|Year : 2016 | Volume
| Issue : 2 | Page : 113-118
A medical school's approach to meeting the challenges of interdisciplinary global health education for resident physicians
Carlough Martha1, Becker-Dreps Sylvia1, Hawes Samuel2, Hodge Bethany3, Martin Ian4, Clark Denniston5
1 Department of Family Medicine, Office of International Activities, University of North Carolina School of Medicine, Chapel Hill, NC, USA
2 Office of International Activities, University of North Carolina School of Medicine, Chapel Hill, USA
3 Department of Pediatrics, University of Louisville School of Medicine, Louisville, USA
4 Department of Emergency Medicine and Internal Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
5 Department of Family Medicine, Executive Associate Dean for Graduate Medical Education, Chapel Hill, NC, USA
|Date of Web Publication||19-Aug-2016|
Department of Family Medicine, Office of International Activities, University of North Carolina School of Medicine, CB 7595, Chapel Hill, NC 27599-7595
Source of Support: None, Conflict of Interest: None
Background: Following a similar trend among United States (US) medical students, US resident physicians are increasingly interested in pursuing global health education. Largely, residency education has lagged behind in addressing this demand. Time and curriculum requirements make meeting this need challenging. The Office of International Activities (OIA) at University of North Carolina-Chapel Hill (UNC-CH) was founded to provide support to students and residents in the area global health. In order to more fully understand resident physicians' attitudes and educational needs, a survey of incoming residents was undertaken. Methods: The OIA administered a survey for incoming first-year residents of all specialties in July 2012. The survey was administered over one month using Qualtrics® and the response rate was 60%. Results: Although 42% of residents had had an international experience during medical school, only 36% reported they felt prepared to address issues of international public health, including travel medicine and immigrant health. Significant barriers to involvement in global health opportunities in residency education were identified, including lack of time, finances and mentorship. Discussion: As has been previously documented for global health education for medical students, this study's residents saw significant barriers to international electives during residency, including lack of elective time, finances and family responsibilities. In response to the survey results, an interdisciplinary educational initiative was developed at our school. This included obtaining buy-in from core residency leadership, establishing a pathway to arrange experiences, competitive scholarships for travel, and initiation of interdisciplinary educational opportunities. Results may serve as a useful model for other academic centers in developed countries.
Keywords: Career choice, global health, global health ethics, health education, international health, internship and residency, resident education
|How to cite this article:|
Martha C, Sylvia BD, Samuel H, Bethany H, Ian M, Denniston C. A medical school's approach to meeting the challenges of interdisciplinary global health education for resident physicians. Educ Health 2016;29:113-8
|How to cite this URL:|
Martha C, Sylvia BD, Samuel H, Bethany H, Ian M, Denniston C. A medical school's approach to meeting the challenges of interdisciplinary global health education for resident physicians. Educ Health [serial online] 2016 [cited 2021 Sep 17];29:113-8. Available from: https://www.educationforhealth.net/text.asp?2016/29/2/113/188750
| Background|| |
Over 30% of North American medical students participate in international electives.  Multiple small studies have documented positive outcomes of student involvement in global health rotations, including improved physical exam skills, improved communication with patients, increased resource-conscious practice, and increased interest in primary care careers and caring for underserved populations. ,,,,, Even just exposure through lectures on global health topics such as HIV/AIDS is associated with medical students' increased willingness to care for patients with HIV. 
Students participating in global health experiences during medical school often enter postgraduate medical training, or residency, expecting additional opportunities. Residents have completed a four-year undergraduate degree, four years of medical school and are enrolled in three to six year practical training programs in specific disciplines, such as surgery, family medicine and radiology. While global health is well integrated into many medical schools, residency education has largely lagged behind. , Studies in both the US and Canada have documented this gap between trainee interest and opportunities. ,, This gap undoubtedly affects the preparedness of resident physicians to later practice effectively in global contexts.
To inform an initiative to broaden global health educational opportunities for residents across our institution, we used several means to identify and clarify resources and barriers to promoting international health experiences for residents. While the issues and situation are US-specific, the experience at the University of North Carolina at Chapel Hill (UNC-CH) can serve as a model for other academic institutions in similar contexts aiming to meet this growing interest for resident physicians.
The global health environment at UNC-CH
Each of UNC-CH's health sciences schools-medicine, dentistry, pharmacy, nursing, allied health and public health-host global health projects. The UNC-CH Institute for Global Health and Infectious Diseases, founded in 2007, is charged with coordinating global health-related efforts across healthcare disciplines, administering and supporting health initiatives in well over 50 countries in a variety of research, education and service capacities. In the Medical School's expanding global health support environment, medical students and residents at all levels can have difficulty navigating the complex placement systems and connecting with faculty for mentorship and educational opportunities. In response, the Office of International Activities (OIA) in the UNC-CH School of Medicine was founded in 2009 to provide curricular, funding, and programmatic support to medical students and residents. The OIA is directed by part-time physician faculty members and staffed by a full-time program manager. In its first four years, the OIA has assisted over 450 medical students traveling to over 40 countries. Resident education in the US is accredited and monitored by the Accreditation Council for Graduate Medical Education (ACGME). Although neither its Common Program Requirements  nor Institutional Requirements  mandate any specific global health rotation oversight, they require every accredited residency program to have oversight over the rationale and quality of all educational experiences. It is not uncommon for institutions to avoid offering global health educational opportunities because of the burden that this requirement brings. But considering the demand and local resources, UNC-CH made the deliberate decision to work toward a standardized approach to support residency programs' efforts to provide quality and safe global health electives. Building on its existing infrastructure for supporting medical students, and with the endorsement of the UNC-CH Graduate Medical Education Committee and the Office of Graduate Medical Education, In 2012 the OIA expanded its reach to support residents. It began assisting residents and programs with career mentoring, selecting sites for international electives, developing educational objectives, providing information on travel health and safety, providing training in ethical and cross-cultural issues, and identifying funding sources.
| Methods|| |
Incoming resident survey
To better match programmatic support to residents' interests and perceived barriers to global health education and educational objectives, we conducted a survey of all first-year residents at the institution. The OIA sent an electronic survey using the Qualtrics® platform to all 158 incoming resident physicians in July 2012. The survey drew from several previous surveys , and collected students' demographic information, details regarding past global health experiences, future career interests in global health, and interests in international educational opportunities during residency. The residents had a one-month window in which to complete the survey on-line. The study was approved by the Institutional Review Board of UNC-CH.
Reponses to survey items were calculated as proportions out of the total number of residents who responded. For some survey items, responses were stratified by resident characteristics, such as for residents with and without prior participation in a global health elective, those in primary care vs. non-primary care residencies, and residents who intended to include global health activities in their future career vs. not. Differences in proportions between groups of residents were assessed with Chi-square tests or Fisher's exact test, where appropriate.
| Results|| |
Of the 158 first-year residents surveyed, 95 responded (60% response rate). Fifty-two (55%) of all respondents were training in primary care specialties (family medicine, internal medicine, pediatrics, and medicine-pediatrics). Other respondents were in residencies in surgery (16%), emergency medicine (9%), psychiatry (6%), and other areas (15%). Institutionally, this represents a disproportionate response from primary care residents, as only 43% of all first-year residents in our institution are in primary care specialties. Over one-half of respondents (54%; n = 51) indicated that they planned to include global health activities in their future careers. Only 4% of these (n = 2) intended to work solely internationally [Table 1].
|Table 1: Characteristics of first-year resident respondents (n=95), their prior global health experiences and future practice plans|
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Thirty-nine respondents (42%) reported that prior to residency they had participated in an international clinical elective or research project during medical school, most of which were one month or less in duration. Most of these electives (62%; n = 24) occurred in Latin America, with the remaining in Africa, Southeast Asia, or the former Soviet Republics. Although primary care and non-primary care residents did not differ statistically in the likelihood of having completed an international elective during medical school, those in primary care specialties were more likely to have trained in Latin America specifically than those in non-primary specialties.
Concerning attitudes towards global health education, just under half (48%) agreed with the statement, "Because of previous experiences in my medical training, I feel well prepared to work in health care internationally," and fewer (37%) reported that they felt prepared to address issues of international public health, including travel medicine and immigrant health [Table 2]. Sixty-two percent felt that learning about global health should be included for all residents of their specialty, and 76% indicated that they were very interested in learning more about global health as part of their residency curriculum. A greater proportion of residents in primary care specialties felt that learning about global health is important to their eventual practice compared to residents in non-primary care specialties (76% vs. 57%, respectively, P = 0.047).
|Table 2: Number and percentage of residents who "agreed" and "strongly agreed" with various attitudes about their prior education and towards global health education; comparison of those in primary care versus nonprimary care residencies|
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The educational activities that residents were most interested in included completing international electives both with a clinical or research focus, live lectures, formal coursework in public health, and global health simulation activities. Interest in activities varied greatly by whether the resident plans to include global health activities in their eventual career, with a greater interest among those with plans to include global health [Table 3]. However, even those who do not plan to include global health activities in their career reported interest in various global health educational activities, including international electives and live lectures.
|Table 3: Residents' interest* in various global health educational activities and comparison of those who do and do not plan to include global health in their future work; n (%)|
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When asked about potential barriers to participating in a global health elective, 67% of respondents said that scheduling issues and lack of elective time would prevent their participation, with higher percentages reporting these barriers among those in non-primary care specialties [Table 4]. Lacks of funding and family responsibilities were other barriers commonly reported.
|Table 4: Perceived barriers to international electives during residency and comparison of those who do and do not plan to include global health in their future work; n (%)|
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| Discussion|| |
The findings of this baseline survey of first-year resident physicians from UNC-CH are consistent with information noted elsewhere about global health education.  The resident physicians who responded to our survey disproportionately represent those in primary care programs at Uncut in most other characteristics assessed the two groups did not statistically differ from one another. It is not surprising that those from primary care programs were more likely to express the attitude that learning about global health issues is important for practicing my medical specialty, and I am very interested in learning more about global health as part of my residency curriculum. The available literature has demonstrated global health educational opportunities in medical school increase the likelihood that students will select a primary care field. While critical questions should be continually asked about the often mixed motivations of all physicians planning to include global health in their careers, U.S. and Canadian institutions training students and residents will need to meet this demand for sound educational opportunities.  These survey results and the described program to support residency education in global health at UNC-CH may be valuable to other similar institutions.
Institutional reorganization for resident global health experiences
In response to a clear growing interest in global health among resident physicians and using the core results of this baseline survey as well as information and ideas from other institutions and key faculty, the OIA set out to create a fully integrated program directed at meeting the educational needs of UNC-CH resident physicians. The OIA began resident programming early in the 2012-13 academic year and this work is ongoing. Important components of this program are listed in [Figure 1].
|Figure 1: Components of Global Health Education during Residency Training|
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The OIA, together with the UNC-CH Office of Graduate Medical Education, clarified institutional requirements for global health electives during residency. Together, these two offices established a system of administrative processing designed to be comprehensive and efficient. As part of this streamlined process, trainees participating in global health electives are required to: 1) Obtain approval from their respective program directors and 2) complete a "Release and Hold Harmless Agreement" and a "Letter of Agreement" for the institution. In addition, the OIA works with residents to review travel health and security requirements for the specific country they will be traveling to, to purchase evacuation insurance, and to ensure completion of two required on-line training modules-Travel Health and Safety, and Cross-cultural Issues, Ethics, and Professionalism. The OIA website (www.med.unc.edu/OIA) has organized information and listing of education opportunities for UNC-CH residents.
Leadership of the OIA gained stakeholder buy-in from core residency and fellowship faculty committed to providing global health opportunities for learners across departments. To supplement the findings of the survey, the OIA leadership met with core faculty from each residency program to assess the current state of global health offerings. During these meetings, the OIA's infrastructure and support to departmental global health endeavors was explained. All residency programs at UNC-CH now have a basic agreement in place with the OIA to assure that residents are able to complete at least one global health elective at some point during residency. The minimum time is two weeks for some specialties with extremely limited time in their curriculum but in most disciplines, residents are able to be away for two to three months over the course of their training.
First-year residents cited the following barriers to completing a global health elective, in descending order: 1) Lack of elective time; 2) lack of money; 3) lack of mentorship/support; 4) family reasons; 5) lack of foreign language skills; 6) concern about political instability; 7) concern for personal safety; and 8) ethical considerations. In response to these barriers, the OIA leadership has worked with residency program directors to increase the number of vetted, high-quality electives available, as well as to optimize the scheduling of these experiences. To help overcome financial challenges, a resident global health scholarship process was established, and the OIA now devotes a portion of its annual budget to support of global health electives. Interested UNC-CH resident scan apply for competitive scholarships of up to US$2000 twice annually.
Members of the OIA leadership team also provide individual mentorship to residents at our institution interested in global health. The OIA often refers trainees to the key faculty in each department for ongoing mentorship. To address safety concerns, the OIA proactively requires every traveling resident to develop a detailed emergency plan as well as to register his or her travel plans with the United States Department of State through the Smart Traveler Enrollment Program (STEP) (https://step.state.gov/step/). Residents are informed that elective travel is not permitted to countries listed with a travel warning by the US State Department or the U.S. Centers for Disease Control and Prevention (CDC). All traveling residents are also expected to purchase evacuation insurance through an institutional agreement with Highway to Health (http://highwaytohealth.com/) and to complete educational modules covering travel health and safety and ethical principles of international electives.
Designing educational opportunities flexible enough to be useful across disciplines and yet fit within the demanding schedules of residents is challenging. In response to the strong interest in "live" lectures, the OIA has been able to feature lectures in various venues showcasing faculty with global health expertise from across the School of Medicine. Examples include a Department of Pediatrics grand rounds presentation on global neonatal health, and a workshop for Emergency Medicine residents on management of obstetric emergencies in resource-limited settings. The OIA also hosts a quarterly interdisciplinary resident journal club focused on global health. Interested residents facilitate the discussion of the featured paper(s) and faculties with expertise in the topic are encouraged to attend to deepen the discussion.
In addition to responding to resident needs, the staff and faculty of the OIA sought to address concerns and interests of residency directors. Global health "tracks" or "areas of concentration" (AOC) are becoming increasingly popular in U.S. residencies, and while there is enormous diversity in terms of the specifics, offering an AOC in global health can serve as a powerful recruitment tool and can present opportunity for niche-building and specialized mentorship. An informal poll of 36 residency and fellowship directors at UNC-CH revealed that more than 60% felt global health education was an important recruiting tool for their programs, but only 35% felt there were currently adequate resources available at UNC-CH to support global health for residents. The OIA is now working with interested program directors and faculty to create an institutional framework for a Global Health Scholars Program and an AOC in global health that will cross disciplines. This will include: Specialty-specific goals and objectives; dedicated elective time for global health rotations; global health coursework (either through the existing Foundations in Global Health course, the UNC-CH School of Public Health Global Health Certificate, or other Travel Health and Tropical Medicine coursework); one-on-one faculty mentoring; and tailored scholarly work (e.g. facilitation of a global health-focused journal club, presentation at a regional or national global health conference, participation in a global research opportunity). Because of the rich institutional global health environment at UNC-CH, this would offer significant possibilities to interact with other faculty and access resources not often available to resident physicians in busy clinical years.
Since 2012, the OIA has provided support to 93 UNC-CH residents and fellows participating in global health electives, in a wide array of clinical, research and public health situations. The OIA is now well established and residents regularly contact OIA leadership and gather information from the website when they are considering an international elective. Although it is clear that incorporating global health learning into residency education is challenging in terms of time commitments and with competing curricular requirements, it becomes possible when mentorship and funding are made available.
Overall, the OIA has expanded services to support residents in an interdisciplinary manner throughout the institution. This work is ongoing and appears to be both fruitful and respected. The survey on past experiences in global health and interest in global health educational opportunities helped to inform this expansion and will serve as a baseline in assessing changes in perceptions of "readiness" for global health work, perceptions of barriers, and interests in the future. The OIA will also seek opportunities to share its experiences of resident education in global health with likeminded institutions, to promote the development of physicians committed and prepared for careers incorporating global health.
The authors would like to acknowledge Dr. Jonathan Kirsch who was Dr. Bethany Hodge's Masters paper advisor and assisted with survey preparation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]