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

Background 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). Methods 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. Findings 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. Interpretation 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. Funding CanHealth International and philanthropic contributions.