With prevalence rates of 20% globally for child and adolescent mental disorders across cultures, there is a critical global public health need for evidence-based psychiatric services for children and adolescents in virtually all countries (1, 2). This need has led to a burgeoning interest in innovative international mental health initiatives (3, 4). Although the focus has been on domestic programs preparing individuals for careers in global health and mental health, there has been a parallel increase in interest from developing countries in learning more about Western clinical and research practices through direct participation in United States and other Western programs (5, 6).
The lack of trained child mental health professionals in low- and middle-income countries is well documented (3). There is less than 1 psychiatrist per 100,000 people in much of Southeast Asia and less than 1 psychiatrist per million in most of sub-Saharan Africa (7). The median number of psychologists in mental health per 100,000 people varies from 0.04, in low-income countries, to 11 in high-income countries (7). Mental health services for children and adolescents in low- and middle-income countries are extremely scarce and greatly limit access to appropriate care (8).
Over the past decade, the Psychiatry Department at Children's Hospital Boston (CHB) began to respond on a case-by-case basis to many inquiries and requests for child mental health training opportunities from students and professionals across the globe. Initially, the Department tried to accommodate individuals at their level of training and with their diverse interests. This proved problematic in offering too variable an experience and creating considerable additional teaching and time-burdens on the faculty. Also, the Department was concerned about “training” individuals who might suggest to programs in their home countries that their experience represented a more complete training in child mental health than was actually the case.
The critical need for global child mental health services together with the lessons learned from these initial CHB training experiences have led to the design of a formal onsite child mental health observership program. This article outlines the development and implementation of the Children’s Hospital Global Partnerships in Psychiatry (CHGP) Observership Program, which is unique in its focus on international child mental health education within an academic children’s hospital. We describe the preliminary results of the application process and the international observer experience.
The CHGP Observership Program is a cross-disciplinary educational program designed for physicians and psychologists coming from outside the United States who have an interest in child and adolescent mental health. The program’s goal is to provide exposure for a cadre of trained individuals from countries all over the world, who can then aid in the development of child mental health policy, foster child mental health clinical programming, and serve as advocates for child mental health in their respective countries.
Conceptually, the program’s mission is congruent with and expands the clinical, programmatic, and advocacy efforts of the Department into a global context and expands CHB’s increasing focus on promoting global health initiatives. Of note, the goal of this program contrasts with many U.S. medical schools and residency programs that have existing observerships, externships, and visiting medical student clerkships that are generally designed to enhance subsequent recruitment into their own residency programs (9). The CHGP program does not accept anyone who expresses the intent to seek full training in the U.S. after the observership, or to emigrate for any reason. “Brain drain” has been defined as the phenomenon by which expertise moves toward more developed countries, leaving poorer countries in comparative scarcity (10). Active steps are taken with the development of this program to screen applicants carefully and create an infrastructure that minimizes the risk of brain drain that is inherent in an international observership of this nature.
The CHGP Observership is designed for physicians and doctoral-level psychologists from outside the U.S.who have no intention of seeking further graduate training or practice opportunities in the United States. Pediatricians, general psychiatrists, or clinical psychologists with an interest in pediatric care are invited to participate. Proficiency in English is required. Existing literature from other international medical elective programs in the U.S. indicates that scholars who are fluent in English are more likely to have a positive elective or clerkship experience, as are the faculty for the program (9).
On the basis of past training, current status in their home country, and future plans, selection criteria were developed, in part, to limit the applicant pool to those whose intent matched the program’s mission and goal. A website was developed that describes the nature and goals of the observership (http://childrenshospital.org/clinicalservices/Site1900/mainpageS1900P18.html). Interested applicants are expected to complete a detailed standardized application form, and a telephone interview is subsequently arranged for those who are considered potential candidates for the program. The latter is an important screening tool because candidates may have different verbal language proficiency than their written applications would indicate, and it also allows for a more in-depth dialogue with applicants, to determine their goals and eligibility for the program.
Applicants are expected to provide a health attestation and immunization record. There is consultation with U.S. immigration legal experts to ensure appropriate visa requirements and processing for individuals from various countries and to provide appropriate documentation with U.S. consulates in these countries. Applicants who are accepted into the program are credentialed by CHB as associated personnel, which allow applicants to observe clinically at Children’s Hospital. The observational nature of the experience is emphasized in the application process.
Because of licensing and insurance requirements, direct clinical care is not a part of the CHGP Observership. However, participation in clinical conferences, ward rounds, and other clinically-related activities is integral to the program. During their orientation, observers are provided with guidelines regarding how to conduct themselves in the clinical settings. They are provided with identification badges indicating their names and status as observers, and they introduce themselves as such to patients. Being a tertiary academic institution, patients are as accepting of observers as they are of all other trainees in the institution.
The program is not intended as a substitute for formal training in the clinical disciplines of child psychiatry or psychology, and it is strictly an observership. We decided not to provide observers with any form of official certificate because of the concern that a certificate might misrepresent the qualifications of the observer to a naïve audience or otherwise be misused. A letter of participation stating the nature of the experience, without any personal evaluation, is provided at the end of the observership.
There is no tuition fee currently associated with this program. The Department has struggled with the issue of how to value the program monetarily. In the earlier iteration of the program, when it was unstructured, a fixed nominal fee was charged for participation. Although participants were willing to pay the fee, the Department generally waived this, given the lack of a structured educational program. Over the past 2 years, no fee has been charged for any participant during this pilot phase of program development and evaluation. All observers are responsible for all costs related to travel, accommodation, and meals.
Core programs and key experiences were identified that would provide a meaningful exposure to contemporary care and lead to learning that could be incorporated into the participant's future professional life. Observers can stay 1–3 months, and a variety of experiences are arranged, depending on their interests.
The following three core rotations are offered:
Psychiatry Consultation Service The Department’s multidisciplinary consultation–liaison service allows many core principles to be imparted, including the nature of communication between different disciplines and the approach to physically ill patients with emotional and behavioral problems. There is the opportunity to learn from rounds and seminars, as well as bedside observation and discussions. CHB, being an international referral center, has a rich and diverse patient population. Cross-cultural issues are, therefore, frequently discussed during rounds and didactic seminars.
Inpatient Psychiatry Service This experience provides the opportunity to observe the evaluation and management of youngsters who present with severe psychiatric illnesses requiring care in the more restrictive, inpatient setting. Team management and overall comprehensive care-management issues are emphasized.
Community and Outpatient Psychiatry Service This service exposes observers to school and health center-based mental health services, outpatient mental health clinics, and specialty clinics (e.g., substance abuse, developmental disorders). Besides seeing outpatient diagnostic and treatment services, the observers are able to see firsthand the impact of collaborative and consultative mental health services delivered in the underserved Boston community. Depending on the observer’s interests, opportunities are also provided for exposure to clinics and programs dedicated to specific ethnic populations, for example, the Latino program, the Somali refugee program, and the Asian community health center.
Led by the co-directors of CHGP, an integration seminar is provided throughout the experience that gives observers an opportunity to talk about their experiences and focus on issues related to policy, advocacy, and cross-cultural psychiatry, as well as address areas of special interest for future career development. All observers receive a set of core child mental health articles and presentations on a CD or flash drive that they may take with them. The educational resource package focuses on topics applicable to global child mental health, including global policy, child rights, and ethics in research, as well as core articles and presentations related to the evaluation and management of common child mental illnesses.
A structured evaluation form is administered at the end of the observership to promote continuous quality improvement. The content of the evaluation form focuses more on the structure and format of the program. Also, a framework of questions is given to the observers during the course of their rotations to highlight differences in systems, training, and patient care in the U.S., as compared with their countries. This serves as a guide for reviewing what they have learned and experienced and puts together a comprehensive narrative by the end of their observership.
Description of Applicants
In a 2-year period, there have been over 150 application requests, from 25 countries, in Asia, Europe, South America, Central America, Africa, and the Middle East. India contributed the highest proportion of applicants, with 30% of requests coming from that country. Aside from Egypt and Nigeria, there have been no application requests from any other African country. This could reflect the lack of mental health clinicians and therefore the fewer individuals with interest in an observership of this nature. It may also indicate that individuals from poorly-resourced countries are less likely to have the financial means or available time necessary for participating in such a program and are therefore less likely to apply.
The Internet is usually the primary source of program information, although some learn of the program from contacts with CHB faculty in their home countries and at international conferences. Over 95% of requests are made via e-mail, although a few applicants made telephone inquiries. About 40% of all observership requests are from applicants seeking opportunities for residency training in the U.S., specifically in the areas of psychiatry, pediatrics, and internal medicine. This is in keeping with existing information about observership programs and externships at other institutions, but not consistent with the goal of the CHGP observership and, to the extent it is possible to ascertain this request, these individuals are excluded.
Description of Observers and Faculty Participation
Over the last 2 years, 10 applicants have been accepted from 7 different countries: Costa Rica, Nigeria, China, Thailand, Ireland, the Czech Republic, and Singapore. About half of these applicants were selected on the basis of existing relationships CHB faculty have with specific countries. The age range of observers was 25–58 years, with 60% in their 30s; there was an equal gender distribution of 5 men and 5 women. Disciplines included six psychiatrists, three psychologists, and one general practitioner, in keeping with the overall applicant pool. All the observers worked at academic or government institutions in their home countries, and 70% were less than 10 years out of training. Although 80% worked with children as part of their clinical practice, 60% had not received formal child-and-adolescent mental health training; 50% participated in the observership on their own initiative and funding, whereas 50% were sent and/or funded by their institutions; 80% of participants requested documentation of participation for their home institutions, and 100% of the observers so far have returned to their countries after completion of the program.
Faculty and trainees with specific international interests have been the most interested in participating in the teaching and supervision of international observers and have contributed most meaningfully in a mentorship role when they have firsthand knowledge and experience about the observer’s home country. Of note, there have been no significant differences in observer satisfaction with the program, with all reporting positive experiences, regardless of their home country or previous CHB faculty contacts.
In recruiting faculty to participate in the teaching and supervision of observers, we found that the Department’s faculty and trainees were very receptive to having international observers join existing rotations, didactic sessions, and individual supervisions, as this minimizes the burden of creating additional training and supervisory experiences. To the extent that the faculty member must make special arrangements to accommodate an observer or to teach in the program, the experience has been less satisfactory for the faculty member and observer.
There have been some benefits to having more than one observer participating in the observership at the same time. Participants benefit from having another person going through adjustments to cultural and other changes within the U.S. with whom they can share experiences, and they gain from each other’s perspectives. Also, it is easier for faculty to arrange rotations for and meet with a couple of observers at a time, rather than have a separate process for each participant. We are, however, mindful to keep the overall number of observers at a volume that can easily be accommodated, so as not to overburden the clinical services.
Observers’ Program Assessment: Pilot Results
In sum, the international observers reported a rich and insightful educational experience, with overall satisfaction with observership. The educational materials provided had a diverse range of information that participants felt would be of ongoing benefit upon returning to their home countries. All participants rated highly the personal and individual contacts made with the Department’s faculty and trainees during the course of their observership. In addition to enhancing their observership experience, the program provides opportunities for networking and ongoing collaboration after its completion.
The CHGP Observership Program suggests that development and implementation of an onsite educational observership experience holds promise in responding to the critical global need for child mental health training and education. The continuing request for the opportunity to participate from across the globe has been heartening, and the benefits have been two-way. Department faculty have been sensitized to service and training needs in developing countries and, through discussion with participants, faculty, and trainees, have learned about some alternative approaches to care, as well as ways to enhance the observer experience.
A program of this nature does have training- and time-costs. A review of the program’s applicant pool indicates that participants who apply for these positions are those with the financial means to do so. Participants who have completed the program indicated that addition of tuition costs would likely make it even more difficult for many potential observers (especially those from developing countries) to participate, given the additional costs for travel, accommodation, and meals. With the continued evolution of the program and a broader set of clinical experiences, the Department has decided that a fee will be charged to cover the administrative costs, materials, and production costs, and provide for some limited faculty compensation. Consideration will be made for a sliding-scale fee to accommodate and encourage the participation of individuals from lower-resourced countries, who may have limited financial capabilities, yet a great need for access to training.
Although the results are promising as another approach to the world’s underserved child mental health needs, the relatively small number of participants to-date limits the findings of CHGP. Whether the findings in one institution can be generalized to other hospitals remains to be determined. The CHGP Observership intends on longer-term follow-up to look into the impact of the observers in their home countries, specifically upon the impact of enhancing access and training.
In summary, the development and implementation of an onsite educational observership experience in an academic teaching setting has significant potential in enhancing international child mental health education as well as building new bridges of collaboration and partnership between the academic psychiatric world and underserved clinical world of our children and adolescents. Children’s hospitals have the potential and opportunity to contribute significantly to the educational needs of international health professionals.