“Over the Shoulder” Training: Impact on the Experience of Local Iraqi Physicians

Abstract

On January 7, 2011, I traded my catheterization lab uniform for body armor and a helmet, and went on my way to support US operations in Iraq as a medical officer. Upon my arrival to Forward Operating Base Prosperity in the International Zone in Baghdad, Iraq, I realized our mission goes beyond treating combat wounds and extends into reconstruction efforts. The “Over the Shoulder” (OTS) program is a joint effort between the Department of Defense and the State Department that allows newly graduating Iraqi physicians to rotate in the Ortiz Clinic to gain knowledge in clinical operations involved in managing a clinic, along with a condensed course in acute trauma care. The Iraqi physicians underwent 2 weeks of condensed training where they learned the basics of clinic flow, from front desk operations to nursing duties and provider responsibilities, as well as the concept of delegation. This was followed by another week of education on trauma care with airway management, peripheral and central intravenous access, x-ray, basic advanced trauma life support, and interventions to include the use of ultrasound, concepts that many of them had been taught in classes but never practiced.1 During my tour, I created 2 tests to assess medical knowledge and clinical operations to optimize the Iraqi physicians' experience as they rotated through the Ortiz Clinic. At the end of the 2 weeks of rotation, both tests were repeated to assess the impact of the program. The average test scores for the medical knowledge section rose from 36% before the course to 84% after the course, and the clinical operation test scores rose from 50% to 76%. In addition, I created a website account with links to American and European medical societies as an electronic resource for evidence-based medicine. Although the impact of the OTS program might be limited to the sample of providers able to attend the course, the benefits may extend beyond this group to other young Iraqi physicians seeking guidance, if the effort is locally maintained. Although the observations I gleaned in Iraq are not scientific, they helped me to identify an array of issues the Iraqi health care and medical education system faces today. First, absence of Iraqi senior physicians to mentor the graduating physicians has led to a lack of consensus about medical practice and the Iraqi standard of care. Most senior Iraqi physicians have fled the country or died, either during the oppressive period of Saddam's regime or during the turmoil of the last decade. The absence of up-to-date electronic and textbook clinical resources as well as senior mentorship is negatively impacting the practice of medicine in Iraq.2,3 The Iraqi medical educational system mirrors the British system, where providers are selected based on grades into medical schools. Graduates then serve in rural areas to compensate the nation for the cost of their education. Discussions with junior physicians rotating through the OTS program revealed that when they are covering rural areas, they provide care to a large volume of population at high risk. And, unlike what we are accustomed to in the United States, they perform this work with little or no support staff, pharmaceuticals, or equipment.3,4 In the coming months and years, collaborative efforts by the United States and other nations could assist in the development of a health care infrastructure in Iraq as the security environment in Iraq improves. Efforts could focus on: Maintaining the OTS program; Sponsoring US/international provider visits to secure hospitals for brief periods to train Iraqi physicians; Establishing registered nurse, licensed vocational nurse, and paramedic educational institutions with similar outlooks and responsibilities as in the United States and in European nations. Establishing these schools will reduce the burden of patient management from the physician and allow for clear delegation of authority; Starting a dialogue between the American/European-based and Iraqi-based medical societies to assess long-term medical education needs in Iraq; Providing short hospital administration courses to existing middle management personnel to improve efficiency in obtaining and maintaining inventories. In my tour in the International Zone in Baghdad, I had the honor of working with men and women from Iraq and the United States who are dedicated to rebuilding the Iraqi health care system. Throughout the ages, the medical profession has stepped up to the challenge and helped health care systems in need. I have no doubt there are providers, institutions, and societies reading this article who may be planning their next contribution to this noble cause. These efforts also honor the sacrifices of soldiers who fought and died for the cause of spreading democracy. Although Iraq remains in the infancy stages of democracy and rebuilding, the courage and dedication I saw in the Iraqi health providers fill me with a sense of hope and accomplishment.