Preparing locally to work globally

Ensuring successful global health electives through mentorship and pre-travel preparation

APPD Annual ConferenceMarch 31, 2012

Who Are We?

• Maneesh Batra – U of Washington• Cindy Howard – U of Minnesota• Nicole St Clair – Medical College of Wisconsin• Donna Staton – AAP SOICH & U Mass

Medical Center• Sabrina Wagner – U of Wisconsin

Collaborators: • Global Child Health Educational Modules Project (GCHEMP) co-

authors: Kevin Chan, Jackie Nohl, Suzinne Pak-Gorstein• Lisa Umphrey, MD: Uganda elective site coordinator• APPD Global Health Track Directors & APPD membership• AAP Section on International Child Health

Conflicts of Interest

• None• Nenhum• 无

• Keine• Aucune• Nessuno• ال شيء• нет

Objectives

11:30-11:40: Discuss resident and program goals for global health electives

11:40-12:15 Review cases that highlight the importance of preparation

12:15-12:25: Discuss optimal methods for preparing residents

12:25-12:45: Provide template preparation resources for your institution and introduce interactive, web-based modules designed to help residents prepare for global health electives

Question 1

At your residency training program, you have:A. No participation in global health electives and no global health-specific curriculum

B. Global health electives are allowed, but no global health curriculum is offered

C. Limited global health curriculum

D. A global health training track

E. A global health track and a fellowship

Question 2

At your residency training program, you have:A. No global health elective sites

B. Global health elective sites that are occasionally used by your residents, but not formally affiliated with your institution

C. Global health elective sites that are part of a formal affiliation with your institution

D. Global health elective sites that involve a bidirectional training partnership

Question 3

At your residency training program, you have:A. No faculty involved in pediatric global health education

B. No faculty with salary-supported time for residency global health education, but some who still assist with global health efforts and training for residents

C. Faculty with salary-supported time for pediatric global health education

D. You are not sure

Question 4

At your residency training program, you have:A. No formal preparation process for global health electives

B. An informal preparation process that does not involve faculty mentorship

C. A faculty mentor who assists with preparing residents for global health electives

D. A formal preparation, on-site support, and debriefing process for residents

Question 5

At your residency training program, you feel like:A. Your program does not prepare residents well for global health electives

B. Your program does a so-so job with preparing residents for global health electives

C. Your program does an awesome job with preparing residents for global health electives, and should be running this workshop

D. You have no idea

Primum non nocere

Potential pitfalls

• Short term international medical trips can be self-serving, ineffective, and unsustainable:– May potentially impose burdens on local health

facilities

– Care delivered may fail to meet current standards of health care in the U.S. or in the country being visited

However

Rotation Goals – resident perspective

• Improve understanding of the diseases that cause most of the world’s pediatric mortality

• Improved physical examination skills

• Explore career options for after residency• Have a ‘break’ from residency and experience a new

place/culture• Reconnect with the inspiration for pursuing pediatrics• Gain language skills• Thrill

Opportunities

• These experiences have additional benefits to participants– Deeper appreciation of issues related to public

health, professionalism, and cultural sensitivity

– Maintain and foster humanism, altruism and compassion when caring for vulnerable populations

Opportunities

• These endeavors have the potential for benefits to the host country– Capacity building– Influx of resources– Ongoing exchange of ideas and knowledge– Opportunities for research and process

improvements

Rotation Goals – program perspective

• Prepare residents for future careers as advocates for underserved populations, both globally and domestically

• Focus on social, economic, environmental, and political influences on child health & health disparities

• Catalyze interaction between residents and community groups, public/global health leaders, policy makers, and child advocates

• Provide a structure for residents to maintain their passion for working in low resource settings

• Attract applicants poised to make contributions in global health & community pediatrics

Program Goals

• Resident safety and well-being

• Resident safety and well-being!!!

• Components of rotation are competency-based

• Adequate supervision to ensure patient safety

• Ethical and responsible engagement of colleagues around the world

• Avoid legal issues and additional risks for the resident’s institution

Guidance on how to do this right?

• Howard et al, Acad Med 2011• Crump et al, Am J Trop Med Hyg 2010• GHEC Code of conduct 2011• Suchdev et al, Ambulatory Peds 2007• Community-Campus Partnerships for Health (CCPH)

http://www.ccph.info/

• A critical theme in all of these publications is partnership:– Participating institutions– Communities– Other organizations

Foundations of a Partnership for Training in Child Health

Mutually beneficial for all

stakeholders

Service

Education

TeamworkSustainability

Collaboration

What makes a good partnership?

• Serves a specific purpose and may take on new goals over time

• Shared mission, values, goals, measurable outcomes and accountability

• Characterized by mutual trust, respect, genuineness, reciprocity and commitment

• Evaluation involves outcomes of relevance to all partners

• Share the benefits of the partnership's accomplishments

Community-Campus Partnerships for Health

Partnerships

This may sound daunting…But remember that every partnership begins

with just 2 people.

Breakout

11:40-12:15 Review cases that highlight the importance of preparation

12:15-12:25: Discuss optimal methods for preparing residents

Welcome Back!

How could some of the problems and challenges discussed in our cases have been prevented or mitigated?

What are the essential requirements programsshould have in place to ensure safe and productive GH rotations?

1. Resident has met recommended prerequisites and rotation is appropriate in scope/goals

2. Faculty mentor here / supervisor there

3. Safety issues addressed: communications, emergency plan; risk reduction

4. Training on ethics & professionalism

5. Evaluation & debriefing process post-return

Preparation Essentials“Minimum requirements”

1. Recommended Requirements for Resident and Rotation …cont’d

Prior to a GH rotation, residents should have:

• Completed 18 months residency/be in good standing

• Attended orientation (logistics/safety/ethics/culture)

--Torjesen K, Mandalakas A, Kahn R, Duncan B.International Child Health Elective for Pediatric

Residents. Arch Pediatr Adolesc Med. 1999 Dec; 153(12):1297-1302.

• Developed sense of cultural humility/respect toward working with limited resources

1. Recommended Requirements for Resident and Rotation

• Minimum of 4 weeks• Adequate safety and

supervision• Structured so resident:

– Not undue burden on hosts– Not working beyond level

of training– Can contribute to team &

meet learning goals

2. Faculty Mentor and On-site Supervisor

• Mentor meets periodically with resident to – Ensure prerequisites met/planning is on track– Review resident’s written goals and objectives– Helps resident anticipate stressors/coping mechanisms– Debrief with resident post-return

• Host preceptor in place and willing to evaluate resident

3. Safety Issues: Communications, Emergencies, Risk Reduction

3. Safety Issues: Communications, Emergencies, Risk Reduction

4. Ethics & Professionalism Training

5. Evaluation & Debriefing Process

• Debriefing meeting (resident & mentor)• Review of evaluations• Recommendations for improving rotation• Medical follow-up (e.g. TB test if needed)• Resources for future GH work• Resident presentation (article or talk)

5. Evaluation & Debriefing Process

Resident prerequisites met; rotation appropriateFaculty mentor here / supervisor thereReliable communications & emergency plansTraining on ethics & professionalismEvaluation & debriefing process

Summary of Program Essentials

Resources for you

Global Child Health Educational Modules

• Prepare residents for overseas experiences

• Provide a broader perspective on public health issues and effective interventions in GH and in working with vulnerable populations –beyond tropical infectious diseases

• Equip residents with a stronger approach in community-based and public health approaches

Specific Aims:

A series of interactive modules on global child health topics for residents

Slide courtesy of Suzinne Pak Gorstein, MD

Approach to Fever

Approach to Fever

Approach to Respiratory

Distress

Approach to Respiratory

Distress

Approach to Altered Mental

Status and Seizures

Approach to Altered Mental

Status and Seizures

Approach to DiarrheaApproach

to Diarrhea

Approach to Injury and

Trauma

Approach to Injury and

TraumaApproach to Emergent

Triage, Assessment and Treatment/Procedure

Approach to Emergent Triage, Assessment and

Treatment/Procedure

Global Neonatal and Maternal

Health

Global Neonatal and Maternal

Health

Refugee and Immigrant

Health

Refugee and Immigrant

Health

MalnutritionMalnutrition

Public Health

Systems and Health Access

Inequities

Preparing the Resident for a Global

Health Elective

Cultural and Ethical

Perspectives in Global

Health

Socio-Political-

Economic Factors that Impact Child

Health

Slide courtesy of Suzinne Pak Gorstein, MD

The community health worker takes

you to a home within the village.

Slide courtesy of Suzinne Pak Gorstein, MD

The

Prep

arat

ion

Pack

et

Q6: Will the preparation packet be a tool that you will use at your institution?

A. Yes

B. No

C. Not sure

Summary: Preparation Resources

Logistics: Preparation Packetz.umn.edu/APPDglobalhealth

Curriculum: • “Global Health Curriculum Toolkit”

(AAP SOICH)• GHEC teaching modules• USAID e-learning courses• Unite for Sight global health e-

learning resources• Unite for Sight Global Health

University• GCHEMP Modules

Conclusions

• This was only 1 piece of the “preparation pie”• It is more than a plane ticket and travel

insurance• Be considerate of the elective sites, their

patients, resources & communities– “Do unto others…”

• Make it academic; no more tourismAnd…let’s pool our resources to optimize

the preparation of residents for global work

Bibliography & Resources

1. Garfunkel L, Howard C. Expand Education in Global Health: It is Time. Acad Pediatr. 2011;11(4):260-2.2. Drain PK, Holmes KK, Skeff KM, et al. Global health training and international clinical rotations during residency: current status, needs, and

opportunities. Acad Med. 2009;84:320-325.3. AFMC Global Health Resource Group and CFMS Global Health Program. Preparing Medical Students for Electives in Low-Resource Settings: A

Template for National Guidelines for Pre-Departure Training. 2008 May.4. Nelson BD, Lee AC, Newby PK, Chamberlin MR, Huang CC. Global health training in pediatric residency programs. Pediatrics. 2008

Jul;122(1):28-33.5. Suchdev P, et al. A Model for Sustainable Short-Term International Medical Trips. Ambul Pediatr. 2007 Jul-Aug;7(4):317-20.6. Drain PK, Primack A, Hung D, Fawzi W, Homes K, Gardner P. Global health in medical education: a call for more training and opportunities.

Acad Med. 2007;82(3):226-230.7. Federico SG, Zachar PA, Oravec CM, Mandler T, Goldson E, Brown J. A successful international child health elective: the University of Colorado

Department of Pediatrics' experience. Arch Pediatr Adolesc Med. 2006 Feb;160(2):191-6.8. Pocket Book of Hospital Care for Children: Guidelines for the Management of Common Illnesses with Limited Resources. World Health

Organization, 2005.9. Torjesen K, Mandalakas A, Kahn R, Duncan B. International child health electives for pediatric residents. Arch Pediatr Adolesc Med. 1999

Dec;153(12):1297-302.10. Haq C, Rothernberg D, Gjerde C, et al. New world views: preparing physicians in training for global health week. Fam Med. 2000;32:566-572.11. Gupta AR, wells CK, Horwitz RI, et al. The International Health Program: the fifteen-year experience with Yale University’s internal medicine

residency program. Am J Trop Med Hyg. 1999;1019-1023.

Thank you!

• Maneesh Batramaneesh.batra@seattlechildrens.org

• Cindy Howarddrcindy@umn.edu

• Nicole St Clairnstclair@mcw.edu

• Donna Statondstaton@massmed.org

• Sabrina Wagnerswagner@pediatrics.wisc.edu

Please fill out the attendance list & evaluation forms