Introduction
The global need for well-educated doctors, and other health professionals, who are able to provide high-quality healthcare, is undisputed, given the many health challenges societies face in the 21st century. Scaling up of health professions education opportunities has been proposed as one means of generating an educated workforce for addressing health system needs and has been a priority of the WHO since the 1950s.1 2 With global recognition of significant health worker shortages,3–6 this focus on increasing health worker output is necessary and unsurprising, leading to the creation of many new education programmes worldwide.
Rizwan et al5 recently mapped trends in the globalisation of medical education programmes: USA, India, Pakistan, China and Brazil currently house the largest number of medical schools.7 While medical education programmes in LMIC and transitional countries8 are being established to improve health human resources within home countries, they are also drawing foreign students, both from countries lacking education opportunities and from countries where student selection is highly competitive.5 Countries in Eastern Europe (such as Poland, Hungary and the Czech Republic), Russia, Ukraine and China have increasingly established English language medical education programmes to attract international students.5 Similarly, in an attempt to attract learners from Canada and the USA, medical education programmes with curricula that emulate the American model have expanded within the Caribbean.6 As a global phenomenon, educating doctors is a growth industry.
Medical education is generally conceptualised as an academic endeavour, best achieved through well-planned delivery of science-informed education practices, tools, structures and processes.9 To support this, research in medical and health professions education has become an area of increasing scholarly attention. This has led to a proliferation of academic activity, including publications, international conference attendance and increasing diversity of professions, perspectives, disciplines and theoretical approaches being recognised as advancing new knowledge in the field.10 In examining the burgeoning literature, it is important to recognise that medical education research is, by academic measures, a relatively recent area of scholarship. It first emerged as an academic field in the 1950s in North America at a time when there was an explosion of scientific medical knowledge, an influx of financial incentives to support research, and a mandate to demonstrate greater public accountability.11 As an area of inquiry, its development was firmly entrenched in EuroAmerican healthcare and higher education structures. The colonial underpinnings of these structures are well documented, including ways that notions of academic legitimacy are based in biomedicine (which ignore traditional and Indigenous healing practices which developed in many different global contexts over millennia12) and are inextricably intertwined with European colonisation of parts of Africa, the Americas and Asia.12–17 In North America and Europe, Flexner’s report in 1910 had enormous impact, entrenching legitimacy of doctor education in high status university settings, which led to the closing of non-university-based programmes including most that provided training for women and black students.18–21
Recognising the colonial and Flexnerian foundations of medical education provides a helpful starting point for examining issues of equity, absence and marginalisation of diverse perspectives within current structures.22 In recent years, explorations of representation, discrimination, harassment, silencing and power differentials have begun to appear in medical education journals. Many are written as commentaries and perspectives pieces, providing reflections on personal experiences and theoretical explorations of ways that dominant approaches (generally white and EuroAmerican centric) constrain and limit the field.23–31 There are some empirical studies examining various aspects of representation within medical education, with recent attention given to gender, sociocultural and racial equity within academic medicine’s leadership, student body and curricula.32–47 There is also growing documentation of the paucity of published voices from low-income and middle-income countries (LMICs) and non-English speaking scholars in medical education journals that position their reach as international.48–52 This parallels the relative absence of authors from LMIC and non-English speaking countries in leading academic journals in many other areas of academia, including health and education.26 53–61
Within medicine, the use of bibliometric methodologies emerged during the late 1700s and early 1800s, but rose exponentially through the 1990s and remained high until 2015 when a moderate decline ensued.62 Bibliometric analyses are one way to identify imbalances, and a growing set of papers are exploring the under-representation of authors from outside of North America and Europe through the application of bibliometrics.56 57 63 64 Maggio et al64 specifically examined authorship of knowledge syntheses by country, with authors from highly ranked North American institutions being dominant. By categorising lead authors by UN region,65 Buffone et al56 found that the majority of authors in the medical education literature were from North America, Northern Europe, Western Europe or Australia. Thomas57 analysed authorship by country of affiliation over a 2-year period, comparing medical education journals to those in education, medicine and biomedical sciences. Examining for all authorship positions, he found that there was greater dominance of authors from the USA, the UK, Canada and Australia in medical education than in other areas. While these studies show that there is an overall dominance of authors from high-income English-speaking countries, there has not yet been a quantification of prestigious authorship positions by country.
In medical education research, first and last author positions are often considered more prestigious and desirable. For many researchers, numbers of first and last authored publications contribute to academic recognition including promotions, tenure, awards, salary support and access to financial support for graduate students and research projects. In addition to individual academic accomplishment, regularly publishing in highly regarded journals in one’s field allows authors to engage in academic debates and shape understandings of which topics are deemed meritorious, noteworthy and interesting. Powerful voices in these academic journals thus help to map the academic landscape, drawing boundaries and labelling worthy areas of exploration. While it is acknowledged that first and last authorship positions denote a higher level of credit for the work, Hedt-Gauthier et al49 found that health research conducted in Africa, or about Africa, was less likely to have first and last authors from LMICs when the publication included collaborating authors from high-income countries (HICs).
While well-established guidelines for defining what constitutes authorship exist and are endorsed by many medical journal editors,55 66 67 guidelines for how authorship positions should be distributed across authors are underdeveloped. Thatje67 provided rules of thumb for determining first and last authorship positions within the natural sciences, noting that disciplinary and national culture may play a role in how decisions are made. Rees et al68 recently noted that while standards of authorship exist within global health research, they do not address power imbalances that exist between authors from LMIC and HIC. A recent consensus statement by Morton et al69 provided guidelines for determining author order in partnerships between LMIC and HIC scholars. However, given the recency of these guidelines, it is yet to be determined whether they will be incorporated into authorship decisions among partnering researchers in the field of medical education.
We undertook a bibliometric analysis of five top medical education journals to determine which countries were represented in first and last authorship positions. Our aim was to provide empirical data about which countries or regions of the world were more or less prominent in the academic spaces dedicated to medical education. While recognising that many other journals, including predominantly clinical journals, also publish medical education research, we chose to focus on journals specifically designed to publish in this area. Thomas’s57 previous work was able to capture articles on the topic of medical education that were published within a broad range of clinical, specialty and disciplinary journals with scopes not exclusive to medical education research. We aimed to build on the work of Thomas57 and chose to focus on journals that primarily published within the field of medical education and health professions education, as they constitute spaces where debates and critiques are intended for audiences who tend to live and breathe within the sphere of medical education. In doing so, our aim was to capture the boundaries of a field that asserts to be international in scope.
In addition to conducting this research, we recognised that the process of doing the research was itself illustrative of issues that may affect publication trends. As a collaborative research team distributed across four continents, we realised that it was important to explicitly discuss issues of power and privilege as part of our analysis meetings. We recognised that we were working our way through specific and concrete research processes and practices in which issues of power, voice, legitimacy and representation were ever-present. As such, we agreed to keep an explicit focus on our research decisions, processes and practices with a view to identifying ways privilege and power were manifest and managed in the shared work. We have included description of relevant aspects of these reflections in the manuscript.