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1. Aebersold, M., Tschannen, D (2013) Simulation in Nursing Practice: The Impact on Patient Care. The Online Journal of Issues in Nursing 18: 6-10
2. Anastakis, D.J., Regehr, G., Reznick, R.K., Cusimano, M., Murnaghan, J., Brown, M., Hutchison, C (1999) Assessment of technical skills transfer from the bench training model to the human model. Am J Surg 177:167- 70.
3. Anderson, J.R., Thompson, W.L., Alkattan, A.K., Diaz, O., Klucznik, R., Zhang, Y. J., Britz, G.W., Grossman, R.G., Karmonik, C (2016) Three-dimensional printing of anatomically accurate, patient specific intracranial aneurysm models. J Neurointerv Surg;8:517-20
4. Badash, I., Burtt, K., Solorzano, C.A., Carey, J.N (2016) Innovations in surgery simulation: a review of past, current and future techniques Ann Transl Med 4:453
5. Bentley, L., Church, J (2008). Should our health service be consultant-led or consultant-delivered? Ann R Coll Surg Engl (Suppl) 90:160-1
6. Bloom, B. S., Engelhart, M. D., Furst, E. J., Hill, W. H., Krathwohl, D. R. (1956). Taxonomy of educational objectives: The classification of educational goals. In:  Handbook I: Cognitive domain. New York: David McKay Company, pp 201
7. Bradley, P., Postlethwaite, K (2003). Setting up a clinical skills learning facility. Med Educ 37: 6–13.
8. Brown, D (2013) The role of simulation in the learning of surgical skills. Ann R Coll Surg Engl (Suppl) 95:292–95
9. Chambers, S., Deehan, D., Gillinder, S (2015). Cadaveric surgical training improves surgeon confidence. Bulletin 97:E1-4
10. Chikwe, J., de Souza, A.C., Pepper, J.R (2004) No time to train the surgeons. BMJ 328: 418–19
11. Cooper, J.B., Barron, D., Blum, R., Davison, J.K., Feinstein, D., Halasz, J., Raemer, D., Russell, R (2000). Video Teleconferencing with Realistic Simulation for Medical Education J Educ Perioper Med 2: E014
12. Cosman, P.H., Cregan, P.C., Martin, C.J., Cartmill, J (2002). Virtual reality simulators: current status in acquisition and assessment of surgical skills. Aust NZ J Surg 72: 30–34
13. Davis, M.C., Can, D.D., Pindrik, J., et al (2016). Virtual Interactive Presence in Global Surgical Education: International Collaboration Through Augmented Reality. World Neurosurg 86:103-11
14. Ericsson, K.A (1996). The acquisition of expert performance: an introduction to some of the issues. In: Ericsson KA, ed. The road to excellence: the acquisition of expert performance in the arts and sciences, sports, and games. Mahwah, NJ: Lawrence Erlbaum Associates, pp.1-50
15. Gilbody, J., Prasthofer, A.W., Ho, K., Costa, M.L (2011). The use and effectiveness of cadaveric workshops in higher surgical training: a systematic review. Ann R Coll Surg Engl 93: 347–352
16. Haynes, A.B., Weiser, T.G., Berry, W.R (2009). A surgical safety checklist to reduce morbidity and mortality in a global population NEJM 360:491-499
17. Kerr, B., O'Leary, J. P (1999). The training of the surgeon: Dr. Halsted's greatest legacy. Am Surg 65:1101–1102
18. Khan, I.S., Kelly, P.D., Singer, R.J. (2014). Prototyping of cerebral vasculature physical models. Surg Neurol Int;5:11
19. Kimura, T., Morita, A., Nishimura, K., Aiyama, H., Itoh, H., Fukaya, S., Sora, S., Ochiai, C (2009) Simulation of and training for cerebral aneurysm clipping with 3-dimensional models. Neurosurgery 65:719-25; discussion 725-6
20. Kneebone, R. (2017) Medicine: Discovery through doing Nature 542:294
21. Kolb, D.A. (1984) Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.
22. McNicholl, B.P (1994) The golden hour and prehospital trauma care. Injury 25:251-4
23. Ponce, B.A., Jennings, J.K., Clay, T.B (2014) Telementoring: use of augmented reality in orthopaedic education: AAOS exhibit selection. J Bone Joint Surg Am 96:e84
24. Sen, A., Hill, D., Menon, D., Rae, F., Hughes, H., Roop, R (2011). The impact of consultant delivered service in emergency medicine: the Wrexham Model. Emerg Med J 41:13-17
25. Sheckter, C.C., Kane, J.T., Minneti, M (2013). Incorporation of fresh tissue surgical simulation into plastic surgery education: maximizing extraclinical surgical experience. J Surg Educ 70:466-74
26. Shenai MB, Dillavou M, Shum C (2011). Virtual interactive presence and augmented reality (VIPAR) for remote surgical assistance. Neurosurgery;68:200-7; discussion 207.
27. Shenai, M.B., Tubbs, R.S., Guthrie, B.L (2014). Virtual interactive presence for real-time, long-distance surgical collaboration during complex microsurgical procedures. J Neurosurgery;121:277-84
28. Tang, J.J., Maroothynaden, J., Bello, F., Kneebone, R. (2013) Public Engagement Through Shared Immersion: Participating in the Processes of Research. Sci Commun 35:654–666
29. Vakharia, V.N., Vakharia, N.N., Hill, C.S (2016) Review of 3-Dimensional Printing on Cranial Neurosurgery Simulation Training. World Neurosurg 88:188-98

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Ericsson's theory of attainment of expertise through  deliberate practice

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Ericsson's theory of attainment of expertise through  deliberate practice

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Bloom et al (1956)

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Addressing existing audiences in different ways:                                                                                                                                                                                                                                                            -Newly developed technologies are now allowing surgeons to collaborate remotely. One such system for remote surgical cooperation is Virtual Interactive Presence and Augmented Reality (VIPAR) (Shenai et al, 2011). This system enables a surgeon in one location to share his visual field as a projected simulation with a surgeon elsewhere. As a result, the operating surgeon or surgeon in-training can be guided in real-time by a more experienced surgeon. The most obvious value of this technology relates to the fact that while trainees may perform operations on-call in the middle of the night unsupervised when traditionally the consultant would be at home and not immediately available, the VIPAR would enable the potential for regular or consistent supervision of the trainee since the senior surgeon could ‘access’ the operative event from home out-of-hours.                                                                                                                                                                                                                                                                                                                                    -The clinical use of VIPAR has been validated in numerous studies. For example, VIPAR has been used in orthopedic surgery and neurosurgery for training residents with an attending surgeon immediately available in an adjoining room (telemonitoring). Residents rated the experience of using VIPAR as very positive (Ponce et al, 2014), although of course data demonstrating that VIPAR improved real performance or patient outcomes is lacking. In addition, VIPAR can be affordable, costing just $15,000 per year of use (Davis et al, 2016). Because of its low cost and clinical usefulness, I believe that VIPAR genuinely represents a promising way to improve collaboration and facilitate training of surgeons. Furthermore, in the UK, the political drive for the National Health Service (NHS) is increasingly towards the provision of a consultant-led or even consultant-delivered 24-hour, seven-days-a-week service (Bentley & Church, 2008; Sen et al, 2011).  VIPAR offers a method of keeping consultants in charge of surgical care and training students without requiring their physical presence in the hospital. VIPAR also strongly harnesses Kolb’s model of experiential learning (Kolb, 1984) in that the trainee can apply his/her skills and experience to the real operative case and then re-assess their actions and adjust based on new information from the case and input from the supervising consultant.   

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Addressing existing audiences in different ways:                                                                                                                                                                                                                                                            -Newly developed technologies are now allowing surgeons to collaborate remotely. One such system for remote surgical cooperation is Virtual Interactive Presence and Augmented Reality (VIPAR) (Shenai et al, 2011). This system enables a surgeon in one location to share his visual field as a projected simulation with a surgeon elsewhere. As a result, the operating surgeon or surgeon in-training can be guided in real-time by a more experienced surgeon. The most obvious value of this technology relates to the fact that while trainees may perform operations on-call in the middle of the night unsupervised when traditionally the consultant would be at home and not immediately available, the VIPAR would enable the potential for regular or consistent supervision of the trainee since the senior surgeon could ‘access’ the operative event from home out-of-hours.                                                                                                                                                                                                                                                                                                                                    -The clinical use of VIPAR has been validated in numerous studies. For example, VIPAR has been used in orthopedic surgery and neurosurgery for training residents with an attending surgeon immediately available in an adjoining room (telemonitoring). Residents rated the experience of using VIPAR as very positive (Ponce et al, 2014), although of course data demonstrating that VIPAR improved real performance or patient outcomes is lacking. In addition, VIPAR can be affordable, costing just $15,000 per year of use (Davis et al, 2016). Because of its low cost and clinical usefulness, I believe that VIPAR genuinely represents a promising way to improve collaboration and facilitate training of surgeons. Furthermore, in the UK, the political drive for the National Health Service (NHS) is increasingly towards the provision of a consultant-led or even consultant-delivered 24-hour, seven-days-a-week service (Bentley & Church, 2008; Sen et al, 2011).  VIPAR offers a method of keeping consultants in charge of surgical care and training students without requiring their physical presence in the hospital. VIPAR also strongly harnesses Kolb’s model of experiential learning (Kolb, 1984) in that the trainee can apply his/her skills and experience to the real operative case and then re-assess their actions and adjust based on new information from the case and input from the supervising consultant.   

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Image below: Consultant surgeon with virtual hand remotely supervises trainee surgeon who is actually operating and has supervior's 'hand' in field of view

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-3D rapid prototyping involves using medical imaging to create patient-specific 3D models that are able to accurately replicate individual patients’ actual anatomical structures (Anderson et al, 2016). This can then enable the planning and rehearsal of various operational steps specific to the actual patient’s anatomy or pathology. Much of the innovative work in 3D rapid prototyping has occurred in my own field of training, Neurosurgery, where 3D printers have been used to produce models of individual patient-specific cerebrovascular pathology in relation to the skull, allowing the surgeon to plan the incision, skull opening, trajectory of dissection, and how best to treat abnormal blood vessels through testing different surgical devices. The major limitation of studies in support of 3D models (Khan et al, 2014; Vakharia et al, 2016) is the lack of patient outcome data since there is no demonstrated link between purported ease of use or improved confidence with 3D models and improved patient outcomes from surgery.                        

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-3D rapid prototyping involves using medical imaging to create patient-specific 3D models that are able to accurately replicate individual patients’ actual anatomical structures (Anderson et al, 2016). This can then enable the planning and rehearsal of various operational steps specific to the actual patient’s anatomy or pathology. Much of the innovative work in 3D rapid prototyping has occurred in my own field of training, Neurosurgery, where 3D printers have been used to produce models of individual patient-specific cerebrovascular pathology in relation to the skull, allowing the surgeon to plan the incision, skull opening, trajectory of dissection, and how best to treat abnormal blood vessels through testing different surgical devices. The major limitation of studies in support of 3D models (Khan et al, 2014; Vakharia et al, 2016) is the lack of patient outcome data since there is no demonstrated link between purported ease of use or improved confidence with 3D models and improved patient outcomes from surgery.                        

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3D Printing for Medical Education & Surgical Training

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The first 3D printer was developed in 1984. It took a very long time before units became available for home and office use. 3D printing of anatomical models used to be very expensive and only available in specialized centers. Now anyone can utilize the technology to whatever field one wishes at affordable rates.

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-Fresh cadaveric tissue faithfully represents the anatomic structures encountered in the real patient during an operation, and therefore can powerfully simulate technical practice and consolidate anatomical knowledge in surgical training. I would argue from my own experience that for those operations that involve learning soft tissue anatomy, tissue handling as well as dissection techniques, the role of cadaveric training is critical and cannot be provided by alternative low or high fidelity models. Indeed, Anastakis et al (1999) described cadaver models as ‘the gold standard for technical skills training’, and there are certainly examples in the literature describing the use of cadavers in American surgical residency programs such as in Plastic surgery that have found an increase in participating surgeons’ confidence from cadaveric simulation (Sheckter et al, 2013; Chambers et al, 2015).                                                                                                                                                                                     -Logistical issues around human cadaveric training include the relatively high expense (Anastakis et al, 1999); the requirement for regular maintenance and special facilities; and the fact that the cadavers are not always reusable. Furthermore, of the several papers in the literature studying the impact of cadaveric simulation, not one has actually demonstrated translation of learnt skills from cadaver training to improved real performance in the operating theatre (Jilbody et al, 2011). Nevertheless, in contrast to the current state of surgical training in the UK, which does not routinely utilise cadaveric practice as part of residency, I would propose an increasing role of this form of hi-fidelity simulation to surgeons of all levels, from junior trainees to experienced surgeons learning new techniques, to help develop and consolidate knowledge of anatomy and the technical skills of tissue dissection. 

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-Fresh cadaveric tissue faithfully represents the anatomic structures encountered in the real patient during an operation, and therefore can powerfully simulate technical practice and consolidate anatomical knowledge in surgical training. I would argue from my own experience that for those operations that involve learning soft tissue anatomy, tissue handling as well as dissection techniques, the role of cadaveric training is critical and cannot be provided by alternative low or high fidelity models. Indeed, Anastakis et al (1999) described cadaver models as ‘the gold standard for technical skills training’, and there are certainly examples in the literature describing the use of cadavers in American surgical residency programs such as in Plastic surgery that have found an increase in participating surgeons’ confidence from cadaveric simulation (Sheckter et al, 2013; Chambers et al, 2015).                                                                                                                                                                                     -Logistical issues around human cadaveric training include the relatively high expense (Anastakis et al, 1999); the requirement for regular maintenance and special facilities; and the fact that the cadavers are not always reusable. Furthermore, of the several papers in the literature studying the impact of cadaveric simulation, not one has actually demonstrated translation of learnt skills from cadaver training to improved real performance in the operating theatre (Jilbody et al, 2011). Nevertheless, in contrast to the current state of surgical training in the UK, which does not routinely utilise cadaveric practice as part of residency, I would propose an increasing role of this form of hi-fidelity simulation to surgeons of all levels, from junior trainees to experienced surgeons learning new techniques, to help develop and consolidate knowledge of anatomy and the technical skills of tissue dissection. 

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cadaveric tissue simulation - Bing images

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Labs - Synthetic Human Tissue and Body Parts - Shark Tank Products

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CONCLUSION                                                                                                                                                                                                                                                                                                                          I believe it is possible to train competent surgeons in the new shortened timeframe but it requires efficient and safe transfer of knowledge and skills to trainees, where quality must compensate for quantity, and here lies the role of simulation through various forms as described above. In the short term, the financial costs of increasing simulation within surgical training – especially using more life-like simulators with instantaneous and complex feedback (high fidelity) – are a possible disadvantage but this may well be offset by greater operating theatre efficiency and potential decreased medico-legal costs (Brown, 2013).

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CONCLUSION                                                                                                                                                                                                                                                                                                                          I believe it is possible to train competent surgeons in the new shortened timeframe but it requires efficient and safe transfer of knowledge and skills to trainees, where quality must compensate for quantity, and here lies the role of simulation through various forms as described above. In the short term, the financial costs of increasing simulation within surgical training – especially using more life-like simulators with instantaneous and complex feedback (high fidelity) – are a possible disadvantage but this may well be offset by greater operating theatre efficiency and potential decreased medico-legal costs (Brown, 2013).

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-There may be an ‘inward-looking’ culture in medicine that holds expertise as an achievable goal only by cumulative apprenticeship-style learning within the medical field itself. This ‘seductive self-sufficiency’ in medicine as Kneebone (2017) succinctly stated, can run the risk of missing important, insightful collaborations with other worlds of work, that may provide new information relevant to clinical practice. In the context of surgical education, I assert that such direct engagements with the practice of other craftspeople and performers may provide enhanced learning for trainees. For example, collaboration between a lace-embroiderer and a vascular surgery team at a leading London hospital has identified techniques from lace-making that could improve surgeons' control over fine sutures when they join arteries together, and has led to the current development of an educational programme for trainees aimed at overcoming problems with thread tangling during surgery. Indeed, it was from outward looking surgeons drawing insights from pilots’ flight checks in the aviation industry that led to the development of the World Health Organisation (WHO) checklist for surgical safety, introduced in 2009, and which has since led to dramatically reduced peri-operative mortality and complication rates by more than a third (Haynes et al, 2009).     

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-There may be an ‘inward-looking’ culture in medicine that holds expertise as an achievable goal only by cumulative apprenticeship-style learning within the medical field itself. This ‘seductive self-sufficiency’ in medicine as Kneebone (2017) succinctly stated, can run the risk of missing important, insightful collaborations with other worlds of work, that may provide new information relevant to clinical practice. In the context of surgical education, I assert that such direct engagements with the practice of other craftspeople and performers may provide enhanced learning for trainees. For example, collaboration between a lace-embroiderer and a vascular surgery team at a leading London hospital has identified techniques from lace-making that could improve surgeons' control over fine sutures when they join arteries together, and has led to the current development of an educational programme for trainees aimed at overcoming problems with thread tangling during surgery. Indeed, it was from outward looking surgeons drawing insights from pilots’ flight checks in the aviation industry that led to the development of the World Health Organisation (WHO) checklist for surgical safety, introduced in 2009, and which has since led to dramatically reduced peri-operative mortality and complication rates by more than a third (Haynes et al, 2009).     

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(00:00 - 04:59)

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Roger Kneebone and Aaron Williamon - Solving stage fright in virtual reality

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Do you hate performing in front of an audience? New virtual reality technology could ease your fears. Imperial's Professor Roger Kneebone and the Royal College of Music's Professor Aaron Williamon discuss a new mobile performance simulator to help musicians, politicians or business leaders, perform in front of an audience.

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Addressing different audiences:                                                                                                                                                                                                                                                                                     -From my own professional experience surgeons and trainees experience very close team-working with nursing staff. Yet none of my training has ever included nurses as participants. I would argue that simulation in surgical training needs to include nurses as participants to enable real team building development. Surgical trainees have an enormous amount to learn from the nursing staff both on the ward and in the operating theatre and vice versa and so two-way mutual sharing of knowledge, skills, and experiences in simulation settings will greatly prepare both sets of professionals for the real-world healthcare environment. For example, the critical patient perspectives that nurses have would give invaluable insights and lessons for surgical trainees to forge closer relationships with patients, whilst surgeon training of nurses to better triage (clinically prioritise) patient admissions may improve patient safety and outcomes. These simulation endeavours that integrate nursing and surgical colleagues are starting to emerge and have been shown to be effective (Aebersold & Tschannen, 2013).                                                     -Until now stimulation within surgical training has focused on the trainee’s development of technical skills, clinical judgement and team-working abilities (Brown, 2013). Engaging the everyday public in surgical simulation has never really been a consideration. But I would argue that this is perhaps an inconsistent position to hold since as surgeons we are taught very early on about the principle of the ‘golden hour’ in emergency treatment – the concept that the first hour following a traumatic injury is the most important time for treatments to make an impact and reduce the risk of death or disability, and therefore that pre-hospital care, which the public are often involved with, is hugely important to subsequent patient outcome (McNicholl, 1994). I therefore strongly advocate that surgical simulation should incorporate scenarios that directly engage the public and train their own basic skills in life support and pre-hospital care. This might involve leadership from trainees to help train the public in simulated scenarios at ‘roadshows’. We could then consider the public as part of the surgical team from a care giving point of view. With this mindset and simulation approach, surgical outcomes in trauma management could well improve.                                                                                                                                                                    -Another reason for public engagement in surgical simulation is that important feedback to the surgeons and trainees themselves may be gained from the public perspective, which is increasingly important today. This two-way sharing of information and insights between layperson and surgeon / surgeon-trainee has been recently demonstrated by researchers at Imperial College London (Tang et al, 2013).               

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Addressing different audiences:                                                                                                                                                                                                                                                                                     -From my own professional experience surgeons and trainees experience very close team-working with nursing staff. Yet none of my training has ever included nurses as participants. I would argue that simulation in surgical training needs to include nurses as participants to enable real team building development. Surgical trainees have an enormous amount to learn from the nursing staff both on the ward and in the operating theatre and vice versa and so two-way mutual sharing of knowledge, skills, and experiences in simulation settings will greatly prepare both sets of professionals for the real-world healthcare environment. For example, the critical patient perspectives that nurses have would give invaluable insights and lessons for surgical trainees to forge closer relationships with patients, whilst surgeon training of nurses to better triage (clinically prioritise) patient admissions may improve patient safety and outcomes. These simulation endeavours that integrate nursing and surgical colleagues are starting to emerge and have been shown to be effective (Aebersold & Tschannen, 2013).                                                     -Until now stimulation within surgical training has focused on the trainee’s development of technical skills, clinical judgement and team-working abilities (Brown, 2013). Engaging the everyday public in surgical simulation has never really been a consideration. But I would argue that this is perhaps an inconsistent position to hold since as surgeons we are taught very early on about the principle of the ‘golden hour’ in emergency treatment – the concept that the first hour following a traumatic injury is the most important time for treatments to make an impact and reduce the risk of death or disability, and therefore that pre-hospital care, which the public are often involved with, is hugely important to subsequent patient outcome (McNicholl, 1994). I therefore strongly advocate that surgical simulation should incorporate scenarios that directly engage the public and train their own basic skills in life support and pre-hospital care. This might involve leadership from trainees to help train the public in simulated scenarios at ‘roadshows’. We could then consider the public as part of the surgical team from a care giving point of view. With this mindset and simulation approach, surgical outcomes in trauma management could well improve.                                                                                                                                                                    -Another reason for public engagement in surgical simulation is that important feedback to the surgeons and trainees themselves may be gained from the public perspective, which is increasingly important today. This two-way sharing of information and insights between layperson and surgeon / surgeon-trainee has been recently demonstrated by researchers at Imperial College London (Tang et al, 2013).               

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Image below: Prof Roger Kneebone and Wellcome Trust fellowship for Simulation and public engagement. Background shows inflatable operative theatre simulation for public viewing.

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INTRODUCTION                                                                                                                                                                                                                                                                                                                              With the reduced working hours mandated for surgical trainees in the UK since the introduction of the European Working Time Directive (EWTD) in 1998, the operative case volume available to the trainee has reduced by up to 80% (Chikwe et al, 2004). Furthermore, new streamlined (‘run-through’) training schemes have been introduced resulting in trainees having fewer years to actually acquire the necessary skills and expertise for independent practice. In addition, increasing surgeon subspecialisation is resulting in an increasing number of complex operations being performed, and simultaneously, surgeons are under more pressure to be accountable for efficient use of operating theatre time. This has resulted in fewer cases of suitable simplicity for the trainee and also a lack of time in theatre for trainee teaching. Therefore, there is a stronger need now than ever before for an expanding role of simulation to bridge the gap in learning from real operative and clinical experience where making mistakes in order to learn and become competent (the ‘learning curve’) is not ethically acceptable nor safe for the patient.                                                                                                                                                                                                                                                                                                                                       From a pedagogical standpoint, simulation enables trainees to learn technical skills safely with stimulating engagement and often instantaneous feedback depending on staff and simulator fidelity factors; perform deliberate repetitive practice to help achieve task mastery as advocated by Ericsson (1996); and importantly have the ‘permission to fail’ with encouragement to make mistakes and explore these in order to find the best techniques or solutions – therefore reaching the highest order of Bloom’s taxonomy of learning (creating/constructing) (Bloom et al, 1956) and reducing stress levels which has been cited as a barrier to learning (Cosman et al, 2002) – so that when faced with the real patient, the trainee’s operative involvement is more effective and safer. Therefore simulation is a powerful pedagogical tool that if expanded within surgical training programmes could address many of the challenges and limitations of current training conditions with respect to gaining competence in operative skills in a no longer adequate Halstedian model of apprenticeship-style surgical training (Kerr & O’Leary, 1999).                                                                                                                                                                                                                                                                                                                                               From an ethical standpoint, the growing need for simulation in surgical training stems from changing patient attitudes. Bradley & Postlethwaite (2003) highlights that patients’ acceptance of being a “passive, uninformed participant in medical education” – a situation more common in the past – “no longer exists today”. I have also witnessed this cultural shift amongst patients over the last 10 years of my own surgical training, where patients today are increasingly enquiring as to who will be doing their operation and their level of expertise and often requesting the senior most surgeon. This is certainly a shift from the more patriarchal care of a decade ago. Therefore in this context, expanding the role of simulation will help the trainee develop procedural skills and show competence outside the clinical setting to then more acceptably and safely transfer these skills to real patients.                                                                                                                             In the following sections I will discuss the ways in which I believe simulation in surgical training should expand and I have categorised these ideas by whether they address a new audience or the same audience but in a new manner.

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INTRODUCTION                                                                                                                                                                                                                                                                                                                              With the reduced working hours mandated for surgical trainees in the UK since the introduction of the European Working Time Directive (EWTD) in 1998, the operative case volume available to the trainee has reduced by up to 80% (Chikwe et al, 2004). Furthermore, new streamlined (‘run-through’) training schemes have been introduced resulting in trainees having fewer years to actually acquire the necessary skills and expertise for independent practice. In addition, increasing surgeon subspecialisation is resulting in an increasing number of complex operations being performed, and simultaneously, surgeons are under more pressure to be accountable for efficient use of operating theatre time. This has resulted in fewer cases of suitable simplicity for the trainee and also a lack of time in theatre for trainee teaching. Therefore, there is a stronger need now than ever before for an expanding role of simulation to bridge the gap in learning from real operative and clinical experience where making mistakes in order to learn and become competent (the ‘learning curve’) is not ethically acceptable nor safe for the patient.                                                                                                                                                                                                                                                                                                                                       From a pedagogical standpoint, simulation enables trainees to learn technical skills safely with stimulating engagement and often instantaneous feedback depending on staff and simulator fidelity factors; perform deliberate repetitive practice to help achieve task mastery as advocated by Ericsson (1996); and importantly have the ‘permission to fail’ with encouragement to make mistakes and explore these in order to find the best techniques or solutions – therefore reaching the highest order of Bloom’s taxonomy of learning (creating/constructing) (Bloom et al, 1956) and reducing stress levels which has been cited as a barrier to learning (Cosman et al, 2002) – so that when faced with the real patient, the trainee’s operative involvement is more effective and safer. Therefore simulation is a powerful pedagogical tool that if expanded within surgical training programmes could address many of the challenges and limitations of current training conditions with respect to gaining competence in operative skills in a no longer adequate Halstedian model of apprenticeship-style surgical training (Kerr & O’Leary, 1999).                                                                                                                                                                                                                                                                                                                                               From an ethical standpoint, the growing need for simulation in surgical training stems from changing patient attitudes. Bradley & Postlethwaite (2003) highlights that patients’ acceptance of being a “passive, uninformed participant in medical education” – a situation more common in the past – “no longer exists today”. I have also witnessed this cultural shift amongst patients over the last 10 years of my own surgical training, where patients today are increasingly enquiring as to who will be doing their operation and their level of expertise and often requesting the senior most surgeon. This is certainly a shift from the more patriarchal care of a decade ago. Therefore in this context, expanding the role of simulation will help the trainee develop procedural skills and show competence outside the clinical setting to then more acceptably and safely transfer these skills to real patients.                                                                                                                             In the following sections I will discuss the ways in which I believe simulation in surgical training should expand and I have categorised these ideas by whether they address a new audience or the same audience but in a new manner.