Creating Meaningful Global Health Rotations

Morgan Congdon, MD, MPH, traveled to Botswana for a monthlong rotation at Princess Marina Hospital (PMH). Younger generations have grown up with technology that allows instant communication with people around the world, and are often very interested in traveling and interacting with others from different cultures and countries. This trend is also true of U.S. pediatric residents, so pediatric residency programs have adapted to provide training opportunities for future leaders in global child health.

Before the internet age, small groups of dedicated medical trainees completed rotations outside of the United States, which they usually planned on their own. The demand for global rotations intensified as internet use increased, but these early experiences lacked oversight and structure.

To address this, experts from several U.S. residency programs established the Pediatric Global Health Educators group under the Association of Pediatric Program Directors (APPD), now known as the APPD Global Health Learning Community (GHLC). The APPD GHLC, along with the American Board of Pediatrics (ABP) and the American Academy of Pediatrics (AAP), has spearheaded efforts that have resulted in more structured experiences for residents, minimizing the burden on host institutions and fostering mutually beneficial collaboration between U.S. trainees and host institutions.

Pillars of excellence: CHOP’s global health rotation

At Children’s Hospital of Philadelphia (CHOP), we have taken the American Board of Pediatrics' (ABP) five-pillar model and adapted it to the Global Health track of our Pediatrics Residency Program. Morgan Congdon, MD, MPH, is among the residents who have participated in the program, traveling in spring 2018 to Botswana for a monthlong rotation at Princess Marina Hospital (PMH), Botswana’s main referral hospital in Gaborone, the capital city. Dr. Congdon had participated in other global health experiences during college and graduate school, but this was her first international rotation as a resident. Her experience, which she shares below, illustrates how each of the five pillars helps to create a meaningful rotation experience.

Pillar 1: Stateside Curriculum

During her first year of residency training, Dr. Congdon met with faculty members of the Global Health Center, including the center’s Medical Director, Andrew Steenhoff, MBBCh, DCH. These meetings gave her a better understanding of CHOP’s global health projects and the sustainable and collaborative work the center is doing around the world.

Pillar 2: Pre-departure Preparation

Before Dr. Congdon left Philadelphia, CHOP’s Pediatrics Residency Program made sure she had all the information she needed for a successful global health rotation. She participated in a series of global health simulations based on a curriculum created by members of the APPD GHLC. This curriculum focuses on common challenges healthcare providers face when working in resource-limited settings, and provides practical approaches for addressing those challenges.

Dr. Congdon also had an in-depth orientation with staff and residency program global health faculty from the Philadelphia-based Botswana-UPenn Partnership (BUP). The orientation included a cultural orientation to Botswana and covered a “day in the life” of a visiting pediatric resident, during which each PMH team member’s role was outlined. For example, Dr. Congdon learned that while in Botswana, she would be what her Batswana counterparts call a “super-intern.” Super-interns have similar medical knowledge and experience as Batswana pediatric residents, but lack institutional knowledge on how things are done in Botswana’s healthcare system. They are also less experienced with managing certain illnesses, such as tuberculosis, that are more common in Botswana than in the United States. 

Dr. Congdon found it helpful that roles were clearly defined early on, and that expectations were set for each team member: “It ensured that we didn’t end up in a situation in which we were uncomfortable or at risk of inadvertently compromising patient safety.”

Dr. Congdon also received a handbook about Botswana, which included details about housing, currency exchange, weather, items to pack, cell phone service and other information that someone would need to know to live outside the United States for a few weeks. “It was reassuring to know that I could refer to the handbook when I needed to,” she says.

Pillar 3: Global Health Elective

When she arrived in Botswana, Dr. Congdon quickly settled in and received an in-country orientation facilitated by the Botswana-based BUP staff. BUP staff reviews the residents’ medical licensing paperwork to make sure their application packets are complete before submitting them to the Botswana Ministry of Health. Once their licenses are approved, residents meet with their clinical teams at the hospital.

At PMH, similar to CHOP, the residents begin the day with morning report at 7:30 a.m. While morning report was familiar, some differences stood out for Dr. Congdon. “In addition to discussing new admissions, colleagues in Botswana report any mortalities that happened overnight, which is a less-frequent event in pediatrics in the United States,” she says.

After morning report, residents pre-round on their patients. As a visiting resident, Dr. Congdon was encouraged both to pre-round on her patients and to supervise a University of Botswana medical student.  The experience gave her the opportunity to practice her medical teaching skills and to learn from the Batswana students, who shared their knowledge of how to accomplish things within the hospital.

The pediatric medical floor at PMH has an open-floor plan separated into medical cubicles with eight beds in each cubicle. The experience of interacting more closely and naturally with patients and families was particularly meaningful for Dr. Congdon. She says, “I felt we were able to bond with families much more than we do in the United States because you are in their sight all day. This is something we lose in the United States when people are in their hospital rooms and can close their doors.”

By mid-morning, it was time to round on the patients with the attending physician. The attending encouraged the University of Botswana senior resident on the team to lead the rounds, with the attending jumping into the discussion and adding teaching points as needed. Used to a more overtly questioning learning environment, Dr. Congdon experimented with asking more questions in a culture that seemed to follow the practice of “what the attending says goes,” and found that her questioning attitude was well-received by the attending physicians and her fellow residents.

After rounds, Dr. Congdon would spend the remainder of her day getting tests done for her patients — including drawing blood for labs — and sending patients for X-rays and speaking to social workers about her patients’ needs. “They were basically the same tasks we do here in the United States,” she says, “but it takes a little longer because it is not all computer based, and you have to draw your own labs and wheel your patients to their tests.”

Pillar 4: Post-return Debriefing

Upon returning to the United States after her four-week rotation, Dr. Congdon had a formal debrief session with the residency directors. In these sessions, she reflected on her rotation experience, including the lessons she learned and the challenges she encountered. “We discussed specific differences in patient care and how we can better prepare future residents for certain challenging scenarios,” she says. “The main challenge that we face upon return to the United States is ‘reverse culture shock.’” During the debrief session, Dr. Steenhoff, and Adelaide Barnes, MD, Assistant Program Director of the Pediatrics Residency Program, discussed this process with the residents and offered advice on how to cope.

Dr. Congdon feels that her experience in Botswana made her a more confident and independent provider. “It was an important rotation to do in my second year because it is a time in which you have to become comfortable making your own medical decisions. Botswana was a good test of that process in our learning. You have people who can help when you need it and who oversee the care you provide, but you are also challenged to walk through the whole process from beginning to end on your own.”

Pillar 5: Evaluation

At the end of each rotation experience in the United States or abroad, residents complete a survey. Additionally, they receive an evaluation from an attending they worked with while they were overseas. Both provide an opportunity for residents to reflect on what they’ve learned and to receive feedback on how they can continue to improve their skills.

When she reflected on her rotation in Botswana, Dr. Congdon found that she took away more from the experience than she had expected. “I was pleasantly surprised by the connections I made with the families, and especially with the Batswana residents,” she says. “I didn’t know what the vibe was going to be on the team as a visiting resident, but it was wonderful. By the end, we had developed strong relationships, and these relationships helped me get through tougher portions of the rotation, like witnessing death and being away from home.” Dr. Congdon was not only able to learn about a different healthcare system; she also learned about a new culture and explored a different part of the world.

“I would definitely recommend this rotation to others because it helps you feel like a doctor. You learn to think on your feet, face new challenges, and see different presentations of disease processes,” Dr. Congdon says. “It is highly valuable for all residents to have an experience in which they step away and see how things are done elsewhere.”

Adds Dr. Barnes: “Global health rotations can be an extremely formative experience for any pediatric resident. The ability to step away from our resource-rich setting and adapt to another is a unique learning opportunity. Our goal is to ensure that when our residents go abroad, they appreciate and learn from our colleagues who work in these low- and middle-income settings. At the end of the day, the resources are different, but the goal is the same: to provide excellent, high-quality care.”