Internationalization of Medical Education: Professional Identity Formation in Healthcare Students Through an International Exchange Program

Abstract

Background

The International Collaboration and Exchange Program (ICEP) and other similar exchange programs can play a crucial role in preparing future health profession students to become global healthcare leaders through virtual exchanges and in-person academic immersion travels (AIT). Recognizing the need to enhance interpersonal skills, the traditional classroom style of teaching may require reassessment. Our study aims to explore ICEP’s impact on participants, specifically their professional identity (PI) levels, to shed light on the effects of virtual and hybrid exchange programs.

Methods

Health profession students from 20 universities across four continents (n = 302) who participated in the ICEP program in 2022–2023 responded to an online, validated Professional Self Identity Questionnaire (PSIQ) both at the program’s initiation and upon its conclusion to assess their self-perceived levels of PI. Statistical analysis was performed using RStudio Version 2023.3.0.386 (2023).

Results

Analyzing the group of students before (PI = 3.63 (1.52)) and after (PI = 3.97 (1.48)) completing two semesters of virtual exchanges within ICEP revealed that students exhibited higher senses of PI upon the program’s completion (p < 0.001). Additionally, the group of students that participated in the 1-week AIT (PI = 4.19 (1.57)) was also found to have a heightened sense of PI compared to students who did not (PI = 3.88 (1.43)) (p < 0.05).

Conclusion

Through the exchanges facilitated by ICEP, students had the opportunity to reinforce their sense of PI. Such exchange programs warrant further exploration for their potential to innovatively integrate professional skills development into health profession education—a valuable aspect in shaping a well-rounded provider.

Introduction

Internationalization of medical education has recently been in the focus of medical education [1]. To date, very often, internationalization is achieved via student mobility programs when students travel to gain different clinical or cultural experiences. There are few reports on hybrid or virtual exchanges. In response to the necessity of cultivating skilled professionals, innovative programs like the International Collaboration and Exchange Program (ICEP) have emerged to reshape the landscape of health professions education. Developed at Columbia University, ICEP is designed with the goal of preparing future health professions students to become global healthcare leaders via international networking, collaboration, and experiential learning [2]. Though leadership skills are becoming increasingly important in healthcare and academia, they are not often taught as part of medical education. Integrating these lessons into an already packed curriculum presents a formidable challenge for educators. In addition to the conventional curricula’s focus on academics, ICEP expands the scope to incorporate other essential skills (Fig. 1), such as empathy and cultural competency, acknowledging the multiple facets that build a leader in healthcare [3]. ICEP aims to instill these skills through engaging elements, providing students with novel learning experiences that captivate their interest and participation (Fig. 2). While international exchange experiences, such as those provided through ICEP, may provide extensive personal and professional benefits [4], the measurement of these outcomes is often overlooked. Existing studies typically examine integrated skills such as cultural competency. However, an aspect that remains unexplored is the formation of professional identity (PI). Current studies have investigated the formation of PI; however, there has yet to be a single established entity that brings together healthcare professionals from multiple countries that specifically aims to foster the development of PI.

Fig. 1.

ICEP learning objectives

Fig. 2.

ICEP program elements

PI is one of the many integrated skills that ICEP aspires to convey as a crucial learning objective through its programming. PI is defined as the attitudes, values, knowledge, beliefs, and skills shared with others within a professional group [5]. PI allows for individuals to see the value of their profession in society [6]. Because of this, PI formation (PIF) is an essential component of the development of young professionals across various fields in healthcare, such as medicine and dentistry. Without a strong sense of PI, healthcare professionals tend to lose sight of their role within their profession and the confidence needed to fulfill their role [6]. This will also have a negative impact on their interactions with colleagues and patients. Additionally, without mentors or role models who have developed a strong sense of PI, they will find it difficult to pass on the core values of the profession to the next generation of healthcare providers [7].

PIF is especially prevalent during the time when students are in university [8], as early adulthood is the time when people begin to gain a sense of who they want to become [9]. In addition to this critical period of time, PIF is fluid and dynamic. It is greatly influenced by several factors such as the imagination of one’s role within the profession, observation of mentors and role models, experimentation of their role as a healthcare professional, and recognition and acceptance by others [10]. In order to foster PI development, the presence of curricular spaces that will allow for collaboration and exchange is crucial [11]. It is noted that the PI of health profession students develops as a result of active participation, which can involve mutual teaching, problem-based learning groups, and exchanges in informal settings [12]. Because of this, simply teaching students what it means to be the “ideal” healthcare professional in a traditional classroom setting is insufficient, as it provides limited opportunities for students to learn from others and be active participants in developing their PI. Thus, changes need to be implemented into university curricula that will allow students to communicate and connect with one another.

ICEP encourages all health profession students to apply to the program, regardless of what year they are in. Students are selected based on their interest in future healthcare leadership roles and interest in international research. Participants are selected by their schools to join ICEP based on academic performance, leadership potential, and interest in global health and collaboration; however, schools in the USA and Cambridge University do not require an internal selection process. With ICEP, students from universities across the globe participated in virtual exchanges which allowed them to share knowledge and skills about healthcare systems, education, law, and ethics with one another as well as learn from experts in the field. In addition to virtual exchanges, students were offered the opportunity to partake in academic immersion travels (AIT) for 1 week. These visits are designed to provide students with an immersive experience within professional fields where they can engage directly with peers and faculty members from partner institutions, fostering cross-cultural communication and understanding. While there is no tuition or fee for any portion of the program, travel arrangements and funding are at the discretion of your school or via personal funds.

In this study, we further explore one of the learning objectives of ICEP, highlighting the program’s capacity to foster PI. We are specifically aiming to determine if ICEP contributes to the formation of PI. We will further discuss the importance of PI in the healthcare profession and the potential for such a program to be incorporated into medical education worldwide. We aim to present ICEP as an educational innovation designed to develop a range of skills in students to become competent, versatile professionals.

Methods

Participants

Students from ICEP were recruited to participate in the survey at the beginning of the program in the fall of 2022 and upon its completion in the spring of 2023. At the time of this study, ICEP has partnered with major leading medical universities on five continents: Africa, Australia, Asia, Europe, and North America (https://www.internationalcollaborationexchange.org). At the time of the study, 658 students were actively participating in ICEP, and each received an email with a survey link inviting them to voluntarily complete an online validated questionnaire (Professional Self Identity Questionnaire, PSIQ) [13]. For the intake questionnaire, students were emailed the survey link once per week for 4 weeks prior to the program’s initiation. Following the conclusion of ICEP, the post-program survey link was distributed weekly for 4 weeks.

Ethical approval was obtained from the Institutional Review Board of Columbia University (IRB approval AAA0003715). Several schools obtained ethical waivers for student participation in the anonymous questionnaire. Informed written consent was obtained from all individual participants included in the study. Participants have consented to the submission of the questionnaire responses to the journal. All students were fluent in the English language as part of the program participation requirements.

Program Elements of ICEP

ICEP brings together students from all around the world through virtual conferences and academic immersion travels (AIT). Guest speakers who are experts in their respective fields were invited to talk about various topics in healthcare during virtual conferences held three to four Saturdays each month. After each lecture, students were divided into breakout rooms with guided discussion questions to work through together. To continue the collaborative efforts, students convened monthly with a designated small group that remained constant throughout the program to discuss diverse topics within healthcare and education. These sessions were complemented by social media and large chat networks utilized by the students, enabling the exchange of information and socialization among all participants (Fig. 2). With students from 20 universities, ICEP provided the opportunity to expose participants to diverse perspectives and insights into healthcare systems worldwide while also helping them collaborate, engage in dialogue, and learn to work effectively with others.

An optional immersion travel (AIT) was offered mid-way through the program to enable students to meet face-to-face during the program and to deepen the connections built online. The AIT for this study’s cohort took place in Paris, France, in March 2023. During the 1 week’s travel, participants were hosted by local ICEP students, allowing them to explore the city, attend lectures, visit research centers, and interact with healthcare professionals, including clinicians, researchers, and educators. This provided students the opportunity to socialize with peers within their field and gain valuable mentorship opportunities.

Questionnaire

A previously validated questionnaire, with an internal consistency measured by Cronbach’s alpha of 0.93, was administered to participants both at the program’s initiation and upon its conclusion [13]. The survey was conducted in English and was administered online using an online survey platform (Qualtrics, Provo, UT). Students were invited to rate their PI using the PSIQ (Table 1) [13]. The PSIQ consists of nine questions on a 6-point Likert scale, classified across three distinct factors: “interpersonal tasks” (teamwork and communication), “profession-specific tasks” (conducting assessments, using records, dealing with emergencies, and teaching), and “generic attributes” (cultural awareness, ethical awareness, and reflection) [13]. This questionnaire thus measured how students identified their view and position as health professionals on a continuum between “first-day student” and “qualified doctor.”

Table 1.

Professional Self Identity Questionnaire (PSIQ)

PSIQ questions
Interpersonal tasks
When I am working with other health and social care professionals, I feel like a 1 st day student
When I am communicating with patients or clients, I feel like a 1 st day student
Profession-specific tasks
When assessing a patient or client, I feel like a 1 st day student
When consulting, using patient or client records, I feel like a 1 st day student
When I find myself in an emergency involving a patient or client, I feel like a 1 st day student
When teaching others, I feel like a 1 st day student
Generic attributes
When engaging with others in a culturally diverse health care environment, I feel like a 1 st day student
When I am considering ethical or moral issues, I feel like a 1 st day student
When reflecting on my practice (experiences) to identify my learning needs, I feel like a 1 st day student

Scale: 6-point scale (1 = “Not true at all for me”, 6 = “Very true for me”)

Organization of Participant Self-ratings

Participants were tasked with self-evaluating their PI based on the nine items presented in the questionnaire. They were prompted to gauge their sense of similarity to a “first-day student” when engaging in these activities, providing ratings on a scale from 1 (“Not true at all for me”) to 6 (“Very true for me”). A lower rating indicated less agreement with feeling like a"first-day student,” suggesting a greater sense of experience in that aspect of the questionnaire. To facilitate interpretation, the questionnaire data were transcribed so that higher numerical values corresponded to increased perceptions of PI. Thus, a score of 6 indicates the highest level of self-perceived professional identity, while a score of 1 represents the lowest.

The survey additionally gathered demographic information from participants, including variables such as age, gender, program type, and program stage. Due to the program’s voluntary nature, each school’s number of participants was unevenly distributed.

Statistical Analysis

The data collected from the study were analyzed using RStudio Version 2023.3.0.386 (2023). To determine statistically significant differences between quantitative variables and control for multiple comparisons, Tukey’s honestly significant difference (HSD) test was applied, with significance set at p < 0.05.

Results

Participant Characteristics

Among the 658 active ICEP participants, the pre-program survey gathered 302 (45.90%) responses. Subsequently, the survey following the completion of ICEP garnered 74 (11.25%) responses. The following demographics of respondents were found to be similar to those of the total cohort. Of the total respondents, 66.06% (183) of participants were female, 33.21% (92) were male, and 0.72% (2) were non-binary. Additionally, 45.64% (131) of participants were under the age of 20, 50.52% (145) were between the ages of 20 and 25, and 3.83% (11) were over the age of 25. Our cohort consisted of 70.43% (212) medical students, 9.97% (30) undergraduate students prior to entry into medical school, 8.64% (26) dental students, 8.31% (25) biomedical sciences students, 1.33% (4) MD/PhD candidates, and 1.33% (4) health sciences students (PhD, pharmacy, etc.). Table 2 displays the demographics of participants. Table 3 presents the distribution of participants by university and country.

Table 2.

Demographic characteristics of participants

	Total
Gender
Male	92
Female	183
Non-binary	2
Total	277
Age
Under the age of 20	131
Between 20 and 25	145
Over the age of 25	11
Total	287
Program
Medical	212
Dental	26
MD/PhD	4
Health sciences (PhD, pharmacy, etc.)	4
Biomedical sciences	25
Undergraduate college	30
Total	301
Program stage
Premedical training (not in medical or dental school yet)	31
Preclinical years of dental school	29
Clinical years of dental school	1
Preclinical years of medical school	195
Clinical years of medical school	17
First year of public health school	1
Second year of public health school	9
Junior training of other health profession school	5
Senior training of other health profession school	3
Total	291

Some students did not answer all the survey questions, resulting in variations in the total response counts

Table 3.

Distribution of participants by university

Country			University
Answer	%	Count	Answer	%	Count
Australia	0.33%	1	The University of Sydney	0.33%	1
China	4.64%	14	Chinese University of Hong Kong	4.64	14
Japan	4.30%	13	Keio University	0.99%	3
			Kyoto University	1.32%	4
			Tokyo Women’s Medical University	1.99%	6
Taiwan	5.96%	18	National Taiwan University	5.96%	18
Austria	4.64%	14	Medical University of Vienna	4.64%	14
Denmark	0.99%	3	University of Copenhagen	0.99%	3
UK	19.21%	58	University of Cambridge	8.61%	26
			King’s College London	10.60%	32
Finland	1.66%	5	University of Helsinki	1.66%	5
France	11.59%	35	University of Paris	11.59%	35
Germany	8.61%	26	Ludwig Maximilian University	3.31%	10
			Martin Luther University	5.30%	16
Italy	2.65%	8	University of Milan	2.65%	8
Spain	17.88%	54	University of Barcelona	17.88%	54
Canada	0.99%	3	McGill University	0.99%	3
USA	16.56%	50	Columbia University	15.56	47
			University of California San Francisco	0.66%	2
			Yale University	0.33%	1
Total	100%	302	Total	100%	302

Analysis of PI Ratings

Tables 4 and 5 display PI ratings across the nine PSIQ items, categorized into their three respective factors, along with the corresponding comparisons. Table 4 compares groups of students based on their responses before and after the full completion of two semesters of programs within ICEP, revealing significant differences in PI levels. After the program, students reported significantly higher senses of PI across interpersonal attributes, profession-specific tasks, and overall PI (p < 0.05).

Table 4.

Comparison between pre- and post-hybrid program

Pre vs. post ICEP
ICEP	Mean (SD)	Mean difference	95% confidence interval		p-value
			Lower bound	Upper bound
Interpersonal attributes
Pre	3.47 (1.46)	0.43	0.15	0.71	0.003*
Post	3.89 (1.40)
Profession-specific tasks
Pre	3.39 (1.58)	0.38	0.16	0.60	< 0.001*
Post	3.77 (1.55)
Generic attributes
Pre	4.07 (1.39)	0.20	−0.02	0.43	0.07
Post	4.28 (1.39)
Total scores
Pre	3.63 (1.52)	0.33	0.19	0.47	< 0.001*
Post	3.97 (1.48)

After the program, students reported significantly higher senses of PI across interpersonal attributes, profession-specific tasks, and overall PI rating

Scale: 6-point scale (1 = lowest self-perceived PI, 6 = highest self-perceived PI)

^*p < 0.05

Table 5.

Comparison between students with and without AIT participation

Participation vs. no participation in academic immersion travels
AIT	Mean (SD)	Mean difference	95% confidence interval		p-value
			Lower bound	Upper bound
Interpersonal attributes
No	3.74 (1.39)	0.52	0.04	1.08	0.07
Yes	4.26 (1.40)
Profession-specific tasks
No	3.67 (1.52)	0.36	−0.07	0.80	0.11
Yes	4.03 (1.59)
Generic attributes
No	4.25 (1.27)	0.10	−0.35	0.56	0.68
Yes	4.36 (1.65)
Total score
No	3.88 (1.43)	0.31	0.03	0.59	0.03*
Yes	4.19 (1.57)

Students who had participated in the AIT were shown to have significantly heightened senses of overall PI compared to students who had not

Rating scale: 6-point scale (1 = lowest self-perceived PI, 6 = highest self-perceived PI)

^*p < 0.05

Table 5 compares groups of students who had participated in the AIT against those who had not. Students who had participated in the AIT (4.19 (1.57)) were shown to have significantly heightened senses of overall PI compared to students who had not (3.88 (1.43)).

Discussion

This study examined the incidental effects of socialization and learning experiences facilitated by ICEP. Self-perceived levels of PI were measured in students prior to the initiation of ICEP and again upon the program’s completion. Due to the program’s nature, we were unable to provide a control group, given the diverse array of students across various universities and education stages. Analyzing responses revealed a statistically significant positive increase in PIF when analyzing the categories of interpersonal attributes, profession-specific tasks, and overall PI. No significant impact was observed for participants’ generic attributes, which include cultural awareness, ethical awareness, and reflection. Participants who had the opportunity to take part in the 1-week AIT to Paris also demonstrated higher senses of overall PI perceptions compared to their counterparts who had not done so.

While these findings hint at a correlation between participation in ICEP and PIF, our emphasis lies in the recognition of PIF as an incidental byproduct of engaging in international exchange programs. Such experiences become valuable for broadening perspectives on practices across diverse contexts, creating a process of mutual learning [14]. This suggests that ICEP has the potential to positively impact PIF in young professionals, which supports the implementation of similar programs into healthcare education. Along with its potential to influence PIF and unlike existing exchange programs, ICEP provides students with a unique environment to help prepare them to step into international leadership roles and participate in global collaborative problem-solving via multidirectional exchanges with students from major international universities. However, future studies could benefit from a comparative cohort to contrast the outcomes of ICEP participants with those who did not participate in similar programs.

It is believed that education is the transformation of the self into new ways of thinking and relating [12]. As PIF occurs largely during one’s educational years [8], it is crucial for PIF to be included as an important educational objective during a student’s time in university [9]. Though we cannot discount the possibility that time spent in school has contributed to their PI development, it is possible that ICEP may have played a role in accelerating this process, given the increased contact time with both students and professionals within their respective fields. Furthermore, students were at different stages in their education. If time at school was the sole factor, then an increase in all years should have been seen, starting with the highest level of PI for the most senior students. Furthermore, the contact time of students with other peers in the health professions increases through participation in the program. Our hypothesis is built on the fact that due to the collaborative nature of ICEP, students had the opportunity to engage in discussion and to collaborate both with and without the guidance of authority figures. Previous literature has shown that mentors who acted as authority figures hindered the progression of groups to learning communities, as students were less likely to debate ideas with an authority figure present [15]. Students were randomly assigned to a breakout room, with each room having five or six students from different universities. When no authority figures were present in these breakout rooms, students shared their thoughts and perspectives more freely [15]. Upon returning from their individual breakout rooms, students engaged in back-and-forth conversations with the speaker and students from other breakout rooms. It has been shown that internet-based networking platforms influence the development of a student’s digital professional identity because students learn how to communicate professionally with authority figures as well as their fellow colleagues [16]. Given the virtual exchange opportunity that ICEP provides, students were able to exchange knowledge and be active participants in their own learning, which in turn could encourage PI development and foster global networking and collaboration.

Students were given the opportunity to deepen the connections that they had formed virtually through an in-person AIT. The 2023 AIT took place in Paris, France, where students gathered at the Columbia Global Center and the University of Paris campus. By gathering students into a common curricular space, ICEP fostered an environment of collaboration and exchange in a structured manner that enabled students to develop a sense of belonging to the healthcare profession [11]. Moreover, the physical presence of students was crucial to PIF [17], as they were able to gain first-hand, in-person exposure to a professional healthcare setting, which consisted of the Parisian medical school and research laboratories. Students were able to imagine the possible roles that they could fulfill upon graduation by observing how these professionals from various cultural backgrounds conducted themselves within their respective roles. Through observation, students not only began to understand how these individuals communicated and collaborated with others but also started to internalize the core values of the profession on a global scale. For instance, if students were to observe a professional acting with dignity and respect, they would be more likely to show the same dignity and respect towards others [17]. This ties into the importance of having role models who will positively influence students. By observing the actions of positive role models, students are more likely to want to develop the qualities and skills of these individuals, as well as gain further insight into what it means to be a healthcare professional [18]. While in Paris, ICEP gave students the opportunity to meet leading researchers from various sectors of healthcare who spoke about not only their research but also why they chose their respective fields and how they got to where they were. The hard work, dedication, and passion that these professionals embodied demonstrated to students the qualities that are needed in international leadership roles, which in turn hopefully inspired students to parallel these traits. Nonetheless, immersion in the healthcare environment of another culture broadened the scope of individual students, allowing for a more comprehensive understanding of PI and the qualities of a healthcare leader in a global context. Studies have indicated that engaging in similar short-term cross-cultural exchanges can yield valuable long-term benefits for professionals in training, enhancing their PIF [19].

While observation is a key component of PIF, interaction is of equal importance. By interacting with professionals, asking questions, and challenging existing notions, students were able to reinforce their knowledge base and enhance their curiosity, resulting in further PI development [17]. The enhanced PI development that was noted post-AIT may be attributed to ICEP allowing for the development of a student’s potential through the observation of and interaction with role models in the medical profession. Additionally, students attended conferences and participated in group discussions, which enabled them to experiment with and enact their role as future healthcare providers. They learned to think critically, work together in teams, and advocate for themselves and for one another, all of which are essential facets of the work of health professionals. Group discussions, revolving around controversial topics in healthcare, encouraged students to learn from one another and improve their communication skills to describe notions that may have a completely different meaning in another country [11]. Students who were placed into a challenging situation like this were motivated to take on leadership roles, problem solve, be independent, and remain calm under pressure, thus allowing them to put into practice the qualities of a professional in their field [17] and enhancing their PI, as observed in our post-AIT results. This kind of experimentation and enactment of the professional role supports ICEP’s potential role in PI development and the program’s goal of preparing students in the health professions for international leadership roles and global collaborative problem solving. Lastly, while it is typically easier for domestic students to connect with fellow domestic students due to fewer language and cultural barriers [11], ICEP promoted interaction among domestic and international students through academic and non-academic activities. According to the literature, international health electives, which provide unique learning opportunities to undergraduate and graduate medical trainees by not only exposing them to various aspects of the profession but also encouraging students to teach other students, have been shown to contribute to PI formation [20]. These early peer-to-peer interactions also found in ICEP encouraged collegiality, long-term bonding, and friendships, which in turn furthered ICEP’s goal of promoting international networking and global collaboration. ICEP allowed students to feel that they belonged to a community of young healthcare professionals, thereby enhancing their sense of PI. In addition, ICEP students shared not only their knowledge about the healthcare systems in their respective countries and their experiences with patient care in university, but also their personal backgrounds and cultures. These exchanges have the potential of raising awareness about differences in healthcare delivery systems and global public health challenges in addition to providing students with cultural competency and international collaboration skills. Because there is no globally accepted construct for what professionalism encompasses, the cultural competency and international collaboration skills that students acquire through ICEP allow them to develop culture-specific concepts of professionalism. This enables students to move towards becoming global medical professionals who are culturally aware and sensitive, thus supporting ICEP’s mission of preparing students for international leadership roles in medicine [21]. Additionally, according to the literature, this kind of global peer exchange encouraged students to remain open-minded [11], thus allowing students to acknowledge the practice of medicine in different countries and accept one another as future healthcare professionals despite their differences. The recognition and acceptance of others that ICEP fosters are crucial to PI development [10].

Looking into the future, ICEP hopes to strengthen the collaborative efforts of those in the wider medical community and encourage communication among international healthcare providers. The program aims to serve as a model for how healthcare professionals should go about the practice of medicine — by seeking out mentors who are able to be pillars of guidance and support, by professionally engaging in difficult yet much needed conversations to address major issues in one’s respective field, and by advocating for their fellow colleagues whether it be virtually or in-person.

Given its international nature, it was expected that ICEP would contribute to an increase in cultural awareness within this cohort. However, the absence of a significant impact on these generic attributes can potentially be attributed to the possibility that students already possessed heightened levels in these areas. The questionnaire employed may not have been sensitive enough to capture these modest shifts in cultural awareness. Other studies are underway to measure cultural competency with more specialized questionnaires. Obtaining qualitative feedback from participants through surveys could also offer valuable insights that are not discernible by this quantitative approach.

This study explored the unique program that ICEP offers while also examining the global aspect of PI, recognizing the impact of cultural and geopolitical factors on its development. By facilitating an environment for students from diverse geographic backgrounds to interact, participants were exposed to varied patient populations, medical practices, and healthcare systems from around the world. Moreover, students had the opportunity to utilize platforms to engage in discussion about unique healthcare experiences from around the world, fostering deeper reflection upon these topics.

Limitations

There are several limitations to this study. Firstly, the low response rate post program posed a challenge, as the follow-up survey displayed much lower response rates compared to the intake survey. Consequently, the diminished sample size may introduce potential bias, calling into question its ability to represent the entire cohort upon comparing groups before and after the program.

Secondly, the observed increase in PI levels may be attributed to the influence of history and maturation effects, given that ICEP ran concurrently with the participants’ regular curricula over the course of 8 months. Throughout the extended duration between the program’s commencement and conclusion, many variables may have contributed to the maturation and development of participants’ PI and self-perception. This may have included additional training, clinical exposure, and coursework. The absence of control over additional influences makes it difficult to claim that ICEP is the sole, or indeed the main factor, to play a role in PI levels. Future studies to compare students who did not participate in the program versus program participants are underway.

Additionally, given the international composition of the cohort, students may have interpreted survey questions differently. While English fluency is a prerequisite for ICEP participation, linguistic nuances may still introduce potential confounding factors.

Lastly, the group of participants encompassed a diverse range of students at various stages in their academic programs. This diversity introduces further uncertainty, as students further along in their studies may already have developed a stronger sense of PI, potentially diminishing the impact of ICEP on their existing PI. Conversely, participants earlier in their programs may have attained disproportionately higher PI development from the program compared to their peers. However, a positive effect of PIF may have occurred as older students may have served as role models and mentors to younger students. Another study including more students stratified by stage of education may help with exploring this hypothesis.

Future studies would benefit from establishing a more controlled environment in order to identify the factors that contribute to PIF. This may enable a thorough examination of the influences on PI, providing a clearer understanding of the complex dynamics forming PI over an extended period.

Conclusion

Given that programs such as ICEP have been found to foster PI development in students, similar programs could be integrated into health profession curricula to enable students to be more active participants in the development of their PI. PI training is essential for students’ career adaptation, encouraging early participation to build a strong foundation in communication, collaboration, and critical thinking, which they can continue refining as they transition into professional life [22]. As PI development occurs more often in informal settings [12], students could be given more opportunities to experiment outside of traditional classrooms where they can interact and work together. Thus, small group discussions and problem-based learning might be helpful in this regard. It is also crucial that students have a strong support system throughout their education [9]. Mentors and role models should be an integral part of that support system to provide them with feedback, instill core values, and encourage them to reflect on what they have observed or experienced. As PI is an essential component of the development of healthcare providers, educators should be encouraged to integrate PI development into their curricula.

Author Contribution

A.W. and G.N. were responsible for the concept and design of the study, and oversaw the data collection and analysis. J.L. was responsible for acquiring the datasets, and conducted the data analysis. J.L. and J.H. collaborated on the first draft of the main manuscript text. All authors critically reviewed and contributed to the final manuscript.

Data Availability

There is no data available for this study. All available data have been reported in the manuscript.

Declarations

Ethics Approval

Ethical approval was obtained from the Institutional Review Board of Columbia University (IRB approval AAA0003715). Several schools obtained ethical waivers for student participation in the anonymous questionnaire.

Consent to Participate

Obtained as part of student questionnaires per IRB.

Consent to Publish

Obtained as part of student questionnaires per IRB.

Conflict of interest

The authors declare no competing interests.