From cultural competence to cross-cultural fluency: a framework for transnational medical education in an era of global health workforce mobility.

Background: As medical education increasingly operates across national boundaries through institutional partnerships, offshore campuses, dual-degree programs, and digital learning platforms, the need for culturally responsive pedagogical frameworks has become urgent. Existing models of cross-cultural medical education were developed primarily for domestic settings and do not adequately address the complexities that arise when curricula, faculty, and learners simultaneously traverse multiple cultural, regulatory, and institutional contexts. This paper proposes a conceptual shift from cultural competence to cross-cultural fluency as a guiding principle for transnational medical education. Main body: Drawing on established frameworks in cross-cultural medical education, global health workforce literature, and transnational education governance, we present a three-tier framework-the Transnational Cross-Cultural Fluency (TCCF) model-designed to address the unique challenges of medical education delivered across borders. The first tier addresses organizational and structural barriers inherent in cross-border educational partnerships, including divergent accreditation standards, regulatory misalignment, and institutional power asymmetries. The second tier focuses on pedagogical and clinical challenges arising from the multiplication of cultural contexts when faculty from one national setting teach students from another who will practice in a third. The third tier examines individual-level processes of professional identity formation, cultural self-reflection, and adaptation when learners and educators navigate multiple institutional cultures simultaneously. For each tier, we propose specific strategies encompassing curriculum design, faculty development, assessment innovation, and governance mechanisms. We critically examine how digital platforms and technology-enhanced learning can serve as both enablers and complicators of cross-cultural fluency in transnational settings. We further address ethical dimensions including epistemic justice, the risk of cultural hegemony in cross-border partnerships, and the imperative for bidirectional knowledge exchange. Conclusion: The TCCF model extends existing cultural competence frameworks by explicitly accounting for the multi-layered cultural transactions that characterize transnational medical education. Moving beyond competence-which implies a finite endpoint-toward fluency-which denotes ongoing adaptive capacity-provides a more appropriate conceptual foundation for preparing healthcare professionals to deliver equitable care across a globalized healthcare landscape. Implementation of this framework requires coordinated effort across partnering institutions, accreditation bodies, and policymakers to ensure that cross-border medical education promotes rather than undermines health equity.