Defining Global Health Tracks forPediatric ResidenciesHeather Haq, MD, MHS,a Adelaide Barnes, MD,b Maneesh Batra, MD, MPH,c Tania Condurache, MD, MSc,d Michael B. Pitt, MD,e

Jeff A. Robison, MD,f Chuck Schubert, MD, MPH,g Nicole St Clair, MD,h Omolara Uwemedimo, MD, MPH,i

Jennifer Watts, MD, MPH,j Christiana M. Russ, MDk

abstractBACKGROUND: Global health (GH) offerings by pediatric residency programs have increasedsignificantly, with 1 in 4 programs indicating they offer a GH track. Despite growth of theseprograms, there is currently no widely accepted definition for what comprises a GH track inresidency.

METHODS:A panel of 12 pediatric GH education experts was assembled to use the Delphi methodto work toward a consensus definition of a GH track and determine essential educationalofferings, institutional supports, and outcomes to evaluate. The panelists completed 3 roundsof iterative surveys that were amended after each round on the basis of qualitative results.

RESULTS: Each survey round had 100% panelist response. An accepted definition of a GH trackwas achieved during the second round of surveys. Consensus was achieved that at minimum,GH track educational offerings should include a longitudinal global child health curriculum,a GH rotation with international or domestic underserved experiences, predeparturepreparation, preceptorship during GH electives, postreturn debrief, and scholarly output.Institutional supports should include resident salary support; malpractice, evacuation, andhealth insurance during GH electives; and a dedicated GH track director with protected timeand financial and administrative support for program development and establishingpartnerships. Key outcomes for evaluation of a GH track were agreed on.

CONCLUSIONS: Consensus on the definition of a GH track, along with institutional supports andeducational offerings, is instrumental in ensuring consistency in quality GH education amongpediatric trainees. Consensus on outcomes for evaluation will help to create quality residentand program assessment tools.

WHAT’S KNOWN ON THIS SUBJECT: One in 4 pediatricresidency programs offer a dedicated global health (GH)track. Despite this growing self-identification amongprograms, there is no widely accepted definition of a GHtrack within a pediatric residency program.

WHAT THIS STUDY ADDS: Using formal Delphimethodology, we achieved consensus among a panel ofpediatric GH education experts on a definition, minimaleducational offerings and institutional supports, andevaluation methods for a GH track in pediatricresidency.

To cite: Haq H, Barnes A, Batra M, et al. Defining GlobalHealth Tracks for Pediatric Residencies. Pediatrics. 2019;144(1):e20183860

aDepartment of Pediatrics, Baylor College of Medicine, Houston, Texas; bChildren’s Hospital of Philadelphia,Philadelphia, Pennsylvania; cDepartment of Pediatrics, University of Washington, Seattle, Washington;dDepartment of Pediatrics, School of Medicine, University of Louisville, Louisville, Kentucky; eDepartment ofPediatrics, University of Minnesota, Minneapolis, Minnesota; fDepartment of Pediatrics, University of Utah, SaltLake City, Utah; gCincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; hDepartment of Pediatrics, Schoolof Medicine and Public Health, University of Wisconsin, Madison, Wisconsin; iCohen Children’s Medical Center ofNew York, Queens, New York; jChildren’s Mercy Kansas City, Kansas City, Missouri; and kBoston Children’s Hospital,Boston, Massachusetts

Drs Haq and Barnes contributed to the design of the study and the Delphi instrument used,performed qualitative analysis, and drafted and revised the manuscript; Drs Batra, Condurache,Pitt, Robison, Schubert, St Clair, Uwemedimo, and Watts contributed to the design of the study andthe Delphi instrument used, contributed to drafting the manuscript, and critically revised all draftsof the manuscript; Dr Russ conceptualized and designed the study and the Delphi instrument used,supervised data collection and qualitative and quantitative analysis, and drafted and revised themanuscript; and all authors approved the final manuscript as submitted.

DOI: https://doi.org/10.1542/peds.2018-3860

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Interest in global health (GH) amongpediatric trainees continues to grow,with increasing numbers of residencyprograms responding to this demandby offering GH electives and dedicatedGH tracks.1–5 In the most recentsurvey of pediatric residencyprograms in 2015, 58% offeredinternational electives, and 1 in 4programs had a GH track.1 In thissurvey, however, the authors did notdefine a GH track but rather allowedprograms to self-identify. In a follow-up survey in 2017 of the programsthat indicated they had a GH track, thevariability in programming inherent toself-definition was highlighted, withthe authors noting concern that someprograms did not meet proposedAmerican Academy of Pediatrics(AAP) standards for GH electives,including duration of experience andpredeparture preparation.5,6

Although several programs havepublished descriptions of variousaspects of their GH track,7–13 orproposed core content suggestions forcurricula,14–16 few have attempted toexplicitly define what a GH track shouldbe.17,18 The lack of a formal consensusdefinition for a GH track makesinterpreting trends of involvementamong programs difficult; limits theability for applicants, trainees, andeducators to easily understand what isbeing offered at various institutions;and makes it challenging to evaluate GHtrack outcomes.

The purpose of this study was to useformal Delphi methodology to achieveconsensus among a panel of pediatricGH education experts on 3 objectives:(1) a definition of a GH track, (2)minimal educational offerings andinstitutional supports required fora GH track, and (3) evaluation methodsfor a GH track in pediatric residency.

METHODS

Panel Selection

To arrive at a definition, we chosea Delphi process framework19 using

consensus-building iterative surveysfor 3 rounds.20,21 Inclusion criteriafor an expert panel included expertisein pediatric GH educationdemonstrated through leadership ofa GH residency track, experience inGH curriculum development, andscholarly output, including peer-reviewed publications orpresentations on pediatric GHeducation. Authors of this articlewere excluded from the expert panel.The authors (members of theAssociation of Pediatric ProgramDirectors GH Learning Community)each sent a list of potential expertpanelists to the principal investigator(PI), who compiled them into a poolof 32 potential participants, of whom28 met inclusion criteria.

From this pool, the PI stratifiedpotential panelists on the basis ofvariables we believed couldsignificantly impact responses basedon differences reported in theprevious survey of self-defined GHtrack leadership.5 These variablesincluded size of the residencyprogram, size of the GH track, andwhether the GH track wasmultidisciplinary. The PI thenconstructed a purposeful sample of12 potential panelists representingdistribution among the criteria ofinterest, with preference given tothose who had authored peer-reviewed publications about GHeducation. The PI sent thoseindividuals an e-mail invitation tovoluntarily participate, includinga detailed description of the studyand notice that survey participationimplied consent. Nine participantsimmediately accepted. For the 3 whodeclined, additional names werepulled from the same categories, andthose 3 accepted.

Consensus research suggests thatpanels smaller than 6 or larger than12 have more limited reliability.12

The author group selected a panelsize of 12 per those recommendationsand for adequate inclusion ofindividuals representing residency

programs and tracks with differentcriteria of interest.

The final panel included at least 5panelists from large programs ($60residents), at least 5 panelists fromsmall to medium programs (,60residents), at least 3 panelists frommultidisciplinary tracks versus tracksthat were specific to pediatrics ormedicine-pediatrics, and at least 3panelists from small GH tracks (,10total residents in the track). Panelistsagreed to a confidentiality clause,thus ensuring independent responses.

Delphi Instrument

The author team developeda literature-based survey focusing onGH track definitions,17,18 minimalrequirements for educationalofferings,4,6,10–12,18,22–24 institutionalsupports,3,18,22 and outcomes forevaluation25,26 (SupplementalInformation). The online survey waspiloted by multiple author teammembers before dissemination.

We first proposed an adapteddefinition of a GH track (objective 1)for panelists to consider.17 Forobjective 2 (determining minimaleducational offerings and supportsrequired of a GH track), we providedcommon educational components (eg,predeparture orientation,1,4,5,18,27

international electives1,6,28,29) andstructural supports (eg, GH trackleadership,1,3,5,18 coordinatorsupport3,5,18) from the literature assuggestions as well as free textoptions. Similarly, for objective 3(outcomes to measure theeffectiveness of a GH track), weprovided possible outcomes of GHtracks from existing literature thatwere organized on the basis ofKirkpatrick’s levels (reaction,learning,30 behaviors,31 and results24,26,32).

Data Collection

The PI’s hospital institutional reviewboard deemed the study exempt fromreview. The survey was distributedvia e-mail and administered by using

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Qualtrics online surveys (Qualtrics,Provo, UT). For the track definition,we asked panelists to accept, reject,accept with changes, or suggest analternative, with open text forcomments to support their choice orrecommendations for change. For theother 2 objectives, we asked paneliststo rank the items as essential, veryimportant, somewhat important, ornot important (4-point Likert scale)and add open-text comments tojustify their ratings or proposealternate wording. On the basis ofconsensus research literature, wedefined consensus as at least 75%agreement for questions asking foragreement or inclusion or a meanscore of ,1.5 or .3.5 for thequestions with 4-point Likertscales.20,21 Items with mean scores.3.5 were defined as areas ofpositive certainty and ultimately wereincluded as essential, whereas itemswith mean scores ,1.5 were areas ofnegative certainty. Average rankingsof 1.5 to 3.5 were considered areaslacking consensus and were furtherexplored in subsequentquestionnaires for the 3 rounds of theDelphi process. Round 1 took placebetween November 17 and December6, 2017; round 2 was betweenJanuary 17 and February 12, 2018;and round 3 was between February28 and March 19, 2018.

Data Analysis

The PI and research assistantanalyzed results from each round andpresented deidentified data to thecoauthors. For areas that lackedconsensus, we analyzed responsecomments and, where applicable,revised items to reflect modalsuggestions for changes that wouldincrease likelihood of consensus inthe next round. If no modalmodifications were identified, thenrespondent explanations as to whythe option or item was acceptable oressential were summarized andshared in the following round. Wepresented overall response rate andquantitative results (mean and bar

graph) and deidentified comments tothe panelists for rounds 2 and 3,generating additional questions whenapplicable, on the basis of qualitativeresponses from the previous surveys.Panelists were asked to review eachquestion and consider altering theirresponses on the basis of themodifications and/or shared data,although they were assured that theyneed not conform. Panelists who didnot agree with the modal responsecategory in rounds 2 and 3 wereagain asked to explain why, and theseexplanations were used to refine theresponse category and move towardconsensus.

For data analysis, we calculatedfrequencies with means, medians, andranges of Likert scale responses.Three reviewers with experience inqualitative analysis (H.H., A.B., anda nonauthor research assistant)independently reviewed allqualitative data, developed a codingscheme, and conducted independentcoding. Using an inductive contentanalysis approach,33 each revieweranalyzed the data to identifyemergent themes and selectrepresentative quotations.

RESULTS

All of the invited panelists (n 5 12)agreed to participate in the Delphiprocess, and we achieved 100%participation for all 3 rounds.

The Delphi process generatedsignificant discussion around theterm “global health” and required all3 rounds to obtain consensus onterminology to define a GH rotation.Although some initially expressedthat a GH rotation should involvecrossing an international border,ultimately a broader definition wasaccepted. “Our local consensus is thatGH is transnational by definition, andtherefore [local-global] experiencesare, if framed correctly, truly GHexperiences.” On the basis of suchcomments, all items were amended inround 2 to use the term “global

health” rather than “international,”unless referring specifically toa cross-border internationalexperience or partnership.

GH Track Definition

After 2 rounds, the panelists achievedpositive certainty on the definition ofa GH track, provided in Fig 1.

Minimum Educational Offerings andInstitutional Supports

Panelists identified with positivecertainty 7 essential components ofa GH track, with 2 offerings describedin the literature deemed not essentialbut important (Fig 2). Panelistsunanimously agreed that formaleducational infrastructure to supportGH rotations is essential, includingpredeparture preparation,preceptorship during GH electives,and postreturn debriefing. Panelistsrecognized scholarly output as anessential component but indicateda wide range of acceptable scholarlyactivity. Panelists also indicated thatscholarly projects should align withhost site priorities and highlighteda need for flexibility in scholarshiprequirements because some projectsmay need to be adapted oncea resident is on site.

After 2 rounds, there were 2 itemsthat did not achieve consensus forbeing essential components of a GHtrack: local or domestic activities inGH and a continuity clinic with anunderserved local population.Panelists recognized that withoutclear definitions of “local-global” orunderserved populations, these termswould need to be standardized beforebeing required components of GHtracks. There was agreement thatcertain domestic experiences couldfulfill the GH rotation requirement ofthe GH track, but panelists did notfeel that all GH track residents mustcomplete a domestic GH experience.Panelists also expressed thata continuity clinic in an underservedsetting could be appealing to GH track

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residents but should not bea requirement.

The panel was asked to comment onwhether the AAP’s suggested 4-weekminimum for a GH elective6 wasappropriate, too short, or too long.The panel agreed with positivecertainty that the 4-week minimumwas appropriate. One panelistdescribed an “educationaldevelopment process” that unfoldsduring a GH rotation and warnedthat if “shortened by a rotation ofless than 4 weeks, [residents are]less likely to achieve clinical,cultural, and system proficiency.”Several panelists commented thata longer duration would be optimalbut recognized schedulingconstraints. As one panelist stated,“4 weeks should be the minimum‘sandals on the ground’ time and notbe cut into by leisure travel during orat the tail end of the rotation.”

The panelists reached consensus ona number of supports deemednecessary to ensure the success ofa GH track (Table 1). After 2 rounds,panelists agreed that a dedicated GHtrack director with salary support orprotected academic time isnecessary “to grow and developa program.” Consensus was notobtained, however, on the degree ofsupport required in the percentageof full-time effort for the GH trackdirector. In addition to dedicatedtime, panelists also endorsedfinancial support for facultyprofessional development,partnership development, andtravel. Finally, administrativesupport for the GH track was notedto be “imperative,” although the size

of the residency program woulddictate the amount of support.

Resident salary support during GHelectives; maintenance of existingmalpractice, health, and disabilityinsurances; and the provision ofevacuation insurance were allunanimously agreed on as essentialduring round 1. Panelists believedthat all were “important safeguardsthat should not be compromised.”

To maximize sustainability andcollaboration, panelists believed thatat least 1 established partnershipshould exist, either by the residencyprogram’s institution or incollaboration with other institutionsor organizations in which theresident is performing the GHelective. Although most agreed thatsome form of on-ground support isessential, the requirement wasconsidered “too prescriptive” andpotentially burdensome to the hostsite partners.

Evaluation Outcomes

For round 1 responses for objective3, the initial use of a Likert scalefailed to adequately differentiate themost useful track outcomes. Forsubsequent rounds, the responsechoice was amended to binomialchoices to include or exclude theitem in a GH track evaluation tool,with the same definition ofconsensus as in objective 1.

Panelists agreed on several outcomemeasures that would effectivelyserve as quality indicators of a GHtrack within a residency program(Table 2). Many of these itemsmeasured resident perceptionsabout their experiences and personal

impact of the track. Panelists agreedthat partner perceptions about thebenefits and challenges of hostingtrack residents at the localinstitution would be helpful so as to“help decrease burden and increasebenefit to [the] host institution inorder to grow a partnership.”

A number of learning outcomes werealso selected as important qualityindicators, including cumulativeassessment of the track residents’improvement in GH knowledge andattitudes, track resident self-evaluation of the ability to recognizeGH-related diagnoses, andcumulative achievement ofcompetency-based milestones.International faculty assessment oftrack residents participating in aninternational elective wasunanimously selected as animportant outcome.

All panelists believed cumulativescholarly work produced by trackresidents should be evaluatedbecause this could serve asa “distinguishing characteristic” ofthe track. Long-term outcomes ofresidents, such as career choice aftergraduation, were deemed essentialto evaluate the impact of GH tracks.International and domestic partnerevaluation of local community andinstitutional impact of the GH trackwas also unanimously agreed on;as 1 panelist commented, “Ifpartnerships are not mutuallybeneficial then they are doomed tofailure.” Finally, to ensure thatresidents are safe during their GHrotations, panelists agreed thatadverse health and safety eventsshould routinely be reported andaddressed, so as to mitigate risk tofuture residents.

Thematic Analysis

Several themes emerged throughoutthe survey rounds, many of whichinfluenced the panel of experts’ rankand rating of items. These themesincluded consideration of programsize, partnership and bidirectionality,

FIGURE 1Consensus definition of a GH track in pediatric residencies.

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and standardization of variouscomponents.

Panelists were cognizant of theimpact of recommendations on smallprograms. For example, althoughagreeing that mentorship was animportant defining factor, theyacknowledged that smaller programsmight have difficulty identifyingfaculty members with adequate GHexperience to serve as mentors.Panelists suggested that membersfrom more resourced programscould mentor residents in smallerprograms. Likewise, althoughpanelists strongly believed that a GHdirector with salary andadministrative support were“essential for ensuring a robust andthriving GH track,” many felt that thismay not be a reality for smallerprograms with fewer overallinstitutional supports and that giventhe number of residentsparticipating in the track, “effortrequired may be less for the GH trackdirector in these programs.” Finally,panelists conceded that althoughhaving an established partnership isideal, this may be less feasible forsmall programs and that “reasonablealternatives include collaboratingwith other programs that have morerobust GH tracks or having a groupof training programs shareinternational sites when possible.”Other suggestions includedcollaborating with otherdepartments within the homeinstitution.

Many panelists considered theimpact on the partnering institutionwhen endorsing certainrecommendations. Many felt thatwhile it is not yet feasible for allinstitutions, establishing “reciprocaleducational arrangements wheretrack residents also host visitinglearners, preferably from the samelongitudinal site,” is an ideal modelfor institutions. Panelists felt thatthis bidirectionality was importantto avoid a sense of paternalism.Having an established partnership

FIGURE 2Educational offerings for GH tracks with consensus results and representative quotations. aMean ofLikert scale responses: 1 5 not important, 2 5 somewhat important, 3 5 very important, 4 5essential. GHT, global health track; IHS, Indian Health Services; QI, quality improvement; TB,tuberculosis.

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was thought to be beneficial for bothdomestic and international locationsfor “ease of communications,familiarity with processes, and long-lasting impacts.” When reflecting onthe importance of partnershipperception, one panelist summarizedthat it is important to “[couch]partnerships in terms of mutualbenefit, equitability, and reciprocity.”

While recognizing this process as anopportunity to establish minimumeducational requirements, panelistsalso articulated the importance ofstandardizing the suggestedrequirements. For example, toensure high-quality predeparturetraining, “basic standards are neededto ensure [that] predeparture

preparation is. . .adequate prior tointernational rotations.” Likewise,although a longitudinal curriculum isconsidered the backbone of thetrack, many advocated for a clearway to “achieve a standard ofknowledge,” even suggestinga standard set of specific readings,modules to complete, or criteria tofulfill, established by variousgoverning bodies (eg, AmericanBoard of Pediatrics, AAP, andAssociation of Pediatric ProgramDirectors).

DISCUSSION

Although GH tracks have becomecommon in pediatric residencyprograms, lack of agreed-on

standardization or consensusdefinition has created challenges foreducators, researchers, andtrainees.1,5 The results of this studyoffer an expert consensus definition(Fig 1) as well as several essentialcomponents, supports, and outcomemeasures (Fig 2; Tables 1 and 2) thatwill be useful for stakeholders in GHeducation. Although others haveproposed models for GH curricula,which include suggested definitionsbased on their programdescription,11,17 the Delphimethodology used here offers a morerigorous approach to determineexpert consensus.

GH curriculum remainsa “supplemental” component of

TABLE 1 Institutional, Faculty, and Resident Supports for GH Tracks With Consensus Results and Representative Quotations

“Essential” Items Representative Quotation(s) Mean at End ofProcessa

For faculty supportsDedicated GH track director with salary support and

protected academic time1,2,7,8,11“To grow and develop a program, especially in a new academic field,

requires dedicated time.”“Having a person with dedicated time and support provides a strong

foundation for the program to be successful.”

3.7

Financial support for faculty professional development,partnership development, and faculty or director travel, ifrequired for program development

“If the program is to truly have a partner site, having the ability to visit,interact, and evaluate the site is key to success.”

3.7

Administrative support for GH track2,7,11 “There must be at least some administrative support. The amountdepends on the size of the group and the availability of other sharedresources.”

3.92

At least 1 established partnership, either by the residencyprogram’s institution or in collaboration with otherinstitutions and organizations, in a resource-limited settingin which residents can perform an (international ordomestic) GH elective2,3,7,8

“I believe that international and domestic GH electives should takeplace under the auspices of long-standing bidirectional partnershipswhenever possible.”

3.75

For resident supportsResident salary support during GH electives2,9 “While travel stipend is not essential, salary support during GH elective

is very important/essential.”3.92

Maintenance of existing malpractice, health, and disabilityinsurance during GH electives2

“Programs have a fiduciary, professional, and ethical responsibility toensure that personal and financial risks are mitigated to the extentthat is reasonable.”

“Maintaining or providing alternate health and disability insurance isvery important when traveling to sites with limited medicalresources, especially given high rates of pedestrian and automotiveinjuries in most LMIC.”

3.92

Evacuation insurance for international electives2 “This must be an expectation to keep trainees safe.” 3.92“Not essential but important” itemsTravel stipend for away elective2 “While this would be nice, our institution’s experience has been that

lack of a travel stipend does not seem to be a barrier to robustparticipation by residents in an international elective.”

2.4

On-ground support (administrative personnel, host facultymembers) to facilitate medical and emergency care forresidents during international rotations.

“I believe having a plan in place to handle such situations is key, buta formalized system may be more burdensome to the hostinstitution, particularly if not used routinely.”

3.5

LMIC, low- and middle-income countries.a Mean of Likert scale responses: 1 5 not important, 2 5 somewhat important, 3 5 very important, 4 5 essential.

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residency training because there arenot Accreditation Council forGraduate Medical Educationmandates pertinent to GH training.However, trainee demand,1,4,34

paired with the desire for residencyprograms to train globally competentpediatricians,3,23,29,35–37 warrantscrutiny over GH educationalofferings nationally. This study offersan “internal policing” of sorts for GHeducators as an attempt to setstandards within our owncommunity that will offer a firmfoundation on which programs cangrow, share resources, and trackoutcomes. The definition and core

components identified in thisstudy offer residency programsa platform on which to build their GHeducation philosophies. Rather thanserving as a checklist, the 7 corecomponents of GH tracks identifiedin this study can serve asa springboard for discussion forbuilding more robust programs. Thisstudy also highlights creativestrategies that small residencyprograms might leverage to achievethe core components. Additionally,residency applicants can considerthese components as they evaluateresidency programs that feature GHtracks.

Several of the factors deemedessential for GH tracks affirmedsuggested best practices publishedelsewhere, such as the need forcomprehensive predeparturetraining,4,18,22 mentorship,18,38 andminimum duration of GH electives.6

The study also offered insights to theimportance of building GH tracksaround sound partnerships withinstitutions and organizations inresource-limited settings, in linewith recent literature.39,40

Postreturn debriefing wasrecognized by panelists as essential,not only to help residents processtheir experiences but also as a form

TABLE 2 Outcomes on Which to Base Evaluations of GH Tracks

Outcomes for Which Consensus Was Achieved % Agreement toInclude

Reaction outcomes by track residentsPerceptions regarding the influence of GH training on personal development as a pediatrician 92Perceptions regarding the influence of GH training on professional development as a pediatrician 92Perceptions regarding the influence of GH training on career trajectory 100Perception of the quality of local GH experiences2 83Perception of the quality of international GH electives2 75Perception of comprehensiveness of predeparture training for international electives 83Evaluation of GH elective site (teaching and supervision while abroad, on-site support, stateside communication, etc) 83Opportunities for GH-related scholarly work2 83Experiences within the GH track that were most impactful on increasing knowledge and skills in global child health 92Most helpful aspects of program 75Program aspects that should change2 75Impact of the program on postresidency career plans2,15,16 92Track residents’ evaluation of program staff and faculty2 100Suggestions for improvement 100

Reaction outcomes by partner organizationsInternational and domestic partner perceptions about the benefits and challenges of hosting track residents at their local

institution100

Learning outcomesCumulative achievement by track residents of competency-based milestones, as measured by summative evaluations from

elective preceptors and GH mentors1475

Cumulative assessment of track residents’ improvement in GH knowledge and attitudes2 75Track resident self-evaluations of ability to recognize a list of GH-related diagnoses and to perform specific procedural

competencies2,1575

Behavior outcomesInternational faculty assessment of track residents participating in an international elective14,18 100

Result outcomesInternational and domestic partner evaluation of local community and institutional impact of GH track 83Long-term outcomes of residents (career choice after graduation: work abroad, care of underserved in medical practice,

legislative advocacy involvement at local, national, international level)2,15,1692

Cumulative scholarly work produced by track residents2,15,16,20 92Health and safety events experienced by track residents while on GH rotations (eg, needle stick)16 83

Outcomes for which consensus was not achievedPerceived use of curriculum and other training modalities (ie, journal clubs, simulation sessions, noon conferences,

predeparture sessions)250

Perceived ease of transition to and from international site2,16,17 50Cumulative case logs from track resident GH rotations2 33Faculty evaluation of resident’s clinical skills and professionalism in response to simulated scenarios19 33Most unanticipated aspects of program2 67

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of quality improvement for therotation and the partnership with thehost site. Three panelists commentedon the importance of using thedebrief as a way to also screen forposttraumatic stress disorder orother mental health symptoms andto refer for counseling as indicated.Although some have written abouttheir programs’ expectations ofa scholarly project as part of their GHtracks,5,24 the panel reachedconsensus that this is an essentialcomponent of the definition.

There are inherent limitations to theDelphi methodology. The expert panelwas limited to GH educators workingin pediatrics in the United States anddid not explore the generalizability ofthese results to other specialties orother countries. The author teamchose a panel of 12 panelists on thebasis of literature about Delphiprocesses,21 but the limited numberof panelists and lack of face-to-faceconversation may have limiteddiscussion. Although care was takenthat drafting of the initial survey wasdone on the basis of existing

literature, and iterative feedback torespondents was done objectively,there remains risk that weunintentionally guided the panel inthe survey design.

CONCLUSIONS

On the basis of consensus of expertopinion, we propose an accepteddefinition of pediatric GH tracks as “alongitudinal area of concentrationdedicated to global child health,offered within a residency program,which includes a formal curriculumand mentorship with requiredscholarly output for a defined cohortof pediatric residents.” Werecommend that residency programswho have GH tracks strive to offer atminimum the institutional supportsand educational opportunitiesdescribed here, including adequatefaculty and institutional resources tosupport GH track residents throughimmersive rotations of at least a 4-week duration, with mentorship andpartnerships to support scholarlywork that is appropriate for their

field site. Several areas for futurestudy were identified by the panel,including a need for standard toolsfor assessments of trainees in GH-specific knowledge, skills, andattitudes and to evaluate the efficacyof GH tracks in preparing residentparticipants to make meaningfulcontributions to improve global childhealth.

ACKNOWLEDGMENTS

We appreciate contributions to datacollection and quantitative analysisby Yonina Frim, contributions toqualitative analysis by KerryCoughlin-Wells, guidance on Delphimethods by David N. Williams, andthe thoughtful participation of thepanelists.

ABBREVIATIONS

AAP: American Academy ofPediatrics

GH: global healthPI: principal investigator

Accepted for publication Apr 9, 2019

Address correspondence to Heather Haq, MD, MHS, Department of Pediatrics, Baylor College of Medicine, 1102 Bates Ave, Houston, TX 77584. E-mail: heather.haq@

gmail.com

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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DOI: 10.1542/peds.2018-3860 originally published online June 18, 2019; 2019;144;Pediatrics 

Watts and Christiana M. RussJeff A. Robison, Chuck Schubert, Nicole St Clair, Omolara Uwemedimo, Jennifer

Heather Haq, Adelaide Barnes, Maneesh Batra, Tania Condurache, Michael B. Pitt,Defining Global Health Tracks for Pediatric Residencies

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