A Post From CFHI’s Medical Director:
I’m just returning from conducting a workshop at the NEGEA Regional Conference. NEGEA is the Northeast educator’s chapter of the AAMC – a gathering of the people who oversee medical student and resident education. Just like many in global health medical education, they are grappling with how to get their hands around the subject and figure out how to increase collaboration.
I was pleased at the warm reception of my presentation on developing global health curriculum and engaging in partnerships for global health rotations. I was equally as pleased to present under the auspices of the conference title “International Health.” The AAMC shared their project GHLO (Global Health Learning Opportunities) which is currently in a pilot stage. They hope to create a program to facilitate global health rotations. I commend them on this important effort and for the embrace of ‘international health’ as the subject of the regional meeting. However, I hope this and other new initiatives doesn’t distract from the AAMC and similar bodies from doing what they know how to do, have done for years, and have the power to do- INFLUENCE THE REQUIRED CURRICULUM AT US MEDICAL SCHOOLS BY MAKING BASIC GLOBAL HEALTH KNOWLEDGE A REQUIREMENT FOR EVERY STUDENT GRANTED AN MD IN THE US.
Issuing a Challenge to Medical Educators and Associations
I challenge the community of medical educators and colleges (AAMC), licensure (LCME) and evaluation bodies (NBME) to consider how much power they wield to make a difference for patients of ‘global health’ and the inadequately numbered workforce that takes care of them (don’t worry, US doctors are not going to abandon US patients when they find out about suffering abroad; US doctors are not the answer to workforce challenges in developing countries…even though many of us would like to be). However, US doctors can be informed and empowered as advocates for the political, socioeconomic, health systems change and skills transfer that are needed to address global health inequities, as well as embrace global citizenship in both their professional and private lives. The AAMC, LCME, and NBME have the power to make US physicians learn why the majority of patients suffer in the world. We must consider ourselves part of the larger world because diseases don’t respect borders, and ‘global health’ is actually in all our back yards. Knowing what is going on outside our domestic bubble will only make us better doctors for our increasingly diverse patient population at home. As things are, we graduate from medical school and aren’t required to have the slightest clue.
It is my personal belief that I was cheated at medical school- nobody told me that 15 million children die each year of malnutrition, no one mentioned that the most common cause of death during childbirth is hemorrhage and only 1% of maternal deaths occur in developed countries. No one mentioned the Millennium Development Goals or what DALYs are and why they’re important. I graduated with a MD in the United States without being taught why the majority of people suffering in the world are suffering. This can’t be right.
Yes, there is global health education happening at every medical school in the US (according to most claims and studies, although comprehensive,updated surveys are limited….I’m not proposing that it is a good use ofour time to continue studying this, but rather it’s time to make it happen.) Yet the reality is that most of the global health curriculum at US medical schools is happening informally during lunch-time meetings, in special pathways that ‘preach to the choir’ of students already interested in and fairly astute about global health issues, during limited elective time, or in the context of student-driven interest groups. I am impressed as I travel though meetings of groups that inform medical education- AAMC, CUGH, GHEC, AMA, AMSA, etc. – that people are pretty much on board with the demand of students for global health exposure. I am also impressed with the number of grandiose plans organizations and institutions are formulating to make dents in global health. Yet I’m appalled that these plans seem to overshadow a basic step toward helping the millions of patients dying of treatable and preventable illnesses every year- teaching our medical students about them. The old adage “Ignorance is Bliss” is apropos. If we don’t teach our medical students about suffering beyond our borders, we can’t guarantee they’ll know about it. It also goes that if we don’t test them on it, we won’t necessarily teach them it….this is how the medical education system works. “Knowledge is power” and thus, lack of knowledge is disempowering. By not requiring US medical students to know basic global health topics, we are disempowering them and in doing so contributing to the global health inequities that claim millions of lives a year and cause millions of more to needlessly suffer from disability.
When I bring this idea to various tables or conference rooms, at least one person says “but what do we teach” and several others nod in enthusiastic agreement with the skeptic. Global health is an amorphous beast in many respects. Luckily, people with more dedicated time and know-how than you or I have given it much thought and come up with competencies for medical students. There are several competency sets out there. One of my favorite sets is by the Joint US/Canada Committee on Global Health Core Competencies.
The next challenge to is “who will teach it,” a valid concern. The irony about many faculty who do global health is that they are often somewhere on the other side of the globe for much of the time and unavailable to teach at their home institution. The other issue is that many people who work globally know their niche very well, but don’t feel competent speaking about basic global health topics. For instance, an Obstetrician may work in Eritrea developing an OB/GYN residency, but doesn’t feel comfortable teaching about the Millennium Development Goals or other basic global health concepts. Unlike many other medical school topics (cardiology, immunology, histology, etc) where the information is consistent and the body of knowledge clearly defined, global health is not so clear cut. You can be practicing global health through telemedicine, working with refugees in your community, or training the trainer in Mexico, but that doesn’t mean you understand basic tenants of global health, such as, “Why is the 3rd world the 3rd world?” If you want to find out view the presentation. Point being- faculty doesn’t feel confident to teach global health.
This too can be overcome. Thanks to GHEC, over 75 modules have been developed with extensive notes and soon-to-be-available quizzes. These can be used for self-instruction by students, as a complement to global health courses (such as UCSF’s Global Health 101 course), or can be used to teach faculty the information they need to teach to students. Faculty development is necessary. There are also many others in the community, in schools of public health, nursing, economics, anthropology to name a few, who can be utilized to teach medical students. I know this is complicated with funding streams, schedules, and academic appointments, but if there’s a will, there’s a way. Any faculty who are interested in getting a primer on global health topics and getting more comfortable teaching them can begin by accessing online resources I’ve linked to here.
Hurdles exist, but they are rather low. Students are demanding this reform and faculty are championing it. I think many feel there’s a hang up when “global health” gets to an administrative level. I could go around knocking on deans’ doors, but I’ve got medicine to practice and a family to care for….so I’m asking the AAMC, LCME, and NBME to strategize together or independently about how they can do what they know best and make global health education a requirement at US medical schools. I will suggest some concrete steps that each body can take. These come from my limited knowledge of how they work, and would welcome any feedback from those who understand these processes better or have been involved in influencing them. Email me at email@example.com to chat.
- NBME: please establish a writing task force on the subject of global health, similar to what was done for end-of-life care. In addition, recruit individuals to write global health competency based questions for USMLE Step 1 and 2. (I am happy to provide some references of qualified folks).
- LCME: please recognize global health content in satisfying your licensure requirements, perhaps these can be considered under ED-10 as “socioeconomic subjects,” ED-11 as “public health,” or ED-20 as “medical consequences of common societal problems” (Full LCME accreditation requirements).
- AAMC: please utilize the Medical School Objectives Project (MSOP) to promote competencies in global health, recognizing global health as a necessary objective of medical education.
I will make note of an effort at the LCME level (MS-20 proposed at May and Sept 2010 gatherings of the LCME) to require pre-departure training for all medical students undertaking an international electives. This effort is led by Kelly Anderson and Michael Slatnik (two Canadian medical students at the time who are now Family Medicine residents), who successfully advocated for such a requirement at all Canadian medical schools. Such change is very possible, thanks to our Canadian counterparts for paving the way.
AAMC, LCME, NBME, and other powerful entities in medical education- in addition to creating novel new programs, please look at your inherent sphere of influence over medical education and consider leveraging your power to make curricular changes. Require US-trained physicians to have minimal knowledge about realities in disease and healthcare in underserved populations around the world. It is only with such knowledge that we physicians can respond to demands both within and beyond our borders and be effective advocates, colleagues, and caregivers.
Jessica Evert, MD
Medical Director, Child Family Health International