Delivering and evaluating a scalable training model for strengthening family medicine in resource-limited environments: the Gaza experience. A mixed-methods evaluation

Summary

The FM PG Diploma was designed and delivered in an attempt to improve patient care in a resource-poor and politically unstable region beset by a higher than average burden of disease and risk factors. This evaluation demonstrates real gains in doctor–patient interaction in terms of the patient experience, and self-reported improvements in skills and abilities in participating doctors. Whether the improvements are sustainable in the long term remains to be seen, but in a country affected by illness, war, and poverty, even short-term gains are a small victory that merit dissemination. Though physicians with the Diploma benefited from this intervention, it may be difficult to implement a patient-centred and a biopsychosocial approach if physicians are not given adequate time in each consultation. UNRWA is engaged in improving the resources and infrastructure of their medical clinics, and the benefits of such engagement are the subject of a further article (in preparation).

Strengths and limitations

The authors acknowledge that the small numbers of physicians and patients included in this evaluation limit the generalisability of the findings. The findings presented here are, in effect, drawn from a pilot intervention. Evaluation of successive years of graduates will generate richer data that will allow elaboration and refinement of the conclusions of this article. Statistical analysis did not take clustering into account; in other words, there were not sufficient numbers of doctors to correlate patient responses for the same doctor. This is another reason to be cautious in the interpretation of the data.

The absence of pre-training assessment of practitioners limits the ability to state with absolute certainty that the difference in patient satisfaction is solely due to the training involved in the Diploma. There is the possibility of bias due to the selection process of the Diploma training: those selected for the Diploma achieved the highest marks in the application test. This could explain some of the observed differences rather than the training programme. It should be noted, however, that academic achievement does not equate to excellent doctors, and the physician and patient feedback focused heavily on improved non-technical facets of health care, which were not assessed in the application test.

Comparison with existing literature

The WHO Astana Declaration on primary health care in October 2018 specifically highlights the needs for training primary care professionals,¹⁰ but this is sometimes easier said than done. Medical education in resource-poor environments is fraught with difficulties.¹¹ Previous educational programmes have identified challenges in recruiting and training local faculty, and establishing leadership;^12,13 inadequate scale up; and lack of coordination.¹⁴ To establish successful programmes, there must be a coordinated effort between government policymakers and an alignment to educational institutions.¹⁵ The FM PG Diploma in Gaza is aligned to an established teaching university in the UK and is truly scalable; there is little difference between training 15 doctors and 150, due to the blended online platforms. The government in Gaza is fractured and unable to develop cohesive policies, but UNRWA provides stable local leadership.

Increasing morale was not a primary aim of this study, but analysis of the focus group discussions reveals a new enthusiasm for work. Learners speak of starting local training programmes and instigating audits. The diplomates have started their own social media group for ongoing dialogue and clinical needs, and set up regular journal club and case presentation sessions. Workforce morale is an important factor in the complex phenomenon of psychological resilience.^16,17 The Middle East has moderate-to-high levels of self-reported burnout among healthcare workers,¹⁸ although the degree of burnout in Palestinian doctors is unstudied and unknown. Additionally, improved healthcare morale is linked to improved patient-reported care outcomes and patient experience.¹⁹

Implications for research and practice

The e-learning platform and the blended form of delivery permits a scalable model, which can train hundreds of doctors as several cohorts every year. For example, 4 cohorts of 25 doctors would equate to 100 doctors per year, but larger cohorts would increase this number dramatically. Importantly, this model keeps costs low, and allows for scaling up in number of learners without massive increases in expenditure.

The synthesis of online and face-to-face teaching methods facilitates on-the-job learning, and minimises disruptions to the ongoing delivery of healthcare services. If this education model were to be adopted elsewhere, it is most likely to be in areas that require urgent postgraduate training but cannot afford to reduce its workforce to do so.

This exploratory study suggests that the postgraduate family medicine educational intervention has improved both the physicians’ and patients’ healthcare experience in an area suffering significant political and economic turmoil, minimal resources, and limited training opportunities. This education model is reproducible in other areas experiencing similar adversities. The programme is scalable, meaning that, without any significant changes in its core material and teaching approaches, the number of participating doctors can be vastly increased, potentially up-skilling scores or hundreds of family doctors every year without removing them from clinical practice. This model of training is practical, low cost, and effective, and many low- and middle-income countries could strengthen their family medicine workforce through such a training programme. A larger and more definitive evaluation is required in order to be more confident and precise in measuring the positive outcomes for this intervention.