By proposing SBT can be expanded in future to access different audiences through public engagement through sequential simulation (SqS), and extending existing SBT practices into selection of surgical trainees and for managing adverse events, this would further translate simulation to real clinical practice.  

While healthcare institution may use this tool for team training of multidisciplinary professionals, sequential simulations can be utilised to reach a diverse audience. Projects involving SqS, such as the school-based workshop to reduce and prevent knife violence (SHARP project), have the capacity to address needs at a community and policy level (Kneebone et al., 2016; Weldon et al., 2016; Powell et al., 2016; MEd M7 Hybrid week presentation, 2023). 

The Simulation-based Holistic Approach for Reducing & Preventing Knife Violence (SHARP) project for instance, presented during the Module 7 hybrid week (2023), engaged us to imagine about how simulation principles of imitating complex public health scenarios could benefit a wider and diverse audience, and made us think about how we could bring about such change in other fields, such as cancer prevention. We especially, appreciated the nominated target audience, where awareness and exposure to such issues at a young age had the potential to permeate into future behaviour. Likewise, the ‘Gossypiboma’ scenario put into practice, demonstrated an adverse event that was anxiety-provoking to the simulation candidate. Although it was not a technical exercise in resolving the ‘mistake’, it highlighted communication skills required to express that an error had been made, and the psychological safety aspects of managing off-handed comments in the simulated operating room, contributing to cognitive load. 

Using simulation as a component for selection of future surgical trainees, such as in Ireland (Hagelsteen et al., 2021), was further explored, as we both felt this was contentious. Surgery is indubitably a high-stakes technical profession, where visuospatial impairments are likely, but not proven, to preclude one’s ability to safely perform surgery, as are certain medical conditions prohibitive in aviation. While the demonstration of technical ability on simulators for pre-vocational trainees calls upon the nature versus nurture argument (McElnay, 2014), it may make evident trainees with an established interest in surgery that have already enrolled in deliberate practice of their skills. Therefore, it was felt that this warranted focus for future research.   

It is described how for various reasons, surgical trainees require opportunities for time and exposure to surgical education and practice outside of the operating room – this gap addressed by simulation-based training (SBT). This is widely evidenced in the literature, however Ayaz & Ismail (2022) suggest the benefits of simulation are more prominent in low- to middle-income countries. Collaboration with local experts and institutions would be necessary to develop relevant scenarios that reflect local disease characteristics and resource limitations; the use of low-cost and low fidelity models (pedagogically comparable to high-fidelity counterparts (Grober et al., 2004)) being applicable in these settings.  This is of personal importance, due to my ongoing involvement in Australasian-Pacific region surgical education. Further to this, the concept of simulation for public engagement in these communities is especially appropriate, where addressing mistrust of modern medicine and disparities in understanding natural history of disease and treatment options, can improve health outcomes.    

Since the European Working Time Directive was introduced, trainees’ working hours in the UK have been limited resulting in less time operating, and trainee dissatisfaction (Skipworth et al., 2008). The COVID-19 pandemic furthered this issue, with trainees in multiple countries and specialities experiencing a decrease in the number of operations performed during this time (Hope et al., 2021). There is therefore interest in how simulation can be used to address the experience gap this has left (Agha and Fowler, 2015). 

One way in which simulation is currently used within surgical education is deliberate practice on a part task trainer, with repeated drills and hours of practice until technical mastery of the trainer is achieved. These provide a useful tool in allowing early stage trainees to become familiar with procedures, and improve their manual skills, however successful transfer of improvement from task trainer to reality is mixed (Crochet et al., 2011; Hashimoto et al., 2015). A potential reason for this may be that these simulators are designed to teach a specific set of technical skills and responses to a situation which is controlled and pre-determined, whereas the reality is a dynamic, evolving issue to which surgeons must respond. 

 

There is no doubt that these play a role in developing essential attributes for future surgical experts. However, we argue that current practices do not address the full range of experiences required of trainees, or allow for a real exploration of the complexities of daily clinical work. 

 

Our proposal is to develop a series of sessions, inspired by Pelletier and Kneebone, (2016b)’s work which considers reality as a shared collective perception. In these sessions, simulation would be approached from a different perspective, one which embraces the playfulness and fantasy involved in simulation (highlighted in a video of participants before a sim session, left hand side) and allows trainee surgeons to consider issues that they face in their daily work, then experiment with solutions in an environment which resembles but which is not the reality in which they exist. Instead of pre-determined simulation scenarios where trainees must perform according to set expectations, there is the potential for simulation to become a two way democratic process through which team dynamics can be explored, and the fantasies of a better medical experience could be realised. We also hope that through the democratisation of a scenario, we may be able to facilitate reciprocal illumination, an idea introduced by Kneebone (2015) where there is a two way transfer of information between the tutor and the participant. 

Aggarwal R, Mytton OT, Derbrew M, Hananel D, Heydenburg M, Issenberg B, et al. (2010). Training and simulation for patient safety. Qual Saf Health Care, 19(Suppl 2): i34-43.

Agha, R. A. and Fowler, A. J. (2015) ‘The role and validity of surgical simulation’, International Surgery, 100(2). doi: 10.9738/INTSURG-D-14-00004.1.

Ayaz O & Ismail FW (2022). Healthcare Simulation: A key to the future of medical education – a review. Adv Med Educ Prac, 13: 301-8.  

Bassot B (2013). The Reflective Journal. Palgrave Macmillan, Basingstoke UK. 

Burke CS, Salas E, Wilson-Donnelly K & Priest H (2004). How to turn a team of experts into an expert medical team: guidance from the aviation and military communities. BMJ Qual Saf, 13(Suppl 1), i96-104. DOI: 10.1136/qshc.2004.009829.

Coats RD & Burd RS (2002). Intraoperative communication or residents with faculty: Perception versus reality. J Surg Res, 104: 40-45. DOI: 10.1006/jsre.2002.6402.

Cosby KS & Croskerry P (2004). Profiles in Patient Safety: Authority Gradients in Medial Error. Acad Emerg Med, 11(12): 1341-45. DOI: 10.1197/j.aem.2004.07.005.

Crochet, P. et al. (2011) ‘Deliberate practice on a virtual reality laparoscopic simulator enhances the quality of surgical technical skills’, Annals of Surgery, 253(6). doi: 10.1097/SLA.0b013e3182197016.

El Boghdady M & Ewalds-Kvist BM (2021). The innate aptitude’s effect on the surgical task performance: a systemic review. Updates in Surgery, 73: 2079-93. DOI: 10.1007/s13304-021-01173-6.

Ericsson KA, Krampe RT & Tesch-Romer C (1993). The role of deliberate practice in the acquisition of expert performance. Psychological Review; 100(3): 363-406. DOI: 10.1037/0033-295X.100.3.363

Fraser KL, Meguerdichian MJ, Haws JT, Grant VJ, Bajaj K & Cheng A (2018). Cognitive Load Theory for debriefing simulation: implications for faculty development. Adv Simulation, 3(28). DOI: 10.1186/s41077-018-0086-1.

Gregory, A. (2022) ‘Millions of UK patients forced to go private amid record NHS waiting lists’, The Guardian, 11 September.

Gregory, A. (2023) ‘NHS faces “alarming” exodus of doctors and dentists, health chiefs warn’, The Guardian, 29 January.

Griswold S, Ponnuru S, Nishisaki A, Szyld D, Davenport M, Deutsch ES & Nadkarni V (2012). The emerging role of simulation education to achieve patient safety: Translating deliberate practice and debriefing to save lives. Pediatr Clin N Am, 59: 1329-40. DOI: 10.1016/j.pcl.2012.09.004.

Grober ED, Hamstra SJ, Wanzel KR, Reznick RK, Matsumoto ED, Sidhu RS & Jarvi KA (2004). The educational impact of bench model fidelity on the acquisition of technical skills: the use of clinically relevant outcome measures. Ann Surg, 240(2): 374-81. DOI: 10.1097/01.sla.0000133346.07434.30.

Hagelsteen K, Pedersen H, Bergenfelz A & Mathieu C (2021). Different approaches to selection of surgical trainees in the European Union. BMC Med Educ, 21(363). DOI: 10.1186/s12909-021-02779-5.

Hashimoto, D. A. et al. (2015) ‘Deliberate practice enhances quality of laparoscopic surgical performance in a randomized controlled trial: from arrested development to expert performance’, Surgical Endoscopy, 29(11). doi: 10.1007/s00464-014-4042-4.

Hope, C. et al. (2021) ‘The impact of COVID-19 on surgical training: a systematic review’, Techniques in Coloproctology. doi: 10.1007/s10151-020-02404-5.

Johnson CE, Keating JL & Molloy EK (2019). Psychological safety in feedback: What does it look like and how can educators work with learners to foster it? Med Ed, 54: 559-70. DOI: 10.1111/medu.14154.

Kassab E, Tun JK, Arora S, King D, Ahmed K, Miskovic D, Cope A, Vadhwana B, Bello F, Sevdalis N & Kneebone R (2011). “Blowing up the Barriers” in Surgical Training: Exploring and Validating the Concept of Distributed Simulation. Ann Surg, 254(6): 1059-65. DOI: 10.1097/SLA.0b013e318228944a.

Kneebone R (2003). Simulation in surgical training: educational issues and practical implications. Med Educ, 37(3): 267-77. DOI: 10.1046/j.1365-2923.2003.01440.x.

Kneebone R, Arora S, King D, Bello F, Sevdalis N, Kassab E, Aggarwal R, Darzi A & Nestel D (2010). Distributed simulation – Accessible immersive training. Med Teach, 32(1): 65-70. DOI: 10.3109/01421590903419749.

Kneebone, R. (2015) ‘When I say ... reciprocal illumination’, Medical Education. doi: 10.1111/medu.12743.

Kneebone R, Weldon S-M & Bello F (2016). Engaging patients and clinicians through simulation: rebalancing the dynamics of care. Adv Simulation, 1(19). DOI: 10.1186/s41077-016-0019-9. 

Kneebone, R. L. (2016) ‘Simulation reframed’, Advances in Simulation, 1(1). doi: 10.1186/s41077-016-0028-8.

Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, Bohnen J, Orser B, Doran D & Grober E (2003). Communication failures in the operating room: an observational classification of recurrent types and effects. BMJ Qual Saf, 13(5): 330-4. DOI: 10.1136/qshc.2003.008425.

McElnay P (2014). Surgical skill: is it nature vs nurture? Clin Teach, 11: 442-3. DOI: 10.1111/tct.12134.

Moglia A, Ferrari V, Morelli L, Melfi F, Ferrari M, Mosca F & Cuschieri A (2013). Distribution of innate ability for surgery amongst medical students assessed by an advanced virtual reality surgical simulator. Surg Endosc, 28: 1830-37. DOI: 10.1007/s00464-013-3393-6.

Nembhard IM & Edmondson (2006). Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. J Organiz Behav, 27: 941-66.  

Peadon R, Hurley J & Hutchinson M (2020). Hierarchy and medical error: Speaking up when witnessing an error. Safety Science, 125. DOI: 10.1016/j.ssci.2020.104648.

Pelletier C & Kneebone R (2016a). Learning safely from error? Reconsidering the ethics of simulation-based medical education through ethnography. Ethnography and Education, 11:3, 267-82. DOI: 10.1080/17457823.2015.1087865.

Pelletier, C. and Kneebone, R. (2016b) ‘Fantasies of medical reality: An observational study of simulation-based medical education oa’, Psychoanalysis, Culture and Society, 21(2). doi: 10.1057/pcs.2015.50.

Powell, P. et al. (2016) ‘Exploring the potential of sequential simulation’, The Clinical Teacher, 13(2), pp. 112–118. doi: 10.1111/TCT.12391.

Sevdalis N, Hull L & Birnbach DJ (2012). Improving patient safety in the operating theatre and perioperative care: obstacles, interventions, and priorities for accelerating progress. BJ Anaes, 109(Suppl 1): i3-16. DOI: 10.1093/bja/aes391. 

Skipworth, R. J. E. et al. (2008) ‘Basic surgical training in the era of the European working time directive: What are the problems and solutions?’, Scottish Medical Journal, 53(4). doi: 10.1258/RSMSMJ.53.4.18.

Stefanidis D, Sevdalis N, Paige J, Zevin B, Aggarwal R, Grantcharov T & Jones DB (2015). Simulation in Surgery: What’s Needed Next? Ann Surg, 261(5): 846-53. DOI: 10.1097/SLA.0000000000000826.

Sweller J (1988). Cognitive Load during problem solving: Effects on learning. Cognitive Sc, 12: 257-85. 

Turton, D. et al. (2019) ‘Simulation: the power of what hurts’, Medical Education. doi: 10.1111/medu.13788.

Yiasemidou M, Glassman D, Tomlinson J, Song D & Gough MJ (2016). Perceptions about the present and future of surgical simulation: A National Study of mixed qualitative and quantitative methodology. J Surg Ed, 74(1): 108-16. DOI: 10.1016/j.jsurg.2016.07.011.

Adverse Event Simulation

The surgical field has worked to emulate the aviation industry in equipping junior doctors with the non-technical skills to vocalise a witnessed error (Burke et al., 2004; Coats & Burd, 2002; Cosby & Croskerry, 2004). However, a systematic review (Peadon et al., 2020) demonstrated current methods were an oversimplification of the realities of surgical hierarchy, with communication failure still a cause (60%) of adverse events (Lingard et al., 2004). 

Team training simulation allows trainees deliberate practice and debriefing of skills in a psychological safe setting, with the presence and participation of senior staff, and without compromising patient safety (Aggarwal et al., 2010; Griswold et al., 2012; Nembhard & Edmondson, 2006). In confronting the stigma of the admission of medical error, simulation should also aim to bring situational awareness of human factors and equip clinicians with opportunity for cognitive load adaption (Pelletier & Kneebone, 2016a; Sevdalis et al., 2012; Sweller, 1988). Debriefing should also recognise the impact of such events on surgeon wellbeing and provide the opportunity for trainees to learn of support available (RCS, 2020; Johnson et al., 2019; Fraser et al., 2018). 

Selection of Surgical Trainees

The use of simulation has application for the selection of trainees to accredited surgical training pathways. While situational judgement tests and clinical scenarios to assess knowledge and non-technical skills can discriminate for future job performance, use of technical simulators is still being explored (Hagelsteen et al., 2021). 

As a craft profession, one could argue that surgical candidates who are most technically apt should be afforded positions in costly training programs (Moglia et al., 2014). Yiasemidou et al. (2016) suggested that there was apprehension in experts; with lack of evidence on assessment of technical aptitude and visuospatial ability being correlated to later surgical competence (Hagelsteen et al., 2021). Moglia et al. (2014) and El Boghdady & Ewalds-Kvist (2021) indicated that gaming experience did not influence performance in simulations, but were able to demonstrate significant findings in identifying pre-vocational trainees with low-level innate aptitude, including pictorial-skill deficiency, who may not be able to be compensated for through deliberate practice of surgical skills.  

 

 As Kneebone discusses in his 2016 paper, simulation allows the freedom to involve patients in care in a way which would not be possible in real practice. Prior studies utilising sequential simulation to examine integrated care pathways for adolescents with asthma have included public engagement, and have shown how such initiatives can provide new insights for clinicians as well as enabling patients to better understand the processes, and challenges, involved in caring for them (Powell et al., 2016). In the UK, doctors are working in a health service under unprecedented strain, with surgical waiting lists are longer than ever (Gregory, 2022). This has understandably caused patient dissatisfaction, as well as significant distress amongst the profession with a worrying proportion of doctors considering leaving or taking time out (Gregory, 2023). Given this tension between the difficulties doctors and patients face, it seems crucial that we develop educational resources which can help us to reach a shared understanding and look to a collaborative approach to solving these issues.