The Role of Graduate Medical Education in Global Health ...

BREAKOUT SESSION

The Role of Graduate Medical Education in Global Health: Proceedings From the 2013 Academic Emergency Medicine Consensus Conference Janis P. Tupesis, MD, Gabrielle A. Jacquet, MD, MPH, SueLin Hilbert, MD, MPH, Amelia Pousson, MD, MPH, Kajal Khanna, MD, JD, Joshua Ross, MD, Sabrina Butteris, MD, and Ian B.K. Martin, MD

Abstract The past 40 years have seen expanded development of emergency medicine (EM) postgraduate residency training programs worldwide. An important part of this educational experience is the ability of resident trainees to participate in experiences abroad. However, little is known about how these experiences shape trainees and the populations they serve. During the 2013 Academic Emergency Medicine consensus conference, a group of educators met to define and outline current trends in graduate medical education (GME) emergency care research. The authors discuss future research questions bridging the gap of GME and global health. ACADEMIC EMERGENCY MEDICINE 2013; 20:1216–1223 © 2013 by the Society for Academic Emergency Medicine

he fields of graduate medical education (GME) and global health have undergone groundbreaking changes over the past 100 years. In 1910, Abraham Flexner published his report creating a framework for the modern medical education system in the United States.1 During the 20th century, educational priorities focused on science- and problem-based curricula.2 More recently, administrative bodies such as the Accreditation Council of Graduate Medical Education (ACGME; United States), Royal College of Physicians

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and Surgeons (Canada), Federation of the Royal Medical Colleges (United Kingdom), and Royal Australasian Colleges (Australia/New Zealand) have identified and endorsed general competencies expected of postgraduate and resident trainees during their training. Since its publication, priorities in the Flexner report have paralleled those seen within global health. These changes have shifted the focus, rigor, and outputs of global health and GME. This article presents research questions based on consensus recommendations addressing

From the Division of Emergency Medicine Department of Medicine (JPT, JR) and the Department of Pediatrics (SB), University of Wisconsin School of Medicine and Public Health (JPT, JR), Madison, WI; the Department of Emergency Medicine, Johns Hopkins University School of Medicine (GAJ), Baltimore, MD; the Department of Emergency Medicine, Boston University School of Medicine (GAJ), Boston, MA; the Department of Emergency Medicine, George Washington University School of Medicine and Public Health (AP), Washington, DC; the Division of Emergency Medicine, Washington University in St. Louis (SH), St. Louis, MO; the Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine (KK), Palo Alto, CA; and the Departments of Emergency Medicine and Internal Medicine, University of North Carolina School of Medicine (IBKM), Chapel Hill, NC. Received July 12, 2013; revision received August 19, 2013; accepted August 20, 2013. This article reports on a breakout session of the May 2013 Academic Emergency Medicine consensus conference in Atlanta, GA: “Global Health and Emergency Care: A Research Agenda.” Breakout session participants: Christine Irvin Babcock, Mark Bronoon, Courtney Clamp, Karen Ekernas, Bianca Grecu, Megan Gussick, SueLin Hilbert, Kate Jacoby, Gabrielle A. Jacquet, Kajal Khanna, Katie Korval, Brandon Libby, Regan Marsh, Ian B. K. Martin, Ernest Mavunua, Ramon Millan, Rachel Moresky, Erica Peethumnougsin, Amelia Pousson, Alex M. Rosenau, Joshua C. Ross, Will Sanderson, Janis P. Tupesis, Oena A. VanMeer, Rishi Vohra, and Michael Weigner. The authors have no relevant financial information or potential conflicts of interest to disclose. Supervising Editor: Mark Hauswald, MD. Address for correspondence and reprints: Janis Tupesis, MD; e-mail; [email protected].

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ISSN 1069-6563 PII ISSN 1069-6563583

© 2013 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12260

ACADEMIC EMERGENCY MEDICINE • December 2013, Vol. 20, No. 12 • www.aemj.org

learner competencies, evaluations, and outcomes in the context of global health and GME that took place at the 2013 Academic Emergency Medicine consensus conference “Global Health and Emergency Care: A Research Agenda.” GLOBAL GME DEVELOPMENT Research Question: What Is the Scope of Global Health Education at the GME Level? Global health experiences for resident and postgraduate trainees have followed a similar historical path to those in other medical education spheres. Physicians have long held an interest in global health, whether it is under the auspices of tropical medicine or international health. For years these types of experiences were largely ad hoc. Trainees were often sent to work in extremely difficult conditions abroad with little to no supervision or preparation. They cared for patients with unfamiliar medical conditions and performed procedures outside of their typical scope of work. Over time, there has been increased focus on education, ethics, best practices, and sustainable partnerships. This new era has brought with it the development of competency-based curricula,3,4 ethical guidelines,5,6 and guidebooks for educators developing global health programs,7 as well as widespread interest among trainees to include these experiences as part of their training. International rotations provide unique clinical, research, and teaching experiences for resident physicians.8,9 As a result, an increasing number of resident physicians are participating in these types of electives.10,11 According to a 2013 survey by King et al.,12 22% of emergency medicine (EM) residents complete international rotations during their residency training. This growth in resident interest and participation in global health rotations extends beyond the specialty of EM; similar results were found in studies focusing on pediatric residents,10 surgery residents,13–16 and radiology residents.17 As a result, increasing numbers of institu-

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tions are offering international rotations to their resident trainees. Currently, 91% of EM residency training programs offer these types of experiences, based either at their home institution or through a preestablished agreement with another institution.12 Some residency programs have gone on to offer academic tracks for residents interested in global health.18–20 Despite increasing interest in global health training experiences for residents, significant administrative barriers exist. The most commonly reported are lack of financial support, scheduling conflicts, difficulty in finding a preestablished clinical training site, paucity of faculty supervision at the site, and concerns over personal safety.21–24 Similar challenges exist for residency program directors, including staffing time lost from resident clinical rotations and lack of administrative and financial support.22,24 Challenges exist for governmental education oversight organizations as well. Accreditation and review committees lack standardized training guidelines that outline established educational core competencies and bidirectional exchange policies. As a result, certain residency review committees do not recognize time spent doing clinical training in another country.22 Commonly identified key characteristics of global health programs at the GME level are outlined in Table 1.10,20,25–28 Attempts have been made to compose a standardized postgraduate training curriculum for international rotations. The Global Health Education Consortium has proposed an educational curriculum for global health rotations.7 Additional curricula have been proposed by many specialties, including EM,27,29 pediatrics,3,4,30–32 family medicine,26 internal medicine,33 and multidisciplinary training programs.34,35 Currently these electives vary in the experiences they provide the learners. Elective offerings are listed on the Emergency Medicine Residents Association and American College of Emergency Physicians international section websites.36,37 These listings are often out of date and inaccurate; in response, there has been a movement to standardize the application process and rotation list-

Table 1 Graduate Medical Education Characteristics

Characteristic Institutional support of program and faculty Designated budget Collaboration with international partner Well-defined curriculum Liability and safety Resident predeparture preparation Resident supervision Evaluation practices Research Other

Anspacher et al.10

Campagna et al.20

X

X

X

X X

X X X X X X Collaboration with other U.S. institutions

Bozorgmehr et al.25

Tupesis et al.27

X X X X X

Administrative support

Evert et al.26

Crossdisciplinary

Hansoti et al.28 X

X X

X

X X

X X X

X X

X X X

X X X Mentoring, sustainability

X X Mentoring, logistic support, standardized application

X X X Logistic support

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Tupesis et al. • GME IN GLOBAL HEALTH

ings.27 In an attempt to improve global health/international rotations, several guidelines for ethics, safety, and best practices in global health training experiences have been written.5,28,38 Recommendations and Priority Areas of Future Research: GME Development Summarized below are the working group’s recommendations for future research consideration. 1. Work to develop a core, multidisciplinary, emergency-based, global health educational curriculum, for programs both in developed countries and in developing countries. Assure that these curricula are comprehensive, but also allow for geographic/regional variability—knowing that analyzing the effect of curricula on learners requires some variability and because different courses will have different goals (research, education, clinical, public health, etc.). Research best practices in development and implementation of these curricula. 2. Develop research methodology to evaluate these core experiences. Specifically, develop and implement tools for predeparture (pre–global health experience) training, clinical rotations, and postreturn (post–global health experience) resident “debriefing.” 3. Study whether or not these educational tools augment trainees’ clinical experiences, educational experiences, and supervisors’ summative evaluations of the learners. Use examinations, standardized encounters, and observations to study. 4. Develop standardized evaluative tools that could give rise to large-scale qualitative and quantitative data sets from learners’ global health experiences. Develop multi-institutional, multidisciplinary research networks to compile and share data. Investigate methods to improve coordination of efforts between global health GME programs and research networks to facilitate above recommendations.

LEARNER COMPETENCIES/EVALUTIONS Research Question: How Should Global Health Learner Competencies and Evaluations at the GME Level Be Developed, Evaluated, and Investigated? Competency-based education defines desired outcomes of training and drives the educational process. Attainment of competencies is an indicator of educational effectiveness and quality. Establishing a defined set of core competencies for EM global health resident education will allow for the consistent collection of data across institutions. This information can then be used to drive curriculum development, further specific research, and answer important questions such as “what qualifications and requisite knowledge should residents have to participate in international rotations?” and “What will be the basis for their evaluation?” Defining and agreeing to a standard set of core competencies creates a common language that can be used to communicate and collaborate across specialties, institutions, and international education networks. In reviewing the literature on competencies in global health across disciplines, including pediatrics, EM, internal medicine, surgery, and public health, eight general themes emerge (Table 2).3,10,29,34,39–42 The greatest challenge currently is determining how to best gather this information. Some learner competencies, such as “understanding of the global burden of disease,” are fairly straightforward and can be easily measured using current standardized methods. Other characteristics, like “cultural competency,” are more intangible and may require methodologies used in other disciplines, such as the social sciences or business sector. One promising learner assessment tool is the Global Health Competency Survey.43 Administered to 429 Canadian family medicine residents and nursing, physiotherapy, and occupational therapy students, the Global Health Competency Survey proved to have good internal consistency and strong validity. This brief

Table 2 Commonly Identified Learner Competencies in Global Health Education at the Graduate Medical Education Level

Competency Cultural competency Health equity and human rights Communication, leadership, and collaboration skills Burden of disease Research, programming and evaluation Ethics and professionalism Healthcare systems and delivery models Social/political/economic awareness

Howard et al.,3 Anspacher et al.,10 McIntosh et al.,29 ACGME Competencies*

ACGME Milestones42

PC, ICS, Prof PC, SBP, Prof ICS, SBP

17, 18 18 20, 23

Howard et al.3

Anandaraja et al.34

Calhoun et al.39

Hagopian et al.40

Goecke et al.41

X X X

X X

X X X

X X X

X

X

X X

X X

X

X

MK PBL, SBP

16 21, 23

X X

X

X X

X

X X

Prof PBL, SBP

17 23

X

X

X

X

Prof, PC

17

X

*Specific milestones listed: 16. PROF1—Professional Values; 17. PROF2—Accountability; 18. ICS1—Patient-centered Communication; 20. PBLI2—Practice-based Performance Improvement; 21. SBP1—Patient Safety; 23. SBP3—Technology. ACGME = Accreditation Council of Graduate Medical Education; ICS = interpersonal and communications skills; MK = medical knowledge; PBL = practice-based learning; PC = patient care; Prof = professionalism; SBP = systems-based practice.


online survey covers five general topic areas that are consistent with the authors’ prior review of the global health literature: 1) confidence level in socioeconomic position and health disparities (eight items), 2) social determinants of health (five items), 3) global health skills to work with patients with different backgrounds and characteristics, 4) health disparities, and 5) travel and migration. Similarly, there are few standard evaluation processes for residents participating in global health rotations, the curriculum designed to prepare them, and the clinical sites where they go to practice. Individual resident evaluations tend to be informal and variable in both intensity and quality.44,45 Some programs use more formal assessments (multiple choice tests, oral examinations, simulation/objective, structured, clinical exam, standardized patient examinations, direct observation/preceptor evaluation, structured journaling or portfolio, projects, self-assessment, patient surveys, and 360-degree evaluations).3,7,44 The evaluation of a resident on a global health rotation is complex, with expected learning occurring in multiple domains, including medical knowledge, clinical skills, and cultural attitudes. Many programs share similar educational objectives, but there are few common objectives and standardized evaluation processes. Many authors have described how several of the ACGME competencies can be fulfilled by international rotations.6–10 These include improved patient care, particularly issues of emergency stabilization in resourcepoor settings; improved physical examination skills in the absence of the ability to rely on imaging; improved comfort with ultrasound-guided procedures; and the domains of critical care, trauma, pediatric, and mass casualty incidents. Other competencies that have the potential to be significantly strengthened by these rotations include increases in medical knowledge, particularly as it relates to so-called “tropical diseases” as well as delayed presentations and advanced stages of common illnesses, and enhanced communication skills, particularly relating to cultural competency and sensitivity. Certain other competencies may require international rotations or similarly “uncomfortable” settings to develop skills in the professionalism domain related to recognizing limits of knowledge in uncommon clinical situations, in the practice-based learning domain related to the use of international guidelines, and in the systems-based practice domain relating to resource utilization (e.g., learning how it feels to elect not to do a procedure due to limited resources) and the interrelated nature of clinical practice with public health organizations, policy-makers, and advocacy groups. In 2012, the ACGME and American Board of Emergency Medicine released the Emergency Medicine Milestones,42 effective as of July 2013.11,12 These 24 milestones are intrinsically linked to the historic core competencies, and many of them can be achieved on international rotations. Correlating the milestones with international rotation preparatory modules and researching evaluation tools will strengthen this relationship and become invaluable as the discipline of global health education and development progresses. Narrative diaries around trainee phy-

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sician experiences with international rotations suggest that the milestones with the potential to be particularly strengthened by these experiences include PC2—Performance of Focused History and Physical Examination; PC6—Observation and Reassessment; PC8—Multitasking (Task Switching); PC12—Other Diagnostic and Therapeutic Procedures: Ultrasound; PC14—Vascular Access; PROF1—Professional Values; PROF2—Accountability; PBLI1—Teaching; and SBP2—Systems-based Management.3,29,46–48 Conversely, international rotations may offer less in the way of exposure to milestones such as PC5—Pharmacotherapy; PC10—Airway Management; and SBP3—Technology.3 It is recommended that a standardized predeparture curriculum be developed and tested for validity with rigorous evaluation components linked to specific EM milestones such as medical knowledge, professional values, accountability, communication, and system-based management. Continued evaluation of the trainee should occur during the rotation and after return. Evaluation modalities will vary for different educational objectives, but the evaluative process should be anchored in the milestones in a similar fashion as has been described for the ACGME core competencies.3 Similarly, there is no standardized evaluation of global health programs. It is recommended that a standardized tool or metric be developed to evaluate international training sites, including overall educational value, ease of arranging experience, predeparture logistics, type of experience with expected administrative responsibilities, research responsibilities and patient care roles and responsibilities, level of supervision and mentorship, and level of service and support.27 Research is needed to help residents, with varying goals and levels of experience, match the multitude of programs with their specific educational needs. One element of this research may involve the development of a standard postexperience evaluation for residents, with planned testing of this metric to be certain that it is an effective measure of value. As the concept of “global health programs” includes a multiplicity of types of experiences ranging from self-study, to lecture/seminar series, to field experiences and medical missions, to formal clinical rotations, evaluative tools need sufficient flexibility and rigor to address all of these types of experiences in a thorough and accurate fashion. Recommendations and Priority Areas of Future Research: Learner Competency Development and Evaluation Learner competencies in global health have been variably defined across disciplines, and there continue to be efforts to develop standardized assessment tools. These are poorly developed in global EM postgraduate training programs. Summarized below are the working group’s recommendations for future research consideration. 1. Develop a standard set of core competencies that creates a common language that can be used to communicate and collaborate across specialties and institutions. This will serve as prerequisite “common language” to ask standardized educational research questions worldwide.

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2. Standardize data collection as it pertains to both learner and program assessments. This will not only help foster meaningful and successful global health experiences, but also be a key component of the evaluation process as performance is tracked over time. 3. Use ACGME EM milestones, with suggested evaluation methodology, to develop standardized clinical, administrative, and research evaluations for learners. Use this evaluation methodology (milestonebased global health evaluation tools) to research the effectiveness and effect of the individual learning process. 4. Devise research protocols that assure that the resulting competency-based evaluation instruments are reliable and validated, specifically in the EM GME setting. 5. Develop research methodologies to assess different global health training programs. This may require incorporating practices from other disciplines. LEARNER OUTCOMES Research Question: How Should the Effect That Global Health Educational Experiences Have on Learner Outcomes Be Investigated? Outcomes to learners, to their domestic institutions, and to international host communities and institutions must be identified. For learners, international rotations can improve clinical skills, facilitate the achievement of competencies and milestones, and affect career choices. For communities, international rotations offer the potential to improve local health workforce dynamics by increasing staff retention, provide energy and workforce to make improvements on health care systems issues, and often are supported by infrastructure that may improve the attractiveness of in-country teaching institutions to potential trainees. Since 1969, academics have postulated that international rotations positively affect physician trainees. At that time, a physician in JAMA wrote, “If as a routine, young American doctors were encouraged to spend some months working in a developing country before they became tied to the responsibilities of practice, the results could be better medicine at home and abroad.”49 International rotations provide an opportunity for immediate and long-term educational and personal growth. Physicians who participate must rely more on patient history and physical examination findings than on diagnostic testing when caring for patients.39 They must strengthen clinical skills and reduce dependence on both laboratory and other diagnostic tests.50–52 As a result, physician trainees learn novel approaches to common problems; this may have long-term effects on health care systems (particularly in resource-limited settings). International rotations may also improve crosscultural understanding and sensitivity in physician trainees by exposing them to new cultures and health care systems.23,33,46,53 The aforementioned examples are associations and not evidence for causation; research to demonstrate the actual effect on learners is crucial. The presence of international opportunities affects choices made by physician trainees from the time of


residency selection. In one study, 54% to 68% of residents ranked programs higher due to international EM offerings.54 Several other studies have demonstrated that international opportunities influence decisions on residency program selection.12,22,54–56 This phenomenon has been shown in residency selection in Canada as well.16 According to King et al.,12 only 1.6% of graduates select their initial jobs outside of the United States. One question that has not yet been studied is whether completing an international rotation affects this choice. In a survey by Birnberg et al.,57 65% of incoming interns reported interest in global health careers; however, only 23% intended to pursue a part-time or fulltime career abroad. The authors also found that interns committed to part-time or full-time careers abroad reported having more past experiences in global health (82% vs. 43% of all others, respectively; p < 0.001).57 Traditionally the focus of research has been on the individual learner and his or her home institution. We know that residents who participate in international rotations report an improvement in their clinical and diagnostic skills and exposure to a broad range and severity of pathology, learn to operate in other health care systems with limited resources, and learn about social determinants of health. However, much of these data are self-reported and subject to recall bias. Developing measurable outcomes in terms of Residency Review Committee/ACGME guidelines will strengthen the argument in support of international rotations as accredited and value-added resident training opportunities. As mentioned previously, there has been little emphasis on host institution outcomes. Recommendations and Priority Areas of Future Research: Learner Outcomes Very little research has been focused on the evaluation of learner outcomes. Future work should be centered on the following questions: 1. Develop strategies to incorporate learner-specific outcomes using standardized evaluation methodology, such as the ACGME milestones. Use these metrics to study individual learner progression through training. 2. Research how global health experiences affect career development, including fellowship placement, job placement, participation in service and volunteer organizations, grant funding obtained, and academic/scholarly productivity. 3. Investigate whether international rotations affect local physicians. 4. Investigate whether global health rotations affect local physician retention. COMMUNITY OUTCOMES Research Question: What Effects Do Global Health Educational Experiences Have on Host Community Outcomes? Over the years, very little emphasis has been placed on host community outcomes. Considering the fact that improvement in the health of the local population is most often the impetus for global health work, this pau-


city of research is particularly striking. Depending on the setting, it may be difficult to demonstrate a clear effect on large regional public health outcomes, such as mortality rates, but focus on hospital-based mortality data may still be possible. In other settings, focusing on a few EM-specific outcomes such as trauma care or sepsis management may be more appropriate. Currently, there are few published data on community-based outcomes for global health programs at the GME level. Small descriptive studies of projects in pediatrics, surgery, and EM suggest that educational and clinical partnerships offer several benefits that may indirectly link to improved community outcomes, including increasing retention of health care workers,58 increasing confidence and sense of ownership among local providers,6 improving systems and health care delivery processes,59 and making in-country teaching institutions more attractive to future trainees.60 One area of global health research that is pertinent to EM and has demonstrated improvement in communitybased outcomes is resuscitation, specifically trauma and neonatal.61,62 While these programs are not specifically focused on GME, they are nonetheless pertinent and offer some direction for future research. Additional related research topics include addressing the rigor with which desired outputs and outcomes within the host community are outlined prior to the initiation of international rotations and the value thereof; investigating the perceptions and attitudes of in-country health workforce related to hosting these experiences, both positive and negative; and describing those programs that have successfully facilitated bidirectional exchanges focused on equity and ethics issues, thereby ensuring that international rotations do not become an “extractive” educational process on the host institutions, regions, and nations. Good examples of the latter can be seen in the narratives of Riviello et al.58 and Hexom et al.59 Identifying host-centered outcomes is essential. It demonstrates a commitment to an equitable and mutually beneficial partnership, thereby strengthening opportunities for further collaboration. It also provides an opportunity to build research capacity within the hosting institutions by directly involving local physicians and trainees in research projects. The next step is using these outcomes to guide the expansion of global health programming at the GME level. Once we have established what each stakeholder expects to gain from a partnership, we can then begin to shape our programs to reflect mutually beneficial relationships. Recommendations and Priority Areas of Future Research: Host Community Outcomes Summarized below are the working group’s recommendations for future research consideration. 1. Develop metrics to evaluate and measure the effects of international rotations on the host country work force and administrative infrastructure. 2. Develop metrics to evaluate and measure the effects of international rotations on host country community health outcomes.

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CONCLUSIONS The development of global health educational programs continues to grow worldwide. Given the paucity of evaluation and outcomes data, there remains a large opportunity for scholarship in this domain. In this article, the writing group presents an overview of global graduate medical education and a summary of recommendations from the 2013 Academic Emergency Medicine consensus conference. The primary goals of the writing group were to review the most current literature focusing on global health learner and program competencies, evaluations, and outcomes and to develop an agenda by which to focus future research in this specific domain. References 1. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. New York, NY: The Carnegie Foundation for the Advancement of Teaching, 1910. 2. Frenk J, Chen L, Bhutta Z, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010; 376:1923–58. 3. Howard CR, Gladding SP, Kiguli S, Andrews JS, John CC. Development of a competency-based curriculum in global child health. Acad Med. 2011; 86:521–8. 4. Suchdev PS, Shah A, Derby KS, et al. A proposed model curriculum in global child health for pediatric residents. Acad Pediatr. 2012; 12:229–37. 5. Crump JA, Sugarman J. Ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg. 2010; 83:1178–82. 6. Suchdev P, Ahrens K, Click E, Macklin L, Evangelista D, Graham E. A model for sustainable shortterm international medical trips. Ambul Pediatr. 2007; 7:317–20. 7. Evert J, Stewart C, Chan K, et al. Developing Residency Training in Global Health: A Guidebook. San Francisco, CA: Global Health Education Consortium, 2008. 8. Kirsch TD, Holliman CJ, Hirshon JM, Doezema D. The development of international emergency medicine: a role for U.S. emergency physicians and organizations. SAEM International Interest Group. Acad Emerg Med. 1997; 4:996–1001. 9. Morton MJ, Vu A. International emergency medicine and global health: training and career paths for emergency medicine residents. Ann Emerg Med. 2011; 57:520–5. 10. Anspacher M, Frintner MP, Denno D, et al. Global health education for pediatric residents: a national survey. Pediatrics. 2011; 128:e959–65. 11. Kerry VB, Ndung’u T, Walensky RP, Lee PT, Kayanja VF, Bangsberg DR. Managing the demand for global health education. PLoS Med. 2011;8: e1001118. 12. King RA, Liu KY, Talley BE, Ginde AA. Availability and potential impact of international rotations in

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27. Tupesis JP, Babcock C, Char D, Alagappan K, Hexom B, Kapur GB. Optimizing global health experiences in emergency medicine residency programs: a consensus statement from the Council of Emergency Medicine Residency Directors 2011 Academic Assembly global health specialty track. Int J Emerg Med. 2012; 5:43. 28. Hansoti B, Douglass K, Tupesis J, et al. A Society for Academic Emergency Medicine (SAEM), Council of Emergency Medicine Residency Directors (CORD) and Emergency Medicine Residents’ Association (EMRA) consensus statement on guidelines for safety of trainees rotating abroad. Acad Emerg Med. 2013; 20:413–20. 29. McIntosh M, Kalynych C, Devos E, Akhlaghi M, Wylie T. The curriculum development process for an international emergency medicine rotation. Teach Learn Med. 2012; 24:71–80. 30. Kamat D, Armstrong RW. Global child health: an essential component of residency training. J Pediatr. 2006; 149:735–6. 31. Nelson BD, Lee AC, Newby PK, Chamberlin MR, Huang CC. Global health training in pediatric residency programs. Pediatrics. 2008; 122:28–33. 32. Stanton B, Huang CC, Armstrong RW, et al. Global health training for pediatric residents. Pediatr Ann. 2008; 37(786–7):92–6. 33. Miller WC, Corey GR, Lallinger GJ, Durack DT. International health and internal medicine residency training: the Duke University experience. Am J Med. 1995; 99:291–7. 34. Anandaraja N, Hahn S, Hennig N, Murphy R, Ripp J. The design and implementation of a multidisciplinary global health residency track at the Mount Sinai School of Medicine. Acad Med. 2008; 83: 924–8. 35. Sawatsky AP, Rosenman DJ, Merry SP, McDonald FS. Eight years of the Mayo International Health Program: what an international elective adds to resident education. Mayo Clin Proc. 2010; 85:734–41. 36. Emergency Medicine Residents’ Organization. International Opportunities for Residents and Medical Students. Available at: http://www.emra.org/Content.aspx?id=291. Accessed Sep 24, 2013. 37. American College of Emergency Physicians. ACEP International Section Observership and Rotation Opportunities. Available at: http://ws.acep.org/EktronApps/InternationalRotations/Default.aspx. Accessed Sep 24, 2013. 38. Hansoti B, Weiner SG, Martin IB, et al. Society for Academic Emergency Medicine’s Global Emergency Medicine Academy. Global Health Elective Code of Conduct. Acad Emerg Med. 2013; 20:1319–20. 39. Calhoun JG, Spencer HC, Buekens P. Competencies for Global Health Graduate Education. Infect Dis Clin N Am. 2011; 25:575–92. 40. Hagopian A, Spigner C, Gorstein JL. Developing Competencies for a Graduate School Curriculum in International Health. Public Health Rep. 2008; 123:408–14. 41. Goecke ME, Kanashiro J, Kyamanywa P, Hollaar GL. Using CanMEDS to guide international health electives: an enriching experience in Uganda


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