 the	 impact	 of	 international	 activities.	 For	example,	 the	 card	 asks	 the	 user	 to	 consider	 if	 they	might	 be	 involved	 in:	 tourism	 (a	 vacation	 at	 risk	 of	objectifying	 poor	 countries),	 romanticism	 (over	emphasizing	 what	 can	 be	 accomplished	 with	volunteerism),	 parasitism	 (incurring	 costs	 to	 a	 low	income	 host),	 careerism	 (cv	 burnishing),	 or	exemptionalism	 (doing	 things	 one	 would	 not	 be	permitted	 to	 do	 at	 home).7	 The	 card	 puts	 ethical	questions	 directly	 into	 the	 pocket	 of	 the	 faculty	member	or	student.	Authors	 including	 Whitehead	 ask	 us	 to	 think	 hard	about	 the	 geo-political	 dimensions	 in	 which	 our	global	 activities	 are	 embedded.8	 In	 an	 era	 when	medical	 schools	 hold	 tightly	 to	 concepts	 of	 social	responsibility,	researchers	like	Whitehead	are	asking	us	 to	 question	 the	 impact	 of	 our	 international	engagements.	 A	 clamouring	 for	 international	partnerships	 between	 institutions	 makes	 this	 work	more	 urgent.	 For	 example,	 University	 of	 Toronto’s	13-year	 partnership	 with	 the	 University	 of	 Addis	Ababa	 has	 stimulated	 a	 great	 deal	 of	 reflection,	debate,	 and	 learning	 on	 both	 sides.9	 From	 these	experiences,	 I	 propose	 a	 sort	 of	 plastic	 pocket	 card	for	 health	 sciences	 schools.	 It	 might	 include	 the	following	questions:		1. How	 does	 the	 project	 align	 with	 the	 social	responsibility	 of	 your	 school	 and	 to	 the	city/region/country/society	 in	 which	 it	 is	located?	How	will	the	project	affect	the	social	responsibility	 of	 your	 partner’s	school/city/region/country/society?		2. Does	 the	 project	 improve	 (or	 worsen)	inequities	 in	 the	 access	 to	 health	 care	 by	patients,	or	to	education	by	students,	in	either	place?	3. Is	 the	 program	 in	 line	 with	 health-human	resource	planning	to	build	national	capacity	of	all	countries	involved?	4. In	 developing	 the	 activities,	 is	 there	 robust	participation	 by,	 and	 credit	 given,	 to	 all	partners?		5. Does	 the	 project	 impose	 any	 healthcare	 or	education	 standards,	 assumptions,	 or	practices	 from	 an	 economically	 or	 culturally	dominant	 country	 that	 do	 not	 fit	 with	 the	cultural,	 economic,	 healthcare,	 or	 education	needs	of	the	partner(s)?	The	many	 interesting	 articles	 in	 this	 special	 edition	grapple	with	these	and	other	challenges.	Canada	has	stood	at	the	nexus	of	international	travel,	trade,	and	engagement	 since	 the	 first	 Europeans	 imposed	themselves	 onto	 the	 land	 of	 North	 America’s	indigenous	 peoples.	 The	 jostling	 of	 cultures	 and	civilizations	 around	 the	 world	 continues	 apace.	 As	the	 authors	 of	 these	 papers	 illustrate,	 health	professions	education	 is	at	 its	best	when	we	reflect	on	 the	 meaning,	 ethics,	 and	 implications	 of	 our	programs	and	practices.		References	1. Hodges	 BD,	 Maniate	 JM,	 Martimianakis	 MA,	 Al	Suwaidan	 M,	 Segouin	 C.	 Cracks	 &	 crevices:	globalization	 discourse	 and	 medical	 education.	Med	Teach.	2009;31(10):910-7.	2. Bleakley	A,	Brice	J,	Bligh	J.	Thinking	the	post-colonial	in	medical	education.	Med	Educ.	2008;42(3):266–70.	3. Martimianakis	 MA,	 Hafferty	 FW.	 The	 world	 as	 the	new	local	clinic:	a	critical	analysis	of	three	discourses	of	 global	 medical	 competency.	 Soc	 Sci	 Med.	 2013;	87:31-8.		4. Paul	R,	Martimianakis	MA,	Johnstone	J,	McNaughton	N,	 Austin	 Z.	 Internationally	 Educated	 Health	Professionals	 in	 Canada:	 Navigating	 Three	 Policy	Subsystems	 Along	 the	 Pathway	 to	 Practice.	 Acad	Med.	2016.	Aug	9.	[Epub	ahead	of	print]	5. Ho	MJ,	Lin	CW,	Chiu	YT,	Lingard	L,	Ginsburg	S.	A	cross-cultural	study	of	students'	approaches	to	professional	dilemmas:	 sticks	 or	 ripples.	 Med	 Educ.	 2012;	46(3):245-56.	Canadian	Medical	Education	Journal	2016,	7(3),	Special	Issue		 e3	6. Frambach	JM,	Driessen	EW,	Chan	LC,	van	der	Vleuten	CP.	 Rethinking	 the	 globalisation	 of	 problem-based	learning:	 how	 culture	 challenges	 self-directed	learning.	Med	Educ.	2012;46(8):738-47.	7. Sparke	 M,	 personal	 communication.	 University	 of	Washington	 International	 Program	 accessible	 at	www.globalhealth.washington.edu	8. Whitehead	 CR.	 On	 gunboats	 and	 grand	 pianos:	medical	 education	 exports	 and	 the	 long	 shadow	 of	colonialism.	Adv	Health	 Sci	 Educ	 Theory	 Pract.	 2016;	21(1):1-4.		9. Toronto	 Addis	 Ababa	 Academic	 Collaboration	[Internet].	 Toronto,	 ON:	 University	 of	 Toronto.	Available	 at:	 http://taaac.com	 [Accessed	 November	20,	2016]				

Health professions education and globalization: a call for reflexivity

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