Dr. Peter G. Brindley
Simulation in surgery should be widely promoted and prioritized. However, to fully realize its potential, we need ongoing resources, vigorous research and a system-wide commitment to continuing improvement. We need to mature the discipline of simulation such that it becomes a central part of the science of improving clinical performance. Without such efforts, simulation may be little more than a “faith-based initiative,” with both zealous supporters and reactionary opponents, but little evidence to sway the ambivalent majority.
Simulation has been appropriately identified by numerous professional societies as a key to patient safety and also as a social justice imperative.28
As such, it is not a luxury, and we should not wait. However, as well as “doing it right now” we must “do it right.” For example, simulation is not yet realistic enough, sufficiently proven or sufficiently resourced to justify a wholesale rejection of bedside learning. It is, therefore, best understood as a supplement to, not a replacement for, traditional training and maintenance of competence.
Simulation can shorten the learning curve, decrease knowledge decay, permit development of manual skills before any exposure to patients, improve performance under stress, finesse teamwork and even optimize communication, all without endangering patient safety.29–31
However, it is not enough to simply spend time on a simulator, just as it is not enough to simply spend time on a clinical rotation. Educational time, no matter what form it takes, must be based on sound principles of adult learning.
Good education means clear expectations of educators but also of learners. Simulation is therefore best understood as a technique, not just a technology.29
It is not just about purchasing expensive manikins and expecting results. A deliberate curriculum is required. This should be accompanied by a realistic, immersive and emotionally engaging experience. This should be followed by reflection, which typically takes the form of a structured debrief by experts in feedback and formative evaluation.30
Therefore, the question is not whether all teaching should take place in the simulation laboratory versus the bedside, but how to harness the best learning from both. In other words, however novel or exciting the educational strategy, it is a means to an end (i.e., patient safety and skill development), rather than an end in itself.
Simulation is far from perfect and far from panacea. Brief simulation exposures are unlikely to model the myriad behaviours required of a surgeon. These include “patient ownership,” following a patient throughout his or her illness and even soldiering on when fatigued. Occasional simulation exposures also fail to duplicate the multiple ways in which the same disease can present whether because of anatomy, physiology, genetics, age or culture.31
As such, it is not outdated to promote the apprentice model — the traditional gradual assumption of responsibility — or to demand volume-based expertise. The optimal balance of simulation and bedside experience will also only be achieved when we understand the impact of finite instructional time, limited funds, increasing clinical loads, the huge reduction in trainee work hours, decreased tolerance for trial and error, and even the attitudes of teachers compared with learners. In addition, to truly transform our approach to medical error, simulation needs to be ingrained throughout medical education.31
Regardless, the first step is to understand why we need to get this right.
Medical errors are the eighth leading cause of death, and as many as 100 000 people die annually from preventable medical errors in the United States alone.29,32,33
Surgeon Atul Gawande has pointed out that most errors are not due to inadequate knowledge (i.e., “ignorance”), but rather problems in transforming that knowledge into meaningful clinical actions, especially under real-world conditions (i.e., “implementation”).33
Other high-risk professions, notably aviation, faced similar challenges but reconfigured how they train and maintain competence. This has been associated with a log reduction in flight fatalities. In other words, practical strategies and modifiable curricula already exist.31–33
The birth of aviation safety coincided with the statement that the modern jet “was too much airplane for one man to fly.”33
In a similar vein, the complexity of patient care means that surgeons cannot be trained as if they work in isolation. As a result, team training is needed, and simulation offers a risk-free strategy. Error mitigation means teaching more than just individual aptitudes such as factual knowledge or procedural dexterity. Instead, simulation can be used to practise strategies that identify, avoid, capture and mitigate error, instead of assuming that they result from mere stupidity, laziness or arrogance.32
In short, simulation becomes an agent of “culture change” as we move from a culture of individual competence to one of collective safety.29,31,33
A modern curriculum should also help surgeons get beyond the discussion of whether we are teaching surgery as an “art” or a “science.” In fact, simulation helps convey that, like aviation, surgery probably better resembles engineering.29–32
Applying engineering principles explains the benefits of teaching strategies, such as checklists, standard operating procedures, redundancies and fail-safes, and why we need to perfect these through simulation.29
It also helps explain how we could better respond to error and how we could modernize curriculum development. For example, when dissecting a typical commercial airline crash, there might be a technical problem or a lapse in judgment, but this alone rarely causes a crash. The crew might also be tired, such that decision-making skills or vigilance erodes. The plane might be behind schedule, adding stress and reluctance to invest extra time for safety. Many crews have not flown together, so are unfamiliar with each other’s style. The sum total of these minor stresses is a team that is “maxed out,” with nothing left if adversity strikes.32–34
This is why a single problem would rarely cause a disaster, but when combined they can, as shown by the “Swiss cheese model” of error.24,32
Any simulation curriculum should mirror this complexity.
Whereas personal responsibility is a vital trait for a surgeon, comprehensive error reduction means taking a system approach. This explains why the “name, blame, shame” approach is frankly outdated. It also explains why our educational traditions are greatly in need of change. Unfortunately, however, medical curricula are often “accidental.”35
For example, we often rely on random clinical presentation. We also rely on teachers covering their favourite topics regardless of relevance and despite evidence that the didactic format rarely aids long-term behavioural change.36
Instead, curricula should be deliberately matched to safety. Just like in engineering, most clinical errors are predictable. In other words, we know which problems warrant our finite attention. Regardless, routine audits could establish major problem areas (i.e., common shortfalls or steps that require particular precision or the coordination of many people). These results should then be shared, rather than being the purview of a select few. A relevant curriculum can then be drafted (using all relevant experts and a modified Delphi approach) and α tested. Next, wide-scale dissemination occurs using the optimized material (i.e., β testing).29
The process then begins again. In this way, simulation educators are not merely passing facts along, but are running the patient safety laboratory for the modern hospital.2
Accordingly, educators become important agents of change and as highly valued as good researchers or clinicians.30–32
Again, it becomes less important whether a simulator is used, but more important what is being taught and how deliberately we do so.
Unfortunately, current curricula typically focus on factual knowledge. However, human performance, not knowledge, is the most common reason for errors.31–35
Therefore, our curricula should address human factors such as leadership, teamwork, situational awareness and communication. These skills, known collectively as “crisis resource management” (CRM),31
can be taught through structured clinical exposure, but are particularly suited to team simulation.29–31
The current trade-off is that simulation is safer, but clinical practice is more realistic. As David Gaba has pointed out, CRM has been widely implemented in almost all high-risk professions except for medicine or surgery.31
Perhaps this was because CRM did not readily lend itself to traditional didactic education. With modern simulators, we are running out of excuses.
Aviation offers a prediction for simulation in surgery. It was about 30 years from the first flight simulators until flight simulation became mandatory. Using the same time-line, surgical simulation may become mandatory for trainees and surgeons alike within this decade. If so, then programs have few options other than to lead, follow or begrudgingly comply. The question is not “can we afford to simulate” but rather “can we afford not to?”32
The goal is to have good simulation, not merely more simulation. The challenge is therefore bigger than one of resources. The simulation challenge is whether we have the humility to learn from others, the insight to expunge the worst of our entrenched traditions and the pride to retain what is best. As Arthur Schopenhauer stated, “All truth passes through three stages. First it is ridiculed. Second it is violently opposed. Third it is accepted as self-evident.”32
That it is time for change should be “self-evident.” The future of surgical simulation, and whether it is “ridiculed” or “violently opposed” will illustrate just how seriously we really take the safety of our patients.