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Global Health Program Director's Guide: Chapter 8

Chapter Authors: Heather Crouse, MD, Jennifer Watts, MD, MPH, Marideth Rus, MD, MEd, Andrew

Key Points

enlightenedThere are many opportunities to participate in GH during fellowship training. A spectrum from electives abroad to formal GH fellowships within subspecialty and general pediatrics fellowships are available. 

enlightenedExamples of GH training opportunities and important information for fellowship program directors are offered in this section.

 

In response to demands of trainees and faculty, GH electives are now offered by many medical schools and residencies, and formal GH tracks are offered by 25% of pediatric residencies. Trainees with early interest and exposure to GH bring their passion for improving child health globally with them into their fellowship and faculty careers and the natural question then becomes: “Where do I go from here?” Programs are responding to the demand for post-residency opportunities by creating GH training pathways in both general pediatrics and subspecialty fellowships.1,2,7,47,50,51

Models for Incorporating GH Into Fellowship

There are a variety of approaches to incorporating GH experiences into fellowships. Some fellows desire a fellowship with focused GH training within general pediatrics, others wish to complete a pediatric subspecialty fellowship in the standard time frame with the opportunity for GH electives within the fellowship, and others desire a subspecialty fellowship that affords them additional time for formal GH training or a degree.

General Pediatrics GH Fellowships

These fellowships seek to train a cadre of academic pediatricians who have the skills and experience necessary to embark on a career in the field of pediatric GH and to become the future leaders of that field. Although the emphasis varies between programs, they generally all focus on developing GH skills in each of the following core areas: clinical topics unique to GH; teaching GH both internationally and in the United States; research skills (which may include public health, quality improvement, epidemiology, or other); leadership; and advocacy. The format of these mentored fellowships varies in duration, curriculum, and location. Fellowships are generally 2 to 3 years in length, and fellows spend anywhere between 40% and 95% of their time living at an international partner site. Didactic training is offered, but the type of training varies between programs: from full master’s degrees (eg, in public or global health) to selected summer GH content, public health, or epidemiology courses. Depending on the funding mechanism, some fellowships require clinical work in the United States, whereas in others all clinical work is done in a global setting. All general pediatrics GH fellowships accept board-eligible pediatricians. Some also accept pediatricians who have completed subspecialty fellowship training, which gives this group of subspecialists an opportunity to complete a rigorous pediatric GH fellowship during which they can also focus their clinical, teaching, and research skills in their chosen subspecialty. For an example of a curriculum in a general pediatrics GH fellowship, refer to Appendix S.

GH Electives Embedded Within Standard Subspecialty Fellowship Training

GH electives are available for many standard-track pediatric subspecialty fellows. This may be most appropriate for fellows who do not want to dedicate additional time for more formal GH training and yet desire GH experiences or in institutions where formal GH fellowships are not available. These electives may be developed in many ways: collaboration with existing institutional resident GH tracks to create fellowship opportunities; utilizing existing institutional global partners; or seeking training opportunities through personal faculty connections. Some institutions have an established GH educator who oversees the GH elective experiences for residents and/or fellows.

The amount of time spent abroad varies depending on the fellow, but it should occur during elective time and the opportunities should be tailored to a fellow’s specific interest. Examples include:

  • Pediatric Emergency Medicine Fellow interested in International Disaster Relief:
    • Attend a Disaster Management course
    • Spend 1 month applying lessons learned with an international disaster response medical team.
  • Pediatric Developmental-Behavioral Fellow interested in GH:
    • Spend 4 to 6 weeks internationally in a general pediatrics setting with an emphasis on diagnosing behavioral and developmental disorders and additional time in specific international autism centers.

With appropriate supervision, subspecialty fellows can also provide invaluable education to international general pediatricians who may lack subspecialty exposure. Time spent internationally is typically organized and arranged through the program director of the subspecialty fellowship as well as the institution’s GH educator (if applicable) to ensure that the fellow is meeting the requirements of the fellowship and of the GH elective (supervision, safety, etc).

Best practices for fellowship GH elective preparation, on-site support, debriefing, and partnerships are consistent with those described in Chapters 4, 5 and 10. When working globally, fellows should continue to receive supervision and mentorship. It is recommended that fellows provide a biweekly report on their activities to the GH and subspecialty fellowship program directors, as well as to their mentors. Communications should be regular and can be via email, video conferencing, or social media.

Combined Subspecialty-GH Fellowships

Many trainees entering a subspecialty fellowship program also have a strong interest in strengthening their foundation and preparing for a career in GH beyond the elective opportunities allowed within the standard constraints of the subspecialty fellowship. Such training is intended for those seeking a career that incorporates both a pediatric subspecialty and GH. Combined subspecialty-GH fellows can complete the standard ACGME-accredited subspecialty fellowship training and additionally receive supplementary non-accredited GH training, either interspersed throughout or added after the subspecialty fellowship time. For the interspersed model, programs usually include an additional 1 to 2 years of training into the total time of the fellowship (for example, a neonatology fellow may spend 3 months a year globally and 9 months a year in the United States, completing core requirements for 4 years total). For the second model, fellows complete the entire subspecialty fellowship with minimal GH time and then complete an additional 1 to 2 years with focus on GH after the subspecialty fellowship is complete. A combination of these two approaches is also possible. For example, a combined subspecialty-GH fellow may complete all required aspects of the subspecialty fellowship curriculum and receive supplementary GH training and experience interspersed throughout the subspecialty fellowship time by utilizing elective and research time for GH experiences. Fellows then commit an additional year following completion of the subspecialty fellowship that integrates faculty-level work in the subspecialty and additional GH training. These models typically vary between institutions and may depend on each fellowship’s funding mechanism. Regardless of the additional GH training time, these combined programs must abide by ACGME requirements and ABP standards for the non-GH subspecialty curriculum to ensure that subspecialty certification requirements are met at the end of training (see “Accreditation and Certification” section below).

Many combined subspecialty-GH fellowships prepare trainees for more than one aspect of GH. Fellows spend time working abroad clinically, learning how to adapt clinical care for their subspecialty into environments with different disease processes or resources. Fellows also receive training on conducting research in global settings, including performing needs assessments, coordinating multiple IRBs, and collaborating with multiple partners. Additionally, some fellows opt to seek additional degrees such as a master’s in public health or education. Other advanced coursework directed toward the fellow’s specific learning needs may include courses in disaster relief, quality improvement, or education.

Appendix T includes a sample of goals/objectives for a combined subspecialty-GH fellowship and how they integrate into ACGME competencies; Appendix U includes an example of a formal combined subspecialty-GH fellowship curricular pathway.

Accreditation and Certification of Fellows Engaging in GH Activities

Mentorship is crucial for both general pediatrics GH fellowships and GH experiences in subspecialty fellowships. It is key during GH work abroad and includes oversight of scholarly activity, clinical care, and research and quality initiatives. Faculty oversight at international locations should always be present and vetted in advance. Fellows should have significant research oversight both in the U.S. and internationally, with GH experts sitting on the Scholarship Oversight Committee (SOC) and research committees for the fellows. Scholarly activity that meets ABP requirements for subspecialty fellowship training may be conducted in global settings with appropriate oversight and supervision.

General Pediatrics GH Fellowships

General academic pediatric fellowships, including those focused on GH, are not accredited by the ACGME. For general pediatrics GH fellowships, as for other non-ACGME accredited fellowships, the graduate medical education office at each individual institution assesses, vets, supports and provides leadership to ensure quality for the fellowship curriculum. Similarly, on completion of the fellowship and with the recommendation of the fellowship director, most institutions provide a certificate certifying completion of a “general pediatrics global health fellowship” at that institution. Graduation requirements vary by institution but generally require demonstration of expertise in the core areas mentioned above.

GH in Subspecialty Fellowships

In order to meet ABP standards for pediatric subspecialty fellowship training, completion of all ACGME-required core curricular subspecialty fellowship requirements should occur in the U.S. at pre-approved program sites — none internationally. International electives should occur only during elective and scholarly activity/research time in fellowship. Continuity clinic requirements should not be decreased or waived for subspecialty fellows completing GH activities; thus, it is recommended that fellows participate in GH during elective time. All SOC meetings should occur while fellows are in the U.S., per ABP requirements. The ABP feels strongly that fellows must have robust oversight by the fellowship director to make sure they are meeting the same requirements as other trainees. 

Pediatric subspecialty fellowships are accredited by the ACGME once program requirements are met. However, the ACGME does not accredit GH fellowships nor the GH portion of a subspecialty fellowship. As for other non-ACGME-accredited fellowships, the fellowship office at each individual institution assesses, vets, supports and provides leadership to ensure quality for the fellowship curriculum. Similarly, on completion of both the subspecialty and GH portions of fellowship and with the recommendation of the fellowship director, most institutions provide a certificate certifying completion of a “combined pediatric subspecialty-GH fellowship” at that institution. Graduation requirements vary by institution but generally require demonstration of expertise in the core areas mentioned above.

Scope of Clinical Practice Internationally (General Pediatrics and Subspecialty)

Time abroad generally includes a combination of clinical care, teaching, advocacy, and research (which varies significantly from translational research, including epidemiology, public health, and quality improvement work). Clinical care may be in- or outpatient, and there is significant variation even in the level of inpatient care, from general pediatrics hospitalist to newborn to subspecialty areas when available. A detailed, well-mentored international orientation is crucial to ensure a smooth transition for the fellow. High-quality, successful, and sustainable international experiences depend on vetted on-site clinical and advocacy mentors. Established, involved on-site research collaborators partnered with experienced home institution mentors maximize both the feasibility and potential impact of a fellow’s scholarly work. Notably, the mentors can be on-site clinicians and do not need to be board certified.

Duration of GH Time During Training

General Pediatrics GH Fellowships

Time abroad varies by program, with fellows spending between 40% and 95% of their fellowship at an international site. There are advantages and disadvantages to spending more time internationally, and fellow candidates should weigh these during the application process as they consider what they seek from their fellowship experience.

GH in Subspecialty Fellowships

GH electives within standard subspecialty fellowship training average 1 to 2 months total. Combined subspecialty-GH fellows typically average from 6 to 12 months abroad, distributed over the entire combined subspecialty-GH fellowship training period. The length of each individual elective depends on the institution and subspecialty fellowship requirements. For fellows spending more than 6 months cumulative time during the subspecialty training abroad, program directors must petition the ABP for a non-standard training pathway (see details below).

Process for Applying for a Non-Standard Training Pathway (for ABP-approved subspecialty programs)

For GH fellowships combined with subspecialty fellowships with ABP oversight, program directors must petition the ABP for permission to create a non-standard training pathway for fellows spending more than 6 months cumulative time during the subspecialty training abroad. This is most appropriate for subspecialty fellowships that have GH tracks embedded within their programs and not separated afterward and should occur before or during the first year of fellowship training. The ABP approves individuals (not programs) for non-standard training pathways, and therefore petitions are required for each fellow.

The application should be addressed to the ABP Vice President of Credentialing and Initial Certification and should include a letter of petition as well as a draft schedule or block diagram of expected subspecialty and GH electives during training. (Appendices V and W contain a template petition.) Once the petition is approved, the Verification of Competence Form that is completed at the end of fellowship can include specifics about what the fellow has actually done during fellowship, including amount of time away and how much was clinical or devoted to research, the nature of his/her scholarly work and the oversight provided, and whether the fellow has completed his/her scholarly work to the satisfaction of the SOC.

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