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Residency Training

The Design and Implementation of a Multidisciplinary Global Health Residency Track at the Mount Sinai School of Medicine

Anandaraja, Natasha MD; Hahn, Sigrid MD; Hennig, Nils MD, PhD, MPH; Murphy, Ramon MD, MPH; Ripp, Jonathan MD

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doi: 10.1097/ACM.0b013e3181850a3b
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Abstract

Global health, as defined by the Global Health Education Consortium, refers to “health issues and concerns that transcend national borders, class, race, ethnicity and culture.”1 As globalization progresses, there is an emerging consensus among medical educators that global health should be a standard component of general medical education in the United States.2 There is also a growing need for specialists in the field, with an increasing number of academic, government, and nongovernmental organizations expanding their delivery of health care to disadvantaged people worldwide.

To address these needs, we developed the Global Health Residency Track (GHRT) at the Mount Sinai School of Medicine of New York University, in New York City, in 2006. Developed under the auspices of the Mount Sinai Global Health Center (GHC), in conjunction with the leadership of the emergency medicine (EM), internal medicine (IM), pediatrics, and combined medicine–pediatrics (med-peds) residencies, this is one of the few multidisciplinary graduate medical education (GME) global health programs in the United States. Both the didactic and practical components were also designed in close collaboration with faculty of the Master of Public Health (MPH) program of the Mount Sinai School of Medicine. As a result, participating residents benefit from being taught a wide range of clinical and public health skills that are essential to working in a medically underserved setting. In this article, we describe the process of creating the GHRT, present its structure, and discuss our experience implementing and evaluating this new program, which is part of a broader initiative to offer global heath education to all levels of students and physicians at our institution. We also briefly review and compare the structure of several other resident-level global health education programs in the United States.

The Mount Sinai Global Health Center

In 2005, the Mount Sinai GHC was created to provide coordination and support for the international research and clinical activities already being carried out by students and physicians and to meet the growing demand for global health education by medical students and residents. To this end, the GHC has collaborated with clinical departments, the school of medicine, and the MPH program at Mount Sinai to design and develop an interdisciplinary educational program. In addition to the GHRT described here, the GHC currently offers an introductory elective course and an integrated global health “course without walls” for the first-year medical students, a Global Health Concentration within the MPH program, and mentoring, guidance, and financial support for global health field experiences for students and physicians. Funding for these programs comes from multiple sources, including the department of medical education and other participating departments, and numerous private donors.

Development of the Global Health Residency Track

Lack of an accredited training program in global health has generally made it difficult for residents to access the education, funding, and mentorship needed to prepare for a career in global health. The GHRT was created to fulfill the need for global health education at the resident level by creating a specialty track within standard residency programs. The goal of the track is to provide participants with a foundation in global health issues and population-based health care, a chance to develop basic research and public health skills in the field, and the opportunity to build professional relationships for future career development. Success of the program was defined as retention of graduates within a global health career path.

The GHRT was developed by faculty members from the departments of pediatrics, EM, community and preventive medicine, and IM, as well as the department of medical education and the MPH program. During the winter of 2005–2006, each member of the GHC faculty met with their respective departmental chairs and residency directors to gauge support for a multidisciplinary global health residency track. These initial meetings resulted in a stated commitment from the department heads of IM, EM, pediatrics, and med-peds to work with our team to create the GHRT. Each department committed to ensuring the American College of Graduate Medical Education requirements would be met, or exemptions requested when necessary, and that their candidate(s) would be free to attend educational events and be guaranteed a two-month call-free block for field work in their senior year. The GHC, in turn, committed to funding the residents’ travel and project expenses, developing and coordinating the educational events, and providing mentoring for field work.

The Structure of the GHRT

The GHRT is structured as a two-year program. Participants are selected through a competitive application process one year before they are eligible to enter the programs (postgraduate year [PGY]-1 for IM and pediatrics, PGY-2 for EM and med-peds). Residents enter the track in their penultimate year of training (PGY-2 for IM and pediatrics, PGY-3 for EM and med-peds). During the first year, participants are required to take the Introduction to Global Health course, which is part of the Global Health concentration of the MPH program. The course is one trimester long and provides an overview of all the “core competency topics,” discussed below (see also List 1). First-year participants are also required to attend a three-day, skills-based workshop. The skills covered include needs assessment, project planning, survey design, and surveillance methods. These are taught via case-based and participatory exercises, including a mock cluster sample survey. First- and second-year residents are asked to attend the annual Mount Sinai Global Health Conference, which focuses on a specific topic each year (such as the impact of climate change on human health or the public health impact of the war in Iraq). The conference brings in expert speakers for lectures and small-group workshops. Residents are also invited to attend a monthly career speaker series, which brings in physicians and public health professionals who work in the field of global health to discuss their educational and career choices. These visitors provide residents with personalized advice for planning their careers in the field.

List 1 Global Health Residency Track Core Competencies and Specific Curriculum Topics, Mount Sinai School of Medicine

During the second year of the GHRT, residents focus on developing a research or public health project in collaboration with a GHC partner organization, which is implemented during the second half of the senior year during the two-month elective block. Senior residents attend monthly research seminars and journal club meetings where they present their project for feedback and discuss relevant published literature on the topic. They also have the option of taking an additional class within the Global Health Track of the MPH program, such as Maternal Child Health, Refugee Health, or Underserved Populations in the U.S. The Introduction to Global Health course, skills-based workshop, career series, and research seminars are credit-earning classes through the MPH program, allowing residents to earn up to nine credits toward a full MPH degree.

Senior GHRT residents graduate from the track when they have completed the requirements of the program, including the required classes and their two months of field work, and have presented the results of their work to the GHC faculty, their residency directors, and coparticipants in the GHRT. Graduating residents are expected to maintain contact with the GHC to serve as mentors for future GHRT participants, to provide outcomes data for surveys evaluating the career paths of GHRT graduates, and to become part of a global health collegial network for career support and future interinstitutional collaborations.

The GHRT Curriculum

Taking into account the limited time available for didactic teaching in the residency schedule, we decided to focus on five areas of “core competency” in global health: (1) epidemiology and research skills, (2) health disparities, human rights, and cultural competency, (3) needs assessment and project development, (4) tropical medicine and infectious disease, and (5) reproductive, maternal, and child health. These competencies were chosen after reviewing existing curricula from global health programs in medical schools, public health schools, and residencies around the country, and after consulting with experts in the field of global health, including the deans of several academic global health programs and the directors of a number of nongovernmental organizations. Lists of relevant topics were generated for each area of competency, with associated learning objectives, and the didactic curriculum (including the courses within the affiliated MPH program) was designed to address these objectives (see List 1). Courses are taught by Mount Sinai GHC faculty as well as by experts from locally based nongovernmental organizations and other academic institutions. Investigation of the available evidence base for best practice in each of the five competency areas takes place through the resident’s presentation of peer-reviewed articles at the research seminar and journal club meetings, and through preparatory work for their field project in their senior year.

Global Health Residency Track Partner Organizations

High-quality field experiences are critical to the success of the GHRT. Our priority during the past two years has therefore been to form partnerships with nongovernmental organizations, hospitals and clinics, and medical schools that are engaged in innovative and effective work in underserved communities domestically or internationally, so that we can place residents there for collaborative public health and research projects. Over the past several years, a number of potential partner organizations were evaluated via visits to Kenya, India, the Dominican Republic, Honduras, Argentina, Uganda, Ethiopia, and the United States. Partner organizations were identified through discussion with experts in the field working domestically and internationally. Ultimately, they were selected on the basis of their ability to provide residents with exposure to successful, ethical, and innovative models of public health, research, or clinical care in the field, their ability to safely host our residents and visiting faculty, and the potential for our residents to effectively contribute to their work. Selected sites include Mario Catarino Rivas Hospital in San Pedro Sula, Honduras; the Comprehensive Rural Health Program in Jamkhed, India; John F. Kennedy Memorial Hospital in Monrovia, Liberia; Makarere University in Uganda; Community Schools in East Harlem, New York City; and the Spirit Lake Nation of North Dakota.

Implementation of the Global Health Residency Track

In May 2006, nine residents from IM, EM, pediatrics, and med-peds were selected into the GHRT from a pool of 17 applicants. We accepted residents to both the junior and senior years of the two-year track, and senior residents entered directly into the second year of the two-year program. This first cohort of Global Health Track residents began their didactic curriculum with a full-day orientation in September 2006, and they progressed together through the various components of the curriculum. During the fall of 2006, senior residents discussed options for project sites with GHC faculty, identified a site, and began developing their projects. Approval was given to project proposals that met the following requirements: (1) residents must work with one of our partner organizations or a well-established organization with similar qualities, (2) the project must involve research or program development relevant to the health issues of underserved populations, and (3) the project must fulfill a need that is agreed on by the host organization. Residents were paired with mentors from both Mount Sinai and the host organization for guidance on project design.

In February 2007, the senior residents’ protected field time was initiated with a preparatory workshop. Topics covered during this workshop included a review of basic epidemiology, cultural competency, human rights and ethics, and travel health and security. Senior residents also used this time to present their projects to GHC faculty and their peers for final discussion and feedback. For their field projects, two residents chose to do projects in India based on prior contacts; one studied HIV/AIDS prevalence in a public hospital setting, and the other worked on a research project investigating the interactions between malaria and hookworm. One resident chose to work with The HealthStore Foundation in Kenya and carried out quality-of-care assessments at their rural clinics. Of the remaining residents, one collaborated with another New York medical institution to design and establish a trauma surveillance system for a public hospital in the Dominican Republic, and the other worked through contacts in the Mount Sinai Department of Community Medicine to carry out a health care needs assessment for children living in homeless shelters in East Harlem.

Senior residents returned from the project sites in April 2007 and graduated with a Certificate in Global Health in June 2007 after presenting the results of their work to their peers and GHC faculty. All graduating residents expressed a commitment to a career in population-based health care in underserved communities. Of the graduates, two of the five residents have taken faculty positions in community hospitals in underserved areas of New York City. One graduate is joining the CDC Epidemic Intelligence Service, and another has accepted a position as a pediatric emergency medicine fellow. Three of the five graduates will continue to be involved with their project sites, either by coordinating and mentoring future residents to continue work on their projects or by serving directly as a program manager or researcher.

A new cohort of five junior residents was selected in April 2007. The GHRT is also expanding this year to accommodate residents from the departments of obstetrics and gynecology and psychiatry. Collaboration with these departments also expands the GHRT teaching faculty and adds new partner organizations to the GHC program.

Monitoring and Evaluation

Although there are a number of published studies that have described the effect of international elective experiences on participants’ knowledge and attitudes,3–5 fewer have looked at their impact on career choices.3,4 An evaluation of the Duke University Medicine Residency International Health Program found that among the nearly one third of residents who changed their career plans during residency, participation in the program was associated with decisions to work in public health, with disadvantaged populations, or in academic medicine, in contrast to residents who did not participate in the program.4 Another survey similarly found that participants of Yale University’s Internal Medicine Residency’s International Health Program were significantly more likely to change their career plans from subspecialty to general medicine.3

We are using several approaches to measure the impact of the Mount Sinai GHRT. The quality of GHRT teaching curricula, speakers, and field sites are evaluated by participating residents via online and in-class evaluations. Focus groups are also conducted during the course of the seminar series to obtain feedback on the effectiveness of these sessions. Evaluations of quality and efficacy have shown high resident approval of didactic offerings to date. On a Likert scale with 1 being the lowest and 5 the highest possible scores, the overall quality of the orientation, seminar series, and workshop were rated as 4.6, 4.4, and 4.4, respectively. “Quantity of new information learned” during the seminar series was rated at 4.3.

A longitudinal outcomes study, designed to track the impact of participation in the GHRT on the primary outcome, career choice, and the secondary outcomes of global heath knowledge and further education or training in global health, was launched in 2006 after a review of similar surveys developed for medical students and residents undergoing international electives. The survey was reviewed by our institutional review board and is administered anonymously online. In addition to direct questions about the participants’ levels of global health knowledge and their proposed career plans, the survey also assesses possible predictors or barriers to retention in a global health career pathway, such as educational and cultural background, financial burden, and domestic status. The survey is administered to each resident on acceptance to the GHRT and is administered again to the residents of each graduating class to track changes in their self-assessed levels of knowledge and in their career and educational choices. Although the conclusions that can be drawn from the first year’s data are limited by the small sample size, we did find that in the 2007 graduating class of five residents, four felt that the curriculum and field experience provided them with knowledge and skills that would be useful for a career in global health. All said that they were pursuing careers working with the underserved in the United States or abroad, and two said that they would “probably” be working at least in part in a developing country. Regarding major barriers to working with an underserved population, two felt that family was a limitation, one responded that financial constraints were a concern, and one said that place of residence was a determining factor.

Lessons Learned

Manipulating residency schedules to allow participation in a special interest track is the most concrete challenge to creating a program of this sort. Despite the cooperation of program directors and chief residents, coordinating schedules across multiple departments to ensure protected time for GHRT residents has been an ongoing challenge, requiring creative thinking and constant reassessment of program structure. After our first year of programming, the curriculum structure was revised to better facilitate residents’ attendance and to improve the utility of the educational modules. The MPH Introduction to Global Health course replaced a monthly seminar series. The three-day skills-based workshop was added in the GHRT junior year, and the senior-year pretrip preparatory workshop was eliminated. These changes allow the residents extra time in the field, ensure that important practical skills are introduced earlier in the program, and allow the GHC to consolidate its teaching activities.

In 2008, we will also direct where senior residents spend their field time. In our first year, although we recommended placement with a partner organization, senior residents were given the option to identify their own field work site. This year, residents will be required to choose from one of our partners. This will help us to ensure a high-quality experience for our residents and will provide continuity at partner sites, enhancing our opportunity to contribute to the work of our partner organizations. Having several generations of GHRT residents working on the same project also allows us to use graduating residents as mentors for incoming residents and, therefore, keeps GHRT graduates connected to the GHC community. Residents will now be required to choose their site and begin work on their project during their junior year, and they will present their projects for peer review and discussion during the research seminar and journal club meetings.

Discussion

We have presented Mount Sinai’s model for providing global health training during residency, which is one of many approaches taken by the growing number of North American training programs with similar educational missions. There are several published descriptions of such programs, and further information was obtained from the Global Health Education Consortium’s new guidebook, titled Developing Residency Training in Global Health.6 Although there are many similarities, programs differ somewhat in their scope and design.

First, the structure of the didactic component is variable. For example, the Brigham Women’s Hospital Residency in Global Health Equity and Internal Medicine gives residents the option of pursuing an MPH from the Harvard School of Public Health, which requires six months of classroom and campus study.6,7 More commonly, programs offer lecture series or blocks: for instance, the Rainbow Babies and Children’s Hospital International Health Track, which is available to pediatric and med-peds residents, provides a two-year (nondegree) didactic curriculum, with monthly lectures on core topics in global health as well as a journal club series.6 The long-established Albert Einstein College of Medicine/Montefiore Primary Care/Social Internal Medicine Program offers, in contrast, an intense immersion month with 70 hours of seminars in the clinical, social, economic, and political realities of health in the developing world.6 Similarly, the new University of Washington/Children’s Hospital and Regional Medical Center Pediatric Residency GLOBAL (Global health Learning Opportunities Building Advocacy and Leadership skills) Pathway features a condensed, four-week, case-based and experiential curriculum at the outset of the program, with the rest of residents’ time geared mainly towards developing and executing a project.6 The Lawrence Family Medicine Residency Global Health Program in Massachusetts emphasizes Spanish-language training, with a 10-day intensive course, in addition to a lecture series.6

Programs also vary with regard to whether they are within a single discipline or are multidisciplinary, like our GHRT. The majority were developed within one residency program or one academic department at a medical center. The University of California–San Francisco Global Health Clinical Scholars Program, in contrast, is a multiresidency program, with participation by nurse and dental trainees as well.6 Duke University’s Hubert-Yeargan Center for Global Health has recently developed a multidisciplinary residency program which is open to participating departments across the medical center. Residents in the departments of medicine and obstetrics and gynecology extend their residency to incorporate course work for the Masters of Science–Global Health program and complete nine months of field work, while psychiatry and neurosurgery residents participate during their standard-length residency program.8 The Yale/Johnson & Johnson Physician Scholars in International Health program selects residents from all specialties to do a four- to six-week elective, participating in capacity-building initiatives in low-resource settings at one of several established partner sites. Approximately half of their participants are Yale residents, one third are from other residency programs, and the balance are career physicians.6

Field work is integral to every global health program, but the duration and purpose of the elective block varies across programs, with some focused on providing trainees with clinical experience in a low-resource setting, and others on research or other project development. The Brigham and Women’s Residency in Global Health Equity and Internal Medicine program provides among the longest periods of field time: residents spend up to 14 months abroad during the course of four years, and they are expected to complete a project such as a clinical research project or efforts leading to the improvement in clinical services at the field site.6,7 The Albert Einstein Social Internal Medicine program has a wide range of domestic global health offerings, and residents can use their elective time to work, among other sites, in an underserved community health center in the South Bronx.6 Typically, however, residents have between 4 and 12 weeks of blocked time for field electives. Programs such as the aforementioned Rainbow program or the St. Joseph’s Regional Medical Center Family Medicine Residency generally focus on optimizing the clinical experience rather than encouraging research, in part because of the shorter duration of the elective block (four to eight weeks).6

The Mount Sinai GHRT shares features with many of the above programs. As we move forward, we are focusing on incorporating further credit-earning MPH classes into the didactic curriculum, expanding collaborations with other clinical departments and academic centers in the Tri-State Area, and developing relationships with partner sites to optimize both the field experience of the residents and the benefits to the host community. Experience with each graduating class, ongoing monitoring and evaluation of our program, and interaction with other residency-based global health programs will help us to refine and strengthen the program in an effort to best meet the needs of our participants and the communities they will ultimately serve.

Acknowledgments

The authors gratefully acknowledge David Muller, MD, Suzanne Rose, MD, and Phil Landrigan, MD, MPH, for their invaluable help in preparing this manuscript.

References

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3 Gupta A, Wells C, Horwitz R, Bia F, Barry M. The International Health Program: The fifteen-year experience with Yale University’s internal medicine residency program. Am J Trop Med Hyg. 1999;61:1019–1023.
4 Miller W, Corey G, Lallinger G, Durack D. International health and internal medicine residency training: The Duke University experience. Am J Med. 1995;99:291–297.
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8 Hubert-Yeargan Center for Global Health. Duke University Medical Center. Web site. Available at: (http://www.dukeglobalhealth.org). Accessed June 23, 2008.
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