Abstract
Introduction
Syria’s health system is rebuilding after prolonged conflict, workforce attrition, and disruption of emergency care. Evidence on emergency preparedness among hospital-based resident physicians remains limited. This study assessed emergency exposure, self-perceived procedural competence, resource availability, and factors associated with competence among resident physicians in selected Syrian governmental hospitals.
Methods
A cross-sectional survey was conducted from 1 to 23 April 2026 among 368 resident physicians working in governmental hospitals, mainly in Damascus and Rif Damascus, Homs, and Lattakia. A structured Arabic questionnaire adapted from a previously published instrument assessed professional characteristics, emergency training and exposure, self-perceived competence, resource availability, and satisfaction. Multivariable linear regression identified factors independently associated with the total competence score.
Results
Emergency exposure was frequent, while self-perceived competence varied by procedure. Confidence was highest for nebulization and oxygen therapy, cardiac compression, and bag-and-mask ventilation, and lowest for defibrillation. Basic resources such as cannulas, oxygen masks, laboratory services, and X-ray services were widely available, whereas glucagon, equipped ambulances, Ventolin, morphine, and Ambu bags were less consistently available. Male sex, prior Advanced Trauma Life Support (ATLS) attendance, and 1–2 years of emergency department experience were independently associated with higher competence scores, while surgical/anesthesiology and pediatrics/obstetrics and gynecology/other specialty groups had lower scores than medical specialties. Ministry of Health hospitals had significantly higher resource availability scores than university teaching hospitals across all three resource domains.
Conclusion
Among resident physicians in the studied governmental hospitals, emergency exposure was frequent but preparedness was uneven. Strengthening emergency readiness will require standardized practical training, objective skill assessment, and more consistent availability of essential emergency resources and referral support.
Keywords: emergency preparedness, resident physicians, self-perceived competence, resource availability, Syria, health system recovery
Introduction
Physicians working outside dedicated emergency departments may still encounter acute, time-critical conditions that require immediate recognition and stabilization. In northwestern Germany, 95.7% of primary care physicians reported at least one emergency in the preceding year, with a mean of 12.9 emergencies per physician.1 Similarly, 3,033 life-threatening emergency calls originated from primary care offices in Ottawa over a three-year period.2 Frequent exposure to emergencies makes preparedness clinically important: appropriate response depends not only on knowledge, but also on practical skills, access to essential medications and equipment, and reliable referral or transport pathways.
Preparedness gaps have been documented across diverse health systems. In the United States, pediatric office emergency preparedness remained suboptimal in a multicenter simulation-based study,3 while work from Bihar, India identified resource shortages, infrastructure limitations, and organizational barriers affecting emergency obstetric and neonatal care.4 Regional studies from Saudi Arabia and Palestine have similarly reported limitations in emergency equipment and medications, advanced life-support training, exposure to emergency cases, ambulance availability, and referral capacity.5–8 Although much of this literature originates from primary healthcare settings, it provides relevant contextual evidence regarding the training and resource requirements of physicians who may be required to provide first-line stabilization. The present study, however, specifically concerns hospital-based resident physicians and should be interpreted within that population.
Syria’s healthcare system has experienced prolonged disruption from conflict, political fragmentation, workforce loss, damaged infrastructure, unstable financing, and inequities in access to care.9,10 As the country enters a period of health-system recovery, understanding the preparedness of early-career physicians who frequently rotate through acute-care and emergency settings is particularly important. Comparable evidence among resident physicians in Syrian governmental hospitals remains scarce. Therefore, this study aimed to assess emergency-case exposure, self-perceived procedural competence, emergency resource availability, satisfaction with emergency services, and factors independently associated with competence among resident physicians working in selected governmental hospitals in Syria.
Methods
Study Design and Participants
This cross-sectional study was conducted from 1 to 23 April 2026 among resident physicians working in governmental hospitals, primarily in Damascus and Rif Damascus, Homs, and Lattakia, with a small number of participants from other governorates. Residents from all training years were eligible if they were actively involved in direct patient care during the study period, completed the key survey variables, and provided voluntary informed consent. Physicians not involved in direct patient care and those who declined participation were excluded. The questionnaire was distributed electronically through Google Forms and as printed copies. Participation was voluntary and anonymous, no identifying personal information was collected, and completion took approximately 8–12 minutes.
Ethical approval was obtained from the Scientific Research Ethics Committee at Homs University (Approval ID: MD10426-3).
Questionnaire and Measures
Data were collected using a structured, self-administered questionnaire administered in Arabic and adapted from the previously published instrument by Hamshari et al.8 The source instrument was developed in a primary healthcare context; in the present study, it was used to assess emergency preparedness among hospital-based resident physicians. The adapted questionnaire was piloted before the main data collection to assess clarity and feasibility, and no substantive revisions were required following pilot testing. The complete administered questionnaire, together with an English translation, is provided as Supplementary File S1.
The questionnaire captured sociodemographic and professional characteristics, including age, sex, marital status, residence, hospital governorate, hospital type, specialty, years of healthcare experience, years of emergency department (ED) experience, work in a private healthcare center after hours, previous attendance of Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), and Advanced Trauma Life Support (ATLS) courses, and previous exposure to emergency management through visual media. For analysis, specialties were grouped into medical specialties; surgical and anesthesiology specialties; and pediatrics, obstetrics and gynecology, and other specialties. Hospital governorate was grouped into Damascus and Rif Damascus, Homs, Lattakia, and other governorates.
Emergency exposure during the previous 12 months was assessed across 12 clinical conditions, with responses categorized as none, 1–2 cases, or more than 2 cases. For the present analysis, self-perceived procedural competence was summarized using eight items: cardiac compression, bag-and-mask ventilation, nebulization and oxygen therapy, IV cannula insertion, urinary catheter insertion, ECG interpretation, defibrillation, and simple suturing. Each item was rated on a four-level response scale coded from 0 (“I do not know where to start”) to 3 (“I will attempt in all cases”). Item scores were summed to generate a total competence score ranging from 0 to 24, with higher scores indicating greater self-perceived competence.
Resource availability was assessed using binary yes/no items grouped into three domains: equipment (15 items), drugs and intravenous fluids (16 items), and supporting facilities (3 items). Available resources were coded as 1 and unavailable resources as 0 and summed within each domain, with higher scores indicating greater reported resource availability. Participants also identified the most common barrier to emergency management. Satisfaction with emergency services was assessed separately for each clinical scenario using five response categories: not satisfied; satisfied, but equipment deficient; satisfied, but medications deficient; satisfied, but more staff training needed; and fully satisfied. Satisfaction items were analyzed individually rather than combined into a total score.
Statistical Analysis
All analyses were performed using SPSS version 26. Categorical variables were summarized as frequencies and percentages, while continuous variables were summarized as mean (standard deviation) or median (interquartile range), as appropriate to their distribution. Internal consistency of the eight-item self-perceived competence score was assessed using Cronbach’s alpha. Emergency-case exposure, individual competence items, resource availability, barriers, and satisfaction were summarized descriptively.
Resource availability domain scores were calculated by summing available items within each domain. Because these scores were not normally distributed, nonparametric tests were used for group comparisons. Mann–Whitney U-tests compared resource availability scores between Ministry of Health hospitals and university teaching hospitals, and Kruskal–Wallis tests compared scores across hospital governorates. When a Kruskal–Wallis test was statistically significant, pairwise post-hoc comparisons were performed with Bonferroni adjustment. For graphical presentation only, mean domain scores were expressed as percentages of the maximum possible score within each domain and displayed with 95% confidence intervals; all inferential tests were performed using the original summed scores.
For the main inferential analysis, multivariable linear regression was performed with the total competence score as the dependent variable. The model used the enter method and included sex, hospital type, prior BLS attendance, prior ACLS attendance, prior ATLS attendance, previous exposure to emergency management through visual media, hospital governorate, specialty group, and years of ED experience. Dummy coding was used for multicategory predictors; the reference categories were Homs for hospital governorate, medical specialties for specialty group, and less than 1 year for ED experience. Regression coefficients were reported as unstandardized coefficients (B), standard errors (SE), standardized coefficients (β), t values, p values, and 95% confidence intervals (CI). Multicollinearity was assessed using tolerance and variance inflation factor (VIF). A two-sided p value <0.05 was considered statistically significant.
Results
Participant Characteristics
A total of 368 resident physicians were included in the analysis. The median age was 26 years (IQR, 26–28). Slightly more than half were male (52.7%), most were currently unmarried (83.7%), and three-quarters resided in urban areas (75.8%). Nearly half belonged to medical specialties (46.2%), followed by surgical and anesthesiology specialties (27.2%) and pediatrics, obstetrics and gynecology, and other specialties (26.6%). Most participants worked in university teaching hospitals (62.2%), while 37.8% worked in Ministry of Health hospitals. Half had previously attended a BLS course (50.0%), while prior ACLS and ATLS attendance were reported by 36.4% and 18.5%, respectively. Equipment shortage was the most commonly reported barrier to managing an emergency case (58.2%), followed by a busy clinic (19.0%) (Table 1).
Table 1.
Sociodemographic and Professional Characteristics of the Study Participants (N = 368)
| Characteristic | n (%) or Median (IQR) |
|---|---|
| Sociodemographic characteristics | |
| Age, years | 26 (26–28) |
| Sex | |
| Female | 174 (47.3) |
| Male | 194 (52.7) |
| Marital status | |
| Currently unmarried | 308 (83.7) |
| Currently married | 60 (16.3) |
| Residence | |
| Urban | 279 (75.8) |
| Rural | 89 (24.2) |
| Hospital governorate | |
| Damascus and Rif Damascus | 163 (44.3) |
| Homs | 144 (39.1) |
| Latakia | 42 (11.4) |
| Other | 19 (5.2) |
| Professional characteristics | |
| Current specialty group | |
| Medical specialties | 170 (46.2) |
| Surgical and anesthesiology specialties | 100 (27.2) |
| Pediatrics, obstetrics and gynecology, and other specialties | 98 (26.6) |
| Hospital type | |
| University teaching hospitals | 229 (62.2) |
| Ministry of Health hospitals | 139 (37.8) |
| Years of experience in healthcare | |
| <1 year | 143 (38.9) |
| 1-5 years | 225 (61.1) |
| Years of experience in the emergency department | |
| <1 year | 183 (49.7) |
| 1-2 years | 123 (33.4) |
| >2 years | 62 (16.8) |
| Working in a private healthcare center after hours | |
| Yes | 50 (13.6) |
| No | 318 (86.4) |
| Training and prior exposure | |
| Previous Basic Life Support (BLS) course attendance | |
| Yes | 184 (50.0) |
| No | 184 (50.0) |
| Previous Advanced Cardiovascular Life Support (ACLS) course attendance | |
| Yes | 134 (36.4) |
| No | 234 (63.6) |
| Previous Advanced Trauma Life Support (ATLS) course attendance | |
| Yes | 68 (18.5) |
| No | 300 (81.5) |
| Previous exposure to emergency management through visual media | |
| Yes | 260 (70.7) |
| No | 108 (29.3) |
| Most common barrier to managing an emergency case | |
| Equipment shortage | 214 (58.2) |
| Busy clinic | 70 (19.0) |
| Limited exposure to emergency cases | 55 (14.9) |
| Difficulty reaching the hospital during emergencies | 29 (7.9) |
Notes: Data are presented as n (%) unless otherwise indicated. Age is summarized as median (IQR) because the distribution was non-normal. Bold text denotes column headings and section labels.
Abbreviations: IQR, interquartile range; BLS, Basic Life Support; ACLS, Advanced Cardiovascular Life Support; ATLS, Advanced Trauma Life Support.
Frequency of Emergency Cases Encountered
Exposure to emergency cases was substantial across several conditions. More than half of participants reported encountering more than two cases during the previous 12 months for cardiac arrest (62.8%), diabetic ketoacidosis (62.8%), convulsions (60.6%), renal colic (59.2%), hypoglycemia (58.2%), acute asthma (56.3%), and myocardial infarction (55.7%). In contrast, acute vaginal bleeding was relatively uncommon, with 77.2% of physicians reporting no such cases during the preceding year (Table 2).
Table 2.
Frequency of Emergency Cases Encountered in the Past 12 Months
| Emergency Case | None | 1–2 Cases | >2 Cases |
|---|---|---|---|
| Acute asthma | 87 (23.6) | 74 (20.1) | 207 (56.3) |
| Myocardial infarction | 83 (22.6) | 80 (21.7) | 205 (55.7) |
| Angina pectoris | 113 (30.7) | 80 (21.7) | 175 (47.6) |
| Cardiac arrest | 57 (15.5) | 80 (21.7) | 231 (62.8) |
| Severe dehydration | 72 (19.6) | 103 (28.0) | 193 (52.4) |
| Renal colic | 80 (21.7) | 70 (19.0) | 218 (59.2) |
| Hypoglycemia | 55 (14.9) | 99 (26.9) | 214 (58.2) |
| Diabetic ketoacidosis | 63 (17.1) | 74 (20.1) | 231 (62.8) |
| Acute gastrointestinal bleeding | 79 (21.5) | 107 (29.1) | 182 (49.5) |
| Acute vaginal bleeding | 284 (77.2) | 47 (12.8) | 37 (10.1) |
| Anaphylaxis | 71 (19.3) | 127 (34.5) | 170 (46.2) |
| Convulsions | 55 (14.9) | 90 (24.5) | 223 (60.6) |
Notes: Data are presented as n (%). Percentages are calculated using the total study sample as the denominator (N = 368). Bold text denotes column headings.
Self-Perceived Competence and Resource Availability
Self-perceived competence varied according to the procedure assessed. The highest proportion of physicians who reported that they would attempt the procedure in all cases was observed for nebulization and oxygen therapy (70.7%), followed by cardiac compression (59.5%) and bag-and-mask ventilation (58.4%). By contrast, only 28.3% reported that they would attempt defibrillation in all cases, while 30.4% indicated that they did not know where to start. The median total competence score was 16 (IQR, 13–20), and the eight-item score demonstrated acceptable internal consistency (Cronbach’s α = 0.775) (Table 3).
Table 3.
Self-Perceived Competence in Performing Selected Emergency Procedures Among Study Participants (N = 368)
| Emergency Procedure | I Do Not Know Where to Start n (%) | I Will Do It Only if No One Else is Available n (%) | I Will Attempt in Most Cases n (%) | I Will Attempt in All Cases n (%) |
|---|---|---|---|---|
| Cardiac compression | 16 (4.3) | 48 (13.0) | 85 (23.1) | 219 (59.5) |
| Bag-and-mask ventilation | 29 (7.9) | 46 (12.5) | 78 (21.2) | 215 (58.4) |
| Nebulization and oxygen therapy | 21 (5.7) | 30 (8.2) | 57 (15.5) | 260 (70.7) |
| IV cannula insertion | 23 (6.3) | 102 (27.7) | 75 (20.4) | 168 (45.7) |
| Urinary catheter insertion | 89 (24.2) | 91 (24.7) | 56 (15.2) | 132 (35.9) |
| ECG interpretation | 72 (19.6) | 69 (18.8) | 75 (20.4) | 152 (41.3) |
| Defibrillation | 112 (30.4) | 78 (21.2) | 74 (20.1) | 104 (28.3) |
| Simple suturing | 77 (20.9) | 84 (22.8) | 51 (13.9) | 156 (42.4) |
| Total competence score, median (IQR) | 16 (13–20) | |||
Note: Bold text denotes column headings and the summary-score label.
Abbreviations: ECG, electrocardiogram; IV, intravenous; IQR, interquartile range.
Resource availability showed a mixed pattern. Several basic items were widely available, including cannulas (95.9%), laboratory services (94.8%), oxygen masks (94.0%), and X-ray services (92.4%). In contrast, some key resources were considerably less available, particularly glucagon (24.2%), side lamps with stands (32.3%), equipped ambulances (37.0%), Ventolin (37.8%), morphine (38.3%), and Ambu bags (41.6%) (Table 4).
Table 4.
Availability of Equipment, Medications, and Supporting Facilities for Emergency Care
| Item | Available, n (%) |
|---|---|
| Equipment | |
| Cannula | 353 (95.9) |
| IV stand | 321 (87.2) |
| Urinary catheter | 332 (90.2) |
| Dressing tray | 259 (70.4) |
| Side lamp with stand | 119 (32.3) |
| Splint | 216 (58.7) |
| Scissors | 293 (79.6) |
| Suture kit | 275 (74.7) |
| Ambu bag | 153 (41.6) |
| Nebulizer | 327 (88.9) |
| Oxygen cylinder with standard fitting | 217 (59.0) |
| Airway equipment | 272 (73.9) |
| Oxygen mask | 346 (94.0) |
| Defibrillator | 292 (79.3) |
| Suction apparatus | 211 (57.3) |
| Drugs and IV Fluids | |
| Sublingual nitrate | 230 (62.5) |
| Glucagon | 89 (24.2) |
| Aspirin | 247 (67.1) |
| Furosemide | 264 (71.7) |
| Morphine | 141 (38.3) |
| Metoclopramide | 265 (72.0) |
| Diazepam | 246 (66.8) |
| Ventolin | 139 (37.8) |
| Hyoscine | 187 (50.8) |
| Normal saline | 275 (74.7) |
| Ringer lactate | 273 (74.2) |
| Dextrose (5%, 10%, or 50%) | 307 (83.4) |
| Adrenaline injection | 301 (81.8) |
| Antihistamine injection | 258 (70.1) |
| Calcium chloride injection | 190 (51.6) |
| Hydrocortisone injection | 272 (73.9) |
| Supporting Facilities | |
| X-ray | 340 (92.4) |
| Laboratory | 349 (94.8) |
| Equipped ambulance | 136 (37.0) |
Notes: Data are presented as n (%). intravenous. Bold text denotes column headings and resource-domain labels.
Abbreviation: IV, intravenous.
Satisfaction with Emergency Services
Satisfaction with emergency services differed according to the clinical scenario. The highest proportions of physicians who were fully satisfied were reported for hypoglycemia (46.7%), severe dehydration (42.4%), and anaphylaxis (38.0%). Full satisfaction was lowest for acute vaginal bleeding (8.7%) and acute gastrointestinal bleeding (14.4%). A need for additional staff training was reported most often for acute vaginal bleeding (38.0%), acute gastrointestinal bleeding (31.5%), and angina pectoris (30.4%) (Table 5).
Table 5.
Resident Physicians’ Satisfaction with Emergency Services Across Selected Emergency Conditions
| Emergency Case | Not Satisfied | Satisfied, But Equipment Deficient | Satisfied, But Medications Deficient | Satisfied, But More Staff Training Needed | Fully Satisfied |
|---|---|---|---|---|---|
| Acute asthma | 30 (8.2) | 64 (17.4) | 99 (26.9) | 69 (18.8) | 106 (28.8) |
| Angina pectoris | 43 (11.7) | 64 (17.4) | 84 (22.8) | 112 (30.4) | 65 (17.7) |
| Severe dehydration | 28 (7.6) | 33 (9.0) | 62 (16.8) | 89 (24.2) | 156 (42.4) |
| Renal colic | 22 (6.0) | 36 (9.8) | 83 (22.6) | 97 (26.4) | 130 (35.3) |
| Hypoglycemia | 21 (5.7) | 39 (10.6) | 67 (18.2) | 69 (18.8) | 172 (46.7) |
| Diabetic ketoacidosis | 28 (7.6) | 43 (11.7) | 83 (22.6) | 98 (26.6) | 116 (31.5) |
| Acute gastrointestinal bleeding | 72 (19.6) | 61 (16.6) | 66 (17.9) | 116 (31.5) | 53 (14.4) |
| Acute vaginal bleeding | 87 (23.6) | 56 (15.2) | 53 (14.4) | 140 (38.0) | 32 (8.7) |
| Anaphylaxis | 26 (7.1) | 29 (7.9) | 97 (26.4) | 76 (20.7) | 140 (38.0) |
| Convulsions | 31 (8.4) | 33 (9.0) | 113 (30.7) | 96 (26.1) | 95 (25.8) |
Notes: Data are presented as n (%). Bold text denotes column headings.
Factors Associated with the Total Competence Score
In multivariable linear regression, the overall model was statistically significant and explained a modest proportion of variability in the total competence score (R = 0.431, R2 = 0.186, adjusted R2 = 0.156, F =13,354 = 6.203, p < 0.001). Male sex was independently associated with a higher total competence score (B = 1.351, 95% CI 0.250 to 2.452, p = 0.016), as was prior ATLS attendance (B = 2.076, 95% CI 0.552 to 3.600, p = 0.008). Compared with medical specialties, lower competence scores were observed among physicians in surgical and anesthesiology specialties (B = −1.998, 95% CI −3.385 to −0.611, p = 0.005) and in pediatrics, obstetrics and gynecology, and other specialties (B = −3.775, 95% CI −5.144 to −2.406, p < 0.001). Having 1–2 years of ED experience was associated with a higher competence score compared with less than 1 year of ED experience (B = 1.651, 95% CI 0.506 to 2.796, p = 0.005), whereas more than 2 years of ED experience was not significantly associated with the outcome (Table 6).
Table 6.
Multivariable Linear Regression Analysis of Factors Associated with Total Competence Score
| Predictor | B | SE | β | t | p | 95% CI for B | Tolerance | VIF |
|---|---|---|---|---|---|---|---|---|
| Constant | 15.609 | 0.927 | 16.846 | <0.001 | 13.786 to 17.432 | |||
| Sex | 1.351 | 0.560 | 0.127 | 2.414 | 0.016 | 0.250 to 2.452 | 0.831 | 1.204 |
| Hospital type | −0.655 | 0.577 | −0.060 | −1.135 | 0.257 | −1.790 to 0.480 | 0.829 | 1.206 |
| Basic Life Support course | −0.097 | 0.676 | −0.009 | −0.144 | 0.886 | −1.426 to 1.232 | 0.567 | 1.763 |
| Advanced Cardiovascular Life Support course | 0.407 | 0.762 | 0.037 | 0.534 | 0.594 | −1.092 to 1.906 | 0.483 | 2.072 |
| Advanced Trauma Life Support course | 2.076 | 0.775 | 0.152 | 2.678 | 0.008 | 0.552 to 3.600 | 0.716 | 1.396 |
| Exposure to emergency management through visual media | 0.936 | 0.570 | 0.080 | 1.641 | 0.102 | −0.185 to 2.057 | 0.962 | 1.040 |
| Governorate: Damascus and Rif Damascus | −0.336 | 0.626 | −0.031 | −0.537 | 0.592 | −1.567 to 0.895 | 0.672 | 1.489 |
| Governorate: Lattakia | −0.265 | 0.915 | −0.016 | −0.290 | 0.772 | −2.065 to 1.535 | 0.767 | 1.304 |
| Governorate: Other | −1.441 | 1.243 | −0.060 | −1.159 | 0.247 | −3.886 to 1.004 | 0.857 | 1.167 |
| Specialty: Surgical and anesthesiology specialties | −1.998 | 0.705 | −0.167 | −2.834 | 0.005 | −3.385 to −0.611 | 0.659 | 1.516 |
| Specialty: Pediatrics, obstetrics and gynecology, and other specialties | −3.775 | 0.696 | −0.314 | −5.424 | <0.001 | −5.144 to −2.406 | 0.685 | 1.459 |
| ED experience: 1–2 years | 1.651 | 0.582 | 0.147 | 2.835 | 0.005 | 0.506 to 2.796 | 0.860 | 1.163 |
| ED experience: >2 years | 0.816 | 0.759 | 0.057 | 1.074 | 0.283 | −0.677 to 2.309 | 0.804 | 1.244 |
Notes: Dependent variable: total competence score. Multivariable linear regression model estimated using the enter method. Model summary: R = 0.431, R2 = 0.186, adjusted R2 = 0.156, F(13, 354) = 6.203, p < 0.001; standard error of the estimate = 4.886. Reference categories were Homs for governorate, medical specialties for specialty, and <1 year for emergency department (ED) experience. Bold text denotes column headings.
Abbreviations: B, unstandardized coefficient; β, standardized coefficient; CI, confidence interval; ED, emergency department; SE, standard error; VIF, variance inflation factor.
Resource Availability by Hospital Governorate and Hospital Type
Figures 1 and 2 display mean resource availability as the percentage of available items within each domain, with 95% confidence intervals. Across hospital governorates, the summed equipment availability score did not differ significantly, H(3) = 4.270, p = 0.234. Significant differences were observed for the summed drugs and IV fluids availability score, H(3) = 14.003, p = 0.003, and the summed supporting facilities availability score, H(3) = 40.089, p < 0.001. Bonferroni-adjusted post-hoc comparisons showed that Homs had significantly lower drugs and IV fluids availability scores than Damascus and Rif Damascus (adjusted p = 0.014) and Lattakia (adjusted p = 0.013). Homs also had significantly lower supporting facilities availability scores than Damascus and Rif Damascus (adjusted p < 0.001) and other governorates (adjusted p = 0.021).
Figure 1.
Resource availability according to hospital governorate. Bars represent the mean percentage of available items within each resource domain; error bars represent 95% confidence intervals.
Figure 2.
Resource availability according to hospital type. Bars represent the mean percentage of available items within each resource domain; error bars represent 95% confidence intervals.
Ministry of Health hospitals had significantly higher availability scores than university teaching hospitals across all three resource domains: equipment (U = 11,922.500, Z = −4.058, p < 0.001), drugs and IV fluids (U = 11,878.500, Z = −4.097, p < 0.001), and supporting facilities (U = 10,794.500, Z = −5.944, p < 0.001) (Figure 1 and 2).
Discussion
Study Context and Main Findings
This study was conducted in a health system that is still recovering after years of conflict, socioeconomic decline, population displacement, workforce losses, and disruption of essential services. WHO reported that urgent healthcare needs in Syria were expected to rise to 16.7 million people in 2025,11 while WHO EMRO reported that only 57% of hospitals and 37% of primary healthcare centers were fully operational, with shortages of supplies, outdated equipment, and damaged infrastructure continuing to strain service delivery.12 WHO describes emergency care as an integrated, time-sensitive platform involving recognition, early treatment, transport, and continued care at the appropriate level of the health system.13 Against this background, the present study evaluated emergency exposure, self-perceived procedural competence, resource availability, satisfaction, and predictors of competence among resident physicians in selected governmental hospitals.
The main analytical finding was that self-perceived competence was independently associated with ATLS attendance, specialty group, ED experience, and sex, whereas BLS and ACLS attendance were not independently associated with competence after adjustment. These findings suggest that perceived emergency competence in this sample was more closely related to professional context, emergency exposure, and possibly the type or intensity of training received than to life-support course attendance alone.
Training and Certification
Prior ATLS attendance was independently associated with a higher total competence score, while BLS and ACLS attendance were not. ATLS may reflect more practical, scenario-based, or hands-on emergency training, but it may also identify physicians who are more motivated, more exposed to emergencies, or more likely to work in settings where emergency skills are reinforced. This partly aligns with evidence from South Africa, where current advanced life-support certification was associated with higher self-perceived competence in emergency skills among specialist trainees.14 It also partly differs from Northern Palestine, where ACLS attendance and ED experience were associated with higher perceived competence among primary healthcare physicians.8 Differences may reflect course content and quality, recency of certification, reinforcement in clinical practice, or the specific procedures included in the respective competence measures.
Only half of participants reported previous BLS attendance. BLS/CPR certification is not currently a uniform mandatory requirement for resident physicians in Syria, which may partly explain this proportion. Given the high frequency of emergency exposure observed, however, the finding supports more systematic integration of standardized basic resuscitation training and regular refresher opportunities within residency programs.
Professional Context and Self-Perceived Competence
Specialty group was one of the strongest predictors of competence. Compared with medical specialties, surgical and anesthesiology specialties and the combined pediatrics, obstetrics and gynecology, and other specialties group had significantly lower adjusted competence scores. This may reflect differences in case mix, current clinical exposure, procedural opportunities, or self-assessment patterns. A South African study similarly found variation in self-perceived emergency competence across disciplines.14 However, the specialty categories in our analysis were broad, particularly the combined pediatrics, obstetrics and gynecology, and other specialties group; the finding should therefore not be interpreted as a precise ranking of individual specialties.
ED experience showed an important but non-linear pattern. Physicians with 1–2 years of ED experience had higher competence scores than those with less than 1 year, whereas more than 2 years of ED experience was not significantly associated with competence. Regional literature supports the general importance of emergency exposure: ED experience was associated with higher perceived competence in Northern Palestine,8 while lack of exposure to emergency cases was identified as a barrier among family physicians in Riyadh.7 The non-linear pattern in our study may reflect the smaller size of the more-than-2-year group, differences between current and past ED exposure, specialty-related confounding, or loss of rarely practiced skills without refresher training.
Male sex was independently associated with a higher total competence score. Because the outcome was self-perceived competence rather than objectively observed performance, this association should be interpreted cautiously. Broader medical education literature indicates that sex differences in self-assessment may partly reflect confidence and reporting patterns rather than actual differences in ability.15,16 The finding should therefore not be interpreted as evidence of superior clinical performance among male physicians.
Emergency Exposure and Preparedness Gaps
The adjusted competence findings are clinically important because emergency exposure was frequent. Although the sample was relatively young and nearly half had less than 1 year of ED experience, more than half of participants reported encountering more than two cases of cardiac arrest, diabetic ketoacidosis, convulsions, renal colic, hypoglycemia, acute asthma, and myocardial infarction during the preceding 12 months. Comparable concerns have been reported in Gaza, where level-four primary healthcare centers were expected to contribute to emergency response during repeated escalations despite incomplete provider and facility preparedness,17 and in Northern Palestine, where primary healthcare physicians functioned as first-contact providers during conflict-related disruption.8 Although these populations and settings differ from our hospital-based resident sample, they reinforce the broader need to maintain emergency readiness outside highly specialized emergency services.
The procedure-specific results identify important practical training gaps. Defibrillation was particularly concerning: only 28.3% of participants reported that they would attempt it in all cases, while 30.4% reported that they did not know where to start. This gap was present despite frequent reported exposure to cardiac arrest and reported defibrillator availability of 79.3%, suggesting that limited hands-on familiarity, supervised practice, or recurrent simulation may be more important explanations than simple absence of cases or equipment. A Spanish study of primary healthcare physicians similarly identified lack of practical skills as a prominent difficulty in emergency care.18
Scenario-specific training needs were also evident. Additional staff training was most frequently reported for acute vaginal bleeding (38.0%), acute gastrointestinal bleeding (31.5%), and angina pectoris (30.4%). These conditions require rapid recognition, stabilization, and escalation or referral, and may expose gaps in scenario-based training, coordination, and access to appropriate resources. Similar concerns regarding severe bleeding emergencies were reported in Northern Palestine.8
Physician competence alone is insufficient when essential resources are unavailable. Although several basic items were widely available, important emergency resources such as glucagon, Ventolin, morphine, Ambu bags, and equipped ambulances were less consistently available, and equipment shortage was the leading reported barrier. Recent community-based evidence from Homs also documented common medication-access problems associated with socioeconomic and geographic factors, underscoring broader post-war challenges in medicine affordability, supply continuity, and access to care.19 Similar resource constraints have been reported in Sudan during the war,20 in Addis Ababa health centers,21 and in Riyadh.7 These comparisons suggest that emergency resource gaps may involve selective absence of critical items rather than complete lack of basic supplies.
Resource availability also differed by institutional and geographic setting. Ministry of Health hospitals had significantly higher availability scores than university teaching hospitals across equipment, drugs and IV fluids, and supporting facilities. Governorate-level differences were observed for drugs and IV fluids and supporting facilities, with Homs showing lower availability in the significant post-hoc comparisons. These findings suggest that resource gaps are not uniformly distributed and may reflect differences in procurement pathways, administrative structure, service organization, supply chains, or referral capacity. A study from Northern Saudi Arabia similarly found that emergency preparedness varied according to facility characteristics.22 Standardized minimum emergency-readiness requirements may therefore help reduce variability between institutions and locations.
Implications
Emergency care strengthening should combine training, resource standardization, and system-level support. Training should extend beyond course attendance to repeated hands-on practice, simulation, and scenario-based refreshers, particularly for low-confidence skills such as defibrillation, ECG interpretation, airway support, catheterization, and suturing. Resource interventions should prioritize minimum emergency-readiness checklists that include essential medications, airway and ventilation equipment, functioning defibrillators, Ambu bags, oxygen delivery systems, and reliable referral or ambulance support. This is consistent with WHO’s framing of emergency care as an integrated, time-sensitive service platform.13
Strengths, Limitations, and Future Research
This study assessed emergency preparedness across multiple connected domains, including emergency exposure, self-perceived competence, resource availability, satisfaction, and predictors of competence, and included physicians from different hospital types and governorates. The multivariable analysis allowed adjustment for training history, specialty group, governorate, hospital type, sex, and ED experience. Several limitations should nevertheless be acknowledged. The cross-sectional design prevents causal inference. Competence was self-perceived and may not reflect objectively observed procedural skill. Resource availability was reported by participants rather than verified through direct facility inventory. Some specialty categories were broad and heterogeneous. The sample was concentrated in governmental hospitals mainly in Damascus and Rif Damascus, Homs, and Lattakia, with only a small number of participants from other governorates; the findings therefore should not be generalized to all Syrian physicians or healthcare settings. The “other governorates” subgroup was small, so resource comparisons involving this category should be interpreted cautiously. Finally, the adjusted model explained a modest proportion of competence variability, indicating that unmeasured factors such as course recency, workload, supervision, institutional protocols, and frequency of actual procedure performance may also be important.
Future studies should incorporate objective skill assessments, direct facility audits, and longitudinal or interventional designs. Such work could determine whether structured training improves retained competence, whether standardized resource checklists translate into better preparedness, and whether observed differences by sex, specialty, or ED experience correspond to differences in objectively measured performance.
Conclusion
Among resident physicians in the studied Syrian governmental hospitals, exposure to serious emergency cases was frequent but preparedness remained uneven. Self-perceived competence was independently associated with ATLS attendance, specialty group, ED experience, and sex, while BLS and ACLS attendance were not independently associated after adjustment. Procedure-specific competence gaps, inconsistent availability of critical resources, equipment shortage, and institutional and geographic variation in resource availability further indicate that emergency readiness depends on both workforce capability and system capacity. Practical and repeated training, objective skill assessment, standardized emergency resources, and stronger referral and support systems should be prioritized as the health system recovers.
Acknowledgment
We thank Mohammad Ghaleb Baddour (Faculty of Medicine, Latakia University, Latakia, Syrian Arab Republic) for his valuable contribution to data collection.
Funding Statement
The authors received no specific funding for this work.
Data Sharing Statement
De-identified data and analysis outputs are available from the corresponding author on reasonable request.
Ethical Approval and Consent to Participate
Ethical approval was obtained from the Scientific Research Ethics Committee at Homs University (Approval ID: MD10426-3). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki (1975, revised 2008). Participation was voluntary and anonymous. All participants provided informed consent prior to participation. For the online survey, consent was recorded through the mandatory first item; for paper forms, written consent was obtained. No identifying personal data were collected.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Consent for Publication
This study does not include the publication of any individual’s personal data, including images, videos, or other identifiable information. All data presented in this study are anonymized and aggregated, ensuring that no participant can be identified.
Disclosure
The authors declare that they have no competing interests.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
De-identified data and analysis outputs are available from the corresponding author on reasonable request.