Reflective Practice and Competencies in Global Health Training: Lesson for Serving Diverse Patient Populations

Global health education is timely.1–3 Pressing global issues, such as emerging infectious diseases, physician shortages, and emigration patterns, exemplify the growing interdependence of economic and social forces worldwide. In the United States, the documentation of racial and ethnic disparities is extensive, and it has been hypothesized that physician cultural competence can help lessen such disparities.4 Cultural competence is framed as “the ability to identify and appropriately respond to cultural issues that affect the health care of patients and their families.”5 In addition, delivery of effective and high-quality patient-centered care increasingly underscores cultural competence as a necessary professional skill.6–9 Houpt et al10 proposed that culturally competent care is required for the effective health care of immigrants and that learners need to have a basic understanding of the medical and social issues involved in the care of diverse patient populations.

To begin addressing these needs, a call has gone out to medical educators to train physicians in culturally effective care, emerging infectious diseases, and a broad range of global health issues.10–12 Concurrently, the proportion of US medical students who completed a global health elective grew from 2.6% in 1985 to 29.9% in 2009.13 This new generation of learners seeks residency training programs that offer global health education11; availability of these programs often is a determining factor when selecting a residency, and programs use them as a recruitment tool.14,15 

Research has shown that participating in global health education has a positive effect on participants' clinical and communication skills16,17 and is associated with career choices in primary care, public health, and serving underserved populations.15,18,19 Such training promises to improve the knowledge, attitudes, and skills of health professionals, but there is a pressing need to establish which training methods should be used and how these curricula most effectively improve health care services for diverse populations.

The purpose of this study was to begin to examine, through reflective practice, how participation in a formal global health training program may influence residents' perspectives when caring for diverse patient populations. Using qualitative methods, we sought to describe resident perspectives while participating in a global health program.

In 2007, Cincinnati Children's Hospital Medical Center (CCHMC) implemented the Global Health Scholars Program (GHSP). The CCHMC is an academic teaching hospital with 475 registered beds, nearly 24 000 admissions per year, and approximately 150 pediatrics residents. Pediatric and combined-pediatric residents at CCHMC were recruited to participate in the GHSP between July 1, 2007, and June 30, 2008. Residents were eligible if they were scheduled to participate in a 2- to 4-week elective abroad to provide clinical services at a foreign destination. Residents scheduled to participate primarily in research activities at their foreign host institution were excluded. Potential participants were identified by reviewing the year-long resident schedule.

Fifteen residents met the eligibility criteria and were invited to participate in the structured program and study by the principal investigator via an e-mail message. There was no financial incentive. Eligible residents could choose not to enroll in the new program or study and still participate in an elective abroad following the previous format with no formal curriculum, mentoring, or instruction. Political unrest in one African nation prevented 2 residents from completing the program, resulting in a final study sample of 13. All 13 eligible residents agreed to participate in the program and study and provided written informed consent. The study was approved by the CCHMC institutional review board.

The goals of the GHSP are to prepare pediatric residents for a global health experience and expose them to different cultures, languages, medical conditions, and care protocols in a context and health care system different from their domestic practice. The activities designed to help the program meet these goals included the following components.

The scholars received a written curriculum that explained the learning aims and guided residents through how to complete a service project while at their host institution. Participants attended didactic lectures presented by program faculty members. These lectures were available to all residents, and topics were chosen based on review of the global health literature and faculty field observations (2b1a1box). Scholars also attended evening meetings at which presentations were made on global health issues and discussed with faculty involved in global health work. Nine formal didactic lectures were given and there was approximately 1 evening meeting or journal club per month during the study period.

Mentoring has an important influence on trainees' personal and professional development. It has long been recognized that structured mentoring is an essential component of successful global health training.20,21 The GHSP provided the participants a global health adviser with international health experience. Prior to departure, the goals of mentoring were to serve as a sounding board for travel preparation, to offer insight into cross-cultural communication, and to counsel on safety and international legal requirements. The objective of mentoring also was to provide an opportunity for debriefing and accountability when the residents returned from their away electives.

Reflective journaling is an integral tool in adult education and is increasingly used in graduate medical education.22,23 Active reflection on the meaning of events encountered during training helps trainees become critical thinkers.24,25 Each scholar was asked to submit 6 journal entries using a semistructured guide to help them focus on their experiences abroad (table 1).

The American Society for Tropical Medicine and Hygiene (ASTMH) Committee on Medical Education published 3 competency domains for global health education in medical training: (1) burden of global disease, (2) immigrant health, and (3) traveler's medicine.10 The burden of global disease domain encompasses knowledge of the diseases that contribute to the greatest morbidity and mortality worldwide (eg, perinatal mortality, human immunodeficiency virus/AIDS) and how health system factors can hinder (or facilitate) access to care. The second domain covers health care issues relating to the growing immigrant population in the United States and the spectrum of diseases that such a demographic shift likely signifies (eg, tuberculosis). Traveler's medicine pertains to the knowledge needed to provide proper prophylaxes, diagnoses, or treatment for diseases that may concern international travelers (eg, malaria). These core ASTMH competency domains have gained acceptance and have been introduced as a starting point in global health education in a number of institutions around the globe.26–28 

In our study, the ASTMH competency domains were used as an initial coding framework to qualitatively analyze residents' reflective journal entries. We collected and combined into 1 transcript the entries from all residents. Two coders (J.C., L.M.G.) independently reviewed the complete transcript and coded pertinent sentences, phrases, and paragraphs using the ASTMH domains as the a priori code book. This is known as a confirmatory (vs exploratory) analysis method.29 In addition to this analysis method, the investigators observed and later developed codes for themes that emerged from the manuscript that were unrelated to the ASTMH competencies. Lastly, the 2 coders reviewed and compared their independently coded transcript, discussing coding convergences and resolving discrepancies. No passage was coded or counted in more than 1 theme category.

There were 53% male and 47% female participants; this was similar to the comparable residency population's demographic of 42.8% and 57.2% respectively. There were 77% non-Hispanic white, approximating the 81.5% in the comparable resident population. Participants chose a spectrum of international experiences based on individual interest and available knowledge and contacts (table 2).

We collected 28 journal entries and identified and coded 133 distinct passages. Of the 3 ASTMH competency domains, only passages with themes associated with burden of global disease and immigrant/underserved health emerged in the journal data. Ten residents (77%) reflected on the domain termed burden of global disease and all 13 reflected on the domain termed immigrant/underserved health. No residents mentioned traveler's medicine in any of their reflections. Two other themes relating to parenting and volunteering in humanitarian efforts emerged. A saturation point30 was reached and neither coder believed that the 2 additional themes were captured using the ASTMH domains, so they were coded and grouped separately. Representative quotations of the ASTMH domains and of the 2 additional themes are presented in the following section.

Residents expressed how their experience overseas led to a heightened awareness of the reality and limitations of health care systems in developing countries. In addition, they expressed greater appreciation for the US health care system itself. Residents' observations included the following:

Many of the journal entries expressed a newfound desire to apply the lessons learned abroad to both the personal and professional lives of the writer when caring for immigrant and underserved populations in his/her native health care system. The lessons learned included the need to become a better listener, to have more patience with others, and a desire to build deeper relationships with patients and families. Residents' reflections included the following:

The first additional theme was related to the residents' observations of the extreme measures parents take to assure their children receive health care. Six (46%) residents reflected on this parenting domain, with 3 of them noting the following:

The other theme that emerged was how residents' experience abroad led to their desire to volunteer in and advocate for future humanitarian outreach. Six (46%) residents reflected on this humanitarianism domain, with 3 of them noting the following:

Our findings suggest that seeing firsthand and considering the plight of children and their parents during the GHSP field experience may have made an important and positive contribution in the residents' perspective as reflected in their journal entries; they also corresponded to 2 of the 3 ASTMH global health education competency domains.10 The residents' reflections suggest that global health training enhances their understanding of and compassion for underserved patients both abroad and at home. Our findings are similar to those seen in other studies of experience-based learning programs.31 This supports the hypothesis that participation in global health electives develops attributes in trainees that can benefit care of diverse patient populations, including improved cultural competence and growth in idealism and enthusiasm, and attitudes conducive to serving immigrant patients and families as well as families on public assistance.32–34 Our study used reflective journaling to capture such learning. Use of reflection in medical education is growing, yet still is limited. To our knowledge, pediatric resident journal entries have not been linked with global health and professional competencies in the care of diverse patient populations.

In our study, many participants voiced a desire to take more time to listen, to build deeper relationships with the families they serve, to further volunteer in humanitarian outreach, and ultimately to become advocates for optimal service and care. In facilitating these future humanitarian and advocacy efforts, faculty may play an additional role through ongoing mentoring. The adviser in the program sought to provide ongoing guidance and an opportunity for debriefing to facilitate re-entry into the home culture. Realizing the educational value of reflection and mentoring, the mentoring methods were continued the following year along with the other didactic components. It must be noted, however, that mentoring a resident can require an intense time commitment, particularly if ongoing mentoring is desired. This underscores the findings in other studies of global health education programs wherein faculty involvement requiring institutional investment proved to be a vital component.1,35 Reflective journaling assignments, one-on-one mentoring sessions, a written curriculum, a lecture series, and an experience abroad thus became essential elements of our formal global health training program.

Our findings accentuate the value of the Accreditation Council for Graduate Medical Education competency-based education, as professional skills are essential in the practice of high-quality care. Professionalism encompasses a commitment to carrying out professional responsibilities with sensitivity to racially and ethnically diverse patient populations and to concurrently provide wise and cost-effective management of resources.36 Work with interprofessional teams abroad increases knowledge about current and alternative biomedical practices and gives participants the opportunity to reflect and evaluate personal and professional assumptions that can lead to advocacy and improvements in patient care at home. Exposure to health care delivery systems in various overseas settings affords residents greater awareness of national systems and the larger international framework in which they exist.37 In our study, the experience seemed to make many participants more aware of health disparities in the global context and motivated some to expect more effective and judicious allocation of resources from themselves once back in their native medical system. Many residents reflected on their desire to become better listeners and greater advocates; their insight highlighted the importance of improved communication skills and the value of systems-based practice education.

Finally, our findings immediately added practical value and facilitated the improvement of the learning environment. For example, none of the residents' reflections echoed competencies in the ASTMH domain of traveler's medicine. This may be because the reflection question guide was not specifcally intended to trigger comments on travel prophylaxis, universal precautions, or personal safety, or that none of the questions in the reflection guide specifcally addressed this topic. Or it may reflect a weakness in the education on travel preparation. The lecture series for the following academic year included added educational components on this subject.

Our study has several limitations. Given the small sample size, it is important not to overstate the apparent association between participation in the GHSP and global health or professional competencies. In the absence of a direct comparative study, the findings should be considered preliminary, and we cannot exclude the possibility that the observations represented previous experience and/or a natural maturing process in the residents irrespective of their experience with global health. In addition, the reflections were semistructured, which may have influenced the themes in the responses; we cannot comment as to what free-form reflection alone may have generated. We acknowledge that participants self-selected to complete an international rotation. Future studies should repeat this analysis with a larger group of learners and with follow-up. Finally, our findings cannot be generalized to residents who travel primarily to complete a basic science research rotation because subjects in this category were excluded from enrollment in the program.

The findings of this study suggest that the GHSP is a useful educational intervention and may help to enhance resident understanding of the complex clinical, social-behavioral, and economic challenges encountered in global health. The findings also support the notion that resident reflections about their educational experiences in the GHSP correspond to at least 2 of the content areas outlined in the ASTMH competency domains. This study points to the potential value of using a global health training program to support residents' acquisition of professional skills that are fundamental to culturally effective care. In addition, it advances the view that reflective journaling may be a valuable tool for evaluating competency-based medical education interventions.

Health care disparities, rapid changes in US demographics, and new accreditation requirements bring culturally and linguistically effective care issues to the forefront. In addition, today's physicians are expected to have a deeper knowledge of emerging disease and global health, and to provide culturally effective care.2,11 Thus, medical educators must bridge the new millennium's health care needs with training goals and competencies aimed at meeting these needs. One way to accomplish this is to develop innovative global health programs that meet the Accreditation Council for Graduate Medical Education requirements and actively involve participants in the learning process. Global health training may be a pathway to harness trainees' compassion and altruism. It follows that enhancing the global health training within US residency programs might ultimately provide a passageway to improve health services for underserved populations throughout our nation.