Global Health Competencies in Residencies and Fellowships Natasha Anushri Anandaraja MD, MPH Mount Sinai Global Health Center
Methods • Review of SAEM, ACEP, AAEM, AAP, AMA, AAFP websites • Review of websites of all fellowships and residencies listed by AMRA, SAEM, AAEM, GHSIG and AMSA as having GH Fellowships or residencies • Personal Communication • Pubmed and Google search for “global health residency competencies” , “global health fellowship competencies” “global health residency “ “global health fellowship”, and “global health competency” • Data from NYS Institution survey
Have Competencies for GH Residencies or Fellowship programs been developed? 1. Accreditation/Academic bodies 2. Individual Residency and Fellowship Programs
Accrediting / Academic Organizations
American College of Graduate Medical Education (ACGME) Competencies: Specific knowledge, skills, behaviors and attitudes and the appropriate educational experiences required of residents to complete GME programs Patient Care Medical Knowledge Practice-based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-based Practice
American Academy of Pediatrics – Section on International Child Health “Competency-based goals 1:Patient Care and 2: Medical Knowledge objectives ...intended as 3: Interpersonal Skills and comprehensive Communication guidelines for pediatric 4: Practice-based residency programs Learning and offering some organized Improvement form of training in global 5: Professionalism or international health” 6: Systems-based Practice
Competency 1. Patient Care Provide family-centered patient care that is development- and age-appropriate, compassionate, and effective for the treatment of health problems and the promotion of health. 1. Use a logical and appropriate clinical approach to the care of patients in a developing country setting, utilizing locally available resources , and applying principles of evidence-based decision-making and problem-solving. 2. Understand the approach to pediatric patients with the following presentations in developing countries and initiate appropriate work-up and management: – Diarrhea/dehydration – Respiratory Distress – Fever – Seizures/Altered Mental Status – Malnutrition (including Severe Acute Malnutrition) 3. Provide culturally sensitive care and support to patients and their families. 4. Participate in health promotion and injury/disease prevention activities in an international setting, utilizing local guidelines and practices.
Competency 2: Medical Knowledge Understand the scope of established and evolving biomedical, clinical, epidemiological and social- behavioral knowledge needed by a pediatrician; demonstrate the ability to acquire, critically interpret and apply this knowledge in patient care and community health. – Epidemiology/Public Health – Malnutrition and Infectious Diseases – Specific Populations • Become familiar with the presentation, diagnosis, management, and prevention strategies of the following specific diseases in resource-limited settings, based on local and international guidelines: – Malaria - uncomplicated and complicated/severe (e.g. Cerebral malaria) – Pneumonia – Diarrhea and dysentery – Measles – Neonatal infections including neonatal tetanus – HIV/AIDS and related infections/complications – Tuberculosis – Typhoid Fever – Dengue Fever
Competency 4: Practice-based Learning and Improvement Demonstrate knowledge, skills and attitudes needed for continuous self-assessment, using scientific methods and evidence to investigate, evaluate, and improve one's patient care practice 1. Identify standardized guidelines (e.g., WHO/UNICEF) for diagnosis and treatment of conditions common to developing countries and adapt them to the individual needs of specific patients 2. Know and/or access appropriate medical resources and apply them to the care of patients in the developing country setting 3. Understand the principles of evidence-based medicine and apply them when reviewing recent literature and considering the implications for impact on practice 4. Work collaboratively with health care team members to assess, coordinate, and improve patient care practices in settings with limited resources 5. Apply and improve upon physical examination skills and clinical diagnosis in settings where diagnostic studies are limited 8. Understand the role of the pediatrician in responding to humanitarian emergencies and disaster relief efforts, within the context of participating local and international organizations, and become familiar with available resources to prepare for volunteering in this setting
Residencies and Fellowships
Residencies and Fellowships • EM, IM, Peds, FP • Curricular components either created specifically for program OR participants take part in associated MPH program or coursework from an outside institution • Many objectives but few competencies • Competencies either created within framework of ACGME competencies or GH-unique objectives/competencies
NYS GH Fellowships and Residency Tracks GH Residency Tracks IEM Fellowships • Columbia • Columbia • Peds • North Shore-LIJ • EM • SUNY Downstate • Mount Sinai • St Luke’s Roosevelt • Interdisciplinary Peds, • University of Rochester IM, EM, Psych • OBGYN
Mount Sinai Interdisciplinary GH Residency GHEC Competency Domains Global Burden of Disease Social and Environmental Determinants of Health Healthcare in Resource Poor Settings Additional Domains: Research in Resource Poor Settings Clinical Tropical Medicine Public Health Programming in Resource Poor Settings
University of Minnesota GH Track for IM and Med-Pediatrics residents Program Components ACGME Competency Domains 1.Tropical Medicine Seminar 1. Medical Knowledge Series or Pediatric Global 2. Patient Care - Physical Exam Health Lecture Series 3. Patient Care - Medical Decision 2. Scholarly Project Making 3. 8 week Tropical Med Global 4. Patient Care - Consultative Health Course Process 4. International Rotation 5. Interpersonal Skills/ 5. ASTMH Exam Communication 6. Educational Portfolio 6. System-Based Practice 7. Practice-Based Learning and Improvement
1. Medical Knowledge • Demonstrates understanding and working knowledge of the IDSA's guidelines for travelers health • Gains sufficient medical expertise and knowledge to successfully pass the Certificate of Knowledge in Clinical Tropical and Travelers' Health Examination offered by the American Society of Tropical Medicine and Hygeine (ASTMH). In order to pass this examination Global Health Pathway Participants must demonstrate competence in the core curriculum as outlined by the ASTMH and presented in the 8 week Trop Med course
2. Patient Care – Physical Exam • Successfully performs a comprehensive, culturally respectful physical exam. • Recognizes normal physical exam findings in ethnically diverse patients. • Reliably identifies physical exam findings specific to commonly encountered diseases in mobile populations, which special attention to: Tropical dermatology Lymphadenopathy Hepatosplenomegaly Rheumatic heart disease • Recognizes physical signs of traditional healing techniques and understands risks of not recognizing these • Understands importance of the physical exam in diagnosis of life threatening conditions (ie tourniquet test for severe Dengue).
3. Patient Care - Medical Decision Making • Tailors evaluation and management decisions according to geographic, epidemiologic, and ethnic risk factors • Conducts a thorough new arrival screening history & exam and order appropriate studies and referrals • Understands how biostatistics, such as positive and negative predictive value, impact the accuracy of diagnostic studies used in mobile populations • Performs thorough, individualized pre-travel consultation including the selection of appropriate anti-malarial prophylaxis regimens with particular attention to the unique risks of the VFR traveler • Triages mobile populations appropriately, taking into account illness risk (ie. decisions regarding the need for hospital admission) • Isolates patients as needed according to infectious risk (eg. droplet precautions for suspected bacterial meningitis vs airborne precautions for suspected tuberculosis) • Knows when and how to seek post-exposure prophylaxis for exposures to selected infectious diseases in local and international clinical settings (eg. management of needle- stick injuries)
Fellowships Competency Sources: • ACGME • Proposed Fellowship Training Program in International Emergency Medicine. Academic Emergency Medicine, 6: 145–149. 1999. VanRooyen, M. J., Clem, K. J.,Holliman, C. J., Wolfson, A. B., Green, G. and Kirsch, T. D Skills and Measurable Objectives 1. Integrate training in EM with knowledge of international health, and apply acquired skills to clinical experience abroad 2. Demonstrate knowledge of public health issues as they pertain to developing countries, 3. Obtain training in critical topics in international health, including tropical medicine, infectious diseases, and general principles of disaster management. 4. Conduct research related to international health care 5. Develop, coordinate, and participate in international educational exchanges 6. Present lectures on topics relating to international EM
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