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

Ethics and consent

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

Research sites

The study was performed in two medical universities (A and B) located in Jiangsu Province, eastern China. Both universities had over 15 years’ experience in teaching international MBBS students, so it was reasonable to regard them as relevant sites from which to gather perspectives of academics engaged in teaching. A similar MBBS curriculum was adopted at these two universities, in line with the requirement by the MOE. MBBS students and Chinese students took separate courses and did not mix in the classroom. The courses for international students were taught principally through the English medium. The majority of their international students were from developing countries in Asia and Africa, and some students were far from proficient in English.

Participants

Purposive sampling was adopted in this study. Criteria for selecting interviewees were: academic titles, years of teaching, gender, and course taught. The aim was to obtain a heterogeneous sample from the medical teaching body at the two universities. Academics were approached individually by phone call and WeChat invitation with the help of two “gatekeepers”. The target sample size before recruitment was around 30, but had to be increased until data saturation was reached (Morse, 1991). A total of 40 academics were approached, but 2 of them declined the interview invitation and another 2 initially agreed but later withdrew by not responding to the researcher’s text messages.

In total, 36 academics (17 males, 19 females) were recruited, including 2 teaching Chinese, 3 teaching nature science, 11 teaching clinical subjects, and 20 basic medical science. The participants had between 2 to 13+ years of experience teaching international students; and all were responsible for teaching the same subject to both Chinese and international students.

Data collection

Semi-structured interviews were conducted with each participant from November 2021 to January 2022. Only the first author and participants were present for each individual interview. Academics from University A participated in face-to-to-face interviews in their office or a small meeting room, where it was perceived to be comfortable and quiet, while online interviews were conducted with academics from University B (due to the coronavirus pandemic). Both face-to-face and online interviews were audio-recorded. Field notes were taken during the interviews. The interview questions, which were pilot-tested, addressed participants’ views on factors affecting student success, and their recommendations for improving teaching quality at classroom level and organizational level.

Before the interview, academics were debriefed concerning the purpose and significance of the study, and the likely length of the interview. Interviews were conducted in a quiet and comfortable environment. In conformity with ethical requirements, all interviewees were assured of anonymity and agreed to audio recording and dissemination of findings. Each interview, conducted in Chinese, lasted for around 30 to 70 minutes.

Data analysis

A thematic approach was used to analyze data (Braun & Clarke, 2006), with recorded audios later transcribed verbatim in Chinese. The 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. Next, the codes were summarized into potential themes for each participant. The primary researcher translated the codes and themes into English. Then the researcher team discussed, adjusted and reached a consensus on final relevant categories. Trustworthiness was guaranteed by member checking, peer auditing and self-reflection. During the whole research process, the primary researcher kept a self-reflective journal to minimize the effect of her own background and work experience on the interpretation of the data.

Theme 1: Teaching pedagogy

An overwhelming majority (86%) of academics perceived their teaching methods and practices to be a major influential factor on international students’ learning. They perceived a mismatch between their teaching approach and the learning characteristics of students. Most academics still relied on traditional teacher-centered lecturing, and tended to read verbatim from slides without properly explaining further or adding practical examples that could enhance the students’ comprehension of the subject. Some academics had noticed that lectures as a learning approach may not be suitable to international students’ learning needs. One academic teaching clinical medicine commented that in a lecture on clinical manifestations and diagnosis of diseases, the students were more concerned about the treatment and recovery from diseases. The academic suggested:

Unlike Chinese students, international students asked more questions and would interrupt the class to express opinions. This made the academics think more about how to communicate with them, and how to improve teaching quality. The majority of academics felt that much of the current teaching was spoon-feeding information and lacking 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 was more heuristic, which would encourage students to learn more actively. They suggested 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 asking questions, guiding students to think, and trying flipped class teaching (setting preparation assignments on a lecture topic before presenting the lecture). However, academics also felt that implementing these changes would be a challenge for them, because it would place more demands on their language ability, subject knowledge, ability to listen and respond to students, and control the class. It was pleasing to note that one of the few academics who already involved international students in interactive class learning activities reported positive changes in performance of these students:

Compared to Chinese students, international students were relatively weaker in basic knowledge and learning. Academics acknowledged the diverse academic abilities of international students and their different culture backgrounds and agreed that teaching approaches should be adjusted to these student characteristics. They also believed that it would be important for them to give culture-relevant examples in class that students were familiar with, make timely summaries of key knowledge points, give practice assignments after class, cover exam points, and provide timely feedback on assignments. An academic teaching radiology gave the example below:

Interviewees reported that real clinical cases needed to be integrated into basic medicine lectures, to help international students understand them better. They added that international students learn better with case examples. Academics without deep clinical experience but who are teaching biochemistry, microbiology, immunology, and parasitology found this to be a challenge. They suggested it was necessary for them to provide more than theory and facts by including relevant clinical knowledge to facilitate the learning of their students. An academic teaching biochemistry, with a background in biology, stated in this regard:

Academics also stated that their lecture slides probably need to be more interesting to attract students’ attention. The academics stated that there may be a need to use different teaching aids beyond writing on blackboard—such as videos, audios, and animations to make the classes more dynamic and understandable for students. An academic teaching pharmacology mentioned how he utilized online technology to make the learning in his class more effective.

Theme 2: Language barriers

After teaching pedagogy, the language barrier was identified as a significant challenge in improving the learning of international students. In discussion, 81% of the interviewees indicated that language differences and difficulties are negatively influencing teaching and learning quality. They also offered potential solutions. These Chinese academics spoke English as a foreign language, while international students spoke English as their first or second language (albeit far from perfectly). This is not a harsh criticism of either group, but merely highlights the actual situation. Mutual communication was constrained because the academics were not necessarily fluent in English, and the students were not necessarily fluent either. Academics found it difficult to understand students’ English accents and expressions, which may not be standard American or British English, particularly with students from India, Nepal, and Pakistan.

Academics revealed that while they could generally command medical English for in their own field after years of teaching, they still struggled with daily-life English and cross-disciplinary English. Limited English vocabulary outside 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 interactively with students. Consequently, students become bored during class, and sometimes were annoyed by poor communication. An academic teaching surgery compared teaching Chinese and international students concerning language in theory lectures.

Academics teaching clinical medicine who were also responsible for clerkship and internship at hospitals, indicated that it was hard to translate some Chinese words concerning a patient’s symptoms to English for the benefit of the students. Sometimes the translation made by an academic would not exactly match the symptoms. This situation was further exacerbated when international students could not comprehend explanations delivered in daily-life Chinese. Therefore, the effectiveness of clerkship and internship learning was adversely affected because of language barriers, as this academic teaching internal medicine explains:

Theme 3: Teaching resources management

Over half of the interviewees (58%) stated that issues with teaching resources also affected teaching and learning. Four sub-issues emerged as part of this theme.

3.1 Demand of textbook 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 academics had to search for textbooks, or create their own materials by drawing on different English and Chinese sources. When the textbook of the academic was different from students’ own books, they could have difficulty understanding lectures. Sometimes, students were not assigned any textbook or relevant learning materials. Moreover, academics responsible for different modules or units in a course would often use different textbooks, which led to inconsistencies. Academics felt it is necessary for experts to develop good textbooks to help students understand and review lecture knowledge; and they suggested universities should purchase specialized English books, medical videos, and question banks for use by staff and students. One academic teaching gynecology commented on her difficulty with textbooks:

3.2 Need for collaborative lesson planning

Seven academics felt that it was important to engage in collective lesson planning for intellectual communication. This is lacking at present, but may be an important procedure for a teaching team to share experiences and discuss which knowledge points are the most important for students to master. In these planning sessions, application of flipped class teaching could be debated, and how to properly create synergies among different topics taught by different academics. Moreover, with collective lesson planning, new academics could be given a demonstration on how to teach international students by more experienced academics. Academics inexperienced in teaching international students expressed their needs to receive teaching tips on pedagogies, and have feedback from more experienced lecturers. However, in most departments, this collective lesson planning and guidance was lacking, particularly clinical medicine subjects because the teachers were busy with their own clinical and research work:

3.3 Weak teaching supervision system

Seven academics reported that universities lacked a sound supervision system for teaching quality, so academics might well conclude that it makes no difference if one teaches well or not. Without a system that has rewards for good performance and penalties for poor performance, academics would have no incentive to teach well. Strengthening supervision of teaching by including regular observation by experts and spot checking of lecture quality was something that some academics desired.

3.4 Inadequate clinical teaching resources

Five senior clinical academics mentioned there was a shortage of well-qualified persons to teach theory, clerkship and mentoring internships in hospitals. In some departments, due to high turnover of staff, there was lack of a stable teaching team responsible for international students. Recently hired academics and new doctors who had minimal or no prior teaching experience were asked to teach these students. Their teaching would be limited to reading their notes or slides aloud, without explanation or discussion. Academics with teaching experience hoped universities and hospitals would attach more importance to consistency in teaching international students, and to introduce incentives to encourage young, qualified doctors to participate in teaching. There was a perceived need to train new academics for future teaching work:

Three academics also mentioned that their course syllabus was obsolete. A senior academic who teaches pediatrics said it was imperative to discuss with international students to know which diseases they needed to learn about for work in their own country. The course syllabus could then be updated accordingly. This would make it easier for students to relate to the content being taught in class. In this regard, academics suggested their departments should evaluate their existing syllabus, and improve it where necessary by making it more relevant.

Theme 4: Attributes of academics

Approximately 50% of interviewees disclosed that the attributes of academics, such as their dedication, passion for teaching, attitude, sense of responsibility, and subject knowledge played a pivotal role in ensuring teaching quality that helps students learn. The academics interviewed commented that much more time and effort is needed to prepare lessons for international students because of the modifications required. Some perceived the workload of preparing a lesson in English was three to ten times greater than preparing a lesson for Chinese students. For instance, they would have to write a lesson script beforehand to read in aloud in class, because it was too challenging to improvise their English during the session. This type of language barrier would not occur in the Chinese class.

The interviewees admitted that many academics were not motivated to engage in teaching international students because universities prioritized research over teaching. There were no incentives for academics to devote time and effort to areas that would not advance their careers. Therefore, they felt more inspired to do research and were much less driven to teach international students, even though they were qualified. Moreover, some academics might become apathetic about teaching, which would affect the quality of their contribution. A typical observation was:

Despite the common perception of heavy workload, challenges, and dissatisfaction with a 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 claimed that instead of placing MBBS education in a peripheral position, university management should attach more importance to MBBS education and to the academics who provide it. They expressed strong 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 claimed that a university should count their teaching performance as part of any evaluation for promotion, rather than solely basing it on number of publications. This would ensure that academics would become more motivated and enthusiastic to teach. A few academics also desired funding opportunities to implement teaching innovations in the MBBS program, but it was not possible. Two academics hoped the university could count their class hours as double or three times more than Chinese class hours, because they spent much more time on lesson preparation and had a need of class hours for academic promotion.

Theme 5: Teacher supervision and guidance

When asked what academics could do to help students improve their academic performance, nearly 50% of the interviewees indicated that there was a need for them monitor their students’ progress more closely, and to push underperforming students harder to be responsible for their study. Students could be lazy and lack self-discipline. Academics felt that if they could devote more time into supervising low-achieving students and talking with them after class to encourage them, the students may feel they are being cared about and be more motivated to study. An academic teaching cell biology highlighted the importance of encouraging and caring about students:

Moreover, six academics felt it was not only important to impart knowledge and skills to students, but also moral and ethical education, values and responsibility in class. They stated that it was critical to educate students to cherish learning opportunities in China, correct their learning attitude, and be responsible for medicine. By doing so, students’ intrinsic motivation could be stimulated with a sense of respect and responsibility, as stated by an academic teaching anatomy:

Theme 6: Teacher-student rapport

Approximately 31% of the interviewees mentioned that getting to know about students and their cultures and establishing good teacher-student rapport would be conducive to better communication and teaching. In particular, communication between academics and students could help build emotional connections and understanding in class. For example, without knowledge of students’ lives and cultures, any academic may accidentally say culturally insensitive statements that can cause discomfort. An academic teaching orthopedics with more than ten years’ teaching experience with international students shared how he successfully developed a good relationship with students by incorporating students’ cultures into class.

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

Theme 7: Detachment of teaching content from license exams

Over a quarter (28%) of the interviewees pointed out that one of the primary reasons why many international students lack interest in learning is probably because the current course content and resources do not correspond closely enough to the demands made in the license exams. Academics usually teach the knowledge that they think is important, and this may not precisely match a curriculum based on the license exam. What is required is a blending of both academics’ specialist knowledge and a prescribed curriculum. This issue was critical, because students would be more motivated to learn things if they perceived them to be useful to them in passing examinations, and in their working life. However, some academics argued that it would be difficult to address license exam needs of students from diverse countries, where exam content may vary. In this situation, it seemed essential to develop a more contextualized curriculum, as explained by an academic teaching anatomy:

Theme 8: Classroom discipline management

Chinese academics felt frustrated and perplexed by international students’ certain behaviors in class. International students were often late for class, left class in the middle for no reasons, listened to music, used smartphones, or would chat with others and made noise. These behaviors negatively influenced the mood and positivity of academics towards international students, as by comparison such discipline problems would rarely occur in Chinese students’ class. Seven academics (19%) stated that it might be students’ own cultural habits, but they should follow Chinese rules. These academics dedicated certain time to disciplining students in class to make students more serious about study. However, more academics emphasized that it was the student administrators’ responsibility to strengthen student discipline management. One academic teaching hygiene explained how she managed class discipline to push students learn.

Theme 9: Assessment styles

Six academics (17%) stated that the current assessment system was problematic, mentioning the exam evaluation system and the final elimination system.

9.1 Exam evaluation system

There is no formative assessment but only a summative assessment based on final exam performance. Academics suggested that the university add formative assessments such as a mid-term exam or in-class quizzes, because it could help academics to follow students’ progress and difficulties, and push students to study harder, and decrease the final exam pressure on students.

One academic teaching pathophysiology mentioned that the evaluation of international students’ academic performance should take into account of their characteristics rather strictly follow the same evaluation system of Chinese students. This academic felt that international students were more interested in practical learning in the laboratory and generally outperformed Chinese students, so the university could consider increasing the weight of practical score into their final course score.

Academics also mentioned they wanted to change the assessment methods, but in most cases, it was beyond their control unless the changes were approved at the organizational level after going through complicated application procedures. One academic teaching parasitology exemplified how their department improved their assessment method based on students’ feedback.

9.2 Final elimination system

Seven academics pointed out university assessment and evaluation systems were less strict with international students. It was perceived as a loose entry and exit to the course, which would have no pressure on students to study. These academics suggested the university should implement a final elimination system to delay graduation or fail those who are disqualified for graduation and a MBBS degree.

Underlying data

The datasets generated and/or analyzed during the current study are not publicly available due to privacy agreements between the researchers and the interviewees. Making the interviews available – considering the relatively low number of international students at both Medical Universities – would likely compromise the anonymity of the respondents, thus breaking the ethical consent agreement that was established. Requests for data can be considered and if considered reasonable (e.g. having a professor position at a university) are available from the corresponding author Hugo Horta (horta@hku.hk) or Qinxu Jiang (e-mail: jiangviolet86@hotmail.com). English language partial transcripts will be provided.

Extended data

figshare: Interview protocol.docx. https://doi.org/10.6084/m9.figshare.20290566.v1 (Jiang, 2022).

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).