Professional and Psychological Influence of the COVID-19 Pandemic on the Training of Medical Residents.

OBJECTIVES: Coronavirus disease 2019 (COVID-19) has profoundly impacted residency and fellowship training and education. However, how and to what extent the COVID-19 pandemic in Lebanon compromised the daily involvement of trainees on the clinical and ethical levels is currently unknown, which this study will shed light on. METHODS: We conducted a cross-sectional survey (30 questions) targeting medical residents delivering healthcare services in Lebanon. Residents from different specialties were included in the study to assess the effect of the pandemic on their education and the ethical obstacles they faced when dealing with patients. RESULTS: A total of 221 postgraduate medical students participated in our study. Results showed that about half of the residents (52.1%) were only able to do a basic physical examination rather than a full examination as a mandatory requirement in the residency curriculum. The majority (60%) agreed that the doctor-patient relationship is contravened. In addition, almost all residents suffered from fear and emotional distress that affected their education (83.7%). CONCLUSION: The findings of this study identify the effect of COVID-19 on residents' training, which affects treatment outcomes and greatly impacts the mental well-being of both healthcare workers and patients.

Acceptance and attitude of Lebanese lawyers and medical students toward surrogate pregnancy: a cross-sectional study.

BACKGROUND: Little is known about the acceptance of specific populations of decision makers in Lebanon regarding surrogacy. This study aimed to explore the acceptance and attitude of Lebanese Lawyers and Medical Students regarding surrogacy. METHODS: In total 248 medical students and 204 lawyers completed a questionnaire to assess socio-demographic data, attitude toward surrogacy, and three different clinical scenarios to assess patterns of thinking. Finally, we validated a scale to assess the acceptance of surrogacy in these two populations. RESULTS: Concerning medical students, 54.8% reported they were supportive of surrogacy, 35.1% were neutral and 10.1% were against. For lawyers, 52.9% were supportive, 25% were neutral and 22.1% were against. Lawyers were more likely to be against surrogacy (p = 0.001). After conducting a multivariate analysis on the whole studied population to find predictors of acceptance of surrogacy, the best predictors were being single (OR 0.415; 95% CI 0.228, 0.753; p < 0.01), a supportive reported attitude regarding surrogacy (OR 5.464; 95% CI 3.65, 8.13; p < 0.001) and believing that surrogacy is a solution worth discussing in Lebanon (OR 4.186; 95% CI 1.709, 10.256; p < 0.01). Concerning the clinical scenarios, they showed that lawyers were more likely to oppose abortion regardless of the reason (p < 0.01). Also, in a case of gestational surrogacy, lawyers were more likely to give the right to the gestational carrier to keep the baby compared to medical students (p < 0.001). CONCLUSION: In conclusion, this study shows that only a minority of medical students and lawyers in Lebanon oppose surrogate pregnancy which warrants exploration of the perspective of other populations of decision makers in Lebanon to better guide legislations.

Withholding and withdrawal of life-sustaining treatments in intensive care units in Lebanon: a cross-sectional survey of intensivists and interviews of professional societies, legal and religious leaders.

BACKGROUND: Little is known about the attitudes and practices of intensivists working in Lebanon regarding withholding and withdrawing life-sustaining treatments (LSTs). The objectives of the study were to assess the points of view and practices of intensivists in Lebanon along with the opinions of medical, legal and religious leaders regarding withholding withdrawal of life-sustaining treatments in Lebanese intensive care units (ICU). METHODS: A web-based survey was conducted among intensivists working in Lebanese adult ICUs. Interviews were also done with Lebanese medical, legal and religious leaders. RESULTS: Of the 229 survey recipients, 83 intensivists completed it, i.e. a response rate of (36.3%). Most respondents were between 30 and 49 years old (72%), Catholic Christians (60%), anesthesiologists (63%), working in Beirut (47%). Ninety-two percent of them were familiar with the withholding and withdrawal concepts and 80% applied them. Poor prognosis of the acute and chronic disease and futile therapy were the main reasons to consider withholding and withdrawal of treatments. Ninety-five percent of intensivists agreed with the "Principle of Double Effect" (i.e. adding analgesia and or sedation to patients after the withholding/withdrawal decisions in order to prevent their suffering and allow their comfort, even though it might hasten the dying process). The main withheld therapies were vasopressors, respiratory assistance and CPR. Most of the respondents reported the decision was often to always multidisciplinary (92%), involving the family (68%), and the patient (65%), or his advance directives (77%) or his surrogate (81%) and the nurses (78%). The interviewees agreed there was a law governing withholding and withdrawal decisions/practices in Lebanon. Christians and Muslim Sunni leaders declared accepting those practices (withholding or withdrawing LSTs from patients when appropriate). CONCLUSION: Withholding and withdrawal of LSTs in the ICU are known concepts among intensivists working in Lebanon and are being practiced. Our results could be used to inform and optimize therapeutic limitation in ICUs in the country.

Normative Data for the Montreal Cognitive Assessment in a Lebanese Older Adult Population.

INTRODUCTION: The Montreal Cognitive Assessment (MoCA), a neuropsychological tool for cognitive decline screening is widely used. In the absence of normative data in Lebanon, this study offers normative data for the MoCA in Lebanese community-dwelling older people and compare scores to those of other countries. METHODS: 164 literate subjects aged 60 and above were recruited to complete the MoCA. RESULTS: The mean MoCA score observed (24.20 points) was lower than that for normal controls (27.4 points) in the original validation study of the MoCA. Regression analysis showed that fewer years of education were associated with lower MoCA scores (p < .000). CONCLUSIONS: This study presents normative data and the findings suggest that cultural differences are evident in cognitive testing.

Comparative study between prison- and community-based treatment satisfaction for opioid use disorder in Lebanon.

PURPOSE: Opioid substitution treatment (OST), such as Buprenorphine, has become a well-established evidence-based approach for the treatment of inmates with opioid use disorder (OUD) in most of the developed world. However, its application in Lebanon remains mainly as a community-based intervention. The purpose of this paper is to highlight the need of its implementation within the Lebanese correctional system. DESIGN/METHODOLOGY/APPROACH: The work is a pilot cross-sectional study that compares two groups: 30 male adult prisoners with OUD convictions receiving symptomatic treatment and 30 male adult community patients with OUD receiving Buprenorphine. The objective was to measure the difference in the patients' general perception and satisfaction of the treatments available. OUD was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria and the level of satisfaction was measured by "Treatment Perceptions Questionnaire (TPQ)." FINDINGS: The prison group reported significantly lower satisfaction when compared to the community group (total TPQ mean scores: M=34.73, SD =4.12 and M=16.67, SD =4.78, respectively, with t (56.76) =15.68, p=0.000). Furthermore, age, marital status, education level and elapsed time in treatment had no significant interactions with the total TPQ score. ORIGINALITY/VALUE: The major principles of the ethics of care and evidence-based safe practices will be proposed for the introduction of Buprenorphine to Lebanese prisons. This work provides an opportunity for the expansion of the Lebanese OST program and consequently other countries in the region could benefit from this experience.

Screening for dementia in Arabic: normative data from an elderly Lebanese sample.

OBJECTIVE: Prevention and treatment of dementia is a global concern that requires involvement of international samples. The purpose of this study is to develop culturally sensitive norms based on normal older Lebanese adults using multiple cognitive screening measures translated into Arabic for regional use. METHODS: Participants were 164 community dwelling older Lebanese adults without cognitive complaints. They were administered the following cognitive measures in Arabic: Alzheimer's Disease 8-item questionnaire, Montreal Cognitive Assessment, Mini Mental Status Exam, Modified Mini Mental Status, Brief Visuospatial Memory Test-Revised, Lebanese Digit Span, Cross-Linguistic Naming Test, and phonemic and semantic fluency tests. RESULTS: Sample characteristics and descriptive statistics for the demographically unadjusted raw scores are first presented (N = 164). Same-form test-retest reliability for each test were computed for 24 participants retested over 2-5 weeks, with reliabilities ranging from .55 to .90; Cronbach alpha coefficients ranged from .34 to .93. Two sets of normative data were constructed. First, base-rates for demographically unadjusted raw scores for the 5th, 10th and 15th percentiles are presented to identify relatively rare occurring performances. Second, using standardized regression-based procedures demographically corrected normative information adjusted for age, education and sex were generated for normative interpretation. CONCLUSIONS: Adapting cognitive tests for use in culturally and linguistically diverse regions of the world not only requires careful translation of test instructions and materials, but construction of culturally sensitive local norms. Our normative data should allow for more accurate identification of cognitive impairment and dementia in Arabic-speaking patients, especially those living in Lebanon.

Sociolinguistic reflection on neuropsychological assessment: an insight into selected culturally adapted battery of Lebanese Arabic cognitive testing.

Neuropsychological tests (NPTs) are highly dependent on education, culture differences as well as age and sex. It is therefore essential to take these factors into consideration when translating NPTs to be used in screening for cognitive impairment. Translations into Arabic must respect the principles of linguistic relativity and cultural specificity of the population under study. The objective is to assess feasibility and outcome of translating neuropsychological tests to Arabic. A team of Lebanese professionals selected a battery of screening NPTs. These tests were translated into Arabic and independently back translated by a team of sociolinguists and cultural specialists. The translations were adapted to suit the Lebanese culture. The final NPT translated versions were reached by consensus of an expert panel and tested on a group of independently living community-dwelling elderly. Translated items had to be modified when: (1) terms could not be translated using one word as required by the test; (2) Concepts were foreign to the culture; (3) Translated words carried multiple meanings; (4) Words were rarely used in Lebanon; (5) Sentences did not have an equivalent; and (6) Words had letters pronounced differently by subgroups in Lebanon. Despite all measures to maintain cultural sensitivity in translations, non-linguistic challenges remained. A battery of cognitive screening tests were translated into Arabic and adapted for the Lebanese population. These adaptations allow for a better assessment of cognitive abilities since they reflect the thought patterns of the population. The challenge is to establish local normative data.

Attitudes Toward Placebo Use in Lebanon.

PURPOSE: Placebo use, both in clinical trials and patient care, is a problematic ethical issue surrounded by opposing arguments from those who advocate its use versus those who do not. This problematic aspect of placebo is more challenging in Lebanon where religious ideologies dominate people's beliefs, and where laws that guide medical care are vague. This paper aims to highlight the cultural ideologies that dominate medical care and the perspectives of people associated with the field. METHODS: The method relied on semi-structured interviews with religious leaders, representatives of society and healthcare professionals. Panel discussions incorporating healthcare professionals, academics, scientists and medical researchers were also organized. FINDINGS: The legal environment in Lebanon is characterized by lack of an appropriate legislative guideline that categorically clarifies the value of the human person in medical care. There is a lack of a common ethical standard within a society characterized by social and political dissent. The culturally upheld principles and actual application of the principles of ethics surrounding patient autonomy were overviewed. Medical practitioners failed to agree to a general outline that should guide the use of placebo where it became evident that each practitioner adopted a subjective framework which ultimately undermines patient autonomy. IMPLICATIONS: The paper proposes that until a new legislative code that clarifies ethical principles properly guiding medical care is coined, the process of placebo use will continue to be subject to the paternalistic assessments of medical professionals.

Healthcare quality in a fragmented society: the Lebanese model.

Quality of health care is largely dependent on a holistic approach to human person (HP). In Lebanon, the medical field, including neurology, seems to be ignorant to the integrity of the human person. The objective of this study is to provide an insight to the importance of reintegrating the HP in the medical field attempting to offer a basis for scientists interested in carrying out similar research in face of the complete lack of studies in Lebanon. This requires the contribution of various health care support systems to bring the topic into public dialogue allowing for a reassessment of the issue. The method utilized included semi-structured interviews, seminars and open discussion panels hosting a variety of representatives from society avoiding medical corporatism. These revealed a contradiction between ideological understanding of the importance of the value of the human person and practical application of this value. Most people who participated in the study acknowledged the importance of catering to the human in suffering as a whole focusing on the physiological aspect of illness but equally so on the spiritual, psychological and mental. However, those same people acknowledged that the situation in Lebanon was not considerate to the principle of unity of human person. The reasons for this discrepancy had their socio-economic and cultural roots and hindered the quality of care delivered to suffering individuals. This cannot be ratified except when all those concerned with medical care acknowledge the problem and show a willingness to deal with it through taking necessary positive action.

Depressive symptoms among surrogate decision makers in Lebanese ICUs.

Surrogate decision making is advocated to protect the vulnerable patient. Family members of patients in intensive care units (ICUs) are prone to develop depressive symptoms which may undermine their decisional capacity. Lebanon is a multicultural country where paternalism still dominates the physician-patient relationship and ethics are far from being the subject of research and studies. This multicenter observational study in the Greater Beirut area attempts to estimate the prevalence of depressive symptoms among surrogates deciding on behalf of ICU patients and to correlate their severity with sociodemographic factors. During the period March-May 2011, direct interviews were conducted and the Patient Health Questionnaire-9 (PHQ-9) was administered to 56 family members who had given consent, regarding therapeutic options, on behalf of ICU patients in seven university hospitals. We looked for relationships, in these surrogates, between severity of depression and age, sex, marital status, level of education, religion and status as the patient's spouse. The prevalence of major depression among surrogates was 61% using a cutoff of 10 on the PHQ-9 scale. Among the surrogates with depression, 15% had untreated moderate-to-severe depression. Severity of depression and suicidal ideation were not related to any of the studied factors. Depressive symptoms are prevalent among family members deciding on behalf of ICU patients, rendering them vulnerable. Appropriate measures should be taken to identify and treat them.

[Ethical quality of nursing care in Lebanon]. / Qualité éthique de l'exercice de la profession d'infirmier au Liban.

OBJECTIVE: The objective was to reflect on the nurse's role and on the determinants of a responsible choice. In order to do it, we tried to answer the following questions: (1) Are the role and the mission of the nursing body well acquired in Lebanon? (2) Are there international and national norms which govern the accomplishment of this mission? (3) At what point does the mission accomplished by the nursing body procure the patient's safety? (4) What are the factors that modify the performance of the nursing body in Lebanon? And, (5) What are the challenges of a good-quality nursing performance? METHODS: We conducted a double arm survey. The first one is made on 160 nurses working in 19 hospitals that succeeded to establish until July 2008 (end of study) at least an ethical committee for medical care. The second one was conducted on the heads of the nursing departments in 49 private institutes, 34 public institutes and 16 universities. RESULTS AND DISCUSSION: The investigated nurses don't know very well the medical and nursing ethics' principles that are very well highlighted in the Husted decisional model and expressed by justice, autonomy, confidentiality, beneficience, veracity and fidelity. This result underlines a fact that affects the nurse's mission and so on the patients' safety. Ninety-four per cent of the nurses think that the education and the communication with the patient is not a priority during their daily work, which hinders the three essential times (analysis, communication and assessment) required to elaborate a freely informed decision. Ethics don't have a solid basis in education. CONCLUSION: We must be concerned by this diagnostic, but it leads to the hope of being able to find together, through a common reflection, the essential characteristics to assume our responsibilities whether in the medical or nursing domain.