Original Article
An analysis of blogs from medical students on “English Parallel” courses in Central and Eastern Europe
Medico-Legal Journal 81(4) 171–176 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1535370213509327 mlj.sagepub.com
John F Mayberry
Abstract During the last 20 years, there has been a significant growth in the training of overseas students especially within the European Union. Informal discussions with past and present students revealed a marked reluctance to take part in interviews about the nature of “English Parallel” courses. Alternative sources of information include blogs and commentaries written on the internet by present and former students at these schools. Such blogs are relatively limited in number and of variable length. They have been written for a variety of reasons and range in content from commentaries on training to wider discussion of life in Central and Eastern Europe. Six blogs were identified from an internet search, and a qualitative approach was adopted for the analysis of text content. Their experience is assessed, and potential approaches to greater integration of training across Europe are considered.
Keywords Medical students, blogs, Europe Parallel
Introduction During the last 20 years, there has been a significant growth in the training of overseas students especially within the European Union (EU). As part of its drive to create a European identity, the EU has long been committed to the principles of mobility between member countries and common recognition and equivalence of qualifications. At the same time, the impact of Perestroika and the collapse of the Warsaw Pact on university training and medical education led to a need for external funding, which was partly met through the emergence of “English Parallel” courses in medicine in Hungary, Czechoslovakia and subsequently in other countries. The availability of objective documentation on clinical training in these Central and Eastern European medical schools through the medium of English is limited. The most obvious source of information would be past and present students. Recorded interviews and subsequent analysis of transcripts would be the most conventional technique for collecting and interpreting such data. However, informal discussions with past and present students revealed a marked reluctance to take part in such interviews. Alternative sources of information include blogs and commentaries written on the internet by present and
former students at these schools. Such blogs are relatively limited in number and of variable length. They have been written for a variety of reasons and range in content from commentaries on training to wider discussion of life in Central and Eastern Europe. However, they have a certain advantage in being produced for this range of reasons and can be analysed in a similar way to other historical texts. The validity of blogs as reliable sources of data has been questioned by Greenslade in an editorial in The Evening Standard. He draws clear attention to the lack of accountability of bloggers and comments that: the internet is the medium of choice for people who wish to get up to no good, especially when it comes to spreading false stories.1
Greenslade advocates the use of “judgement” to decide whether the contents of the blog are true.
Digestive Diseases Centre, Leicester General Hospital, Leicester, UK Corresponding author: John F Mayberry, Digestive Diseases Centre, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK. Email: [email protected]
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According to Krippendorff,2 six questions need to be addressed in every content analysis: 1. 2. 3. 4.
Which data are analysed? How are they defined? What is the population from which they are drawn? What is the context relative to which the data are analysed? 5. What are the boundaries of the analysis? 6. What is the target of the inferences?
Method Population and sampling strategy
Data analysis A qualitative approach was adopted to the analysis of text content. This was considered important as the plan was to investigate themes linked to adaptation to study in a foreign culture, rather than quantifying the occurrence of certain words or phrases linked to those themes. Statements within these domains were then classified as positive or negative. A comparison was made between the codifiers to assess the level of agreement in allocating statements to groups and to classifying them as positive or negative.
Reliability and validity
An internet search using Google was carried out between 19 March 2009 and 10 April 2009 in order to identify blogs or web pages written by medical students who were currently studying medicine in a university in Central or Eastern Europe. The criteria used to make the selection included: 1. Internal evidence that the author was a medical student currently or had graduated within less than one year. 2. The blog or web page contained a significant amount of material related to the medical course including its content and aspects of teaching. Blogs which simply described social events were excluded from the analysis. 3. Blogs or web pages which had entries for more than one date. These data were drawn from a population of web reports, blogs and forums which had open access on the worldwide web. The stated purpose of most blogs was to educate prospective students about the nature of English Parallel courses in medicine in Central and Eastern Europe.
Methods of data collection The search terms used to identify relevant blogs included medical student, Czech, Slovakia, Hungary, Poland, Romania and Bulgaria in various combinations. The blogosphere was scanned with the monitoring services Technorati and Blogstreet, but this failed to identify any additional sites. Each of the selected blogs or web pages was reviewed independently by two medically qualified assessors for statements which related to three domains: 1. Learning environment, including teaching methods 2. Forms of assessment of student progress 3. Adaptation by the student and cultural issues.
Blogs are limited in their value because their authors have an agenda. They often concentrate on defects in systems and as such may overemphasise the negative aspects of a programme of training. They are neither monitored nor subject to peer review. Any analysis, therefore, must be placed within the published literature and findings which are contrary to such published work viewed with care. However, blogs can give a “richness” to our understanding, especially of students’ feelings and perceptions. The agreement between the two coders as to relevant texts and which domain they described was greater than 80%.
Results The following blogs or web pages, which met the above criteria, were identified by using Google: 1. The Pragueress and Miseducation of Dan Kameny3 2. No pain, No gain and some other Philosophical thoughts4 3. To all those planning to go to study medicine in Hungary5 4. Stallion6 5. Shrey and Euromd.7 These six blogs or web pages were of variable length. Some addressed specific issues linked to medical education and were written over relatively short periods, but drew on the student’s whole period of study. However, Pragueress and Miseducation was written over five of the six years that Dan Kameny was a medical student in Prague. Blogs 2 and 5 describe medical education in the Czech Republic, while 4 is from Poland. The majority of relevant texts described the learning environment and teaching methods with forms of assessment the second most common domain. There were limited references to adaptation to culture.
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There were a number of common themes that emerged from the blogs. Positive aspects of the learning environment included: 1. An opportunity to become more involved in areas that were of particular interest to the student, including an opportunity for practical experience. 2. An emphasis on basic science. For example, Both of them had spent considerable time in America training at hospitals which I knew (Mayo Clinic, and Mt. Sinai in NYC) They were extremely knowledgeable, extremely articulate, and very willing to teach me stuff and talk to me. Also, along the way anything you are interested in if you pursue it you will not be turned away. (Pragueress)
Negative aspects of the learning environment included: 1. 2. 3. 4.
Long, uninteresting and repetitive lectures. Class rooms which are too small. Classes with too many students. Teachers whose command of English was limited.
For example, 99% of the time it is just us sitting in a room way too small for our class size while someone reads off the Powerpoint presentation and tells us stuff which is not only boring but totally impractical to medicine. I took some short videos of class to show how packed in we are. It’s like a cattle car, it even smells like one sometimes too. (Pragueress) Half the clinicians cannot speak English well either. (Euromd)
They give you a “topic list” at the beginning of each year — with roughly 200 topics. You will pick 1-2-3-4-5 topics in the exam, depending on the subject. (Euromd)
Negative aspects of forms of assessment included: 1. Cheating is commonplace. 2. Limited advice on how to prepare and register for examinations. 3. Use of frequent testing to force students to study. For example, you never know how to prepare for exams at this school until you fail it and see what they expect and then you hope it doesn’t change too much before you take the exam for the second time. (Pragueress) You always have some sort of test in some subject every week so you’re forced to study. In fact the grading standards are so extremely high that getting a 3 (which is a pass) is equivalent to somewhere around 85%!!! So you can imagine how extra hard the exams are. That being said many of the students do pass (although 10-15-20 students fail out every year). (Other Czech Blogs) You can “pay” tutors by taking extra practice sessions/ private lessons so that “they remember you in the exam.” (Euromd)
Common themes amongst cultural adaptation included: The opportunity to experience a different culture and to be exposed to a different form of clinical practice. The most common negative feeling was of being a “foreigner” who was not integrated into local teaching but was separated by the very English nature of the English Parallel course. For example,
Positive aspects of forms of assessment included: 1. Examiners can be flexible in their approach to assessment. 2. Most examinations are oral and based around a topic list.
Some are here to really help you, some could care less . . . just know why you are all here, and make the best of it. The people are nice . . . almost all polish (younger generation) can speak some form of English. (Stallion)
For example, I went for the exam today, got questions I knew, the examiner was fine, he was fair and wasn’t an asshole. In this case I was glad that my teacher could see that the test was imperfect and he could evaluate me on a more individual level. I thanked him for that. (Pragueress)
Discussion Blog has been defined as follows: A contraction of weblog, a form of on-line writing characterised in format by a single column of text in
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reverse chronological order (i.e. most recent content at the top) with the ability to link to individual articles. There is usually a sidebar displaying links, and the content is frequently updated.8
Within this strict definition, the “blogs” utilised in this research may be better described as blog-like postings or web pages. However, this semantic difference is of little importance to the interpretation of their content. A typical Central or Eastern European learning environment is characterised by didactic lectures in an overcrowded small classroom. The lecturer is likely to have a poor command of English. Such a situation is one with which Hofstede could empathise. The Power Distance Index for Poland is 68, 57 for the Czech Republic and 46 for Hungary compared to 35 for the UK and 28 for Ireland.9 In contrast to these countries, the UK and Ireland score highly on individualism and are less concerned with a structured society. For students moving away from such an environment, didactic teaching in formal crowded classrooms is opposite to their usual experiences and expectations. Teekens10 has encouraged lecturers in the international classroom to reflect on their own background and acknowledge the need to adapt to this new environment. There are signs that some institutions are taking note. In the English Parallel course at Yerevan in Armenia, steps are being taken to: . Identify learning goals and objectives for modules . Improve presentation skills.11 While in the Ukraine, it is hoped to overcome these differences by developing links to institutions where modern techniques of teaching are employed.12 Many of the critical remarks made in these blogs are common to students studying in a foreign environment. They represent a form of culture shock, which can lead on to depression and loneliness.13,14 A good-quality learning environment would help overcome these problems. It will only be achieved when the European Association for Quality Assurance in Higher Education takes on this role and is given powers to ensure that all universities deliver on these requirements. Such an organisation could also ensure that students at medical schools in western areas of the EU are given adequate instruction in both basic sciences and practical procedures. The need for practical training has been recognised by the General Medical Council (GMC).15 However, the basic science content of medical courses has, on the whole, been reduced with greater emphasis being placed on patient contact. Examinations on English Parallel courses are frequent and often lead to cheating. This is partly due to the pressure and lack of advice on preparation.
Certainly, cheating is a recognised problem in Central and Eastern Europe. Such behaviour is a fitness to practise issue and the GMC would refuse registration to those guilty of such misconduct. The GMC defines cheating and plagiarism as: . “Cheating in examinations, logbooks or portfolios” . “Passing off other’s work as one’s own”16 Such activities have been reported in Poland17 and Croatia.18 The GMC also enjoins students to: take effective action if they have concerns about the honesty of others.19
However, the jurisdiction of the GMC does not extend outside the UK. It is clear that the GMC needs to take an active interest in UK citizens training abroad. This should include provision of mentoring and educational support. Although the blogs report opportunities to experience different cultures in a positive way, they emphasise the separation of the English Parallel course from indigenous training. This may lend support to the description of English Parallel students as “tourists” rather than “sojourners”. The need to develop links between students on English Parallel course and indigenous training programmes is urgent. It could be encouraged by pairing international with home students for combined subjects once a week. The development of support networks helps integrate students and gives them a sense of belonging. Clearly, the experiences described by students on their blogs fits in with published work on non-medical students in a foreign environment. The need to develop both official and unofficial support networks is urgent and would improve the learning environment as well as help achieve the wider objectives of the EU in relation to tertiary education. Medical students have been drawn to centres of excellence for training for many centuries. Although “pull” factors have included charismatic teachers, “push” factors such as an absence of good-quality teaching at home have also played a significant part, British students travelled to Bologna and Padua in the 15th and 16th centuries and to Leiden in the 18th century. In the 19th century, gender and financial issues were important “push” factors that caused British students to go to Brussels, Zurich and Paris to qualify as medical practitioners. The concept of qualifying abroad only became unusual for British students during the 20th century. At that time, the growth of medical schools and the formalisation of examinations and registration procedures meant that most British medical students stayed at home and, indeed, many overseas candidates, especially from the Commonwealth, came
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to train in the UK. The political changes in Eastern Europe during the 1980s and 1990s led to a need for universities to seek new forms of financing, and the English Parallel course was born. It first emerged at Semmelweis University, Budapest and later at Charles University, Prague. It gave medical schools a guaranteed income in hard currency. It offered Englishspeaking students an opportunity to train in medicine, which they had been denied because of lack of finance or problems gaining admission to medical school in their own countries. Its limitations were that it did not give rights of practice in the UK, Ireland or the USA. However, the accession of a number of Central and Eastern European countries into the EU opened up registration in the UK and Ireland. Students who graduated from these countries have automatic rights of registration and from 2004 their numbers dramatically increased.20,21 Although British students have sought training in Europe over past centuries, Central and Eastern Europe were not traditional destinations. Information on the readiness with which medical students adapted to these new learning environments is severely limited. However, there is a literature on other students who have studied abroad and critical analysis demonstrates the following common features: . . . .
Initial optimism followed by disillusion Culture shock Homesickness Isolation.22,23
There are actions which can be taken by the host institution and individual students which can lessen these effects. They include: . Training staff to be culturally aware . Encouraging the emergence of support networks, which include local nationals . Provision of a good-quality learning environment . Effective instruction in the language of the host nation. The dramatic growth in the number of English Parallel courses within and without the EU together with the rising number of graduates is evidence of the need for such courses. The fact that many now confer rights of automatic registration with the GMC and the Medical Council of Ireland is demonstrated by the explosion in numbers after 2004. Most of these registrants are new graduates within a year or less of their qualifying examinations. It seems likely that English Parallel courses will have an output of British graduates equivalent to one UK medical school each year. These numbers will have consequences for the manpower
planning programmes of the Department of Health and will impact directly on job availability for graduates from British universities. Ultimately, European law will ensure that such jobs are not ring-fenced and must be open to all European graduates. Sadly, a commonly held view is that of Bullimore: They will be replaced by EU graduates whether or not the EU graduate is as skilled or appropriately experienced to provide our health care needs.24
The idea that European training is less good than British training has no substance. Indeed, work with Erasmus students has shown that the standards achieved by British students are lower than those from other parts of Europe.25 Rather, students from the UK should be prepared to work throughout the Union as this will be the future market place for medicine. It is likely that British graduates from EU universities will be amongst those that drive forward the concept of professional mobility within the Union. However, these students receive no support from organisations such as the GMC, medical defence organisations, the student section of the British Medical Association or even the Department of Health. Interestingly, a recent article on workforce planning and international medical graduates recognised an ongoing need to bring overseas graduates within training structures, but completely failed to acknowledge the substantial number of British citizens training elsewhere in Europe.26 The most common negative feeling reported in medical student blogs was the failure to integrate with the local student and host communities. This feeling of isolation is a contributory factor to the “culture shock” experienced by many medical students when they first join an English Parallel course. Support networks are important in overcoming these difficulties and there is a place for such networks to be encouraged and supported from the UK. They would also have a role in helping students deal with the learning environment and forms of assessment, which are very different to that experienced by most students in Western Europe. The “distance” between teacher and student is significantly greater in Central and Eastern Europe and leads to a more didactic style and more formal relationship. It is the nature of this relationship that might contribute to the more ready acceptance of cheating by students and teachers. Clearly, there is also a place for the development of support and training networks between medical and clinical teachers throughout Europe and there are signs that this is beginning to happen with some institutions, such as Semmelweis.27 The emergence of international medical schools with mobility of graduates is not a new phenomenon.
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Its origins extend back to the emergence of medical schools and the readiness of students to seek education where it was provided. This remains true and reflects a market demand for training, which is matched by a need for health services to be staffed. English Parallel courses are growing in number as are the number of their graduates. Within the EU, there are at least 20 such courses with a probable annual output of between 200 and 800 British graduates. Since 2004, the number of graduates who have registered with the GMC has increased but has not yet reached these figures. There is no official register of British students training in Europe and no financial support of them. This contrasts with countries such as Norway.28 As a result, the Department of Health is unable to plan for the integration of these doctors into the Health Services of the UK or to have any input into their training. References 1. Greenslade R. Health warning: rumours in cyberspace may seriously damage your credibility. The Evening Standard, Business, 15 April 2009, Wednesday, p.28. 2. Krippendorff K. Content analysis: an introduction to its methodology, 2nd ed. Thousand Oaks, CA: Sage, 2004. 3. http://pragueressofkameny.blogspot.com (accessed 19 March 2009). 4. http://ishthatmedicalstudent.blogspot.com/2009/03/nopain-no-gain-and-some-other.html (accessed 19 March 2009). 5. http://www.valuemd.com/hungarian-medical-schools/ 127731-medical-schools-education-hungarydebrecensemmelwies-szeged.html (accessed 10 April 2009). 6. http://www.valuemd.com/medical-university-lodz/145 407-any-word-students-lodz-so-far-07-a.html (accessed 10 April 2009). 7. http://www.valuemd.com/czech-republic-slovakiamedical-schools/159817-charles-uni-1stfaculty.html (accessed 31 March 2009). 8. http://www.samizdata.net/blog/glossary.html (accessed 29 May 2009). 9. http://www.clearlycultural.com/geert-hofstede-culturaldimensions/individualism/ (2009, accessed 29 May 2009). 10. Teekens H. A description of nine clusters of qualifications for lecturers. In: Teekens H (ed.) The international classroom. Teaching and learning at home and abroad. The Hague: Nuffic, undated, 2000, pp.43–45. 11. Markosyan AM and Kyalyan GP. Recent medical education reforms at the Yerevan State Medical University. New Armenian Med J 2008; 2: 67–73. 12. Kovalchik LY, Oleshchuk OM, Lisnychuk NY, et al. Medical education in Ukraine: Reality and motion in
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European higher educational space. GMS Zeitschrift fu¨r Medizinische Ausbildung 2007; 24: Doc 95. Oberg J. Cultural shock: adjustment to new cultural environments. Pract Anthropol 1960; 7: 177–182. Oei TPS. Depression and loneliness in overseas students. Int J Soc Psychiatry 1990; 36: 121–130. Chan D and Drover G. Teaching and learning for overseas students: the Hong Kong connection. In: MacNamara D and Harris E (eds) Overseas students in higher education. Issues in teaching and learning. London: Routledge, 1997, p.60. http://www.gmcuk.org/education/undergraduate/ undergraduate_policy/tomorrows_doctors.asp# Clinical%20and%20practical%20skills (2009, accessed 26 June 2009). Open Society Institute (2002) Monitoring the EU Accession Process: Corruption and Anti-Corruption Policy, p.444. Hrabak M, Vujaklija A, Vodopivec I, et al. Academic misconduct among medical students in a post-communist country. Med Educ 2004; 38: 276–285. http://www.gmcuk.org/education/undergraduate/ undergraduate_policy/professional_behaviour.asp#B7 (2009, accessed 26 June 2009). Mayberry JF. The development of medical education in Eastern Europe during the 20th century and the emergence of ‘English parallel’ courses. Scottish Med J 2013; 58: 46–52. Mayberry JF. The registration of medical graduates from Eastern European Union countries with the General Medical Council (GMC) and the Medical Council, Ireland. Ulster Med J 2013; 82: 71–74. Murphy-Lejeune E. An experience of interculturality: student travellers abroad. In: Aldrede G, Byram M and Fleming M (eds) Intercultural experience and education. Clevedon: Multilingual Matters Ltd, 2003, p.105. Cobb A. Social support as a moderator of life stress. Psychosomat Med 1976; 38: 300–314. Bullimore D (2006) Non-European doctors and change in UK policy: Ten thousand international medical graduates may be affected http://www.bmj.com/cgi/eletters/ 332/7546/913-c (2006, accessed 18 October 2013). Teichler U and Maiworm F. Transition to work: the experiences of former ERASMUS students. London: Jessica Kingsley, 1994. Zaman S. Workforce planning and international medical graduates. BMJ Careers 2009; 339: 5. Vlad I. Students at Canberra to study in Hungary. Stud British Med J 2009; 12: 6. Aasland OG and Wiers-Jenssen J. Norwegian medical students abroad – career plans, personality, smoking and alcohol use. Tidsskr Nor Laegeforen 2001; 121: 1677–1682.
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An analysis of blogs from medical students on “English Parallel” courses in Central and Eastern Europe
Medico-Legal Journal 81(4) 171–176 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1535370213509327 mlj.sagepub.com
John F Mayberry
Abstract During the last 20 years, there has been a significant growth in the training of overseas students especially within the European Union. Informal discussions with past and present students revealed a marked reluctance to take part in interviews about the nature of “English Parallel” courses. Alternative sources of information include blogs and commentaries written on the internet by present and former students at these schools. Such blogs are relatively limited in number and of variable length. They have been written for a variety of reasons and range in content from commentaries on training to wider discussion of life in Central and Eastern Europe. Six blogs were identified from an internet search, and a qualitative approach was adopted for the analysis of text content. Their experience is assessed, and potential approaches to greater integration of training across Europe are considered.
Keywords Medical students, blogs, Europe Parallel
Introduction During the last 20 years, there has been a significant growth in the training of overseas students especially within the European Union (EU). As part of its drive to create a European identity, the EU has long been committed to the principles of mobility between member countries and common recognition and equivalence of qualifications. At the same time, the impact of Perestroika and the collapse of the Warsaw Pact on university training and medical education led to a need for external funding, which was partly met through the emergence of “English Parallel” courses in medicine in Hungary, Czechoslovakia and subsequently in other countries. The availability of objective documentation on clinical training in these Central and Eastern European medical schools through the medium of English is limited. The most obvious source of information would be past and present students. Recorded interviews and subsequent analysis of transcripts would be the most conventional technique for collecting and interpreting such data. However, informal discussions with past and present students revealed a marked reluctance to take part in such interviews. Alternative sources of information include blogs and commentaries written on the internet by present and
former students at these schools. Such blogs are relatively limited in number and of variable length. They have been written for a variety of reasons and range in content from commentaries on training to wider discussion of life in Central and Eastern Europe. However, they have a certain advantage in being produced for this range of reasons and can be analysed in a similar way to other historical texts. The validity of blogs as reliable sources of data has been questioned by Greenslade in an editorial in The Evening Standard. He draws clear attention to the lack of accountability of bloggers and comments that: the internet is the medium of choice for people who wish to get up to no good, especially when it comes to spreading false stories.1
Greenslade advocates the use of “judgement” to decide whether the contents of the blog are true.
Digestive Diseases Centre, Leicester General Hospital, Leicester, UK Corresponding author: John F Mayberry, Digestive Diseases Centre, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK. Email: [email protected]
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According to Krippendorff,2 six questions need to be addressed in every content analysis: 1. 2. 3. 4.
Which data are analysed? How are they defined? What is the population from which they are drawn? What is the context relative to which the data are analysed? 5. What are the boundaries of the analysis? 6. What is the target of the inferences?
Method Population and sampling strategy
Data analysis A qualitative approach was adopted to the analysis of text content. This was considered important as the plan was to investigate themes linked to adaptation to study in a foreign culture, rather than quantifying the occurrence of certain words or phrases linked to those themes. Statements within these domains were then classified as positive or negative. A comparison was made between the codifiers to assess the level of agreement in allocating statements to groups and to classifying them as positive or negative.
Reliability and validity
An internet search using Google was carried out between 19 March 2009 and 10 April 2009 in order to identify blogs or web pages written by medical students who were currently studying medicine in a university in Central or Eastern Europe. The criteria used to make the selection included: 1. Internal evidence that the author was a medical student currently or had graduated within less than one year. 2. The blog or web page contained a significant amount of material related to the medical course including its content and aspects of teaching. Blogs which simply described social events were excluded from the analysis. 3. Blogs or web pages which had entries for more than one date. These data were drawn from a population of web reports, blogs and forums which had open access on the worldwide web. The stated purpose of most blogs was to educate prospective students about the nature of English Parallel courses in medicine in Central and Eastern Europe.
Methods of data collection The search terms used to identify relevant blogs included medical student, Czech, Slovakia, Hungary, Poland, Romania and Bulgaria in various combinations. The blogosphere was scanned with the monitoring services Technorati and Blogstreet, but this failed to identify any additional sites. Each of the selected blogs or web pages was reviewed independently by two medically qualified assessors for statements which related to three domains: 1. Learning environment, including teaching methods 2. Forms of assessment of student progress 3. Adaptation by the student and cultural issues.
Blogs are limited in their value because their authors have an agenda. They often concentrate on defects in systems and as such may overemphasise the negative aspects of a programme of training. They are neither monitored nor subject to peer review. Any analysis, therefore, must be placed within the published literature and findings which are contrary to such published work viewed with care. However, blogs can give a “richness” to our understanding, especially of students’ feelings and perceptions. The agreement between the two coders as to relevant texts and which domain they described was greater than 80%.
Results The following blogs or web pages, which met the above criteria, were identified by using Google: 1. The Pragueress and Miseducation of Dan Kameny3 2. No pain, No gain and some other Philosophical thoughts4 3. To all those planning to go to study medicine in Hungary5 4. Stallion6 5. Shrey and Euromd.7 These six blogs or web pages were of variable length. Some addressed specific issues linked to medical education and were written over relatively short periods, but drew on the student’s whole period of study. However, Pragueress and Miseducation was written over five of the six years that Dan Kameny was a medical student in Prague. Blogs 2 and 5 describe medical education in the Czech Republic, while 4 is from Poland. The majority of relevant texts described the learning environment and teaching methods with forms of assessment the second most common domain. There were limited references to adaptation to culture.
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There were a number of common themes that emerged from the blogs. Positive aspects of the learning environment included: 1. An opportunity to become more involved in areas that were of particular interest to the student, including an opportunity for practical experience. 2. An emphasis on basic science. For example, Both of them had spent considerable time in America training at hospitals which I knew (Mayo Clinic, and Mt. Sinai in NYC) They were extremely knowledgeable, extremely articulate, and very willing to teach me stuff and talk to me. Also, along the way anything you are interested in if you pursue it you will not be turned away. (Pragueress)
Negative aspects of the learning environment included: 1. 2. 3. 4.
Long, uninteresting and repetitive lectures. Class rooms which are too small. Classes with too many students. Teachers whose command of English was limited.
For example, 99% of the time it is just us sitting in a room way too small for our class size while someone reads off the Powerpoint presentation and tells us stuff which is not only boring but totally impractical to medicine. I took some short videos of class to show how packed in we are. It’s like a cattle car, it even smells like one sometimes too. (Pragueress) Half the clinicians cannot speak English well either. (Euromd)
They give you a “topic list” at the beginning of each year — with roughly 200 topics. You will pick 1-2-3-4-5 topics in the exam, depending on the subject. (Euromd)
Negative aspects of forms of assessment included: 1. Cheating is commonplace. 2. Limited advice on how to prepare and register for examinations. 3. Use of frequent testing to force students to study. For example, you never know how to prepare for exams at this school until you fail it and see what they expect and then you hope it doesn’t change too much before you take the exam for the second time. (Pragueress) You always have some sort of test in some subject every week so you’re forced to study. In fact the grading standards are so extremely high that getting a 3 (which is a pass) is equivalent to somewhere around 85%!!! So you can imagine how extra hard the exams are. That being said many of the students do pass (although 10-15-20 students fail out every year). (Other Czech Blogs) You can “pay” tutors by taking extra practice sessions/ private lessons so that “they remember you in the exam.” (Euromd)
Common themes amongst cultural adaptation included: The opportunity to experience a different culture and to be exposed to a different form of clinical practice. The most common negative feeling was of being a “foreigner” who was not integrated into local teaching but was separated by the very English nature of the English Parallel course. For example,
Positive aspects of forms of assessment included: 1. Examiners can be flexible in their approach to assessment. 2. Most examinations are oral and based around a topic list.
Some are here to really help you, some could care less . . . just know why you are all here, and make the best of it. The people are nice . . . almost all polish (younger generation) can speak some form of English. (Stallion)
For example, I went for the exam today, got questions I knew, the examiner was fine, he was fair and wasn’t an asshole. In this case I was glad that my teacher could see that the test was imperfect and he could evaluate me on a more individual level. I thanked him for that. (Pragueress)
Discussion Blog has been defined as follows: A contraction of weblog, a form of on-line writing characterised in format by a single column of text in
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reverse chronological order (i.e. most recent content at the top) with the ability to link to individual articles. There is usually a sidebar displaying links, and the content is frequently updated.8
Within this strict definition, the “blogs” utilised in this research may be better described as blog-like postings or web pages. However, this semantic difference is of little importance to the interpretation of their content. A typical Central or Eastern European learning environment is characterised by didactic lectures in an overcrowded small classroom. The lecturer is likely to have a poor command of English. Such a situation is one with which Hofstede could empathise. The Power Distance Index for Poland is 68, 57 for the Czech Republic and 46 for Hungary compared to 35 for the UK and 28 for Ireland.9 In contrast to these countries, the UK and Ireland score highly on individualism and are less concerned with a structured society. For students moving away from such an environment, didactic teaching in formal crowded classrooms is opposite to their usual experiences and expectations. Teekens10 has encouraged lecturers in the international classroom to reflect on their own background and acknowledge the need to adapt to this new environment. There are signs that some institutions are taking note. In the English Parallel course at Yerevan in Armenia, steps are being taken to: . Identify learning goals and objectives for modules . Improve presentation skills.11 While in the Ukraine, it is hoped to overcome these differences by developing links to institutions where modern techniques of teaching are employed.12 Many of the critical remarks made in these blogs are common to students studying in a foreign environment. They represent a form of culture shock, which can lead on to depression and loneliness.13,14 A good-quality learning environment would help overcome these problems. It will only be achieved when the European Association for Quality Assurance in Higher Education takes on this role and is given powers to ensure that all universities deliver on these requirements. Such an organisation could also ensure that students at medical schools in western areas of the EU are given adequate instruction in both basic sciences and practical procedures. The need for practical training has been recognised by the General Medical Council (GMC).15 However, the basic science content of medical courses has, on the whole, been reduced with greater emphasis being placed on patient contact. Examinations on English Parallel courses are frequent and often lead to cheating. This is partly due to the pressure and lack of advice on preparation.
Certainly, cheating is a recognised problem in Central and Eastern Europe. Such behaviour is a fitness to practise issue and the GMC would refuse registration to those guilty of such misconduct. The GMC defines cheating and plagiarism as: . “Cheating in examinations, logbooks or portfolios” . “Passing off other’s work as one’s own”16 Such activities have been reported in Poland17 and Croatia.18 The GMC also enjoins students to: take effective action if they have concerns about the honesty of others.19
However, the jurisdiction of the GMC does not extend outside the UK. It is clear that the GMC needs to take an active interest in UK citizens training abroad. This should include provision of mentoring and educational support. Although the blogs report opportunities to experience different cultures in a positive way, they emphasise the separation of the English Parallel course from indigenous training. This may lend support to the description of English Parallel students as “tourists” rather than “sojourners”. The need to develop links between students on English Parallel course and indigenous training programmes is urgent. It could be encouraged by pairing international with home students for combined subjects once a week. The development of support networks helps integrate students and gives them a sense of belonging. Clearly, the experiences described by students on their blogs fits in with published work on non-medical students in a foreign environment. The need to develop both official and unofficial support networks is urgent and would improve the learning environment as well as help achieve the wider objectives of the EU in relation to tertiary education. Medical students have been drawn to centres of excellence for training for many centuries. Although “pull” factors have included charismatic teachers, “push” factors such as an absence of good-quality teaching at home have also played a significant part, British students travelled to Bologna and Padua in the 15th and 16th centuries and to Leiden in the 18th century. In the 19th century, gender and financial issues were important “push” factors that caused British students to go to Brussels, Zurich and Paris to qualify as medical practitioners. The concept of qualifying abroad only became unusual for British students during the 20th century. At that time, the growth of medical schools and the formalisation of examinations and registration procedures meant that most British medical students stayed at home and, indeed, many overseas candidates, especially from the Commonwealth, came
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to train in the UK. The political changes in Eastern Europe during the 1980s and 1990s led to a need for universities to seek new forms of financing, and the English Parallel course was born. It first emerged at Semmelweis University, Budapest and later at Charles University, Prague. It gave medical schools a guaranteed income in hard currency. It offered Englishspeaking students an opportunity to train in medicine, which they had been denied because of lack of finance or problems gaining admission to medical school in their own countries. Its limitations were that it did not give rights of practice in the UK, Ireland or the USA. However, the accession of a number of Central and Eastern European countries into the EU opened up registration in the UK and Ireland. Students who graduated from these countries have automatic rights of registration and from 2004 their numbers dramatically increased.20,21 Although British students have sought training in Europe over past centuries, Central and Eastern Europe were not traditional destinations. Information on the readiness with which medical students adapted to these new learning environments is severely limited. However, there is a literature on other students who have studied abroad and critical analysis demonstrates the following common features: . . . .
Initial optimism followed by disillusion Culture shock Homesickness Isolation.22,23
There are actions which can be taken by the host institution and individual students which can lessen these effects. They include: . Training staff to be culturally aware . Encouraging the emergence of support networks, which include local nationals . Provision of a good-quality learning environment . Effective instruction in the language of the host nation. The dramatic growth in the number of English Parallel courses within and without the EU together with the rising number of graduates is evidence of the need for such courses. The fact that many now confer rights of automatic registration with the GMC and the Medical Council of Ireland is demonstrated by the explosion in numbers after 2004. Most of these registrants are new graduates within a year or less of their qualifying examinations. It seems likely that English Parallel courses will have an output of British graduates equivalent to one UK medical school each year. These numbers will have consequences for the manpower
planning programmes of the Department of Health and will impact directly on job availability for graduates from British universities. Ultimately, European law will ensure that such jobs are not ring-fenced and must be open to all European graduates. Sadly, a commonly held view is that of Bullimore: They will be replaced by EU graduates whether or not the EU graduate is as skilled or appropriately experienced to provide our health care needs.24
The idea that European training is less good than British training has no substance. Indeed, work with Erasmus students has shown that the standards achieved by British students are lower than those from other parts of Europe.25 Rather, students from the UK should be prepared to work throughout the Union as this will be the future market place for medicine. It is likely that British graduates from EU universities will be amongst those that drive forward the concept of professional mobility within the Union. However, these students receive no support from organisations such as the GMC, medical defence organisations, the student section of the British Medical Association or even the Department of Health. Interestingly, a recent article on workforce planning and international medical graduates recognised an ongoing need to bring overseas graduates within training structures, but completely failed to acknowledge the substantial number of British citizens training elsewhere in Europe.26 The most common negative feeling reported in medical student blogs was the failure to integrate with the local student and host communities. This feeling of isolation is a contributory factor to the “culture shock” experienced by many medical students when they first join an English Parallel course. Support networks are important in overcoming these difficulties and there is a place for such networks to be encouraged and supported from the UK. They would also have a role in helping students deal with the learning environment and forms of assessment, which are very different to that experienced by most students in Western Europe. The “distance” between teacher and student is significantly greater in Central and Eastern Europe and leads to a more didactic style and more formal relationship. It is the nature of this relationship that might contribute to the more ready acceptance of cheating by students and teachers. Clearly, there is also a place for the development of support and training networks between medical and clinical teachers throughout Europe and there are signs that this is beginning to happen with some institutions, such as Semmelweis.27 The emergence of international medical schools with mobility of graduates is not a new phenomenon.
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Its origins extend back to the emergence of medical schools and the readiness of students to seek education where it was provided. This remains true and reflects a market demand for training, which is matched by a need for health services to be staffed. English Parallel courses are growing in number as are the number of their graduates. Within the EU, there are at least 20 such courses with a probable annual output of between 200 and 800 British graduates. Since 2004, the number of graduates who have registered with the GMC has increased but has not yet reached these figures. There is no official register of British students training in Europe and no financial support of them. This contrasts with countries such as Norway.28 As a result, the Department of Health is unable to plan for the integration of these doctors into the Health Services of the UK or to have any input into their training. References 1. Greenslade R. Health warning: rumours in cyberspace may seriously damage your credibility. The Evening Standard, Business, 15 April 2009, Wednesday, p.28. 2. Krippendorff K. Content analysis: an introduction to its methodology, 2nd ed. Thousand Oaks, CA: Sage, 2004. 3. http://pragueressofkameny.blogspot.com (accessed 19 March 2009). 4. http://ishthatmedicalstudent.blogspot.com/2009/03/nopain-no-gain-and-some-other.html (accessed 19 March 2009). 5. http://www.valuemd.com/hungarian-medical-schools/ 127731-medical-schools-education-hungarydebrecensemmelwies-szeged.html (accessed 10 April 2009). 6. http://www.valuemd.com/medical-university-lodz/145 407-any-word-students-lodz-so-far-07-a.html (accessed 10 April 2009). 7. http://www.valuemd.com/czech-republic-slovakiamedical-schools/159817-charles-uni-1stfaculty.html (accessed 31 March 2009). 8. http://www.samizdata.net/blog/glossary.html (accessed 29 May 2009). 9. http://www.clearlycultural.com/geert-hofstede-culturaldimensions/individualism/ (2009, accessed 29 May 2009). 10. Teekens H. A description of nine clusters of qualifications for lecturers. In: Teekens H (ed.) The international classroom. Teaching and learning at home and abroad. The Hague: Nuffic, undated, 2000, pp.43–45. 11. Markosyan AM and Kyalyan GP. Recent medical education reforms at the Yerevan State Medical University. New Armenian Med J 2008; 2: 67–73. 12. Kovalchik LY, Oleshchuk OM, Lisnychuk NY, et al. Medical education in Ukraine: Reality and motion in
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