forms in the education of healthprofessionals in LMICs, the con-ceptual framework developed byBurgis-Kasthala et al.6 suggests thatthe success of capacity-buildingprogrammes depends on how well aprogramme manages the tensionsamong the priorities of the variousstakeholders, international expec-tations and national needs. Burgis-Kasthala et al. recommend that:

‘explicit consideration must begiven to the positive and negativeeffects of global influences, theorganisational climate of the pro-gramme and how it can be evalu-ated, and the professionalidentities that such programmesengender.’6

REFERENCES

1 Bowers JZ. Imperialism and medi-cal education in China. Bull HistMed 1974;48(4):449–64.

2 Bleakley A, Brice J, Bligh J. Think-ing the post-colonial in medicaleducation. Med Educ 2008;42(3):266–70.

3 Pruitt SD, Epping-Jordan JE. Pre-paring the 21st century globalhealthcare workforce. BMJ2005;330 (7492):637–9.

4 Bowe CM, Lahey L, Kegan R,Armstrong E. Questioning the ‘bigassumptions’. Part II: recognisingorganisational contradictions thatimpede institutional change. MedEduc 2003;37 (8):723–33.

5 Elizondo-Montemayor L, Hernan-dez-Escobar C, Ayala-Aguirre F,Aguilar GM. Building a sense ofownership to facilitate change: thenew curriculum. Int J Leader Educ2008;11 (1):83–102.

6 Burgis-Kasthala S, Kamiza S, BatesI. Managing national and interna-tional priorities: a framework forlow-income countries. Med Educ2012;46:478–56.

7 Sockett H. Designing the Curriculum.London: Open Books 1976;1–133.

8 Blizard PJ. International standardsin medical education or nationalstandards ⁄ primary health care –which direction? Soc Sci Med1991;33 (10):1163–70.

9 Astor A, Akhtar T, Matallana MA,Muthuswamy V, Olowu FA, Tallo V,Lie RK. Physician migration: viewsfrom professionals in Colombia,Nigeria, India, Pakistan and thePhilippines. Soc Sci Med 2005;61(12):2492–500.

10 Jimenez-Arango A. Medical educa-tion and medical care in develop-ing countries. Am J Public HealthNations Health 1966;56 (12):2126–32.

11 Harden RM. AMEE Guide No. 14:Outcome-based education: Part 1.An introduction to outcome-basededucation. Med Teach 1999;21(1):7–14.

12 Elizondo-Montemayor L, Cid-Gar-cıa A, Perez-Rodrıguez BA, Alarcon-Fuentes G, Perez-Garcıa I, David S.Outcome-based national profile ofMexico’s medical graduates. MedTeach 2007;29 (7):691–8.

13 Koo D, Miner K. Outcome-basedworkforce development and edu-cation in public health. Annu RevPublic Health 2010;31 (1):253–69.

14 Serour G. Healthcare workers andthe brain drain. Int J Gynaecol Obstet2009;106 (2):175–8.

The culturally sculpted self in self-directed learningGary Poole

The word ‘self’ in self-directedlearning (SDL) indicates a locus forboth the responsibilities related tolearning and the outcomes of thatlearning. Self-directed learning is

conducted by the student and forthe student. Frambach et al.1 re-mind us that beliefs about respon-sibility for learning and theoutcomes of that learning areinfluenced by culture and may varyfrom one culture to the next so thatresponsibility may be located in theindividual or in the collective. Out-comes, we learn from the article,1

can be perceived in a number ofculturally determined ways, such asin personal growth or examinationperformance. However, whatever aprogramme’s desired outcomesmay be, its students must bring to itand build selves that are compatiblewith those outcomes.

Self-directed learning is conducted by thestudent and for the student

In addition to locating responsibil-ity and outcomes, the term ‘self-directed learning’ reminds us thatattributes of the learner are cogentin this form of learning. In SDL,students confront who they are aslearners and just what learningentails. For example, Frambachet al.1 indicate that secondaryschool experiences play an impor-tant role in preparation for SDL.These experiences shape students’views of both who they are as

Vancouver, British Columbia, Canada

Correspondence: Dr Gary Poole, Centre forHealth Education Scholarship, Faculty ofMedicine, University of British Columbia,Jim Pattison Pavilion North, VGH 910 West10th Avenue, Suite 3300, Vancouver, BritishColumbia V5Z 1M9, Canada.Tel: 00 1 604 875 4111 (ext. 67644);Fax: 00 1 604 875 8221;E-mail: gary.poole@ ubc.ca

doi: 10.1111/j.1365-2923.2012.04312.x

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learners and what it means tolearn.

Whatever a programme’s desired out-comes, its students must bring and build

selves that are compatible with thoseoutcomes

Hence, the concept of self figuresprominently in self-direction interms of the locus of responsibilityand outcome, as well as in theattributes and beliefs the self bringsto and develops when learning. It isthis prominence of self that hasdrawn Jennifer Kong and myselfto explore the self one bringsand the self one builds in SDL.Frambach et al. invite an expansionof our thinking in this regardto include considerations ofculture.1

When the authors refer to a stu-dent’s degree of preparation forSDL,1 I believe they are alluding toconsiderations of fit between theself and the demands of the learn-ing environment. In this vein,Hendry and Ginns2 identify attri-butes that they postulate enhanceone’s readiness for SDL. Theseinclude critical self-evaluation,learning self-efficacy, self-determi-nation and effective organisation.There is a lot of ‘self’ in theseattributes. Students must thinkabout themselves and ask someimportant questions. Can I effec-tively evaluate my own perfor-mance? Do I believe I can learnindependently? Am I indepen-dently motivated to learn? Can Istay organised?

The effort required to answerthese questions calls for a kind of‘constructive narcissism’. One mustbelieve that thinking about the selfis not ‘self-ish’, but necessary.Indeed, the process of reflectionthat includes the self as an objectof that reflection is considered

central to successful SDL.3 Thenature of this sort of reflectionwill vary across cultures andindividuals.4,5

One must believe that thinking about theself is not ‘self-ish’, but necessary

Furthermore, the way we thinkabout ourselves may well involvethe making of comparisons, bothwithin one’s self and between selfand others. The authors’ dataindicate that students in Asianand Middle Eastern contexts aremore competitive in nature thantheir Western counterparts.1 Iwould argue that ‘competitive’refers to a tendency to defineone’s self in comparative terms.Competitive students requireexternal, comparative data fromthings like examinations. Inproblem-based learning (PBL)settings, such students maycontinually compare their knowl-edge with that of other groupmembers. Contributing to others’knowledge would make thecomparison with self less favour-able; this is not the sort ofthinking that is conducive togood PBL work.

Thus far, I have focused on the selfthe learner brings to SDL. It isequally important to consider theself the learner builds during self-directed opportunities (G Poole,J Kong; unpublished research,2012). Regarding this buildingprocess, Frambach et al. remind usthat potentially students may inter-nalise what we might infer to be thePBL culture as much as they exter-nalise their cultural ways on thePBL setting.1

The way we think about ourselves mayinvolve making comparisons, both within

one’s self and between self and others

Internalisation of the PBL cultureinvolves the development of attri-butes that are conducive to self-direction and their incorporationinto one’s sense of self. To thisend, Frambach et al. provide evi-dence to indicate that students‘increasingly internalised the prin-ciple of SDL as they moved fromYear 1 to Year 3’.1 I would suggestthat this principle concerns thelocus of responsibility for learningdiscussed earlier in this commen-tary and consistent with the defi-nition of the principle the authorsprovide in their paper.1 I would gofurther to suggest that the processof internalisation, in this case,involves a comparison betweenwho students think they are andwhat they think is required of themin PBL. Over time, they build a selfthat they see as fitting more aptlywith the demands and learningopportunities of PBL.

Internalisation of the PBL cultureinvolves the development of attributes

that are conducive to self-direction

A pressing question for medicaleducators, regardless of their cul-ture, concerns whether we wantour students to build selves thatsupport SDL. Certainly, inWestern medical schools, in whichSDL opportunities that rangefrom PBL to self-directed scholarlyprojects are common, the answerwould be yes. In their concludingremarks, however, Frambach et al.1

caution against the assumptionthat Western values can be uni-versally applied. They state:‘Rather than taking on the cul-tural and contextual challenge ofadopting student-centred, prob-lem-based methods, it might bewiser for medical educationaliststo rise to the challenge ofexploring or creating alternativesthat best fit their particularcontext.’1

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The process of internalisation involves acomparison between who students thinkthey are and what they think is required

of them

For example, in North America anotion such as ‘adaptive expertise’6

is considered an important educa-tional outcome. Cooke and col-leagues6 draw a distinction betweenthe kind of expertise that requiresthe well-learned application ofknowledge to solve a problem andthe creative processes that generatenew approaches or that allow forthe kinds of foresight that antici-pate problems before they happen.Mylopoulos and Regehr assert that‘adaptive expertise is understood asthe product of a learned skill setthat must be encouraged and prac-tised from the earliest stages oftraining’.7 They are not alone inthis assertion. Indeed, a theme of

Cooke et al.’s Educating Physicians6

is that we need curricular reformthat allows students to build a senseof self that includes this kind ofexpertise.

Other cultures will have their owndesired outcomes in mind formedical education. Whatever thosemight be, students will need tobring and build selves that arecompatible with those outcomes. Inso doing, they are sculpted by theirculture and their learning environ-ments.

REFERENCES

1 Frambach J, Driessen E, Chan L-C,van der Vleuten CMP. Rethinkingthe globalisation of problem-basedlearning: how culture challengesself-directed learning. Med Educ2012;46:738–47.

2 Hendry GD, Ginns P. Readiness forself-directed learning: Validation of

a new scale with medical students.Med Teach 2009;31 (10):918–20.

3 Fisher M, King J, Tague G. Devel-opment of a self-directed learningreadiness scale for nursing educa-tion. Nurse Educ Today 2001;21:516–25.

4 Markus HR, Kitayama S. Cultureand the self: implications for cogni-tion, emotion, and motivation. PsychRev. 1991;98 (2):224–53.

5 Zhu Y, Han S. Cultural differencesin the self: from philosophy to psy-chology and neuroscience. Soc PersPsychol Compass 2008;2 (5):1799–811.

6 Cooke M, Irby DM, O’Brien BC.Educating physicians. A call for reformof medical school and residency. SanFrancisco: Jossey-Bass 2010;50.

7 Mylopoulos M, Regehr G. How stu-dent models of expertise and inno-vation impact the development ofadaptive expertise in medicine. MedEd. 2009;43:127–32.

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