Resident interest and participation in global health (GH) electives across specialties is growing.1–6 These opportunities typically involve short-term clinical and/or educational experiences in resource-limited settings. Many residency programs require residents to complete an academic project as part of the GH experience.2,4,7–9 In addition to meeting the Accreditation Council for Graduate Medical Education requirement that residents participate in scholarly activity, these projects provide opportunities for residents to collaborate with colleagues from resource-limited settings to address an identified need, practice working across cultures, and gain experience in a self-directed project.7,9–12
Consensus recommendations within the GH education community suggest that these projects should mutually benefit the international partners who host U.S.-based residents. These recommendations include proposed best practices regarding mentorship, project planning, needs assessments, and sustainability.7,11,12 While some have raised the concern that monthlong GH electives provide insufficient time to complete an independent research project,11,13–15 there has been little description of the range of academic projects residents pursue during their GH electives or the extent to which these projects are consistent with proposed best practices.7,11,12
The purpose of this study is to describe the range of academic projects that pediatric and medicine–pediatric residents at the University of Minnesota (UMN) have completed while on GH electives over the last 10 years, and examine the extent to which these projects are aligned with best practices, with the hope that this will better inform future discussions and recommendations on what types of academic projects are both feasible and valuable during these electives.
Context of study
The UMN pediatric residency program has had a GH track since 2005 to train pediatric and medicine–pediatric residents in the knowledge and skills needed for medical service for underserved children in and from low-income countries. GH track residents participate in a competency-based curriculum (described elsewhere16), in which they receive mentoring and postgraduate year (PGY) 2, 3, and 4 residents can participate in a GH elective hosted by one of UMN’s international partners. The elective is typically a four- or eight-week clinical experience in a community or hospital setting that takes place after structured predeparture training, which includes content on management of medical conditions (e.g., malaria, malnutrition); discussions on the logistics of travel (e.g., packing list, acquiring visas); health and safety planning; and simulation exercises meant to mimic the practical and emotional challenges of working in a limited-resource setting.17
As part of the GH elective, residents are required to complete an academic project. Residents may determine their own projects within the broad expectations that they work with the host partner, preferably prior to departure, to identify a need within the medical institution or community, and that they apply quality improvement, education, research, or public health principles to that need.7,16 Prior to departure, residents are expected to meet with GH faculty at their home institution to discuss their project idea, objectives, preparation, and expected outcomes, and are connected with an international partner faculty member if feasible. All residents are expected to work with a U.S.-based faculty mentor for the duration of their elective. In addition, PGY2 residents are required to travel with a U.S.-based faculty mentor. On return from their elective, residents are required to provide a written summary, oral presentation, or poster presentation of their project. For their summary or presentation, residents are prompted to provide a summary of project activities (what they did, how it worked, roadblocks encountered, and outcome). Residents who do not turn in summaries or presentations are not eligible for a travel stipend reimbursement.
Project summaries or presentations
During the 10-year study period from 2005 to 2015, 86 unique residents participated in a GH elective, with 10 (12%) participating in more than one (during this 10-year time frame, a summary or presentation of an academic project was required for only one GH experience). We received written summaries or copies of presentations (e.g., posters or slides; hereafter grouped together as summaries) from 84 (98%) residents. Of these 84 summaries, we excluded 11 (13%) duplicate projects (i.e., summaries from projects in which more than one resident participated) from analysis. Six (7%) additional summaries were excluded for not meeting the study inclusion criteria of describing a completed academic project undertaken at an international site or because the resident described not being able to implement a project for unclear reasons. This resulted in a total of 67 (80%) unique projects (Figure 1) from 16 countries, with more than half (38 [57%]) from sub-Saharan Africa (Figure 2).
With institutional review board approval from UMN (IRB#1203E11227), we conducted a document review of the 67 summaries to determine the range of projects residents completed and the extent to which these projects reflect best practices.7,11,12 Prior to our review, the summaries were deidentified by the GH track coordinator to the extent that was possible. We were specifically interested in (1) the types of projects residents completed; (2) when the resident generated their project idea; (3) whether the resident mentioned working with a mentor from the home institution, host institution, or both; (4) whether the resident conducted a needs assessment; and (5) whether there were plans for sustainability. The criteria we used to code the summaries for each of these categories are described below.
Type of project.
The categories we used to code the project type came from the broad principles of quality improvement, education, research, and public health that residents are asked to apply in their projects.18 The project types were (with subcategories in parenthesis) (1) education (at host site, at home institution); (2) clinical research (interventional [screening, trial], noninterventional [data analysis/chart review, case report/series]); (3) basic science; (4) quality/process improvement (patient care related, education related); and (5) service project. As our analysis spanned 10 years and as our residents were not formally trained in quality improvement methods until 2014, projects did not need to demonstrate the rigor of standardized quality improvement methodology to be categorized as quality/process improvement19; instead, they needed to describe an attempt to address an identified need in a clinical or educational process. We coded each summary to the single best category that described the project. Projects that could not be coded into one of the six categories were coded as “other.”
Timing of project idea generation.
If the timing of idea generation for the project was explicitly mentioned, we coded it as “before travel” or “on-site” as appropriate.
Explicitly mentioned a mentor.
If a mentor was explicitly mentioned, we coded “yes” for mentor, as well as whether the mentor was based at the “home institution,” “international partner institution,” or “both.”
Reported conducting a needs assessment.
The criteria for coding a project as “yes” for a needs assessment was evidence that the resident had communicated about host site needs with host faculty or residents either prior to or during their elective.
Indicated plans for sustainability.
The criteria for coding a project as “yes” for sustainability plans was evidence of the development of a tangible resource, ongoing resident participation in the project, and/or continuation of data collection after the resident returned to the home institution.
Two authors (M.B.P. and S.P.G.) independently coded each deidentified summary and then met to compare their coding results. Areas of disagreement were discussed until a consensus was reached.20 They calculated the number and percentage of each category for the overall data set as well as by PGY and elective duration to explore the potential bearing these variables might have had on projects. They selected representative projects as examples for inclusion below.
Two separate authors (C.R.H. and T.M.S.) with institutional knowledge of the projects beyond the summaries rated them for quality based on incorporation of best practices, degree of local engagement and collaboration, the residents’ initiative, degree of completion of the project, and potential impact of the project at the host site or home institution.
The categorization of projects by type, timing of idea generation, explicit mention of a mentor, report of a needs assessment, and indication of plans for sustainability is summarized in Table 1. A further breakdown of best practices and project types by PGY and elective duration is presented in Table 2, and representative examples of project types are given in Table 3.
Forty-six (69%) of the 67 projects were categorized into two project types: quality/process improvement (28 [42%]; of these, 20 [71%] were patient care related and 8 [29%] were education related) or education (18 [27%]; of these, 13 [72%] were at host site and 5 [28%] were at home institution). Another 14 (21%) projects were categorized as clinical research (of these, 9 [64%] were noninterventional and 5 [36%] were interventional).
Two-thirds of the summaries explicitly mentioned a mentor (45 [67%]), and more than half explicitly reported conducting a needs assessment (38 [57%]). Quality/process improvement projects were the most likely to include some type of needs assessment, with 23/28 (82%) of these projects done in response to a stated or observed need. Of the 42 (63%) summaries that indicated the timing of project idea generation, 30 (71%) indicated the idea was developed after arriving at the host site. Most summaries indicated plans for sustainability (45 [67%]). Of the 22 (33%) summaries that did not indicate sustainability plans, 12 (55%) described finite projects, such as written case reports, which, by their nature, are not necessarily intended to be sustainable projects (data not shown).
All projects included in this study met the program’s requirements for academic projects, with the majority being rated as good quality (50 [75%]), 10 (15%) identified as high quality, and 7 (10%) as low quality.
Our residents undertook a wide range of academic projects during their GH electives. Most projects were quality/process improvement or education projects. This may reflect the lower barriers to and higher flexibility of undertaking these types of projects in a short time frame. Despite program guidelines that project ideas be in place prior to departure, most residents who pursued these types of projects indicated that their idea was generated after arriving at the host site; many of these residents indicated that they had predeparture plans for a different project. Some changed plans because of difficulties experienced once on-site, such as the inability to receive the necessary approval in time to complete the intended project, while others indicated that they identified new needs on arrival that they found more meaningful to address. In contrast, all but one interventional clinical research or basic science project summary indicated that the project idea was generated prior to travel, indicating that these types of projects may require more predeparture planning. Additionally, all but one of the summaries in this category mentioned joining a U.S.-based mentor’s preexisting project, indicating that leveraging the areas of expertise and existing projects of mentors may provide entry points for multiple residents. For example, five interventional clinical research or basic science projects involved assessing the efficacy of phototherapy delivery for treatment of neonatal hyperbilirubinemia, with these residents all working on one U.S.-based mentor’s ongoing project in this area.
Quality/process improvement projects were the most likely to include some type of needs assessment which ranged from responding to explicit needs expressed by host faculty and trainees, such as requests for assistance in clinical decision making through the creation of order sets for common conditions based on locally available therapies and World Health Organization guidelines, to needs that residents observed once at their host site, such as the need for a supply checklist for resuscitation carts. While fewer clinical research and basic science project summaries reported the completion of a needs assessment, it is possible that one was completed as part of the U.S.-based mentor’s preexisting research project.
All residents are expected to work with a mentor, and the majority of summaries explicitly stated that they did so. For those summaries that did not mention working with a mentor, this may simply reflect that the residents were not asked to specifically address mentorship in their written summaries. Indeed, anecdotal evidence from program leadership indicates that nearly all of these residents who did not explicitly state working with a mentor in their summary did actually work with one. Notably, PGY2 and PGY4 residents explicitly stated that they worked with a mentor more frequently than PGY3 residents (85%, 83%, and 62%, respectively). For the PGY2 residents, it is possible that this difference reflects that they were required to travel with a U.S.-based faculty member, had closer contact with their mentor, and, therefore, included them in their summary. Similarly, all but one resident participating in an interventional clinical research project stated that they worked with a mentor, likely reflecting that this type of project requires residents to work more closely with their mentor. It may be that some of the residents who did not explicitly mention working with a mentor were not working as closely with their mentors, with the mentors serving a more consultative role, and that these residents therefore did not mention them in their summaries.
This underscores the need for better documentation and closer monitoring of whether mentoring is actually occurring to ensure that residents are receiving guidance as they develop and implement their projects. Previous research has shown that residents doing GH electives often lack an understanding of local context and demonstrate significant gaps in knowledge of local disease processes, culture, and health systems.21,22 Therefore, mentoring is essential to ensure that residents are not basing their projects on misinformed needs assessments or suggesting projects that may not be appropriate or feasible in the local setting. It also highlights the need for programs to prepare their residents to be visitors in a different system and work with their hosts to develop local, rather than U.S.-based, solutions.12
Residents are encouraged to consider sustainability through discussions with their host sites as they develop their projects and to pursue projects for which there is the potential to make sustainability plans.11,15 We found that the majority of quality/process improvement, education, and service projects indicated plans for sustainability. This was most often a tangible resource developed by the resident, such as a picture-based training guide for the locally available ultrasound machine and an institution-specific antibiogram. Many residents described a process for sustaining their projects, such as providing education on neonatal jaundice and phototherapy in conjunction with teaching the construction of a phototherapy box. Some projects provided opportunities for sustainability by serving as a launching pad for future projects. One example was the development, by host request, of a malnutrition order set by one resident, which was followed two years later by a chart review performed by other residents examining the outcomes of implementing the order set. By supporting similar collaborative longitudinal academic projects, we might better promote and measure the sustainability of these endeavors.11,12 Although sustainability may not be a realistic goal for all projects completed on a short-term rotation, it is critical that residents learn and practice the process of considering sustainability with international partners. Follow-up with our host sites is needed to determine whether projects have been sustained and to better understand what types of projects are more likely to be sustained.
Our experience over 10 years suggests that academic projects are both a feasible and important part of GH training. We have observed that the goals of identifying a need and ways to address it provide residents with opportunities to develop critical skills in GH. They must engage with their host colleagues and community to better understand their needs and possible solutions. Those participating in larger, preexisting research projects have the chance to gain firsthand experience of conducting research in a resource-limited setting. Learning how to consider solutions in these environments requires observation, creativity, humility, flexibility, initiative, respect, and collaboration—all essential skills for success in GH.12,23–25
The extent to which residents observed, showed engagement, and sought solutions is reflected in the quality of the projects. All of the projects included in this study met the program’s requirements for academic projects, as judged by two of the authors. Nearly all were considered to be of good quality, with residents demonstrating engagement and collaboration with their host colleagues and communities and showing initiative to develop and implement projects with the potential to have an impact on their host site or at their home institution. The small number of lower-quality projects were characterized by less engagement with the host site and projects with limited scope and little potential for impact on our international partners, such as a written summary with no plans for dissemination. In contrast, the highest-quality projects were characterized by strong local engagement and collaboration to identify an important need, initiative in attempting to address the need, and proactive steps taken to ensure that the project had the potential to have a sustained impact at the host site. Examples of high-quality projects include the implementation of a glucose-6-phosphate-dehydrogenase deficiency screening program in a community that included training laboratory faculty to continue to run the assay and service projects that partnered to create meaningful advocacy work that supported the needs of the host site, such as redesigning the partner hospital’s Web site to feature host faculty.
We have learned several important lessons from our 10-year experience. The first is that ensuring and documenting that all residents receive mentoring to reduce the possibility of them pursuing projects with misinformed needs assessments or unfeasible solutions is important. Further, follow-up during the elective is essential to make sure that mentoring continues to occur. We have also learned that it is crucial to ensure that residents are adequately prepared for the GH elective and their project. For example, we have strengthened our predeparture training, adding additional simulations which focus on cultural challenges often encountered abroad17 and a standardized medical knowledge test that residents must pass before they can participate in the elective. Another lesson is that although developing a project idea prior to departure is important, it is perhaps also as important to teach residents how to do a thorough needs assessment once on-site and to be adaptable, so they can adjust their plans if needed. Several of the highest-quality projects were developed once the resident was on-site, suggesting that a careful on-site needs assessment and flexibility support quality projects. Finally, we have learned that projects are a critical learning opportunity for each GH experience; therefore, we now require residents to complete an academic project on every GH elective they take.
Our study has several limitations. First, this is a single program at one institution, which may limit the generalizability. Additionally, we reviewed residents’ summaries where they responded to a broad prompt to describe their experience that did not require the inclusion of specific information. Consequently, we were only able to code what residents documented in their summaries, which is likely to have led to an underestimate of several categories. For example, we were only able to comment on the presence of a mentor if the resident chose to include that information in their summary. While 67% explicitly mentioned working with a mentor, anecdotal evidence from the program leadership indicates that nearly all residents worked with a mentor. Additionally, we were only able to code for intended sustainability plans. Although it is reassuring that most residents were considering sustainability, we do not know if these plans were actually carried out. Finally, the summaries are self-reported and may reflect residents’ bias to represent their work in a positive light; having faculty from the partner institutions also provide feedback would add richness to our understanding and a valuable perspective. Indeed, we aim to provide mutually beneficial experiences with our GH partners including shared discussions about academic project expectations.7,11,12 However, further engagement is needed to better understand our partners’ perspectives including the benefits, risks, burdens, and unintended consequences of requiring an academic project. In addition to the possibility of residents proposing projects that include inappropriate recommendations or that are impractical in that medical setting, it is essential to consider the burden on human and other tangible resources that is entailed in supervising such experiences and to keep an open dialogue with partners about what worked well and what should be changed.12
In our 10-year experience, residents have completed a wide variety of academic projects during GH electives, most commonly quality/process improvement and education projects. The projects were largely aligned with best practices, with most summaries indicating that the resident worked with a mentor, conducted a needs assessment, and made plans for sustainability. Further study, including qualitative approaches with international partners, is needed to determine the longer-term benefit or harm of such projects and hosts’ perspectives of them.
Acknowledgments: The authors wish to acknowledge the residents and mentors, both stateside and from our international partners, who were involved in the global health projects over the last decade. They also wish to thank Dr. Chandy John for his mentorship.
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