Global Health Training in Radiology Residency Programs
Article Outline
Rationale and Objectives
To measure perceptions of radiology residents regarding the imaging needs of the developing world and the potential role of an organized global health imaging curriculum during residency training.
Materials and Methods
An electronic survey was created and then distributed to residents in accredited US radiology residency.
Results
Two hundred ninety-four residents responded to the survey. A majority (61%) planned to pursue future international medical aid work, even though a similar proportion (59%) believed that they would be ill-prepared with their current training to pursue this career goal. The vast majority (91%) of respondents stated that their residency program offers no opportunities to participate in global health imaging experiences. Most surveyed residents felt that an organized global health imaging curriculum would improve understanding of basic disease processes (87%) and cost-conscious care (82%), prepare residents for lifelong involvement in global health (80%), and increase interpretative skills in basic radiology modalities (73%). If such a curriculum were available, most (62%) of surveyed residents stated that they would be likely or very likely to participate. Many (58%) believed the availability of such a program would have influenced their choice of residency program; a similar proportion of residents (75%) believed that the availability of a global health imaging curriculum would increase recruitment to the field of radiology.
Conclusion
Many radiology residents are motivated to acquire global health imaging experience, with most survey respondents planning to participate in global health initiatives. These data demonstrate an imbalance between the level of resident interest and the availability of global health imaging opportunities, and support the need for discussion on how to implement global health imaging training within radiology residency programs.
Key Words: Public health, international development, resident, global health, radiology
As globalization progresses, there is increasing agreement among medical educators that global health should be a standard component of general medical education in the United States (1). There is also a growing need for medical specialists in global health efforts, particularly as an increasing number of academic, government, and nongovernment organizations expand delivery of health care to developing nations in efforts to address the marked inequities in disease burden relative to health care expenditure (Fig 1). Radiology is an important component of global public health programs, including those that address tuberculosis, AIDS-related diseases, trauma, breast cancer screening, and maternal-infant health care. Yet, the World Health Organization reports that approximately two thirds of the world’s population lacks adequate access to medical imaging; the scarcity of imaging services in developing regions contributes to a widening disparity of health care and limits the role of radiology in global public health programs that require imaging 1, 2, 3, 4, 5, 6. Efforts to redress this lack of access to imaging services in the developing world have encountered significant challenges, including limited access to equipment, poor sustainability, shortages of trained personnel, inadequate infrastructure, and lack of interest 1, 2, 4, 5, 6, 7.
Figure 1
Graphical representation of health care inequities in the developing world.
Medical trainee interest and participation in global health is rapidly increasing (8). The proportion of medical students who completed a global health elective increased from 6% in 1980 to 22.3% in 2004; 65% of US medical schools now offer international elective opportunities (9). In a parallel effort, various medical specialties have sought to incorporate global health training into their programs 10, 11. For example, 45% of family medicine programs, 71% of emergency medicine programs, and 52% of US pediatric programs offer access to international clinical rotations for their residents 10, 12, 13, 14. Residents, especially those with previous international experience in medical school, have reported selecting their training programs in part on the basis of available global health training opportunities 12, 15, 16, 17, 18, 19. As more medical students acquire international health care experiences, access to global health training opportunities may become an even more important consideration when selecting residency programs.
The role of the field of radiology in global health outreach has become more visible in recent years, as evidenced by new American College of Radiology (ACR) programs such as the Barry Goldberg/Maurice Reeder International Travel Grant Program and the Foundation International Outreach Committee; imaging-based nonprofit organizations such as RAD-AID; and individual radiologist initiatives which are frequently highlighted in ACR publications 7, 20, 21. These efforts share a common goal to increase access to medical imaging to underserved populations in the developing world. Yet despite a growing cohort of global health imaging initiatives, there are no formal curriculum guidelines and virtually no training programs that provide radiology trainees structured opportunities to develop skills and experiences in global health imaging applications.
We suspect, based on our experience, that there is widespread interest in global health imaging, electives, and training among radiology residents, a lack of such programs, and that a large proportion of residents would participate if a global health imaging elective curriculum were integrated into residency training. As a first step toward discussing a format for formal global health radiology training within US radiology residency programs, a survey was designed to gauge the perceptions of radiology residents about the role of radiology in delivering health care to the developing world, as well as interest in potential training opportunities for radiology residents in global health. The electronic survey was made available to all radiology residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Materials and methods
Participants
We conducted a survey of the accredited radiology residency programs in the United States between April 2010 and June 2010.
Instrument
The survey was designed to obtain response rates in the eligible respondent population (radiology residents) that would reach 95% or greater confidence level with 10% or less sampling error; based on a total population of 4669 allopathic radiology residents in the United States, 95 unique survey responses were needed to satisfy this criteria. Pilot survey content was developed based on hypothesized and known global health residency opportunities and a review of the literature. The first pilot survey was reviewed by five senior radiology residents (postgraduate year [PGY]-IV) and two attending physicians at the principal investigator’s institution. Based on their comments, a second pilot survey was developed and administered to residents attending two large academic institutions (n = 44). Specific feedback was received from the respondents of the pilot survey concerning the following metrics: Was each question clear? Are there unknown words/phrases/acronyms? Is there a better way to ask a particular question? Are there questions with answer choices that “lead” you toward a particular answer? What questions were they expecting to see but did not? Strictly closed-ended question responses were based on a Likert scale. Open-ended questions responses were “click all that apply” and included a free-text “other” response; the option lists for these question formats were as exhaustive as possible and built upon data in the literature when available. The pilot survey was then revised to reflect feedback and finalized.
The finalized survey was deployed electronically on www.surveymonkey.com, and the online links to the survey were distributed through the Association of Program Directors in Radiology to all US radiology residency program directors via email, with a request that they distribute the survey link to the residents. The online survey consisted of 35 questions; the measurement objectives with total number of questions asked and distribution of questions per type are as follows: “background,” 1 total (1 yes or no); “details of previous experience,” 4 total (2 free response, 1 multiple choice, 1 yes or no); “unmet needs of medical imaging in the developing world,” 2 total (1 nominal rating, 1 free response); “perception of imaging needs,” 1 total (1 nominal rating); “perceptions of the current state of imaging in the developing world,” 2 total (1 nominal rating, 1 free response); “future imaging needs of the developing world,” 1 total (1 categorical ranking); “future interest,” 2 total (2 yes or no); “perceptions of the role of American radiologists in the developing world,” 3 total (1 free response, 2 multiple choice); “international imaging curriculum,” 8 total (4 free response, 1 yes or no, 3 multiple choice; “international radiology elective rotation,” 6 total (5 multiple choice, 1 free response); and “demographic information,” 4 total (2 free response, 2 multiple choice).
Survey-takers were able to choose whether to respond to all or only some of the questions. Respondents were notified that the questionnaire would take approximately 5–10 minutes to complete. No enticements were offered to the survey participants. The sponsoring organization and investigators received no compensation for the work.
Analysis
IP addresses were used to identify the US Census Bureau regions and subregions from where surveys were submitted. IP address database at www.maxmind.com was used (six IP addresses could not be located). A cartographic representation of survey respondents was created using Stat-Planet Map Maker (www.sacmeq.org/statplanet/) (Fig 2). Absolute difference was calculated by taking the percent of survey respondents from a subregion and subtracting the % of actual residents training in that subregion (Table 1).
Figure 2
Cartographic representation of survey respondent IP addresses using Stat-Planet Map Maker (www.sacmeq.org/statplanet/). IP addresses: www.maxmind.com was used (six IP addresses could not be located). States with no radiology residency programs are indicated with “N/A.”
Table 1. Geographic Distribution of Radiology Resident Sample Population Relative to Actual Radiology Resident Population (ie, Does the Geographic Distribution of Surveyed Residents Mirror the Real Geographic Distribution of Radiology Residents?)
| Subregion | Region | |||
|---|---|---|---|---|
| West (%) | Midwest (%) | South (%) | Northeast (%) | |
| Pacific (CA, WA, OR, AK, HI) | 7.1 | |||
| Mountain (WY, ID, MT, NV, UT, CO, AZ, NM) | −2.3 | |||
| West North Central (ND, SD, NE, KS, MO, IA, MN) | −1.8 | |||
| East North Central (WI, MI, IL, IN, OH) | −2.0 | |||
| West South Central (TX, OK, AR, LA) | −2.5 | |||
| East South Central (MS, AL, KY, TN) | 2.5 | |||
| South Atlantic (FL, GA, SC, NC, VA, DC, MD, WV, DE) | 5.9 | |||
| Middle Atlantic (PA, NY, NJ) | −6.5 | |||
| New England (ME, VT, NH, CT, MA, RI) | −0.4 | |||
| Totals | 4.8 | −3.8 | 5.8 | −6.9 |
Statistical analysis was performed with STATA/IC v11.0. Determination of significance was performed as follows: for ordinal dependent variables, the Mann-Whitney U test was using a significance level of P < .05; for nominal dependent variables, the Pearson chi-square or Fisher’s exact (for cells with less than five elements) tests were performed using a significance level of P < .05. Bootstrapping with 1000 repetitions (excluding empty cells) was performed to generate confidence intervals around medians. Survey percentage confidence intervals were calculated at 95% confidence level using the total US radiology resident population of 4669 provided by the ACR.
Results
A total of 294 individuals responded to the survey between April 2010 and June 2010. Average age was 31 years. Residents from PGY-1 to PGY-5 participated; the majority of respondents were in the middle of their training (PGY-2 through PGY-4) and from a variety of programs throughout the United States (Fig 2). There was no significant association between having worked in the developing world and region of respondent (W, NE, S, NW). There was no significant association between age, PGY, or gender and having worked in developing world.
Prior Experience
A total of 29% (84/294) of respondents had performed work in the developing world (Fig 3a). Of these, 91% (68/75) had participated in international medical care, 29% (22/75) in public heath, and 23% (17/75) through religious/missionary organizations. Countries of participation spanned 5 continents, including Haiti, Uganda, Republic of Congo, India, China, Guatemala, Mexico, Iran, and Brazil. Most participants worked in their respective countries for either less than 1 month (49%; 37/75) or 1–6 months (37%; 28/75); 12% (9/75) of participants were involved in their work for greater than 1 year.
Figure 3
Survey responses regarding (a) prior work in the developing world, (b) perceived unmet need for medical imaging, (c) plans for further international aid work, and (d) perceived adequate preparation for developing world imaging during residency. Confidence intervals are based on sample size (response count for each panel), resident population of 4669 (from American College of Radiology; 1336 was used for (b) 28.6% × 4669 = 1336), and confidence level of 95%.
Perceptions on Radiology’s Role in Global Health
A total of 85% (68/80) of respondents with experience in developing countries perceived an unmet need for medical imaging in these countries (Fig 3b). Respondents were asked to rank different imaging modalities based on perceived need in developing countries. Modalities included computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, ultrasound, radiography, mammography, interventional radiology, and general fluoroscopy. Among those with experience in developing countries, plain radiography and ultrasound were thought to be the most useful imaging modalities for health care practitioners in the developing world. Modalities of intermediate utility were interventional radiology and diagnostic fluoroscopy. Mammography was thought to be one of the least useful modalities, followed by MRI and nuclear medicine (Fig 4).
Figure 4
Perceived clinical utility of imaging modalities in the developing world. Modality median score does not change significantly with prior experience working in the developing world or based on geographic region of respondent (95% confidence interval).
When asked if the need for medical imaging services in the developing world will increase over time, 243 of the 294 (83%) total participants responded. Of these, 97% (235/243) felt that the need for medical imaging would increase. When asked which disease entities required attention from radiology in developing countries, 45% (108/237) of 237 respondents prioritized infectious disease as a leading application of imaging, 32% (77/237) prioritized cancer screening, and 22% (51/237) mentioned maternal/fetal imaging.
A total of 232 residents selected a response to the question “What is the role of American radiologists in meeting the medical imaging needs of the developing world?” Of these, 72% (168/232) answered either performing teleradiology services, assisting with technical planning, or being physically present onsite collaborators; only 2% (5/232) perceived no role for radiologists in developing world health systems. A total of 55% (127/234) of participants thought that American radiologists would be likely or very likely to work together with the medical community to improve health care delivery in the developing world. Approximately 31% (72/234) were uncertain, and fewer than 15% (35/234) thought that American radiologists were unlikely/not likely to contribute. However, when asked to characterize the current level of involvement of radiologists in helping to meet the needs of the developing world, only 18% (42/234) thought that American radiologists were at least somewhat involved.
Participation in Global Health and Training Opportunities
Of 294 respondents, 61% (143/234) plan on pursuing international medical aid work in the future, and 72% (138/193) of that subgroup hope to specifically pursue aid work in medical imaging (Fig 3c). Of these, the majority of respondents answered either performing teleradiology services (72.4%; 168/232), assisting with technical planning (71.6%; 166/238), or being physically present onsite collaborators (67.7%, 157/238).
When asked about international radiology opportunities in their training program, 229 residents responded. The majority (67%; 154/229) stated that their residency offers no international radiology opportunities; only 4% (10/229) of those surveyed stated that their residency programs offered an international radiology rotation. Most (59%; 134/226) of residents surveyed stated that they would be ill-prepared by the end of residency to assume a role in improving access to and availability of medical imaging in the developing world (Fig 3d).
Global Health Imaging Curriculum and Clinical Rotation
A total of 224 of surveyed residents thought that several approaches would be useful for the creation of a developing world imaging experience. These include an international elective rotation (53%; 119/224), lecture series and case presentations (52%; 117/224), and the opportunity for international teleradiology/teleconferencing (51%; 116/224). Many residents also stated that a developing world imaging curriculum (33%) or formal fellowship/Masters in Public Health program (27%; 75/224) should be certified by a national body such as the ACR or American Board of Radiology (ABR).
A majority of surveyed residents (64%; 144/226) believed that an international rotation would be an integral component of any proposed developing world imaging curriculum (Fig 5c). Suggested rotation duration was 1–4 weeks (42%; 95/226) or 1–3 months (52%; 117/226). The majority of residents surveyed believed that some sort of research/academic project should be considered during such an international rotation (65%; 151/227). A majority of respondents (55%; 124/227) were “most likely” or “definitely” interested in collaborating with or sharing overseas sites for international radiology elective rotation with residents from other US programs; ideally, this would be a rotation fulfilling common core competency guidelines for graduate medical education (Table 2).
Figure 5
Survey responses regarding (a) likelihood of participation in international imaging during residency, respondents with prior experience more likely to have higher median score, confidence intervals based on sample size of 188 (responded to question), resident population of 4669 (from American College of Radiology [ACR]), and confidence level of 95%. (b) Possible effects of an international curriculum on resident recruitment to radiology, respondents with prior experience more likely to have higher median score, confidence intervals based on sample size of 190 (responded to question), resident population of 4669 (from ACR), and confidence level of 95%. (c) Effect of an international radiology curriculum on residency choice, respondents with prior experience more likely to have higher median score; confidence intervals based on sample size of 191 (responded to question), resident population of 4669 (from ACR), and confidence level of 95%. (d) The importance of an international elective rotation as a part of an international radiology curriculum, respondents with prior experience more likely to have higher median score, confidence intervals based on sample size of 189 (responded to question), resident population of 4669 (from ACR), and confidence level of 95%.
Table 2. Application of ACGME Core Competencies in a Global Health Imaging Elective Clinical Rotation
| ACGME Competency | Global Health Imaging |
|---|---|
| Medical Knowledge | Exposure to new clinical diseases in multiple modalities |
| Patient Care | Improving patient care through imaging consultation, screening, and direct imaging intervention |
| Professionalism | Adapting to providing care in low-resource health care systems to underserved populations |
| Interpersonal and Communication Skills | Cultural competency, communication, and clinical applications in a new cultural context;learning from and educating new clinical colleagues |
| Practice-based Learning and Improvement | Application of clinical skills to a new environment and disease processes, learning new imaging applications in developing world clinical settings |
| Systems-based Practice | Exposure to developing world practice environment and understanding low-resource cost-conscious care |
If a developing world imaging curriculum was available, more than 62% (142/227) of surveyed residents stated that they would be likely or very likely to participate (Fig 5a). Some residents even felt that the availability of such a curriculum would have influenced their specific choice of residency program to a small (38%; 86/226) or large extent (20%; 20/226) (Fig 5c). A similar proportion of residents believed that the availability of this curriculum would increase recruitment to the field of radiology (Fig 5b).
Challenges
When asked about the challenges in implementing a developing world curriculum, the most commonly cited barriers were funding (90%; 202/224), time constraints (74%; 166/224), perceived lack of institutional support/interest (56%; 125/224), and no available infrastructure in which to participate (56%; 125/224). The majority of residents (89%; 201/227) stated that they had no awareness of current funding sources for international imaging rotations (Table 3). More specifically, even though various radiologic societies, such as the ACR, offer specific travel grants to residents for this purpose, only 5% (10/227) of residents stated that they were aware of such opportunities. These barriers contrasted with the broad benefits that those surveyed believed an international curriculum would provide. In particular, most surveyed residents felt that a developing world imaging curriculum would improve understanding of basic disease processes (87%; 195/222) and cost-conscious care (82%; 182/222), prepare residents for lifelong involvement in international radiology (80%; 179/222), and increase interpretative skills in basic radiology (73%; 161/222) (Table 4).
Table 3. Respondent Awareness Regarding Funding for an International Elective Rotation
| Regarding an international radiology elective rotation, are you aware of possible funding sources? | |||
|---|---|---|---|
| Answer Options | Response (%) | Response Count | 95% CI |
| No | 88.5 | 201 | ±4% |
| Yes, through my training program | 2.2 | 5 | ±1.9% |
| Yes, through my affiliated university graduated medical | 3.1 | 7 | ±2.2% |
| Yes, through various radiological societies (eg, American College of Radiology, Radiological Society of North America) | 5.7 | 13 | ±2.9% |
| Yes, through multiple sources | 2.2 | 5 | ±2.2% |
Table 4. Potential Goals for Radiology Rotation
| Which goals (if any) listed below do you believe that an international radiology curriculum during residency would achiever? (check all that apply) | |||
|---|---|---|---|
| Answer Options | Response (%) | Response Count | 95% CI |
| Increased interpretive skill in basic radiology | 72.5 | 161 | ±5.7% |
| Increased understanding of cost-conscious care | 82.0 | 182 | ±4.9% |
| Increased understanding of diverse disease | 87.8 | 195 | ±4.2% |
| Preparing residents for lifelong international radiology | 80.6 | 179 | ±5.1% |
| Others (please specify) | 1.8 | 4 | ±1.7% |
Subgroup Analyses for Residents with Differences in Prior International Experience
The 29% of surveyed residents who had prior experience working in the developing world were suspected, presurvey, to be much more likely to provide responses in the vein that international radiology work is necessary during training and worth pursuing after residency. Given this suspected bias, additional subgroup analyses of the survey questions detailed previously were performed, parsing the respondents into “prior experience working in the developing world” and “no prior experience.”
There was a statistically significant difference in responses between these two subgroups to several survey questions or question parts. Specifically, with regard to the opinion that radiologists would be useful as physically present onsite collaborators, there was a statistically significant difference in responses between residents that had prior international experience (63% agreed) compared to those that did not (50% agreed; P = .035). There was a statistically significant association between prior international experience and having interest in serving “on-site volunteer efforts as part of a medical team” (67% vs. 42%; P < .0001) as well as “visiting developing world institutions/medical centers to teach/lecture after residency” (58% vs. 41%, P = .01). The correlation between prior experience and planning to perform international work in the future was statistically significant (90% of residents with international experience vs. 50% of residents without experience; P < .0001). Additional analyses revealed that residents with prior international volunteer experience were significantly more likely than the respondents without experience to participate in a developing world imaging curriculum (2 ± 0.7 weighted response vs. 0 ± 0.8), believe that availability of international radiology opportunities would have affected their residency program choice (1 ± 0.4 vs. 0 ± 0.96), and believe that an international elective rotation is an important component of an international radiology curriculum (80% vs. 58%; P = .0044). Residents without prior international experience were significantly less likely than their colleagues with experience to be aware of possible sources to fund an international radiology elective rotation (81% vs. 91%; P < .05).
Discussion
The aim of our study was to evaluate the perception of radiology residents regarding the role of radiology in global health care. We also assessed radiology resident interest in dedicated global health imaging curricula including international electives, as well as perceived challenges to such participation. The overwhelming majority (85%; 68/80) of trainees perceived an unmet need for international medical imaging, in agreement with data published by the World Health Organization, and nearly all respondents thought that these imaging needs would increase over time in developing countries. Most (61%; 143/234) of those surveyed plan on pursuing international medical aid work in the future, and 72% (138/193) of that subgroup hope to specifically perform international aid work in medical imaging. Although more than half of surveyed residents hope to pursue international medical imaging work in the future, a similar proportion feel that they would be ill-prepared by the end of their residency training to do so, as a large majority (91%; 220/229) stated that their residency offers no developing world radiology opportunities. A total of 58% (131/226) of respondents to our survey felt that the availability of a global health imaging curriculum would have influenced their specific choice of residency, whereas a similar proportion of residents believed that the availability of such a curriculum would increase recruitment to the field of radiology. Subgroup analyses revealed that respondents with prior international volunteer experience were significantly more likely to believe that international radiology work during residency was important and should involve a defined curriculum with onsite presence by radiologists. Given the documented rise in medical trainees with prior experience in global health experiences, this finding helps to validate the need for further discussion of the role of radiology in future international training and outreach efforts.
These data therefore suggest an imbalance in the proportion of radiology residents interested in pursuing training in global health and the availability of programs that provide this experience. One way to address this could be the development of a formal global health imaging curriculum; our data show that the majority of resident respondents support the development of a formal global health imaging curriculum, including certification by a national body such as the ABR or ACR. Participation by training programs could be optional, supplemental, or integrated into core radiology residency training as a part of the existing curriculum. An accrediting organization, in developing a standardized curriculum, may endorse specific goals and objectives related to the subspecialty application of imaging in global health in order to guide residency training programs in building global health programs.
A practical means of training within the larger framework of a formal global health imaging curriculum could be accomplished in part through international elective clinical rotations. Programs in specialties outside radiology have had established onsite international residency training opportunities for over three decades 17, 18, 22. In 2006, 52% of US pediatric programs offered formal international clinical rotations, with 7% of these eventually establishing either a formal global health track or certificate program (13). Similar to national trends in other specialties, our data show that a majority of surveyed residents believe that an international elective rotation would be an integral component of any proposed global health imaging curriculum. Indeed, to move toward reducing global health care disparities, onsite global health imaging experiences are critical to improving access to medical imaging in the developing world. To meet educational quality standards, radiology residency rotations in developing countries should adhere to the same rigorous standards as rotations in the United States. For example, radiology residents involved in direct patient care abroad must be supervised by qualified radiologists. Qualified attending radiologists may be from the resident’s home institution or accredited onsite practitioners. Rotations must also be guided by competency-based goals and objectives as established by the ACGME, which include medical knowledge, patient care, communication skills, professionalism, systems-based practice, and practice-based learning (Table 2). As has been shown by similar efforts in other medical specialties, an international elective rotation for radiology residents can satisfy all ACGME core competencies (Table 1). Faculty participating in international electives would be responsible to ensure that curriculum learning objectives are met through the training experience. To facilitate broad participation, residency review committees could adopt more flexible accreditation requirements and grant a specified number of hours or procedures during international rotations that would count toward the qualifications of board certification. Accreditation oversight organizations, such as the ACGME, ABR, or others, could also establish criteria and identify components necessary for acceptable international rotations.
Another model for global health imaging training might instead be via a fellowship or dual degree program, an option selected by 27% of respondents. Indeed, a postgraduate global health imaging training model fellowship program as an alternative to an elective rotation during residency may avoid disrupting current residency training or placing a disproportionate burden on smaller residency training programs. However, the decision as a field to implement a fellowship or dual degree option in the current residency training environment that currently offers few opportunities by which trainees can explore global health imaging through an elective experience during residency may, given the potential opportunity costs alone, encounter significant difficulty in recruiting participants, dedicated faculty, and funding.
Although the establishment of a global health imaging curriculum and elective international imaging rotations are likely to be beneficial for trainee and institution, many challenges exist. Survey respondents cited funding as well as time constraints as the most challenging obstacles for participation in a global health imaging curriculum and international elective rotation. Currently the funding available to institutions for graduate medical education is composed of direct graduate medical education disbursements and indirect medical education disbursements to compensate medical schools for the higher costs of patient care in educational institutions; reimbursements can only be used to support residents participating in approved clinical service activities and are subject to audit by the Centers for Medicare and Medicaid Services (CMS). These funds could not be used to fund a resident for an international global health elective rotation.
Timing of participation is another significant impediment; the duration of a clinical elective rotation requires a balance between the time required for adaptation to a new environment and the logistical constraints associated with the resident’s absence. However, recent restructuring of the certifying board exams may significantly free up senior radiology residents; time that was previously made available for fourth-year trainees to study for the “oral” board exams may be allocated, in part, to residents interested in participating in global health imaging training.
A third challenge is program support. Even a highly motivated program director may find a lack of broad administrative support for a global health curriculum and elective rotation. In addition, identifying faculty willing to provide oversight that would ensure quality training and mentoring during these rotations may be challenging and may, in turn, deter resident participation. A survey of pediatric residency program directors found that those with more than two faculty members involved in global health activities, a greater number of residents, and more than 4 weeks of call-free elective time during the PGY-2, had significantly greater resident participation in international rotations (13). This speaks to the need for a broad commitment on the part of the department to engage in global health training. Future studies may seek to investigate faculty interest in global health imaging opportunities.
Last, leaders in global health training have recently raised ethical considerations regarding short-term international clinical training experiences and have called for “formal ethical guidance, such as that afforded in the research setting” (23). Indeed it is important to consider defining specific ethical guidelines to include in a global health imaging curriculum to ensure that disparities are not exacerbated or even exploited by one party in this complex relationship.
Limitations
Our study has several limitations. We relied on the program directors to forward the survey to program trainees, and this may have altered natural response patterns, especially as program directors with interest in the topic of global health may have been more motivated to distribute the link. In addition, we found that nearly one third of our respondents had done previous volunteer work, whereas a majority planned to do so while in practice. Although the proportion of those with prior global health experience is similar to cited literature for all graduating medical students (22%), the respondents to our survey may have been predisposed toward volunteerism, and thus we may not have captured those residents for whom international training and volunteerism were not a priority. We did not include in the survey additional questions that had similar objectives for the purpose of identifying respondent consistency. Despite the limitations of these data, this survey provides an important framework for further discussion.
In conclusion, global health inequities are well documented, including the lack of access to medical imaging. Many radiology residents are motivated to acquire training in the delivery of global health care, and plan to participate in global health initiatives, which in turn may help address the disparities in global health care. Our data support the need to further explore mechanisms for global health imaging training within radiology residency programs, which could include a structured global health curriculum and international elective rotation. However, a consensus among the leaders of radiology residency training is likely necessary to formalize a system that can overcome significant barriers and provide global health training within the residency framework that will achieve educational and service goals.
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PII: S1076-6332(11)00089-4
doi:10.1016/j.acra.2011.02.009
© 2011 AUR. Published by Elsevier Inc. All rights reserved.
