Becoming Agents of Change: Contextual Influences on Medical Educator Professionalization and Practice in a LMIC...

Medical educators are particularly needed in Low- and Middle-Income Countries (LMIC), where medical schools have grown rapidly in size, number, and global outlook in response to persistent health workforce shortages and increased expectations of quality care. Educator development is thus the focus of many LMIC programs initiated by universities and governments of high income countries. While signs of medical educator professionalization such as postgraduate qualifications, specialized units, and professional associations have emerged in LMIC, whether these relate to programs originating from outside LMIC contexts is unknown. This study investigated the contextual influences on the long-term impact of an international faculty development program a decade after its delivery in a LMIC context - Vietnam.

Ten years after an international aid program to develop clinical skills teaching expertise in Vietnam, we conducted in-depth qualitative interviews with eight medical educators from all eight participating medical schools. Selected for their leadership potential, each participant had completed the Maastricht Masters in Health Professions Education during the program. Interview transcripts underwent thematic analysis, using the Theory of Practice Architectures as a conceptual lens to highlight the contextual influences on professional practice.

Four themes were identified: Careers and Practices before, during, and after the program, Unrecognized and Unseen practice, Structural Restraints on individual advancement and collective activity, and the Cultivation of Connections through social traditions. Participants reported being in well-established teaching delivery roles. However, the absence of professionalizing discourses and material resources meant that practice was restricted and determined by institutional leadership and individuals' adaptations.

Informed by the theory of practice architectures, we found that change in medical education practice will falter in contexts that lack supporting discursive, material-economic, and socio-political arrangements. While there were emerging signs of individual agency, the momentum of change was not sustained and perhaps unapparent to Western framings of educational leadership. Practice architectures offers a framework for identifying the contextual features which influence practice, from which to design and deliver sustainable and impactful interventions, and to advance context-relevant evaluation and research. Our findings suggest that faculty development delivered across diverse contexts, such as in distributed or transnational medical programs, may have more effect if informed by a practice architectures analysis of each context.