1. Development of Family Medicine Global Health Training at Loma Linda University

2. Development of Family Medicine Global Health Training at Loma Linda University 2014 Family Medicine Global Health Workshop San Diego, October 12, 2014 Kevin Shannon, MD, MPH – Pgm Dir, FM/PM Residency Hobart Lee, MD – Pgm Dir, FM Residency Jason Lohr, MD – Dir, Clinical Operations, SAC Hlth System Marc Debay, MD, MPH, PhD – Asst Pgm Dir, PM Residency

3. Objectives At the end of this session, participants will: »Understand how to overcome common organizational barriers to training Family Medicine residents in global health »Understand the advantages and disadvantages of each of the four Global Health training options for Family Medicine residents at Loma Linda University »Understand the future plans and aspirations for Global Health training at Loma Linda University, and the attendant challenges

4. Overview of Panel Presentation: »Introduction and history of GH at LLU (Shannon) »Current GH resident training choices (Lee) »Global Service Concentration and Global Service Pathway (Lohr) »Future directions and conclusions (Debay) »Questions and Answers (Panel)

5. Development of Global Health Residency Training at LLU Kevin Shannon, MD, MPH Director, Family and Preventive Medicine Residency Program Director, Preventive Medicine and Public Health 4 th -year LLU School of Medicine Rotation

6. Early History »Founded over 100 yrs ago: University in 1904 and Medical School in 1909 »LLU has graduated more physicians than any other medical school west of the Mississippi ~ over 10,000 graduates (as of 2011)

7. Mission »Faith based: “To Make Man Whole” » Adventist (SDA) roots and fibers: ~ Service oriented ~ Whole person care, spiritual values ~ Mission oriented: >1,000 graduates have served globally, and >100 graduates currently serving globally

8. Lifestyle Medicine »Global focus: healthy living ~Corn flakes, soy milk, etc. »Definition – treating diseases naturally – nutrition, physical activity, rest, social and spiritual supports ~evidence based; cause focused; foundational to chronic disease care »Global chronic disease epidemic

9. Global Foundation »LLU is a health professions university ~8 schools: Medicine, Public Health, Dentistry, Nursing, Pharmacy, Allied Health, Behavioral Health, Religion ~Global health programs/outreach in each school »Connected to SDA health care worldwide ~Over 170 hospitals / 400 clinics; on all continents ~Universities in Mexico, Argentina, Philippines, Kenya ~Adventist Development & Relief Agency (ADRA)

10. LLU and Global Health »Our Global Health emphasis evolved: ~First 60-70 yrs – starting hospitals ~Last 30-40 yrs – community development (but still a lot of hospital care done) ~Last 15-20 yrs – supporting the creation of medical schools in Majority World »Global health is part of who we are – always has been, likely always will be

11. GH Programs by educational level »Medical Students ~Deferred Mission Appointee (DMA) ~Students for International Mission Service (SIMS) ~Mission Interest Group (MIG) ~Christian Medical and Dental Association (CMDA) »Residents ~International Electives/’encourages”/GSC/GSP ~Specialty-specific opportunities »Faculty ~Administration/Consultation; Emergency relief

12. LLU International Rotations

13. Acute Care vs Community Care »LLU has a strong history, current set of affiliations and ongoing opportunities with both: ~Hospital-based individualized Acute care ~Chronic/community/ based, population care »There is a need for both, …thus the FM/PM program

14. Family Medicine – Preventive Medicine Combined Residency Program » Swelling of MS interest in lifestyle and global medicine… » New PM chair (double boarded) with FM-PM combined program experience » Approved Jan 2005; expanded to 4 residents/yr in 2006 » 4 Years: 36 months FM / 24 months PM ‘counted’ » Longitudinally integrated ~FMC continuity clinic throughout all rotations ~5 quarters of PM in R2-R4 years ~MPH classes on line all 4 years Employee Tuition Benefit 8 units/calendar yr

15. FM/PM: Serving the underserved… Joel: Honduras James: Malawi Aaron & Sally: Nepal Greg: Rural Oregon Jessica: China Andre: Brazil

16. LLU GME: International Rotations »International electives – most of our history »Barriers to integrating ACGME-approved “encouraged” international rotations into programs: ~Medicare residency funding (LLUMC International Services Program has allowed programs to maintain resident salary/benefits/malpractice x > 20 yrs) ~ACGME continuity requirements (FM RRC) ~ACGME approval requirement ~(not lack of interest or willingness of residents)

17. LLU GME “approved [international] rotations within accredited programs” »General Surgery began “encouraged” international rotation within pgm: 2012-13 (only U.S. GS program) »FamMed/PrevMed began “encouraged” international rotation within pgm: 2013-14 »These are both based in our “Field Station” in Malawi, where Adventist missionary FM/PM and GS docs work and teach.

20. Other LLU GME international rotation locations with relationships to pgms: »Anesthesiology – Zambia »Emergency – New Guinea, Philippines »ENT – Honduras, Micronesia »Internal Medicine – Botswana »Ophthalmology – Zambia »Ortho – Haiti, Malawi »Pediatrics – Guam, China »Plastics – India »Psychiatry – Guam »Of 165 LLU residents per training year, average of 15% participate (more in some programs than others)

21. Current Global Health Programs for Residents at LLU Hobart Lee, MD Director, LLU Family Medicine Residency Program

22. GH Resident Training Choices »International Electives »Standardized Global Health Curriculum for FMRP »Global Service Concentration »Global Service Pathway

23. School of Medicine LLU Medical Center LLU Children’s Hospital Behavioral Medical Center Loma Linda University LLU Health Care Physicians Groups Global Health Institute: International Involvement Coordination and Support ProTector Honduras Mission Interest Group Int’l Behavioral Health Trauma Team GSS DMA Global Resident Community International Benefit Malawi Field Station Overseas Heart Team China Palestine

24. FM International Electives »Approved by Global Health Institute »Salary and benefit support when in conjunction with existing SDA hospitals, Adventist hospitals (AHI or ADRA) »Examples: »2013 Kenya »2013 Guam »2013 Trinidad »2011 China »2009 Bolivia »2009 Nepal

25. Standardized Global Health Curriculum for FMRP »Patient care: To learn how to take a history and perform a physical examination appropriate for the location, taking into account the culture. To use laboratory and diagnostic studies appropriate to a different healthcare system. To apply whole person care appropriate to a different culture. »Medical Knowledge: To gain knowledge about unique medical conditions in the population being served. To learn to use appropriate and available treatment options. To learn how culture affects a patients response and adherence to health care recommendations. »Interpersonal Skills/Communication: To provide education and counseling to patients and families, possibly using a translator. To learn adaptive skills enabling effective participation as a member of the local health care team. To learn about cultural differences which affect health care.

26. Standardized GH Curriculum… »Practice Based Learning: To acquire medical knowledge in a different teaching environment. To facilitate education of local health care professionals. To learn standardized guidelines for diagnosis and treatment of conditions common to the local population and adapt them to the individual needs of a patient. »Professionalism: To demonstrate a commitment to professional behavior in interaction with staff. To demonstrate sensitivity to patient and professional culture. »System Based Learning: To learn how to practice quality health care within that area’s health care system. To analyze the strengths and opportunities to improve another health care system within the local cultural setting. To demonstrate the ability to appropriately improve a different health care system.

27. Standardized GH Rotation (Malawi): »4 weeks with OB rotation with low risk deliveries and opportunities for C-sections ~Average: 7 deliveries and 3 C-sections »Rotation in pediatrics clinic and HIV clinic »Opportunities to rotate with inpatient internal medicine, pediatrics, surgery, and specialty outpatient clinics (e.g. infectious disease clinic)

28. Global Service Concentration And Global Service Pathway Jason Lohr, MD Director of Clinical Operations, and Asst. Medical Director of Family Medicine, SAC Health System

29. Global Service Concentration (GSC) »Offered by Graduate Medical Education office for all interns, residents, and fellows »Includes a Basic and Advanced pathway »Upon completion of either the basic or advanced concentration, the resident will be prepared to participate in ongoing short-term or long-term international health opportunities

30. GSC Description The basic concentration includes:  global health lectures  international service electives  local community-based service programs  mentorship with experienced global health clinicians The advanced concentration includes above plus:  global health online course (Univ. Minnesota)  become member of the ASTMH  take the ASTMH exam, and receive a CTropMed certificate.

31. GSC Education Goals To prepare future leaders in global health service To strengthen current global partnerships through both short-term and long-term mission service To encourage local, community-based service opportunities

32. GSC Objectives Provide global service lectures monthly by experts in infectious disease, global health, and development Provide opportunities for international service electives at numerous clinical sites around the world Provide the opportunity for global health training through online Global Health course Provide the opportunity to be a member of the American Society of Tropical Medicine and Hygiene (ASTMH)

33. GSC Objectives (continued) Provide the opportunity to take the ASTMH exam and receive a CTropMed certificate Provide local, community based service opportunities Provide mentorship with experienced global health clinicians

34. GSC Requirements Basic concentration  Street medicine-twice during residency training  Attendance of at least 50% of Global Service lectures  One month International service elective  Presentation of one month international service elective Advanced concentration  All basic plus University of Minnesota online global health course and passing ASTMH exam

35. GSC History » Piloted 2012-13: 4 residents » Now, 2014-15: 9 residents (3 are FM)

36. Global Service Pathway (GSP) New program Between multiple departments (Internal Medicine, Family Medicine, Pediatrics), the GSP provides customized postgraduate experiences that prepare physicians for international practice and service. GSP also allows residents to provide health care in an international setting, while achieving basic competencies in Global Health.

37. GSP Goals Provide health care in low and middle income countries on a long term basis. Confidently provide short term relief to permanent international health care workers. Pursue humanitarian relief missions through voluntary agencies such as Adventist Disaster and Relief Agency International (ADRA), International Medical Corps (IMC), International Rescue Committee (IRC), Medicines Sans Frontiers (MSF or Doctors without Borders).

38. GSP Goals (continued) Provide health care to travelers Provide health care to persons with HIV Cooperate with international HIV initiatives. Provide health care to underserved domestic populations. Nurture long term relationships with experts in Tropical and Traveler’s Health.

39. GSP Objectives HIV Specialist Credential: HIV through AAHIVM http://www.aahivm.org/ Clinical Tropical Medicine and Traveler’s Health Certificate of Knowledge Diploma  ASTMH Tropical Medicine Course (American Society)  University of Minnesota/Centers for Disease Control & Prevention  On-line education: 7 Modules  On-site UMN/CDC Global Health Course  Optional Disaster Camp  CtropMed Online Exam Review

40. GSP Objectives (continued) Health Emergencies in Large Populations (H.E.L.P) Certificate  Center for Refugee and Disaster Response, Bloomberg School of Public Health, Johns Hopkins with the International Committee of the Red Cross. 2 months mentored international experience at affiliated international sites Primary Care Clinic in addition to HIV clinic. Choice of a Global Medicine related project for residency academic project. A clinical vignette, village assessment, nutrition study, community service project is acceptable.

41. Resident Support » Approximately $10,000 total cost » Supported completely for Deferred Mission Appointees (DMAs) » Open to any resident, even if not Adventist

43. Future Directions and Conclusions Marc Debay, MD, MPH, PhD Asst. Program Director, LLU Preventive Medicine Residency Program

44. Future Directions 1.Overall Strategies 2.Educational Programming 3.Priority Training Activities in 2011-2012

45. 1. Overall Strategies 2011/2014 »Increase FM & PM involvement in GH Institute »Develop partnerships with US / global organizations »Support DMA program as cornerstone of LLU GH training »Develop alternative global health education models »Develop faculty with global health interest / expertise / involvement  Increasing; e.g., recruitment cooperation  With Malamulo, Malawi  More DMAs in FMPM, due partly to marketing  “Encouraged” Malawi rotation at ‘field station  Added Lohr and Shannon

46. 2. Educational programming 2011 vs 2014 »Define two levels of training »Develop standardized international rotations »Increase access to Global Health concentration »Seek ACGME approval  4 levels…  Done  Increased to 3 FM; basic vs. advanced helps  In process

47. 3. Priority training 2011 vs. 2014 »Implement new Global Health Area of Concentration »Plan, supervise, evaluate international rotations »Advisor/mentor residents with definite GH focus »Include GH lectures in weekly FM and PM Grand Rounds  Done  Developing

48. Conclusions »History of faith-based, global mission of LLU: ~Remains main strength to build on ~Is major driver of learners’ interest in GH and LLU, which remains strong »The four international GME training options meet the needs of many residents »Strategies for GH training development have supported significant progress in curriculum development in last few years; increased, substantial implementation is plan; needs further planning, marketing and evaluation

49. Questions?