Global Health Education as a Translational Science in Graduate Medical Education

摘要

The emergence of global health as a core component of medical education is a relatively recent phenomenon.1 Over the last 20 years, graduate medical education (GME) has documented the growth, curriculum development, and trainee benefits of global health electives (GHEs).2 Scholarship, predominantly focused on evidence-based benefits and clinical outcomes of GHEs at the community level, has not occurred at the same pace. Efforts to standardize and understand benefits of a GHE curriculum should occur in parallel with the need to monitor and evaluate the effects of GHEs on clinical and public health outcomes. Viewed within the framework of a translational science, GHEs have the potential to (re)focus attention on improved clinical health outcomes in low-resource settings. The process of understanding (global) medical education as a translational science involves: rigorous study on clinical skill and knowledge (T1), the translation of said knowledge into the delivery of better health care (T2), and the study of improved patient or public health outcomes (T3).3 Current global health education and scholarship are primarily focused on academic understanding at the T1 and T2 levels but is most lacking at the T3 level. Both high-quality clinical health studies from global health settings4 and studies linking educational activities and health outcomes in the United States5 do exist. There is far less literature linking GHEs and clinical outcomes. The presence of visiting health workers is assumed to yield health benefits to local populations, but little explicit data exist beyond small descriptive studies.6,7;Background In 2001, 20% of surveyed graduating medical students had experience in global health.8 Ten years later, more than 30% reported having participated in some kind of global health opportunity.9 In response to student demand, GME has expanded elective opportunities and global health partnerships.10 Internal medicine, emergency medicine, and pediatrics now all offer formal fellowship opportunities in international health.11 Academic medical centers have aimed to improve educational experiences by standardizing GHEs with emphasis on curricular development and formal competency requirements, including the development of electives, tracks, and didactic study in global health.12 Additionally, authors have proposed distinct educational strategies13 and standardized medical school–based curriculum guides.14;Benefits of Global Health (Current T1 Data) A growing literature purports the benefits of GHEs on US trainee education. Previously published benefits include introduction to a wider spectrum of disease states, improved physical examination skills and clinical acumen, improved cultural sensitivity, and exposure to alternative health delivery models with a broader emphasis on cost and resource allocation.15 Resident participation in GHEs also impacts future career choices and the likelihood that a graduate will volunteer abroad, work with underserved communities, and pursue a public health career.16,17;Clinical and Public Health Outcomes (Building T2 and T3 Data) Current published work monitoring and evaluating international electives has focused on US application of standards and trainee center metrics—including adherence to published guidelines, resident understanding of core competencies, quality of learning, educational opportunities and didactics, clinical exposure, and depth of faculty preceptorship.18,19 It is less certain whether GHEs and methods to standardize curriculum have led to better health care (T2) and improved clinical and public health outcomes (T3). Even in the most sophisticated systems, demonstrating patient and community outcomes as a function of education and training is difficult.20 The problem of linking elective activities and clinical outcomes is exacerbated even in well-thought-out GHEs.21 While these constraints are real, the study of clinical data as linked to educational practice will improve educat