Editorial: Medical Education in Difficult Circumstances

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Introduction "Let us pick up our books and our pens.They are our most powerful weapons.One child, one teacher, one book and one pen can change the world."Malala Yousafzai (United Nations General Assembly, 2013) These are the words of a brave 15-year-old girl who had recovered after being shot in the head the year before for courageously taking a stand against an oppressive regime that opposed education for women.Against the odds, she fought for a cause in which she believed.For Malala, education provides each of us (as well as collectively) with the power to change the status quo.Medical and health professional education has the power to change lives, but for many, challenges and difficulties need to be overcome.
We live in an increasingly volatile, uncertain, complex and ambiguous (VUCA) world, a world that is plagued by war, conflict, political upheaval, emerging epidemics and natural disasters (Lemoine et al., 2017).Events of the last few years, particularly in the Middle Eastern region, has led to millions of refugees, including some health care practitioners and students, who have left their country of birth in search of a safer place to hopefully study or work.Amidst the challenges of this complex world, medical education, like life, must continue but many students and doctors have to study and work in the most difficult of circumstances, perhaps even under duress.The description above reflects some of the most extreme difficult circumstances, lying at the furthest end of a spectrum, which ranges from terrible and tragic situations to more mundane or entrenched, but important issues, such as lack of teaching resources, institutional sexism or racism, rigidity in curriculum development and financial constraints.
In 2007, Gibbs wrote that: "As an international community that is seemingly passionate about medical education and shares a belief that the future of a country's health relies on the education of its future healthcare workers we (as an international community of educators) have to sit up and recognise the problems faced by our peers".Almost a decade later, as medical educators, we still have to ask ourselves whether we are indeed doing our best to assist our colleagues and their students who may be experiencing a range of difficulties and challenges studying or working.AMEE, the Association for Medical Education in Europe, has taken a stand.Recognising that 'difficulties' are contextual and, to better understand the spectrum of challenges facing medical educators across the globe (with the view to being able to offer possible strategies or solutions in some circumstances), 'Medical Education in Difficult Circumstances' was identified as a theme for the 2016 AMEE Conference in Barcelona.Based on the information gathered at the various plenaries, symposia, oral and poster presentations and a specific workshop, this editorial attempts to provide some insight into the deliberations of the conference participants and provides the stimulus for AMEE members to contribute to the MedEdPublish January-March 2017 themed issue of 'Medical Education in Difficult Circumstances'.Can impact at different levels, ranging from an individual, an institution or organisation or even a system (e.g.health care system); Can be an acute or crisis situation or a long term issue; Does not allow goals to be achieved; May be morally distressing; Can impact on the mental and physical well-being of students or faculty.
At one of the 2016 AMEE plenaries, Dr Ewa Pawlowicz, a recently graduated doctor from Poland, presented a student perspective on 'Medical Education in Difficult Circumstances'.Ewa's summary below reminds us to work with students as partners as we deliberate on the many challenges we collectively face in medical education: "Students, if treated as partners in addressing and responding to challenges, are of a great value to medical education.Since students 'suffer' directly from a range of 'difficulties' in their medical training and education, they should become active agents in helping to resolve some of the problems.As students 'live' the curriculum, they can often identify issues long before they become difficulties.With their fresh approach to 'seeing' things, students can be agents of change, which is particularly important in countries where curriculum models are out-dated, traditional and overloaded with theoretical knowledge.
International student organisations such as the International Federation of Medical Students' Association (IFMSA) or the European Medical Students' Association (EMSA), provide students with several opportunities for sharing experience and knowledge about different health care and medical education systems as well as facilitating their participation in exchange programmes.Although internships abroad should be an integral part of curricula, many medical students are still denied the opportunity of taking part in them.
Students should constantly develop their knowledge and awareness about medical education, what would allow them to become reliable and proper partners for medical school authorities.Raising students' responsibility for their learning and education is probably the best way to increase their motivation to engagement.Students' organisations should also create long-term strategies and consolidate their actions, what might lead to better recognition of students' voice in the academic community.Thanks to these actions students may become true change leaders in medical education".
The authors would value additional perspectives from students and doctors in training in terms of the difficulties they have or face and how they cope.
During the same plenary, Professor Philip Cotton, Vice-Chancellor of the University of Rwanda Medical School, provided an insightful account of how the restructuring of a University and its medical school, in the aftermath of one of the bloodiest conflicts seen in Africa, has been achieved through a common vision and a determination to succeed.Below is a summary from Professor Cotton about his unifying work at the University of Rwanda.
"Stumbling blocks into stepping stones; celebrating medical education in Rwanda.
The University of Rwanda was created two years ago (2014) from the merger of the seven public Universities.There are now 31,000 students on 14 campuses.It is the majority provider of doctors and nurses, and the sole provider of all other health care professionals.The merger is complete and during these two years, in response to predicted needs, we have opened the first-ever dental school, doubled the intake into medicine, and started the first ever Masters degrees in clinical nursing for 160 candidates.The challenges facing students and faculty, and delivery of teaching in clinical environments, are not new but the opportunities that emerge are exciting and energising." In his plenary, Professor Cotton highlighted that the ability to move forward in difficult circumstances requires, amongst many other things, high-level administrative support.We therefore invite university and faculty administrators, programme managers and curriculum support staff to share their experiences by contributing to this themed issue of MedEdPublish.
Table 1 provides a summary of a number of the identified challenges and difficulties that emerged from the fruitful discussions during the AMEE workshop, "Medical Education in Difficult Circumstances", in Barcelona.Also provided are some examples and contexts as well as some broad suggestions and strategies for coping and dealing with the identified issues.We believe, however, that there is much work that still needs to be done and therefore appeal to the international community of health professions' educators and students to assist in identifying additional 'difficult circumstances' or offer strategies and solutions to those which have already been identified.

Conclusions
With events such as the Paris Agreement on reducing carbon emissions to mitigate climate change now international law and the recent election of Donald Trump as the next US president, we move into a new era in our global history.Some may claim that our future as a global community is uncertain.What we do know, however, is that change will happen.We also know that with change come challenges, some of which may be painful.As a global community of medical and health professional educators, we stand at a crossroads.We have two options: we can either bury our heads in the sand (for which we may pay dearly later) or we can step up and work collaboratively to tackle these difficulties and support our colleagues.We believe we need to take the latter path.We hope that by identifying common difficulties in medical and health professions education, we can collectively find solutions and strategies to overcome some of the most pressing issues facing students and doctors today and tomorrow.

Notes On Contributors
Professor Trevor Gibbs, MD, SFHEA, DA.FAcadMED, MMedSc, FRCGP, FAMEE -Trevor is an independent Professor and Consultant in Medical Education and Primary Care.As Deputy Editor of Medical Teacher he has specific responsibility for the development of AMEE Guides, the BEME Guides, and the Medical Education around the World series.His experience in General Practice and interest in medical education have given him the opportunity to develop curricula in many parts of the world, specifically in those regions in which medical and healthcare education is often a challenge.He has a special interest in the social accountability of medical schools.

Haipeng Xiao
The First Affiliated Hospital, Sun Yat-sen University This review has been migrated.The reviewer awarded 5 stars out of 5 This is a well-written editorial that provides an overview of contextualized difficulties in medical education throughout the world, pointing out underlying ones as well for further solutions.Crucial as the issue is, we rarely find any relevant article about how to be the voice of the less fortunate and help tackle the difficulties in a timely and effective manner.This inspiring article is thus especially helpful for those involved in difficult circumstances.

Richard Hays James Cook University
This review has been migrated.The reviewer awarded 5 stars out of 5 Thanks to the authors for this summary of some of the challenges that face medical educators and health professional learners throughout the world.Medical education can be complex anywhere, but in much of the developed world there is relatively secure funding, plenty of high quality candidates for faculty positions, political stability and personal safety.The session at the recent AMEE meeting highlighted the differences that many of our colleagues face in trying to do the same job as those of us in more fortunate circumstances.It will be interesting to see where this discussion leads.At the moment the title of the theme is probably deliberately broad.However, this means that a very wide range of complex issues are included, and makes difficult the task of working on solutions, which may also be complex.I look forward to reading other contributions to this themed issue, as through open discussion it may be possible to develop practical advice and assistance to overcome some of the difficult circumstances.After all, in the increasingly globalised world, we all have a vested interest in seeing high standards of medical education and medical practice everywhere.

First
, we offer a description of what 'difficult circumstances' means, a collection of meanings which emerged from the 2016 AMEE Conference workshop: A 'difficult circumstance' Is recognised as being out of the ordinary, i.e. beyond what is difficult in everyday life (and which may be context-specific); May result from a conflict of values or beliefs; Michelle McLean, MSc, PhD, MEd -Professor Michelle McLean is the Academic Lead for Problem-based Learning (PBL) in the undergraduate medical programme at Bond University, Gold Coast, Australia.Having worked on three continents in three very different contexts, Michelle's interests include diversity in learning and teaching and preparing the future medical workforce for an increasingly complex world.Her interest in 'Medical Education in Difficult Circumstances' stems from growing up in South Africa during Apartheid and being in an academic position when transformation of higher education was required to address decades of inequity.Ewa Pawłowicz graduated from medical faculty of Medical University of Lodz in 2015, and is at present studying for a clinical PhD.As a student she was an member of International Federation of Medical Students' Associations (IFMSA) and worked for Standing Committee on Medical Education, taking part in many international meeting and projects.She participated in clinical exchange programmes in Sweden, USA and Portugal.Since 2013 she has cooperated with Centre for Medical Education in Lodz with a focus on enhancement of student engagement in medical education in Poland.Professor Judy McKimm, MBA, MA(Ed), BA(Hons), PGDip (HSW), SFHEA, FAcadMed's -Judy's current role is Director of Strategic Educational Development and Professor of Medical Education in the College of Medicine, Swansea University.Judy initially trained as a nurse and has an academic background in social and health sciences, education and management.She is programme director for the Leadership Masters at Swansea and Director of ASME's International Educational Leadership programme.

Table 1 .
Categories of difficulties identified in medical and health professions' education.It's an inspiring although saddening opening remark, given that it involves issues as difficult as wars and major disasters.I can't agree more to quote Malala as a role model for medical education in difficult circumstances, who was also mentioned earlier by Professor Trevor Gibbs in his first ESME course for the First affiliated hospital, Sun Yat-sen Medical University.One may say though Malala's just lucky to have MedEdPublish survived after being shot.Still no one can deny that she deserves the Nobel Prize as a teenager, given the underlying positive psychology and stepping up to inequality, sending so much hope and faith in education to the rest of the world despite all the life-threatening difficulties.It's an inspiring article for China as well, which reminds me that development of medical education was not smooth from the very beginning with stumbling blocks.Like invisible wars, bureaucracy and inefficiency are not uncommon within the system, where innovation and change won't happen without resilience.Thanks to the leaders' determination and collaboration between AMEE and China, many 'first' s for China and Sun Yat-sen arose and many more will follow as more practical solutions promoted by people who share the spirit of Malala, who keeps fighting for what we all believe.Thus I'm also excited to read Professor Xiao Haipeng's review which addresses quite a few of his thoughts for the future, faculty development being one of the highlights certainly.One of my classmates in CUHK is a Yemeni lady, whose research is about role of public health in war, the norm in her country.The same powerful weapons chosen by more, Malala is NOT alone.No conflicts of interest were disclosed.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Table1is a very useful 'tool' of analysis of uncommon situations for finding possible way out.Build coping mechanism and promoting positive psychology are also highlighted, which are tremendously important in time of difficulties.There are probably still some issues worth addressing: 1.In table 1, considering the severity of the issues, broad strategies for Global issues could be more: a. promote hope and resilience by relevant NGO, Government's social accountability; b.Demonstration of immediate awareness and prompt competence,c.Humanitarian aids and civilian protection; d.Post-conflict reconstruction; e. Local empowerment and capacity building.2.In the health and education system issue, examples for low resources may include lack of quality supervision of education, lack of feedback, lack of motivation mechanism.Examples for competing values could involve student-centered vs teacher-centered.Solution could be establishment of motivation mechanism.3.In the organizational teamwork issue, the examples could be "bureaucracy and inefficiency".Solution could be ' promotion of evidence-based medical education'.4. The examples for "individual or personal issues" could be "lack of faculty support system" , and the solution could be 'faculty development'.No conflicts of interest were disclosed.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.