SUMMARY Review date: 1969 to 2003, 34 years. Background and context: Simulations are now in widespread use in medical education and medical personnel evaluation. Outcomes research on the use and effectiveness of simulation technology in medical education is scattered, inconsistent and varies widely in methodological rigor and substantive focus. Objectives: Review and synthesize existing evidence in educational science that addresses the question, ‘What are the features and uses of high-fidelity medical simulations that lead to most effective learning?’. Search strategy: The search covered five literature databases (ERIC, MEDLINE, PsycINFO, Web of Science and Timelit) and employed 91 single search terms and concepts and their Boolean combinations. Hand searching, Internet searches and attention to the ‘grey literature’ were also used. The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality. Inclusion and exclusion criteria: Four screening criteria were used to reduce the initial pool of 670 journal articles to a focused set of 109 studies: (a) elimination of review articles in favor of empirical studies; (b) use of a simulator as an educational assessment or intervention with learner outcomes measured quantitatively; (c) comparative research, either experimental or quasi-experimental; and (d) research that involves simulation as an educational intervention. Data extraction: Data were extracted systematically from the 109 eligible journal articles by independent coders. Each coder used a standardized data extraction protocol. Data synthesis: Qualitative data synthesis and tabular presentation of research methods and outcomes were used. Heterogeneity of research designs, educational interventions, outcome measures and timeframe precluded data synthesis using meta-analysis. Headline results: Coding accuracy for features of the journal articles is high. The extant quality of the published research is generally weak. The weight of the best available evidence suggests that high-fidelity medical simulations facilitate learning under the right conditions. These include the following:

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Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review

Traditionally, surgeons have been trained and evaluated on the basis of their performance of surgical procedures in live patients. This article in the Medical Education series explores the use of mechanical devices for the teaching and evaluation of surgical skills.

Teaching Surgical Skills — Changes in the Wind

Background:
This study examined the impact of virtual reality (VR) surgical simulation on improvement of psychomotor skills relevant to the performance of laparoscopic cholecystectomy.

Methods:
Sixteen surgical trainees performed a laparoscopic cholecystectomy on patients in the operating room (OR). The participants were then randomized to receive VR training (ten repetitions of all six tasks on the Minimally Invasive Surgical Trainer—Virtual Reality (MIST-VR)) or no training. Subsequently, all subjects performed a further laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotape, and assessed by two independent and blinded observers using predefined objective criteria. Time to complete the procedure, error score and economy of movement score were assessed during the laparoscopic procedure in the OR.

Results:
No differences in baseline variables were found between the two groups. Surgeons who received VR training performed laparoscopic cholecystectomy significantly faster than the control group (P = 0·021). Furthermore, those who had VR training showed significantly greater improvement in error (P = 0·003) and economy of movement (P = 0·003) scores.

Conclusion:
Surgeons who received VR simulator training showed significantly greater improvement in performance in the OR than those in the control group. VR surgical simulation is therefore a valid tool for training of laparoscopic psychomotor skills and could be incorporated into surgical training programmes. Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Randomized clinical trial of virtual reality simulation for laparoscopic skills training.

In the past few years, considerable developments have been made in the objective assessment of technical proficiency of surgeons. Technical skills should be assessed during training, and various methods have been developed for this purpose 

Surgical competence entails a combination of knowledge, technical skills, decision making, communication skills, and leadership skills. Of these, dexterity or technical proficiency is considered to be of paramount importance among surgical trainees. The assessment of technical skills during training has been considered to be a form of quality assurance for the future.1 Typically surgical learning is based on an apprenticeship model. In this model the assessment of technical proficiency is the responsibility of the trainers. However, their assessment is largely subjective.2 Objective assessment is essential because deficiencies in training and performance are difficult to correct without objective feedback.3

The introduction of the Calman system in the United Kingdom, the implementation of the European Working Time Directive, and the financial pressures to increase productivity4 have reduced the opportunity to learn surgical skills in the operating theatre. Studies have shown that these changes have resulted in nearly halving the surgical case load that trainees are exposed to.5 Surgical proficiency must therefore be acquired in less time, with the risk that some surgeons may not be sufficiently skilled at the completion of training.6 This and increasing attention of the public and media on the performance of doctors have given rise to an interest in the development of robust methods of assessment of technical skills.7 We review the research in this field in the past decade. Our objectives are to explore all the available methods, establish their validity and reliability, and examine the possibility of using these methods on the basis of the available evidence.

We collected information for this review from …

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Objective assessment of technical skills in surgery

Background Surgical skills are required by a wide range of health care professionals. Tasks range from simple wound closure to highly complex diagnostic and therapeutic procedures. Technical expertise, although essential, is only one component of a complex picture. By emphasising the importance of knowledge and attitudes, this article aims to locate the acquisition of surgical skills within a wider educational framework.

Simulators Simulators can provide safe, realistic learning environments for repeated practice, underpinned by feedback and objective metrics of performance. Using a simple classification of simulators into model-based, computer-based or hybrid, this paper summarises the current state of the art and describes recent technological developments. Advances in computing have led to the establishment of precision placement and simple manipulation simulators within health care education, while complex manipulation and integrated procedure simulators are still in the development phase.

Evaluation Tension often exists between the design and evaluation of surgical simulations. A lack of high quality published data is compounded by the difficulties of conducting longitudinal studies in such a fast-moving field. The implications of this tension are discussed.

The wider context The emphasis is now shifting from the technology of simulation towards partnership with education and clinical practice. This highlights the need for an integrated learning framework, where knowledge can be acquired alongside technical skills and not in isolation from them. Recent work on situated learning underlines the potential for simulation to feed into and enrich everyday clinical practice.

Simulation in surgical training: educational issues and practical implications.

Objective assessment of surgical technique is currently impossible. A virtual reality simulator for laparoscopic surgery (MIST VR) models the movements needed to perform minimally invasive surgery and can generate a score for various aspects of psychomotor skill. Two studies were performed using the simulator: first to assess surgeons of different surgical experience to validate the scoring system; second to assess in a randomised controlled way, the effect of a standard laparoscopic surgery training course. Experienced surgeons (> 100 laparoscopic cholecystectomies) were significantly more efficient, made less correctional submovements and completed the virtual reality tasks faster than trainee surgeons or non-surgeons. The training course caused an improvement in efficiency and a reduction in errors, without a significant increase in speed when compared with the control group. The MIST VR simulator can objectively assess a number of desirable qualities in laparoscopic surgery, and can distinguish between experienced and novice surgeons. We have also quantified the beneficial effect of a structured training course on psychomotor skill acquisition.

Validation of virtual reality to teach and assess psychomotor skills in laparoscopic surgery: results from randomised controlled studies using the MIST VR laparoscopic simulator.

C Sutton

Papers

Validation of virtual reality to teach and assess psychomotor skills in laparoscopic surgery: results from randomised controlled studies using the MIST VR laparoscopic simulator.