Faculty Reflections About Participating in International Medical School Curriculum Development, a Qualitative Study

Abstract

Nazarbayev University School of Medicine selected the University of Pittsburgh School of Medicine to guide their curricular development. University of Pittsburgh faculty members teaching in the medical school were asked to help develop the curriculum in Nazarbayev. Some were asked to travel to Nazarbayev University to provide mentoring. Realizing that this would be a new activity, we wanted to investigate the perceived motivations, rewards, and barriers to participation. We conducted open-ended interviews of University of Pittsburgh faculty members, who were asked to participate in a project about motivations for accepting or rejecting the offer. We asked those accepting about the benefits and negatives. Nineteen faculty members agreed to 30 min interviews, which were digitally recorded and transcribed. All interviews were coded. Participating faculty members felt that reviewing their courses improved them. Most noted increased altruism and felt improved as educators. Some felt angst in providing their curricula. Several felt that traveling was challenging, but video conferencing technologies facilitated communication. Interviewees desired tangible rewards. This study highlights faculty perceptions of international curricular development. Faculty members felt that rewards included an improved native curriculum and personal and professional enrichment. Time constraints and distance were the main challenges and the primary reason others declined. The faculty perceived multiple benefits from this curricular development and collaboration. More transparency regarding expectations and the degree of assistance Nazarbayev University needed may have assuaged these fears.

1. Introduction

In recent years, numerous medical schools have created partnerships with foreign medical schools. The motivations for, and goals of, the ventures differ. Many of the partnerships involve transfers from resource-rich to disadvantaged institutions, often as part of global health initiatives [1,2,3,4,5,6,7]. Some have focused on narrow exchanges in research or education between developed institutions [8,9]. Others have involved developing branch campuses of established Western universities in rapidly developing countries with available resources [10,11]. Descriptions of partnerships outside these models remain rare.

After achieving independence from the Soviet Union in 1991, Kazakhstan rapidly developed its economy and national infrastructure. However, the national government became aware of deficits in education and in healthcare. In 2010, the Nazarbayev University (NU) was established in the city of Astana, along a Western model, to develop leadership for the country. Each school within NU established a partnership with a university in the United States or the United Kingdom selected through a competitive bidding process. The partnering university provided guidance in curricular and faculty development, but NU remained the sponsoring university. The University of Pittsburgh School of Medicine (UPSOM) was selected to advise the Nazarbayev University School of Medicine (NUSOM) in 2012. Traditionally, medical schools in Kazakhstan enroll students after high school and have five-year-long densely didactic curricula. The NUSOM curriculum is four years post-baccalaureate, taught in English, and reflective of modern Western educational practices. NUSOM graduated its first class in June 2019.

When UPSOM entered this project, their steering committee members knew that they would be asking faculty members to do things for which they had not been trained or had not experienced before. Both basic scientists and clinicians would need to interact with NUSOM faculty members who had completely different backgrounds and ideas around pedagogy. Key stakeholders at UPSOM would need to motivate their faculty to a new task.

Such requests are not uncommon for a medical faculty. In the current academic climate, faculty members are frequently asked to preform co-teaching activities outside their departments. Furthermore, efforts to give students clinical experiences in “real world” settings have led medical schools to engage community-based clinicians as preceptors [12]. Many of them have had little or no training in teaching, have different motivations, and face different barriers than traditional academic faculty [6,7].

Faculty members from the University of Pittsburgh who actively teach in the medical school were asked to help develop and formalize the curriculum for NUSOM. Some of these faculty members were also asked to travel to NUSOM to provide hands-on mentoring. As the project unfolded, we noted that, while most of the faculty were eager to participate, some individuals were reluctant or even refused. We sought to explore the rationales behind their decisions, and for those who did participate, we wanted to learn what they had taken from their experiences. Specifically, the goals of this study were to interview those in the faculty who were asked to participate in the UPSOM-NUSOM project about motivations for accepting or rejecting the offer to participate. For those who accepted, we also sought to assess what benefits were gained or detriments were noted, personally and professionally.

2. Materials and Methods

Project process:

The process through which the NUSOM curriculum was developed merits a discussion. As NUSOM was simultaneously building its medical school and hiring faculty, staff, and administrators anew, it faced numerous challenges. Faculty members often arrived on campus shortly before their courses began. They needed to teach outside their areas of expertise and participate in multiple courses. This “just in time” process required intensive mentoring from UPSOM faculty members.

A process evolved that consisted of three phases. In the first phase, the course leaders at both schools were introduced and set objectives. In the second phase, they conducted teleconferencing and emails where course materials were developed and exchanged. The process culminated in a week-long “master class”. During this week, members of one school visited the others’ campus for intensive preparation. After each course was delivered to the students, the partnering course leaders debriefed course feedback, exam scores, and general logistics. The UPSOM faculty members who participated, and their administrative departments, were reimbursed for their effort and lost time.

Study design:

Between June and August 2017, one-on-one semi-structured interviews featuring open-ended questions were conducted with University of Pittsburgh faculty who had been asked to participate in the NUSOM project. Purposive sampling was utilized in selecting faculty members to participate. Faculty members were invited to participate in the interviews via email. All interviews were conducted in offices at the University of Pittsburgh School of Medicine by one of two study investigators. The interview questionnaire utilized for each interview was identical [Figure 1]. The interviews averaged 30 min each.

Data collection:

The interview questionnaire was devised utilizing input from the project steering committee at UPSOM. Prior to beginning the interview, an introductory script was read to the participants indicating that their answers to the questions would be kept anonymous and would not be shared with any of the UPSOM leadership at any point. Specifically, the participant’s name would not appear on the interview file, transcription, or analytic files. A key file of each interview and interviewee was maintained using a code system in a secure file. The key file was used to replicate or verify an analysis during the project. Upon completion of the project’s analysis, coding, and manuscript writing, the key file was destroyed.

Data analysis:

The authors utilized the theory of phenomenology for the data collection and analysis of each interview. It was felt that this would be a better framework than grounded theory, as the authors wanted to assess the subjective perspectives and experiences of the UPSOM participants [13,14,15,16]. To ensure the reflexivity and overall neutrality of the interview process, it was decided that the author with the least direct contact to participants would be the primary interviewer. This allowed for the least amount of subjectivity with follow-up questioning. Two authors (A. K. and R. S.) independently reviewed three complete interviews and utilized the constant comparative method to build the code book for analysis. After each of the first three interviews were completed, the authors met to discuss differences and adjudicate discrepancies. Sentences and phrases were abstracted and assigned codes. The themes, made up of several codes, were inductively formulated and refined as additional interviews were completed. The study was performed with permission of the University of Pittsburgh’s Institutional Review Board.

3. Results

We completed 19 interviews of School of Medicine faculty. Interviewees consisted of 14 men and 5 women. Regarding academic ranks, there were ten full professors, seven associate professors, and two assistant professors. All 19 interviews were coded, despite saturation after approximately 10 interviews. The interviews were divided into three primary categories: interviewees who agreed to participate and traveled to Kazakhstan, interviewees who agreed to participate only at our home institution, and interviewees who did not agree to participate. Out of the total number of codes, four primary themes emerged.

The first theme that emerged was that participants felt that working on the NUSOM project improved the medical school curriculum at the University of Pittsburgh. The director of one of the second-year courses noted the following:

…Actually, in going through our <slides>, we used the same sort of pretty intense scrutiny to go over our material and say this doesn’t belong here. We can throw this out. And so, we ended up actually working quite a bit on our stuff as well. So, it was reviewing what they had and then actually sharing with them what we had as well.

Another second-year course director noted:

It wasn’t exactly how I planned on spending my spring, but going through the entire course…with fresh eyes I could see some overlaps. I could see some holes. I could see jumps in their <Lecturers> logic where they launch from step A to step B…all the way to G and it’s like, okay how did you get here? And a second-year student is simply not going to understand that gap.

A second theme was that most noted that, after working on the project, they had an increased sense of altruism, particularly to the medical education community. Two interviewees noted similar viewpoints:

You know, to play even a small role in that <NUSOM Project>, it sort of makes me feel good about myself. That’s why most people volunteer…it makes them feel good about themselves. But, you know, it’s <also> really sort of helping others.

They <the NUSOM faculty> wanted to do the best job that they could, and I felt that it was one of the best mentoring experiences I’ve ever had. They were just really good people to work with.

A third theme was that the UPSOM faculty members felt that they themselves had improved as both leaders and educators. Faculty members felt that communication between the organizing administration, both from their home institution as well as the foreign institution, would allow for them to stay motivated with tasks pertinent to the curriculum development.

I think I actually bugged the NUSOM Project leaders saying that I wanted to be part of it. I love teaching in all sorts of different venues because I think that teaching in different venues makes me a better teacher.

Another course director similarly stated the following:

So, I’ve taught in all the way from undergraduate, all the way to post-medical, CME conferences. I’ve taught in Japan and those experiences have always been selfishly very beneficial to my knowledge base but also give me an opportunity to teach.

Finally, there were some negative feelings about the project, as communications caused UPSOM faculty members to have angst in providing the curricula that they had worked hard to build.

There were some issues about how much we share with this people and copyrighted material and stuff. And I think that had caused so many headaches that by the time it got down to me. People were exhausted by it, and I just gave them everything.

I think the problem boils down to it’s one thing to sit here and plan how best to work with them, and it’s another to get there and realize what they need is different from what you planned on doing with them.

There were four participants who participated in these focus group interviews and who did not travel to Kazakhstan. One participant agreed to interview for this study, but declined to participate in the project altogether. There were additional participants who were asked to participate in focus groups who did not participate in the Kazakhstan project, but they declined to be interviewed. For the group of participants who did participate but did not travel abroad, as well as the interviewee who declined completely, two primary themes arose. One theme was time away from family. The other theme was the difficulty with obtaining coverage for clinical work. One participant noted,

I actually was asked if I wanted to go. I am the current <prominent leadership role> here, and I have kids and a <physician> husband. So for me to disappear for 10 days would be nothing short of catastrophic right now. So, like I have clinical duties and parenting duties left and right that would have amounted to parsing out and dumping on about 10 different people lots of stuff, and trying to manage it from thousands of miles. So, no I decided that was not going to work for me.

Another participant who participated in the project but did not travel illustrates the counterpoint to the primary theme.

Since I didn’t travel, participating didn’t impact my work here at all, except for the occasional early mornings, but it wasn’t bad. But no more so than I would normally experience.

4. Discussion

This qualitative study highlights the motivations, barriers, and rewards of a faculty during the process of creating an internationally affiliated medical school. For most participants, this was a unique experience. The faculty at the UPSOM devoted both time and educational material to make the project a success. Faculty members were rewarded by improving their curriculum for future medical students, by feelings of altruism, and by an enhanced pleasure from teaching. Participating faculty members’ negative impressions centered on time constraints and unwillingness to share materials that they had developed. Many of the time constraints were related to competing professional demands. Those who declined to travel cited distance and time from home, falling behind in other work, and being inadequately compensated for the task. The latter complaint was in spite of receiving honoraria for their participation.

The previous literature has commented on several of the themes we encountered with our faculty. Kanter articulates a number of motivations and benefits from these international medical education relationships [17]. He included enhanced reputation, bilateral educational benefits, humanitarian aspects, and financial benefits. He also warns of distractions that may cause the neglect of home duties, cultural misunderstandings, and creating competition between partners. In her articles about cross-border curricular partnerships, Waterval similarly describes research, financial, and reputation rewards [18,19]. She advocates for transparency in planning and the importance of faculty and staff development. She cautions about differences in learning environments and dissimilar organizational structures. Participants in her interviews described academic advantages to partnerships that mirrored our respondents’ comments.

There are several striking parallels between our findings and those described by others regarding clinical teaching, particularly for those who are community-based or engaged less than full time as educators. Clinical obligations infringe on time allocated for teaching, and inconveniencing colleagues with coverage issues is particularly vexing. Like having students, this project decreased clinical productivity for participants. Inefficiencies and unclear expectations compounded the problems [6,7]. Again, akin to clinical educators, our faculty described a variety of intrinsic and extrinsic motivating factors that helped to overcome barriers [20]. As with clinical teachers, most of our faculty members who participated in this project enjoyed it and expressed a desire to do so again.

The study has some notable limitations. Firstly, it involves only two schools, and care must be taken in generalizing unique circumstances. As in most qualitative studies, we had a small sample within UPSOM. Although we reached thematic saturation, our findings may not reflect widespread ideas. The interviews were performed at varying times following participation in the program, which may have introduced recall bias.

From an UPSOM administrative perspective, we have learned that our curriculum is transferable, both in terms of content and process. We now have a cadre of educators who are both willing and able to facilitate the international mentoring process. We have learned some lessons from the process. A project like this one needs to have transparency regarding the goals, duties involved with participation, and rewards for participants. The project steering committee became aware that it needed to appreciate the concerns, doubts, and conflicts faced by the faculty and to minimize them. Those concerns were addressed with orientation meetings for both new and ongoing participants prior to trips or undertaking new aspects of the project. Steering committee members gave grand rounds on the subject in order to broaden awareness among the faculty.

5. Conclusions

The UPSOM faculty was able to provide intensive assistance to the new medical school at NUSOM, and many of the UPSOM faculty members expressed professional and personal satisfaction from their experiences. Although many eagerly participated in the project, faculty members expressed concerns.

We would offer the following advice, as well as future research considerations, to those contemplating a similar project. First, make the project goals clear to all involved. Then, emphasize the positives, such as financial rewards for participation, feedback, and a chance to review your course. Avoid the perception of negatives, such as the appearance of an unfunded mandate. Participation should be clearly voluntary and informed. That is, participants need to understand the project and their proposed role in it. Be sensitive to those who have constraints or conflicts that limit their participation. Be flexible and plan ahead so as to minimize the impact on home schedules. Do not let this project detract from their usual duties. Lastly, disengage travel from participation. Some may want to assist the project, but are unable or unwilling to make the trip. Future research perspectives could include assessments of whether student satisfaction with courses at the home institution changed before and after faculty participation in the project. Additionally, how translatable one country’s medical teaching is to another could be assessed using an examination of the graduation success of students in the newly formed medical school.