Building Competencies Through Bilateral Medical Exchanges

1. Building Competencies Through Bilateral Medical Exchanges Rachel A. Umoren, MD

2. International Service Learning in the Indiana University School of Medicine IU-Moi University (MUSM) IU-Universidad Autonomo del Estado de Hidalgo (UAEH)

3. International Service Learning in the Indiana University School of Medicine Interdepartmental Residency track in global health -- Internal Medicine, Pediatrics, OB, Family Practice, and General Surgery residents

4. MUSM Medicine or Pediatrics registrars visiting IUSOM • 4-6 months of pediatric or medicine subspecialty electives during their 2nd year of residency UAEH Pediatrics registrars visiting IUSOM • 4 weeks of pediatric subspecialty rotations during their 3rd year of residency International visitors

5. Improve student’s clinical skills Increased knowledge of tropical medicine and community health(Thompson MJ, et al., 2003) Increased cultural and linguistic competence(Grudzen CR, et al., 2007) Careerchoices to work in underserved settings(Gjerde C, et al., 2004; Castillo et. al., 2010) Medical institutionsin developing countries may also benefit (Drain PK, et al., 2007) Global Health Electives

6. In 1999, the Accreditation Council for Graduate Medical Education (ACGME) introduced the Outcome Project • Need to evaluate residents’ training in six general competencies • Interpersonal and communication skills • Professionalism • Practice-based learning and improvement • Systems-based practice • Patient care • Medical knowledge ACGME Core Competencies

7. Communication • Communicate effectively with patients across a broad range of socioeconomic and cultural backgrounds • Communicate effectively with physicians, other health professionals, and health related agencies

8. Professionalism • Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles • Demonstrate sensitivity and responsiveness to a diverse patient population

9. Practice Based Learning and Improvement • Investigate and evaluate care of patients • Appraise and assimilate scientific evidence • Continuously improve patient care based on constant self-evaluation and life-long learning

10. Systems Based Practice • Work effectively in various health care delivery settings and systems relevant to their clinical specialty • Participate in identifying system errors and implementing potential systems solutions

11. International Service Learning:Developing the Competent Physician

12. To investigate the possible influence of the exchange program on resident education in relation to the competencies of communication, professionalism, practice based learning and improvement, and systems-based practice. • To identify barriers and facilitators to achieving these core ACGME competencies Study Aims

13. Study Methods • Internal Medicine or Pediatrics residents who had visited any of the institutions for a minimum of four weeks from the year 2002 to the present • Five focus groups • Five key informant interviews • Conducted by a trained facilitator

14. Data Analysis: The Grounded Theory Process Charmaz, K. 2007. Understanding Grounded Theory

15. Demographics • 35 residents and faculty • 21 US learners; 14 International learners • Male : Female ratio 1:1 for US learners and 2:1 for International learners • Average time elapsed since international elective: • US participants: 2 years • International participants: 1.3 years

16. Communication • Cultural expectations • Language barriers/accents • Team expectations

17. Communication I think there is also a cultural difference [in Kenya]. They don’t want to tell you “No”. They don’t want to tell you that something is not gonna work, or something can’t be done, or something wasn’t done. So if you try and find something out about the patient’s care like if they were given medication or something… you later find out that the pharmacy didn’t have it in stock…but they just did not want to tell you. You could not troubleshoot because you didn’t know what actually happened -- US learner studied in Kenya Silence is not golden in America …it is always good to be vocal and explain things more than is necessary. In Kenya when you speak a lot people think that you are disrespectful. --Kenyan learner studied in US • Cultural expectations

18. Communication • Team expectations • I stayed pretty quiet on the days when the attending was there mostly because that was very much the culture, you don’t step up and the resident I think I heard her say maybe three words and this was when the attending was there, and mostly it was, “I will check that”. So the top down culture is very ....predominant • -US learner studied in Kenya

19. Professionalism • Ethical challenges • Health care professional role • Health care professional biases

20. Professionalism • I worked on the adult wards [in Kenya].... there were numerous patients that were at end stage with an illness and which required pretty heroic efforts and you just didn’t have them available and so truly your decision making can be....comfort care type of issues right off the bat. – US learner studied in Kenya • One thing that was kind of tough is just the cultural perception that you never give bad news and so the medicine team leader, tries to tell like it is, “You’ve got bad cancer, you’re gonna pass away...” and then it gets translated, “Everything will be fine.” • - US learner studied in Kenya • [In the US] they over-investigate a patient just for the sake of covering themselves so they were not treating the patient they were treating themselves - Kenya learner studied in the US • Ethical challenges

21. Professionalism • Health Care Professional biases [The Kenyan physicians] were just a little bit more focused on their reality and I was still trying to use the U.S. reality of like, “What do you mean there is no more?” - US learner studied in Kenya

22. Practice Based Learning & Improvement • Evidence based medicine • Team Development • Development of self

23. Practice Based Learning & Improvement • Evidence based medicine • “I think evidence based medicine is very nice in a resource-rich society where you have choices.” – US learner studied in Kenya • [In Kenya] there is a fine line between discussing evidence based medicine in sort of educationly stimulating way versus crossing that line to “Well this is how it should be done, and you won’t or can’t” ...and I think we walked that line a couple of times – US learner studied in Kenya

24. Practice Based Learning & Improvement • Team development I had very open registrar who asked my opinion or we would talk about things very much in a joint fashion and sort of discuss things…When I went to the peds side I had a different registrar. He was much more closed off and I very much felt I needed to be in the background… -US learner studied in Kenya I think that the feeling of competition: of I’m going to do this, or I’m going to do that; causes them not to care. But [in Mexico], since we are a team, we have to support each other; you can’t allow anyone to lag behind because if so, your team won’t perform well and you want to have a good team, so we help each other a little more... - Mexican learner studied in the US

25. Systems Based Practice • Access to care • Quality of care • Improvement of Exchange

26. Systems Based Practice • Access to care • I think probably the delay in people coming [to the hospital] is just truly the time it takes for them to get there…it is an indigent population and people are riding their bikes, others are walking… -US learner studied in Kenya • Everything there [in Kenya] is determined by money,...if you don’t have the money up front, then you don’t get care • -US learner studied in Kenya • …sometimes even the [US physicians] who are providing treatment are unable to do much if the insurance company is not going to agree to pay for it - Kenya learner studied in the US

27. Systems Based Practice • Quality of care And then having access to the level of care necessary is not always possible either. There was a limited number of oxygen canisters available..... so although you can access care it may not even be the appropriate level of care based on just limited resources -US learner studied in Kenya

28. To investigate the possible influence of the exchange program on resident education in relation to the competencies of communication, professionalism, practice based learning and improvement, and systems-based practice • To identify barriers and facilitators to achieving these core ACGME competencies Study Aims

29. Hyperboloid Bridge

30. Bridge to Competency A B

31. Bridge to Competency A B

32. Resident Competency Communication Facilitator • Barrier

33. Bridge to Competency A B

34. Conclusions • Learners were able to identify and discuss key areas related to the ACGME competencies of communication, professionalism, practice based learning and improvement, and systems based practice • We identified potential barriers and supports to the development of ACGME competencies during global health electives

35. Implications • Develop self-reflective activity for learners • Training for mentors • Develop a program evaluation plan

36. Acknowledgements IUSM Pediatrics Ed Liechty, MD Diane Lorant, MD Sarah Stelzner, MD Rachel Vreeman, MD, MS Jason Woodward, MD Medicine Debra Litzelman, MD Megan Palmer, Ph.D. IUSN Mary Riner, Ph.D. MUSM LameckDiero, MB.ChB Samuel Ayaya, MB.ChB Facilitators Jennifer Custer (IUSM) Cathy Luthman (IUSM) Beatrice Koech (MUSM) Eunice Walumbe (MUSM)

37. Questions & Discussion