The Problem with Competencies in Global Health Education Quentin Eichbaum, MD, Phd, MPH, MFA, MMHC
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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 Academic Medicine, Vol. 90, No. 4 / April 2015 1 Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited. Commentary 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,