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Liberia
SIM, SIM/Liberia, ELWA Hospital (ELWA)
PI: Rick Sacra
Other team members: David Okiror
Project Duration: December 1, 2018 - August 31, 2023
Focus Areas: Family Medicine, Faculty Development Program
Final Summary of Project Activities
According to project PI Dr. Rick Sacra, the impact of this project has been nothing short of monumental. Family Medicine, a field that was virtually unknown in Liberia ten years ago, is now common knowledge at all levels of healthcare administration, including the Ministry of Health, the Liberia College of Physicians and Surgeons (LCPS), County Health Teams, and District Hospitals. Even though residency training only began in July 2017, by August 2023 there were 15 graduates from the membership program recognized by LCPS, serving as medical directors of hospitals and health centers, county health officers, and junior faculty within the Family Medicine Residency (FMR) Program. Furthermore, a new rotation in Family Medicine is slated to begin for final year medical students in 2024-2025 according to the revised A. M. Dogliotti (AMD) College of Medicine Curriculum. The USAID PEER/Liberia Partnership program can be especially proud that this funding catalyzed the development of a new primary care specialty in Liberia even during the COVID-19 pandemic, which could have easily derailed a project like this. Family Medicine will contribute to a shift toward more holistic and cost-effective care nationwide, in collaboration with all the other specialties that have faculties within LCPS. Following are summaries of the activities undertaken by the SIM/ELWA team under each of their three objectives, with explanations for those which proved impractical or were reworked during the course of the grant.
Objective 1: Strengthen medical training and build subspecialty medical capacity in Liberia through hospital-based residency training, medical student teaching, faculty development, subspecialty care training to family physician trainees, and behavioral health training
Under Objective 1, the first activity was to create a structured curriculum for FMR which aligns with the West African College of Physicians (WACP) curriculum. This has been accomplished as we follow the WACP, which itself has revised its curriculum several times. The ELWA Hospital Family Medicine Faculty received full five-year accreditation from WACP in 2020. A new 2023 WACP curriculum includes online core knowledge modules and is being implemented starting with the 2023 class of residents, with the residents being trained by fellows of the West African College and LCPS. Rotation plans have been developed and documented with the partnership of UMass FMR collaborators. Much needed updates to LCPS policies and procedures and their adoption for Family Medicine were accomplished through the intense involvement of Family Medicine faculty in rewriting the LCPS Residency Policies and Procedures document in 2019/2020 and orienting all residents to this document. Feedback about training, rotations, and faculty from both faculty and residents was been solicited through detailed questionnaires both periodically (in association with residency retreats held in 2019 and 2021) and after each rotation, with this feedback helping drive decisions about rotation content and faculty assignments. The recruitment of core Family Medicine faculty was a key goal under this objective. The program chair’s salary was initially funded by core USAID PEER funds, but those costs have now transitioned to partial funding by another long-term partner, African Mission Healthcare, for sustainability. Supplemental funds were used to bring in two additional core faculty, one of whom continues to develop the Part 2 Fellowship program/curriculum.
Under the project’s “Core Faculty” theme, SIM/ELWA deployed UMass Global Health Fellows to work in Liberia. The COVID pandemic interrupted this process, but even so, three UMass Global Health Fellows served 6-8 week stints in Liberia alongside UMass FM Residents (supported by UMass funds), who taught and coordinated Journal Clubs, clinical rounds, CPR training, and ALSO (Advanced Life Support in Obstetrics) training. The UMass team (Dr. Valdman and Maria Barluenga) was instrumental in assisting ELWA to organize schedules for clinical instruction, lectures, coordinating the mix of remote and in-person didactic sessions with the academic coordinator. The graduates who remained on as Junior Faculty, Dr. Igwilo and Dr. Korha, have been mentored and developed in their teaching and administrative skills.
The second theme under objective 1, which involved medical student teaching, was delayed by the constraints of working with the A.M. Dogliotti College of Medicine and their curriculum review system. However, SIM/ELWA joined in crafting the new curriculum, which is gradually being implemented. A complementary set of Family Medicine didactics and clinical teaching was put into the final year curriculum, to be implemented in 2024/25, with focus on gerontology, lifestyle medicine, travel medicine, and palliative care.
For the third theme, Faculty Development, the initial plan to use the “Training of Tomorrow” course was scrapped after in depth consultation with both UMass partners and Fellows within the WACP. It became clear that only WACP-approved training would be accepted in this context. After consultation with WACP fellows/faculties, Dr. Sacra and his team revised these plans and used the “Doctors As Educators” course, as well as sending their faculty and senior residents to the faculty development seminars provided by other USAID PEER partners in collaboration with LCPS.
Subspecialty Care Training was the focus of the fourth theme, and the team recruited faculty and provided subspecialty-based training in HIV/viral hepatitis care (by UMass fellows), Obstetrics (by an OB/GYN specialist funded by USAID), ENT (by a specialist from Ghana who made six one-month visits to teach intensive rotations to two residents at a time), Ophthalmology, Mental Health, Microbiology, and Pathology. Pediatrics was provided by another resource. This allowed the SIM/ELWA team to provide the full range of subspecialty training required by the WACP Family Medicine curriculum. Many of these didactic sessions are now in UMass Family Medicine databank.
For the fifth theme, Behavioral Health (BH) Training, Dr. Liz Dykhouse from UMass provided interactive remote didactic sessions to residents, providing a full range of BH resources, including the trainees’ self-assessments of their own reactions to patients and to the traumas and stresses of physician practice, as well as a full range of BH tools for patients with a wide range of mental health issues.
Objective 2: Improve the ability of Liberia to conduct clinical research
An initial set of four research trainings was conducted in 2019, funded by PEER (carried out by UMass in collaboration with other partners and JFK departments), each running four half-days. A second set of trainings was carried out in 2020, in online/zoom format due to COVID-19. This led to a set of eight pilot projects being approved, including one led by a family physician resident. These research projects continue in various states of completion as of August 2023. Thanks to supplemental funds provided by PEER/Liberia, the team organized a research training in December 2022, based at ELWA Hospital and conducted by Dr. Trish McQuilkin (UMass Pediatrics) in collaboration with three local faculty from the Liberia College of Health Sciences (LCHS). Participants included one part-2 senior resident, four FMR graduates, and five Family Medicine faculty members. A follow-on mentoring scheme was put in place to allow ongoing pursuit of research opportunities through an agreement with one of the local Liberian faculty through the fall of 2024. Research outputs include presentations at various Scientific Sessions by Family Physicians, including “ELWA Hospital Primary Care Intervention to Manage COVID-19 during the First Peak of the Epidemic from April 2020 to August 2020 in Monrovia, Liberia. Outcomes and Lessons Learned” by Dr. David Okiror and 14 others, presented at the recent LCPS Annual General and Scientific Meeting. Research is probably the area where Liberia has the largest gaps and needs before developing state-of-the-art outputs, but this grant has done a lot to introduce trainees to research fundamentals.
Objective 3: Increase access to specialty care for Ebola survivors and the broader population
By the time funding was received in December 2018, the Ebola epidemic had faded to the back of peoples’ minds. There were still a few Ebola survivors attending the ELWA Hospital Continuity Clinic at the beginning of the project, and they were folded into the ongoing efforts to improve access to high-quality Family Medicine care at ELWA. Family Medicine’s emphasis on developing curriculum, a quality improvement mindset, and training time in the outpatient setting should go a long way toward improving preventive and chronic disease care in Liberia in the long run.
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