Consensus Competencies for Postgraduate Fellowship Training in Global Neurology

Abstract

Background and Objectives

Use a modified Delphi approach to develop competencies for neurologists completing ≥1 year of advanced global neurology training.

Methods

An expert panel of 19 United States–based neurologists involved in global health was recruited from the American Academy of Neurology Global Health Section and the American Neurological Association International Outreach Committee. An extensive list of global health competencies was generated from review of global health curricula and adapted for global neurology training. Using a modified Delphi method, United States–based neurologists participated in 3 rounds of voting on a survey with potential competencies rated on a 4-point Likert scale. A final group discussion was held to reach consensus. Proposed competencies were then subjected to a formal review from a group of 7 neurologists from low- and middle-income countries (LMICs) with experience working with neurology trainees from high-income countries (HICs) who commented on potential gaps, feasibility, and local implementation challenges of the proposed competencies. This feedback was used to modify and finalize competencies.

Results

Three rounds of surveys, a conference call with United States–based experts, and a semistructured questionnaire and focus group discussion with LMIC experts were used to discuss and reach consensus on the final competencies. This resulted in a competency framework consisting of 47 competencies across 8 domains: (1) cultural context, social determinants of health and access to care; (2) clinical and teaching skills and neurologic medical knowledge; (3) team-based practice; (4) developing global neurology partnerships; (5) ethics; (6) approach to clinical care; (7) community neurologic health; (8) health care systems and multinational health care organizations.

Discussion

These proposed competencies can serve as a foundation on which future global neurology training programs can be built and trainees evaluated. It may also serve as a model for global health training programs in other medical specialties as well as a framework to expand the number of neurologists from HICs trained in global neurology.

Interest in global health and the globalization of American academic medicine has increased substantially among recent generations of health care trainees.¹ In the last 35 years, the number of medical students in the United States who spent time working internationally has risen from 6% to 29%.² While most of the global health electives have predominantly focused on primary care, obstetrics, and infectious diseases, interest in global neurology experiences is also increasing. The growing recognition of the burden of neurologic disease in low- and middle-income countries (LMICs) has been accompanied by increasing interest in and demand for global neurology experience among neurology postgraduate trainees in the United States. A survey of US and Canadian neurology residency program directors revealed that 93% would make time available for residents to participate in international electives if funding was available.³ Global neurology is also increasingly recognized as a viable career path among United States–based neurologists in academic medicine^4-6 as reflected by the formation of a Global Health Section of the American Academy of Neurology (AAN) in 2011, which currently includes 611 members,⁷ and the American Neurological Association (ANA) International Outreach Committee.⁸

In spite of growing interest, models for training neurologists in high-income countries (HICs) interested in pursuing a career in global neurology have not been well- delineated. A recent study of global health competencies in all medical training programs in the United Kingdom failed to reveal a single neurology-related global health competency in any program,⁹ and a survey of neurology trainees in Europe demonstrated insufficient opportunities for global health training.¹⁰ Some educators have attempted to incorporate aspects of global neurologic care in LMICs into standard curricula for postgraduate neurology training in the United States.^11-13 These attempts have generally been comprised of either global health courses within a curriculum without travel or short-term international trips tailored to medical students and neurology residents. Given the growing interest in integrating opportunities for global health training in neurology residencies and the emergence of recognized global neurology training programs,^7,14-16 a formal training curriculum is needed to ensure all trainees receive adequate, ethical, and appropriate training. However, competencies designed specifically for neurologists in HICs wishing to complete an extended (≥1 year) fellowship in global neurology have not been previously explored.

Following previously defined definitions of competency and competency-based medical education,^17,18,19 a panel of United States–based neurologists with extensive experience in global neurology education was convened to develop competencies intended for use in postgraduate global neurology training programs for trainees from HICs. These were subsequently critically reviewed and edited by a group of neurologists based in LMICs with experience working with neurology trainees from HICs, and the final comprehensive list of agreed on competencies is presented here.

Methods

A panel of United States–based neurologists with experience in global neurology in LMICs (Table 1) was selected from the AAN Global Health Section and the ANA International Outreach Committee to participate in a modified Delphi method to generate consensus competencies. A modified Delphi method was used given its strengths in achieving consensus among a group of experts, especially when participants are separated by physical distance.²⁰ The stages for the Delphi method include identifying a research problem, selecting experts, developing a questionnaire, conducting anonymous iterative questionnaire rounds, collecting individual and group feedback between rounds, and summarizing the findings. While the classic Delphi and modified Delphi methods are similar with regard to procedure and intent, participants never meet or have direct interaction in the classic Delphi approach.

Table 1.

Diversity and Expertise of United States–Based Expert Participants

An initial list of broad global health competencies was generated by the principal investigators (N.S. and D.R.S.) by reviewing the literature for both neurology-based competencies and general global health competencies.^{9,21,22,23-29} All domains and competencies identified in the literature review were compiled in a comprehensive list which constituted the initial survey sent to participants. Of note, individual competencies identified by literature review were modified to be specific to neurology. For example, the competency, “Describe how globalization contributes to the spread of communicable and chronic disease,” was modified to, “Describe how globalization contributes to the spread of communicable and chronic neurologic disease.” In addition, both individual competencies and proposed domains were modifiable during the subsequent Delphi process. The initial survey was reviewed by medical education experts (V.K. and S.A.T.) with specific attention to ensure the wording and formatting was consistent with standards of the Accreditation Council of Graduate Medical Education. The finalized initial survey consisted of 72 competencies across 9 domains.

The survey was sent through email to expert panelists who were asked to rate each competency based on appropriateness for inclusion among a list of essential competencies for global neurology fellowship training using a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). In the first survey round only, each item also included an open response option to provide comments or suggest wording changes to existing competencies, and participants were also able to propose their own competencies for inclusion. Surveys were administered using Qualtrics (Provo, UT), and questionnaire responses were anonymous to ensure all responses carried equal weight.

Mean scores were calculated for each competency, and all qualitative feedback and new competencies proposed by participants were summarized. A revised survey was sent to the group including all competencies that did not reach consensus criteria in the first round as well as competencies with proposed word changes and newly proposed competencies. After responses were collated, a third survey was sent that included only competencies that had not reached consensus during the second round. Finally, a conference call was used in the fourth round to discuss and come to consensus on remaining competencies.

Consensus competencies then underwent formal review by a group of neurologists from LMICs with experience working with neurologists based in HICs (Table 2) to provide feedback on potential gaps, feasibility, relevance, and local challenges in implementation of the competencies. LMIC experts reviewed the competencies, completed a semistructured questionnaire regarding inappropriate and missing competencies, and then participated in a focus group discussion to further identify relevance, high-priority and low-priority competencies, and finalize new competencies for inclusion in the final list.

Table 2.

Diversity and Expertise of LMIC-Based Expert Participants

Data Analysis

Average ratings for each competency were calculated. Based on previously published methods,²⁰ panelists reached consensus to automatically include competencies with a mean rating of >3.5 and exclude competencies with a mean rating of ≤3.0. Competencies with a mean rating between 3.01 and 3.50 were included in the subsequent survey round for further consideration and voting.

Standard Protocol Approvals and Participant Consents

Consent acknowledgment was included at the beginning of the expert survey (United States–based experts) and structured questionnaire (LMIC experts). The Johns Hopkins University School of Medicine Institutional Review Board approved this study with a waiver of written informed consent. Anonymized data not published within this article will be made available by request from any qualified investigator.

Results

Invitations to participate were sent to 23 United States–based global neurology experts. Two did not respond, and 1 declined to participate. Of the 20 experts who agreed to participate, 1 did not respond to any surveys and was excluded. Nineteen panelists completed the round 1 survey, 18 panelists completed the round 2 survey, and 19 panelists completed the round 3 survey. Fourteen panelists participated in the conference call in round 4, and the remaining 5 provided feedback through email and agreed on the final competencies. Figure summarizes the process and results of each round, and Tables 3 and 4 display a list of the resulting 47 competencies divided over 8 domains. eAppendix 1 (links.lww.com/WNL/C726) contains the detailed analysis and consensus for each round for competencies and domains.

Figure. Summary of the Process and Results of Each Round Required for Achieving Consensus on the Global Neurology Curriculum.

Table 3.

Global Neurology Competencies Reaching Consensus in the First 4 Domains: “Cultural Context, Social Determinants of Health, and Access to Care;” “Clinical and Teaching Skills and Neurologic Medical Knowledge;” “Team-Based Practice;” and “Developing Global Neurology Partnerships”

Table 4.

Global Neurology Competencies Reaching Consensus in the Last 4 Domains: “Ethics,” “Approach to Clinical Care,” “Community Neurologic Health,” and “Health Care Systems and Multinational Health Care Organizations”

The main reasons cited by panelists for excluding certain competencies included competencies being too broad, too basic (i.e., ideally should have been achieved during neurology residency), not specific to global health, not teachable, or not measurable.

LMIC experts noted competencies were highly relevant to their settings overall and rated the most important competency domains/subdomains as clinical skills and cultural context, social determinants of health and access to care, team-based practice, and developing global neurology partnerships. As a result, competency domains are listed in this order to reflect their relative perceived importance. Policy-focused competencies were believed to be least relevant overall but, nevertheless, were still deemed important. Based on input from the LMIC experts, wording changes were made to 6 competencies and an additional 3 competencies were added, 1 each to the following domains: clinical and teaching skills and neurologic and medical knowledge, team-based practice, and health care systems and multinational health care organizations.

Furthermore, during the focus group, the LMIC neurologists emphasized empathy, ethical behavior, respect, the ability to adapt medical knowledge and skills to local resources, and understanding sociocultural aspects of the country as key aspects of actualizing the competencies, with “respect” and “bidirectional exchange” being particularly important. It was noted that many times, LMIC investigators have experienced international collaborators “coming, taking, and leaving” rather than collaborating and building together. Other elements such as sustainability, capacity building, and an emphasis on cost-effective practice were also noted as crucial to maintaining the longevity of programs. Cultural context, including the stigma of neurologic disorders, and the need for an intentional focus on advocacy were identified as crucial areas for neurologists working in LMIC settings.

Discussion

This modified Delphi process resulted in 47 competencies regarded as essential for neurologists from HICs pursuing training in global neurology. Formal competency-based global health curricula have become an accepted standard in global health training,^24,30 albeit with varying models and outcomes.^31,32 Accepted formal competencies that are observable, measurable,^17,18 and appropriately structured to reflect specific educational outcomes agreed on by neurologists from HICs and LMIC partners with experience in this area may result in trainees feeling more comfortable enrolling in global neurology training programs. In addition, appropriate competencies may engender greater support for global neurology activities at the administrative and financial levels of academic neurology departments.

The Delphi method has been used previously to develop a consensus fellowship curriculum.²⁰ Using the combined expertise of US-based global neurologists and LMIC-based neurologists with experience collaborating with and/or training neurologists from HICs has resulted in this set of extensive, well-researched proposed competencies for US-based neurologists or neurologists trained in other HICs pursuing postgraduate training in global neurology.^33-35 Our consensus curriculum was reviewed by neurologist colleagues in LMICs and adjusted to reflect their comments on the content and perceived importance of each competency domain.

Challenges to implementing, monitoring, and evaluating this postgraduate competency framework³⁶ include possible mismatch of existing competencies with patient or population needs, lack of international teamwork and collaboration, a scarcity of medical institutions in LMICs, and limited capacity of LMIC institutions to expand their educational opportunities to external trainees. Currently, the number of global neurology trainees is small, but adequate resources for development and implementation of programs and curricula exist in many countries. Implementation of the competency framework developed here would require several steps, including developing partnerships across geographic boundaries, identifying in-country resources (including available technology for neurodiagnostics and virtual training), and identifying in-country neurology mentors.¹¹ Consulting other global health programs, program directors, and curriculum experts for first-hand experiences and advice can be invaluable when implementing a new program in a new country, particularly when seeking the expertise and experience of in-country educators and clinicians.³³

This study has clearly articulated goals for United States–based neurologists or neurologists from other HICs pursuing fellowship training of at least 1 year in global neurology. As such, a comprehensive list of competencies was developed that are likely unachievable for neurology postgraduate trainees or medical students who seek a short-term global neurology experience in an LMIC. The proposed competencies could, however, serve as a starting point for educators interested in developing competencies for short-term to medium-term global neurology experiences or further adapted to “milestones” for residents or students pursing such experiences. Thus, this more complete list of competencies could be prioritized and pared down to those appropriate for and achievable in an experience of shorter duration.

Furthermore, not every competency included in this list will be applicable to or appropriate to all LMIC settings in which a trainee may pursue global neurology training. We anticipate that individual programs will choose the most applicable competencies for their trainees and will likely not include all 47 competencies for every trainee in every program. Finally, given the limited number of neurologists who pursue formal global neurology training, a formal accreditation or board examination evaluating these competencies is unlikely, and adherence to these competencies will likely be undertaken and evaluated only at the individual program level. It is also important to recognize that the final list of global neurology competencies proposed here does not address the postgraduate neurology training needs in many LMIC settings. A comparative inspection of the vast difference in number of trained adult neurologists—4.75 per 100,000 people in HICs vs 0.13 per 100,000 in LMIC³⁷—demonstrates the astounding lack of access to neurologic expertise that many patients with neurologic disorders encounter and the concomitant lack of neurology training programs³⁸ in the parts of the world that need them most. The consensus competencies presented here were developed for Unites States–based neurologists who have already completed neurology residency and, thus, have acquired a solid foundation of clinical knowledge and skills in general neurology. As such, the proposed competencies are likely not appropriate in their current form to serve as curricula for neurology training programs developed in LMICs. However, 1 goal of HIC global neurology programs should be to provide training, networking, and capacity building in the local institutions in which they are working through strengthening and developing collaborations, sharing expertise, enhancing networking opportunities for local physicians and trainees, and building capacity at a local level. This can then be followed by other formal international exchange or research programs for health care workers from LMICs such as the Fulbright exchange program.³⁹ As such capacity develops, neurologists in LMICs would ideally be involved in reshaping these competencies which could then serve as a starting point to be adapted and incorporated into local curricula once appropriately contextualized.

Finally, while outside the scope of this study, we acknowledge the implementation challenges and local burden that are required to effectively develop and institute a global neurology training program in an LMIC setting. These considerations are certain to vary substantially from location to location and even from institution to institution within a given location. To begin to gain perspective on and address implementation issues that may be more widespread and generalizable between locations, we convened a panel of LMIC neurologists from across several world regions with experience working with neurologists from HICs. While we sought a broad representation of experts from around the world, not every world region was represented, nor was every potential content within represented world regions. However, context-specific considerations such as language proficiency, cultural competency training, compensation for partnering institutions and mentoring, as well as medicolegal practicalities, are essential components of any program—regardless of setting—that intends to implement and use the competencies defined herein. As such, strong international partnerships and open discussions between collaborators will be essential to considering and equitably implementing these competencies at any institution worldwide and should be undertaken before beginning a global neurology training program anywhere in the world.

While the field of global health neurology is still in its infancy, this proposed curriculum could serve as a starting platform and framework to help grow the number of young neurologists trained in global neurology and may also serve as a model for global health training programs in other medical specialties. The rapidly evolving dynamic of the global health community will virtually ensure that the proposed competencies will likely change over time as perceptions evolve within the field of global health. As such, these competencies should be seen as a starting point for programs training neurologists from HICs in global neurology and should be adapted as needed to the changes affecting the field of global health, such as increasing migration patterns, conflicts, and emergence and re-emergence of neurotropic pathogens.

Glossary

AAN

American Academy of Neurology

ANA

American Neurological Association

HIC

high-income country

LMIC

low- and middle-income country

Appendix. Authors

Study Funding

The authors report no targeted funding.

Disclosure

The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.