Abstract
Despite widespread resident interest in global health and underserved care, few otolaryngology residency programs offer a formal global health experience. This article is the first to characterize a formal otolaryngology global health and underserved care track with a focus on how this curriculum integrates with and supplements resident education. Components of the track include longitudinal limited-resource field experiences in domestic and abroad settings, a related quality improvement project, and completion of a formalized global health educational curriculum. In addition to delivering humanitarian aid, residents in this track obtain a unique educational experience in all 6 core competencies of the Accreditation Council for Graduate Medical Education. Early barriers to implementation included identifying mentorship, securing funding, and managing busy resident schedules. In this work, we detail track components, schedule by track year, keys to implementation, and potential educational pitfalls.
Resident education in global and underserved health has been narrowly explored in the otolaryngology literature. From a 2021 survey of otolaryngology residents, Toman et al found that 80% of residents would participate in a global health elective if offered; however, only 37% of otolaryngology residencies offered any global health experience. 1
This article is the first to characterize a global health and underserved care (GHUC) track for otolaryngology residents. We hypothesized that this track would integrate with key otolaryngology training objectives and supplement resident education without disrupting the core curriculum. While early outcomes data are limited, our primary aim in this descriptive commentary is to characterize the track’s key components, perceived benefits, and early barriers to implementation to increase interest and awareness in the specialty.
Track Objectives and Design
The Accreditation Council for Graduate Medical Education (ACGME) highlights 6 core competencies as a conceptual framework for an otolaryngology resident to graduate to autonomous clinical practice: professionalism, patient care and procedural skills, medical knowledge, practice-based learning, interpersonal skills, and systems-based practice. 2 In addition to delivering humanitarian aid, this track was designed to provide a unique educational experience in all 6 competencies. Based on the partnerships available at our institution and characteristics of successful track programs in other specialties,3-5 the following 4 objectives were established for the Rush GHUC track:
Participate in a longitudinal experience in a resource-limited setting abroad
Lead and coordinate a longitudinal experience in a domestic resource-limited setting
Implement a quality improvement project related to underserved health suitable for publication
Complete a written and team-based global health educational curriculum
Current partnerships include a number of local homeless shelters, a regional partnership with a rural health critical access hospital, and a biannual otolaryngology and audiology mission abroad in the rural western Dominican Republic. Table 1 describes current GHUC track components, implementation, cost to residents, and ACGME competencies. A track map by resident year is presented in Table 2 .
Component Descriptions for GHUC Educational Track in Otolaryngology Residency.
Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; CDC, Centers for Disease Control and Prevention; ENT, ear, nose, and throat; GHUC, global health and underserved care; PI, principal investigator.
Organizations such as Community Empowerment 10 partner with local leadership to facilitate essential health care and help to develop locally sustainable programs.
Program Map for GHUC Educational Track in Otolaryngology Residency.
Abbreviations: GHUC, global health and underserved care; PGY, postgraduate year; QI, quality improvement.
Before matriculation: application to GHUC track, including written statement of interest due to program director in May prior to PGY1.
Discussion
Since its implementation 4 years ago, resident satisfaction with the GHUC track has been extremely high. As the first class has not yet completed the program, formal outcome metrics across the core competencies are not yet available, but formative resident feedback has consistently commended the domestic and international field experiences in particular. Field experiences provide residents procedural growth and exposure to a variety of otolaryngology pathology, including less frequent maladies and conditions, such as massive goiter, cleft lip and palate, microtia, and burns. Residents learn to collaborate with patients and health care providers of diverse cultural backgrounds, understand various health care delivery models, and develop innovative treatment plans in resource-constrained settings. The program has generated unique research and impactful quality improvement initiatives, and literature suggests that residents who participate in international electives are more likely to pursue careers in academic medicine or public service.1,6 Importantly, the communities served are overwhelmingly appreciative. Health benefits extend beyond the individual visits as communities become more engaged within the health care system. Overall, in early formative feedback for the GHUC track, residents have attested that program involvement solidifies an underlying purpose in medical education and reduces burnout.
Other groups have described implementation of a global surgical elective with barriers similar to those that we have encountered.5,7,8 Mentorship, funding, scheduling, and call/coverage responsibilities can be arduous to navigate. We have implemented a number of strategies to help mitigate additional time spent toward the track objectives. Residents at our institution complete a research and scholarship rotation in 2 protected blocks of 3 months. GHUC track residents utilize a portion of the scholarship blocks toward abroad field experiences so that clinical rotation coverage or vacation time is not required. Notably, there is no out-of-pocket costs for abroad experiences ( Table 1 ). Residents also typically receive 1 or 2 protected afternoons each month to pursue educational and research initiatives. Outside these protected times, remaining track objectives are accomplished outside of work hours, including many of the domestic field experiences and quarterly Health Equity Journal Club. Feedback thus far has maintained that these extracurricular opportunities are enriching rather than cumbersome, but the experiences are monitored closely with continual program evaluation. Cases performed while on international electives are not currently approved to count toward minimums. 2 The ACGME cites concerns for potential work hour violations, inadequate supervision, inadequate opportunity for perioperative care, and questionable continuity as reasons for limiting international elective credit. 9 We recognize these possible limitations, although resident experience in our program has been quite contrary. Close partnership with community leaders and local providers has allowed us to establish reliable care continuity for families whom we serve in the Dominican Republic community. 10 Residents coordinate perioperative care abroad with anesthesiologists and internists and are directly supervised by home otolaryngology faculty with the same work hour standards as our home institution.
There is ample opportunity for future work in the global health domain of otolaryngology graduate medical education, including formal program evaluation and outcomes data, but the GHUC track outlined here presents a framework that integrates with ACGME core competencies and is feasible to implement.
Conclusions
There are many potential beneficial global health experiences, but a longitudinal track consisting of an academic curriculum, a field experience in abroad and domestic limited-resource settings, and a research component is feasible to implement and provides a well-rounded and enriching experience to develop future leaders in this domain.
