Graduate Medical Education in Lebanon: Challenges, Support, and Adaptation Amid the Compounding Crises.

Introduction: Graduate Medical Education (GME) systems often face disruptions. In Lebanon, repeated crises over the past several years, including political instability, economic collapse, the COVID-19 pandemic, and military conflict, raise questions about institutional support, clinical residents' preparedness, and the resilience of the GME system. This study aims to examine clinical residents' perceived preparedness and competency at graduation, the challenges they faced during compounding national crises, and how training institutions supported them and adapted GME to maintain training and well-being. Methods: In June 2024, we conducted a cross-sectional survey of graduating clinical residents including fellows and residents, in a large academic medical center in Lebanon. Thirteen questions were developed by a group of program directors from different specialties. Quantitative data assessed residents' self-perceived preparedness across six ACGME core competencies. In parallel, qualitative data explored the challenges residents faced, institutional interventions, and residents' recommendations. Descriptive statistics were used to analyze quantitative data. Qualitative analysis of open-ended survey responses was guided by Maslow's Hierarchy of Needs to understand residents' challenges, while inductive thematic analysis was used to synthesize the institutional strategies. Results: 127 of 133 (95%) residents and fellows across a wide range of specialties, including medical-surgical specialties, completed the survey. Despite ongoing training disruptions, most residents felt well-prepared in core competencies, including 67% for patient care, 54% for medical knowledge, 57% for systems-based practice, 69% for communication skills, 72% for professionalism, and 61% for Practice-Based Learning and Improvement. Open-ended responses revealed that the crises provided opportunities for residents to develop their skills in the systems-based practice competency domain. Five themes on residents' challenges emerged: meeting basic needs, ensuring well-being, maintaining family and social life, fostering professional growth and clinical experience, and fulfilling career aspirations. Institutional strategies, particularly through the provision of essential financial support, structured emotional and psychological support programs, faculty and program leadership social support, sustained career support and supervision amid crisis, and career mentorship and support, helped maintain continuity in resident training despite severe challenges. Some challenges were beyond the institution's resources and control. Discussion: The unique resilience of Lebanese GME programs despite multiple external disruptions highlights the strengths and vulnerabilities of institutional support systems. While the study identified several significant challenges faced by residents and fellows, it underscored the importance of prioritizing their well-being, fostering a supportive learning environment, and developing crisis-relevant competencies to ensure the continued success of medical education in the face of future challenges.