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The necessity for simulation in all domains

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The necessity for simulation in all domains

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The purpose of this essay is to explore the rationale for surgical educators to expand simulation to other and existing audiences. This discussion addresses methods by which to expand simulation using a multimedia approach. However, It is useful first to define simulation in order to understand its requirement. 

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The purpose of this essay is to explore the rationale for surgical educators to expand simulation to other and existing audiences. This discussion addresses methods by which to expand simulation using a multimedia approach. However, It is useful first to define simulation in order to understand its requirement. 

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Ker and Bradley describe simulation as “a technique which can be used to facilitate any learning, whether in the cognitive, psychomotor or affective domains” (2010, pp. 175). It is “not defined in terms of either high (or low) technology, nor is it confined to interactions with people or models, physical or virtual” (2010, pp. 176). 

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Ker and Bradley describe simulation as “a technique which can be used to facilitate any learning, whether in the cognitive, psychomotor or affective domains” (2010, pp. 175). It is “not defined in terms of either high (or low) technology, nor is it confined to interactions with people or models, physical or virtual” (2010, pp. 176). 

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To provide some context for simulation, Kneebone (2003) describes a trainee surgeon, gradually building necessary skillsets for independent practice through the fusion of factual knowledge, clinical judgement and operative skill. The influential learning theories relevant to simulation that Kneebone (2003, pp. 268-269) summarises is in Table 1. 

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To provide some context for simulation, Kneebone (2003) describes a trainee surgeon, gradually building necessary skillsets for independent practice through the fusion of factual knowledge, clinical judgement and operative skill. The influential learning theories relevant to simulation that Kneebone (2003, pp. 268-269) summarises is in Table 1. 

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Table 1. Kneebone’s (2003) summary of influential theories of adult learning.

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Table 1. Kneebone’s (2003) summary of influential theories of adult learning.

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Ker and Bradley (2010, pp. 176) summarise some of the societal, political, clinical and educational influences that are driving simulation development over the last 40 years in Figure 1.  

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Ker and Bradley (2010, pp. 176) summarise some of the societal, political, clinical and educational influences that are driving simulation development over the last 40 years in Figure 1.  

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Figure 1. Ker and Bradley’s drivers for simulation development (2010, pp. 176)

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Figure 1. Ker and Bradley’s drivers for simulation development (2010, pp. 176)

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As the learning requirements of the trainee are secondary to the clinical needs of the patient, there is an increasing expectation from simulation to facilitate learning. Simulation must buffer the deficit in learning as educators move away from the apprenticeship model and to meet the requirements from the various stakeholders. 

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As the learning requirements of the trainee are secondary to the clinical needs of the patient, there is an increasing expectation from simulation to facilitate learning. Simulation must buffer the deficit in learning as educators move away from the apprenticeship model and to meet the requirements from the various stakeholders. 

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In the wake of scandalous events such as the Bristol heart scandal, Smith (1998) identifies the consequential transformations in assessment and evaluation of competences and technical expertise. 

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In the wake of scandalous events such as the Bristol heart scandal, Smith (1998) identifies the consequential transformations in assessment and evaluation of competences and technical expertise. 

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We are now in an era of transparency involving not only the accountability of a doctor but also reliability and validity of performance monitoring data. Another driver of simulation has been the challenges the surgical profession faces as a result of the European Work Time Directive. 

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We are now in an era of transparency involving not only the accountability of a doctor but also reliability and validity of performance monitoring data. Another driver of simulation has been the challenges the surgical profession faces as a result of the European Work Time Directive. 

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Cresswell (2009) reports the significant difficulty in training surgeons within newly imposed time constraints and the need for more efficient ways of learning. Again, surgical educators must use simulation to compensate for fewer opportunities to attend theatre for shift workers. 

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Cresswell (2009) reports the significant difficulty in training surgeons within newly imposed time constraints and the need for more efficient ways of learning. Again, surgical educators must use simulation to compensate for fewer opportunities to attend theatre for shift workers. 

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The Royal College of Surgeons (RCS) (2014) outlines a range of domains and subdomains of good surgical practise (Table 2) to help guide trainee development in the context of stakeholder expectation. 

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The Royal College of Surgeons (RCS) (2014) outlines a range of domains and subdomains of good surgical practise (Table 2) to help guide trainee development in the context of stakeholder expectation. 

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Table 2. Royal College of Surgeons of England (2014) Domains of good surgical practice.

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Table 2. Royal College of Surgeons of England (2014) Domains of good surgical practice.

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Within the domain of knowledge, skills and performance, the RCS explicitly recommends the appropriate application of simulation to facilitate the learning of new procedures. 

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Within the domain of knowledge, skills and performance, the RCS explicitly recommends the appropriate application of simulation to facilitate the learning of new procedures. 

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However, from the constructivist standpoint, given experiential learning has been globally limited due to sociopolitical and clinical restraints, it arguable that simulation has a role to play in facilitating development in all domains of good practice. 

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However, from the constructivist standpoint, given experiential learning has been globally limited due to sociopolitical and clinical restraints, it arguable that simulation has a role to play in facilitating development in all domains of good practice. 

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When patient safety is concerned, it would be reasonable from the behaviourist stance to assume ethically repetitive practice with simulation would allow for a safer but still supervised operation to proceed. 

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When patient safety is concerned, it would be reasonable from the behaviourist stance to assume ethically repetitive practice with simulation would allow for a safer but still supervised operation to proceed. 

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Gallagher et al. (2005) suggest simulation-based skills training can produce a ‘trained novice’ with pre-automation of basic technical aspects that in turn allows a narrower focus on learning the operational steps and how to manage unexpected events. Such a practice can have a significant measurable benefit.

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Gallagher et al. (2005) suggest simulation-based skills training can produce a ‘trained novice’ with pre-automation of basic technical aspects that in turn allows a narrower focus on learning the operational steps and how to manage unexpected events. Such a practice can have a significant measurable benefit.

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Zevin et al. (2014) have shown that repetitive use of simulation reduces operation time, lowers the complication rates and improves clinical outcomes.

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Zevin et al. (2014) have shown that repetitive use of simulation reduces operation time, lowers the complication rates and improves clinical outcomes.

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Renwick et al. (2005), Itani et al. (2005) and Kanakala et al. (2010) all report that patient outcomes of those operated on during training courses were not significantly different. 

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Renwick et al. (2005), Itani et al. (2005) and Kanakala et al. (2010) all report that patient outcomes of those operated on during training courses were not significantly different. 

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However, it is debatable that these data may not necessarily be representative given consultants on training courses may have formal training on teaching. They are also more likely to be experienced with teaching and supervising when compared to the average operating consultant. 

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However, it is debatable that these data may not necessarily be representative given consultants on training courses may have formal training on teaching. They are also more likely to be experienced with teaching and supervising when compared to the average operating consultant. 

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Expanding into the other domains of good practice, surgical educators can also optimise patient safety by applying the use of simulation further to clinical decision-making. 

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Expanding into the other domains of good practice, surgical educators can also optimise patient safety by applying the use of simulation further to clinical decision-making. 

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Evans et al. (2015) describe ‘Septris’, a portmanteau of the words sepsis and Tetris, describing a mobile-accessible, case-based, online game that takes an innovative approach to teach early sepsis identification and evidence-based management. 

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Evans et al. (2015) describe ‘Septris’, a portmanteau of the words sepsis and Tetris, describing a mobile-accessible, case-based, online game that takes an innovative approach to teach early sepsis identification and evidence-based management. 

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https://med.stanford.edu/septris/game/SeptrisTitle.html

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Another example is the surgical environment of clinical knowledge ops (SICKO) created by Lin et al. (2015). 

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Another example is the surgical environment of clinical knowledge ops (SICKO) created by Lin et al. (2015). 

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SICKO is a novel gaming platform validated as a training and assessment platform with interactive modules that teach practising surgeons pre- and intraoperative decision-making skills for common surgical pathologies. 

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SICKO is a novel gaming platform validated as a training and assessment platform with interactive modules that teach practising surgeons pre- and intraoperative decision-making skills for common surgical pathologies. 

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http://med.stanford.edu/sm/archive/sicko/game/SICKO.html

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Surgical educators could expand the use of these to all junior levels. Simulations such as these are relatively cost-effective once designed and have invaluable use in training and re-training surgeons of all levels. 

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Surgical educators could expand the use of these to all junior levels. Simulations such as these are relatively cost-effective once designed and have invaluable use in training and re-training surgeons of all levels. 

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Amid the COVID-19 pandemic, this is of particular relevance given Royal College of Surgeons (2020) guidance emphasising adaptability to provide a service in alternate surgical and nonsurgical roles.

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Amid the COVID-19 pandemic, this is of particular relevance given Royal College of Surgeons (2020) guidance emphasising adaptability to provide a service in alternate surgical and nonsurgical roles.

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In addition to optimising patient safety, simulation also has a role in facilitating communication and teamwork, an integral component for delivering safe, high-quality patient care. Leonard et al. (2004) report communication failures as a widespread cause of avoidable patient harm. 

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In addition to optimising patient safety, simulation also has a role in facilitating communication and teamwork, an integral component for delivering safe, high-quality patient care. Leonard et al. (2004) report communication failures as a widespread cause of avoidable patient harm. 

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However, high fidelity simulators are of limited use outside centres of simulation due to the considerable costs.  

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However, high fidelity simulators are of limited use outside centres of simulation due to the considerable costs.  

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Kneebone et al. (2010) introduce the concept of distributed simulation as a solution; a self-contained ‘set’ for creating simulation environments within an inflatable enclosure, known as the distributed simulation theatre (Figure 2).  

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Kneebone et al. (2010) introduce the concept of distributed simulation as a solution; a self-contained ‘set’ for creating simulation environments within an inflatable enclosure, known as the distributed simulation theatre (Figure 2).  

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Figure 2. Kneebone et al. (2010) distributable simulation theatre

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Figure 2. Kneebone et al. (2010) distributable simulation theatre

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Distributed simulation in action: Click video to play

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Distributed simulation in action: Click video to play

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By being easily transportable, it can deliver high fidelity contextualised simulation at a fraction of the cost typical of static centres. There is also the added flexibility of recreating a variety of clinical scenarios to meet user need. 

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By being easily transportable, it can deliver high fidelity contextualised simulation at a fraction of the cost typical of static centres. There is also the added flexibility of recreating a variety of clinical scenarios to meet user need. 

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Physical or hybrid simulations (Figure 3) can give the added dimension for simulation of trauma without the need for complicated and costly mannikins. 

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Physical or hybrid simulations (Figure 3) can give the added dimension for simulation of trauma without the need for complicated and costly mannikins. 

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Figure 3. Kneebone et al. (2010)  hybrid simulation

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Figure 3. Kneebone et al. (2010)  hybrid simulation

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In a feasibility study by Harris et al. (2013), the use of an inflatable enclosure is adequately intuitive for a researcher naïve to distributed simulation in areas outside of regular simulation use and high acceptability. 

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In a feasibility study by Harris et al. (2013), the use of an inflatable enclosure is adequately intuitive for a researcher naïve to distributed simulation in areas outside of regular simulation use and high acceptability. 

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Surgical educators can utilise distributed simulation in several ways. At an elementary level, medical students often have their first terrifying memories of theatre, desperate not obstruct or decontaminate equipment. 

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Surgical educators can utilise distributed simulation in several ways. At an elementary level, medical students often have their first terrifying memories of theatre, desperate not obstruct or decontaminate equipment. 

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The inflatable enclosure could provide a transition step to teach theatre preparation and etiquette to a variety of students and trainees other than surgeons such as anaesthetists, scrub nurses and theatre assistants. 

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The inflatable enclosure could provide a transition step to teach theatre preparation and etiquette to a variety of students and trainees other than surgeons such as anaesthetists, scrub nurses and theatre assistants. 

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These also have a use in conjunction with high fidelity virtual reality (VR) simulations such as Lapsim and MIST-VR described in a systematic review by Alaker et al. (2016), shown to be more effective than video trainers, and parallel to box trainers. VR itself is a rapidly developing field and increasingly used in centres.   

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These also have a use in conjunction with high fidelity virtual reality (VR) simulations such as Lapsim and MIST-VR described in a systematic review by Alaker et al. (2016), shown to be more effective than video trainers, and parallel to box trainers. VR itself is a rapidly developing field and increasingly used in centres.   

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Rangarajan et al. (2020) describe augmentation with haptic feedback improving the fidelity, realism and in turn, the training effect of VR simulators. Surgical educators may develop the use of these for practising high stakes complex or seldom occurring operations.

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Rangarajan et al. (2020) describe augmentation with haptic feedback improving the fidelity, realism and in turn, the training effect of VR simulators. Surgical educators may develop the use of these for practising high stakes complex or seldom occurring operations.

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High Fidelity VR in action: Click on video to play

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High Fidelity VR in action: Click on video to play

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Full clip at https://www.youtube.com/watch?v=p4vO64Y27JE

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As surgical educators increasingly utilise simulation to facilitate learning, surgeons of all levels are developing a new form of literacy. 

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As surgical educators increasingly utilise simulation to facilitate learning, surgeons of all levels are developing a new form of literacy. 

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Case and Bruce describe literacy as “best understood through the concept of participation. Literacy enables participation, and new technologies give rise to new forms of participation, and hence new literacies” (2011, pp.76). 

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Case and Bruce describe literacy as “best understood through the concept of participation. Literacy enables participation, and new technologies give rise to new forms of participation, and hence new literacies” (2011, pp.76). 

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However, the use of simulation is concentrated at large centres with funding to sustain high fidelity models. Solutions such as distributed and hybrid simulation have the potential to have widespread and standardised use, as do existing technologies as they become cheaper to reproduce. 

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However, the use of simulation is concentrated at large centres with funding to sustain high fidelity models. Solutions such as distributed and hybrid simulation have the potential to have widespread and standardised use, as do existing technologies as they become cheaper to reproduce. 

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If this were to become the case, the next organic step in expanding the use of simulation would be in examination. 

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If this were to become the case, the next organic step in expanding the use of simulation would be in examination. 

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Platforms similar to Septris and SICKO have the potential to be used in surgical membership examinations, should multiple-choice questions become computerised in the future. 

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Platforms similar to Septris and SICKO have the potential to be used in surgical membership examinations, should multiple-choice questions become computerised in the future. 

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There is also the potential for a role of distributed simulation in observed structured clinical examinations (OSCE) examinations at all levels allowing evaluation of clinical and professional competencies in a manner that is contextualised and less fragmented. 

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There is also the potential for a role of distributed simulation in observed structured clinical examinations (OSCE) examinations at all levels allowing evaluation of clinical and professional competencies in a manner that is contextualised and less fragmented. 

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Automated methods of assessment within simulation may provide the added theoretical benefit of performance measurement free from assessor subjectivity. 

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Automated methods of assessment within simulation may provide the added theoretical benefit of performance measurement free from assessor subjectivity. 

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Other considerations when expanding the use of simulation

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Other considerations when expanding the use of simulation

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However, Badash et al. (2016) highlight the importance of accountability of surgical educators for the efficacy of the surgical training and requires educators to have a methodical approach when it comes to verifying if the designed standard of training is effective. 

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However, Badash et al. (2016) highlight the importance of accountability of surgical educators for the efficacy of the surgical training and requires educators to have a methodical approach when it comes to verifying if the designed standard of training is effective. 

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Surgical educators must justify how, where, when, which and frequency of simulations use in clinical training. 

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Surgical educators must justify how, where, when, which and frequency of simulations use in clinical training. 

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A Health Quality (2017) report, for example, demonstrated no high-quality evidence that robot-assisted radical prostatectomy improves functional and oncological outcomes compared with open and laparoscopic approaches for prostatectomy. 

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A Health Quality (2017) report, for example, demonstrated no high-quality evidence that robot-assisted radical prostatectomy improves functional and oncological outcomes compared with open and laparoscopic approaches for prostatectomy. 

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It is easy to become blind to the futility of technological leaps at disproportionate costs to the National Health Service or of little benefit to patient outcomes. 

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It is easy to become blind to the futility of technological leaps at disproportionate costs to the National Health Service or of little benefit to patient outcomes. 

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It is also essential to establish an appropriate target audience. Alaker et al. (2016) have not been able to identify who exactly benefits the most from the simulation in a systematic review. Surgical educators must, therefore, take a careful, pragmatic approach.

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It is also essential to establish an appropriate target audience. Alaker et al. (2016) have not been able to identify who exactly benefits the most from the simulation in a systematic review. Surgical educators must, therefore, take a careful, pragmatic approach.

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The surgical trainees of today are subject to a much harsher socio-political landscape than their predecessors. In the effort to comply with demands or restrictions influenced by multiple stakeholders, surgical educators must devise ways to buffer the lack of hands-on or experiential learning previously obtained from direct patient contact. 

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The surgical trainees of today are subject to a much harsher socio-political landscape than their predecessors. In the effort to comply with demands or restrictions influenced by multiple stakeholders, surgical educators must devise ways to buffer the lack of hands-on or experiential learning previously obtained from direct patient contact. 

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Surgical educators, however, are fortunate in that there are currently multiple solutions rapidly in development aimed at facilitating learning and development in all domains of good surgical practice. 

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Surgical educators, however, are fortunate in that there are currently multiple solutions rapidly in development aimed at facilitating learning and development in all domains of good surgical practice. 

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However, educators must be careful to maintain a sensible financial perspective. Septris and SICKO are platforms that are free, accessible, and quickly disseminated, including throughout the developing world. 

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However, educators must be careful to maintain a sensible financial perspective. Septris and SICKO are platforms that are free, accessible, and quickly disseminated, including throughout the developing world. 

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The distributed simulation theatre is a cost-effective solution that may foster the widespread use of simulation in the United Kingdom and may also have global applications. Indeed, there may be a point in time where the use of simulation has become widespread and standardised. 

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The distributed simulation theatre is a cost-effective solution that may foster the widespread use of simulation in the United Kingdom and may also have global applications. Indeed, there may be a point in time where the use of simulation has become widespread and standardised. 

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All participants in, or related to, the field of surgery may become simulation literate. Surgical educators must also, therefore, explore the role of simulation as a minimally fragmented contextualised solution that could theoretically be free of subjectivity with automation.

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All participants in, or related to, the field of surgery may become simulation literate. Surgical educators must also, therefore, explore the role of simulation as a minimally fragmented contextualised solution that could theoretically be free of subjectivity with automation.

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Background Image Credits: NASA, ESA, P. Oesch (University of Geneva), and M. Montes (University of New South Wales)

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Background Image Credits: NASA, ESA, P. Oesch (University of Geneva), and M. Montes (University of New South Wales)

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Hubble Paints Picture of the Evolving Universe

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Astronomers have just assembled one of the most comprehensive portraits yet of the universe's evolutionary history.