Simulator Training: The Future? Mike Larvin RCS Director of Education Professor of Surgery University of Nottingham at Derby

Imitation of reality for research, testing, training or education Requires: valid source information simplifying approximations and assumptions validity, reliability, fidelity Simulation

Technological triggers: Cold war “Tennis for Two” (1957) Higinbotham (Brookhaven) used missile trajectories Sputnik 1 (1957) Launched atop a modified ballistic missile

UG: less practical surgery PG1-2: foundation years PGY3-4: core MRCS PGY5-8+: specialty FRCS Less experience, WTD New technologies to learn Patients and trainees have changed Surgical training has changed

medical errors kill 98,000 people annually $37 to $50 billion for adverse events resident 80h week, less direct interaction bioterrorism threats and crisis management Public drivers US IOM 2004

Generation ‘X’ = most of you Followed ‘baby boomer’ generation Born 1961 to 1981, ‘13 th US generation’ - premarital sex, atheistic, republican, less respect for parents and authority - greater formal education Generation X: Tales for an Accelerated Culture Douglas Coupland, 1991

Followed ‘Generation X’ Born early 1980s to mid-1990s - rapid communication, peer orientation, instant gratification, stimulating work - family breakdown, tech-savvy, ‘open’ Hunter-Gatherers of the Knowledge Economy David Berreby, 1999 Generation ‘Y’ = junior trainees

Followed ‘Generation Y’ Born early mid-1990s to 2000s - baby boomlet - highly connected, lifelong use of comms and media technologies such as WWW - “digital natives”: instant messaging, texting, MP3, mobile phones, YouTube Grown Up Digital: How the Net Generation is Changing Your World Don Tapscott 2009 Generation ‘Z’ = coming soon

Trainees still require: Knowledge they prefer e-learning Skills technical, decisions, comms: like simulation Structure curriculum and assessment: online is fine

STEP ® Foundation and Core MMC and ISCP competences MRCS preparation 8 A4 printed modules e-learning, video, web simulation e-community and college days

Courses and programmes Medical SchoolF1/F2ST1/2ST3/4ST5/6Consultant Plus Anatomy ATLS® BSS, FSS, SSS CCrISP® Communication STEP® Core STEP® Foundation Core Specialty Skills Core Surgical Sciences e-Surgery (DoH) Aesthetics Plastics Breast Cardiothoracics Coloproctology Emergency & Trauma OMFS Orthopaedics Otorhinolaryngology Urology MIS Neurosurgery Paediatrics Vascular Surgery Professional Practice - Training the Trainers - Training and Assessment in Practice Executive Leadership SAS Leadership Professional Forum Research Network International Network Operating Theatre Team Project Military Operations Surgical Training (MOST - MoD)

College courses RegionalCollegeTotal CoursesParticipantsCoursesParticipants

anatomy, physiology, history, behaviour, physical findings cadavers, prosections, plastinates plastics animal tissue Active simulation

‘Human in the loop’ simulation Ideal when: real environment too expensive or risky need to learn in "safe" environment test mistakes in safety-critical systems ‘type change’ after basic pilot training Interactive simulation

‘live’: real people, simulated kit, real world hi-fidelity, samples likely performance ‘virtual’: real people, simulated kit and world VR training ‘constructive’: sim people, kit and world behavioural training and assessment Training simulation types

Sim Man 3g (Laerdel) life-sized mannequin responds to injected drugs programmed for life threatening emergencies can be changed ‘on the fly’ High-fidelity live simulation

1985, K Semm’s ‘pelvi-trainer’ for laparoscopy Haptics included ἅ πτεσθαι - to “contact” or “touch” Laparoscopy

visual components by computer graphics touch components by haptic feedback input/output: force feedback could be widely distributed via standard web browsers with standard game joysticks Virtual simulators

2010: Symbionix ‘Laparotrainer’ for laparoscopy Haptics not included Laparoscopy

Largest capital project since post-war rebuilding Eagle project

Wolfson Surgical Skills Centre anatomy teaching procedural simulation

Simulation Centre skills laboratory minimal access, critical care operating theatre

Synthetics and animal tissue

Minimal access and critical care

Operating theatre

Teaching suite

Lower cost simulation

improved health outcomes, reduced errors reduced health care costs, enhanced quality better skills, lower malpractice rates more flexible training at correct pace allows practice and mistakes, improves skills without consequence to the patient Benefits

Despite their proven effectiveness, junior surgeons usually have to pay to attend courses from their own pocket Donaldson, 2009 Costs

Simulator training: the future? More simulation, improved models Expensive, collaboration makes sense Preparation for work-based training NOT a substitute for the ‘real thing’ More versatile than patient-based training Useful in standardising assessment