Increasing Care for Underserved Communities Through a Global Health Residency Training Program

Introduction

Global health (GH) is “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide [1].” A cornerstone of GH is equity in both healthcare and social determinants of health, and so, by definition, GH is the act of caring for underserved populations everywhere in the world. The term global refers to the scope of health issues rather than geographic location, and thus is practiced locally as well as internationally. GH education within academic medicine in the United States of America (USA) focuses on teaching knowledge and skills to medical trainees that enable them to address equity in health across a range of contexts, and often specifically includes clinical training to promote health for vulnerable communities [1]. These efforts align with calls to address social determinants of health from many groups [2–4]. Concepts of global health training apply internationally and locally, given the persistent inequities in healthcare access and health outcomes across populations in the US and around the world [5, 6]. Within the US, some of these inequities are directly linked to workforce shortages of primary care providers, now reaching crisis levels [7–9].

Global health training is increasingly integrated into medical school and residency curricula [2–4, 10–15], though a 2017 systematic review found that certain specialties had higher percentages of residents participating in global health training compared with others [5]. High global health training specialties included preventive medicine (83%), emergency medicine (74%), and general surgery (71%) [5]. Notably absent from the top three specialties with global health training opportunities in the USA are the core primary care specialties: internal medicine (IM), family medicine, pediatrics, and obstetrics and gynecology. Multiple studies have demonstrated the positive association between global health training and intention to practice in underserved settings [16, 17]. Thus, we propose that incorporating global health education into IM residency training will better equip doctors to provide care to vulnerable populations both locally and internationally and potentially improve health outcomes.

We created an innovative global health longitudinal training program to provide IM residents with didactic education on global health topics and diverse clinical experiences. Based on the authors’ literature review, this is the first detailed description of a GH curriculum, taught asynchronously without extension of a standard 3‑year residency program and with associated outcomes related to knowledge, skills, and attitudes affecting intention to and actual practice of working in underserved settings. Formal didactics were complemented by practical training experiences in local Federally Qualified Health Centers (FQHCs), prisons/jails, the Indian Health Service and tribal health centers in Alaska, Arizona, California, and Oregon, and a public hospital in Botswana, located in Southern Africa. Here, we describe the impact of this program on residents’ perceived preparedness to care for underserved populations, and their intention to serve these populations after graduation.

Methods

Global health scholars program (GHSP) description and participant selection

Established in 2014, the GHSP supplements the clinical and didactic training of the core IM program. It is offered to categorical residents interested in enhancing the standard IM residency training with care of underserved populations locally and internationally. Approximately ten interns apply per year, which represents approximately 33% of categorical interns.

The GHSP employs an adaptation of Knowles Adult Learning Theory using the following principles: self‑concept (autonomy and self‑directed learning), experience (encompassing both prior and current experience, the latter informing the “learner’s need to know”), orientation to learning (contextual and problem‑centered), motivation to learn (intrinsic and personal value), and readiness to learn (relevance to real‑life situations and incorporating developmental tasks) [18]. (Figure 1) These principles inform the GHSP at a number of levels, from the foundational concepts such as global health ethics and reflective practice to the array of educational settings through which content is delivered, including small group sessions, case discussions, self‑paced learning, and learner‑selected immersive clinical rotations. See Supplementary Table 1 for more details about the curriculum. The GHSP addresses topics related to the key curricular domains of social/structural competency, health equity, social and structural determinants of health, racism, colonialism, cost‑conscious care, ethics, and systems‑based practice. Many topics align with core competencies defined by the Accreditation Council for Graduate Medical Education [19]. Formal didactics include a resident‑led journal club every two months, eight noon conferences per year, plus additional context‑specific didactics during clinical rotations (Supplemental Table 1).

Figure 1

GHSP residents use their 3‑week elective time during PGY‑2 and PGY‑3 to complete global health clinical rotations (Figure 2). During PGY‑2, residents can choose to stay in the Portland area, where they work in underserved clinics and FQHCs that serve migrant and/or seasonal farmworkers and others with barriers to receiving healthcare. Alternatively, residents can choose to rotate at a site serving American Indian/Alaskan Natives, including the Alaska Native Medical Center in Anchorage, AK, or Indian Health Services (IHS) sites in Salem, OR, Tuba City, AZ, and Round Valley, CA. During PGY3, residents can complete a second rotation at one of the above sites. Alternatively, they may choose to rotate at Scottish Livingstone Hospital in Molepolole, Botswana, a longstanding international partner site where residents contribute to clinical education and quality improvement activities alongside an OHSU GHSP faculty member (author S.U.S.K) who lives and works in Botswana year‑round. Travel to these sites was notably disrupted by the coronavirus disease 2019 (COVID‑19) pandemic and residents in the GHSP during 2020–2022 completed only local (Portland area) rotations.

Figure 2

Findings

Between 2015 and 2022, admission to the program included 10–13 interns per year, with a completion rate of 6–8 residents at graduation and a drop‑out of about 4–5 residents per class. The primary reasons for dropping out included residents wanting to use elective time for fellowship‑related research and inability to travel to Botswana during the pandemic.

The survey was sent to 45 participants and was returned by 37 for an 82.2% response rate. Most participants were between the ages of 31 and 35 years (67.6%) and identified as non‑Hispanic (97.3%) and white (89.2%) (Table 1). Seven were current residents or fellows; the majority trained between 2018 and 2023.

Perceived changes in knowledge before and after training are shown in Table 2. The pre‑training scores ranged from 2.43 for Use of structural analysis to examine challenges faced by underserved populations to 3.67 for both Effects of physical and emotional health among those without housing and Critically reflect on clinical experiences during residency. The post‑training scores ranged from 3.17 for Use of structural analysis to examine challenges faced by underserved populations to 4.40 for Effects of inequities in healthcare on underserved communities (Table 2). All 16 perceived knowledge variables increased statistically after training as compared to before training (p ≤ 0.007). The effect sizes ranged from 0.750 to 1.230, all of which were above the Cohen’s d threshold of 0.50 due to educationally meaningful differences.

Among the seven current residents or fellows, three (42.9%) reported a moderate intention and two (26.8%) reported a high or very high intention to practice in underserved settings (Table 3). Nine (40.9%) GHSP graduates reported currently practicing in underserved settings, with most in urban underserved settings (Table 3). In addition, nearly all (90.0%) reported providing clinical services to patients on Medicaid, with houselessness, or with limited English proficiency in practice, mostly as hospitalists or specialists (Table 3). Whether training occurred before or during COVID‑19 did not appear to affect practice intentions or decisions (See Supplementary Tables).

Supplementary materials show differences in demographic characteristics, scores, and intention to practice in underserved settings among those who trained before the COVID‑19 pandemic and those who trained during it, illustrating that the greatest increase in scores occurred among trainees in the pre‑COVID period (Supplementary Tables 2–4).

Complete qualitative findings are included in Supplementary Material Table 5. Briefly, five themes emerged when participants described the best aspects of the GHSP. The first was Different learning setting and populations, or the value of working with patients who were culturally, ethnically, and racially heterogeneous within diverse settings both inside and outside the USA. An exemplar for this theme is:

The second emergent theme was Transformative learning impacting personal and professional growth, or the extent that the GHSP training program affected perceptions of the kind of physician participants wanted to be and how they approach clinical practice. An exemplar is:

The third emergent theme was Learning from each other, which reflected an appreciation of what local clinicians, clinic teams, patients, and other residents taught them about patient care in underserved settings. An exemplar is:

The fourth emergent theme was Complementary learning experiences, or an appreciation of learning opportunities that supplemented their education. Specific examples of cited learning opportunities included journal club, structured curriculum, online modules, and advocacy training. An exemplar is:

The final emergent theme was Social determinants of health focus, or the perspective that the GHSP learning experiences broadened participants’ perspectives on inequities that affect the health and wellness of communities and how these factors might be mitigated by their efforts as physicians. An exemplar is:

Three themes emerged regarding what aspects of the GHSP could be improved. The first was Better alignment between curriculum and clinical experiences, or a desire for better structures for interactive learning and clinical practice experiences that more solidly aligned with global health concepts. Several respondents specified praxis opportunities that were novel to the learning context, such as advocacy. This was closely linked to a stated desire for more opportunities to apply these skills during clinical experiences. An exemplar for this theme is:

The second emergent theme was Training site expansion, or a desire for additional local and global clinical experiences with different populations, especially for US‑based sites and local marginalized communities. An exemplar is:

The final emergent theme was Supplementary activities that participants identified as those they thought would benefit program participants, including opportunities to interact with other learners and experts engaged in global health. An exemplar for this theme is:

Discussion

We undertook this study to assess the extent to which a program such as the GHSP could address physician workforce issues in vulnerable communities. We found that 72% of residents or recent graduates of the program rated their intention to practice in underserved locations as moderate to very high, with nearly 41% of program graduates actively providing care in such communities. According to an Associatio of American Medical Colleges (AAMC) residency training report (2012–2021), only 24.1% of recent US residency graduates across all specialties reported working in a medically underserved area) [25]. This number is very similar for both graduates of IM (25.3%) and family medicine (26.1%) residencies, and in Oregon where 25.6% of all physicians practice in underserved areas [25]. Qualitative findings on the benefits of GHSP indicated that participants are indeed experiencing valuable clinical training in underserved locations. They appreciate both the diversity of the patients seen as well as the settings they are seen in. Many commented on how the experiences opened their eyes to the harms associated with health inequities and influenced their views on the physicians they wanted to be, as both advocates for patients and caregivers.

Transformative education, where deep fundamental shifts in world view occur related to educational experiences [26], certainly occurred here. Residents rotated in unfamiliar and often disorienting settings, which likely forced them to engage in introspection. A recent scoping literature review by Vipler et al. (2021) on transformative education in graduate medical education (GME) found that professional identity formation is often associated with such educational experiences [26]. Taken together, these findings suggest that both local and international GH experiences were educationally invaluable in triggering transformational learning.

To our knowledge, this is the first study to compare residents’ self‑reported knowledge, perceived preparedness, and intention to care for underserved populations following completion of an IM global health training program, as well as practice patterns post‑residency training. Our findings suggest the GHSP is significantly impactful in both training outcomes and career choices. In addition to assessing pre‑post differences, we also provided effect size values that further underscore the educational impact. Residents demonstrated changes in knowledge in care for houseless, indigenous, incarcerated, and immigrant patient populations and content related to structural racism, historical trauma, structural violence, and social determinants of health. Residents were more likely to work with underserved patient populations including the houseless, indigenous, immigrant, and resource‑poor (Medicaid) following graduation.

We felt it was not appropriate to ignore the global pandemic that occurred during the study period, and for this reason we included subanalysis in supplementary material. These data suggest the pandemic experience itself strongly affected awareness of the individual and collective responsibility for the well‑being of others and may explain why residents training during the COVID‑19 pandemic had higher baseline knowledge of global health matters. Importantly, independent of global events, the global health training program showed meaningful impacts on training outcomes and thus could be a key strategy to address physician shortages in underserved populations, including in primary care.

One area we would like to develop further is understanding how global health training empowers physicians in training and independent clinical practice to engage in advocacy. While important medical advances have occurred over the past decades, health disparities at national and global levels are overwhelming; increasing physician advocacy is an important professional activity to address these [27, 28]. Models for advocacy training in residency curricula have been illustrated by Peluso et al. [29], who developed a four‑session program on Advocacy and Activism with formal didactic teaching, training in basic skills, debate and discussion, and development and presentation of interprofessional advocacy projects. We plan to include more training in advocacy for future GHSP trainees and then assess how many of these trainees undertake subsequent advocacy work in their communities and beyond. Many of the other emergent themes regarding program improvements had been implemented prior to conducting this survey, with anticipated benefit to future cohorts.

Operating this program requires substantial programmatic resources and success is dependent on residents completing all requirements. To ensure commitment to the practice of global health, our program implemented a more formal selection process in July 2022, where residents were required to answer a series of short essay questions describing their interest in global health and how the program will help them achieve their goals. These are reviewed by the Associate and Assistant Program Directors to aid in GHSP participant selection. Furthermore, residents are no longer permitted to leave the program after enrolling, except in cases of extenuating circumstances. Moving forward, we plan to study the impact of these changes on attrition rate, changes in knowledge career choices, and resident satisfaction with the program.

The strengths of this study include achieving a response rate of 82%, which is considerably higher than other survey studies in residency education, which range from 3–50% [30]. Second, we utilized a retrospective pre‑post questionnaire design, which helps mitigate response shift bias that can lead a respondent to inaccurately assess their pre‑program knowledge or skills based on a dynamic understanding of the topic or question [20, 21]. Third, analysis of free text qualitative responses was performed independently by two separate investigators (S.U.S.K. and P.C.), with consensus meetings used to finalize these data.

Study limitations include that the outcomes were based on self‑report; thus, there were no objective measures of the program’s impact on residents’ knowledge or skills. That said, we are confident in the accuracy of the self‑reported data regarding practice in under‑resourced areas. In addition, respondents may have suffered from recall bias, particularly those who graduated several years prior to this study. Also, confounders related to time in independent practice could exist as well as other demographic characteristics, such as gender identity, race/ethnicity, and maturity and experience physicians attain in post‑residency practice could affect their perspectives. Another limitation was that we included a single residency training program, which limits generalizability, and the sample size was modest.

Conclusion

The GHSP appears to provide transformative educational experiences to residents with direct impact on intention to practice and actual practice in underserved settings. Nearly three‑quarters of current trainees reported moderate‑to‑high intention to practice in an underserved setting and nearly 41% of graduates reported current work in underserved settings. These rates are significantly higher than those observed for graduates of US general internal medicine or family medicine residencies and those practicing in underserved areas in Oregon [25]. Many self‑reported knowledge gains on global health topics were statistically higher post‑program compared with pre‑program. Future research should focus on the impact of GH curricula on practice patterns across all medical specialties, as our research suggests this is a potential tool to address physician shortages in underserved communities.

Funding Sources

The Department of Internal Medicine, Division of Hospital Medicine at Oregon Health and Science University supported this work. The authors have no other direct source of funding for this research.

Authorship

All authors had access to the data and made substantial contributions to the data analysis, drafting of the manuscript, and revision. All have provided final approval of this version.

Ethics Approval and Consent to Participate

The Oregon Health and Science University IRB reviewed study activities and determined it was not human subjects’ research (IRB #25182).

Availability of Data and Materials

We will provide raw data upon request as long as a data use agreement is in place.

Competing Interests

The authors have disclosed any potential conflicts of interest in an attached document.

Additional Files

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Abbreviations