Study design and setting
This qualitative thematic content analysis study explored the challenges of teaching English to medical students in Iran and was designed to ensure high standards of credibility, dependability, confirmability, and transferability [22] based on four criteria of Lincoln and Guba [23]. This study followed a multi-step approach in collecting data from respondents to ensure validity. Such an approach allowed for an in-depth inquiry into the exact nature of challenges in the specified setting. The research was conducted at medical universities across Iran, involving experienced medical English instructors and medical science students from various academic years. This setting provided a rich context for understanding the unique challenges within the medical education framework. The study was conducted from September 2023 to February 2024.
This study has been designed and written following the 32-item Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure integrity and transparency. COREQ gives extensive guidance for integrity and transparency for qualitative research using interviews and focus groups. The COREQ checklist directed reporting around: researcher characteristics and reflexivity, study design, data collection, analysis, and findings. Details regarding the research team’s backgrounds and roles, participant selection, interview procedures, and data analysis are provided to ensure methodological transparency and reproducibility [24].
Participants/ sampling
The study targeted a diverse group of participants, including instructors and students. The study involved participants from five medical universities across Iran, selected to represent diverse geographic and institutional contexts. Universities were chosen based on their active medical English programs and willingness to participate in the study.
Both instructors and students were recruited through purposive sampling to ensure participants had relevant experience with medical English education.
Inclusion criteria for instructors included being faculty members with at least three years of experience teaching medical English and familiarity with modern educational methods and technologies.
The purposive sampling procedure started with five initial samples and eventually reached data saturation with 13 samples.
The inclusion criteria for students included the non-guest medical university students from various academic years enrolled in medical English courses within the last three years at one of the selected universities. Visiting students from other universities and those who did not wish to continue with the interviews were excluded from the study. Student purposive sampling also started with five initial samples and reached saturation with 10 samples.
This method allowed for a broader perspective on the challenges encountered in medical English education. This diversity enhances the generalizability of the findings within the context of Iranian medical education. The selection of study participants continued until the saturation of data. Finally, a total of 23 (13 instructors and 10 students) were recruited for this study, balancing different educational backgrounds and experiences.
All participants were informed of the study and signed the informed consent form.
During the study period, students who were registered for the medical English course and officially enrolled in the university’s medical program were referred to as “non-guests.” To preserve uniformity in the curriculum exposure and educational context, visiting or guest students from other institutions were not allowed.
Students’ Grade Point Average (GPA)_ on a 0–20 scale, as commonly used in Iranian universities_ was gathered as required information on participants’ academic backgrounds, their academic standing in relation to their experiences learning medical English is framed by this measure.
Tools/ instrument
The research instrument was a semi-structured questionnaire with 10 main questions and several probing questions, which were used during in-depth interview sessions. These questions underwent a thorough refinement process during the pilot phase. To increase the validity of the research, triangulation was employed, incorporating insights from experienced medical educators and research faculty at the medical university involved in the study, following the guidelines outlined in AMEE Guide No. 87, which emphasizes best practices in medical education research [25]. Additionally, a constructive approach was taken through cognitive interviews, where the researcher engaged in discussions with colleagues from the fields of public health and medical education.
The interview guide was developed by the research team for this specific study, based on prior literature and expert input. The semi-structured interview guides, developed separately for instructors and students, are provided in both English and Persian as Supplementary Files 1,2,3, and 4. These guides include core and probing questions to ensure consistency and depth across interviews. (see Supplementary Files 1,2,3 & 4)
Interview Questions.
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1.
What are the primary challenges you face in teaching English to medical students in Iran?
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2.
How do you perceive the effectiveness of current English language instruction for medical students?
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3.
Which language skills (listening, speaking, reading, writing) do you emphasize most in your classes, and why?
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4.
How do institutional policies and available resources affect your teaching of English in medical schools?
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5.
What infrastructural or organizational needs do you think are necessary for improving EMP instruction?
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6.
What strategies do you use to overcome language barriers among your students?
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7.
What role does technology play in facilitating or hindering English language learning for medical students?
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8.
In your experience, how does English proficiency impact students’ academic performance and clinical competencies?
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9.
How do you currently use technological tools in your courses? Are there any tools or platforms you find particularly effective?
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10.
What are your thoughts on incorporating gamification (using game-like elements) into EMP teaching? Have you used or considered such methods?
In addition to the main questions, which were conducted in a comfortable and open environment tailored to the conditions and choices of the participants, more detailed questions might have been asked to further explain the topic. Also, depending on the participants’ responses, follow-up questions were sometimes posed to elicit deeper answers.
Data collection
Research team and reflexivity
The research team was made of four members: two with expertise in e-learning and medical education (ZZ, ZK), one with a background in qualitative research and English for Medical Purposes (NZ), and one with experience in teaching English as a foreign language (AF). The interviews were conducted by ZZ (Ph.D. candidate in e-learning), who had prior experience in qualitative interviewing and no direct teaching relationship with the participants, minimizing the chance of bias. Throughout the research process, the research team discussed coding strategies, worked together to create the interview guides, and regularly reflected on their positionality and assumptions throughout the research process.
Interviews
Semi-structured interviews were conducted in a quiet, private setting to create an environment where the discussion could be openly shared. Interviews were conducted either face-to-face or online (via Google Meet), depending on participant preference and considering geographical dispersion among the participants from different medical universities (Medical Universities of Iran).
Each interview lasted approximately 45 to 60 min and was audio-recorded with the participants’ approval. The interviews were then transcribed verbatim for analysis. The interviewer followed a semi-structured guide tailored to each participant group (instructors and students), allowing for flexibility to probe emerging topics. The interviewer maintained field notes to capture non-verbal cues and contextual factors.
Before interviews, participants received a brief explanation of gamification, including definition, application, and examples such as language-learning apps and scenario-based simulations. This guaranteed shared understanding while allowing participants to reflect on their experiences with or without being directly exposed to such methodologies.
To ensure comfort and clarity during data collection, all interviews and questionnaires were conducted in the participants’ native Persian (Farsi). Richer, more complex answers were made possible by this decision. Persian interview guides and questionnaires were created, and for analysis and reporting purposes, they were subsequently translated into English.
Data analysis
Thematic content analysis was employed to analyze the transcribed interviews and transform raw qualitative data into meaningful insights in an iterative and dynamic approach.
Data analysis followed the steps outlined by Braun and Clarke for thematic analysis [26], including familiarization with the transcripts, coding by two independent researchers (ZZ, ZK), and iterative theme development through team discussions. Discrepancies in coding were resolved through consensus. To increase trustworthiness, member checking was performed by sharing preliminary findings with selected participants for feedback.
The analysis involved several steps:
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Familiarization with the Data: Repeated reading of interview transcripts and field notes to gain a deep understanding of the data.
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Identifying Significant Statements: Carefully selecting statements that captured the essence of participants’ experiences and generating preliminary descriptive labels for deeper analysis.
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Coding and Theme Development: Coding the data to identify significant themes related to the challenges faced by both instructors and students and categorizing these codes into broader themes that represent common issues in teaching and learning specialized English.
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Theme Review and Refinement: Reviewing themes to ensure they accurately represent the data in their most appropriate form.
Analysis was conducted based on the following definitions:
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Theme: Overarching conceptual category representing major research findings.
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Sub-themes: Secondary interpretive layer providing contextual understanding.
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Open Codes: Specific descriptive elements extracted directly from raw data.
In recording and transcribing the interviews, efforts were made to maintain the integrity of the text without altering the expression of sentences and phrases. After extracting themes, the interview transcripts were sent to participants for review and confirmation. Additionally, the themes and sub-themes were reviewed by three peers with PhDs in Medical Education and English Language Education. The analytical process involved continuous refinement of coding categories, creating a flexible framework. Researchers were receptive to emerging insights, repeatedly revisiting and adjusting initial codes based on consultation and peer feedback. This iterative approach provided a dynamic and comprehensive qualitative analysis that captured the complexity of the research phenomenon. In addition to qualitative content analysis, the frequency of each code was also counted. This method, which is considered quantitative content analysis, helps to consider the frequency and emphasis placed on each code.
Reflexivity
Reflexivity was critical throughout the research process, as it involved reflecting on the researchers’ biases, experiences, and assumptions that could influence data collection and analysis. The frequent discussions between the research team allowed various perspectives to be considered, minimizing the probability of any single bias occurring. The researchers also mentioned their backgrounds in language education, which would influence how they viewed the data. This constant reflection helped the researchers be conscious of their perspectives and aware of how they may influence the data analysis.
Trustworthiness
Some strategies were used to enhance trustworthiness, including member checking, which entailed sharing findings with participants to receive their feedback on the accuracy of interpretations, and triangulation, which consisted of comparing data from various participants, such as medical students and instructors. This approach ensured a complete understanding of the real challenges in learning and teaching medical English.
Audit trails were maintained during the data collection, analysis, and decision-making stages. Furthermore, peer debriefings were convened with colleagues unrelated to the study to share research findings and interpretations with them. All these increased the credibility and dependability of the study’s findings, which have provided useful insights into the many faces of English language education in medical contexts in Iran.
Ethical considerations
This study received ethical approval from the Institutional Review Board of Shiraz University of Medical Sciences (IR.SUMS.REC.1403.510).
Before participation, all individuals had an information sheet with details of the study’s objectives, procedures, and possible harms and benefits. Written informed consent was obtained from each participant with an emphasis on their voluntary participation and ability to withdraw from participation at any time without repercussion. Participants were also given privacy and comfort, conducting interviews in the locations chosen by participants. During face-to-face interviews, a quiet and private room was secured prior to the interview at the university or an alternate location mutually agreed upon, to decrease interruptions and reasonably protect confidentiality.
Remote participants were offered a secure link to participate (Google Meet) while maintaining the ability to ensure a private consultation on both sides. Confidentiality was strictly maintained. All recordings and transcripts of the interviews were anonymized by removing identifying information and assigning each participant a unique code. All data (raw) was only accessible by the research team, and was stored securely on password protected devices. Audio and video recordings were completed for transcription analysis purposes only, and would be deleted after the study.
In discussing results, we were careful to report the data in aggregate form and not to disclose any information that could indirectly identify the participants. Participants were forewarned of the questions or nature of the questions and of the materials that would be audio or video recorded in advance of the interview. Each participant was emailed the interview guide in advance of the interview so they could review the subject matter and prepare for the interview. All the procedures were conducted under the Declaration of Helsinki and institutional policy guidelines.
