Simulation-based training: a solution to improve quality of care in Africa - Pr. Pierre Bey

“The first time is never on the patient”! This is a credo dear to Professor Pierre Bey. Through this interview, he reveals to us how and why simulated procedures allow us to learn better even in medicine. You can find it here👇

C3M : Can you introduce yourself in a few words?

Pr Bey: I am a professor emeritus (that is to say retired) of radiotherapy oncology at the University of Lorraine. I also held the responsibilities of hospital director.

I was director of the Center for the Fight Against Cancer in Nancy and director of the Institut Curie hospital in Paris.

Since my retirement, I have been very involved in actions to support the management of childhood cancer in Africa, French-speaking Africa and sub-Saharan Africa and specifically for one type of tumor: eye cancer.

I returned to live in Nancy two and a half years ago and was asked to become administrator of the virtual hospital of Lorraine (HVL).

The HVL is an economic interest group that practices training through simulated medical procedures in health.

This virtual hospital is a pooling of resources from the University of Lorraine, the Faculty of Medicine, the Nancy University Hospital and the Lorraine Cancer Institute.

C3M : What is simulated procedure training in the healthcare sector? A rather broad topic…

Pr Bey: This answers to a need that the Haute Autorité de Santé (HAS) in France has clearly expressed.

It concerns both the initial training of health staff and ongoing training.

The concept is simple: “The first time: never on the patient”!

This is how e-training through simulated procedures was invented.

Traditionally in medicine, we learn by mentorship, in contact with elders, masters.

They exhibit theory and practice. We are with them at the beginning in contact with patients and gradually, we are released to be alone with the patients.

The HAS therefore created this notion of "replacing the patient with something that imitates him".

It can be mannequins, robots, or scenarios.

This is what we do in the HVL.

We, therefore, have a learning process that takes place through scenarios.

The student or health professional who comes to us for ongoing education is put in a situation.

We study how he behaves in this situation. Then, we debrief with him to see everything that has been done correctly and provide areas for improvement.

We are therefore in an atmosphere that is completely "de-stressed". We no longer have to worry about the patient.

For example, when you are a student and you perform an invasive procedure such as a spinal tap, it is a weighty procedure, unpleasant for both the patient and the practitioner ...

Learning this procedure on a mannequin changes everything.

The student repeats this procedure. Then we decipher review what has been done correctly and what needs to be reworked.

As it turns out, much of the learning in medicine can be done in this manner.

This concept is duplicated all the way down to the relationship with the patient!

Concretely, we put students or health staff in a situation.

For example, the admission of the patient is simulated. We work on behavior with the patient. Today, technology allows us to have mannequins who answer the learner's questions.

Technology helps a lot to really find oneself in a real situation but with a “fake” patient.

It is a way of learning by disconnecting the potential stress that may exist on the patient's side, but also on the side of the one who is doing a procedure for the first time.

Behavior: how we behave with certain patients, how we announce bad news ...

Everything is subject to simulated procedure training in the health field. This concerns doctors, but not only: nurses and all staff who are in contact with patients.

What is the particular interest for lower and middle-income countries?

The particularity of these countries is that they currently have a very limited amount of healthcare staff, whether they are doctors of different specialties or nurses.

Here, more than anywhere else, there is a need to make the best use of these skills. That is to say, to have skills that are perfectly suited to what is expected in the particular situation in which they find themselves.

The idea is to provide doctors around the world (especially in Africa and Asia) with training simultaneously in efficient facilities and through simulated procedures.

In this case, we are not in the initial stage of training. We are more in the case of ongoing training, that is to say, additional training of doctors that are already trained.

We help them acquire complementary skills to meet a particular need.

For example, imagine setting up a hospital to fight infectious diseases.

Typically, today with the coronavirus, if we want to help train doctors who have not had specific training for a new disease, we can ensure that all additional training is focused on this subject.

We use simulated procedure training because we can do it remotely.

We can also train trainers who can come to France to train in a renowned simulated training center such as the Virtual Hospital of Lorraine, who will then go into the field to pass on that training to the other members of the team. This opens up very significant possibilities.

Once again, an eminently important point: you must always first identify additional training needs before deploying a project of this scope.

C3M: Finally, this "train a trainer" mode of training can really help to overcome the shortage of doctors in Africa and deserted medical areas.

Prof Bey:

This is obviously not going to increase the number of doctors.

The goal is to orient and reorient the skills according to the needs of the moment or the needs on a particular project.

The question of local medical priorities is a public health issue that is discussed on a case-by-case basis.

For example, only local authorities can direct pediatricians in the country in question to priority pathologies, such as childhood cancer, malnutrition or infectious diarrhea.

There is a lot of urgency in all lower and middle-income countries. I am frequently asked, "Is it reasonable to be interested in childhood cancer when they are going to die of malnutrition…".

It's not a reason.

We must be attentive regarding the means we mobilize to achieve the goal.

But we can also reverse the reasoning… Should we cure these children of malnutrition only so that they die from a cancer that is highly curable?...!

Today, these childhood cancers have the particularity of being curable in 80% of cases if the diagnosis is made early enough and if we have the means to treat them. It is all the more feasible as the necessary means to reach it are not excessive.

It is still and always will be, a question of balance to be found in each country according to the varying capacities in human resources devoted to health.

C3M: in concrete terms, what are the conditions for implementing simulated procedure training? How can this be done?

Pr Bey: We are involved with C3Medical in a program with the company ADEN (via its Akilacare offer ), based in Shanghai.

They have an offer that can build a hospital in six months! The basic module corresponds to 180 beds and adapts to the needs of the country.

The finished hospital is efficient and sustainable.

They are not in tents, nor in emergency hospitals, but real hospitals adapted to local constraints and challenges. We are associated with this project for the simulated procedure training portion.

In this hospital, there is an integrated module for training through simulated procedures with a dedicated area of materials and suitable equipment because it does not involve robotic surgery.

We intervene in the learning of medical practices that are rather basic but oriented towards the objectives of this hospital.

During the 6 months of construction, with the country's authorities, we identify:

· the medical objectives of this hospital,         

· the personnel who will work there,         

· The additional training needs of the teams, depending upon the existing situation in the country and the orientation that the authorities wish to give to this hospital.         

For our part, we devise a tailor-made complementary training program.

We saw a number of wonderful facilities, often well equipped, but had not taken into consideration the staff who would be working there ...

This is what we want to avoid.

C3M: So it's a very agile system.

Prof Bey: Exactly. The idea is to have great flexibility, not to be locked into a straitjacket by deploying the same system everywhere with the same skills.

This is the best way to create a mess.

Medical resources are scarce human resources that need to be better developed and that we must perfectly aim towards what is expected of the original goal.

The initial part of the project is discussions with the country's authorities and the management of this future hospital.

This is a crucial step since it is absolutely necessary to understand what they want to achieve with this hospital.

C3M: It's really tailor-made!

Pr Bey: It is tailor-made, in a very innovative design.              

C3M: Innovative due to the speed of construction with this partner and the modular aspect.

Pr Bey: Indeed, it greatly increases the chances that such a hospital, once it's installed, will function and, more importantly, function quickly. There are other constraints, but this approach greatly increases the chances of success.

I have traveled a lot and seen facilities that are not optimally serving at their full capacity. It's a shame because whatever the country, the means are always limited.

C3M: How do human resources work in this situation?

Pr Bey: These are qualified human resources that are the product of long training courses ... You have to identify what they can contribute. However, there should be no 'use' for things that can be done by other people and skills.

It is this overall reflection that is innovative.                      

C3M: The concept in itself is reminiscent of the proverb which says "when a man is hungry, it is better to teach him to fish ..."

Pr Bey: "… than to bring him fish". We quite agree. With this type of project, we are in a support process, to help the smooth running of local projects by responding to the needs and expectations of the country.

C3M: What I really appreciate about this approach is the human side at the heart of this reflection.

Prof Bey: For me, it's vital.

It is capital. Otherwise, we would not have embarked on these projects.

We can only be there to support the local teams. We must therefore help them when they are in difficulty.

And God knows they encounter many difficulties ...

I admire what these teams are able to do in conditions that are sometimes extremely difficult. We are there to support, to help, but in no case to do substitute ourselves for them.

C3M: Last question Professor, do you have a source to recommend to learn more about the HVL?

Simply the HVL site or the YouTube channel.