Global Health Residency and Fellowship Core Curriculum

The aim of the Duke Global Health Residency and Fellowship Program is to prepare trainees to bridge clinical practice with public health principles in order to reduce health disparities both locally and abroad. Participants in the program come from multiple departments across Duke University Medical Center and extend their specialty training through their work in the program. This expanded residency and fellowship provides additional opportunities for global health clinical service, research, and education.

The Global Health Residency and Fellowship core curriculum focuses on general issues related to clinical practice, research, and health policy in low resource settings. Within the curriculum, particular attention is given to issues of cultural sensitivity and medical and research ethics. Global Health Residents and Fellows, regardless of their discipline, will obtain a profound appreciation for the determinates and consequences of health disparities in the communities where they work, and special attention will be given to understanding key prevalent causes of morbidity and mortality encountered in resource-poor settings.

Objectives of the curriculum are achieved during three major assignments or rotations. The core rotations are:

• Site Assessment
  This rotation at a Duke University international partner site takes place prior to starting master’s classes in August. The site assessment helps inform research ideas and guide master’s thesis topics and allows trainees to begin studying site-specific clinical and cultural issues.

• Master’s Training
  Eligible trainees enroll in the Master of Science in Global Health degree program (MSc-GH) offered by the Duke University Graduate School in conjunction with the Duke Global Health Institute. The MSc-GH program offers Global Health Residents and Fellows opportunities to develop and refine skills in research study design, quantitative and qualitative methods, and to understand some of the key health policy and ethical challenges confronting those engaged in global health careers.

• On-site Global Health Training
  During On-site Global Health Training, residents and fellows spend 7-12 months conducting mentored research and clinical care at their international partner site. Research conducted during this time is expected to be used towards a master’s paper of publishable quality. During the rotation, trainees attend relevant clinical and research conferences.

Regarding financial support: Financial support for trainees provided by the Global Health Residency and Fellowship Program includes salary, graduate school tuition, and limited support for travel related expenses. Trainees are responsible for their own living expenses while overseas.

A.) Global Health Competencies

Regardless of specialty training, all residents and fellows will be expected to demonstrate competencies in the following areas to be effective global health physician leaders.

1. Patient Care

1. Demonstrate culturally appropriate, caring, and respectful behavior in all patient interactions.

2. Gather essential information from patients by performing a complete history with appropriate use of translators and progressive acquisition of skills in the local language and dialects

3. Demonstrate culturally sensitive and efficient physical examination skills.

4. Make informed decisions about diagnostic and therapeutic interventions with an understanding of the resource limitations of the practice setting.

5. Develop culturally appropriate counseling and education methods for patients and families.

6. Demonstrate creative and effective use of information technology in patient care.

7. Perform indicated procedures as needed, adapting to the constraints of resource-limited settings.

8. Serve as a model for effective inter-departmental communication and collaboration within the institution.

9. Demonstrate a commitment to the culturally sensitive application of medical ethics to patient care in this setting.

10. Demonstrate an active awareness of relevant continuous quality improvement initiatives that are achievable in this setting.

11. Demonstrate a commitment to patient safety and autonomy in all endeavors.

12. Advocate for quality of patient care at all times.

13. Demonstrate the appropriate application of public health knowledge and methodology when implementing patient care plans.

2. Global Public Health Research

1. Complete master's degree in global health or public health.

2. Engage in research project of global public health significance.

3. Develop a working understanding of the local and regional research needs of the communities in which the trainee is working.

4. Develop a practical understanding of the existing research programs and institutional review protocols already in place.

5. Understand the historical, economic, and cultural issues that may have an effect on research initiation and implementation in the relevant health care facilities and communities.

6. Demonstrate practical applications of medical research ethics with special attention to issues of distributive justice and autonomy.

7. Demonstrate an appropriate understanding of the pitfalls and challenges of medical research in under represented and often impoverished populations.

8. Lead a research project that is regionally relevant and involves one or more nationals in key investigative roles.

9. Discuss the vagaries and challenges of the informed consent process in patients who do not speak the common medical language and in those who may be illiterate or who may not have a shared conception of respect for autonomy.

3. Personal

1. Demonstrate a commitment to continuing education despite limited access to educational resources.

2. Identify areas for personal and practice improvement.

3. Demonstrate receptiveness to instruction by local physicians and non-physician providers.

4. Facilitate the education of learners within the system by serving as a teacher and role model to local medical students, residents, nurses, and faculty.

5. Demonstrate the ability to discuss medical errors in a culturally sensitive manner and a willingness to learn from these errors.

6. Begin a process of self-analysis that will foster an awareness of the additional stress that can be encountered when practicing in a different country and socio-cultural setting.

7. Develop a personal system for stress reduction and coping mechanisms for the inevitable tragic medical events one will encounter in this setting.

4. Health Disparities

1. Demonstrate an understanding of key proximal determinates of health disparities.

2. Work to find solutions to health disparities.

3. Demonstrate an ability to discuss the ethical principles that are most important in health care delivery in under-resourced settings (e.g., the relative importance of justice vs. beneficence).

4. Discuss the role of foreign health professionals in the medical systems of developing nations.

B.) Learning Experiences

The master's program will provide trainees with the opportunity to look at health from a population-level perspective. The course work will broaden their skill set as physicians by being better able to identify and evaluate the social and environmental determinants of health. They will be required to work with students from various educational backgrounds and disciplines on group projects, thereby developing their team-building and collaboration skills. They will acquire knowledge and skills necessary to lead investigative or service projects by further developing their quantitative skills, which they will then put to use overseas. The health programs management training will provide trainees with skills in coalition building, program administration, cultural competency, and funding procurement. The Duke Global Health Institute also provides numerous opportunities for participation in global health lecture series.

While abroad, trainees will be have exposure to the prevalent causes of morbidity and mortality encountered in resource-poor settings. Trainees will deepen their understanding of health disparities while caring for patients whose health is compromised due to social determinants.

Their patient care will demonstrate the practical implementation of their public health knowledge. Because of the constraints, trainees will improve their clinical abilities in problem solving, physical examination proficiency, and foreign language communication skills. On-site faculty will supervise trainees clinical and research activities and provide mentorship as needed.

C.) Program Requirements

To successfully complete the Global Health Residency and Fellowship Program, trainees must complete the following minimum requirements:

Research

• Depending on your overseas site, it may be extremely difficulty to initiate your own research project (as opposed to working on an already existing project). Any individual projects must be discussed with the program director and your research mentor. All regulatory documents must be submitted in sufficient time for project completion.

• All research must be compliant with the Duke Institutional Review Board (IRB) and local and national ethics committee requirements.

• Submit a brief research proposal (1-3 pages) for approval by the program director and your research mentor upon return from your site assessment trip.

• Meet regularly with your research mentor and the program director according to a mutually agreed upon schedule.

• Submit multiple grant applications for funding with the goal of identifying a sustainable funding mechanism post GHRP. Suitable project funding mechanisms will be discussed with your mentor and program director upon return from the site assessment.

• Produce one or more global health topic oriented manuscripts of publishable quality. Manuscripts for publication should be approved by GHRP leadership prior to submission and must cite collaborators and funding sources.

Didactics

• Complete or work towards completion of Masters of Science in Global Health. GHRP trainees who already have advanced degrees (e.g., MPH, MHSc, or PhD) in relevant fields will work with the Program Director to identify relevant coursework from these or other programs to further enhance global public health training.

• Actively participate in our Multidisciplinary Global Health Journal Club. Our bi-weekly journal club is also open to all research mentors. GHRP will work with trainees/fellows to schedule a regular meeting time around class and clinical schedules. Trainees are expected to lead journal club on a rotating basis.

• Engage in language training, either individually or with a tutor.

Administrative

• Work proactively with the HYC to complete all required administrative paperwork on time. This includes, but is not limited to IRB submission, travel documents, licensing documents and new hire paperwork (if applicable).

• Abide by all requirements established by your primary specialty program director to establish board eligibility if you are completing a traditional post-graduate training program at the Duke Medical Center. This includes, but is not limited to engaging in clinical activities as discussed with your research mentor and the program director.

• Attend a travel clinic or health department to receive all necessary immunization prior to departure.

• Work full time at your overseas location. Personal vacation and travel should be cleared with your local faculty mentor or supervisor and must be in compliance with the guidelines of your departmental residency program.

• Complete rotation and program evaluations as required as well as debriefs upon return from your overseas rotations.

Other Key Deliverables

• The research project should be planned with a target to complete the project prior to terminating the residency/fellowship program, with a deliverable of a draft manuscript for submission to a journal.

• Generate a log of at least five instructive patient cases in which social determinants have played a major role in the health and health access of a given patient.

• Present a topical or project-related academic talk to the Duke medical and global health community once during your master's year.