The Problem with Competencies in Global Health Education Quentin Eichbaum, MD, Phd, MPH, MFA, MMHC

Commentary

The Problem With Competencies in Global Health Education Quentin Eichbaum, MD, PhD, MPH, MFA, MMHC

Abstract The demand for global health health competencies. Developing such host countries, and (3) shortcomings educational opportunities among competencies presents several unique associated with assessing competencies students and trainees in high- challenges, including (1) a failure to in resource-limited settings. To income countries (HICs) has led to a take sufﬁcient account of local contexts meet these challenges, the author proliferation of available global health coupled with a lack of inclusiveness recommends reenvisioning the approach programs. In keeping with the drive in developing these competencies, (2) to competencies in global health using towards competency-based medical the disjunction between the learning fresh metaphors, innovative modes of education, many of these programs approaches of “individualism” in HICs assessment, and the creation of more have been deﬁning their own global and the relative “collectivism” of most appropriate competency domains.

Interest in “global health” among students In this paradigm of global health include the viewpoints and experience and trainees in high-income countries education in which trainees from HICs of health professionals in the host (HICs), especially in North America and travel to LMICs usually for relatively LMICs. In some instances, this had Europe, has increased briskly over the past short elective periods of one or more led to competencies that prioritize the decade. This demand has led to a frenzied months (or a year), the development of interests of the HIC program rather growth in the number of available global competencies in global health has been than the health contexts of the host health education and training programs. problematic. I argue that three factors country. For example, Hagopian and Because the development of such programs contribute to this difficulty: colleagues2 provide a guide to the has been competitive and hence at times process of developing global health 1. The process of developing global rushed, global health curricula may have competencies that does not appear to health competencies is often poorly defined goals and objectives. insufficiently inclusive of input from include participation or input from host country health professionals and host countries. Morever, they suggest Currently, the predominant structure furthermore fails to take adequate that programs develop competencies as of global health programs includes account of local health contexts. a strategy to promote and convey their “electives” or “rotations” of a defined “identity and distinct values” to student time period during which trainees from 2. There remains an unresolved applicants. To my mind, the prime HICs engage in health work in low- and disjunction between “individualist” focus of global health competencies middle-income countries (LMICs). and “collectivist” approaches to should not be to further the interests of Educators in global health now generally learning and competency in HICs a training program but should, instead, agree that such training programs and LMICs. be unambiguously linked to local health should be competency based in order to system needs and contexts. facilitate the education and assessment of 3. The methods applied and resources available for global trainees in resource-constrained settings Frenk and colleagues1 insist that “All in LMICs. Frenk et al,1 in a landmark health competency assessment are frequently inadequate. aspects of the educational system are article in The Lancet, similarly argued for deeply affected by the local and global competency-based education of health I examine these factors in this contexts. Although many commonalities professionals derived from the contexts of might be shared globally, there is local local “health needs and systems.” Commentary and conclude by suggesting three ways in which we might begin to distinctiveness and richness.” An ongoing reenvision our approach to competencies debate about competencies is whether they are “context-linked” or “context- Dr. Eichbaum is associate professor of medical in global health. education and administration, associate professor of free.” By emphasizing the importance of pathology, microbiology, and immunology, director understanding the system in which one of global health electives, and clinical fellowship A One-Sided Process Oblivious to practices medicine, the Accreditation program director, Vanderbilt University School of Contexts? Medicine, Nashville, Tennessee. Council for Graduate Medical Education Several programs have attempted to (ACGME) systems-based practice Correspondence should be addressed to Dr. Eichbaum, competency suggests a link between Vanderbilt University School of Medicine, TVC 4511C, distill a definitive list of “global health 2–4 1301 Medical Center Dr., Nashville, TN 37232; e-mail: competencies.” The process of competency and context, but the context [email protected]. deriving these lists of competencies, of this widely accepted competency however, has frequently been driven lacks specificity and remains generic. Acad Med. 2015;90:00–00. First published online by consensus between programs in The context-free perspective posits that doi: 10.1097/ACM.0000000000000665 HICs and has often failed to sufficiently “[A] competent practitioner is generally

competent—that is, their performance participation and dynamic interactions prior to working in global health settings. in one situation should predict within the group. According to the Indeed, global health competencies, it is future performances in other, similar collectivist view, “Competence … is argued, are devised specifically to avert situations.”5 Context-free competencies not possessed by the individual but such dissonance. These competencies can be taught and practiced independent negotiated by the group, through work include cultural competency specific of the particularities of specific health and talk.”5 Sfard7 made the metaphoric to the local contexts of LMICs and, contexts. This conveniently simplifies distinction in learning between more broadly, the ACGME systems- their teaching and assessment. “participation” and “acquisition” that based practice competency and the relate, respectively, to collectivism and CanMEDS collaborator competence. In global health, however, contexts vary individualism. Participation refers to the As Lingard5 points out, however, these widely. Seasoned workers in global health dynamic learning that occurs through competencies fall short because they are understand that being competent in one the group: “Participation is learning” and still “conceptualized at the level of the health context may not translate into “learning (like participation) is viewed individual” as attributes to be “acquired,” competence in a different context. Most as a continuous process” rather than “possessed,” and assessed rather than would argue that competencies in global as an “acquisition” or attribute of the arising dynamically through social health are inextricably linked to contexts. individual.5 Participation views learning interaction and participation. Yet too often the compendium of global as inextricably linked to its context rather health competencies that HIC trainees than transferable across contexts. The disjunction between the individualist are expected to achieve are not linked and collectivist viewpoints, however, also to specific contexts but remain generic The distinction between individualist and creates a conundrum in global health and context-free so as to be conveniently collectivist learning theories is of central education for effective assessment of applicable to any one of the multifarious relevance to global health education competencies. LMIC sites trainees in a specific program and the question of competence. HICs might choose for their elective visit. are individualist, whereas LMICs are Assessing Competencies in Global Whether competencies are context-free or generally collectivist in their approach to Health Education context-linked is important because this learning. Collectivist cultures understand determines how such competencies are themselves primarily in terms of the The individualist approach to learning developed, assessed, and maintained. group or collective they belong to; assumes that knowledge and competency they are intrinsically participatory and can be assessed. This assumption collaborative and give precedence to underlies the slew of assessment Individualist and Collectivist the goals, wishes, and decisions of the strategies in medical education, including Approaches collective over their own. licensures, board exams, continuing In a seminal essay, “Rethinking medical education, and maintenance of competence in the context of When trainees from individualist competence assessments. Collectivism teamwork,” Lingard5 compares and HICs engage in global health work in and resource-limited settings present contrasts the “individualist” and the the collectivist settings of LMICs, a a more complicated challenge to “collectivist” approaches to learning disjunction of perspectives, attitudes, assessment. and competence—a discourse of central and approaches to learning may lead relevance to the problem of competency to dissonance, if not discord, in work The participatory and collaborative in global health. In HICs of North and academic environments. That such qualities of collectivism are dynamic and America and Europe, which rank high in dissonance frequently occurs with HIC context-dependent. The assumption that autonomy and individualism,6 learning is trainees working in the collectivist we can reliably assess individual trainees viewed as something that occurs “within settings of LMICs became apparent in global health settings for competencies the individual.” This “individualist” during a session on global health like “communication,” “collaboration,” approach to learning views competence competencies at the 2014 Consortium of or “cultural” competence is misguided as an attribute or quality that individuals Universities for Global Health conference according to Lingard5 because it “reduces “acquire” and “possess.” If learning in Washington, DC. Several faculty the social exchange to individual and competence are “housed” within complained about the insensitivity to and qualities.” the individual, they “move with” the lack of awareness about group dynamics individual and are not linked to contexts. displayed by trainees whose proactive, Besides the collectivist disjunction, the If competencies are attributes the individualist approach to learning and constraints of resource-limited settings individual can acquire through learning, health care jarred at times with the further complicate effective assessment we can assess them by testing the participatory and collaborative norms of of competency in several ways. First, individual, and we can reward individuals collectivism in host countries. in resource-limited settings, direct who demonstrate superior performance. observation of trainees for competency A common rejoinder to suggestions assessment is often not possible The individualist view of learning of dissonance as a consequence of the because of a lack of available faculty and competence contrasts with individualist–collectivist disjunction or the demands of faculty workload “collectivist” (social or distributed) in global health education is that in overcrowded hospitals and clinics. learning theories in which learning is HIC trainees receive ample didactic Holmboe8 has drawn attention to the “situated” or “distributed” within a preparation and are usually required to inadequate quantity and quality of direct group or community and arises through demonstrate “global health competency” observation in assessing competency,

even in the resource-rich settings of training environment and demonstrated colleagues13 bridges individualism HICs: “[T]he quality and quantity of that the “competence” of the specific and collectivism by conceding that direct observation has been persistently training environment affected each “cognition is to some degree shared insufficient across the medical education trainee’s ensuing level of competence. across individuals” and that humans continuum…. Effective assessment Inadequate (“incompetent”) programs possess both individual wisdom and requires direct observation.” produce incompetent trainees. also need social connectedness. Previous Resource-constrained systems lacking concepts of distributed cognition14 Second, faculty in LMICs assessing a certain level of competence may lack and collaborative cognition15 did not trainees from HICs may lack a frame of the capacity and capability to effectively encompass the social and participatory reference for effective assessment of such assess the competency of visiting dimension of “shared mind.” “Sharing” trainees, who were educated in different trainees. would, for instance, require that medical education systems and often global health competencies not be trained in high-tech tertiary care settings. Finally, to cope with the generally developed one-sidedly in HICs but, What are the trainees expected to know recognized waning of competency over rather, be inclusive of input from health and not know? How should they compare time, education systems in HICs have professionals working in the resource- alongside local trainees? How should implemented multifarious continuing limited settings of LMICs. Likewise, in the trainees’ learning improvement be medical education and maintenance of developing global health competencies, determined given the generally short competence programs. We have not yet the health contexts of LMIC settings duration of visits? Faculty in LMICs adequately developed such programs should be included and “shared.” may have different modes and ranges for maintaining competence in global of assessment and, even if presented an health. Physicians developing careers Self-directed assessment that draws on assessment instrument by the incoming in global health over several years may group participation HIC trainee for his or her assessment, risk overconfidence about working Given the challenges of assessing may have insufficient familiarity with the in specific resource-limited contexts, competencies in resource-limited settings, instrument to apply it reliably. especially because the health care systems a more feasible mode of assessment may in many LMICs are quite changeable be self-directed assessment. The challenge Third, the “checklist” format that as a consequence of epidemiologic, of this approach rests in the ability of is frequently used as a matter of socioeconomic, and political flux. convenience for competency assessment the individual to accurately perceive in global health settings is inadequate. performance deficiencies and seek Reenvisioning Competency in Visiting trainees may present such appropriate feedback, assessment, and Global Health 16 checklist assessment forms from guidance. Eva and Regehr coined the their home institution to their host Given these problems in developing phrase “self-directed assessment seeking” supervisory faculty and request that they and assessing competencies in global to describe a process in which trainees complete the form by the end of the visit health, are such competencies infeasible? actively engage in seeking assessment, and period. Checklists appear convenient, Or might we rethink our approach to faculty and programs empower them to especially in the global health setting, competency? As a humble start, I suggest do so. In collectivist settings the trainee given the constraints of faculty and time, three ways in which we might reenvision might also engage other health workers, differences in contexts, and the limited competencies in global health. such as nurses, administrators, and communication between home and host community workers, in seeking ongoing faculty. However rather than making Reenvisioning the individualist– formative feedback and assessment. 17 assessment objective, checklists have collectivist disjunction Holmboe and colleagues have suggested “led to trivialized and mechanistic types Reenvisioning the individualist– incorporating more “qualitative” and of assessment.”9 In global health, there collectivist disjunction in global health “narrative” approaches to assessment that is also a tendency for host faculty, who requires that we first acknowledge that allow for “words instead of numbers.” may not have had time to adequately each approach has validity and merit. Such approaches may allow a level of observe trainees, to overrate their visitors Lingard5 indicates that individualism and specificity for the trainee to implement for the sake of maintaining goodwill. As collectivism each have important roles in improvements and devise learning plans a result, trainees may overestimate their “[d]rawing our attention to some aspects with group participation. capabilities and competence. of competence and leaving other aspects unaddressed.” This approach may require an element Fourth, resource-constrained systems of resourcefulness that global health may themselves quite often not yet Lingard5 furthermore proposes that trainees tend to be adept at, as well as a be sufficiently “competent” for the competence has “the potential for participatory approach between trainee training and assessment of competent multiple constructions.” One might and faculty that aligns with collectivism. practitioners. Carraccio and Englander10 therefore consider “rethinking” or In resource-constrained settings, learners call attention to the “importance of reenvisioning our metaphorical more directly encounter the limits of their the clinical microsystem in which one constructs of competence to encompass knowledge and ability. Bjork,18 Schmidt,19 trains.” They cite the seminal studies of both individualism and collectivism. Eva,20 and others have propounded the Asch and colleagues11 that examined the For example, the metaphor of “shared notion that a major way in which learning complication rates of obstetricians in mind” proposed by Epstein and Street12 occurs lies in understanding the limits of the United States as a function of their and further developed by Leung and our knowledge and in making mistakes.

Koriat and colleagues21 coined the term “interprofessional collaboration (IPC).” 8 Holmboe ES. Realizing the promise of “desirable difficulties” to describe the “Transprofessional education” goes a competency-based medical education [published online October 7, 2014]. Acad notion of creating mistake-inducing step further in the context of global Med. doi: 10.1097/ACM.0000000000000515. learning tasks that make the learner health by including community health 9 Schuwirth LWT, van der Vleuten CPM. uncertain and uncomfortable but workers in health professions education. Assessing competence: Extending the result in enhanced learning retention. approaches to reliability. In: Hodges B, Such desirable difficulties are naturally Additional competency domains Lingard L, eds. The Question of Competence: Reconsidering Medical Education in the encountered in resource-limited settings might also focus (through concepts Twenty-First Century. Ithaca, NY: Cornell and, as described, provide unique like the “shared mind,” detailed above) University Press; 2012;113–130. opportunities for learning. As Eva on bridging the divide between 10 Carraccio CL, Englander R. From Flexner and colleagues22 point out, the value individualism and collectivism. to competencies: Reflections on a decade and the journey ahead. Acad Med. of desirable difficulties may include 2013;88:1067–1073. the motivation and self-monitoring 11 Asch DA, Nicholson S, Srinivas S, Herrin J, to deliberately seek out self-directed Conclusions Epstein AJ. Evaluating obstetrical residency assessment opportunities and information Developing competencies for students programs using patient outcomes. JAMA. of relevance to enhancing performance. and trainees in global health education 2009;302:1277–1283. 12 Epstein RM, Street RL Jr. Shared mind: The participatory and social engagement presents a number of distinct challenges Communication, decision making, and of other health professionals in such self- that have gone unrecognized while the autonomy in serious illness. Ann Fam Med. directed assessment may provide further discipline has rapidly expanded in size 2011;9:454–461. monitoring and alleviate the need for and scope. We should address these 13 Leung ASO, Epstein RM, Moulton C-AE. The competent mind: Beyond cognition. ongoing direct observation. challenges in a timely and inclusive In: Hodges B, Lingard L, eds. The Question manner with effective and reliable of Competence: Reconsidering Medical Defining new global health methods of assessment. This may call for Education in the Twenty-First Century. competency domains reenvisioned metaphors of sharing and Ithaca, NY: Cornell University Press; inclusiveness, different approaches to 2012;155–176. Given the shortcomings of current global 14 Hutchins E. Cognition in the Wild. health competencies, we may need to assessment, and possibly the development Cambridge, Mass: MIT Press; 1995. define additional competency domains. of new competency domains. 15 Rogoff B. Cognition as a collaborative One such domain may derive itself from process. In: Damon W, Kuhn D, Siegler RS, Funding/Support: None reported. eds. Handbook of Child Psychology. Volume the nature of “resource-constrained (or 2: Cognition, Perception, and Language. 5th resource-limited) settings.” These settings, Other disclosures: None reported. ed. New York, NY: J. Wiley; 1998:xxvi. although challenging, also offer unique 16 Eva KW, Regehr G. “I’ll never play opportunities for learning. 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