Simulation based training

BMJ 2005; 330 doi: (Published 3 March 2005)
Cite this as: BMJ 2005;330:493

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We read the article by Moorthy et al. elaborating the benefits and implications of simulation for individual and team training and the assessment of training with interest [1]. In light of growing pressure on service provision and quality assessment, the time and money spend on simulated training and assessment should be carefully weighed against the protected time which will be lost from real life training. Simulation is an important tool when learning new techniques, to give an introduction and understanding of the situation or procedure, and should be an integral part of all training courses. However, to use simulation as an assessment tool is controversial.

Phacoemulsification cataract surgery training has been referred to as an example for basic surgical training in the UK [2]. Papers have cited that high volume and high quality services have led to a worrying impact on training for the trainees. In Ophthalmology, where the basic microscopical skills course is a part of the training requirement for all trainees, the course simulates experience with microscopes, sutures and surgery for almost all the ophthalmic procedures. Wet labs are scheduled as part of the weekly protected teaching sessions to give hands on experience for trainees to familiarise with new procedures. Simulation training not only helps build the trainee’s confidence but also is a documented evidence of familiarity with a technique.

In Urology, this is mirrored. Training courses are coming into vogue especially in endoscopic and laparoscopic urology. However, the training courses remain handicapped with the lack of tactile simulation and the dynamic movements seen in patients. This is overcome to a certain extent with the use of animal tissues in wet labs but opportunities are limited. Futuristic models may rectify these problems but until then……

When transposed to actual surgery, training is a mutual effort, the will to learn and to be taught in a safe and apt way. Simulation in the best sense can fail a new trainee when factors such as nervousness, the difference in tissue resistance, inappropriate or sub optimal instruments and the theatre environment come into play. Simulation can hardly substitute the experience gained by tutorship from an experienced trainer with a critical eye. Surgical training starts with preoperative assessment, careful choice of case and discussion with the trainer about the technique, possible stumbling blocks and difficulties perceived. A major hurdle faced by the trainer and trainee would be the difference in dexterity, which requires dedication and planning on the choice of approach, suitable for both. Freeman et al. in their article on modular phacoemulsification training [3] elaborates on real life demands and restrictions adapting to the needs of trainees. Surgical situations faced are never the same in the “routine” procedures, even for the minor procedures.

To use simulation as an assessment rather than to hone ones’ skills has to be very carefully put forward. A surgeon who performs well with simulation need not be as effective in a real life scenario, though it could be stand true that a good surgeon should be able to perform reasonably well under simulation. Therefore, scoring on a simulated assessment might not be the best way to assess practical skills. The interaction between trainer and trainee on a ‘one to one’ basis remains the ideal training and assessment method.


1. Simulation based training is being extended from training individuals to teams. Moorthy K, Vincent C, Darzi A. BMJ 2005; 330: 493- 494

2. Watson MP, Boulton MG, Gibson A, Murray PI, Moseley MJ, Fielder AR. The state of basic surgical training in the UK: ophthalmology as a case example. J R Soc Med 2004; 97: 174-178

3. Freeman MJ, Singh J, Chell P, Barber K. Modular phacoemulsification training adapted for a left-handed trainee. Eye 2004; 18: 35-37

Competing interests: None declared

Competing interests: None declared

Rani T. Sebastian, Senior House Officer in Ophthalmology

Joe Philip

Royal Liverpool University Hospital, Liverpool L7 8XP

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Dear Editor, Moorthy et al’s editorial emphasises that there is a need to develop robust measures of individual and team performance to underpin surgical training and evaluation(1) and that such measures are not sufficiently developed for routine use in summative assessments. These are sentiments with which we wholeheartedly agree. In Scotland, the NOTSS (Non-Technical Skills for Surgeons) project has been developing such a measure in the form of a behavioural marker system for individual surgeons(2). Establishing the validity and reliability of the system has been prioritised before testing its utility in theatre. Subject to acceptable results, the NOTSS system will be used to structure feedback in the operating room or simulator, and guide non-technical skills training.

NOTSS was developed using an iterative process, based on a model of systems design(3) and the ANTS (Anaesthetists Non-Technical Skills) system(4). Five methods of data collection were used to identify the critical non-technical skills for surgeons. These included a literature review, analyses of adverse event reports, observations in theatre, cognitive interviews with 27 consultant surgeons and a questionnaire survey with 352 theatre staff from 17 hospitals in Scotland. Four independent panels of consultant surgeons were involved in developing the skills taxonomy, behavioural markers, and rating form that comprise the system. The reliability of this system is currently being tested using standardized scenarios.

The NOTSS system focuses on individual skills of the surgeon rather than the team’s skills on the basis of task analysis which revealed that surgeons and trainees did not consistently work with the same core team in theatre. Surgeons tend to work with many combinations of assistant, scrub nurse, and anaesthetist. This does not mean that studying the team’s performance as Moorthy et al. have done is not an important endeavour. Rather, the NOTSS system focuses on rating and developing the ‘portable’ team skills in individuals which can aid awareness, co-ordination, and communication across many ad-hoc teams. We feel that this complements the work of Moorthy et al. and more accurately reflects the current needs of the surgical domain.

Yours sincerely, Steven Yule, Research Fellow, School of Psychology, University of Aberdeen


1. Moorthy K, Vincent C, Darzi A. Simulation Based Training. BMJ 2005;330:539-540.

2. (current at 5/3/05).

3. Gordon SE. Systematic Training Programme Design: Maximising Effectiveness and minimizing Liability. Englewood Cliffs, NJ: Prentice Hall, 1993.

4. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, & Patey R. Anaesthetists’ Non-Technical Skills (ANTS): Evaluation of a behavioural marker system. Br J Anaesth 2003; 90, 580-588.

Competing interests: None declared

Competing interests: None declared

Steven J Yule, Research Fellow

Rhona Flin, Simon Paterson-Brown, David Rowley, Nikki Maran

School of Psychology, University of Aberdeen AB24 2UB

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