Maintenance of Certification: You Can Make Your Global Health Work Count

Global health (GH), defined as issues that transcend national boundaries and a call for actions by key stakeholders to determine the well-being of all people,¹ is an expanding field. In 2014, 25% of active pediatric-training programs had dedicated GH tracks, and 66% had faculty identified to lead GH efforts for their training programs.² Those traveling abroad for GH experiences as trainees are likely to remain involved later in their careers in varying capacities.^3,4 GH also includes pediatricians engaged locally with immigrant or refugee communities in the United States. Engagement in GH activities takes various forms, from clinical care to advocacy, research, and policy making.⁵ As with other niche areas of pediatrics, GH practitioners may wrestle with issues relevant to their unique areas of practice, including incorporating GH activities into professional requirements and development.⁶ Challenges include maintaining clinical skills relevant for the US setting or skills relevant for short-term trips internationally, balancing between staying current with US medicine and practicing in a resource-limited sphere, finding continued learning activities relevant to the practice of pediatrics internationally, and charting a career path in this field. Thus, there is a growing population of board-certified pediatricians who may want or need to incorporate a GH focus into their maintenance of certification (MOC) activities. MOC activities have emerged as a framework for the American Board of Pediatrics (ABP) to “ensure pediatricians have completed accredited training, continue to expand their medical knowledge, improve their practice and patient safety.”⁷ Thus, it has 4 components: documentation of professional standing, a proctored multiple-choice examination or the online MOC assessment, documentation of self-assessment and learning, and (part 4) quality improvement (QI).⁸ 

The QI requirement provides GH practitioners an opportunity to creatively think about systems improvements for spheres of practice that are often stretched and in need of small, incremental changes to drive solutions. “The inherent aspects of QI–being locally relevant, locally driven, and using local data to improve health care quality–align well with the skills of the 21st century clinician, as outlined in the Lancet commission.”^9,–11 The MOC part 4 requirement can be fulfilled in a number of ways, the scope of which is rapidly expanding.⁸ However, QI in GH settings may be challenging. In this article, we aim to address some of the unique challenges providers who work in GH may face when pursing MOC part 4 or improvement in practice and to highlight opportunities these providers may seek to fulfill these requirements.

Since the introduction of a QI project requirement into MOC in 2010, the options for receiving part 4 MOC credit have expanded greatly.⁸ One can obtain credit through individual or small-group projects, leadership pathways, large-group initiatives, ABP online performance-improvement modules (PIMs), or online modules from other groups. The potential uses of these different pathways in GH are as broad as they are for domestic projects and potentially encompass the full range of GH activities. Similar to domestic QI projects, the key is to use QI to help identify issues and improve current practices. Given the realities of working in settings in which issues affecting health systems are overwhelming and funds are minimal, QI provides a methodology to make small, incremental changes that are locally relevant and locally driven. Table 1 provides examples of QI projects in GH that could be considered for earning MOC part 4 credit.

As one embarks on QI projects in the GH arena, a number of challenges arise that should be considered. First, US-trained pediatricians are often working as the guest or partner of hosts in settings in which QI methodology may not have been as rapidly or systematically adopted. This presents an opportunity to introduce QI methodology to new audiences, but the time it takes to lay the foundation for a project must be incorporated into any project plan. Second, if there is agreement on the benefits of QI, the next challenge is obtaining the data. For QI projects, one may need to develop novel tools for gathering information because approaches to record keeping that may not involve a searchable electronic health record can pose challenges. Methods to improve data recording could constitute a stand-alone QI project. Third, QI projects usually involve an intervention that requires additional evaluations or paperwork, and as in domestic projects, providers must minimize increasing the workload of already overstretched GH partners.¹² Finally, although these challenges may not be unique to GH, doing this crossculturally and possibly with language barriers adds complexity to finding solutions. Methods and tools to minimize barriers must be creatively considered and shared. For example, tools addressing troubleshooting of QI projects when data are incomplete, missing, or difficult to access would be beneficial. Sharing of best practices in GH QI would be extremely useful to both GH clinicians and their partners as reference materials.

GH pediatricians based overseas, particularly those not linked to US academic centers, may not have access to QI training or natural exposure to QI. Thus, they may find themselves needing to learn these skills without the resources of their US-based counterparts. The ABP has links to step-by-step guides to developing and reporting a QI effort (https://www.abp.org/content/yourown-qi-project). A learning module, focusing on basic QI principles, is available on the ABP Web site, which additionally provides part 2 MOC and continuing medical education credit. This module could be adapted as a teaching tool for use with GH partners. The current list of ABP MOC part 4 PIMs are designed for domestic practitioners and issues. Thus, they are often not easily transferable to GH environments. A step in making MOC part 4 more accessible would be to create PIMs or model projects in which the topic or methodology is easily adapted to the international setting. Practitioners and leaders in GH need to build and share projects and platforms to learn from each other and provide solutions for this workforce.

With increasing numbers of US pediatricians working in GH settings, sharing resources, experiences, and best practices to address the aforementioned issues is essential to MOC for GH practitioners. More importantly, this would help them to continue to improve the care they provide to vulnerable children. In this article, we focused on MOC part 4; however, all aspects of maintaining certification present challenges and should be addressed individually. There is a need for a more in-depth understanding of the issues of MOC for GH practitioners; what are the challenges and potential solutions that have been tried? The future of pediatric GH and the careers of US-trained pediatricians following this career path depend on creating an environment that promotes rather than prevents pediatricians from serving in capacities that are geographically or structurally removed from traditional US pediatric practice and infrastructure. Recognizing the issue is the first step in creating a solution.

The members of the GH Task Force of the ABP include Linda Arnold, Maneesh Batra, Sabrina Butteris, Chris Cunha, Jon Klein, David Nichols, Cliff O’Callahan, Michael Pitt, Andrew Steenhoff, and Nicole St Clair.

ABP

American Board of Pediatrics

GH

global health

MOC

maintenance of certification

PIM

performance-improvement module

QI

quality improvement