Introduction

I learned the anatomy of the brachial plexus in three rooms. In the first, an anatomy hall with good light and a glass-doored cabinet of bone, the nerves traced themselves obediently on the cadaver while a professor named each one. In the second, my bedroom, where a drone held a steady note above the city while I tried to memorise the same nerves from a computer screen. In the third, on a road between two checkpoints, I revised the same anatomy from my iPad while waiting to continue the journey.

Each room produced a student. None produced the student the curriculum had in mind.

What the curriculum had in mind was presence. Modern medical education, for all its competencies and rubrics, still rests on an older intuition: that a clinician is formed at the bedside, in the company of patients and doctors, through repetitions of looking, listening, touching, speaking, and being observed in return. The ritual of the physical examination is one of the few rituals our profession has not surrendered. Generations of students have inherited it as one inherits a language, by living among speakers. Experiential learning and clerkship-based education remain central to the formation of clinical competence and professional identity. ^{Reference Yardley, Teunissen and Dornan1,Reference Dornan, Tan and Boshuizen2} To train in a place where the bedside is sometimes unreachable is to discover, slowly, what that inheritance depends on.

This perspective reflects my experience of learning medicine and later practising it as a young doctor in Palestine. I have written it with deliberate restraint. The aim is not to assign blame but to make a particular educational reality legible to colleagues who, I trust, would want to know.

Part I. Learning medicine as a student

When I graduated from high school, only a limited number of universities in the West Bank offered medical education. Studying abroad was theoretically possible, but in practice, it was not a viable option. I was eighteen years old, the only child in my family, and neither my parents nor I felt comfortable with the idea of leaving home and moving to another country. As a result, I enrolled in the nearest medical school available to me, even though it was more than fifty kilometres from my hometown.

To continue my studies, I had to relocate and rent accommodation near the university. Looking back, that was the beginning of a journey very different from what many people imagine medical school to be. Because of movement restrictions, reaching the university often required passing through multiple checkpoints. The university itself was located close to the separation barrier and did not have its own teaching hospital. Instead, students completed clinical training in hospitals located across different cities. As we progressed through medical school, we frequently changed accommodation and adapted to new environments depending on where our training was assigned.

Conflict was not a distant background to education; it was part of everyday life. There were days when we attended lectures in the morning and later saw tear gas reaching the university grounds. There were nights when we went to sleep expecting an ordinary day ahead and woke up to gunfire or nearby military activity. A hospital that the day before had received people one knew, or people connected to friends and family, could be the hospital in which a rotation was held the next morning. These were not exceptional weeks on which one could base the instability of a whole period. They became normal things: the material circumstances of education rather than its interruption.

At the same time, the ordinary demands of medical education continued. There were examinations, long hours of studying, clinical assessments, and the constant pressure to perform well. An exam could take place after a night in which the city had not had time to sleep. A lecture could be delivered through a learning management syste’m because a road had closed. The disruption was not only a loss of contact hours. It was the loss of a particular kind of attention.

The bedside functions almost like a stage: it guides what the student can notice. The patient’s breathing, the touch of a hand, the way a family member stands at the foot of the bed, and the silences before a difficult answer—these are pieces of information that clinical training quietly absorbs. They do not come fully through a camera. During the COVID-19 pandemic, medical schools across the world learned that online teaching could preserve parts of the curriculum but could not replace the embodied, relational, and practical dimensions of clinical training. ^{Reference Rose3,Reference Khalil, Mansour and Fadda4} In a conflict-affected setting, emergency remote learning was not a temporary preference but one more layer added to an already interrupted education.

The psychological consequences were often less visible. Cognitive load theory helps explain why learning under chronic stress may become less efficient: working memory is limited, and stress competes for the same mental space needed for comprehension and retention. ^{Reference Sweller5} In practice, this meant that pages had to be read again and again, lectures watched twice, and material that might have taken one hour in ordinary circumstances could take three. Attention changed from a natural state of mind into a task of constant control and direction. One learns the characteristic tiredness of having read but not absorbed and learns to reserve time for it.

Marks and transcripts can hide this. Some students compensate by over-exerting themselves, and assessment records were never designed to show the conditions under which learning took place. The records may show nothing exceptional. The learning behind them, however, may have been extraordinary. Medical students everywhere experience anxiety, fatigue, and the familiar shadows of impostor syndrome; these are well documented. ^{Reference Dyrbye, Thomas and Shanafelt6} What was added here was a sustained background sense that the conditions of one’s life were not under one’s control.

The clinical detachment we are trained to cultivate becomes difficult to locate when the patients one is learning to care for are increasingly hard to distinguish from one’s neighbours, relatives, or oneself. The literature on moral distress, moral injury, and healthcare work in conflict-affected settings offers language for experiences that are otherwise difficult to name. ^{Reference Williamson, Murphy and Greenberg7,Reference Bou-Karroum, El-Harakeh and Kassamany8} We read it with the unsettled gratitude of people who recognise themselves in print.

The situation became even more challenging in October 2023, when the war in Gaza began during the early months of my final year of medical school. Clinical training was temporarily suspended, and uncertainty became part of daily life. Even after training resumed, transportation became increasingly difficult. Roads were frequently closed, checkpoints multiplied, and travel times increased dramatically. Because I live in a village, reaching my training hospital required passing through several checkpoints and navigating repeated road closures. A journey that should have been straightforward could take hours.

The war affected not only training but also the milestones that many students anticipate with pride. My graduation class never had the opportunity to celebrate with a graduation ceremony. This may seem insignificant compared with the larger events occurring around us, but it reflected a broader reality: many personal and professional milestones were overshadowed by circumstances beyond our control.

This should not be treated as a virtue. To claim that hardship teaches what comfortable situations cannot is a way of comforting the reader and flattering the writer at the same time. The cost of these years was real and uncompensated. Yet, it would also be untruthful to remain silent about the ways the experience changed me. One who has waited at a checkpoint to attend a lecture sees access to healthcare differently from someone who has only read about social determinants of health. One who has prepared for an examination amid unrest may understand non-adherence, delay and fear differently. These are not lessons I would have chosen in this form. Nevertheless, they are elements of the doctor I am becoming.

Isolation from the broader medical student experience was among the least visible costs. International conferences, exchanges, electives abroad, and even informal participation in global student networks became difficult or, at intervals, impossible. We read the same journals as our peers, about competency-based curricula, simulation centres, and interprofessional learning, and sometimes felt as though we were reading dispatches from a profession to which we belonged only partly. This is not a grievance. It is a description of a gap that the global academic community could narrow, if it chose to.

From student to doctor

I first learned what it meant for the bedside to be unreachable as a medical student. I learned it again, differently, after graduation.

Part II. Practising medicine as a young doctor

Graduation did not bring immediate stability. Due to the large number of medical graduates and the limited capacity of training hospitals, I waited seven months before starting my internship. The number of hospitals approved for training is limited, and available resources often struggle to accommodate the growing number of graduates. This created another period of uncertainty at a time when many young doctors are eager to begin building their careers.

During my internship, I became increasingly aware of the challenges facing healthcare workers beyond medical education itself. Hospitals operated under significant pressure, with limited resources and healthcare systems under sustained strain. On several occasions, hospitals were subjected to military raids, and members of the medical staff were arrested. Attacks on healthcare and restrictions affecting healthcare delivery have been repeatedly documented in conflict settings, including the occupied Palestinian territory. ^9–11 These events reminded me that healthcare facilities and workers do not always operate in protected environments.

One experience remains particularly memorable. While accompanying a patient during an ambulance transfer to another hospital, the ambulance was stopped, and our journey was delayed at a checkpoint. For healthcare workers, time is often one of the most valuable therapeutic resources available. Experiencing a delay while transporting a patient made clear how external forces can directly affect medical care. The bedside was no longer only something I could not always reach as a student. It was also something my patient could not always reach as quickly as they needed.

After completing my internship, I faced another challenge familiar to many young Palestinian doctors: the lack of available residency programmes and employment opportunities. In order to continue learning and gaining experience, I volunteered in a cardiology department. Although it was unpaid, the responsibilities were similar to those of employed physicians. My duties included morning rounds, patient documentation, case presentations, echocardiography, emergency department coverage, ward responsibilities, coronary care unit duties, and on-call shifts. I worked approximately seven hours per day, five days per week, without financial compensation.

Despite these difficulties, my time in cardiology became one of the most meaningful periods of my training. I was also the only female physician in the department. Throughout my medical education and clinical training, I rarely encountered women working in cardiology. The limited visibility of women in cardiology is not unique to my setting and has been described internationally as one factor influencing specialty choice and career progression. ^{Reference Douglas, Rzeszut and Bairey Merz12} This reality sometimes made the specialty seem even more difficult to pursue, but it also strengthened my determination.

During internship and elective rotations, I developed a genuine passion for cardiology. What began as an academic interest gradually became a professional goal. Conflict, uncertainty, delayed training, limited opportunities, and financial challenges all created obstacles along the way. However, these experiences did not diminish my commitment to medicine. If anything, they reinforced it.

There is also a longing produced by isolation. I seek out every opportunity I can and would seize any chance to train beyond these borders, in the wards and laboratories of those who teach the discipline best. I want to be precise about what such a wish is and is not. It is not a wish to leave. I pursue the best of medicine elsewhere as an expression of attachment to this place rather than a retreat from it. I look for the finest mentors I can reach because I hope to return to my country and offer what they gave. To bring expertise home, to carry it back across a checkpoint, is, I have come to believe, its own quiet form of care.

What the academic community could do

If isolation is one of the hidden costs of medical education in conflict-affected settings, academic connection is one possible response. At minimum, academic continuity should be treated as part of humanitarian responsibility in protracted crises, alongside the more visible needs of food, water, shelter, and medical supplies. Education in emergencies frameworks emphasise that learning is not a luxury postponed until stability returns but a protective and developmental need. ^13,14

For medical education, this could mean flexible accommodations in international examinations and residency pathways for students whose transcripts reflect involuntary interruption. It could mean remote mentorship that is not merely symbolic, elective opportunities designed for students who cannot easily travel, and partnerships that allow teaching, supervision, and research participation to continue despite mobility restrictions. It also requires an academic practice: referencing, studying, and interacting with the educational output of these environments, rather than viewing them only as local or political problems. The global health and conflict medicine literature has expanded over the past decade, but the discussion about medical education in these scenarios remains comparatively limited. ^{9,Reference Alhaffar and Janos15}