AMA Journal of Ethics. March 2018, Volume 20, Number 3: 253-260.
Linking Global Health to Local Health within an Ob/Gyn Residency Program
Global health training offered through UCSF’s EMPOWUR program prepares ob/gyn residents to work in under-resourced communities locally as well as globally.
Sara Whetstone, MD, MHS, and Meg Autry, MD
Trainees are desirous of opportunities to work in global health settings during residency and afterwards. A recent survey revealed that many residents in obstetrics and gynecology even use their free time and own funds to secure such experiences . Providing opportunities during training for work in international settings and in undeserved domestic communities has the potential to increase the physician workforce ready to care for underserved populations. Residents and students who have experiences with underserved populations develop a more informed perspective on health care delivery, resource allocation, and cost effectiveness [2-5]. More importantly, students and residents who train in low-resource settings are more likely to work in underserved areas locally and abroad in the long term [2-5]. Yet one survey of US physicians showed that roughly three-fourths of respondents felt unable to address social determinants of health and ill equipped to provide quality care to underserved populations .
Since the evidence demonstrates that experiences in caring for underserved populations leads to extended commitments to work in areas of need, we believe that training programs should prepare residents to care for underserved populations in this country and globally. However, we reject the assumption that just working in an underserved community will lead to appropriate skill acquisition and expertise. While many programs have residents rotate through safety net hospitals and spend elective time in international settings, at the University of California, San Francisco (UCSF), we believe that we have further developed these experiences into a curriculum that improves health care provision for women by intentionally training residents to address the particular medical and nonmedical needs of underserved populations.
The mission statement of the obstetrics and gynecology residency program at UCSF is to improve the health and well-being of all women. We emphasize the word “all” as we embrace and value the notion of inclusivity. We assert that all women, domestically and internationally, with resources and without, deserve to have opportunities to improve their lives and make decisions about their bodies that are consistent with their values and goals. Given these values and assertions, our mandatory resident training includes deliberately structured, supported, and integrated educational experiences in both global and local health. In this paper, we describe our approach to training obstetrics and gynecology residents to care for vulnerable women in our community and in international settings.
Instituting Domestic Training Programs for Underserved Populations
Many states in the US, including California, Texas, Georgia, and Wisconsin, have instituted programs in conjunction with their public academic institutions to help meet their workforce needs as well as address inequities in the provision of health care to their citizens [7-10]. In California, funding has been available since 1973 to support primary care programs to prepare physicians to work in under-resourced settings in the state . In 2014, this opportunity was extended to obstetrics and gynecology programs , and the UCSF residency program was a fortunate recipient of this funding. Despite UCSF’s long history of commitment and service to underserved populations, this funding enabled us to implement a more robust and intentional curriculum on caring for vulnerable populations in our state and in our country. Our mandatory and integrated curriculum is entitled EMPOWUR—Educating, Mentoring, and Preparing Ob/Gyns to Care for Women in Under-Resourced communities. It aims to graduate obstetrician-gynecologists who are prepared, committed, and inspired to provide excellent care to underserved women within the United States. To accomplish this goal, we focus on the following four curricular pillars of the EMPOWUR program:
The EMPOWUR curriculum not only strives to prepare residents to be clinically competent in the care of underserved women domestically but also hopes to equip trainees with the knowledge and skills necessary to recognize disparities, to develop trusting and engaged relationships with the community, and to address nonmedical factors associated with health inequity. This long-term and broader vision for our training reflects the call for clinician-educators to prepare physicians to address social and institutional barriers to health . While the EMPOWUR clinical experience is focused on vulnerable domestic populations and community work, the didactic curriculum and advocacy work is applicable internationally and complements our global health training.
Creating Ethical Global Health Experiences for Trainees
In our didactic program, we have embraced a broader definition of global health—one that explicitly includes inequities both in our country and globally . From a practical perspective, there has been increasing recognition that the skills needed to practice successfully in international settings—such as those required to surgically manage postpartum hemorrhage and provide safe, respectful maternity care—are similar to those needed to work with underserved populations in our own country . By timing the global health experience to chronologically follow the clinical experience of the EMPOWUR program, residents are better prepared in terms of their skills and knowledge and, more importantly, better positioned to engage with local physicians in their efforts to address disparate outcomes.
Our curriculum in global health occurs primarily in the third year of residency and includes an online didactic course as well as an experiential component. UCSF obstetrics and gynecology residents spend four weeks at Mulago Hospital, the teaching hospital affiliated with Makerere University College of Health Sciences in Kampala, Uganda; they rotate alongside Ugandan house staff and provide advanced obstetric and gynecologic care. Mindful of the pitfalls of short-term experiences in global health, our program has been deliberately structured to maximize benefits to the host community while at the same time augmenting the learner’s experience in understanding global inequity . Key features of our global health program include:
We have developed a supportive and collaborative global health experience that strives to link global health and local health training and facilitate greater conversation about equity, social justice, and interconnectedness. Our pedagogical approach to global health education is one in which trainees are taught how to provide responsible, equitable care and challenged to transfer these principles and clinical approaches to the clinical setting in which they work. Additionally, faculty members strive to model collaborative and bidirectional work with local agencies and Ugandan physicians, hoping to demonstrate principles of community engagement that can be used in communities abroad and in our own backyard. We believe that global health training, when properly structured, adds to trainees’ preparation in caring for marginalized women and increases the likelihood that they will ultimately work to address disparity in their careers.
We believe that we have constructed a robust curriculum on caring for underserved populations that emphasizes didactic and experiential exposure both locally and globally. In order to improve the health of all women, we feel an obligation to adopt a more expansive approach to clinician education that includes intentional preparation for work in low-resource settings. Accordingly, we aim to train clinically competent women’s health practitioners who have the skills needed to care for marginalized populations and to address social and institutional barriers to health. While this paper has focused on women’s health and training in obstetrics and gynecology, the concepts and principles are certainly applicable to most specialties. By pairing curriculum and experiential learning in both domestic and global health, we hope to encourage future work with underserved populations in our state, our nation, and our world. We believe that residents who participate in our unique curriculum are more likely to pursue this path and be content in their choice because they are exposed to the benefits and realities of this work. We hope that our educational model inspires our trainees to develop a larger vision of patient care, one in which they can continue to address inequities and to improve women’s health, regardless of where they choose to practice.
Sara Whetstone, MD, MHS, is an assistant professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco. Her long-term commitment to improving the health and well-being of women from underserved communities in the US began as an undergraduate at Brown University, where she majored in community health. It continues today in her work as a faculty member and assistant ob/gyn residency director, developing didactic and community-based experiences for residents. She is currently participating in the Association of Professors of Gynecology and Obstetrics Academic Scholars and Leaders Program to advance these efforts in ob/gyn training nationally.
Meg Autry, MD, is a professor of obstetrics and gynecology in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco, where she is also the residency director and director of graduate medical education. She is an army veteran and the past president of the Association of Professors of Gynecology and Obstetrics. She serves on the editorial board of Obstetrics and Gynecology and the American College of Obstetricians and Gynecologists presidential task force for global health, and her grant funding focuses on workforce development and interprofessional education.
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