Solutionism across borders: Sorting out problems, solutions and stakeholders in medical education internationalisation.

Internationalisation in medical education is a broad term with multiple appearances and is not seldomly presented as a goal in itself. In global university rankings, internationalisation is often a key pillar, driving efforts to recruit more international faculty and students, and initiate more international collaborations. Yet, what problems does internationalisation fix in medical education? Or does it perhaps create more problems than it solves? This special issue on solutionism encourages us to question the status quo and carefully analyse the complexity of problems to ensure beneficial and appropriate outcomes of proposed interventions. We take up this challenge reflecting on themes around internationalisation in medical education.

Internationalisation in medical education is a broad term with multiple appearances and is not seldomly presented as a goal in itself

Two papers in this issue , inspired us to consider internationalisation in terms of the problems and solutions it addresses and creates. Rowland et al apply the so‐called ‘garbage can model’ to the context of patient engagement modalities in health professions education. The model, based in organisational sciences, presents a way to conceptually sort the relationship between problems, solutions and stakeholders. Organisational decision‐making, according to this model, is ‘not entirely rational, but instead a messy process of problems, solutions, and stakeholders situated together in a particular decision‐making space’ (ie the garbage can). One of the model's assumptions is that the way problems and solutions are linked together is often assumed, rather than made explicit—a pattern that we recognise in the context of internationalisation in medical education.

Rowland and colleagues list multiple patient engagement modalities that are routinely implemented without fully understanding which problem they address and how. The authors describe how this can unintentionally create new problems for stakeholders involved. Similarly, internationalisation efforts in medical schools around the world take many shapes, including student exchange programmes (often referred to as ‘global health education’), curriculum internationalisation, cross‐border partnerships in research and education, or international student recruitment in dedicated international medical programmes. These and other responses to a globalising world could be considered solutions to challenges and problems, as well as opportunities, that globalisation creates. However, the alignment between, on the one hand, the challenges and opportunities of globalisation, and, by contrast, the internationalisation modalities or solutions that are being applied, is not always evident.

The alignment between the challenges of globalisation and the internationalisation solutions that are being applied is not always evident

When attempting to explicitly link solutions to problems as the garbage can model promotes, unintended issues become clear. For example, international exchanges enable exposure to different disease patterns and hence could be argued to provide a solution to the diversification of medicine as a result of globalisation. However, global health electives also give rise to a number of ethical and equity issues with potential damaging effects on host institutions’ communities in low‐ or middle‐income countries. Another example concerns institutions that engage in cross‐border curriculum partnerships for academic or economic benefits, without fully questioning what it brings to their students and faculty in light of the complexities of implementing a curriculum across institutions. Notwithstanding many successful and well‐designed partnerships, some have notoriously dissolved for multiple reasons, affecting their stakeholders in the process. These examples urge us to stop and pause before implementing an internationalisation modality, and to question the connection between problem, solution, and potential new problems.

Additionally, a question that arises from the garbage can model with particular relevance for the internationalisation context is: Whose problems are being solved? The issue of stakeholders also is central in the paper by Nisbet et al, who use Cultural Historical Activity Theory (CHAT) to shed a new perspective on clinical placement scarcity. Using CHAT, studying the subjects or actors that engage together in an activity and their (shared) objectives is central to a deepened understanding of problems and helps to develop nuanced responses. Nisbet and colleagues point out how, in their clinical context, the students’ activity of education and the health professionals’ activity of patient care were perceived as competing, contributing to an experienced scarcity of clinical placements. In a collaborative research project, they reconnected these activities by identifying shared objectives, which inspired a redesign of service delivery utilising student placements.

A question that arises from the garbage can model with particular relevance for the internationalisation context is: Whose problems are being solved?

When applying some of the questions that CHAT raises to the issue of clinical placements in a context of international electives, we also encounter potentially competing interests among different actors. The incoming elective student intends to see and learn, the host institution might benefit financially or experience placement scarcity, while patients and supervising clinicians might feel pressured to cross a language barrier. These stakeholders could be regarded as subjects in disrupted activity systems with seemingly competing objectives. To reconnect their activities they might engage, through ‘cycles of expansive learning’, in the (re)design of international electives as a beneficial internationalisation modality for all. This CHAT‐based approach could be similarly inspiring for other modalities that involve multiple stakeholders on different levels and in different contexts, such as institutional partnerships and international medical programmes.

Both Rowland and colleagues and Nisbet and colleagues address the risk of transferring solutions across contexts and advocate for detailed local analysis. This issue is very tangible in medical education internationalisation, where for example curriculum elements and teaching methods are routinely applied across borders, sometimes literally copied from elsewhere. In this context, it is interesting to consider two distinct ideological perspectives that have been found to underpin internationalisation efforts in medical education. , The perspective of medicine as a universal profession entails the idea that the medical profession is essentially identical across the world and a good doctor in one place is a good doctor anywhere. This ‘universalist’ view not only enables mobility of physicians and students, but also facilitates for example standardisation of education, assessment and accreditation. In the other perspective, the medical profession is regarded as highly context‐dependent and requirements for good medical practice are influenced by national or local culture, language, health system characteristics and health beliefs. In this ‘contextualist’ view, internationalisation is necessary in medical education because of changing disease patterns and global migration that both diversify local health care contexts. It thus encourages curriculum internationalisation and international elective placements.

The [issue] of transferring solutions across contexts is very tangible in medical education internationalisation

The two perspectives are often presented as views that see problems differently and offer different solutions to globalisation challenges. Yet, we recognise that the tensions between standardisation and contextualisation will always remain, and what matters is how we navigate these tensions. Following Rowland and colleagues, therefore, we endorse the idea of moving from ‘problems to be solved’ to ‘polarities to be navigated’ and we encourage critical reflection on the complexities of internationalisation modalities in medical education.

The tensions between standardisation and contextualisation will always remain, and what matters is how we navigate these tensions

Sorting out the problems, solutions and stakeholders in the international garbage can, and looking for shared objectives of international activity systems may help this navigation. This process may be more complicated in international contexts, as stakeholders may have different ideas about how to conduct such analysis, and decisions in one place may influence education or health care contexts across borders. Perhaps determining a sorting strategy with all stakeholders involved could be a first step.