The case for why and in what ways surgical educators should in future expand the use of simulation to address different audiences or to address existing audiences in different ways by Samim Ghorbanian

The case for why and in what ways surgical educators should in future expand the use of simulation to address different audiences or to address existing audiences in different ways by Samim Ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt Simulation Module Essay Submission - Imperial M.Ed en-us 2019-03-17 19:51:49 UTC 2026-01-02 18:43:29 UTC hello@padlet.com How to use this Padlet samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/342164075 Follow the arrows...]]> 2019-03-17 19:56:06 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/342164075 The theories behind Simulation samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/342164844 2019-03-17 20:01:22 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/342164844 How to Utilise Simulation samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/342174159 2019-03-17 21:07:45 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/342174159 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/342175286 "Being entirely honest with oneself is a good exercise"]]> 2019-03-17 21:15:51 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/342175286 Figure 13.2 Drivers for the development of simulation samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348905267 2019-04-05 13:03:08 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348905267 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348932018 2019-04-05 14:04:25 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348932018 The Pressures on Modern Training samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348932302
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 21^stcentury 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.

]]> 2019-04-05 14:04:59 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348932302 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348942596 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.

]]> 2019-04-05 14:25:17 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348942596 The good old days... samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348957153 2019-04-05 14:53:28 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348957153 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348957418
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.

]]> 2019-04-05 14:54:01 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348957418 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348972060 Surgical education was previously learnt by repeatition, this cant be the safest way forward...]]> 2019-04-05 15:25:24 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348972060 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348976568 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).

]]> 2019-04-05 15:35:27 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348976568 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348981005 “Simulation offers a safe, non‐clinical environment designed to meet the educational needs of a range of learners.”
Kneebone, 2003

]]> 2019-04-05 15:46:31 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348981005 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348984668 "Theoretic models provide generalizable explanations of natural phenomenon confirmed through observations, experimentation, and logical reasoning across various settings."
Chauvin 2015]]> 2019-04-05 15:56:17 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348984668 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348989616 2019-04-05 16:09:01 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348989616 SIMULATION IS NOT JUST SAFE REPETITION samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348991595 2019-04-05 16:13:13 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348991595 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348994586 Kolb’s 4-stage experiential learning cycle.

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

]]> 2019-04-05 16:20:25 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348994586 The Simulated Excercise samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348997006 2019-04-05 16:27:01 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348997006 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348997278 Planning and thinking about the simulation alone or with a trainer]]> 2019-04-05 16:27:53 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348997278 DEBRIEF + REFLECTION samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348997594 2019-04-05 16:28:41 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/348997594 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349003498 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.

]]> 2019-04-05 16:44:47 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349003498 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349003919 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.]]> 2019-04-05 16:45:54 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349003919 Applying Theory to Simulation... samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349018249 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. ]]> 2019-04-05 17:21:28 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349018249 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349019142 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.]]> 2019-04-05 17:23:19 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349019142 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349063169 2019-04-05 19:12:14 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349063169 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349064497 The whole point of the doomsday machine...is lost if you keep it a secret!
Dr Strangelove]]> 2019-04-05 19:16:31 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349064497 How to make it Meaningful.... samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349068477 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).

]]> 2019-04-05 19:31:12 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349068477 samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349070283 Example of OSAT Score sheet]]> 2019-04-05 19:38:49 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349070283 Bench-Top Models samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349075814 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).

]]> 2019-04-05 20:03:13 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349075814 Low Fidelity Bench Top Bench top samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349076340 Microsurgery]]> 2019-04-05 20:05:31 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349076340 High Fidelity Bench top samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349076908 Microsurgery - Live Rat]]> 2019-04-05 20:08:19 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349076908 Other Forms of Surgical Simulation samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349082622 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).

]]> 2019-04-05 20:36:52 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349082622 High FIdelity VR Model samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349088578 2019-04-05 21:16:35 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349088578 Hybrid simulators samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349089363 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).

]]> 2019-04-05 21:22:44 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349089363 Simulation for Non - Technical Skills samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349089875 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).

]]> 2019-04-05 21:27:29 UTC https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349089875 References samim_ghorbanian https://padlet.com/samim_ghorbanian/mcn8cw7yvsxt/wish/349095937

Agha, R. A. & Fowler, A. J. (2015) The role and validity of surgical simulation. International Surgery. 100 (2), 350-357.

Brehmer, M. & Swartz, R. (2005) Training on bench models improves dexterity in ureteroscopy. European Urology. 48 (3), 458-463.

Brydges, R., Manzone, J., Shanks, D., Hatala, R., Hamstra, S. J., Zendejas, B. & Cook, D. A. (2015) Self-regulated learning in simulation-based training: a systematic review and meta-analysis. Medical Education. 49 (4), 368-378. Available from: https://doi.org/10.1111/medu.12649. Available from: doi: 10.1111/medu.12649.

Capella, J., Smith, S., Philp, A., Putnam, T., Gilbert, C., Fry, W., Harvey, E., Wright, A., Henderson, K. & Baker, D. (2010) Teamwork training improves the clinical care of trauma patients. Journal of Surgical Education. 67 (6), 439-443.

Chauvin, S. W. (2015) Applying educational theory to simulation-based training and assessment in surgery. Surgical Clinics. 95 (4), 695-715.

Chikwe, J., de Souza, A. C. & Pepper, J. R. (2004) No title. No Time to Train the Surgeons.

Davis, D. & Lee, G. (2011) The use of standardized patients in the plastic surgery residency curriculum: teaching core competencies with objective structured clinical examinations. Plastic and Reconstructive Surgery. 128 (1), 291-298.

de Montbrun, S. L. & MacRae, H. (2012) Simulation in surgical education. Clinics in Colon and Rectal Surgery. 25 (03), 156-165.

Grober, E. D., Hamstra, S. J., Wanzel, K. R., Reznick, R. K., Matsumoto, E. D., Sidhu, R. S. & Jarvi, K. A. (2004) The educational impact of bench model fidelity on the acquisition of technical skill: the use of clinically relevant outcome measures. Annals of Surgery. 240 (2), 374.

Kneebone, R. (2003) Simulation in surgical training: educational issues and practical implications. Medical Education. 37 (3), 267-277. Available from: https://doi.org/10.1046/j.1365-2923.2003.01440.x. Available from: doi: 10.1046/j.1365-2923.2003.01440.x.

Parsons, B. A., Blencowe, N. S., Hollowood, A. D. & Grant, J. R. (2011) Surgical training: the impact of changes in curriculum and experience. Journal of Surgical Education. 68 (1), 44-51.

Peters, J. H., Fried, G. M., Swanstrom, L. L., Soper, N. J., Sillin, L. F., Schirmer, B., Hoffman, K. & Sages FLS Committee. (2004) Development and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. Surgery. 135 (1), 21-27.

Phillip, H., Fleet, Z. & Bowman, K. (2003a) The European working time directive-interim report and guidance from the royal college of surgeons of England working party. London: Royal College of Surgeons.

Phillip, H., Fleet, Z. & Bowman, K. (2003b) The European working time directive-interim report and guidance from the royal college of surgeons of England working party. London: Royal College of Surgeons.

Reznick, R., Regehr, G., MacRae, H., Martin, J. & McCulloch, W. (1997) Testing technical skill via an innovative “bench station” examination. The American Journal of Surgery. 173 (3), 226-230.

Taffinder, N., Smith, S., Mair, J., Russell, R. & Darzi, A. (1999) Can a computer measure surgical precision? Reliability, validity and feasibility of the ICSAD. Surg Endosc. 13 (suppl 1), 81.

Tan, S. S. Y. & Sarker, S. K. (2011) Simulation in surgery: a review. Scottish Medical Journal. 56 (2), 104-109.

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