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Global Electives in Pediatrics

Global Electives in Pediatrics. David Pugatch, M.D., Roy Kao, M.D.’07 Division of Pediatric Infectious Diseases Brown Medical School/Rhode Island Hospital. Overview. Global need for GHE’s Domestic need for GHE’s Benefits of GHE’s for residents/students Angkor Hospital for Children

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Global Electives in Pediatrics

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  1. Global Electives in Pediatrics David Pugatch, M.D., Roy Kao, M.D.’07 Division of Pediatric Infectious Diseases Brown Medical School/Rhode Island Hospital

  2. Overview • Global need for GHE’s • Domestic need for GHE’s • Benefits of GHE’s for residents/students • Angkor Hospital for Children • National Pediatric Hospital • Preparing for a GHE

  3. The Global Need UNICEF. State of the World’s Children 2006.

  4. The Global Need UNICEF. State of the World’s Children 2006.

  5. The Global Need 90% of all deaths occur in just 42 countries UNICEF. State of the World’s Children 2006.

  6. The Global Need Causes of Death in Children <5, 2000-2003 In addition, undernutrition underlies 53% of deaths. Bryce J, Boschi-Pinto C, Shibuya K, Black RE, WHO Child Health Epidemiology Reference Group. “WHO estimates of the causes of death in children.” Lancet 2005; 365:1147-52.

  7. Tuberculosis

  8. Globalization of Health • Diseases of the developing world are more and more our problems. • Immigrant and Refugee Health • Air travel and SARS, WNV, Avian Flu

  9. Refugee Health • Health problems of refugees reflect the health problems back home. • 44% of refugees to the U.S. are children under 18. US. Dept of State. Proposed Refugee Admissions for Fiscal Year 2006 Report to the Congress .

  10. Culturally Effective Care • By 2020, 44.5% of children in US will belong to a racial or ethnic minority group. • Future of Pediatric Education II Taskforce force: Likely to have implications for the utilization of medical services.. And acceptance of interventions by caregivers. • AAP, COMSEP, APA, RRC advocate teaching culturally effective care • However, many programs have difficulty creating curricula to address it. US Census Bureau. Projections of the Total Resident Population by 5-Year Age Groups, Race, and Hispanic Origin With Special Age Categories. Middle Series, 2016–2020. Washington, DC: Population Projections Program, Population Division, US Census Bureau; 2000.

  11. Globalization of Health • Diseases of the developed world are becoming more prevalent in the developing world. • Diseases related to urbanization, overpopulation, tobacco, motor vehicle accidents • Cancer and heart disease on the rise.

  12. Culturally Effective Care • 96% of residents in a recent study believed it was important to address cultural issues when providing care. • However, by the 3rd year of Pediatric Residency, many felt unprepared to treat patients in families: • Who were new immigrants (23.5%), • With beliefs at odds with Western medicine (29.1%), • Used alternative/complementary medicine (30.6%) • Distrusted US Health System (30.4%) Weissman JS, et al. JAMA. 2005; 294(9): 1058-1067.

  13. Clinical Knowledge • Participants motivated to learn rapidly because everything is new. (Taylor 1994) • Improved history taking, physical exam (Haq 2000, Nuckton 1999) • Improved diagnostic skills, clinical reasoning (Esfandiari 2001, Nuckton 1999) • Reduced dependence on laboratory testing and other procedures (Haq 2000, Esfandiari 2001)

  14. Clinical Knowledge • Increased Tropical medicine knowledge of participants… And non-participants through seminars (Miller 1995) • Infectious disease cases, diarrhea, dehydration, dermatology. 18% never seen before, 5% never seen at such advanced stage. (Federico 2006) • Parasites, different differential diagnoses of diarrhea, chest pain, shortness of breath (Nuckton 1999)

  15. Cost-Effective Care • Adapt practices to challenges of resource-constrained setting (Nuckton 1999) • Found cost-effective care to be important as patients often had to pay for tests and rx out of pocket. (Nuckton 1999) • Reduced dependence on lab testing (Esfandiari 2001, Haq 2000, Barry 1986)

  16. Culturally-Effective Care • Consideration and sensitivity to cultural factors in pt care(Haq 2000) • Communication with pts of different backgrounds, use of second language, importance of nonverbal language (Haq 2000) • Adapt care non-judgementally to cultural beliefs(Nuckton 1999) • Helps to gain insight on the human side of care when surrounded by different, non-hospital settings.(Chiller 1995) • Getting along with different kinds of people (Taylor 1994)

  17. Community-Based Care • Increased participation in community health activities(Haq 2000) • Use of community health in care of patients (Haq 2000) • Importance of socioeconomic factors, education, prevention(Haq 2000) • Appreciation of health care delivery in developing nations.(Gupta 1999) • Learning concepts of sustainable development (Taylor 1994)

  18. Serving the Underserved • Prepared to recognize and respond to health care needs and beliefs of immigrants who have come from those regions (Esfandiari 2001) • Recognition of need in the US as well. Work overseas uniquely prepared and motivated them to serve the poor in america. (Taylor 1994)

  19. Influences on Careers • Involvment in international relief organizations such as MSF, Global 2000, WHO. 80% returned to do more work.(Esfandiari 2001) • 4X more likely to be interested in working in resource-poor areas than non-participants. (Chiller 1995). • Work in public health or disadvantaged areas of US or abroad(Miller 1995) • Work with underserved upon return (Haq 2000) • Academic general medicine.(Miller 1995) • Generalists or infectious disease rather than other subspecialties. (Gupta 1999)

  20. Personal Growth • Effects on the personal lives of the participants, including their understanding of the world and sociocultural factors.(Miller 1995) • Open-mindedness, realization of privilege (Haq 2000) • Student rated satisfaction extremely high, • Best experience of their medical school years. (Imperato 2004) • Role models of medical altruism(Taylor 1994)

  21. Electives in Cambodia • Angkor Hospital for Children (AHC) Siem Reap • National Pediatric Hospital (NPH) Phnom Penh

  22. AHC: Location • Siem Reap • Population ~90,000 • Rapidly developing tourist town • Provincial capital for one of the poorest and most rural provinces in Cambodia

  23. Clinical Work • Outpatient – 400 patients triaged daily • Inpatient – 26 bed peds ward • 14 bed LAU, 3 bed ICU • F/u for HIV, TB • Rashes, abscesses • ARI • CP • Typhoid fever • Dengue hemorrhagic fever • Malaria • Diarrhea with dehydration • Intestinal parasites • Measles • Tetanus • Opportunistic infections. • Malnutrition • Pneumonia • Congenital heart disease • Glomerulonephritis • Rheumatic fever • Disseminated TB (incl meningitis)

  24. Community Work • Home Care HIV and Severe Malnutrition Counting medications taken Supplying with protein (eggs) • Capacity Building, Education Vegetable garden on site Teaching parents to grow foods with essential nutrients Infrastructure (Physical and Training) Outreach, health promotion

  25. Research • Pneumonia, antibiotics use • Malnutrition in HIV/AIDS • G6PD Deficiency • Child Maltreatment • Alternative medicine • Always looking for cost-effective ways to reduce mortality

  26. Medical Education • Daily lecture topics for junior residents or nurses • Presenting journal clubs • Avian flu, rheum, EKG, critical care • AHC serves as CME-like site for many other doctors in region.

  27. Specific benefits

  28. Preparation • Maximize educational value of the elective, minimize dangers. • Medical: diseases, conditions, public health infrastructure. • Preventing health, safety dangers • Cultural education – how to act • Country education – economic, historical, environmental aspects

  29. Preparation • www.cdc.gov/travel • Recommended vaccines for Cambodia: • HepA, HepB • Japanese encephalitis • Rabies • Typhoid • Tetanus booster as needed • Malaria prophylaxis • Insect repellent, long sleeve clothing, permethrin bednets • Many come in series, so sign up 4-6 wks early • OTC AntiDiarrheal (bismuth, loperamide) + empiric antibiotic • Your prescription medications

  30. Preparation • State.gov travel warnings and country information • Travelregistration.state.gov • Precautions are as in many tourist areas one might visit – generally safe, but must exercise caution. • Pickpockets, scam artists

  31. References • Pust RE, Moher SP. Medical education for international health. The Arizona experience. Infect Dis Clin North Am. 1995 Jun;9(2):445-51. • Federico SG, Zachar PA, Oravec CM, Mandler T, Goldson E, Brown J. A successful international child health elective: the University of Colorado Department of Pediatrics' experience.Arch Pediatr Adolesc Med. 2006 Feb;160(2):191-6. • Esfandiari A, Drew CR, Wilkerson L, Gill G, Drew CR. An international health/tropical medicine elective. Acad Med. 2001 May;76(5):516. • Miller WC, Corey GR, Lallinger GJ, Kurack DT. International health and internal medicine residency training: the Duke University experience. Am J Med. 1995;99(3):291-297. • Haq C, Rothenberg D, Gjerde C, Bobula J, Wilson C, Bickley L, Cardelle A, Joseph A. New world views: preparing physicians in training for global health work. Fam Med. 2000 Sep;32(8):566-72. • Imperato PJ. A third world international health elective for U.S. medical students: the 25-year experience of the State University of New York, Downstate Medical Center. J Community Health. 2004 Oct;29(5):337-73. • Nuckton T, Luther K, Weinberger M, et al. Residency training in developing nations: an international elective for U.S. physicians in training. Teach Learn Med. 1999;11:207-213. • Chiller TM, DeMieri P, Cohen I. International health training: the Tulane experience. Infect Dis Clin North Am. 1995;9:439-443. • Gupta A, Wells C, Horwitz F, et al. The international health program: the fifteen-year experience with Yale University's Internal Medicine Residency Program. Am J Trop Med Hyg. 1999;61:1019-1023. • Ravdin JI, Peterson PK, Wing E, Ibrahim T, Sande MA. Globalization: a new dimension for academic internal medicine. Am J Med. 2006 Sep; 119(9):805-10. • Taylor CE. International experience and idealism in medical education. Acad Med. 1994 Aug;69(8):631-4. • Northrup RS Preparing students for overseas electives. Acad Med. 1991 Feb;66(2):92. • Barry M, Bia FJ. Departments of medicine and international health. Am J Med. 1986 Jun;80(6):1019-21. • Weissman JS, et al. Resident physicians' preparedness to provide cross-cultural care. JAMA. 2005; 294(9): 1058-1067.

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