Virtual Mentor. March 2010, Volume 12, Number 3: 184-189.
The University of Washington Pediatric Residency Program Experience in Global Health and Community Health and Advocacy
The University of Washington Pediatric Residency Program Experience in Global Health and Community Health and Advocacy embodies essential principles of successful short-term rotations from academic medical centers to resource-limited countries.
Kym Ahrens, MD, MPH, F. Bruder Stapleton, MD, and Maneesh Batra, MD, MPH
Among medical trainees, interest in international health experiences is at an all-time high. In the past 25 years, the percentage of graduating North American medical students who have participated in global health electives has risen from 6 percent to almost 30 percent [1, 2]. Involvement in international health experiences has also increased among resident physicians. In our own pediatrics residency program at the University of Washington, the percentage of residents reporting participation in an international health experience has almost doubled in the past 10 years, from 32 percent to 58 percent, and the majority of residents who report this type of experience prior to residency express interest in similar experiences during residency as well.
Learning ObjectiveIdentify essential principles for successful short-term rotations from academic medical centers to resource-limited countries.
As a result of this increased interest, nearly all medical schools have incorporated some form of global health teaching into their curricula . Many residencies have also established formal international electives  or even specialized tracks to train physicians interested in global health careers . These experiences have undeniable benefits to participants. Medical trainees who have participated in international experiences report increased knowledge of tropical diseases and advanced presentations of diseases encountered in the United States, improved physical examination skills, and a deeper appreciation of issues related to public health, professionalism, and cultural sensitivity [5-9]. They are also more likely than their peers to report an interest in caring for underserved populations in the United States or in devoting their careers to international medicine [7, 8, 10].
Due to the demands of medical education, the duration of international health electives for medical trainees can be quite short. (These trips are particularly limited when they include residents who have a severely curtailed ability to take time off; they frequently have substantial patient care responsibilities assigned to them and are only paid for their physical presence at their home institution.) Concern has been expressed that short-term international medical trips, including those for medical trainees, can be self-serving, ineffective, and unsustainable. These trips may impose burdens on local health facilities or result in the delivery of care that does not meet standards in the U.S. or in the country being visited [11-13].
We assert that international health electives for resident physicians can be conducted ethically if undertaken with forethought and careful planning. In 2008, in collaboration with staff members from a non-governmental agency (NGO) in El Salvador, several physicians from our institution, including the primary author of this article, outlined a set of principles to guide short-term international medical trips . We summarize these principles below and subsequently illustrate their application to resident-focused international health electives, using an example from our own institution.
To conduct a short-term international health trip involving residents in an ethical manner, we believe that institutions should:
In 2008, after 2 years of planning guided by these principles, the University of Washington Pediatric Residency Program launched a combined experience in global health (GH) and community health and advocacy (CHA). The mission and curricula of these two “pathways” were developed by an advisory council consisting of trainees and faculty engaged in these activities. The mission of the global health component was designed collaboratively with partner institutions in Kenya. The pathways’ mission is to equip interested pediatric residents with the knowledge and experience to reduce health disparities among children in the U.S. and abroad. With the support of Seattle Children’s Hospital and the Department of Pediatrics of the University of Washington, we created a curriculum based on the principles of collaboration, teamwork, education, service, and sustainability, with mutual benefit for all stakeholders involved.
Both the CHA and GH pathways consist of 4 months of activities during the second and third years of residency. In the first month, residents work together in an experiential, interactive curriculum that exposes them to issues in public health, social justice, program evaluation, media training, and ethics. The curriculum includes small group discussions with leaders and potential mentors in child advocacy and public and global health; experiential learning with local organizations engaged in activities in these fields; the development of an individualized learning plan to focus independent work in future months; and a series of problem-based learning sessions through which residents engage the community. The pathways are combined for the first month to highlight commonalities in the skills needed to work with underserved populations domestically and abroad and to encourage the development of common goals and interests among the residents. Furthermore, we chose to focus on the public health needs of the community rather than on clinical management in order to underscore the importance of health promotion and disease prevention in sustaining change.
In the second month of the curriculum, residents design projects with their assigned preceptors based on objectives identified in their learning plans. A critical feature of this portion of the curriculum is that the resident identifies specific knowledge and skills he or she will obtain during the month, along with means for measuring whether or not the objectives were met.
Following this preparatory education, each resident subsequently participates in a two-month experience in either domestic advocacy or global health. The global health experience is based in a rural district hospital in Kenya, where our residents are paired with pediatric residents from the University of Nairobi. In this manner, our residents are integrated into the local health structure, which ensures that they are given appropriate clinical supervision and that clinical care is provided in an ethical and locally relevant manner. In addition to the hospital-based component of this elective, residents also spend time in the community, identifying educational needs of local health workers and barriers to accessing services. To ensure the impact is sustainable, we concentrate our efforts on one partnership with a single hospital, so that the residents’ work builds on that of their predecessors and the program has a presence at the site 8 months out of the year. To support these ongoing partnerships, we have arranged funding for an in-country resident coordinator to facilitate logistics for both the Seattle-based and Kenyan residents and an in-country faculty advisor to oversee the educational experience, maintain relationships with partner institutions, and provide mentorship during the elective.
At the culmination of each rotation, the resident pairs present their findings and recommendations to the provincial hospital, representatives of the public health community and to faculty and trainees at both the University of Washington and the University of Nairobi. Furthermore, both residents are formally interviewed regarding their experiences and give written feedback on all aspects of the rotation. Upon return to the U.S., the Seattle-based resident is required to debrief further with the preceptor. Semi-annually, a summary report of the educational activities and progress towards reaching each institution’s educational and service objectives are discussed in person. This evaluative process results in a written agenda of future directions for strengthening the collaboration between institutions and the educational program for the residents.
We believe that the example provided by the GH pathway experience at the University of Washington illustrates that the above principles can guide the development of sustainable, ethically sound international health electives. The incorporation of international health experiences into residency programs has the potential to benefit residents greatly and to improve public health both locally and globally.
Kym Ahrens, MD, MPH, is an acting instructor and senior research fellow in the Adolescent Medicine Division of the Department of Pediatrics at the University of Washington and Seattle Children’s Hospital.
F. Bruder Stapleton, MD, is Ford/Morgan Professor and chair of the Department of Pediatrics at the University of Washington in Seattle. He is also associate dean of the School of Medicine and the chief academic officer at Seattle Children’s Hospital.
Maneesh Batra, MD, MPH, is an assistant professor in the Division of Neonatology of the Department of Pediatrics at the University of Washington and Seattle Children’s Hospital and associate director of the pediatric residency program.
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