Global child health: An essential component of residency training

Article Outline

• Global child health core curriculum
• Third-world experience
• Global child health as a career path
• Summary
• References
• Copyright

International child health experience has become an essential component of residency training. Over the past few decades, increased globalization has led to a “shrinking” of the world. Substantial numbers of families are immigrating to North America, and numerous children from “third-world” countries are being adopted by North American families.¹ Changes in the health of people in one area of the world can quickly impact the well-being of people globally. Thus, it is increasingly important for our clinicians to be well trained in recognizing and managing health conditions not seen routinely in the past. Moreover, the culture of medicine is one of service to those in need, and today, perhaps more than ever before, we are finding medical students, residents, and faculty committed to contributing beyond the boundaries of “first-world” medicine.

Academic departments and program directors are faced with the challenge of how to provide a global child health experience within a curriculum that is already challenged by many demands. All residents need core information and experience, some residents will want the opportunity for direct experience in third-world medicine, and others will look for a career path in global child health. Programs need to provide or make accessible to residents each of these components of global child health.

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Global child health core curriculum 

Each residency program should establish a core global child health curriculum. A faculty member with third-world experience should be identified to be in charge of the pathway. The components of the curriculum should consist of regularly scheduled educational activities in global health, as well as direct clinical experience. This clinical experience can be gained locally, through mechanisms such as new immigrant/travel/adoption clinics, or through direct third-world exposure, as described in the next section.

There is strong support for a core global child health curriculum within residency programs. A recent survey of US pediatric residency programs conducted by one of us (Kamat) found that 70% of the 87 programs responding to this survey include instruction in international health during resident training. This is in contrast to a survey conducted in 1995, which found that only 25% of pediatric residency programs offered international electives at that time.² The 2006 survey found that the most common educational activities are lectures on topics in international health and elective rotations abroad. Approximately 70% of residency programs that do not have a well-organized international experience reported the desire to establish such a program.

Given this high level of interest, we should encourage cross-institutional collaboration in the development of core curriculum and the creation of on-line learning tools and other materials that will provide residents with the core knowledge, and skills, in global child health. Departments and programs should influence examination boards to include this content as part of core pediatric examinations.

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Third-world experience 

Residents should also have the opportunity to gain direct experience in a third-world setting. This is an important option that many of our residents seek and that can be extremely rewarding and life-changing. Residents who have participated in an international experience have been shown to develop commitment to underserved populations and frequently change their career paths to global health.²

The American Academy of Pediatrics has developed consensus guidelines for the international experience. It is recommended that a resident travel to an international site after 18 months of training, at which point he or she will be expected to have developed sufficient knowledge of pediatric practice so as to be able to gain maximum benefit from the experience. The rotation should be at least 4 weeks in duration to maximize the clinical and cultural experience. The rotation must be well structured with clearly stated goals and objectives and provide the resident with a safe working environment with appropriate supervision and performance evaluation. Adding a research component to the program can make this an even more valuable experience for the resident, help engage collaborative efforts with the host site, and support greater understanding of the issues involved in third-world health research, including cultural competencies, the intricacies and sensitivities involved in performing third-world research, and the various sets of international guidelines, laws, and ethics that must be considered.

It is essential that the relationship with the partner site be clearly established and that a written agreement be in place defining the roles, expectations, and limitations of the program. It is particularly important to recognize that in many third-world situations, trainees, no matter how experienced, may consume the valuable time of local clinicians. There is an increasing expectation that the sending partner provide some reciprocal benefit to the receiving partner; (ie direct compensation, teaching assistance, or possibly exchange training of receiving institution trainees). Bilateral exchange, if possible, should be established to strengthen the relationship between the 2 institutions.

Those choosing to work in a third-world setting must address numerous important issues before entering the program. This involves assessing the country’s political stability, ensuring availability of effective supervision, and defining communication strategies (ie, language training, on-site faculty with English skills, availability of interpreters). Faculty members need to prepare each resident for the trip. This includes providing basic knowledge of the country to which he or she is going (ie, history, culture, customs, politics), ensuring that visa requirements are met, and teaching about preventive measures, such as water and food precautions, vaccinations/prophylaxis, and other safety measures. There needs to be a clear plan concerning personal support for the trainee (ie, housing, transportation, general orientation).

It is important for the faculty in charge of the international rotations to stay in touch with residents when they are abroad and provide them with on-going support and also help them after they return, to prevent reverse culture shock. Residents should be asked to share their experiences through presentations or informal “brown bag” sessions.

Residents will gain many benefits from their international experience. They will improve their knowledge of third-world medicine and their clinical diagnostic skills. The experience will also helps shape attitudes and values and increases understanding of global child health issues. The resident is also challenged to improve his or her cultural sensitivity and communication skills.

Having an international experience as a part of a pediatric residency program is also a good recruiting tool. Excellent residents are drawn to programs that have a more global child health perspective and that offer an international experience.

Difficulties arise in organizing international experiences for residents. In the United States, many hospitals may not be willing to let their residents leave the state because of the potential financial loss. The Accreditation Council for Graduate Medical Education requires that all educational activities for residents during training be supervised by qualified physicians; arranging for such supervision abroad often can be difficult. Communication, not only with patients, but also with the supervising physicians, is also an issue in many countries where English is not the first language. It can also be difficult to obtain evaluations in a timely manner from supervising physicians because of the lack of understanding of the process. Travel to international sites is expensive, and limited resources are available to support this resident activity. The International Child Health service of the American Academy of Pediatrics is one such resource. Residents have personal reasons (financial, family) that limit their ability to participate. In addition, a program may require this to be an “elective” experience, thereby reducing important elective opportunities within the program.

Providing a high-quality third-world experience for residents is difficult, time-consuming, and expensive, but the payoffs can be tremendous. This argues for a multi-institutional collaborative effort in building quality third-world experiences for our residents while ensuring strong support for the host communities. For example, a long-established Canadian Pediatric Society sponsored program with Umbrere Medical School in Uganda draws faculty and residents from across Canada, offering a very efficient mechanism for resident experience.³

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Global child health as a career path 

The world needs more bright, committed, knowledgeable, and experienced pediatricians to make a career of global child health. The opportunities are enormous and the needs great. Access to information and mentors should be as readily available to residents interested in a career in global child health.

Department chairs and universities should look toward developing more training programs and devising creative ways to support the building of capacity.

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Summary 

Programs that offer these 3 components of engagement in global child health will be doing a tremendous service in building future capacity. This will result in a resident body more comfortable in their roles as global physicians, whether working in their own community or contributing to other communities around the world. Despite the difficulties in international experience, those residents who have participated have enriched their lives. We, as educators, should do our best to support these opportunities.

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References 

1. McGuinness TM, Dyer JG. International adoption as a natural experiment. J Pediatr Nursing. 2006;21:276–288
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2. Torjesen K, Mandalakas A, Kahn R, Duncan B. International child health electives for pediatric residents. Arch Pediatric Adolesc Med. 1999;153:1297–1302
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3. Brenner JL, Godel JC. Capacity building for child health: Canadian pediatricians in Uganda. Pediatr Child Health. 2005;10:273–276
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