Interest in global health education has grown among medical students and residents, and medical schools and residencies have responded with both increased coursework and international experiences. In a study from 2008, 59% of medical schools offered international clinical elective rotations for residents; 45% offered opportunities for clinical research abroad for medical students; 32% offered research opportunities for residents; and 11% had formal global health track options for students (1). Several reports have described the demand and successful techniques for structuring global health-related medical student experiences in both the United States and Canada (2–7).
Residents also express a growing interest in global health, and trainees have begun outlining important ethical considerations for doing this work (8–11). International Health Experiences (IHEs) have been associated with positive effects on participants’ clinical skills and attitudes, particularly with diverse patient populations, and an increased likelihood for a career choice in an underserved area (seeing patients on public assistance, immigrants, and multicultural patients) (2, 8, 12). Many highly qualified residency applicants have had formative global health experiences and may wish to continue during residency (9, 10). There is also educational value of learning informed by an international perspective, and several of the general medical competencies for graduate medical education are well addressed through this framework (13, 14). Given these imperatives, residency programs in many specialties have begun to implement global health tracks (8).
Psychiatry residency programs are just beginning to respond to global mental health (GMH) education and training needs, even though mental illness is a serious global health problem (7, 13, 14). Fourteen percent of the entire global burden of disease can be attributed to neuropsychiatric disorders, according to a World Health Organization (WHO) study using risk factors projected to 2020 (15). For this reason, many endorse the WHO’s proposition that there is “No Health Without Mental Health,” and leading journals have published articles highlighting the opportunities and challenges in GMH (15, 16).
A recent report has outlined the justification and theoretical components of a Global Mental Health Program (GMHP) within a residency program (14). We report on the development of a real-life GMHP, including lectures, mentorship, and IHEs, and the impact of the GMHP on topic choice for resident scholarship and recruitment in the residency program. Last, we discuss issues related to funding for the GMHP.
The GMHP is an educational intervention in a university-affiliated program with 60 adult psychiatry residents. The GMHP began in 2008, with a biweekly elective lecture series devoted to GMH topics. During the 2008–2009 academic year, the GMHP added several components, including expanded core and elective didactics, a mentoring program, clinical community service electives, and an IHE during a 3-month elective in the PGY-2 year or during the PGY-4 year. During the IHE, the program provided salary and benefits for up to 1 month, and the resident donated 2 weeks of vacation time. Many of the IHEs are developed through existing faculty international collaborations, although some are developed through resident initiative. None have involved direct provision of clinical care, although IHEs have often included observation in clinical settings. Examples of IHEs are included in the Results section.
An oversight committee, composed of a resident from each year of training and three faculty members, meets monthly to review and plan curricular activities, develop mentoring plans, and develop funding for the program. The goals and objectives of the GMHP include
Increase global mental health awareness among trainees and faculty.
Implementation of program objectives in clinical and didactic settings.
Improve awareness of and ability to address access to mental health care for underserved populations.
Practice principles of cross-cultural psychiatry.
Develop and support collaboration among trainees and faculty.
Partner with current electives and clinical placements.
Develop new global health didactic and clinical electives and selectives.
Identify and partner with potential faculty mentors with global mental health interests.
Develop international sites for possible bi-directional exchanges of faculty, residents/fellows and medical students.
Consult with clinical and didactic curriculum leaders to develop new opportunities within the existing and developing curriculum.
Provide guidance for residents/fellows interested in global mental health during training.
Identify and develop funding for international or GMH-related clinical electives and scholarly projects.
More information on the required portfolio of experiences for resident recognition at graduation, a possible 4-year plan, and the governing council and program components can be found at the following link: http://medicine.yale.edu/psychiatry/education/residency/training/gmhp/133_90774_Yale_GMHP_Governance_07212011.pdf.
A syllabus of topics covered in the GHMP Elective can be found at the following website: http://psychiatry.yale.edu/education/residency/training/gmhp/courses.aspx.
In order to determine the impact of the GMHP, we compared faculty and residents’ experiences in GMH for 3 years before and 3 years after initiation of the program. In order to determine whether the GMHP affected their decision to attend the residency program, an anonymous, web-based survey was sent to the current PGY-1 residents (who were recruited while the GMHP was active) and to the PGY-4 residents who began as PGY-1’s in our program (and so were recruited before initiation of the GMHP). University HIC exemption was granted to conduct this survey. When applicable, statistical analyses were done, with IBM SPSS 19, using Pearson chi-square statistics with 1 degree of freedom (df). All other data are reported as frequencies.
Development of a GMHP had a significant impact on the residency program and the department (see Table 1). Before development of the GMHP, there were few didactic sessions in the residency related to GMH. Although a pilot program for International Health Experiences (IHEs) existed, only one resident had completed an IHE. Since the implementation of the GMHP, there were significant increases in the number of core didactic sessions devoted to GMH, and an elective was developed that added 60 hours of didactics per year. There was a significant increase in the number of IHEs in the PGY-2 year, as well as a significant increase in the number of mentored scholarly projects completed by residents.
TABLE 1.Advances Made Since the Implementation of a Global Mental Health Program in 2008: Comparison Between 2005–2008 and 2008–2011
| Add to My POL
|Area||Before GMHP 2005–2008||After GMHP 2008–2011||Significance|
|Core curriculum topics with GMH applications, hours||5/400 (1%)||24/400 (6%)||<0.001|
|GMH elective curriculum, hours||0||60||N/A|
|Clinical elective sites with GMH affiliation||1||2||N/A|
|Number of PGY-2 funded international health experiences (IHEs)||1/36 (3%)||8/36 (22%)||0.006|
|Overall funded IHEs||1||11||N/A|
|Residents with mentored and funded PGY-2 GMH scholarly projects||1/36 (3%)||11/36 (31%)||0.002|
|Overall resident scholarly projects||1||14aa||N/A|
|Funding Sources for IHEs||2||7||N/A|
|PGY-1 residents who report GMH opportunities as a factor in their decision to come to the residency program||1/8 (12.5%)bb||6/10 (60%)cc||0.027|
Table 2 shows selected examples of the IHE projects that residents completed, as well as the funding source for the IHE. The funding sources for resident IHEs and scholarly projects has expanded since the development of the GMHP and now include R25 research education training grants, hospital, nonprofit-organization, non-governmental organization, departmental, professional organization fellowship, and foreign-government support. Given the variety of funding sources, residents were required to complete a scholarly project appropriate to the experience and the requirements of the funding source.
TABLE 2.Examples of Resident International Health Experiences (IHEs), Funding Sources, and Scholarly Work
| Add to My POL
|International Health Experience||Funding Source||Scholarly Work|
|Barbados: research in drug-related psychosis||NIMH faculty grant||Part of larger research project|
|China: access to psychiatric care||R25 grant; NGO||Book chapter, presentation|
|China: diagnosis and treatment of posttraumatic stress disorder after a natural disaster||R25 grant; NGO; professional organization grant; foreign government grant||Presentations|
|China: epidemiology of methadone-maintained patients||R25 training grant||Manuscript in process|
|India: mental health systems and Ayurveda practice||Professional organization grant||Manuscript in process|
|Jordan: evaluation of mental health treatment systems in refugee camps||NGO||Development of NGO international guidelines|
|Malaysia: time to initiation of IV heroin use||R25 grant||Abstract, poster, manuscript in process, presentation|
|Thailand: clinical work in substance use||R25 grant||Part of larger research project|
The presence of the GMHP significantly affected recruitment to the residency; 83% of residents (10/12) beginning their PGY-1 year in 2010 and 66% of residents (8/12) beginning their PGY-1 year in 2007 responded to the survey about whether GMH was important in their decision to come to the residency program. The presence of a GMHP appeared to significantly affect recruitment, with 60% of residents recruited in 2010 reporting an interest in our GMH opportunities at Yale as a factor in their decision to come to our residency, as compared with 12.5% in 2007 (Table 1).
The impact of having a defined GMHP, with core residency didactics, a regularly-scheduled GMH elective, funded and supported IHEs, and facilitated mentorship leading to scholarly productivity is evident from the increased number of presentations on GMH issues in both the core and elective didactic programs and in the increased number of IHEs and academic productivity of the residents. Although the major effect is seen at the level of the residents, there is clearly an effect on the department’s culture, as well. This impact is mediated through a specific GMHP (one of only two official programs in the residency), publicity about GMHP events through e-mail and on the departmental website, involvement of faculty in attending and presenting at the GMH elective, and mentoring residents doing IHEs, and discussion of GMH funding and initiatives at the highest levels of the department. The value of long-term investment of faculty in supporting residents’ involvement in the GMHP and the ingenuity of both faculty and residents in developing funding for IHEs has promoted the success of the program.
Although many in academia appreciate the value of GMH experiences in psychiatry for enhancing curriculum in general education competencies and cultural understanding in working with populations with diverse backgrounds, a recent report has documented the ambivalence with which many residency training directors view GMH and, especially, the provision of IHEs (13, 17). There are many practical and financial administrative barriers that must be overcome in order to provide these opportunities, and it is understandable that many residency directors, faced with increasing regulations and decreasing budgets, may be reluctant to develop GMH-oriented IHEs. The development of an oversight committee provides some additional support for the training director and brings the creative energy of faculty and residents who are passionate about GMH. Without this passion and creativity, developing funding from professional organizations, NGOs, and foreign governments would likely have happened more gradually.
This study has also documented the significant effect that having a GMHP has had on recruitment of residents to our program. Many of the most talented applicants to our residency program have had formative IHEs during medical school or have participated in a global health track or certificate program. As a residency program, we are also committed to recruiting applicants from diverse backgrounds, who have had diverse life experiences and who have demonstrated commitment to care of underserved populations. Having a GMHP has served as a way to demonstrate our department’s commitment to these principles and has been attractive to prospective applicants with these interests. Of course, having now recruited residents with these interests, sustaining the GMHP has grown more important as many residents are hoping to enter the GMHP and complete an International Health experience (IHE).
Focusing on GMH research as the major component of our IHEs has been a central tenet of our program. Although IHEs have value in exposing residents to diverse populations and healthcare delivery systems, they also bring ethical concerns, including
Licensing requirements and other administrative barriers like malpractice insurance, which must be overcome to practice medicine in international settings
Short-term clinical rotations with little opportunity for patient follow-up or continuity
Resident competency in practicing in health systems that are often quite different from our own
Quality and availability of supervision, especially in low-income settings
Little opportunity for reciprocal relationships in which residents from international sites participate in a clinical elective in the U.S. (because of U.S. licensing requirements that preclude residents from international sites doing clinical work)
Initially, a focus on GMH research was due to practical considerations of finding funding to support residents’ salaries and benefits during the IHE. However, we believe that having IHE participants focus on research provides opportunities for them to learn about research ethics in international settings, provides opportunities to observe clinical work and the healthcare system without being responsible for patient care, provides pre-existing structures for supervision and mentorship, and can provide reciprocal research opportunities for residents from international sites to come to the United States to participate in research training. We have focused on research collaborations with international partners to foster long-term relationships that are mutually beneficial to both residents and each department.
This report is limited to the experience of one program, and so the results may not generalize to other programs. We acknowledge the importance of motivated residents willing to seek and apply for funding and faculty willing to mentor residents completing IHEs and scholarly projects. The program also benefits from the international experiences many of our residents bring to the program. Although a small minority of our residents are international medical graduates, the majority of experiences have been outside of the residents’ culture of origin.
Further investigation should include the impact of this program on residents’ cultural competency. We look forward to following the careers of residents who have participated in the program to determine their eventual impact on serving diverse populations in the U.S. and abroad, contributing to the scientific literature on GMH, and participating in training future generations of leaders in GMH.
The purpose of a comprehensive GMHP within a psychiatry residency program is to ensure that all residents are knowledgeable about GMH and to provide additional options for those residents with a special interest in GMH that can result in meaningful products of their work. These additional didactic, clinical, and research electives, and international health experiences provide a more in-depth understanding of GMH, as well as a focus on issues of health disparities, access to care, and cross-cultural psychiatry in the local community. The impact of having a defined and supported GMHP is evident in both the residency program and department, where demonstrable changes have been associated with the development of the GMHP.