Critical care capacity and care bundles on medical wards in Malawi: a cross-sectional study.

INTRODUCTION: As low-income countries (LICs) shoulder a disproportionate share of the world's burden of critical illnesses, they must continue to build critical care capacity outside conventional intensive care units (ICUs) to address mortality and morbidity, including on general medical wards. A lack of data on the ability to treat critical illness, especially in non-ICU settings in LICs, hinders efforts to improve outcomes. METHODS: This was a secondary analysis of the cross-sectional Malawi Emergency and Critical Care (MECC) survey, administered from January to February 2020, to a random sample of nine public sector district hospitals and all four central hospitals in Malawi. This analysis describes inputs, systems, and barriers to care in district hospitals compared to central hospital medical wards, including if any medical wards fit the World Federation of Intensive and Critical Care Medicine (WFSICCM) definition of a level 1 ICU. We grouped items into essential care bundles for service readiness compared using Fisher's exact test. RESULTS: From the 13 hospitals, we analysed data from 39 medical ward staff members through staffing, infrastructure, equipment, and systems domains. No medical wards met the WFSICCM definition of level 1 ICU. The most common barriers in district hospital medical wards compared to central hospital wards were stock-outs (29%, Cl: 21% to 44% vs 6%, Cl: 0% to 13%) and personnel shortages (40%, Cl: 24% to 67% vs 29%, Cl: 16% to 52%) but central hospital wards reported a higher proportion of training barriers (68%, Cl: 52% to 73% vs 45%, Cl: 29% to 60%). No differences were statistically significant. CONCLUSION: Despite current gaps in resources to consistently care for critically ill patients in medical wards, this study shows that with modest inputs, the provision of simple life-saving critical care is within reach. Required inputs for care provision can be informed from this study.

Applying the WHO-ICRC BEC course to train emergency and inpatient healthcare workers in Sierra Leone early in the COVID-19 outbreak.

BACKGROUND: Treating critical illness in resource-limited settings during disease outbreaks is feasible and can save lives. Lack of trained healthcare workers is a major barrier to COVID-19 response. There is an urgent need to train healthcare workers to manage COVID-19. The World Health Organization and International Committee of the Red Cross's Basic Emergency Care course could provide a framework to cross-train personnel for COVID-19 care while strengthening essential health services. METHODS: We conducted a prospective cohort study evaluating the Basic Emergency Care course for healthcare workers from emergency and inpatient units at two hospitals in Sierra Leone, a low-income country in West Africa. Baseline, post-course, and six month assessments of knowledge and confidence were completed. Questions on COVID-19 were added at six months. We compared change from baseline in knowledge scores and proportions of participants "very comfortable" with course skills using paired Student's t-tests and McNemar's exact tests, respectively. RESULTS: We enrolled 32 participants of whom 31 completed pre- and post-course assessments. Six month knowledge and confidence assessments were completed by 15 and 20 participants, respectively. Mean knowledge score post-course was 85% (95% CI: 82% to 88%), which was increased from baseline (53%, 48% to 57%, p-value < 0.001). There was sustained improvement from baseline at six months (73%, 67% to 80%, p-value 0.001). The percentage of participants who were "very comfortable" performing skills increased from baseline for 27 of 34 skills post-training and 13 skills at six months. Half of respondents strongly agreed the course improved ability to manage COVID-19. CONCLUSIONS: This study demonstrates the feasibility of the Basic Emergency Care course to train emergency and inpatient healthcare workers with lasting impact. The timing of the study, at the beginning of the COVID-19 pandemic, provided an opportunity to illustrate the strategic overlap between building human resource capacity for long-term health systems strengthening and COVID-19. Future efforts should focus on integration with national training curricula and training of the trainers for broader dissemination and implementation at scale.

Examining Parity among Black and Hispanic Resident Physicians.

BACKGROUND: The US physician workforce does not represent the racial or ethnic diversity of the population it serves. OBJECTIVES: To assess whether the proportion of US physician trainees of Black race and Hispanic ethnicity has changed over time and then provide a conceptual projection of future trends. DESIGN: Cross-sectional, retrospective, analysis based on 11 years of publicly available data paired with recent US census population estimates. PARTICIPANTS: A total of 86,303 (2007-2008) to 103,539 (2017-2018) resident physicians in the 20 largest US Accreditation Council for Graduate Medical Education resident specialties. MAIN MEASURES: Changes in proportion of physician trainees of Black race and Hispanic ethnicity per academic year. Projected number of years it will then take, for specialties with positive changes, to reach proportions of Black race and Hispanic ethnicity comparable to that of the US population. KEY RESULTS: Among the 20 largest specialty training programs, Radiology was the only specialty with a statistically significant increase in the proportion of Black trainees, but it could take Radiology 77 years to reach levels of Black representation comparable to that of the US population. Obstetrics/Gynecology, Emergency Medicine, Internal Medicine/Pediatrics, and Orthopedic Surgery demonstrated a statistically significant increase in the proportion of Hispanic trainees, but it could take these specialties 35, 54, 61, and 93 years respectively to achieve Hispanic representation comparable to that of the US population. CONCLUSIONS: Among US residents in the 20 largest specialties, no specialty represented either the Black or Hispanic populations in proportions comparable to the overall US population. Only a small number of specialties demonstrated statistically significant increases. This conceptual projection suggests that current efforts to promote diversity are insufficient.

Epidemiology of traumatic injuries presenting to an ED in Central Haiti: a retrospective cohort study.

BACKGROUND: In Haiti, like many low-income countries, traumatic injuries are leading causes of morbidity and mortality. Yet, little is known about the epidemiology of traumatic injuries in Haitian EDs. Improved understanding of injury patterns is necessary to strengthen emergency services and improve emergency provider education. METHODS: This was a retrospective cohort study of trauma patients at an academic hospital in central Haiti over 6 months. Visits were identified from the electronic medical record, and paper charts were manually reviewed. Data, including demographics, timing of presentation, injuries sustained, treatments received and ED disposition were extracted using a standardised form and later analysed in SAS V.9.3. RESULTS: Of 1401 patients, 66% were male, and the average age was 26.8 years. Most visits were due to road traffic injuries (RTIs; 48%) followed by falls (22%). Trauma mechanism varied significantly by age (p<0.001): falls predominated in children under 5 years (56%) versus RTIs for adults (59%). Only 14% of patients injured on motorcycles used helmets and 30% of those injured in motor vehicles used seatbelts. Only 18% of patients arrived within 1 hour of the trauma. Skin or soft tissue injuries were the most common (58%), followed by extremity or pelvic fractures or dislocations (23%). Most patients (81%) were discharged, 14% were admitted or stayed over 24 hours in the ED and 0.8% died in the ED. Of the admitted patients, 61% had surgery, 79% of which were orthopaedic. Patients using helmets or seatbelts were more likely to be discharged than those not using protective equipment (p=0.008). CONCLUSIONS: In this trauma population, RTIs and falls were the most common trauma mechanisms, safety feature use was rare, and most injuries were musculoskeletal. Presentation was delayed and mortality was low, but many patients required surgery. These findings have significant clinical, public health, operational and training implications.

Strengthening Health Systems While Responding to a Health Crisis: Lessons Learned by a Nongovernmental Organization During the Ebola Virus Disease Epidemic in Sierra Leone.

An epidemic of Ebola virus disease (EVD) beginning in 2013 has claimed an estimated 11 310 lives in West Africa. As the EVD epidemic subsides, it is important for all who participated in the emergency Ebola response to reflect on strengths and weaknesses of the response. Such reflections should take into account perspectives not usually included in peer-reviewed publications and after-action reports, including those from the public sector, nongovernmental organizations (NGOs), survivors of Ebola, and Ebola-affected households and communities. In this article, we first describe how the international NGO Partners In Health (PIH) partnered with the Government of Sierra Leone and Wellbody Alliance (a local NGO) to respond to the EVD epidemic in 4 of the country's most Ebola-affected districts. We then describe how, in the aftermath of the epidemic, PIH is partnering with the public sector to strengthen the health system and resume delivery of regular health services. PIH's experience in Sierra Leone is one of multiple partnerships with different stakeholders. It is also one of rapid deployment of expatriate clinicians and logistics personnel in health facilities largely deprived of health professionals, medical supplies, and physical infrastructure required to deliver health services effectively and safely. Lessons learned by PIH and its partners in Sierra Leone can contribute to the ongoing discussion within the international community on how to ensure emergency preparedness and build resilient health systems in settings without either.

Challenges connecting emergency department patients with oral health care: A qualitative analysis of patients, emergency department clinicians, and dentists.

BACKGROUND: Unmet dental need shares many risk factors with unmet health-related social needs (HRSN) such as housing and food security and are a common cause for seeking treatment at the emergency department (ED). METHODS: The authors recruited a purposive sample of English-speaking and Spanish-speaking patients, ED clinicians at 3 urban EDs, and dentists from nearby communities to participate in qualitative interviews to explore barriers to and facilitators of screening for HRSN and unmet dental needs in the ED. Themes were identified from transcripts using a modified grounded theory approach. RESULTS: Interviews were conducted with 25 ED patients, 19 ED clinicians, and 4 dentists. Four themes were identified: (1) a preference for formalized resources, which more frequently exist for HRSN than for oral health; (2) frequent use of ad hoc resources that are less reliable or structured, particularly for dental referral information; (3) limited knowledge of oral health care resources in the community; and (4) desire for more assistance with identifying and addressing resource needs for both HRSN and oral health. Patients were amenable to screening through a variety of modalities and felt it would be helpful, but clinicians emphasized the need for easier referral processes because of frequent failure to connect patients to oral health care. CONCLUSIONS: More robust infrastructure and clinician support are needed to ensure successful referral and screening without undue provider burden for both medical and dental clinicians. PRACTICAL IMPLICATIONS: Patients are amenable to screening for unmet oral health needs and HRSN in the ED, which may improve access to care.

Evaluation of emergency care education and triage implementation: an observational study at a hospital in rural Liberia.

INTRODUCTION: In Liberia, emergency care is still in its early development. In 2019, two emergency care and triage education sessions were done at J. J. Dossen Hospital in Southeastern Liberia. The observational study objectives evaluated key process outcomes before and after the educational interventions. METHODS: Emergency department paper records from 1 February 2019 to 31 December 2019 were retrospectively reviewed. Simple descriptive statistics were used to describe patient demographics and χ2 analyses were used to test for significance. ORs were calculated for key predetermined process measures. RESULTS: There were 8222 patient visits recorded that were included in our analysis. Patients in the post-intervention 1 group had higher odds of having a documented full set of vital signs compared with the baseline group (16% vs 3.5%, OR: 5.4 (95% CI: 4.3 to 6.7)). After triage implementation, patients who were triaged were 16 times more likely to have a full set of vitals compared with those who were not triaged. Similarly, compared with the baseline group, patients in the post-intervention 1 group had higher odds of having a glucose documented if they presented with altered mental status or a neurologic complaint (37% vs 30%, OR: 1.7 (95% CI: 1.3 to 2.2)), documented antibiotic administration if they had a presumed bacterial infection (87% vs 35%, OR: 12.8 (95% CI: 8.8 to 17.1)), documented malaria test if presenting with fever (76% vs 61%, OR: 2.05 (95% CI: 1.37 to 3.08)) or documented repeat set of vitals if presenting with shock (25% vs 6.6%, OR: 8.85 (95% CI: 1.67 to 14.06)). There was no significant difference in the above process outcomes between the education interventions. CONCLUSION: This study showed improvement in most process measures between the baseline and post-intervention 1 groups, benefits that persisted post-intervention 2, thus supporting the importance of short-course education interventions to durably improve facility-based care.

Race and Ethnicity and Primary Language in Emergency Department Triage.

Importance: Emergency department (ED) triage substantially affects how long patients wait for care but triage scoring relies on few objective criteria. Prior studies suggest that Black and Hispanic patients receive unequal triage scores, paralleled by disparities in the depth of physician evaluations. Objectives: To examine whether racial disparities in triage scores and physician evaluations are present across a multicenter network of academic and community hospitals and evaluate whether patients who do not speak English face similar disparities. Design, Setting, and Participants: This was a cross-sectional, multicenter study examining adults presenting between February 28, 2019, and January 1, 2023, across the Mass General Brigham Integrated Health Care System, encompassing 7 EDs: 2 urban academic hospitals and 5 community hospitals. Analysis included all patients presenting with 1 of 5 common chief symptoms. Exposures: Emergency department nurse-led triage and physician evaluation. Main Outcomes and Measures: Average Triage Emergency Severity Index [ESI] score and average visit work relative value units [wRVUs] were compared across symptoms and between individual minority racial and ethnic groups and White patients. Results: There were 249 829 visits (149 861 female [60%], American Indian or Alaska Native 0.2%, Asian 3.3%, Black 11.8%, Hispanic 18.8%, Native Hawaiian or Other Pacific Islander <0.1%, White 60.8%, and patients identifying as Other race or ethnicity 5.1%). Median age was 48 (IQR, 29-66) years. White patients had more acute ESI scores than Hispanic or Other patients across all symptoms (eg, chest pain: Hispanic, 2.68 [95% CI, 2.67-2.69]; White, 2.55 [95% CI, 2.55-2.56]; Other, 2.66 [95% CI, 2.64-2.68]; P < .001) and Black patients across most symptoms (nausea/vomiting: Black, 2.97 [95% CI, 2.96-2.99]; White: 2.90 [95% CI, 2.89-2.91]; P < .001). These differences were reversed for wRVUs (chest pain: Black, 4.32 [95% CI, 4.25-4.39]; Hispanic, 4.13 [95% CI, 4.08-4.18]; White 3.55 [95% CI, 3.52-3.58]; Other 3.96 [95% CI, 3.84-4.08]; P < .001). Similar patterns were seen for patients whose primary language was not English. Conclusions and Relevance: In this cross-sectional study, patients who identified as Black, Hispanic, and Other race and ethnicity were assigned less acute ESI scores than their White peers despite having received more involved physician workups, suggesting some degree of mistriage. Clinical decision support systems might reduce these disparities but would require careful calibration to avoid replicating bias.

Outcomes of Invasive and Noninvasive Ventilation in a Haitian Emergency Department.

Background: Limited data exist on the outcomes of patients requiring invasive ventilation or noninvasive positive pressure ventilation (NIPPV) in low-income countries. To our knowledge, no study has investigated this topic in Haiti. Objectives: We describe the clinical epidemiology, treatment, and outcomes of patients requiring NIPPV or intubation in an emergency department (ED) in rural Haiti. Methods: This is an observational study utilizing a convenience sample of adult and pediatric patients requiring NIPPV or intubation in the ED at an academic hospital in central Haiti from January 2019-February 2021. Patients were prospectively identified at the time of clinical care. Data on demographics, clinical presentation, management, and ED disposition were extracted from patient charts using a standardized form and analyzed in SAS v9.4. The primary outcome was survival to discharge. Findings: Of 46 patients, 27 (58.7%) were female, mean age was 31 years, and 14 (30.4%) were pediatric (age <18 years). Common diagnoses were cardiogenic pulmonary edema, pneumonia/pulmonary sepsis, and severe asthma. Twenty-three (50.0%) patients were initially treated with NIPPV, with 4 requiring intubation; a total of 27 (58.7%) patients were intubated. Among those for whom intubation success was documented, first-pass success was 57.7% and overall success was 100% (one record missing data); intubation was associated with few immediate complications. Twenty-two (47.8%) patients died in the ED. Of the 24 patients who survived, 4 were discharged, 19 (intubation: 12; NIPPV: 9) were admitted to the intensive care unit or general ward, and 1 was transferred. Survival to discharge was 34.8% (intubation: 22.2%; NIPPV: 52.2%); 1 patient left against medical advice following admission. Conclusions: Patients with acute respiratory failure in this Haitian ED were successfully treated with both NIPPV and intubation. While overall survival to discharge remains relatively low, this study supports developing capacity for advanced respiratory interventions in low-resource settings.

Critical Care Units in Malawi: A Cross-Sectional Study.

Background: The global burden of critical illness falls disproportionately outside high-income countries. Despite younger patient populations with similar or lower disease severity, critical illness outcomes are poor outside high-income countries. A lack of data limits attempts to understand and address the drivers of critical care outcomes outside high-income countries. Objectives: We aim to characterize the organization, available resources, and service capacity of public sector critical care units in Malawi and identify barriers to improving care. Methods: We conducted a secondary analysis of the Malawi Emergency and Critical Care Survey, a cross-sectional study performed from January to February 2020 at all four central hospitals and a simple random sample of nine out of 24 public sector district hospitals in Malawi, a predominantly rural, low-income country of 19.6 million in southern Africa. Data from critical care units were used to characterize resources, processes, and barriers to care. Findings: There were four HDUs and four ICUs across the 13 hospitals in the Malawi Emergency and Critical Care Survey sample. The median critical care beds per 1,000,000 catchment was 1.4 (IQR: 0.9 to 6.7). Absent equipment was the most common barrier in HDUs (46% [95% CI: 32% to 60%]). Stockouts was the most common barriers in ICUs (48% [CI: 38% to 58%]). ICUs had a median 3.0 (range: 2 to 8) functional ventilators per unit and reported an ability to perform several quality mechanical ventilation interventions. Conclusions: Although significant gaps exist, Malawian critical care units report the ability to perform several complex clinical processes. Our results highlight regional inequalities in access to care and support the use of process-oriented questions to assess critical care capacity. Future efforts should focus on basic critical care capacity outside of urban areas and quantify the impact of context-specific variables on critical care mortality.

Mass Casualty Incident Management for Resource-Limited Settings: Lessons From Central Haiti.

OBJECTIVE: Mass casualty incidents (MCIs) have gained increasing attention in recent years due multiple high-profile events. MCI preparedness improves the outcomes of trauma victims, both in the hospital and prehospital settings. Yet most MCI protocols are designed for high-income countries, even though the burden of mass casualty incidents is greater in low-resource settings. RESULTS: Hôpital Universitaire de Mirebalais (HUM), a 300-bed academic teaching hospital in central Haiti, developed MCI protocols in an iterative process after a large MCI in 2014. Frequent MCIs from road traffic collisions allowed protocol refinement over time. HUM's protocols outline communication plans, triage, schematics for reorganization of the emergency department, clear delineation of human resources, patient identification systems, supply chain solutions, and security measures for MCIs. Given limited resources, protocol components are all low-cost or cost-neutral. Unique adaptations include the use of 1) social messaging for communication, 2) mass casualty carts for rapid deployment of supplies, and 3) stickers for patient identification, templated orders, and communication between providers. CONCLUSION: These low-cost solutions facilitate a systematic response to MCIs in a resource-limited environment and help providers focus on patient care. These interventions were well received by staff and are a potential model for other hospitals in similar settings.

Three decades of demographic trends among academic emergency physicians.

Purpose: To describe trends in emergency medicine faculty demographics, examining changes in the proportion of historically underrepresented groups including female, Black, and Latinx faculty over time. Methods: Data from the Association of American Medical Colleges faculty roster (1990-2020) were used to assess the changing demographics of full-time emergency medicine faculty. Descriptive statistics, graphic visualizations, and logistic regression modeling were used to illustrate trends in the proportion of female, Black, and Latinx faculty. Odds ratios (OR) were used to describe the estimated annual rate of change of underrepresented demographic groups. Results: The number of full-time emergency medicine faculty increased from 214 in 1990 to 5874 in 2020. Female emergency medicine faculty demonstrated increases in representation overall, from 35 (16.36%) in 1990 to 2247 (38.25%) in 2020, suggesting a 3% estimated annual rate of increase (OR 1.03, 95% CI 1.03-1.04) and within each academic rank. A very small positive trend was noted among Latinx faculty (n = 3, 1.40% in 1990 to n = 326, 5.55% in 2020; OR 1.01, 95% CI 1.01-1.02), whereas an even smaller, statistically insignificant increase was observed among Black emergency medicine faculty during the 31-year study period (N = 9, 4.21% in 1990 and N = 266, 4.53% in 2020; OR 1.00, 95% CI 0.99-1.00). Conclusions: Although female physicians have progressed toward equitable representation among academic emergency medicine faculty, no meaningful progress has been made toward racial parity. The persistent underrepresentation of Black and Latinx physicians in the academic emergency medicine workforce underscores the need for urgent structural changes to address contemporary manifestations of racism in academic medicine and beyond.

The Malawi emergency and critical care survey: A cross-sectional national facility assessment.

BACKGROUND: Data on emergency and critical care (ECC) capacity in low-income countries (LICs) are needed to improve outcomes and make progress towards realizing the goal of Universal Health Coverage. METHODS: We developed a novel research instrument to assess public sector ECC capacity and service readiness in LICs. From January 20th to February 18th, 2020 we administered the instrument at all four central hospitals and a simple random sample of nine of 24 district hospitals in Malawi, a landlocked and predominantly rural LIC of 19·1 million people in Southern Africa. The instrument contained questions on the availability of key resources across three domains and was administered to hospital administrators and clinicians from outpatient departments, emergency departments, and inpatient units. Results were used to generate an ECC Readiness Score, with a possible range of 0 to 1, for each facility. FINDINGS: A total of 114 staff members across 13 hospitals completed interviews for this study. Three (33%) district hospitals and all four central hospitals had ECC Readiness Scores above 0·5 (p-value 0·070). Absent equipment was identified as the most common barrier to ECC Readiness. Central hospitals had higher median ECC Readiness Scores with less variability 0·82 (interquartile range: 0·80-0·89) than district hospitals (0·33, 0·23 to 0·50, p-value 0·021). INTERPRETATION: This is the first study to employ a systematic approach to assessing ECC capacity and service readiness at both district and central hospitals in Malawi and provides a framework for measuring ECC capacity in other LICs. Prior ECC assessments potentially overestimated equipment availability and our methodology may provide a more accurate approach. There is an urgent need for investments in ECC services, particularly at district hospitals which are more accessible to Malawi's predominantly rural population. These findings highlight the need for long-term investments in health systems strengthening and underscore the importance of understanding capacity in LIC settings to inform these efforts. FUNDING: Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Department of Emergency Medicine, Brigham and Women's Hospital.

Back to the bedside: the 8-year evolution of a resident-as-teacher rotation.

BACKGROUND: Teaching our residents to teach is a vital responsibility of Emergency Medicine (EM) residency programs. As emergency department (ED) overcrowding may limit the ability of attending physicians to provide bedside instruction, senior residents are increasingly asked to assume this role for more junior trainees. Unfortunately, a recent survey suggests that only 55% of all residencies provide instruction in effective teaching methods. Without modeling from attending physicians, many residents struggle with this responsibility. OBJECTIVES: We introduced a "Resident-as-Teacher" curriculum in 2002 as a means to address a decline in bedside instruction and provide our senior residents with a background in effective teaching methods. DISCUSSION: Here, we describe the evolution of this resident-as-teacher rotation, outline its current structure, cite potential pitfalls and solutions, and discuss the unique addition of a teach-the-teacher curriculum. CONCLUSION: A resident-as-teacher rotation has evolved into a meaningful addition to our senior residents' training, fostering their growth as educators and addressing our need for bedside instruction.

Liberia's First Health Workforce Program Strategy: Reflections and Lessons Learned.

Following civil war and the Ebola epidemic, Liberia's health workforce was devastated, essential health services and primary care were disrupted, and health outcomes for maternal and child mortality were amongst the worst in the world. To reverse these trends, the government of Liberia developed the Health Workforce Program (HWP) Strategy 2015-2021. With the goal of building a resilient and responsive health system to ensure access to essential services and the ability to respond to future crises, this strategy aimed to add 6,000 new professionals to the workforce. In the context of the COVID-19 pandemic, we share lessons learned from the program's development and first years of implementation.

The Role of Family Medicine Training in Addressing Workforce Challenges in Rural Liberia - Early Implementation Experience.

Background: Liberia has a severe shortage in the health workforce, which is amplified in rural areas. Many talented Liberians leave the country for post-graduate education; those physicians who do stay are concentrated in Monrovia. Objective: We initiated a family medicine specialty training program (FMSTP) to increase the number of well-trained physicians who have the knowledge, skills, and commitment to meet the health needs of the Liberian people. Methods: The Liberian College of Physicians and Surgeons (LCPS) family medicine program is a three-year post-graduate course that follows the West African College of Physician (WACP) curriculum. The program has a longitudinal rural training component supported by Partners in Health in Maryland county, where residents gain experience in a remote and under-served region. The program is evaluated through resident evaluations and ultimately bench-marked by accreditation and exam pass rates. Findings: The FMSTP commenced in July 2017, and the first rural rotation was in January 2018. To-date 13 residents have completed a total of 43 rotations in Maryland. Residents surveyed highly rated the faculty and their rural rotations. They identify more hands-on involvement in patient care, exposure to community health, and one-on-one time with faculty as the greatest assets of the rural training experience. Accreditation from the WACP was granted in December 2018. One of the graduating residents from the first class in 2020 is now serving as the first Liberian family medicine specialist in Maryland County. Discussion: Investing in a strong rural training component in our FMSTP has not only strengthened the program but has also built the infrastructure to establish our rural site as an attractive teaching hospital for intern doctors and nursing students. As the program continues to grow, success will be measured by the proportion of Liberian medical students entering the family medicine training program, retention of family medicine physicians in rural areas, and ultimately progress towards universal health coverage (UHC).