The Changing Landscape of Global Child Health Education in the United States and the Effects of the COVID-19 Pandemic and Civil Unrest.

The events of recent years have affected the landscape of global child health education (GCHE) in the United States. War, racism, forced displacement, and the coronavirus disease 2019 (COVID-19) pandemic had global repercussions that reached US GCHE. The aim of this article is to examine the effect of these events on the landscape of GCHE in the US. Key areas of GCHE have been reframed, reshaped, and accelerated by these events. Travel restrictions accelerated virtual learning opportunities. Core curriculum needed to be reconsidered to address antiracism, equity, and decolonization. Expansion of GCHE activities, including local-global electives, was needed to meet increased resident demand and help address local community needs. Inequities in international partnerships were further highlighted, requiring new approaches. Global research education and practices were also affected with a rapid expansion in virtual opportunities and further development of education in equitable research practices. [Pediatr Ann. 2023;52(9):e324-e329.].

More Than Just a Passport: Resources and Implementation Strategies to Optimize Preparation for Global Health Work.

During the past decade, many resources have been developed to support trainees and clinicians seeking to prepare for global health work. For time-constrained health care providers, figuring out how to prepare can be overwhelming. Given the wide variation in types of travelers and work plans, there is not a "one size fits all" preparation resource. This article offers a summary of preparation topics that all travelers should consider; compiles curated, high-yield resources designed to prepare health care providers for global health experiences; and provides implementation strategies to best meet the unique needs of each traveler, taking into consideration factors such as provider expertise (trainee vs practicing clinician), solo versus group travel, and time available before departure. These curated resources include a variety of training modalities (self-directed, group-based, train-the-trainer, and in-person courses), all summarized here to empower health care providers to create individualized, comprehensive preparation plans before engaging globally. [Pediatr Ann. 2023;52(9):e330-e334.].

Long-Term Impact of Global Pediatrics Curriculum, Experience, and Mentorship in Pediatric Residency.

Global health education is offered increasingly during residency training. The University of Minnesota has offered a global pediatrics track to residents since 2005. This study aimed to understand the impacts of a global pediatrics track on graduates' career choices, skills, and current engagement in global health. An electronic survey was sent to 110 track graduates in February to April 2020. Data were analyzed with descriptive statistics and paired t-tests. Content analysis of written comments was conducted. The response rate was 62% overall, varying by question. Overall, 75% of responding graduates reported global pediatrics track participation affected their career choices. Eighty-four percent recalled plans to work in global health after graduation and 64% of respondents reported working in global health abroad or at home at the time of the survey. Incorporation of public health and global research represented the greatest percentage change in career plans from the time of enrollment to graduation (24% and 27%, respectively). Ninety-five percent of respondents reported that track participation improved their ability to elicit information about cultural beliefs and practices, and 86% reported improvement in cost-conscious care. An increase in global health knowledge and skills was the most common category of impact cited by respondents. Neonatal resuscitation, bubble continuous positive airway pressure, and homemade spacers for metered-dose inhalers were the most used global health-adapted skills. Our study found that graduates of the global pediatrics track perceive their participation affected their knowledge, skills, and attitudes positively, with the potential to improve clinical care and promote health equity locally and globally.

Communicating value to patients-a high-value care communication skills curriculum.

INTRODUCTION: With rising health care costs in the United States, trainees will be increasingly challenged in discussing testing stewardship with patients. OBJECTIVE: We piloted a high-value care (HVC) communication skills curriculum utilizing the Four Habits Model for communication. We hoped residents would 1) learn to apply the Four Habits communication model to HVC discussions with standardized patients (SP) and 2) improve value-based communication skills through training in a high-intensity curriculum with feedback from trained faculty facilitators and peers. METHODS: Thirty interns at the University of Minnesota were randomized to a standard HVC communication SP encounter (n = 15) or a high-intensity HVC communication skills curriculum (n = 15). The high-intensity curriculum included video and audio-recorded SP encounters followed by facilitated small group discussions/feedback. Experiences were reported in a post-intervention survey; communication skills were assessed with the CARE empathy scale. RESULTS: 70% (21/30) of interns (57% high intensity, 43% standard) responded to the survey. In total, 88% of high intensity v. 44% of standard interns agreed/strongly agreed that the curriculum was valuable for their communication skills. High-intensity interns were more likely to report that feedback was valuable with subsequent incorporation of feedback into future patient encounters. High-intensity participants also reported higher levels of interest in future HVC curricula (55% vs 22%). CONCLUSION: There was no difference in overall performance on the CARE empathy scale. Our HVC high-intensity skills curriculum was well received by interns and provided opportunities to practice structured conversations and debrief around testing stewardship.

The Minnesota Model: A Residency Global Health Track Framework.

Residency programs are increasingly responding to the growing demand for global health (GH) education by forming dedicated GH tracks. These tracks incorporate a targeted curriculum, support best practices surrounding GH electives such as predeparture preparation and post-return debriefing, and encourage meaningful engagement with international and domestic partners. The University of Minnesota's pediatric residency has had a formal GH track since 2005, and although they have shared several curricular components in the literature, they have yet to provide a comprehensive summary of their GH track. In this article, the authors provide a thorough description of their evolving GH track model, highlighting outcomes and sharing free resources, with the goal of providing a concise, replicable GH track framework for educators seeking to provide more formal GH education within residency programs.

Learning Abroad: Residents' Narratives of Clinical Experiences From a Global Health Elective.

BACKGROUND: While resident participation in global health (GH) rotations has grown, little is known about trainee perceptions of the personal value of these international clinical experiences and their importance to the objectives of GH training. OBJECTIVE: We sought to better understand the clinical scenarios experienced during international rotations that residents perceived as most meaningful and the frequency of these experiences across scenarios and participating residents. METHODS: Using the conceptual framework of Schön's reflection on action, we asked University of Minnesota GH track pediatric and internal medicine-pediatric residents to describe 10 clinical scenarios they found interesting or impactful during their 2016-2017 GH elective. We conducted a qualitative analysis of the deidentified resident narratives and mapped themes to the Accreditation Council for Graduate Medical Education (ACGME) competencies. RESULTS: All eligible residents (n = 13) participated, yielding 129 unique clinical scenarios from 7 countries. We identified 5 thematic groups: (1) addressing challenges in making diagnoses in resource-limited settings; (2) dealing with patient outcomes different from those expected in the United States; (3) encountering and managing diseases in a different clinical context; (4) encountering and managing diseases in a different cultural context; and (5) reflecting on learning and self-growth. Of the 129 unique clinical scenarios, 30% (n = 39) had not been previously experienced by participants. Across the 5 themes, all ACGME core competencies were addressed. CONCLUSIONS: Residents identified meaningful scenarios of their GH experiences that are relevant to the educational and clinical objectives of GH training.

Interactive value-based curriculum: a pilot study.

BACKGROUND: Current health care costs are unsustainable, with a large percentage of waste attributed to doctor practices. Medical educators are developing curricula to address value-based care (VBC) in education. There is, however, a paucity of curricula and assessments addressing levels higher than 'knows' at the base of Miller's pyramid of assessment. Our objective was to: (1) teach residents the principles of VBC using active learning strategies; and (2) develop and pilot a tool to assess residents' ability to apply principles of VBC at the higher level of 'knows how' on Miller's pyramid. METHODS: Residents in medicine, medicine-paediatrics and medicine-dermatology participated in a 5-week VBC morning report curriculum using active learning techniques. Early sessions targeted knowledge and later sessions emphasised the application of VBC principles. Medical educators are developing curricula to address value-based care in education RESULTS: Thirty residents attended at least one session and completed both pre- and post-intervention tests, using a newly developed case-based assessment tool featuring a 'waste score' balanced with 'standard of care'. Residents, on average, reduced their waste score from pre-intervention to post-intervention [mean 8.8 (SD 6.3) versus mean 4.7 (SD 4.6), p = 0.001]. For those who reduced their waste score, most maintained or improved their standard of care. DISCUSSION: Our results suggest that residents may be able to decrease health care waste, with the majority maintaining or improving their management of care in a case-based assessment after participation in the curriculum. We are working to further incorporate VBC principles into more morning reports, and to develop further interventions and assessments to evaluate our residents at higher levels on Miller's pyramid of assessment.

The Collaborative Role of North American Departments of Pediatrics in Global Child Health.

Appeals for health equity call for departments of pediatrics to improve the health of all children including those from underserved communities in North America and around the world. Consequently, North American (NA) departments of pediatrics have a role in global child health (GCH) which focuses on providing health care to underserved children worldwide. In this review, we describe how NA departments of pediatrics can collaboratively engage in GCH education, clinical practice, research, and advocacy and summarize best practices, challenges, and next steps for engaging in GCH in each of these areas. For GCH in low- and middle-income countries (LMICs), best practices start with the establishment of ethical, equitable, and collaborative partnerships with LMIC communities, organizations, and institutions engaged in GCH who are responsible for the vast majority of work done in GCH. Other best practices include adequate preparation of trainees and clinicians for GCH experiences; alignment with local clinical and research priorities; contributions to local professional development and ongoing monitoring and evaluation. Challenges for departments include generating funding for GCH activities; recruitment and retention of GCH-focused faculty members; and challenges meeting best practices, particularly adequate preparation of trainees and clinicians and ensuring mutual benefit and reciprocity in NA-LMIC collaborations. We provide examples of how departments have overcome these challenges and suggest next steps for development of the role of NA departments of pediatrics in GCH. Collaborative implementation of best practices in GCH by LMIC-NA partnerships can contribute to reductions of child mortality and morbidity globally.

Developing mentorship in a resource-limited context: a qualitative research study of the experiences and perceptions of the makerere university student and faculty mentorship programme.

BACKGROUND: The aim of mentorship is to build the mentees capacity, enhance their skills and improve their ability to produce desired outcomes. However, the mentoring relationship is vulnerable to a number of challenges that may undermine its effectiveness and sustainability. We aimed to explore the experiences and perceptions of student and junior faculty mentees and senior faculty mentors at the Makerere University College of Health Sciences and identify the key factors defined by mentees and mentors as necessary for a successful mentorship program. METHODS: A qualitative design involving focus group discussions (FGDs) and key informant interviews (KII) was used. A total of eight KII and four FGDs were conducted, audio recorded and transcribed verbatim. Open coding of the transcripts was performed, and major themes were identified through multiple readings based on thematic analysis. RESULTS: Six key themes were shared by the mentees and mentors including: 1) defining the role of the mentor; 2) desired characteristics of a mentor and a mentoring relationship, with an emphasis on mutual trust and respect; 3) overlapping roles of mentors and supervisors; 4) issues with the process for identifying mentors, including the benefits and drawbacks of the mentee selecting mentor vs. being assigned a mentor; 5) current barriers to mentoring, including lack of knowledge about current program, lack of formal structure, uncertainly about who should initiate relationship, and unclear roles and expectations and 6) recommendations for the future development of mentoring programme, including the need for a formalized programme, and training adapted to the local context. CONCLUSIONS: The mentees and mentors described the role of the mentor and desired characteristics of mentors and a mentoring relationship similarly. Most concerns about mentoring occurred when current mentoring programmes and practices were not well aligned with these desired characteristics. Recommendations for future development of mentoring included greater formalization of mentoring with mentoring programmes based on shared expectations and adapted to the local context.

Pediatric Resident Academic Projects While on Global Health Electives: Ten Years of Experience at the University of Minnesota.

PURPOSE: Many residency programs require residents to complete an academic project as part of a global health (GH) elective. However, there has been little description of the range of projects residents have pursued during GH electives or the extent to which these projects are consistent with proposed best practices. METHOD: The authors conducted a document review of 67 written summaries or copies of presentations of academic projects (hereafter, summaries) completed by pediatric and medicine-pediatric residents at the University of Minnesota while on GH electives from 2005 to 2015. Two authors independently coded each summary for the type of project completed; when the project idea was generated; explicit mention of a mentor from the home institution, host institution, or both; whether a needs assessment was conducted; and whether there were plans for sustainability. RESULTS: Most of the 67 projects were categorized into one of three project types: quality/process improvement (28 [42%]), education (18 [27%]), or clinical research (14 [21%]). Most summaries explicitly mentioned a mentor (45 [67%]), reported conducting a needs assessment (38 [57%]), and indicated sustainability plans (45 [67%]). Of the 42 summaries that indicated the timing of idea generation, 30 (71%) indicated the idea was developed after arriving at the host site. CONCLUSIONS: Residents undertook a wide range 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 the resident worked with a mentor, conducted a needs assessment, and made plans for sustainability.

Describing Failure in a Clinical Clerkship: Implications for Identification, Assessment and Remediation for Struggling Learners.

BACKGROUND: In addition to training future members of the profession, medical schools perform the critical role of identifying students who are failing to meet minimum standards in core competencies. OBJECTIVE: To better understand reasons for failure in an internal medicine clerkship. DESIGN: A qualitative content analysis of letters describing reasons for students' failure. PARTICIPANTS: Forty-three students (31 men) who failed the internal medicine clerkship at the University of Minnesota Medical School, 2002-2013. APPROACH: We conducted a qualitative content analysis of the 43 letters describing reasons for students' failure. We coded critical deficiencies and mapped them to the Physician Competency Reference Set (PCRS) competency domains and classified them into two categories: conduct (unprofessional behaviors) and knowledge and skills specific to the practice of medicine. We then calculated the frequency of each critical deficiency. We statistically tested for relationships between gender and critical deficiencies in each of the competency domains. KEY RESULTS: We coded 50 critical deficiencies with all codes mapping to a PCRS competency domain. The most frequently cited deficiencies were "insufficient knowledge" (79 % of students) and "inadequate patient presentation skills" (74 %). Students exhibited critical deficiencies in all eight competency domains, with the highest concentrations in Knowledge for Practice (98 %) and Interpersonal and Communication Skills (91 %). All students demonstrated deficiencies in multiple competencies, with 98 % having deficiencies in three or more. All 43 students demonstrated deficits in the knowledge and skills category, and 81 % had concurrent conduct issues. There were no statistically significant relationships between gender and critical deficiencies in any competency domain. CONCLUSIONS: This study highlights both the diversity and commonality of reasons that students fail a clinical clerkship. Knowing the range of areas where students struggle, as well as the most likely areas of difficulty, may aid faculty in identifying students who are failing and in developing remediation strategies.

Making Global Health Rotations a Two-Way Street: A Model for Hosting International Residents.

As US residency programs are increasingly offering global health electives for their trainees, there is a growing call for these opportunities to include bidirectional exchanges-where residents from both the US and international partner institutions rotate at the other's site. Curricular, logistical, and funding challenges of hosting residents from an international site may be barriers to developing these programs. In this report, the authors describe an 8-year experience of a US institution hosting residents from a resource-limited international partner and provide a framework for others institutions to develop bidirectional exchanges. They also report the visiting international residents' perceptions of the impact of the exchange on their clinical practice, teaching, career paths, and their home institution.

Pediatric Global Health Education: Past, Present, and Future.

Recent outbreaks of diseases erroneously thought by many to be contained by borders or eliminated by vaccines have highlighted the need for proper training of all residents in global health. Beyond infectious diseases, all pediatricians should know how to care for other conditions in global child health, ranging from malnutrition to the nuances of care for immigrant and refugee children. The call for broader education for pediatric residents in global health has been increasing over the last decade, with all major pediatric organizations underscoring its importance in statement and action. Herein, the current status of global child health education in pediatric residency training in the United States is summarized, highlighting where it has been, where it is now, and where it should go next.

Accuracy of self-monitoring during learning of radiograph interpretation.

CONTEXT: Despite calls for the improvement of self-assessment as a basis for self-directed learning, instructional designs that include reflection in practice are uncommon. Using data from a screen-based simulation for learning radiograph interpretation, we present validity evidence for a simple self-monitoring measure and examine how it can complement skill assessment. METHODS: Medical students learning ankle radiograph interpretation were given an online learning set of 50 cases which they were asked to classify as 'abnormal' (fractured) or 'normal' and to indicate the degree to which they felt certain about their response (Definitely or Probably). They received immediate feedback on each case. All students subsequently completed two 20-case post-tests: an immediate post-test (IPT), and a delayed post-test (DPT) administered 2 weeks later. We determined the degree to which certainty (Definitely versus Probably) correlated with accuracy of interpretation and how this relationship changed between the tests. RESULTS: Of 988 students approached, 115 completed both tests. Mean ± SD accuracy scores decreased from 59 ± 17% at the IPT to 53 ± 16% at the DPT (95% confidence interval [CI] for the difference: -2% to -10%). Mean self-assessed certainty did not decrease (rates of Definitely: IPT, 17.6%; DPT, 19.5%; 95% CI for difference: +7.2% to -3.4%). Regression modelling showed that accuracy was positively associated with choosing Definitely over Probably (odds ratio [OR] 1.63, 95% CI 1.27-2.09) and indicated a statistically significant interaction between test timing and certainty (OR 0.72, 95% CI 0.52-0.99); thus, the accuracy of self-monitoring decayed over the retention interval, leaving students relatively overconfident in their abilities. CONCLUSIONS: This study shows that, in medical students learning radiograph interpretation, the development of self-monitoring skills can be measured and should not be assumed to necessarily vary in the same way as the underlying clinical skill.

Teaching high-value care: a novel morning report.

BACKGROUND: Despite rising health care costs and calls for the incorporation of high-value care (HVC) into medical training, there are few described curricula to address this need. METHODS: We designed a single-group pre/post comparison to evaluate the impact of a 45-minute HVC morning report in one academic internal medicine programme on the trainees' self-reported knowledge of costs for common diagnostic tests, impact on future ordering practices and the educational value of the intervention. Medical trainees completed a diagnostic evaluation for a hypothetical case within the constraints of a budget during the morning report. Trainees completed a pre/post intervention survey regarding knowledge and attitudes towards HVC, and an evaluation of the intervention. The Wilcoxon signed rank test was used to determine differences between the pre/post intervention survey responses. There are few described curricula to address the need for the incorporation of high-value care into medical training RESULTS: Fifty-eight trainees participated in the educational activity: 57 completed the survey and 54 completed the evaluation. Our results indicate a significant increase following the morning report intervention in: the trainees' self-reported understanding of the cost for diagnostic tests (p < 0.001); the likelihood the cost of diagnostic tests would affect their future ordering practices (p < 0.001); and the likelihood that the cost of diagnostic tests would affect their timing of a diagnostic evaluation (p ≤ 0.001). The results also indicated a significant decrease in the likelihood that trainees would order extra diagnostic evaluations following the intervention (p = 0.015), and 96 per cent felt that the session was educationally valuable. DISCUSSION: A morning report incorporating cost of care can significantly increase trainees' perceived understanding of cost and affect self-reported ordering practices in an educationally valuable intervention.