Global Health Imaging Curriculum in Radiology Residency Programs: The Fundamentals Mary F. Wood, MDa, M. P. Lungren, MDb, C. M. Cinelli, MDc, B. Johnson, MDd, A. Prater, MD, MPHe, S. Sood, MDc, R. E. Gerber, MDc

Recent advances in imaging technology have created new opportunities for medical imaging to improve health care in resource-restricted countries around the world. Radiology residents are increasingly interested in global health and imaging outreach, yet infrastructure and opportunities for international outreach are limited. With the recent change in the ABR exam schedule, residents now have more flexibility in the fourth year of training to pursue elective interests, including participation in global health projects. Creating a formalized global health imaging curriculum will improve the quality, quantity, and overall impact of initiatives undertaken by residents and their training programs. A curriculum is proposed that provides content, opportunities for global health project development, and established metrics for effective evaluation and assessment. Four components considered integral to a global health imaging curriculum are described: (1) global and public health education; (2) targeted travel medicine education; (3) basic imaging proficiency; and (4) practice attitudes and accountability. Methods are presented of differentiating curricula to increase applicability across the spectrum of training programs that vary in available resources. A blueprint is presented for formalizing a global health curriculum or elective rotation within a program, as well as a resource for residents, radiologists, and organizations to make a meaningful impact on global health. Key Words: International, global health, elective, curriculum, radiology residency J Am Coll Radiol 2014;-:---. Copyright © 2014 American College of Radiology


Many medical specialties have had a tremendous impact on improving the provision of health care in developing countries [1-3]. The field of radiology, however, has lagged in terms of organized and consistent contributions [1,4-7]. The World Health Organization reports that two-thirds of the world population has no access to radiology services, specifically because of severe shortages of imaging equipment, personnel, and qualified radiologic interpretation. US organizations and institutions annually conduct approximately 6,000 international short-term health care missions in resource-poor countries, with a a

Department of Radiology, Eastern Virginia Medical School, Norfolk, Virginia.


RAD-AID International, Chevy Chase, Maryland.


Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts.


Department of Radiology, Stanford University School of Medicine, Stanford, California. e

Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia. Corresponding author and reprints: Mary F. Wood, MD, Eastern Virginia Medical School, Department of Radiology, PO Box 1980, Norfolk, VA 23501-1980; e-mail: [email protected].

ª 2014 American College of Radiology 1546-1440/14/$36.00

total cost of w$250 million. Only a minority of these efforts, however, focus on imaging [1,5-7]. The arena of global health imaging provides an opportunity to influence the quality and safety of health care delivery in regions that are underserved, particularly in population screening with mammography, prenatal complication triage with ultrasound, and infectious disease diagnosis (such as tuberculosis and AIDS) with radiography. Advances in technology have diminished many of the geographic and equipment portability barriers that once precluded meaningful global outreach and education in radiology. Available tools now include portable ultrasound, cellular phone data transfer, and web-based communication [1,5-7]. Successfully incorporating imaging services into resource-poor countries requires a multifactorial model, taking into consideration a population’s culture, disease patterns, political environment, and health care system. Moreover, compared to many other medical specialties, the modern radiology enterprise consists of a wide range of skilled professionals with diverse expertise, including radiologists, nurses, technologists, medical physicists, engineers, IT specialists, and administrators [1,5-7]. Health care professionals benefit from specialized knowledge and skills developed and shared by each of 1

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these complementary groups. Collaborative outreach must integrate these unique perspectives to ensure sustainable, comprehensive project development [1,5-7]. Over the past few years, trainee interest in international outreach has grown significantly. Participation by US medical graduates in international health initiatives has risen from 5.9% in 1978 to 22.3% in 2004. Nearly all of these students consider the experience to be enriching and, in many cases, the best part of their medical education [8]. To date, however, motivated radiology residents and fellows have primarily developed meaningful projects on an independent basis [2,9]. Very few (less than a dozen) well-established, current institutional opportunities exist that pair structured global health and radiologic specialty training. In addition to implementation and reproducibility considerations, there are very few established funding opportunities, such as the ACR Goldberg-Reeder Resident Travel Grant, for pioneering trainees [2,9]. Both current and prospective radiology residents acknowledge the importance and value of international outreach as part of their training. Recently, Lungren et al reported that although the majority of surveyed trainee radiologists plan to pursue future international medical aid work, they are poorly prepared [10]. The overwhelming majority of trainees asserted that an organized global health imaging curriculum would improve understanding of basic disease processes and cost-conscious care, allow development of interpretative skills in basic radiology modalities, and prepare residents for life-long involvement in global health (Table 1). The recent change in the ABR exam schedule affords new elective and selective opportunities during the fourth year of radiology residency. The opportunity for fourth-year programming was addressed in the Association of Program Directors in Radiology (APDR) Residency Restructuring Committee Report published by Deitte et al [11] and will have a dedicated section in the ACGME Milestone Project. Accordingly, the ACGME recently established Guidelines for International Rotations in Diagnostic Radiology that outline basic

requirements for brief international clinical and/or research electives in the fourth year of radiology training [12]. Thus, a global health curriculum for radiology residents now needs to be established to provide a pathway for imaging-related trainees to develop, implement, and participate in effective and sustainable global radiology projects. The ACR Resident and Fellow Section International Outreach Subcommittee’s aim is to present a reproducible outline for the implementation of a global health imaging curriculum in radiology training programs. We hope these guidelines will allow the flexibility required to apply to varied educational environments, engender a unique desire for scholarship and service, advance the standard of global health care, and train future international leaders. GLOBAL HEALTH IMAGING CURRICULUM

Many necessary components should be considered for effective curriculum development that is applicable at both the individual and institutional levels. Table 2 Table 2. Global health curriculum scope Curriculum Components Specific Proposed Components A. Curriculum content

B. Global health project development

Table 1. Radiology resident perspectives on global health training Less than 10% of surveyed residents reported developingworld opportunities at their residency programs, the lowest of the surveyed specialties (pediatrics was the highest with 74%; the second-lowest was orthopedics with 19%). Approximately 30% of surveyed residents performed prior work in the developing world, with prior international outreach rendering these residents more likely to support its importance during training. 60% of radiology residents would likely/very likely participate in international rotations if offered. 60% of radiology residents believe that international rotations are important for resident curriculum. Note: Table data are from Reference 11: Lungren MP, Horvath JJ, Welling RD, et al. Global health training in radiology residency programs. Acad Radiol 2011;18:782-91.

C. Evaluation and assessment

1. Global and public health education 2. Targeted travel medicine education 3. Practical radiographic and sonographic experience with potential for concentration in specific skill sets 4. Demonstration of appropriate practice attitudes and accountability 1. Needs assessment and project development accounting for regional culture, political environment, disease prevalence, health care system, and resources 2. Necessary approval from local and international training programs and organizations, including as applicable the Institutional Review Board and Ministry of Health 3. Logistical considerations including funding/industry partnerships, scheduling, and travel planning 4. Language proficiency þ/- arranged translation 5. Interpersonal communication and relationship building 6. Adaptability to necessary change and challenges 1. Engagement in personal assessment and reflection 2. Solicitation of supervisor and peer feedback 3. Results measurement and reporting 4. Discussion of outcome implications 5. Formal presentation at local, regional, national, or international meeting(s) 6. Published material in a peer-reviewed journal

Wood et al/Global Health Imaging Curriculum 3

outlines the essential structure and components of a global health imaging curriculum, best implemented by focusing on both short-term and longitudinal projects throughout the trainee’s 4 years of residency. The foundation of international health-related topics would be reviewed, in some cases leading to a global radiology experience. At the conclusion of the global health imaging program, an evaluation should assess resident competency based on outlined curriculum objectives as well as project improvement, maintenance, and growth. According to the ACGME, at the completion of residency training, the trainee should demonstrate proficiency in the 6 defined core competencies: patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal and communication skills [13]. Global health education relates to all of these established benchmarks in the following proposed objectives (Table 3). A global health imaging curriculum should provide content, opportunities for global health project development, and established metrics for effective evaluation and assessment.

Table 3. ACGME competency categories with suggested curriculum objectives ACGME Competency Proposed Curriculum Category Objectives A. Patient care

B. Medical knowledge

C. Practice-based learning and improvement


There are 4 components that are considered integral to a global health imaging curriculum. These are highlighted in Table 4 and include: (1) global and public health education; (2) targeted travel medicine education; (3) basic imaging proficiency; and (4) practice attitudes and accountability.  Global and public health education: Global health education should include broad topics such as socioeconomic, environmental, religious, and political factors as determinants of health and disease. Travel to some regions might require education about public health and human rights issues specific to immigrant, migrant, internally displaced, and refugee populations.  Targeted travel medicine education: Traveler safety is paramount. Up-to-date knowledge of the current regional climate is imperative. Site-specific epidemics, acute/chronic diseases, health-risk prevention and maintenance (including vaccination schedules), and variations in services for noncitizens should be researched prior to travel.  Basic imaging proficiency: Residents should have experience with and demonstrate proficiency in basic imaging modalities applied to global health imaging facilities [4,14], specifically radiography and ultrasonography. Depending on the curriculum scope, specific skills may be targeted, such as competence in ultrasound-guided interventional procedures or mammography.  Practice attitudes and accountability: A culturally sensitive approach to radiology’s implementation, screening and diagnosis relating to disease, healing, death, and dying should be researched, observed, and implemented. Residents should demonstrate professionalism, adaptability, and reflection about their own biases pertaining to care delivery and patient autonomy [3,15].

D. Systems-based practice

E. Professionalism

F. Interpersonal and communication skills

1. Suggest treatment strategies based on regional influences and available resources. 2. Acknowledge practice limitations and seek consultation to provide optimal patient care. 3. Interact with patients in a culturally specific fashion. 1. Formulate relevant differential diagnoses based on environment and customize treatment plans. 2. Participate in local didactic, multidisciplinary, and case-based imaging conferences. 1. Assess need and make evidencebased decisions about resource allocation and service delivery. 2. Learn about effective advocacy and educational strategies to develop global imaging services. 3. Identify local, regional, and international resources for medical imaging assistance. 1. Understand social, judicial, health equity, and international policy issues that affect service distribution. 2. Comprehend how resource disparity affects availability of medical imaging. 3. Tailor diagnostic and interventional radiology outreach to specific community needs. 1. Maintain patient confidentiality. 2. Conduct ethical and reliable teamoriented practice patterns. 3. Implement thoughtful and responsible projects. 1. Perform culturally specific diagnostic interpretation and clinical management with patients and their families/caregivers. 2. Use interpreters when necessary.

After understanding what the 4 components of a global health imaging curriculum entail, the next step is to identify resources for each. In Table 4, we identify some of the current useful resources for this area of ongoing development. Global Health Project Development

Extensive research should guide global health outreach project design, factoring in regional culture, political environment, disease prevalence, health care system, and available resources. If a program or institution has already established a global health imaging experience, many of the following steps can be streamlined. The program director, graduate medical education office, and international partners must approve new proposals.

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Table 4. Global health imaging curriculum content resources Curriculum Component Resource 1. Global and public health education

RAD-AID International, ACR-Resident and Fellow Section International Outreach Subcommittee, and other like-minded organizational websites; university-based public health courses/seminars 2. Targeted travel Centers for Disease Control, US State medicine Department, country or subspecialtyspecific American chapters and education conferences, country-specific Ministry of Health website, training program’s travel clinic 3. Basic imaging Residency programs case and topicproficiency based conferences, review courses such as American Institute for Radiologic PathologyTM (AIRP), online tutorials and journals, and general and specialty-specific domestic and international meetings 4. Practice attitudes Informal and formal mentorship, selfand accountability reflection, international peer-to-peer exchanges

Project objectives should be scrutinized for feasibility and scope given the allotted time, likelihood of community integration, and sustainability. Many logistical considerations are required for a successful global health project. It may be necessary to pursue industry and organizational partnerships to obtain adequate funding and equipment based on outlined project and travel-related demands. Advance scheduling should account for call responsibilities and resident duties, testing dates, and milestone requirements. Travel considerations include obtaining passports and visa(s), airfare, accommodations, transportation, and language proficiency/translational services with strong consideration of feasibility and safety. Perhaps most important but also most subtle is the need for strong interpersonal communication between invested parties with ongoing dedication to collaboration. Interactions and practices must be customized, emphasizing cultural respect, understanding, and flexibility that will allow for inevitable changes and unforeseen challenges [3,4,10]. Evaluation and Assessment

Upon return to one’s residency program, time should be set aside for comprehensive resident evaluation. At the project’s conclusion, the resident should not only reflect on their experience, but also solicit feedback from the community to allow for objective project quality improvement. Additionally, an assessment should be made of accomplished curriculum objectives. Supervisor and relevant peer and/or patient feedback should be given. Results should be reported and implications of findings discussed in advance of formal presentation, whether spoken or written, in a domestic or international forum.


High-quality global health education includes customized instruction, problem-based learning, and small group discussion in addition to community health opportunities [16,17]. Interdisciplinary, team-based clinical rotations in domestic rural and/or underserved areas help further skill development [17]. Future opportunities may include enrollment in web-based, public health learning modules focused on radiology outreach. Domestic and international mentors should be chosen carefully to advise residents as educators and role models. We outline educational models that vary by level of program involvement and associated resources, bearing in mind the 5 pillars of the ACR that are useful in providing an educational foundation: advocacy, clinical research, economics, education, and quality and safety. Individual Project Curriculum

This category applies to individual radiology residents who have an interest in global health imaging without an established program or significant institutional support, and for whom developing a curriculum will largely be a self-directed effort. Under these circumstances, the individual project commonly arises from a specific global health-related topic or place of interest. Early involvement with a faculty mentor and developing in-country organizational and/or institutional contacts becomes important in project planning and implementation. Acquiring background knowledge involves substantial self-directed research related to global health imaging epidemiology. Educational tools for this type of project are likely to include online resources, journals, interested local and global faculty, interdepartmental support, and national or international meetings. Relationships with knowledgeable, available international contacts are critical for all components of this curriculum. Individual global health imaging projects as part of a final, deliverable global health imaging curriculum may include the following examples:  Establishment of funding pathways for access to imaging services for immigrant, migrant, or otherwise marginalized communities;  Outreach to a specific community indicating imaging equipment needs and establishing appropriate programs for quality, safety, utilization, and maintenance;  Educational projects addressing the need for global health imaging online resource and curriculum development;  Research projects exploring global health topics including epidemiology of common and/or chronic regional diseases, access to care, or utilization of imaging services. Low-Resource Residency Program Curriculum

A radiology residency program with interest among several residents and faculty in providing a global health

Wood et al/Global Health Imaging Curriculum 5

imaging curriculum, but lacking significant institutional resources or an established international institutional relationship, would be appropriate for this category. A faculty champion and a small group of interested trainees usually lead efforts. The ultimate goal of this type of global health imaging curriculum is to develop a data-driven pilot program. Metrics would be put in place to justify broader support for a sustainable curriculum allowing multiple residents to participate, ideally as a global health imaging elective or selective. Mentorship is advised and can be conducted by one or multiple interested faculty leaders. Curriculum content allows for a range of specific global health topics. Educational tools would be similar to those in the preceding model, but the format would allow for small group discussions, journal clubs, online webinars, international exchanges, and/or broader community involvement. Residents and/or faculty could present didactic or case-based instruction based on global health imaging resources. Professional relationships with interested domestic and/or international contacts become essential for program and elective rotation establishment and sustainability. Residents could pursue projects as individuals or as a group, with a cooperative initiative often being more feasible. Examples of global health projects in this category include:  Participation in and/or establishment of a mobile women’s health clinic to domestic immigrant or international underserved communities through public health screening programs;  Educational programs addressing specific imaging topics and providing on-site and/or remote assistance;  Web-based journal clubs with international attendees about global health or other relevant, valuable topics;  Multidimensional research initiatives addressing imaging education, implementation, impact, and/or outcomes. High-Resource Residency Program Curriculum

This category refers to residency programs with significant institutional support for interdepartmental collaboration, established global health projects, and international exchanges across many medical specialties. This curriculum will vary by scope and scale of the initiative, is likely to be influenced by existing global health resources and/or programs, and may include an existing international global health elective rotation. Mentorship is a vital component and can be fostered by selected attending-resident pairs, fellow-resident pairs, or any combination of such. However, unlike other models, opportunities exist to incorporate faculty mentors from a variety of disciplines and specialties. Curriculum content can be broad, ideally multidisciplinary, and may include targeted instruction about specific interests within radiology. Intradepartmental seminars and

visiting lectureships from other medical and public health specialties may be conducted. Global health imaging project examples at this level may include:  Establishment of a resident educational exchange program with one or multiple international residency programs;  Interdepartmental research initiatives exploring the role of imaging in global public health epidemiology, screening, treatment, and outcomes measures;  Clinical programs providing imaging interpretations and/or education for underserved clinics or communities;  Providing longitudinal imaging services for a specific community, organization, or institution with an established program in another field of medicine (eg, surgery or obstetricsegynecology). CONCLUSION

In summary, we have provided basic guidelines for sophisticated, multi-tiered international outreach curriculum development for radiology trainees. Future outcomes and directions may include project maintenance and growth, online resource and curriculum development, exploration of formal certification, and implementation of recently established ACGME Guidelines for International Rotations in Diagnostic Radiology. ACKNOWLEDGEMENTS The authors thank Brad Short, Lauren Alfero, and Rusty Brown, MD, Kristen DeStigter, MD, and Paul Ellenbogen, MD, for their support. REFERENCES 1. Everton KL, Mazal J, Mollura DJ. White paper report of the 2011 RADAID Conference on International Radiology for Developing Countries: integrating multidisciplinary strategies for imaging services in the developing world. J Am Coll Radiol 2012;9:488-94. 2. Gerber RE, Brant WE, Petroze RT, et al. Picturing the climate: radiologic assessment of Rwandan imaging capacity. J Am Coll Radiol 2012;9: 69-73. 3. Bazemore AW, Huntington M. The pretravel consultation. Am Fam Physician 2009;80:583-90. 4. Sekhar A, Eisenberg RL, Yablon CM. Enhancing the resident experience with global health electives. AJR Am J Roentgenol 2012;198:W118-21. 5. Mollura DJ, Mazal J, Everton KL, et al. White paper report of the 2012 RAD-AID Conference on International Radiology for Developing Countries: planning the implementation of global radiology. J Am Coll Radiol 2013;10:618-24. 6. Welling RD, Azene EM, Kalia V, et al. White paper report of the 2010 RAD-AID Conference on International Radiology for Developing Countries: identifying sustainable strategies for imaging services in the developing world. J Am Coll Radiol 2011;8:556-62. 7. Mollura DJ, Azene EM, Starikovsky A, et al. White paper report of the RAD-AID Conference on International Radiology for Developing Countries: identifying challenges, opportunities, and strategies for

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Global health imaging curriculum in radiology residency programs: the fundamentals.

Recent advances in imaging technology have created new opportunities for medical imaging to improve health care in resource-restricted countries aroun...
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