A framework for the identification of competencies required from Syrian pulmonologists during COVID-19 pandemic

Competency-based medical education (CBME) embraces several challenges for physician training worldwide and has the potential to alter contemporary medical education (1,2). It has been considered as a priority approach that should be implemented to overcome the COVID-19 pandemic (3,4). The traditional framework that begins with the question “what do pulmonologists need to know about COVID-19?” should be modified to the question “what cognitive, skill, and attitude competencies are required by pulmonologists to face COVID-19?”

Pulmonary medicine is considered one of the most critical specializations in medicine and society, since respiratory diseases represent the largest percentage that affect humans (5). Moreover, during COVID-19 pandemic, pulmonologists were at the frontline in the battle against the virus and were directly exposed to infection hazards (6).

It is clear that pulmonologists should be appropriately prepared to ensure that all necessary preventive and protective measures are taken to maximize occupational safety and minimize health risks (7). In addition, they should be properly trained to provide the best health care during assessment, treatment, and following up. Pulmonologists should also be successful role performers, since they must possess performance abilities that allow them to operate across a broad range of situations over an extended period of time (8).

In this regard, a systematic framework of competencies should be designed in which the observable abilities of pulmonologists, integrating multiple components such as knowledge, skills and attitudes could be identified.

Therefore, the aim of this research was using Delphi methodology to identify the basic competencies required for pulmonologists to face Covid-19 within the local settings of the Syrian Arab Republic.

This study was undertaken to identify a list of essential competencies required from pulmonologists in order to offer the best health care for patients with respiratory diseases including COVID-19 using Delphi technique. The ethical approval was obtained from the ethical committee at the Syrian Virtual University (Number 211710, dated 22/09/2020). In addition, informed consent was obtained from all participants in the focus group. This research was designed and reported according to Conducting and Reporting Delphi Studies (CREDES) guidelines (9). After obtaining the ethical approval, a descriptive and qualitative study was conducted. The study included a survey, which was designed based on a review of medical literature and a consultation of a group of experts in the field of pulmonology in the health sector in Syrian Arab Republic.

To formulate a preliminary list of basic competencies for pulmonologist, a focus group method was employed. The focus group included five pulmonologist consultants who accepted to participate in this research virtually using Zoom platform.

Consultants were asked to identify competencies required for pulmonologists after explaining about the aim of the study. The discussion resulted in 92 items, which were documented and categorized into cognitive, skills and attitude domains.

Then, Delphi methodology, through three cycles, was implemented in the second step of the process to identify essential competencies required from pulmonologists to face COVID-19. Pulmonologists who were affiliated with the Syrian Association of Thoracic Medicine and Surgery of a minimum of 5 years of experience and who have practiced as pulmonologists in Syrian hospitals during the peak of COVID-19 pandemic from 2020 to 2021 were considered experts and invited to be part of the expert panel. A 110 pulmonologists, who met the expert panel criteria, were invited by the principal investigator MS to participate in this study. However, only 67 pulmonologist accepted the invitation. The response rate was 61%.

In the first cycle of Delphi, a specific questionnaire was designed using google forms and distributed through social media. The questionnaire included introduction about the aim of study together with explanation about the privacy policy that the research team will follow in order to ensure the confidentiality of participant’s data. In addition, the questionnaire included the preliminary list that was suggested by focus group. Participants were asked to evaluate each competency using a 5 point Likert scale according to its importance from 0 to 5 as following (Not important at all, Not important, Neutral, Important, Very important). In addition, an empty field was added at the end of the questionnaire for participants to suggest important competencies that were not reported in the preliminary list.

The second Delphi’s cycle questionnaire contained a summary of results extracted in the first cycle and the modified list of competencies according to experts’ suggestions. Similarly, participants were asked to evaluate each competency. A minimum mean value of 2.5 or more was considered the essential for each competency to move to the third and final cycle of Delphi’s technique. In the third cycle, the obtained competencies from the second cycle were sent again to all participants for re-evaluation using the previously described method.. Competencies suggested by at least 80% of experts were included in the final list. The data were analyzed using IBM SPSS Statistical Package, the reliability of the survey was tested through Cronbach’s Alpha, Descriptive statistics including Mean of the answers to know the trend of the answer based on Likert Scale and standard deviation to know homogeneity of answers.

The number of pulmonologists who accepted to be part in the expert panel was 67 out of 110(61%). A total of 46 competencies were suggested by the focus group including 10 items in the cognitive domain, 15 skills and 21 competencies in the attitude domains.

In the first Delphi’s cycle questionnaire, the experts panel suggested five additional competencies in the cognitive domain (n=1), 1 was added to the skills domain and 3 were added to the attitude domain.

In the second Delphi cycle, answers mean of all competencies suggested by focus group and experts panel exceed the threshold to qualify for the third cycle (Mean value ≥ 2.5).

In the final cycle of Delphi technique, most of the answers were considered items either important or very important, and with a small standard deviation, which indicates the homogeneity of the answers and their convergence to their arithmetic mean.

However, as stated earlier, only competencies with the mean > 4.21 (80%), which corresponds to (very important) was adopted as an accepted competencies to be in the final core list, and all competencies whose mean was < 4.21 were excluded (Table 1).

As shown in Table 2, the final list of essential competencies required from pulmonologists in order to offer the best health care for patients with respiratory diseases including COVID-19 using Delphi technique contained 45 items and were distributed as following: 10 related to cognitive domain, 11 related to skills domain and 24 related to attitude domain.

This research was undertaken to identify “Cognitive”, “Skills” and “Attitude” competencies, which are the basis of creating a generation of specialists in Pulmonology with a high level of competence to meet the needs of patients with pulmonary diseases such as COVID-19 and to take personal and community measures to fight the pandemic. The identification of competencies would be helpful to design integrated training programs of high standards that can recruit more qualified pulmonologists to cover the lack of pulmonologists in most governmental medical institutions (10).

Based on competency –based medical education, several studies have identified the essential competencies required from the health professionals in order to approach patients with COVID-19 (11–14).

Essential clinical skills and training are insufficient and not based on modern medical education. Thus, it is important to improve the quality of education and training and to design a structured integrated educational and training program capable of bridging educational gaps (15). The Delphi Technique is well-thought-out as one of the most valuable techniques for identifying competencies in medical education (16,17). It has several advantages over other decision-making methods, since it facilitates ownership and increases acceptance of the generated consensus rather than possible bias developed by dominant individuals (18,19).

This study have employed two research methodologies including a focus group method to generate a preliminary list of competencies and the Delphi technique method with 3 cycles to refine and complete the preliminary competency list as recommended by previous studies (20–22). The highest score for the cognitive competencies was the clinical signs and symptoms of respiratory diseases, which emphasizes the need for the pulmonologist to have a broad theoretical knowledge of the basics of chest diseases.

For skill competencies the highest score was for the clinical examination, this can confirm the importance of this competency for a pulmonologist to provide diagnoses of chest diseases, such as COVID-19.

The collected data showed that the continuous learning and studying about respiratory diseases, including COVID-19 were the most important attitude competency, as this competency can increase the knowledge of pulmonologists and enhance their ability to follow up patients during illness, recovery and rehabilitation. The response rate to the survey was 100%, which can indicate that every participant of the surveyed pulmonologists believe in the importance of developing training for residents in pulmonology, as COVID-19 pandemic has shown a significant impact on clinical and theoretical training in the field pulmonology and respiratory infectious diseases. The participant’s perspectives have shown that all of the attitude competencies were very important. Previous work has reported negative attitude towards providing health care to patients with SARS-CoV-2 infection and thoughts it was ethical to refuse care to patients with COVID-19. However, they also indicated that health workers might change their attitude due to improved knowledge about transmission and increasing availability of treatment over time (23).

Researchers addressed the need for protecting health workers by providing services and interventions to enhance physical safety and lower burnout risk (24).

The findings of this study have emphasized the need of equipping pulmonologists with attitude competencies to enable them to provide patients with pulmonology diseases with the best health care.

In conclusion, a list of 45 competencies has been identified. It is hoped that they will guide and enable pulmonologists to provide the best health care to patients with respiratory infections, especially during the COVID-19 pandemic. It will also guide decision makers to design training programs that can address these competencies.