Medical students and residents have a growing interest in global health (GH) training because of increased awareness of healthcare inequities and a desire to make a difference. Tragedies such as the 2010 earthquake in Haiti prompted many trainees to volunteer their services and led others to call for universal training in GH including clinical experience in low- and middle-income countries (LMICs) (1, 2). Primary-care and specialty training programs are responding to this interest by developing GH programs, including placements in LMICs (3–6). The American Association of Directors of Psychiatric Residency Training (AADPRT) recognized this with its opening keynote speaker, who issued a call-to-arms for psychiatry to join the GH movement at its annual meeting in 2011 (7). Mounting formal programs will become increasingly urgent if the U.S. federal government is to fund an International Service Corps for Health as part of a health diplomacy initiative (8). It is especially critical for psychiatry to develop formal global mental health (GMH) training elements or tracks for residents, given the large contribution of mental illness to the global burden of disease and the paucity of mental services in LMICs (9–13). Although a few training programs have GMH components, more are needed (14–16). To our knowledge, this is the first article to describe GMH training for U.S. psychiatric residents with an interest in GH. We present a justification for a GMH track and describe guidelines for a seminar series and an LMIC training experience. In academic institutions with a comprehensive effort in GH, there may also be significant opportunities for psychiatric programs to collaborate with programs in other specialties and with schools of public health and nursing.
Justification for GMH Training
The justification for training U.S. psychiatric residents with an interest in GH is to develop leaders who can address health inequities so that people of all nations can have access to high-quality and comprehensive mental health services. Since all lives are of equal value, the large gaps in mental health status within and between countries are both inequitable and unacceptable. High-, middle-, and low income countries can learn from one another by adapting global knowledge to meet local needs (17, 18).
Consistent with this view are the changes in health education that emphasize a GH perspective. A recent commission noted a number of problems with the current state of professional health education worldwide; these include poor teamwork, narrow technical focus without broader contextual understanding, lack of continuity-of-care experiences, predominantly hospital-based training at the expense of primary care, and weak leadership to improve healthcare system performance (19). The report recommended the development of a system-based educational approach with the goal of producing health professionals worldwide who are educated to search and mobilize knowledge and to engage in critical reasoning and decision-making. When combined with ethical conduct training, health professionals would be competent to participate in patient- and population-centered healthcare systems. The report stressed the importance of team-oriented education including competencies for effective teamwork and leadership. A special emphasis was placed on becoming an agent capable of effecting change within a system of care. It involves a population-centered education committed to surmounting disciplinary silos and hierarchical relationships; this is accomplished by emphasizing collaboration with professionals and paraprofessionals across disciplines. The report also recommended that academic and educational health centers be networked to systems of care that have extensive primary-care clinical operations. Future educational systems should be part of global networks, alliances, or consortia that utilize information technology to meet educational objectives. Central to these reforms is the view that medical education and the care of patients are fundamentally collaborative efforts requiring curricular structures that present opportunities for learners to encounter problems in differing contexts. Trainees must learn to collect and analyze information and progress in their capacity for clinical reasoning and decision-making. Pedagogies should involve learners in experiences that encourage inquiry while allowing guided observation and reflection. Where gaps in knowledge exist, trainees are expected to pursue self-directed learning.
A GMH track would extend over 1-or-more years of residency training and include a seminar as well as a placement in an LMIC. It should require a scholarly product and should develop residents' educational and leadership skills. Since LMIC populations share many issues with immigrant, marginalized, and impoverished populations in the United States, it might also include clinical experiences with these populations, especially if they were located in settings away from academic medical centers and involved a team approach to care (20).
A GMH seminar might examine the mental health effects of: poverty, food insecurity and malnourishment, migration, refugees and asylum-seeking, war crimes (rape, torture, genocide, kidnapping, child soldiers), post-conflict recovery, low literacy, domestic violence, child abuse, indentured servitude and slavery, natural disasters, human rights issues, and the mistreatment of vulnerable populations—woman, children, mentally ill and homeless persons, and orphans (21). Comparing U.S. with LMIC systems of mental health care would improve understanding of health policy and financing and would highlight various delivery systems for seriously mentally ill persons (12, 15). Exploring the role of traditional healers, paraprofessionals, self-help groups, open pharmacies, and family and community support systems might assist residents adapting to a team approach to care as part of an LMIC placement. Another theme for the seminar is what Kleinman describes as the “category fallacy” (22). This is where clinicians or researchers from one culture (high-income countries) dismiss indigenous illness categories (LMICs) as culturally specific and replace them with culturally-specific disease categories of their own. He noted that culture influences the perception, labeling, experience of symptoms, course, and response to the disorder, not to mention its treatment. The seminar might also be useful for residents in the program's research track, who are involved in an LMIC project. Related topics might address the practicalities and ethics of clinical research in LMICs (23). Does the research address health priorities of the LMIC? What precautions are necessary when obtaining consent from vulnerable populations (e.g., children, women, impoverished individuals, those with low literacy and education, and minority or marginalized groups)? Is it possible to obtain informed consent in settings with minimal or absent healthcare when participating in the study may be viewed as preferential to no care otherwise? If the outcome is positive, are there realistic plans to apply the intervention or treatment to the LMIC population?
Before developing an LMIC placement, training directors need to weigh the added value of such an experience, as compared with working with a marginalized U.S. population (20, 24). Caring for an immigrant population in America might challenge residents with language differences, barriers related to stigma, and cultural beliefs about mental illness and its treatment. However, the resident likely will live and work within modern facilities and will have access to consultants in other specialties, medical technology, medications, and reliable communication systems. They will also remain embedded within the familiar U.S. healthcare system (i.e., values, standard practices, regulations, laws, financing, etc.). Hence, it will not provide an immersion in a different culture and healthcare system and will not force residents to understand and care for mental disorders from a novel perspective (15, 16). However, these are not mutually exclusive experiences, and caring for a marginalized U.S. population might be the best preparation for an LMIC placement. There are a number of practical and ethical challenges for a U.S. residency program in arranging a time-limited LMIC placement (25). Foremost is the nature of the relationship with the LMIC institution. Usually, this is within a medical school, hospital, or clinic, but it could be with an NGO (non-government organization) or other organizations that are providing mental health care in the LMIC. Longitudinal, well-structured, and respectful partnerships, with formal affiliation agreements, allow defined clinical, educational, or research roles to be developed for the resident that meet the learning objectives of the U.S. program and address the needs and priorities of the LMIC institution (14, 25). Typical clinical experiences are working in primary-care settings or in large outpatient psychiatric clinics. In contrast, ad-hoc short-term clinical roles (often referred to as “medical tourism”) may have little value for the LMIC and may burden local clinical and educational resources (6, 26). Formal agreements need to ensure that all legal and regulatory requirements are met in the host country. The arrangements must be equitable and represent fair value for both the host and the sending institution. One equitable approach would be a bidirectional agreement so that LMIC trainees get to spend time in the U.S. educational system. This option presents formidable issues related to funding, immigration, housing, and approval for participating in clinical activities in the United States.
A major challenge for training programs is identifying resources to support an LMIC placement. Funding for a trainee's time away from reimbursable clinical activity is challenging. An ideal arrangement would entail one or more faculty having an ongoing relationship with the LMIC institution and participating in either on-site or remote supervision. An LMIC training experience is usually supported by private donors or other departmental discretionary funds, but may also require residents to share certain expenses. Where there are research or research training grants, residents can develop their research skills by filling a meaningful role in an ongoing project. Programs, often with the assistance of their institution's Graduate Medical Education office, can also assist residents with pre-travel issues; namely, travel arrangements, visa applications, immunizations and medications for endemic diseases, medical evacuation insurance, and housing arrangements in the LMIC (25, 27). Language instruction and cultural preparation (e.g., knowledge of local laws, customs, personal dress, gender issues, gestures) are also extremely helpful. Post-travel medical evaluation is also important (28, 29).
Because of the many issues inherent in an LMIC placement, program directors need to consider the criteria for choosing residents. A first step is working with the resident to develop clear learning goals and outcomes. A previous successful experience of volunteering or work in a low-resource setting with scholarly dissemination may be predictive of success. Language skills, cultural background, passion for a specific project or underserved population, epidemiologic training, and plans for a career focused on underserved populations are additional factors to consider.
Psychiatric Resident Issues
Many residents view themselves as global citizens with a strong interest in GH, and they are usually motivated by a spirit of volunteerism and a desire to make a humanitarian contribution (14, 15). Inherent in an LMIC experience is the challenge of working in a different culture and set of customs. The uniqueness of the situation presents personal and professional challenges and may promote habits of inquiry and innovation. It may force increased introspection and self-awareness, require the development of new interpersonal relationships, and necessitate acculturation to a new “hidden curriculum.” It may also promote a greater sense of autonomy, given the marked change in peers, social supports, and supervisors (14–16, 30, 31). Residents and training directors need to be mindful that an LMIC placement is not without risks, especially when health resources and safety-net structures that are taken for granted in the United States may simply not exist (15, 27–29). Being involved in a motor vehicle accident or being a target of crime can take on extra layers of complexity when they occur abroad. Exposure to endemic diseases may pose additional risks (27–29). In certain LMICs, there is risk of unanticipated violence associated with political instability. Strong emotional reactions may occur with exposure to individuals suffering from extreme poverty, malnutrition or starvation, human rights violations, and serious and often fatal illnesses that might respond to treatment in a setting with greater health resources. Finally, persecution is a risk when the resident is perceived as a member of a group that has potential for being a discrimination target (ethnic, religious, gender, sexual orientation, etc.)
The potential educational benefit of an LMIC placement can be conceptualized through the six ACGME competencies:
LMICs are likely to have very modest resources, with a paucity of health professionals, a limited choice of psychotropic medications, and little or no access to acute-care facilities, as compared with the United States. Large numbers of patients may need to be seen each day. Confronting mentally ill individuals in such settings with a different treatment team forces residents to be adaptive learners and to progressively solve problems and challenges not faced in the U.S. What is the role of the psychiatrist and what are the roles of other health professionals and paraprofessionals? How does the resident form a therapeutic relationship with the patient and family? How are psychiatric emergencies managed? How are comorbid medical conditions managed in the absence of primary or specialty care? Are there opportunities for the resident to change clinical practices in the LMIC or to change patterns of care when they return to the United States?
Clinical experiences in an LMIC may expose residents to certain conditions or illnesses that are rare or less obvious in the U.S. For example, food-insecure individuals may suffer from anxiety and depression as they confront the daily challenge of providing adequate and safe nutrition for themselves and their families (32). Seeing this in stark relief in an LMIC may heighten awareness of more modest forms of food insecurity at home (33). Understanding culturally-determined presentations of common psychiatric syndromes and rating their severity may expand conceptualizations of these illnesses. For example, in certain LMICs, somatic symptoms (e.g., “sick heart”), may represent the most common presentation of depressive disorders (22, 34). Conventional symptoms related to mood may be absent. Residents may also be exposed to conditions unusual at home such as cerebral malaria, depression associated with tuberculosis, catatonia, and methanol poisoning from alcoholic beverages.
Practice-Based Learning and Improvement (PBLI)
The lack of laboratory and technological support may emphasize the importance of interviewing, mental status, and physical examinations and clinical observation. As one example, family involvement in patient care is often a standard and powerful determinant of treatment outcome in LMICs. Accompanying this are different views on confidentiality, with families often providing more information than the patient. How does a resident engage the family and, at the same time, reconcile this with confidentiality practices in the U.S. (14–16)? PBLI could be enhanced through debriefing after return home and by a critical reflective process.
Interpersonal and Communication Skills
Communication may be challenging for residents, especially if there are language differences. Utilizing an interpreter may increase resident comfort and efficiency in communicating by intermediary and may present an opportunity for gaining clarity about cultural differences. Even without a language barrier, residents need to familiarize themselves with culturally-relevant information, including nonverbal gestures and expression of emotions. Local concepts of mental illness may be quite different. If psychosis is understood to be the result of possession by spirits, how does the resident inform the patient and family about the diagnosis and the basis for the treatment plan (35)?
Residents will also be challenged by communicating with individuals who have low literacy and little education. An LMIC experience may be especially useful in forcing residents to communicate without reference to jargon or complex medical terminology. Providing explanations and utilizing question-and-answer sessions may promote patient involvement and understanding. “Teach-back” sessions at the end of the encounter may allow patients and families the opportunity to explain in operational terms what is expected of them. Even though this may be a common experience in LMICs, health literacy is a major concern in the United States, as well (36). Limited health literacy hampers access to information, restricts decision-making, and strongly reduces the effectiveness of health care. More and more responsibility for improving this situation in the U.S. is being placed on clinicians and healthcare systems. The educational setting can also present communication challenges. Cultural differences in diagnostic categories may lead to misunderstandings (14, 15, 22); and questioning professors or senior clinicians with the intent of improving understanding may be perceived as disrespectful. Similarly, small-group discussions may be socially awkward and difficult to implement. Teaching interviewing techniques to medical students may raise avenues of inquiry that are deemed socially inappropriate (14). Residents need to be mindful of these issues and negotiate and modify their behavior accordingly.
Residents are likely to face issues related to social justice: the impact of poverty on health; the lack of universal education; and the unequal rights of women, children, and other groups marginalized by race, minority status, religion, or caste status (37). Such exposure may heighten awareness of similar but more subtle versions of these issues in the United States. Residents may be confronted with ethical dilemmas when they observe or are requested to participate in practices that are not consistent with U.S. standards or are violations of human rights (15). Prolonged detention without clinical justification, ECT without anesthesia, and clinical research without informed consent are examples (23–25, 30, 31). There may also be situations in which the resident experiences social pressure to render services or judgments beyond their skill-set or experience. Being able to recognize this and politely decline requires courage and professionalism (30, 31, 38). The LMIC experience can potentially challenge a resident's core values and may motivate him or her to reflect on basic assumptions about healthcare and motivation and goals as a physician and psychiatrist. Discussion of these issues with supervisors in a timely fashion can facilitate learning, promote professional growth, and minimize emotional distress.
There may be unique approaches to care in LMICs that are uncommon in the United States. For instance, there is evidence for the effectiveness of a community-based rehabilitation model of care utilizing community health workers in the treatment of schizophrenia in rural India (39). Experiencing this approach first-hand allows the resident to understand the strength and limitations of such an approach and how it might be adapted to the U.S. or to their future practice. It also has relevance to the collaborative-care model practiced in the U.S. that relies on care-workers or nurses for the coordination of treatment of mental disorders within the primary-care setting (40).
There is evidence from medical students and residents in other specialties that clinical experience in LMICs as part of training results in physicians who are more likely to practice among underserved, multicultural, and immigrant populations in the United States (1, 3, 6, 9). This probably reflects a combination of selection bias and the idea that LMIC experience alters career paths. Programs that develop GMH training will need to evaluate the cost–benefit analysis for residents, the training program, and the host country. Tracking resident career paths and determining their time spent caring for underserved populations will be a critical outcome measure. Separate from impact on career trajectory are more fundamental issues of shaping resident values and attitudes about social justice, the treatment of vulnerable populations, and the impact of poverty on mental health status. Residents may also gain unique insights into regional or national mental health systems and their social relevance and patient-centeredness. By entering the health environment of an LMIC, residents are forced to “break set” and view mental health care practices and policy in a new light. Through introspection, residents have an opportunity to reflect upon their core values and examine many of the basic assumptions of mental health care systems in the U.S. The fundamental justification for GMH training is to inspire psychiatric residents to address mental health inequities in underserved populations in the U.S. as well as in developing countries (1, 2, 17, 18).