Global health (GH) has become a desired activity for pediatric trainees, and the number of GH fellowship programs has doubled in the last 12 years.1–5 The GH training landscape was first surveyed in 2010,6 and since then numerous reports of individual GH fellowships and GH opportunities within subspecialty training have been published.7–14 In 2020, 224 pediatric fellowship programs offered formal or informal GH training opportunities.14
For trainees seeking advanced GH skills postresidency, the availability of GH training within a fellowship influences their choice and ranking of programs.15–19 Programs are responding to this demand by creating both stand-alone GH fellowships and training within existing subspecialty or general pediatrics fellowships.10,12–14,20–22 This rapid, nonstandardized expansion has created variability in structure, duration of training, field experiences, and curricula. Improving physician GH training in high-income countries (HICs) could positively impact pediatric care globally, ideally preparing future leaders to collaboratively work with partners, ensure equitable relationships, mutually beneficial relationships, and inform resource allocation. Standardization of curricula, mentorship expectations, and institutional support are necessary to ensure high-quality GH fellowship training.21
Educators and trainees benefit from standardization of pediatric training.23–27 Consistency in medical education is achieved by accreditation, the external recognition of adherence to a set of standards. Accreditation promotes best educational practices, enhances scholarship, and galvanizes institutional legitimacy, support, and funding. Among pediatric GH training programs, 71% believe national accreditation of GH fellowships would define minimum programmatic standards, and 64% believe it would improve recruitment and legitimize GH as a subspecialty.14 Many of those who disagreed believed accreditation is important but were concerned about increased logistical burdens on programs and rigid mandates that may restrict the wide diversity of offerings across GH fellowship programs.14
GH training is one of the primary mechanisms for physicians in HICs to impact global child health. The aim of a GH fellowship is to train a physician who is a culturally competent academic leader, knowledgeable about GH issues, has field experience and mutually beneficial bidirectional partnerships, and is equipped to move the field of GH forward. We describe the development of a national accreditation process for pediatric GH fellowships.
Methods and Processes
In 2013, the American Board of Pediatrics formed the GH Task Force to develop a strategic plan for global child health efforts. GH fellowship accreditation was identified as a priority area. A pediatric GH fellowship educators group (PedGH-FEG) was formed in conjunction with the American Board of Pediatrics GH Task Force to assess accreditation feasibility and identify a path forward. This group of 19 GH educators from 16 US institutions initially convened in 2019. Members of the PedGH-FEG were self-identified from a landscape survey21 or through personal invitation of known GH fellowship programs. This group developed organically as GH fellowship training has evolved in the United States, similar to the development of other more recent pediatric fellowships, such as child abuse and hospital medicine. Members represent programs of various sizes and a mix of both stand-alone and subspecialty-combined GH fellowships. Before the first meeting, members were surveyed about their support for accreditation of pediatric GH fellowships: 44% responded “yes,” and 44% responded that they “needed more information.” After meeting, 100% of the GH educators endorsed the accreditation of pediatric GH fellowships. To further the accreditation process, 3 subgroups were created to: (1) outline a leadership and communication structure, (2) develop mission and vision, and (3) review and draft competencies.
The PedGH-FEG pursued accreditation through the Academic Pediatric Association (APA), which accredits Academic General Pediatric (AGP) fellowships.28 The APA’s mission29 aligned with the goals of the PedGH-FEG, and the PedGH-FEG modeled processes after the APA AGP fellowship documents and infrastructure.25,30,31 In contrast to subspecialties that focus on content specific knowledge (eg, cardiology or critical care) and are accredited by the American Committee on Graduate Medical Education (ACGME), the GH fellowship was felt to be more analogous to other APA fellowships, focused on providing an additional lens to an existing skill set and medical knowledge base. Accreditation through the APA empowered the PedGH-FEG to develop the minimum standards for training programs to ensure quality and encouraged flexibility to account for differences in training programs while also benefitting from experienced AGP mentors. The PedGH-FEG designed the GH fellowship accreditation process to build upon the strong academic base of ACGME accredited pediatric programs to ensure sufficient infrastructure and high-quality training in base pediatric competencies.
Mission and Vision
Mission and vision statements were composed using a modified Delphi process (Table 1).
Mission and Vision of the Pediatric Global Health Educators
| Mission and Vision . | |
|---|---|
| Mission | To advance the ethical and equitable practice of global child health by identifying standards for pediatric global health fellowships, providing guidance to training programs, and establishing a collaborative network of fellowship programs engaged in global child health. |
| Vision | To improve the wellbeing of vulnerable children, irrespective of where they were born or live, we will equip future pediatric GH leaders clinically and in scholarship, education, and advocacy with the fundamental skills to succeed in disciplines spanning from academia to policy and programming. |
| Mission and Vision . | |
|---|---|
| Mission | To advance the ethical and equitable practice of global child health by identifying standards for pediatric global health fellowships, providing guidance to training programs, and establishing a collaborative network of fellowship programs engaged in global child health. |
| Vision | To improve the wellbeing of vulnerable children, irrespective of where they were born or live, we will equip future pediatric GH leaders clinically and in scholarship, education, and advocacy with the fundamental skills to succeed in disciplines spanning from academia to policy and programming. |
Development of Core Program Elements
Preliminary work on GH competencies at the residency and fellowship level has been described.32–36 Pediatric GH fellowships focus on acquiring skills in different domains, including research, clinical care, teaching, and advocacy. A PedGH-FEG subcommittee worked collaboratively to create program application documents adapted from the APA AGP fellowship accreditation application. The subcommittee members were from both stand-alone and subspecialty-combined programs of varying sizes and resources to ensure representation across program types. There was a deliberate effort to ensure that requirements be equally accessible to all program types and sizes. This process is similar to other subspecialties, which have created consensus-based training goals, objectives, and core curricula to improve quality and consistency of training while simultaneously recognizing the importance of alternative approaches that emphasize each program’s unique strengths and character.23,30
The program requirements document outlines required (“core”) (Table 2) and recommended components. Program requirements were created in the spirit of growth and “mentoring up,” rather than a “pass or fail” assessment. Core requirements comprise just 7% of overall requirements and describe the essential requirements for the structure of the training program, duration, and scope of training, program leadership, mentorship, and scholarly oversight, program design, scholarly activity, evaluation, and logistical support. The remaining requirements are provided for programs to assess their resources and identify gaps or areas for growth, with an overall goal of continuous improvement. Specific metrics are provided for each requirement, providing programs with concrete examples of requested supporting documentation and information (Table 3).
Core Program Requirements
| Requirementsa . | Description . |
|---|---|
| Core requirements | An accredited GHF program should exist in conjunction or affiliation with residency or fellowship program(s) accredited by the Accreditation Council for Graduate Medical Education. |
| All GHF programs must have a designated program director. | |
| All GHF programs must have at least 1 collaboration with international partner. | |
| All GHF programs must have a mentor experienced in GH scholarly work available to support fellows in their scholarly activity. | |
| All GHF programs must provide comprehensive logistical support for experiences outside of the sponsoring institution. | |
| Duration and scope of training | GHF programs must provide at least 1 year of focused GH training in which clinical, educational, or research activities are dedicated to GH. This minimum 1 year of focused training can be within the existing fellowship or in addition to the individual’s training (as in the case of a stand-alone GHF). |
| Program director | The program director must be a faculty member in good standing at the sponsoring institution. |
| Mentor | Each trainee must have at least 1 faculty member with significant GH experience who will guide the fellow’s career decisions through the training period. |
| Scholarship oversight committee | Each GH fellow must have a scholarship oversight committee. |
| Program design | Every GHF program must develop written educational goals and objectives. |
| Scholarly activity | Upon completion of training, fellows will submit an original scholarly product. |
| Evaluation | The program must have formal mechanisms by which the knowledge, skills, and professional growth of the GH fellows, based on the program’s written educational goals and objectives, are evaluated at least annually at their international site (when applicable) and at the sponsoring institution. |
| Logistical support | To support experiences outside of the sponsoring institution, the GHF must provide, at minimum: a predeparture curriculum, onsite support, postreturn debriefing, fellow salary while abroad, maintenance of malpractice, health and disability insurance while abroad, and evacuation insurance. |
| Requirementsa . | Description . |
|---|---|
| Core requirements | An accredited GHF program should exist in conjunction or affiliation with residency or fellowship program(s) accredited by the Accreditation Council for Graduate Medical Education. |
| All GHF programs must have a designated program director. | |
| All GHF programs must have at least 1 collaboration with international partner. | |
| All GHF programs must have a mentor experienced in GH scholarly work available to support fellows in their scholarly activity. | |
| All GHF programs must provide comprehensive logistical support for experiences outside of the sponsoring institution. | |
| Duration and scope of training | GHF programs must provide at least 1 year of focused GH training in which clinical, educational, or research activities are dedicated to GH. This minimum 1 year of focused training can be within the existing fellowship or in addition to the individual’s training (as in the case of a stand-alone GHF). |
| Program director | The program director must be a faculty member in good standing at the sponsoring institution. |
| Mentor | Each trainee must have at least 1 faculty member with significant GH experience who will guide the fellow’s career decisions through the training period. |
| Scholarship oversight committee | Each GH fellow must have a scholarship oversight committee. |
| Program design | Every GHF program must develop written educational goals and objectives. |
| Scholarly activity | Upon completion of training, fellows will submit an original scholarly product. |
| Evaluation | The program must have formal mechanisms by which the knowledge, skills, and professional growth of the GH fellows, based on the program’s written educational goals and objectives, are evaluated at least annually at their international site (when applicable) and at the sponsoring institution. |
| Logistical support | To support experiences outside of the sponsoring institution, the GHF must provide, at minimum: a predeparture curriculum, onsite support, postreturn debriefing, fellow salary while abroad, maintenance of malpractice, health and disability insurance while abroad, and evacuation insurance. |
GHF, global health fellowship.
The minimum standards listed here are for illustrative purposes and are subject to change through the iterative process that is used to enhance the accreditation process.
Sample Metrics for Selected Core Program Requirements
| Metric . | Examples of Supporting Documentation . |
|---|---|
| 1.1. An accredited GHF program should exist in conjunction or affiliation with residency or fellowship program(s) accredited by the ACGME. | Letter certifying current accreditation of the affiliated program |
| 1.2 All GHF programs must have a designated program director. | Identify program director and contact information |
| 1.3 All GHF programs must have at least 1 collaboration with international partner (ref. Sec.6.1). | Provide site name and location with terms of reference agreement, memorandum of understanding or letter of support from collaborating site(s) |
| 1.4. All GHF programs must have a mentor experienced in GH scholarly work available to support fellows in their scholarly activity. Program director may also serve as mentor. | Identify mentor(s) and provide evidence of past scholarly work |
| 1.5 All GHF programs must provide comprehensive logistical support for experiences outside of the sponsoring institution (international and/or local-global). | Programs can reference the following document for guidance on comprehensive considerations surrounding GH electives. It is necessary to provide, where applicable, evidence of trainee salary support, malpractice insurance coverage, disability insurance coverage, emergency contact, occupational exposure guidelines, 24/7 emergency access line, and international emergency evacuation insurance. https://www.abp.org/sites/abp/files/pdf/ghpdgchap4table7.pdf |
| Metric . | Examples of Supporting Documentation . |
|---|---|
| 1.1. An accredited GHF program should exist in conjunction or affiliation with residency or fellowship program(s) accredited by the ACGME. | Letter certifying current accreditation of the affiliated program |
| 1.2 All GHF programs must have a designated program director. | Identify program director and contact information |
| 1.3 All GHF programs must have at least 1 collaboration with international partner (ref. Sec.6.1). | Provide site name and location with terms of reference agreement, memorandum of understanding or letter of support from collaborating site(s) |
| 1.4. All GHF programs must have a mentor experienced in GH scholarly work available to support fellows in their scholarly activity. Program director may also serve as mentor. | Identify mentor(s) and provide evidence of past scholarly work |
| 1.5 All GHF programs must provide comprehensive logistical support for experiences outside of the sponsoring institution (international and/or local-global). | Programs can reference the following document for guidance on comprehensive considerations surrounding GH electives. It is necessary to provide, where applicable, evidence of trainee salary support, malpractice insurance coverage, disability insurance coverage, emergency contact, occupational exposure guidelines, 24/7 emergency access line, and international emergency evacuation insurance. https://www.abp.org/sites/abp/files/pdf/ghpdgchap4table7.pdf |
GHF, global health fellowship.
The program application form was structured to address specific challenges in accreditation of GH fellowships.37 GH fellowships can stand alone or be combined with other subspecialty fellowships. Even within an institution, the available resources, personnel, support structure, and relationships integral to GH training may vary. Each GH fellowship within an institution will apply for accreditation individually, but to eliminate redundancy, the first section of the application identifies common requirements within the institution. Subsequent fellowship applications from that institution can leverage the common portion of the application.
Implementation and Dissemination
After finalization of application processes, a Global Health Pediatric Accreditation Committee (GH-PAC) was created within the APA to evaluate applications. The group includes a mix of faculty and fellows from GH programs across the United States. To ensure uniform accreditation reviews, the APA facilitates standardized training and mentoring of this committee.
The GH-PAC will ensure that their assessment tools effectively assess a variety of GH programs, including those with a single trainee versus multiple trainees, small versus large academic centers, general pediatrics versus focused fellowships, subspecialty versus based GH fellowships, and large GH programs with multiple fellowship programs within an institution. The pilot accreditations will include at least 1 stand-alone GH fellowship as well as 1 embedded within a pediatric subspecialty fellowship. The pilot phase will permit modifications of the application materials and accreditation process. After the pilot phase, other programs will be welcomed to apply for accreditation or to receive consultation from members of the GH-PAC to discuss accreditation readiness.
The PedGH-FEG began disseminating their work to the pediatric community in 2022 through presentations and workshops at national and international pediatric meetings. These forums welcomed engagement and feedback from other stakeholders in pediatric education and GH.
Conclusions and Future Directions
The PedGH-FEG seeks to enhance pediatric GH training at the fellowship level by partnering with the APA to develop a transparent, high-quality accreditation process for pediatric GH fellowships in the United States. Here we have described our process thus far and recognize that the path to development of an accredited subspecialty is iterative. As currently structured, we believe this process effectively balances standard setting for pediatric GH training and maintains sufficient flexibility to foster innovation and allow participation by many types of programs. In the future, the accreditation framework offered by the APA could provide a model for other GH fellowships in other nonpediatric specialties. We hope these guidelines will ensure that future GH fellowship graduates are equipped to improve the wellbeing of all children, irrespective of where they were born or live.
Acknowledgments
We thank the members of the Pediatric Global Health Educators Group (PedGH-FEG) who came together in October 2019 to plan the Pediatric Global Health Fellowship. In addition to the authors, members included: Marideth Rus, MD, MsEd; Elizabeth Fitzgerald, MD; Jennifer Watts, MD, MPH; Michelle L. Niescierenko, MD, MPH; Rupa Kapoor, MD; Rachel Bensman, MD, MPH; Michael J. Alfonzo, MD, MS; Adelaide Barnes, MD; Sabrina M. Butteris, MD; Donna Crisp; Adriana Deverlis; Valerie Haig; Adrian Holloway, MD; Phuoc V. Le, MD, MPH, DTM&H; Stephen Ludwig, MD; Patricia McQuilkin, MD, MS; Monika Metzger, MD, MSc; and Mazvi Rankin. Teri Turner,* MD, MPH, MEd, and Paul M. Darden,* MD served as mentors throughout the process (* represent APA leaders).
Drs Bauserman, Crouse, and Eckerle conceptualized and designed the paper and drafted the initial manuscript; Drs Vinograd, Steenhoff, Robison, Batra, and Cohn conceptualized, designed, and authored portions of the paper; and all authors critically reviewed and revised the entire manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.
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