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...and in this video against the backdrop of a London Underground station and a dramatic dimly lit operating theatre. These representations of anatomy and surgery are not copies of the real world. Their insertion into these stylised settings only serves to heighten the sense of hyperreality. We are consumers.

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Practice surgery anytime, anywhere with Touch Surgery

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In these two promotional videos for commercial offerings, anatomy and surgical simulation with graphic detail is superimposed on a cosy scene of candles and soft furnishings in the first instance...

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Project Esper: Mixed Reality Anatomy Learning

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Hyperreality under test

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Stories of simulation

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Blade Runner - Deckard Meets Rachel Pt 1

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Hands on simulation need not be restricted to surgical simulation. There are correspondences between other crafts that require expertise and a deep embodied knowledge that is hard to express in text or spoken words. Cross cutting shared skills may not only relate to dexterity; they could also explore the liminal spaces that cushion expertise such as the understanding in handling materials between what is lost beyond repair and what can be salvaged. It may also help make connections to further our understanding of deliberate practice and experiential learning across crafts; perhaps the repetitive skill in making pockets for a jacket or carving straight lines as a stonemason’s apprentice relate to harvesting veins in cardiac surgery? This approach may also help us engage with medical students, who arrive at university with so many lived experiences and skills that may be applicable to their future surgical practice.

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Closer to home, we might pay more attention to the core message of this presentation: Those who design and build surgical simulators are crafting models of the world in their own image, grounded in their beliefs and experiences. As the distinctions between simulation and reality become more blurred and ill-defined, we must amplify the voices of under-represented members of our surgical community to avoid the imbalances of the past being hard baked into a future reality by design, not merely neglect.

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Expanding surgical simulation around the globe

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Expanding surgical simulation around the globe

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Technology is sure to improve, with advances in fidelity further blurring the lines between reality and fantasy. Technological advances however are often expensive and slow to impact training in Low & Middle-Income Countries. Imagination, however, is free. Through the research and experience of groups like ICCESS, we may be able to help surgeons in countries where cost is a barrier to simulation think in an imaginative way about how best to use the funds they have. Perhaps surgeons in resource scarce regions have even more honed tactile, embodied understanding of procedures than colleagues in the US and Europe? One exciting avenue of research would be to take a ‘Thinking With Your Hands’ type workshop to a LMIC to see whether surgeons in practice there could design something elegant and cheap that served the needs of their students?

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Simulation and the language of speculative fiction

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Simulation and the language of speculative fiction

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By discussing simulation and the meaning of a digitally constructed reality we inevitably approach Baudrillard’s (somewhat) opaque text ‘Simulacres et Simulation’. In it he proposes that the signs and symbols with which our society has become so saturated now bear no resemblance to any known reality which they claim to represent. In the fourth stage of his sign-order, simulation consumes the ‘whole edifice’ of representation in itself, becoming a pure simulacrum and a truth in its own right. There is now only a new kind of social reality, in which the simulation is indistinguishable from reality; hyperreality. In popular culture, themes of hyperreality and simulation are found in the writings of William Gibson, JG Ballard and Philip K Dick. Through film, we have an aesthetic underpinning of our appreciation of simulation, perhaps seen best in Ridley Scott’s imagining of ‘Do Androids Dream of Electric Sheep’ and the replicants of Blade Runner.

How does this help us imagine the surgical simulator of the future? Often speculative fiction speaks to our very deepest hopes and fears for the future. In Peripheral, William Gibson’s latest book, a woman witnesses what she believes to be a murder while subbing in as a security guard in the beta version of a virtual game. She cannot be sure if what she has seen is gameplay or an actual murder; a swarm of tiny robots pierce the victim’s cheek ‘like a nanobot chainsaw’. It is at once absurd and strangely plausible. As robotics and VR merge, the interface that a surgeon is presented with for a real operation may be indistinguishable from that of her simulator. Perhaps in a nostalgic touch, for a ‘real’ operation the image of the patient will be depicted in the simulator in ‘old fashioned’ drapes or kidney dishes will appear on the side of the operating table when a tissue sample needs to be given out. These visual skeuomorphisms may reassure the surgeon she is operating on a real person.

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Although all three scenarios seem very different, they are all similar in that they demand feats of imagination from the student and the designer of the simulation.

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Upbeat classical musak, no blood, no gore, no other staff. The surgeon hero glides through a tibial nail untroubled by the voiceless torso of the supine patient or a complaining anaesthetist...

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Osso VR  |  Virtual Surgery.  Real Results.

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Simulation and the language of imagination

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Simulation and the language of imagination

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In talking about surgical simulation, we retreat into language that echoes narratives about reality and simulation from our wider culture. Motifs of simulation and simulacra have appeared throughout art and literature; as the Golem, Frankenstein’s monster or in Ovid’s Metamorphoses. There is an echo of Galatea in the still form of the simulation mannequin, formed to be a perfect patient through the desire of her physician Pygmalion. We talk of simulation ‘scripts’ that serve a satisfying narrative arc and assign roles to the people playing parts in the ‘resuscitation room’. In our day at the simulation lab at Chelsea and Westminster, I noticed that we were all reluctant to look through the two-way mirror when speaking to the control room; as instinctive players, we were hesitant in breaking the fourth wall. But simulation is not drama. Imagine watching a doctor punch a resuscitation mannequin in rage. The sight is shocking and transgressive, even if the only ‘person’ harmed is a silicone doll. By contrast, audiences sit through Titus Andronicus and ponder the meaning of ‘Revenge’ as Tamora tucks into a pie made with the bodies of her children. Here, no one judges the actor to be a cannibal. In this example, we may see Kant's quality of ‘disinterestedness’ (see Lyas' Aesthetics) in aesthetic judgement being respected in the theatre, but absent in the simulation lab reflecting an interesting tension between our use of art-language and the real-theatre of simulation.

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I can experience simulation through my hands, concentrating on my personal practice in the pursuit of excellence. In the simplest sense, I can practice the movements that make up an operation, so that my journey along the ‘learning curve’ is not gained at the expense of patient care. This is a compelling vision of expert practice, drawing on experimental research in domains held in high esteem in society such as classical music, chess and the aviation industry. It is interesting to note that there is less attention in the psychological literature to sports such as snooker than these more prestigious activities, despite the similarities in attention, perception and performance under pressure. Perhaps researchers are more drawn to creating the next Joshua Bell than understanding the route to mastery undertaken by Ronnie O’Sullivan in the smoky snooker halls of Chigwell? As a surgeon using simulated deliberate practice, I hope that I can transcend ‘arrested development’ and push through to a higher level of surgical expertise.

This model of the surgical world makes some contentious assumptions. Firstly, there is the implicit understanding that expertise can be objectively measured and studied in laboratory conditions; in Ericsson’s own words ‘…the focus should not be on recognised experts, but on individuals who exhibit reproducibly superior performance on representative, authentic tasks in their field.’. More fundamentally, in a nod to the behaviourist roots of Expertise Theory, the experience of the individual is foregrounded at the expense of an understanding of a shared, socially constructed model of work. To understand this wider, embodied dimension to surgical practice, I might design a simulation that promotes understanding through sharing and consider the sociocultural theories that underpin this.

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It is intuitively appealing to think of simulation as a safe space in which surgical trainees can test the limits of their confidence and skills in decision making whilst protecting patients from harm and for understandable reasons, this is also how simulation is marketed to the public and to the profession itself. It also appears true that the case for learning through simulation in surgery is made on a firm grounding in learning theory and empirical evidence from psychological research.  One example of a popular, persuasive model of simulation in surgery relates to deliberate practice and the claims made by psychologists such as K. Anders Ericsson in their belief that expert performance is related to simulation and practice.

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In making a box trainer, the designer needs a deep embodied understanding of the procedure she is trying to simulate, perhaps even at an instinctive inaccessible level, that enables the most important movements or manoeuvres to be captured by the task. The student then needs a leap of imagination to place this deliberate practice back into context and find the connections between other similar experiences within their own mind.

In the simulation lab, the designer and student construct a shared reality during the running of a scenario. When the simulation starts, the model created by the designer springs to life, each time subtly different as interpreted through the imagination and experiences of the students taking part.

In VR simulation, the designers of today are shaping the surgical reality of tomorrow by curating the interface between the act of surgery on the human body and the visual, haptic and auditory cues that the surgeon receives.

In all three cases, the act of imagination may mediate how the student or surgeon relates their experience in simulation to their beliefs about the future.

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Using laparoscopic simulators and saw bones trainers represents a hands-on experience, but one which is decontextualized; a skill abstracted from its environment and distilled down to the essence of the procedure.

By contrast, in immersive simulation, such as that in resuscitation training in a simulation lab, a student needs to look outwards for authentic cues from the environment and from her colleagues. She is tasked to manage a professional response to the simulation while maintaining a fragile suspension of disbelief as if in a macabre dramatic sketch.

With haptics and virtual reality simulation, there may be no need for any physical presence at all beyond the interface with the system. The surgeon is now forced to consider where the line is drawn between simulation and reality, and whether the two can (or should) be disentangled.

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Simulation allows surgeons to explore multiple facets of their practice within the bounds of a hand-crafted world that settles somewhere between dream-like fantasy and the dangers of reality. In simulating a system, the designer reveals their understanding of how the world works and when designing simulation for training, betrays their beliefs about how the world should be.

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As students, we dutifully suture pigs’ trotters and thread polo mints onto wooden dowels in the hope that the skills we are practising will pay off in the future. We are used to standardised patient encounters and confidently answering the questions of a mannequin in the simulation lab, voiced by a disembodied controller behind plate glass. We hope for haptic machines in the near future that mimic the hidden contours of the human body and high-fidelity immersive environments which promise to make the invisible seen and the impossible made real. What unites these visions of simulation and what separates them? Will new technology dictate the progress of simulation in surgery or are our attitudes and beliefs about the future just as important?

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Imagination: sometimes it's a ninja cat riding a unicorn holding a Desert Eagle.