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The International Doctoring Endeavor… A Not-so-trivial Pursuit!
1Andrew CK Law, 2Evelyne P Anand
1Department of Psychiatry, RCSI & UCD (Malaysia Campus), Penang, Malaysia
2Library Services, RCSI and UCD (Malaysia Campus), Penang, Malaysia Email: [email protected]
ABSTRACT
A degree in medicine has long been one of the most sought-after pursuits for secondary school and university graduates worldwide. For various reasons, sizable number of students would flock overseas to pursue medical studies. These international medical students, while having their opportunities to follow their doctoring desire, they also have distinct challenges to overcome. One Malaysian medical school has a unique curriculum where students spend first half of their studies in Dublin, then return to Penang for the second half of the course. This brief report addresses some pertinent issues that international students frequently encounter.
Keywords: Medicine; curriculum; international students
1. INTRODUCTION
Numerous individuals worldwide have the desire to pursue a career a medicine. Proportions of them would enter medical schools in their own countries; however, many would choose medical schools in foreign nations for the following reasons: i) in many countries, the number of qualified applicants far exceed medical schools’ available positions (The Association of Faculties of Medicine of Canada, 2019); ii) medicine is a “graduate-entry” programme in North America, and many determined youngsters would desire to pursue their medical studies upon completion of secondary education (Garrud & McManus); iii) the qualities of medical education vary between countries (Aftab et al., 2021); iv) to experience another country and gain independence (Byrne & Brugha, 2019; Özoğlu, Gür & Coşkun, 2015); and v) affordability of the education. These international medical students (IMS) constitute a sizeable fraction of future doctors all over the world; according to the International Federation of Medical Students Associations, there are currently about 1.3 million IMS in 130 countries.
Studying overseas would indeed allow students to satisfy their educational and personal wishes; however, IMS face interesting challenges, from language difficulties to cultural discrimination (Byrne & Brugha, 2019; Huhn, et al., 2016; McGarvey, Karivelil, & Byrne, 2021).
Moreover, as medical degrees are usually not “transnational”, many IMS would face difficulties
393 in returning to their home countries for postgraduate medical training upon graduation (Morgan, Crooks & Snyder, 2017). Some countries would even not recognize overseas medical degrees (Herfs & Haalboom, 2007). Despites these hurdles, many would go abroad for their medical education.
The Royal College of Surgeons of Ireland (RCSI) & University College Dublin (UCD) Malaysia Campus (RUMC) is a foreign university branch campus located in Penang, Malaysia.
The undergraduate medicine curriculum is a five-year “transnational” programme. Students spend the first 2.5 years in Dublin for ‘pre-clinical” study – either at RCSI or UCD, then another 2.5 years of clinical study in Penang. Students receive the National University of Ireland (NUI) medical qualifications upon graduation, and the NUI degrees are well-recognised in Ireland, Malaysia, and many other countries. The uniqueness of this programme attracts many qualified students from Africa, Asia, Australia, Middle East, and North America. The IMS representation of each class is roughly 10% in recent years. As all students spend the first part of their medical training in Dublin, students from Malaysia can technically also be considered as IMS when they are studying in Ireland. As RUMC is strategized to further strengthen its IMS services, better understanding of our students’ needs and challenges as IMS is warranted. This article aims to address some IMS concerns that are particularly relevant to our institution.
2. CULTURAL DIFFERENCES
Malaysia is a multicultural country with Malays, Chinese, and Indians as the predominant ethnic groups. In addition, there are sizable populations of other Asians and Westerners residing in the major Malaysian cities and towns. The most current national census showed that over 60% of Malaysians practice Islam and it is considered as the religion of the federation.
Intercultural difference is one of the biggest worries for IMS (Huhn, et al., 2016). In one Irish qualitative study utilizing focus group discussions found that diverse cultural norms could significantly hinder intercultural friendship establishment; e.g., misunderstanding on personal space – closeness to each other, hugging, and shaking hands (Byrne, et al., 2019; O’Reilly &
Milner, 2015). For Malaysians practicing Islam, socializing may remain gender-specific – e.g., female students were uneasy going to the gymnasium when male students were present.
Gathering would be restricted to places that do not serve pork or alcohol. Issues could occur from sharing accommodation and cooking utensils with non-Muslim schoolmates (Byrne, et al., 2019; Brown & Holloway, 2008). Intriguingly, tension may also arise among students from a
394 similar culture if one chose not to conform to the home country’s social norm when overseas (Byrne, et al., 2019). Malaysian students going abroad do not only potentially encounter cultural challenges from their Irish counterparts, but also from their own RUMC classmates from overseas. While we often identify individuals by their apparent ethnicities, the literature has indicated that categorizing students into specific ethnic groupings may not be appropriate.
It is particularly important for those originating from multicultural societies, e.g., “Malaysians”
and “Canadians”.
The situation is somewhat reversed two-and-a-half years later when students return to Penang for their clinical training – the Malaysian students are no longer considered as IMS, but those who entered the programme from overseas continue to be IMS. For IMS originating from Europe or North America, they would likely to be more accustomed to the Dublin lifestyle, where those coming from the Middle East might find the Malaysian way of life more palatable (Mahmud, Amat, Rahman & Mohd. Ishak, 2010).
3. LANGUAGE BARRIER
The entire RUMC curriculum is delivered in English. All applicants must present evidence of satisfactory language command prior to acceptance. For IMS coming to Penang for their clinical studies, a short “medical Bahasa Melayu” course is offered. When IMS going to foreign countries where their mother tongue is not widely spoken – e.g., Asian students going to Western nations and Caucasian students arriving to Asia countries, they are often apprehensive regarding their communication capability (Yeh & Inose, 2003). The potential language issue could impact not only academic performance, but also integration and socialization (Gatwiri, 2015).
For many Malaysian students studying in an English-speaking country, language per se is often not a significant communication barrier, as they tend to be multilingual – able to converse in English and their own ethnical languages. Despite the apparent proficiency of languages, some students find appreciating accents, colloquialisms, jokes, and non-verbal communications challenging (Byrne, et al., 2019). Moreover, when it comes to academic or professional communications, non-native English speakers could be disadvantaged (Tayem, AlShammari, Albalawi, & Shareef, 2020). Although professional translators are provided for medical students during their clinical postings in Penang, the levels of quality and accuracy tend to vary, and at times insufficient when obtaining detailed psychiatric histories are required (Chapnick, 2019). While classmates are usually helpful to translate, IMS are in general
395 reluctant to continue “pestering” fellow students. Overseas students think that some clinical learning opportunities are missed due to language barrier. Malaysian students, on the other hand, they tend to have difficulty in using English in conveying information to patients in an easily understandable manner.
4. POSTGRADUATE MEDICAL TRAINING
Most IMS are bright students and have no trouble graduating from their medical studies. For those coming to RUMC, as they are not Malaysians, they cannot be considered for housemanship training in the country. Getting a postgraduate training position is probably the toughest battle for them. For some IMS, their home countries do not permit any foreign medical school graduate to engage in internship training, and some countries have extremely limited places for graduates trained in other countries (Mahmud et al, 2010). Out of all professions, medicine is arguable the most difficult for graduates from foreign medical school to obtain local training positions. Moreover, an undergraduate medical degree is virtually worthless if the graduate cannot continue into postgraduate training. At both RCSI and UCD, due to the high number of IMS, they provide excellent services to prepare students for returning to their home countries, e.g., review courses for licensing examinations, career advice and planning services.
At RUMC, the Virtual Learning Environment is used to provide career resources for the students. Students are encouraged to use commercial online learning platforms to prepare for licensing examinations, and the enrollment fee to the online course will be reimbursed upon completion of the examination. As RUMC students would need to return to Malaysia, they could therefore not be able to attend the RCSI review course for the Step 1 of the United States Medical Licensing Exam, which is usually held annually during students’ third year at RCSI.
For students attending RUMC, many of them – local and international – plan to undergo internship training overseas, and the school does provide various resources to assist. Each year, a number of graduates with Honors will be successful in securing housemanship positions; however, several IMS in recent years are not able to transition into postgraduate training smoothly for academic and various personal reasons.
5. FURTHER DISCUSSIONS
Studying abroad undoubtedly offers exciting and mind-broadening experiences. Despite all the prior preparation and apparent readiness of being an international student, challenges -
396 many unforeseeable - remain. Modern advances in telecommunication have likely alleviated some apprehension and brought home closer. In addition to maintain academic excellence, IMS would need to adapt different cultures, engage in new social circles, and manage their emotions. It is therefore understandable that IMS might not be able to capitalize on all the opportunities available when overseas. For many universities’ “pre-departure orientation”
sessions, much time is spent on reassuring the students when presenting what students should expect, and the negatives are often minimized or neglected.
Compared to some other countries, IMS in Malaysia experience relatively less language obstacles, as the majority of the population can communicate in certain level of English. In clinical settings, depending on the medical specialty, history-taking can be problematic at times as the essence of the communication could be “lost in translation”.
Furthermore, in social situations, IMS would feel left-out when their classmates are conversing in their native languages. The offering of a short “survival” language course cannot provide the required foundation for IMS to build upon.
Students choose to study medicine abroad for many reasons. One major deterrent for them not to go overseas is the potential difficulty in returning to their home country to practice.
For example, students in Hong Kong would forego their offers to study at highly prestigious institutions overseas for this reason. International medical graduates often face more difficulties in securing internship training. RUMC has been improving its support for IMS in the recent years; however, more avenues could be explored to optimize IMS services. While some of the discussed issues are “generic” for all international students – and indeed most would be, the difficult in gaining postgraduate training in medicine is unique for IMS. Realizing and identifying the pitfalls in the “IMS journey” are the important initial steps towards change.
Qualitative studies with focus groups can be the useful next step to gain more in-depth understanding of any institution-specific issues.
6. CONCLUSION
This brief article covers only the tip of the “IMS hurdling iceberg”. There are many other issues that IMS would experience, e.g., homesickness, harassment, and discrimination. The awareness that students from overseas have different needs and struggles must be established among faculty members. Different institutions would likely have their unique sets of concerns. Getting students involved in qualitative discussions could be a useful initiative to
397 elicit specific issues. Only with more precise understanding of IMS’ perceptions without prejudice, we can then develop tailored strategic solutions to optimize the IMS experience.
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