Core Content, Competencies, and Accreditation in US Global Health Fellowships: A Survey of Leaders’ Perspectives

INTRODUCTION

Over the past two decades, the number of global health (GH) fellowships offered across medical specialties in the United States has grown steadily, with 122 programs currently listed in the Global Health Fellowship Database.^1,2 This growth reflects increasing interest from medical trainees^1,3,4; the growing importance of GH training to address the globalization of diseases and pervasiveness of health disparities³; and the expansion of the discipline, now an area of practice within most clinical specialties. Although there is not a widely accepted, single definition of GH, a common definition is “an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide.”⁵ This definition reflects the widening focus of GH from its origins in tropical medicine and infectious disease to include social determinants of health, health disparities, health equity, advocacy, and care of increasingly mobile populations around the world.⁵

Current GH fellowship programs reflect the breadth and diversity of the discipline across multiple specialties. These postgraduate programs vary in core content covered (the knowledge, skills, and attitudes needed to practice GH), and decisions about educational content made within specialties and programs draw from a variety of sources for core content.^6–8 Programs vary in core competencies (the observable abilities of trainees in activities integrating knowledge, skills, and attitudes),⁹ with several specialties developing specialty-specific core GH competencies.^10–12 Programs vary in their requirements and practices, although best practices and ethical guidelines have been created in specific areas, such as predeparture preparation, postreturn debriefing, health and safety, and international partnerships.^13–15 Programs also vary widely in structure from fellowships focusing primarily on GH training to programs combining GH with other subspecialty training.^1,16 They vary in length from several months to several years, and they also vary in the amount and type of international or local–global experience (domestic community or field experience with clinical and nonclinical experiences emphasizing topics such as public health, socioeconomic and political sciences, and medical sciences)⁸ included.^1,16

With the field of GH maturing and the continuing growth in GH fellowships, questions related to the lack of standardization of core content, competencies, and program requirements across fellowships increase in importance. Namely, does variability in fellowship programs lead to variability in the competencies that graduates achieve? Would standardized core content and competencies, possibly across specialties, result in better-trained GH practitioners?

Would standardization of program requirements and practices reduce the potential negative impacts on trainees,^17,18 hosting institutions,^19,20 and the communities being served,^19,21,22 which may result from the uneven uptake of best practices by programs?¹⁶

One approach to standardization across programs is through fellowship accreditation in which an external body provides formal oversight of adherence to defined standards. Although accreditation can establish minimum program standards, it may also have negative impacts, such as increased programmatic burdens and restrictions. There is currently no widespread accreditation of GH fellowship programs in the United States. In general, fellowships can be accredited by the Accreditation Council of Graduate Medical Education (ACGME),²³ the most recognized accrediting body in the United States, which leads to subspecialty certification from the American Board of Medical Specialties (ABMS). Alternatively, fellowships can be accredited by a specialty-specific “focused practice,”²⁴ by a professional society such as the Academic Pediatric Association (APA), or not at all. At present, two specialties have accreditation or endorsement processes for GH fellowships. Since 2022, pediatric GH fellowships can be accredited by APA,²⁵ and emergency medicine has developed an endorsement process for GH fellowships through the Society of Academic Emergency Medicine (SAEM).²⁶ Individual trainees can document their knowledge through Certificate of Knowledge tests offered by professional societies, such as the American Society of Tropical Medicine and Hygiene (ASTMH)²⁷ and the International Society of Travel Medicine.²⁸ Trainees can also pursue advanced degrees, such as a Master of Public Health, or concentrations in GH across graduate programs.

Given the growth in GH fellowships across specialties, the lack of standardized core content and competencies, and the potential benefits of standardization through accreditation, ASTMH convened a national committee of GH educators to explore the feasibility of developing an accredited GH subspecialty. In the fall of 2019, the Global Medicine Exploratory Committee (GMEC) was formed with 11 members representing a range of specialties (infectious disease, internal medicine, pediatrics, family medicine, emergency medicine, and immigrant and refugee health) and a range of roles in GH education, which included a resident physician trainee. A key aspect of the committee’s work and the purpose of our study were 1) to understand United States-based GH fellowship leaders’ perspectives on whether core content and competencies exist in GH that are relevant across specialties and 2) to understand these leaders’ perceptions of the need for some type of accreditation, including ACGME accreditation, which would be required for a formal subspecialty recognition. Although previous studies have surveyed GH fellows²⁹ and single specialties¹⁶ about their perceptions of accreditation, we found no previous multispecialty studies of GH fellowship leaders’ perceptions of accreditation.

MATERIALS AND METHODS

STATISTICAL ANALYSES

We calculated descriptive statistics (frequencies and percentages) for the closed-ended questions. We used SPSS v. 25 (IBM Corp., Armonk, NY) for all statistical analysis. We conducted qualitative content analysis³¹ to analyze the two open-ended prompts: “Please describe why you selected the form of accreditation you indicated” and “Please include any additional comments you would like to share about the benefits of, need for, barriers to, or possible negative impacts of offering an ACGME accredited fellowship in global health.” One author (T. F. Siegert) read the written comments and created a set of initial codes. Two authors (T. F. Siegert and S. P. Gladding) then met, and they reviewed and refined the codes. The authors then reread and independently coded the written comments using the refined codes, and they met to compare their coding and discussed any disagreements until consensus was reached. The authors then sorted the codes related to reasons for supporting a specific form of accreditation from the codes related to potential impacts of accreditation, and they further sorted those codes for positive and negative impacts of accreditation. The authors then grouped related codes describing the potential negative impacts of accreditation into broader categories. Finally, the authors selected illustrative quotes. The authors selected quotes addressing ACGME accreditation specifically and quotes addressing accreditation generally for each potential impact of accreditation to which they were coded. We conducted the qualitative analysis using Microsoft Word.

RESULTS

We identified 129 program leadership contacts. Of the 129 survey invitations sent, 4 were returned as undeliverable, and 12 were returned with responses that either the program information was incorrect (i.e., the program was not a fellowship program or did not have a GH component) or the program contact was incorrect. Ten of these responses included corrected program contacts to whom we sent new survey invitations. This resulted in 123 valid invitations sent to contacts at 118 programs, including 52 program contacts in emergency medicine, 25 in family medicine, 16 in pediatrics, 14 in internal medicine, 8 in multidepartmental programs, 6 in obstetrics/gynecology, and 2 in surgery. Forty-five individuals completed the survey, resulting in a response rate of 37%. Responses to individual questions were not required, so the number of responses varied by question and is indicated in the tables, the supplemental figures, and below.

Eighty-four percent (37/44) of respondents were GH fellowship program directors, 2% (1) were associate program directors, and 16% (7) were GH faculty members. One respondent indicated that they did not have a role in GH education (this response ends the survey without asking additional questions). Fifty-two percent (23/44) of respondents were involved with GH fellowships in emergency medicine, 25% (11) were in pediatrics, 16% (7) were in family medicine, 11% (5) were in internal medicine, 2% (1) were in internal medicine–pediatrics, and 2% (1) were in obstetrics and gynecology (Table 1). For subsequent questions where results are reported by specialty, we report the responses from the five respondents who selected both emergency medicine and pediatrics as “pediatrics/emergency medicine,” and we report the response from the one respondent who selected both internal medicine and internal medicine/pediatrics as “pediatrics/internal medicine.”

DISCUSSION

As the field of GH continues to develop and mature, considerations of the value of standardized core content, competencies and program requirements, and the benefits of accreditation for GH fellowships become increasingly important. To our knowledge, this is the first multispecialty study to assess the perceptions of United States-based GH fellowship program leaders about core content and accreditation. We found consensus around the existence of important core content for trainees across specialties. Opinions were divided on the need for accreditation, with a slight majority indicating that ACGME accreditation is unnecessary.

We found that most respondents (89%) agree that there is important core content for fellows to learn regardless of specialty, and a slight majority indicated that some standardized core content and competencies are “very” or “extremely” important. This suggests a potential base from which a GH subspecialty could be developed as specified core content and competencies provide the foundation for defining a medical subspecialty. We also found concerns expressed in the written comments about standardization: specifically that standardization could lead to a loss of individual programs’ flexibility to tailor their curriculum to their learners’ interests and goals and that it could decrease the overall breadth and variability of GH fellowships offered. These concerns are consistent with other specialties when considering fellowship accreditation.^32–34 They also suggest that developing and implementing core content would require more discussion and consensus building, particularly given the breadth of GH within and between specialties.

Our data show a lack of agreement about whether accreditation would be beneficial and if so, what type of accreditation. Respondents’ differing perspectives on the best approach to accreditation largely centered on two issues: standardization versus flexibility and a multispecialty approach versus a specialty-specific approach. Respondents who indicated that accreditation through professional societies, professional certification, or focused practice would result in training the most competent GH practitioners noted these non-ACGME pathways would allow for specialty-specific practices, competencies, and goals and that they were more flexible approaches. Respondents selecting ACGME accreditation emphasized that it promotes high standards and allows for broad specialty inclusion. Future discussions of accreditation for multispecialty GH fellowships would need to consider how specialty-specific needs could be balanced with standardization across specialties.

In our study, a slight majority of respondents “disagreed” or “strongly disagreed” that ACGME accreditation is needed. This is consistent with a recent survey of GH fellows, which found that 50% of fellows were “not at all” concerned about accreditation by ACGME or other regulating bodies and that 52% did not desire fellowship accreditation.²⁹ The perceived barriers to ACGME accreditation identified as “very” and “extremely” important by a substantial majority (>65%) in our study related to increased restrictions, requirements, and burdens. These have been noted with other specialties considering ACGME accreditation.^32–34 We also found additional concerns specific to GH fellowships, including financial concerns regarding restrictions on using Centers for Medicare & Medicaid Services funding for international rotations and decreased fellow salaries because of ACGME restrictions. There were also concerns related to the global context of GH, specifically the impact of accreditation on international partnerships, the ability for trainees from low- and middle-income countries (LMICs) to participate in fellowships, and the implications and potential unintended consequences of centering accreditation for GH in the United States. Given the colonial origins of GH and the goal of equity in GH education,³⁵ these considerations are especially important. These concerns highlight challenges of ACGME accreditation for GH fellowships because of the international aspects of training and suggest a need for innovative approaches to accreditation to be successful.

Notably, we found variation by specialty regarding ACGME accreditation. Sixty-six percent of respondents in pediatrics “agreed” or “strongly agreed” that ACGME accreditation is needed compared with 11% of respondents from emergency medicine. It is possible that this difference may, in part, reflect pediatric GH educators’ recent successful implementation of accreditation through APA²⁵ as this was a precursor to pursuing ACGME accreditation for several pediatric subspecialties. Emergency medicine practitioners may feel, in contrast, that their SAEM endorsement process is sufficient. This suggests that specialties practicing GH may have different interests and needs related to fellowship accreditation that may present challenges for developing a multispecialty fellowship. There are recent successful examples of ACGME-accredited subspecialties accessible from multiple primary specialties, such as clinical informatics,³⁶ addiction medicine,³⁷ and hospice and palliative medicine.³⁸ Some of the approaches and lessons learned from these subspecialties may be relevant to GH fellowship accreditation discussions, particularly approaches to defining a subspecialty³⁸ and developing a partnership with an appropriate member board of ABMS.^37,38

Our study has several limitations. Limiting our study population to the primary medical specialties may affect the generalizability of our findings to other specialties. Although we identified, to the best of our abilities, all known United States-based GH fellowships in these specialties, there may be programs that we did not identify and therefore, did not include in our study. Our response rate of 37%, although similar to other comparable national physician surveys,³⁹ may also limit the generalizability of our findings, with the small number of responses per specialty preventing us from conducting statistical subgroup analysis by specialty.

There are several important next steps in exploring accreditation for United States-based GH fellowships. Further work is needed to better understand the perceptions of other key stakeholders in GH fellowships and accreditation, including colleagues from institutions involved with GH fellowships worldwide, particularly LMIC colleagues and institutions as well as trainees. A broad dialogue with stakeholders should consider key questions suggested from this study, such as how to determine core content, how to fund accredited fellowships, how to allow for broad trainee participation including LMIC participants, how to balance needs for flexibility with standardization, and where to center (geographically and organizationally) an accreditation process. A potential avenue for understanding stakeholder perceptions and consensus building would be dedicated time during relevant meetings, such as at the annual meetings of ASTMH and the Consortium of Universities for Global Health, or to convene a symposium or conference. Further work is also needed to determine whether some of the potential benefits of standardization could be achieved without accreditation. For example, would an approach such as self-reported compliance with consensus external standards work, or is regulatory oversight by an external body through some type of accreditation needed? Additionally, if needed, are there differences in potential benefits depending on the type of accreditation?

CONCLUSION

In conclusion, this current study suggests that most GH fellowship leaders of United States-based programs feel that there is important core content across specialties. Although some leaders see a potential connection between accreditation and the promotion of standardized content and requirements, our study suggests that there is not a consensus, apart from in pediatrics, that GH fellowship accreditation of any kind should be pursued. A majority disagreed with pursuing ACGME accreditation specifically. More work is needed to better understand broader stakeholder perceptions and build consensus before multispecialty core content and competencies can be defined or accreditation can be pursued. At this time, specialty-specific approaches, such as those currently used by pediatrics and emergency medicine, may be more feasible.

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