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Interview Pr Bey - Simulation-based training, a solution to improve the quality of care in Africa.
"Never the first time on the patient"! This is a credo dear to Professor Pierre Bey. Through this interview, he reveals how and why simulation allows us to learn better even in Medicine.
C3M: Can you introduce yourself in a few words?
Prof. Bey: I am an emeritus (i.e. retired) professor of radiotherapy and cancer at the University of Lorraine. I have also held responsibilities as a hospital director.
I was director of the cancer center in Nancy and director of the Curie Institute hospital in Paris.
Since my retirement, I have been very involved in actions to support the treatment of children's cancers in Africa, in French-speaking Africa and in sub-Saharan Africa for one of the tumors, eye cancer.
When I came back to live in Nancy two and a half years ago, I was asked to become the administrator of the Virtual Hospital of Lorraine (HVL).
The HVL is an economic interest group (GIE) that practices training through simulation 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 simulation-based training in the healthcare sector? A vast subject...
Prof. Bey: This responds to a need that has been well expressed by the Haute Autorité de Santé (HAS) in France.
It concerns both the initial training of health care personnel and continuing education.
The concept is simple: "Never the first time on the patient"!
That's how this simulation-based training was invented.
Traditionally in medicine, one learns by companionship, in contact with the elders, the masters.
They explain the theory and the practice. At the beginning, we are with them in contact with the patients and gradually, we are left alone with the patients.
So the HAS created this notion of "replacing the patient with something that simulates him".
This can be mannequins, robots or simulations.
This is what we do in the HVL.
So we have a learning process that takes place through scenarios.
The student or health professional who comes for continuing education is put in a situation.
We study how he behaves in this situation. Then, we debrief to see with him all that was done correctly and to bring improvement axes.
So we are in an atmosphere that is completely "de-stressed". We don't have this worry about the patient anymore.
For example, when you are a student and you do for the first time an aggressive act like a lumbar puncture, it is a heavy act, not pleasant for the patient nor for the practitioner...
Learning this gesture on a mannequin changes everything.
The student repeats this gesture. Then we decipher a posteriori what you did correctly and what you need to rework.
Finally, you can turn a very large part of learning in medicine like that.
This concept is duplicated right down to the relationship with the patient!
In concrete terms, we put students or healthcare personnel in situations.
For example, we simulate the reception of the patient. We work on behavior with the patient. Today, technology allows us to have mannequins that answer the learner's questions.
The technology helps a lot to really be in the real situation but with a "fake" patient.
It is a way to learn by disconnecting from the anxiety that may exist on the patient's side, but also on the side of the one who is doing gestures for the first time.
Behavior: how to behave with certain patients, how to give bad news...
Everything is subject to training through simulation in the health field. This concerns doctors, but not only: nurses, all personnel who are in contact with patients.
What is the particular interest for low and middle income countries?
The particularity of these countries is that they have a very limited number of health care personnel at present. Whether it is doctors of different specialties or nurses.
Even more than elsewhere, there is a need to make the best use of these skills. That is, to have skills that are perfectly adapted to what is expected of them in the particular situation in which they find themselves.
The idea is to provide doctors around the world (particularly in Africa and Asia) with additional training and high-performance facilities.
In this case, we are not in initial training. We are in the realm of continuing education, that is to say, the complementary training of already trained physicians.
We help them acquire additional skills to meet a particular need.
For example, let's say we create a hospital to fight infectious diseases.
Typically, today with the coronavirus, if we want to help train physicians who have not had specific training for a new disease, we can ensure that all additional training is focused on this subject.
We use simulation training because we can do it remotely.
We can also train trainers who can come to France to be trained in a recognized simulation center such as the Virtual Hospital of Lorraine, who will then go into the field to train the other members of the team. This opens up very important possibilities.
Once again, an eminently important point: always identify the need for additional training before deploying a project of this scope.
C3M: Finally, this "train the trainer" training method can really help to overcome the lack of doctors in Africa and the medical deserts.
This will obviously not increase the number of physicians.
The goal is to orient and redirect skills according to the needs of the moment or the needs of 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 conditions, such as childhood cancer, malnutrition or infectious diarrhea.
There is a lot of urgency in all the low and middle income countries. People always say to me, "Is it reasonable to be interested in childhood cancer when they are going to die of malnutrition?
This is not a reason.
We must be careful about the means we use to achieve the objective.
But we can also reverse the reasoning... We will cure these children of malnutrition so that they die of a cancer which 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. This is all the more feasible as the necessary means are not phenomenal.
It is still 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 simulation-based training? How can it be carried out?
Prof. Bey: We are involved with C3Medical in a program with ADEN (via its Akilacare offering), based in Shanghai.
It offers a hospital built in six months! The basic module corresponds to 180 beds and can be adapted according to the needs of the country.
In the end, the hospital is efficient and sustainable.
They are not in tents, nor emergency hospitals but real hospitals adapted to the local constraints and issues. We are associated with this for the training through simulation part.
In this hospital, a module is integrated to deliver training through simulation with a dedicated space, materials and equipment adapted, because it is not robotic surgery.
We intervene in the learning of medical practices often quite basic, but oriented on the objective of this hospital.
During the 6 months of construction, with the country's authorities, we identify :
- what this hospital is for,
- the personnel who will work there,
- the need for additional training for the teams, always depending on the existing situation in the country and the direction that the authorities wish to give to the hospital.
On our side, we take care of making a complementary training program tailored to your needs.
We have seen a certain number of magnificent establishments, often very well equipped, but without prior reflection on the personnel who will work 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 waste.
Medical resources are scarce human resources that must be optimized and that must be perfectly oriented to the expected results, to the initial objective.
The initial part of the project are discussions with the authorities of the country and the management of this future hospital.
This is a crucial step because it is essential to understand what they want to do with this hospital:
C3M: It's really custom-made!
Prof. Bey: It's custom-made, in a very innovative design.
C3M: Innovative because of the speed of construction with this partner and the modular aspect.
Prof. Bey: Indeed, this greatly increases the chances that such a hospital, once installed, will function and especially 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 fully used in an optimal way. It is a pity, because in any case the means, whatever the country, are always limited.
C3M: What about human resources?
Prof. Bey: They are human resources qualified after long training... We must identify what they can bring. However, they should not be "used" for things that can be done by other people and skills.
It is this whole reflection that is innovative.
C3M: The concept itself is reminiscent of the proverb that says "as a man is hungry, it is better to teach him to fish...".
Professor Bey: "... than to bring him fish". We agree. With this type of project, we are in an approach of accompaniment, of appropriation, of help to the good progress of the local projects answering the needs and expectations of the country.
C3M: What I appreciate about this approach is the human side at the heart of this reflection.
Prof. Bey: For me, it is vital.
This is crucial. Otherwise, we would not have embarked on these projects.
We can only be there to support the local teams. We have to help them when they are in difficulty.
God knows they meet some...
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 way to do things for them.
C3M: Last question Professor, do you have a source to recommend to learn more about LVH?