Table 4 Themes and exemplary quotes from Group A’s chat discussions

1. Discussion content enabled the tutors to plan the next session from real time problems residents encountered in their clinics

M: “We want to talk about differential diagnosis, red flags and management. How to advise parents and how to reassure them as they are always anxious about their sibling.”

T: “The other case is about girls not walking straight ‘gait problems’.” (also sent a video of the child with limping gait)

M: “I was choosing a topic of headaches. There is luck here as headache as somewhat connection with anemia and connection in general with fatigue which has been discussed with us in previous tutorial.”

R: “I have two case discussion that I would like to share with you this Saturday. The first one is about a patient 8 year old coming with mild gastroenteritis

2. Building trust and relationships within the group

Continuing the above text from R about the 8 year old: “His mother asked for CBC (complete blood count). On physical exam patient was well, not pale. I asked the mother why she wants me to do a CBC she said because her son feels tired these days. I was against repeating CBC and told the mother that she needs to give him ORS and come again in two weeks for follow up and re-evaluate his tiredness. Mom came back in two weeks bringing her youngest daughter 6 months for vaccination but was referred to me for evaluation as she had bronchiolitis. When I started examining her daughter she told me in an angry way:

‘Do you remember when I asked you to do a CBC for my son and you refused !! I went to another doctor who did the CBC and he saw amoeba in his CBC.’”

R posed a question to the group: “What do you think so far about what happened and what to do next? PS: unfortunately I become upset.”

3. Sharing feelings openly in the group is also demonstrated in the above quote. Another example about a case seen after an earlier session included discussion of the topic:

T: “Good morning. Today I deal with another case of alopecia areata but now I was more comfortable and I felt with trust. Thanks our teachers.”

4. Seeking help and support from their peers became more frequent as the trust and relationships grew in the group and they started using their skills mix and asking for support from each other

Having discussed how to manage her father with poorly controlled blood pressure, polypharmacy and diabetes mellitus with the group in a tutorial session, M then sought the help from L, a fellow resident in the group who ran a diabetes clinic

M: “Good evening. Today my dad started basal insulin. He was so afraid of the needle. I brought him to the clinic and me and L gave him the injection and showed him how to take it. It was easy. He was happy that there is no pain with the needle. I will follow him closely

These sessions help me to organize my ideas in a systematic way. Gave me the courage to take decisions with confidence. And simplify the cases which I thought was hard. Thanks a lot.”

5. Evidence of the use of and interest in guidelines and patient education leaflets

M: “Thanks a lot for your effort everybody. Can we have a NICE guideline for anemia and fatigue. In order to print it and have it with us at the clinics.”

T shared a complicated case about a fever and concluded: “I send to her Arabic brochures about dealing with high fever.”

6. Feedback on the tutorial sessions

T: “The most important thing that changed is my personality. I was Very nervous when I deal with angry patients. Now I learned patience. Also I learned from the last session the case of M's dad, some art of medicine, how to deal with polypharmacy. I printed some of the important schemes for diagnosis and management diseases. Really we are lucky to join this group. Thanks a lot.”

L: “Good evening. Me and R will be on duty this Saturday…what about our session, we don't like to miss it.”