Introduction
The contemporary medical environment has become increasingly specialized and complex, making it impossible for any single expert to address all emerging challenges [1]. The field of global medicine requires effective teamwork among professionals from diverse academic backgrounds to address health issues across varied cultural and socioeconomic settings [2-4]. The failure of teamwork has been recognized as a major contributor to compromised patient safety and poorer clinical outcomes, emphasizing the importance of team communication and interprofessional collaboration as core components of patient safety education [5,6].
In response to these demands, the need to foster teamwork skills has been increasingly emphasized in medical education and global medicine curricula. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), an evidence-based patient safety framework, highlights the centrality of effective teamwork [7]. The World Health Organization has similarly identified teamwork as a core competency in its patient safety curriculum guide for medical students [8], while in Korea, guidelines such as “Social competencies of Korean doctors” have emphasized teamwork and collaboration as essential competencies for physicians [9]. Efforts to cultivate collaborative learning cultures, including the development of learning communities in medical education, are also understood within this context [10].
Studies have demonstrated that structured teamwork education significantly improves outcomes in medical environments [11-13]. A recent scoping review reported that teamwork is among the most frequently achieved competencies in interprofessional education (IPE) programs, while also identifying challenges such as logistical constraints and hierarchical power dynamics [14]. Although faculty collaboration and student teamwork in Korean IPE have progressed, obstacles such as scheduling conflicts, faculty shortages, and limited resources continue to hinder program implementation [15].
Global health teamwork presents unique characteristics compared to TeamSTEPPS and IPE. While TeamSTEPPS focuses on standardized clinical communication and IPE emphasizes collaboration among healthcare professionals, global health teamwork requires collaboration among individuals from diverse disciplinary backgrounds working in resource-limited and culturally complex international environments. Moreover, global health programs frequently involve cooperation with foreign governments, international organizations, and local institutions, introducing additional diplomatic and cross-cultural complexities. This context entails challenges such as methodological diversity, cultural adaptation, multi-institutional coordination, and ethical considerations in international development cooperation. Given these unique features and the limited availability of theoretical frameworks for global health teamwork development, a qualitative case study methodology was selected to provide an in-depth understanding. This study specifically focused on graduate students. Whereas undergraduate education centers on foundational competency, the graduate level is a critical stage of professional socialization during which learners begin forming distinct professional identities [16,17].
The path for a team of professionals from diverse backgrounds to become effective is rarely straightforward. Teams commonly encounter challenges such as initial uncertainty, role conflicts and task-related conflicts, and communication difficulties [18]. The establishment of psychological safety, defined as a shared belief that the team is safe for interpersonal risk-taking, including admitting mistakes, asking questions, or suggesting new ideas, is emphasized as a core feature of high-performing teams [19,20].
In medical practice, teamwork is essential because collaboration and communication among professionals directly influence the quality of care. In global medicine, teamwork becomes even more complex due to cultural diversity, resource limitations, and the need to work with international stakeholders. Understanding how teamwork evolves from initial formation to project completion, and how interactions influence performance, is particularly important in global health settings. However, within global medical education, studies examining this developmental process remain limited.
This study aimed to address this gap by exploring the following research questions. (1) How does teamwork develop, and what characterizes each phase in a global medicine graduate program? (2) What efforts are necessary in medical education to effectively foster and develop teamwork skills?
Methods
1. Three-semester curriculum
The International Development Cooperation Expert Training Program at the Seoul National University Graduate School of Human Systems Medicine implemented a three-semester curriculum integrating theory, methodology, and field experience. The curriculum was intentionally structured with escalating complexity, beginning with foundational theories of program design and evaluation, advancing to mixed methods research training through collaborative activities, and culminating in a team-based field practicum. This graduated progression ensured that teams acquired adequate skills at each stage before advancing to more demanding tasks. Teamwork served as the pedagogical backbone of the curriculum, linking theoretical learning with practical application. An overview of the curriculum is provided in Appendix 1.
2. Study design
This study employed a qualitative case study methodology to analyze the teamwork development process. To explore the multifaceted dimensions of teamwork formed over the three-semester course, semi-structured interviews were used as the primary data collection method.
3. Participants and data collection
The study included 10 participants: one professor who designed and led the program, one teaching assistant who supported program operations, and eight graduate students. Because the objective was to examine the entire trajectory of teamwork development from its initial formation to its completion, only students who had finished all three semesters were eligible for interviews. Students who had completed fewer semesters or declined participation were excluded. Students were assigned to quantitative or qualitative research teams to complete collaborative research projects. The first author, who also participated in the program, later conducted interviews with all participants to explore their teamwork development experiences. Interviews were conducted individually for 45–120 minutes, either in person or through remote platforms. Interview duration varied depending on participants’ roles, the complexity of their experiences, and the depth of their reflections. The semi-structured format also enabled extended discussion of themes that emerged during the interviews. The interview questionnaire is presented in Appendix 2. Table 1 presents the characteristics of the professor and teaching assistant, and Table 2 describes the student participants. Age information was intentionally omitted to protect anonymity and respect privacy preferences.
4. Ethical considerations
The study received approval from the Institutional Review Board (IRB) of Seoul National University Hospital (IRB approval no., 2501-017-1602), and all participants provided written informed consent after receiving information about the study’s purpose and procedures. Participants were clearly informed that participation was voluntary and would not influence their course grades. They were also notified that all responses would be anonymized and that identifying details would be removed prior to analysis. Individual responses were kept strictly confidential, and faculty members had no access to student-specific data. The research team consisted of two authors: the first author (a student) and the corresponding author (the professor). To mitigate potential power imbalances, the first author conducted all interviews privately, without the professor present, ensuring that students and the teaching assistant could express their thoughts freely. Personal experiences in the program were cross-examined to assess whether they influenced interpretation of the data. Reflexivity was maintained through regular memo writing by the first author to monitor potential bias stemming from the dual role as both researcher and participant.
5. Data analysis
All interviews were audio-recorded with participants’ consent and fully transcribed in the original spoken language. Transcript analysis followed the six-step thematic analysis procedure proposed by Braun and Clarke [21] in 2006. The first step involved extensive familiarization with the data; the first author read all transcripts multiple times to gain a deep understanding of participants’ teamwork experiences and to generate initial ideas about developmental patterns. The second step involved systematically generating initial codes across the entire dataset to identify key elements. In the third step, related codes were grouped to search for broader themes, leading to the identification of five major themes representing distinct phases of teamwork development: team building, adjustment, rule setting, implementation, and adaptation. The fourth step consisted of reviewing these themes through a two-level process. First, all coded data extracts within each theme were examined to ensure internal coherence and relevance to teamwork formation. Second, the five themes were assessed against the entire dataset to determine whether they sufficiently explained the teamwork development process and accurately reflected participants’ experiences. The fifth step involved defining and naming each theme to clearly represent the essence of each developmental phase and its sequential relationships. In the final step, the analysis report was produced by selecting representative quotations that illustrated each theme and constructing a coherent narrative explaining how interdisciplinary teams develop in global medicine contexts. To enhance reliability, the corresponding author provided methodological guidance and reviewed the coding framework and thematic development. Two independent researchers also conducted cross-validation of initial codes and emerging themes. Additionally, member checking was performed with selected participants, who reviewed the key themes and interpretations and confirmed that the analysis aligned with their experiences. Figure 1 illustrates the research process.
Results
Through thematic analysis, this study identified five major phases in the development of teamwork: team building, adjustment, rule setting, implementation, and adaptation. These phases emerged as a sequential developmental process, with each phase building upon the previous one as teams progressed through the three-semester curriculum. Key facilitators influenced the transitions between phases. Initially, structured task requirements created natural pressure points that encouraged teams to move from team building to adjustment. Subsequently, the successful resolution of conflicts and clarification of leadership roles were pivotal in establishing team norms, enabling the transition from adjustment to rule setting. The establishment of psychological safety then facilitated efficient collaboration, marking the shift from rule setting to implementation. Finally, the environmental demands of the field practicum required adaptive flexibility, which enabled the transition from implementation to adaptation. The following section provides an in-depth exploration of each phase, illustrating how teamwork evolved and matured and incorporating participant quotations to exemplify each sub-theme (Figure 2, Table 3).
1. Phase 1: team building
1) Initial relationship building
When teams first formed, students described an atmosphere characterized by caution and reserve.
“At first, my team members were reserved and cautious with each other.” (Student 1)
“In the beginning, there was a vague uncertainty about how students from diverse majors should communicate and how we could connect each other's expertise.” (Student 5)
2) Task-oriented collaboration
Early in the program, clear assignments offered concrete starting points for collaboration.
“What the class can provide is clear assignments. When the assignment requirements are clear, people can easily collaborate around shared goals.” (Student 2)
“I believe our team was successful because everyone had a common goal of gaining something from the project evaluation practice, which is why everyone participated actively without any free riders.” (Student 4)
3) Role and competency uncertainty
Despite these structural supports, some students expressed concern about their ability to contribute meaningfully, especially when their academic background was not directly related to international health.
“Initially, I was worried because I don’t have a background in international health, but I found I could contribute through quantitative research skills.” (Student 8)
“The first semester was focused on methodology. Since my major also has similar courses, the content itself wasn’t entirely new to me. However, it was presented at a much more sophisticated level than what I was accustomed to, so it was quite challenging.” (Student 6)
2. Phase 2: adjustment
1) Role conflict
With the initial trust and structure established, teams began negotiating responsibilities. Disagreements and confusion often arose as students attempted to determine appropriate role distributions and decision-making processes.
“When you have 10 people, there’s a tendency for everyone to just do their own task, and it's difficult to pay attention to what others are doing.” (Student 5)
“When everything is decided entirely within the team, it becomes difficult to judge whose opinion is correct, and we tend to follow certain people.” (Student 2)
2) Task-related conflict
A distinctive issue was conflict arising from differing approaches to the task, particularly between quantitative and qualitative methodologies.
“There wasn’t a well-defined structure for how the two teams should collaborate. We understood we were implementing mixed methods, but the ‘how’ was left up to us to figure out.” (Student 4)
“While the essence of our course was mixed methods research, the qualitative and quantitative teams unfortunately operated in isolation. Ideally, we should have engaged in collaborative discussions and cross-validated each other's findings. However, being preoccupied with our individual team responsibilities prevented this integration, which was disappointing.” (Student 8)
3) Leadership and followership challenges
Leadership and followership emerged as essential but fluid roles during negotiation.
“Leadership is needed to form a team, and that leadership is really important. But what equally matters is followership, understanding when to lead and when to support others’ leadership.” (Student 3)
“Our team leader did an excellent job of role distribution. Thanks to our team leader’s sacrifice and leadership, our team was able to operate well.” (Student 7)
3. Phase 3: rule setting
1) Communication norms
As roles and relationships stabilized, teams began establishing communication norms that strengthened trust.
“Above all, it’s important to be a good listener to each other.” (Student 5)
“When disagreements arise, a process of resolving problems through evidence-based communication and consensus building is necessary.” (Student 3)
2) Clarification of responsibility and authority
To manage accountability, teams negotiated formal and informal rules regarding participation, deadlines, and decision-making authority.
“I tried to provide team leaders with both responsibility and authority. They needed to lead team members while also being recognized for their efforts.” (Professor)
“The role of the team leader is important, and a certain degree of directive leadership to ensure accountability is also necessary.” (Student 6)
3) Establishing psychological safety
A critical component of effective teamwork was developing a climate where members could acknowledge limitations without fear of judgment. As norms became established, students gradually built the trust necessary to express vulnerability.
“In graduate school, there’s also the matter of saving face. It’s really hard to say that you don’t know something.” (Student 1)
“The class proceeds under the assumption that every student knows. So, people like me, who didn’t know much, often felt like we were falling behind. Therefore, a comfortable atmosphere where students can freely say they don’t know is important for teamwork.” (Student 2)
4) Leadership stabilization
Effective teams found that stable leadership became increasingly important as they grew in size and complexity.
“I think the leadership of the team leader becomes extremely important, especially in larger groups. Knowing when to cut discussions short and when to move forward with decisions even if some opinions aren’t fully heard.” (Student 5)
4. Phase 4: implementation
1) Efficient role performance
By the implementation phase, teams had established stable work rhythms. Members increasingly relied on one another’s expertise, assigning responsibilities based on individual strengths and prior experience.
“For the work that came to me, I tried my best to meet deadlines and such, so as not to cause any trouble for the team.” (Student 6)
2) Creative problem-solving
The team’s disciplinary diversity enabled creative problem-solving and fostered innovative approaches to complex tasks.
“Because we came from diverse fields, we were able to approach problems creatively and achieve strong results.” (Student 1)
“The process of engaging in collective problem-solving and making decisions as a team was a great learning experience.” (Student 7)
3) Resource optimization
As teams matured, members voluntarily selected tasks aligned not only with their skills but also with their personal interests, which enhanced engagement and ownership. Clear delegation and well-defined accountability facilitated the timely completion of complex assignments, even under compressed schedules.
“Team members stepped forward to take on tasks aligned with their strengths and areas of experience, which made our work distribution quite effective.” (Student 7)
“Thanks to the team members from various majors, the knowledge needed to solve complex tasks was naturally shared within the team.” (Student 8)
5. Phase 5: adaptation
1) Field environment adaptation
The field experience in Cambodia introduced abrupt shifts and persistent uncertainties, including unpredictable local conditions and challenges in coordinating with stakeholders.
“The first day was primarily orientation, and by the second and third days, we were beginning to adapt and gradually preparing more effective research.” (Teaching assistant)
“There were unexpected difficulties in Cambodia, such as the fatigue from communicating through translators and the doubt about whether my intentions were being accurately conveyed.” (Student 1)
2) Flexible role adjustment
Success in the field depended on the team’s willingness to adjust previously established roles, assume new responsibilities when necessary, and work under non-ideal conditions. Teams learned to prioritize collective goals over individual preferences, which strengthened cohesion.
“I think we need to make an effort to understand each other. Even if things do not go as planned, rather than blaming one another, we should adjust our roles, focus on the next steps, and adapt quickly.” (Student 1)
“Since this was my first time doing qualitative research and fieldwork, I realized that following theory in the field was almost impossible. We had to be flexible and adapt our roles and methods to the actual conditions.” (Student 5)
3) Knowledge transfer and trust reinforcement
The intensity of the shared field experience facilitated strong and enduring professional relationships. These bonds extended beyond the program and provided a foundation for continued collaboration in future international health work.
“Now we’re so close that whenever someone needs assistance, everyone is willing to help. We even talk about helping each other with research projects and papers in the future.” (Student 1)
“This experience has given me the courage to try new things and reduced my fear or resistance towards participating in future team activities.” (Student 7)
Discussion
This study aimed to examine how teamwork develops among graduate students in an interdisciplinary medical education program. The research identified and articulated a five-phase teamwork development process: team building, adjustment, rule setting, implementation, and adaptation. The five-phase model, derived from thematic analysis of participant interviews, extends Tuckman’s framework by capturing distinctive features of medical education contexts and the unique demands of interdisciplinary global health training.
This aligns with existing research, such as Tuckman’s model of group development [22] and the model of team development by Hut and Molleman [23], while also illustrating the specific dynamics characterizing interdisciplinary teamwork in global medicine education. Unlike previous models centered on general team development or collaboration among healthcare professionals, the process examined here addresses the distinctive challenges of interdisciplinary global health teamwork.
This study identified four major findings. First, at the initial phase of interdisciplinary team formation, providing clear and specific task objectives was found to be an effective strategy for fostering collaboration [24]. Second, during the adjustment phase, when conflicts emerged, framing these conflicts as a natural part of team development and creating structured opportunities for open discussion facilitated more constructive resolution [25,26].
Third, psychological safety emerged as a cornerstone principle in the rule setting phase. Defined as an environment where members can express opinions, acknowledge knowledge gaps, and ask questions without fear of adverse consequences, psychological safety is a recognized hallmark of high-performing teams [19,20]. Participants described reluctance to admit a lack of knowledge due to concerns about embarrassment (Student 1) or perceived expectations that all members already possessed the required expertise (Student 2). These findings highlight how the absence of psychological safety can impede genuine collaboration and learning.
Finally, the adaptation phase underscored the decisive role of the field practicum [27]. The challenging and unpredictable nature of this experience served as a pivotal trial, strengthening team cohesion and enhancing problem-solving capacities to their peak [28].
This study identifies four essential strategies necessary for effectively fostering and developing teamwork skills in medical education. First, fostering psychological safety is vital, as it enables members to acknowledge limitations and communicate openly. Edmondson [19] notes that psychological safety is not simply about maintaining a positive atmosphere but about creating conditions where individuals feel comfortable expressing themselves, which is crucial for team learning. Grailey et al. [29] similarly emphasize that high psychological safety improves creative performance and quality improvement. In healthcare, hierarchical cultures can inhibit communication from learners. In this study, cultural norms around preserving dignity and high academic achievement made students reluctant to acknowledge shortcomings. Overcoming such barriers requires deliberate, long-term interventions. Programs should extend over sufficient periods, such as the three-semester structure in this study, and intentionally incorporate interpersonal engagement opportunities, including shared meals and regular team activity sessions. In global medicine training, classes should therefore be designed with explicit attention to supporting students’ psychological safety. For example, in the second semester of this program, each class included over an hour of dedicated team activity time in preparation for the subsequent field practicum in Cambodia.
Second, the implementation of integration strategies for multidisciplinary teams is essential. Medical education should emphasize the development of integrative approaches that respect each profession’s unique perspectives and methodologies, including those of clinicians, public health specialists, and health policy professionals. Such integration must go beyond simple role distribution and focus on mechanisms that generate true synergy. Clear task objectives alone are insufficient; programs must explicitly define individual roles and establish concrete systems for collaboration. Consistent with Tuckman’s model, a team becomes an effective problem-solving unit only after internal conflicts have been addressed and functional roles established [22]. Such structural clarity reduces ambiguity in clinical settings. By preventing dominance by only a few members and promoting balanced participation, integrated role systems allow medical teams to navigate uncertainty more effectively [30].
Third, the adaptation phase highlighted that real-world challenges act as a catalyst for advanced teamwork. Although these experiences are demanding, they foster stronger interpersonal bonds and lead to measurable improvements in teamwork, adaptability, and problem-solving capabilities. This aligns with the experiential learning theory by Kolb [31], which posits that concrete experiences in authentic settings drive transformative learning through reflection and experimentation. In this program, the demanding and unpredictable nature of the Cambodia field practicum significantly enhanced team effectiveness and mutual trust. International medical settings also present unique challenges, including communication difficulties arising from language and cultural barriers. Furthermore, as participants described, teams must make rapid decisions amid resource constraints and ethical dilemmas. Therefore, while providing opportunities for field experience, training must also prioritize cultivating cultural competency, overcoming language barriers, and strengthening the team’s ability to devise ethical and contextually appropriate solutions under real-world constraints.
Fourth, teamwork education benefits from curricula that progressively increase in complexity and difficulty. Such scaffolding is essential because teams must build a solid foundation before tackling high-stakes collaborative challenges, such as managing simulated patient crises. Introducing highly difficult tasks prematurely may overwhelm developing teams and hinder learning. Medical education programs should therefore adopt scaffolded approaches that allow natural skill progression, moving from classroom-based collaboration, such as problem-based learning (PBL), to more complex simulations and ultimately to supervised clinical practice. This developmental trajectory aligns with Vygotsky’s concept of scaffolding [32].
This study has limitations due to its qualitative design and the fact that it was conducted at a single graduate school of medicine with a small number of participants. Nonetheless, the aim of this research was to provide a rich, in-depth understanding of a complex teamwork process, which can offer valuable theoretical insights and practical guidance for other programs. The professor–student dynamics inherent in the research setting present another potential limitation. However, measures such as ensuring voluntary participation without any effect on grades and guaranteeing strict anonymization were implemented to mitigate this bias. Future research could include comparative studies across multiple institutions and programs or longitudinal studies examining how teamwork skills evolve over time following program completion.
Importantly, in the context of global medical education, in-depth empirical investigations into the developmental process of teamwork remain scarce. The strategies identified in this study offer insights that can be applied across diverse medical education contexts. For example, in undergraduate and graduate PBL settings, the principles of initial relationship building and psychological safety are crucial for fostering effective collaborative learning environments. Similarly, in clinical practice, leadership development, flexible role adjustment, and structured communication can substantially strengthen multidisciplinary collaboration and team-based approaches to patient safety. By providing a structured framework for team development, this study is expected to contribute to the advancement of essential teamwork competencies required in modern medical practice.
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