Medical Teacher
ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
Medical education in Palestine Ben Kerr Winter, Ra'ad Mohammed Salamma & Kinda Adli Qabaja To cite this article: Ben Kerr Winter, Ra'ad Mohammed Salamma & Kinda Adli Qabaja (2015) Medical education in Palestine, Medical Teacher, 37:2, 125-130, DOI: 10.3109/0142159X.2014.971721 To link to this article: https://doi.org/10.3109/0142159X.2014.971721
Published online: 21 Oct 2014.
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Date: 06 January 2018, At: 01:20
2015, 37: 125–130
AROUND THE WORLD
Medical education in Palestine BEN KERR WINTER1, RA’AD MOHAMMED SALAMMA2 & KINDA ADLI QABAJA3 1
University of Sheffield, UK, 2Tulkarm Governmental Hospital, Palestine, 3Queen Alia Hospital, Palestine
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Abstract Palestine has a short history of medical education: the first medical school opened in 1994 and a further three have opened since. Doctors are trained against a backdrop of military occupation and ineffective governance, complicating the development and delivery of effective education. Postgraduate education is a particular weakness, with disorganised residency programmes prioritising service provision over the training of specialists, leading to poorer patient care and low morale. This unfavourable learning environment leads into a situation where opportunities for continuing professional development are scarce. Links between healthcare and education providers in Palestine and countries with advanced health systems have great potential for allowing best practice in medical education to be shared and to provide high quality training opportunities that address gaps in Palestine’s health education system.
Introduction Palestine has existed as a sovereign state since only 2012, but the region known as Palestine today has a long and rich history. The country is perhaps best known for two features: being a land of spectacular religious significance for three major faiths and for the ongoing conflict with Israel. For centuries, it has also served as a melting pot of different cultures, whose people have travelled to Palestine as traders, pilgrims, scholars and soldiers. Palestine is a small and relatively densely populated country, the West Bank is 5640 km2 and Gaza 360 km2. Today Palestine has a population of 4.5 million (1.8 million of these in Gaza), over 50% of whom are under the age of 25 years. The fertility rate in Gaza is higher than in the West Bank, with 4.2 births per woman compared to 2.8. Life expectancy at birth has risen from 63 years in 1980 to almost 75 years in 2014 (United Nations Development Programme 2013; The World Factbook 2014a,b). With increasing age, the Palestinian health system faces a growing multi-morbid population, requiring doctors capable of managing ever more complex patients. The major causes of morbidity and mortality in Palestine are now non-communicable diseases. Ischaemic heart disease, cerebrovascular disease, cancer and pathology related to diabetes account for the majority of deaths (Husseini et al. 2009). Doctors cannot treat these conditions with knowledge gleaned from textbooks alone, they must be trained in a collaborative approach to medicine where they can educate and involve patients in long-term management. This article aims to provide an overview of the medical education system in Palestine. It will identify and provide
Practice points
A highly fragmented healthcare landscape makes coordinating medical education and setting standards between different facilities and providers difficult. Undergraduate medical education has developed rapidly since the first medical school opened in 1994. Traditional and lecture-based courses remain: the introduction of modern learning is hampered by a lack of qualified teaching staff. Residents are generally dissatisfied with disorganised training programmes that emphasise service provision over training. This is an area that needs reform to improve staff morale and improve quality of care. A formal system for continuing medical education needs to be established, and a culture fostered where doctors actively keep up to date with developments in their field.
an analysis of the challenges faced in undergraduate and postgraduate training and continuing medical education, and will suggest potential opportunities for development. The information in this article comes from a range of sources. Two of the authors, R.M.S. and K.A.Q., have conducted most of their medical education in Palestine and have extensive first-hand experience of how medicine is taught. The other author, B.K.W., conducted a series of semistructured interviews with a range of individuals involved in health and education in Palestine, in order to ensure that a diversity of perspectives informed this article. Twenty-one participants were asked about their experiences of medical
Correspondence: Dr. Ben Kerr Winter, Medical Education, Medical School, The University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK. E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/15/020125–6 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2014.971721
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education, both positive and negative, as well as opportunities for improvement. The sample included two heads of clinical departments, seven residents, three interns, eight medical students and a specialist who worked in a leadership role for an Non-Governmental Organisation (NGO). In addition, BKW observed 12 teaching sessions. Ten of these were for clinical medical students at two different institutions, one session was for residents and one was for senior specialists and residents. Participants were informally debriefed afterwards to gain feedback on the perceived value of the sessions and to assess how representative they were of the medical education system.
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A background to Palestine In order to understand medical education in Palestine, it is necessary to first have an understanding of the complex geopolitical situation. Palestine’s recent history has been turbulent, and regional conflict influences every aspect of life in the country. Since 1949, Palestine has been divided into two territories, the West Bank and Gaza, separated in between by Israel. Palestine has been under Israeli military occupation since 1967, before which Gaza was controlled by Egypt and the West Bank by Jordan (BBC 2014a). This fact has significance for both the provision of healthcare and medical education. In the West Bank, over 60% of land is designated ‘‘Area C’’, which is under total Israeli security and civil administration (United Nations Office for the Coordination of Humanitarian Affairs 2013a). Construction or renovation of buildings in Area C is strictly controlled and largely prohibited, forcing residents to live in poor-quality housing, whilst these and other controls limit economic activities, perpetuating poverty (B’Tselem 2013). Both of these pose a threat to good health. Similarly, construction and maintenance of healthcare and education facilities in Area C is significantly impeded by the Israeli authorities (United Nations Office for the Coordination of humanitarian Affairs 2013b). Within the West Bank, the movement of Palestinians is restricted by Israel through a series of bureaucratic and physical obstacles. These include a complex system of passes required to access Jerusalem, military checkpoints, impassable road blocks, an eight-metre high concrete separation wall and roads that Palestinians are forbidden from using (United Nations Office for the Coordination of Humanitarian Affairs 2012). The Israeli human rights organisation, B’TSelem, recorded 99 permanent military checkpoints in the West Bank in 2014, with an average of 256 temporary ‘‘surprise’’ checkpoints every month (B’Tselem 2014). The time taken to pass through checkpoints is unpredictable and can vary from minutes to hours, delaying patients, clinicians and students from reaching healthcare facilities. Gaza also faces many difficulties. Israel withdrew its permanent military presence from Gaza in 2005, but has operated a land, air and sea blockade since then. This prevents virtually all movement of people in and out and places huge restrictions on the movement of equipment and materials (World Health Organisation 2012). Gaza has faced further 126
isolation and a loss of international support as a consequence of the election of Hamas to government, a party that is staunchly opposed to Israel and considered violent and even terrorist by many countries (BBC 2014b).
Healthcare in Palestine Palestine has a huge diversity of healthcare providers and a fragmented healthcare landscape, a fact that can make coordinating medical education and setting standards difficult. Hospitals are a mixture of governmental, private and those run by NGOs (e.g. Doctors Without Borders 2014; Palestine Red Crescent Society 2014), international bodies (e.g. The UN), and religious institutions. The health infrastructure in Palestine has received significant investment since 1994 when responsibility for healthcare was transferred from the Israeli Ministry of Defence to the Palestinian Authority (Schoenbaum et al. 2005). Prior to this, the Palestinian healthcare system had been starved of funds and resources by the Israeli military administration, leading to shortfalls in healthcare provision and human resources (Giacaman et al. 2009). Subsequent financial investment has been significant, but development has been hampered by inefficient and corrupt governance by the Palestinian authorities and a lack of effective planning (Giacaman et al. 2003). The healthcare sector operates in difficult and unpredictable financial circumstances, making budgeting and long-term planning troublesome. Donor-aid incomes vary from year to year, and tax revenues collected from Palestinians by the Israeli government, the major source of Palestinian Authority income, are sporadically withheld. Standards vary considerably between different facilities, with government hospitals generally providing a poorer standard of care. The tertiary hospital for Palestine is located in East Jerusalem, cut off from the West Bank by the Israeli separation wall that requires special permission to cross. Healthcare is funded through a combination of insurance schemes, out-of-pocket payments and taxation. Sixty percent of the population is enrolled in the government’s health insurance scheme. This is provided free to those in poverty, the families of prisoners in Israeli jails and to those whose health problems are ‘‘intifada related’’ – occurring due to the actions of the Israeli military.
Medical schools There are four medical schools in Palestine, two in the West Bank and two in Gaza. Each year, 150–200 medical students graduate from medical schools in Palestine (FAIMER 2014). Al-Quds University opened a medical school in 1994 in Abu Dis, a village just west of Jerusalem. This was the first medical school in Palestine. Before this, Palestinians went abroad to train, often to Jordan, Egypt or Russia (previously many students trained in the Soviet Union). An-Najah University in Nablus, a city in the north of the West Bank, began training doctors in 1999. The university initially delivered the Al-Quds course, before developing its own curriculum and becoming
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an independent medical school in 2008. An-Najah opened a new teaching hospital in 2013 as a focus for its clinical education. Al-Azhar University in Gaza enrolled its first medical students in 1999, again initially following the Al Quds curriculum. In 2006, a second medical school opened at the Islamic University of Gaza. The Islamic University was extensively damaged by Israeli airstrikes as part of the ‘‘Operation Cast Lead’’ offensive in December 2008 and January 2009. The attack destroyed the university’s laboratories as well as damaging the central library and computer facilities. Medical schools in the West Bank are accredited and regulated by the Palestinian Ministry of Education and Higher Education, based in Ramallah. Those in Gaza are governed by the counterpart authority based in Gaza. Today, it is still common for students to attend medical schools abroad, particularly in Egypt, Jordan and Russia. Graduates from Russia face difficulties integrating into the medical community on their return to Palestine, where business is conducted in a mixture of Arabic and English, and where most doctors have trained in a system modelled on the UK and USA. Palestinian doctors report significant differences in the style of medical practice between doctors trained in Russia and those trained elsewhere.
Restrictions on access to education Palestine is a small country, but the restrictions on movement described above, in combination with the country’s hilly terrain, mean that journey times between home, university, hospitals and clinics are long. This places an extra burden on the wellbeing of students and residents (postgraduates in specialist training) who already work long hours. In addition, the unpredictability of time spent at military checkpoints means doctors and students can be late for teaching sessions and clinical duties, impacting on medical education. As stated above, special permission is required for Palestinians who want to access the Palestinian tertiary hospital in occupied East Jerusalem. Most students and doctors are granted passes lasting six months or less, with no guarantee of renewal. Over 20% of the Al Quds medical school class of 2014 have been refused permission for unspecified security reasons, a typical figure for each year. For these students, exposure to the highest quality clinical care and teaching is then compromised.
Admission Admission to medical school is very competitive, only those with the highest grades from examinations at the end of secondary education are accepted. In addition, prospective students are interviewed to assess their suitability to study and practice medicine, focusing on motivation, maturity and character.
The undergraduate medical courses Undergraduate medical courses in Palestine last six years. The first three years are a combination of basic science and preclinical medicine; years four to six are clinical. English is the official language of all courses, but in reality, a mixture of Arabic and English is often used. Pre-clinical courses are traditional and lecture-based, structured around subjects rather than systems. There is a desire in some universities to introduce greater small group work, but this is held back by a lack of suitably qualified staff to act as facilitators. Students report variable quality of teaching in the preclinical years, with some teaching considered to be outdated in its content. An-Najah medical school has started introducing students to the clinical environment earlier, with one day per week in the third (pre-clinical) year spent in a clinical setting. Clinical students are rotated through placements around the West Bank or Gaza, depending on the medical school, in a mixture of governmental and private hospitals and community settings. Doctors are paid by the medical schools to provide teaching and supervision for students, and the hosting hospitals also receive payment. The range of healthcare facilities and types of facility seen by clinical students gives them excellent exposure to different medical staff and styles of practice, something the students interviewed valued. However, they report significant variation in the educational value of different placements. On a number of placements, students reported that medical staff have too little time to teach. Large patient loads mean that at ward rounds and in clinics, senior doctors sometimes have no time to effectively involve students, and may provide as little as one hour or even no dedicated teaching time per week. Some students report difficulties in the private hospitals, with a proportion of paying patients unwilling to interact with medical students. Students provide feedback to the medical schools at the end of each placement. Across all hospitals, students reported insufficient focus on education, with teaching frequently viewed as a distraction from the hospital’s core purpose of service delivery. Peer teaching, where senior clinical medical students teach more junior students, occurs on an informal and ad hoc basis. This teaching is often well received by students, who are grateful for extra teaching and for the approach of a teacher who has more recently been at the same stage of education. Assessment is by a combination of written examinations (predominantly multiple choice questions) and Objective Structured Clinical Examinations with a mixture of real and simulated patients. Workplace-based assessments are used in some medical schools. For example, at Al-Quds medical school in the clinical years, 20% of a student’s mark from each unit comes from the supervisor’s assessment of their performance during the placement. All medical schools charge fees from the students. This is largely funded through family contributions, but some scholarships and loans are available from the universities.
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Fees are in the region of $8000 US Dollars per year for Palestinian students, a significant cost given that the average annual household expenditure in Palestine is approximately $12,000 US Dollars (Palestinian Central Bureau of Statistics 2011).
HINARI scheme (World Health Organisation 2014). Some doctors choose to take out individual subscriptions to specific journals; but for many, this practice is prohibitively expensive. Some journals, for example, the New England Journal of Medicine, are made available free inside Palestine. However, overall, a lack of access to research has a detrimental effect on medical education.
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Postgraduate education After medical school, doctors traditionally complete a one-year internship, where they move to a different specialty and different facility approximately every two months. All internships include medicine, surgery, paediatrics, obstetrics and gynaecology, psychiatry and public health. In 2012, the system was changed to allow Palestinian graduates to begin a residency programme immediately after medical school, if they choose. All graduates from abroad must undertake an internship. Interns have limited responsibility for patient care and are not expected to make many decisions independently. After an internship, doctors apply for a residency programme. Residents train in a particular specialty and have considerable responsibility for service provision. Residency programmes last for four to five years. Specialist training is broad with limited opportunity for sub-specialisation. For example, there are no specific training programmes for respiratory or renal medicine or any other medical specialty, only internal medicine. This produces doctors that are competent at independently managing a wide range of pathology, including multi morbid patients, but lack expertise in any one area. A potential positive consequence of this is that patients may be passed from clinician to clinician less than they would be in countries where there is considerable sub-specialisation, for example, the UK. Many residents strive to complete additional sub-specialist training abroad, but this is difficult to organise. Residents report a lack of teaching from senior doctors and feel the long hours they work (often well over 100 hours per week) leave insufficient time for personal study. Despite being on a postgraduate training programme, residents feel that the balance between training and service provision leans too far towards the latter. The problem is particularly serious in the government-run hospitals and subsequently has a negative impact on both patient care and staff morale. Some of the most senior doctors working in facilities in Palestine have completed postgraduate training in Europe, particularly the UK and the USA. This training is perceived to be of a high standard compared to that available locally. Having doctors with overseas experience returning to senior positions in Palestinian healthcare services allows new techniques and ideas to be introduced to domestic graduates and residents. For example, evidence-based medicine is currently in its infancy in Palestine, being driven in part by doctors who have experience of this approach from overseas. Access to up to date research is a problem for both residents and doctors who have completed their formal training. Hospitals subscribe to only a limited number of medical journals, if any, despite Palestine being eligible for some support through the World Health Organisation’s 128
Licensing and continuing medical education All doctors must complete a national examination to gain their license to practice independently. This consists of multiple choice questions and covers all specialties. The exam must be passed before taking up a residency programme and is typically sat at the end of the internship year. The medical license is valid for life, with no requirement to continue to develop skills or to maintain proficiency. There is no formal system of continuing medical education in Palestine. Conferences and courses are held infrequently on an ad hoc basis, often with financial support from pharmaceutical companies.
Opportunities for improvement Medical education in Palestine is still evolving; it was only 20 years ago that all doctors were trained abroad. Consequently, it is likely that with time, many aspects of medical education will improve as the system continues to develop organically. However, there are approaches that could expedite improvements. The variable quality of clinical placements for undergraduate medical students requires a coordinated response from the medical schools and the Ministry of Health. Increased use of student feedback would allow specific areas of concern to be identified and acted upon, where possible. Although many healthcare providers operate under considerable financial and human resource constraints, improved organisation, planning and feedback to teachers would allow for improvements at minimal cost. Minimum teaching requirements should be agreed between medical schools and clinical education providers and clearly communicated to medical students, with compliance closely monitored. Residency programmes require reform to improve the morale and competence of doctors in specialist training. Greater exchange of knowledge must take place between senior specialists and residents, both in day-to-day clinical practice and in time set aside for formal teaching. Many residents feel unsure of how they are progressing in their training compared to what is expected, so greater constructive feedback from senior staff should be provided, whilst curricula and expectations of residents at different stages must be made clearer. Reform of postgraduate training is a significant undertaking and must carefully consider the views of all stakeholders, as well as the health needs of the Palestinian population. Whilst many residents feel unsatisfied with their postgraduate training, there is
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currently little momentum for change at senior levels in the medical community, which prevents necessary development. Developing links between healthcare and education providers in Palestine and countries with advanced healthcare and education systems has great potential for improving the education of Palestinian undergraduates and postgraduates. Exchanges of clinicians and teaching staff, in both directions, allows practice and experience to be shared, as well as providing opportunities for direct teaching. Teaching by visiting academics and staff seconded to Palestinian medical schools could help to circumvent, in the shortterm, shortages of high quality teaching staff resident in the country. Examples of such partnerships are OxPal (2014), a link between Palestinian medical schools and doctors from Oxford, UK, and a link between Al-Quds University and the University of Gothenburg, Sweden, as part of Sweden’s Linnaeus-Palme international education development programme (Linnaeus-Palme 2013). An evaluation of the OxPal partnership demonstrates that its direct teaching has proven very valuable to students, although there has been no assessment of its impact in improving the domestic educational environment in Palestine (Penfold et al. 2014). Partnerships that facilitate the training of postgraduates overseas would also be of great benefit. Links between hospitals in the UK and low-income countries are becoming increasingly common, and these and other similar schemes have great potential here. Palestine does not have the capacity to provide sub-specialist training; sub-specialists are simply too few, so overseas training is necessary to build capacity initially. The opportunity to spend one year or more training in Europe or North America either during or after a residency programme could significantly enhance the clinical ability of a Palestinian doctor in a specific area of medicine. Likewise, exchanges of faculty in the medical schools could facilitate the introduction of more varied, modern teaching methods into Palestine. Inevitably, there is a risk that overseas training may contribute to a ‘‘brain drain’’, with a proportion of doctors not returning. However, many undergraduates and postgraduates who have previously completed some training overseas do return to Palestine, suggesting that strong cultural ties to their home country would encourage doctors to continue their careers in Palestine, bringing their valuable overseas experience with them. Efforts to increase access to medical journals in resource poor settings are in motion globally. This is also an issue that the Palestinian Ministry of Health could take the lead on locally, given that it affects all healthcare providers in Palestine. Coordinating subscriptions between healthcare providers, utilising the World Health Organisation HINARI subsidy scheme and involving overseas funding partners has the potential to significantly increase access to research whilst keeping costs to a minimum. More frequent professional conferences and meetings would help doctors who have completed training to keep their knowledge up to date. Regular departmental teaching sessions, journal clubs and larger conferences organised by
medical associations allow best practice to be shared and new ideas to be introduced to the audience. Two of the authors of this paper (R.M.S. and K.A.Q.) attended a large scientific meeting organised by internal medicine physicians in the West Bank in 2014. The feedback from attendees was positive, and it was felt that in-depth discussion of complex cases, presented by experts, helped to raise the standard of medicine that the doctors present practiced.
Conclusion Palestine faces many difficulties in its social, political and economic spheres, and medical education is no exception. The development of undergraduate medical education in Palestine over the past 20 years is a great success. Although the system is not without its imperfections, the country now trains many of its own doctors who feel prepared for medical practice and who are enthusiastic about serving the population. The greater challenges lie after graduation. Residents feel overworked and undertrained, frustrated by how little knowledge is imparted by senior doctors. At the end of the residency, there is little opportunity for the subspecialist training necessary to provide the highest standards of patient care. Once training is complete, there is no system for ensuring doctors keep their skills and knowledge up to date, and few formal opportunities for continued medical education. Partnerships with advanced healthcare and education providers provide an opportunity to build capacity that is not available domestically, sharing best practice in medical education and facilitating overseas training for clinicians and teaching staff. There is incredible enthusiasm amongst Palestinian students and doctors for greater training and the opportunity to develop skills that will help improve the health and education systems. Capitalising on this energy will further advance the health of the Palestinian population.
Notes on contributors BEN KERR WINTER, BSc, MBChB (Hons), graduated from medical school at the University of Manchester, UK. He has strong interests in global health and medical education and until recently was based at Al-Makassed, a Palestinian hospital in East Jerusalem. RA’AD MOHAMMED SALAMMA, MD, graduated from medical school at Al Quds University, Palestine. He has undertaken part of his medical education in Poland and has been heavily involved in the International Federation of Medical Student Associations. KINDA ADLI QABAJA, MD, graduated from medical school at Al Quds University, Palestine. She has experience of medical education in primary, secondary and tertiary healthcare settings in the West Bank.
Declaration of interest: The authors have no conflicts of interest.
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ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
Medical education in Palestine Ben Kerr Winter, Ra'ad Mohammed Salamma & Kinda Adli Qabaja To cite this article: Ben Kerr Winter, Ra'ad Mohammed Salamma & Kinda Adli Qabaja (2015) Medical education in Palestine, Medical Teacher, 37:2, 125-130, DOI: 10.3109/0142159X.2014.971721 To link to this article: https://doi.org/10.3109/0142159X.2014.971721
Published online: 21 Oct 2014.
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Article views: 193
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Date: 06 January 2018, At: 01:20
2015, 37: 125–130
AROUND THE WORLD
Medical education in Palestine BEN KERR WINTER1, RA’AD MOHAMMED SALAMMA2 & KINDA ADLI QABAJA3 1
University of Sheffield, UK, 2Tulkarm Governmental Hospital, Palestine, 3Queen Alia Hospital, Palestine
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Abstract Palestine has a short history of medical education: the first medical school opened in 1994 and a further three have opened since. Doctors are trained against a backdrop of military occupation and ineffective governance, complicating the development and delivery of effective education. Postgraduate education is a particular weakness, with disorganised residency programmes prioritising service provision over the training of specialists, leading to poorer patient care and low morale. This unfavourable learning environment leads into a situation where opportunities for continuing professional development are scarce. Links between healthcare and education providers in Palestine and countries with advanced health systems have great potential for allowing best practice in medical education to be shared and to provide high quality training opportunities that address gaps in Palestine’s health education system.
Introduction Palestine has existed as a sovereign state since only 2012, but the region known as Palestine today has a long and rich history. The country is perhaps best known for two features: being a land of spectacular religious significance for three major faiths and for the ongoing conflict with Israel. For centuries, it has also served as a melting pot of different cultures, whose people have travelled to Palestine as traders, pilgrims, scholars and soldiers. Palestine is a small and relatively densely populated country, the West Bank is 5640 km2 and Gaza 360 km2. Today Palestine has a population of 4.5 million (1.8 million of these in Gaza), over 50% of whom are under the age of 25 years. The fertility rate in Gaza is higher than in the West Bank, with 4.2 births per woman compared to 2.8. Life expectancy at birth has risen from 63 years in 1980 to almost 75 years in 2014 (United Nations Development Programme 2013; The World Factbook 2014a,b). With increasing age, the Palestinian health system faces a growing multi-morbid population, requiring doctors capable of managing ever more complex patients. The major causes of morbidity and mortality in Palestine are now non-communicable diseases. Ischaemic heart disease, cerebrovascular disease, cancer and pathology related to diabetes account for the majority of deaths (Husseini et al. 2009). Doctors cannot treat these conditions with knowledge gleaned from textbooks alone, they must be trained in a collaborative approach to medicine where they can educate and involve patients in long-term management. This article aims to provide an overview of the medical education system in Palestine. It will identify and provide
Practice points
A highly fragmented healthcare landscape makes coordinating medical education and setting standards between different facilities and providers difficult. Undergraduate medical education has developed rapidly since the first medical school opened in 1994. Traditional and lecture-based courses remain: the introduction of modern learning is hampered by a lack of qualified teaching staff. Residents are generally dissatisfied with disorganised training programmes that emphasise service provision over training. This is an area that needs reform to improve staff morale and improve quality of care. A formal system for continuing medical education needs to be established, and a culture fostered where doctors actively keep up to date with developments in their field.
an analysis of the challenges faced in undergraduate and postgraduate training and continuing medical education, and will suggest potential opportunities for development. The information in this article comes from a range of sources. Two of the authors, R.M.S. and K.A.Q., have conducted most of their medical education in Palestine and have extensive first-hand experience of how medicine is taught. The other author, B.K.W., conducted a series of semistructured interviews with a range of individuals involved in health and education in Palestine, in order to ensure that a diversity of perspectives informed this article. Twenty-one participants were asked about their experiences of medical
Correspondence: Dr. Ben Kerr Winter, Medical Education, Medical School, The University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK. E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/15/020125–6 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2014.971721
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education, both positive and negative, as well as opportunities for improvement. The sample included two heads of clinical departments, seven residents, three interns, eight medical students and a specialist who worked in a leadership role for an Non-Governmental Organisation (NGO). In addition, BKW observed 12 teaching sessions. Ten of these were for clinical medical students at two different institutions, one session was for residents and one was for senior specialists and residents. Participants were informally debriefed afterwards to gain feedback on the perceived value of the sessions and to assess how representative they were of the medical education system.
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A background to Palestine In order to understand medical education in Palestine, it is necessary to first have an understanding of the complex geopolitical situation. Palestine’s recent history has been turbulent, and regional conflict influences every aspect of life in the country. Since 1949, Palestine has been divided into two territories, the West Bank and Gaza, separated in between by Israel. Palestine has been under Israeli military occupation since 1967, before which Gaza was controlled by Egypt and the West Bank by Jordan (BBC 2014a). This fact has significance for both the provision of healthcare and medical education. In the West Bank, over 60% of land is designated ‘‘Area C’’, which is under total Israeli security and civil administration (United Nations Office for the Coordination of Humanitarian Affairs 2013a). Construction or renovation of buildings in Area C is strictly controlled and largely prohibited, forcing residents to live in poor-quality housing, whilst these and other controls limit economic activities, perpetuating poverty (B’Tselem 2013). Both of these pose a threat to good health. Similarly, construction and maintenance of healthcare and education facilities in Area C is significantly impeded by the Israeli authorities (United Nations Office for the Coordination of humanitarian Affairs 2013b). Within the West Bank, the movement of Palestinians is restricted by Israel through a series of bureaucratic and physical obstacles. These include a complex system of passes required to access Jerusalem, military checkpoints, impassable road blocks, an eight-metre high concrete separation wall and roads that Palestinians are forbidden from using (United Nations Office for the Coordination of Humanitarian Affairs 2012). The Israeli human rights organisation, B’TSelem, recorded 99 permanent military checkpoints in the West Bank in 2014, with an average of 256 temporary ‘‘surprise’’ checkpoints every month (B’Tselem 2014). The time taken to pass through checkpoints is unpredictable and can vary from minutes to hours, delaying patients, clinicians and students from reaching healthcare facilities. Gaza also faces many difficulties. Israel withdrew its permanent military presence from Gaza in 2005, but has operated a land, air and sea blockade since then. This prevents virtually all movement of people in and out and places huge restrictions on the movement of equipment and materials (World Health Organisation 2012). Gaza has faced further 126
isolation and a loss of international support as a consequence of the election of Hamas to government, a party that is staunchly opposed to Israel and considered violent and even terrorist by many countries (BBC 2014b).
Healthcare in Palestine Palestine has a huge diversity of healthcare providers and a fragmented healthcare landscape, a fact that can make coordinating medical education and setting standards difficult. Hospitals are a mixture of governmental, private and those run by NGOs (e.g. Doctors Without Borders 2014; Palestine Red Crescent Society 2014), international bodies (e.g. The UN), and religious institutions. The health infrastructure in Palestine has received significant investment since 1994 when responsibility for healthcare was transferred from the Israeli Ministry of Defence to the Palestinian Authority (Schoenbaum et al. 2005). Prior to this, the Palestinian healthcare system had been starved of funds and resources by the Israeli military administration, leading to shortfalls in healthcare provision and human resources (Giacaman et al. 2009). Subsequent financial investment has been significant, but development has been hampered by inefficient and corrupt governance by the Palestinian authorities and a lack of effective planning (Giacaman et al. 2003). The healthcare sector operates in difficult and unpredictable financial circumstances, making budgeting and long-term planning troublesome. Donor-aid incomes vary from year to year, and tax revenues collected from Palestinians by the Israeli government, the major source of Palestinian Authority income, are sporadically withheld. Standards vary considerably between different facilities, with government hospitals generally providing a poorer standard of care. The tertiary hospital for Palestine is located in East Jerusalem, cut off from the West Bank by the Israeli separation wall that requires special permission to cross. Healthcare is funded through a combination of insurance schemes, out-of-pocket payments and taxation. Sixty percent of the population is enrolled in the government’s health insurance scheme. This is provided free to those in poverty, the families of prisoners in Israeli jails and to those whose health problems are ‘‘intifada related’’ – occurring due to the actions of the Israeli military.
Medical schools There are four medical schools in Palestine, two in the West Bank and two in Gaza. Each year, 150–200 medical students graduate from medical schools in Palestine (FAIMER 2014). Al-Quds University opened a medical school in 1994 in Abu Dis, a village just west of Jerusalem. This was the first medical school in Palestine. Before this, Palestinians went abroad to train, often to Jordan, Egypt or Russia (previously many students trained in the Soviet Union). An-Najah University in Nablus, a city in the north of the West Bank, began training doctors in 1999. The university initially delivered the Al-Quds course, before developing its own curriculum and becoming
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an independent medical school in 2008. An-Najah opened a new teaching hospital in 2013 as a focus for its clinical education. Al-Azhar University in Gaza enrolled its first medical students in 1999, again initially following the Al Quds curriculum. In 2006, a second medical school opened at the Islamic University of Gaza. The Islamic University was extensively damaged by Israeli airstrikes as part of the ‘‘Operation Cast Lead’’ offensive in December 2008 and January 2009. The attack destroyed the university’s laboratories as well as damaging the central library and computer facilities. Medical schools in the West Bank are accredited and regulated by the Palestinian Ministry of Education and Higher Education, based in Ramallah. Those in Gaza are governed by the counterpart authority based in Gaza. Today, it is still common for students to attend medical schools abroad, particularly in Egypt, Jordan and Russia. Graduates from Russia face difficulties integrating into the medical community on their return to Palestine, where business is conducted in a mixture of Arabic and English, and where most doctors have trained in a system modelled on the UK and USA. Palestinian doctors report significant differences in the style of medical practice between doctors trained in Russia and those trained elsewhere.
Restrictions on access to education Palestine is a small country, but the restrictions on movement described above, in combination with the country’s hilly terrain, mean that journey times between home, university, hospitals and clinics are long. This places an extra burden on the wellbeing of students and residents (postgraduates in specialist training) who already work long hours. In addition, the unpredictability of time spent at military checkpoints means doctors and students can be late for teaching sessions and clinical duties, impacting on medical education. As stated above, special permission is required for Palestinians who want to access the Palestinian tertiary hospital in occupied East Jerusalem. Most students and doctors are granted passes lasting six months or less, with no guarantee of renewal. Over 20% of the Al Quds medical school class of 2014 have been refused permission for unspecified security reasons, a typical figure for each year. For these students, exposure to the highest quality clinical care and teaching is then compromised.
Admission Admission to medical school is very competitive, only those with the highest grades from examinations at the end of secondary education are accepted. In addition, prospective students are interviewed to assess their suitability to study and practice medicine, focusing on motivation, maturity and character.
The undergraduate medical courses Undergraduate medical courses in Palestine last six years. The first three years are a combination of basic science and preclinical medicine; years four to six are clinical. English is the official language of all courses, but in reality, a mixture of Arabic and English is often used. Pre-clinical courses are traditional and lecture-based, structured around subjects rather than systems. There is a desire in some universities to introduce greater small group work, but this is held back by a lack of suitably qualified staff to act as facilitators. Students report variable quality of teaching in the preclinical years, with some teaching considered to be outdated in its content. An-Najah medical school has started introducing students to the clinical environment earlier, with one day per week in the third (pre-clinical) year spent in a clinical setting. Clinical students are rotated through placements around the West Bank or Gaza, depending on the medical school, in a mixture of governmental and private hospitals and community settings. Doctors are paid by the medical schools to provide teaching and supervision for students, and the hosting hospitals also receive payment. The range of healthcare facilities and types of facility seen by clinical students gives them excellent exposure to different medical staff and styles of practice, something the students interviewed valued. However, they report significant variation in the educational value of different placements. On a number of placements, students reported that medical staff have too little time to teach. Large patient loads mean that at ward rounds and in clinics, senior doctors sometimes have no time to effectively involve students, and may provide as little as one hour or even no dedicated teaching time per week. Some students report difficulties in the private hospitals, with a proportion of paying patients unwilling to interact with medical students. Students provide feedback to the medical schools at the end of each placement. Across all hospitals, students reported insufficient focus on education, with teaching frequently viewed as a distraction from the hospital’s core purpose of service delivery. Peer teaching, where senior clinical medical students teach more junior students, occurs on an informal and ad hoc basis. This teaching is often well received by students, who are grateful for extra teaching and for the approach of a teacher who has more recently been at the same stage of education. Assessment is by a combination of written examinations (predominantly multiple choice questions) and Objective Structured Clinical Examinations with a mixture of real and simulated patients. Workplace-based assessments are used in some medical schools. For example, at Al-Quds medical school in the clinical years, 20% of a student’s mark from each unit comes from the supervisor’s assessment of their performance during the placement. All medical schools charge fees from the students. This is largely funded through family contributions, but some scholarships and loans are available from the universities.
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Fees are in the region of $8000 US Dollars per year for Palestinian students, a significant cost given that the average annual household expenditure in Palestine is approximately $12,000 US Dollars (Palestinian Central Bureau of Statistics 2011).
HINARI scheme (World Health Organisation 2014). Some doctors choose to take out individual subscriptions to specific journals; but for many, this practice is prohibitively expensive. Some journals, for example, the New England Journal of Medicine, are made available free inside Palestine. However, overall, a lack of access to research has a detrimental effect on medical education.
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Postgraduate education After medical school, doctors traditionally complete a one-year internship, where they move to a different specialty and different facility approximately every two months. All internships include medicine, surgery, paediatrics, obstetrics and gynaecology, psychiatry and public health. In 2012, the system was changed to allow Palestinian graduates to begin a residency programme immediately after medical school, if they choose. All graduates from abroad must undertake an internship. Interns have limited responsibility for patient care and are not expected to make many decisions independently. After an internship, doctors apply for a residency programme. Residents train in a particular specialty and have considerable responsibility for service provision. Residency programmes last for four to five years. Specialist training is broad with limited opportunity for sub-specialisation. For example, there are no specific training programmes for respiratory or renal medicine or any other medical specialty, only internal medicine. This produces doctors that are competent at independently managing a wide range of pathology, including multi morbid patients, but lack expertise in any one area. A potential positive consequence of this is that patients may be passed from clinician to clinician less than they would be in countries where there is considerable sub-specialisation, for example, the UK. Many residents strive to complete additional sub-specialist training abroad, but this is difficult to organise. Residents report a lack of teaching from senior doctors and feel the long hours they work (often well over 100 hours per week) leave insufficient time for personal study. Despite being on a postgraduate training programme, residents feel that the balance between training and service provision leans too far towards the latter. The problem is particularly serious in the government-run hospitals and subsequently has a negative impact on both patient care and staff morale. Some of the most senior doctors working in facilities in Palestine have completed postgraduate training in Europe, particularly the UK and the USA. This training is perceived to be of a high standard compared to that available locally. Having doctors with overseas experience returning to senior positions in Palestinian healthcare services allows new techniques and ideas to be introduced to domestic graduates and residents. For example, evidence-based medicine is currently in its infancy in Palestine, being driven in part by doctors who have experience of this approach from overseas. Access to up to date research is a problem for both residents and doctors who have completed their formal training. Hospitals subscribe to only a limited number of medical journals, if any, despite Palestine being eligible for some support through the World Health Organisation’s 128
Licensing and continuing medical education All doctors must complete a national examination to gain their license to practice independently. This consists of multiple choice questions and covers all specialties. The exam must be passed before taking up a residency programme and is typically sat at the end of the internship year. The medical license is valid for life, with no requirement to continue to develop skills or to maintain proficiency. There is no formal system of continuing medical education in Palestine. Conferences and courses are held infrequently on an ad hoc basis, often with financial support from pharmaceutical companies.
Opportunities for improvement Medical education in Palestine is still evolving; it was only 20 years ago that all doctors were trained abroad. Consequently, it is likely that with time, many aspects of medical education will improve as the system continues to develop organically. However, there are approaches that could expedite improvements. The variable quality of clinical placements for undergraduate medical students requires a coordinated response from the medical schools and the Ministry of Health. Increased use of student feedback would allow specific areas of concern to be identified and acted upon, where possible. Although many healthcare providers operate under considerable financial and human resource constraints, improved organisation, planning and feedback to teachers would allow for improvements at minimal cost. Minimum teaching requirements should be agreed between medical schools and clinical education providers and clearly communicated to medical students, with compliance closely monitored. Residency programmes require reform to improve the morale and competence of doctors in specialist training. Greater exchange of knowledge must take place between senior specialists and residents, both in day-to-day clinical practice and in time set aside for formal teaching. Many residents feel unsure of how they are progressing in their training compared to what is expected, so greater constructive feedback from senior staff should be provided, whilst curricula and expectations of residents at different stages must be made clearer. Reform of postgraduate training is a significant undertaking and must carefully consider the views of all stakeholders, as well as the health needs of the Palestinian population. Whilst many residents feel unsatisfied with their postgraduate training, there is
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currently little momentum for change at senior levels in the medical community, which prevents necessary development. Developing links between healthcare and education providers in Palestine and countries with advanced healthcare and education systems has great potential for improving the education of Palestinian undergraduates and postgraduates. Exchanges of clinicians and teaching staff, in both directions, allows practice and experience to be shared, as well as providing opportunities for direct teaching. Teaching by visiting academics and staff seconded to Palestinian medical schools could help to circumvent, in the shortterm, shortages of high quality teaching staff resident in the country. Examples of such partnerships are OxPal (2014), a link between Palestinian medical schools and doctors from Oxford, UK, and a link between Al-Quds University and the University of Gothenburg, Sweden, as part of Sweden’s Linnaeus-Palme international education development programme (Linnaeus-Palme 2013). An evaluation of the OxPal partnership demonstrates that its direct teaching has proven very valuable to students, although there has been no assessment of its impact in improving the domestic educational environment in Palestine (Penfold et al. 2014). Partnerships that facilitate the training of postgraduates overseas would also be of great benefit. Links between hospitals in the UK and low-income countries are becoming increasingly common, and these and other similar schemes have great potential here. Palestine does not have the capacity to provide sub-specialist training; sub-specialists are simply too few, so overseas training is necessary to build capacity initially. The opportunity to spend one year or more training in Europe or North America either during or after a residency programme could significantly enhance the clinical ability of a Palestinian doctor in a specific area of medicine. Likewise, exchanges of faculty in the medical schools could facilitate the introduction of more varied, modern teaching methods into Palestine. Inevitably, there is a risk that overseas training may contribute to a ‘‘brain drain’’, with a proportion of doctors not returning. However, many undergraduates and postgraduates who have previously completed some training overseas do return to Palestine, suggesting that strong cultural ties to their home country would encourage doctors to continue their careers in Palestine, bringing their valuable overseas experience with them. Efforts to increase access to medical journals in resource poor settings are in motion globally. This is also an issue that the Palestinian Ministry of Health could take the lead on locally, given that it affects all healthcare providers in Palestine. Coordinating subscriptions between healthcare providers, utilising the World Health Organisation HINARI subsidy scheme and involving overseas funding partners has the potential to significantly increase access to research whilst keeping costs to a minimum. More frequent professional conferences and meetings would help doctors who have completed training to keep their knowledge up to date. Regular departmental teaching sessions, journal clubs and larger conferences organised by
medical associations allow best practice to be shared and new ideas to be introduced to the audience. Two of the authors of this paper (R.M.S. and K.A.Q.) attended a large scientific meeting organised by internal medicine physicians in the West Bank in 2014. The feedback from attendees was positive, and it was felt that in-depth discussion of complex cases, presented by experts, helped to raise the standard of medicine that the doctors present practiced.
Conclusion Palestine faces many difficulties in its social, political and economic spheres, and medical education is no exception. The development of undergraduate medical education in Palestine over the past 20 years is a great success. Although the system is not without its imperfections, the country now trains many of its own doctors who feel prepared for medical practice and who are enthusiastic about serving the population. The greater challenges lie after graduation. Residents feel overworked and undertrained, frustrated by how little knowledge is imparted by senior doctors. At the end of the residency, there is little opportunity for the subspecialist training necessary to provide the highest standards of patient care. Once training is complete, there is no system for ensuring doctors keep their skills and knowledge up to date, and few formal opportunities for continued medical education. Partnerships with advanced healthcare and education providers provide an opportunity to build capacity that is not available domestically, sharing best practice in medical education and facilitating overseas training for clinicians and teaching staff. There is incredible enthusiasm amongst Palestinian students and doctors for greater training and the opportunity to develop skills that will help improve the health and education systems. Capitalising on this energy will further advance the health of the Palestinian population.
Notes on contributors BEN KERR WINTER, BSc, MBChB (Hons), graduated from medical school at the University of Manchester, UK. He has strong interests in global health and medical education and until recently was based at Al-Makassed, a Palestinian hospital in East Jerusalem. RA’AD MOHAMMED SALAMMA, MD, graduated from medical school at Al Quds University, Palestine. He has undertaken part of his medical education in Poland and has been heavily involved in the International Federation of Medical Student Associations. KINDA ADLI QABAJA, MD, graduated from medical school at Al Quds University, Palestine. She has experience of medical education in primary, secondary and tertiary healthcare settings in the West Bank.
Declaration of interest: The authors have no conflicts of interest.
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