Constructive dialogue: Strengthening our knowledge by exploring cross-cultural differences

Abstract

Our aim in curating this 2025 ‘State of the Science’ issue was to encourage colleagues across the globe to work together to highlight different ways of seeing, developing, enacting and imagining health professions education. In part, it is a celebration of 50 years passing since this journal changed its name from the ‘British Journal of Medical Education’ to simply ‘Medical Education’. Reflecting a five-decade long goal of striving to ‘extend communication among medical teachers in different countries’,¹ recent empirical work has indeed demonstrated how impactful a name can be.²

Informed by discussion with the wider Medical Education International Editorial Advisory Board, we sought empirically grounded and conceptually rich overview articles built around authors' perspectives on issues that are core to our applied field. Most included manuscripts arose from encouraging pairs of authors from different parts of the globe, who often did not know each other beforehand, to work together to explore similarities and differences in their perspectives along with how those perspectives came to be. The challenge put before them was not simply to debate their understanding but to engage in genuine conversation aimed at advancing both authors' (and, in turn, the field's) thinking. One author was asked to offer a voice from a region or cultural group that has been historically dominant in the field; the other was asked to offer a voice that has been under-represented. Via these constructive dialogues, we hoped to move discussions in the literature about the importance of context towards engaging with context, shining light explicitly on how it influences one's education or research approaches and attitudes. We did not ask for extensive reviews of existing literature (which is mostly dominated by studies from a few countries in the Global North), instead remaining open regarding the precise format and issues authorship teams wished to adopt. Despite (or perhaps because of) offering such flexibility, constructively engaging in such dialogue was no easy task; that many authorship groups dropped out and many others needed deadline extensions provides evidence for how hard this work is at the same time as giving us reason to celebrate the contributions that were delivered.

Combined with a serendipitously submitted article examining contextual influences on new medical school development,³ the resultant papers were contributed by authors from five different continents and 16 countries with a roughly 50:50 split between countries categorised as Global North and Global South.⁴ Their content demonstrates the complexity of context along with how it is made up of multiple dynamically interacting patterns in a manner that is reminiscent of Bates and Ellaway's description.⁵ In fact, the papers can be loosely grouped based on whether they focus on physical location, what participants bring to bear to that location, and the broader cultural influences that flow from the interactions of location, participation and identity.

As a physical location, the context that surrounds an activity, Kirubakan and colleagues conducted the aforementioned examination of the processes underpinning the establishment of new medical schools in medically under-served areas in three continents³; Han and Kumwenda focused on online learning, considering the historical lack of representation of the Global South in the design of online medical education, as well as the resulting consequences and potential approaches to build more equitable partnerships⁶; Cleland and colleagues, in contrast, applied their comparison of sociohistorical and cultural influences to medical school selection and widening access policies and practices across five countries from four continents.⁷

At a people level, what Bates and Ellaway referred to as what individuals bring to health professions education, Jain and Alwazzan, along with Razack et al., explore personal aspects of context including gender identity, race, disability and specific cultural characteristics, such as those held by learners and colleagues from Indigenous groups.^{8, 9} What becomes clear from these two papers is that what is foregrounded to be important for inclusion differs depending on local history and priorities and that solutions need to acknowledge this embeddedness.

The largest group of papers examined, again loosely drawing upon Bates and Ellaway, describe that which is experienced and the societal cultures within which and in relation to which health professions education takes place—the norms and practices of different settings, countries and contexts. In this regard, Finn et al. consider practices of inclusive assessments for health professions education across three different countries¹⁰; Kent and Haruta present a dialogue about the differences in interprofessional education competencies between Australia and Japan along with the systems and patient expectations which underpin each¹¹; Olmos-Vega and Stalmeijer consider the extent to which research conducted on workplace learning to date has addressed contextual characteristics to enable the evaluation of its transferability across professional contexts, cultures and borders¹²; van Schalkwyk and Frambach reflect on how social inequalities and power relations in different contexts might play out in postgraduate student–supervisor relationships¹³; and Karunaratne et al. consider how cultural tendencies such as power distance and individualism versus collectivism shape the learning and application of clinical reasoning skills in different cultures.¹⁴

Finally, two papers looked explicitly at how novel ways of questioning everyday ‘taken for granted’ things such as time¹⁵ and connection¹⁶ might help inform and enhance medical education practices globally. Consideration of alternative, or more specifically, non-Western, ways of seeing the world to aid learning about, and from, each other is also mentioned by other authors, notably Razack et al.,⁹ who introduce the concept of Ubuntu from Southern Africa and Cleland and colleagues who draw on the Chinese tradition of he er butong.⁷

While we have tried to neatly locate each paper within Ellaway and Bates' conceptual model, the individual papers all work within different contextual patterns of context because these are fundamentally interdependent. For example, university institutional policies are influenced by the country's values, funding agreements, broader politics and so forth, while also being in dialogue with the faculties, practices, people and activities that reflect their implementation. The complexity of our field is glaringly obvious when one turns to examining the influence of context through these articles, but we hope that explicitly considering the embeddedness of our assumptions and practices raises their degree of examination and yields further insight into where change can be leveraged for equity.

Collectively, in fact, we believe these papers to fundamentally be about focusing light on inequalities in our field. They question, criticise and challenge the systemic biases against ‘non-core world regions and non-elite agents of the system of knowledge production’.¹⁷ In doing so, the papers and accompanying commentaries highlight that the myriad cultural and epistemic differences between different geopolitical locations are just that; not better, not worse, just different. The focal topics are diverse, but each paper steps back and questions Westernised systems of knowledge production while advocating for heterogeneity of ideas, approaches and voices in our field. The gauntlet is thrown down with respect to understanding that theories, methodologies and traditions from countries currently under-represented in the international journals in our field are as valuable as those determined by the countries that have dominated. Indeed, each author group offers alternative ways of thinking and acting that move beyond current positions and can expand how we think about inclusivity.

Of course, the goal is mutual respect, not to get everyone to use or adopt every way of doing or thinking; precisely because context is important, there are limits to transferability. Yet, as always, and as seen in some of the included papers, the use of theory can help increase the likelihood that others can learn from, use and build on research. We are, thus, advocates of ‘glocalization’, discussed by Han and Kumwenda,⁵ the notion of tailoring global phenomena and adjusting based on culture, systems and preferences to prioritise fit for purpose in different contexts. More studies examining the cross-cultural applicability of ideas in health professions education are needed, and we would be delighted to see comparative studies that examine the application of different ideas coming from new directions.

In sum, we hope you find that this State of the Science issue challenges existing hegemonies. Its aim is to inspire international academic discourses between colleagues from dominant and under-represented countries in a way that helps bring new, authentic voices to the centre and generates new ideas for education scholarship, including more focus on context. We acknowledge, of course, that one special issue is not going to break down barriers that have been established over hundreds of years by practices such as colonialisation, but we hope this special issue represents a small but significant step forward in the fight against systemic inequalities, unfairness and biases within our field.

All three authors were involved in the conceptualisation of this paper. JC prepared the original draft. KE and RA reviewed and edited the document.