Howard, Cynthia R. MD, MPHTM; Gladding, Sophia P. PhD; Kiguli, Sarah MBChB, MMED, MHPE, Hons; Andrews, John S. MD; John, Chandy C. MD
An increasing number of medical schools and residency programs in the United States are recognizing the demand from students and residents to provide training in the care of children from and in developing countries. Ninety percent of the world's children live in developing countries, and annually approximately 10 million of those children will die, often from preventable conditions.1 Of those who survive, many do not reach their developmental potential because of recurrent infection, chronic malnutrition, and poverty.2 In addition, a growing number of children and families who immigrate to the United States are arriving from resource-poor areas of the world, which results in increasingly multicultural and multinational pediatric patient populations. Medical schools and pediatric residency programs have responded to these changing demographics by adding curricula and clinical experiences to better train future practitioners to care for an increasingly global population.3 A 2007 survey by Nelson and colleagues4 documented that the number of pediatric residency programs offering global health electives had doubled since a similar survey was conducted in 1996.
The American Academy of Pediatrics (AAP) has advanced four principal guidelines to guide residency programs in developing international child health electives: (1) prerequisite clinical training, (2) adequate pretravel orientation and preparation, (3) preceptorship by host and U.S. faculty, and (4) formal posttravel evaluation and feedback.5
A survey revealed that, although many of the programs sending residents abroad observed elements of these four principles, most did not fulfill all of them. Specifically, predeparture preparation was lacking: Only 36% of programs provided predeparture clinical training, and only 55% provided predeparture orientation and preparation.4
Residency programs should meet specialty guidelines, such as those set by the AAP, but they should also align with new approaches in residency education in general. The Accreditation Council for Graduate Medical Education (ACGME), the body that creates the standards for residency program accreditation, has moved toward a system of competency-based education and evaluation.6 This shift emphasizes the importance of documenting competency as an outcome, rather than judging practice readiness solely on completion of rotation time requirements and a written test administered at the end of training. The ACGME Outcome Project introduced the six competency areas in 1999, and the pediatrics certifying board, the American Board of Pediatrics, adopted them shortly thereafter. Adherence to the ACGME requirements for residency training will require programs to develop formal competency-based curricula and/or training programs in global child health.
In this report, we describe the process by which we developed a competency-based pediatric global health curriculum within the University of Minnesota (UMN) Department of Pediatrics. We believe that this process can serve as a model for other residencies wishing to develop similar training programs or curricula in global child health.
In the Division of Global Pediatrics, we define “global health” as “the health of underserved populations in or from developing countries.” We recognize that many different definitions of global health exist, but we have chosen this definition because it both emphasizes the historic focus on underserved populations in developing countries and includes individuals from these populations who have immigrated to the United States. The mission of UMN's educational track in global child health, which began in 2005, is to improve the health of children in and from developing countries through the medical education of the next generation of pediatricians. The track is open to all residents who match into either UMN′s pediatrics or its internal medicine/pediatrics residency program. The formal track is an option within either of those programs, and participation is voluntary. Since 2007, 44 pediatrics and medicine/pediatrics residents have earned a certificate in global child health, and 42 have completed an international elective.
The track has undergone continuous revision in response to resident feedback, updates in the literature, and improvements in educational content.
Most recently (2009–2010), the track consisted of the following elements:
* 36 noon conferences, held the first Monday of each month across three years
* Six evening journal clubs or seminars per year
* Annual grand rounds on a topic of global health importance presented by invited faculty
* Annual grand rounds presented by senior residents on their international elective projects
* Individual mentorship for every resident in the global health track
* Participation in a global health elective: either an international elective (four to eight weeks) in one of our seven international partner sites or a local elective (four weeks) in immigrant health, international adoption, or Native American tribal health
* Opportunity to complete the UMN eight-week American Society of Tropical Medicine and Hygiene certificate course
Core curricular content is presented during the noon conference to all residents. All residents who want to earn a certificate in global child health must attend all of these sessions. If they miss one, they must view a recording of the presentation and complete a brief quiz about it online. In addition, all residents on the track must present an academic project during grand rounds or an evening journal club. They complete this project, under the supervision of faculty at partner sites, as part of their required local or international elective. Each resident's assigned mentor assists both in designing an individual learning plan and in career planning.
Development of a Competency-Based Curriculum in Global Child Health
The didactic and clinical curriculum already in place prior to the 2009–2010 academic year was not competency based. To begin developing our competency-based curriculum in global child health for pediatrics residents, we considered what expertise we would require to build such a curriculum in a thorough manner. We concluded that we needed input from physicians who have backgrounds providing clinical care either in developing countries or in the United States to immigrant populations. Additionally, we sought faculty with expertise in the education of pediatric residents, with experience in the evaluation of educational outcomes, and with knowledge of current education and assessment methods. We formed an international and interdisciplinary team of individuals from the UMN Center for Global Pediatrics, the UMN pediatrics residency program, and the UMN College of Education and Human Development, as well as colleagues from the Department of Paediatrics and Child Health at Makerere University in Kampala, Uganda. UMN team members had backgrounds in general pediatrics, educational and assessment methods, or pediatric subspecialties (including intensive care, neonatology, and infectious diseases). Each member also had either clinical or educational experience in the developing world. Team members from Uganda included the chair of the pediatric department (S.K.) and a senior pediatric consultant, both with extensive clinical experience and educational expertise. We also consulted a chief resident who was a graduate of the previous global health program. We received a grant from the UMN Office of International Programs to support the development of this curriculum.
Two members of the working group (C.H. and S.G.) conducted a literature search on competency-based residency education. They provided a summary of this literature and the sentinel articles4,6–10 to the working group (S. K, J.A., S.G., and C.H.) which met in August 2007 in Kampala for a weeklong planning conference. During the conference, we discussed the current literature available on competency-based education in pediatrics, reviewed the ACGME competency domains, and developed the goals of the project. We shared these goals with the entire Makerere pediatric faculty, who provided further suggestions and input.
We decided on an open, collaborative, and iterative process to develop the competencies. Two members of the working group (C.H. and S.G.) developed the initial draft of the competencies based on the entire group's weeklong discussion. We then shared this draft with the Makerere members of the working group via e-mail, requesting their revisions and additions. Two members of the group (C.H. and S.G.) then incorporated the Makerere feedback into a new iteration of the competencies.
In-person meetings were also critical to the process. Makerere faculty members traveled to Minnesota in 2008 and 2009 for multiday conferences during which we further discussed and refined the competencies through roundtable discussions. The process required multiple cycles of sharing drafts, incorporating feedback, and holding in-person discussions before we reached a consensus. At every stage, we consulted the literature and sought advice from subspecialists with international and immigrant health care expertise. All members of the working group approved the final version of the competencies.
Two questions guided the process. First, how do we train new physicians to be globally competent pediatricians? Second, what knowledge, skills, and attitudes does a pediatrician need in order to work effectively in resource-poor settings? The goals for the working groups in both the United States and Uganda were (1) to develop specific goals, objectives, and performance standards for each of the six ACGME competency domains and (2) to design assessment tools for evaluation of each competency.
We developed the competency-based curriculum in global child health in the six steps outlined in the following sections.
1. Defining global child health competencies
We (C.H. and S.G.) began the process of developing curricular goals and objectives by, as mentioned, reframing each of the ACGME competency statements6 in the context of global health (Table 1). The members of the working group agreed, after extensive discussions and multiple drafts, that the written competencies reflect the real-life competencies in global child health that pediatric residents must master.
2. Defining goals and objectives for each competency
After reframing the domain statements, we drafted goals and objectives for each of the six competencies. Our approach was to examine published literature,2,9–16 public policy,1,17,18 expert opinion, and personal experience. The key considerations that we discussed as we developed the goals and objectives for each competency follow:
2a. Patient care.
We based the goals and objectives within the patient care competency domain on three observations. First, the goals must reflect the particular cultural and community context in which the residents will train. Residents must be prepared for the everyday challenges of caring for children and families from countries and cultures different from those who have historically lived in Minnesota.
Second, the ability to provide compassionate and culturally appropriate care during the dying process is an important skill for the practitioner in a global health setting. Of the estimated 10 million children1 who die annually throughout the world, the vast majority live in developing countries. Our Ugandan colleagues, in fact, noted that in the developing world care is often of a palliative rather than a curative nature.
Finally, standard approaches to clinical care for specific conditions are often different in developing countries than they are in the United States. An understanding of the reasons for these differences, including resource limitations, differences in disease presentation, and differences in the cultural acceptability of specific interventions, is critical to any curriculum in global health. Faculty at UMN emphasize these differences during the local culture seminars, and faculty at partner sites help residents identify these and other differences as they work together during the international and local electives.
2b. Medical knowledge.
We based the content for core medical knowledge on two main sources: (1) Black and colleagues'11 report in the Lancet Child Survival Series 2003–2005, which outlines the major causes of child mortality for children under five years of age, including newborns, in the developing world, and (2) a 2007 meta-analysis of developmental morbidity in children in the developing world, conducted by the International Child Developmental Steering Committee.2 Factors affecting child development are key to medical knowledge for global child health because as mortality begins to decrease in developing countries, long-term complications of childhood diseases increase. We also included in this domain the knowledge of global indicators of child health, such as the under-five mortality rate. This measure, which varies from U.S. indicators,19 is recognized by international health agencies (e.g., the World Health Organization, the United Nations, World Bank) but is not typically taught in medical schools or residencies in the United States. Knowledge of global child health indicators is necessary to understand the epidemiology of newborn, child, and maternal mortality and morbidity, potential interventions, and health policy implications worldwide.
Finally, although the medical knowledge domain is often considered strictly in terms of specific diseases or pathophysiology, fluency in global health requires an understanding of the ethical, social, economic, and political issues in developing countries. Therefore, we agreed to dedicate parts of the didactic curriculum specifically to these issues.
2c. Interpersonal and communication skills.
Developing the goals and objectives for this domain was challenging: We had to navigate the boundaries between the global health track and the general residency program because, given the multicultural population of the Twin Cities, cross-cultural communication skills are critical for all residents. We therefore addressed the types of interpersonal skills necessary in an international context that may differ from those needed to communicate across cultures in clinical practice in the United States.
In discussion, the group noted that a necessary skill is realizing that one is a guest in the international setting. It is essential that the residents view their role as a privilege. Thus, the working group concluded that when working internationally, an attitude of humility is absolutely necessary to establish healthy relationships with colleagues and community. Another competency in this domain is the ability to deliver bad news to a family and to discuss this news in a culturally competent manner. For example, our Ugandan colleagues noted that Ugandan families are less likely to expect the level of detail expected by families from the United States. Telling parents in Uganda that their child is going to die may result in the family leaving the hospital to seek medical care elsewhere.
The professionalism domain became the broadest in scope. Goals and objectives addressed a wide range of topics from norms expected in U.S. culture (e.g., punctuality, respect for authority) to attitudes ideal for other cultural contexts (e.g., willingness to learn from colleagues trained in a medical education system different from one's own). Objectives related to ethical practice proved the most challenging to articulate because of the potential tension between different countries' clinical approaches and cultural mores. For example, which is the more professional choice: maintaining cultural humility or advocating an approach to patient care that seems optimal from the perspective of one's own health care system? Choosing cultural humility may require accepting a clinical approach that seems unethical from the perspective of one's own culture and medical training.
In all countries, varying levels of professionalism, clinical skill, and ethical conduct exist. Physicians in both domestic and international settings need the ability to anticipate how they might react in a challenging situation, especially one in which they disagree with the medical management of a patient, as well as the ability to find ways to respectfully disagree when appropriate. Differences due to cultural context, care that is appropriate in resource-limited settings, and respect for international partner site mentors are all specific to global health, so we designed goals and objectives to help residents in the global child health track achieve competency in these areas.
2e. Practice-based learning and improvement.
Training in global health offers a unique opportunity for U.S. residents to “identify strengths and deficiencies and limits in [their] own knowledge and expertise,”6 because they confront diseases they would not typically encounter in their training in the United States. Global child health objectives, therefore, address the development of strategies to practice evidence-based medicine in resource-poor settings. For example, the practice-based learning and improvement domain in our curriculum requires residents to develop a means for addressing knowledge gaps in settings with limited educational and electronic resources. Residents must also learn to adjust their practice to the locally available diagnostic and therapeutic resources and to the cultural norms of the society in which they are working.
As mentioned, all residents are required to do an academic project with a faculty mentor while on elective. The project must be relevant to the community in which they are working, and it must have the potential to improve practice. For example, some projects have entailed setting up an affordable assay for G-6-PD-deficient anemia at the university medical center in Uganda and introducing not only a screening protocol for neonatal hyperbilirubinemia but also a treatment procedure using a phototherapy box made from local materials in a village in Nicaragua.
2f. Systems-based practice.
The results of the global health knowledge assessment, which has been administered as a pretest to incoming UMN residents since 2006, have indicated a deficiency in residents' understanding of health care systems in the international context. Knowledge of international health care policy (e.g., the United Nations Millennium Development Goals and the Integrated Management of Childhood Illnesses) was particularly deficient among incoming UMN interns. Knowledge of global health policy makers and major donors such as the World Health Organization, United Nations, and the Gates Foundation was also lacking.
Recognizing that the health care of a child depends on larger systems beyond the care provided by the pediatrician, we included objectives that reflect the importance of situating the child and his or her family within their local, national, and international health care contexts in order to be able to deliver effective care.
3. Determining postgraduate training levels appropriate to each objective
Because the pediatric global health track spans three years of residency, the development of a competency-based curriculum requires, for each of the competency areas, level-specific objectives, performance standards, and assessment tools. For each objective, we determined the postgraduate level (from internship through postresidency fellowship) at which the objective should be achieved. In determining the appropriate level for achievement of a particular objective, we considered information that would both benefit a first-year resident and provide a framework for continuing education during the subsequent years of training. For example, for a first-year resident, basic knowledge of the predominant immigrant cultures in the Twin Cities might prove to be invaluable in providing competent patient care during the initial clinical rotations, whereas knowledge of rheumatic heart disease and malnutrition would likely benefit more experienced residents who are preparing for an upcoming international elective. Table 2 provides further examples of objectives assigned to each of the postgraduate levels.
4. Determining objectives appropriate for all residents versus objectives specifically required of track participants
Objectives determined to positively affect the health care of children who are international adoptees, international travelers, immigrants, or refugees are offered to all residents. For example, we believe that all UMN pediatric residents must gain a basic understanding of the predominant immigrant and refugee communities in Minnesota in order to be adequately prepared to practice in that state. That pediatric residents learn the health beliefs and practices of these cultures is particularly essential. Residents on the global health track are expected to master this information and integrate it into their practice. Table 2 highlights specific objectives and the formats used to target the appropriate educational group—all residents versus track participants.
5. Aligning the pediatric global health curriculum with the general residency education program
The next step was to bring the competencies into alignment with the general structure of the residency program and the already-established global health didactic curriculum. We made changes to the curriculum to ensure that each of the curricular goals and objectives was supported in the appropriate educational format. For example, before implementation, the curriculum was based primarily on the presentation of medical knowledge to residents attending evening seminars. Table 2 outlines examples of the formats we chose for several specific objectives.
6. Defining evaluation methods
The assessment of residents and the overall evaluation of the global health track require the development of measurement tools designed specifically for evaluating the global child health competency domains. We have begun the processes of developing and implementing new assessment tools and of using the results of those tools both to monitor residents' progress in each of the competency domains and to continuously improve the global child health track. In place at this time are (1) the pre- and the postresidency test, each an objective 55-question test focused on medical knowledge, (2) a written evaluation completed by the preceptor at the end of the local or international global health elective, and (3) a written peer critique of the academic project. Faculty-guided journaling and case studies began in 2009–2010, and we are preparing to incorporate the objective structured clinical skills exam as an evaluation method.
Developing evaluation methods is challenging but critical to success. As Carraccio and colleagues8 have acknowledged, “the development of appropriate assessment tools to measure competence remains the challenge of this decade.” Ultimately, these assessment tools will rely on the creation of national standards to determine what constitutes competence. We outline proposed evaluation methods for selected goals and objectives in Table 2.
Others have previously described global health tracks20 and global training programs,4,21 but we could find no published literature on competency-based curricula in global child health for residents—despite both the move toward competency-based education in all areas of residency and the increasing interest in global health among trainees. The AAP developed a competency-based curriculum in global child health in 2009.21 The curriculum is online but has not yet been published elsewhere. We participated in the creation of the AAP curriculum but decided to continue with our own curriculum development independently because our approach and the resulting competencies differ from the AAP curriculum in important ways. First, we rewrote the ACGME competency domains to reflect a global perspective. Second, we developed the goals and objectives in collaboration with international partners because we believe the perspectives and contributions of global physicians and medical educators are essential. Third, our program specifies the level of training for achievement of each goal and objective. Fourth, we determined core goals and objectives for all residents, regardless of whether they chose to participate in the track. And, finally, our program includes an evaluation method for each objective.
The UMN Pediatrics Residency Competency-Based Curriculum in Global Child Health is available online at the UMN Division of Global Pediatrics Web site (http://www.med.umn.edu/peds/global/Competencies/home.html)22 so that other residency programs can benefit from the work and modify it as necessary to fit their global health education needs. We think this description of our process, combined with the resulting curriculum, charts new directions in global health education for residents. But the final significance of our work will be gauged by the evaluation of outcomes and documentation of competency for those residents completing the program. Toward that end, we have already begun the iterative process of obtaining resident feedback, assessing outcomes, and applying further refinements to the curriculum.
We learned several lessons in the process of developing the competency-based curriculum that may be useful to other residency programs wishing to develop and conduct competency-based education in global child health. First, collaboration with international partners is critical. The input received from our partners at Makerere University was essential, as the faculty at Makerere have the greatest expertise in determining the knowledge, skills, and attitudes necessary to practice medicine in the developing world. The Makerere faculty provided critical input and feedback, including ideas that the U.S.-based team members would not have considered, throughout the process. Our curriculum reflects the shared knowledge of UMN and Makerere faculty. We believe it will contribute significantly to best practices in preparation of globally competent pediatricians.
Second, the evaluation of competencies in medical education is one of the major challenges to the implementation of competency-based curricula. The interdisciplinary collaboration between the College of Education and Human Development and the medical school at UMN in the area of curriculum development and assessment was critical. Faculty trained in educational evaluation (S.G.) had expertise in the development of reliable and valid assessment tools. Even physicians who are educators often lack this expertise. Our colleagues in education (S.G., S.K., and J.A.) will continue to work with us to implement the overall evaluation plan, which, as mentioned, will guide continuous improvement of both resident and residency program performance.
Third, the competency-based curriculum in global child health provides residents with new information that is relevant to children throughout the world. Successful completion of the curriculum equips them to work in many different regions of the globe. Naturally, as we developed the global child health curriculum, we recognized that competencies necessary to provide medical care abroad are also invaluable for practice in the United States. This is certainly true in Minneapolis and St. Paul, but also increasingly throughout the United States, both in urban and rural settings where populations of immigrants, refugees, and international adoptees reside. Cross-cultural and transnational competencies, in addition to medical knowledge of diseases not routinely seen in developed nations, are becoming increasingly necessary for pediatricians practicing in Minnesota and elsewhere in the United States as well as abroad. The addition of the global child health curriculum to the general residency curriculum provides the basis for training globally competent pediatricians.
We believe that the six-step process we have outlined for the development of our competency-based curriculum in global child health will be useful to other U.S. or international institutions seeking to develop similar programs from the ground up. The goals, objectives, and methods of evaluation can be modified for other specialties interested in integrating global health into an existing curriculum. The components outlined here can be adapted to residencies of different sizes and with differing capacities for delivering global health education. Furthermore, the evaluation methods we developed allow assessment of competency in specifically global child health, in contrast to all previous assessment methods which measured only medical knowledge.
To reach the goals and objectives will take commitment, organization, and constant reappraisal of the achievements of individual residents and of our program. Long-term evaluation of the program is necessary to determine whether it is truly successful in improving global health education in a pediatric residency. We will undoubtedly find areas of weakness that will require revision. Nonetheless, the development of this formalized, competency-based curriculum is a critical step forward in training new physicians to provide competent health care for children throughout the world.
The authors would like to thank the members of the working group that developed these competencies. In addition to the authors, members of the working group included Jared Austin, MD, Israel Kalyesubula, MBBS, Thomas George, MD, Tina Slusher, MD, Ann Fandrey, BA, and Rita Reber.
Cynthia Howard received a University of Minnesota Office of International Programs grant to develop the competencies.
These competencies were presented at a table topic forum at the 19th annual conference of the Global Health Education Consortium on April 10, 2010 in Cuernavaca, Mexico, and at the first meeting of the Midwest Global Child Health Educators' Consortium on September 15, 2010 in Madison, Wisconsin.