Global Health Toolkit

Note: The presence of visitors and learners predictably diverts attention and resources from patient care in all settings. This could affect patient safety and health system integrity in resource-limited settings. Therefore, recognize that participation in direct clinical care is only one means by which resident physicians can develop the knowledge, skills, and attitudes to become advocates for reducing health disparities and functional clinicians in resource-limited settings. Not all competencies below may apply to all residency-level global health tracks or elective experiences.

Objectives that map to milestones

Competencies to be assessed regarding preparation for providing clinical care in resource-limited settings:

1. Describes the key components of a history and physical exam needed to create a differential diagnosis for common acute illnesses and emergent situations in resource-limited settings. Quickly recognizes urgent and emergent situations that may present in a low-resource setting.
2. Discusses the risks and benefits of using symptom-based care in settings without adequate diagnostic capabilities.
3. Describe diagnostic and management strategies and resources not accessed electronically that could be used to improve patient case in resource-limited settings.
4. Identifies ways in which non-communicable diseases may present and progress that differ from high-resource settings.
5. Identifies the major causes of morbidity and mortality affecting the populations in resource-limited settings including LMICs.
   
   Competencies to be assessed if direct clinical care is expected or requested by a host institution and appropriately supervised (not all competencies will apply in all settings):Applies principles of cultural humility and ethics when learning and working with all persons, especially those who are vulnerable due to poverty, language, education, remote location, social/racial/gender-based hierarchies, etc.
6. Accepts uncertainty and maintains continuity (if locally appropriate to do so) while managing patients with undifferentiated illness in resource-limited settings.
7. Identifies patients for whom a procedure is indicated and works within the local health system to understand issues of consent and access and who is equipped to perform it.
8. Performs procedures within scope of practice and under appropriate supervision in resource-limited settings. Able to counsel patients about indicated procedure(s) and able to obtain informed consent
9. Applies WHO (and/or in-country/local) clinical practice guidelines to the care of patients in resource-limited settings.

Core content

• INFECTIOUS
  • Management of HIV/malaria/TB in low resource areas
  • Differential for and management of diarrheal illnesses in LMICs
  • Management of pneumonia in LMICs
  • Triage of and differential of Fever in LMICs
    
    
• NON-COMMUNICABLE
  • Management of non-communicable diseases in low resource settings
  • Prevention and Health Promotion
    
    
• INJURY/TRAUMA
  • Demonstration of basic skills in trauma and emergency care in low resource settings
    
    
• MATERNAL/NEONATAL/NUTRITON
  
  • Management of common OB issues and NSVDs
  • Demonstration of basic neonatal resuscitation skills
  • Demonstration of competency in basic reproductive and sexual health issues
    
    
• OTHER
  • Review of country-specific guidelines
  • Course in GH ethics/Cultural humilty
  • End of life/palliative care
  • Addressing mental health and psychosomatic illnesses in a culturally specific and appropriate manner
    
    
• BASIC PROCEDURES (In addition to core FM procedures)
  • Manage closed fractures and dislocations in low resource settings
  • Develop ultrasound point-of-care diagnostic skills
  • Perform routine microscopic lab skills
  • Placing basic lines

Optional (Advanced) Content

• Management of high risk OB
• Advanced POCUS Skills
• Pubic symphysiotomy
• Emergency and essential surgical procedures (such as C-section, management of ectopic pregnancy, uterine evacuation, management of wounds, burns, and infections, anesthesia and resuscitation, tubal ligation, appendectomy, vasectomy, etc.)
• Advanced skills in preparedness and response to natural disasters and humanitarian emergencies
• Cervical cancer screening using VIA (Visual Inspection with Acetic Acid)

Patient Care Resources    

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Objectives that map to milestones 

1. Create a differential diagnosis and discuss pathophysiology for common regional illnesses.
2. Improve basic clinical and diagnostic skills to better function in resource limited areas globally.
3. Summarize the presentation, diagnosis, management, and prevention of global infectious and noninfectious causes of morbidity and mortality.
4.  Demonstrate knowledge of unique aspects of health care of immigrants and refugees.
5. Understand key concepts of injuries and traumas common in LMIC.
6. Describe and interpret the following core health indicators: neonatal mortality rate, maternal mortality rate, infant mortality rate, and under-five mortality rate, and be able to compare the differences in these core health indicators between LMICs and HICs.
7. Discuss the differences between the top causes of neonatal, infant, child, and adolescent morbidity and mortality for low and middle-income countries (LMIC) and high-income countries (HIC).
   

Core content

• INFECTIOUS
  • HIV/AIDS
  • Malaria
  • TB
  • Viral hemorrhagic illnesses (Ebola, Dengue, etc)
  • Other viral (hepatitis, Zika, COVID-19, etc)
  • Other vector-borne Illnesses (Chagas, river blindness, Africa)
  • Sleeping Sickness, tick-borne) *Rabies
  • Diarrheal disease *GI parasites *Other parasites
  • Neglected tropical diseases overview (Filariasis, etc)
  • Pneumonia in LMIC
• NON-COMMUNICABLE DISEASE in LMIC
  Anemia, obesity, mental health, CVD, CVA HTN, DM, COPD, asthma
• INJURIES/TRAUMA
  Common injuries, wound care, fracture management, rehab
• MATERNAL/NEONATAL/NUTRITIONz
  • Malnutrition *Core maternal and women's health issues in LMIC
  • Neonatal issues in LMIC (prematurity, birth asphyxia, stunting)
• OTHER
  • Global burden of disease
  • Core health indicators and major causes of morbidity and mortality
  • Basic travel medicine
  • Travel safety
  • Common issues in refugees and migrants domestically
  • Disaster response

Medical Knowledge Resources

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Objectives that map to milestones

1. Identify and apply appropriate medical resources, including references and standardized guidelines (eg. WHO/CDC/country-specific guidelines) for diagnosis and treatment of conditions common to resource-limited settings and adapt them to the individual needs.
2. Self-reflects, analyzes, and institutes behavioral change(s) to narrow the gap(s) between expectations and actual performance.
3. Demonstrate mentoring and teaching skills appropriate for context, including learner assessment and flexibility in low-resource settings.
4. Recognize personal practice limitations and seek consultation with other health care professionals and systems resources to provide optimal care within a global context.

Core content

• WHO/CDC/country-specific guidelines and policies
• Country-specific health system structure(s) and referral process
• Use of offline evidence-based resources and tools for use in limited-resource health care settings (print materials, etc.)
• Teaching in low resource settings

Optional (advanced) content

• Grant writing and paper writing
• Planning, implementing, and evaluating training program
• Research skills

Practice-Based Learning and Improvement Resources

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Objectives that map to milestones

1. Display effective communication skills (including both spoken language and nonverbal cues) and humility when discussing medical information with families from different cultures, particularly those with limited English proficeincy (LEP).
2. Demonstrate effective use of an interpreter.
3. Identify cultural issues/beliefs that could cause confusion or misinterpretation when communicating with families about certain issues (ie. death and dying, etc).
4. Demonstrate cultural humility while working in an unfamiliar setting, acknowledging the local expertise and perspectives of colleagues familiar with that environment
5. Identify common ethical concerns that may arise in global settings.
6. Communicates information effectively with all health care team members in settings they may be unfamiliar with.
7. Uses appropriate channels to offer clear and constructive suggestions for system improvement while acknowledging system limitations and cultural differences.
8. Demonstrates basic cross-cultural communication skills including basic language greetings, awareness of power differential in interactions, posture of learner not expert.

Core Content

• Use an interpreter appropriately
• Global Health Ethics Course
• Cultural Humility Course
• Role of different healthcare providers in LMIC
• Demonstrate diplomacy and build trust with community partners
• Awareness of best practices in partnership building

Interpersonal and Communications Skills Resources

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Objectives that map to milestones

1. Learn about and experience different cultures and increase cultural awareness.
2. Recognize the complexities of privacy issues specific to cultural differences.
3. Demonstrate a commitment to professional behavior while working collaboratively with health care team members and being respectful of differences in knowledge, practices, and culture.
4. Reflect on personal power and privilege and how this effects interactions in global health.
5. Identify the impact of culture-based gender roles within family and society as it applies to the physician-parent interaction, as well how the gender of a child may affect health-seeking behaviors and outlook.
6. Reflect on and describe personal biases that may affect decision-making when caring for diverse and vulnerable populations and develop strategies to avoid them.
7.  Anticipate possible conflicts that may arise while serving in an unfamiliar clinical setting by devising strategies for managing one’s stress, well-being, behavior and communication, security, and professional responsibility.
8. Describe signs and symptoms of “culture shock” and issues surrounding clinical care with resource limitations and understand how the experience of “culture shock” may affect one’s professionalism.
9. Demonstrate capacity for compassion (desire and commitment to do something to address human suffering).
   Employ self-care, work-life balance in low-resource settings.
10. Demonstrate commitment to service, equity, and principles of social justice and decolonization in global health.
11. Demonstrate commitment to self-directed learning, to recognition of personal limitations/competencies, and to engagement in strategies to address these limitations.

Core Content

• Cultural humility training
• Global Health Ethics Training
• Core tenets of decolonizing Global Health

Optional (Advanced) Content

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Objectives that map to milestones 

1. Discuss the global burden of disease.
2. Describes how components of a complex health care system are interrelated in LMICs, how different healthcare systems can be structured, and how this impacts patient care.
3. Describes local quality improvement initiatives.
4. Identifies specific population and community health needs and inequities in their local population in resource limited areas.
5.  To gain a framework for improving health of individuals and communities in resource limited areas.
6. Understand how to advocate for different issues in resource limited areas both domestically and abroad.
7. Understands coordination of care of patients in LMICs, the roles of the interprofessional team members, and their role in the team abroad (and how that might differ from their role in the US).
8. Describe the relationship between access to and quality of water, sanitation, food and air on individual and population health.
9. Describe major public health efforts to reduce disparities in global health (such as Sustainable Development Goals (SDGs) and Global Fund to Fight AIDS, TB, and Malaria).
10. Develop understanding and awareness of the health care workforce challenges in LMIC, the factors that contribute to this, and strategies to address this problem.

Core Content

• Interplay between culture and health (including alternative or traditional medicine, atypical therapies, and delays in seeking care)
• Barriers to care in LMIC
• Barriers to care in refugees and migrants in LMIC and HIC
• Health care systems (including country specific if needed)
• Water, sanitation, and hygiene (WASH) and health
• Basics of public health including epidemiology and contact tracing
• Social Determinants of Health
• Concepts in developing/implementing quality improvement (ex. PDSA cycle)

Optional (Advanced) Content

• Conducting a needs assessment
• Perform an inventory of resources in a given clinical setting in order to understand how that setting functions and to identify possible areas of improvement while considering long-term sustainability
• Design context-specific health intervention based on needs assessment
• MPH or other formal Public health training

Systems-Based Practice Resources

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