After Global Health Training—The Path Forward (Commentary)

Over the past 15 years, multiple graduate medical education training programs have established global health career pathways. These tracks, some of which have benefited from decades of experience with short-term elective rotations,¹ were developed in response to the sustained interest of a steady stream of medical school graduates intent on shaping their careers to address global health disparities. In this issue of the Journal of Graduate Medical Education, 2 articles highlight the promises and challenges faced by graduates of global health programs. Palazuelos and colleagues² describe the early career paths of graduates of a global health residency program at Brigham and Women's Hospital in Boston, Massachusetts. Though the majority of graduates were engaged in a career in global health, they faced substantive challenges, including ill-defined career pathways, a lack of institutional support and long-term mentorship, relatively low salaries, educational loan debt, and expanding family obligations.² In a second article, Brown and colleagues³ systematically reviewed job postings of major global health employers seeking physicians for overseas placement. Having previous overseas experience, a master's degree, and language skills were frequently listed as desirable qualifications, and many global health employment opportunities involved administrative or public health skills.³ Taken together, these studies highlight the uphill battles that many graduates of global health training programs face early in their careers.

Aspiring global health physicians are typically idealistic individuals who demonstrate remarkable commitment and unique talents. Arguably, the most successful graduates of global health training programs demonstrate an existential commitment to health equity, the depth of which motivates them to overcome myriad challenges. The physician-philosopher and Holocaust survivor Viktor Frankl writes in Man's Search for Meaning (quoting Friedrich Nietzsche), “He who has a why to live for can bear almost any how.”⁴ My own experience with individuals pursuing advanced global health training is that their deep understanding of human dignity and their dedication to human flourishing grounds their commitments to health equity. It is not surprising, then, that graduates of such programs often settle for lower-paying salaries, extend their training, dedicate extra time to learn new skills, forge new collaborations, and are prepared to give up many creature comforts of life in the United States. These are highly motivated, inspired, and often inspiring individuals who are a joy to mentor and to coach. But how do we help them navigate early career transitions, institutional expectations, and family obligations? The path forward is through strong mentorship and solid institutional commitments.

Those based in academic settings need faculty mentors who provide dispassionate, informed career guidance, serve as life coaches, and advocate within and beyond their institutions for their mentee's engagement with health disparities. The best global health mentors nudge trainees toward better self-understanding, not only of their strengths and weaknesses across various competency domains but also how vocational fulfillment (whether in research, education, clinical care, administration, or policy) can be married to a particular global health need. And graduates of global health training need to earn a reasonable wage. According to the Association of American Medical Colleges' 2018 questionnaire, 72% of graduating medical students carry outstanding loans, with a median debt of $195,000.⁵ For some, substantive salary support comes from clinical activities that can easily be blocked in shifts, such as hospitalist positions for internists and pediatricians (nearly 60% of graduates from the Brigham and Women's Hospital Residency in Global Health Equity were engaged in global health careers as hospitalists),² laborist positions for obstetricians, and emergency medicine positions. These roles may be more conducive to work overseas than positions with extensive outpatient responsibilities.

For trainees seeking to build global health careers in the research arena, navigating funding can be daunting. Experienced research mentorship is critical to guide mentees toward appropriate funding opportunities and to offer constructive feedback on manuscripts and grant proposals. Those aspiring to research-oriented global health careers may particularly benefit from early career opportunities for advanced training in research methods, such as MSc-Global Health, MPH, and PhD programs. Recognizing the particular value of physician-scientists, who are uniquely positioned to address clinically relevant research questions, the National Institutes of Health has created several clinically oriented, mentored research career development awards (K08, K23) offered across multiple institutes that can fund global health work. In addition, the Fogarty International Center has created an International Research Scientist Development Award (K01) to provide support and protected research time for early career investigators seeking to develop careers and research activities that address health priorities in low- or middle-income countries. Other potential sources for global health research funding include the Bill & Melinda Gates Foundation, the Centers for Disease Control and Prevention, and a host of foundations and specialty-specific associations. The summary of employment listings offered outside traditional clinical and research settings presented by Brown et al³ highlights opportunities for physician engagement with large nongovernmental organizations, primarily in administrative and public health roles.

Good life coaching acknowledges that sometimes, just beyond the earliest phases of global health training, life events happen (eg, marriages, spousal career opportunities, children) to global health graduates. Growing family commitments may require a shift in career priorities from international to domestic settings. But glaring health disparities exist domestically, and graduates of global health training programs are particularly well-suited to pivot from overseas clinical and research projects to domestic ones involving, for instance, indigent, minority, and refugee populations.

Those with deep existential commitments to addressing global health disparities can engage differently and reengage at various phases in their careers. A shining example of this model is Joseph J. Mamlin, MD, professor emeritus of medicine at Indiana University School of Medicine, who spent 2 years early in his career working in a medical school in Afghanistan, then transitioned to Indiana University for the greater part of his career, and following retirement has spent nearly 18 years coleading an academic medical partnership in western Kenya.⁶ The underlying commitment to global health endures seasons of life, and graduates of global health programs should remain nimble to reengage globally at various stages of their careers.

Finally, institutional support is vital. Forward-looking institutions cultivate and engage global health across multiple mission areas and programs and recognize that global health career pathways add value to their institutions. Clinicians who have been trained partially in global settings bring back experience with diverse, often advanced, pathology that broadens their clinical knowledge and benefits trainees and colleagues at their home teaching institutions. Moreover, individuals with global health experience have honed clinical skills in settings with unique resource constraints, and they often develop mature understandings of sociocultural, environmental, and policy determinants of health outcomes that can be adapted to local contexts. Through participating in research and implementation projects abroad, many have the opportunity to promote and adapt effective health solutions from resource-constrained settings to their home institutions in a form of reverse innovation.⁷ But if we overemphasize institutional self-interest in promoting global health careers, we miss the point. Global health is not about us; it is about others. The goal of investing in global health career pathways is to improve the health of disadvantaged populations, and it is a tangible investment in social justice, health equity, and the promise of the next generation of caring physicians.