Recent articles in this magazine have highlighted the plight of registrars’ surgical skills training. Stories of a bygone era of 100-hour working weeks, where logbooks were futile when operating day and night, ring loudly in the ears of today’s Trainees who struggle to accumulate the numbers to become a confident surgeon. RANZCOG training is evolving in an attempt to address the issue, but ultimately all registrars must obtain surgical competency across a broad range of procedures, with fewer cases per Trainee. New methods of surgical training are needed in order to adapt to a world influenced by safe working hours, a large number of Trainees and reduced surgical cases secondary to the advancement of medical therapies. The use of simulation will be a vital tool to ensure the Trainees of the future obtain the skills necessary to make them a competent specialist.

Theory of simulation

It is helpful to reflect on how technical skills are acquired. The Fitts/Anderson model describes a progression though cognitive, associative and autonomous phases of learning (see Table 1).1 Traditionally, a Trainee is like an apprentice, observing senior surgeons and operating under their guidance until sufficient mastery of
a procedure is achieved (the associative phase). The autonomous phase is only reached after unsupervised repetition of procedures. This model served surgical training well during an in an era of mostly open surgical procedures, a large volume of cases and an acceptance of a degree of error during training.

Simulation training supports a Trainee’s progression through the cognitive, associative and autonomous phases in a simulated procedure, in a safe environment. This allows consistent, accurate and automatic performance of tasks prior to live surgery. While this does not mean that a Trainee can then perform live surgery without supervision, it creates a ‘pre-trained novice’2, who now possesses the ability to spare attention to comprehend his or her supervisor’s instructions and gain a superior learning experience from each live surgery.

History of simulation

While the understanding of the neuropsychology of skill acquisition is recent, medical practitioners have understood the value of simulated practice for centuries. Descriptions of the early use of simulation for medical education make fascinating (and often morbid) reading, detailing anatomical models dating back to the 11th century and birthing simulators from as long as 250 years ago.3 Madame du Coudray, a French midwife, revolutionised obstetric care in 18th century France using an intricate and adaptable birthing simulator. Travelling the countryside on her bicycle, she taught illiterate French peasant girls how to deal with all manner of obstetric emergencies using her ‘machine’. Further lessons came from Vienna in the 19th century, when a move away from artificial simulators to cadavers for simulation resulted in a ten-fold increase in maternal mortality (subsequently expanding the availability of cadaveric models) until the association of puerperal fever and hand hygiene was finally proved.

Evidence for simulation

There is ample evidence that skills learned in simulation transfer to patient care, with improved performance demonstrated over a range of procedures, including: CPR, laparoscopic surgery, endovascular procedures, endoscopy and even cardiac auscultation. Specifically in our specialty, team training for obstetric emergencies has reduced rates of brachial plexus injuries and hypoxic-ischemic encephalopathy4,5, while laparoscopic simulation training has been shown to improve performance in laparoscopic gynaecological surgery. Larsen in 20096 randomised junior trainees learning laparoscopy to simulator training versus usual training. When performing a live salpingectomy, the simulator-trained group completed the salpingectomy in half the time (12 versus 24 minutes), and achieved technical proficiency scores equivalent to surgeons with experience of 20–50 laparoscopies, as opposed to the control group whose scores equated to less than five procedures. This is a remarkable demonstration of the power of simulation training. Other randomised controlled trials have had shown similar improvements with simulator training in laparoscopic tubal sterilisation.7,8

Phase Processes Example
Cognitive Understands/problem-solves the mechanics of the task by acquiring knowledge and watching demonstrations
Performs the task slowly and deliberately
Thinks through or verbalises task steps during execution
Learns that to rotate tip of laparoscopic instrument you turn the rotation knob at handle
Has to consciously think through this before or as doing it
Associative Begin to develop association between the cognitive component and the psychomotor tasks
Performs the task with greater efficiency and less error
No longer thinks through steps or verbalises during execution
Begins to turn rotation knob on instrument when wants to rotate tip with less conscious thought
Still somewhat inefficient
Autonomous Psychomotor movements are automated
Cognitive involvement is eliminated
May lose ability to verbalise or describe steps
Automatically and efficiently turns rotation knob when wants to rotate tip of instrument

Integrating simulation into training

Despite the evidence for use of simulation, uptake remains surprisingly patchy and the reasons are unclear. In the implementation of a surgical simulation curriculum in the US, identified barriers include lack of protected time, lack of personnel, associated costs and work hours restrictions.9 Attitudes may also play a role, with one study suggesting that while 92 per cent of surgical trainees believed simulated laparoscopic skills transfer to the operating theatre, only 57 percent agreed that laparoscopic simulator proficiency should be demonstrated prior to operating theatre exposure.10 The discrepancy between belief and action is peculiar. It is interesting to ponder how the general public may respond to a question regarding the necessity for trainee surgeons to demonstrate simulation proficiency prior to operating on patients. Perhaps the response may be: ‘What? Do you mean they don’t have to do that already?’

In contemplating a future simulation curriculum, a successful design process should critically consider all phases of the trainee’s skill acquisition. There should be a cognitive component, where students can understand the context of psychomotor skills they are about to learn. For surgical training, this may include relevant aspects of instrumentation, anatomy, procedural steps, errors and teamwork considerations. Trainees should be able to rehearse psychomotor tasks on a validated simulator and receive feedback on their progress using clearly defined performance criteria. A program should have elements of deliberate practice, distributed practice and variability of practice and should continue until proficiency is demonstrated. A certain amount of ‘overtraining’ can also be useful. Feedback is a vital part of trainees improving and maintaining enthusiasm.

It should not be assumed that the provision of the tools for a simulation program is enough to guarantee success. Trainees need to be motivated to participate, especially considering the multiple demands on a trainee’s time. Mandated, protected and supervised time to train provides the external motivation for trainees to engage in a simulation curriculum. Compulsory proficiency before live operating theatre performance may prove a strong motivator for learning, perhaps furthered by some healthy competition with peers.

In developing simulation curricula, it is also important to consider the ease of dissemination and adoption. It is no wonder that the American College of Surgeons had difficulty in implementing their simulation curriculum given its cost of more than US$30 000 per student.11 Operating on live animals and cadavers undoubtedly provides a premium learning opportunity, but the costs are prohibitive if considering widespread implementation. These models are perhaps best reserved for advanced training.

Where to now?

We know that evidence exists to support simulation. Some elements of simulation training are already occurring and understanding what is happening is the first step towards integrating simulation in a united approach. The international simulation community has recently developed a framework for curriculum development.12 Development of a curriculum will require significant input from all regions, and perhaps should initially focus on basic procedures for junior trainees. Prior to developing a curriculum, we first need to understand the likely economic, organisational and psychological barriers to widespread acceptance and implementation. Implementation will require a significant investment of time, energy (and money). It will also be vital at the outset to have in place a rigorous evaluation process to ensure that we are getting it right.

The perfect way to train is an enigma, however, simulation is a key strategy to ensure our patients stay safe while we train tomorrow’s specialist. In 2003 Ziv13 stated, with respect to medical education, ‘Although such risks [patient harm] are usually considered an unavoidable concomitant of training, the harm caused is ethically tolerable only when minimised to the degree possible by medical pedagogy.’ More than ten years later, with knowledge that the old training model isn’t working, simulation is the ‘ethical imperative’. We must continue to assess, improve and evaluate our training curricula in our role as the trainers of the specialists of the future and guardians of the highest standard of care for our patients.