Factors related to university teaching that influence academic success of international medical students in China

Ethics and consent

This study was approved by the Ethics Committee of Xuzhou Medical University (XZMU20200028) and the Institutional Review Board of Nanjing Medical University (NJMUIRB774) in September 2020. All of the informants gave written and oral informed consent to participate in the study.

Research sites

The study was conducted in two medical universities (A and B) located in Jiangsu Province in eastern China, which has a well-developed economy and offers high-quality education. We selected these universities due to the availability of suitable academic staff and because they were representative of the MBBS programmes taught in other universities in the province. Both had accepted international MBBS students for over 15 years, so it was reasonable to regard them as relevant sites at which to gather the perspectives of academics engaged in teaching.

Both universities applied similar MBBS curricula, which followed the requirements of the MOE. International and Chinese MBBS students took separate courses and did not attend the same classes. English was the principal teaching medium of the courses for international students. Most of these students were from developing Asian and African countries, and some were far from proficient in English.

Informants

We took a purposive sampling approach in this study. We based our selection of interviewees on the subjects they taught and their gender, years of teaching international medical students, educational background, and career stage. Our aim was to obtain a heterogeneous sample of medical teaching staff from the two universities. Academics were approached individually via phone calls and WeChat invitation with the help of two ‘gatekeepers’. Our target sample size before recruitment was approximately 30, but we increased this to 40 to achieve data saturation (Morse, 1991). Of these, two declined the interview invitation and another two initially agreed but later withdrew by failing to respond to the researcher’s follow-up text messages.

Thus, a total of 36 academic teaching staff (17 men, 19 women) were recruited, of whom 2 taught Chinese, 3 taught nature science, 11 taught clinical subjects, and 20 taught basic medical science. Their experience of teaching international students ranged from 2 to over 13 years, and all were responsible for teaching the same subject to both Chinese and international students (Table 1).

Data collection

A semi-structured interview was conducted with each participant between November 2021 and January 2022. Only the first author and one participant were present in each interview. Academics from University A participated in face-to-to-face interviews in their offices or a small meeting room that was perceived by the participants to be comfortable and quiet, while the interviews with academics from University B were conducted online (due to the COVID-19 pandemic). Both the face-to-face interviews and the online interviews were audio-recorded and notes were taken throughout. The interview questions, which were pilot-tested, addressed the participants’ views on factors affecting student success, and their recommendations for improving teaching quality at the classroom and organisational levels.

The academics were initially briefed about the probable length of the interviews and the purpose and significance of the study. To conform with ethical requirements, all interviewees were assured of their anonymity and agreed to the audio recording and dissemination of the findings. Each interview was conducted in Chinese and lasted for around 30 to 70 minutes.

Data analysis

A thematic approach was taken to the data analysis (Braun & Clarke, 2006), with the audio recordings later transcribed verbatim. These Chinese transcripts were coded manually by the primary researcher, who immersed herself in the data and noted down her initial ideas on emergent themes. Initial codes were generated based on identified key words and phrases. These codes were then summarised into potential themes. The primary researcher translated the codes and themes into English. The research team then discussed, adjusted, and reached a consensus on a final set of categories. The integrity of the process was ensured through member checking, peer auditing and self-reflection. The primary researcher kept a self-reflection journal throughout the process to minimise the effects of her own background and work experience on the interpretation of the data.

Theme 1: Pedagogy and content alignment

1.1 Challenges in teaching pedagogy

Most of the academics perceived their teaching methods and practices to have a major influence on international students’ learning. However, they perceived a mismatch between their teaching approaches and the learning characteristics of these students. They mainly relied on traditional teacher-centred lecturing and tended to read verbatim from slides, without giving adequate further explanations or offering practical examples that could enhance the students’ comprehension of the subject. Some noted that as a learning approach, lectures may not be suitable to meet international students’ needs. A teacher of clinical medicine commented that in a lecture on clinical manifestations and diagnoses of diseases, the students were primarily concerned about the treatment and recovery aspects. The teacher suggested:

International students asked more questions than Chinese students and were willing to interrupt the class to express their opinions. This led the academics to consider how they could better communicate with them and how to improve the quality of their teaching. Most felt that much of the current teaching involved spoon-feeding information and lacked interaction. Lecturers were failing to grasp students’ attention and hold their interest in class, which often affected their exam performance. Interviewees felt that teaching innovations such as case-based learning (CBL) and problem-based learning (PBL) should be used to teach international students, because this type of teaching mode is more heuristic and thus encourages students to learn more actively. They suggested that CBL and PBL would increase the involvement of international students in learning activities. They could also make more frequent use of individual and group presentations and discussions, encourage students to ask questions, guide students to think, and try flipped class teaching (setting preparation assignments on a lecture topic before presenting the lecture). However, the academics also felt that implementing these changes would be a challenge for them, because it would place more demands on their language skills, subject knowledge, ability to listen and respond to students, and control the class. One of the few academics who already involved international students in interactive class learning activities reported positive changes in the performance of these students:

International students’ basic knowledge and learning were poorer than those of Chinese students. The lecturers acknowledged the diverse academic abilities of international students and their different cultural backgrounds and agreed that they should adjust their teaching approaches accordingly. They also believed that they should give culturally relevant examples in class that the students were familiar with, make timely summaries of key knowledge points, give them practice assignments to complete after class, cover exam points, and provide timely feedback on their assignments. An academic teaching radiology gave the following example:

The interviewees reported that real clinical cases should be integrated into basic medicine lectures to help international students understand them, and they thought that the students would learn better with case examples. Academics without extensive clinical experience but who taught biochemistry, microbiology, immunology, and parasitology found this to be a challenge. They said that they had to provide more than theory and facts and include relevant clinical knowledge to properly teach their students. An academic teaching biochemistry who had a background in biology stated as follows:

Some of the academics also acknowledged that their lecture slides probably needed to be more interesting. They stated that it may be necessary to use teaching aids in addition to writing on the blackboard, such as video, audio, and animation, to make the classes more dynamic and easy to understand for students. An academic teaching pharmacology mentioned how he used online technology to make the learning in his class more effective.

1.2 Alignment of teaching content with licence exams

Over a quarter of the interviewees noted that a primary reason why many international students lack interest in learning is that the current course content and resources do not correspond closely enough to the requirements of the licence exams. Academics usually teach the knowledge that they think is important, and this may not precisely match a curriculum based on the licence exam. A combination of academics’ specialist knowledge and a prescribed curriculum is required. This is a critical issue, as students will be more motivated to learn if they perceive that what they are asked to learn will be useful for passing examinations and in their working lives. However, some of the academics interviewed argued that it would be difficult to address all of the licence exam needs of students from diverse countries, as the content is likely to vary. Developing a more contextualised curriculum therefore seems essential, as explained by an academic teaching anatomy:

Theme 2: Language barriers

In addition to teaching pedagogy, language barriers were identified as a significant challenge to successfully teaching international students. Most of the interviewees indicated that language differences and difficulties negatively influenced their teaching and students’ learning quality. They also offered various potential solutions. These Chinese academics spoke English as a foreign language, while international students spoke English as their first or second language (although many were far from perfect in English). This is not a criticism of either group, but merely reflects the actual situation. Communication was therefore limited because the academics were not necessarily fluent in English, and neither were many of the students. The academics often found it difficult to understand their English accents and expressions, as they may not speak standard American or British English, particularly those from India, Nepal, and Pakistan.

The academics admitted that while they generally had a good command of medical English in their own field after years of teaching, they still struggled with day-to-day and cross-disciplinary English. This limited vocabulary outside of their field affected their teaching and was one of the main reasons why they often resorted to reading verbatim from slides rather than explaining concepts in their own words, and why they avoided engaging with students. Consequently, their students become bored during class and were sometimes annoyed by the poor communication. One academic who taught surgery noted the difference between Chinese and international students in terms of language in theory lectures.

Academics teaching clinical medicine who were also responsible for clerkships and internships at hospitals indicated that it was hard to translate some Chinese words concerning a patient’s symptoms into English. Sometimes the translation was not completely accurate, and international students could not comprehend explanations delivered in conversational Chinese. Therefore, the effectiveness of clerkship and internship learning in clinical medicine was adversely affected because of language barriers, as one academic teaching internal medicine explained:

Theme 3: Resource management and learning environment

3.1 Management of teaching resources

Over half of the interviewees stated that issues with teaching resources also affected teaching and learning. Four sub-issues emerged within this theme, as follows.

3.1.1 Demand of textbooks and teaching materials

Twelve academics complained that they lacked easy access to necessary textbooks, English question banks, and other relevant teaching materials, such as reference books and videos. Universities did not mandate or provide any particular textbook for academics to use, and the academics had to seek out textbooks or create their own materials by drawing on various English and Chinese sources. If the textbooks were different from the students’ own, they could find it difficult to understand the lectures. The students were at times not assigned any textbooks or relevant learning materials. In addition, academics responsible for different modules or units in a course often used different textbooks, which led to inconsistencies. Thus, they felt that experts should develop good textbooks to help students understand and review the knowledge learned in the lectures, and they suggested that universities should purchase specialised English books, medical videos, and question banks for staff and students to use. One academic teaching gynaecology commented on her difficulty with using textbooks as follows:

3.1.2 Need for collaborative lesson planning

Seven academics felt that it was important to engage in collective lesson planning to ensure effective communication. This approach is currently lacking, but can be important for a teaching team to share experiences and discuss which knowledge points are the most important for students to master. These planning sessions can be used to discuss the application of flipped class teaching and how to properly create synergies among different topics taught by different academics. Experienced academics could also advise new members of staff about how to teach international students through collective lesson planning. Those inexperienced in teaching international students expressed their need to receive teaching tips about appropriate pedagogies, and to obtain feedback from more experienced lecturers. However, in most departments, and particularly in clinical medicine subjects, collective lesson planning and guidance was lacking, as the teachers were busy with their own clinical work and research:

3.1.3 Weak teaching supervision system

Seven academics reported that universities lacked a sound system for supervising teaching quality. This may lead academics to conclude that it makes no difference whether their teaching is of a good standard. Without a system that rewards good performance and penalises poor performance, academics have no incentive to teach well. Some of the interviewees stated that strengthening the supervision of teaching through regular observation by experts and spot-checking lecture quality would benefit academics.

3.1.4 Inadequate clinical teaching resources

Five senior clinical academics mentioned that there was a shortage of well-qualified personnel to teach theory, clerkships, and mentoring internships in hospitals. Due to the high turnover of staff, some departments lacked a stable team responsible for teaching international students. They were often taught by recently hired academics or new doctors who had minimal or no prior teaching experience. Their approach was limited to reading their notes or slides out loud, without any explanation or discussion. Those with teaching experience felt that universities and hospitals should attach more importance to consistency in teaching international students, and should introduce incentives to encourage young, qualified doctors to participate in teaching. A perceived need to train new academics for future teaching work was observed:

Three academics also mentioned that their course syllabuses were obsolete. A senior academic who taught paediatrics said it was imperative to discuss with international students which specific diseases were common in their own countries, and thus what they needed to learn about. The course syllabus could then be updated accordingly. The students could then more easily relate to the content being taught in class. These academics suggested their departments should evaluate their existing syllabuses and improve them by making them more relevant where necessary.

3.2 Classroom discipline management

Chinese academics felt frustrated and perplexed by some of the behaviour of international students in class. These students were often late to class, left in the middle of the class for no reason, or listened to music, used smartphones, and chatted with others and made noise during class. The mood of the teaching staff and their attitudes towards international students was adversely affected by such behaviour, as such discipline problems would rarely occur in classes of Chinese students. Seven academics stated that although such behaviour might be due to cultural differences, the students should follow Chinese rules. The academics dedicated time to disciplining the students to make them aware of the seriousness of their studies. However, some emphasised that it was the responsibility of the student administrators to properly manage student discipline. One academic teaching hygiene explained how she managed class discipline and encouraged students to learn.

3.3 Assessment methodologies

Six academics stated that the current assessment system was problematic, and they specifically mentioned the exam evaluation system and the final elimination system.

3.3.1 Exam evaluation system

Only a summative assessment based on final exam performance was conducted at the two focal universities, with no formative assessment. Some of the participants suggested that the university should add formative assessments such as a mid-term exams or in-class quizzes, because this could help academics follow students’ progress, identify any difficulties, push students to study harder, and reduce the pressure they felt regarding the final exam.

A teacher of pathophysiology suggested that any evaluation of international students’ academic performance should take into account their specific characteristics rather than strictly following the approach for Chinese students. This academic also felt that international students were more interested in practical learning in laboratory classes and generally outperformed Chinese students in these classes, so the university could consider increasing the weight of the practical score in their final course scores.

Some also mentioned they wanted to change the assessment methods, but in most cases, this was beyond their control, as the changes had to be approved at the organisational level after going through complicated application procedures. One participant who taught parasitology noted how their department had improved the assessment method based on students’ feedback.

3.3.2 Final elimination system

Seven academics pointed out that the universities’ assessment and evaluation systems were less strict for international students. This was perceived as a loose approach to entering and exiting the course, and did not put pressure on students to study. These academics suggested the university should implement a final elimination system to delay graduation or fail those who do not have the ability to graduate or attain an MBBS degree.

Theme 4: Teacher attributes and guidance

4.1 Addressing teacher attributes

Nearly half of the interviewees acknowledged that the attributes of academics, such as their dedication, passion for teaching, positive attitude towards teaching, sense of responsibility, and subject knowledge, play a pivotal role in ensuring teaching quality and thus enabling students to learn. They suggested that much more time and effort is needed to prepare lessons for international students, due to the modifications required. Some regarded the workload of preparing a lesson in English to be three to ten times greater than preparing a lesson for Chinese students. For instance, they had to write a lesson script beforehand to read aloud in class, because it was too challenging to improvise in English during the session. This type of language problem would not occur in Chinese classes.

The interviewees admitted that many academics were not motivated to teach international students because their universities prioritised research over teaching. Academics had no incentives to devote time and effort to areas that would not advance their careers. Therefore, although they were qualified to teach international students, they felt more motivated to conduct research. Apathy regarding teaching also affected its quality. A typical observation was as follows:

Despite the common perceptions of a heavy workload and challenges and dissatisfaction due to the lack of incentives, some academics maintained a personal commitment to their teaching out of a sense of responsibility and self-improvement.

When asked about what incentives universities could provide to motivate academics, the interviewees said that university management should attach more importance to MBBS education and to the academics who provide it, instead of regarding the field as peripheral. They emphasised the need for continuous professional learning to improve pedagogies, and assistance with oral English through formal or informal learning opportunities at home or abroad. Several academics suggested that their teaching performance should be regarded by the university as part of its evaluation for promotion, rather than solely basing it on the number of publications. This would motivate academics to teach and make them more enthusiastic about teaching. A few academics also said they had sought funding so they could implement teaching innovations in the MBBS programme, but had been unsuccessful. Two academics felt that the university should count their class hours as double or three times more than for Chinese classes, because they spent much more time on lesson preparation and class hours were considered in terms of academic promotion.

4.2 Supervision and guidance by teachers

When asked what academics could do to help students improve their performance, nearly half of the interviewees indicated that there was a need for them monitor their students’ progress more closely, and to push underperforming students harder, to make them aware they were responsible for their own learning. Some students were lazy and lacked self-discipline. The academics felt that if they could devote more time to guiding low-achieving students and talking with them after class to encourage them, students might feel that their teachers are concerned about them and become more motivated to study. An academic teaching cell biology highlighted the importance of encouragement and caring about students:

Six academics felt that it is important to impart not only knowledge and skills to students but also moral and ethical education, values, and a sense of responsibility. They stated that it is critical to teach students to cherish learning opportunities in China, to ensure they have the correct learning attitudes, and to acknowledge their role in medicine. This would stimulate students’ intrinsic motivation and instil in them a sense of respect and responsibility, as stated by an academic teaching anatomy:

4.3 Establishment of teacher–student rapport

One third of the interviewees mentioned that getting to know students and their cultures and establishing good teacher–student rapport are conducive to better communication and teaching. Good communication between academics and students can help build emotional connections and understanding in the classroom. For example, without knowledge of students’ lives and cultures, an academic might accidentally be culturally insensitive and cause discomfort. An academic teaching orthopaedics with more than ten years’ experience of teaching international students shared how he successfully developed a good relationship with students by incorporating aspects of their culture into his class.

An academic teaching anaesthesiology mentioned that those who taught clinical subjects generally knew less about their students, and thus they failed to establish a good rapport. This made their lectures seem rigid and lacking attention to the students as individuals. Those who taught clinical medicine suggested that universities should arrange activities to increase communication between staff and students, which is particularly important for younger academics.