Transnational medical education programmes and preparation for different country medical practice: A systematic review

Abstract

Background

Medical education is becoming more internationalised. Increasing numbers of students engage in Transnational Medical Education Programmes, pursuing their Primary Medical Qualification outside of their home country; with plans to transition back to their home country – or a third country – after graduation. Medical education is however, inextricably embedded within medical contexts, and a potential mismatch exists between graduates' place of training and place of practice in terms of the knowledge, skills and values required to practice safely in a different context.

Aim

What types of Transnational Medical Education programmes can be identified from the international literature? What are the strengths and weaknesses of these programmes and do they prepare students for international practice?

Methods

This review was based on the PRISMA‐Guidelines for systematic reviews. We searched five electronic databases: MEDLINE, EMBASE, CINAHL, WEB of Science and ERIC. No date or language restrictions were placed on the inclusion criteria. Data extraction was completed by two independent reviewers. Quality appraisal was carried out using the Mixed Methods Appraisal Tool (MMAT), and a narrative synthesis of the included papers was conducted.

Results

Our literature search identified 12 studies. From the included studies we were able to identify three types of Transnational Medical Education Programme, and a number of strengths and weaknesses of these programmes. Strengths were: increasing medical workforce capacity, enhancing the quality of education locally, promoting intercultural competence and increasing exposure to new ways of working (enhanced communication skills, shared decision‐making, experience of multidisciplinary teamwork and patient‐centeredness). Weaknesses were: potential curriculum misalignment within the context of clinical practice, language barriers and encountering differences in hierarchical systems, shared decision making and patient‐centredness all of which impact preparation for practice.

Conclusion

Transnational medical education programmes address shortages within the medical workforce by creating additional training opportunities. They can also drive up the quality of medical education locally. There is, however, a potential mismatch between the curriculum and the place of practice which can impact upon graduates' preparation for professional practice.

Short abstract

While transnational medical education is seen to boost workforce & local training quality, mismatches in curriculum, language & practice culture may hinder grads' readiness for international care. #MedEd #GlobalHealth

1. INTRODUCTION

Medical education has traditionally trained doctors to practice in the context within which they were educated. However, medical training is becoming increasingly more internationalised, with current estimates suggesting that 15% of healthcare workers are practicing in countries different to those in which they were born, and different to where they received their primary qualification. ¹ There are two driving factors, 1) a growth in branch campuses training medical students overseas, and international medical programmes which are designed to train doctors for practice elsewhere ² , ³ , ⁴ , ⁵ and 2) an increasing dissatisfaction with clinical practice in some countries, leading to a large proportion of medical graduates to leave, or plan to leave their own country to practice elsewhere. ² , ³ , ⁴ In a recent UK study, involving graduates from all 44 UK medical schools, over 30% of ‘home’ graduates intended to emigrate. ³ Similar findings have been reported in Ireland, with studies showing that between 53% and 88% of Irish national medical students and recent graduates planned to emigrate. ² , ⁵

We know that International Medical Graduates (IMGs) – doctors who qualified outside of the country in which they practice ⁶ , ⁷ – need support to make a successful transition to their new host country ⁶ , ⁸ , ⁹ , ¹⁰ , ¹¹ ; however, doctors who have been deliberately trained for practice elsewhere also encounter challenges as regards the knowledge, skills and behaviours needed to begin work. ¹² This latter point is a largely unreported area of study.

The internationalisation of medical training is evidenced by the continued growth in transnational education. ¹³ This typically takes the form of a ‘host’ medical school developing a branch campus overseas and then delivering the same (or similar) curricula as the ‘home’ institution, ¹⁴ but in a different cultural and healthcare context. ¹⁵ Such arrangements are also referred to as ‘cross‐border curriculum partnerships’ ¹⁵ , ¹⁶ and have predominately been agreements between institutions in the Global North (often referred to as ‘Western’ countries) ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ and those in the Middle‐East, East and South‐East Asia – the Global South. ¹⁴ , ²¹ , ²² , ²³ These partnerships have been viewed as an opportunity for home institutions to increase their reach, and for the host institution to broaden access to education and drive up local standards. ¹³ , ¹⁴ They can also be significant income generators, and play a role in soft‐diplomacy. ¹⁴ , ²² , ²⁴ , ²⁵ It is estimated that UK providers of TNE alone had over 500 000 students studying for a UK TNE in 2020–2021, contributing approximately £25.6 billion to the UK economy in 2020. ²⁶

The internationalisation of medical education has also led to an increase in international medical programmes, whereby international students study alongside other international, and/or local students on local programmes, or ‘English Parallel’ courses – English language versions of an existing local curriculum, are typically designed to prepare students for practice elsewhere, not in the local healthcare system. ²⁷ , ²⁸ German language parallel programmes are also available at universities in some Central‐European medical schools. ²⁹ Additionally, medical schools catering primarily for overseas students – whereby students complete their pre‐clinical and clinical training in different locations – began to emerge in the 1970s, most notably in the Caribbean ³⁰ and have proven particularly popular with medical students from the USA and Canada. ³⁰ , ³¹ , ³² Estimates suggest that there are currently over 200 medical schools offering International Medical Programmes with the aim to prepare medical students for careers elsewhere. ³³

Transnational Education (TNE) has been defined as “all types of higher education study programmes, or sets of courses of study, or educational services (including those of distance education) in which the learners are located in a country different from the one where the awarding institution is based”. ³⁴ We propose the following addition: “and programmes where it is intended for the student to practice elsewhere upon graduation”, making the definition more encompassing and includes the growth of both international medical programmes and programmes whereby pre‐clinical and clinical training occurs in different locations.

The decision to study medicine through TNE, as defined above, is driven by a number of factors. These include: competitive cost; the limited availability of medical school placements in the student's home country; the reputation and location of the medical school; and the ability to begin medical education earlier than would be possible in an individual's home country. ³² , ³⁵ , ³⁶ However, many of the students who complete the programmes identified above, plan to return to their home country, or progress to another country once they complete their Primary Medical Qualification (PMQ). ³² , ³⁷ , ³⁸ Brouwer et al, (2022) found that almost half of all graduates from International Medical Programmes were practising elsewhere immediately following graduation. Two years after graduation this had risen to 73%. They note that only graduates native to the country were likely to have remained at this point. ³³ This aligns with OECD research which notes a growing trend for medical students to train outside of their home country, with many of those from OECD countries planning to return to their home country after gaining their PMQ. ³⁶

It cannot be assumed that the TNE curricula will prepare graduates for international practice as clinical practice, ethics and professionalism within medicine are inextricably embedded within the context of medical education. ³⁹ , ⁴⁰ Hofstede pioneered research on the prevailing values within different countries and how these values shape behaviour. ⁴¹ Concepts from this work such as power distance (the extent to which less powerful members of institutions accept and expect that power is distributed unequally), suggest that students trained in a highly hierarchical environment will struggle to adapt to both patient and colleague expectations in a flatter system, and vice versa. ³⁹ Moreover, dimensions of national culture have been linked to differences in medical communication. ⁴²

To date, the success of TNE in preparing medical students to begin practice is largely underexplored, despite its continued growth and popularity. Preparedness for practice has been defined as “the readiness of students to work in clinical practice”, ⁴³ i.e. the attainment and demonstration of the necessary skills and knowledge to work safely. ⁴⁴ This includes: the doctor‐patient relationship; the ability to perform clinical procedures; prescribing medication, and learning how to operate within the structures and systems of a given healthcare service. ⁴⁵ , ⁴⁶ Preparedness should also be understood as the interplay between medical skills and knowledge, and non‐domain specific skills, such as problem‐solving, critical thinking, adaptability, self‐efficacy and cultural competency. ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰

To practice safely, graduates of TNE programmes need to be prepared to work in different healthcare systems internationally, understand different communication patterns with colleagues, patients and their families, as well as variations in cultural, ethical and social norms. ¹⁷ , ⁵¹ , ⁵² , ⁵³ For example, Rothwell et al reported that students attending a branch campus in Malaysia were taught about Western practices such as patient‐centredness and shared decision‐making, but only saw this in practice when they took part in a student exchange at the UK campus; highlighting a mismatch in what is taught and what is experienced. ¹⁸ This mismatch can lead to professional dilemmas causing ‘suffering’ for clinicians who were torn between cultures, ⁵⁴ for example, non‐disclosure of a diagnosis to a patient in Ireland or the UK occurs only in exceptional circumstances, whereas in countries such as China, Malaysia and Saudi Arabia, a more family‐centred approach is preferred and disclosure may be mediated through the patient's relatives who traditionally take on a major role in supporting the patient once transferred home. ⁵⁵ , ⁵⁶ , ⁵⁷

Much is known about IMGs and the challenges experienced by this diverse group when transitioning to practice elsewhere after having trained and practiced in their local context. ⁶ , ⁸ This knowledge is largely situated within the context of a transition to medical practice and settings within the ‘Global North’ from the ‘Global South’ ⁵⁸ , ⁵⁹ and/or the use of interventions or programmes that might be developed to support this transition. ⁶ , ¹⁰ We know less about the challenges experienced by graduates of TNE medical programmes, who differ from IMGs in the sense that they have been deliberately trained to begin practice elsewhere following graduation, or who begin practice in the location of training having followed a non‐local curriculum (i.e. the branch campus model). There is a responsibility, and a need, for providers of TNE medical programmes to ensure that such graduates have a degree of preparation for these diverse settings to ensure patient safety, and to support the transition to the local healthcare system.

This systematic review aims to explore the experiences of Transnational Medical Education programme graduates as they leave their medical programmes to begin practice globally. Specifically, it aims to address to the following research questions:

1. What types of Transnational Medical Education programmes can be identified from the international literature?

2. What are the strengths and weaknesses of these Transnational Medical Education programmes?

3. Do these Transnational Medical Education programmes facilitate preparation for international practice?

2. METHODS

The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were followed for the reporting of this review. ⁶⁰

2.1. Identifying relevant studies

In December 2022, five electronic databases were searched in consultation with a university librarian: MEDLINE, EMBASE, CINAHL, WEB of Science and ERIC. These databases were chosen to ensure literature from both education and health fields would be returned. No date or language restrictions were applied.

The Boolean operators ‘OR’/’AND’ were used to widen and limit the search as appropriate. Truncation of keywords was also used to broaden the search terms and identify alternate word endings, e.g. ‘curriculu*’ for curriculum and curricula.

The search strategy included key terms that aimed to identify studies that captured the experience of transnational medical programme graduates as they began practice in diverse global settings, e.g. ‘graduate$’, ‘international practice’, ‘global practice’, ‘preparedness’.

The search strategy was adapted accordingly to suit the standards of each database. Details of search strategies across the five databases are available in the supplementary materials section. The electronic database searches were followed by citation and reference list searches to identify any additional studies.

2.2. Inclusion and exclusion criteria

This review included research studies that focused on the preparedness of medical graduates to begin practice outside of the country in which they had achieved their PMQ. Studies that examined the preparedness of graduates from the branch campuses of overseas medical schools, who transitioned to practice within the host country, and studies where students completed their PMQ across multiple settings were also included. All primary research (qualitative and quantitative), book chapters, theses and dissertations were eligible for inclusion. No limitations were placed on the date of publication, or language.

The review excluded studies that reported on preparedness within a national context (i.e. graduates following an Irish medical curriculum, who remained in Ireland to begin their intern year); studies that examined the preparedness of IMGs – or compared the preparedness of local graduates with IMGs – where no information was available about the previous experiences of IMGs or the initial medical curriculum followed (e.g. location of study); and finally preparedness for anything other than the intern year (e.g. elective modules). Opinion pieces, letters, editorials and perspective pieces were excluded.

2.3. Study selection

Titles and abstracts were screened by two reviewers (GE and/or HK/JCAC). Where possible, any disagreements were resolved through discussion between reviewers to reach a consensus. Where consensus could not be achieved, a third reviewer (RA/JI/MS) was consulted.

Full texts were read and screened by two reviewers (GE and/or HK/JCAC) to determine eligibility for inclusion. Again, any disagreements were resolved through discussion between reviewers. Where consensus could not be gained, a third reviewer (RA/JI/MS) was consulted.

2.4. Charting the data

A data extraction form was developed by the first author (GE) using Google Forms. This allowed all reviewers to work concurrently and for the adoption of a standardised approach. The form was designed to extract the following data from studies that were selected for full‐text review: author(s); title; year of publication; aim/purpose of the study; study location(s); participant information; methods; key results/outcome of the study; and an explanation for the inclusion/exclusion of the full‐text resource. Completed entries using the Google Form automatically populated a Google Sheet, which provided a database of all reviewers' comments, and was downloadable as an Excel Spreadsheet. GE reviewed all titles selected for full‐text review, and at least one other author (HK/JCAC) reviewed full‐text articles using the data extraction form to check for completeness. A summary of the included studies is provided in the supplementary materials.

Analysis of data from the included studies followed the data charting exercise. Details on the commonalities and differences of the pathways of transnational medical education graduates, and details of their programmes of study identified within the included studies, allowed for the development of programme types, and the subsequent categorisation of studies according to Programme Type (see Tables 1 and 2). Similarly, the strengths and weaknesses of Transnational Medical Education Programmes identified within the included studies, and how these strengths and weaknesses impacted preparation for practice, allowed for the generation of themes and subthemes (Table 3).

TABLE 1.

Transnational medical education programme types.

	Programme type
	A – PMQ* all in one outside country	B – PMQ across two or more countries	C – PMQ at branch campus
Description	Programmes where individuals complete the entirety of their PMQ abroad and returns to their home country, or moves to a third country to begin practice.	Programmes where individuals complete a component of their training in one country and returns to home or third country to complete the remainder of their training.	Programmes where individuals study a foreign curriculum at a branch campus in a host country. They may remain in or leave the host country to begin practice.
Example Institution	RCSI University of Medicine and Health Sciences, Ireland 61 Tbilisi Medical Academy, Georgia 62 University of Debrecen, Hungary 63	RUMC, Malaysia 64 St. George's University, Grenada 65 Ross University, Barbados 66	RCSI Medical University of Bahrain, Kingdom of Bahrain 67 NuMed, Malaysia 68 Monash University, Malaysia 69
Papers	Al Sinawi, H. et al (2017) 70 Brouwer, E.E. et al (2022) 33 Chur‐Hansen, A. (2004) 51 Kassim, S.S. et al (2016) 37 Mathews et al (2023) 38 Sitobata & Mohammadnezhad (2022) 53	Mathews et al (2023) 38 Morgan et al (2017) 32 Motala, M. & van Wyk, J. (2016) 71 Motala, M. & van Wyk, J. (2021) 52 Sui, X. et al (2019) 72	Kassim, S.S. et al (2016) 37 Rashid‐Doubell, F. & Doubell, T.P. (2019) 17 Waterval et al (2018) 15

^*PMQ = primary medical qualification.

TABLE 2.

Example graduate type pathways.

Programme type	Home country	Location of pre‐clinical training	Location of clinical training	Country of practice
A	Canada	Hungary	Hungary	Canada
B	Malaysia	Ireland	Malaysia	Malaysia
C	Jordan	Bahrain	Bahrain	USA

TABLE 3.

Themes and subthemes (preparation for practice).

Themes	Subthemes
Strengths of Transnational Medical Education Programmes	Enhancing workforce capacity, widening participation and helping with local medical shortages Enhancing quality of education locally Embedding clinical exposure in the place of intended medical practice
Weaknesses of Transnational Medical Education Programmes	Curriculum misalignment with context of practice Hierarchical systems and different clinical practices in practice country Difference in communication styles Language barriers

2.5. Quality appraisal

Quality appraisal was completed using the Mixed Methods Appraisal Tool (MMAT). ⁷³ The MMAT allows for the appraisal of studies within a mixed‐methods systematic review that possesses heterogenous study designs using a single tool. ⁷⁴ The methodological quality of the included studies was considered acceptable, with most studies performing well. Where studies performed less well, information was typically less clear regarding the pre‐testing or prior validation of survey tools, or insufficient information was provided regarding the study sample, e.g. total sample sizes and reasons for non‐response. Additional information on the quality appraisal is included as supplementary materials.

3. RESULTS

The database searches yielded a total of 1936 results. These were exported into EndNote and once duplicates were removed, 1620 results remained. Seven articles were identified from other means (i.e. citation searching, scanning the reference lists of included articles). A total of 63 articles were shortlisted for full‐text review following title and abstract screening, and 12 articles were ultimately included for synthesis (see Figure 1 for PRISMA flow diagram).

FIGURE 1.

PRISMA flow diagram for study selection. [Color figure can be viewed at wileyonlinelibrary.com]

3.1. Study characteristics

3.1.1. Geographic characteristics

A wide range of countries and geographical regions were represented, including Africa, Asia, Europe, North America and Oceania. Eleven of the studies were set across two or more countries. One was centred on an individual country ¹⁷ – however, the institution in this paper was an overseas campus of an Irish medical school.

3.1.2. Experiential characteristics

Ten studies focused solely on the experiences of those undergoing transnational medical education, or beginning practice following completion of a transnational medical education programme. In addition to these populations, two studies included the viewpoints of other relevant parties, i.e. local students/graduates, deans of schools and senior faculty members. ³² , ⁷²

3.1.3. Study design characteristics

Of the 12 included studies, six had a qualitative design. ¹⁷ , ³² , ³⁸ , ⁵¹ , ⁵² , ⁵³ Four had a quantitative design, ¹⁵ , ³⁷ , ⁷⁰ , ⁷¹ and two adopted a mixed‐methods approach. ³³ , ⁷² Qualitative methods of data collection included interviews, focus groups and content analysis of print media. Quantitative methods of data collection were exclusively survey‐based, using a combination of closed and open‐ended questions. Two studies were longitudinal, comparing the experiences of participants pre‐ and post‐graduation. ³³ , ⁵¹

3.2. Transnational medical education programme types

From the 12 identified studies it was possible to identify three different programme types. These Programme Types are detailed below and further summarised in Table 1. Example pathways taken by the graduates of these programmes are detailed in Table 2.

3.2.1. Programme Type A (PMQ all in one outside country)

Internationally orientated programmes that train doctors for the entirety of their PMQ in a location outside of their home country. One example of these is the English language ‘parallel’ programmes that run alongside local language programmes in some central‐ and eastern‐European countries. Graduates not remaining will 1) return to their home country, e.g. a student from Canada studying in Ireland who returns to Canada to begin practice, or 2) begin practice in a third country after qualifying, e.g. a Polish student in Hungary who begins practice in the UK. Six studies explored this Programme Type. ³³ , ³⁷ , ³⁸ , ⁵¹ , ⁵³ , ⁷⁰

3.2.2. Programme Type B (PMQ divided between two or more countries)

These are hybrid programmes whereby individuals begin their PMQ in one country and complete it in another. The latter country could be the individual's home country or a third country. They may then begin practice in their home country or a third country.

Two types of hybrid programmes were evident in the included studies. Firstly, programmes where medical students complete their pre‐clinical training in one location, before completing their clinical training elsewhere – typical of medical schools located in the Caribbean – where students generally complete clinical training at an affiliated hospital overseas, most often in the USA. ³² These programmes have a uniquely international student body and do not typically train students for local practice. ³¹

The second type of programme is one where students begin studying in one location and return to their home country to complete their training. Clinical practice may begin prior to, or following, the transition point. For example, South African students who complete part of their training in Cuba, but return to South Africa to complete their studies as part of the South African–Cuban Medical Collaboration. ⁵² , ⁷¹ , ⁷² This collaboration is designed to recruit black South Africans from poorer, rural backgrounds who receive a scholarship to study medicine with the agreement that will return to serve their home communities once they qualify, for a period equal to their medical training, to alleviate doctor shortages in those locations. ⁷⁵

Five studies explored this Programme Type. ³² , ³⁸ , ⁵² , ⁷¹ , ⁷²

3.2.3. Programme Type C (PMQ at branch campus)

This is a branch campus model whereby individuals study a foreign curriculum at a host country's branch campus. Graduates may be local or international and may remain in or leave the host country to begin practice, e.g. a Bahraini national studying at a branch campus of an Irish institution located in Bahrain. The student may remain or leave Bahrain to begin practice upon graduation. Three studies explored this Programme Type. ¹⁵ , ¹⁷ , ³⁷

3.3. Synthesis of results

A narrative synthesis was adopted as the most suitable approach to present the results of this review. According to Popay et al the defining feature of a narrative synthesis is that it “adopts a textual approach to the process of synthesis to ‘tell the story’ of the findings from the included studies”, ⁷⁶ which allows for a detailed exploration of similarities and differences. ⁷⁷

From the included studies we were able to identify three Programme Types (Table 1), and two overarching themes and seven subthemes (Table 3). The Programme Types and themes identified for synthesis were agreed by the research team at regular meetings following the data charting exercise, and were guided by the aims and research questions identified in the introductory section.

The remainder of this explores the Programme Types within the context of the identified themes and subthemes.

3.4. Strengths of transnational medical education programmes

3.4.1. TNE enhances capacity, widens participation and helps with local medical shortages

One of the major strengths of all TNE programmes (Types A, B and C) is the increase in the medical workforce numbers. ³² , ³³ , ³⁸ For example, in Canada students are attending TNEs and returning to practice in their home country, ³² , ³⁸ meeting an important need and gap identified by the WHO. ⁷⁸

In addition, some programmes are intentionally widening participation and facilitating doctors to work in underserved areas. ⁵² , ⁷¹ , ⁷² For example, one programme recruits students via scholarships from rural underserved areas with the intention that they return to practice in these areas ⁵² , ⁷¹ , ⁷² (Type B). Work in these areas is not considered desirable for many locally trained doctors, who expressed a preference to work in speciality roles in urban areas, and/or the private sector. ⁷²

Moreover, some programmes had a particular focus on community and preventive health which aligned with the graduates' future practice in primary healthcare settings in rural settings (Type B). ⁵² , ⁷¹ , ⁷² The training of these graduates had emphasised health promotion and disease prevention, ⁵² , ⁷¹ , ⁷² again fulfilling a gap in local medical provision and preparing graduates for work in these areas.

A particular strength of some TNEs is that they intentionally provide support to make their graduates competitive for residency matching in the intended site of practice (Type A and C). ³⁷ Other programmes intentionally select students to train overseas with the expectation that they return home to practice in underserved areas, thereby meeting a local gap in provision (Type B). ⁵² , ⁷¹ , ⁷²

Some TNEs have an established record of sending graduates back to their home countries to begin practice, ³⁸ producing some graduates who have equal levels of matching, i.e. they are more likely to get into their place of choice (Type A), ³⁸ this supports the need for additional doctors in the home country. However, those that do not match are likely to be directed to shortage specialities, e.g. family practice and psychiatry, thus meeting an important gap in the medical workforce provision (Type A, B and C). ³⁵ , ⁵² , ⁷¹

Where the TNE provider does not directly support student transition there is evidence that they do this themselves. For example, graduates from all types typically sought out career support to familiarise themselves with the planned destination country's healthcare system, e.g. achieving licensure, securing reference letters from local practitioners, acquiring knowledge of postgraduate training programmes and establishing informal connections with previous cohorts of graduates to better understand their experiences of transition. ³³ , ³⁷ , ³⁸ , ⁵¹ , ⁵² , ⁷² They also made the most of opportunities for clinical experiences and electives in the intended country of eventual practice. ³³ , ³⁸

3.4.2. Enhancing quality of education locally

Driving up the quality of medical education was identified as a specific request of the countries hosting the branch campuses. The national intent was to bring in overseas universities to drive up local medical educational standards: this was particularly evident in Type C and some Type B programmes ¹⁵ , ¹⁷ ;. However, while all programmes increase the medical workforce; we noted not all programmes necessarily drove up the quality of medical education as this was already high in some countries receiving these graduates. For example, Canadians educated in Ireland returning to Canada ³⁸ in contrast with those returning to a country that wanted to drive up educational quality. ⁵¹

As regards the enhanced quality of medical education, there was evidence for improved knowledge, skills and behaviours, as well as exposure to a new way of working, e.g. enhanced communication skills, shared decision‐making, the experience of multidisciplinary teamwork and patient‐centeredness. ¹⁵ , ¹⁷ , ⁵² , ⁷¹ , ⁷² For example, Type C programme graduates who had attended an international branch campus, had been attracted to the status of the home university and the diversity of the student cohort. ¹⁵ They considered it preferable to attend a local medical school as there was a greater emphasis on student‐centred teaching methods which was credited with supporting students to develop a sense of responsibility, independence, confidence and assisting in fostering collaboration with others. ¹⁵ , ¹⁷

Intercultural learning opportunities were identified as a further strength of all Programme Types ¹⁵ , ³³ , ⁷² that supported future practice in diverse cultural settings. ³³ Opportunities for intercultural learning emerged as a result of working with diverse patient populations in the place of training ¹⁵ as well as exposure to diverse, international student cohorts on many TNE programmes. ³³ Being exposed to different languages was also attributed to supporting graduates to be more culturally adaptable across diverse settings. ⁷²

3.4.3. Embedding clinical exposure in the place of intended medical practice

All medical Programme Types facilitated preparation for practice by enabling access to placements in the place of eventual intended practice. ¹⁷ , ³² , ³⁸ , ⁵¹ , ⁵² , ⁷¹ , ⁷² This varied from short elective placements in the student's home country (Type A), ³⁸ , ⁵¹ through to the entirety of their clinical training period (Type B and C). ¹⁷ , ³² , ³⁸ , ⁵² , ⁷¹ , ⁷²

Beginning medical practice in the same place as their medical school increased graduates preparation for practice; as students were already familiar with the healthcare system and had already worked in the same health settings; providing exposure to real practice in advance of starting work (Type B and C). ¹⁵ , ¹⁷ , ⁵² , ⁷¹ , ⁷² Also, graduates of Type B programmes who attended medical schools in the Caribbean, but completed clinical placements in North American settings reported these placements enhanced their preparation for practice. ³² , ³⁸

There was also evidence that graduates of Type A programmes benefitted from clinical exposure. For example, Omani graduates who had completed their PMQ in New Zealand before returning to Oman reported feeling more prepared to begin practice than local graduates as a consequence of earlier clinical practice, which started in year two. ⁷⁰

3.5. Weaknesses of transnational medical education programmes

3.5.1. Curriculum misalignment which hindered preparation for practice

Across all Programme Types there was the potential for curriculum misalignment within the eventual context of clinical practice. i.e. the absence of relevant knowledge and skills to begin work in the country of intended practice, given the curriculum was developed for another context. ³³ , ³⁸ , ⁵¹ , ⁵³ , ⁷¹ , ⁷² For example, graduates of Type A programmes often reported being well prepared to begin practice from a knowledge perspective, but lacked the clinical exposure and practical skills of local graduates. ³² , ³³ , ³⁸ , ⁵¹ Canadian nationals returning to Canada noted that they had primarily observed seniors during clinical placements and that they had less direct responsibility for patients, ³⁸ whereas graduates of local Canadian medical programmes had been assigned their own patients, and had responsibilities within the clinical teams. ³⁸ Likewise, those returning from Cuba and China to practice in Vanuatu noted that the opportunity to gain practical experience with patients had been limited, with most hands‐on patient activities being completed by senior colleagues. ⁵³

Similarly, there may have been a different expectation, depending on the context, for example, graduates returning to begin practice in Vanuatu (a remote island where the scope of practice is necessarily greater) reported being treated more like registrars than interns as they were assigned tasks would have been completed by seniors in their place of training, and were evaluated as though they were registrars. ⁵³ Likewise, Malaysian graduates returning home from Australia (Type A) were expected to perform procedures for which they had insufficient training, such as lumbar punctures or attending at births (Type A). ⁵¹

Another example was misalignment as regards awareness of the local burden of disease. Type B programme graduates returning to their home country to begin work were frequently compared to their locally trained counterparts as lacking knowledge about HIV/AIDS, Trauma and Tuberculosis, which was more prevalent in South Africa compared to Cuba. ⁵² , ⁷¹ , ⁷² These doctors were sometimes required to complete an additional year to make up the ‘deficits’ in their medical training prior to beginning practice. ⁷²

Missed opportunities for the study of healthcare‐related topics and content specific to the host country were issues encountered by Type C programme graduates who remained in the country of training. Due to the transposed nature of the curriculum, some content needed revision to the host country context. For example, Waterval et al (2018) cite the use of European data on the epidemiology of diabetes, despite local prevalence being significantly worse, missing its urgency in the host country. ¹⁵ There was also the potential for graduates of this programme to have missed important cultural, ethical and legal issues relevant to the host country, e.g. patient confidentiality, and treating patients of a different gender. This could affect communication and interactions with colleagues and patients, and create professional dilemmas for newly qualified doctors. ¹⁵ , ¹⁷ Rashid‐Doubell and Doubell (2019) point to an example of a medical intern observing nursing staff openly disclosing patient information to an unrelated hospital visitor. ¹⁷

3.5.2. Hierarchical systems and different clinical practices

Studies report that healthcare systems hierarchies differ by country and this reduced preparation for practice (Type A, B and C). ⁵¹ , ⁵³ For example, Bahraini graduates commented that senior colleagues could be confrontational and that the quality of their internship depended upon finding favour with seniors who controlled the tasks assigned to them (Type C). ¹⁷ Graduates expected shared decision making, patient centredness and collaboration in multi‐disciplinary teams, but these were absent in their eventual clinical environment. ⁵¹ , ⁵² , ⁵³ , ⁷¹

3.5.3. Difference in communication styles

Patient‐centred communication is a feature of many transnational education programmes but we noted graduates often use a more doctor‐centred approach to support patient preferences. ⁵¹ , ⁵² , ⁷² Graduates of Type A programmes returning to Malaysia from Australia noted that patients were more likely to defer to doctors, and had lower levels of medical and health literacy compared to those they had worked with during training. ⁵¹ Similarly, graduates of Type B programmes returning from Cuba noted that patients in South Africa might be less assertive, and were perceived to have lower levels of health literacy than Cubans. ⁵² , ⁷¹

3.5.4. Language barriers

A further area that proved challenging for graduates across all Programme Types was beginning practice using a different language to that used in medical school. ¹⁵ , ¹⁷ , ³³ , ⁵¹ , ⁵² , ⁵³ , ⁷¹ , ⁷² Although language skills had the potential to promote intercultural learning opportunities, language barriers could lead to tension and miscommunication, with the potential for adverse effects on professional relationships and patient safety. ⁷⁹ Moreover, they could limit the graduates' ability to communicate medical knowledge and understand patient's symptoms. For example, Malaysian graduates of an Australian medical school (Type A) identified the broader range of terminology used to describe types of pain in English compared to Malay, and felt unable to fully explain illnesses and disease in their native language. Being a speaker of the patient's language did help, however, and workarounds such as using the vernacular when communicating with patients were consequently adopted. ⁵¹

Senior colleagues of Cuban‐trained doctors in South Africa (Type B) commented that a major weakness was that returnees would have to spend time translating from Spanish into English. ⁷² They felt that fluency in one of South Africa's other official languages, e.g. Afrikaans, would be more useful. However, the returnees considered exposure to a different language an advantage of their transnational educational background, stating that it increased their confidence when speaking with patients, and made them more adaptable to different cultural settings. ⁷²

Language problems typically began during clinical rotations for graduates of Type C programmes. ¹⁵ , ¹⁷ For example, the language of education and clinical training differed, e.g. English and Arabic. Achieving only a limited proficiency in the local language had restricted the graduates ability to communicate with patients during clinical training which impacted negatively on their perceived preparedness to practice upon graduation. ¹⁵ , ¹⁷

4. DISCUSSION

This review aimed to explore what types of Transnational Medical Education programmes could be identified within the international literature and to appraise their strengths and weaknesses as regards preparation for practice. We identified three different TNE medical education ‘Programme Types’, and provided a synthesis of these within the context of the generated themes.

All Programme Types were shown to increase medical workforce numbers, providing additional places for medical students unable to gain entry to medical school in their home countries, or whose preference was to attend an international medical school that is perceived to/can have higher standards than the local school. ³² , ³³ , ³⁸ There were also opportunities to improve the quality of education (in terms of knowledge, skills and behaviours), and exposure to new ways of working, e.g. enhanced communication skills, shared decision making, experience of multidisciplinary teamwork and patient‐centeredness ¹⁵ , ¹⁷ , ⁵² , ⁷¹ , ⁷² ; promoting intercultural learning opportunities ¹⁵ , ³³ , ⁷² and embedding clinical practice in the place of intended practice. ¹⁷ , ³² , ³⁸ , ⁵¹ , ⁵² , ⁷¹ , ⁷²

Type B (PMQ across two countries) and C (PMQ at a branch campus) programmes differed to Type A programmes in that they were often established for a specific purpose, e.g. as an invitation from the host country to broaden access to education and drive up local educational standards, ¹⁶ or as a means in which to widen participation and facilitate doctors to work in underserved areas ⁵² , ⁷¹ , ⁷² – using Transnational Educational as a way in which to serve local needs. Types B and C are potentially strong models if graduates remain in the country of training following completion of their PMQ. We know, however, that this is not always the case and many will begin practice elsewhere ¹⁵ due to a shortage of local postgraduate training opportunities ⁸⁰ or challenging local working conditions. ⁸¹ Places on these types of medical programmes may also be filled by those from other countries for whom the programmes were not originally intended. In two studies of branch campus models of TNE between 30 and 40 different nationalities were represented within the student cohort, ¹⁵ , ¹⁷ which raises questions around the extent to which these programmes are addressing local workforce and educational needs.

All three Programme Types identified in this review are potentially stronger models in terms of preparing graduates for practice elsewhere than traditional IMGs, whose transition to practice in a location outside of the country in which they gained their PMQ is unplanned. This transition is unplanned in the sense that they have been trained in a local context for local practice, with no expectation that they will practice elsewhere. We know that IMGs can struggle to adapt within a new host country and that they will undoubtedly encounter differences in practice, for example, cultural issues, ⁵⁸ , ⁵⁹ , ⁸² language and communication differences, ⁹ , ⁵⁹ , ⁸² , ⁸³ shared decision‐making and differences in power dynamics, ⁵⁸ , ⁸³ poor understanding of local healthcare systems. ⁷ , ⁵⁸ , ⁵⁹ , ⁸² Moreover, the nature of IMGs medical training may differ to that of medical graduates in the host country. In their systematic review on the intercultural challenges experienced by IMGs, Michalski et al found that for many IMGs medical education was orientated more towards the sciences, with less focus on psychological and social determinates of health and well‐being. ⁵⁸

Initiatives designed to familiarise IMGs with local practice and to explore issues around differences in ethical and professional frameworks are increasingly common, for example, ‘Welcome to UK Practice’, a workshop designed to support doctors who are trained elsewhere to develop a better understanding of the ethical and professional standards within UK practice. ⁸ , ¹¹

Although graduates of TNE programmes will also encounter potential challenges, these groups have been deliberately trained to begin practice elsewhere following graduation or to begin practice in the location of training having followed a non‐local curriculum (i.e. the branch campus model). Training providers delivering these programmes know that they are sending their graduates to begin practice elsewhere, or that that there may be differences between the home country curriculum and host country practice. We have provided evidence which suggests that training providers are looking at the potential challenges, and are developing up‐front supports to assist with these transitions. IMGs are not prepared in the same way, instead arriving in a new country and immediately being expected to fill gaps in rotas, leaving them unaware of their own learning needs ⁶ and potentially vulnerable when things go wrong, e.g. scapegoating. ⁸²

Whether doctors are trained in a local context for local practice, or deliberately trained for practice elsewhere, there is, undeniably, a global movement of doctors. ¹ , ² , ³ , ⁴ , ⁵ As such all educators need to move towards a more international outlook, recognising the need to train global doctors who are more prepared to navigate different healthcare systems, are culturally competent, and adaptable to work in diverse and changing settings.

4.1. Challenges and solutions

No curriculum can fully prepare graduates to begin practice elsewhere, and a number of challenges encountered by graduates of TNE medical programmes were explored in the synthesis: curriculum misalignment within the context of clinical practice, cultural differences in work‐based practices, different communication styles and language barriers. Clinical practice, ethics and professionalism within medicine are inextricably linked with cultural context, ³⁹ , ⁴⁰ and the prevailing values within different countries will shape the training received. Within the synthesised literature, graduates did not expect their programmes to provide them with all of the requisite skills required to begin practice and knew that they had to take active steps to fill any gaps, ³¹ , ³³ , ³⁸ for example, familiarising themselves with the local burden of disease. ⁵² There are, however, several ways in which TNE programmes might support their graduates to begin practice that can minimise some of the challenges they may encounter.

4.1.1. Creating opportunities for clinical exposure prior to starting work

Completing a component of medical training in the country of intended practice may help to minimise the challenges that TNE medical programme graduates encounter when beginning practice elsewhere. In this sense, graduates of Type B programmes have a potential advantage as their clinical training may be completed in the country of intended practice as they benefit from additional opportunities for acculturation (acclimation to new work‐based, cultural and societal norms and values) ⁸⁴ , ⁸⁵ and enculturation (the process of socialisation by which medical students ‘become doctors’, e.g. developing skills in clinical reasoning), ⁸⁶ , ⁸⁷ , ⁸⁸ whilst simultaneously gaining international exposure at the pre‐clinical stage of training. Type C graduates remaining in the country of medical education to begin practice will also have relevant clinical exposure, however, their pre‐clinical training may not align with the local context, as the curriculum is transposed from elsewhere and differences in legal and ethical issues, as well as differences in hierarchal structures might be present. ¹⁷ Opportunities for acculturation and enculturation for Type A graduates will necessitate seeking external opportunities, e.g. overseas electives and placements that will provide relevant clinical exposure. Type C graduates pursuing practice elsewhere would also need to take advantage of such opportunities.

Electives have been shown to develop medical graduates with higher reported levels of cultural competency ⁸⁹ ; enhanced clinical skills ⁹⁰ ; and their overall professional and personal development. ⁹¹ By participating in electives students have been shown to develop their understanding of physicians' roles across diverse settings and to navigate healthcare delivery in unfamiliar situations. ⁹² Well‐designed electives, for which students are adequately prepared, ⁹³ could be one way in which to support the preparedness of TNE medical programme graduates.

4.1.2. Orientation to practice and career support

Graduates of any Programme Type returning to their home country will have some advantages, i.e. familiarisation with the home healthcare system. ³⁵ , ³⁸ Evidence also suggests that they might also benefit from personal contacts that could support them to secure electives and training opportunities and navigate the postgraduate education system. ³⁸

At the postgraduate level, induction programmes designed to integrate doctors into local practice have been developed, e.g. Welcome to UK practice ⁸ , ¹¹ which was identified above. Where large populations of graduates from a TNE programme are returning to the same country, they may benefit from orientation sessions e.g. support to work in more hierarchical settings ⁹⁴ , ⁹⁵ delivered before transitioning to practice. Support should also be provided from a career's perspective, for example facilitating connections with alumni, designating curriculum time to prepare for licensing exams, supporting students in securing and completing electives in the target country, and organising international careers events. ³³

4.1.3. Adapting the curriculum for a local context

Where a curriculum is transposed from a home to a host institution, content should be adapted to better suit the culture and context of the host country. For example, the development of ‘core’ outcomes that are aligned with the home institution, and ‘secondary’ outcomes which are culturally appropriate to the site of delivery, ⁹⁶ and content is delivered in a way which develops competence in the host country's cultural, ethical and legal norms and values. ⁹⁶

The suitability of clinical teaching should also be considered, and clinical cases that are contextualised within the local system of care, as opposed to those used by the home institution could be adopted and additional emphasis placed on specialities more likely to encountered in the host country. ¹⁹

4.1.4. Language and communication support

Barriers in communication may be minimised if the graduate is native to the host country or has proficiency in locally spoken language(s). ⁵¹ Language barriers would be minimised if language acquisition were included in medical programmes, as has been demonstrated. ⁹⁷ , ⁹⁸ An understanding of idioms, regional accents, dialects and non‐verbal communication is also important ⁵⁹ , ⁹⁹ as is understanding culturally specific communication. ⁸³ The quality and availability of communication skills training is variable. It may not be fully integrated into the curriculum, or where it is, may focus more on science and the collection of information from patients, as opposed to interpersonal factors. This leaves graduates poorly equipped to manage complex interactions (whether with patients or other health professionals). ⁵⁹ , ⁸³

Clinical exposure in the intended country of practice is an important means in which to develop an understanding of the required language and communication skills required when beginning practice. The use of virtual patients has also been shown to be an effective way in which to teach communication skills. ¹⁰⁰ However, virtual patients must enable the assessment of a range of communication skills, i.e. non‐verbal communication, building rapport, etc. and not purely focused on the collection of information. Virtual patients can be made for a range of patient types, and contexts, and could also address a number of issues previously mentioned, such as ethical and legal issues. ¹⁰¹ , ¹⁰²

4.2. Limitations

As the focus of this review was on TNE preparation for international practice, the number of included studies was modest. There are more studies reporting on the experiences of doctors who transition to practice internationally (IMGs) or from the perspective of the host country, generally arriving at a later career stage, ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ however we were interested in TNE programmes that deliberately train medical students for practice elsewhere. The authors acknowledge that the small number of included studies does limit the extent to which conclusions can be drawn about the Programme Types and the strengths and weaknesses of these in preparing graduates for practice. However, the review does provide a foundation, and framework, for future empirical work in this area.

5. CONCLUSION

Medical education is increasingly internationalised, with students crossing borders to qualify before returning home or pursuing a career elsewhere. Indeed, attracting international students to pursue training overseas is well established in medical programmes and this trend is likely to expand more in the future. Transnational medical education programmes increase the capacity for medical workforce training, can drive up local standards, promote intercultural competence, and increase exposure to a new way of working (enhanced communication skills, shared decision making, experience of multidisciplinary teamwork and patient‐centeredness). Challenges include potential curriculum misalignment within the context of clinical practice (e.g. the burden of disease), language barriers and encountering differences in hierarchical systems, shared decision making and patient‐centredness.

5.1. Implications for practice

• Medical education is becoming more international and all medical programmes need to acknowledge this and consider that a large proportion of their graduates will transition to another country and consider what support can be provided to either retain them or equip for international practice.

• TNE programmes that deliberately train medical students for practice elsewhere should consider preparation for international practice; equipping them with core skills, knowledge and behaviours.

• Graduates of medical TNE programmes benefit from an international medical education, such as student‐focused teaching methods and different approaches to practice including patient‐centred care; shared decision‐making; exposure to multidisciplinary team working and bi‐directional cultural exposure. All of which may drive up standards.

• Challenges include potential misalignment between curricula and local practice and enculturation to different ethical, legal and healthcare systems.

• Induction and orientation programmes could support orient to local practice and assist graduates of TNE programmes to begin practice in their destination country.

AUTHOR CONTRIBUTIONS

Gareth Edwards: Conceptualization; methodology; writing – original draft; writing – review and editing; project administration; formal analysis. Muirne Spooner: Writing – review and editing; writing – original draft; supervision; methodology. Richard Arnett: Conceptualization; writing – original draft; writing – review and editing; supervision; methodology. Helen Kelly: Methodology; formal analysis; writing – original draft; writing – review and editing. Jezzdin Carr Alif Carr: Methodology; writing – original draft; formal analysis; writing – review and editing. Jan Illing: Conceptualization; writing – original draft; writing – review and editing; methodology; supervision.

ETHICS STATEMENT

There were no ethical issues identified in conducting this review. No ethical approval was required.

DISCLOSURE STATEMENT

The authors report no conflict of interest.

Supporting information

Data S1. Supporting information

Data S2. Supporting information

Data S3. Supporting information

Edwards G, Spooner M, Arnett R, Kelly H, Carr JCA, Illing J. Transnational medical education programmes and preparation for different country medical practice: A systematic review. Med Educ. 2025;59(9):924‐937. doi: 10.1111/medu.15660

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.