Participation in global health activities by U.S. medical students has grown substantially in recent decades.1 Although global health interest has grown, many schools still do not offer structured global health curricula, and there is little standardization for didactic, clinical, scholarly, and cultural components across programs.2,3 The past decade saw the development of essential competencies to guide global health curricular development.4-10 However, many programs lack well-defined competencies outlining critical skills for global health practitioners. The most notable global health competency framework identifies 39 competencies across 11 domains and was published in 2015 by an interdisciplinary expert panel from the Consortium of Universities for Global Health (CUGH). Many of the identified competencies include not only knowledge acquisition but also skills building and attitude formation.4 Particularly in resource-limited settings involving different cultures, political climates, and power dynamics, effective global health practitioners need competence in cultural humility, inter-professional collaboration, ethical conduct, and promotion of health equity. One major challenge is for educators to identify methods to teach these competencies that will enable students to become successful global health practitioners.
Aspects of various global health curricula have been published. Some describe didactic curricula focused on topics such as cultural competency and communication.11 Others describe educational formats including e-learning or simulation-based learning to teach competencies such as ethics or professional practice in low-resource settings.12-14 Many programs involve international electives or service-learning experiences, and best practice approaches have been proposed to help students in short-term global health experiences build skills in cross-cultural effectiveness, capacity building, and collaboration while addressing the needs of host communities and partners.15-18 Although there are some published descriptions of global health capstones for pharmacy and bioengineering students, there are no known published descriptions of global health capstones as part of an educational curriculum for medical students.19,20
The Global Medicine (GMED) Program is a longitudinal four-year track for select medical students that began in 2012, in response to increased interest in global health at the University of Illinois Chicago College of Medicine (UICOM). Completion of a longitudinal capstone project is required as part of the GMED program. Using a global health capstone project as an educational method for medical students is a novel construct. Although capstones are reported in other disciplines, they have not been routinely incorporated into global health medical student programs. Other fields found capstones beneficial because they allow students to:
- Become involved in sustainable impact-oriented research.21
- Build skills in scholarship and professionalism including writing, presenting, and integrating “core theoretical concepts to form a broad view of professionalism.”21-23
- Develop research mentorships and relationships with faculty.21
In this paper, we describe the global health capstone including how the capstone can be used to teach essential global health competencies, and we report on characteristics of the global health capstone for the first 35 graduates of the GMED Program. This educational method may be of value to other global health educators who wish to develop or strengthen their global health training programs for health professions students.
Development of the Global Health Capstone
The UICOM GMED Program recruited its first class in 2012 and has since graduated four classes. The program’s goal is to improve the health of populations worldwide by training the next generation of global health leaders.24 As part of the program, each GMED student must develop, implement, and present a capstone project to successfully complete the program. The global health capstone is defined as a longitudinal scholarly work focused on expanding knowledge and understanding of global health issues among underserved populations throughout the world. The capstone culminates in an oral presentation and reflection paper at the end of the final year of medical school. In 2019, we added an additional requirement of a formal written paper. The capstone is designed to allow students to acquire knowledge and skills through project planning and implementation.
The global health capstone was developed by a multidisciplinary group of faculty with global health and education experience following the steps outlined in the following section:
- Develop Global Health Capstone Objectives
Faculty identified global health capstone objectives that focused on skills-building and complemented other components of the global health curriculum. The following objectives were identified for GMED students completing the capstone project:
- Demonstrate and apply an understanding of global health education competencies;
- Identify and utilize credible and scholarly sources of information concerning global health topics and perform an in-depth review of the literature;
- Define an overall purpose and associated specific aims for the project;
- Collaborate with a faculty mentor to ensure adequate progress on the project and receive regular feedback and evaluations;
- Demonstrate effective professional and scientific communication skills through written products and presentations;
- Apply critical thinking skills and a scientific methodology to the analysis of a project.
- Define Capstone Focus and Parameters
Koplan defines global health as, “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care.”25 Using this definition of global health to frame the focus of the capstone, students were instructed to identify a global health area that they might want to study further.
Because the UICOM has additional special tracks that address urban and rural health, we further required that global health capstone projects should focus on issues in low- and middle-income countries (LMICs) or people from LMICs. This narrower focus allowed our program to avoid overlap with the other programs at our institution that concentrate on domestic health disparities.
- Describe Capstone Structure
Capstone projects could vary in structure and content depending on students’ interests. All students received faculty advising that provided guidance for capstone completion. Projects could focus on original global health research or be comprised of curriculum design, program implementation, field practicum, systematic review, or a meta-analysis. All students were expected to demonstrate an understanding of these accepted global health core competencies:4
- Global Burden of Disease
- Globalization of Health and Healthcare
- Social and Environmental Determinants of Health
- Capacity Strengthening
- Collaboration, Partnering, and Communication
- Ethics
- Professional Practice
- Health Equity and Social Justice
- Program Management
- Sociocultural and Political Awareness
- Strategic Analysis
Table 1 identifies how the global health capstone described can be used as a tool to address each competency domain and provides illustrative examples from completed student projects.
- Identify Capstone Requirements and Timeline
Specific deliverables were identified for the capstone project that would be required throughout the four years of medical school (Figure 1). During the first year, each student identifies a particular global health issue, performs a literature review, writes a brief paper, and delivers a short oral presentation on his/her selected topic to peers and faculty. In the second year, each student identifies a specific project, defines his/her role in that project, establishes methods and a timeline for project completion, and prepares and presents a scientific poster. In the third and fourth years, students focus on capstone project implementation and evaluation, culminating in oral presentations summarizing their work. In their final presentations, students identify the global health problem addressed; describe the methods, results, and conclusions of the completed projects; and discuss the implications of their projects on the health of underserved communities and on their future practice as global physicians. Graduating students also submit a self-reflection paper upon capstone completion. This paper encourages students to reflect on their accomplishments, articulate the challenges and successes of their projects, and internalize their experiences to translate knowledge acquired to their personal and professional growth.
It is critical to note that the capstone is only one component of the GMED program. In addition to the regular medical school curriculum, the GMED program includes didactic instruction, colloquia, and skills-building workshops described elsewhere.24 GMED programming also includes exposure to supplementary content (e.g. cultural competency, economic perspectives of global aid, ethics of volunteerism) as well as alternative interactive learning formats including film reviews, book club discussions, and simulation-based cases.
- Adapt and Revise Capstone Requirements
Based on student feedback and faculty observation, several modifications were made to the original capstone design. We revised and more precisely defined the focus for global health capstone projects; this adaptation was made in response to project proposals that did not clearly have transnational health relevance. We adapted the capstone objectives to include updated global health competencies. The original GMED curriculum addressed global health competencies identified in 2010 by the Global Health Education Consortium. An expanded and updated list of competencies was identified by CUGH in 2018, and we revised our capstone objectives and guidelines to reflect this change.4,10 A written scholarly paper was added as a requirement for 2019 graduates. Submitting an abstract to a non-UICOM conference was added as a third year requirement that will take effect starting in 2020. Ongoing capstone adaptations based on the findings of this review include instituting a new mentorship program (see Discussion).