Postgraduate Medical Education in Sub-Saharan Africa: A Scoping Review Spanning 26 Years and Lessons Learned

Dutch post-graduate training in Global Health and Tropical Medicine: a qualitative study on graduates' perspectives

INTRODUCTION

The Dutch Medical Doctor-Global Health (MD-GH) prepares to work in low-resource settings (LRS) by completing a hybrid postgraduate training program of 2 years and 9 months, with clinical and public health exposure in the Netherlands and a Global Health residency in LRS. The objectives of the program include acquiring clinical skills to work as a physician in a setting with different (often more severe) pathology and limited resources. In public health teaching, emphasis is given, among other, to adapting to a culturally different environment. After graduation, MD-GH work in a wide variety of countries and settings for variable time. As part of a curriculum review, this study examines MD-GHs' perception of the quality of the training program and provides recommendations for improvement.

METHODS

A qualitative study was performed. Thematic analysis was applied to semi-structured interviews with 23 MD-GH who graduated between 2017 and 2021.

RESULTS

MD-GHs predominantly worked as clinicians; several were (also) involved in management or capacity building. The clinical training program adequately addressed general skills, but did not sufficiently prepare for locally encountered, often severe, pathology. During the training, adequate supervision with clear learning goals was found pivotal to a positive learning experience. Gaps included clinical training in Internal Medicine (particularly infectious diseases and non-communicable diseases) and Paediatrics. Public Health teaching as well as cultural awareness should be intensified and introduced earlier in the program. The Global Health residency was considered important, but tasks and learning outcomes varied. Teaching, supervision, and capacity building were considered increasingly important key elements of working in LRS. Consensus favoured the current duration of the training program without extension.

DISCUSSION

While the generalist nature of the MD-GH training was appreciated, the program would benefit from additional clinical training in infectious diseases, non-communicable diseases, and Paediatrics. Moving forward, emphasis should be placed on structured mentorship, enhanced public health teaching, and standardized residency programs with clearly delineated objectives to better equip MD-GH professionals for their multifaceted roles in LRS. Moreover, future revisions of the training program should incorporate the perspectives of host institutes in LRS and tailor the training needs.

Pediatric and Congenital Cardiac Services: An Innovative and Empowering Approach to Global Training and Equitable Care

Congenital heart disease is a leading cause of preventable death in children, with a disproportionate impact on low- and middle-income countries. Despite progress in treating congenital heart disease globally, significant challenges remain in accessing specialized cardiovascular care, particularly cardiac surgery, in low- and middle-income countries. This review examines current models of assistance and proposes a novel global training program to address these inequities. Key challenges identified include building program infrastructure, training health care providers, ensuring financial sustainability, and promoting local engagement. The proposed program, structured under a new international organization, will leverage emerging technologies to deliver accessible and rigorously assessed training in pediatric and congenital cardiac care. By collaborating with local experts and global partners, the program will promote access to education for various health care personnel involved in congenital heart disease care, establish credentialing standards, and foster global collaboration. This unified, scalable approach aims to bridge the health equity gap and accelerate progress toward comprehensive and sustainable cardiac care programs worldwide.

Mandatory research projects during medical specialist training in Australia and New Zealand: a survey of trainees' experiences and reports

OBJECTIVE

To determine how many specialist trainees are required to conduct research projects, how they conduct these studies, and their views on the value of these activities; to assess the design and reporting quality of their research reports.

STUDY DESIGN

Online, anonymous survey.

SETTING, PARTICIPANTS

Current and recent trainees (past five years) at Australian and New Zealand specialist colleges, recruited through eleven colleges and snowballing; survey was available 31 March - 31 December 2021.

MAIN OUTCOME MEASURES

Whether trainees were required to conduct research as part of specialty training; how they conducted their projects; the skills mix of the project team and access to relevant expertise and supervision; trainee views on mandatory research during specialty training; research engagement after training. Respondents were invited to submit project reports for reporting and methodological quality evaluation.

RESULTS

A total of 371 people commenced the survey; 361 respondents provided answers about mandatory research projects during specialist training, including 311 (86%) who had been required to complete projects. Seventy-six of 177 people who had completed projects (43%) provided information about 92 projects and submitted 34 project reports for evaluation. Thirty-eight projects (41%) investigated questions developed by the trainees alone; in 48 cases (52%) trainees had planned their projects with little outside input; of the 69 study protocols developed (75% of projects), 60 were developed by the trainees. The median proportion of time devoted to the research project exceeded 50% for trainees in ten of twelve colleges. Respondents typically worked in non-collaborative teams, restricted to members of their own specialty, and additional expertise was limited to statisticians, allied health professionals, and nurses. Eighty-seven of 174 participants who had completed projects (50%) felt that doing so was very or moderately important for their clinical careers; 36 of 67 respondents (54%) supported the requirement for scholarly projects during specialty training; 33 of 61 respondents (54%) had participated in research after completing training, and 44 (72%) had considered doing so. Twenty-five of 34 available reports had been published; in 27 assessable reports, methods and results reporting was generally poor, and the risk of bias moderate to high in all but three. Participants criticised using their own time for projects and their potentially low quality results.

CONCLUSION

For trainees who undertake specialty training, the time commitment and poor quality research associated with mandatory research projects were frequently concerns. Medical colleges should focus on research training tailored to individual career aspirations and training needs.

Developing a Psychiatry Residency Program in a Low- and Middle-Income Country: Botswana's Experience

Like many other low- and middle-income countries, Botswana has struggled to address the shortage of doctors, particularly specialists. In 2009, the country's first medical school offering an undergraduate medical program was established. A needs and feasibility assessment was conducted with relevant stakeholders to explore the need for specialty training programs in all medical school departments. As a result, three residency programs were established a year after the undergraduate program, but psychiatry was not included in this first crop of residency programs. Existing strengths in the university and healthcare systems were leveraged to successfully establish a four-year Master of Medicine residency program in psychiatry, which began in January 2020. The program aims to produce psychiatrists who are familiar with the local mental health needs. The first batch of students completed their training in December 2023. This paper reflects on and describes the development of a psychiatry residency program in Botswana and contributes a process grounded in educational program development models and educational theories that others can utilize. Botswana's experience may be helpful to other low- and middle-income countries, particularly in sub-Saharan Africa, that want to establish and run a locally developed residency program in psychiatry.

Ensuring Continuity of Health Professions Training Amid a Global Pandemic: Lessons From the Uganda Safe Schools Initiative

ABSTRACT

Uganda experienced 2 COVID-19 waves that challenged health professional education. All health professions training institutions (HPTIs) in Uganda closed in March 2020. Cognizant of the threat to quality education and the frontline workforce, the National Council for Higher Education (NCHE) and Seed Global Health partnered to examine the risks and benefits of HPTI reopening through the Safe Schools Initiative (SSI). This article described the processes to unify stakeholders in health professions education and the outcomes from these discussions during the COVID-19 pandemic in Uganda.During the first COVID-19 wave, the SSI conducted consultative meetings with key stakeholders. The SSI developed guidelines around student welfare and issued standard operating procedures (SOPs) for HPTI reopening. The NCHE recommended in-person learning for final-year students and online learning for junior years, resulting in HPTIs being the first academic institutions to reopen in the country. During the second COVID-19 wave, schools closed again. The SSI utilized recently published literature and quantitative data to inform decision making in addition to expert consensus. The NCHE recommended immediate phased reopening for students in clinical years, blended learning for nonclinical years, and prioritizing health professions education in future lockdowns. Consequently, HPTIs reopened within a month of closure. The SSI demonstrated that national advocacy for health professions education can be effective when engaging stakeholders to build consensus around difficult decisions.Key lessons learned from the SSI include the following: (1) collaborating across sectors in health professions education can amplify change, (2) occupational health guidelines must include health professions students, (3) investing in online education and simulation has value in outbreak-prone areas, and (4) systemic inequities in health professions education will require persistence and advocacy to correct. Future pandemic preparedness must prioritize HPTIs to ensure quality education and continuity of a frontline workforce.

Education and Training Models for Remote Learning

Our international partnerships have fostered longstanding collaborative relationships leading to the development of unique, locally-designed, and sustainable training programs that serve as models for global health education and cooperation.

Virtual reality technology for surgical learning: qualitative outcomes of the first virtual reality training course for emergency and essential surgery delivered by a UK-Uganda partnership

INTRODUCTION

The extensive resources needed to train surgeons and maintain skill levels in low-income and middle-income countries (LMICs) are limited and confined to urban settings. Surgical education of remote/rural doctors is, therefore, paramount. Virtual reality (VR) has the potential to disseminate surgical knowledge and skill development at low costs. This study presents the outcomes of the first VR-enhanced surgical training course, 'Global Virtual Reality in Medicine and Surgery', developed through UK-Ugandan collaborations.

METHODS

A mixed-method approach (survey and semistructured interviews) evaluated the clinical impact and barriers of VR-enhanced training. Course content focused on essential skills relevant to Uganda (general surgery, obstetrics, trauma); delivered through: (1) hands-on cadaveric training in Brighton (scholarships for LMIC doctors) filmed in 360°; (2) virtual training in Kampala (live-stream via low-cost headsets combined with smartphones) and (3) remote virtual training (live-stream via smartphone/laptop/headset).

RESULTS

High numbers of scholarship applicants (n=130); registrants (Kampala n=80; remote n=1680); and attendees (Kampala n=79; remote n=556, 25 countries), demonstrates widespread appetite for VR-enhanced surgical education. Qualitative analysis identified three key themes: clinical education and skill development limitations in East Africa; the potential of VR to address some of these via 360° visualisation enabling a 'knowing as seeing' mechanism; unresolved challenges regarding accessibility and acceptability.

CONCLUSION

Outcomes from our first global VR-enhanced essential surgical training course demonstrating dissemination of surgical skills resources in an LMIC context where such opportunities are scarce. The benefits identified included environmental improvements, cross-cultural knowledge sharing, scalability and connectivity. Our process of programme design demonstrates that collaboration across high-income and LMICs is vital to provide locally relevant training. Our data add to growing evidence of extended reality technologies transforming surgery, although several barriers remain. We have successfully demonstrated that VR can be used to upscale postgraduate surgical education, affirming its potential in healthcare capacity building throughout Africa, Europe and beyond.

Efficacy of the Gulu University Reproductive Health Simulation Training for final year medical students and interns: a before-and-after study

Background

Reproductive health emergencies, such as postpartum hemorrhage, contribute significantly to maternal and neonatal morbidity and mortality in Uganda due to knowledge and skills gaps. Medical interns, intern midwives, and nurses are crucial as frontline healthcare workers in responding to these emergencies. Our proposed hands-on strategy involves comprehensive simulation-based training (SBT) to equip these healthcare workers with the essential knowledge to manage common reproductive health emergencies and procedures in the country.

Objectives

The study aimed to assess the effectiveness of comprehensive SBT in improving the knowledge of interns and fifth-year medical students on reproductive health emergencies and procedures at Gulu University and its Teaching Hospitals in Uganda.

Design

A before-and-after study.

Methods

A 4-day SBT was conducted for fifth-year medical students and interns (nurses, midwives, and doctors) at Gulu University Teaching Hospitals, focusing on reproductive health emergencies. Pre- and post-tests with 40 multiple-choice questions were used to evaluate knowledge enhancement, the scores were summarized as medians and interquartile ranges. Paired sample t-tests was used to test the difference in pre- and post-test scores. Independent sample t-tests compared median post-test results between interns and students, with a p-value <0.05 considered significant.

Results

A total of 153 participants were enrolled, the majority being males (78.4%, n = 120) and medical students (73.9%, n = 113). Among the 40 interns, 55% (n = 22) were doctors, 30% (n = 12) were midwives, and 15% (n = 6) were nurses. The study participants showed an increase in knowledge, with median post-test scores higher than pre-test scores for all participants [63% (interquartile ranges, IQR: 57-71%) versus 49% (42-54%), with a median difference of 14% (8-23%), p < 0.001].

Conclusion

The SBT effectively imparts key knowledge competencies to the interns and fifth-year medical students. We recommend that SBT be included as part of the course units that students should take and for continuous medical education for qualified healthcare workers in resource-limited settings.

Surgical residents' perceptions of the operating theatre educational environment at St. Paul's Hospital Millennium Medical College: A cross-sectional survey

Background

The educational environment refers to the "climate" that influences all aspects of learning in an educational context and the experience in the operating room is particularly crucial in surgical residents learning. Hence, this study aimed to assess surgical residents' perceptions of the operating theatre educational environment and associated factors in the surgical department at St. Paul's Hospital.

Methods

This cross-sectional study was conducted in March 2022 among surgical residents at St. Paul's Hospital Millennium Medical College to assess their perceptions of the operating room educational environment using the OREEM questionnaire. Descriptive statistics (mean, median, SD) were used to summarize demographic data and OREEM scores. The student t-test and one-way analysis of variance (ANOVA) testing followed by posthoc tests were used for comparison of quantitative data, with p-values < 0.05 considered significant.

Results

Of the participants, 103 (79.8%) were male and 26 (20.2%) were female with a mean age of 28 years. The overall mean score was 69% with subscale scores for teaching and training at 47.9/65.0 (73.7%), learning opportunities at 34.5/55.0 (62.7%), the atmosphere at 28.9/40.00 (72.4%) and workload/supervision/ support at 27.5/40.0 (68.7%). Male and female residents differed significantly in perceptions of "atmosphere" (t127 = 3.35, p < 0.001) and in junior versus senior residents' perceptions of the "learning opportunities" and "atmosphere" at p-values of 0.023 and 0.028 respectively. However, age, marital status, and specific surgical training programs did not have a significant effect on the scores.

Conclusion

Overall, residents had positive perceptions of their training and teaching, learning opportunities, the atmosphere in the operation theatre, and the supervision they received in the operation theatre. The operating room's "teaching and training" component received the highest score, while the operating room's "learning opportunities" component received the lowest. This indicates the importance of establishing a positive learning environment with sufficient "hands-on" experience, especially during emergencies. In addition, preoperative planning, case discussions, and feedback after the surgery should be routine.

"Feeling Like an Island": Perceptions of Professional Isolation Among Emergency Nurses

INTRODUCTION

Professional isolation, feelings of being isolated from one's professional peers and lacking mentoring and opportunities for professional interaction, collaboration, and development, is a challenge for workers across the labor market. The notion of professional isolation is particularly prevalent in low-resource health care settings and is common among emergency nurses.

METHODS

This study explored the perceptions of professional isolation among emergency nurses working in a low-resource environment using individual interviews with 13 participants in 5 settings in Lesotho.

RESULTS

The data were analyzed using qualitative content analysis and revealed an overarching theme of "feeling like an island" containing 3 categories, namely lack of interprofessional collaboration and consultation, skills mismatch, and enforced loneliness.

DISCUSSION

This study suggests that lack of interprofessional collaboration and consultation, skills mismatch, and enforced loneliness have influenced feelings of professional isolation among emergency nurses working in low-resource environments. The findings of this research lend support to the idea that communities of practice may have a potential impact in addressing professional isolation.

Barriers and Solutions to Successful Problem-Based Learning Delivery in Developing Countries - A Literature Review

Problem-based learning (PBL) was introduced in the 1960s as an alternative to traditional teacher-centered and discipline-based preclinical medical education. A literature review was conducted to explore the barriers and solutions to successful PBL uptake and delivery in developing countries. The review involved the search of articles and scientific studies on PubMed, The Lancet, and Scielo. The review focused on the medical education literature, using as a primary search criterion "problem-based learning" in combination with "developing countries" and "education". The search was limited to articles in Spanish and English published between 2011 and November 2021, except for three articles due to their relevance to the subject. Faculty development programs are the cornerstone when implementing a new methodology in developing countries. Early career development, PBL methodology, and the available assessment options should be the primary learning objectives of these programs. Stakeholders will need to plan using available resources following the experience of other countries and institutions encouraging collaborative development. Evaluation and assessment will be crucial to understand the impact of PBL, and considerations should be taken to implement an integrated curriculum. Medical Education Research should be encouraged, appraised, and disseminated to improve evidence-based decision-making, creating a constant development cycle. PBL is innovative and represents many unanswered questions that will develop in the following decade as more schools implement new methodologies and Research on PBL.

Perceptions of resources available for postgraduate family medicine training at a South African university

BACKGROUND

 Clinical training is one of the roles of family physicians (FPs) in decentralised postgraduate training. Effective training requires skilled trainers and sufficient resources. Little is known about the resources available for decentralised clinical training in district health systems in low- to middle-income countries, especially in sub-Saharan Africa.

AIM

 To explore FPs' and registrars' perceptions of the available resources in a decentralised postgraduate family medicine (FM) training programme.

SETTING

 Five decentralised training sites affiliated with the University of the Witwatersrand across two provinces in South Africa.

METHODS

 This qualitative study forms part of a broader project evaluating a FM registrar training programme using the logic model. Semistructured interviews were conducted with a purposive sample of 11 FPs and 11 registrars. The interviews were transcribed verbatim and analysed thematically.

RESULTS

 Three themes were identified: 'Impact of resource constraints', 'Family physicians' skills and knowledge could be further improved' and 'Family physicians need additional support to optimise their training role'. The additional resources needed include more FPs, equipment, infrastructure and funding. Knowledge and skills of FPs were reported variable and needed further improvement. Additional support was required from peers, the district management and the university.

CONCLUSION

 Well-resourced decentralised training environments with sufficient skilled trainers and adequate resources are needed to positively influence FP training and supervision, especially in middle-income countries like South Africa.Contribution: Clinical trainers need adequate resources and support from peers, district management and the university for effective decentralised clinical training.

Initiatives to enhance medical subspecialist training in Zambia: A cross-sectional analysis

Introduction

There is a significant shortage of medical subspecialists in Zambia. The government of Zambia, through programmes at the Ministry of Health, spends considerable resources to send patients outside the country for subspecialist medical treatment. The objective of this analysis was to evaluate the current situation pertaining to medical subspecialty training at the University of Zambia School of Medicine (UNZASOM) and to illustrate the new programmes that are to be introduced.

Methods

We collected data from formal desk reviews on the state of medical specialisation in Zambia, the UNZASOM graduation archives and patient referral records at the Ministry of Health (MoH). In addition, information on planned subspecialist programmes is presented.

Results

From the first graduates in 1986up to 2019,UNZASOM produced 351medical specialists, 63 (18%) in Internal Medicine, 77 (22%) in Obstetrics &Gynaecology, 82 (23%) in Paediatrics&Child Health, 68 (19%) in General Surgery, 17 (5%) in Anaesthesia & Critical Care, 20 (6%) in Orthopaedics &Trauma and 8 (2%) in Urology. The remaining graduates were in Ophthalmology, Psychiatry, Infectious Diseases, Paediatric Surgery and Pathology contributing 1% each. To enhance medical subspecialist training at UNZASOM, new curricula for Breast Surgery, Urology, Glaucoma, Vitreo-retinalSurgery, Adult Gastroenterology, Forensic Pathology, Dermatology & Venereology, Ophthalmology, Gynaecological Oncology and Paediatric anaesthesia, Infectious Diseases, and Gastroenterology were developed. Since 2013, only 44% of patients requiring subspecialist treatment out of Zambia got assisted with the remainder still on the waiting list or having had bad outcomes.

Conclusions

These programmes will provide an opportunity for accessible and affordable medical subspecialization training for Zambia and its neighbouring countries. With enhanced infrastructural support, the subspecialists will contribute toward enhanced healthcare provision and improvement in patient outcomes. They will also form a cohort of trainers to expand the space for quality training and skills building of specialists and subspecialists in the region and beyond.

An Online, Modular Curriculum Enhances Surgical Education and Improves Learning Outcomes in East, Central, and Southern Africa: A Mixed-Methods Study

Objective

We aimed to determine the impact of a standardized curriculum on learning outcomes for surgical trainees in East, Central, and Southern Africa (ECSA).

Background

As surgical education expands throughout ECSA, there is a recognized need for a standardized curriculum. We previously described the design of a novel, large-scale, flipped-classroom, surgical curriculum for trainees in ECSA.

Methods

In January 2020, the first year of curricular content for trainees of the College of Surgeons of ECSA was released, containing 11 monthly thematic topics, each with 2 to 5 weekly modular subtopics. We aimed to evaluate 3 outcomes utilizing data sources incorporated into the curriculum structure. Learner engagement was assessed by the number of trainees completing curriculum topics. User experience was evaluated using quantitative and qualitative feedback responses to embedded surveys for each content week. Curriculum impact on trainee examination performance was assessed by comparing certification examination scores stratified by the number of curricular topics each trainee completed.

Results

Two hundred seventy-one trainees (96%) in 17 countries accessed at least 1 weekly module. Trainees completed a median of 9 topics (interquartile range: 6-10). The feedback survey response rate was 92% (5742/6233). Quantitative and qualitative responses were positive in overall module value (93.7% + 2.6%), amount of learning experienced (97.9% + 1.4%), confidence in achieving learning objectives (97.1% + 2.4%), and ease of use of the module (77.6% + 5.98%). Topic-related certification examination performance improved significantly with increased completion of thematic topics.

Conclusions

A standardized surgical curriculum in ECSA demonstrated excellent trainee usage, positive feedback, and improved examination scores.

Design of a Novel Online, Modular, Flipped-classroom Surgical Curriculum for East, Central, and Southern Africa

Objective

We describe a structured approach to developing a standardized curriculum for surgical trainees in East, Central, and Southern Africa (ECSA).

Summary Background Data

Surgical education is essential to closing the surgical access gap in ECSA. Given its importance for surgical education, the development of a standardized curriculum was deemed necessary.

Methods

We utilized Kern's 6-step approach to curriculum development to design an online, modular, flipped-classroom surgical curriculum. Steps included global and targeted needs assessments, determination of goals and objectives, the establishment of educational strategies, implementation, and evaluation.

Results

Global needs assessment identified the development of a standardized curriculum as an essential next step in the growth of surgical education programs in ECSA. Targeted needs assessment of stakeholders found medical knowledge challenges, regulatory requirements, language variance, content gaps, expense and availability of resources, faculty numbers, and content delivery method to be factors to inform curriculum design. Goals emerged to increase uniformity and consistency in training, create contextually relevant material, incorporate best educational practices, reduce faculty burden, and ease content delivery and updates. Educational strategies centered on developing an online, flipped-classroom, modular curriculum emphasizing textual simplicity, multimedia components, and incorporation of active learning strategies. The implementation process involved establishing thematic topics and subtopics, the content of which was authored by regional surgeon educators and edited by content experts. Evaluation was performed by recording participation, soliciting user feedback, and evaluating scores on a certification examination.

Conclusions

We present the systematic design of a large-scale, context-relevant, data-driven surgical curriculum for the ECSA region.

Advances in training of the specialized human resources for health in Tanzania: the case of Muhimbili University of Health and Allied Sciences

BACKGROUND

Increasing the number of specialized human resources for health is paramount to attainment of the United Nations sustainable development goals. Higher learning institutions in low-and middle-income countries must address this necessity. Here, we describe the 5-years trends in accreditation of the clinical and non-clinical postgraduate (PG) programmes, student admission and graduation at the Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania, highlighting successes, challenges and opportunities for improvement.

METHODS

This was a retrospective longitudinal study describing trends in PG training at MUHAS between 2015 and 2016 and 2019-2020. Major interventions in the reporting period included university-wide short course training programme to faculty on curricula development and initiation of online application system. Data were collected through a review of secondary data from various university records and was analyzed descriptively. Primary outcomes were the number of accredited PG programmes, number of PG applicants as well as proportions of applicants selected, applicants registered (enrolled) and students graduated, with a focus on gender and internationalization (students who are not from Tanzania).

RESULTS

The number of PG programmes increased from 60 in 2015-2016 to 77 in 2019-2020, including programmes in rare fields such as cardiothoracic surgery, cardiothoracic anesthesia and critical care. The number of PG applications, selected applicants, registered applicants and PG students graduating at the university over the past five academic years had steadily increased by 79, 81, 50 and 79%, respectively. The average proportions of PG students who applied, were selected and registered as well as graduated at the university over the past five years by gender and internationalization has remained stably at 60% vs. 40% (male vs. female) and 90% vs. 10% (Tanzanian vs. international), respectively. In total, the university graduated 1348 specialized healthcare workers in the five years period, including 45 super-specialists in critical fields, through a steady increase from 200 graduates in 2015-2016 to 357 graduates in 2019-2020. Major challenges encountered include inadequate sponsorship, limited number of academic staff and limited physical infrastructure for teaching.

CONCLUSION

Despite challenges encountered, MUHAS has made significant advances over the past five years in training of specialized and super-specialized healthcare workforce by increasing the number of programmes, enrollment and graduates whilst maintaining a narrow gender gap and international relevance. MUHAS will continue to be the pillar in training of the specialized human resources for health and is thus poised to contribute to timely attainment of the health-related United Nations sustainable development goals in Tanzania and beyond, particularly within the Sub-Saharan Africa region.

Surgical Trainee Supervision During Non-Trauma Emergency Laparotomy in Rwanda and South Africa

OBJECTIVE

The primary objective was to describe the level of surgical trainee autonomy during non-trauma emergency laparotomy (NTEL) operations in Rwanda and South Africa. The secondary objective was to identify potential associations between trainee autonomy, and patient mortality and reoperation.

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective, observational study of NTEL operations at 3 teaching hospitals in South Africa and Rwanda over a 1-year period from September 1, 2017 to August 31, 2018. The study included 543 NTEL operations performed by the acute care and general surgery services on adults over the age of 18 years.

RESULTS

Surgical trainees led 3-quarters of NTEL operations and, of these, 72% were performed autonomously in Rwanda and South Africa. Notably, trainee autonomy was not significantly associated with reoperation or mortality.

CONCLUSIONS

Trainees were able to gain autonomous surgical experience without impacting mortality or reoperation outcomes, while still providing surgical support in a high-demand setting.

Internal Medicine Residents' Perceptions of the Learning Environment of a Residency Training Program in Ethiopia: a Mixed Methods Study

INTRODUCTION

The learning environment is an important determinant of the quality of medical education. Having a good learning climate leads to improved learning process, satisfaction with education, and helps achieve the goals of the curriculum. Assessment of the quality of learning environment helps with the identification of areas that need improvement. The aim of this study was to assess the learning environment of internal medicine training program in Ethiopia.

METHODS

A mixed methods study using a cross-sectional survey using Postgraduate Hospital Educational Environment Measure and a qualitative study using a focus group discussion was done on internal medicine residents from December 2020 to May 2021. Comparison of quantitative data was done using Mann-Whitney U-Test and Kruskal-Wallis H-test. P-value <0.05 was considered statistically significant.

RESULTS

A total of 100 residents participated in the study. The overall total mean score of the responses of the participants was 70.87 (±19.8) with mean perceptions of role autonomy, perceptions of teaching and perceptions of social support of 25.9 (±7.1), 27.1 (10.2) and 17.9 (±5.1), respectively. These values suggest the presence of plenty of problems in the program. Higher mean scores were reported by males and by earlier years of residency. Ten residents participated in the focus group discussion. Four recurring themes that negatively affect learning environment were identified and included excessive workload, inadequate teaching activity, non-conducive hospital physical environment and lack of diagnostic and therapeutic modalities.

CONCLUSION

The internal medicine residency learning environment has many challenges that need immediate attention and follow-up.

Comparing the drivers of medical student emigration intention across two African nations

BACKGROUND

Sub-Saharan Africa faces the highest relative need for health care workers in the world and the emigration of physicians significantly contributes to this deficit. Few studies have explored development of these patterns during medical education. This study investigates career aspirations of medical students in two African nations with similar Human Development Indices, but distinct differences in training structure to better inform retention strategies.

METHODS

A cross-sectional survey was administered in 2018 to medical students in Madagascar (University of Antananarivo, University of Mahajanga) and Tanzania (Kilimanjaro Christian Medical College, KCMC). Outcomes included emigration/career intentions, and factors influencing these decisions. Analysis utilised chi-square and Fisher's exact tests (α < 0.05, two-tailed) for statistical differences, logistic regression and qualitative content analysis of free text data.

RESULTS

A total of 439 students responded to the survey with a response rate of 12.9% from Antananarivo (n = 142/1097), 11.6% from Mahajanga (n = 43/370), and 60.0% from KCMC (n = 254/423). Significantly more Malagasy (49.7%, n = 90/181) than Tanzanian (25.2%, n = 54/214) students expressed emigration intent (P < .001). Malagasy students indicating research, possibility of working abroad, or work intensity as influencing career choice more frequently expressed a desire to emigrate. Satisfaction with computer/internet access was inversely correlated with a desire to work abroad. In comparison, Tanzanian students reporting income potential as influential in their career choice or attending a private high school were more likely to express a desire to work abroad. Qualitative content analysis of free text data demonstrated deficits in faculty availability, diversity of training locations and a particular emphasis on infrastructure challenges within Madagascar.

INTERPRETATION

A significant number of students desire to work abroad. Emigration interests are influenced by access to postgraduate training, infrastructure and opportunities in academia, which differ across countries. Efforts to retain physicians should consider these country and institution-specific factors that influence medical student desire to emigrate.

An International Virtual Classroom: The Emergency Department Experience at Weill Cornell Medicine and Weill Bugando Medical Center in Tanzania

Emergency medicine (EM) is rapidly being recognized as a specialty around the globe. This has particular promise for low- and middle-income countries (LMICs) that experience the largest burden of disease for emergency conditions. Specialty education and training in EM remain essentially an apprenticeship model. Finding the required expertise to educate graduate learners can be challenging in regions where there are low densities of specialty providers.We describe an initiative to implement a sustainable, bidirectional partnership between the Emergency Medicine Departments of Weill Cornell Medicine (WCM) in New York, NY, USA, and Bugando Medical Center (BMC) in Mwanza, Tanzania. We used synchronous and asynchronous telecommunication technology to enhance an ongoing emergency medicine education collaboration.The Internet infrastructure for this collaboration was created by bolstering 4G services available in Mwanza, Tanzania. By maximizing the 4G signal, sufficient bandwidth could be created to allow for live 2-way audio/video communication. Using synchronous and asynchronous applications such as Zoom and WhatsApp, providers at WCM and BMC can attend real-time didactic lectures, participate in discussion forums on clinical topics, and collaborate on the development of clinical protocols. Proof of concept exercises demonstrated that this system can be used for real-time mentoring in EKG interpretation and ultrasound technique, for example. This system was also used to share information and develop operations flows during the COVID-19 pandemic. The use of telecommunication technology and e-learning in a format that promotes long-term, sustainable interaction is practical and innovative, provides benefit to all partners, and should be considered as a mechanism by which global partnerships can assist with training in emergency medicine in LMICs.

Scoping reviews in medical education: A scoping review

OBJECTIVES

Over the last two decades, the number of scoping reviews in core medical education journals has increased by 4200%. Despite this growth, research on scoping reviews provides limited information about their nature, including how they are conducted or why medical educators undertake this knowledge synthesis type. This gap makes it difficult to know where the field stands and may hamper attempts to improve the conduct, reporting and utility of scoping reviews. Thus, this review characterises the nature of medical education scoping reviews to identify areas for improvement and highlight future research opportunities.

METHOD

The authors searched PubMed for scoping reviews published between 1/1999 and 4/2020 in 14 medical education journals. The authors extracted and summarised key bibliometric data, the rationales given for conducting a scoping review, the research questions and key reporting elements as described in the PRISMA-ScR. Rationales and research questions were mapped to Arksey and O'Malley's reasons for conducting a scoping review.

RESULTS

One hundred and one scoping reviews were included. On average, 10.1 scoping reviews (SD = 13.1, median = 4) were published annually with the most reviews published in 2019 (n = 42). Authors described multiple reasons for undertaking scoping reviews; the most prevalent being to summarise and disseminate research findings (n = 77). In 11 reviews, the rationales for the scoping review and the research questions aligned. No review addressed all elements of the PRISMA-ScR, with few authors publishing a protocol (n = 2) or including stakeholders (n = 20). Authors identified shortcomings of scoping reviews, including lack of critical appraisal.

CONCLUSIONS

Scoping reviews are increasingly conducted in medical education and published by most core journals. Scoping reviews aim to map the depth and breadth of emerging topics; as such, they have the potential to play a critical role in the practice, policy and research of medical education. However, these results suggest improvements are needed for this role to be fully realised.

Implementation and evaluation of a specialized diabetes clinic in Guinea-Bissau: lessons learnt from the field

Introduction

diabetes care in Guinea-Bissau (GB) is characterized by a lack of properly trained healthcare professionals (HCPs) and guidelines for diagnosis, treatment and follow up of patients. To address these issues, this project was launched with the objective to train HCPs in the management of diabetic patients and establish a specialized diabetes clinic in the Hospital Nacional Simão Mendes, a public tertiary care hospital in Bissau, capital of GB. This project is led by the Geneva University Hospitals (HUG) in collaboration with the Swiss Association for the Aid to Diabetic People in Guinea-Bissau, with the support of the International Solidairty Office (SSI) of the State of Geneva, and AIDA (Ayuda, Intercambio y Desarrollo).

Methods

specialists from the HUG in collaboration with local experts in GB developed and delivered a culturally and contextually adapted training course pertaining to diabetes care to HCPs in this hospital. Pre and post training tests were conducted to assess differences in knowledge and practices. Following the training program, a diabetes clinic was set up and an audit was conducted to assess its performance.

Results

a total of 24 HCP attended the training program and exhibited statistically significant improvements in their knowledge pertaining to diabetes care (mean difference between pre and post-test = 14.53, SD 11.60, t=-4.8, p < 0.001). The diabetes clinic was established and provided consultations 2 days per week. A total of 63 patients consulted at this clinic, of which 49 had type two diabetes treated with oral antidiabetic drugs and 14 were type 1 diabetics treated with insulin. Patients had blood glucose measurements and received therapeutic, dietary and physical activity counselling. Several barriers leading to occasional interruptions of service were encountered, including a political instability in the country and strikes of healthcare staff demanding better wages and working conditions.

Conclusion:

this study delineates the feasibility of setting up a diabetes consultation clinic in GB despite important barriers. To ensure successful running of such consultation clinics, continued buy-in and support from stakeholders should be ensured. Diabetes training should be incorporated in pre-and post-graduate training curriculums of all HCP to help shape a better workforce.

Self-reported confidence and perceived training needs of surgical interns at a regional hospital in Ghana: a questionnaire survey

BACKGROUND

Due to disparities in their regional distribution of the surgical specialists, those who have finished "housemanship," which is the equivalent of an internship, are serving as main surgical care providers in rural areas in Ghana. However, the quantitative volume of postgraduate surgical training experience and the level of self-reported confidence after formal training have not been investigated in detail in sub-Saharan Africa.

METHODS

The quality-assessment data of the Department of surgery at a regional hospital in Ghana was obtained from the convenience samples of house officers (HOs) who had their surgical rotation before July 2019. A self-reported questionnaire with 5-point Likert-type scale and open-ended responses regarding the 35 topics listed as learning objectives by the Medical and Dental Council of Ghana were retrospectively reviewed to investigate the volume of surgical experience, self-reported confidence, and perceived training needs.

RESULTS

Among 52 respondents, the median self-reported number of patients experienced for each condition was less than 11 cases. More than 40% of HOs reported that they had never experienced cases of liver tumor (n = 21, 40.4%), portal hypertension (n = 23, 44.2%), or cancer chemotherapy/cancer therapy (n = 26, 50.0%). The median self-confidence score was 3.69 (interquartile range, 3.04 ~ 4.08). More than 50% of HOs scored ≤2 points on the self-confidence scale of gastric cancer (n = 28, 53.8%), colorectal cancer (n = 31, 59.6%), liver tumors (n = 32, 61.5%), and cancer chemotherapy/cancer therapy (n = 38, 73.1%). The top 3 reasons for not feeling confident were the limited number of patients (n = 42, 80.8%), resources and infrastructure (n = 21, 40.4%), and amount of supervision (n = 18, 34.6%). Eighteen HOs (34.6%) rated their confidence in their surgical skills as ≤2 points. Of all respondents, 76.9% (n = 40) were satisfied with their surgical rotation and 84.6% (n = 44) perceived the surgical rotation as relevant to their future work. Improved basic surgical skills training (n = 27, 51.9%) and improved supervision (n = 18, 34.6%) were suggested as a means to improve surgical rotation.

CONCLUSIONS

Surgical rotation during housemanship (internship) should be improved in terms of cancer treatment, surgical skills, and supervision to improve the quality of training, which is closely related to the quality of surgical care in rural areas.