Getting Started in Global Health: A Practical Guide for Gastroenterology Fellows.

INTRODUCTION

Gastroenterology (GI) fellows in the United States are overwhelmingly interested in global health, but they have limited educational opportunities while in training.[1] This has important implications for future gastroenterologists' preparedness to competently engage in advancing health equity in the face of a growing burden of digestive disease in low- and middle-income countries.[2,3] This article provides practical steps on how GI fellows can get involved in global health during training. The potential benefits of global health experiences for trainees are many and include the following: rich clinical education from exposure to diverse and more mature cases and pathology; an appreciation of the need for judicious use of healthcare resources (a valuable lesson given the high cost of health delivery in developed countries); and greater cultural awareness and empathy—an attribute that is crucial in caring for an increasingly multicultural and multilingual US population.

GETTING INVOLVED IN GLOBAL HEALTH

Arguable, global health exposure is best obtained through immersive experiences in resource-limited settings, and the most apparent and robust means of attaining this is by participating in international electives. Below, we provide suggestions on how fellows can obtain hands-on, international, clinical experiences while in fellowship.

Setting the stage for an international elective rotation

Take time for some personal reflection on your motivation for seeking a global health elective and enumerate your goals for the rotation.

Meet with your fellowship program director and mentors to discuss your interest early in your process. Besides the need to obtain approval for such an endeavor, this will also give you the chance to tap into their networks and identify people and opportunities in global health that may align with your clinical interests. The ideal elective experience is one where your activities are supervised by either a local or US-based physician and during which a curriculum is created and personalized to meet your needs while meeting the core competencies of the Accreditation Council of Graduate Medical Education.

If you are interested in going to specific countries or regions of the world or have language preferences, this should be forefront in your search. To maximize the benefits of such an experience for you and your local hosts, it may be best to visit a country where you are proficient in one of the major languages. In the end, you may still need a translator if working with a rural population or in multilingual settings.

Be clear on your specific area(s) of interest, such as hepatology or endoscopy, and first seek opportunities that best align with these. However, it is essential to be open to any GI-related clinical experiences because there is often little subspecialization in resource-constrained settings.

In the search for international opportunities, first look to see if there are any gastroenterologists at your institution that are engaged in global health work, and consider setting up your elective with one of them. Besides the intangible benefits derived from the rapport that may already exist between you and a familiar faculty member as you navigate clinical practice in a foreign country, this arrangement also allows for continuity in the supervision of your clinical progress. You may be able to obtain credit for endoscopies and other procedures performed under the supervision of your regular GI faculty while abroad.

When there are no readily available opportunities with local GI physicians, international experience can be obtained by connecting with global health-oriented GI faculty at other US or foreign institutions and by participation in mission-based excursions. The former is preferred because it offers the advantage of being supervised by teaching faculty and is usually more robust with regard to opportunities for learning and research.

Look into and apply for institutional or extramural funding that may support your travel because international trips are expensive on a trainee salary.

Before traveling

Ensure that you have obtained the required medical license and local institutional clearance to practice medicine. In most countries, visiting medical professionals are granted a temporary or limited license for the duration of their stay.

Visit your local travel medicine clinic to obtain recommended vaccinations and prophylactic medications against locally relevant diseases such as malaria, and consult with your graduate medical education office to ensure no institutional limitations on travel. This is also a good time to inquire about institution-provided travel insurance and coverage for medical evacuation.

Take time to do some studying on prevalent GI diseases in the host location. In certain parts of Africa, eg, hepatic schistosomiasis is one of the most commonly encountered causes of chronic liver disease, but a US-based trainee may not be familiar with the epidemiology and sequelae of this condition.

Inquire if your host institution needs specific medical supplies and if you are permitted to bring medical supplies into the country. Also inquire if they will accept recently expired hardware supplies. If needed and allowed, consider collecting recently expired supplies in your endoscopy laboratory such as banding kits or sourcing them from industry representatives that may want to donate supplies. Avoid bringing materials that are unlikely to be used.

What to do while in the country

Clinical activities should be supervised, and you should not engage in any activities that are outside of your scope of practice or level of competence.

Seek to understand the workings of the local health system, and work to build genuine personal relationships with your local counterparts. Follow their cues to understand the norms of clinical practice in that context.

Teach as much as is possible. As a board-certified internist and a GI trainee from a resource-rich setting, your medical knowledge is valuable, and you should seek out and interact with medical students and residents as often as you can. The state of endoscopic knowledge and practice is often inadequate in resource-limited settings, and you may find that you may be more knowledgeable in certain aspects of endoscopy. Share your knowledge!

Learn as much as is possible. There will likely be conditions prevalent in the host country that you have rarely or never encountered. Your hosts will certainly be more knowledgeable about these conditions, so learn from them.

Where feasible, seek to develop a research project with a host partner. This should be on a locally relevant topic and should follow the ethical guidelines of the host country.

After the elective rotation

Take some time to reflect on your experiences and assess whether your preset goals were met. This exercise will allow you to better align any future global health activities with your personal objectives.

Be proactive in servicing the professional relationships made with the local providers and visiting health professionals that you may have met during your elective. If potential research collaboration opportunities were identified during your rotation, this should be further explored with partners in the host setting.

Share your experience with colleagues at your home institution. Give a presentation at GI Grand Rounds or another educational conference. This will likely inspire other trainees to pursue global health electives, and you can serve as a resource for them.

If there is continued interest in global health activities in the resource-limited setting after your training, collaborate with the host institution to establish short to medium-term goals that will foster the improvement and sustainability of GI capacity in that setting.

The current state of global health education for US-based GI fellows is poor, and trainees need to be resourceful in seeking out rich international experiences that meet their personal objectives. It is hoped that in the future, GI fellowship programs will systematically incorporate global health into their curricula because this can reduce the barriers to trainee engagement in global health.

DISCLOSURES

Author contributions: K. Chudy-Onwugaje is the sole author and is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.