PARTNERSHIPS FOR ENHANCED ENGAGEMENT IN RESEARCH (PEER) Liberia University of Massachusetts Medical School (UMass) PI: Olga Valdman (original PI: Patricia McQuilkin) Other team members: Steven Hatch, Stuart Levitz, Ann Moormann, Sanjay Ram, Olga Valdman Project Duration: June 1, 2018 - August 15, 2023 Focus Areas: Clinical Research Training, Family Medicine, Infectious Diseases Final Summary of Project Activities Since 2018, the collaboration between multiple partners from the U.S. and Liberian sides on the PEER/Liberia grant has accomplished most of the goals set from the beginning, at times even going above and beyond. The involvement of the University of Massachusetts (UMass) team focused predominantly on Family Medicine and the collaboration with ELWA hospital in Liberia. Additionally, together with their Liberian colleagues they developed a robust research training course, supported pilot research projects, and developed and implemented an infectious disease teaching curriculum. Specifically, the following accomplishments should be noted relative to the three objectives in the work plan: Objective 1: Strengthening medical training and building specialty and subspecialty medical capacity in Liberia During the five years of the project, UMass helped ELWA and the Liberian College of Physicians and Surgeons (LCPS) to develop a robust Family Medicine training program. Here are some activities undertaken: Developed a three-year curriculum in line with West African College of Physicians (WACP) standards. Created policy and procedures for residency administration, including a three-year template for rotation schedules, recruitment, admission process, orientation, disciplinary actions, promotion, and approaches to working with challenging learners. Supported preparation of residents for WACP exams, of whom 23 sat for the WACP primary exams and 20 passed those exams during the course of the grant. Additionally, one Family Medicine (FM) graduate passed the WACP membership exam. Locally, in training and graduation exams were developed utilizing both the WACP format, Liberian priorities, and Objective Structured Clinical Examination (OSCE) testing. Conducted extensive work on the evaluation front, including development of rotation evaluations, faculty and resident feedback forms, on-the-fly professionalism evaluations, and semi-annual evaluations providing residents with comprehensive formative and summative feedback and support for improvement. E-formats of these evaluations were also developed to facilitate efficiency, completion, and data tracking. Developed specialty rotations with curriculum and structure for Otorhinolaryngology (ENT), Ophthalmology, Family Medicine, Community Medicine, and Radiology. At the time of initiation of this work, there were no ophthalmology or ENT faculty in Liberia. Therefore, such faculty were recruited from the Ghana College of Physicians and sponsored to come and train FM residents twice a year while also developing local capacity for these specialties; now the rotation can be run in-country, no longer requiring overseas faculty travel. Created other specialty training as per work plan, including HIV medicine through UMass HIV fellows developing and delivering an HIV management curriculum, as well as a longitudinal Behavioral Health curriculum developed and delivered by the director of behavioral health education at UMass Chan Medical School, Dr. Liz Dykhouse. Placed three UMass Global Health fellows in Liberia for a combined total of seven months providing bed-side teaching, aiding curricular development, introducing teaching modalities, and delivering lectures. Organized several faculty retreats bringing faculty from J.J. Dossen and ELWA hospital together with residents to collaborate, reflect, and plan for upcoming years. Delivered more than 200 hours of didactic lectures remotely and posted the recorded videos at https://libraryguides.umassmed.edu/c.php?g=499787&p=7779362 with open access to build sustainable education material access. Although the team was unable to develop a focused family medicine rotation for the medical students due to the timing of the A.M. Dogliotti School of Medicine (AMD) curriculum reform and new curriculum roll-out, they were able to send residents and fellows to physician-as-teacher trainings and develop a team structure where students and especially interns in the ELWA and J.J. Dossen hospitals work closely with FM residents and fellows who provide clinical and evidence-based teaching. Through these activities, the team achieved their stated project objectives. Family Medicine has become one of the most sought-after specialties, attracting the highest number of medical students applying each year. Thanks to PEER support, the UMass researchers have recruited and supported four Family Medicine faculty as well as Ob/Gyn faculty; additionally, several graduates of training activities under the project are serving in junior faculty/mentorship roles at ELWA and other hospitals across the country. The number of Liberian physicians trained in family medicine increased from 7 to 22, with 13 more candidates in the training process as of the fall of 2023. ELWA received a five-year accreditation from WACP in 2020 and LCPS in 2022 for both residency and fellowship training (the first fellowship in Liberia to be accredited by LCPS). The first LCPS fellow in Family Medicine is slated to graduate in 2024 and will become a faculty member, while others will be starting their fellowship in the next year. Through the participation of the UMass team in the AMD curriculum reform, they were able to ensure that family medicine is formally incorporated as a stand-alone rotation in the medical school curriculum for the first time in history of medical training in Liberia; the rotation is set to begin in the 2024-2025 academic year. Postgraduate medical education in Family Medicine in Liberia has improved dramatically; the chair of LCPS named Family Medicine as the strongest residency in Liberia. Family Medicine is now contributing to the pool of Liberian specialists, with four graduates per year. Although there are no exact data on improved patient outcomes in terms of reduced morbidity and mortality in Liberia, observations of the situation indicate that the physician staffing levels at the ELWA, J.J. Dossen, and several other hospitals where FM graduates have been placed have improved dramatically. It can be reasonably expected that the presence of highly trained medical doctors, especially in rural areas where commonly there might only be nurses and para-professionals available, is expected to translate to improved morbidity and mortality. Objective 2: Improve the ability of Liberia to conduct clinical research In this objective UMass took leadership not only through Family Medicine but across PEER/Liberia initiatives. The original PI for the UMass team, Dr. Patricia McQuilkin, led the development of PEER/Liberia research training. She developed several iterations of research training courses with lectures given by Liberian and U.S. faculty across more than five institutions. In years 1 and 2, several in-person research workshops were held with close to 100 participants joining at least some lectures and 23 completing the full training series. As COVID broke out in 2020, the training was adapted to a virtual platform and became a longitudinal series of 13 two-hour sessions delivered online and recorded. A total of 60 trainees took part in the online training and 72 more listened to the recordings later on. In year 3, the training was pivoted to a train-the-trainer model focusing on training 15 teaching apprentices (TAs) and supporting local faculty in taking over the course, which has now (as of 2023) been integrated into the new Master of Public Health program and the University of Liberia training curriculum. The TAs trained were engaged in the latest supplemental funding year (2022-2023) by Family Medicine to assist with the research training course that took place in December 2022 for FM fellows and faculty, as well as supporting ongoing research development. Family Medicine developed monthly journal clubs for residents, as well as research-in-progress meetings for faculty and senior residents supported by Liberian research experts. By the end of the grant in the fall of 2023, the previously trained TAs had become the key faculty in Family Medicine research training, as well as other courses provided by the University of Liberia. In addition to developing a comprehensive curriculum, building the workforce, and transferring ownership of the training to local partners, the UMass PEER team launched a pilot project grants program that funded eight research projects supported and mentored by the PEER research team. Dr. Andrews has completed and published her project. Drs. Ireland, Ekyinabah, and Oguni have completed their projects and have used the results to pursue fellowship status in the West African College of Physicians. Drs. Gorpudolo, Gbalon, and Sanoe have completed data collection and were working on data analysis. Dr. Barclay completed collecting data and was working on analysis. Objective 3: Develop an outpatient residency continuity clinic to care for Ebola survivors and the broader population Through the PEER grant initiatives, Family Medicine established a continuity clinic at ELWA Hospital for the first time in the country. Family Medicine residents were assigned patients to follow on an inpatient and outpatient basis, including Ebola survivors. A staff member dedicated to scheduling and coordinating appointments was hired and given a phone that patients were able to call to set up appointments. Unfortunately, during Covid this effort was significantly disrupted and has taken time to rebuild. However, the residents who were involved in the pilot have seen the value and impact of continuity and are eager to pursue it in other settings in which they are working and leading now. Additionally, ELWA had a cohort of Ebola survivors who were monitored and connected to specialty care, including ophthalmology at the L.V. Prasad Eye Institute. In addition, Advanced Life Support Obstetrics (ALSO) training, which was initially started in April 2022 and continued in June 2023, has been a tremendous success. In April 2022, Dr. Olga Valdman and senior UMass FM resident Dr. Rebecca Gwaltney organized three distinct courses on ALSO in accordance with American Academy of Family Physicians standards and protocols. A total of 17 people were trained as providers and 9 as faculty, and 5 others audited the course. All participants reflected on the rigor and impact the training had on their skills to provide safe maternity care. Mannequins and equipment were donated to ELWA to continue performing such trainings all year round. In 2023, the UMass team engaged the local faculty on the ground, especially Dr. Susan Kimono, director of the Ob/Gyn department at ELWA, as well as faculty responsible for obstetrics training of FM residents, in preparing for the course, updating course materials, and delivering the bulk of the content with UMass support. Two more instructors were trained in 2023 as well. For the three-day provider course this year, 13 Family Medicine residents, one general practitioner, and 5 midwives participated. Although 3 individuals had to re-take the final exam, they were able to do it successfully on their second attempt, joining the other 16 who passed the course initially. Because the course had been offered the previous year, it was decided that residents who had taken it previously would have to take it again. All 7 of them unanimously agreed that taking it for the second time fully solidified their skills and improved their comfort level in managing obstetrical emergencies. They were even able to apply skills to several cases that presented on the ward, and several reported doing vacuum-assisted deliveries successfully for patients who previously would have been taken for cesarean sections. During the course of the entire PEER grant, in addition to trainings mentioned above the UMass team also implemented Basic Life Support (BLS) training with the help of UMass/ Family Health Center of Worcester Global Health fellow Dr. Duy Nguyen, who traveled to ELWA in 2021 to conduct BLS training and provide mannequins and materials for ongoing learning.  Another capacity building highlight of the project was the visit of key Liberian partner Dr. David Okiror to the United States in the spring of 2023 to present at the Society of Teachers of Family Medicine annual conference with Dr. Rick Sacra of SIM/ELWA and Dr. Olga Valdman of UMass, after which he spent one week visiting the UMass Family Medicine Department. The bilateral exchange of ideas and practices and the collaboration that has developed between two sister Family Medicine training programs have been powerful and will continue to bear fruit for the trainees for both programs. In summing up the impacts of this five-year effort, PI Dr. Olga Valdman notes that despite any challenges and ups and downs, this investment has been transformational to the health system and to specialty training in Liberia: “Although we know that this grant was an anomaly for PEER, which traditionally funds and supports research initiatives, we want to applaud USAID for investing in medical education at the specialty level. Family Physicians trained through this grant both as clinicians and researchers will now be leaders across the country leading primary care teams and setting up standards and processes, and the impact of this investment will have many ripple effects to come.” Back to PEER Liberia Grant Recipients