First presentation of Graves' thyroid storm complicated by catastrophic antiphospholipid antibody syndrome: A case report.

Catastrophic antiphospholipid antibody syndrome is a rare and severe subtype of antiphospholipid syndrome with multisystemic organ failure due to thromboembolic events, resulting in high mortality rates. The association between catastrophic antiphospholipid antibody syndrome and autoimmune thyroid diseases is rarely reported in the literature. We report a case of a 35-year-old previously healthy female with Graves' thyroid storm, positive lupus antibodies, and probable catastrophic antiphospholipid antibody syndrome. Her hospital course was complicated by extensive venous thromboembolism, superior vena cava syndrome, thromboembolic strokes, and Takotsubo cardiomyopathy. Eventually, this led to an unfortunate death secondary to profound shock after 8 days despite emergent treatment. Our case report discusses the link between autoimmune thyroid disorders and catastrophic antiphospholipid antibody syndrome. We emphasize the difficulty in diagnosing catastrophic antiphospholipid antibody syndrome in extremely ill patients and stress the significance of considering it as a possible cause in thyrotoxicosis patients with multiple organ failure and hypercoagulability. Early recognition and prompt management are crucial in improving outcomes in these patients.

Palliative care education: a nationwide qualitative study of emergency medicine residency program directors in the United Arab Emirates.

BACKGROUND: Emergency medicine (EM) physicians routinely care for patients with serious life-limiting illnesses. Educating EM residents to have general skills and competencies in palliative medicine is a global priority. The purpose of this study was to describe the current status of palliative and end-of-life education in EM residency programs in the United Arab Emirates (UAE) and to identify barriers and opportunities to inculcating palliative care (PC) instruction into EM training in a non-Western setting. METHODS: Using the American College of Emergency Medicine's milestones for Hospice and Palliative Medicine for Emergency Medicine as a question guide, semi-structured interviews were conducted with program directors of all 7 EM residency programs in the UAE from January through July 2023. Qualitative content analysis was conducted to identify recurring themes. RESULTS: All program directors agreed that PC knowledge and skills are essential components of training for EM residents but have had variable success in implementing a structured PC curriculum. Six themes emerged, namely the educational curriculum, PC policies and practices, comprehensive PC services, cultural and religious barriers to PC, EM scope of practice, and supporting residents after patient death. CONCLUSION: UAE national EM residency curriculum development is evolving with an emphasis on developing a structured PC curriculum. As EM residencies implement policies and programs to improve care for patients and families dealing with serious illness, future studies are needed to assess the impact of these initiatives on patient quality of life and physician well-being.

Components of effective letters of recommendation: A cross-sectional survey of academic faculty.

INTRODUCTION: Conventional merit-based criteria, including standardized test scores and grade point averages, have become less available to residency programs to help distinguish applicants, making other components of the application, including letters of recommendation (LORs), important surrogate markers for performance. Despite their impact on applications, there is limited published data on LORs in the international setting. METHODS: A cross-sectional survey of academic faculty was conducted between 9 January 2023 and 12 March 2023 at two large academic medical centers in the United Arab Emirates. Descriptive statistics were used to tabulate variable frequencies. RESULTS: Of the 98 respondents, the majority were male (n = 67; 68.4%), Western-trained (n = 66; 67.3%), mid-career physicians (n = 46; 46.9%). Most respondents (n = 77; 78.6%) believed that the purpose of an LOR was to help an applicant match into their desired program. Letters rarely included important skills, such as leadership (n = 37; 37.8%), applicant involvement in research (n = 43; 43.9%), education (n = 38; 38.8%), or patient advocacy (n = 30; 30.6%). Most faculty (n = 81; 82.7%) were not familiar with standardized letters of recommendation. Only 7.3% (n = 7) of respondents previously received training in writing LORs, but 87.7% (n = 86) expressed an interest in this professional development opportunity. CONCLUSION: There is variability in perceptions and practices related to LOR writing in our international setting, with several areas for improvement. Given the increasing importance of LORs to a candidate's application, faculty development is necessary.

Development of an acute medical unit to optimize patient flow and early discharges in a tertiary care hospital in the United Arab Emirates.

BACKGROUND: Hospitals worldwide are seeing an increased number of acute admissions, with resultant emergency department (ED) crowding and increased length of stay (LOS). Acute Medical Units (AMUs) have developed throughout the United Kingdom and other Western countries to reduce the burden on EDs and improve patient flow. Limited information is available on AMUs in the Middle East. The purpose of this study is to describe the development of the first AMU in the United Arab Emirates (UAE) for general medical patients and its impact on LOS, early discharges, ED boarders, and readmission rates. METHODS: We established a consultant-led AMU in a tertiary hospital in the UAE. A retrospective comparative review of all general medical admissions to the AMU between August 1, 2020 and December 31, 2020 and all admissions to the traditional medical wards between August 1, 2019 and December 31, 2019 was conducted. RESULTS: The average LOS reduced from 10 to 5 days (95% CI [4.14-6.25], p < 0.001) after the introduction of AMU. Early discharges increased by 22%. The number of outliers and number of patients boarding in ED reduced significantly (111 in 2019 vs. 60 in 2020, p < 0.05; 938 in 2019 vs. 104 in 2020, p < 0.001 respectively), with a decrease in ED waiting time from 394 min to 134 min (95% CI [229.25-290.75], p < 0.001). There was no increase in 30-day readmission rates. CONCLUSION: Restructuring the system of care can reduce LOS, overcome discharge barriers and improve patient flow. Similar units can be developed in hospitals throughout the UAE and the region to reduce LOS and improve patient flow through acute care units.

Medical Resident Awareness of Predatory Journal Practices in an International Medical Education System.

INTRODUCTION: Learning research methodology is increasingly becoming an essential part of graduate medical education worldwide, with many regulatory and accreditation bodies requiring residents to participate in scholarship. Research methodology workshops have become a standard part of medical curricula; however, there is limited data on how much training on journal selection and the publication process trainees receive. The alarming growth of predatory journals has made it increasingly difficult for researchers, especially trainees and early career physicians, to distinguish these publications from reputable journals. The purpose of this study is to assess the knowledge of reputable and predatory publishing practices amongst medical trainees in an international medical education setting in the United Arab Emirates. METHODS: A survey on credible journal practices based on the 'Think. Check. Submit' initiative was sent to all graduate medical education trainees at two large academic medical centers in Abu Dhabi, United Arab Emirates. Descriptive statistics were used to tabulate variable frequencies. RESULTS: Over half of the 160 respondents reported receiving prior research methodology training and 42.5% had at least one publication. The majority of the trainees selected impact factor and the quality of the peer-review process as characteristics of reputable journals. Ambiguous editorial board and rapid publication process were recognized as characteristics of predatory journals by >65% of trainees, however, 95% of all trainees were unaware of Beall's list or other resources to help select a journal for publication. 15.2% of trainees who received unsolicited emails from publishers submitted their manuscripts to the unfamiliar journals, citing peer recommendation and pressure to publish from their training programs as reasons. CONCLUSION: Trainees in the United Arab Emirates were mostly unaware of reputable publication practices and are vulnerable to publishing in predatory journals. Policy and educational reform are necessary to maintain the credibility and integrity of the scientific process.

Medical student experiences and perceptions of palliative care in a middle eastern country.

INTRODUCTION: Teaching in palliative care (PC) is an important component of medical education. Yet, studies in many countries document a fragmented and inconsistent approach to PC teaching. The goal of this study is to assess PC education, experience, and comfort levels in providing end-of-life care in recently graduated medical students. METHODS: A survey was distributed to medical student applicants to residency programs at a large academic medical center in the United Arab Emirates. Descriptive statistics were used to tabulate variable frequencies. RESULTS: Of 226 surveys, 183 were completed (80.7% response). Over half of respondents (104/183, 56.8%) did not receive any formal PC education or training in medical school. General introduction to PC (64%), pain management (68%), and non-pain symptom management (56%) were the most common topics. Only 13% (24/183) of medical students participated in PC rotations. Only 25% of participants (46/183) reported assessment of PC knowledge or skills. Gender differences were noted, with women more comfortable discussing prognosis (Pearson Chi-square value 8.67, df 3, p < 0.013) and assessing decision-making capacity (Pearson Chi-square value 15.02, df 3, p < 0.005). Few students expressed comfort with any aspect of PC. The majority of respondents (174/183, 95%) felt that it is important to receive PC education in medical school. CONCLUSIONS: Most newly graduated medical students reported limited education in PC, with minimal clinical experience. The vast majority described a lack of comfort in providing care for dying patients and their families. Educational reform is necessary to embed PC knowledge and skills into medical school curricula.

Palliative care training: a national study of internal medicine residency program directors in the United Arab Emirates.

BACKGROUND: Internal medicine residents are responsible for providing much of the direct care for palliative and terminally ill patients in teaching hospitals in the United Arab Emirates (UAE). To date, little systematic information is available on the prevalence of palliative care (PC) programs or faculty in UAE academic hospitals, or on the nature of PC education in internal medicine residency programs in the country. METHODS: Semi-structured interviews were conducted with program directors of all 7 internal medicine residency programs in the UAE. Qualitative content analysis was conducted to identify recurring themes. RESULTS: All program directors agreed that PC knowledge and skills are an essential component of training for internal medicine residents, but have had variable success in implementing the components. Three themes emerged, namely lack of structured PC training, perceptions of resident preparedness, and barriers to implementing a PC curriculum. CONCLUSION: Internal medicine residency programs in the UAE currently lack structured, mandatory PC curricula and have limited opportunities for formal teaching and assessment of PC knowledge and skills. The planned development of comprehensive oncology and palliative care centers and ongoing curricular reform in teaching hospitals in the country will provide important opportunities to train a cadre of competent health professionals to provide high quality palliative and end-of-life care to UAE patients and their families.

The Impact of an Acute Medical Unit in Internal Medicine on Resident Education.

Background: Medical trainees are expected to provide care for increasingly sick and treatment intensive patients. To improve patient care, hospitals worldwide have developed acute medical units (AMUs), dedicated medical wards that provide care for patients during the first 24 to 72 hours of an emergency medical hospital admission. A distinguishing feature of these units is that they are supervised by senior clinicians and offer multidisciplinary patient-centered care. Little is known about the impact of AMUs on trainee supervision and education. Methods: In this educational case study, we describe the evolution, process and structure of our AMU service. We also provide resident and teaching faculty perceptions of the impact of this intervention on education and supervision. Results: Questionnaire results showed that residents and teaching attendings believed that supervision and education were improved on the AMU, as compared to the traditional medical ward model. Residents also felt that their knowledge and clinical skills in managing acute patients improved. Procedure skills were less impacted by the intervention. A small number of residents believed that the AMU model worsened supervision and education. Conclusion: Integrating medical trainees into an AMU allowed for early evaluation and input from senior clinicians and increased opportunities to work in and learn from multidisciplinary teams, contributing to improved resident supervision and education. Future studies are needed to assess the long-term impact of the AMU on educational outcomes.

How Internal Medicine Residents Deal with Death and Dying: a Qualitative Study of Transformational Learning and Growth.

BACKGROUND: Dealing with death and dying is one of the most common sources of work-related stress for medical trainees. Research suggests that the degree of psychological distress that students and residents feel around providing care for terminally ill patients generally decreases as training progresses. However, there is a dearth of literature that directly addresses how trainees learn to manage emotions and process grief when patients die. OBJECTIVE: To gain insight into medical resident experiences in caring for the dying, including the role of training level and use of support networks and coping strategies to manage personal reactions to patient death. DESIGN: A thematic analysis of focus group interviews was conducted, and patterns that reflected resident coping and managing experiences with patient death were identified. PARTICIPANTS: Internal medicine residents from all year levels and recent graduates from two large academic medical centers in the United Arab Emirates. APPROACH: Qualitative study using a phenomenologic approach. RESULTS: Residents undergo transformational learning and growth in their experiences with death and dying. Five major themes emerged: emotions, support, education and experience, coping strategies, and finding meaning. As residents progress through their training, they seek and receive support from others, improve their end-of-life patient care and communication skills, and develop effective coping strategies. This transformational growth can enable them to find meaning and purpose in providing effective care to dying patients and their families. Positive role modeling, faith and spirituality, and certain innate personality traits can further facilitate this process. CONCLUSION: Understanding the complex emotions inherent in caring for dying patients from the perspective of medical residents is a critical step in creating evidence-based educational innovations and policies that support trainees. Residency programs should work to foster reflective practice and self-care in their trainees and teaching faculty.

Internal medicine residents' perceptions and experiences in palliative care: a qualitative study in the United Arab Emirates.

BACKGROUND: Palliative medicine is a newly developing field in the United Arab Emirates (UAE). The purpose of this study was to gain a deeper understanding of the experiences of internal medicine residents providing end-of-life care to patients and their families, and how those experiences shape their learning needs. METHOD: Nine focus groups were conducted with internal medicine residents and recent graduates from two large academic health centers in the UAE between 2019 and 2020. Through an iterative process, data were collected and examined using constant comparison to identify themes and explore their relationships. RESULTS: Fifty-two residents and graduates participated. Residents frequently care for terminally ill patients and their families, but lack confidence in their skills and request more structured education and training. Cultural and system related factors also impact palliative care education and patient care. Five main themes and associated subthemes were identified: (1) clinical management of palliative patients, (2) patient and family communication skills, (3) religion, (4) barriers to end-of-life education, and (5) emotional impact of managing dying patients. CONCLUSION: Our findings can help guide program development and curricular changes for internal medicine residents in the region. Structured education in end-of-life care, with a focus on fostering culturally sensitive communication skills and spirituality, can improve resident education and patient care. Clear and transparent policies at the institution level are necessary. Programs are also needed to assist residents in developing effective coping strategies and emotionally navigating experiences with patient death.

Multi-Disciplinary Discharge Coordination Team to Overcome Discharge Barriers and Address the Risk of Delayed Discharges.

BACKGROUND: Delays in hospital discharge occur when patients are medically cleared but continue to remain hospitalized. Discharge delays can result in reduced levels of treatment, placing patients at risk of functional decline, falls and hospital-related adverse events. The Institute of Medicine has highlighted timely, efficient, and safe hospital discharge as a marker for quality care. Hospitals, however, are often unable to meet discharge targets. Research has shown improvements in discharge planning through system-level approaches that integrate health care and social work. The purpose of this study is to describe the development and implementation of a multidisciplinary team intervention to overcome discharge barriers for patients with prolonged hospitalization. We also evaluated the impact of the intervention on length of stay, readmission rates and care team satisfaction and morale. METHODS: A multidisciplinary discharge coordination team met weekly to proactively raise and resolve patient-related discharge issues for all patients admitted to the general medicine wards. Members included hospitalists, case managers, social workers, hospital finance representatives, and patient representatives. One of the hospital physicians facilitated the meetings. RESULTS: Barriers to discharge included patient and family reluctance to discharge, medical delays in performing diagnostic tests or procedures, long-term care facility acceptance delays, and prolonged wait times for insurance approvals. Our multipronged approach decreased length of stay in our delayed discharge patient population from 15.45 days to 9.04 days, a 41.5% reduction, without an increase in readmissions. The healthcare team perceived the weekly multidisciplinary team meetings quite positively; 90% of respondents agreed that the meetings improved communication and increased their sense of support. CONCLUSION: Our intervention was successful in improving hospital processes to overcome barriers to patient discharge. We believe that similar multidisciplinary meetings can be implemented in hospitals throughout the region to decrease risks of prolonged hospitalization and, ultimately, improve hospital efficiency and care delivery.

Truth Disclosure at the End of Life: A Qualitative Study of Internal Medicine Residents in the United Arab Emirates.

BACKGROUND: Respect for patient autonomy has become the guiding biomedical ethical tenet in the West; yet, moral values are contextual and culturally relevant. In the collectivist society of the Middle East, families and physicians have historically believed that concealing truth about a terminal illness is more ethical and compassionate. Recent studies reveal a trend toward truth disclosure. OBJECTIVE: To gain insight into resident experiences with, and barriers to, truth disclosure in terminally ill patients in the United Arab Emirates (UAE). METHODS: Focus group interviews were conducted with first through fourth year internal medicine residents and recent graduates at two large academic medical centers in the UAE. Qualitative thematic content analysis was used to identify themes related to communication and truth telling in end-of-life care. RESULTS: Residents revealed that non-disclosure of medical information in serious illness is a common practice in UAE hospitals. Barriers to truth telling include family objection, deficits in medical training, and inconsistently implemented institutional guidelines. CONCLUSION: Educational and policy interventions are needed to improve physician-patient communication, decrease patient-family-physician tension, and alleviate trainee moral distress.

Undergraduate palliative care education in the United Arab Emirates: a nationwide assessment of medical school deans.

BACKGROUND: The provision of comprehensive, high quality palliative care (PC) is a global public health concern. In the United Arab Emirates (UAE), palliative medicine services are limited, and most patients in need of PC are treated in the acute hospital setting, where health professionals of all specialties provide treatment. Improving end-of-life care requires teaching medical students, residents, and other healthcare professionals about PC. The purpose of this study was to assess the current status of PC education in medical schools in the UAE, and to identify barriers to successful implementation of a PC and end-of-life curriculum. METHODS: The authors conducted semi-structured interviews with deans from all medical schools in the UAE. Data were analyzed using qualitative content analysis. RESULTS: All medical school deans in our study recognized the importance of inculcating palliative and end-of-life care into the undergraduate curriculum, but there was substantial variability in implementation, with opportunities for improvement. Barriers to the successful implementation of an undergraduate PC curriculum include (1) lack of student awareness and interest in PC, (2) inconsistent clinical exposure to PC, (3) lack of specialized PC faculty, (4) limited clinical facilities for PC training, (5) lack of a multidisciplinary approach to PC education, and (6) cultural barriers to PC education. CONCLUSIONS: Understanding challenges to teaching PC in the undergraduate medical curriculum can help inform educational interventions to improve PC knowledge and skills for UAE medical students. Curricular and policy reform are necessary to educate a future generation of health professionals, who can provide high quality palliative care services to UAE patients and their families.

Escherichia coli bacteremia due to urinary tract infection complicated by acute myocarditis: A rare complication.

Acute myocarditis is a rare complication of Escherichia coli urinary tract infection and sepsis. We report the case of a previously healthy 55-year-old female who presented to our emergency department with diarrhea and hypotension. The basic metabolic panel results showed an increase in inflammatory markers and an acute kidney injury. Urine and blood cultures grew Escherichia coli. The patient subsequently developed sudden chest pain and shortness of breath, diffuse ST-segment elevation, and cardiac enzymes' elevation. Coronary angiogram was normal, and transthoracic echocardiogram demonstrated normal ventricular functions. Cardiac magnetic resonance imaging was highly suspicious of myopericarditis. The patient made a full recovery after infection treatment with intravenous antibiotics, aspirin, and colchicine.

Post-infectious and post-acute sequelae of critically ill adults with COVID-19.

BACKGROUND: Data on the post-acute and post-infectious complications of patients who have recovered from severe coronavirus disease 2019 (COVID-19) are limited. While studies report that approximately 5-15% of COVID-19 hospitalized patients require intensive care and mechanical ventilation, a substantially higher number need non-invasive ventilation and are subject to prolonged hospitalizations, with long periods of immobility and isolation. The purpose of this study is to describe the post-infectious sequelae of severe viral illness and the post-acute complications of intensive care treatments in critically ill patients who have recovered from severe COVID-19 infection. METHODS: We performed a retrospective chart review of adult patients initially hospitalized with confirmed COVID-19 infection, who recovered and were transferred to a general medical ward or discharged home between March 15, 2020 and May 15, 2020, dates inclusive, after an intensive care unit (ICU) or high dependency unit (HDU) admission in a designated COVID-19 hospital in the United Arab Emirates. Demographic data, underlying comorbidities, treatment, complications, and outcomes were collected. Descriptive statistical analyses were performed. RESULTS: Of 71 patients transferred out of ICU (n = 38, 54%) and HDU (n = 33, 46%), mean age was 48 years (SD, 9.95); 96% men; 54% under age 50. Mean ICU stay was 12.4 days (SD, 5.29), HDU stay was 13.4 days (SD, 4.53). Pre-existing conditions were not significantly associated with developing post-acute complications (Odds Ratio [OR] 1.1, 95% confidence interval [CI] 0.41, 2.93, p = 1.00). Fifty nine percent of patients had complications; myopathy, swallowing impairments, and pressure ulcers were most common. Delirium and confusion were diagnosed in 18% (n = 13); all were admitted to the ICU and required mechanical ventilation. Of note, of all patients studied, 59.2% (n = 42/71) had at least 1 complication, 32.4% (n = 23) had at least 2 complications, and 19.7% (n = 14) suffered 3 or more sequelae. Complications were significantly more common in ICU patients (n = 33/38, 87%), compared to HDU patients (n = 9/33, 27%) (OR 17.6, 95% CI 5.23, 59.21, p <0.05). CONCLUSION: In a subset of critically ill patients who recovered from severe COVID-19 infection, there was considerable short-term post-infectious and post-acute disability. Long-term follow-up of COVID-19 survivors is warranted.

Intelligent Graduate Medical Education Dashboard (IGMED) to Enhance Trainee Oversight During the COVID-19 Pandemic.

BACKGROUND: Medical residents comprise a large, but unique, subset of the physician workforce. They serve as front-line staff, but are trainees, regulated by duty hour and supervision restrictions. Heightened oversight is necessary to ensure resident supervision and safety whilst mobilizing this important workforce during crisis. This manuscript describes the development and implementation of an institutional crisis dashboard to facilitate timely information gathering and decision-making regarding resident activities during the COVID-19 pandemic. OBJECTIVE: The purpose of the study was to develop an intelligent graduate medical education dashboard to centralize and integrate data to support accurate, timely decisions in several areas: (1) track redeployment; (2) ensure adherence to supervision and duty hour regulations; and (3) monitor infection control and safety measures. METHODS: The dashboard is a live Microsoft Excel database saved to a shared fileserver. All existing databases within the education department were reviewed to form a foundational template. A monitoring section provides at-a-glance information on trainee assignments. Embedded color-coded flags attached to specific responses immediately highlight areas of deficiency. RESULTS: The dashboard facilitated the efficient mobilization of trainees, while ensuring assignments followed education regulations. It allowed the education office to centralize and proactively arrange mass scrubs orders, facemask fitting, and personal protective equipment training. It was a monitoring system that enabled recognition of safety concerns in real-time, including identifying areas where residents were most exposed or infected. CONCLUSION: The dashboard improved the efficiency of crisis response, while prioritizing resident safety. It is feasible, low cost and easily accessible, even during Internet disruption. It can be used by hospitals worldwide, including low resource settings.

Rebuilding Graduate Medical Education After a Crisis: Perspectives of Medical Residents in the United Arab Emirates.

Pandemics create unprecedented public health challenges that require comprehensive and coordinated responses from health care systems and can, thereby, cause substantial and prolonged disruption to residency training. The coronavirus 2019 (COVID-19) pandemic has impacted medical education worldwide. Currently, there is a gap in the literature from the trainee's perspective, and little advice on resuming post-pandemic operations. As internal medicine residents serving on the frontlines of a COVID-19 designated government hospital in the United Arab Emirates, we also faced significant challenges and uncertainties during the pandemic. We are fortunate to have overcome the initial surges and have spent the past 6 months navigating a new reality. We believe that the COVID-19 crisis provides an opportunity for graduate medical education programs worldwide to implement targeted changes that can lead to sustainable improvements in the system. In supporting learning during these times, our residency program has adopted flexible scheduling, focused on frequent and transparent communication, incorporated different strategies to build community and promote psychological wellbeing, and advanced virtual teaching modalities. The aim of this article is to share the strategies that have helped us to move forward in the aftermath of the first phases of the pandemic, whilst we prepare for the uncertainty of the future. We hope that the lessons we have learned can help inform other programs as they react and adapt to the global after-effects of this crisis.

An exploratory analysis of factors contributing to resident pass rates on a national licensure OSCE in the United Arab Emirates.

PURPOSE: To explore resident perceptions of factors contributing to pass rates on a high-stake licensing objective structured clinical exam (OSCE). MATERIALS AND METHODS: A cross-sectional survey was administered to all 51 applicants of the April 2019 internal medicine Arab Board OSCE examination in Abu Dhabi, United Arab Emirates (UAE), and included questions on preparedness, stress level, and prior educational experiences. Exposures were evaluated for correlation against Arab Board pass rates using Pearson correlation and the two-tailed significance was recorded. RESULTS: All 51 examinees completed the survey (100% response rate). Participants were primarily female n = 35 (67%) and all completed residency training in the UAE. Gender differences were noted, with higher pass rates for the male residents (13/35, 37% females vs. 8/16, 50% males, P < 0.05). Further, 65% (P < 0.001) of female examinees reported higher levels of anxiety than male residents. Examinees reported regular exposure during residency to clinical skills training (74%), standardized patients (71%), simulation (66%), and OSCEs (72%) but none of these educational modalities correlated with higher pass rates. Of multiple exam preparation modalities, only self-directed learning with deliberate practice, the intentional repetition of a task with feedback, was associated with higher pass rates. CONCLUSION: Clinical exam skills are vital for trainees to deliver high-quality primary healthcare services. National licensure OSCEs have become the norm in the Arab world for assessing resident clinical exam skills. Our results suggest that residency programs should encourage residents' intentional deliberate practice and mastery learning in the acquisition and retention of physical examination techniques.

Covid-19 pandemic research opportunity: Is the Middle East & North Africa (MENA) missing out?

BACKGROUND: The Covid-19 pandemic has caused fear and panic worldwide, forcing healthcare systems to disregard conventional practices and adopt innovation to contain the infection and death. Globally, there has been a rapid proliferation of research studies and clinical trials assessing risks, infectivity and treatment. METHODS: This review assesses the opportunities and challenges in the Middle East North Africa (MENA) region to engage in the conduct of high quality clinical trials during the Covid-19 pandemic. RESULTS: Opportunities are abundant for conducting clinical trials in MENA countries, including substantial cost savings, academic health centers, integrated health information systems, international accreditation, and international collaborations. Yet, the MENA region has missed out on opportunities to advance patient research during prior infectious disease outbreaks caused by the Severe Acute Respiratory Syndrome, Ebola, and the Middle East Respiratory Syndrome, as evidenced by the lack of concerted research and clinical trials from the region. A large vulnerable population, especially the poor expatriate work force, the current isolation of the health centers, and the lack of an expert network or field trained task force, all contribute to challenges preventing the formation of a pan Arab research enterprise for epidemics. CONCLUSION: Quality clinical research is critical during public health emergencies to identify treatments and solutions. The efficient conduct of clinical trials requires innovative strategies in research design, approval, and dissemination. Many countries in the MENA region have an opportunity to quickly ramp up research capacity and contribute significantly to the fight against the Covid-19 global threat.