One of my objectives here is to expand qualitative research skills in the Family Medicine Department and at the medical school. A degree in medicine involves three years of undergraduate work and three years of graduate work. Candidates must complete some kind of research project. Professors are biased toward quantitative research, so there is lots of room for growth in the qualitative realm.

One year of internship follows medical school. During that time, graduates rotate through surgery, medicine, obstetrics, and pediatrics at a hospital. After that they have a license to practice medicine as a general practitioner (GP). GPs have little experience in the outpatient setting and are bio-medically focused. As a result doctors prescribe lots of medicine, do little assessing for depression, and make lots of referrals to specialists. No continuing medical education is required. You have your MD and you are free to be hired in the refugee camps, the ministry of health, hospitals or go into private practice. This approach burdens the system and results in problematic and out of date patient care.

Typical specialties include medicine, pediatrics, gynecology/obstetrics, surgery, etc. Family Medicine (FM) as a specialty was introduced here in 2011. It is the only specialty (other than psychiatry) that looks at psycho social issues, and the only one that focuses on evidence based medicine. FM as a specialty is young in the Arab countries compared with the US and UK, where FM just turned 50 and is almost 70, respectively. FM in Lebanon was established 37 years ago and 20+ years ago in Jordan. Family Medicine is a 4 year specialty in Palestine, with the first two years focused in the hospital and the final two in the outpatient settings. Weekly lectures are done at the university. Residents must complete a fairly comprehensive research project. Forward thinking faculty, want to grow qualitative work here. That's where I come in.

Family Medicine lends itself to qualitative research because much of what we do is talk to patients, so interviewing is a well honed skill. Two of the 4th year residents, Drs. A and T are examining barriers to getting the recommended ophthalmic exam to screen for retinopathy (damage to the eyes due to diabetes which can be treated and should be monitored). After a 2 hour session for residents and faculty about how to run a focus group, with two opportunities for facilitating a group and using their questions with colleagues, Drs. A and T were ready to go. The retinopathy exam is not available at the Tulkarem Ministry of Health (MOH) clinic, so Drs. A and T hypothesized that patients weren't getting it because they didn't want to pay to see a private physician or go to a nearby city to get the exam at another MOH facility, a 30-45 minute drive.

Six to eight participants is the ideal number for a focus group. Dr. T invited 10 patients from her clinic in Tulkarem, expecting some to not come. She facilitated the group, and Dr. A took notes. They engaged an undergrad studying laboratory medicine to help as well. She had just completed a study for Harvard about cervical cancer awareness by interviewing women in public places like on the street, at mosques, etc. I met the three of them at a restaurant so the residents didn't need to secure permission from MOH to do the focus group--too much red tape.

I hired a taxi to take me to Tulkarem, to wait and take me back to Nablus. Tulkarem is a mainly agricultural community with a population of 50,000. It has a rich history dating back to the 1100s when it was ruled by Sunni Muslims who kept the Crusaders out. Ottoman rule followed, then the British Mandate, then Jordan after WW1, and now it is part of the occupied Palestinian Territories. (Occupied by Israel.) A refugee camp, settled by refugees from the Haifa and northern Israel coastal area adds 10,000 more to the population. During the Second Intifada (2000-2007) Tulkarem was a site of attack and the city was sometimes closed to entry and exit. Tulkarem is less than 10 miles from the Mediterranean Sea, but residents cannot visit.

Participants were already gathering outside the restaurant when I arrived. The restaurant brought out a carafe of Arabic coffee and tiny paper cups. One participant had lived in Saudi Arabia and still wore the full face veil. She carefully lifted it to sip her coffee. All the patients who were invited showed up. (I never had that happen in the US.) One patient even brought a friend who was a diabetic, so he was included. There was also a midwife, a clinic nurse, and a policeman among others. All the women covered their hair. The prevalence of Diabetes in the Palestinian population is high in the range of 15.3% compared to a worldwide prevalence of 6%, and nearly 9% in the US.

We gathered in a back room for the focus group. Dr. T did a lovely job of facilitating the group, describing the ground rules and managing interruptions which grew as the group got comfortable. Dr. A and the lab student recorded the session on their phones and took notes. Dr. T drew out a quiet man who was making notes on a small notebook he kept in his pocket. We learned later he was writing down questions about his own health and medications, which she needed to deflect until the group was over. I don't speak Arabic, but I had a good sense of what happened by watching conversation flow and body language. The group lasted just over an hour. Patients lingered to ask additional questions and one asked Drs. A and T to look at his feet. In true Palestinian style, Dr. T invited me to a celebratory lunch. Relationships and food are top priorities. And in true American style, I had to decline because I had another commitment. Oh well.

I debriefed with Drs. T, A and the lab student. They were most surprised that fear of bad results kept patients from getting the test. But they have only completed the first group. The next one is schedule later this week and I will attend. It fills my heart to see my training efforts put to such good use and to have such eager learners.