A Comprehensive Framework for International Medical Programs: A 2017 consensus statement from the American College of Academic International Medicine

Abstract

International Journal of Critical Illness and Injury Science (journal)
---- The American College of Academic International Medicine (ACAIM) represents a group of clinicians who seek to promote clinical, educational, and scientific collaboration in the area of Academic International Medicine (AIM) to address health care disparities and improve patient care and outcomes globally. Significant health care delivery and quality gaps persist between high‑income countries (HICs) and low‑and‑middle‑income countries (LMICs). International Medical Programs (IMPs) are an important mechanism for addressing these inequalities. IMPs are international partnerships that primarily use education and training‑based interventions to build sustainable clinical capacity. Within this overall context, a comprehensive framework for IMPs (CFIMPs) is needed to assist HICs and LMICs navigate the development of IMPs. The aim of this consensus statement is to highlight best practices and engage the global community in ACAIM’s mission. Through this work, we highlight key aspects of IMPs including: (1) the structure; (2) core principles for successful and ethical development; (3) information technology; (4) medical education and training; (5) research and scientific investigation; and (6) program durability. The ultimate goal of current initiatives is to create a foundation upon which ACAIM and other organizations can begin to formalize a truly global network of clinical education/training and care delivery sites, with long‑term sustainability as the primary pillar of international inter-institutional collaborations.

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188 © 2017 International Journal of Critical Illness and Injury Science | Published by Wolters Kluwer - Medknow
Position Paper
A Comprehensive Framework for
International Medical Programs: A 2017
consensus statement from the American
College of Academic International
Medicine
Manish Garg, Gregory L. Peck1, Bonnie Arquilla2, Andrew C. Miller3, Sari E. Soghoian4,
Harry L. Anderson III5, Christina Bloem2, Michael S. Firstenberg6, Sagar C. Galwankar7,
Weidun Alan Guo8, Ricardo Izurieta9, Elizabeth Krebs10, Bhakti Hansoti11,
Sudip Nanda12, Chinenye O. Nwachuku12, Benedict Nwomeh13, Lorenzo Paladino2,
Thomas J. Papadimos14, Richard P. Sharpe15, Mamta Swaroop16,
Stanislaw P. Stawicki12, On behalf of the ACAIM Consensus Group on International
Medical Programs Temple University School of Medicine,
Philadelphia, Pennsylvania, 1Rutgers:
Robert Wood Johnson Medical School,
New Brunswick, 15Warren Hospital,
St. Luke's University Health Network,
Phillipsburg, NJ, 2Suny Downstate
Medical Center, Brooklyn, 3East Carolina
University, Greenville, NC, 4NYU Langone
Health, New York, 8Jacobs School of
Medicine and Biomedical Sciences,
Buffalo, NY, 5St. Joseph Mercy Hospital,
Ann Arbor, Michigan, 6Summa Health
System, Akron, 13Nationwide Children’s
Hospital, Columbus, 14University of
Toledo College of Medicine and Life
Sciences, Toledo, OH, 7University of
Florida College of Medicine, Jacksonville,
9University of South Florida, Tampa, FL,
10Thomas Jefferson University Hospital,
Philadelphia, 12St. Luke’s University
Health Network, Bethlehem, PA, 11Johns
Hopkins Medicine, Baltimore, MD,
16Northwestern University Feinberg
School of Medicine, Chicago, IL,
United States of America
Address for correspondence:
Dr. Stanislaw P. A. Stawicki,
St. Luke’s University Health Network,
Bethlehem 18015, PA,
United States of America.
E‑mail: stawicki.ace@gmail.com
ABSTRACT
The American College of Academic International Medicine (ACAIM) represents a group of
clinicians who seek to promote clinical, educational, and scientific collaboration in the area
of Academic International Medicine (AIM) to address health care disparities and improve
patient care and outcomes globally. Significant health care delivery and quality gaps persist
between high‑income countries (HICs) and low‑and‑middle‑income countries (LMICs).
International Medical Programs (IMPs) are an important mechanism for addressing
these inequalities. IMPs are international partnerships that primarily use education and
training‑based interventions to build sustainable clinical capacity. Within this overall
context, a comprehensive framework for IMPs (CFIMPs) is needed to assist HICs and LMICs
navigate the development of IMPs. The aim of this consensus statement is to highlight best
practices and engage the global community in ACAIM’s mission. Through this work, we
highlight key aspects of IMPs including: (1) the structure; (2) core principles for successful
and ethical development; (3) information technology; (4) medical education and training; (5)
research and scientific investigation; and (6) program durability. The ultimate goal of current
initiatives is to create a foundation upon which ACAIM and other organizations can begin to
formalize a truly global network of clinical education/training and care delivery sites, with
long‑term sustainability as the primary pillar of international inter‑institutional collaborations.
Key Words: Academic International Medicine, comprehensive framework for international
medical programs, International Medical Programs, The American College of Academic
International Medicine
FOREWORD
The American College of Academic International Medicine
represents clinicians from every specialty and from every
discipline of the health sciences. Our membership includes
practitioners from around the world. The following consensus
statement is intended to represent the physician voice to and
from every field of medicine.
Access this article online
Website: www.ijciis.org
DOI: 10.4103/IJCIIS.IJCIIS_65_17
Quick Response Code:
Cite this article as: Garg M, Peck GL, Arquilla B, Miller AC,
Soghoian SE, Anderson HL, et al. A Comprehensive Framework for
International Medical Programs: A 2017 consensus statement from the
American College of Academic International Medicine. Int J Crit Illn Inj
Sci 2017;7:XX-XX.
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Garg, et al.: A comprehensive framework for international medical programs
International Journal of Critical Illness and Injury Science | Volume 7 | Issue 4 | October-December 2017 189
growing demand for the aainment of enhanced quality
of patient care, including standardized practices, clinical
protocols, and technological implementations. There is
a growing need to invest in access and outcome‑based
policies to enhance local health care infrastructure,
workforce, and capacity in resource‑limited seings.[5]
It is difficult to improve health systems without first
ensuring that basic infrastructure and resources are
present. Paul Farmer has referred to these needs as the
“four S’s” of “sta, stu, space, and systems.”[6‑8] IMPs
are instrumental in supplying knowledge, technology,
and eective care to people living in regions with limited
health care resources and/or care delivery platforms.
Moreover, IMPs provide personnel and logistics to
support sustainable efforts in partner communities
while facilitating the translation of current concepts and
medical advances into improved clinical outcomes. For
clarity, IMPs are not “global health” (GH) programs
where public health experts focus on the performance
of research in LMICs. In this context, the objective of
IMPs is to work in tandem with GH researchers to
ensure the optimization of structure and function of
clinical enterprises, supporting the provision of high‑
quality, timely and affordable care. At the same time,
IMPs should strive to ensure safe and well‑structured
environments for medical education and training.[9,10]
These core concepts serve as the rationale to advance
IMP bidirectional exchange, where participants of low‑
resource countries are able to engage in education and
training opportunities in high‑resource seings.
THE STRUCTURE OF INTERNATIONAL
MEDICAL PROGRAMS
There are four main personnel roles in IMPs: program
directors, program managers, team leaders, and
health specialists.[11] Program directors oversee all
IMP operations, champion collaborative vision, and
set administrative, educational/training, and research
goals. Program managers are responsible for day‑to‑day
operations, regulatory and compliance documentation,
and facilitate the interaction between trainees and the
clinical/academic environment. Team leaders directly
supervise trainees during patient care. Health specialists
serve as short‑ or long‑term advisors, program ocers, or
consultants. Together these roles provide complimentary
personnel for successful IMPs structuring [Figure 2].
Core competencies fall into five general categories:
(1) basic and public health skills, (2) management skills,
(3) communication skills, (4) cross‑cultural skills, and
(5) analytical and research skills Figures 2 and 3.[11,12]
Basic and public health skills are subdivided into public
health, disease control, and prevention competencies.[13]
INTRODUCTION
Significant disparities in health care delivery
persist between high‑income countries (HICs) and
low‑and‑middle‑income countries (LMICs). International
Medical Programs (IMPs) are an important mechanism of
American medical outreach to address these inequalities.
IMPs are international partnerships that use primarily
education and training‑based interventions, broadly
defined in this consensus as Academic International
Medicine (AIM), to build local clinical capacity in
low‑resource settings [Figure 1]. Professional and
ethical frameworks for research‑based international
medical partnerships and participation in short‑term
international training experiences exist;[1‑3] however,
few guidelines are available to support the design,
development, and wider adoption of IMPs. In practice,
IMPs face a variety of challenges including, but not
limited to, lack of sustainability; inconsistent funding
and resources; poorly dened structure; and non‑specic
long‑term goals and/or deliverables. When several HICs
collaborate, poor interinstitutional coordination can
result in confusion, misallocation, and maldistribution
of limited resources.[4]
This consensus statement outlines key issues and core
principles, identied during the 2017 AIM Congress by the
leadership of American College of Academic International
Medicine (ACAIM). Here we introduce the Comprehensive
Framework for International Medical Programs (CFIMPs)
with the goal to promote and improve access to quality
medical care globally. The CFIMPs [Table 1] highlights key
aspects of IMPs including: (1) structure; (2) core principles
for ethical development; (3) information technology; (4)
medical education and training; (5) research and scientic
investigation; and (6) program durability.
RATIONALE FOR INTERNATIONAL MEDICAL
PROGRAMS
Institutions across the United States (US) have worked
diligently to advance medicine worldwide through the
prism of bidirectional development. In LMICs, there is
Academic International
Medicine
International clinical
education and training-
based interventions that
place a priority on
improving health care
disparities and achieving
health equity for all people
worldwide
International Medical
Programs
International partnerships
that use primarily
education and training-
based interventions to build
local clinical capacity in low
resource settings
Figure 1: Definitions of Academic International Medicine and International
Medical Programs

Garg, et al.: A comprehensive framework for international medical programs
International Journal of Critical Illness and Injury Science | Volume 7 | Issue 4 | October-December 2017
190
Intuitively, appropriate technical expertise and sound
understanding of the epidemiology and pathology of
diseases can help achieve project outcomes.
Management skills are subdivided into financial,
human resource, administration, and contact‑related
competencies. IMP personnel must be adept at
policy formulation, planning and development, and
multidisciplinary team building as these are critical
management skills.[11]
Communication skills are subdivided into negotiations,
mentoring, conict resolution, and advocacy competencies.
Other important communication skills include English
language fluency, sufficient proficiency in pertinent
site‑specific languages, as well as technical/specialist
consultation or advisory skills.[11,14]
Cross‑cultural skills are essential to IMP work and
include the ability to communicate effectively with
people from dierent socioeconomic, ethnic, and cultural
backgrounds.[15,16] In LMICs, clinicians must be able to work
independently in complex social and cultural seings with
extremely limited resources and high poverty levels. IMP
personnel should be able to adapt to diverse educational
and cultural backgrounds, and interface eectively with
both public and private sectors while exhibiting culturally
sensitive professional standards of conduct.
Finally, IMP personnel should possess fundamental
analytical and research skills (including research
ethics) in accordance with international standards
and guidelines.[11] They need to develop necessary
institutional and legal frameworks and identify key
infrastructure needs and required resources. For
each of the above competencies, IMPs should aim to
achieve mastery of cultural competence and integration
[Figure 3].[12] The ethnocentrism‑ethnorelativism
continuum of intercultural sensitivity as it pertains to
the current discussion is presented in Figure 4.[17]
CORE PRINCIPLES FOR SUCCESSFUL
DEVELOPMENT OF INTERNATIONAL
MEDICAL PROGRAMS
AIM serves an important role in both HIC and LMIC
health systems.[18] An eective AIM approach is to develop
or work within partnerships built on shared goals and
objectives as the platform for international exchange.
Considerable time and eort is required to build the level
of trust; mutual understanding and experience needed
to achieve transparent and productive relationships; and
the understanding of needs, aims, and mechanisms.[19]
Reciprocal benets and liabilities should be thoughtfully
examined and clearly communicated. This investment of
faculty time and eort should be quantied using organized
metrics to ensure successful development of IMPs. Although
partnerships involved in each IMP will be unique in their
aims and applications, some general themes apply. The
following are several commonly encountered perspectives
presented as a platform for discussion as part of the CFIMPs.
PROMOTING SUSTAINABILITY: AVOIDING
THE “VOLUNTOURISM” TRAP
IMPs must be thoughtfully designed and implemented
Table1: Outline of the American College of Academic
International Medicine Comprehensive Framework for
International Medical Programs (CFIMPs)
Structure of IMPs
Define personnel roles
Develop specific competencies
Develop necessary institutional and legal frameworks
Identify key infrastructure needs and required resources
Core principles for successful IMP development
Assurance of reciprocity within partnerships
Established organizational metrics for international faculty efforts
Promoting and ensuring sustainability
Ensuring stakeholder input and reconciliation of goals/priorities
HIC perspective
LMIC perspective
Existing IMP models with measurable outcomes
Investments in capacity to sustain improvements in care
Creating supply chains to support medical and educational capacity
Adherence to established regulatory frameworks and requirements
Learning from United States Military humanitarian assistance
operations
IT support for the development, evaluation, and benchmarking of IMPs
Addressing basic infrastructure, connectivity, hardware, and
software challenges
Emphasis on data security, privacy, and patient clinical information
protection
Strategies for initiating, operationalizing, maintaining, and securing
an EMR in low-resource settings
Selecting fiscally responsible and adaptable IT platforms
Medical education and training
General considerations common to HIC and LMIC-based IMP curricula
Value of IMPs and AIM to trainees
University hospitals and academic health centers as IMP sponsors
and incubators of AIM faculty champions
Establishing a system of competencies and milestone-based
academic systems
Framework for bidirectional faculty and trainee assessment
International standardization and accreditation systems: 360-degree
perspective
Research and scientific investigation
Using established research guidelines, frameworks, infrastructure,
and networks to create synergies
Collaborating with scientific and civil society organizations with
track records of successful implementation and completion of
international research projects
Bidirectional participation to enhance research quality
Keys to IMP durability
Ensuring the collaboration and expansion of bidirectional efforts
within IMPs
Regularly conducted peer-review of IMP performance, including the
analysis of SWOTs
Ensuring communication, engagement, cultural acceptability, and
regulatory oversight
Diversification of funding mechanisms to optimize long-term
sustainability
IMPs: International Medical Programs, HIC: High-income country, LMICs:
Low-and-middle-income countries, IT: Information technology, AIM: Academic
International Medicine, SWOTs: Strengths, weaknesses, opportunities, and
threats, EMR: Electronic medical record

Garg, et al.: A comprehensive framework for international medical programs
International Journal of Critical Illness and Injury Science | Volume 7 | Issue 4 | October-December 2017 191
to achieve measurable institutional and societal
benefit. The term “voluntourism” has been used to
describe the practice, whereby travelers from HICs
participate in voluntary work within LMICs.[20,21]
While this form of medical outreach is genuinely
motivated by a desire to help others, it may easily be
perceived as a self‑serving "vacation", unregulated
skills acquisition, or pseudo‑academic activity to
enhance one's professional resume. The lack of proper
organizational framework or supervision also puts into
question the integrity of such unstructured medical
trips. Short‑term “volunteer vacations,” “drive‑by
humanitarianism,” and “parachute medicine” rarely
have sustainable impact on the host environment and
raise ethical and moral concerns about international
medical outreach in general.[10,20,22‑25]
Promoting sustainability involves short‑, intermediate‑, and
long‑term commitments (e.g., dedication to consistent
presence), bidirectional exchange of personnel and
trainees with reciprocal agreements (i.e., starting
student/resident electives with memoranda of
understanding, consideration of international faculty
appointments, etc.), operational/logistical support, and
the development of IMP champions on both sides. Joint
needs analysis, with dissemination and implementation
of corresponding plans, are both critical to successful IMP
outcomes. The benchmarking process should include
periodic assessments of goals, highlighting achievements
and addressing failures, anticipating emerging target areas
of focus, and securing nancial and personnel support.[26,27]
HIGH‑INCOME COUNTRY PERSPECTIVE
From an organizational perspective, participation
in IMPs supports HIC institutional excellence by
enhancing national and international impact. IMP
participation also serves to aract high‑quality trainees
and faculty. It has been suggested that future physicians
cannot serve impoverished communities effectively
without first understanding the structural forces that
contribute to societal inequalities.[6] International
rotations have grown exponentially over the last decade,
and well‑structured programs inuence trainee choices
in undergraduate and graduate medical education
and fellowship.[9] International electives provide rich
learning opportunities to demonstrate professionalism,
practice‑based learning, and system‑based practice (SBP),
competencies challenging to teach in a homogeneous
learning environment.[28] Despite evidence that
international clinical electives can be educationally
and professionally benecial to both high‑resource and
low‑resource country trainees, participation remains
challenging for American residents.[29] Only 59% of
residency programs oer international clinical rotations
to residents, and as few as 10% of residents participate
Figure 3: The continuum of cultural competence. International Medical Programs
should strive to embrace bi-directional mastery within each domain
[12]
Figure 4: The continuum of intercultural sensitivity. International Medical Programs
should embrace bidirectional ethnorelativism
[17]
Personnel Competencies
Program
Directors
Program
Managers
Team Leaders Health
Specialists
Basic & Public
Health Management
Cross-Cultural Analytical &
Research
Communication
Trainees
Figure 2: International Medical Program structure organized by personnel needs and competencies. Trainees are integral to the model as they supply an expanded
work force that can advance to a personnel role. Trainees also shape and are educated via the competencies. Partnerships should designate and create site-specific
structure for sustainability and academic validity
[11]

Garg, et al.: A comprehensive framework for international medical programs
International Journal of Critical Illness and Injury Science | Volume 7 | Issue 4 | October-December 2017
192
when such opportunities are available.[30] Students
participating in IMPs develop improved cultural
sensitivity, clinical and communication skills, resource
utilization, and are more likely to work in underserved
areas upon training completion.[31,32] Faculty serving in
LMICs are beer prepared to model and teach important
skills not otherwise obtainable at home. The institutional
benet of LMIC work includes more patient‑centered
clinical care, improved community relations, and
potential for “reverse innovation” to improve health‑care
quality through exposure to new ideas and processes that
are eective in other systems.[18,33,34]
Although AIM training is not regulated by the Accreditation
Council for Graduate Medical Education (ACGME)
certication requirement, the ACGME competency‑based
assessment requirements may provide an important
framework for IMP‑based education.[35] AIM training
programs should incorporate common goals for clinical
care oversight and faculty development.[36,37] Published
clinical practice models may provide a template for
collaboration in this domain.[38,39]
LOW‑AND‑MIDDLE‑INCOME COUNTRY
PERSPECTIVE
IMPs are founded on mutual, bidirectional benefit.
This may include any combination of personnel,
physical resources, electronic reference access, didactic
opportunities, research collaboration, educational
exchanges, or formal mentorship.[40,41] Care must be
taken to ensure that HIC learners do not impede LMIC
learner education by diverting resources, cases, or
procedures. Conversely, LMIC learners should benet
from short‑term rotations in HICs, encouraging the
exchange and import of skills, ideas, and perspectives
needed to become the leaders of advancement or change
in their home countries. When accepting reciprocal LMIC
learners, IMPs should encourage policies that discourage
the “brain‑drain” phenomenon. It is counterproductive
when LMIC students and medical personnel travel to
HICs to pursue alternative training and upon completion
sele in the HICs rather than returning home with their
valuable knowledge and skill set.[42]
Retention programs with financial and sociopolitical
incentives are key to promoting the development of
local expertise.[40,43] Programs that expand local capacity
should be supported by all stakeholders, including
governments. An example is the human resources in
health program run by the Rwandan Ministry of Health
and supported by the Clinton Health Access Initiative.
Highlights include long‑term (i.e., 1‑year) HIC faculty
commitment to help develop Rwandan faculty and a
gradual phasing out of HIC faculty as Rwandan trainees
gradually move into full‑time faculty positions to
ensure program sustainability.[44,45] Similarly, the Afya
Bora (Swahili for “Beer Health”) Consortium, formed
in response to the need for qualied health care leaders,
consists of five Africa‑US partnerships in Botswana,
Kenya, Uganda, Tanzania, and Cameroon.[46] The
consortium works to develop a powerful collaboration
by merging and consolidating education, training, and
research experiences and resources. A focused mission
prepares future global leaders for careers in health care
seings to leverage governmental and nongovernmental
organizations (NGOs) to transform health care delivery
systems to beer serve the citizens of LMICs.[46]
INVESTMENTS IN CAPACITY TO SUSTAIN
IMPROVEMENTS IN CARE
Education is most effective as a tool for change if it
addresses not only “what” to do differently but also
“how” and “why” to do it. IMPs should consider the
totality of structural, socioeconomic, and institutional
resources, along with the barriers that impact clinical
change processes when designing and implementing
interventions. Achieving sustainable improvements
in clinical care require that programs also address
specific intervention and initiative implementation
within the existing LMIC service structure and systems.
Workforce, quality assurance, and research capacity
must be addressed in addition to clinical skills training.
Importantly, material resources to sustain or measure
the impact of desired changes strengthen the ability of
partners in LMICs to translate education and training into
improved downstream processes and health outcomes.
CREATING SUPPLY CHAINS TO SUPPORT
MEDICAL AND EDUCATIONAL CAPACITY
Needs assessments performed before IMP initiation
ensure that plans and supply chains are appropriate
and sustainable. Ideally, IMPs can leverage available
equipment and maintenance contracts from existing
local organizations. Basic supplies may be locally
available, but it is critical to ensure that ample resources
to sustain improvements are in place to support patient
care and subsequent education and training initiatives.
When selecting locations, the understanding of the low‑
resource site equipment and infrastructure landscape
is advantageous. Donated supplies that fit the needs
assessments and are compatible with locally available
components are crucially important. ACAIM does not
advocate the use of expired supplies, and any reuse
of supplies must be made on a case‑by‑case basis as
determined by the inter‑institutional collaborative
agreement. Moreover, all stakeholders need to agree on
supply quality standards to maximize care safety and
ecacy. For most IMPs, logistical issues are common and

Garg, et al.: A comprehensive framework for international medical programs
International Journal of Critical Illness and Injury Science | Volume 7 | Issue 4 | October-December 2017 193
usually addressable within the context of local cultural,
local social, and economic considerations. However,
advanced planning and care ensures that local custom
requirements and pathways are well understood before
shipping so that recipients are able to receive and use
donated items without undue expense.
ADHERENCE TO ESTABLISHED REGULATORY
FRAMEWORKS AND REQUIREMENTS
The most pernicious variety of “voluntourism” exists
when private placement organizations promote and
elevate HIC volunteers in expert roles while discounting
LMIC health workers with relevant training, superior
skills, and contextual knowledge.[47] Even highly
experienced clinicians need to develop cultural and
SBP competencies to practice safely and eectively in
new environments. It is critical that medical students,
residents, and other unlicensed participants do not
engage in unsupervised medical activities and/or perform
procedures that they are not permied to perform in their
home countries.[24] Within this broader context, IMPs
may help ensure that adequately licensed, prepared, and
motivated participants adhere to regulatory frameworks
(local and international), medicolegal implications, and
clinical practice standards relevant to their proposed
activities. Particularly, when trainees from HICs are (or
may become) involved in direct patient care decisions
in LMICs, the HIC institution has a duty to provide
adequate predeparture training, supervision, and
oversight. Rules and regulations (including credentialing)
are predetermined and agreed upon by all participants
to prevent health care outside professional scope and
training. This requires that HIC institutions recognize
and support the involvement of dedicated faculty in the
process.
Minimum accreditation standards are urgently needed
to help facilitate safe and eective IMP development.
Professional hospital and training program accreditation
organizations such as the Joint Commission International
are well placed to lead in this domain.[48] ACAIM
members may make visits to accrediting partners with
the expressed purpose of cooperation and bidirectional
information sharing. Among our near‑term goals, a
dedicated ACAIM taskforce will develop and maintain
an edited resource guide to assist institutions from HICs
and LMICs with milestones, regulatory frameworks,
and requirements.
LEARNING FROM UNITED STATES MILITARY
HUMANITARIAN ASSISTANCE OPERATIONS
The US military frequently engages in global humanitarian
aid and consequently can oer signicant knowledge
and experience in this domain. Historically, it was
noted that the Department of Defense humanitarian
assistance program achieved improved outcome‑based
measures of eectiveness by utilizing medical after‑action
reports, analyses of lessons learned, and expert‑based
feedback on internationally accepted standards in
humanitarian assistance.[49,50] Coordinated efforts
were subsequently made to disseminate emergency
management experiences in the following content
areas: (1) planning of regional/global collaboration
with public–private cooperation; (2) international
humanitarian action; (3) coordination of leadership;
(4) ethics in disaster management; (5) resilience
management; (6) training programs and exercises; (7)
human resources; (8) communication; and (9) civil‑military
cooperation.[51] Global medical humanitarian efforts
generally lag behind the military, and thus, there are
many clinical and operational experiences that can help
shape IMP development.
Military personnel undergo specialized preparation that
is potentially relevant to IMP leadership. One example
is diplomacy training that exists for military physicians
who deploy internationally.[52] Core concepts range from
understanding governance and international cooperation
to practical challenges in collaborative research and
capacity building. Finally, academic institutions can
draw parallels between IMP and military deployments
among their faculty members, especially in terms of
approaches to accounting for clinical productivity and
deployment‑related logistics.
INFORMATION TECHNOLOGY SUPPORT
FOR THE DEVELOPMENT, EVALUATION,
AND BENCHMARKING OF INTERNATIONAL
MEDICAL PROGRAMS
In LMICs, information technology (IT) challenges are
pervasive. Opportunities for improvement can be found in
the following areas: (1) basic infrastructure (e.g., electricity
availability and reliability); (2) connectivity (e.g., data
sharing, internet access, wireless, and wide area network);
(3) hardware (e.g., computers, tablets, servers, printers,
backup technology, peripherals, and interface devices);
and (4) software (e.g., EMR systems, patient photographs,
and disease progression picture archival).[53,54] A critical
emphasis needs to be placed on ensuring data security,
privacy, and appropriate mechanisms to protect patient
clinical information.
Strategic IT investments facilitate eective communication,
which is critical to eective IMP operations. For example,
implementing technology to support web‑based
conferencing may have great value.[55‑57] Partnerships for
initiating, operationalizing, maintaining, and securing an

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International Journal of Critical Illness and Injury Science | Volume 7 | Issue 4 | October-December 2017
194
EMR in LMICs may seem daunting, but experience and
technological advances suggest otherwise.[58] Web‑based
platforms and open‑source software are available and
may help defray costs associated with initiating and
maintaining EMR systems in LMICs.[59] With decreasing
costs, greater performance and reliability, and a smaller
device footprint‑storage capacity ratio, the reality of
providing and supporting some type of inexpensive and
adaptable IT platform is integral to contemporary IMP
eorts. Important considerations regarding the design
and implementation of IT and information management
solutions are presented in Table 2.
MEDICAL EDUCATION AND TRAINING
Trainee IMP participation has increased steadily over
the past 3 decades. In 1984, 6% of graduating US
medical students took part in international health
electives; this number has increased significantly
since then, with medical students self‑reporting GH
experiences on the Association of American Medical
Colleges Graduate Questionnaire in the range of 20‑
30%.[60] Despite growing interest, most trainees are
unable to participate in IMPs.[30] This may represent
a missed opportunity since the value of educational
involvement in AIM can be substantial for trainees.
International learning experiences may be empowering
and the highlight of one's training.[61,62] Moreover, many
trainees report a heightened sense of social responsibility,
improved cultural sensitivity, and improved clinical and
communication skills following IMP participation. Nearly
95% say it increased the likelihood they would volunteer
with low‑resource populations in the future.[31,32,63,64]
Despite evidence that international clinical electives
can be educationally and professionally beneficial to
both HIC and LMIC trainees, bidirectionality remains
challenging to secure. Even when logistically feasible,
elective rotations can be inconsistently structured.[29] It is
critical that participating trainees experience rst hand
the health‑care needs of the international community in
an organized and consistent manner.
AIM provides unique knowledge and competencies
that are currently underrepresented in medical
education. For example, it expands trainees’ immigrant
health knowledge, particularly in socioeconomically
disadvantaged communities.[33] Trainees must be prepared
for these knowledge and competency needs prior to an
AIM experience. Ideally, predeparture preparation for
trainees participating in international electives includes
both classroom and immersive experiential components.
[36] Among program directors who reported resident
participation in international rotations (approximately
73%), only 15.4% reported predeparture training specic
to working abroad. In addition, only 47% of responders
knew if liability insurance covered the residents’ work,
while 31% were not covered and 22% were unaware of
coverage. Furthermore, only 45% of the international
rotation sites had been evaluated for safety by a faculty
member.[36] Targeted predeparture training, dedicated
faculty supervision, professional liability insurance
agreements, and site‑specic safety veing are essential
parts of the CFIMPs. Multiple solutions to the issues
described above have been proposed. Aforementioned
published practice and curriculum models may be of
benet,[38,39] and bidirectional faculty development may
be optimized using universally available web‑based
resources.[37]
The global society is becoming increasingly
interconnected. IMPs provide experiential education
and opportunities for professional development while
allowing trainees to contribute as global citizens.
Participants attain valuable knowledge and skills,
including cultural competence.[65] Structured exposure to
technology‑limited practice seings sharpens history and
physical examination skills, encouraging more ecient
resource utilization. Trainees may also become more
familiar with unusual or advanced disease processes
and gain functional plasticity (i.e., operational SBP skills)
by learning how to navigate very dierent health care
systems [Figure 5].
Clinical care, education, and research are the traditional
pillars of academic medical practice. Through their
leadership in these domains, teaching hospitals help
establish and maintain best practices and standards
of care. IMPs seek to incorporate these state‑of‑the‑art
processes and practices across their international
partnerships through the development of AIM faculty
champions. Such institutional AIM champions must
eectively integrate local and global health delivery plans
with their departmental and college leadership while
being mindful of organizational strategic alignments
and plans.[70,71,72]
Figure 5: The value of International Medical Programs and Academic International
Medicine to trainees

Garg, et al.: A comprehensive framework for international medical programs
International Journal of Critical Illness and Injury Science | Volume 7 | Issue 4 | October-December 2017 195
ACCREDITATION SYSTEMS: 360‑DEGREE
PERSPECTIVE
Physician competency expectations can vary widely
between countries. Practice prerequisites ensure that
care of consistent quality is delivered.[18] In 2004, the
WHO and World Federation for Medical Education
partnered to develop accreditation standards for basic
medical education.[68] This partnership contributed
to better clinical training and improved standardized
test performance across a broad range of seings. The
ACGME has also expanded its global presence with the
ACGME‑International. This new entity has received a
positive reception from international medical students,
and many countries have adopted its standardized
accreditation systems.[69] ACAIM will utilize a
multidisciplinary consensus group to promote thoughtful
standardization, accreditation, and harmonization of
metrics with existing organizations. Strategic IMP‑centric
ACAIM planning initiatives are highlighted in Figure 6.
RESEARCH AND SCIENTIFIC INVESTIGATION
Research and analytical skills are among the core
competencies of international health workers.[11] Reasons
to engage in AIM or GH research begin with data needs
for regional, national, and global population health
indicators.[73] Currently, the quality and reliability of
captured data can be highly variable.[37] Some countries
do not have institutional review boards (IRB), informed
consent processes, or systems for patient protection
in research.[37] IMPs may participate in research to:
(1) improve study quality; (2) teach study design
methodologies, (3) develop informed consent procedures
and/or IRBs, (4) enhance population access to clinical
studies, (5) increase sample size, (6) decrease study
completion times, and (7) improve research proposal
AIM milestones to
assist trainees in
their professional
development
A collaborave
framework for
faculty and
trainee
assessment
Standardizaon
and accreditaon
metrics in tandem
with exisng
organizaons
Figure 6: American College of Academic International Medicine International
Medical Program strategic planning initiatives
IMP‑BASED MEDICAL TRAINING:
ESTABLISHING COMPETENCIES AND
MILESTONES
Trainees participating in IMPs can fulfill ACGME
competencies of patient care, professionalism,
practice‑based learning and improvement, interpersonal
and communication skills, medical knowledge, and
SBP. SBP is perhaps the most gradual of the ACGME
competencies to master because it requires good
understanding of dierent health care systems, knowledge
of safety and quality principles, and the ability to
successfully navigate health care economics. By requiring
the participant to engage in a complex operational
system intended to continually improve organizational
performance and resource‑utilization, IMPs uniquely
augment a trainee’s ACGME specialty‑specific
achievement of SBP milestones.[66] ACAIM aspires to
create appropriate AIM milestones to assist trainees
in their professional development, across various
specialties, and more importantly with the valuable
input and participation of both LMIC and HIC faculty
members.
FRAMEWORK FOR BIDIRECTIONAL FACULTY
AND TRAINEE ASSESSMENT
Program assessments should occur before, during, and
after IMP rotations, incorporating bidirectional trainee
and faculty feedback. Assessment tools developed
collaboratively with international faculty should take
into account environment‑specic cultural norms.[67] It is
important for trainees to perform planned self‑assessment,
focusing primarily on general ACGME competencies
and milestones. Trainees may also receive assessments
specic to their IMP‑based educational experience (i.e.,
patient care versus research). ACAIM will create a task
force to examine a collaborative framework that guides
bidirectional faculty and trainee assessment.
INTERNATIONAL STANDARDIZATION AND
Table 2: Information technology requirements and
solutions for successful international medical information
management programs
1. Basic infrastructure
2. Connecvity
3. Hardware
4. Soware
1. Web-based conferencing
2. Web-based plaorms and
open source soware
3. Academic instuons
4. Health organizaons
5. Medical informacs
professional organizaons

Garg, et al.: A comprehensive framework for international medical programs
International Journal of Critical Illness and Injury Science | Volume 7 | Issue 4 | October-December 2017
196
competitiveness.[37] Collaborations may be based on
local, virtual, or hybrid presence. Beyond study design,
IMP personnel may serve as advisors, co‑investigators,
or assist with statistical analyses, manuscript or grant
writing, and publishing.[37]
Researchers should utilize appropriate guidelines for
the reporting of health‑care research as outlined by the
Enhancing the Quality and Transparency of Health
Research Network.[74] In addition, the Guidelines for
Accurate and Transparent Health Estimates Reporting
were created to dene best practices for documenting
studies that report on global health outcomes.[74] Although
compliance with these guidelines is not an absolute
indicator of study quality, it does ensure that key
information is available so that an informed reader can
judge the study’s quality and use results appropriately.[73]
RESEARCH AND CIVIL SOCIETY
ORGANIZATIONS
When conducting international research, investigators
are encouraged to engage with local civil society
organizations (CSOs). Common in LMICs, CSOs are
nonprot organizations that aim to enhance the well‑
being and prosperity across communities. Motivated
to protect and empower the vulnerable, CSOs work in
areas such as community development, service provision,
advocacy, activism, and research.[75] Of note, research
and advocacy are among the main CSO health sector
functions, along with service provision, social welfare and
support activities. They are at the forefront of supporting
innovations intended to solve challenging issues facing
local communities. IMP–CSO partnerships are important
to ensuring that research eorts help improve the well‑
being of involved communities.[75] CSOs are able to
constructively impact research agendas by providing
appropriate contextual framework for both governments
and researchers.[75] Conversely, they can disrupt scientic
endeavors if they deem scientific premises invalid or
harmful to the local communities, as occurred when ACT
UP Paris successfully campaigned to halt the anti‑HIV
Tenofovir trials (Gilead Sciences, Inc.) in Cambodia and
Cameroon.[76,77]
CSOs come in ve types: (1) NGOs, (2) community‑based
organizations, (3) faith‑based organizations, (4) voluntary
health organizations, and (5) networks.[75] NGOs
work outside direct government control and can be
local, national, or international.[78] Community‑based
organizations draw membership from the communities
they serve.[75] Faith‑based organizations draw the purpose
of their work from a particular religious belief and
may work through local centers of faith.[75] Volunteer
health organizations often focus on a specic disease or
syndrome (e.g., diabetes or hypertension) and promote
research and trial participation, treatment access, and aid
for the aicted. Finally, networks are groups comprised
of various organizations and individuals that converge
around common issues.[75]
CSOs may assist research through advocacy with
policy‑makers and various funding sources. They
may function as a community interface and may
be an access point to vulnerable or stigmatized
communities (e.g. refugees).[75] Furthermore, many
CSOs are research‑focused and contain experienced
biomedical and social scientists, representing an often
underutilized resource for collaboration on areas such
as epidemiology, social sciences, product development,
knowledge translation, health services, and policy
research.[75] Finally, CSOs are critical when determining
if proposed research is in the best interests of the local
communities, ensuring respect toward their views and
rights.[75]
Figure 7: Key factors critical to International Medical Program viability. Each of the color-coded phases may take between 1-2 years to complete

Garg, et al.: A comprehensive framework for international medical programs
International Journal of Critical Illness and Injury Science | Volume 7 | Issue 4 | October-December 2017 197
Table 3: Key concepts important to developing successful IMPs
and ensuring program durability (adapted from John et al.[25])
1. Mutual respect and benefit
2. Trust
3. Good communication
4. Clear roles and expectations
5. Community engagement
6. Public engagement
7. Cultural acceptability
8. Post-trial obligations/benefit
sharing
9. Collaboration
10. Civil society organizations
11. Affordability
12. Accessibility
13. Regulatory navigation
14. Collection, management and
storage of biological materials
15. Addressing corruption and poor
governance
16. Management of unintended
consequences
KEYS TO IMP DURABILITY
We highlight 16 keys to navigating successful international
partnerships to ensure durability [Table 3].[25]
The inclusion of international collaborators as colleagues
will promote reciprocal long‑term relationships.[25]
Conversely, paternalistic aitudes (e.g., “I know what’s
good for you”) will impede progress.[25] Transparency,
frequent communication, sharing a common vision,
early definition of clear roles and expectations,
and planning for future studies with site primary
investigators can facilitate mutual trust.[25] Moreover,
maintaining humility, power dierential awareness,
collaborative action, and accountability is critical for
durable eorts.[79]
The authors of this ACAIM consensus thus present
a model for IMP viability [Figure 7]. Collaborators
will navigate viability phases from conception to
durability in a time frame dependent on the experience/
commitment of the participants and the resources
available. During the conception phase, collaborators
will identify stakeholders and determine needs
assessments and funding sources. This will be critical
to ensure bidirectional accountability, supervision, and
nancial resource allocation. During the second phase
of development, collaborators will design, execute and
reect on pilot experiences. This will lead to the creation
and refinement of IMP‑specific competencies and
sustainability. During the third phase of investment,
policy and governance, collaborators will secure
long‑term institutional support; create investments in
capacity, supply chains and information technology;
and adhere to regulatory requirements to ensure
continued promulgation with institutional leaders
in the proper framework. During the final phase of
durability and centers of excellence, collaborators will
ensure bidirectional ow of learners and leaders and
add scholarship opportunities (i.e., peer‑reviewed
publications, scientic presentations), economic growth
(i.e. grant funding, donations), and social reputation/
impact (i.e. positive community outcomes, global
community public relations). The authors encourage
thoughtful establishment of site‑specic IMP viability
with the above model.
Community engagement is essential for high quality,
eective, and ethical IMP conduct.[80,81] It serves to facilitate
beer understanding, permission, mutual ownership,
and organizational legitimacy. Public engagement is
a bidirectional process that provides individuals with
trustworthy information (e.g., radio, newspapers,
television, social media, schools, churches, etc.) on key
policy issues. It then elicits input, and integrates it into
decision‑making and social action.[80] The prioritization
of IMP efforts toward ensuring cultural acceptability
of a proposed project and its seamless integration in a
culturally inclusive manner is critical to successfully
managing any potential unintended consequences.
Two‑way processes that strengthen the capacity and
collaboration between public and private sectors in
low resource settings create sustainable science and
technology infrastructure.[80] Furthermore, access to
knowledge and technology must be affordable and
accessible, both being ethical concepts rooted in the
notion of equity.[80]
CONCLUSIONS
Global connectivity is growing at an exponential rate.
This manuscript outlines the CFIMP as well as key steps
for fostering successful international collaboration within
the proposed framework. As an US representation for
the AIM community, ACAIM’s goal is to help create a
platform that will foster the creation and durability of high
quality, viable IMPs. It is our hope that such IMPs will
help facilitate closer inter‑institutional, interdisciplinary,
cross‑cultural, and bidirectional collaborations. We also
believe that it is the model of shared governance and
shared responsibility that will produce the most optimal
long‑term results for both US‑based participants and
their international counterparts around the globe. We
invite all health‑care providers to share their knowledge
and commitment with us. This, in turn, will allow the
AIM community to create, disseminate, and implement
the necessary knowledge, experience, innovation,
understanding, and reproducibility across existing and
new IMPs.
Acknowledgment
This consensus statement is being published across all
ACAIM‑sponsored periodicals (International Journal
of Critical Illness and Injury Science and International
Journal of Academic Medicine) as requested by the
combined ACAIM Boards of Governors and Directors as
well as the Multidisciplinary Consensus Group on IMPs.
Justications for parallel publication of this important
material include wider dissemination of knowledge and

Garg, et al.: A comprehensive framework for international medical programs
International Journal of Critical Illness and Injury Science | Volume 7 | Issue 4 | October-December 2017
198
signicant dierences in readership distribution of both
periodicals. The parallel publication of this document
has been approved by editors of both journals and by all
co‑authors of this scholarly work.
Members of the Multidisciplinary Consensus Group
on International Medical Programs included (complete
alphabetical list): Bonnie Arquilla (Brooklyn, NY);
Harry L. Anderson III (Ann Arbor, MI); Christina
Bloem (Brooklyn, NY); Jordan Kapper (Bethlehem,
PA); Silvana Dal Ponte (Porto Alegre, Brazil); Paula
Ferrada (Richmond, VA); Sagar C. Galwankar (Tampa,
FL); Ramon E. Gist (New York, NY); Vicente H. Gracias
(New Brunswick, NJ); Weidun Alan Guo (Bualo, NY);
Bhakti Hansoti (Baltimore, MD), Ricardo Izurieta (Tampa,
FL), Marian McDonald (Allentown, PA), Alaa‑Eldin A.
Mira (Bethlehem, PA), Sudip Nanda (Bethlehem, PA);
Chinenye O. Nwachuku (Bethlehem, PA); Benedict
Nwomeh (Columbus, OH); Thomas J. Papadimos
(Toledo, OH); Gregory L. Peck (New Brunswick, NJ);
Sco Plan (Tampa, FL); Richard P. Sharpe (Phillipsburg,
NJ); Ziad C. Sifri (Newark, NJ); Sari Soghoian (New York,
NY); Stanislaw P. Stawicki (Bethlehem, PA); and Mamta
Swaroop (Chicago, IL).
The authors would also like to acknowledge the following
individuals for their support during the consensus
planning and drafting process: Charles H. Cook (Boston,
MA); Susan D. Moa‑Bruce (Columbus, OH); Mayur
Narayan (New York, NY); James P. Orlando (Bethlehem,
PA); Kiran C. Patel (Tampa, FL).
CONSENSUS TEAM LEADERSHIP CONTACT
INFORMATION
Manish Garg, MD, FAAEM, President‑Elect of ACAIM,
Professor and Senior Associate Residency Program
Director, Temple University Hospital Department of
Emergency Medicine, Director of Global Medicine at
Lewis Katz School of Medicine at Temple University,
Philadelphia, PA; E‑mail: Manish. Garg@tuhs.temple.
edu; Twier: @TheGargFather
Gregory Peck, DO, FACS, Member, ACAIM Board
of Governors, Associate Director of Acute Care
Surgery Fellowship, Associate Director of Trauma,
Rutgers– Robert Wood Johnson Medical School,
New Brunswick, NJ; E‑mail: peckgr@rwjms.rutgers.edu;
Twier: @DrGregoryPeck; Facebook: @RUglobalsurgery
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
REFERENCES
1. LarkanF, UdumaO, LawalSA, van BavelB. Developing a framework
for successful research partnerships in global health. Global Health
2016;12:17.
2. CrumpJA, Sugarman J; Working Group on Ethics Guidelines for
Global Health Training(WEIGHT). Ethics and best practice guidelines
for training experiences in global health. Am J Trop Med Hyg
2010;83:1178-82.
3. BhuttaZA. Ethics in international health research: Aperspective from
the developing world. Bull World Health Organ 2002;80:114-20.
4. Anderson HL 3rd, ArquillaB, FirstenbergMS, GargM, GalwankarSC,
GraciasVH, etal . Mission statement of the American College of Academic
International Medicine. Int J Crit Illn Inj Sci 2017;7:3-7.
5. Philibert I. International medical education outreach: Benets for US
medical education and practice: An interview with Joseph Kolars, MD.
JGrad Med Educ 2009;1:162-3.
6. DrobacP, MorseM. Medical education and global health equity. AMA J
Ethics 2016;18:702-9.
7. Farmer P. Diary. Vol.36. London, England: London Review of Books;
2014. p.38-9.
8. AlkireBC, RaykarNP, ShrimeMG, WeiserTG, BicklerSW, RoseJA, et al.
Global access to surgical care: Amodelling study. Lancet Glob Health
2015;3:e316-23.
9. Drain PK, Primack A, HuntDD, FawziWW, HolmesKK, Gardner P,
etal. Global health in medical education: Acall for more training and
opportunities. Acad Med 2007;82:226-30.
10. HansonL, HarmsS, PlamondonK. Undergraduate international medical
electives: Some ethical and pedagogical considerations. JStud Int Educ
2011;15:171-85.
11. AkbarH, HillPS, R otemA, RileyID, ZwiAB, MarksGC, et al. Identifying
competencies for Australian health professionals working in international
health. Asia Pac J Public Health 2005;17:99-103.
12. Cross TL. Toward a Culturally Competent System of Care: AMonograph
on Eective Services for Minority Children who are Severely Emotionally
Disturbed. Washington, DC: Georgetown University Child Development
Center; 1989.
13. AschengrauA, SeageGR. Essentials of Epidemiology in Public Health.
Burlington, MA: Jones & Bartlett Publishers; 2013.
14. FulmerHS, Adams AC, Deuschle KW. Medical student training in
international cross-cultural medicine. JMed Educ 1963;38:920-31.
15. JohnsonJP, LenartowiczT, ApudS. Cross-cultural competence in
international business: Toward a denition and a model. JInt Bus Stud
2006;37:525-43.
16. Le RouxJ. Eective educators are culturally competent communicators.
Intercult Educ 2002;13:37-48.
17. BennettMJ. Developmental Model of Intercultural Sensitivity. Hoboken,
NJ: Wiley Online Library; 1998.
18. Frenk J, ChenL, BhuttaZA, Cohen J, CrispN, EvansT, etal. Health
professionals for a new century: Transforming education to strengthen
health systems in an interdependent world. Lancet 2010;376:1923-58.
19. Wall AE. Ethics for International Medicine: APractical Guide for Aid
Workers in Developing Countries. Lebanon, NH: University Press of New
England; 2012.
20. McLennan S. Medical voluntourism in Honduras: ‘Helping’ the poor?
Prog Dev Stud 2014;14:163-79.
21. SnyderJ, DharamsiS, CrooksVA. Fly-by medical care: Conceptualizing
the global and local social responsibilities of medical tourists and
physician voluntourists. Global Health 2011;7:6.
22. deVries CR, Price RR. Global Surgery and Public Health: ANew Paradigm.
Sudbury, MA: Jones & Bartlett Publishers; 2012.
23. Dupuis CC. Humanitarian missions in the third world: a polite dissent.
Plastic and reconstructive surgery 2004;113:433.
24. LaskerJN. Hoping to Help: e Promises and Pitfalls of Global Health
Volunteering. Ithaca, NY: Cornell University Press; 2016.
25. JohnCC, AyodoG, Musoke P. Successful global health research
partnerships: What makes them work? Am J Trop Med Hyg 2016;94:5-7.
26. Bao J, Rodriguez DC, Paina L, OzawaS, BennettS. Monitoring and
evaluating the transition of large-scale programs in global health. Glob

Garg, et al.: A comprehensive framework for international medical programs
International Journal of Critical Illness and Injury Science | Volume 7 | Issue 4 | October-December 2017 199
Health Sci Pract 2015;3:591-605.
27. Firestone R, RoweCJ, ModiSN, SieversD. e eectiveness of social
marketing in global health: Asystematic review. Health Policy Plan
2017;32:110-24.
28. GladdingS, ZinkT, HowardC, CampagnaA, SlusherT, JohnC, et al.
International electives at the university of minnesota global pediatric
residency program: Opportunities for education in all accreditation
council for graduate medical education competencies. Acad Pediatr
2012;12:245-50.
29. Monroe-WiseA, KiboreM, KiarieJ, NduatiR, MburuJ, DrakeFT, etal.
e clinical education partnership initiative: An innovative approach to
global health education. BMC Med Educ 2014;14:1043.
30. McKinley DW, Williams SR, NorciniJJ, Anderson MB. International
exchange programs and U.S. medical schools. Acad Med 2008;83:S53-7.
31. HaqC, RothenbergD, GjerdeC, BobulaJ, WilsonC, BickleyL, e tal . New
world views: Preparing physicians in training for global health work. Fam
Med 2000;32:566-72.
32. Ramsey AH, Haq C, GjerdeCL, RothenbergD. Career inuence of
an international health experience during medical school. Fam Med
2004;36:412-6.
33. BjorklundAB, CookBA, Hendel-PatersonBR, WalkerPF, StauerWM,
BoulwareDR, et al. Impact of global health residency training on medical
knowledge of immigrant health. Am J Trop Med Hyg 2011;85:405-8.
34. Syed SB, Dadwal V, Rutter P, StorrJ, HightowerJD, Gooden R, et  al.
Developed-developing country partnerships: Benefits to developed
countries? Global Health 2012;8:17.
35. ZinkT, SolbergE. Development of a global health curriculum for
family medicine based on ACGME competencies. Teach Learn Med
2014;26:174-83.
36. MorrisSC, SchroederED. Emergency medicine resident rotations abroad:
Current status and next steps. West J Emerg Med 2016;17:63-5.
37. Alagappan K, Schafermeyer R, HollimanCJ, IsersonK, Sheridan IA,
KapurGB, et al. International emergency medicine and the role for
academic emergency medicine. Acad Emerg Med 2007;14:451-6.
38. ThomasHA, BinderLS, ChapmanDM, Kramer DA, LaMantiaJ,
PerinaDG, et al. e 2003 model of the clinical practice of emergency
medicine: e 2005 update. Acad Emerg Med 2006;13:1070-3.
39. HockbergerRS, BinderLS, ChisholmCD, CushmanJT, HaydenSR,
SklarDP, e tal . e model of the clinical practice of emergency medicine:
A2-year update. Ann Emerg Med 2005;45:659-74.
40. Ng-KamstraJS, GreenbergSL, Abdullah F, AmadoV, AndersonGA,
CossaM, eta l. Global surgery 2030: Aroadmap for high income country
actors. BMJ Glob Health 2016;1:e000011.
41. KraekerC, ChandlerC. “We learn from them, they learn from us”:
Global health experiences and host perceptions of visiting health care
professionals. Acad Med 2013;88:483-7.
42. Wernick B, Wojda TR, Wallner A, Yanagawa F, Firstenberg MS,
Papadimos TJ, et al. Brain drain in academic medicine: Dealing with
personnel departures and loss of talent. Int J Acad Med 2016;2:68.
43. RivielloR, OzgedizD, HsiaRY, AzzieG, NewtonM, TarpleyJ, etal . Role
of collaborative academic partnerships in surgical training, education,
and provision. World J Surg 2010;34:459-65.
44. Binagwaho A, Kyamanywa P, Farmer PE, Nuthulaganti T, Umubyeyi B,
Nyemazi JP, et al. e human resources for health program in Rwanda–A
new partnership. NEngl J Med 2013;369:2054-9.
45. NdengaE, UwizeyeG, ThomsonDR, Uwitonze E, MubiligiJ,
Hedt-GauthierBL, etal. Assessing the twinning model in the Rwandan
Human Resources for Health Program: Goal setting, satisfaction and
perceived skill transfer. Global Health 2016;12:4.
46. OusmanK, PolomanoRC, SeloilweE, OderoT, TarimoE, MashallaYJ,
et al. Interprofessional fellowship training for emerging global health
leaders in Africa to improve HIV prevention and care: e afya bora
consortium. JAssoc Nurses AIDS Care 2016;27:331-43.
47. SullivanN. International clinical volunteering in tanzania: Apostcolonial
analysis of a global health business. Glob Public Health 2017:1-15.
48. Joint Commission International, Joint Commission on Accreditation of
Health care Organizations. Joint Commission International Accreditation
Standards for Hospitals. Joint Commission Resources; 2002.
49. ReavesEJ, SchorKW, Burkle FM Jr. Implementation of evidence-based
humanitarian programs in military-led missions: PartI. Qualitative gap
analysis of current military and international aid programs. Disaster Med
Public Health Prep 2008;2:230-6.
50. ReavesEJ, SchorKW, Burkle FM Jr. Implementation of evidence-based
humanitarian programs in military-led missions: PartII. e impact
assessment model. Disaster Med Public Health Prep 2008;2:237-44.
51. AdiniB, OhanaA, FurmanE, RingelR , GolanY, FleshlerE, et al. Learning
lessons in emergency management: e 4thInternational Conference
on Health care System Preparedness and Response to Emergencies and
Disasters. Disaster Mil Med 2016;2:16.
52. Katz R, Blazes D, BaeJ, PuntambekarN, PerdueCL, FischerJ, etal .
Global health diplomacy training for military medical researchers. Mil
Med 2014;179:364-9.
53. JawhariB, LudwickD, KeenanL, ZakusD, HaywardR. Benefits
and challenges of EMR implementations in low resource settings:
Astate-of-the-art review. BMC Med Inform Decis Mak 2016;16:116.
54. FritzF, TilahunB, DugasM. Success criteria for electronic medical record
implementations in low-resource settings: Asystematic review. JAm Med
Inform Assoc 2015;22:479-88.
55. WongA, VohraR, RuhaAM, KoutsogiannisZ, GraemeK, DarganPI,
et al. e global educational toxicology uniting project(GETUP): An
analysis of the rst year of a novel toxicology education project. JMed
Toxicol 2015;11:295-300.
56. PereiraBM, CalderanTR, SilvaMT, SilvaAC, Marttos AC Jr., FragaGP,
et al. Initial experience at a university teaching hospital from using
telemedicine to promote education through video conferencing. Sao
Paulo Med J 2012;130:32-6.
57. MarsM. Building the capacity to build capacity in e-health in Sub-Saharan
Africa: e KwaZulu-Natal experience. Telemed J E Health 2012;18:32-7.
58. MoucheraudC, SchwittersA, BoudreauxC, GilesD, KilmarxPH, NtoloN,
et al. Sustainability of health information systems: Athree-country
qualitative study in Southern Africa. BMC Health Serv Res 2017;17:23.
59. WolfeBA, MamlinBW, BiondichPG, FraserHS, Jazayeri D, AllenC,
etal. e OpenMRS system: Collaborating toward an open source EMR
for developing countries. AMIA Annu Symp Proc 2006;2006:1146.
60. Bazemore AW, HeneinM, Goldenhar LM, Szaarski M, Lindsell CJ,
Diller P, et  al. The effect of offering international health training
opportunities on family medicine residency recruiting. Fam Med
2007;39:255-60.
61. PurnellCA. Operation smile and the guwahati comprehensive cle care
center: Multidisciplinary global activism in plastic surgery. Plast Surg
Nurs 2016;36:180-1.
62. PurnellCA. Operation smile and the guwahati comprehensive cle care
center: Multidisciplinary global activism in plastic surgery. Plast Surg
Nurs 2014;34:181-2.
63. CampbellA, ShermanR, MageeWP. e role of humanitarian missions
in modern surgical training. Plast Reconstr Surg 2010;126:295-302.
64. CampbellA, SullivanM, ShermanR, MageeWP. e medical mission and
modern cultural competency training. JAm Coll Surg 2011;212:124-9.
65. C oupetS. International health electives: Strengthening graduate medical
education. JAm Osteopath Assoc 2012;112:800-4.
66. Hayward AS, JacquetGA, Sanson T, MowaH, Hansoti B. Academic
aairs and global health: How global health electives can accelerate
progress towards ACGME milestones. Int J Emerg Med 2015;8:45.
67. AroraG, ConduracheT, BatraM, ButterisSM, DownsT, GarfunkelL,
etal . Miles away milestones: AFramework for assessment of pediatric
residents during global health rotations. Acad Pediatr 2017;17:577-9.
68. Karle H; Executive Council, World Federation for Medical Education.
International recognition of basic medical education programmes. Med
Educ 2008;42:12-7.
69. Ibrahim H, Abdel-Razig S, NairSC. Medical students’ perceptions of
international accreditation. Int J Med Educ 2015;6:121-4.
70. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al.
Global Surgery 2030: evidence and solutions for achieving health, welfare,
and economic development. Lancet 2015. 2015;386:569-624.
71. World Health Organization. Increasing access to health workers in
remote and rural areas through improved retention: Global policy
recommendations. World Health Organization; 2010.
72. Redwood-Campbell L, Pakes B, Rouleau K, MacDonald CJ, Arya N,
Purkey E, et al. Developing a curriculum framework for global health
in family medicine: emerging principles, competencies, and educational
approaches. BMC Medical Education 2011;11:46.
73. StevensGA, AlkemaL, BlackRE, BoermaJT, CollinsGS, EzzatiM, etal.
Guidelines for accurate and transparent health estimates reporting: e
GATHER statement. Lancet 2016;388:e19-23.

Garg, et al.: A comprehensive framework for international medical programs
International Journal of Critical Illness and Injury Science | Volume 7 | Issue 4 | October-December 2017
200
74. e_EQUATOR_Network. Enhancing Quality and Transparency of
Health Research; 2017. Available from: http://www.equator-network.
org/.[Last accessed on 2017Oct11].
75. BhanA, SinghJA, UpshurRE, SingerPA, DaarAS. Grand challenges in
global health: Engaging civil society organizations in biomedical research
in developing countries. PLoS Med 2007;4:e272.
76. SinghJA, MillsEJ. e abandoned trials of pre-exposure prophylaxis for
HIV: What went wrong? PLoS Med 2005;2:E234.
77. Mills EJ, SinghS, SinghJA, Orbinski JJ, Warren M, UpshurRE, et al .
Designing research in vulnerable populations: Lessons from HIV
prevention trials that stopped early. BMJ 2005;331:1403-6.
78. DelisleH, RobertsJH, MunroM, JonesL, GyorkosTW. e role of NGOs
in global health research for development. Health Res Policy Syst 2005;3:3.
79. KohrtBA, MarienfeldCB, Panter-BrickC, TsaiAC, WainbergML. Global
mental health: Five areas for value-driven training innovation. Acad
Psychiatry 2016;40:650-8.
80. BerndtsonK, DaidT, TracyCS, Bhan A, CohenER, UpshurRE, etal.
Grand challenges in global health: Ethical, social, and cultural issues
based on key informant perspectives. PLoS Med 2007;4:e268.
81. PangT. Commentary on ‘reflections and recommendations on
research ethics in developing countries’ by S.R. Benatar. Soc Sci Med
2002;54:1145-6.