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A large part of simulation in surgery relates to non-technical factors, these can include communication skills, professionalism, human factors in theatres and critical care or trauma moulages. These types of simulation can include either real patients or actors acting in scenarios designed to push trainees and develop their non-technical skills. Use of actors to simulate difficult patient scenarios allows for trainers to provide feedback and prepare trainees for difficult patient interactions which can be better handled by trainees having experienced them before (Davis, 2011).

Aside from communication skills with patients, effective teamworking is a key skill for trainees to develop both as team members and effective leaders. Simulated scenarios in Sim labs are key to this and have been utilised extensively by both Surgery and Anaesthesia these types of simulated training have been shown to improve both team performance and patient care (Capella, 2010).

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Hybrid simulators combine physical simulators and VR simulators, they integrate computer based simulations utilising virtual reality programs or not and aim to to create sophisticated mannequins which can be manipulated to provide a more realistic environment (Kneebone, 2003).

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The panacea for simulation seems to lie in costly Virtual reality (VR) or computer-based simulation and although the technology has yet to reach a point where this is a cost-effective viable model there are of high fidelity models with haptics integrated. This work has been focussed around Laparoscopic surgery where skill acquisition of basic laparoscopic skills including cutting, transferring and clipping hs been validated using a basic setup of equipment such as a lap box, laparoscopic instruments, camera and a light source (Peters, 2004, Sarkar, 2011). Laparoscopic surgery seems well suited to VR which uses computer generated 3D images to allow trainees to manipulate. Both bench top models and VR models can utilise Hand motion analysis to provide further objective feedback about progress (Taffinder 1999).

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Microsurgery - Live Rat

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Microsurgical Repair of the Rat Sciatic Nerve

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Microsurgery

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Microsurgery 'All tied up' tasking microsurgical knot tying MI4

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Bench-top models can be low or high fidelity and use animal models or synthetic material to teach craft skills in a risk-free environment. A multitude of models exist including those for both bowel and vessel anastomosis as well skills such as excision of skin lesions. Importantly these have validated scoring systems most notably the objective assessment of technical skill (OSATS) score produced by Reznick et al (demonstrated in the diagram). This type of objective assessment tool is incredibly useful when trying to identify a trainees Zone of Proximal development as it can use simulation to identify where trainees are under performing and tasks can set based on those outcomes. Although there is overwhelming evidence in the literature demonstrating the benefits of benchtop models in skill acquisition (Brehmer, 2005, Anastakis, 1999, Montburn 2005). A drawback of these models is fidelity and when high and low fidelity models were compared un-surprisingly there was some difference on skill acquisition, but importantly there was skill acquisition in both models (Grober, 2004).

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Example of OSAT Score sheet

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Adapted from Website http://www.microsurgeryeducation.com
Utilising Benchtop simulation in a systematic way allows for development of surgical skills which can be transferred to the operating theatre. Below is a diagram demonstrating how trainees can use benchtop models to develop their psychomotor skills. Some of the other benefits of bench-top simulation include aiding in skill acquisition for psychomotor skills are that practice is limited only by Time and Availability of Resources, there is an evidence base for Significant Skill Acquisition and both low and high Fidelity models confer some level of benefit (Montburn, 2005).

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The whole point of the doomsday machine...is lost if you keep it a secret!
Dr Strangelove

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Kolbs 4 stage process is a distillation of what we expect to happen with expieriance, we treat patients, think about what we did and learn. Simulation mimics this process but in a controlled environment, application of Kolbs model can never truly replace expieriance as it will be impossible for trainees to behave exactly as they would in a real life situation regardless of the fidelity of the model being used but it does allow for trainees to experience and engage with situations and surgical models and learn from them, moving learners forward in their learning curve. As this will be done in an educational setting it should seen as a stepping stone within the model of deliberate practice put forward by Ericsson (Ericsson, 1993). Importantly because simulation is a malleable resource each iteration of the simulation can be built to fulfil a trainee’s weakness or present them with a new challenge. Meaning that the simulation can work within Vygotskys zone of proximal development (ZPD), where learning progress can be optimized.

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Properly undertaken simulation allows trainees to develop a learning curve and by applying Kolbs experiantial learning cycle in areas of learning sitting within their personal Zone of Proximal Development they can develop their learning curve through Ericssons Deliberate Practice.

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Broadly learning theories can be subdivided into 2 groups psychological and educational. Chauvin reports on the work Custers and Boshuizen on how these groups differ; psychological theories focus around what occurs within a learner’s mind but educational theories takes a far broader view looking at the factors that make up the learners surrounding also. There are a multitude of pedagogies and taxonomies looking at how learners develop and grow and these can be applied to simulation in variety of ways, importantly Chauvin raises the point that learning is more than an opportunity to practice and provision of knowledge so for simulation to work as an effective tool it needs to be viewed as something more than repetitive practice.

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In Experiential Learning Theory shown in the diagram Kolb and Fry applied a 4 step process to learning;

Having an experience

Observation during and reflection on experience to form concepts

Formulation of concepts, generalisations, principles, and rules

Testing or experimentation with these concepts, generalisations, principles, and rules in new situations.

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Planning and thinking about the simulation alone or with a trainer

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"Theoretic models provide generalizable explanations of natural phenomenon confirmed through observations, experimentation, and logical reasoning across various settings."
Chauvin 2015

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“Simulation offers a safe, non‐clinical environment designed to meet the educational needs of a range of learners.”
Kneebone, 2003

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I feel the most convincing argument for integrating of simulation is an ethical one. It is a given that trainees will eventually develop both technical and non-technical skills by treating patients but rarely is there a cost attributed to that and given the possibility of avoiding potential harm and demonstrable benefits in other industries such as aviation, simulation has an ethical imperative behind it (Ziv, 2003; Montbrun, 2012).

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Surgical education was previously learnt by repeatition, this cant be the safest way forward...

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The torrents of change have necessitated the embrace of the new. Martyred is the apprenticeship model, one in which all knowing mentors lovingly nurtured trainees like the beloved prairie dog (when it manages to refrain from eating its young) asking for nothing in return other than complete submission of body, person and soul to the subjective whims of a largely unregulated system with the key quality check of being able to play flanker on the hospital rugby team. The good old days; apprenticeships, polio and small pox. Nostalgia for the training systems of yesteryear often wears rose tinted glasses that Elton John would be proud of. The new approaches of objective competency-based training and the introduction of appropriate simulation training shouldn’t simply be seen as Surgical Educators reflexively battling the tide against political and societal change and trying to make do but I would argue are representative of a fairer, more objective and safer way of training surgeons today. The pedagogic approaches underlying our understanding Simulation and how it improves training are largely evidence based and can provide a better solution.

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The diagram demonstrates how training has changed through Societal Expectations, Political Accountability and Professional Regulation. Throwing into the mix EWTD,  Calmanization and Health Education England’s “Shape of Training” report which documented how Rota Gaps, Shift Patterns and the requirement of trainees to provide service provision have degraded time dedicated for the training and skill acquisition it is all to clear to see novel solutions are required.

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An apt description of the current paradigm in surgical education could be attributed to a nobel prize winning writer, and although Dylan's cry that “the times they are a-changin'” was unlikely directed specifically at the multitude of pressures being placed upon modern surgical training, I would like to think on some level he was speaking to the stakeholders of 21st century surgical education. The drivers for simulation diagram taken from Batistas chaper in Understanding Medical Education: Evidence, Theory and Practice by Swanick demonstrates a some of the drivers that have rung the death knoll for the traditional model of surgical education.

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Bob Dylan  The Times They Are A Changin' 1964

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Figure 13.2 Drivers for the development of simulation

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Figure 13.2 Drivers for the development of simulation

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"Being entirely honest with oneself is a good exercise"

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Follow the arrows...

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Kolb’s 4-stage experiential learning cycle.

(Adapted from Kolb DA. Experiential learning. Englewood Cliffs (NJ): Prentice Hall; 1984.)