How we developed a locally focused Global Health ...

Medical Teacher

ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20

How we developed a locally focused Global Health Clinical Preceptorship at Weill Cornell Medical College Amita Kulkarni, Elizabeth R. Francis, Taryn Clark, Nichole Goodsmith & Oliver Fein To cite this article: Amita Kulkarni, Elizabeth R. Francis, Taryn Clark, Nichole Goodsmith & Oliver Fein (2014) How we developed a locally focused Global Health Clinical Preceptorship at Weill Cornell Medical College, Medical Teacher, 36:7, 573-577, DOI: 10.3109/0142159X.2014.886764 To link to this article: http://dx.doi.org/10.3109/0142159X.2014.886764

Published online: 06 Mar 2014.

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Date: 18 February 2016, At: 12:42

2014, 36: 573–577

HOW WE. . .

How we developed a locally focused Global Health Clinical Preceptorship at Weill Cornell Medical College AMITA KULKARNI1, ELIZABETH R. FRANCIS2, TARYN CLARK2, NICHOLE GOODSMITH2 & OLIVER FEIN2 1

The Warren Alpert Medical School at Brown University, USA, 2Weill Cornell Medical College, USA

Downloaded by [Penn State University] at 12:42 18 February 2016

Abstract Background: Global health educational programs within U.S. medical schools have the opportunity to link their ‘‘global’’ focus with local circumstances by examining the challenges underserved communities face in the United States. Aim: Students in Weill Cornell Medical College’s Global Health Clinical Preceptorship (GHCP) learn history-taking and physical examination skills while gaining exposure to local health care disparities and building cultural competency. Methods: First-year medical students in the program are placed in the office of a physician who works with underserved patient populations in New York City. Students receive an orientation session, shadow their preceptors one afternoon per week for seven weeks, complete weekly readings and assignments on topics specific to underserved populations, attend a reflection session, and write a reflection paper. Results: In three years, 36% of first-year students (112 of 311) opted into the elective GHCP program. Students reported gaining a better understanding of the needs of underserved patient populations, being exposed to new languages and issues of cultural competency, and having the opportunity to work with role model clinicians. Conclusions: The GHCP is a successful example of how global health programs within medical schools can incorporate a domestic learning component into their curricula.

Introduction

Practice points

With a growing interest in global health among medical students in the United States (Brewer et al. 2009; Anderson & Kanter 2010), a variety of educational programs have been developed to address the unique challenges of working with resource-poor populations (Stapleton et al. 2006; Macfarlane et al. 2008; Quinn 2008). While these programs often focus on international settings, the developed world has similar populations (Mayberry et al. 2000; Institute of Medicine 2003). In the U.S., for example, infant mortality rates in certain regions surpass rates in developing countries (Baltimore City Health Department (BCHD) 2009; AHRQ 2011), and the diverse patients that U.S. physicians care for include the uninsured, immigrants, human trafficking victims, and refugees. The importance of healthcare disparities and cultural competency training in U.S. medical education has been recognized recently by the Liaison Committee on Medical Education, which requires the inclusion of such themes in medical education, i.e. Standards IS-16, ED-22, and ED-21 (Betancourt & Cervantes 2009; LCME 2011). The goal is to provide medical trainees with knowledge about underserved populations and to improve communication between patient and provider, which leads to better health outcomes and decreased health disparities (Brach & Fraser 2000; Kripalani et al. 2006). Many medical schools throughout the

Global health programs within medical schools should integrate locally-focused clinical opportunities for students to work with resource-poor populations. Clinical preceptorships offer a convenient avenue for pre-clinical students interested in global health to gain experience with local underserved patient populations. Global health clinical preceptorships expose medical students to issues of local health disparities and help build cultural competency. Incorporating guided reflection and self-directed learning can enhance the value of the global health clinical preceptorship experience.

United States have embraced these topics by providing their students with opportunities to work with local underserved populations (Ko et al. 2005; Doran et al. 2008). Weill Cornell Medical College (WCMC) offers programs such as the Comprehensive Center of Excellence in Disparities Research and Community Engagement, which focuses on reducing health disparities in medically underserved racial and ethnic minority populations in New York.

Correspondence: Amita Kulkarni, The Warren Alpert Medical School at Brown University, 6 Pratt Street, Apt 1L, Providence, RI 02906, USA. Tel: 1-973-896-2221. E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/70573–577 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.886764

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Our aim Global health programs within medical schools can offer an appropriate avenue for students to develop skills for working with underserved communities, in the U.S. and abroad. The Global Health Clinical Preceptorship (GHCP) at WCMC provides exposure to culturally competent practices and local health care disparities, building skills for future practice domestically or internationally.


Setting and participants The GHCP is one component of the WCMC Global Health Curriculum (GHC), a student-driven, longitudinal four-year elective program launched in 2009 by a group of WCMC students and faculty to impart global health knowledge and skills to medical students (Francis et al. 2012). Like many medical schools throughout the country, WCMC has a clinical preceptorship program within the course Medicine, Patients, and Society, which is required for all first-year medical students. Each student is assigned to two practicing physicians, one in the fall and the other in the spring, with whom he or she spends one afternoon per week for seven weeks in order to learn history taking and physical examination skills. The GHCP is conveniently integrated into this program. Students who elect to participate in the GHC are placed specifically with physicians working with ‘‘Global Health’’ populations for one semester (defined below). In addition to the pre-existing requirements of the general clinical preceptorship, which include six hours of lectures focused on cultural competency and health disparities, GHCP students complete complementary educational readings and written reflection assignments.

What we did In the spring of 2009, an organizing committee of students and a faculty advisor first defined their concept of a ‘‘Global Health Preceptor:’’ A clinician practicing in an underserved area of New York City and/or treating an ethnically or economically underserved population, including immigrant, homeless, indigent, refugee, asylee, HIV-positive, or uninsured patients. Global Health Preceptors are aware of the unique challenges inherent in working with different patient populations and are open to sharing their expertise with students. The committee identified physicians in the pre-existing WCMC preceptorship program who met these criteria, then expanded the pool by recruiting additional faculty based on recommendations from current preceptors, student feedback from 2009 to 2010 GHCP pilot year, and student interest surveys. All 16 current Global Health Preceptors hold a faculty appointment and most work within the NewYork-Presbyterian Healthcare System, which extends throughout four of the five boroughs of New York City. Many of these preceptors mentor at least two students per semester. Upon formal approval to incorporate the GHCP into the pre-existing, first-year preceptorship program, the committee developed a GHCP syllabus using literature on global health curricula core competencies (Evert et al. 2006; 574

Koehn & Swick 2006; Houpt et al. 2007) and cross-cultural education (Tervalon 2003; Betancourt 2004; Like 2011) as guides. The syllabus elaborates on topics specific to working with underserved populations, such as language discordance, cultural barriers, health insurance, and immigrant issues. The syllabus includes: An orientation session to provide background on the communities and patient populations each student will encounter based on their preceptorship placement, moderated by a faculty member Weekly readings from academic journals and the popular press Guided questions, related to the week’s topic, for students to discuss with the preceptor and patients One final reflection session, moderated by a faculty member A short writing assignment, allowing students to reflect on their preceptorship experience and offer programmatic feedback The GHCP syllabus adopts a patient-centered model that emphasizes physician-patient communication. By focusing on the intersection of multiple cultures, rather than stereotypical generalities of specific subgroups, GHCP allows students to develop a cross-cultural mind-set that can be applied to individual cases (Like et al. 1996).

Role of feedback and reflection As the elective GHCP experience fits within a larger, mandatory medical school course, managing GHCP-specific requirements while continually improving the program is an evolving process. In the pilot year, students completed a final qualitative feedback survey to assess whether the experience met their expectations and if they would recommend the assigned physician to future students. Since then, new learning and assessment methods have been gradually introduced to enhance students’ experiences. The GHCP currently incorporates many elements of selfdirected learning, in which students are expected to formulate goals, identify resources, implement appropriate activities, and evaluate outcomes (Barrows 1983; Spencer 1999). When students enroll in the GHCP, they share what they hope to gain from the seven-week experience. In the final feedback survey, students are asked to consider if those initial learning objectives were met. Students are encouraged to follow the syllabus at their own pace, and are given resources and guiding questions that they can individualize based on their particular clinical setting, be it an emergency room or community clinic. The faculty-moderated discussion and reflection paper allow students to share insights from their preceptorships, and discuss any challenges they encountered. The value of reflection and reflective learning in professional development has been well-documented, for instance, it has been shown to promote enhanced self-awareness and critical thinking skills required in clinical settings (Branch & Paranjape 2002; Mann et al. 2009). The prompts for the reflection papers (Table 1) are open-ended to facilitate a deeper examination of the

A Local Global Health Clinical Preceptorship

experience and are intended to guide students in retrospectively considering their GHCP from a number of perspectives (Kumagai & Lypson 2009; AAMC 2012). All students in the program are required to attend a two-hour final reflection session that is moderated by a faculty member, who is selected for his or her experience working clinically with underserved populations as well as ability to respectfully facilitate student discussions. The session begins with each student briefly describing their preceptorship placement and their general opinion of the experience. After initial introductions, students share topics they discussed in their reflection papers in order to generate a larger group discussion. The reflection sessions are intentionally loosely structured to encourage candid conversation.


GHCP program evaluation In the first three years of this elective program, 36% of first-year WCMC students (112 of 311) chose to participate. During the Table 1. Suggested prompts for student reflection writing assignment.

What makes your experience qualify as a ‘‘global health’’ preceptorship? Describe any challenges of the global health preceptorship you have experienced or witnessed. Compare and contrast your global health preceptorship with your non-global health preceptorship. Describe any social inequalities you have seen in your preceptor’s practice. Are there ways these can be improved or better addressed? Expand on the environment you worked in. (i.e.: the physical office, the patient population, the interactions between staff and patients, physicians and patients, etc.) Expand on any illness or complication that seemed particularly prevalent in the population you were observing.

2009–2010 pilot year, 35 students participated, 36 students in 2010–2011, and 41 students in 2011–2012. In a qualitative survey about their experiences, students reported working with a diverse range of patients during their GHCP (Table 2). The survey included an optional open-ended section in which students could elaborate on the personal value of the GHCP. In the survey as well as reflection papers, students cited the value of exposure to: Various insurance plans and the impact of insurance on access and comprehensiveness of care Challenges associated with language barriers between patients and providers Office settings with high patient volume, and relative understaffing Social determinants of health, and the physician’s ability to address patients’ health concerns while considering confounding social factors Clinicians who served as positive role models and dedicated instructors In their papers, some students described feeling challenged or frustrated by the situations they experienced. One student was disappointed at not being able to practice taking a complete history with his preceptor because there were too many patients to see. Another student felt challenged by her inability to accurately document a patient’s chief complaint because she didn’t fully understand the patient’s Spanish. In the open-ended section of the feedback survey, several students requested more opportunities for reflection, suggesting the future possibility of additional small-group weekly sessions or writing assignments. The GHCP continues to be refined based on feedback from preceptors, students and faculty. In addition to the existing assessments, in the future, the GHCP will consider requiring

Table 2. Characteristics of global health clinical preceptorship offices.

GHCP office locations in New York City Central Brooklyn Chelsea, Manhattan Coney Island, Brooklyn Downtown Manhattan East Harlem, Manhattan Flushing, Queens South Bronx

a

Preceptor’s specialtya

Patient populations observedb

Emergency Medicine (13%) Family Medicine (19%) Infectious Disease (13%) Internal Medicine (63%) Pediatrics (13%)

African-Americans Drug Treatment or Substance Abuse Elderly Hispanics HIVþ patients Homeless Immigrants from Latin America, Caribbean, West Africa, Europe, South Asia, East Asia Intravenous drug users Low socio-economic status Medicaid/Medicare recipients Men who have sex with men (MSM) Prisoners Refugee/Asylum Seekers Uninsured/Underinsured Well-insured

Languages spoken by patientsb Albanian Arabic Bengali Cantonese Creole English French Georgian Gujarati Hindi Italian Korean Kurdish Macedonian Mandarin Polish Russian Spanish Turkish Urdu Yiddish

Due to some preceptors with multiple board-certified specialties, the total percentages may exceed 100%. As described by students in feedback surveys.

b

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student portfolios and patient logs, which have been shown to promote self-directed learning and reflection (Sandars 2009).

What to do next


Application of GHCP principles to other medical schools The successful implementation of the GHCP at WCMC was aided by the ethnic and socioeconomic diversity of New York City, as well as the existence of a mandatory preceptorship program into which the GHCP could be integrated. However, many of the principles taught through the GHCP can be applied to other medical schools. The following are suggestions for designing a similar program at other schools: Target population: The definition of a Global Health Preceptor should be relevant to the location and context of the medical school. For example, it could be expanded to include physicians working with underserved rural populations. Development of new affiliations with physicians, clinics and hospitals in low-income and culturally diverse communities: In order to expand the opportunities for medical students, medical schools may need to build new relationships with clinicians and hospitals that serve lowincome and culturally diverse communities. Students should be given the opportunity to develop a preceptorship experience in such communities. Flexibility in timing: To accommodate the curriculum and schedule of a particular medical school, the timing of the preceptorship could be shifted to the fourth year, in the form of a more advanced clinical experience or away rotation. Opportunities for reflection: Working with faculty and student schedules, schools could provide diverse settings for reflection – both guided and self-directed – in order to help students make the most of their individual experiences. Utilization of supplemental electronic media: Numerous online courses and resources pertaining to health care disparities and cultural competency are available to meet the needs of individual programs (Like 2011). Irrespective of setting, it is important that the GHCP focuses not only on underserved populations within the school’s proximity, but also provides a broad perspective of resourcepoor communities globally (Dolhun et al. 2003).

Conclusion The GHCP program at WCMC exposes medical students to a diverse range of patients and preceptor role models, and emphasizes that health disparities exist in all settings, locally and internationally. Survey results indicate that the majority of students feel the program provides a unique opportunity to understand the social, cultural, and economic aspects of health and healthcare disparities. With the support of the administration, the student-faculty committee successfully integrated a GHCP into the medical school’s general preceptorship program. The development of 576

the GHCP began with the definition of criteria for Global Health Preceptors, identification and recruitment of suitable preceptors, and creation of a syllabus. The program has been continually refined based on student and faculty feedback. By adapting this general plan, other medical schools could develop similar programs, providing students with a valuable enrichment to the traditional medical school curriculum and an experience that helps them develop skills to be more effective providers in the future, in any setting.

Notes on Contributors AMITA KULKARNI, is a MD student, The Warren Alpert Medical School at Brown University. ELIZABETH R. FRANCIS, MPH, is a MD student, Penn State College of Medicine. TARYN CLARK is a MD student, Weill Cornell Medical College. NICHOLE GOODSMITH, PhD, is a student, Weill Cornell/Rockefeller/ Sloan-Kettering Tri-Institutional MD-PhD Program. Dr. OLIVER FEIN, MD, is an Associate Dean (Affiliations), Weill Cornell Medical College. (Kulkarni and Francis were former Global Health Fellows, Weill Cornell Medical College)

Acknowledgements The authors wish to thank the following who helped to develop and refine the Global Health Clinical Preceptorship: Andrea Lorenze, Eunee Park, Daniel Shapiro, Carrie Bronsther, and Stacy Chu. The GHCP program would not have been possible without the support and coordination of Dr Joseph Murray and Ms Caryn Davi. Finally, the authors would like to thank the clinicians that volunteer their time to serve as Global Health Preceptors in the program. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

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