Residents working with Médecins Sans Frontières: training and pilot evaluation

Widespread global health inequalities and the resulting shortage of humanitarian health workers have led to an increased presence of young doctors in disaster and humanitarian crises [1]. However, although well-prepared humanitarian workers are more necessary than ever [2], traditional medical education struggles to meet the demands posed by globalization and the dramatic escalation of violence [3].

Training objectives for physicians working with Médecins Sans Frontières (MSF) differ from the set of skills acquired in medical schools and residency programs. These professionals are in fact confronted with unique challenges and ethical dilemmas [3] including, but not limited to, different spectra of diseases, limited resources, cultural diversity, and social disruption. For these reasons, training objectives should be set far beyond individual job-specific skills and incorporate a set of core medical and non-medical competencies that all humanitarian workers must possess [4]. Essential to the preparation process before first deployment are therefore clearly defined learning objectives, curricula tailored to the nuances of humanitarian settings, state-of-the-art teaching tools, including high fidelity simulation, and assessment to determine competency [5].

Despite the need for curricula built on a testable package of knowledge and skills, evaluating the effectiveness of training programs is generally not an essential component of preparedness for humanitarian health workers [6], or at best is limited to measuring satisfaction or knowledge. Assessing whether students improve their ability to handle complex situations is of paramount importance to guarantee the best outcomes for vulnerable populations; for this reason, this manuscript describes a training program designed to prepare medical residents for their first deployment with Médecins Sans Frontières and presents the results of a pilot assessment of its effectiveness.

Expatriate health providers have been observed to be ill-prepared during recent humanitarian emergencies due to lack of experience in international relief and inadequate understanding of the local context [4, 18]. For this reason, the international humanitarian community has been drawing attention to the compelling need for competency-based training curricula based on a standard set of cross-cutting and profession-specific competencies [4, 19]. Since young doctors, born in a new era of highly-specialized medicine, have been increasing their presence in international aid projects, good preparation and performance oversight are paramount to guarantee best practice also in resource-strained settings [9].

To our knowledge, this is the first study that describes the implementation and evaluation of a course based on published cross-sectorial and profession-specific competencies, jointly developed by an academic center and a robust humanitarian organization. Interestingly, while 61% of training programs for humanitarian workers in Europe [19] are defined as “competency-based”, none of them incorporates previously published competency sets. Evaluating the effectiveness of training programs is necessary to ensure credibility and decide whether they should be continued or not. In this regard, the assessment of a course for humanitarian workers using the first three levels of the Kirkpatrick’s evaluation model and including high fidelity simulation represents a real novelty.

Overall, students’ satisfaction (Level 1) with the program was high. In particular, the delivery method and the residential phase were highly appreciated. It is worth noting that, aside from course curriculum and students’ previous academic background, the structure of the program and the educational environment also play a central role in learning [20]. Over the last years, medical education has shifted toward different delivery modes in an attempt to achieve better educational outcomes. The combination of face-to-face lectures and online teaching, defined as blended learning, strengthens the interaction between course participants, lecturers and resources [21] and represents a flexible pedagogical system [22].

Our study showed that students’ competency in simulated humanitarian scenarios increased after course completion (Level 2). The term “competency” is defined as the set of knowledge, attitudes and skills required to accomplish a task. A competency-based training must ensure the acquisition of a theoretical understanding of relevant concepts in the field of humanitarian assistance (e.g., learning the Simple Triage And Rapid Treatment (START) triage algorithm), promote a positive predisposition toward the working methods and actions to be adopted in low-resource settings (e.g., recognizing the importance of applying the START triage), and develop students’ practical skills (e.g., conducting good quality triage in case of a mass casualty event). Yoon et al. [23] used the Kirkpatrick model to evaluate a continuing professional development training for physicians and physician assistants. In their study, a single 5-point Likert scale form filled by trainers and trainees was used to assess learning. However, it is important to highlight that the inclusion of separate tests for knowledge (e.g., multiple choice), attitudes (e.g., Likert scale questionnaire), and skills (e.g., performance test) should be preferred whenever possible [14].

Our results reflect a clear improvement in participants’ knowledge and overall performance in a high-fidelity scenario, while no change in attitude was evident. A plausible explanation may lie in the selection process itself. Since all students were highly motivated and had decided to take part in the course on a voluntary basis, a positive attitude was to be expected.

In a recent study, Schwartz et al. highlighted the prominent role that simulations, and particularly high-fidelity simulations, may play in enhancing residents’ skills in the management of complex cases [24]. Simulated environments are an invaluable setting to teach crisis resource management (CRM) skills [25], which are extremely important in humanitarian contexts. Some challenges commonly encountered in the field (e.g., communication barriers and shortage of resources) can be easily reproduced through simulation, giving students the chance to become acquainted with similar situations, receive feedback and improve their performance with no risks to patients. At the same time, simulated scenarios allow for the evaluation of performance objectives, reflecting how students would use in the field the competencies acquired through training [11]. In their review entitled “Transfer of learning and patient outcome in simulated crisis resource management”, Boet et al. found that CRM simulations improve not only learners behavior in the workplace but also, and more importantly, patient outcomes [26].

According to Kirkpatrick et al., [14] a positive reaction and evidence of improvement in learning do not necessarily lead to desired changes in behavior. The transfer of learning to the workplace is heavily conditioned by the so-called ‘work climates’, and these are clearly established by a supervisor’s reaction to students’ practical application of the competencies acquired. To promote an encouraging work environment, heads of department and supervisors should be informed about the students’ participation in the training program, and preferably be involved in its development [14]. In our case, keeping MSF field evaluators blinded was mandatory to prevent biases; however, all participants received very good feedbacks. The reason for this may be the fact that educational needs were decided and endorsed by a panel of experts that included MSF training staff. This ensured that the practical concepts, organizational principles and techniques taught complied with the organization’s best practice standards.

The collaboration between an academic center and a robust humanitarian organization allowed us to demonstrate the effectiveness of a pre-deployment training course in improving participants’ learning. This may have several promising implications:

It is our hope that this collaborative initiative will serve worldwide as a model to bridge the gap between academia and field operations and contribute to the growth and professionalization of the humanitarian health sector.

Over the last decade, the humanitarian community has stressed the need to improve the quality of response through further investments in training for aid workers. Residents were highly satisfied with our training program and their knowledge and skills in simulated humanitarian environments improved as a result of participation. The implementation of this project shows how academia can successfully partner with humanitarian aid organizations to promote the professionalization of future humanitarian health workers. Further studies should be conducted to assess whether training programs effectively increase the competence of humanitarian workers in the field and if this translates into improvement of patients’ outcomes or further advantages for deploying organizations.