Copyright 2006 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2006
To describe the organizational features of an international child health elective (ICHE) and to document the diversity of diagnoses observed by residents.
Faculty from the Department of Pediatrics, University of Colorado Health Sciences Center, Denver, created a steering committee in 1999 to develop and direct an ICHE, including selecting residents, selecting and organizing sites, and creating objectives and a year-long preparatory curriculum. The elective was piloted in 2000 and repeated in 2002 and 2004.
Setting and Participants
Residents chose from 4 ICHE sites in Peru and Guatemala, where they observed clinical care in various clinical settings during a 4-week elective.
Main Outcome Measures
The ICHE was evaluated via written evaluations by faculty and residents as well as written and oral reports by participating residents.
During the 2000 and 2004 electives, residents recorded clinical cases in a data-entry log. Of the patients logged, 18% had illnesses never seen before by the residents and 5.6% had illnesses in advanced stages not previously seen by the residents. Strong reciprocal relationships were created between the department and participating international institutions. Residents reported uniformly that the elective was a valuable element of their training.
Planning and faculty involvement in ICHEs helps to ensure achievement of elective objectives. Well-organized ICHEs have the potential to augment resident education. The experience at our institution demonstrates that ICHEs can provide experience with a variety of medical systems, exposure to diverse pathophysiologic conditions, and opportunities for collaboration with international colleagues.
Pediatric resident international child health electives (ICHEs) in developing countries provide a unique educational experience and are an important component of pediatric residency training in the United States.1 This type of elective provides cross-cultural medical experiences with exposure to different health care delivery systems, rarely seen diseases, and opportunities for language immersion. Previous studies have indicated that international electives may influence career decisions, leading to an increased desire to work with underserved populations and a higher likelihood of choosing a career in primary care.2- 5
Many residency programs have developed international health electives (IHEs) with various formats. A 1995 survey of pediatric residency programs in the United States, Canada, and Puerto Rico showed that 25% of the responding programs offered formal or informal ICHEs.1 These data suggest that ICHEs are a common component of pediatric residency training. Accordingly, the American Academy of Pediatrics has developed consensus guidelines that outline goals for pediatric residents wanting to participate in ICHEs and for programs seeking to organize ICHEs.1
There are several reports in the literature about the educational value of IHEs, most of which rely on survey data.2,3,5- 9 However, despite the prevalence of ICHEs in pediatric training programs and the American Academy of Pediatrics consensus guidelines, the literature reports relatively few successful pediatric ICHEs and little information about how they are organized.6,10- 12 Information about costs to residents and to the residency program, preparation of residents for travel abroad, structure of electives, site selection, and participant selection is beneficial to residency programs that seek to create successful ICHEs.
The University of Colorado Health Sciences Center Department of Pediatrics (UCDP), Denver, developed an ICHE that was piloted in April 2000. The elective has continued biannually, with the third wave of residents participating in the spring of 2004. During that period, the elective has evolved and has been successful as measured by resident and faculty evaluations, the overall safety of all participants, and the development of a reciprocal relationship with the participating institutions abroad.
The objectives of this article are to describe the organizational features of the elective, to outline the format of the elective in a way that might serve to assist other programs in the development of similar electives, and to describe the unique pathologic conditions seen in the clinical cases by the residents.
In 1999, a steering committee consisting of faculty members with interest and experience in international child health was formed with the intent of developing an ICHE that would be available to UCDP residents.
The elective was specifically designed to attract residents who did not have previous experience working or traveling in developing countries, and who would otherwise be unlikely to do so. Through an organized and positive experience, we expected to foster an interest in international health in this group. Additionally, it had been noted in our institution that residents with previous international experience were successful in organizing and completing IHEs independently. Although interns may have had more time to cultivate an interest after such an experience, the committee decided to restrict the elective to second- and third-year residents for 3 main reasons: (1) there would have been logistical challenges in meeting and preparing interns in less than 12 months; (2) interns in our program are scheduled for only 1 elective month throughout their first year; and (3) more experienced residents would have more knowledge of and insight into pediatric medicine and its practices in the United States, thus maximizing the educational exchange.
Participating residents were chosen 12 months in advance to facilitate planning and schedules. Electives were arranged for the fall of the following year. Groups of residents chose one of the designated sites for a month-long rotation. The residents selected their rotations on the basis of areas of interest from a variety of services or clinics at each institution. The rotation was primarily observational, although many opportunities were provided for hands-on learning through physical examination and case discussions. The decision to make the experience observational was driven principally by UCDP’s liability concerns. While abroad, residents were expected to give a collective grand rounds presentation in Spanish on the structure of pediatric training programs and the logistics of being a resident in Colorado. Clinical observations in both clinic- and hospital-based settings occurred during a 3-week period. A 1-week period was allowed at the end of each month for travel and cultural and language immersion.
At the end of the elective, residents completed a descriptive evaluation of the elective and the clinical experience obtained during the rotation. Other postrotation requirements included a formal oral presentation representing all aspects of the rotation to faculty and peers at a noon conference as well as an evening presentation open to both groups of funders. In 2002, a written report on the residents’ topic of choice germane to the objectives was added. These topics were agreed on before residents left for the ICHE, to avoid redundancy.
Members of the UCDP faculty accompanied the residents during various parts of the elective months. They were assigned to solve organizational issues that could not be anticipated a priori and to provide support to ease the transition for residents who had little experience traveling outside the United States. Several opportunities for didactic teaching sessions in each of the faculty members’ areas of expertise were arranged in advance. Faculty members were also asked to evaluate the elective experience and to provide feedback on their return.
Institutions for exchange were identified on the basis of preexisting working relationships between faculty at UCDP and faculty at the proposed ICHE sites. All sites chosen were teaching institutions where residents could be incorporated into a traditional teaching structure and supervised by faculty on rounds or in clinics. A critical element in the design of the elective was reciprocity between institutions; in addition to UCDP residents rotating abroad, residents from host countries would be welcomed to rotate at UCDP. Agreements to this effect were signed between UCDP and all ICHE rotation sites on initiation of the elective.
The committee developed a written description of the elective and a set of objectives. These objectives were presented and agreed on by all participating departments (UCDP and those abroad) and were approved by the Pediatric Residency Program Committee and the chair of pediatrics from the home program:
To gain perspective on the role of pediatrics in health care delivery in the developing and developed world
To gain experience with common medical and public health problems in developing and developed countries
To experience different medical systems, cultural practices, and understandings of disease causation and treatment
To analyze residency and academic training curricula, issues, and problems in developing and developed countries
To gain facility in medical practice and social interaction in a second language
To share current scientific information in an area of expertise with international colleagues.
A comprehensive orientation program was structured for the participating UCDP residents. The orientation consisted of monthly dinner meetings where a variety of topics were covered, including aspects of tropical medicine, cultural and language competency, a general overview of Peru and Guatemala, information about travel in developing countries, and safety issues specific to the ICHE. Orientation dinners were also used as a forum for discussing organizational details of travel and the elective. Residents were asked to sign a release form created by the UCDP and agreed on by the University of Colorado Health Sciences Center legal department, copies of which are available on request from the corresponding author.
The UCDP agreed to cover the costs of resident salaries and benefits during the ICHE. This was justified by the assumption that such electives are worthwhile educational experiences and the fact that UCDP residents may choose to spend up to 2 months of their residency at sites other than UCDP-affiliated hospitals. Grant funding was received from UCDP, the Colorado Chapter of the American Academy of Pediatrics, and a private foundation (Community Child Health Foundation, Denver, Colo), which covered the cost of housing for residents while abroad as well as group ground transportation to and from the hospital. Residents received most of the recommended travel vaccines through the hospital’s employee health clinic or the county immunization clinic at no or minimal charge. Residents paid for the additional travel costs, including airfare, food, local travel, and additional transportation. Residents spent approximately $1000 on ICHE expenses, not including the costs of travel on weekends or during allotted vacation time.
In addition to resident salaries, in 2004 the Department of Pediatrics began providing an administrative support person for the steering committee, as well as supporting 5% of 1 full-time faculty member as acting committee chair. Departmental support on this level can be particularly difficult to attain. The support of the department was thought to be essential to the success of an elective of this scale. All of these agreements were negotiated over time. Table 1 gives a timeline for development and execution of the elective. This study met the exclusionary criteria from the Colorado Institutional Review Board.
Residents were selected for participation on the basis of their stated interest in the ICHE, availability, schedule flexibility, language abilities, and essays when necessary. All participating residents had completed more than 18 months of pediatric residency training. Although the pilot elective included 7 residents, in its current format it is limited to 3 to 4 residents in a given month because of staffing constraints within the training program.
The residents’ ability to speak Spanish has been quite variable. Those who were fluent have suggested in their evaluations that their ability to follow along on rounds provided them with a more comprehensive medical experience than that of their peers. However, those with limited language skills indicated that their comprehension on medical rounds improved exponentially as the month progressed. Additionally, they reported that their conversational skills were aided tremendously by the experience.
All participating groups of residents successfully completed the oral and written requirements of the elective. Residents and faculty stayed together in hotels or with families located near the hospitals. This allowed faculty to have firsthand knowledge of the daily logistics of each site. Additionally, faculty made rounds at the host institutions and gave lectures in Spanish on topics of interest to the host sites.
While abroad, each group gave a general overview of the University of Colorado Health Sciences Center training program. On their return, each group also presented an overview of their experience at a noon conference to the faculty and their peers. Since 2002, all residents fulfilled the additional requirement of submitting a written report on a variety of aspects of the residents’ experiences, including pediatric training in Peru, the Peruvian health care system, infectious disease and public health issues in Peru, infectious disease–related morbidity and mortality, anatomy of a rotavirus outbreak, vaccine-preventable diseases, other infectious diseases, barriers faced by health care reform, the neonatal intensive care unit experience, an interview with Edwin Asturias, MD, infectious disease in Guatemala, overview of the pediatric residency in Guatemala, and overview of the Guatemalan health care system. These reports serve as testimony to the variety of health care issues that these residents were exposed to in their various experiences. Additionally, the reports were compiled into a yearly comprehensive overview and presented to both the faculty committee and the funders. In conjunction with the oral presentations, these reports served as a way for the department to document the fulfillment of the elective’s outlined objectives.
Originally, residents were able to choose among 3 sites located in large cities; in 2002 a regional site in Cusco, Peru, was added at the residents’ request (Table 2). An agreement has recently been reached to add a site in Quito, Ecuador, for the 2006-2007 rotations.
In April 2000, 7 pediatric residents and 5 faculty members from UCDP participated in the pilot elective at 2 sites in Lima, Peru. In 2002 and 2004, the elective sites were expanded to include the cities of Cusco and Guatemala City, Guatemala. Six residents and 6 faculty members participated in 2002, and 8 residents and 5 faculty members participated in 2004. In spring 2006, 6 residents are slated to rotate in Lima during 2 separate months and 3 will be in Guatemala City.
During the 2000 and 2004 electives, a data-entry log was used to record all clinical cases seen by the residents. Recorded data included the patient’s age and sex, inpatient vs outpatient setting, and a diagnostic code identifying the general category of disease. Residents also identified which of the diagnoses they had not seen previously, and which had never been seen in such an advanced state. Thirteen of 14 participating residents completed the case logs, for a participation rate of 93%. A total of 890 cases were recorded; Table 3 gives the variety of diagnoses the residents observed during the rotation. There was a preponderance of infectious disease cases on the inpatient service, whereas in the outpatient service most cases were in the areas of dermatology and diarrhea or dehydration related to gastroenteritis. Of the cases observed, almost 18% were illnesses not previously seen by the residents and 5.6% were illnesses in advanced stages that the residents had never seen before. Many of the infectious diseases were unusual and had not been observed previously by the residents (Table 4).
Feedback from resident and faculty evaluations of the elective was uniformly positive. Constructive ideas were solicited each year regarding ways to improve the elective, and these ideas were implemented whenever possible. For example, language tutoring was made available at one of the sites, so that residents who were less fluent would have an increased opportunity to improve their Spanish skills. Additionally, a smaller, more regional hospital site (Cuzco) was made available per resident request; in 2002, residents spent up to 1 week in Cuzco, and in 2004 two residents spent their entire elective in Cuzco. Although this site provided more opportunities for the residents to participate actively as medical team members, the case logs disclosed that residents on the rural rotation saw fewer patients overall and fewer illnesses that were new to them or in more advanced stages than they had previously seen (Table 5). This led to the cancellation of Cuzco as a permanent site.
The reciprocal agreements between institutions have been successful. The UCDP has hosted approximately 4 visiting residents per year since the inception of the ICHE, mostly from the Instituto Nacional de Salud del Nino and Cayetano Heredia School of Medicine in Lima, Peru. This is consistent with the initial agreement, which specified a maximum of 1 visiting resident for every 1 sent between UCDP and the affiliated host sites. Furthermore, since the inception of the elective, UCDP has matched 3 South American graduates into its residency program, further enabling the ongoing cultural and educational exchange (eg, a primary facilitator of the development of the new site in Ecuador was a second-year resident from Quito). Finally, in December 2004, Dr Asturias, who serves as the site coordinator in Guatemala, visited Denver and the Children’s Hospital as a visiting professor. The feedback from both institutions in Lima as well as Guatemala has been overwhelmingly positive. The program has been strongly encouraged to expand the elective to a yearly event to facilitate planning by both sites.
Despite these successes, the goal of reciprocity has had limitations. For instance, there have been no visiting residents to Denver from Guatemala. Most of the feedback on this limitation has centered on the expense of housing and transportation associated with a prolonged stay in the United States.
The information provided about the organization, implementation, and evaluation of our elective is valuable to other pediatric training programs that are trying to create ICHEs. A significant amount of planning and faculty time, energy, and involvement is necessary to ensure that these ICHEs are a valuable learning experience and not simply an opportunity for “medical tourism.” Given the detailed objectives, pretrip curriculum, pretrip and posttrip oral presentations, patient logs, language tutoring, final written reports, and evaluations, our ICHE has grown in popularity not only with the house staff but with the faculty and administration as well. We hope that these electives will gain in popularity in US pediatric training programs because of what they add to resident education and possible future international health involvement from graduating residents.
In his article on overseas electives, Northrup9 wrote, “a two-month elective in a developing country can be a profound experience, often resembling a religious conversion, and can dramatically alter . . . perceptions of health, health care, and societal and personal responsibility.” Our results support this perception. Given current restrictions on elective time and time away from the program, our experience has primarily been restricted to 1 month, but we found that 1 month can serve as an excellent beginning in international health. Northrup went on to emphasize the importance of organization in achieving an effective elective experience. We believe that the careful planning and organization that went into the development of the UCDP elective helped to ensure a positive experience for all participants.
A recent study suggested that the availability of international opportunities during residency positively affects residency program ranking by medical students.13 Thus, IHEs may offer value as “recruiting tools” for training programs. Anecdotal evidence suggests that this is becoming true at the UCDP residency program. At a recent meeting with the intern class of 2004-2005, all of the residents reported having had some knowledge of the ICHE before their acceptance to the program. In addition, approximately 75% expressed interest in participating, and about 50% stated that it was a major factor in their ranking process. Further elucidating the effect on recruitment, the incoming intern class of 2005-2006 reported unanimous knowledge of the elective before match selection, 67% reported it as a major factor in ranking, and 96% stated an interest in participating. This level of interest has encouraged the department to expand the elective to a third country and provide it on a yearly basis.
The UCDP residents saw diverse pathologic conditions during their clinical observations in the institutions in which they were placed during the 2000 and 2004 electives. Data entry logs show that the residents observed many types of diseases that they had not encountered in the United States. This evidence of enhanced clinical experience supplements the residents’ own evaluation that the elective was of value to them.
Several reports have documented that residents who have participated in an IHE are more likely to improve their knowledge of tropical medicine, to change their career plans toward areas of primary care and public health,4 and to reduce their dependence on laboratory testing because of increased awareness of health care costs.14 In 2003, Thompson et al3 reviewed the literature on the topic of IHEs and discovered only 1 study that used quantitative data (National Board of Medical Examiners examination scores) rather than self-administered questionnaires to evaluate the educational effects of these programs. Our experience provides objective evidence to contribute to the pool of data supporting the benefits of IHEs.
Correspondence: Steven G. Federico, MD, Denver Health Medical Center, 777 Bannock St MC0132, Denver, CO 80204 (firstname.lastname@example.org).
Accepted for Publication: August 21, 2005.
Author Contributions: All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Previous Presentation: The outcomes of this study were presented in abstract form at the annual meetings of the Pediatric Academic Societies; May 2001; Baltimore, Md; and April 2005; Washington, DC.
Acknowledgments: We acknowledge M. Douglas Jones, MD; Mimi Glode, MD; Adam Rosenberg, MD; and Jacinto Hernandez, MD, from the UCDP for their support of the ICHE. We also acknowledge the help of Jaime Zegarra, MD (Cayetano Heredia School of Medicine), Jorge Candela, MD (Instituto Nacional de Salud del Nino), Edwin Asturias, MD (Hospital Roosevelt), and Felix Hidalgo, MD (Hospital Regional) in creating and maintaining successful rotation sites in their home cities.
Federico SG, Zachar PA, Oravec CM, Mandler T, Goldson E, Brown J. A Successful International Child Health ElectiveThe University of Colorado Department of Pediatrics’ Experience. Arch Pediatr Adolesc Med. 2006;160(2):191-196. doi:10.1001/archpedi.160.2.191