Global Health Program Director's Guide: Chapter 10

Chapter Authors: Michael Pitt, MD, Trish McQuilkin, MD & Christiana Russ, MD

Preface to Chapter 10: Partnerships and Bidirectional Trainee Exchanges

This chapter is one of the invaluable resources incorporated into the ABP program director’s guide to GH education.

The presence of faculty and trainees on the ground in a resource-limited setting fills a much-needed expertise gap, even if it is for a short time. In the specific case of my institution, visiting trainees on GH electives have served as moderators during tutorials and bedside teaching for students and have been a big source of motivation and inspiration for junior doctors planning to enter residency in pediatrics. This has been very important for us as we have struggled over the years to get medical officers into pediatric residency programs.

Bidirectional exchanges, however, may be the ultimate goal for partners in resource-limited settings hosting trainees from resource-rich settings for GH electives. This offers trainees/faculty from a host institution the benefit of seeing health care in a different perspective and learning/observing practice from an organized health system perspective. It builds trust in the relationship and gives them the feeling that their site is not just a receiving end but an integral part of the partnership.

Even though the bidirectional exchange may be spelled out in an initial memorandum of understanding (MOU) signed by both partners, there are generally obstacles that may impede the participation of partners from resource-limited settings. These may include but are not limited to costs involved in travel, acquiring travel visas (generally a bigger problem for trainees than faculty), selection of the appropriate person for the program (many settings may not have residents and there is a real challenge that lower cadre of staff will not be granted travel visas), and finding a reliever in situations where the partner may be the only clinician for the institution.

The authors of this chapter have expertly delineated the benefits derived from bidirectional exchanges and the challenges that are likely to be encountered. They have also offered possible solutions to the challenges.

I do believe that this will serve as a great resource, both for professionals already involved in global partnerships/bidirectional exchanges and those who are yet to get involved. I also believe it is the way forward for the future of global partnerships in GH education.

Alhassan Abdul-Mumin, MD, Cert PGPN, FGCP
Senior Pediatrician and Senior Lecturer, University for Development Studies
School of Medicine and Health Sciences and Tamale Teaching Hospital
Tamale, Ghana

Key Points

enlightenedIt is important to strive for mutually beneficial partnerships with global colleagues with agreement upon and alignment of goals, clear expectations, and frequent communication.

enlightenedFor some global partners, that mutuality may include the establishment of bidirectional trainee and faculty exchanges, which confer many known benefits to both partners as summarized in this chapter.

enlightenedObstacles to bidirectional exchange implementation will vary at each institution. Common challenges are summarized here, and solutions as well as implementation strategies are offered, including the establishment of a stateside consortium to support global partnerships.

The previous chapters described the fundamental substrates necessary to build an ethically sound platform to support GH training in residency. The importance of mutually beneficial partnerships with global colleagues is emphasized throughout those chapters. An increasing body of literature delineates better practices for establishing and maintaining global partnerships46 (see Appendix O). Well-functioning partnerships require agreement on and alignment of goals and objectives, clear expectations of roles and responsibilities of both partners, and frequent communication, whether via formal evaluation or informal conversations and debriefing.

Some research shows that the majority of such partnerships are built on relationships and networks of individual faculty members, and that the goals of the partnerships may evolve over time.35 Faculty may require institutional support in the form of funding and travel time to develop and maintain such partnerships. For partnerships requiring sustained commitment of personnel (such as education-based capacity development initiatives), many programs have found benefit in developing a consortium with other U.S.-based institutions to support global partnerships.52,53

Many global partnerships will include the development of bidirectional exchanges of trainees. In these experiences, rather than merely sending trainees from resource-rich to resource-limited settings, the flow of learners goes in both directions. In this chapter, the authors briefly highlight some of the documented benefits of bidirectional exchanges and provide an overview of challenges for their implementation paired with strategies to overcome them. This chapter will focus only on bidirectional trainee exchanges, which are a small subset of global partnership opportunities. Principles of partnership, partnership best practices, medicolegal aspects of hosting trainees (eg, as observers versus clinicians), and sources of funding to support partnerships (including funding for the exchange of trainees) are outside of the scope of this chapter.

Benefits of Bidirectional Exchanges

Programs that have participated in bidirectional exchanges note several of the same benefits for international trainees as those that have been reported for trainees traveling from resource-rich to resource-limited settings. In addition to the international trainees gaining medical knowledge, increasing awareness of other health systems and cultures, and bringing changes back to their home institutions, there are other programmatic benefits of engaging in these exchanges. Just as international host faculty often cite the benefit of new perspectives and peer education on rounds, hosting international colleagues provides an opportunity to integrate a GH perspective into rounds and teaching conferences such that even those who do not plan to engage in international field work are able to gain insight into different approaches to care. Exploring how differing values affect care can yield insights that are also relevant domestically, particularly introducing cultural humility. Presence of the exchange may improve the experience for both sets of trainees when they themselves travel to participate, and the collaboration of the exchange may strengthen commitment from both parties. Moreover, these exchanges set the stage for ongoing needs assessments and provide opportunities to ensure that the goals and objectives of both partner institutions are being fulfilled. Table 10 provides a brief summary of reported benefits to both institutions of engaging in bidirectional exchanges.



Challenges and Possible Solutions

As with any new initiative, obstacles can be expected when initiating the hosting of international trainees. Although no system will likely be the same, the growing number of these exchanges provides proof that the obstacles can be overcome. Table 11 provides a summary of obstacles encountered during the implementation of a bidirectional exchange between Lurie Children’s Hospital in Chicago and Bugando Medical Centre in Mwanza, Tanzania, and offers the approach they took to overcome each challenge. Table 12 provides a timeline used by Indiana University in preparation for hosting residents from Kenya as part of an established bidirectional exchange. These tables are intended to serve as examples, with the caveat that different countries and partnerships bring unique strengths and challenges, and there is no “one size fits all” approach to bidirectional partnerships.





Most hospitals and health systems have strict observation requirements limiting the opportunity for visiting trainees to have hands-on clinical encounters. State laws vary regarding this, and there may be an opportunity for legislative advocacy if applicable. However, this need not be a barrier to providing meaningful experiences when hosting international trainees. Trainees are able to participate in existing educational conferences and clinical rounding/shadowing, and with minimal planning one can arrange valuable one-off experiences ranging from working with a radiologist to read plain films (often these trainees work in settings without access to a radiologist), working in pediatric subspecialties that may not exist in the trainee’s home country, or meeting with a scientific librarian to review options for answering clinical questions online. Table 13 provides a summary of the four-week curriculum used by Lurie Children’s Hospital for its exchange program.



Global Partnerships Models

Although this chapter focused primarily on single institutional partnerships, there are many models of partnerships that exist for US training programs, including but not limited to the following:

  • Stateside consortia with a single international partner (or an international consortia partner): There are several successful models that involve collaboration between U.S. Academic Medical Centers (AMCs) to share training partnerships. Such collaborations have multiple benefits, including offsetting logistical burdens of partnership coordination, providing more consistent staffing by visiting trainees and faculty when desired by global partners, and offering more diversity of engaged collaborators across disciplines.5
  • Tripartite (or more) partnerships: A single international partner may be engaged in collaborations with multiple institutions. In such cases, it is important to have transparency of discussions and for all partners to be mindful of intercountry and local dynamics.
  • Academic–NGO partnerships: Some U.S. training programs partner with NGOs that are closely affiliated with global partners to support training collaborations.

Offering to host trainees from global partner institutions that host trainees themselves is a step toward true parity in these GH experiences and an emerging best practice. Although obstacles exist when implementing these bidirectional exchanges, they are surmountable and often mirror the challenges that partner institutions in resource-limited countries take on when hosting trainees. Table 14 provides a summary checklist to consider when pursuing a bidirectional exchange.



Program Readiness Assessment for GH Training

A snapshot “readiness assessment” checklist for training programs navigating development of a GH training infrastructure is located in Appendix L.

enlightenedFor those seeking to employ a GH track director and/or a GH track program coordinator, sample position descriptions are included in Appendices B and C.

Citation: St Clair N, Abdul-Mumin A, Banker S, Condurache T, Crouse H, Helphinstine J, Kazembe P, Lukolyo H, Marton S, McQuilkin P, Pitt M, Rus M, Russ C, Schubert C, Schutze G, Steenhoff A, Uwemedimo O, Watts J, Butteris S. Global health in pediatric education: an implementation guide for program directors. American Board of Pediatrics Global Health Task Force Publication, in collaboration with the American Academy of Pediatrics Section on International Child Health and the Association of Pediatric Program Directors Global Health Learning Community. September, 2018.