Successful International Medical Education Research Collaboration

The Challenge

Globalization of medical education has become the norm. Despite unprecedented advancements in international education in recent decades, published international educational studies are limited, with few examples of multinational collaborative work.^1,2 The literature focuses on single institution studies or cross-sectional designs, and medical education research tends to be dominated by a relatively small number of medical schools and countries, primarily reflecting a Western perspective.¹ The global movement toward competency-based medical education has created demand and opportunities for collaborative networks for educational research.³ Yet developing and maintaining a successful international network poses significant challenges, including managing multiple, geographically dispersed stakeholders who are culturally diverse, may not share a language, have unequal power relationships, and possess varying expertise in research methodology and academic writing.

What Is Known

International collaborative research studies are increasing with the globalization of medical education, movement to competency-based frameworks, and expansion of international accreditation. Collaborative studies are published in high-impact journals and are cited more than single nation studies.⁴ Researchers participating in international collaborations extend their networks and intellectual companionship, improve efficiency and productivity, may gain access to additional funding, and help non-native English-speaking researchers publish in high-impact journals. Based on a literature review of teamwork, research globalization, and research collaborations, as well as lessons learned from personal experience as a multinational research collaborative, we offer the following recommendations to successfully create, support, and maintain international collaboration in medical education research.

How You Can Start TODAY

1. Develop an idea and formulate a research focus: Use the FINER criteria (feasible, interesting, novel, ethical, and relevant) to develop a good research question and Glassick's criteria for scholarship to guide project development. Aim to make the study and its outcomes timely, relevant, and aligned with the educational needs of interest to the research team and to the broader international academic medicine community.

2. Create a diverse team of enthusiastic individuals, cognizant of experiences, knowledge, and skills: Select team members based on multiple factors, including location, culture, resources, expertise, skills, and interests. Collaborators should have a contextual, cultural, and historical understanding of their country's education system. Be pragmatic: consider time availability and language and begin by collaborating with countries that are geographically close or share historical, political, or cultural relations.⁵ Sharing educational experiences can then become a nidus for international collaboration with diverse perspectives, which enhance creativity, innovation, and group performance. Include an experienced “senior mentor” to help navigate this process.

3. Develop roles, responsibilities, and timelines: Regularly discuss and review roles, responsibilities, and expectations, as these can vary among team members and over time. If a collaborator's work or life situation changes, make adjustments. Set reasonable and achievable timelines. Tips: break work into “doable chunks,” distribute labor to allow team members to work independently between meetings, and share tasks (in design, data collection, analysis) to prevent inequalities that can undermine collaboration. Never end a meeting without scheduling the next one. Avoid postponing or canceling meetings, even if some members cannot participate. Keep meeting minutes (rotating responsibility among the team) and circulate to document decisions and inform members. Allow a brief period of time at the beginning of every meeting for friendly “catching up” to help foster team bonding and collegiality.

4. Discuss authorship criteria early: Author order should reflect level of contribution. Its importance may vary with one's academic rank and home institution's promotion criteria. Use published expectations for authorship, adapting as needed to apply to collaborators' local settings. Team members must set expectations early to maintain collaboration and integrity of their scholarly output. If writing multiple manuscripts, develop a matrix of authors for each paper to ensure different members take responsibility as first or senior author. Those who do not merit authorship but have contributed should be included in the “acknowledgement” section.

5. Understand and address ethics board requirements: International research collaborations are generally expected to have institutional review board (IRB) or ethics board approval from each participating site, with research ethics requirements varying from country to country, often resulting in significant delays.⁶ Collaborators should recognize that research protocols, which ignore local norms or do not promote national research interests, may not be approved despite regulatory compliance.⁶ Involve a statistical expert (if appropriate for your study) at an early stage and submit an IRB application as soon as possible. You may need to educate your local board if medical education research is novel in a particular setting.

6. Embrace technology: Group videoconferencing provides virtual meeting spaces to strengthen group relationships. Files and documents can be stored and shared on a variety of secure online platforms during and after meetings. Project management software provides online collaborative platforms to plan projects and assignments and to track progress. Social networking sites and groups facilitate real-time communication. Ensure all team members have access to and are comfortable with selected technologies, recognizing the need to be flexible, inventive, and prepared for occasional technology disruptions or failures.

7. Monitor success of your interdisciplinary research team: Attend to group processes and dynamics as they are closely related to success. Discuss and periodically check the 7 characteristics needed for effective and successful collaborations: cohesion, communication, goals, leadership, mutual respect, reflection, and team purpose.⁷ The project leader should ensure all participants' opinions are heard. Be cognizant that not everyone will be comfortable voicing dissent in a group setting, especially collaborators not fluent in the dominant language. Recognize that educational terminology differs from country to country, and miscommunication can occur even among English-speaking collaborators.

What You Can Do LONG TERM

1. Schedule team meetings while attending international medical education conferences: The Association for Medical Education in Europe (AMEE), the ACGME Annual Educational Conference, the Asia Pacific Medical Education Conference (APMEC), and the Ottawa Conference offer opportunities to build and strengthen collaboration through face-to-face meetings. You can solicit expert feedback on the team's work and find inspiration for new projects, present and disseminate your work to build the group's reputation on local and international levels, and network to build future collaborations.

2. Explore but don't count on funding: Although funding has been shown to improve educational research quality, funding opportunities for medical education research are limited.⁸ Multinational collaborators should explore funding options available from all involved countries, including government grants, public granting agencies, private philanthropy and foundations, professional associations, as well as individual universities and hospitals. Seek ways to collaborate without funding and pool existing resources available to team members at their home institutions, such as research assistants and statistical and reference manager software.

3. Ensure an inclusive team with equal participation and advancement of all members: Collaboration should be a mutually beneficial professional relationship, based on respect, transparency, and reciprocity. Be aware that international collaboration can lead to power imbalances among team members, particularly for researchers in resource-poor or academically peripheral countries.^5,9 Attend to researchers whose first language is not the dominant language of the team. Awareness of interpersonal communication skills (from body language to tone, such as when voicing dissent), appreciation of traditional hierarchies, willingness to admit lack of knowledge or understanding, and appreciation for constructive feedback are competencies necessary for successful international collaboration. Deliberately include and actively engage women and minorities, as they are less likely to participate in research collaborations that may lead to publication.¹⁰ Since collaboration is a significant driver of research output and scientific impact, actively engaging female and underrepresented minority researchers will bring together a group of diverse thinkers to produce high-quality, innovative research. Use the collaboration as an opportunity for all team members to build capacity, advance research skills, and contribute to a research agenda that is reflective of national interests. Consider these strategies: rotate who “leads” calls or writes minutes, create smaller subcommittees (for larger collaborations), distribute authorship responsibilities, and rotate leadership of specific aspects of a project.

4. Pay it forward and you will be paid back: Once a team is established and successfully performing, consider adding junior researchers who will benefit from the expertise of current members, as early career academic faculty often face barriers to collaboration. This is especially true for clinician educator researchers in international settings where formal clinician educator academic tracks and recognition of scholarly activity may be lacking. Bringing on new, enthusiastic team members can refresh the collaboration, add expertise previously lacking, and be fulfilling for senior investigators serving as role models and mentors. Collaboration can add deeper meaning to one's personal life and professional career.