Discussion
This study explored junior doctors’ perceptions of global health and sustainable development, the education they have received on these issues and the relevance of this knowledge in their current and future work. Junior doctors agreed on the issues’ relevance for health and healthcare and described the utility of what they had been taught on these issues in clinical patient meetings. However, to what extent every Swedish medical doctor needs this knowledge and to what extent they encounter ‘global health’ or ‘sustainability’ in their daily practice was a point of contention. They reflected on heterogeneity in the conceptual understanding of global health and the apparent disconnect between what they had been taught and their regular work, including challenges in applying their knowledge. In contrast to global health, sustainability was seen as a more ‘local’ issue, but still, as something that was beyond the typical scope of medical doctors’ responsibilities.
Global health and sustainability were seen primarily as extracurricular activities for medical students. This was also true for junior doctors, who felt that they could choose to engage with these issues in their spare time if they had the interest. The vast extracurricular opportunities available for students were contrasted with a lack of opportunities to pursue this interest as junior doctors. Despite the view that some level of knowledge is needed for all medical doctors, further engagement in global health was not seen as highly valued by neither educators nor traditional employers in the healthcare sector. In the academic setting, this could be related to the view that ‘soft’ subjects are lower on the perceived ‘knowledge hierarchy’ than ‘hard’ medical knowledge.17 In the clinical setting, the lack of support could be related to limited resources, forcing medical doctors to keep a narrow focus on the biomedical perspective, rather than looking at the broader picture, including social determinants of health, prevention and sustainable development. The challenge of focusing on long-term sustainability has been similarly voiced in focus group discussions between medical, nursing and public health students in Kazakhstan,18 which the authors referred to as ‘Prioritisation of immediate patient care’.
When discussing sustainability, participants primarily described environmental issues rather than ‘economic’ or ‘social’ dimensions, possibly reflecting the current societal discourse. Despite personal interest in sustainability issues, its relevance in the work context was perceived as less distinct. It was often described as a ‘system issue’ that should be dealt with at ‘higher levels’, and beyond the scope of what an individual doctor, especially at junior level, could influence. Exactly where the level of responsibility was seen to lie was perceived as unclear, thus highlighting the need to better define responsibilities for driving sustainable practices in the healthcare sector. A previous study of Italian university students found that healthcare students were more negative towards learning about the Sustainable Development Goals in comparison to students in other disciplines, which the authors suggested might be due to the false assumptions about its lack of relevance for healthcare/medicine.19 Similarly, previous studies of healthcare workers have described a discordance between personal and professional action,20 where sustainability is seen as a secondary or tertiary priority when put in relation to direct patient care.21 Yet, sustainability was described as a more ‘local issue’ and something that could be pursued for example in primary healthcare practice, where one could take small, concrete actions to ‘green’ their practice, for example by preferential choices of medicines with less environmental impact. Despite the view of sustainability as a system-level issue, small-scale engagement was seen as tangible and realistic in certain contexts. The view of sustainability as a topic that is hard to act on in the clinical setting could perhaps be due to how sustainability is taught, or not taught. As argued by Engebretsen et al,22 there is a need for a ‘radical transformation’ of medical education and to use the 2030 Agenda as a basis for fostering critical thinking regarding sustainability. The authors call for decolonisation, not only of global health education but rather of the overall medical education and practice.
Participants described a disconnect between their daily reality in a Swedish clinical setting and the ‘global health they had been taught. This has been similarly voiced by students in the UK,17 and our results indicate that this perception holds also as medical students progress to early career stages. This could be due to the educational framing of global health as healthcare abroad,4 or as healthcare in resource-scarce settings. Sweden is a high-income country, with healthcare as a universal welfare benefit, and a high average life expectancy at birth.12 Still, participants described how they had used global health skills and knowledge in the Swedish setting, such as when caring for individual patients with migration backgrounds or infectious diseases not endemic in Sweden. More indirect examples were also voiced, reflecting how social determinants affect the health of individual patients, but these examples were not consistently recognised as applied global health knowledge. Yet, the global health relevance for Swedish medical doctors is likely to increase in the future, as there are growing health gaps among different socioeconomic groups, despite the high level of publicly financed healthcare and low preventable mortality.12
There are similarities in the perceptions of global health and sustainable development education among current and future medical doctors globally. A South Korean qualitative study highlighted a wish among students for an early introduction to the subject, a lack of clear understanding of the term ‘global health’, and implied difficulties in applying this knowledge.23 Global health education was viewed as a necessary component in medical education, not only to acquire knowledge but also to shape career trajectories. Postgraduate teachers in a UK-based study similarly described heterogeneity in the understanding of global health among general practitioner specialist trainees.24 This has been echoed in the ongoing debate, with the definition and understanding of the term being continuously revised.4 25–27 This highlights the need for a consensus on the definition of global health and its scope, to facilitate further curricular development. The perspectives on environmental sustainability of medical, nursing and public health students have previously been studied in Kazakhstan,18 where environmental sustainability was similarly perceived as an important component of a medical curriculum.
There is still some scepticism regarding the relevance of global health and sustainable development. Despite a lack of scientific evidence, Blum et al describe anecdotal evidence that only a minority of students strongly support the inclusion of international and global aspects of health in their course (estimated to be approximately a quarter), the majority of students are either indifferent (around half) or consider the topics unimportant to them as professionals, and with no legitimate place in the medical programme (approximately a quarter).17 In a previous survey conducted in Sweden, the majority of medical students were positive towards global health education, but the transferability across settings is uncertain.9
Key stakeholders in Swedish medical education have described difficulties in effectively teaching all knowledge and skills that medical practitioners need in their clinical careers28 due to the risk of ‘curriculum overload’ given the limited teaching time. Students should be equipped with thorough medical knowledge, clinical skills, the ability to collaborate in and lead teams, and the capacity to skilfully handle patient meetings, and provide counselling on how patients’ health can be improved. There were disagreements about whether global health and sustainable development are core issues that all medical students should have in-depth knowledge about, or a ‘niche’ topic, relevant for a few students per class.28 Curriculum overload was similarly voiced by students and educators in a UK medical school, as part of a case study on health promotion education, including a global health component.29 Given the contrast to biomedical learning, the authors highlighted the risk that assessment-driven students could struggle. The need to further display the importance of knowledge on global health was emphasised, to avoid devaluation through strategic learning on the subject. The effective incorporation of global health into medical education therefore requires well-defined strategies and well-designed curricula, through vertical and/or horizontal integration, avoiding undesired curriculum overload.
This raises the question of how global health should be taught both globally and, for the purpose of this study, in Sweden specifically. Global health and sustainable development are broad concepts, encompassing the entire 2030 Agenda and intersections with social issues that intersect with health. With the definition of global health emphasising marginalised populations and populations in need,3 and the global burden of disease being skewed to low- and middle-income countries,30 is it reasonable that teaching is also skewed towards this? Arguably, overemphasis on the global dimension may risk enhancing the somewhat outdated idea of global health as healthcare abroad. On the other hand, a survey study from Germany indicated that ‘population health’ in a more local perspective was less popular than education framed as ‘global health’.31 As such, finding a balanced pedagogic model remains a challenge. Depending on how global health is taught and how medical doctors are expected to apply knowledge, different pedagogical models may be needed. Previous literature has suggested various models adapted for different student groups depending on their interests and the epistemological vision of educators. Martimianakis and Hafferty have proposed three models: the universal global doctor (who can practice anywhere); the culturally versed global doctor (culturally competent in the local and international setting); and the global doctor advocate (equipped to use social determinants of health to advocate for marginalised populations in policy contexts).32 Rowson et al have proposed three models for three different types of medical doctors: the ‘globalised doctor’, the ‘humanitarian doctor’ and the ‘policy doctor’.31 Similarly, Eaton et al
33 have outlined three pedagogic approaches which can underpin teaching in medical schools: ‘additive’, where global health teaching is an addition to the main curriculum (optional); ‘integrated’, where teaching is embedded into the mainstream curriculum, and ‘transformative’, in which teaching is ‘embedded throughout the programme, with a dynamic and interactive effect on both’. We argue, similarly to Rowson et al,31 that all medical doctors should have knowledge of global health and sustainability, and that in the modern, interconnected world, medical doctors are inevitably ‘globalised doctors’ who need to be culturally versed and ‘socially minded’. Hence, we advocate for a transformative teaching model, where global health and sustainable development are present throughout the programme. Personal interest may steer future medical doctors down more specialised paths such as specialisation in public health/social medicine or working as ‘humanitarian doctors’ or ‘policy doctors’, for whom additive modules may be beneficial.
Methodological considerations
The current study has several strengths. A major strength is the inclusion of junior doctors’ views and experiences on sustainable development, in addition to global health. The sample included junior doctors working in a variety of different clinics and hospitals in Sweden, and both males and females were included.
Several aspects enhance the trustworthiness of this study. The qualitative study design with in-depth interviews allowed participants to express themselves freely. It was made clear during the interview that no wrong answer existed to the questions asked and participants were encouraged to speak their minds, allowing for deeper knowledge and understanding. Another strength is that all interviewers themselves were junior doctors, ensuring an understanding of the participants’ context and therefore increasing the credibility of the findings.
Other strengths are the detailed description of the analytical process and the use of rich quotations, which increases the transparency and confirmability of the findings. Also, the research team regularly held debriefing sessions during the analysis, to discuss and ensure consensus regarding the categories and themes that were developed during the process.
A possible limitation is that the interviews were conducted by four interviewers who might have variations in their techniques when interviewing. However, to minimise this risk, a semi-structured interview guide was developed which was used for each interview. Also, the interviewers received training together, tested the interview guide on one another and provided feedback on the completed interviews. Although some of the interviewers had previously worked at the same hospital as the participants, it is unlikely that their previous contact impacted the interview process.
According to our preinterview questionnaire, all of the study participants stated that they were positively oriented towards global health and sustainable development, and a subset declared having been actively engaged in the topics (4/16). Although we did not collect data from non-participants, we deem it plausible that junior doctors with a particular interest in global health and sustainable development might be more likely to show an interest in participation, thus skewing the findings towards more favourable views on global health integration in medical training. Self-selection of participants who are particularly interested in a topic is a general dilemma affecting research, and interview studies would be no exception. Thus, the extent to which the current findings would be transferable to the broader population of medical professionals, within or outside of Sweden, remains unknown. Nevertheless, a previous study among Swedish medical students found that 83% wanted to add more global health education to the curriculum.9
The use of some digital interviews may also be considered a limitation of this study. Although in-person interviews are the ‘gold standard’, there is ample evidence that online interviews also work well,34 and this created the possibility of interviewing participants from different geographic locations which was beneficial. Also, the topic was not regarded as having the type of sensitivity that would require face-to-face interviews.
