Chinese is widely recognized as a complex and challenging language, particularly for individuals whose native languages differ significantly in terms of grammar, phonetics, and writing systems. Despite receiving short-term Chinese language training prior to their studies in China, international students often struggle to communicate effectively with instructors due to the language’s complexity and insufficient preparation time. Over 70% of international students in China come from non-English-speaking countries in Asia, Africa and Latin America (Biney and Cheng, 2021), many of whom speak English with strong accents. Since China is also a non-English-speaking country, this linguistic gap frequently leads to communication barriers between instructors and international students (Li et al., 2020). Additionally, students with poorer English tend to be less adept at communication, social interaction, and cultural understanding in healthcare settings, demonstrating more homesickness and achieving inferior academic progress (Wang et al., 2015). These language barriers severely impact the transmission of knowledge between teaching and learning (Jiang et al., 2024b; Liu et al., 2017), and cause some international students to become passive in the learning process (Tan et al., 2022).

International students came from different countries around the world with varied levels of basic education (Medved et al., 2013). There are significant differences in the overall quality and basic cultural knowledge between international students and domestic medical students who participate in unified entrance examinations. In addition, due to different educational concepts at home and abroad, international students prefer interactive teaching method that allow for spontaneous questioning and timely feedback from instructor. International students in China experience higher acculturative stress than those in developed countries (e.g., Europe, America, and Oceania), particularly those from Africa and Asia (Yu et al., 2014). Socioeconomic status and cultural factors such as values of face and the ideology of individualism and collectivism, significantly contribute to these differences in stress (Yu et al., 2014). Significant variations in educational approaches, medical environments, and a lack of social support further hinder international students’ adaptation to domestic teaching methods.

Anesthesiology is a highly practical discipline that emphasizes hands-on operation skills, such as tracheal intubation, arterial puncture, central venous puncture, and various nerve blocks. Therefore, anesthesiology teaching requires international students to not only master the theoretical basics of anesthesiology but also need considerable opportunities to practice and communicate (He et al., 2022). In clinical education, communication with patients is a fundamental element of learning. However, compared to their Chinese counterparts, international medical students often encounter language barriers during clinical rotational internships, as Chinese patients rarely speak English. Additionally, foreign interns are less recognized and accepted by Chinese patients, often refusing to allow their participation in clinical practice (Müller-Wolff et al., 2024). All these factors make it difficult for international medical students to integrate theory and practice in clinical settings, significantly reduces the effectiveness of their education.

Anesthesiology is distinct from other disciplines due to its high practicality and the urgency required in managing emergencies promptly. Therefore, education for anesthesiologist focuses on equipping students with high-quality perioperative knowledge, diverse practical skills, critical thinking, and the capacity for continuous learning (Mossenson et al., 2021; Rock, 2000). It involves foundational disciplines such as anatomy, physiology, pathophysiology, and pharmacology, while also integrating knowledge from internal medicine, surgery, emergency medicine, and critical care medicine. The wide scope of knowledge in this discipline makes it difficult for international students to master all related knowledge in a short time. Additionally, anesthesiologists frequently collaborate with various surgical departments, which necessitates mastering a range of complex and specialized anesthesia techniques. Therefore, anesthesiology education demands an integrated and comprehensive approach to develop both the technical proficiency and interdisciplinary knowledge essential for effective clinical practice, particularly for international students facing additional learning challenges.

Surgeries or invasive treatments require a multidisciplinary team collaboration. Anesthesiologists are responsible for assessing the patient’s overall condition before surgery, creating a personalized anesthesia plan (Bastola et al., 2024). The accuracy and success of this plan depend on the anesthesiologist’s comprehensive understanding and proficiency in multidisciplinary knowledge and surgical techniques. During the surgery, anesthesiologists need to proficiently manage breathing and circulation, and perform various invasive procedures and monitoring techniques to ensure the safety (Oliveira et al., 2017; Alekseev, 2015). Meanwhile, anesthesiologists are responsible for managing postoperative pain to accelerate patient recovery. In short, accurately assess patient’s condition, timely provide interventions, maintain and regulate vital functions, and finally ensure the patient safety during the perioperative period are the primary mission of anesthesiologists (Drake, 2013).

Anesthesiology education holds unique significance due to its integration of rapid physiological control, high-stakes decision-making, and multidisciplinary collaboration. One of the most amazing aspects of anesthesia is its ability to induce an instantaneous transition from consciousness to unconsciousness in patients, that is unparalleled in any other in medicine. However, medical students new to the field often focus disproportionately on mastering invasive procedures while overlooking essential skills such as perioperative assessment and the interpretation and regulation of intraoperative vital signs (Spijkerman et al., 2025), which are critical for patients safety and effective clinical care.

Furthermore, the Accreditation Council for Graduate Medical Education (ACGME) in the United States has proposed six core competencies for clinical physicians: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (Batalden et al., 2002). Given the inherently collaborative nature of anesthesiology, educators must go beyond technical instruction to foster crisis management, teamwork, and lifelong learning abilities—key components of a clinician’s global competence (Yang et al., 2019). Meanwhile, faculty role models significantly influence learner engagement. For instance, a study showed that 94% of students interested in pursuing a career in anesthesia considered the presence of inspiring role models as a decisive factor (Watts et al., 1998). So, instructors should set exemplary standards during anesthesia management, allowing students to feel the professionalism, communication skills, and interpersonal handling capabilities.

Notably, most international anesthesiology students in China originate from low- and lower-middle-income countries in Asia and Africa, with the majority intending to return home countries after graduation to strengthen the local healthcare system (Li et al., 2020; Jiang et al., 2024b), which also play a valuable role in both the global health workforce. Consequently, the primary goal of educating international students in anesthesiology is to develop qualified medical professionals for their home countries. This dual focus, technical mastery and global professionalism, ensures graduates are equipped to address both immediate clinical demands and long-term healthcare challenges in their home countries.

Effective international anesthesiology education begins with faculty development, and young teachers serve as a driving force within teaching teams (Huhn et al., 2016). Typically, these educators possess impressive academic backgrounds, excellent lifelong learning capabilities, and a rapid adaptability to embrace new concepts, making them the backbone to internationalized education. However, most young teachers still struggle with weak spoken communication and limited medical terminology knowledge. Limited English proficiency among instructors and a lack of confidence are key factors contributing to academic difficulties of international students, often leading to decreased engagement and participation (Jiang et al., 2022). Therefore, it is essential to establish a core team of instructors with overseas academic or clinical experience to ensure foundational language competency (Yang et al., 2019; Rashid et al., 2020). Additionally, the implementation of medical English workshops focusing on anesthesiology terminology and clinical communication scenarios (e.g., preoperative evaluation, pain management protocols) could strengthen instructors’ professional language proficiency in real clinical contexts. These immersive, English-only case discussions could reinforce practical language application. Furthermore, the application of AI-powered tools (e.g., speech recognition software) can provide instructors with real-time feedback on pronunciation and fluency, creating a robust system for developing both faculty and student language competencies in authentic clinical settings.

Clinical training in China requires Chinese proficiency for patient interactions (Liu, 2022). Given that English-speaking patients are exceptionally rare in Chinese healthcare settings, international students lacking basic Chinese proficiency face significant barriers in conducting preoperative evaluations, comprehending patient conditions, and developing appropriate anesthesia plans (Akanuma, 2023). Therefore, bilingual education serves as a critical bridge, enabling international students active communication with patients, understanding and grasp their conditions, shortening their distance, and ultimately earning patient trust through enhanced clinical interactions (Liu and Chong, 2024). The impact of language proficiency, particularly Chinese competence, on international medical students’ clinical performance cannot be overstated. Although theoretical instruction may be delivered in English, clinical practice inevitably demands interaction with Chinese-speaking patients and healthcare staff, where language barriers became acutely apparent. Students with better Chinese speaking skills and active communication initiatives had significantly better clinical experiences, as these skills were crucial in internships and patient care roles. The implementation of bilingual teaching should adopt a progressive approach, aligned with international students’ needs and curriculum arrangements. The pedagogical progression should begin with English-dominant instruction supplemented by Chinese, then gradually transition to balanced bilingual teaching while incorporating interactive methodologies such as bilingual anesthesia videos, clinical case discussions, and teaching rounds (Müller-Wolff et al., 2024). Through professional bilingual teaching, instructors can provide international students with practical clinical training, a better understanding of various anesthesia-related issues, and improved clinical anesthesiology education.

PBL represents a paradigm shift in medical education, using clinical problems as the foundation for active learning (Chilkoti et al., 2014). This heuristic approach positions students as primary investigators who collaboratively explore authentic clinical scenarios under faculty guidance. The open-ended nature of PBL fosters critical thinking beyond classroom boundaries, and creates an inclusive environment that promotes learner autonomy and research engagement. A recent study at Xi’an Jiaotong University has introduced English-based PBL into the Histology and Embryology course for international medical students, with over 70% of participants reporting high satisfaction and notable improvements in critical thinking and clinical reasoning skills (Hoy, 2021). Particularly valuable for international students, PBL enhances long-term cognitive development through its emphasis on self-directed problem-solving.

The key to PBL lies in the design of problems, which should be based on the overall curriculum and knowledge structure, aligning with course objectives and practical plans. Teachers need to design problems tailored to students’ varying levels of understanding of anesthesia theory. While PBL is problem-oriented, it may compromise the completeness of foundational theoretical knowledge. Students with weaker self-directed learning abilities might struggle, leading to confusion, deviation from learning goals, and ultimately inadequate preparation and engagement in PBL courses.

CBL is a robust clinical teaching methodology that immerses students in authentic patient care scenarios. In this approach, students assume the role of attending physicians, to synthesize and apply theoretical knowledge to conduct comprehensive patient evaluations, formulate differential diagnoses, and develop evidence-based management plans. CBL framework emphasizes self-directed learning through individual case analysis, collaborative group discussions to explore diagnostic and therapeutic alternatives, and faculty-facilitated synthesis of clinical reasoning principles (Duan et al., 2021). When contrasted with PBL, CBL demonstrates distinct advantages in clinical education settings by offering a more structured yet equally interactive approach to learning. While both methods promote active engagement, CBL framework allows for more efficient time utilization through focused clinical scenarios, ensures systematic coverage of core competencies, and provides clearer guidance for learners navigating unfamiliar healthcare systems. This balance of structure and flexibility makes CBL particularly valuable for international medical students, as it maintains the benefits of interactive learning while offering explicit clinical anchors to facilitate adaptation to new medical environments. Qu Qicai et al. demonstrated that CBL methods significantly improved theoretical scores, engagement, and learning efficiency among international anesthesiology students compared to traditional lectures-based methods at the Second Affiliated Hospital of Kunming Medical University (Qu et al., 2018).

However, CBL implementation presents certain challenges. Instructors demands substantial prepare time compared to traditional lectures. Additionally, the structured nature of cases may potentially limit student initiative if not properly balanced with open-ended inquiry. The PBL-CBL hybrid model combines the strengths of both approaches, in which instructors select typical clinical cases to teach, posing questions that encourage students to integrate theoretical knowledge with practical applications, to help students connect theoretical knowledge with real-world applications, thereby enhancing their clinical skills and problem-solving abilities (Yang et al., 2023).

The flipped classroom approach reshapes the traditional teaching paradigm by reversing the roles of classroom and homework time: students learn new content before class, while class time is dedicated to group collaboration and teacher-led Q&A (Martinelli et al., 2017). This pedagogical shift fosters greater student engagement, encourages critical thinking, and facilitates hands-on application in class. In the field of anesthesiology, where both theoretical understanding and procedural competence are equally vital, students can first build a foundation through pre-class online resources, then apply and reinforce this knowledge through in-class simulation and discussion-based training (Kurup and Hersey, 2013). Implementing the flipped classroom model effectively, however, requires robust digital infrastructure and the adoption of innovative teaching tools. In the context of the “Internet Plus” era, online teaching has become an indispensable component of medical education, offering both opportunities and challenges for anesthesiology training. Huang et al. (2022) demonstrated that a flipped classroom model significantly improved academic outcomes for international medical students in anesthesiology, achieving pass rates of 80–86.7% and over 80% student approval for enhancing learning interest, self-directed skills, and clinical competence. Rich multimedia content—including instructional videos, interactive modules, and virtual case simulations—enhances theoretical comprehension and bridges the gap between knowledge and clinical practice. These resources also facilitate interdisciplinary integration, promote deeper understanding through repetition, and support the personalized learning pace of international students.

Evidence suggests that compared with traditional lectures, a flipped classroom model enriched with CBL significantly boosts international students’ motivation and classroom participation. Analysis of clinical case sharpens their ability to pose and solve problems, while structured engagement with medical literature enhances their capacity to connect theory with practice (Yang et al., 2024). Overall, the flipped classroom model offers an adaptable, student-centered framework that aligns well with the learning needs of international anesthesiology students and supports the development of their clinical reasoning and communication skills in a more active and contextualized learning environment.

In addition to theoretical knowledge and practical skills, anesthesia practitioners need to develop clinical thinking, judgment, and effective teamwork, and master handling various emergencies. While the operating room remains a critical setting for clinical training, not all perioperative emergencies can be demonstrated live due to patient safety concerns. Simulation-based teaching addresses this gap by providing a risk-free and immersive setting, allowing learners to engage in realistic clinical situations. This method not only replicates the urgency of perioperative crises but also reinforces the timely decision-making required for effective resolution (Mossenson et al., 2021). Simulation helps international students quickly and effectively grasp knowledge, turning theory into practice (Lim and McIvor, 2015). It also highlights the anesthesiologist’s role as a key member of the multidisciplinary team, emphasizing that crisis management hinges on clear communication and collaborative problem-solving. By repeatedly practicing in simulated high-pressure environments, students develop confidence and proficiency in handling emergencies. A study comparing high-fidelity simulation-based teaching with case-based discussions in terms of student satisfaction and knowledge acquisition found that simulation-based teaching resulted in higher student satisfaction, particularly in the debriefing phase, while both methods showed similar effectiveness in knowledge acquisition (Vijayaraghavan et al., 2019).

International students often lack opportunities to engage in clinical diagnosis and treatment, impairing their ability to conduct preoperative evaluations and manage anesthesia perioperatively. This lack of engagement not only reduces their clinical exposure but also compromises the overall effectiveness of education. “One-on-One” partnership model represents a structured and evidence-based approach to addressing the multifaceted challenges faced by international medical students while simultaneously enriching the educational experience of domestic students. At its core, the model establishes carefully matched partnerships between domestic and international students, creating a symbiotic relationship that transcends conventional mentoring paradigms. Academically, these partnerships facilitate knowledge exchange through collaborative learning activities such as joint case study analyses, simulation training exercises, and research projects (Szlachta, 2013).

Yang et al. (2022) found that pairing international and local medical students significantly improved attendance and exam performance of international students, while over 80% of domestic students reported enhanced language skills. Therefore, “One-on-One” partnership helps international students overcome integration barriers by facilitating language skills through daily interactions, improving academic expectations via direct mentoring, and reducing isolation through meaningful peer connections (Han, 2023; Zhou et al., 2023). The model incorporates specific interventions to bridge learning style differences, with domestic students typically exhibiting deeper conceptual approaches while international students often demonstrate greater adaptability to blended learning environments (Han, 2023). Importantly, the partnership serves as a crucial psychosocial support mechanism, providing international students with accessible emotional support and practical guidance in navigating both academic systems and healthcare environments (Rekenyi et al., 2023).

China’s ‘Innovation Action Plan for Artificial Intelligence in Higher Education’ advocates accelerating the integration of AI technologies into education to reform traditional teaching methods and enhance educational governance. In anesthesiology, AI is revolutionizing perioperative care, from personalized risk assessments and anesthesia planning to real-time physiological monitoring, robotic assistance during surgical procedures, and optimization of postoperative recovery. These advances not only enhance clinical accuracy and patient safety but also introduce new levels of efficiency and individualized care.

The integration of AI technologies such as machine learning, deep learning, and natural language processing (NLP) represents a transformative shift in medical training, particularly benefiting international students through personalized and adaptive learning approaches. AI-driven adaptive learning platforms offer opportunities for automated feedback, language support, and intelligent assessment, particularly beneficial for international students. Virtual reality (VR) simulations combined with AI create immersive training environments for practicing complex procedures, while intelligent tutoring systems provide 24/7 access to updated clinical knowledge. And AI-powered virtual simulations and deep learning techniques can support immersive VR simulation-based training in anesthetic procedures (Singhal et al., 2023). Collectively, these developments are poised to reshape anesthesiology education by fostering more interactive, data-informed, and competency-based learning experiences (Connor, 2019; Cote and Kim, 2019). Additionally, AI can provide virtual learning assistants to help clinical instructors answer students’ questions accurately online, ultimately improving training outcomes and optimizing teaching management. Additionally, the article also discusses ethical and interpretability challenges of AI, which can be integrated into medical curricula to foster students’ critical thinking and ethical awareness. Collectively, these applications suggest that AI can significantly enrich anesthesiology education through personalized, interactive, and globally relevant learning approaches. If AI is utilized to design authentic lifelike training simulations and provide students with personalized feedback, anesthesia education might be transformed (Shukla et al., 2024).

Effective anesthesia education for international students requires addressing language barriers, cultural gaps, and institutional support. Instructors need targeted English training—especially in medical terminology and clinical communication—through workshops, immersive practice, and AI-assisted tools. And a phased bilingual curriculum should bridge classroom theory and clinical practice, starting with English-dominant instruction and gradually transitioning to Chinese for real-world application (Tu et al., 2003). In the early stage, instructor is delivered approximately 70% in English, focusing on foundational theories and standardized protocols to establish a common medical language framework. During the mid-stage, the language ratio shifts to a balanced 50% English and 50% Chinese, emphasizing case-based learning and simulated patient-provider dialogues to enhance both clinical reasoning and communication skills. In the late stage, Chinese becomes the dominant language (around 70%), aligning with real-world clinical practice and the localization of medical protocols, including traditional Chinese medicine (TCM) analgesia methods. To facilitate this transition, progressive Chinese language training should be integrated into the medical curriculum, with an emphasis on perioperative terminology and patient interactions (Imbo and LeFevre, 2011). Additionally, cultural adaptation programs, such as workshops on Chinese healthcare norms and hospital immersion experiences, can facilitate smoother integration into clinical environments. These measures collectively ensure that international students develop both the linguistic proficiency and cultural competence necessary for effective practice in China.