|Year : 2018 | Volume
| Issue : 3 | Page : 245-248
What's New in Academic Medicine? Advocating for global health program funding in academic medicine
Diane L Gorgas, Pamela L Potter
Office of Global Health, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
|Date of Web Publication||24-Dec-2018|
Dr. Diane L Gorgas
Office of Global Health, The Ohio State University Wexner Medical Center, Columbus, Ohio
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gorgas DL, Potter PL. What's New in Academic Medicine? Advocating for global health program funding in academic medicine. Int J Acad Med 2018;4:245-8
|How to cite this URL:|
Gorgas DL, Potter PL. What's New in Academic Medicine? Advocating for global health program funding in academic medicine. Int J Acad Med [serial online] 2018 [cited 2019 Dec 11];4:245-8. Available from: http://www.ijam-web.org/text.asp?2018/4/3/245/248332
The community of physicians with academic international interests continues to grow. As we advocate, both individually and as a collective group, for increased recognition of and resources for Global Health/International Medicine (GH/IntMed) endeavors for practitioners and learners alike, we are met with similar points of concern from medical leadership. Why should GH/IntMed programming receive a piece of the ever-shrinking pie that is medical education and medical practice dollars?
This question is posed in a number of different forms including: (1) Why put faculty time and resources into GH projects with a focus on low- and middle-income countries (LMICs) when there are challenges with access to healthcare in our own backyard? (2) How will this benefit our learners or improve faculty and staff satisfaction in their present work environment? (3) In the current climate of nationalism, why should training programs and medical centers seek to reach beyond their immediate borders, or more broadly, to overseas locations?
Although there are various practice and educational environments where we work, these questions are the great equalizer and ones that are echoed throughout our training environments. A perspective in answering this question may come from an examination of what the medical schools, universities, and community hospitals, who have been able to argue successfully for robust investment in GH used as unifying rationale for their investors. This article will seek to outline several evidenced-based points arguing for the expansion of existing GH programs and the creation of IntMed experiences for those institutions without existing programs.
Within any medical training setting, leadership (the dean or the equivalent at community programs) is concerned with all aspects of a healthy education system including education, research, clinical care, community engagement, and leadership. Although the personally and ethically impassioned arguments conventionally associated with the development of GH programs may be the initial seeds used to rationalize GH funding, these may fall on barren soil if they do not directly relate to one of these core mission areas. Arguments of “doing the right thing for our world neighbors,” ethical considerations in reaching out beyond our own borders, and the quintessential image of saving babies in Africa are not likely to sway administrators tasked with caring for and educating students and patients in their own institution and immediate community. Universally, leaders care about the health of the world, but local and national pressures to improve the reputation and general strength of their home institutions may outweigh these motivations.
Understanding how our passion for IntMed and GH translates into deliverables for medical center and education leadership is the key, and this article will seek to divide these into GH's impact on each of the five mission areas of the deans and leaders of academic training programs.
One of the clear-cut metrics medical school deans use to track the success of an educational program is the selectivity of the school for the most competitive students. For any leaders and faculty who have a role in learner recruitment, it is clear that there are significant generational interests of current medical school candidates in GH, social justice, and health equities. A report of the Center for Strategic and International Studies attributes “significant changes in American higher education that places greater emphasis on and resources for internationalization, in response to students' greater awareness of the world starting at an early age and facilitated by the global media.” Interest in and demand for GH programming by students is an ever-increasing factor in their selection of a medical school. In a survey of medical and nursing students at Johns Hopkins University, over 60% stated an interest in career pathways in GH and IntMed. GH interest is evident among the current cohort of prospective learners (both medical students and residents) whether the interests ultimately translates into a GH experience or not.
These interests can serve as an exceptional recruiting tool for graduate medical studies. Prospective students can gauge the school's commitment to GH through webpages, current student attestations (via social media or face to face), and the presence of advanced graduate medical education opportunities (GH fellowships).
Beyond use as a recruitment tool, benefits of a well-designed undergraduate GH curriculum have been shown to improve a student's clinical skills, certain attitudes, and medical knowledge. The medical school curriculum is bursting at the seams with core content area, and debates about what constitutes core knowledge for every student versus those with a specific interest in GH/IntMed are ongoing negotiations in curriculum development.
In regard to specialty selection of residency training programs by medical students, nationally, we have recognized the disproportionate need for primary care practitioners. As a reflection of this disproportionate gap in primary care physicians, US News and World Report now publish two national rankings of medical schools; one traditional list focused on research and a second for primary care, which includes a significant rating percentage for students choosing primary care as a residency training path. If a medical school has a commitment to increasing student selection of a primary care career, curriculum development in GH can have a significant impact. In a study by Bruno et al., students who took part in a GH experience chose primary care careers, 57% of the time, versus a national average of around 39% and a local average of 44%. The authors did not argue whether this was a causative relationship or just an association, but the ultimate outcome correlates with selection of a primary care residency training program. This directly impacts the primary care ranking for a school. Moreover, there is an increased incidence of choosing a career in an underserved region.
At the graduate level, there is significant heterogeneity in GH curricula, with no single strategy for teaching GH to graduate medical learners. The quality of literature is marginal, and the body of work overall does not facilitate assessment of educational or clinical benefit of GH experiences. As mirrored in the medical student candidate, there appears to be tremendous interest in GH opportunities at the graduate level, but the chances of this translating into committed experiences and future career direction specifically in GH for graduate learners are yet not clearly defined.
An intersection between education/primary care ranking and community outreach is the topic of health equities (or healthcare disparities). GH experiences are associated with a learner's likelihood to serve an underserved (generally rural) population. Advocating for robust investment in GH can arguably be linked to a training institution's goals at decreasing health disparities.
The current state of IntMed across the US is quickly segueing from the populist view of a “mission doctor” to a more academically based practitioner with ties to GH, policy development, and evidence-based programming to improve the health sector in a sustainable way. Approaching GH/IntMed from an evidenced-based perspective means adhering to sound research methodologies, seeking funding, and developing a sustainable matrix for augmenting GH/IntMed research. Federal grants have conventionally been the building blocks for successful research careers in GH. GH initiatives provide unique opportunities to foster interdisciplinary research working groups. Coordination of health-based projects with other sectors such agriculture, education, energy, water, or civil engineering not only can lead to more significant community development and improvement but also can open nontraditional revenue streams to support GH endeavors.
The cornerstone of all promotion and tenure guidelines is dissemination of academic productivity, and the opening of venues for this by focusing on interdisciplinary projects is highly desirable in the current climate of medical research. Unique opportunities for collaboration with public health, preventative medicine, nursing, pharmacy, dentistry, optometry, allied health, and veterinary medicine exist in GH venues. Within the house of medicine, the interdisciplinary possibilities of multispecialty coordination and teambuilding through research are powerful.,
From a clinical care perspective, GH has a key role in preparing us to face challenges of emergency preparedness and endemic control. Preestablished GH connections and cross-cultural work and information exchange will help protect our academic institutions and even our country at large by speeding up a coordinated response to future pandemics. “Ultimately, what drives science is still relationships. The time to build trust is now, outside of the pandemic setting. Then, when you have a crisis, you can be on the phone to someone in Indonesia and they trust you because you've worked together and you didn't steal their samples.” Although this is not an area tracked by national metrics, medical leadership likely has a keen eye on its development.
In addition, medical leadership will clearly know the national reporting on outcomes through the Accountable Care Organization (ACO), National Surgical Quality Improvement Program (NSQIP), and other outcome-based rankings, which will be an important determinant for them to track. No research has been done directly on the presence of GH/IntMed programming and the ACO and NSQIP ratings, but the link of previous practice in LMICs in medically impoverished areas may well prove to be correlated with the practice of cost-containment in medicine and improved outcomes for the underserved.
Healthcare equities and disparities of care are coming to the forefront as a priority for socially responsible organizations. The natural tie between delivering healthcare to the socioeconomically disadvantaged in LMICs and regional and local health equities is clear. “GH academic partnerships are centered around a core tension: They often mirror or reproduce the very cross-national inequities they seek to alleviate. On the one hand, they risk worsening power dynamics that perpetuate health disparities; on the other, they form an essential response to the need for healthcare resources to reach marginalized populations across the globe.”
A core value of IntMed is community engagement. To highlight this bond to medical center administration, one need only reach as far as the creation of practice agreements with international institutions and medical centers, and the pivot point in most GH initiatives, health advocacy.
Cultural competency training, although jointly shared with diversity and inclusion initiatives, fits integrally within IntMed/GH programming. A key for success of any remote GH experience is predeparture cultural competency training. This naturally translates into a more advanced understanding of local immigrant and refugee populations. The PEW Research Center reports that 20 major U.S. cities account for the majority of immigrant and refugee residents, representing 65% of the nation's total. Understanding the healthcare needs of first-generation Americans or newly immigrant and refugee populations is a key component of any training program, regardless of location.
There remain commensurate diversity lags in the enrollment of students and faculty to serve these disenfranchised populations. How does this fit in with the dean's or medical center leadership's community engagement and clinical care goals? In the future, as the next generation of learners with more GH exposure ascends into leadership positions, does this naturally translate into a better appreciation and sensitivity for cultural diversity and cultural intelligence? Will these current GH learners become strong advocates for cultural diversity, workplace integration, and the aspirational goal of having the cultural representation of health care providers mirror that of the communities they serve? The direct connectivity of strength in GH and learners, faculty, or staff diversity has yet to be explored.
A necessary component of GH experiences is the decentralized learning environment that they require. How can we leverage the key components of successful curriculum development in a decentralized model and apply it locally to answer regional health equity challenges? Does being an institutional leader in GH uniquely prepare GH program experts to develop learner curricula around other underserved populations? And would GH leaders be the natural choice for university leadership to turn to in developing off-site educational experiences regionally and locally?
Cultural competency is addressed as one of the core competencies in GH education. Although alluded to in vague terms in many specialty's assessment milestones, the focus on specific assessment of cultural competency within the structure of GH is deliberate and clear.
An additional mission area for the dean's focus is being a good leader. Essential to this is developing good relationships with trainees, faculty, staff, and alumni. In turn, this can mean the dean must understand the passions of his or her “constituents.” How many GH student cohorts block off time to meet with the dean and tell her/him about their GH experiences?
How many faculty in institutions know of parallel efforts that their colleagues (even inside their own department) may have in GH? Has there been a forum to share lessons learned and current initiatives? Has the dean been invited? What are best practices in sharing GH interests, opportunities, and passion among an employment force, medical center, or institution-wide, which may number in the hundreds or thousands?
Alumni of GH experiences are first-hand consumers of the benefits of a robust GH curriculum. Are we doing all we can to query alumni about the formative aspects of their GH experiences? Have the alumni been approached as donors to specifically fund GH experiences for current learners? In each of these ways, GH leaders can foster professionalism, diversity, and a positive learning environment.
What role does GH have in the overarching picture of quality of life in LICs? Admittedly, well-designed and well-funded GH initiatives, be they patient care, educational, or research centered, have only limited capacity when operating in an environment which is politically, agriculturally, educationally, or energy poor. The optimal integration of GH programs should take place in collaboration with improvement efforts in each of these other sectors. These interdisciplinary partnerships can help to achieve the greatest GH benefits of innovations, whether simple or highly technological.
Although this article has focused on the rationale for advocating to medical leadership, should the goal of GH programs be broader? The ultimate success of elevating all quality of life indicators in low-income countries must be through a multisector approach and is best operationalized with more holistic advocacy of support.
| References|| |
Merson MH, Page KC. The Dramatic Expansion of University Engagement in Global Health: Implications for U.S. Policy. A Report of the CSIS Global Health Policy Center. Washington, DC: Center for Strategic and International Studies; April, 2009.
Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P, et al.
Global health in medical education: A call for more training and opportunities. Acad Med 2007;82:226-30.
Cox JT, Kironji AG, Edwardson J, Moran D, Aluri J, Carroll B, et al.
Global health career interest among medical and nursing students: Survey and analysis. Ann Glob Health 2017;83:588-95.
Thompson MJ, Huntington MK, Hunt DD, Pinsky LE, Brodie JJ. Educational effects of international health electives on U.S. and Canadian medical students and residents: A literature review. Acad Med 2003;78:342-7.
Peluso MJ, Encandela J, Hafler JP, Margolis CZ. Guiding principles for the development of global health education curricula in undergraduate medical education. Med Teach 2012;34:653-8.
Petterson SM, Liaw WR, Phillips RL Jr., Rabin DL, Meyers DS, Bazemore AW, et al.
Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med 2012;10:503-9.
Bruno DM, Imperato PJ, Szarek M. The correlation between global health experiences in low-income countries on choice of primary care residencies for graduates of an urban US medical school. J Urban Health 2014;91:394-402.
Bills CB, Ahn J. Global health and graduate medical education: A systematic review of the literature. J Grad Med Educ 2016;8:685-91.
Anderson HL, Arquilla B, Firstenberg MS, Garg M, Galwankar SC, Gracias VH, et al
. SPECIAL EDITORIAL: Mission statement for the American College of Academic Int Med: Empowering individuals, nurturing wellness, promoting excellence, stimulating minds, striving for sustainability, and celebrating inclusion. Int J Acad Med 2016;2:121-6. [Full text]
Heimburger DC, Carothers CL, Blevins M, Warner TL, Vermund SH. Impact of global health research training on career trajectories: The Fogarty international clinical research scholars and fellows program. Am J Trop Med Hyg 2015;93:655-61.
Barthélemy E, Mallol V, Hannaford A, Pean C, Kutua R, de Haydu C, et al.
Exploration of global health careers across the medical fields. Ann Glob Health 2017;83:613-20.
Valois C, Foley V, Grand'Maison P, Dumont J. Enriching health-professional programs in global health: Development and implementation of an interdisciplinary and integrated approach. Can Med Educ J 2017;8:e75-83.
Yong, E. Trials at the ready: Preparing for the next pandemic. BMJ 2012;344:e2982.
Dawe R, Pike A, Kidd M, Janakiram P, Nicolle E, Allison J, et al.
Enhanced skills in global health and health equity: Guidelines for curriculum development. Can Med Educ J 2017;8:e48-60.
Citrin D, Mehanni S, Acharya B, Wong L, Nirola I, Sherchan R, et al.
Power, potential, and pitfalls in global health academic partnerships: Review and reflections on an approach in Nepal. Glob Health Action 2017;10:1367161.
Danso K. Nativity and health disparities: Predictors of immigrant health. Soc Work Public Health 2016;31:175-87.
Talib Z, van Schalkwyk S, Couper I, Pattanaik S, Turay K, Sagay AS, et al.
Medical education in decentralized settings: How medical students contribute to health care in 10 sub-Saharan African countries. Acad Med 2017;92:1723-32.
Sawleshwarkar S, Negin J. A review of global health competencies for postgraduate public health education. Front Public Health 2017;5:46.
Dzau VJ, Ackerly DC, Sutton-Wallace P, Merson MH, Williams RS, Krishnan KR, et al.
The role of academic health science systems in the transformation of medicine. Lancet 2010;375:949-53.