GLOBAL HEALTH INITIATIVES
Global Health Training in Ophthalmology Residency Programs Peter G. Coombs, MD,* Brad H. Feldman, MD,† Andreas K. Lauer, MD,‡ Robison V. Paul Chan, MD,* and Grace Sun, MD* Department of Ophthalmology, Weill Cornell Medical College, New York, New York; †Department of Ophthalmology, Wills Eye Hospital, Jefferson Medical College, Philadelphia, Pennsylvania; and ‡Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon *
PURPOSE: To assess current global health education and international electives in ophthalmology residency programs and barriers to global health implementation in ophthalmology resident education.
interested in development of global health resources and plan to further develop global health opportunities. ( J Surg C 2015 Program Directors in Surgery. Pub72:e52-e59. J lished by Elsevier Inc. All rights reserved.)
METHODS: A web-based survey regarding participation in
KEY WORDS: international electives, global health, ophthalmology, residency program curriculum, survey
global health and international electives was emailed to residency program directors at 116 accredited ophthalmology residency programs via an Association of University Professors in Ophthalmology (AUPO) residency program director listserv.
COMPETENCIES: Patient Care, Medical Knowledge, Profes-
sionalism, Interpersonal and Communication Skills, PracticeBased Learning and Improvement, Systems-Based Practice
RESULTS: Fifty-nine (51%) ophthalmology residency pro-
gram directors responded. Thirty-seven program directors (63%) said global health was important to medical students when evaluating residency programs. Thirty-two program directors (55%) reported developing international electives. Reported barriers to resident participation in international electives were: 1) insufficient financial support, 2) inadequate resident coverage at home, and 3) lack of ACGME approval for international electives. Program directors requested more information about resident international electives, funding, and global ophthalmology educational resources. They requested ACGME recognition of international electives to facilitate resident participation. More than half (54%) of program directors supported international electives for residents. CONCLUSIONS: This survey demonstrates that program
directors believe global health is an important consideration when medical students evaluate training programs. Despite perceived barriers to incorporating global health opportunities into residency training, program directors are Study was conducted at the Weill Cornell Medical College, New York, NY. Supported by the St. Giles Foundation (R.V.P.C.), the iNsight Foundation (R.V. P.C.), Ophthalmology Residency Education Fund (A.K.L.), and Research to Prevent Blindness (G.S., A.K.L., R.V.P.C., P.G.C.) Correspondence: Inquiries to Grace Sun, MD, Weill Cornell Medical College, 1305 York Avenue, 11th Floor, New York, NY, 10021; E-mail: [email protected], [email protected]
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INTRODUCTION Ophthalmologists have been leaders of global health since the 1970s, from ORBIS International's flying eye hospitals surgical education missions to the SEVA Foundation's and the Carter Center's efforts to eradicate river blindness and treat trachoma.1-6 The term global health refers to the complex relationship between the health of societies and the interdependence between them; it is concerned with pooling knowledge and resources with the goal of improving health and health equity for people worldwide.7 Global health training is an increasingly important component of medical education. Currently, more than 25% of medical trainees have pursued global health experiences before residency, and most medical schools now have global health incorporated into their curriculum.8,9 Global health training is also an emerging trend in Graduate Medical Education. International electives, for example, are offered in residency training programs across a variety of specialties including anesthesia, pediatrics, otolaryngology, emergency medicine, and surgery.8,10-13 The benefits of resident participation in global health training align with Accreditation Council for Graduate Medical Education (ACGME) training core competencies: medical knowledge, improved communication skills, increased cultural sensitivity and understanding, and improved systems-based practice.14-19
Journal of Surgical Education & 2015 Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.04.007
Global health and international opportunities were not formally recognized in ophthalmology residency training until July of 2013 when the ACGME Residency Committee (RC) for ophthalmology allowed credit for elective international rotations of up to 1 month. The purpose of this study, conducted with the Global Alliances Secretariat of the American Academy of Ophthalmology (AAO), was to gain information on global health initiatives in ophthalmology residency programs and to determine if additional resources are needed. We surveyed ophthalmology residency program directors to (1) evaluate the extent to which their programs and departments are participating in global health and international electives, (2) evaluate interest in global health, and (3) to identify perceived obstacles in implementing global health curricula and international electives in ophthalmology graduate medical education.
METHODS A web-based survey was designed to address ophthalmology residency program interest in global health and international electives, characterize the structure of such electives, and identify obstacles in sustaining these electives. The survey consisted of 16 questions: 13 multiple-choice and singleresponse questions and 3 additional free-text response questions (Table 1). All 116 ACGME-accredited ophthalmology residency programs were invited to participate. The survey was sent to residency program directors via an Association of University Professors in Ophthalmology (AUPO) residency program director listserv in October 2012. A reminder e-mail was sent in January 2013 to those who had not responded. The response goal was to have greater than 50% participation from the ophthalmology program directors. Survey analysis was performed blind to any program identifiers to prevent any bias in the interpretation of responses. To gain information on the broad range of activities in which ophthalmology residency programs participate, a strict definition of global health or global ophthalmology was omitted.
RESULTS Participation and Interest in Global Health by Ophthalmology Residency Programs A total of 59 program directors responded to the survey for a response rate of 51%. Of these, 37 (63%) felt that global health opportunities were either important or very important to medical students applying to ophthalmology residency programs. In total, 32 programs reported developing or supporting programs abroad for residents. Of the 59 programs
represented in this survey, only 10 (17%) do not currently participate in global health. Of those 10 programs, 7 have plans for future participation. Moreover, 44 programs (75%) are considering increasing future participation above present levels (Fig. 1). Overall, 24 programs (41%) provide both educational resources for residents and are also supporting or developing programs abroad. Structure of Global Health Electives in Ophthalmology Residency Programs Of the 59 ophthalmology residency programs who participated, 29 (50%) reported that their residents take part in global health electives that combine surgical and nonsurgical activities, and 21 programs (35%) have residents that participate in nonsurgical electives (Fig. 2). In total, 34 (58.3%) of programs have relationships with specific international sites or send their residents to sites that are known to their program's faculty members or alumni (Table 2). Most programs allow residents to use either academic time (15 programs, 25.4%) or a combination of academic and vacation time (26 programs, 44.1%) for international electives, although 9 programs (15.3%) permitted international electives during resident vacation time alone. Departmental Support of Global Health Initiatives in Ophthalmology Residency Programs In total, 33 programs (56%) support faculty in volunteer programs, 32 programs (54%) participate in exchange programs or hosting foreign fellows, and 23 departments (39%) collaborate on research in the developing world. In addition, 18 programs (31%) reported involvement in at least 2 of these 3 areas. Moreover, 13 programs (22%) were involved in all 3 areas questioned, and 1 program selected 4 answer choices indicating involvement beyond the specific areas mentioned in the survey. Overall, 38 programs (65%) provide partial or full financial support to residents for their time abroad, with 18 programs (30%) providing partial or full financial support to faculty. There is a global ophthalmology faculty director at 25 programs (42.4%), and 8 programs have a nonphysician administrative director (13.6%). There were 7 programs that indicated having both a faculty director as well as a nonphysician administrative director. Perceived Obstacles to Ophthalmology Residency Programs Participating in Global Health The major obstacles to resident participation in global ophthalmology identified by this survey were as follows:
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TABLE 1. Ophthalmology Residency Program Director Global Ophthalmology Survey 1. Name of program 2. Total number of residents in the program 3. Indicate how your ophthalmology residency program is participating in global ophthalmology (check all that apply): Developing or supporting programs abroad for residents (e.g., sending residents abroad for international experience) Providing residents with educational resources on global eye health Not currently participating in global ophthalmology Not currently participating in global ophthalmology, but considering future participation Other: 4. Indicate how your ophthalmology department is participating in global ophthalmology (check all that apply): Supporting volunteer programs for faculty Participating in educational exchanges or hosting foreign fellows Collaborating on research in the developing world Not currently participating in global ophthalmology Not currently participating in global ophthalmology, but considering future participation Other: 5. If your training program is not currently participating in global ophthalmology programs, what are the obstacles (check all that apply)? Lack of resident interest Lack of financial support Activities abroad (i.e., surgical experience) are not ACGME approved Lack of resident coverage at home Lack of knowledge of appropriate programs abroad Other: 6. Approximately how many hours per year does your training program devote to teaching global ophthalmology topics? 0 1-5 6-10 11-15 415 7. Does your program or department provide financial support to trainees or faculty for the purposes of volunteering or training in developing countries (check all that apply)? Yes, we provide partial financial support to trainees Yes, we provide full financial support to trainees Yes, we provide partial financial support to faculty Yes, we provide full financial support to faculty No, we do not allocate funding for these activities 8. If your program supports resident time abroad, the residents are sent primarily for Surgical experience Nonsurgical experience Both surgical and nonsurgical experience Not applicable 9. Residents who go abroad for an international experience use Vacation time for this activity Academic time A combination of vacation and academic time Not applicable 10. Residents who go abroad for an international experience go to A designated site (i.e., site that has an established relationship with your program) A designated site with faculty or alumni from your institution A non–program-specific site (e.g., resident chooses site that has no affiliation with your program) Not applicable 11. Has your program or department assigned someone to oversee global ophthalmology activities (check all that apply)? Yes, we have assigned a faculty director Yes, we have assigned an administrative director No
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TABLE 1 (continued) 12. How important do you think the availability of global ophthalmology opportunities are to medical students in evaluating ophthalmology programs? Not important Unsure Somewhat important Very important 13. Is there a global health program at your Institution or University? Yes No Not Sure Varies by department 14. What resources could the American Academy of Ophthalmology offer to assist you and your department in the development or implementation of global ophthalmology programs? (Free text) 15. Can you provide us with the name(s) of your chief resident(s) for the 2012-2013 academic year so that we can contact them regarding a separate resident survey of global ophthalmology? (Free text) 16. Additional comments on global ophthalmology: (Free text)
(1) insufficient financial support, (2) inadequate resident coverage at the home institution, and (3) the lack of ACGME approval for resident activities abroad (Table 3). Overall, 20 program directors (33.3%) considered a lack of knowledge of programs abroad a barrier to participation, and 22 programs (37%) selected more than one of these answer choices as an obstacle. Perceived Needs for Improving Global Health in Ophthalmology Residency In response to a free-text question regarding how the AAO could help ophthalmology residency programs implement global health programs and international electives, 18 program directors mentioned a need for information about existing opportunities for residents. Moreover, 9 program directors stated a need for didactic resources for residents, 7 35
program directors recommended ACGME approval of credit for resident experiences abroad, and 7 program directors requested assistance in identifying funding for electives. When prompted for additional free-text comments, 19 program directors described plans to pursue further development of international opportunities for residents, whereas 2 program directors responded that it was not worthwhile to provide international opportunities to trainees during residency.
DISCUSSION There is a growing interest in global health training among medical students and residents.9 There is much in the literature about resident participation in global health
32
30 25
24
Number of 20 Programs (out of 59) 15 10 10
7
5 0 Developing or Providing residents Not currently supporng with educaonal parcipang in resources on global health programs abroad for residents global health
Not currently parcipang in global health, but considering future parcipaon
Type of Global Health Activity FIGURE 1. Current participation in global ophthalmology in residency programs. Journal of Surgical Education Volume 72/Number 4 July/August 2015
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TABLE 2. Characteristics of Currently Used Global Ophthalmology Sites
major obstacles for developing or expanding international electives during ophthalmology residency are financial support, inadequate resident coverage at the home institution, lack of information about international opportunities for electives, and the lack of ACGME approval for international electives. This survey showed that ophthalmology residency program directors feel medical students value global health opportunities when assessing residency programs. This may have practical implications for recruitment to ophthalmology residency programs. A study of family medicine residents showed that residents who participated in international health training valued this more than traditional factors of location, faculty quality, resident quality, and spousal preference when they were evaluating residency programs.20 In a study of emergency medicine residents, 62% of residency program applicants felt that global health electives were a positive factor in ranking their programs, and 68% of applicants with previous global health experience would rank programs higher if they offered international opportunities.21 Overall, 78% of anesthesia residents indicated that the availability of a global health track factored into their residency ranking.13 It is conceivable that these trends apply to ophthalmology applicants as well, making international electives an important part of recruitment. There is already interest and involvement in global health in ophthalmology residency programs. In our survey, 31 programs (55%) already support residents going abroad for international electives and 44 programs (75%) intend to increase this support. Moreover, 53 programs (90%) currently incorporate global health into their educational curricula. A similar survey performed in 2005 showed that only 21% of programs were teaching global health and 47% had resident participation in international electives.22 These numbers suggest increasing interest. This may reflect the new generation of physicians in training, which has an increased interest in global health.9,17 Some barriers prevent ophthalmology programs from offering global health electives. The most common barriers identified were a lack of funding, a lack of ACGME
Percentage and Number (n) Out of 59 Responders
TABLE 3. Most Common Obstacles to Participation in Global Ophthalmology
FIGURE 2. Characteristics (Surgical vs nonsurgical) of current global ophthalmology experiences.
from other subspecialties (Table 4); however, there is very little reported on ophthalmology resident participation in global health. This survey gathered information about ophthalmology residency programs' current involvement in global health, the perceived importance of global health in ophthalmology residency training, and the obstacles and complexities of establishing global health curricula and international electives for ophthalmology residents. This survey is particularly timely given the recent endorsement of 1-month international elective credit toward resident training by the ACGME RC in ophthalmology. The key findings of this survey are as follows: (1) the majority of ophthalmology residency program directors who responded feel that global health opportunities are important to medical students going into ophthalmology when they are evaluating residency programs; (2) the majority of ophthalmology programs represented in this survey are already supporting international opportunities for their residents and incorporating global health into their residency curriculum, and of those programs that are not currently involved in global health, the majority already have plans to develop programs for residents; and (3) the
Characteristic An affiliated site (i.e., a site that has an established relationship with the ACGME-accredited ophthalmology residency program) A site affiliated with faculty or alumni from the home institution A non–program-specific site (e.g., resident chooses site that has no affiliation with the ACGMEaccredited ophthalmology residency program) Not applicable e56
35.0% (20) Reported Obstacle 23.3% (14) 21.7% (13)
20.0% (12)
Lack of financial support Lack of resident coverage at home Activities abroad (i.e., surgical experience) are not ACGME approved Lack of knowledge of appropriate programs abroad Lack of resident interest Other
Percentage and Number (n) Out of 59 Responders 77.8% (46) 66.7% (39) 63.0% (37) 33.3% (20) 22.2% (13) 14.8% (9)
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approval of the electives, a lack of information regarding available opportunities, and inadequate resident coverage at home institutions. Similar obstacles are cited by other specialties in the literature.10,23,24 Past reports show that despite high interest, only 10% of pediatric residents participate in international electives and much of the participation was dependent on recent program faculty participation.10 Among surgery residents, the most common barriers reported are family, financial aid, and scheduling time for the elective, as well as lack of accreditation of the electives.24 For the latter, the experience of other specialties could guide ophthalmology in addressing these obstacles. The General Surgery Residency review committee and the American Board of Surgery announced rules allowing international electives to count toward graduation requirements, including surgical cases, 2 years ago.12 The
ophthalmology RC made a first step last July by offering credit for international electives up to 1 month; however, surgical cases of ophthalmology residents abroad are not yet counted toward graduation requirements. Guidelines for awarding residency credit for surgeries abroad may be a logical next step. Additionally, focus groups for ophthalmology program directors to share information on existing international opportunities and funding sources, as well as development of international electives through global health offices at the residency programs’ home institutions, may be valuable. Finally, ophthalmology residency program directors in this survey cited a need for didactic material for residents. There is much interest in international electives; however, the didactic component to global health training cannot be forgotten. A global health curriculum, elective or otherwise, should have
TABLE 4. Residency Global Health Programs Subspecialty
Interest in Global Health
Global Health Didactics
International Electives
Notes
Pediatrics (Nelson et al.10)
15% Of programs have a 47% Of 52% Of programs with majority of residents programs residents participating in interested in global have a formal global health electives health global health curriculum 450% Of residents are 60% Of programs have Review Committee for Surgery Surgery interested in informal electives available approved international (Mitchell participating in electives for graduation et al.12) international electives credit in 2011 490% Of residents 44% Of residents responding Barriers to participation in Anesthesia reported some interest in participated in international electives, identified in this (McCunn international anesthesia electives despite high survey, were family et al.13) experiences interest commitments, financial aid, and work/coverage restraints 450% Of family medicine Residents 450% Of residents in Internal International elective Internal and internal medicine participate in medicine and Family Medicine participants are more likely residents participated in international medicine participate; 20%(Sawatsky to care for immigrants, some way, indicating lectures and 30% of Yale residents et al.14 and patients on public Gupta high interest teaching participate; duration of assistance, and go into et al.26) electives was from 4-12 wk general medicine. long; locations include international academic centers and private practices 65% Of residents 425% Of programs 100% Of participants report ENT (Volsky participate when participate in international humanitarian aid as a et al.16) opportunities are electives; 96% of the reason for participation; available experiences are partly 76% report the clinical surgical experience is good enough for ACGME credit Ophthalmology 75% Of programs report 490% Of Electives are mostly a The Review Committee for (Coombs plans to increase programs combination of surgical and Ophthalmology to the et al., This participation in global have at least clinical experiences ACGME approved electives paper.) ophthalmology 1 h of up to 1 mo for graduation didactics in credit their curriculum ENT, ear nose throat.
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clearly defined goals and objectives and address ACGME core competencies. Example objectives include (1) demonstrate knowledge of global eye disease epidemiology and (2) demonstrate understanding of ethical issues of global health training. These former and latter objectives of a global health curriculum address the ACGME core competencies of ophthalmic knowledge and professionalism, respectively, and resources are already available to implement them. The AAO launched an online resource called the Global Ophthalmology (GO) Guide (www.aao.org/GOGuide), a resource detailing epidemiology and standard treatments of eye diseases around the world. The International section of the Ophthalmic News and Education (ONE) Network of the AAO website contains lectures on ethical issues of global health. Evaluation of any implemented global health curriculum is important, and we believe that residents can be evaluated using the existing ACGME Ophthalmology Milestones tools. There are several limitations to this study that should be discussed. First, a possible response bias in which program directors who are more enthusiastic about global ophthalmology or already involved may have been more likely to respond to the survey. There were, however, some responses in the free-text comments from program directors who did not feel that global health training was important for their residency, indicating that the responses did capture differing opinions on the topic. Second, the response rate was incomplete: 59 of 116 programs (51%) responded and therefore the results and suggestions may not be generalizable to all residency programs. A follow-up e-mail was sent to encourage completion of the survey, and the survey was limited to a small number of specific questions to limit survey fatigue and promote completion. A response rate of 51% is as good or better than the average response rate for recent surveys published in the ophthalmology literature.25 Third, a strict definition of global health or global ophthalmology was not provided to the program directors who took part in this survey. This omission of a strict definition was intentional, as many ophthalmologists participate in international work in many different forms, from performing surgery abroad, to advocacy, teaching, and even in developing educational material for international trainees. A strict definition of global ophthalmology was therefore not included to capture all of these activities. As previously mentioned, the survey was limited to a smaller number of specific questions, and follow-up surveys may be important to further elucidate the current participation of ophthalmology residency programs in global health training.
CONCLUSION Ophthalmology residency programs are incorporating global health into resident training and are citing the value of international opportunities. We have identified the perceived obstacles to including international opportunities in e58
ophthalmology training programs, which are logistical, regulatory, and financial. Despite these challenges, program directors are interested in continuing and building on global health training in residency training. Given the recent approval of international opportunities by the ophthalmology RC, the formation of focus groups to address the development of global ophthalmology resources and share logistical and practical experiences is suggested. Future investigations should focus on how to best incorporate global health into training curricula through international experiences, didactics, and research. Participation in international electives offers our trainees and practicing physicians unique learning opportunities in unfamiliar settings. In many of these settings, ophthalmology is practiced effectively and efficiently despite limitations in resources. Resident training in global ophthalmology offers the hope of preparing a generation of ophthalmologists to more effectively tackle the burden of global blindness.
ACKNOWLEDGMENTS The authors would like to acknowledge the American Academy of Ophthalmology for their support in conducting this study.
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center.org/health/river_blindness/index.html〉; 2013. 3. The SEVA Foundation. 〈Available at: http://www.seva.
org/site/PageServer〉 Accessed 20.05.13. 4. Prakalapakorn SG, Smallwood LM, Helveston EM.
ORBIS telemedicine users. Ophthalmology. 2012;119 (4):880-881. 5. Ruit S, Tabin G, Chang D, et al. A prospective
randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal. Am J Ophthalmol. 2007;143(1): 32-38 [e2]. 6. Lee AG, Golnik KC, Tso MOM, Spivey B, Miller K,
Gauthier TM. The international council of ophthalmology: vision for ophthalmic education in an interdependent world. Am J Ophthalmol. 2012;154(4): 620-624 [e2]. 7. Koplan JP, Bond TC, Merson MH, et al. Towards a
common definition of global health. Lancet. 2009;373 (9679):1993-1995.
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8. Drain PK, Holmes KK, Skeff KM, Hall TL, Gardner
18. Haq C. New world views: preparing physicians in
P. Global health training and international clinical rotations during residency: current status, needs, and opportunities. Acad Med. 2009;84(3):320-325.
training for global health work. Fam Med. 2000;32 (8):566-571.
9. Panosian C, Coates TJ. The new medical “mission-
19. Evert J, Stewart C, Chan K, Rosenberg M, Hall T.
aries”—grooming the next generation of global health workers. N Engl J Med. 2006;354(17):1771-1773.
Developing Residency Training in Global Health: A Guidebook. San Francisco: Global Health Education Consortium; 2008.
10. Nelson BD, Lee AC, Newby PK, Chamberlin MR,
20. Bazemore AW, Henein M, Goldenar LM, Szaflarski
Huang C-C. Global health training in pediatric residency programs. Pediatrics. 2008;122(1):28-33.
M, Lindsell CJ, Diller P. The effect of offering international health training opportunities on family medicine residency recruiting. Fam Med. 2007;39 (4):255-260.
11. Morton MJ, Vu A. International emergency medicine
and global health: training and career paths for emergency medicine residents. Ann Emerg Med. 2011; 57(5):520-525. 12. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM.
Elective global surgery rotations for residents: a call for cooperation and consortium. World J Surg. 2011;35 (12):2617-2624. 13. McCunn M, Speck RM, Chung I, Atkins JH, Raiten
JM, Fleisher LA. Global health outreach during anesthesiology residency in the United States: a survey of interest, barriers to participation, and proposed solutions. J Clin Anesth. 2012;24(1):38-43. 14. Sawatsky AP, Rosenman DJ, Merry SP, McDonald
FS. Eight years of the Mayo International Health Program: what an international elective adds to resident education. Mayo Clin Proc. 2010;85(8):734-741. 15. Hau D. Global health training during residency: the
Weill Cornell Tanzania experience. J Grad Med Educ. 2011;3(3):421-424. 16. Volsky PG, Sinacori JT. Global health initiatives of US
otolaryngology residency programs: 2011 global health initiatives survey results. Laryngoscope. 2012;122(11): 2422-2427. 17. Anspacher M, Frintner MP, Denno D, et al. Global
health education for pediatric residents: a national survey. Pediatrics. 2011;128(4):e959-e965.
21. Dey CC, Grabowski JG, Hsu E, VanRooyen MJ.
Influence of international emergency medicine opportunities on residency program selection. Acad Emerg Med. 2002;9(7):679-683. 22. Gattey DM, Lauer AK. International ophthalmology
in training programs. Ophthalmology. 2006;113(12): 2379-2380. 23. Powell AC, Casey K, Liewehr DJ, Hayanga A, James
TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg. 2009;208(2): 304-312. 24. Powell AC, Mueller C, Kingham P, Berman R,
Pachter HL, Hopkins MA. International experience electives, and volunteerism in surgical training: a survey of resident interest. J Am Coll Surg. 2007;205 (1):162-168. 25. Wong RK, et al. Training fellows for retinopathy of
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Global Health Training in Ophthalmology Residency Programs Peter G. Coombs, MD,* Brad H. Feldman, MD,† Andreas K. Lauer, MD,‡ Robison V. Paul Chan, MD,* and Grace Sun, MD* Department of Ophthalmology, Weill Cornell Medical College, New York, New York; †Department of Ophthalmology, Wills Eye Hospital, Jefferson Medical College, Philadelphia, Pennsylvania; and ‡Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon *
PURPOSE: To assess current global health education and international electives in ophthalmology residency programs and barriers to global health implementation in ophthalmology resident education.
interested in development of global health resources and plan to further develop global health opportunities. ( J Surg C 2015 Program Directors in Surgery. Pub72:e52-e59. J lished by Elsevier Inc. All rights reserved.)
METHODS: A web-based survey regarding participation in
KEY WORDS: international electives, global health, ophthalmology, residency program curriculum, survey
global health and international electives was emailed to residency program directors at 116 accredited ophthalmology residency programs via an Association of University Professors in Ophthalmology (AUPO) residency program director listserv.
COMPETENCIES: Patient Care, Medical Knowledge, Profes-
sionalism, Interpersonal and Communication Skills, PracticeBased Learning and Improvement, Systems-Based Practice
RESULTS: Fifty-nine (51%) ophthalmology residency pro-
gram directors responded. Thirty-seven program directors (63%) said global health was important to medical students when evaluating residency programs. Thirty-two program directors (55%) reported developing international electives. Reported barriers to resident participation in international electives were: 1) insufficient financial support, 2) inadequate resident coverage at home, and 3) lack of ACGME approval for international electives. Program directors requested more information about resident international electives, funding, and global ophthalmology educational resources. They requested ACGME recognition of international electives to facilitate resident participation. More than half (54%) of program directors supported international electives for residents. CONCLUSIONS: This survey demonstrates that program
directors believe global health is an important consideration when medical students evaluate training programs. Despite perceived barriers to incorporating global health opportunities into residency training, program directors are Study was conducted at the Weill Cornell Medical College, New York, NY. Supported by the St. Giles Foundation (R.V.P.C.), the iNsight Foundation (R.V. P.C.), Ophthalmology Residency Education Fund (A.K.L.), and Research to Prevent Blindness (G.S., A.K.L., R.V.P.C., P.G.C.) Correspondence: Inquiries to Grace Sun, MD, Weill Cornell Medical College, 1305 York Avenue, 11th Floor, New York, NY, 10021; E-mail: [email protected], [email protected]
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INTRODUCTION Ophthalmologists have been leaders of global health since the 1970s, from ORBIS International's flying eye hospitals surgical education missions to the SEVA Foundation's and the Carter Center's efforts to eradicate river blindness and treat trachoma.1-6 The term global health refers to the complex relationship between the health of societies and the interdependence between them; it is concerned with pooling knowledge and resources with the goal of improving health and health equity for people worldwide.7 Global health training is an increasingly important component of medical education. Currently, more than 25% of medical trainees have pursued global health experiences before residency, and most medical schools now have global health incorporated into their curriculum.8,9 Global health training is also an emerging trend in Graduate Medical Education. International electives, for example, are offered in residency training programs across a variety of specialties including anesthesia, pediatrics, otolaryngology, emergency medicine, and surgery.8,10-13 The benefits of resident participation in global health training align with Accreditation Council for Graduate Medical Education (ACGME) training core competencies: medical knowledge, improved communication skills, increased cultural sensitivity and understanding, and improved systems-based practice.14-19
Journal of Surgical Education & 2015 Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.04.007
Global health and international opportunities were not formally recognized in ophthalmology residency training until July of 2013 when the ACGME Residency Committee (RC) for ophthalmology allowed credit for elective international rotations of up to 1 month. The purpose of this study, conducted with the Global Alliances Secretariat of the American Academy of Ophthalmology (AAO), was to gain information on global health initiatives in ophthalmology residency programs and to determine if additional resources are needed. We surveyed ophthalmology residency program directors to (1) evaluate the extent to which their programs and departments are participating in global health and international electives, (2) evaluate interest in global health, and (3) to identify perceived obstacles in implementing global health curricula and international electives in ophthalmology graduate medical education.
METHODS A web-based survey was designed to address ophthalmology residency program interest in global health and international electives, characterize the structure of such electives, and identify obstacles in sustaining these electives. The survey consisted of 16 questions: 13 multiple-choice and singleresponse questions and 3 additional free-text response questions (Table 1). All 116 ACGME-accredited ophthalmology residency programs were invited to participate. The survey was sent to residency program directors via an Association of University Professors in Ophthalmology (AUPO) residency program director listserv in October 2012. A reminder e-mail was sent in January 2013 to those who had not responded. The response goal was to have greater than 50% participation from the ophthalmology program directors. Survey analysis was performed blind to any program identifiers to prevent any bias in the interpretation of responses. To gain information on the broad range of activities in which ophthalmology residency programs participate, a strict definition of global health or global ophthalmology was omitted.
RESULTS Participation and Interest in Global Health by Ophthalmology Residency Programs A total of 59 program directors responded to the survey for a response rate of 51%. Of these, 37 (63%) felt that global health opportunities were either important or very important to medical students applying to ophthalmology residency programs. In total, 32 programs reported developing or supporting programs abroad for residents. Of the 59 programs
represented in this survey, only 10 (17%) do not currently participate in global health. Of those 10 programs, 7 have plans for future participation. Moreover, 44 programs (75%) are considering increasing future participation above present levels (Fig. 1). Overall, 24 programs (41%) provide both educational resources for residents and are also supporting or developing programs abroad. Structure of Global Health Electives in Ophthalmology Residency Programs Of the 59 ophthalmology residency programs who participated, 29 (50%) reported that their residents take part in global health electives that combine surgical and nonsurgical activities, and 21 programs (35%) have residents that participate in nonsurgical electives (Fig. 2). In total, 34 (58.3%) of programs have relationships with specific international sites or send their residents to sites that are known to their program's faculty members or alumni (Table 2). Most programs allow residents to use either academic time (15 programs, 25.4%) or a combination of academic and vacation time (26 programs, 44.1%) for international electives, although 9 programs (15.3%) permitted international electives during resident vacation time alone. Departmental Support of Global Health Initiatives in Ophthalmology Residency Programs In total, 33 programs (56%) support faculty in volunteer programs, 32 programs (54%) participate in exchange programs or hosting foreign fellows, and 23 departments (39%) collaborate on research in the developing world. In addition, 18 programs (31%) reported involvement in at least 2 of these 3 areas. Moreover, 13 programs (22%) were involved in all 3 areas questioned, and 1 program selected 4 answer choices indicating involvement beyond the specific areas mentioned in the survey. Overall, 38 programs (65%) provide partial or full financial support to residents for their time abroad, with 18 programs (30%) providing partial or full financial support to faculty. There is a global ophthalmology faculty director at 25 programs (42.4%), and 8 programs have a nonphysician administrative director (13.6%). There were 7 programs that indicated having both a faculty director as well as a nonphysician administrative director. Perceived Obstacles to Ophthalmology Residency Programs Participating in Global Health The major obstacles to resident participation in global ophthalmology identified by this survey were as follows:
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TABLE 1. Ophthalmology Residency Program Director Global Ophthalmology Survey 1. Name of program 2. Total number of residents in the program 3. Indicate how your ophthalmology residency program is participating in global ophthalmology (check all that apply): Developing or supporting programs abroad for residents (e.g., sending residents abroad for international experience) Providing residents with educational resources on global eye health Not currently participating in global ophthalmology Not currently participating in global ophthalmology, but considering future participation Other: 4. Indicate how your ophthalmology department is participating in global ophthalmology (check all that apply): Supporting volunteer programs for faculty Participating in educational exchanges or hosting foreign fellows Collaborating on research in the developing world Not currently participating in global ophthalmology Not currently participating in global ophthalmology, but considering future participation Other: 5. If your training program is not currently participating in global ophthalmology programs, what are the obstacles (check all that apply)? Lack of resident interest Lack of financial support Activities abroad (i.e., surgical experience) are not ACGME approved Lack of resident coverage at home Lack of knowledge of appropriate programs abroad Other: 6. Approximately how many hours per year does your training program devote to teaching global ophthalmology topics? 0 1-5 6-10 11-15 415 7. Does your program or department provide financial support to trainees or faculty for the purposes of volunteering or training in developing countries (check all that apply)? Yes, we provide partial financial support to trainees Yes, we provide full financial support to trainees Yes, we provide partial financial support to faculty Yes, we provide full financial support to faculty No, we do not allocate funding for these activities 8. If your program supports resident time abroad, the residents are sent primarily for Surgical experience Nonsurgical experience Both surgical and nonsurgical experience Not applicable 9. Residents who go abroad for an international experience use Vacation time for this activity Academic time A combination of vacation and academic time Not applicable 10. Residents who go abroad for an international experience go to A designated site (i.e., site that has an established relationship with your program) A designated site with faculty or alumni from your institution A non–program-specific site (e.g., resident chooses site that has no affiliation with your program) Not applicable 11. Has your program or department assigned someone to oversee global ophthalmology activities (check all that apply)? Yes, we have assigned a faculty director Yes, we have assigned an administrative director No
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TABLE 1 (continued) 12. How important do you think the availability of global ophthalmology opportunities are to medical students in evaluating ophthalmology programs? Not important Unsure Somewhat important Very important 13. Is there a global health program at your Institution or University? Yes No Not Sure Varies by department 14. What resources could the American Academy of Ophthalmology offer to assist you and your department in the development or implementation of global ophthalmology programs? (Free text) 15. Can you provide us with the name(s) of your chief resident(s) for the 2012-2013 academic year so that we can contact them regarding a separate resident survey of global ophthalmology? (Free text) 16. Additional comments on global ophthalmology: (Free text)
(1) insufficient financial support, (2) inadequate resident coverage at the home institution, and (3) the lack of ACGME approval for resident activities abroad (Table 3). Overall, 20 program directors (33.3%) considered a lack of knowledge of programs abroad a barrier to participation, and 22 programs (37%) selected more than one of these answer choices as an obstacle. Perceived Needs for Improving Global Health in Ophthalmology Residency In response to a free-text question regarding how the AAO could help ophthalmology residency programs implement global health programs and international electives, 18 program directors mentioned a need for information about existing opportunities for residents. Moreover, 9 program directors stated a need for didactic resources for residents, 7 35
program directors recommended ACGME approval of credit for resident experiences abroad, and 7 program directors requested assistance in identifying funding for electives. When prompted for additional free-text comments, 19 program directors described plans to pursue further development of international opportunities for residents, whereas 2 program directors responded that it was not worthwhile to provide international opportunities to trainees during residency.
DISCUSSION There is a growing interest in global health training among medical students and residents.9 There is much in the literature about resident participation in global health
32
30 25
24
Number of 20 Programs (out of 59) 15 10 10
7
5 0 Developing or Providing residents Not currently supporng with educaonal parcipang in resources on global health programs abroad for residents global health
Not currently parcipang in global health, but considering future parcipaon
Type of Global Health Activity FIGURE 1. Current participation in global ophthalmology in residency programs. Journal of Surgical Education Volume 72/Number 4 July/August 2015
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TABLE 2. Characteristics of Currently Used Global Ophthalmology Sites
major obstacles for developing or expanding international electives during ophthalmology residency are financial support, inadequate resident coverage at the home institution, lack of information about international opportunities for electives, and the lack of ACGME approval for international electives. This survey showed that ophthalmology residency program directors feel medical students value global health opportunities when assessing residency programs. This may have practical implications for recruitment to ophthalmology residency programs. A study of family medicine residents showed that residents who participated in international health training valued this more than traditional factors of location, faculty quality, resident quality, and spousal preference when they were evaluating residency programs.20 In a study of emergency medicine residents, 62% of residency program applicants felt that global health electives were a positive factor in ranking their programs, and 68% of applicants with previous global health experience would rank programs higher if they offered international opportunities.21 Overall, 78% of anesthesia residents indicated that the availability of a global health track factored into their residency ranking.13 It is conceivable that these trends apply to ophthalmology applicants as well, making international electives an important part of recruitment. There is already interest and involvement in global health in ophthalmology residency programs. In our survey, 31 programs (55%) already support residents going abroad for international electives and 44 programs (75%) intend to increase this support. Moreover, 53 programs (90%) currently incorporate global health into their educational curricula. A similar survey performed in 2005 showed that only 21% of programs were teaching global health and 47% had resident participation in international electives.22 These numbers suggest increasing interest. This may reflect the new generation of physicians in training, which has an increased interest in global health.9,17 Some barriers prevent ophthalmology programs from offering global health electives. The most common barriers identified were a lack of funding, a lack of ACGME
Percentage and Number (n) Out of 59 Responders
TABLE 3. Most Common Obstacles to Participation in Global Ophthalmology
FIGURE 2. Characteristics (Surgical vs nonsurgical) of current global ophthalmology experiences.
from other subspecialties (Table 4); however, there is very little reported on ophthalmology resident participation in global health. This survey gathered information about ophthalmology residency programs' current involvement in global health, the perceived importance of global health in ophthalmology residency training, and the obstacles and complexities of establishing global health curricula and international electives for ophthalmology residents. This survey is particularly timely given the recent endorsement of 1-month international elective credit toward resident training by the ACGME RC in ophthalmology. The key findings of this survey are as follows: (1) the majority of ophthalmology residency program directors who responded feel that global health opportunities are important to medical students going into ophthalmology when they are evaluating residency programs; (2) the majority of ophthalmology programs represented in this survey are already supporting international opportunities for their residents and incorporating global health into their residency curriculum, and of those programs that are not currently involved in global health, the majority already have plans to develop programs for residents; and (3) the
Characteristic An affiliated site (i.e., a site that has an established relationship with the ACGME-accredited ophthalmology residency program) A site affiliated with faculty or alumni from the home institution A non–program-specific site (e.g., resident chooses site that has no affiliation with the ACGMEaccredited ophthalmology residency program) Not applicable e56
35.0% (20) Reported Obstacle 23.3% (14) 21.7% (13)
20.0% (12)
Lack of financial support Lack of resident coverage at home Activities abroad (i.e., surgical experience) are not ACGME approved Lack of knowledge of appropriate programs abroad Lack of resident interest Other
Percentage and Number (n) Out of 59 Responders 77.8% (46) 66.7% (39) 63.0% (37) 33.3% (20) 22.2% (13) 14.8% (9)
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approval of the electives, a lack of information regarding available opportunities, and inadequate resident coverage at home institutions. Similar obstacles are cited by other specialties in the literature.10,23,24 Past reports show that despite high interest, only 10% of pediatric residents participate in international electives and much of the participation was dependent on recent program faculty participation.10 Among surgery residents, the most common barriers reported are family, financial aid, and scheduling time for the elective, as well as lack of accreditation of the electives.24 For the latter, the experience of other specialties could guide ophthalmology in addressing these obstacles. The General Surgery Residency review committee and the American Board of Surgery announced rules allowing international electives to count toward graduation requirements, including surgical cases, 2 years ago.12 The
ophthalmology RC made a first step last July by offering credit for international electives up to 1 month; however, surgical cases of ophthalmology residents abroad are not yet counted toward graduation requirements. Guidelines for awarding residency credit for surgeries abroad may be a logical next step. Additionally, focus groups for ophthalmology program directors to share information on existing international opportunities and funding sources, as well as development of international electives through global health offices at the residency programs’ home institutions, may be valuable. Finally, ophthalmology residency program directors in this survey cited a need for didactic material for residents. There is much interest in international electives; however, the didactic component to global health training cannot be forgotten. A global health curriculum, elective or otherwise, should have
TABLE 4. Residency Global Health Programs Subspecialty
Interest in Global Health
Global Health Didactics
International Electives
Notes
Pediatrics (Nelson et al.10)
15% Of programs have a 47% Of 52% Of programs with majority of residents programs residents participating in interested in global have a formal global health electives health global health curriculum 450% Of residents are 60% Of programs have Review Committee for Surgery Surgery interested in informal electives available approved international (Mitchell participating in electives for graduation et al.12) international electives credit in 2011 490% Of residents 44% Of residents responding Barriers to participation in Anesthesia reported some interest in participated in international electives, identified in this (McCunn international anesthesia electives despite high survey, were family et al.13) experiences interest commitments, financial aid, and work/coverage restraints 450% Of family medicine Residents 450% Of residents in Internal International elective Internal and internal medicine participate in medicine and Family Medicine participants are more likely residents participated in international medicine participate; 20%(Sawatsky to care for immigrants, some way, indicating lectures and 30% of Yale residents et al.14 and patients on public Gupta high interest teaching participate; duration of assistance, and go into et al.26) electives was from 4-12 wk general medicine. long; locations include international academic centers and private practices 65% Of residents 425% Of programs 100% Of participants report ENT (Volsky participate when participate in international humanitarian aid as a et al.16) opportunities are electives; 96% of the reason for participation; available experiences are partly 76% report the clinical surgical experience is good enough for ACGME credit Ophthalmology 75% Of programs report 490% Of Electives are mostly a The Review Committee for (Coombs plans to increase programs combination of surgical and Ophthalmology to the et al., This participation in global have at least clinical experiences ACGME approved electives paper.) ophthalmology 1 h of up to 1 mo for graduation didactics in credit their curriculum ENT, ear nose throat.
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clearly defined goals and objectives and address ACGME core competencies. Example objectives include (1) demonstrate knowledge of global eye disease epidemiology and (2) demonstrate understanding of ethical issues of global health training. These former and latter objectives of a global health curriculum address the ACGME core competencies of ophthalmic knowledge and professionalism, respectively, and resources are already available to implement them. The AAO launched an online resource called the Global Ophthalmology (GO) Guide (www.aao.org/GOGuide), a resource detailing epidemiology and standard treatments of eye diseases around the world. The International section of the Ophthalmic News and Education (ONE) Network of the AAO website contains lectures on ethical issues of global health. Evaluation of any implemented global health curriculum is important, and we believe that residents can be evaluated using the existing ACGME Ophthalmology Milestones tools. There are several limitations to this study that should be discussed. First, a possible response bias in which program directors who are more enthusiastic about global ophthalmology or already involved may have been more likely to respond to the survey. There were, however, some responses in the free-text comments from program directors who did not feel that global health training was important for their residency, indicating that the responses did capture differing opinions on the topic. Second, the response rate was incomplete: 59 of 116 programs (51%) responded and therefore the results and suggestions may not be generalizable to all residency programs. A follow-up e-mail was sent to encourage completion of the survey, and the survey was limited to a small number of specific questions to limit survey fatigue and promote completion. A response rate of 51% is as good or better than the average response rate for recent surveys published in the ophthalmology literature.25 Third, a strict definition of global health or global ophthalmology was not provided to the program directors who took part in this survey. This omission of a strict definition was intentional, as many ophthalmologists participate in international work in many different forms, from performing surgery abroad, to advocacy, teaching, and even in developing educational material for international trainees. A strict definition of global ophthalmology was therefore not included to capture all of these activities. As previously mentioned, the survey was limited to a smaller number of specific questions, and follow-up surveys may be important to further elucidate the current participation of ophthalmology residency programs in global health training.
CONCLUSION Ophthalmology residency programs are incorporating global health into resident training and are citing the value of international opportunities. We have identified the perceived obstacles to including international opportunities in e58
ophthalmology training programs, which are logistical, regulatory, and financial. Despite these challenges, program directors are interested in continuing and building on global health training in residency training. Given the recent approval of international opportunities by the ophthalmology RC, the formation of focus groups to address the development of global ophthalmology resources and share logistical and practical experiences is suggested. Future investigations should focus on how to best incorporate global health into training curricula through international experiences, didactics, and research. Participation in international electives offers our trainees and practicing physicians unique learning opportunities in unfamiliar settings. In many of these settings, ophthalmology is practiced effectively and efficiently despite limitations in resources. Resident training in global ophthalmology offers the hope of preparing a generation of ophthalmologists to more effectively tackle the burden of global blindness.
ACKNOWLEDGMENTS The authors would like to acknowledge the American Academy of Ophthalmology for their support in conducting this study.
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