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Global Health Program Director's Guide: Chapter 2

Chapter Authors: Sumeet Banker, MD, MPH & Jill Helphinstine, MD

Key Points

enlightenedGH-specific objectives can be applied to all competency domains (patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice). Examples are offered in this section for both Tier 1 (all trainees) and Tier 2 learners (trainees on GH electives). For trainees enrolled in GH tracks (Tier 3), programs are encouraged to develop additional objectives that are pertinent to the content of their GH track.

enlightenedThis section provides the “how to” for educators seeking to integrate GH into their curriculum, including: 1) Strategies for incorporating GH-specific objectives into existing and new residency curricula, 2) High-yield educational resources currently available (online and print), and 3) Considerations for mapping GH education to board specifications.

 

Tier 1 Learners: Competency-based Objectives for All Trainees

There is widespread recognition that GH principles of worldwide social determinants of health, cultural humility, and acquisition of skills employed in resource-limited settings should be learned by all members of the growing pediatric workforce. These principles apply just as much to the care of children at home as to those abroad. Specific curricula and objectives are necessary to accomplish the task of educating all pediatric trainees, but they have not yet been developed for this population of learners in a format that may be broadly adapted by academic institutions.

For the purposes of this guide, GH objectives for all pediatric trainees were adapted from available literature3,4,8–11 and developed with expert consensus from the American Board of Pediatrics (ABP) Global Health Task Force Trainee Workgroup. These objectives were developed to represent what all pediatric trainees should ideally know about GH and the care of children at home and abroad. Each objective is mapped to an existing competency for pediatric trainees as outlined by the ABP in the Pediatric Milestones Project (2012) and adopted by the Accreditation Committee on Graduate Medical Education (ACGME) in the Program Requirements for Graduate Medical Education in Pediatrics. These competencies are italicized below and contain a reference to the ACGME Program Requirements document. Of note, the authors chose to highlight additional local GH competency-based objectives in Chapter 3. Some of the objectives noted below will overlap with those in Chapter 3, and this overlap is intentional.

 

 

Tier 2 Learners: Competency-based Objectives for Trainee Participants in GH Electives

This set of objectives includes additional objectives that should be achieved by trainees embarking on short-term elective experiences in international or domestic resource-limited settings. General principles and best practices in GH apply to these experiences, and it is important to ensure achievement of these competency-based objectives prior to the start of the elective. For more detailed information on considerations for pre-departure preparation, please refer to Chapter 5 of this guide.

 

 

 

Tier 3 Learners: Compentency-based Objectives for Resident Participants in GH Tracks

When applicable, programs are encouraged to identify additional objectives for trainees committed to a longitudinal GH track. Such objectives can be tailored to the specific emphases and curriculum of the program’s GH track, which vary at each institution based on local needs, local faculty expertise, and other factors.

Strategies for Incorporating Objectives into Residency Curriculum

GH curricula may fit a variety of active and passive educational formats to suit the objectives and needs of the learners. These include traditional didactic sessions such as conferences and grand rounds, as well as interactive sessions such as case conferences, journal clubs, and simulations; examples of curricular integrations from these formats are included above (Table 1). When delivering core GH curricular elements, it is important to work within the existing educational framework of the residency program in order to reach a broad audience of trainees and normalize GH topics within the residency curriculum. 

Innovative Strategies for Integration of Objectives

Although pediatric residency programs vary with respect to size, location, training sites, and availability of faculty with specific GH interests, there are some general approaches to integration of GH principles into residency curricula that may be adapted to fit all programs. These approaches have varying degrees of time/resource commitment and are outlined below.

Integrating Content into Existing Residency Curriculum

Implementing a new GH curriculum from scratch can be an arduous task. Integrating GH principles into existing curricular offerings such as didactic conferences and morning reports allows programs to harness the strength of the existing curriculum. Although instructors and lecturers may not have specific expertise in GH, they may have some familiarity based on their depth of knowledge on their given topic. They may be able to add a section to their talk on the GH implications of the disease process, how it may present clinically in resource-poor areas, or special considerations for immigrant/refugee populations. Some examples are included below, and additional examples may be found in Table 1.

  • Integrating acute malnutrition in low- and middle-income countries (LMIC) into a discussion of rural food insecurity in high-income countries (HIC)
  • Incorporating cases of refugees and immigrants with mental health problems into a lecture on post-traumatic stress disorder (PTSD) and/or generalized anxiety disorder
  • Noting the global burden of pneumonia-related mortality when teaching about community-acquired pneumonia
Adapting New Content from Existing Resources

The next step on the time/resource continuum would be to adapt existing resources to design a GH curriculum that meets the needs of the trainees at a given program. Groups of GH educators with experience in service and research have collaborated to create web-based resources for global child health education. These resources vary in terms of the technology necessary to run the modules, variety of topics covered, and target audience. A list of options is in Table 4 below, (with bold text indicating resources that authors consider high yield for U.S. pediatric trainees). 

“Participating in the global health track has helped develop my capabilities as a physician. The simulations and journal clubs I have experienced this year have helped introduce me into what I may experience on my own when practicing globally or locally in poor resource settings. I especially enjoyed the simulation where we have limited resources...It provides great experience in learning how to use the limited resources to the best of my abilities and to the best of my patient's needs.”

- Anonymous trainee

Harnessing Local Expertise to Create Original Content

Creating new content altogether can be an attractive option because it allows the teacher to highlight his or her areas of expertise, while also tailoring the discussion to the local context (eg, specific immigrant population, community resources, and the baseline knowledge level of trainees).

Although they may not have specific designation as such, GH educators may be found in many places, both on faculty and in the community. Faculty teachers can be found and recruited from many pediatric divisions as well as other disciplines (eg, internal medicine, emergency medicine, obstetrics, surgery, etc) and other schools (eg, nursing, public health, dentistry, public policy/law, etc). Examples include:

  • Obstetrician or infectious disease specialist provides global context on improvements in maternal-to-child transmission of HIV
  • Faculty surgeon discusses successes/struggles in reducing pediatric morbidity and mortality from trauma due to road traffic accidents in East Africa by working with a regional Ministry of Health to enforce helmet laws.

Teachers can (and should) also be found in the community. Many governmental and nongovernmental organizations advocate for rights for and provide services to immigrants, refugees, adoptees, and the impoverished/under-insured. Training programs can capitalize on the local expertise of these organizations to provide practical context and real-life examples of the interplay between health and well-being. Examples include:

  • Social worker from local refugee resettlement agency discusses cultural barriers to health care-seeking behaviors in local Central African refugees
  • Supervisor from local Interpreter Services outlines best practices when utilizing a language interpreter
  • Medical director of local Department of Health discusses surveillance, monitoring, and preparedness for local outbreaks of infectious diseases.

 

 

Mapping GH Objectives to Board Specifications

The American Board of Pediatrics prepares a content outline for the purpose of developing certification examinations for pediatricians. Residency curricular content in GH may help achieve competence in many of the categories listed in that document. GH content may provide particular benefit in addressing the following topic domains:

  • Nutrition and nutritional disorders
  • Preventive pediatrics (immunizations)
  • Infectious diseases
  • Environmental exposure to hazardous substances
  • Psychosocial issues
  • Ethics

Regarding trainee assessment, no standardized tool currently exists for Tier 1 trainees pertaining to GH-specific competency-based objectives. However, a milestone-based assessment tool developed  by a group of GH educators is described in the literature; although it was designed specifically for GH electives, it could be modified for stateside assessments.12

 

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. abp.org/ghpdguidehome