Global Health Course
GOALS AND OBJECTIVES
A. Overview:
The program of the June Global Health Elective is designed to provide the house officer with the knowledge and skills needed to diagnose and treat diseases of the developing world, mostly Africa, South America and Asia in preparation for a global health experience in Uganda.
The June GH Elective consists of one block of 4 weeks, with classes, rounds and workshops for 3.5 days, and clinic for 1.5 days. The GH rotation/elective is available to all Internal Medicine PGY IIs..
Residents work in teams under the supervision of the GH Faculty, particulary Dr. G Paccione
B. Level based Rotation Goals and Objectives:
PGY2:
Competency 1: Patient Care
Prepare, through the elective, to provide patient care that is age-appropriate, compassionate, and effective for the treatment of health problems and the promotion of health in the developing world.
1. Use a logical and appropriate clinical approach to the care of patients in a developing country setting, utilizing locally available resources, and applying principles of evidence-based decision-making and problem-solving through participation in daily Global Health Clinical Workshops.
2. Understand the approach to patients with the following presentations in developing countries and initiate appropriate work-up and management:
Diarrhea/dehydration
Respiratory Distress
Fever
Seizures/Altered Mental Status
Malnutrition (including Severe Acute Malnutrition)
Chronic Disease: HT, DM, Epilepsy, etc
HIV and wasting illnesses
TB
CHF, ascites, etc.
3. Understand what culturally sensitive care and support to patients and their families means in the African context.
Competency 2: Medical Knowledge.
Understand the scope of established and evolving biomedical, clinical, epidemiological and social-behavioral knowledge needed by an Internist; demonstrate the ability to acquire, critically interpret and apply this knowledge in patient care and community health.
Epidemiology/Public Health:
1. Describe the epidemiology, trends, and major causes of child, maternal and adult mortality and morbidity in developing countries, and contrast to that in developed countries.
2. Recognize the major underlying socioeconomic and political determinants of infant/child health, and how these impact inequities in child survival and health care access between and within countries.
3. Describe known effective interventions, including prevention and treatment, for reducing under 5 mortality and morbidity (e.g., vitamin A supplementation, exclusive breastfeeding, etc.).
4. Recognize the major underlying socioeconomic and political determinants of chronic disease in the developing world, and how these impact inequities in mortality between and within countries.
5. List the leading causes of maternal mortality in the developing world, how they are impacted by health care systems, and contrast them with those in industrialized countries.
6. Identify epidemiological trends and significance of emerging infectious diseases in the developing world.
7. Understand the impact of environmental factors, including safe water supply, sanitation, indoor air quality, vector control, industrial pollution, climate change and natural disaster on health in developing countries.
8. Demonstrate a basic understanding of health indicators and epidemiologic tools and methods, and how they may be used in settings with limited resources to monitor and evaluate the impact of public health interventions.
9. Understand the common injuries, including motor vehicle accidents, ingestions, and burns that contribute to morbidity and disability in the developing world, and describe prevention strategies.
Malnutrition and Infectious Diseases:
10. Recognize signs and contrasting features of:
Underweight
Stunting (chronic malnutrition)
Acute Malnutrition – severe/moderate, complicated/uncomplicated
Micronutrient deficiencies (iron, vitamin A, iodine, zinc)
Low birth weight and associated maternal risk factors
Understand and compare the different anthropometric measures used to diagnose malnutrition, and principles of prevention and management of these different disorders.
11. Describe the interaction between malnutrition/micronutrient deficiencies and infectious diseases in infants and young children.
12. Become familiar with the presentation, diagnosis, management, and prevention strategies of the following specific diseases in resource-limited settings, based on local and international guidelines:
Malaria - uncomplicated and complicated/severe (e.g. Cerebral malaria)
Pneumonia
Diarrhea and dysentery
Measles
HIV/AIDS and related infections/complications
Tuberculosis
Typhoid Fever
Dengue Fever
13. List the vaccine-preventable diseases and the immunizations available in developing countries, and know the current international vaccine policies and recommendations (WHO EPI).
14. Identify conditions that contribute to morbidity and impaired cognitive development in the developing world such as intestinal parasites, hearing loss, birth complications, anemia, infections (eg cerebral malaria), nutritional deficiencies, injuries, and environmental toxin exposures.
Specific Populations
15. Describe common health issues faced by immigrant and refugee populations in developed nations.
16. Describe health issues of populations in the developing world affected by humanitarian crisis, including refugees, internally displaced, and orphans.
17. Understand the challenges faced by people living with disabilities in resource-poor settings, and describe prevention strategies and models of support
Competency 3: Interpersonal Skills and Communication
Demonstrate interpersonal and communication skills that result in information exchange and partnering with patients, their families, their communities, and professional associates.
Understand the issues involved in effective communication approaches with individual patients and promotional messages in communities with limited literacy and education
Competency 4: Practice-based Learning and Improvement
Demonstrate knowledge, skills and attitudes needed for continuous self-assessment, using scientific methods and evidence to investigate, evaluate, and improve one's patient care practice.
1. Identify standardized guidelines (e.g., WHO/UNICEF) for diagnosis and treatment of conditions common to developing countries and adapt them to the individual needs of specific patients.
2. Know and/or access appropriate medical resources and apply them to the care of patients in the developing country setting.
3. Understand the principles of evidence-based medicine and apply them when reviewing recent literature and considering the implications for impact on practice.
4. Understand the role of physical examination skills and clinical diagnosis in settings where diagnostic studies are limited.
5. Identify and utilize the resources needed to prepare for an international rotation or work in a less developed country.
6. Understand the role of the internist in responding to humanitarian emergencies and disaster relief efforts, within the context of participating local and international organizations, and become familiar with available resources to prepare for volunteering in this setting.
Competency 5: Professionalism.
Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diversity when caring for patients in a developed or developing country setting.
1. Be aware of appropriate professional behavior in interactions with staff and professional colleagues and be respectful of differences in knowledge level and practices.
2. Give examples of cultural differences relevant to care of international populations and how traditional medicine and Western/scientific medicine can conflict with or complement one another.
3. Identify common ethical dilemmas and challenges confronted when working in a setting with limited resources or different cultural values.
4. Understand the ethical standards and review processes for research with human subjects carried out in developing countries.
5. Recognize personal biases in caring for patients of diverse populations and different backgrounds and how these biases may affect care and decision-making.
6. Understand and be sensitive to the profound inequities in global health and how individuals can contribute to diminishing these disparities.
Competency 6: Systems-based Practice
Understand how to practice high-quality health care and advocate for patients within the context of the health care system.
1. Compare and contrast different health care delivery settings in the developing world, including hospitals, clinics and the community, and the roles of different health care workers as they apply to patients in developing countries, such as the physician, nurse, community health worker, traditional birth attendant, etc.
2. Identify the major governmental and non-governmental organizations active in international child health, and give examples of initiatives and programs that impact health (WHO, UNICEF, Global Fund, GAVI, etc.). Understand how the policies and funding structures of these organizations as well as donor nations impact global child health.
3. Describe international goals and strategies for improving health (such as the Millennium Development Goals), and how these have impacted policy, funding and development of health programs worldwide.
4. Develop understanding and awareness of the health care workforce crisis in the developing world, the factors that contribute to this, and strategies to address this problem.
5. Identify different health care systems and fee structures between and within countries, including the public and private sectors, and understand the impact of these systems on access to patient care and quality of care.
6. Demonstrate sensitivity to the costs of medical care in countries with limited resources and how these costs impact choice of diagnostic studies and management plans for individual patients.
7. Contrast the advantages and disadvantages of different approaches to implementing health care interventions in developing countries, such as vertical or targeted programs vs integrated, focused vs comprehensive, facility-based vs. community. Describe the WHO Integrated Management of Childhood Illness (IMCI) program as an example.
GLOBAL HEALTH ROUNDS
The 13 “Global Health Rounds” that we will have over the course of the month enlist course participants as teachers and discussants of the Global Health literature. The goals of the rounds are to introduce and discuss the GH literature; to cover important themes that aren’t presented in the Core curriculum, or additional, interesting angles on Core topics; and to stimulate discussion by ensuring that most rounds participants have a stake in the topic through their preparation/presentation.
To maintain a small-seminar atmosphere, there will be 3 separate GHRs every morning with 8-9 participants per GHR: two GHRs with residents, one GHR with students. Each of the 3 GHRs has been sub-divided into 3 groups, A-B-C, with each group responsible for 2 GHR presentations per week. Thus all residents and students will have 3 GHR's/week, with 2 groups presenting 2-4 articles each for a total of 4-8 articles per GHR. All group members are expected to peruse and be familiar with all their group-assigned readings - at least the abstracts of all the articles - but for their individual presentations, to read carefully and present only the article they are assigned. Sometimes there are 2(-3) folks assigned one article: in that case, just split the pages to present and/or choose different themes to comment on (the faculty facilitator may help in this), but please, each read the entire article! Other times one person is assigned 2 short readings. The average # of pages per presentation is less than 7 per GHR, varying between 3 and 10.
Each article will be the topic of discussion for about 10 minutes. The basic idea is for the participant(s) to present the most salient points of their selected article(s) in about 7-12 minutes (per article, not per presenter), with 5 minutes reserved for discussion. Thus, we will aim to cover an average of about 6 articles per GHR...over about 90 minutes. Discussion can occur after each article or at the end.
Admittedly, there are many, many points in each article, and each could be conceivably discussed for an hour! Thus, EDITING IS KEY! We’ve tried to help the editing process by preparing TEACHING OBJECTIVES (T.O.s) for each article - which you should address, but can go beyond. As you read an article, we suggest “bullet” the principle teaching points aiming at whatever is NEW, or particularly INTERESTING to you, or really CORE to the thrust of the article. Before presenting an article, please jot down your key points and why they’re key on a separate page beforehand. Do NOT laboriously plod through nor superficially flip through the article during the session.
There are different types of articles in the GHR portfolio. If original research, summarize briefly the methods and results, and discuss the implications of the article (not a journal club critique); if a review, cover “new” and “interesting” only, don’t try to be comprehensive; if an editorial, focus on the foundations of the opinions expressed, and the key points of the editorialist’s reasoning. The T.O.s help keep to these guidelines.
Keep TIME in mind: 7-12 minutes per article, max, (somewhat depending on the total # of articles) and if the article is shared, half that per presenter. Please see the reading list for assignments: for each GHR the Groups are designated next to each article, with #’s next to the group, thus e.g. C1, 4. The numbers refer to the individual participants as indicated on the JUNE GH Course Schedule. Pairings vary each GHR, so different participants share articles throughout the month. If dividing an article to share, please do so by subheading theme, not simply page numbers so the presentations are cohesive….
GLOBAL HEALTH WORKSHOPS
The Global Health Workshop (GHW) is an educational experiment in tropical medicine organized around clinical presentations rather than causal microbes, in which knowledge about the various diseases emerges first from their symptoms rather than their microbiology.
The goal of the workshops is to train clinicians to take better care of patients - using just history, physical exam and very basic laboratory tests - in low resource settings, specifically on the medicine wards of Kisoro District Hospital in rural Uganda. They are centered around, and indeed start with, short clinical vignettes, many from Kisoro and emphasize clinical reasoning: the identification of important clinical data, the conceptual “framing” of the diagnostic problem using selected variables, the elaboration and organization of a differential diagnosis, and a cost-effective approach to appropriate empiric therapy.
Thus, the workshops assume a basic familiarity with various tropical diseases prevalent in East Africa, many of which you last came across in Microbiology or Infectious Disease lectures in medical school. Rather than repeating those microbe/disease-oriented lectures, the hope is that in preparation for the GHWs, you will “read up on the basics” of the diseases’ epidemiology and clinical presentations from the short, well-written ID chapters in Harrison’s – which you have received, pared down electronically, to focus on these aspects.
For each workshop, the group will be divided in 4 discussion teams of ~4 residents each. A case vignette will be handed out and read aloud, and then the groups will huddle and discuss the questions that follow – which usually start with the diagnostic “frame” and move into differential diagnosis, significance of certain findings, etc. After about 7-10 minutes, we reconvene and compare our analyses, and I comment, move us toward the diagnosis, and wrap up. Each case takes 15-20 minutes; we aim for 3, occasionally 4, cases per GHW – which takes about an hour; and then we have a 20 minute powerpoint summary of the key points. Over the course of the month, we will have 15 GHWs and cover ~55-60 different cases and tropical disease presentations.