|Year : 2017 | Volume
| Issue : 2 | Page : 211-214
What's new in academic medicine? Can international medicine be an academic track?
Diane L Gorgas1, Michael I Prats2, David P Bahner2
1 Department of Emergency Medicine; Center for Global Health, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States of America
2 Department of Emergency Medicine, Division of Ultrasound, The Ohio State University Wexner Medical Center; Department of Emergency Medicine, Columbus, Ohio, United States of America
|Date of Web Publication||9-Jan-2018|
Dr. David P Bahner
Department of Emergency Medicine, Division of Ultrasound, The Ohio State University Wexner Medical Center; Department of Emergency Medicine, Columbus, Ohio
United States of America
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gorgas DL, Prats MI, Bahner DP. What's new in academic medicine? Can international medicine be an academic track?. Int J Acad Med 2017;3:211-4
|How to cite this URL:|
Gorgas DL, Prats MI, Bahner DP. What's new in academic medicine? Can international medicine be an academic track?. Int J Acad Med [serial online] 2017 [cited 2018 Sep 25];3:211-4. Available from: http://www.ijam-web.org/text.asp?2017/3/2/211/222487
Global health disparities in the 21st century still exist despite the exponential amount of knowledge and connectivity that defines modern societies. International medicine has grown significantly as more people volunteer their time or participate in exchange and development programs. United States (US) based academic medical centers have reaped the rewards of having an interested, engaged faculty in regards to global health, yet despite the accolades brought to the institutions and the recruitment advantages brought to bear by these faculty, there has been little tangible acknowledgement of their efforts as rewarded by the established promotion and tenure system.
We read with great interest, the two articles “A comprehensive framework for international medical programs: A 2017 consensus statement” from the American College of Academic International Medicine by Garg et al. and the “American College of Academic International Medicine 2017 Consensus Statement on International Medical Programs: Establishing a system of objective valuation and quantitative metrics to facilitate the recognition and incorporation of academic international medical efforts into existing promotion and tenure paradigms” by Peck et al., Both articles explicitly delineate important best practices regarding International Medical Programs (IMPs) and make a compelling argument for the consideration of establishing Academic International Medicine (AIM) as a valid academic advancement track.
The authors clearly articulate the benefits of IMPs and their goals to formalize a global network of inter-institutional and international collaborations. For high income countries (HICs), there is advantage to the institution in increasing visibility and creating recruitment advantages to faculty and trainee applicants; however, the more impactful outcome of these programs is the potential to alter future practice at the home institution. Trainees can develop improved awareness and cultural sensitivity that is an essential component of patient-centered care. By taking part in a cross-cultural exchange, there is an increased chance that learners will care for underserved patients., Other benefits to the HIC based institutions include decrease in ethnocentricity and chauvinism of learners and faculty alike who have taken part in cross cultural exchanges and in turn, their US based cohorts by osmosis of attitudes, as well as significant improvement in global knowledge, global engagement, and intercultural competency. Despite the advantages offered by catering to the desires of a globally engaged learner and scholar pool, the long-term success of integrating IMPs into medical education must come from ingrained values, clearly spelled out in mission and vision statements at the most overarching and unifying institutional level. Impassioned learners and scholars can be the impetus of a change in values, but grassroots advocacy for a change in institutional focus needs to be embraced by the highest levels of administration. The crucible of academia has the ethical obligation to remain steadfast in the pursuit of science and the inherent reality that we are all citizens of the world. Accordingly, the institutional commitment within HICs cannot be taken for granted and should be the driver for development of IMPs.
Although seemingly intuitive, the benefits to low and middle-income countries (LMICs) are subject to many pitfalls. As the authors note, IMPs should take care to build trust through longitudinal programs with empowerment of endogenous health care workers and establishment of sustainable systems for clinical care, research, and academic advancement. Bidirectional programs whereby students of the LMICs travel to HICs for training are beneficial, but care must be taken to avoid a “brain-drain” phenomenon. Careful consideration of timing of exchange opportunities to maximize LMIC exposure while providing a setting for cross-cultural exchange which will benefit the LMIC institutions as a whole (not just an individual's capacity to improve his or her academic or practice pathway) is key, as is the selection of individuals for exchange programs on both sides of the equation. Immigration uncertainties will complicate any exchange programs, yet successful programs can overcome these obstacles. These successful programs represent the ideals of the academic community and accept the reality of global interconnectivity despite the economic and political barriers that may arise. The ultimate goal of bidirectional exchange programs is to augment care delivered to recipients within the home institution's venue, be that in the LMIC or HIC. Clear expectations for training period and goals, selection of participants who have shown commitment to and investiture in the LMIC system, and economic incentives by the LMICs can help to mitigate this risk. Although the cost of travel alone can limit opportunity for LMIC scholars, the current state of the HIC training environment can present additional challenges. The potentially learner-saturated environment in HICs such as the United States may not be accommodating to outside learners and scholars dependent on gaining knowledge and skills to bring back to their country. Practice limitations almost invariably relegate these LMIC participants to an observational role, and regional practice difference including the relative lack of high-tech procedural support in LMICs can make HIC experience value limited. Likewise, the applicable educational environment in LMICs should be carefully reviewed and selected based on similar considerations to learners and scholars from HICs. Clearly, more work is needed to create systems to support these efforts and a multidisciplinary IMP task force may be just such a logistical solution.
The authors highlight that both HICs and LMICs have similar academic challenges. Whether those challenges are access to care or knowledge, resources, space or systems, the disparities can be better addressed when IMPs are clearly articulated with roles, responsibilities, and processes in place. Furthermore, it is imperative that other causes for disparity within the LMICs are not neglected while focusing on medical care. Addressing basic needs such as water quality, sustainable energy, agriculture, education, and business is integral to a successful IMP. A multi-disciplinary team approach that integrates efforts in ameliorating these deficiencies will not only improve the success of the health care efforts but lead to an overall greater impact to the LMIC. For reference, the Mandela Washington Fellows program (https://yali.state.gov/washington-fellowship/) exemplifies this commitment of institutions to multifaceted exchange programs. The articles emphasize core components of IMPs and the competencies requisite for success thus allowing a pathway for those interested in navigating these challenges a framework from which to start and where to go.
The accompanying article by Peck et al., complements the article on a comprehensive framework for IMP'S by incorporating international medical programs into more traditional promotion and tenure pathways with objective valuations. The authors make an argument for addition of an international track to the existing academic achievement tracks of scholar/educator, clinical excellence, clinical educator, and research paths that are offered by many institutions. The authors thoughtfully and comprehensively explain that to add a track solely dedicated to international medicine is a logical step as international collaboration has become much more common in the 21st century. The authors make a passionate argument for the creation of such a track, with detailed discussion of equivalency of scholarly engagement and production in the LMIC setting. Their ideas in formulating this pathway may serve as the groundwork to instigate discussion within the global health community and address disparities of care within the academic community, rather than as a completed and vetted template for adoption into academic evaluation paths. Although we are incredibly supportive of their efforts and applaud the beginning of this conversation, we realize that this proposed path could meet resistance and criticism as a separate entity.
Arguments against the pathway could likely stem from two main critiques. First, the idea that equivalence can be argued for international endeavors may be a difficult one, especially when the formulations are based on time dedicated to the activity rather than productivity or outcomes. The key in shepherding this pathway forward will be twofold A) to point to the significant body of literature which already exists focusing on outcomes and effectiveness of international work, not just effort in IMPs and B) Continuing to contribute to the literature base, be it along pathways of educational pedagogy and methodology or clinical outcomes. Secondly, an international pathway is defined by location as opposed to product, and therefore to compare it to the aforementioned traditional tracks is a comparison some may take issue. Critics may use this argument against the necessity of an international track but miss the point that international medicine is a scholarly focus in and of itself. Could international scholarship be able to be placed under an already established and accepted academic pathway such as educator, scholar, or clinician? Could not the same value already assigned to the components of these tracks suffice in judging international work? Perhaps, although a blend of traditional and historical promotion criteria into an IMP seems the ideal, this should be viewed as an aspirational goal, and real limitations to the success of applying HIC standards to work in LMIC settings must be appreciated. Developing a rubric which fairly and universally acknowledges the efforts and productivity of faculty working in LMIC settings is exactly what the authors have outlined, and is precisely what needs to be proposed as an adjunct to the traditional academic promotion and tenure process in some form.
As the collective writers of this editorial, a Vice Chair of Academic Affairs and director of Global Health, a junior faculty member with global health aspirations, and a seasoned senior author with extensive international experience, we would anticipate the discussion of non-equivalency of tracks and unequal valuation of time dedicated versus outcomes demonstrated to be criticisms leveled by our colleagues and leadership. These valid critiques balanced with subjective concepts of impact and reputation cloud the quantification of IMPs within our current institutional hierarchy. We find significant merit in the authors' timely contributions to the discussion with these two articles on international medical programs. These articles represent a distillation of years of discussion about how best to value global health work, and the proposal of a structure to reward this work is a major administrative breakthrough. It is clear that the community of faculty in IMPs is speaking with a clear voice that because of the immense value embedded in these academic international endeavors, the time and effort spent in IMPs should finally be recognized by promotion and tenure committees on equal footing with other scholarly pursuits. As we reflect on the service components of our international actions, we all find great reward in the exchange of ideas. Not only for the native populations we visited, but also for us personally to see firsthand another international perspective on life and health and death. The focus on international academic pursuits is vitally important, and we understand the authors' aspirations of establishing academic pathways for international medicine. This work is instrumental in initiating the discussion in this area yet there are many more details to map, including the economics and safety of these endeavors by all parties. Scholarly pursuits and the codification of international medicine is important, yet change in medicine is historically slow. The catalyst for change would most likely succeed from a multi-pronged approach; the voices of learners at all levels, faculty with interest and passion in international health and in disparities of care, and international institutions in both HICs and LMICs developing teaching and research collaborations, all culminating in a central message of acknowledgement of and reward for IMPs.
International Medical Programs and Academic International Medicine are vital concepts that serve multiple important purposes in medical education, including helping focus early learners into careers which provide for the underserved; allowing for institutional reputation and expertise to be disseminated globally; and encouraging cross-cultural exchange of ideas. Current political leadership nationally is making significant budgetary cuts in international health. This will mean the decentralization of the values and benefits of IMPs and AIM in higher education, and a push of individual institutions to embrace the commitment to philosophies and benefits of global medicine. These programs should be integrated into the academic offerings at each institution and barriers should be overcome for those that participate and scholarly pursue a career in academic international medicine. Placing the development, nurturing, and delineation of a fair and suitable reward mechanism for academic advancement in this international arena is paramount, and will be a challenge facing nearly every major medical training center both in the United States and abroad in the coming years.
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