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Year : 2020  |  Volume : 33  |  Issue : 1  |  Page : 20-23

“Doctor, teacher, translator:” International medical students' experiences of clinical teaching on an English language undergraduate medical course in China

1 Medical School, University College London, 74 Huntley Street, London, United Kingdom
2 School of Medicine, Ningbo University, Ningbo, Zhejiang 315211, PR China

Date of Submission27-Aug-2019
Date of Decision29-Apr-2020
Date of Acceptance04-May-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Mohammed Ahmed Rashid
GF/664, University College London Medical School, Royal Free Hospital, London, NW3 2PF
United Kingdom
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/efh.EfH_212_19

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Background: Like many Chinese universities, Ningbo University (NBU) has two undergraduate medical courses – one taught in Mandarin for domestic students, and one taught in English for international students. This study examines the experiences of medical students who recently completed the English language program that has a particular focus on clinical placements. Methods: In-depth, face-to-face, semi-structured interviews were conducted with 10 final year medical students at NBU in April 2019. Transcripts were analyzed using inductive thematic analysis. Results: All medical student participants were non native English speakers and had a limited grasp of Chinese. Their clinical teachers were all fluent in Chinese and had variable command of English. The large majority of patients in the teaching hospitals where placements took place spoke only in Chinese. Despite the obvious challenges arising from this, students still had predominantly positive experiences of clinical placements. Although students recognized that their clinical teachers' English proficiency was variable, they felt that other attributes, such as enthusiasm, interactivity, and a desire to teach were more important factors to their learning experiences. Discussion: Despite challenging linguistic circumstances, non native English-speaking students were able to navigate the challenges of studying clinical medicine from teachers with limited English language skills and with patients who spoke virtually no English. Further studies should explore the perceptions of teachers of the program, and graduate outcomes when these students enter the workplace. Educators involved in supporting international medical students should note that non technical curricular areas such as professionalism may require greater attention where language barriers exist.

Keywords: Clinical placements, globalization, international students

How to cite this article:
Rashid MA, Xu L, Nicholson JG, Gill D. “Doctor, teacher, translator:” International medical students' experiences of clinical teaching on an English language undergraduate medical course in China. Educ Health 2020;33:20-3

How to cite this URL:
Rashid MA, Xu L, Nicholson JG, Gill D. “Doctor, teacher, translator:” International medical students' experiences of clinical teaching on an English language undergraduate medical course in China. Educ Health [serial online] 2020 [cited 2023 Jan 29];33:20-3. Available from:

  Background Top

Globalization has had a profound impact on the world, including medical education. The mobility of doctors as a workforce and the desire for their qualifications to be transferrable has prompted policy-makers to consider approaches to “universalize” medical education, for example, through the World Federation of Medical Education global standards.[1]

It is not just doctors who are increasingly mobile but also medical students.[2] While this can partly be explained by overall migratory patterns, it is also due to increasing numbers of international fee-paying students. Indeed, enhanced international student recruitment is one of a range of strategies by which universities have transformed from “academy to global business.”[3] Although much of this focus has been on universities in North America, Europe, and Australia, the marketization of higher education has been happening across the world.

China has the second-biggest economy in the world, and while it has been renowned for being one of the world's top exporters of international students, recent years have also seen Chinese universities become increasingly internationalized and diverse organizations.[4] Ningbo University (NBU) is a university jointly sponsored by the Chinese Ministry of Education and the Zhejiang Provincial Government. Founded in 1986, it is a multi-faculty university with approximately 25,000 students. As well as its 5-year undergraduate medical program taught in Chinese, NBU has a second 6-year medical program, which is specifically for international students and taught in English. Potential students need to have completed their pre university education in English and must take Mandarin classes in the first two academic years of the course.

This trend of medical students studying overseas, often in countries where they do not speak the local language, creates distinct challenges for medical educators. It is particularly important in clinical education, where communication with patients is a crucial tenet of learning. This study aims to help educators in these settings to deliver an effective education by an in-depth exploration of the experience of their students. It focusses on the following research question: what are the experiences of international medical students on clinical placements where language barriers exist with their teachers and patients?

  Methods Top

In-depth, face-to-face, semi-structured interviews were conducted with medical students who had just completed the final year of the English language undergraduate medicine program at NBU. This program includes both preclinical placements, which are lecture-based courses based at the university, and clinical clerkships, in groups of 10–20 students, at one of a series of affiliated hospitals.

Students were invited to take part in an e-mail from the course administrator, although the sample was influenced by the fact that interviews took place outside of the teaching term, which meant a minority of students were not available. Concerned with the possible influence of power relations, those involved in delivering the program did not conduct interviews. Two interviewers (AR and JN) completed all interviews for consistency. The content of the interviews spanned all aspects of placements, including logistic, clinical, and educational areas. Interviews continued until the data saturation were reached.

Audio recordings and field notes during interviews were used to generate transcripts for each interview. Data were analyzed using inductive thematic analysis.[5] The authors independently completed analyses before tackling areas of discrepancy by consensus meetings and agreeing on an overarching thematic index. Quotes for each theme were collated to illustrate them effectively. Adapting Bandura's social cognitive theory[6] for application in medical education, Kaufman and Mann suggest that effective learning factors fit into three categories: those relating to the student, the learning activity, and the learning environment.[7] Themes emerging from this study were categorized according to these groups.

Written informed consent was obtained from all study participants. This study was approved by the Research Ethics Committee at University College London (15443/002).

  Results Top

Interviews were conducted with final year medical students at NBU, in the period between their final examinations and results day. The students were from India, Bangladesh, and Iran, and their native languages included Hindi, Gujarati, Bengali, and Persian. Although none spoke English as their first language, they had all completed their primary and secondary education in English and spoke it fluently. A total of 12 themes were identified. In [Table 1], these are presented according to the categories outlined by Kaufman and Mann[7] with illustrative quotes for each.
Table 1: Categorized themes and illustrative quotes

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The first set of themes related to students themselves. It was clear that having spent at least 5 years in China, participants felt that they had adapted to the cultures and practices. Although some described the challenge of this adaptation, there was an overwhelmingly positive feeling about life and education in the country overall. Participants described their ability to empathize with the difficult job that their clinical teachers undertake, having to juggle the roles of doctor, teacher, and often patient translator. Despite language barriers meaning their direct interaction with patients were limited, students did not perceive this as a major impediment to their learning, as they valued the translated encounters and were able to achieve learning goals through independent study.

Further, themes related to learning activities. Participants valued interactive teaching methodologies, including case-based teaching and clinical reasoning. Some teachers introduced sessions that students considered experimental, such as role play. These were thought to be extremely effective but not used enough. The opportunity to talk to patients was clearly limited by the language barrier that participants faced. The Chinese language lessons they received did not suitably prepare them for challenging clinical conversations. On occasion, they were supported by dedicated translators. At other times, their clinical teachers translated. Teaching pace was considered important, and teachers who struggled with English were often felt to be “too slow,” and thus limit learner engagement.

Authentic learning experiences were especially valued by participants. Some clinical teachers were highly enthusiastic and would invite students to join them on night and weekend shifts. This was considered highly valuable. Although some participants observed their teachers be “kind” and “good” to patients, the overriding focus of teaching was perceived as focused on clinical topics, with a less dedicated emphasis on professional behaviors and attitudes, which are important aspects of clinical learning.

An important theme linked to the learning environment was that of feedback. Participants had regular opportunities to provide feedback on teachers and placements, and provided examples of improvements that occurred in response to complaints. Participants also valued the chance to receive feedback from their teachers, although some expressed a desire for more. Group size on placement was raised by a number of participants. Although some felt that it would have been better to have smaller groups, others were more content, having spoken to medical student friends in their home country, where the groups were considerably bigger.

The English language ability of clinical teachers was raised by all participants. A spectrum of proficiency was described, from total fluency to barely satisfactory. An overriding sentiment from participants was that teacher enthusiasm was more important than their linguistic ability. Participants described excellent relationships with some teachers, and some even shared their private social networking accounts to invite follow-up questions.

  Discussion Top

This study investigated the experiences of non native English speakers as international students in an English language undergraduate medical course in China. Overall, the experiences of clinical placements for these students are remarkably consistent with medical student experiences throughout the world,[8],[9] where the language of patients and students are shared. Although there were clear language barriers hindering communication with clinicians and patients, the enthusiasm and commitment of the majority of their clinical teachers mostly compensated for this. The use of recognized approaches in clinical education, including interactive, case-based methods, clinical reasoning, and maximizing authentic workplace experiences, all helped to ameliorate the inherent challenges that students faced.

The existing literature on studying medicine as an international student highlights that students are likely to face “lower social and environmental quality of life” compared with domestic peers.[10] Although students in this study did not describe problems with acculturation and indeed felt that they had settled when into their student lives in China, this may be because they are close to graduation, and earlier stage students may differ in their perspectives.

An ethnographic study focussed exclusively on South Indian students from low socioeconomic groups studying medicine in China found, as in this study, a tension around learning the Chinese language.[11] Although it was clearly important to interact with patients, it is a difficult language to learn, and as students almost exclusively wanted to return and practice at home after graduation, it was not seen as a useful part of their career goals.

The strengths of this study lie in the fact that it “gives voice” to a rarely considered group in medical education. Members of the research team were from neither China nor any country of origin of participants, offering a sense of “neutrality” in their perspective. As this was an exploratory study, a limitation of this study is that its generalizability to other settings is complicated by the complexity of sociocultural, educational, and linguistic factors at play.

Although the students were toward the end of their course, thus allowing them to reflect back on the totality of their experience, they may have incompletely recalled their true perceptions. In particular, responses may have been affected by social desirability bias, which is greater in many Eastern cultures.[12] The perspectives of medical students who have not yet transitioned to professional life may also be limited by a lack of awareness about their own competence.[13] The relative lack of focus on professionalism highlighted by students is particularly noteworthy and suggests that there may be learning gaps not fully appreciated by students that warrant further exploration. Given the important and nuanced effects of medical professionalism on the quality of care provided by doctors, this is likely to be a crucial but challenging area for further examination.

The findings from this study emphasize the importance of enthusiastic and accessible teachers in clinical education. Further research on international medical students should triangulate these findings of student experiences with those of their clinical teachers and patients, as well as those in postgraduate medical education who are involved in the training of doctors who have graduated from similar courses. As graduates are likely to practice medicine in health care systems and settings different to China as doctors, further research should also focus on their experiences and outcomes after graduation, with a particular focus on competence and unmet learning needs. Medical educators involved in supporting international medical students should recognize the need to create supportive learning environments that nurture professionalism as well as clinical skills.

Financial support and sponsorship

This study was supported by a Global Engagement Fund award by University College London.

Conflicts of interest

Author LX is involved in the senior leadership of Ningbo University.

  References Top

Karle H. Global standards and accreditation in medical education: A view from the WFME. Acad Med 2006;81:S43-8.  Back to cited text no. 1
Stevens FC, Simmonds Goulbourne JD. Globalization and the modernization of medical education. Med Teach 2012;34:e684-9.  Back to cited text no. 2
Hawthorne L, Minas IH, Singh B. A case study in the globalization of medical education: Assisting overseas-born students at the University of Melbourne. Med Teach 2004;26:150-9.  Back to cited text no. 3
Yuan R, Li S, Yu B. Neither Local nor Global: Chinese University Students' Identity Paradoxes in the Internationalization of Higher Education. Higher Education; 2018. p. 1-6.  Back to cited text no. 4
Robson C, McCartan C. Real World Research. Chichester: John Wiley & Sons; 2016.  Back to cited text no. 5
Bandura A. Social cognitive theory: An agentic perspective. Annu Rev Psychol 2001;52:1-26.  Back to cited text no. 6
Kaufman DM, Mann KV. Teaching and learning in medical education: How theory can inform practice. In: Understanding Medical Education: Evidence, Theory and Practice. West Sussex, UK: Wiley–Blackwell; 2014. p. 7-30.  Back to cited text no. 7
Dornan T, Muijtjens A, Graham J, Scherpbier A, Boshuizen H. Manchester clinical placement index (MCPI). Conditions for medical students' learning in hospital and community placements. Adv Health Sci Educ Theory Pract 2012;17:703-16.  Back to cited text no. 8
Dornan T, Boshuizen H, King N, Scherpbier A. Experience-based learning: A model linking the processes and outcomes of medical students' workplace learning. Med Educ 2007;41:84-91.  Back to cited text no. 9
Henning MA, Krägeloh C, Moir F, Doherty I, Hawken SJ. Quality of life: International and domestic students studying medicine in New Zealand. Perspect Med Educ 2012;1:129-42.  Back to cited text no. 10
Yang P. Compromise and complicity in international student mobility: The ethnographic case of Indian medical students at a Chinese university. Discourse Stud Cultural Politics Educ 2018;39:694-708.  Back to cited text no. 11
Middleton KL, Jones JL. Socially desirable response sets: The impact of country culture. Psychol Marketing 2000;17:149-63.  Back to cited text no. 12
Edwards M, Kelly T, Gainsborough N, Halligan A. Evolving doctors from medical students. J R Soc Med 2013;106:347-50.  Back to cited text no. 13


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