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Global Health Program Director's Guide: Chapter 4

Chapter Authors: Nicole St Clair, MD, Sabrina Butteris, MD, & Omolara Uwemedimo, MD, MPH

Key Points

enlightenedTraining programs that offer GH electives need to ensure that a minimum infrastructure is in place to support an ethically sound, safe training experience with appropriate pre-departure, on-site, and post-return support. A comprehensive checklist and programmatic recommendations are provided in this section. 

enlightenedIdentifying safe, ethically sound elective options for trainees is difficult and will likely require departmental investment in the development of training partnerships and/or trainee investment in elective fees. 

enlightenedDebriefing and evaluation are important components of the GH elective that are frequently overlooked; suggestions for both are offered. 

 

GH electives are frequently requested by trainees and have the potential to serve as both a capstone and a transformative experience for trainees with GH interests. However, they also require a great deal of preparation, consideration, oversight, and investment on the part of the trainee, the training program, the institution, and the host partner. The purpose of this section is to provide a summary of the minimum infrastructure recommended for training programs to offer GH electives. Chapter 5 will summarize the fundamental components for trainee preparation for GH electives.

For the purposes of this chapter, the authors define a GH elective as one that occurs in a setting with relative resource limitations (compared with a trainee’s home institution), either internationally or domestically outside of the trainee’s usual setting (eg, an Indian Health Services clinic). This chapter does not sufficiently cover recommendations for trainees who are pursuing electives in other high-resource but culturally different settings (eg, an elective at a European tertiary care hospital), although many principles covered here can be used for those experiences. The recommendations provided are applicable to the typical duration of GH electives (4-8 weeks); longer experiences require additional consideration that are outside of the scope of this guide, although many of the same principles apply.

Notably, the ideal duration of a GH elective is unclear, but for multiple reasons the authors suggest a minimum of 4 weeks and longer if feasible, while recognizing the time constraints inherent to pediatric training. This suggestion stems from the following logic:

  • A minimum of 4 weeks has previously been recommended by GH education leaders in the pediatric community;31
  • Trainees demonstrate a learning curve that improves proportionately with time on-site, particularly pertaining to patient care efficiency;32
  • There are emerging opinions from host institutions that GH electives less than 4 weeks are insufficient and do not allow visitors time to acclimate and become contributing members of the team;33,34
  • Although it has not been studied, anecdotal evidence suggests that trainees struggle most with culture shock during the first 1 to 3 weeks of their elective, thereby placing them at risk for needing to leave at the peak of their frustration/culture shock if their elective is less than 4 weeks;
  • GH electives are associated with high costs of travel, making short trips less cost-effective;
  • Particularly for trainees rotating at partnership sites, there are often projects (community-based, advocacy, research, or other) that are initiated or continued as part of the sustained institutional collaborations. In order to contribute to such projects, a trainee usually needs to have at least 4 weeks on-site.

GH Elective Site: Easier Said Than Done

The authors recognize that this guide would be especially useful if there were a list of GH elective sites that offered free, supervised, safe, short-term training opportunities. However, that sort of list is not feasible for many reasons, which include but are not limited to the following:

  • Visiting trainees utilize host resources and time due to multiple factors, including housing, orientation, supervision, language barriers, differences in clinical practice, clinical resource utilization, and the trainee’s obligate (and sometimes difficult) process of adjusting to the new setting. Those are a few of the many reasons why host institutions cannot open their doors to all visiting trainees.
  • There is very little direct benefit to the host institutions who accommodate short-term visiting trainees, unless it is part of a larger partnership agreement that offers bidirectionality or other incentives (such as academic collaboration, elective fees, donations, etc).
  • Training programs that do offer GH electives at partnership sites are hesitant to advertise the opportunities to other training programs because (1) their institutions are investing significant resources to ensure that the partnership is mutually beneficial; (2) they usually have a careful preparation process to best support their trainees and minimize the host burden (and they cannot ensure that other training programs will provide similar preparation); (3) there is usually not enough capacity at the host site to support multiple visitors; and (4) few institutions have the administrative infrastructure to coordinate logistical support (scheduling, pre-departure training, on-site support, and post-return debriefing) for trainees outside of their institutions.

In short, if an institution is seeking GH electives to offer to trainees, there are currently three options:

  1. Develop and sustain a partnership with a host institution to support short-term electives for trainees under an agreement that is mutually beneficial for both institutions.
    • Partnerships require significant investments of time, resources, and ongoing communication and evaluation from both institutions
    • Partnership agreements (memoranda of understanding) vary based on the goals and needs of both institutions. An example is offered in Appendix Y.
    • For more information on bidirectional partnerships, refer to Chapter 10.
    • For an overview regarding principles of global partnerships and best practices for global partnerships, refer to Steenhoff et al, Pediatrics, 2017.46
  2. Develop and sustain a stateside partnership with a program that has an ongoing global partnership and create a mutually beneficial plan to engage trainees in global health electives through the training partnership. 
  3. Seek an opportunity from organizations that offer GH electives that are associated with fees to support the host institutions (examples in Appendix M).
    • Fees can range significantly, from $100 to $1,000 per week, so investigation into the fee structure is necessary.
    • These opportunities require careful vetting to ensure that there are appropriate experiences and supervision for visiting trainees.

Determining partnerships appropriate for GH electives can be daunting for faculty without prior GH experience, as many relationships are initially formed through existing institutional or personal contacts.35 A needs and assets assessment can be helpful to define successful relationships. Expectations of both the host and home institutions should be clearly stated, and appropriate supervision should be available for the duration of the trainee’s elective.36 Assessing a cost-benefit ratio to the trainees, program, host institution, and the patient population will help guide the choice of a partnership and elective site.

A comprehensive checklist of considerations for GH electives is offered in Table 7 to help guide the process of choosing a GH elective and/or training partnership for both trainees and program directors. Please refer to that checklist throughout Chapters 4 and 5. An additional checklist for bidirectional partnerships is offered in Chapter 10.

 

 

Home Institution Considerations Prior to Offering GH Electives

Prior to offering GH electives to trainees, authors recommend that home institutions have the following minimum infrastructure in place for the trainee before and during the GH elective:

  • Salary support
  • Malpractice and disability insurance coverage
  • Review process for the elective site (safety, supervision, etc.; refer to Table 7)
  • Trainee application/screening process that reviews goals and objectives
  • Program Letter of Agreement with host institution that outlines supervisory plans for the visiting trainee (and a Memorandum of Understanding with the host institution if part of a larger partnership)
  • Safety guidelines and emergency protocols (including communication plans)
  • Pre-travel health assessments (eg, travel clinic) and on-site health protocols (eg, occupational exposure guidelines)
  • Pre-departure training that at minimum includes: travel logistics, health, safety, culture shock, site-specific mentorship, professionalism, and ethics
  • On-site support, communication & supervision
  • Debriefing & evaluation processes
  • Post-travel health assessment  
Salary Support, Malpractice and Disability Insurance Coverage

The ability to provide salary support and coverage for malpractice and disability insurance during GH electives varies by institution, for a variety of reasons that are beyond the scope of this guide. The authors strongly encourage training programs to ensure that their malpractice and disability insurance policies provide coverage for trainees engaged in off-site electives, including international locations. This may require close communication with the graduate medical education office to navigate coverage options. The author team does not have a list of vendors that provide short-term malpractice or disability coverage for trainees on GH electives. The decision whether to pursue a GH elective when salary and/or insurance support is absent is at the discretion of the trainee, the residency program, and the graduate medical education office. Notably, ensuring salary support for trainees on GH electives may require advocacy with the home institution and its department of pediatrics. Advocacy tools have been offered in the literature to assist educators in recruiting resources for GH education.37

Program Letter of Agreement/Memorandum of Understanding

A program letter of agreement (PLA) and a memorandum of understanding (MOU) are useful tools to lay out mutually agreed upon terms for training and institutional partnerships. A PLA is recommended by the ACGME for trainee off-site electives. A PLA is not intended to be a legal document but is instead an educational agreement that does the following:38 

  • Identifies the faculty members who will assume both educational and supervisory responsibilities for trainees
  • Specifies these faculty members’ responsibilities for the teaching, supervision, and formal assessment of trainees
  • Specifies the duration and content of the educational experience
  • States the policies and procedures that will govern trainee education during the assignment.

If there are additional details that are pertinent to the nature of a training partnership, then institutions may opt for a memorandum of understanding or a contract that outlines the expectations of the partners (eg, who pays for the visiting trainee, who provides malpractice insurance coverage, etc). Additional details can be added depending on the nature of the partnership. An example of an MOU for a bidirectional training partnership is provided in Appendix Y. MOUs and PLAs are institution-specific and should be developed in collaboration with the Risk Management office, graduate medical office, GH educators, host institutions, and other pertinent parties.

Safety Considerations

International travel involves an inherent increase in safety risks, particularly pertaining to physical illness and injury and psychological trauma. According to Galvin et al, the risk of having any type of illness during international travel approaches 50%. The leading causes of mortality during GH electives are motor vehicle crashes and drownings.39 The Galvin report provides prevention strategies for global medical education programs that are summarized in Figure 3. Many institutions address safety concerns through pre-departure education, on-site safety recommendations, and requirement of the purchase of supplemental evacuation insurance (Appendix E). Additionally, some institutions request that trainees review and sign a “Risk Reduction Agreement” prior to their GH electives and review safety concerns with the host supervisor upon arrival. Because motor vehicle and motorcycle crashes are the leading cause of morbidity and mortality for travelers, many institutions either forbid or strongly discourage trainees from driving themselves (and instead suggest hiring in-country drivers who are familiar with local traffic customs and terrain and avoiding motorcycles as modes of transport).

An example of a risk reduction agreement can be found in Appendix F.

Health Considerations

Trainees should be strongly encouraged to consider any personal health issues prior to travel, as exacerbations of underlying physical or mental health issues are common during travel.

Appendix H offers an example of a health self-assessment form for trainees to consider bringing to their pre-travel health care appointments at either a travel clinic or with their primary care physician.

Trainees should obtain the following at their pre-travel health care visits:

  • Destination-specific health information (refer to CDC travel medicine guidelines)
  • Vaccines pertinent to the destination site (refer to CDC travel medicine guidelines)
  • Malaria prophylaxis, if applicable (refer to CDC travel medicine guidelines), and guidance on strategies to avoid mosquito bites (netting, repellent, etc)
  • Standard travel prescriptions (refer to CDC travel medicine guidelines)
  • Occupational exposure guidelines and HIV post-exposure prophylaxis prescription. Refer to Appendix G for an example of GH elective post-exposure prophylaxis guidelines that can be adapted to meet specific institutional needs.40 Some host institutions may have their own occupational exposure guidelines that can be reviewed by the home institution to ensure that appropriate resources and recommendations are in place for trainees.
  • Guidance pertaining to prevention and management of hemorrhagic fevers if traveling to an endemic region
  • Anticipatory guidance about staying healthy while traveling (peeling fruits, not using ice, what to do if diarrhea develops, avoiding risk-taking behaviors, avoiding substance abuse, etc).

Additionally, trainees are encouraged to discuss potential health concerns with their host institution prior to departure to ensure that they bring appropriate supplies. Pregnancy in particular is an important consideration for female and male trainees, and travel plans should be carefully considered based on stage of pregnancy, future plans for pregnancy, destination (eg, regions of Zika risk or where malaria is endemic), access to emergency health care services at the elective site, and personal/family concerns.

Emergency Considerations

Trainees are susceptible to a number of emergencies during their travel, including political unrest, natural disasters, motor vehicle accidents, and many more. Programs are encouraged to establish emergency safety nets and clear options for communication with trainees abroad as outlined in Figure 4. Some institutions provide phones for trainees to use during electives to ensure ease of communication. Additionally, the authors recommend that trainees purchase evacuation insurance if not already covered under their health insurance policies. Details regarding this and additional coverage options are provided in Appendix E.

An example of a Global Health elective emergency card can be found in Appendix E.

Pre-Departure Training

The authors strongly recommend that programs offer pre-departure training prior to GH electives, either through their own institution or by referring trainees to free online training materials. At minimum, such training should cover logistical, health, safety, ethical, professional, and cultural considerations pertinent to working at the destination site and specific to the host population and resources. More details regarding pre-departure training components and resources are provided in Chapter 5.

Supervision During GH Electives

Supervisory arrangements for the visiting trainee should be outlined in the institutional program letter of agreement and should provide detail from the host site regarding which provider(s) will be available as supervisors for the duration of the elective. When determining oversight plans for GH electives, program directors must be aware of the following:

  • It is not uncommon for providers in low-resource settings to maintain both private and public employment and thus be present at one clinical setting in the morning and a different setting in the afternoon. If, for example, a trainee will be working in a public hospital, it is important to determine who is available for preceptorship during the entire time that the trainee is at the facility, including any times that the primary supervisor may be absent.
  • It is not uncommon for hospitals in low-resource settings to be staffed primarily by medical officers. These are physicians who enter into clinical practice directly after medical school and 1 to 2 years of internship but do not specialize via specific residency training programs. In those settings, pediatricians usually serve as consultants, with rounding models and in-hospital presence that vary based on the clinical setting. It is not uncommon for visiting trainees to work primarily alongside the medical officers (or clinical officers, who are similar to mid-level providers), as opposed to the pediatricians. Although the on-site officers have superior experience with local practice and care guidelines, there may at times be a mismatch in pediatric-specific knowledge and practices. It is important to determine, prior to the elective, a chain of oversight for the visiting trainee if/when any clinical differences of opinion or concerns arise.
  • It is not uncommon for tertiary facilities in low-resource settings to be staffed with only one pediatrician at a time, often while balancing multiple competing activities (teaching, research, administration, etc).
  • Training programs are encouraged to create a plan for the visiting trainee if the identified preceptorship for the elective has an unexpected absence. This will vary by institution, but the authors strongly discourage training programs from allowing an elective to continue if an on-site provider is not available to facilitate mentorship, given that practice paradigms, diagnoses, and resources can be distinctly different from those in-home settings.
  • Remuneration agreements for host supervisors vary based on pre-existing partnership agreements and host institution policies. There is not a unified approach to remuneration across institutions, but it is important to engage in discussions regarding support of host supervisors, as significant time is invested in coordinating electives and hosting visiting trainees.
  • Requirements for what credentials are necessary for on-site supervisors are determined by the trainee’s institution (eg, MD versus pediatric-trained versus advanced practice provider [APP]). The authors recommend that, at minimum, an MD should be identified for preceptorship, unless in a low-acuity, community-based setting where an APP could be appropriate. In high-acuity settings (such as a PICU or hospital ward), the authors recommend that someone with pediatric-specific training at least be available for consultation when needed for complicated cases.

In some instances, trainees travel with supervisors from their home institution, and those supervisors accompany them for part or all of their elective. When those supervisors already have experience working at the host site, this can be greatly beneficial to the trainee and partnership, as it allows the visiting supervisor to assist with trainee orientation and onboarding and promotes ongoing faculty-level communication and collaboration.

Projects During GH Electives

Some training programs have a scholarly project requirement during GH electives. Recently, the University of Minnesota conducted a review of the 67 GH track resident projects that occurred over a period of 10 years and included efforts related to quality improvement (42%), education (27%), clinical research (21%), and service projects (7%).41 In addition to addressing the ACGME requirement that residents participate in a scholarly activity, these projects offer trainees an opportunity to collaborate cross-culturally, develop skills in different areas of scholarship (eg, project development, implementation, evaluation, and/or dissemination) and identify a focus area for their elective experience.

Scholarly projects can be widely variable in scope. Invariably, priority must be placed on ethical integrity during the processes of planning, implementation, and dissemination, and projects should ideally engage host institution personnel as co-leaders whenever feasible. Of particular importance are the principles of beneficence -- ie, ensuring that projects are able to provide substantial benefit to the participants involved. Additionally, visiting trainee projects should not impose on projects or mentorship that are needed for local trainees. In light of these priorities, it can understandably be argued that less than 4 weeks is an insufficient amount of time to engage trainees in a scholarly project, particularly as they are navigating new systems and likely experiencing culture shock.

Additionally, it is of the utmost importance that there is ample time preceding the intended time of project implementation to communicate sufficiently with the host institution to determine a mutually beneficial project proposal that would be mentored, sustainable, approved by all pertinent parties (including home and on-site IRBs, when applicable), and not drain local resources. The time commitment needed to pursue a well-crafted and executed project cannot be minimized, as there are myriad additional steps (and probable delays) compared to those associated with U.S.-based scholarly projects. Some of these include in-depth conversations with host country partners about local needs and priorities, which may also include conducting a formal needs and assets assessment to help guide project ideas. Even if a project idea is developed prior to the elective (often informed by communication with the host institution and/or with trainees who visited the site previously), the project frequently changes once the trainee is on-site and has an opportunity to perform a more thorough needs assessment.

Once a project idea is created, considerable time needs to be invested into the development of a rigorous project proposal for initial review by both partners. This proposal can serve as a baseline document for IRB determination of projects involving human subjects research that need formal IRB review. A standard template for a proposal should at minimum include the following elements (with additional components at the discretion of the host supervisor):

  • Objectives, background, hypothesis, significance, methods
  • Timeline: What is a realistic estimate of the time needed to carry out every step of the project? (This can be done with the project advisor to review the trainee’s clinical commitment.)
  • Additional resources and identified funding
  • Contingency plan: Of particular importance, this is a secondary plan for achieving project objectives and/or an alternative project plan, given the tenuous nature of funding, personnel, and infrastructure that may be available in global, low-resource settings.
  • Dissemination: Trainees should be required to not only present results to their U.S.-based institution but also to identify a venue or manner in which they will share with host country partners and discuss how host partners will be engaged in the project and may use the results to benefit the involved community. Trainees should engage host institution partners in co-authorship whenever applicable, and authorship criteria should be discussed in advance of the project.

Author experience suggests that if scholarly projects are required during GH electives, they are most successful with advance planning of at least a year. Many institutions require extended timelines for IRB reviews, have lower thresholds for requiring IRB review, require IRB fees, and have different review structures (eg, national review as opposed to institutional review). Projects are best conducted under the auspices of sustained institutional partnerships, where trainee presence is more consistent, there is a trusting relationship between institutions, there is a higher likelihood of on-site collaborators, and where trainees can hand off projects to future visiting trainees and/or on-site colleagues to ensure sustainability. Careful monitoring and ongoing communication with the host institution is necessary to ensure that the projects are ethically sound and mutually beneficial.

It is also important to note that time for project dissemination, not solely implementation, should be carefully articulated. It is advisable that issues regarding authorship, travel award beneficiaries, and any other personal “benefits” of project dissemination be discussed as early as possible in the process. All pertinent parties, including personnel from the host institution who were actively engaged in the project, should be involved in analysis of findings, co-authorship, and dissemination of findings in presentations, abstracts, and/or manuscripts. Table 8 offers opportunities for scholarly dissemination of GH elective project results.

“Overall, this elective provided an opportunity for me to see what clinical care and public health efforts can look like in a limited resource setting with cultural barriers to allopathic medicine, yet in my own language. When I engage in Global Health in the future I will take this example as a benchmark for quality care. I am grateful for the experience; it was an excellent learning opportunity.”

- Leah Phillippi, MD, MPH

 
 
 
Ethical Concerns During GH Electives

Working in areas with resource limitations, particularly where patient morbidity and mortality can be high and trainee emotions may be labile, involves a heightened risk of ethical concerns related to the trainee’s presence and interventions. These include but are not limited to:

  • Donations: Many health systems utilize a pay-for-service model, so trainees encounter scenarios where there are urgent or life-threatening conditions and the patient cannot afford the diagnostic evaluation and/or treatment. Although the knee-jerk response for trainees is often to cover the costs, there are significant downstream effects to direct payment, including unsustainable precedent setting and undermining the local social support infrastructure for the hospital. To best prepare for these scenarios, some institutions provide guidelines for donations for their trainees, an example of which can be found in Appendix K.
  • Sustainability: Issues surrounding sustainability of interventions arise frequently with short-term GH work, including whether there are local providers (and resources) to sustain treatment plans that are initiated by the visitor (eg, continuation of antihypertensive medications, monitoring of a condition post-procedure, etc). Partnership with local providers and the local health systems infrastructure, discussion about these items during the pre-trip orientation, and continued communication with the host institution after departure can help to mitigate those concerns.
  • Scope of expertise: Although uncommon, there are instances when trainees pursue GH electives for the opportunity to perform procedures or other medical treatments that are outside of their usual scope of practice in the United States. These unethical intentions should be actively screened for with GH elective application processes, the development of individual trainee goals and objectives, and pre-departure mentorship.
  • Standards of care: Trainees may at times experience complacency due to resource limitations and may perceive that the only option is to accept a substandard level of care compared with that in their home institutions. This can be detrimental to health systems and patient care. Accountability to appropriate standards of care can be encouraged through pre-departure expectation setting and careful on-site mentorship.
  • Respect for faith/religion: In many instances, the religious beliefs among the patient population during the GH elective are different than those of the visiting trainee. Discussions of the visitor’s religious preferences can impose on patient comfort and rights, as patients are in the vulnerable position of requiring medical care regardless of religious status.
  • Unprofessional relationships with locals: Many issues can arise when relationships extend beyond standard professional boundaries during the trainee’s elective. Examples include engaging in sexual relations or when a local patient, villager, or member of the health care team requests the visiting trainee to extend monetary or other support (eg “sponsor” a visit to the United States or pay for a specific expense).

Crump and colleagues provide helpful analyses pertaining to ethical considerations for GH electives and propose best practices for trainees and institutions that warrant careful review in pre-departure training and mentorship meetings.36 Additionally, bidirectional training partnerships should be considered if both institutions are seeking exchange opportunities for their trainees (Chapter 10).

On-Site Support

Logistically, it is often difficult to maintain regular communication with trainees during their GH electives — time zone differences, busy schedules, and internet access can all create barriers. Interestingly, though, GH electives have the 

potential to be the most vulnerable, dangerous, and life-changing months of a trainee’s career, which argues for establishing checkpoints to ensure that things are going smoothly. For trainees who participate in an elective that is part of a larger institutional partnership, there are usually established venues for communication as well as safety nets, whereby on-site supervisors can more easily access stateside mentors if there are concerns.

However, this is more difficult in non-partnership GH electives. Program directors may want to consider some of the following communication strategies:

  • Schedule phone calls at the beginning, middle, and end of the elective, in addition to providing ongoing emergency access options for trainees to access a stateside faculty mentor (scheduled check-ins and emergency access can be logistically very difficult because of time zone differences and an unpredictable schedule for the trainee)
  • Facilitate email communication at the beginning of the elective and at least weekly. Some GH educators provide weekly guided questions for their trainees to promote reflection. Examples from Cincinnati Children’s Hospital Medical Center Global Health Education Program are as follows:
    • Week 1: Describe initial impressions of your host site, medical setting, or any aspects of host culture that have particularly made an impression on you.
    • Week 2: Describe the benefits and challenges you have encountered in your work experience and/or describe the benefits and challenges you have encountered in your experience outside of work.
    • Week 3: Describe an experience that challenged your perceptions/values/morals or a specific interaction where cultural differences were apparent and left you discouraged. How did you work through this experience?
    • Week 4/Final week: Describe your feelings about leaving your site. What are the challenges, what are the joys? and/or describe what challenges you anticipate upon arriving home and how you anticipate sharing your experiences with friends/family and colleagues.
  • Create a private blog for trainees to utilize to facilitate communication with home mentors and colleagues
  • If part of a larger partnership, consider establishing routine collaborative teleconferences, such as morning reports
  • When feasible, encourage trainees to schedule meetings with their on-site supervisor at the beginning of the elective (to discuss goals and objectives), middle, and end (for a pre-return debriefing). Trainees should also have full contact information for their host supervisor(s).
Debriefing

When trainees return from their GH electives, they often experience reverse culture shock, which is a complicated reintegration emotional experience in which readjustment to their home setting (both personally and professionally) is difficult. It is not uncommon for them to feel frustrated about the amount of resources that are utilized for clinical care at their home institutions and also to have difficulty communicating about their GH elective experiences to friends, family, and colleagues. The authors recommend that within 2 weeks of their return trainees have a debriefing meeting (minimum of 1 hour) with a faculty mentor who has experience working in GH settings. If an experienced faculty member within the department is not available, consider pursuing mentors from other departments for assistance. Additionally, many helpful debriefing resources exist, including online guides and service learning reflection toolkits.42,43

“My clinical experience of working in both a rural clinic and a regional hospital in Uganda was invaluable to expanding my clinical knowledge and ability to provide care to critically ill children with minimal and inconsistent resources. Locally, I worked with a refugee organization, Pan-African Community Association, to develop a pediatric health education curriculum for community health promoters to improve pediatric health literacy in the local refugee population. The skills I have gained from working both locally and internationally have expanded my clinical skills and knowledge especially of typical tropical diseases as well as atypical or late presentation of more common diseases, such as cancer or sepsis. I also gained skills as a clinical instructor by teaching both basic exam and neonatal resuscitation skills which I plan on continuing in the future.”

- Vanessa Thomas, MD

The authors also recommend that returning trainees set up similar debriefing meetings with close family and friends because the typical circumstances of responding to a “How was your trip?” question in a hurried setting will not be sufficient for them to process the often complicated and complex experiences that they had during their electives.

Although it is important for the debriefing meeting to feel like a safe, informal, and open venue for the trainee, some GH educators also find benefit in providing guiding questions during the meeting. Such questions include but are not limited to the following:

  • Describe two patient stories or interactions that resonated with you.
  • Reflect on two cultural or interpersonal interactions that had an impact on you.
  • How has the transition back to your home institution been going?
  • Using a few cases, describe some of the differences between clinical practice at the elective site compared with your home institution.
  • Many trainees who have shared similar experiences had an adjustment period when they returned from their GH elective. Have you experienced any of the following (eg, sadness, frustration, irritability, sleep disturbance, hypervigilance, difficulty concentrating, etc)? In what settings did these occur? How are you working through those feelings?

Additionally, some GH educators encourage trainees to respond to reflection questions during their elective (eg, weekly) and/or to write a reflective essay upon their return. Examples of post-return guided essay questions, provided by Cincinnati Children’s Hospital Medical Center, include:

  • How has your participation in a GH elective affected your career decisions, if at all, and how?
  • How did your experience impact your approach to or thoughts on providing care to families in the United States?

The debriefing meeting is also an important opportunity to remind trainees to complete their evaluations and to schedule an appointment with occupational health if there were any exposures during the elective. Trainees should also have a repeat interferon gamma release assay (eg, QuantiFERON) or PPD test approximately 3 months post-return because of the possibility of TB exposure.

Finally, it is important to find time to debrief with the host supervisor(s) after the trainee’s return, both to obtain feedback on the trainee’s experience and also to inform modifications for future trainee electives, particularly in the context of training partnerships.

Post-Return Presentations

Many trainees provide presentations (eg, morning reports, grand rounds, case conferences, reflection pieces published in a local venue) pertaining to their GH elective experience upon their return. The authors strongly recommend that trainees design their presentation as if members of the host institution were in the audience. Furthermore, it is recommended that they review their presentations first with a GH faculty mentor and if possible also with their host site supervisor or other host site contact (either in person prior to departure or by email), to ensure that photos, descriptions, tone, and case discussions are appropriate, demonstrate cultural humility, and are ethically sound.

Trainee Assessment

Assessment of the trainee during a GH elective is complicated by many factors, most notably because the on-site supervisors are usually in-country physicians who are busy and often unfamiliar with standard milestones-based assessment paradigms. The authors encourage the use of multiple touchpoints for obtaining evaluative data, including stateside faculty interactions with the trainee during preparation and debriefing sessions; on-site communication; trainee self-assessments; abbreviated written assessments from in-country supervisor(s); and, when possible, verbal discussions regarding the trainee’s performance with in-country partners. Additional details pertaining to trainee assessment are provided in Chapter 6.

Choose Your Own Adventure: GH Elective Case Scenarios for Residency Program Directors

Included in Appendix P are a number of case scenarios, many of which are based on true situations, to assist program directors as they develop their foundations and policies surrounding GH electives at their institutions. These cases are not intended to provide an exhaustive list of all possible scenarios that trainees may encounter but are instead meant to prompt a critical approach to developing a strong infrastructure for preparation, on-site, and post-return support for GH electives at each institution.

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