Global Health Education Does it help with FM recruitment? How is it done without funding? STFM Medical Student Education Conference Feb. 2 – 5, 2012 Join the conversation! Our Twitter hashtag is MSE 1
Presenters David Holmes, M. D. Clinical Associate Professor Director, Family Medicine Clerkship and Electives S. U. N. Y – Buffalo, Dept. of Family Medicine 716 -829 -3800 dholmes@buffalo. edu Karen Devlin Course Coordinator S. U. N. Y – Buffalo, Dept. of Family Medicine 716 -829 -2602 kadevlin@buffalo. edu Tiffany Leung, MS-4 University at Buffalo 646 -409 -8886 tiff 84@gmail. com
Global Health – A great way to mentor teenagers & inspire them to care for others
Why Should We Be Interested In Global Health? 1. Increased globalization requires that future physicians understand health issues in an international context. 2. More and more students are interested in global health 3. In order to meet the primary health care needs of all Americans and everyone in the world, we need more family physicians
Why Should We Be Interested In Global Health? 4. It teaches clinical skills and cultural sensitivity 5. It helps students (and physicians) remember why they wanted to go to medical school in the first place. It’s an antidote to cynicism and burn-out. “As medical practice in the developed world becomes distracted by economic issues, attention to the needs of the poor and underserved populations of the world may restore a sense of purpose and humanism to an increasingly market-driven medical profession. ” Wilson, C & Pust, R. Why teach international health? A view from the more developed part of the world. Education for Health. 1999: 12; 85 -89
% of US Medical Students Participating in International Experiences* Year % of UB** Students % of All US Students 1984 6% 1989 -1995 12 -15% /yr 2003 20% 2005 25% 2007 26% 2008 21% 2009 17% 30% 2010 15% 31% 2011 24% 31% * Data is from the AAMC Graduate Questionnaires ** UB = State University of New York at Buffalo
Do you believe that your instruction in global health issues was… School - Year Inadequate Appropriate Excessive UB – 2010 62% 38% 0% All Schools - 2010 40% 59% 1% UB – 2011 52% 48% 0% All Schools - 2011 38% 61% 1% Data from the AAMC Graduate Questionnaires
% of Students Choosing Family Medicine as Their Specialty Year % UB Students Going % All US Students into FM Going into FM 2007 8. 3% 2008 3. 3% 2009 1. 0% 6. 4%* 2010 9. 1% 7. 9%** 2011 5. 7% 8. 4%** * Data from the AAMC Graduate Questionnaires ** Data from National Residency Matching Program (NRMP)
Medical School Curriculum Heck, J. & Wedemeyer, D. “A survey of American medical schools to assess their preparation of students for overseas practice. ” Acad Med, 1991: 66; 78 -81 Of the 26 Schools that had Int’l Health Curriculum, the administering departments were: – – Family Medicine or Family/Community Medicine – 38% (10/26) Public Health/Preventive/Community Medicine – 38% (10/26) Other (IM, Ped, Social Med, Geographic Med, Med Humanities) – 23% (6/26) This is in contrast to the older model of having int’l health taught by experts in tropical medicine Should Family Medicine departments be leading the way regarding international health curriculum and experiential learning?
Do International Experiences Influence Specialty Choice? Ramsey et al. Career Influence of an international health experience during medical school. Fam Med 2004: 36(6); 412 -6 • • • Univ of Wisconsin Int’l Health Fellowship Program - 2 wks prep. course work followed by 6 -8 wks field experience in a developing country 60 Sr. med students, 1995 -97, funded by a 2 yr grant from the National Security Education Program Survey 4 -7 yrs after completion of the Program, 42 surveys completed (70% response) 31% - spend most of their time working with underserved pts. 67% - have been involved in community health projects 74% - practice primary care 29% - have MPH degree 57% - have done further work in developing countries 67% - believed the Program influenced their careers
Specialty Choices of UW Int’l Health Fellowship Program Participants Compared with All US Physicians (n=42) Ramsey et al. Career Influence of an international health experience during medical school. Fam Med 2004: 36(6); 412 -6
The Educational Impact of Clinical Rotations in Developing Countries Bissonette R, Route C. The educational effect of clinical rotations in nonindustrialized countries. Fam Med 1994; 26: 226 -31 Questionnaires to all the students who did an int’l rotation 1984 -1991 (28/30 returned) Results • Increased skill and confidence in taking histories and doing P. E. ’s • Heightened awareness of cost issues and the importance of public health and preventive medicine • Greater appreciation of the role of family & culture in health and disease • Decreased reliance on technology • “While no causative relationship can be adduced from this study, the fact that 70% of the students who completed these rotations entered primary careers suggests at least a reinforcing effect. ”
Comparison of Travelers & Nontravelers at Two Points in Time (Class of 2002) Godkin M & Savageau J. “The effect of medical students’ international experiences on attitudes toward serving underserved multicultural populations. ” Fam Med 2003: 35(3); 273 -8 1 st Yr Sept. 3 rd Yr March Planned Travelers* Comparison of student cohorts Nontravelers *For planned travelers (1 st yrs) and travelers (3 rd yrs), the travel experience occurred during the summer immediately after 1 st yr.
Results • 60% of all travelers listed primary care as their career preference both before and after their international experience (including 32% indicating family medicine)
Results – Changes Between Travelers and Nontravelers as 1 st and 3 rd Year Students Variable Yr Travelers (n=18) Nontravelers (n=76) t-Stat P value Sig. Yr 1 ->3 Interest in working with underserved 1 3 4. 06 3. 08 3. 24 4. 14 3. 429 <. 001 Still sig. Interest in int’l component in 1 career 3 4. 67 4. 53 3. 16 3. 29 7. 682 5. 453 <. 001 Still sig. Need to know another language 1 3 4. 72 4. 71 3. 63 3. 56 6. 100 6. 807 <. 001 Still sig. Need to know patient’s financial constraints 1 3 4. 22 4. 53 3. 78 3. 90 1. 974 3. 038 . 051. 003 Still sig.
Results – Changes Between Travelers and Nontravelers as 1 st and 3 rd Year Students Variable Yr Travelers Nontravelers t-Stat P value Sig. Yr 1 ->3 Interest in rural medicine 1 3 3. 61 3. 24 3. 00 2. 85 2. 022 1. 215 . 046. 228 No longer sig Interest in public hlth component to career 1 3 4. 17 3. 82 3. 41 3. 65 3. 298 0. 927 . 001. 360 No longer sig Need to work 1 collaboratively with other 3 professionals 4. 61 4. 59 4. 24 4. 26 2. 221 1. 673 . 029. 098 No longer sig (n=18) (n=76)
Results – Changes Between Travelers and Nontravelers as 1 st and 3 rd Year Students Variable Yr Travelers (n=18) Nontravelers (n=76) t-Stat P value Sig. Yr 1 ->3 Enthusiasm about being a physician 1 3 4. 78 4. 47 4. 68 4. 03 0. 738 1. 945 . 462. 050 Newly sig. Sense of idealism about role as a physician 1 3 4. 17 4. 24 3. 92 3. 50 1. 090 3. 880 . 279 <. 001 Newly sig. Need to know living/ working situations of pts. 1 3 4. 39 4. 53 4. 24 4. 18 0. 880 2. 017 . 381. 047 Newly sig. Interest in primary care 1 3 3. 94 3. 65 3. 70 3. 13 0. 969 2. 090 . 335. 043 Newly sig. >> So if you go overseas your enthusiasm and interest in primary care drops, but not as much as if you stay home.
Educational Effects of Int’l Health Electives Thompson M, et al. “Educational effects of int’l health electives on U. S. and Canadian medical students and residents: a literature review. ” Acad Med 2003; 78: 342 -347 • • Purpose: to evaluate the educational effects of IHE’s on participants 8 studies reviewed involving 522 med students and 166 residents Conclusions: 1. IHE’s appear to be associated with choosing careers in primary care specialties and in underserved communities 2. IHE’s had a positive influence on clinical diagnostic skills 3. IHE participants reported numerous attitudinal changes such as gaining a greater appreciation for the importance of public health, cross-cultural communication, breast feeding, and health service delivery especially in underserved communities 4. IHE’s increased knowledge and training in tropical diseases
Effects of International Health Electives on Medical Student Learning and Career Choice Jeffrey J, Dumont R, Kim G, Kuo T. “Effects of International Health Electives on Medical Student Learning and Career Choice. ” Fam Med 2011; 43(1): 21 -8 Review of 11 Key Articles 1990 -2009 Summary of Major Findings Int’l Health Electives. . . 1. Strengthened history and physical exam skills 2. Increased knowledge of tropical disease and immigrant health 3. Were associated with attitudinal changes such as greater appreciation for the importance of cross-cultural communication 4. Influenced career choices: more likely to enter primary care fields, work in low-income clinics and/or pursue graduate degrees in public health
My conclusion regarding the research that has been done • Global health experiences don’t increase medical student interest in primary care, but they help lessen the decline in interest between 1 st yr and 3 rd yr. • The strong 3 rd year gravitational pull towards cynicism and towards subspecialty careers is tough to overcome, but global health experiences seem to help.
Percent (%) Specialty Choice of SUNY-Buffalo Students Who Did Int’l Health Electives 2001 -2010 (n=131) Primary Care = 46%
Regions Where SUNY-Buffalo Students Participated in International Electives 2001 -2010 (n=131)
% of Student Travelers Going Into Primary Care and Family Medicine University n Years % in PC of travelers % in FM of travelers UB 28 ’ 84 -’ 91 70% Wisconsin 42 ’ 95 -’ 97 74% UMass 146 ’ 97 -’ 03 60% 32% UB – All 131 ’ 01 -’ 10 46% 12% UB non-China (FM Dept) 70 ’ 01 -’ 10 20% UB China only (IM Dept) 61 ’ 01 -’ 10 % in FM of total class 3% 5. 6% (‘ 07 -’ 10) Does the dept. running the global health elective have an influence on student specialty choice?
Global Choices: International Health & Medical Student Residency Preferences Med Ed. 2009; 43: 1078 -1080 • Cross-sectional survey of 82 med students (80% response rate) of attendees at 2004 AAFP Nat’l Conf of FM Residents and Med Students in Kansas City, Mo. • 91% felt that training in global health should be offered by all FM residency programs • 81% noted that a residency offering int’l health opportunities would be more or much more appealing than one that did not
Recommendations – Med. Student Education 1. Establish a formal “Global Health Education Program” or “Office of Global Health Education” within the Dept. of Family Medicine and market its global health opportunities to students. 2 Actively encourage students to engage in a 3 rd yr or early 4 th yr global health elective. 3. Encourage FMIG to be leaders in global health issues and activities at the medical school. Develop an annual FMIG int’l medical trip that both clinical and pre-clinical students could participate in. 4. Research: Give travelling students a pre and post trip survey regarding interest in FM. Give same survey to non-travelling students. Compare results with what specialties the students match into.
Recommendations FM Residency and Fellowship Programs 1. Develop a Global Health Tract within the FM Residency Program 2. Develop a combined FM Residency – MPH program in conjunction with the School of Public Health 3. Develop an international health fellowship program (Emergency Medicine seems to be taking the lead on this)
International Medical Fellowships UMass Int’l Emergency Medicine Fellowship: “The fellowship is a two year program which incorporates the Masters of Public Health degree, clinical emergency department responsibilities, and international field work where the fellow is expected to develop clinical, research and administrative skills. ” http: //www. umassmed. edu/emed/fellowship/internationalem. aspx? linkidentifier=id&itemid=101900 “Hi, I'm going into FM, but I'm also interested in international medicine fellowship (IMF). I thought FM offered IMF. Was I mistaken? When I search for IMF on Google, Emergency Medicine seems to be the more popular way to get to it. I have found only one IMF through Google located in Wichita, Ka. Is there anyone who knows whether we can have IMF through FM? ” http: //forums. studentdoctor. net/showthread. php? t=519896
Student Perspectives U. B. Global Health Elective • • Strengths I will probably never see the pathology that I have experienced here I finally learned Spanish! Great exposure to healthcare and its delivery in other countries Total immersion in a culture I was able to do many procedures Exposure to students & residents from other countries Makes me grateful for what I have
Student Perspectives U. B. Global Health Elective Challenges and Weaknesses • Language !! It was difficult to communicate with patients and therefore participate in patient care • Didn’t bring bug spray and sun block • Everyone gets diarrhea at some point • Did not get a lot of information or actual rotation turned out to be different than what was advertised - but everything worked out • Transportation problems
Haiti June 27 – July 5, 2011
Highlights • Provided medical and dental care to approx. 525 patients – Local medical clinic – outreach project of a local church – Tent city – Canaan – Apparent Project – Gurlin’s Orphanage
Challenges • Language Barrier – Primary language: Creole – Minimal/No English – Communication depends solely upon interpreters – Limited number of interpreters – Interpreters with limited/no medical background – Unable to understand patients’ medical records and missed lab results
Challenges • Large patient volume • Broader DDx
Challenges • Limited resources – Medications – Diagnostic tools – Treatment options – Long term care
Challenges • Cultural differences & others – Living habits and customs – Diet – Economic difficulties
Impact • • Broaden medical knowledge Improved history taking and physical exam skills Decreased reliance on technology Increased awareness of cost issues and public health Increased interest in serving the underserved Increased interest in global health Self-improvement – – Patience Perseverance Teamwork Personal values, etc.
Family Medicine or Internal Medicine? ! • Well-rounded training to serve the underserved at home and worldwide • Be prepared for my future medical trips • Take care of patients of all ages • Perform minor procedures • Obstetrics • And more…
Summary • International Health Elective – Influenced my career choice – Solidified my interest in primary care – Strengthened my commitment to serve those less fortunate at home and worldwide – Increased awareness of the various challenges in global medicine – Better understanding of international health issues and how to integrate them into our daily practice
Total cost • Approx. USD$1500 – Airfare, housing, food (breakfast and dinner), ground transportation, interpreters • Funding – Family support – Loans
Nuts and Bolts UB Global Health Education Program Dept. of Family Medicine
U. B. Global Health Elective Family Medicine Dept. • 4 th year medical students work in clinical sites in developing countries • Students practice in settings where they rely solely on their fund of knowledge and use their history and physical exam skills • Part of the clinical team, supervised, and use minimal technology • Can be ambulatory, inpatient, or both
U. B. Global Health Elective Family Medicine Dept. • 13% of 4 th year students have participated in a global health elective each year since 2008 • Countries visited: Kenya, Costa Rica, Ecuador, Mexico, India, East Timor, Tanzania, South Africa, Thailand, Uganda • Digitizing student experiences for the web • Display bulletin board
Interest Groups That Promote Global Health at UB • Family Medicine Interest Group (FMIG) • International Health Interest Group (IHIG) (not officially part of the FM Dept, but Dr. Holmes is the faculty advisor) • Global Health Club (School of Public Health) • Christian Medical and Dental Associations (CMDA) All these groups sponsor presentations/discussions about int’l health topics (usually with lunch or dinner)
Steps to Take Student Instructions for doing a global health elective 1. Search websites and review the Global Health Education Binders (in FM office) for info about various global health electives
Steps to Take Student Instructions for doing a global health elective 2. Meet with Dr. Holmes to discuss your interests, get information and ask questions. 3. Decide where you want to go and with which organization. 4. Complete the UB Away Elective Course Approval Form
U. B. Global Health Away Elective Course Approval
Steps to Take Student Instructions for doing a global health elective 5. Make necessary preparations – get updated passport and visa (if needed) – get immunizations, malaria prophylaxis, diarrhea medication, bug spray with DEET, etc (Travel Clinic at Student Health Ctr. ) – Review www. cdc. gov/travel/ – Review http: //travel. state. gov/travel. Click on “Tips for Traveling Abroad” and then “Register with Embassies” – Travel evacuation insurance MUST BE OBTAINED. Check with your health insurance company to make sure it will cover you when you are in another country.
Steps to Take Student Instructions for doing a global health elective 6. Meet with Dr. Holmes for a “Briefing Session” before trip 7. Keep a journal reflecting on your experiences while away 8. Afterwards, meet with Dr. Holmes for a “Debriefing Session” Discuss your experiences and what you learned from them Turn in 2 pages from your journal that you are willing to share Turn in grade form and experience evaluation form Show Dr. Holmes your pictures and give 3 -5 to him for bulletin board display – Provide a brief written description of what you did and what you learned to display with pictures on the bulletin board – – 9. Consider giving a talk on your experience (optional)
U. B. Global Health Elective Evaluation Form That Students Complete
U. B. Global Health Elective
U. B. Global Health Elective
Questions Comments Suggestions
Other Slides
Reasons for Int’l Health Curriculum Wilson, C & Pust, R. Why teach international health? A view from the more developed part of the world. Education for Health. 1999: 12; 85 -89 1. Traveler’s health – more people travelling to other countries 2. Increasingly cross-cultural population – immigrants and refugees 3. Moral imperative to serve the underserved home and abroad – healthcare disparities 4. Need for research and mutual learning with colleagues in other cultural settings 5. Value of global perspective on health care issues – permanent changes in perspectives, attitudes, and practice patterns are often noted by those who participate in int’l health activities (Bissonette, 1994)
LCME Accreditation Requirements June 2010 ED-21. The faculty and medical students of a medical education program must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments. Instruction in the medical education program should stress the need for medical students to be concerned with the total medical needs of their patients and the effects that social and cultural circumstances have on patients’ health. To demonstrate compliance with this standard, the medical education program should be able to document objectives relating to the development of skills in cultural competence, indicate the location in the curriculum where medical students are exposed to such material, and demonstrate the extent to which the objectives are being achieved.
LCME Accreditation Requirements June 2010 ED-22. Medical students in a medical education program must learn to recognize and appropriately address gender and cultural biases in themselves, in others, and in the process of health care delivery. The objectives for instruction in the medical education program should include medical student understanding of demographic influences on health care quality and effectiveness (e. g. , racial and ethnic disparities in the diagnosis and treatment of diseases). The objectives should also address the need for self-awareness among medical students regarding any personal biases in their approach to health care delivery.
ACGME Competencies Patient Care Medical Knowledge Professionalism July 2007 Interprofessional & Communication Skills Practice Based Learning and Improvement Systems-Based Practice FAMILY MEDICINE RRC REQUIREMENTS IV. A. 5. d) Interpersonal and Communication Skills Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Residents are expected to: IV. A. 5. d). (1) communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds;
ACGME Competencies July 2007 FAMILY MEDICINE RRC REQUIREMENTS IV. A. 5. e) Professionalism Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate: IV. A. 5. e). (5) sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.
Family Medicine Positions Offered & Filled in March 2011 Family medicine residency programs filled 2, 576 positions
Strategies to Meet the Global Health Interests of Medical Students Drain et al. Acad Med. 2007; 82: 226 -230 1. Integrate global health topics into core medical curricula 2. Offer courses on global public health and tropical med 3. Offer various elective courses, for instance medical anthropology, int’l development and health, or health and human rights 4. Establish a global health pathway or track to recognize int’l experiences and training 5. Offer combined degree programs (e. g. MD/Ph. D, MD/MPH) in global health
Strategies to Meet the Global Health Interests of Medical Students (con’t) Acad Med. 2007; 82: 226 -230 6. Provide academic, logistic, and financial support for int’l rotations (typical & perhaps optimum amt of time is 6 -8 wks per rotation) 7. Establish a global health administrator or office within the medical school 8. Form int’l partnerships with developing country institutions 9. Create more scholarships and financial support for int’l exchanges 10. Make an int’l clinical rotation a routine part of medical ed.
Global Health Training and Residency Programs Acad Med. 2009; 84: 320 -325 • Residents, of all specialties, have expressed growing interest in global health training and int’l clinical rotations • Int’l rotations broaden medical knowledge, reinforce PE skills, encourage practicing medicine among underserved populations
Survey Years Respondents % of residents who felt that int’l opportunities influenced their residency selections % of residents who wanted to pursue int’l clinical rotations 1982 -1996 (Gupta et al 1999) IM residents/ grads at Yale 28% (53/192) N/A 1988 -1995 (Miller et al 1995) IM residents/ grads at Duke 24% (68/280) 55% (55/100) 1994 -2003 (Bazemore et al 2007) FM residents at U of Cincinnati Most sig. factor for choosing residency among int’l health track participants N/A 2000 -2001 (Dey et al 2002) 1 st Yr EM residents at 122 programs 47% (173/369) 86% (350/406) 2005 -2006 (Federico et al 2006) 1 st Yr Ped residents at U Co. 67% (? sample size) 96% (? sample size) 2004 -2005 (Ozgediz et al 2005) Surg residents at UCSF N/A 90% (25/28) 2006 (Powell et al 2007) Surg residents at NYU Acad Med. 2009; 84: 320 f
Resources • American Medical Student Association (AMSA) amsa. org/AMSA/Homepage/About/Committees/Global/Interna tional. Health. aspx • Evert J, Stewart C, Chan K, et al. Developing Residency Training in Global Health: A Guidebook. San Francisco, Calif: Global Health Education Consortium; 2008 • Global Health Education Consortium: globalhealtheducation. org • U Mass Med School Office of International Medical Education umassmed. edu/intmeded • Indiana University-Purdue University-Indianapolis (IUPUI) Global Health Student Interest Group (GHSIG) https: //ghsig. usg. iupui. edu/Home/tabid/1559/Default. aspx
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