A competency-based digital medical education model in conflict-affected settings.

Abstract

Medical education in conflict-affected settings faces severe barriers, including collapsed infrastructure, faculty shortages, and sex-based exclusion. This study evaluated first-term learning outcomes among Afghan female medical trainees whose university education was interrupted following restrictions on women's access to higher education. Most participants resided in Afghanistan, with a minority in neighbouring countries. The Canadian Virtual Medical University Initiative (CVMUI) delivers a fully online, competency-based curriculum aligned with Entrustable Professional Activities (EPAs). We implemented a multi-system, pre-internship digital curriculum spanning five EPAs (cardiovascular, respiratory, gastrointestinal, musculoskeletal, and central nervous systems). Lecturio provided theoretical instruction, and CyberPatient enabled simulation-based clinical training. The study was conducted from November 2024 to July 2025 at a single virtual site (CVMUI). Ninety-two Level I-II female students who had previously been enrolled in medical school in Afghanistan were recruited; inclusion criteria were English proficiency (TOEFL iBT ≥70), reliable internet access, and commitment ≥15 h/week. The main outcomes were changes in knowledge (multiple-choice questions) and clinical skills (virtual Objective Structured Clinical Examinations) measured pre- and post-training. Secondary outcomes included student satisfaction and curriculum quality. Analyses used Shapiro-Wilk tests for normality, paired t-tests or Wilcoxon tests, and effect sizes. Level I students demonstrated significant knowledge gains across all systems (mean increases +52 to +58 points; p < 0.0001). Level II students showed substantial improvements in knowledge, clinical performance, and total scores (mean differences 57-62 points; large effect sizes). More than 90% of participants rated learning objectives, feedback, and educational climate as very good or excellent. Convergent findings across knowledge, skills, and satisfaction supported strong construct validity and alignment with prior pilot data. A fully digital, simulation-enabled, competency-based model can deliver high-quality pre-internship medical education in conflict-affected settings, offering a scalable and equitable pathway for women excluded from traditional training. Future work should examine integration of this model into national and international credentialing frameworks. CanHealth International and philanthropic contributions.