Healthcare Education

The Evolution of Healthcare Education Ė opportunities for the UAE

Methodist International in Dubai, hosted and sponsored a roundtable discussion at the Emirates Towers Hotel in Dubai in October last year to discuss the evolution of Healthcare Education and Training opportunities in UAE. Fourteen healthcare leaders from various education and training institutes, healthcare regulatory bodies, healthcare providers, and technology-related companies participated in the discussion. Middle East Health provides excerpts from the thought-provoking discussion.


Dr Sarper Tanli, Executive Director of Methodist International, welcomed the guest of honour Dr Brian Dunkin, the director for The Methodist Institute for Technology, Innovation and Education (MITIE) in Houston, United States. As a surgeon at The Methodist Hospital in Houston he believes the future of surgical training requires hands-on education in a simulated environment, not only for medical students and residents, but also for highly skilled surgeons who want to learn new techniques and re-tool their skills in advancing technologies.

The Presentation

Dr Dunkin opened the roundtable discussion with a 15 minute presentation about simulation and the need to have continuous access to it throughout oneís medical career.

In summary, he said: ďWhen we think of simulation we think of nursing students, medical students, even students in the various allied healthcare professions going to an area and working on simulators as part of their curriculum and learning some basic skills. Certainly thatís an important part of the mission of simulation, but I want to broaden the horizon a little bit.

ďIf we look at the world of healthcare and the people that are in need of training and particularly in need for incorporating simulation in their training, itís not so much on trainees, but rather on practicing healthcare professionals.

ďWhen you get out of the structured training environment and the umbilical cord is cut at the medical school or nursing school, how do you stay abreast of your field? How do you incorporate new techniques and new technologies into your practice without disrupting your practice? Thatís the focus that I want us to think about.

ďWhen you get into that world, you start to talk about user simulation privileging and credentialing. Because I am a surgeon, if I go somewhere to learn a new technique I want to be able to convince my credentialing body in my hospital that I am ready to use that new technique. So how do we do that and how can simulations play a role in that?

ďIf I want to learn how to use new techniques, new technology in the operating room, typically I will go to some type of an educational event that may be wrapped in CME (Continuous Medical Education). I think most people are familiar with this, But CME, as a learning opportunity, is really focused on practicing physicians and nurses as well as allied healthcare professions. Itís important, but really it is a limited measure of knowledge, often itís just a measure of attendance.

ďVery few credentialing bodies will take a simple CME certificate and say: ĎOk I accept that you are ready to go into the operating room to do that new operation,í so we need to do this better.

ďAn interesting article was published by Barbara Bass, the chair of surgery at Methodist. It outlines a number of principles. One of the principles states that criteria for granting new privileges should be based on new education and training with demonstration of technical proficiency in a proper training environment, essentially demonstrating technical proficiency in simulated environment. This should be part of the credentialing process.

ďAt MITIE (Methodist Institute for Technology, Innovation and Education) we have developed the concept of an educational home. We want to create educational homes for practicing healthcare professionals where they can return throughout their career to learn new techniques and new technology and incorporate it into their practice.

ďYou do individual training, but you also have team training in order to introduce the innovation to the general healthcare community.

ďHow many MITIEs do you need out there for your educational homes? I would argue that we need a worldwide network of them. ďI would say that certainly the future of surgical privilege and I would argue that any procedurally placed medicine privileging, is going to require hands-on testing in a simulated environment. We have already started down that road and I think that we need to think differently about simulations. Itís not just about residents and medical students and nursing students. Itís not just about human patient simulators and airway mannequins. There is lots of opportunity in this area which can really foster better delivery of healthcare across multiple domains.Ē

The Discussion

The roundtable discussion was moderated by Dr Sarper Tanli who directed a relatively informal and free-flowing discussion among the panellists with leading questions. Following is a summary of the panel discussion, highlighting key points of interest.

Dr Sarper Tanli
How do we use the medical education programmes in our organisations? What is the impact on your staff and on the patients? How are you engaged in medical simulation in your operations and what are the impacts you see on your medical and clinical staff? How does this impact on patient safety?

Jo Hubbard
At the Corniche Hospital, 99% of all of our education is done together Ė so we have physicians, obstetricians, nurses, gynaecologists and administrators, etc. having education sessions together. We have found simulation to be very useful. It has actually changed how staff respects each other and teamwork and communication has improved.

Halla Ibrahim
Medical education should be given not only for residents and trainees but also for continuing medical education, especially for those who are teaching the trainees and residents. As Jo was saying, teamwork and communication are important.

Patients donít want to be guinea pigs. They donít want to feel that the person is doing something on them for the first time or even the second or third time. So I think in terms of the patient-centric approach to patient safety, simulation has a very important role.

In our institution we have a budget for education, because it so important to keep up to date with skills and knowledge.

There is also pharmaceutical support for sending doctors to conferences, but instead of funnelling that money into conferences or sending someone abroad to listen to a lecture, you could invest that money in a simulation exercise where they get hands-on training.

Dr Brian Dunkin
When you get into the kind of science of validating simulation training it gets messy quite quickly and its labour intensive. It has been hard to convince all the stakeholders in the medical world about why we are doing this and showing them what we get out of it.

If I am going to invest in dollars, I need to know what I am going to get out of it. There are a couple of possibilities here. What we need is a better way to validate this work. For example, there may be some opportunities in the UAE that are not available in other parts of the world. For instance, we could decide that in a particular area we are going to institute best practice.

We develop a training programme to do that and we measure the outcome. In this type of controlled environment using best practice we can say Ďthis is how it was, these were our results before and these are the results afterí. So that way you can start to touch on what is valuable.

Everybody believes inherently that in education there is value, but we have got to get better at showing the results of education. If I get my workforce up to a certain standard quicker through simulation training, I know, even if the [staff] turnover is quicker, I am getting more production out of them. We should start thinking that way and see the value of simulation beyond the medical residents. We need to convince all the stakeholders of the value of this training and we have to be smart about how we measure it.

Dr Hatem Farej Al Ameri
I think when it comes to undergraduate and post-graduate education it is very structured and more and more youíll find that graduates from different parts of the world are almost similar. When it comes to professional development and CME, there are wide variations because the educators are quite different; the environment is different and patients are different. It is not proven that simulation can do a better job than hands-on training. Because of this people are not jumping at the idea of using simulation. It is also expensive and very hard to maintain. If you buy a mannequin now, in a yearís time there will be a new techniques.

Dr Brian Dunkin
Measuring competence is hard, part of the reason is we havenít agreed on what it is. What is competence? How do you know thatís right and thatís wrong? We have got to get there.

Dr Hatem Farej Al Ameri
The target will not be how we measure it. First we have to identify what is important and look at it because staff turnover is high. You have to do this constantly every two years or so. So if we have to try it, test it and measure the outcomes at this rate Ė we donít have the luxury of having that kind of cycle.

Lauren Arnold
In the UAE a decree was issued in 2009 to ratify standards for nursing practice, education, registration, etc. The UAE nursing and midwifery council is currently gathering all stakeholders so that we can standardise nursing practice across all fronts and one thing, of course, is competency validation. It doesnít seem that anyone has the exact answer as to the definition of competence: How to measure it, how to guarantee it, which is what we are aiming for.

Simulation has a lot of promise for a number of reasons, particularly in the UAE. As we gather a healthcare workforce from around the world, we have to create a minimum standard of quality to guarantee safety. So if we think about a competent nurse or midwife from that perspective we can at least start to guarantee the public that we are providing safe care because we can do this in a simulated environment.

Mohammad Nasaif
There is a lot of focus on competency. If we go through a series of simulation courses does that make us competent? The competency has to come first and simulation has a place in this. I feel that lecturing is increasingly becoming less effective. People like simulation. With the help of the industry we could focus the conferences or big gatherings into more workshop- oriented events rather than big lectures.

Mehdi Attarha
As Dr Dunkin mentioned, standardisation and communication are very important for us. We have the same challenges that all of you around this table have Ė that is, to have the best education, we need to understand the true impact on any kind of education Ė with simulation and hands-on being a part of it. There needs to be collaboration between the public and private providers, and importantly the regulators. We have good representation around the table here from HAAD (Health Authority Abu Dhabi) and MoH (UAE Ministry of Health). So unless these things are mandated, we are not going to see the impact of any kind of education or training with hands-on or simulation. In my opinion, if I may say so, the excellent things being done in Abu Dhabi, the excellent things being done in Dubai, as well as by the MoH Ė they have great initiatives Ė but I think we have to move beyond physical borders and in a combined effort bring it all together if we truly want to see the impact of training and education on quality of healthcare.

Russel Jones

I would like to emphasise that much of the recent research in simulation shows that across professional training, it is particularly effective, and things such as swapping roles Ė not to practice clinical skills, but to practice empathy and to practice communication Ė has such a tremendous effect on improving patient outcomes and efficiency in the real world.

Kathleen Meehan

As an education institution, we work very closely with the health authority and the regulatory authorities. This is where we can possibly come in with the facilities. We have spoken to the authorities and we had some discussion on simulation.

Working within the framework of the regulatory authorities and also with the nursing and midwifery council, we made a successful approach to UAE-based national minimum standards.

To try and standardise other disciplines across the country we need patience. Thatís the role I see the colleges and educational institutes providing.

Dr Hatem Farej Al Ameri
We have to look at exactly how the situation is with health professionals and what shortage we have. We have a tremendous shortage when it comes to health professionals and nursing. We have to prioritise our needs. I have to keep all this in mind. For example in Abu Dhabi, which is the most advanced when it comes to work force, we need around 600-700 nurses a year, but we have supply for around 150. If you look at the other emirates it is much harder. I agree in a way that we have to look how to optimise their skills, but we have to put everything in its place, all factors together and come up with an equation which balances supply, quality and sustainability.

Dr Brian Dunkin
You are concerned about raising the bar to a point where you make an existing problem worse. I completely understand, but I would think through this. Could you use education simulation as an enticement for recruitment? Maybe, maybe not. So I am a basic nurse and you need a skilled nurse in a certain area and I am going to put you through this programme that will raise your skills. We come up with a level 1, 2, 3 nurse. That gets you from a level 1 to a level 2. I would use that as a recruiting tool. For example, I need people in a particular area and this is the pool that I will attract them from, then I should develop a programme for this pool.

Dr Sarper Tanli
What are your comments on how to finance the training programmes? How could we sustain these programmes?

Dr Fuzan AlKhalidi
I think there are a few things that we have to look into. First, to set up simulation centres we need to find out find out what training is required. We need to understand what sort of simulation and training can be provided and obviously you have to invest. I think government support is also required.

Mohammad Nasaif
The key point is developing a faculty and retaining it. Retaining a faculty is very difficult when private practice is more profitable than teaching.

Jo Hubbard
Well I think the key is research. The heath authority in Abu Dhabi is investing in research. Surgeons in Abu Dhabi are involved in hospital-based research teams. There are a lot of doctors who have been there many years and who are very good in the teaching faculty, who want to be called on to do research.

Dr Fuzan AlKhalidi
I agree with Mohammad Nasaif, developing this faculty and keeping them will be the challenge in the future.

Dr Brian Dunkin
Just a word about retention. A couple of things have to be done. First of all you have to have an infrastructure that uses time efficiently. Surgeons canít be spending any of their time on cautionary positioning. There has to be an infrastructure and it seems very logical, but itís so difficult to have that. I run MITIE, but I also get paid to do an operating room and do cases and so when I come to teach a course it has to be very big and there has to be a team that does it. So it is important to have an infrastructure in place that uses a surgeonís time or a nurseís time to the max.

I donít feel the strong attraction to go somewhere else because I am already sharing what I am doing there and I am part of that community. So letís work at that, letís have a community here where you can foster that connectivity with live case demonstrations and conferences. Invite people and show your expertise. This is an exotic place that they would love to come and be a part of. I think that you could quickly develop a leadership role in this area.

Dr Zahra Saeed Baalawi
But how do we get the government, especially the UAE Government, to invest in a very transitory workforce? Itís very easy to say we can only invest in national nurses or physicians. It is easy to get funds for that. I am going to train 5% nationals and 95% expatriates next year. How can you ask the key funders to invest in this very transient expatriate workforce?

Mohammad Nasaif
So how would you suggest the system should be? For example, the people who tend to stay with us are people who are stuck in hospital-based jobs like emergency. Private practice is not a very good idea in this part of the world. For a general surgeon it is very clear Ė one day in clinic is much better than one in teaching.

Halla Ibrahim
But I think people are now coming to value medical education and starting to realise that there is a lot to be done on the medical education front. So we need to invest more and I think thatís starting to happen. They are not getting paid for it but they are getting protected time to teach so you are not expected to be as busy if you spend half a day teaching residents. You may not be getting more money, but you get time and sometimes time is more precious than money. So you are getting time and the acknowledgement of the people who realise what you do and you are valued for that.

Dr Brian Dunkin
We are talking about creating a culture of academics, not everything can be motivated by Ė how many cases can I do, how much money I earn. Thatís certainly a component, but you need a culture where different things motivate different people. Iíve always worked in academics thatís why I wasnít thinking of the money, because thatís the environment that I wanted and the trade-off was that academia provided me with an environment that encourages that work and recognition too. I like to do cases, but I like to do it in that block. It takes time to develop that mentality and that interest.

Even in simulation I guess there are opportunities to come here and do things in simulation in an academic way that may not be possible anywhere else. So thatís a potential enticement to get someone to come here and build that infrastructure, create an academic programme or create a simulation programme wrapped in academia that lives on beyond the person who decided to set it up.

Dr Sarper Tanli
Dr Hatem, looking at regulations Ė how much regulation do we need in medical education that involves simulation? Not just regulation of the schools, but also regulations for companies that provide the simulation courses.

Dr Hatem Farej Al Ameri
I think simulation is going to be a tool that will be directed towards whatever strategy is developed. For example, because itís a small community, the business is small. Thereís only one insurance company in Abu Dhabi, for example. Once we notice that there is an increase, we jump in and we create standards. As soon as it is standardised, we look at patient safety for the patients. We do not do much about the outcome, which is bad. Thatís why I think that sometimes you have to step in. [For example] now we are putting a pause on paediatric surgery because there is no standard fellowship. Everybody can do it because they have done a course. This is a where a simulation strategy that involves credentialing can help.

Dr Brian Dunkin
The States has the same problem in paediatric surgery. There are very strict guidelines with insurance companies although itís the surgical society that controls the programme. Basically surgical societies decided to establish centres of excellence in paediatric surgery and they have specific criteria for what the surgeonís expertise is. Then insurance companies said they wonít pay for paediatric surgery outside the centre of excellence. That has got rid of that entrepreneur- like medical practice and put more focus on the centres of excellence.

There has been a firewall between education and the sales industry in the United States which is not in place in other parts of the world. Iíve seen that relationship between sales and education used effectively and positively in other parts of the world Ė meaning a contract for some type of product which makes sense to the hospital is also linked to a certain amount of funding for education, not necessarily just for that type of product, but in general. Iíve seen some very beneficial things that have brought resources into the educational budgets of hospitals which would never have been there before. Industry should be willing to do that because it makes sense. Thatís another opportunity that I donít have at my centre.

Dr Zahra Saeed Baalawi
Itís great, but itís also a double-edged sword. Education is very commercially oriented, so in terms of regulations in general, or especially in terms of medical care, you see a sort of variation in quality because you got people going around very commercially oriented.

So I think with everybody trying to develop a simulation centre, you are going to get commercially oriented simulation centres opening up everywhere.

Dr Brian Dunkin
It has to be transparent so that people know what the commercial relationship is. Maybe it needs to be restructured in the agreement so that educational grants are unrestricted.

Lauren Arnold
There is a lot of research required in nursing, so we are starting a research centre. We have completed our analysis on the nationwide study on nursing and nursing attributes in the UAE, so those findings will give us an idea of what sort of challenges are out there. We hope the findings will help us develop evidencebased policy going forward. One thing I am sure we will find is a call for more continued medical education Ė so it will be great to work with all of your simulation centres to help prioritise how we continue to develop our workforce.

Diederik Zeven
I think there is no misunderstanding on the need for simulation in education. We all agree on that. There are a lot of interesting discussions going on here, but now letís action it also. When we meet again in this forum in a year from now we can see what development has taken place.

Russel Jones
I think two things are commendable: One is an agreement that simulation can be used for continuing medical education by professionals. The other important point Ė and this is key to the success of simulation in this country and many others Ė is that related to retention of healthcare professionals.

Dr Sarper Tanli thanked all attendees for sharing their views on simulation and education and concluded the roundtable saying: ďThere are opportunities for simulation to be used to develop the career path of healthcare professionals, to attract people and retain them. I would like to see as a common goal the establishment of a national education home network. If we put all the players and stakeholders in clinical education together and create a list of all the potential needs and availabilities, it will become an interesting network which can share resources.Ē

ďI would love to see this come to fruition on a national level in the UAE. In the long run it will benefit patients.Ē

 Date of upload: 21st Jan 2012


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