Rheumatology capacity building: implementing a rheumatology curriculum for Liberian health-care providers in 2016

Abstract

Introduction

Liberia has no rheumatology providers for the nation’s 4.7 million people. We proposed a short course format rheumatology curriculum to educate Liberian providers as an initial step in providing graduate medical education in musculoskeletal health.

Method

A 1-week training curriculum in rheumatology encompassing introduction to musculoskeletal exam and approach to rheumatology diagnosis and management was designed. The curriculum used multiple education methods including interactive lectures, bedside training, and hands-on learning.

Results

A 1-week rheumatology training curriculum for 24 local physicians was feasible. The execution of the designed rheumatology curriculum in Liberia relied upon a mixed method format that was both didactic and case-based. A survey of the Liberian trainees revealed that the curriculum was salient to care of patients and barriers to optimal learning such as time and space limitations were identified.

Conclusions

A 1-week rheumatology training education program is possible and relevant to local providers, but training length and setting may need to be optimized. Future training will aim to minimize barriers to education and expand the cohort of providers with rheumatologic knowledge in Liberia.

Introduction

Access to graduate medical training in areas of resource scarcity is a barrier to meeting the needs of underserved patient populations [1]. Musculoskeletal health is neglected in much of sub-Saharan Africa in general, and West Africa in particular. The burden of rheumatic disease in sub-Saharan Africa is not known, but the World Health Organization determined rheumatic and musculoskeletal disease to be the second leading cause of disability worldwide [2]. The burden of musculoskeletal disease is large, setting the stage for health disparity.

Inequalities exist at many levels: for patients’ access to care, for providers’ access to training, research opportunities, and rheumatology referral services [3]. In sub-Saharan Africa (excluding South Africa), there are less than 20 rheumatologists serving 800 million people. The ideal physician to patient ratio has been defined as a minimum of 1 rheumatologist per 150,000 people [4]. In the USA, there is one rheumatologist for every 41,000 adults [5, 6]. In Liberia, no rheumatologist is available to serve the approximately 4.7 million people residing there, reflecting a nationwide physician shortage [7, 8]. In the wake of the Ebola virus disease epidemic of 2014–2016, the need for rheumatology access was clearly seen when nearly half of Ebola survivors and almost a quarter of non-Ebola controls complained of joint pain [9].

Because there are no physicians trained in rheumatology, the incidence and prevalence of rheumatic disease in this particular environment are not known. However, surveys (by trained rheumatologists) in other African countries suggest that disease prevalence matches or exceeds that of higher income nations [10]. The shortage of health-care providers trained to recognize and treat rheumatic disease is unlikely to be resolved without a concerted effort to collaborate with established programs that are endowed with adequate educational resources. One mechanism to address this is for indigenous health-care providers to undergo foreign medical training and then return to their country of origin [6]. Another mechanism is to offer expert seminars for local health-care providers. We aimed to leverage the support of the International League Against Rheumatism (ILAR) granting process in the setting of an existing clinical research site in Liberia to enhance rheumatology capacity-building in a low-income country through an on-site 1-week rheumatology training course. We conducted post-training evaluation of our educational outreach in order to assess effectiveness and relevance of the project.

Setting

The educational intervention occurred at the PREVAIL clinic at John F. Kennedy Medical Center in Monrovia, Liberia. The Partnership for Research on Ebola Virus in Liberia (PREVAIL) is a partnership between the US National Institutes of Health (NIH) and the Liberian Ministry of Health. Ebola virus disease (EVD) survivors reporting musculoskeletal complaints subsequent to recovering from the acute Ebola infection were evaluated by NIH rheumatologists. These EVD survivors were enrolled in the PREVAIL III Protocol [9] which is a natural history study of EVD survivors, their close contacts, and other controls. The study was approved by the institutional review boards of the National Institute of Allergy and Infectious Diseases and the Liberian National Research Ethics Board. All evaluated EVD survivors provided written informed consent. Support for the project was also provided by a grant from the ILAR. Finally, a project charter formalizing the collaborative effort was enacted between the PREVAIL clinic and the locally involved medical center.

Methods

Implementing graduate medical training in a non-Western setting risks alienation of learners if the voice, ideology, and cultural values of the learning group are not respected. Therefore, creating a curriculum within the framework of adult learning theory requires sensitivity to the issue of assumptions behind hegemonic knowledge. To this end, we relied upon an internal document developed by the Liberia Postgraduate College of Physicians and Surgeons (publication date 3/20/2013) entitled, “Harmonized Internal Medicine” (Fig. 1). This document asserts the need to address the shortage of physicians in Liberia. It specifically highlights the need to train physicians to fill positions at all levels from regional hospitals to government hospitals. In addition to calling for improved access to health care for the population in general, the document further identifies the learner motivation, which is to ultimately join the ranks of the Liberia College of Physicians.

Fig. 1.

Document developed by the Liberian Postgraduate College of Physicians and Surgeons entitled “Harmonized Internal Medicine”

Based upon this exposition, we were able to develop a statement of need for our rheumatology curriculum. Specifically, the Liberian document identified core knowledge deficiencies including: (1) to improve knowledge in “Connective Tissue Disorders” and (2) to improve knowledge in “Disorders of Joints.” Examples of each of these core areas were included in the curriculum document. Systemic lupus erythematosus, rheumatoid arthritis, osteoarthritis, infectious arthritis, and gout were five such locally identified learning priorities.

The curriculum was then reviewed by the local rheumatology training team, including local Liberian physician leaders. Teleconferences between our teaching team and on-site physician leaders enable us to prioritize and refine the curriculum in advance of the rollout.

To address the educational priorities and needs outlined by the learners, the rheumatology curriculum objectives were designed to provide a framework for students to think clinically (Table 1). Curriculum development followed a learning-centered approach as detailed extensively elsewhere [12].

Table 1.

Rheumatology curriculum objectives for Liberia

Objectives

To recognize classic clinical presentations of rheumatological diseases

To formulate a differential diagnosis of common rheumatological symptoms and signs

To understand and interpret basic diagnostic testing

To identify the general prognosis for common diseases

To identify basic principles of treatment of common diseases of major organ systems

To recognize how organ function changes over the lifespan

To introduce joint arthrocentesis techniques and demonstrate on joint models [11]

On-site curriculum execution relied upon a mixed methods format that was both didactic and case-based. The three instructors were physicians trained in rheumatology and immunology. Two instructors had prior global health education experience in Monrovia, Liberia, prior to this initiative.

All physicians and medical monitors who provided care to individuals enrolled in the PREVAIL studies were invited to participate. Additionally, three recognized health facilities providing care to survivors were asked to send their physicians.

The main aim of the study was to implement the training. As a secondary aim, we assessed whether the implemented training was clear and useful to the learners. A formal questionnaire to assess the teaching session was administered to all Liberian health-care providers who attended the teaching session. In brief, the questionnaire included 11 questions which allowed learners to rate multiple components of the education session on a 5-point Likert scale ranging from “Strongly Disagree” (score = 1) to “Strongly Agree” (score = 5) (Supplementary file 1) [13]. In addition, the questionnaire contained five write-in questions regarding learner’s opinions about the session. The questionnaire contained line items for learners to rate: (1) clarity of rheumatology instruction, (2) relevance of rheumatology education to their daily care of patients, (3) confidence in the ability to diagnose and manage basic rheumatology disease, (4) knowledge gained resulted in clinically useful changes in practice, and (5) assessment of allotted time and space to teach the objectives defined in core rheumatic disease knowledge. The surveys were completed anonymously to ensure learners could give honest evaluation of instruction. The ratings were entered into a database, and summary statistics were performed in R [14]. The write-in responses were aggregated and reviewed for major themes. Representative quotes for each theme identified were extracted from surveys. In this pilot 1-week training program, we did not have the resources or time to administer pre-training and post-training knowledge assessments to the trainees.

Results

The instructors provided a 1-week rheumatology training course to 24 health-care providers in Liberia. The course covered all topics outlined in the curriculum and was modified iteratively based on the pace and interest of learners in the training environment. The course was offered for 2 sequential weeks to allow for some providers to attend, while others attended to community clinical needs. Challenges to implementation of the curriculum are summarized in Table 2 and Fig. 2. A formal curriculum was presented which covered topics such as musculoskeletal exam, acute and chronic arthritis, rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, and approach to joint aspiration and injection. The trainees were provided with handouts of lecture material and web links to rheumatology education resources, although many of the learners did not have consistent access to the Internet [15]. The didactics were interactive lecture format with PowerPoint visual aids [16]. The didactics were complemented with bedside education of musculoskeletal examination of EVD survivors with musculoskeletal symptoms. The visits took place in the PREVAIL III clinic located at JFK Hospital in Monrovia, Liberia. The ratio of instructor to learner was 1:6 for bedside training. Each learner had multiple opportunities to observe and perform a joint exam alongside a trainer. Each learner had the opportunity to document relevant findings under guidance of a rheumatologist. The clinic sessions were 30–45 min per patient, depending on complexity of the case. Additionally, a half-day session was dedicated each week for practicing arthrocentesis with model joints of the shoulder and knee (Figs. 2 and 3).

Table 2.

Challenges to rheumatology training in Liberia

Challenges

Limited time for teaching

Lack of space in patient care areas which allow for both focused didactics and proximity to patient care areas for case-based instruction

Timely and consistent patient scheduling for case-based or hands-on teaching

Lack of access to diagnostic tools (X-ray, ultrasound, MRI)

Lack of access to medications

Lack of local expert consultant or teleconsultant to provide ongoing case-based education

Absence of rheumatology trained physicians in the country creates a lack of exposure to rheumatology for trainees at every level of training

Lack of access to physical therapy services

Fig. 2.

Planned curriculum, challenges, and revised curriculum

Fig. 3.

Joint injection training with Liberian health-care providers using model joints

The questionnaire responses which assessed quality and utility of our 1-week rheumatology training program demonstrated that learners felt that the training was of high quality and very useful for daily practice (Table 3).

Table 3.

Health-care provider questionnaire response rating summary

Response rating using a Likert scalea
Questionnaire item	Mean rating	Minimum rating
Objectives were clear	4.9	4
Participation was invited and encouraged	4.9	4
Topics covered were relevant to me	5	5
Materials distributed were relevant to me	4.4	3
Content was organized/easy to follow	4.5	4
Trainers were knowledgeable about topics	4.9	4
Trainers were prepared	4.7	4
Training objectives were met	4.5	4
Time allotted was sufficient	3.9	2
Meeting room and facilities were adequate/comfortable	4.2	3

Discussion

In order to ensure non-Western hegemonic “educational priorities,” our statement of need for the curriculum was generated by relying upon the voice of the Liberian Postgraduate College of Physicians and Surgeons in a document entitled, “Harmonizing Internal Medicine.” To meet the needs of the learners, the curriculum was informed by the delineation of core knowledge deficiencies identified by this document. This, in turn, enabled us to generate a statement of goals (curriculum objectives). Ultimately, implementation of the curriculum emphasized clinical presentation, differential diagnosis, initial diagnostic testing, and the basics of treatment. Information about patient education was necessarily included. The learners all felt that the training was of good quality, with mean ratings related to clarity of objectives and trainer knowledge all at levels greater than 4.5 (correlating with Agree or Strongly Agree on the survey).

The rheumatology curriculum was found to be highly relevant in this training environment because course relevance was the only question item to garner a unanimous rating of 5 on the questionnaire. On the other hand, the trainees felt that the course was too short. A question about sufficient time allotment of the course was the only item to score a 2 (Disagree). Moreover, this concern was also highlighted as a theme in the write-in responses. Additionally, although our mixed methods teaching model allowed for formal didactics as well as case-based learning at the bedside, we were hampered in that the lecture space was neither quiet nor of adequate size for the trainees. A theme related to the inadequacy of space that impeded trainees’ ability to learn emerged in the written questionnaire (Table 4).

Table 4.

Representative quotes from rheumatology curriculum learners

Topic	Representative quote
Relevance of training	“I highly appreciate this opportunity. Rheumatology assessment and training is a topic I know little about. I recommend expansion/future training”
	“This training will be very helpful [be]cause this is one of our common cases”
Inappropriate setting for didactic instruction	“I humbly request that these sorts of training be held in a noise-free environment”
Best aspect of training	“The training was interactive, practical and participatory”
Need for more resources	“Training needs to improve availability of diagnostic materials”
	“Diagnostic tools should be available”
Need for further training	“More time should be allotted [for training]”
	“The training needs to be more than a week. At least of month of [such] training is adequate”
	“This training was remarkable and interesting. I hope there will be room for consultation or link in case of doubt for future rheumatologic assessment”
	“I recommend a yearly refresher training in this discipline”

Our effort presented herein demonstrates that applying con-temporary adult education theory to a resource-poor nation requires an understanding of how learning is shaped by the sociocultural environment. For example, restricted access to technology forced us to relocate learning from the walls of an educational institution to a real-world learning society. By embedding the learning in the PREVAIL clinical structure, we were able to address demographic restrictions on access to learning. In essence, we leveraged the combined strengths of two governments with a unified aim. Consequently, the learning occurred in a hybrid setting, namely, the learning occurred both in a formal setting and a nonformal setting. This is because the clinic, itself, was the classroom. In this manner, the learning was also able to remain sensitive to indigenous culture. This has been termed “work-based” learning [17]. Our team wanted to engage with our learners through a few different teaching modalities. We chose a formal lecture to introduce approach to rheumatology diagnosis and introduce basic concepts of disease [16]. Although this was a formal lecture, we deliberately included intermittent question and answer sessions, as interactive lectures can increase interest and improve the learning experience for the teacher and trainee [18]. We paired these lectures with bedside assessment of Ebola disease survivors in smaller groups (six trainees per instructor). This allows for trainees to observe an integrated history and physical exam and model rheumatology physical exam skills on patients with musculoskeletal symptoms [19, 20]. Bedside patient-based training can improve learner engagement through active learning and also impart expertise of rheumatology specialists outside of the lecture format [21]. In addition, we employed a small group joint injection training session. This session consisted of four to six trainees per instructor and used model knee and shoulder joints with real-time feedback of injection accuracy for the learner (Fig. 3). Such experiential learning can enhance the training experience for health-care providers [22]. Our project is one step down the path of capacity building in Liberia. The next step forward will entail implementing training that ultimately captures teamwork competencies [23].

The challenge of providing for specialty education for healthcare providers in a resource-poor setting with no rheumatology providers is difficult. It is likely that in order to redress this difficulty, a combination of educational options will be needed. This may include online courses, short on-site courses, longer off-site courses, and links to consultants via telehealth [24]. Limited Internet access will continue to be a barrier to e-learning in this setting. Through our pilot experience, we learned that any such teaching modality will have to be refined based upon feedback so that future sessions are designed optimally to enhance trainee experiences. Some of the frustrations expressed by the learners included the lack of diagnostic tools for rheumatologic cases, especially access to plain X-ray.

Unfortunately, access to X-ray equipment and interpretation was beyond the resources of the current training program. In the future, on-site bedside musculoskeletal ultrasound training may be a cost-effective compromise to help overcome this limitation [25]. Ongoing support will be needed to sustain this initiative.

Securing sustainable funding for international education rheumatology initiatives is a challenge. Other subspecialties in Liberia have had success finding academic institution collaborators in high-income nations [26, 27]. Building healthcare capacity in a low-income nation involves education. A program to improve orthopedic capacity in Haiti successfully combined education with infrastructure development during the stages of disaster relief. By forming a partnership between nongovernmental organizations and local health-care providers, an educational program was able to improve capacity while passing along skills most relevant to the local patient population [28]. Other nations in sub-Saharan Africa have employed different methods to address the rheumatology health-care gap [29]. In Kenya, the UWEZO project was developed as a collaboration between Kenyan health-care system, the UK, and Sweden. In this model, both physicians and patients participate in a short course musculoskeletal health “train the trainer” program. Such a course aims to develop a group of health-care professionals and patients with rheumatology skills to identify rheumatology diagnoses and train others in the community [30]. In Ethiopia, a nonprofit organization, Rheumatology for All [31], provides funding for physicians to travel to South Africa for a 2-year rheumatology fellowship training [32]. These physicians will then return to provide rheumatology care. Similarly, the ILAR East Africa program has grown the number of rheumatologists in Kenya from two to six, which includes the first pediatric rheumatology provider in the region [33]. Such initiatives improve capacity but require funding and a long-term commitment to the region. We will consider various funding options for ongoing rheumatology education and collaboration including institutional training partnerships, private foundations, and additional ILAR funding.

Our study had other limitations. We did not approach all medical facilities in Liberia to send medical providers to the training, and we acknowledge that some of the EVD survivors seek care in areas more accessible to them than the three recognized health facilities surveyed. We did not have the resources to administer pre-training and post-training rheumatology knowledge assessments to our trainees. Such metrics will be critical to add to future sessions to measure the impact of the training on the attitudes, knowledge, and practice of medical providers in Liberia. We did not formally assess Internet access among our trainees, but Internet access has been a barrier to graduate medical education in Liberia [34]. Dedicated assessment of Internet and computer access will be an important component of future curriculum development in this setting.

In summary, we demonstrated that a short course rheumatology curriculum is feasible and relevant to health-care providers in Liberia. Fundamental logistics such as space, teaching supplies, case-based scheduling, and assessment modalities continue to pose significant challenges to the implementation of on-site specialty training in a resource-poor setting.

Key Points.

• Liberia, like many nations in sub-Saharan Africa, has no trained rheumatologists to serve the nation’s population.

• Education and capacity building for rheumatologic care in short course format are relevant and feasible to local health-care providers.

• Further efforts are needed to develop and evaluate continuing rheumatology education in Liberia.