OBJECTIVE: To assess exposure to global health (GH) training, future plans to work or volunteer abroad, and the importance of GH training in program selection among graduating pediatric residents.
METHODS: A national, random sample of graduating pediatric residents was surveyed in the 2008 American Academy of Pediatrics' Annual Graduating Residents Survey. Questions specific to GH training were included.
RESULTS: The adjusted survey response rate was 59% (546 of 927); 534 residents from 170 programs responded to at least 1 GH question. GH training was an essential/very important factor in selecting a residency program for 22% of the respondents, and 21% reported participating in GH training during residency. In multivariate analyses, participation in GH training was associated with being single (adjusted odds ratio [aOR]: 1.90 [95% confidence interval (CI): 1.10–3.27]), graduating from a US medical school (aOR: 2.45 [95% CI: 1.14–5.28]), lower educational debt (aOR: 2.63 [95% CI: 1.54–4.49]), and training at a larger program (aOR: 2.73 [95% CI: 1.47–5.06]). One-third of respondents reported definite/very likely plans to work/volunteer in a developing country after residency; these respondents were more likely to be single (aOR: 1.82 [95% CI: 1.14–2.92]) and international medical school graduates (aOR: 2.10 [95% CI: 1.19–3.73]). Fewer than 50% of respondents received education in the majority of topics considered essential to GH training.
CONCLUSIONS: GH-training opportunities are important to pediatric residents when selecting a program, and many are graduating with intentions to volunteer/work in a developing country after residency. The low exposure to GH topics among a broad cross-section of pediatric residents suggests that additional work is needed to adequately prepare pediatricians for work in GH after residency.
WHAT'S KNOWN ON THIS SUBJECT:
Residency programs are increasingly offering global health education. Specific programs have highlighted resident interest and participation in global health training. This training and future overseas work plans have not been assessed among a national sample of pediatric residents.
WHAT THIS STUDY ADDS:
Opportunities for global health training are important to pediatric residents in program selection. Residents with varied clinical practice goals indicate future plans to work overseas. However, reported exposure to education in specific global health topics is low during pediatric residency training.
Increasing interest in global health (GH) among US medical students and residents has been paralleled by growth in opportunities to participate in international medical electives during training. Among graduating medical students surveyed, 40% reported participating in a GH elective or volunteer experience during medical school in 2010, up from 22% in 2003.1,2 Over the past decade, a similar trend in pediatric residency training has been documented. A 1995 survey of Pediatric Residency Programs in the United States, Canada, and Puerto Rico found that 25% of responding programs offered international electives for residents, with few offering a formalized curriculum or educational structure.3 Just over 10 years later, a survey of pediatric training programs in the United States, Puerto Rico, and the Caribbean found that 52% reported resident participation in international electives, 47% reported a formalized curriculum, and 6% offered either a GH track or certificate program.4
The growth in interest and opportunities for trainees in GH may be driven in part by demographic trends in the United States that have resulted in greater numbers of immigrant children and returned travelers that pediatricians may be caring for more frequently.5,6 In addition, the vast majority of the 8.1 million deaths each year in children age <5 years, primarily from preventable causes, occur in developing countries.7 Such disparities may lead trainees to seek education and experience that will allow them to influence the health of children beyond the borders of the United States.
Previous studies of medical students and residents from varying disciplines have demonstrated important benefits to medical education associated with GH training and international experience, including increased medical knowledge, greater reliance on clinical diagnostic skills, enhanced cultural sensitivity, increased sense of idealism, heightened awareness of social determinants of health, and greater understanding of cost-effective care.8,–,13 International health electives during medical school or residency have been associated with interest in practicing primary care,8,9,14 preference for working in underserved communities,9,10,14,15 and plans to pursue a career in public health.11
Despite the significant growth in GH training opportunities and documented benefits of this training, numerous barriers have impeded the promotion and implementation of high-quality GH education during residency. These barriers include lack of standardized learning objectives, lack of recognition and support by national curriculum regulatory bodies, and insufficient data describing the impact of GH training and experience on resident education and subsequent career plans.16,–,19 Until now, no comprehensive survey of pediatric residents' experiences and future plans in GH had been conducted at the national level. This cross-sectional survey, developed by the Section on International Child Health Residency Education Working Group of the American Academy of Pediatrics (AAP), assesses resident interest in GH education, exposure to GH education during residency, and future work or volunteer plans in GH among a large random sample of graduating pediatric residents from across the United States.
A national random sample of 1000 third-year graduating pediatric residents was surveyed by the AAP during and after their last months of training (May to November, 2008). The residents were randomly selected from an AAP database of graduating residents from all US pediatric programs. Residents were included regardless of AAP membership status. Residents from dual-degree programs, such as internal medicine/pediatrics programs, were not included. Residents were contacted up to 4 times by the US Postal Service, and up to 4 times by e-mail, for up to 8 contacts. The mailed survey included a postage-paid return envelope, and the e-mail included a link to the online survey.
The AAP Graduating Resident Survey is conducted annually and includes core questions on residents' demographic characteristics, training experiences, and career intentions. The 2008 survey also included a set of questions focused on GH training during residency and future plans to work in a developing country. The global health topics chosen for inclusion were considered to be essential to GH education of pediatric residents, on the basis of consensus of the AAP Section on International Child Health Residency Education Working Group.
No remuneration was provided to respondents. The survey was approved by the AAP institutional review board.
Measures and Analyses
Frequencies were used to describe respondent characteristics. χ2 tests were used to compare (1) resident characteristics and participation in GH curriculum and (2) resident characteristics and plans to work/volunteer in a developing country.
Two multivariate logistic regression models were developed to examine which characteristics of residents were predictive of (1) participation in GH training and (2) plans to work/volunteer in a developing country in the future (definite/very likely versus somewhat likely/unlikely/definitely not). Predictor variables for both models included gender, age (<31.5 years or ≥31.5 years), have children (yes or no), married (yes or no), international medical school graduate (IMG) (yes or no), program size (<15, 15–25, or >25 residents per class), educational debt <$100 000 (yes or no), and future clinical practice goal (primary care, subspecialty/both primary care and subspecialty, or hospitalist). These characteristics were chosen because they provided a demographic profile of residents or because they had been shown previously to be associated with GH training or experience.8,–,11,14 Age, educational debt, and program size were categorized on the basis of the response data.
We used a t test and χ2 test to conduct an analysis of nonresponse bias comparing age and gender of the respondents with those of nonrespondents. The number of cases in each statistical analysis varied slightly because of missing values for specific questions. P values of ≤.05 were considered statistically significant for all inferential tests.
Of the 1000 residents surveyed, 546 (55%) returned the survey. Seventy-three additional respondents returned the survey indicating that they were not graduating pediatric residents; the adjusted response rate was 546 of 927 (59%). Data were analyzed only for those respondents who answered at least 1 GH question (n = 534). There was no significant age difference between respondents (mean age, 31.4 years) and nonrespondents (mean age, 31.7 years) (P = .22). Females were more likely to respond (62%) than males (53%) (P < .05). Residents from 170 different training programs participated. Demographic characteristics of the respondents are shown in Table 1. The demographic characteristics of the respondents are similar to data reported on graduating pediatric residents from other years,20,21 as well as data on third-year pediatric residents reported by the American Board of Pediatrics.22 The percentage of IMGs was comparable to the overall proportion of IMGs among graduating pediatric residents in 2008.22 Survey questions and distribution of responses are shown in Table 2.
Education/Training in GH Topics
Less than 50% of all respondents received education in 7 of 8 topics considered essential to GH training (Table 2). One-quarter of all respondents did not receive training in any of these topics. Among respondents with definite/very likely plans to work or volunteer abroad, exposure to topics ranged from 25% to 58%; 43% reported receiving training to prepare for work or volunteer experience in a developing country (data not shown). Among respondents who reported participating in GH training exposure to specific topics varied greatly; 75% received education in diagnosis and management of tropical diseases, whereas 34% received training in responding to humanitarian emergencies (data not shown).
Participation in GH Training
Bivariate analyses revealed several resident characteristics related to report of participation in GH training (Table 3). In multivariate analyses, the characteristics independently related to participation in GH training were being single, graduating from a US medical school, lower educational debt, and training at a larger program.
Plans to Work or Volunteer in a Developing Country
Characteristics of respondents with plans to work or volunteer in a developing country after residency are shown in Table 4. In bivariate analyses, neither future clinical practice goal nor reported position/job after residency (latter not shown) was significantly associated with future plans to work in a developing country. In multivariate analyses, being single and graduating from an international medical school remained independently associated with plans to work in a developing country. Residents who participated in GH training were more likely than those who did not participate to report plans to work or volunteer in a developing country (62% vs 26%; P < .001).
To the best of our knowledge, this is the first US national sample of pediatric residents to be surveyed on the importance of GH in residency program selection, exposure to GH education, and future plans for overseas work. More than 1 in 5 graduating residents reported that GH played an essential or very important role in choosing their residency program, and 21% participated in GH training during residency. One-third of respondents planned to work or volunteer in a developing country after residency. Overall, less than one-half of the residents received training in most GH topics.
Our survey is unique because it demonstrates a high level of interest among a nationally representative sample of pediatric residents who were not specifically targeted for their interest or participation in GH. Previous surveys have demonstrated substantial increases in the number of pediatric residency programs offering resident international electives as well as formal curricula, and 15% of programs surveyed in 2006–2007 reported that the majority of their residents had an interest in GH.4 Although these surveys provide meaningful data regarding the growth of GH-training opportunities for residents, they did not directly survey residents. In addition, programs with existing interest in GH may have been more likely to respond and thus overrepresented. There have been reports of resident interest and participation in GH training in pediatric programs as well as in other disciplines; however, they have originated from institutions with existing GH programs and therefore are not representative of all residents.10,11,23,–,26
The resident characteristics associated with participating in GH curricula were not surprising. The association of larger program size with opportunities for GH training is consistent with previous findings4; larger programs are likely to have more flexibility in resident scheduling and perhaps also in funding. In multivariate analyses, being unmarried remained a predictive variable for both participation in GH training and plans to work abroad in the future. Family obligations may present challenges for residents interested in GH to work or volunteer abroad; alternatively, residents with commitments to marriage or family made before or during residency may have less interest in international work. Finally, participation in GH training was associated with less student loan debt. Resident physicians with large debt burden may have decreased ability to pursue opportunities in GH because of lack of adequate compensation or the perceived expenses of living/working abroad.
Twenty-one percent of respondents were IMGs; this outcome is comparable to the overall proportion of IMGs among graduating pediatric residents in 2008.22 IMGs were more likely than US medical graduates to report plans to work or volunteer abroad, yet less likely to report participating in GH training. This finding could be due to a number of factors, including previous training and clinical experience in a developing country, and lack of perceived need for GH training. The large number of IMGs in pediatric residency, coupled with the high percentage planning to work abroad after residency, further supports the need for US residency training to address child health on a global level. The specific educational needs and interests among this subset of residents require additional exploration.
The majority of responding graduating residents indicated that GH training was at least somewhat important when choosing a residency program. Residents at specific pediatric, internal medicine, and family medicine residency programs have reported that the presence of GH programming positively influenced the ranking of that program during the match process.11,23,27 In a national survey of first-year emergency medicine residents, 62% of respondents reported the availability of an international elective as a positive factor in ranking programs.28 Our results are the first to document interest among pediatric residents at a national level, and may have important implications for residency program recruitment.
Although experience in a developing country during medical school or residency has been associated in some studies with specific career intentions,9,–,11,14,29 such as primary care, our results did not support these findings. More than 25% of responding residents with primary care, hospitalist, and subspecialty practice goals reported definite or very likely plans to work or volunteer in developing countries in the future. Residents planning hospitalist careers did tend to be more likely to report such plans than other residents; however, this finding was not statistically significant. The clinical and teaching expertise of both generalists and subspecialists are relevant in developing countries. In addition, the lifestyle characteristics of disciplines such as hospitalist medicine may prove conducive to pursuing international work. These data demonstrate the universality of interest in GH and suggest that GH education should not necessarily be limited to any specific group of pediatric residents.
Overall exposure to the majority of GH topics was low, particularly for certain topics such as ethical issues in working/volunteering in developing countries and preparation for humanitarian emergencies. Among those who reported definite or very likely future plans to work or volunteer abroad in the future, exposure to individual topics was slightly higher but varied greatly from 25% to 58%, and only 43% reported receiving education or training to prepare for volunteer experience in a developing country. Because global health is not required by curriculum regulatory bodies, the lack of consistent exposure to GH education both across residents and across topics may reflect a lack of standardized curriculum guidelines.
The overall response rate to the survey was low (59%), and women were more likely to respond than men; these characteristics are similar to those of other surveys of pediatricians.30 However, the survey was not targeted to residents on the specific topic of GH, and missing data for any individual question was low (<5%), and thus the overall low response rate was unlikely to create a response bias to the GH questions. We were unable to distinguish the type and duration of GH training in which residents participated. Previous surveys have addressed the scope of programming, which can range from brief didactic sessions or a single international elective, to a more comprehensive GH track.3,4 Similarly, we were not able to obtain information on how residents were exposed to GH topics (ie, single lecture, special course, direct clinical experience). Because significant variation in GH curricula exists, additional research is needed to elucidate the specific components of GH training, and how these different experiences affect resident education, competency in GH, and future career plans.
Pediatric trainees value the importance of gaining the knowledge and skills necessary to competently care for all children, not only those in high-income countries. This study demonstrated that many pediatricians are completing residency training with intentions to provide care for children in developing countries in the future, yet their overall exposure to education specific to this population is low. These results highlight the need for residency programs to provide GH educational opportunities and mentorship for residents. Additional work needs to be done to support residency programs in their endeavors to effectively train residents in GH and ensure that consistent, high-quality education is provided.
This research was supported by the AAP.
- Accepted June 14, 2011.
- Address correspondence to Melanie Anspacher, MD, Pediatric Hospitalist Division, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC 20010. E-mail:
Drs Spector and O'Callahan are members of the American Academy of Pediatrics Section on International Child Health, Executive Committee.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- GH —
- global health
- AAP —
- American Academy of Pediatrics
- IMG —
- international medical school graduate
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- Copyright © 2011 by the American Academy of Pediatrics