A description of the resident’s age, gender and geographic location in Palestine are presented in Table 3 along with the composition of the three tutorial groups, the number of sessions, and the medical knowledge/clinical cases discussed. We then present the themes and subthemes of the 118 documents described above. Because of the differences found between the tutorial groups, we also examined each group as an entity.
Tutorial Groups
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Group A
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B
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C
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Initial Number of residents
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5 = 4 females/1 male
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4 = 3 male; 1 female
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4 = 2 male; 2 female
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Final # of resident
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6 females
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4 = 3 male
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3 = 2 male; 1 female
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Tutor demographics
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1 F British GP; 1 M US FM Arabic speaker
working in Jordan
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3 Rotating British GP (2F 1M), no Arabic
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3 British GP M, 1 Arabic speaker familiar with context
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Total # Sessions
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11
|
9
|
8
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Timing: Day, Time,
Palestine EEST*
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Weekday 1200
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Weekend 1800
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Weekday 2100
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Resident attendance
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Regular
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Sporadic
|
Consistent minus 1
|
Resident session report
|
Complete
|
Complete
|
Complete
|
Resident evaluation
|
Complete
|
Incomplete
|
Incomplete
|
Used Role Play
|
Yes
|
yes
|
yes
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WhatsApp group
|
yes
|
no
|
no
|
Table 4. Themes and exemplary quotes from Group A’s chat discussions.
1. Discussion content enabled the tutors to plan the next session from real time problems residents encountered in their clinics
M: “We want to talk about differential diagnosis, red flags and management. How to advise parents and how to reassure them as they are always anxious about their sibling.”
T: “The other case is about girls not walking straight ‘gait problems’.” (also sent a video of the child with limping gait)
M: “I was choosing a topic of headaches. There is luck here as headache as somewhat connection with anemia and connection in general with fatigue which has been discussed with us in previous tutorial.”
R: “I have two case discussion that I would like to share with you this Saturday. The first one is about a patient 8 year old coming with mild gastroenteritis. . .
2. Building trust and relationships within the group
Continuing the above text from R about the 8 year old: “His mother asked for CBC (complete blood count). On physical exam patient was well, not pale. I asked the mother why she wants me to do a CBC she said because her son feels tired these days. I was against repeating CBC and told the mother that she needs to give him ORS and come again in two weeks for follow up and re-evaluate his tiredness. Mom came back in two weeks bringing her youngest daughter 6 months for vaccination but was referred to me for evaluation as she had bronchiolitis. When I started examining her daughter she told me in an angry way:
‘Do you remember when I asked you to do a CBC for my son and you refused !! I went to another doctor who did the CBC and he saw amoeba in his CBC.’”
R posed a question to the group: “What do you think so far about what happened and what to do next? PS: unfortunately I become upset.”
3. Sharing feelings openly in the group is also demonstrated in the above quote. Another example about a case seen after an earlier session included discussion of the topic:
T: “Good morning. Today I deal with another case of alopecia areata but now I was more comfortable and I felt with trust. Thanks our teachers.”
4. Seeking help and support from their peers became more frequent as the trust and relationships grew in the group and they started using their skills mix and asking for support from each other.
Having discussed how to manage her father with poorly controlled blood pressure, polypharmacy and diabetes mellitus with the group in a tutorial session, M then sought the help from L, a fellow resident in the group who ran a diabetes clinic.
M: “Good evening. Today my dad started basal insulin. He was so afraid of the needle. I brought him to the clinic and me and L gave him the injection and showed him how to take it. It was easy. He was happy that there is no pain with the needle. I will follow him closely.
These sessions help me to organize my ideas in a systematic way. Gave me the courage to take decisions with confidence. And simplify the cases which I thought was hard. Thanks a lot.”
5. Evidence of the use of and interest in guidelines and patient education leaflets
M: “Thanks a lot for your effort everybody. Can we have a NICE guideline for anemia and fatigue. In order to print it and have it with us at the clinics.”
T shared a complicated case about a fever and concluded: “I send to her Arabic brochures about dealing with high fever.”
6. Feedback on the tutorial sessions.
T: “The most important thing that changed is my personality. I was Very nervous when I deal with angry patients. Now I learned patience. Also I learned from the last session the case of M's dad, some art of medicine, how to deal with polypharmacy. I printed some of the important schemes for diagnosis and management diseases. Really we are lucky to join this group. Thanks a lot.”
L: “Good evening. Me and R will be on duty this Saturday...what about our session, we don't like to miss it.”
The major themes of knowledge, skills, attitudes, cultural disconnects and tutorial logistics emerged. All three groups reported the knowledge and skills acquired, with group A listing the most followed by groups B and C. Knowledge gained was related to details learned in case-based discussions such as how to read a complete blood count, obtaining a stool culture on diarrhea due to the high rates of parasite-caused diarrhea in Palestine, and learning how to start insulin. Groups B and C focused on clinical knowledge and tutors noted that it was often difficult to get the residents off the topic of disease management knowledge and onto the educational goals for the program.
Skills acknowledged by the residents fell into the following categories: 1) Consistently using a systematic approach toward a patient which included proficiencies such as taking a thorough illness history, conducting a thorough medication review, performing an exam, inquiring about red flags, remembering to assess psychosocial factors, and safety netting which involved arranging follow up with the patient. 2) The use of evidence-based guidelines to guide decisions included such topics as refraining from ordering unnecessary labs and identifying useful guidelines to reference for diagnoses such as hypertension or fatigue. 3) Good communications skills such as ICE (patient’s ideas, concerns and expectations should be asked), listening well, purposefully asking both open and closed questions, and using silence to allow the patient to feel emotion such as grief. 4) The importance of patient education; and 5) Learning how to give feedback were the final subthemes. Once again, group A residents recorded the most skills in their evaluations followed by B and C. See Table 2, columns 2–4.
Attitudes were frequently noted by the residents in group A and rarely noted in groups B or C. These included the benefit of interaction with colleagues; valuing the experience of the tutors, including the perspectives of other medical cultures (UK and US); seeing every patient as an opportunity to learn; recognizing that not every problem requires a solution; and reflections on professional boundaries and bioethics. Only group A residents mentioned feeling open and honest and willingly shared clinical difficulties during the sessions. One resident in group A even presented her father as a case for the residents to discuss and guide her. Tutors focused on attitudes and skills with the remediating resident including the importance of lifelong learning and team leading skills.
These collegial attitudes likely led group A to form a social media chat group after the second session so they could share real-time problems they were encountering in clinic. Midway through the program, the residency director assigned the male resident in Group A to another group and added a female resident, who was frustrated by the passivity of the colleagues in her original group. A review of the chat record showed that the number of messages increased with time. Although the residents were well known to each other, this was the first time that they consulted with one another about practice-related questions on a regular basis. Many guidelines and treatment algorithms were shared between the residents as well as pictures of dermatological cases and even a video of a child with a gait problem. The messages showed increasing honesty and vulnerability as well as increased confidence in their clinical expertise. The tutors planned sessions based on the content shared, received immediate feedback about the sessions, and saw evidence of guideline use. Tutors did respond to some questions posed on the chat, but much of the support was from one resident to another. For exemplary text see Table 4.
Groups B and C were less collegial and comments to the Resident Tutorial Evaluation question: “What do I still need to learn?” more commonly showed answers such as “From my side .... nothing” or “as a fourth year resident I don’t need this.”
Group B and C covered fewer of the recommended skills and attitudes in Table 2 and the tutors in Group C rarely turned in a tutorial debrief. Group C residents showed less reflection in their session evaluations.
Cultural disconnects: Evaluation reports and the residency director’s notes from check-ins with the residents showed trouble with a tutor speaking English too quickly, residents offended by the humor of one UK tutor, and nuances during case presentations and discussions that were misunderstood without an Arabic tutor present. A lack of understanding of the Palestinian context and the types of cases encountered caused discussions to get bogged down in disease management instead of the approach to the patient and the process of thinking through care decisions that reflected a more patient-centered approach.
Logistics lessons learned: Role plays were done by all groups and seemed to work the best if the residents did the role play in Arabic, with an Arabic tutor present. Role plays done by the tutors or performed in English by the residents occurred in several cases, and were deemed less effective. Tutors who asked residents to prepare for sessions and to bring cases from their clinical work and were well-prepared themselves had better resident participation in sessions. Tutor pair instability due to the voluntary nature of the role, and busy clinical schedules of their own, resulted in less organized sessions. PowerPoint used with discussions was initially tried and then avoided because it was easier to manage discussions when all faces were in view with a second tutor managing the chat function.
Both the tutors and residents experienced a learning curve with the Zoom platform. Weak home internet systems often caused problems such as needing to turn off cameras or residents needing to sign on several times and missing parts of the session. Erratic electricity due to regional cuts was also a challenge. One resident noted on their evaluation: “I am very lucky because the electricity was on.” Lockdowns due to COVID quarantines and needing to be on medical duty sometimes interrupted attendance. Although residents were assigned to times that were agreeable to them, interruptions still occurred due to family obligations and background noise from children and music.
Survey Results
The follow-up survey two years later had a 77% response rate (10/13). We suspect that the three who did not respond did not find the tutorial particularly helpful and were the less active members in their groups. Nine of the responders were in clinical practice, one also had a private clinic, and one served an administrative role in government. In addition to seeing patients, one supervised residents, one taught courses at the medical school, and two conducted research. Graduates doing patient care (9/10) in family health centers were able to use their Family Medicine skills most of the time. Too many patients to see, followed by unsupportive administrations and colleagues were the main barriers for using their Family Medicine skills.
Most reported attending all the tutorial sessions, were motivated to participate, and would have done so if it wasn’t obligatory (7/10). All felt the tutors created a safe learning environment and most (9/10) felt the manner of teaching was useful. Two thirds (6/10) thought their colleagues actively participated and three did not, with one interpreting a colleague’s attitude as “thinking the tutorials were a joke.” Another was aware that a peer signed on to Zoom but was not listening. Barriers to participation included: unstable internet (4) and other obligations at home (6) despite confirming the best times beforehand. Two found it hard to understand the tutors, two thought the cases didn’t relate to the patients they saw, and one felt the covered topics were unhelpful. The most valuable parts of the tutorial were help in organizing thinking (5), networking with colleagues (4), learning the UK perspective (3), the chat group (3), and increased confidence in patient care decisions (3). Most (7/9) in clinical practice used decision support such as Epocrates and the American Family Physician.