Postgraduate medical education in fragile conflict-affected settings: A scoping review

Postgraduate medical education (PGME) is a vital pillar of health system resilience, yet it faces catastrophic disruption in Fragile Conflict-Affected settings. This review maps the fragmented body of evidence (current practices, challenges, quality indicators, and accreditation mechanisms), synthesizes insights, and highlights research and policy gaps within PGME programs in these environments. This scoping review was guided by Arksey & O'Malley, Levac et al., and PRISMA-ScR methodological frameworks. A comprehensive search was run across academic databases with additional searches of relevant organizational websites, and library catalogues to uncover grey literature. Elicit (AI) was used as a complementary search tool. The search included studies published between January 2015 and August 2025. Thematic analysis was applied to synthesize the evidence. Of 252 unique records identified, 32 met the inclusion criteria. In terms of geographical location, the countries most frequently reported on were Syria and Ukraine, with the majority of studies taking place over the last three years. Four primary themes were identified: Current Practices and Adaptations, Challenges, Quality and Accreditation, and Innovations and Resilience. Studies and reports from Syria, Ukraine, and Sudan highlighted divergent adaptive pathways, from institutional resilience and frontline training to severe fragmentation and reliance on external support. Consistently, the body of literature is scarce due to systemic barriers (brain drain, research destruction, ethical hurdles). Quality and accreditation emerged as the weakest pillar, often relying on subjective evaluations. PGME in FCA settings demonstrates adaptability through innovations like virtual curricula and diaspora partnerships, yet it is characterized by fragmented evidence and a critical lack of quality assurance. Six recommendations are proposed, focused on institutionalizing resilience models, strengthening program legitimacy through hybrid, internationally benchmarked accreditation [World Federation for Medical Education and Accreditation Council for Graduate Medical Education standards], and integrating mental health and peacebuilding competencies to ensure long-term health system recovery and stability.