Global Health Education in US Pediatric Residency Programs

Discussion

This is the most comprehensive assessment of US pediatric residency training opportunities in global child health, including data from all but 1 pediatric training program. This is also the first study to quantify the breadth of US pediatric residency programs’ international partnerships. GH opportunities in pediatric residency programs are prevalent, and increasingly formalized as GH tracks. Furthermore, our findings help identify certain program characteristics that are associated with key GH curricular elements, which can help guide residency programs in successful GH education implementation.

Two previous US-based studies have attempted to quantify the number of pediatric residency programs offering GH opportunities.^4,9 Consistent with these studies, we found that the number of pediatric residency programs offering GH training opportunities and tracks continues to rise. In 1995, 25% of programs offered international field experiences, 52% in 2006, and 58% in this study. We suspect that the 1995 and 2006 numbers may be overestimates given that response rates were 65% and 53%, respectively, and programs with opportunities may have been more likely to respond. The actual increase in international field experiences offered may, therefore, be even larger. The commitment of programs to GH education through the development of a formalized track also has increased substantially, with 49 programs (24.7%) now reporting that they have a GH track, compared with only 6 (6%) in 2006.

These increases in GH training opportunities translate into a sizable number of US pediatric residents abroad each year. Short-term GH experiences have distinct benefits in improving resident understanding of the diseases responsible for the largest proportion of childhood mortality; instilling a deeper appreciation for issues related to cultural humility, professionalism, and public health; and helping to maintain and foster compassion, humanism, and altruism when caring for the world’s most vulnerable populations.^3,8,10–12 Nonetheless, GH experiences come with nontrivial risks to the participants, residency programs, host institutions, and communities. Residents struggle with the emotional challenges of practicing in a resource-limited environment, are subject to the inherent safety risks involved with international travel, and may endure financial strain given the cost of these experiences. Residency programs are faced with challenges in ensuring that their residents are participating in safe, educationally valuable experiences, and mitigating legal and ethical conflicts. Visiting trainees may fail to deliver care that meets current standards (in the United States or the host country) if they are not supervised appropriately. Further, provision of adequate supervision may impose burdens on partner institutions, exacerbating preexisting human resource capacity limitations.^13–18

The importance of these aspects of GH training are underscored through the emerging literature on best practices for developing ethical, sustainable, and educationally robust GH training experiences,^16,19–24 which include the provision of adequate preparation and orientation before the resident embarks, along with adequate supervision during the experience. Such elements are requisite for programs sending residents overseas, and programs should establish partnerships with institutions, communities, and programs having shared goals, measureable outcomes, parity, and reciprocity.²³

Despite these accepted best practices, we found that both pretravel preparation and formal partnerships remain critical national gaps. As may have been expected, results from our study suggest that larger programs, those with GH tracks, or a with GH faculty leader are significantly more likely to report having pretravel training and established partnerships. Establishing and maintaining a GH training track and GH partnerships require substantial institutional commitment and a core group of dedicated faculty. As such, we were not surprised that smaller residency programs reported having fewer tracks and GH opportunities as compared with medium and large programs with a larger faculty from which to draw.

Because we hypothesized that the presence of a GH track may be the most important determinant of whether a program offers pretravel training, and because having a GH track was associated with each program characteristic (ie, program size, GH faculty lead, international partnership), we repeated the analysis shown in Table 4 after adjusting for the presence of a GH track. Even after accounting for the presence of a GH track, the relationships between pretravel training and program size, a GH faculty lead or international partnerships remained significant (data not shown), suggesting there are independent effects of each of these characteristics on pretravel preparation beyond simply having a GH track. Note that there are few small programs with GH tracks, so the strength of this conclusion is limited and will need to be reexplored as more small programs develop GH tracks. Our observation that medium-sized programs have effect sizes between small and large-sized programs may suggest a “dose-response” relationship between program size and the offering of GH education elements. Future work exploring the barriers and facilitators to offering pretravel preparation, as well as formal partnerships, would be highly valuable.

One strategy to overcome the gap in pretravel training is through resource and information sharing, because much of the pretravel content is uniformly applicable. This approach would minimize the burden, particularly for smaller programs, for developing a new curriculum and is a major outcome objective of this collaborative effort.

Another important observation from this work identifies geographical areas hosting a very high density of partnerships. Perhaps the most striking example of this is in Haiti, a country approximately the size of Vermont, where 22 programs report having partnerships. Adding the Dominican Republic, with which Haiti shares the island of Hispaniola, the number increases to 32 programs. Similarly, in East Africa, 40 US pediatric residency programs have partnerships in the neighboring countries of Uganda, Tanzania, and Kenya. The impact of GH partnerships, particularly those involving trainees (who by definition require orientation, assessment, and supervision), on colleagues and institutions in resource-limited settings cannot be overstated,²³ and should be monitored in these regions. By coordinating efforts, orientation, and schedules across programs working in the same areas, some of the burden imposed on partners abroad could be offset.

In addition to our international partners, we also should pay special attention to the burdens that our programs and trainees place on domestic GH partners who are often working in resource-limited settings in the United States. Given the sizable health disparities that exist in the United States, engaging residents in these experiences during their training is important. Yet with nearly half of all pediatric residency programs offering domestic GH experiences, the scale of this impact is not inconsequential. This is another area requiring collaboration and coordination across programs.

Findings from our work should be interpreted with certain limitations in mind. Data were self-reported and discrete definitions were not provided for all terms used in the database, which could have introduced bias. We developed the data collection tool for the database, and the program and educational elements included may not represent every important characteristic relevant to this topic. The data collected represent only 1 academic year (2013–2014), and we cannot confirm if these data are reflective of all recent years. As we update the database and make it publically available via the APPD GH PEG Web site, moving forward we hope that additional years’ worth of data will provide clarity about trends in GH education over time. Finally, as the primary goals of the study were to guide programmatic features of the APPD GH PEG, to identify avenues for collaboration, and to assess the current state of pediatric GH education in the United States, we did not assess quality, longevity, or outcomes of each of the curricular elements. This information could be helpful for guiding program and pediatric GH education impact and improvement, and will be important next steps.