Global Health

Global Health Educational Goals & Objectives

Physicians today must train with a global perspective. They must become familiar with the epidemiology and natural history of disease, and inequities in health care resources and access to care within global health systems. Having the opportunity to practice in an underserved area, particularly in an international setting, expands the scope of residents’ medical and surgical knowledge, reinforces physical exam and procedural skills, and highlights the importance of cross cultural sensitivity. This exposure also encourages the subsequent practice of medicine in underserved and multicultural populations. This rotation is an elective experience designed to (1) provide the resident with the knowledge and skill necessary to diagnose and manage diseases specific to developing countries, (2) gain perspective on global public health issues, including the balance of social, environmental, and organizational factors that influences access to care, (3) enhance understanding of diverse cultures, political systems, and religions and their impact on health, (4) hone history, exam, and procedural skills in a resource-limited, technology poor environment, (5) provide an opportunity for collaborative exchange with local health care providers as well as other visiting providers from around the world, and (6) explore career opportunities in Global Health.

Faculty will facilitate learning in the 6 core competencies as follows:

Patient Care and Procedural Skills

I. All residents must be able to provide compassionate, culturally-sensitive, resourceappropriate care with the goal of improving the health of patients, families, and communities.

II. Residents will

• demonstrate the ability to take a culturally-aware, focused medical history with an awareness of local public health and environmental issues that influence presentation of disease
• differentiate between stable and unstable symptoms and elicit risk factors for the development of chronic disease
• identify barriers to patient compliance and care when creating a treatment plan

II. Residents should be able to perform a physical exam appropriately focused on the patient’s presenting complaint.

IV. Residents will learn to effectively select and safely perform appropriate procedures, including understanding the indications, contraindications, complications, limitations, and interpretation of results.

Medical Knowledge

I. Given the broad scope of Global Health, this curriculum is not intended to be an allencompassing list. Rather, it is designed to focus on skills critical to the core of the practice of global medicine, including the ability to recognize and treat select unique illnesses and illnesses late in their presentation. Appropriate sections of our subspecialty curricula will supplement the learning goals and objectives listed in this curriculum.

II. Residents will become familiar with the epidemiology, physiology, and natural history of common infectious and chronic diseases in the area and become skilled in the timely triage of and approach to acute changes in health status.

III. Residents will develop clinical decision-making and critical thinking skills to facilitate the diagnosis and treatment of disease as appropriate to their subspecialty.

IV. Residents will understand external factors that determine health and disease in the local setting, including access to clean water, food, and sanitation; physical safety and human rights issues; health literacy, and in this country, insurance issues.

IV. Residents will become familiar with local religious and cultural influences on vaccination rates, transfusion practices, treatment adherence, morbidity, and mortality.

V. Residents will become aware of the safety and availability of therapeutic drugs and other treatments.

VI. Residents will understand issues affecting health care maintenance for different populations, including domestic violence, prevention of cardiovascular disease, injury prevention, nutrition and weight loss, oral care, smoking cessation, substance abuse, and vaccination.

VII. Residents will be exposed to pertinent topics in travel medicine. Residents may have the opportunity to travel abroad to pursue further inquiry relating to Global Health.

VIII. Residents will understand how to effectively manage patient health in a setting with minimal if any available laboratory and imaging studies.

Practice-Based Learning and Improvement

I. Residents should be able to access current clinical practice guidelines before the rotation to understand applicable evidence-based strategies for patient care in those destinations.

II. Residents should learn to function as part of a health care team to optimize patient care.

III. All residents should respond with positive changes to feedback from members of the health care team.

Interpersonal and Communication Skills

I. Residents must be sensitive to cultural nuances and communicate

• in a manner that builds rapport with patients and families and effectively conveys information to other health care professionals
• effectively via an interpreter when necessary to educate patients and families
• at a level effective for the health literacy of the patient population
• with an understanding of local cultural approaches to healing, death, and dying

Professionalism

I. All residents must demonstrate strong commitment to carrying out professional responsibilities as reflected in their conduct, ethical behavior, attire, interactions with colleagues and community, and devotion to patient care.

II. All residents should be able to educate patients and their families in a manner respectful of gender, age, culture, race, religion, disabilities, national origin, socioeconomic status, and sexual orientation on choices regarding their care.

III. Residents should be able to use time efficiently in a high-volume setting to see patients and chart information.

IV. Residents should be able to provide constructive criticism and feedback to more junior members of the team.

Systems-Based Practice

I. Residents must have an understanding of available care strategies, taking into account the social, economic, and psychological factors that affect patient health and availability and cost of resources.

II. In caring for domestic immigrant, migrant, and refugee populations, residents should understand the impact of insurance status on patient access to care and be aware of the availability of case workers, counseling services, and other community resources to maximize care.

III. Residents must be aware of current quality issues in global health care.

Teaching Methods

I. Supervised patient care

• Residents will initially be directly observed with patients, to further the development of excellent history taking, physical exam, and procedural skills.
• As residents become more proficient, they will interact independently with patients and present cases to faculty.

II. Conferences

• Specialty-specific didactics

III. Independent study

• Journal and textbook reading
  • Residents are encouraged to pursue regular reading/study based on patients seen during the day.
• Additional reading as recommended by Attending physician
  • Kidder, Tracy. Mountains Beyond Mountains. New York: Random House, 2003. Print.
• Online educational resources
  • World Health Organization
  • Up To Date
  • Clinical Key

Evaluation

I. Reflection and self-evaluation via journaling is encouraged to record observations, to compare and contrast the experience with their clinical rotations in the U.S. and to record lessons learned.

II. Residents may be asked to do a formal presentation to peers and faculty based on their clinical experience.

III. Verbal feedback from participating staff

IV. Attending written evaluation of resident at the end of the rotation, based on observations and chart review.

Rotation Structure

I. Residents must be in good clinical standing and beyond their PGY-1 year to pursue a global health experience for clinical credit. This elective is not available in the last year of training for those whose colleges require that their final year be done in their home institution. Residents may not pursue this elective if it will extend their training beyond the expected completion of residency.

II. Residents must arrange the experience with the permission of and in conjunction with their Program Director.

• Proposed sites will be reviewed by the Program Director for clinical experience, faculty supervision, and compliance with our program requirements as listed in our Residency Handbook.

III. The availability of international experiences frequently changes and must be confirmed prior to any planning.

• Requirements and rotation duration varies by experience. Opportunities will be considered on a case-by-case basis.

IV. For residents wishing to advance their understanding of global health outside of an international elective, individual options can be arranged with their Program Director, including experiences in the CMH CFH clinics in low income areas, homeless clinics, and via Public Health.

V. Residents will be assigned to a preceptor based on the clinical experience they are pursuing. Faculty members who are affiliated with our program are available to supervise selected domestic and international experiences.

VI. Residents should meet with their attending prior to leaving to review expectations to optimize patient care and resident learning.

VII. Residents should notify the attending physician as well as the Program Director promptly if on any occasion they cannot be at their assigned location at the designated time.

VIII. Residents interested in research on global health topics may identify a mentor and develop a research design prior to their clinical experience.

IX. Hours worked must be consistent with ACGME requirements and are subject to approval by the Program Director.