Background The COVID-19 pandemic has escalated the use of telemedicine in both high and low resource settings however its use has preceded this, particularly in conflict-affected settings. Several countries in the WHO Eastern Mediterranean (EMR) region are affected by complex, protracted crises. Though telemedicine has been used in such settings, there has been no comprehensive assessment of what interventions are used, their efficacy, barriers, or current research gaps. Main body A systematic search of ten academic databases and 3 grey literature sources from January 1st 2000 to December 31st 2020 was completed, identifying telemedicine interventions in select EMR conflict-affected settings and relevant enablers and barriers to their implementation. Included articles reported on telemedicine use in six conflict-affected EMR countries (or territories) graded as WHO Health Emergencies: Afghanistan, Gaza, Iraq, Libya, Syria and Yemen. Data were extracted and narratively synthesised due to heterogeneity in study design and outcomes. Of 3419 articles identified, twenty-one peer-reviewed and three grey literature sources met the inclusion criteria. We analysed these by context, intervention, and evaluation. Context: eight related to Afghanistan, eight to Syria and seven to Iraq with one each in Yemen and Gaza. Most were implemented by humanitarian or academic organisations with projects mostly initiated in the United States or Europe and mostly by physicians. The in-country links were mostly health professionals rather than patients seeking specialist inputs for specialities not locally available. Interventions: these included both SAF (store and forward) and RT (real-time) with a range of specialities represented including radiology, histopathology, dermatology, mental health, and intensive care. Evaluation: most papers were observational or descriptive with few describing quality measures of interventions. Conclusions Telemedicine interventions are feasible in conflict-affected settings in EMR using low-cost, accessible technologies. However, few implemented interventions reported on evaluation strategies or had these built in. The ad hoc nature of some of the interventions, which relied on volunteers without sustained financial or academic investment, could pose challenges to quality and sustainability. There was little exploration of confidentiality, ethical standards, data storage or local healthcare worker and patient acceptability.
We read with interest Shields's article 1 that evaluated the impact of teaching attendings how to ask their colleagues questions during bedside rounds. The authors stated that this had the potential to increase the engagement of multidisciplinary team members and learning opportunities. These are qualities that can be lacking in rounds, as shown in research and our personal experiences. 2 However, we would like to discuss how overly broad aims made it unclear who would benefit from the intervention and how they would benefit, thus reducing the study's clinical relevance.The study objectives seemingly focused on improving clinical teaching during bedside rounds by teaching attendings to ask more questions. However, we would argue that each group of participants gains different information from rounds. For example, residents may desire teaching on diagnostic strategies, while nurses aim to advocate for patients, and patients might want their condition explained in layman's terms. 3 The article assessed the number and type of questions asked by attendings and to whom they were directed, but it was not clear whether attendings were taught to adapt their questioning style to each participant group. The study's "question, listen, respond" conceptual framework encourages teachers to assess students' responses (listen) and tailor their next question to improve learning (respond). 4 The findings of the study potentially support our argument. Nurses and patients rated how "engaging" and "worthwhile" rounds were and no significant differences between the experimental and control groups were reported. Meanwhile, residents in the experimental group rated the rounds significantly higher. 1 In future research, the authors could consider using the audio-visual recordings of rounds to assess the appropriateness of attendings' questions to the role of each team member.We also believe that the authors could have evaluated participant's perception of how the round was "worthwhile" or "engaging", to offer insight into which part of the intervention was efficacious and identify confounding factors. Participants' satisfaction may not be due to the increased number or type of questions alone, but how the questions were asked, such as the attendings' use of body language or appropriateness of the topic.
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