Global health education in emergency medicine residency programs

The Impact of Global Health Experiences on the Emergency Medicine Residency Milestones

OBJECTIVES

Identify the impact of experiences in global health (GH) on the Accreditation Council for Graduate Medical Education (ACGME) competencies in emergency medicine (EM) residents and describe the individual characteristics of EM residents with global health experience compared to those without.

METHODS

From 2015 to 2018, 117 residents from 13 nationally accredited United States EM residency training programs were surveyed. Specifically, the survey gathered demographic data and information regarding timing, type, location and duration of short term experiences in global health (STEGH). The survey collected both qualitative and quantitative data regarding resident experiences, including number of procedures performed and self-assessment of the impact on their residency milestones. ACGME milestone data from survey respondents was collected from each resident's training program coordinators. Chi-squared analysis and t-tests were conducted to assess differences between residents with STEGH and those without. A generalized linear model (GLM) was utilized to assess the effects of time and experience with interaction on achieving milestones in each of the competency domains, to compare milestone achievement over time between residents with STEGH and those without.

RESULTS

Out of 117 EM residents, 60 were female (44%), the mean age was 30 years (standard deviation = 3.1), and 84 (71.8%) reported STEGH in general, including prior to residency (64.5%). 33 (28.2%) reported having completed STEGH during residency. The results of the GLM analysis showed that residents with STEGH during residency had significantly higher scores compared to those without the experience or STEGH pre-residency across all six competencies.

CONCLUSIONS

STEGH in EM residents was associated with higher milestone achievement in certain ACGME competency domains including medical knowledge, practice-based learning and improvement, and professionalism. Participation in STEGH during residency appeared to show the strongest effect, with higher scores across all six competencies.

Highlights and Perspectives From a Collaborative Global Health Pathology Experience in Trinidad and Tobago

OBJECTIVES

Global health education is important during residency training in exposing doctors to conditions that are not common in the United States and developing their awareness of global health care disparities. Most medical decisions are based on results from anatomic or clinical pathology laboratories, which are essential services for appropriate medical care in international settings. Nevertheless, US pathology residency trainees have limited global health exposure and thus are rarely exposed to diagnostic services in these settings. Moreover, literature documenting what is needed to create a global health elective in pathology is limited.

METHODS

We designed an international pathology elective in Trinidad and Tobago involving one main public hospital site and several off-site laboratories. Objectives and goals were established before the rotation. Apart from daily mentor-led education sessions, the trainee participated in teaching, quality improvement projects, and cultural experiences. Engagement with medical officers, personnel staff, and people in the community was encouraged.Results: Challenges encountered included funding, transportation, limited laboratory resources, medical registration, and malpractice insurance. These were mitigated through carefully planned steps, including communicating with registration bodies and liaising with pathology organizations for funding.

CONCLUSIONS

Overall, the global health rotation was successful. We provide a detailed roadmap for other pathology training programs interested in establishing similar global health electives.

Trainee Perspectives Regarding Advanced Clinical Global Health Fellowships in North America

Postgraduate clinical global health (GH) training is a rapidly evolving field. To understand and improve training opportunities, we sought the perspectives of current and former trainees related to their advanced clinical training or global health fellowships and the anticipated impact on their careers. Clinical GH fellowships across North America were identified through websites and previous studies. An e-mail was sent to program directors to invite all current and former GH fellows to complete a web-based questionnaire. We contacted 100 GH fellowship programs. Fifty-two fellows from 10 different specialties completed the survey. The median fellowship length was 23.3 months, with an annual median of 4.8 months spent in low-income and middle-income countries, which was less than their reported ideal of 6 months. The majority reported satisfaction, the anticipation of career benefits, and that they would recommend fellowship training to others. Challenges included insufficient funding, mentorship, and formal curricula. Conducting research in high-income countries was a significant negative predictor of fellowship satisfaction. Most fellows (73.1%) were not at all or only a little concerned about the absence of fellowship accreditation, with only 17.3% desiring accreditation. Survey respondents were largely satisfied with their training and valued program flexibility and educational opportunities, including advanced tropical medicine certificates or diplomas. However, to improve fellowship training, improvements are needed in mentorship, standardized curricula, institutional support, and funding. For GH fellowship training to be effective and sustainable, institutions will need to balance the needs of fellows, training programs, and the communities (low-, middle-, and high-income countries) where the fellows serve.

Global Health Training in U.S. Emergency Medicine Residency Programs

OBJECTIVES

Formal education in global health (GH) and short-term experiences in GH (STEGH) are offered by many emergency medicine (EM) residency programs in the United States. In an increasingly connected world, training in GH and STEGH can provide essential knowledge and practical skills to trainees, particularly at the graduate medical education level. The current core programmatic components and the essential competencies and curricula that support ethical and effective STEGH, however, still vary widely. The authors conducted a survey of the 228 EM residency programs in the United States to describe the current state of GH training and STEGH.

METHODS

An online survey was developed in REDCap by a team of GH faculty. In July 2018, programs were invited to participate via individual invitation of program directors from a directory. The programs received two reminders to participate until January 2019.

RESULTS

Of the 84 programs that responded, 75% offer STEGH and 39% have longitudinal GH curricula. Within these programs, only 55% have dedicated GH faculty and only 70% have dedicated sites. Both faculty and residents encounter funding and insurance barriers; most notably, only 20% of programs that offer STEGH provide evacuation insurance for their residents. Most residents (95%) engage in clinical work along with teaching and other activities, but 24% of programs do not allow these activities to fulfill any residency requirements. Finally, only 80 and 85% of programs offer preparatory and debriefing activities for residents, respectively.

CONCLUSIONS

While the results of this survey show progress relative to prior surveys, there are still barriers to implementing GH curricula and supporting safe, ethical, and effective STEGH, particularly in the form of continued financial and logistic support for faculty and for residents, in U.S. EM training programs.

Pre-departure and Post-elective Requirements for Global Health Electives: Survey of Canadian Royal College Emergency Medicine Programs

Objectives: Global Health (GH) electives offer unique learning opportunities; however, risks to trainees and host populations should be minimized through pre-departure training and post-elective debriefing. In a 2016 study, only three Canadian residency programs mandated such training, although specific data on Emergency Medicine (EM) programs is lacking. This study aimed to identify GH elective requirements and perceived training gaps among EM programs.

Methods: We conducted two email surveys (one each for EM program directors [PDs] and residents) regarding training requirements and perceived gaps for GH electives. We also contacted university postgraduate medical education (PGME) and GH offices, via their online publicized emails, to assess university-wide requirements and resources.

Results: Nine PDs responded, with 78% reporting having residents participate in GH electives. Many PDs (67%) believed residents were moderately prepared for GH electives, while 33% felt they were unprepared to some degree. Forty seven out of an estimated 380 EM residents responded with 35% having completed a GH elective during residency. Of those, only one (6%) reported feeling very prepared, and 43% believed there was a need to improve trainings. Uncertainty around training requirements was reported, and residents identified challenges faced on electives, as well as priority topics for training. Responses from PGME and GH offices indicated that pre-departure training and post-elective debriefing were required or available at more universities than was indicated by the PD and resident respondents. However university requirements varied widely, with some exclusively requiring basic travel information and Health and Safety checklists or modules. The disparate responses indicate that residents and PDs may either be unaware of university requirements or not utilize available training resources for GH electives.

Conclusions: Although Canadian EM residents participate in GH electives, the majority of training programs do not require pre-departure training or post-elective debriefing. PDs and residents report varying levels of preparedness, and residents acknowledge a variety of challenges during GH electives. This information can be used to inform pre-departure training and post-elective debriefing and encourage EM residents to access available university-wide training.

Global Health-related Training Opportunities. A National Survey of Pulmonary and Critical Care Medicine Fellowship Programs

Rationale: Clinical and research training opportunities in global health are of increasing interest to medical trainees, but little is known about such opportunities in U.S.-based pulmonary and pulmonary/critical care medicine (PCCM) fellowship programs.Objectives: Summarize currently available global health-related training opportunities and identify potential barriers to implementing global health curricula among U.S.-based PCCM fellowship programs.Methods: We sent a confidential, online, targeted needs assessment to PCCM fellowship program directors and associate program directors. Data collected included program demographics, currently available global health-related clinical and research training opportunities, potential barriers to the implementation of global health-related programmatic content, and perceived interest in global health-related training opportunities by current and/or prospective trainees. To evaluate for nonresponse bias, we performed an online search to identify global health-related training opportunities offered by nonresponding programs.Results: Out of 171 surveyed programs, 63 PCCM fellowship programs (37%) provided survey responses. Most responses (n = 56, 89%) were from combined PCCM training programs; 66% (n = 40) of programs offered at least one component of global health-related clinical or research training. Overall, 27% (n = 17) had a Ruth L. Kirschstein National Research Service Award Institutional Research Training Grant (National Institutes of Health T32), 73% (n = 46) had fewer than 35 faculty members, and 51% (n = 32) had at least one faculty member conducting global health-focused research. Most responding programs (66%, n = 40) offered at least one global health-related educational component. Among programs that would like to offer global health-related training components, the most common barriers included competing priorities for lecture content and a lack of in-division mentors with global health experience, a champion for global health-related activities, and established partnerships outside the United States.Conclusions: PCCM program leaders are interested in offering global health-related training opportunities, but important barriers include lack of mentorship, dedicated fellowship time, and established global partnerships. Future research is needed to better understand global health-related interests and training needs of incoming fellows and to design creative solutions for providing global health-related training across academic institutions with variable global health-related training capacities.

Global Health Education Programs in the Americas: A Scoping Review

Background:

The interest in Global Health (GH) as an academic discipline has increased in the last decade. This article reports the findings of a scoping review of studies about Global Health education in the Americas.

Objective:

To analyse educational programs on global health in the Americas.

Method:

Five electronic databases were used in a scoping review: PubMed, Scopus, Web of Knowledge, CINAHL, and Lilacs. Data collection happened in November 2017–March 2018. The following stages were rigorously observed: identification, selection, charting, and summarizing the studies that were included. To process the data, we used IRaMuTeQ software.

Findings:

Forty-six studies were identified and organized in categories: 1) diversity of the topics addressed in GH; 2) models of teaching; 3) emotional, cultural, and collaborative aspects in teaching GH; 4) student preparation for GH experiences; and 5) structures required for a GH course.

Conclusions:

The existing global health curriculum in the Americas is diffuse and limited, with a greater focus on clinical aspects. Thus, a minimum curriculum for students from different areas is needed. Results evidenced that the teaching of global health in the Americas is still incipient, although it is promising. The lack of a common curriculum for the courses in the region makes it difficult to train sensitive and capable professionals to achieve the 2030 Sustainable Development Goals.

Leveraging Peer Teaching for Global Health Elective Preparation: Implementation of a Resident-Led Global Health Simulation Curriculum

Introduction. As more trainees engage in global health electives, the call for best practices in predeparture preparation grows. However, many residency programs may not have the infrastructure or staffing in place to consistently meet these expectations. Objective. To assess the feasibility, benefits, and limitations of having residents trained to facilitate and implement a global health preparatory simulation curriculum. Approach. In 2016, we had 5 residents undergo online Simulation Use for Global Away Rotations (SUGAR) facilitator training. Since then, we have conducted 3 simulation sessions from 2016 to 2018. Feedback was obtained from 75% of our participants, which was found to be similar to feedback obtained from attending-led models. Lessons Learned. A resident-led global health preparatory curriculum provides a sustainable model for residency programs without placing additional burden on attending faculty.

The Practitioner's Guide to Global Health: an interactive, online, open-access curriculum preparing medical learners for global health experiences

BACKGROUND

Short-term experiences in global health (STEGH) are increasingly common in medical education, as they can provide learners with opportunities for service, learning, and sharing perspectives. Academic institutions need high-quality preparatory curricula and mentorship to prepare learners for potential challenges in ethics, cultural sensitivity, and personal safety; however, availability and quality of these are variable.

OBJECTIVE

The objective of this study is to create and evaluate an open-access, interactive massive open online course (MOOC) that prepares learners to safely and effectively participate in STEGH, permits flexible and asynchronous learning, is free of charge, and provides a certificate upon successful completion.

METHODS

Global health experts from 8 countries, 42 institutions, and 7 specialties collaborated to create The Practitioner's Guide to Global Health (PGGH): the first course of this kind on the edX platform. Demographic data, pre- and posttests, and course evaluations were collected and analyzed.

RESULTS

Within its first year, PGGH enrolled 5935 learners from 163 countries. In a limited sample of 109 learners, mean posttest scores were significantly improved (p < 0.01). In the course's second year, 213 sampled learners had significant improvement (p < 0.001).

CONCLUSION

We created and evaluated the first interactive, asynchronous, free-of-charge global health preparation MOOC. The course has had significant interest from US-based and international learners, and posttest scores have shown significant improvement.

Pre-departure Training for Healthcare Students Going Abroad: Impact on Preparedness

Background:

Many medical and nursing schools offer opportunities for students to participate in global health experiences abroad, but little is known about the efficacy of pre-departure training in preparing students for these experiences.

Objectives:

The primary aim was to identify characteristics of pre-departure training associated with participants’ reporting a high level of preparedness for their global health experiences. Secondary objectives included identifying students’ preferred subjects of study and teaching modalities for pre-departure training.

Methods:

A questionnaire was distributed to all medical and nursing students at our institution from 2013 to 2015. Questions addressed prior global health experiences and pre-departure training, preferences for pre-departure training, and demographic information.

Findings:

Of 517 respondents, 55% reported having a prior global health experience abroad, 77% of whom felt prepared for their experience. Fifty-three percent received pre-departure training. Simply receiving pre-departure training was not associated with perceived preparedness, but pre-departure training in the following learning domains was: travel safety, personal health, clinical skills, cultural awareness, and leadership. Perceiving pre-departure training as useful was also independently associated with self-reported preparedness. Students’ preferred instruction methods included discussion, lecture, and simulation, and their most desired subjects of study were travel safety (81%), cultural skills (87%), and personal health (82%).

Conclusions:

Incorporating travel safety, personal health, clinical skills, cultural awareness, and/or leadership into pre-departure training may increase students’ preparedness for global health experiences. Student perceptions of the usefulness of pre-departure training is also associated with self-reported preparedness, suggesting a possible “buy-in” effect.

Pre-departure Training for Healthcare Students Going Abroad: Impact on Preparedness

BACKGROUND

Many medical and nursing schools offer opportunities for students to participate in global health experiences abroad, but little is known about the efficacy of pre-departure training in preparing students for these experiences.

OBJECTIVES

The primary aim was to identify characteristics of pre-departure training associated with participants' reporting a high level of preparedness for their global health experiences. Secondary objectives included identifying students' preferred subjects of study and teaching modalities for pre-departure training.

METHODS

A questionnaire was distributed to all medical and nursing students at our institution from 2013 to 2015. Questions addressed prior global health experiences and pre-departure training, preferences for pre-departure training, and demographic information. Findings: Of 517 respondents, 55% reported having a prior global health experience abroad, 77% of whom felt prepared for their experience. Fifty-three percent received pre-departure training. Simply receiving pre-departure training was not associated with perceived preparedness, but pre-departure training in the following learning domains was: travel safety, personal health, clinical skills, cultural awareness, and leadership. Perceiving pre-departure training as useful was also independently associated with self-reported preparedness. Students' preferred instruction methods included discussion, lecture, and simulation, and their most desired subjects of study were travel safety (81%), cultural skills (87%), and personal health (82%).

CONCLUSIONS

Incorporating travel safety, personal health, clinical skills, cultural awareness, and/or leadership into pre-departure training may increase students' preparedness for global health experiences. Student perceptions of the usefulness of pre-departure training is also associated with self-reported preparedness, suggesting a possible "buy-in" effect.

Using Simulation in Global Health: Considerations for Design and Implementation

STATEMENT

Providers and educators increasingly participate in global health work during their careers. Simulation can play an important role in both preparing learners for work in resource-limited settings and training providers in these countries. However, little guidance exists for educators interested in creating and implementing scenarios for these settings. We discuss several key considerations unique to global health simulation ranging from addressing common cultural differences surrounding healthcare and varied regional approaches to disease identification and management to understanding precisely what resources exist in the setting and what strategies can be used to provide care when the expected resources are not available. We also discuss specific strategies for considering sustainability and for facilitating scenarios in these settings. We developed our recommendations on the basis of existing literature and our own work designing and implementing simulation curricula in resource-limited countries and preparing providers for work in these settings.

Global health education in United States anesthesiology residency programs: a survey of resident opportunities and program director attitudes

BACKGROUND

Interest in global health during postgraduate residency training is increasing across medical specialties, and multiple disciplines have categorized global health training opportunities in their arena. No such cataloging exists for anesthesiology residency programs. The aim of this study was to assess and characterize global health opportunities and the attitudes of program directors (PDs) in U.S. anesthesiology residency programs towards this training.

METHODS

A cross-sectional 20-question survey on global health opportunities was distributed to 128 ACGME accredited anesthesiology residency program directors via email between October 2015 and January 2016. Descriptive statistics and exploratory inferential analyses were applied. Maximal nonresponse selection bias was estimated.

RESULTS

The overall response rate was 44%. Of those who responded, 61% reported that their residency program had a global health elective, with a maximal bias estimate of 6.5%. 45% of program directors with no global health elective reported wanting to offer one. 77% of electives have articulated educational goals, but there is substantial heterogeneity in curricula offered. Program director attitudes regarding the value of global health programs differed significantly between those with and without existing programs.

CONCLUSIONS

The proportion of U.S. anesthesiology residency programs offering global health electives is similar to that in other medical specialties. There is inconsistency in program structure, goals, curriculum, and funding. Attitudes of program directors differ between programs with and without electives, which may reflect bidirectional influence to be investigated further. Further studies are needed to codify curricula, assess effectiveness, and validate methodologies.

Pediatric Resident Academic Projects While on Global Health Electives: Ten Years of Experience at the University of Minnesota

PURPOSE

Many residency programs require residents to complete an academic project as part of a global health (GH) elective. However, there has been little description of the range of projects residents have pursued during GH electives or the extent to which these projects are consistent with proposed best practices.

METHOD

The authors conducted a document review of 67 written summaries or copies of presentations of academic projects (hereafter, summaries) completed by pediatric and medicine-pediatric residents at the University of Minnesota while on GH electives from 2005 to 2015. Two authors independently coded each summary for the type of project completed; when the project idea was generated; explicit mention of a mentor from the home institution, host institution, or both; whether a needs assessment was conducted; and whether there were plans for sustainability.

RESULTS

Most of the 67 projects were categorized into one of three project types: quality/process improvement (28 [42%]), education (18 [27%]), or clinical research (14 [21%]). Most summaries explicitly mentioned a mentor (45 [67%]), reported conducting a needs assessment (38 [57%]), and indicated sustainability plans (45 [67%]). Of the 42 summaries that indicated the timing of idea generation, 30 (71%) indicated the idea was developed after arriving at the host site.

CONCLUSIONS

Residents undertook a wide range of academic projects during GH electives, most commonly quality/process improvement and education projects. The projects were largely aligned with best practices, with most summaries indicating the resident worked with a mentor, conducted a needs assessment, and made plans for sustainability.

Global health training among U.S. residency specialties: a systematic literature review

BACKGROUND

Interest in global health training during residency is increasing. Global health knowledge is also becoming essential for health-care delivery today. Many U.S. residency programs have been incorporating global health training opportunities for their residents. We performed a systematic literature review to evaluate global health training opportunities and challenges among U.S. residency specialties.

METHODS

We searched PubMed from its earliest dates until October 2015. Articles included were survey results of U.S. program directors on global health training opportunities, and web-based searches of U.S. residency program websites on global health training opportunities. Data extracted included percentage of residency programs offering global health training within a specialty and challenges encountered.

RESULTS

Studies were found for twelve U.S. residency specialties. Of the survey based studies, the specialties with the highest percentage of their residency programs offering global health training were preventive medicine (83%), emergency medicine (74%), and surgery (71%); and the lowest were orthopaedic surgery (26%), obstetrics and gynecology (28%), and plastic surgery (41%). Of the web-based studies, the specialties with the highest percentage of their residency programs offering global health training were emergency medicine (41%), pediatrics (33%), and family medicine (22%); and the lowest were psychiatry (9%), obstetrics and gynecology (17%), and surgery (18%). The most common challenges were lack of funding, lack of international partnerships, lack of supervision, and scheduling.

CONCLUSION

Among U.S. residency specialties, there are wide disparities for global health training. In general, there are few opportunities in psychiatry and surgical residency specialties, and greater opportunities among medical residency specialties. Further emphasis should be made to scale-up opportunities for psychiatry and surgical residency specialties.

Near-peer emergency medicine for medical students in Port-au-Prince, Haiti: an example of rethinking global health interventions in developing countries

BACKGROUND

During a 3-year time frame, a partnership between medical trainees in Haiti and the United States was forged with the objective of implementing an emergency response skills curriculum at a medical school in Port-au-Prince. The effort sought to assess the validity of a near-peer, bidirectional, cross-cultural teaching format as both a global health experience for medical students and as an effective component of improving medical education and emergency response infrastructure in developing countries such as Haiti.

METHOD

Medical students and emergency medicine (EM) residents from a North American medical school designed and taught a module on emergency response skills in PAP and certified medical students in basic cardiac life support (BLS) over 2 consecutive years. Five-point Likert scale self-efficacy (SE) surveys and multiple-choice fund of knowledge (FOK) assessments were distributed pre- and postmodule each year and analyzed with paired t tests and longitudinal follow-up of the first cohort. Narrative evaluations from participants were collected to gather feedback for improving the module.

FINDINGS

Challenges included bridging language barriers, maintaining continuity between cohorts, and adapting to unexpected schedule changes. Overall, 115 students were certified in BLS with significant postcurriculum improvements in SE scores (2.75 ± 0.93 in 2013 and 2.82 ± 1.06 in 2014; P < 0.001) and FOK scores (22% ± 15% in 2013 and 41% ± 16% in 2014; P < 0.001). Of 24 Haitian students surveyed at 1-year follow-up from the 2013 cohort, 7 (29.3%) reported using taught skills in real-life situations since completing the module. The US group was invited to repeat the project for a third year.

CONCLUSIONS

Near-peer, cross-cultural academic exchange is an effective method of medical student-centered emergency training in Haiti. Limitations such as successfully implementing sustainability measures, addressing cultural differences, and coordinating between groups persist. This scalable, reproducible, and mutually beneficial collaboration between North American and Haitian medical trainees is a valid conduit for building Haiti's emergency response infrastructure and promoting global health.

Emergency Medicine Resident Rotations Abroad: Current Status and Next Steps

INTRODUCTION

International rotations for residents are increasingly popular, but there is a dearth of evidence to demonstrate that these rotations are safe and that residents have appropriate training and support to conduct them.

METHODS

A survey was sent to all U.S. emergency medicine (EM) residencies with publicly available e-mail addresses. The survey documents and examines the training and support that emergency medicine residents are offered for international rotations and the frequency of adverse safety events.

RESULTS

72.5% of program director responded that their residents are participating in rotations abroad. However, only 15.4% of programs reported offering training specific to working abroad. The results point to an increased need for specific training and insurance coverage.

CONCLUSION

Oversight of international rotations should be improved to guarantee safety and education benefit.

Global health education in general preventive medicine residencies

Opportunities for global health training during residency are steadily increasing. For example, surveys show that more than half of residency programs now offer international electives. Residency programs are increasingly recognizing that global health training improves communication skills, fosters awareness of health disparities, and inspires careers in primary care and public health. Although research has focused on global health education in other specialties, there is a paucity of research on global health training in public health and general preventive medicine (GPM). We sought to describe the extent of global health training across GPM residencies, capture the perspectives of program directors regarding competencies residents need for careers in global health, and identify program directors' perceived barriers to providing global health training. The survey was sent electronically to 42 U.S. GPM residency program directors from September to October 2013. Twenty-three completed surveys were returned. Information from residencies that did not complete the study survey was collected through a predefined search protocol. Data analysis was performed from February through July 2014. Among program directors completing the survey, the most common types of reported global health education were courses (n=17), followed by international rotations (n=10). Ten program directors indicated that resident(s) were involved in global health training, research, or service initiatives. Commonly perceived barriers included funding (87%), scheduling (56.5%), and partnership and sustainability (34.8%). Through global health coursework, research, and practicum rotations, GPM residents could acquire skills, knowledge, and attitudes contributing to careers in global health.