International EM, Medical Education

Responding to the Demand: EM Residency Programs and Global Health Experiences

Although the majority of residency programs offer elective opportunities, few provide the foundation for formal global health experiences. Yet the benefits of international clinical rotations for a physician's development have long been recognized.

Global Health has become a growing field of interest among recent medical students and medical residents. A 2011 study showed that as many as 60% of medical school graduates used “global health experiences” as criteria for their residency ranking decisions.1,2 Emergency medicine in particular has drawn substantial interest from “globally minded” future physicians. It has been reported that 68% of EM residency applicants with prior global health experience ranked residency programs with global health opportunities higher.3 Furthermore, up to 86% of EM residents reported that they would like to participate in an international rotation during residency;4 however, there is often inadequate guidance and support from most accredited organizations, hospital systems, and residency programs.4

Although the majority of residency programs offer elective opportunities, few provide the foundation for formal global health experiences. With that said, one can clearly see that programs with established global health experiences or tracks will likely be more attractive to graduating medical students, thus more competitive in the match.

Why Focus on Global Health?
The benefits of international clinical rotations for a physician’s development have long been recognized. These include improved physical exam skills, broader medical knowledge, and improved procedural competency.5 By providing care to underserved populations around the world, residents are exposed to the challenges of practicing medicine in the face of language barriers, cultural differences, and scarcity of resources.

In addition to the individual physician’s development, the knowledge and skills acquired abroad can also help our future leaders meet the current needs of the U.S. health care system, which is seeing a continual rise in the number of immigrants.6 Health care providers who are accustomed to working in resource-limited environments have been shown to order fewer tests and feel more comfortable in their clinical judgment.7 This is not only crucial for meeting the ever-changing demands of our country’s health care system now, but also in building for the future.

Global populations bring an understanding of regional disease processes. Global health experiences broaden knowledge through exposure to different diseases and to advanced stages of diseases that may be treated earlier in developed nations. During one recent experience in Peru, a first-time seizure led to a diagnosis of neurocysticercosis – and to an important understanding that 50% of first-time seizures in patients from endemic regions are attributed to neurocysticercosis.8 With the transient nature of the global population, we must be prepared to diagnose illnesses that have previously been limited to developing countries and provide culturally sensitive care to a global population. 

Data suggests that roughly 74% of trainees who participate in a global health course or elective and have experience caring for patients internationally are drawn to working in underserved and multicultural communities.9 This is becoming increasingly important because with more than 300 million border crossings per year in the United States alone, knowledge of tropical medicine, parasitology, and epidemiology will be paramount to the early detection of communicable and non-communicable diseases here at home.7 Residents with prior global health experiences are better equipped to serve patients of the U.S. and the world.4 We need robust global health programs in our residencies now to prepare the next generation of doctors for the global population they will treat. 

The importance of global health experiences is underscored for many of us in the modern EM residency program. For instance, University Hospital in San Antonio, Texas, serves a global population. The ED patient population arises from a community of 100+ different national citizenships, with patients from more than 130 different countries in any given calendar year. Texas is one of the top states for refugee settlement, with San Antonio being one of the largest resettlement cities within Texas. Students, residents, and faculty have the opportunity to volunteer at the San Antonio Refugee Health Clinic, a multi-disciplinary clinic that provides free care to refugees who have relocated to San Antonio. The global health curriculum at UT Health focuses on health issues that transcend national boundaries with a focus on social and economic determinants of population health.

Global Health: Training for the Future
Health care is not one-size-fits-all, and the future of medicine must take into account all aspects of a person’s life – not simply their physical well-being. Global health rotations offer unique training in this regard.

As an outsider unfamiliar with local customs – and possibly not fluent in the language – you must work harder to build trust and respect. You must go an extra step to understand the factors influencing your patient’s decision and ability to seek or continue medical care. Treatment plans typically offered in the U.S. may not be a good option elsewhere, for a number of reasons.

During a global health rotation, physicians are able to take a step back and find a sustainable solution, one that does not require a complete transformation of lifestyle or abandonment of important cultural practices. This is a crucial skill as medicine moves forward, at home and abroad.


References

1. Morton MJ, Vu A. International Emergency Medicine and Global health: Training and Career Paths for Emergency Medicine Residents. Ann Emerg Med. 2011;57:520-525.

2. Wayman, BS, Rodgers, JB, Vander Noot, RM, Irvine, SW. Residency Rank List: Does Prior Global Health Exposure Affect the Match? West JEM. 2015 July. Vol 16(4): S29-30.

3. Dey CC, Grabowski JG, Gebreyes K, Hsu E, VanRooyen MJ. Influence of international emergency medicine opportunities on residency program selection. Acad Emerg Med. 2002 Jul;9(7):679-83.

4. Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. Global Health in Medical Education: A Call for More Training and Opportunities. Acad Med. 2007; 82:226-230.

5. Barry M, Bia FJ. Departments of Medicine and International Health. Am J Med. 1986;80(6):1019-1021.

6. Zong J, Batalova J. Migration Policy Institute: Frequently Requested Statistics on Immigrants and Immigration in the United States. http://www.migrationpolicy.org/print/15856#.WdK7IopJn8w. Published March 8, 2017. Accessed October 2, 2017.

7. Martin IB, Jacquet GA, Levine AC, et al. (2013) Global health and emergency care: a postgraduate medical education consensus-based research agenda. Acad Emerg Med. 20: 1233-1240.

8. Medina M, Rosas E, Rubio F, Sotelo J. Neurocysticercosis as the main cause of late-onset epilepsy in Mexico. Arch Intern Med. 1990;150:325–27.

9. Landrigan PJ, Ripp J, Mruphy RJ, Claudio L, Jao J, Hexom B, Bloom HG, Shirazian T, Elahi E, Koplan J. New Academic Partnerships in Global Health: Innovations at Mount Sinai School of Medicine. Mt Sinai J Med. 2011 May-Jun; 78(3):470-482.

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