Attitudes of Surgeons Towards Learning with Simulation


Keval & Bello


Simulators and Simulation




Imperial College


In the United Kingdom (U.K.), working time restrictions, target driven healthcare provision and the patient safety agenda, have led to major reductions in junior surgeons’ operative experience. Simulation has been proposed as a method for redressing this and subsequently its funding has increased.

Despite this, surgical simulation appears not to be as widely employed when compared with other high-risk industries, nor is it used in the U.K. as much as it is abroad. Additionally, literature regarding barriers to the widespread adoption of simulation and, its current usage rates is sparse.


The vast majority of U.K. surgeons support simulation and the use of educational principles in surgical education.

Current low usage rates are due to perceived barriers to widespread adoption. In particular, simulation’s high cost and lack of trained facilitators are the most pressing concerns.

Summary of Work

Questionnaires were sent to surgeons within London and Wessex deaneries. The questionnaire contained an introductory section, two attitude analyses and a final section assessing benefits and barriers of surgical simulation.


Specific aims of the study are listed in the details section


Take-home Messages

There is a clear role for surgical simulaiton's use in the U.K.

Vast majority of surgeons support simulations use

Current levels of usage are low mainly due to the following perceived obstacles:

  • high cost of purchasing and running simulation equipment
  • lack of trainers available to facilitate simulated learning

Please refer to the details section

Summary of Results



A variety of surgeons responded to the questionnaire

Attitudes towards the inclusion of simulation and educational principles in surgical education were mostly supportive (see figure 1)

Despite this, use of simulation was low (1.5 hours/month on average) & there was little consistency over simulation’s perceived benefits.

Surgeons sited a median of 3 barriers to the widespread uptake of surgical simulation. (see figure 2  )





All references are listed in the details section



Reduction in operative experience


  • Higher surgical trainees in the U.K. traditionally spent approximately 80,000 hours learning the art of surgery as an apprentice. During this time, the apprentice would accumulate the wealth of experience from his seniors and, though technical and clinical skills were the primary focus of teaching, with ample time, the trainee would also passively learn the non-clinical skills required for independent surgical practice1. This would primarily be achieved by trainees modelling the behaviours of the consultant surgeons whom they held in high esteem2, 3.
  • This enormous exposure to surgical practice allowed future surgeons to deal with even rare complications. Unfortunately, the training received by each individual was dependant on the mix of cases encountered and therefore, neither guaranteed nor standardised. In addition, there was poor reliability in assessing trainee performance and adequacy of training was related to amount and breadth of clinical exposure4.
  • Recently however, multiple factors have culminated to transform the face of surgical training. Changes in European legislation led to Calman’s reforms and then to implementation of the European Working Time Directive (EWTD). In combination, these changes have resulted in a reduction of surgical training time. Post EWTD trainees are expected to complete only 6,000 - 8,000 hours of speciality training2, 5, a mere tenth of the training time higher-surgical trainees received in the past.


Use of Simulation in Surgery

  •  Simulation’s ability to provide learner focused training, sustained deliberate practice, deliver reduced risk to patients, whilst still allowing trainees to learn from their mistakes6 has led many, including the Chief Medical Officer, to propose it as a tool to bridge the experience gap and to train for rare and infrequent events7.
  •  Learning with surgical simulation is supported by several leading educational theories, including behaviourist, experiential learning cognitive apprenticeship and legitimate peripheral practice. Additionally, simulation can provide immediate feedback and can assess learners performance.

Surgical Simulation in the U.K

  • The last published survey conducted in London around 2005 showed that despite 80% of surveyed surgeons supporting the use of surgical simulation to augment laparoscopic training, only 25% of consultants and 33% of higher surgical trainees had used surgical simulators.

Surgical Support for simulation

Interestingly, senior surgeons are more supportive of simulation than junior surgeons. In particular, senior surgeons believe that simulation could improve open surgery skills (p=0.013), reduce risk to patients (p=0.002) and that simulation should have more of a role in assessment (p=0.036) when compared to junior surgeons.


Barriers to simulation

Respondents believed that several barriers were responsible for the attitude behaviour mismatch observed. On average, surgeons cited 3 major barriers for simulation to overcome before widespread adoption was possible (xbar 3.1 - SD 1.5).



However, we suggest that, by sharing costs between surgical departments, by incorporating simulation into a well designed curriculum (paying close attention to the educational theories underpinning surgery) and, by having simulated modules with simulation suites located in sites with sufficient space, the widespread use of simulation in the U.K. can be achieved.

Summary of Work


  • The primary aim of this study was to assess whether general surgeons believe surgical simulation to be useful in post-graduate surgical education.
  • This study additionally, evaluated the current levels of surgical simulation in the U.K. and, relationships between use of simulation and the seniority of the surgeon, the surgeon’s attitudes towards surgical education, and the surgeon’s attitudes towards simulated operating.
  • Furthermore, this study canvased opinions regarding current barriers to the widespread use of surgical simulation in post-graduate surgical education.



A questionnaire with four distinct sections was devised to accomplish these aims. 

Take-home Messages

I would like to thank my supervisor, Dr. Fernando Bello for his invaluable advice and support, Miss Lucy Parker for her help and invaluable assistance in the ethical approval process, and Nick Sevdalis for his statistical advice during this project.


Most of all I would like to thank all of the respondents who took time out of their busy schedules to complete my questionnaire. Without their help, this study would not have been possible.





Finally, I would like to thank my wife, Dr Shruti Patel without whose support, I would not have been able to complete this challenging work.

Summary of Results

Variety of Respondents

Of 49 received questionnaires respondents varied by age (26 - 67), seniority (SpR to Professor) and surgical specialty.

Attitudes Towards Surgical Education And Simulation

The majority of surgeons supported the use of simulation (41/46) and, the use of educational principles (30/46s) in surgical education (see figure 1).


Simulation’s Perceived Benefits

There were almost no difference in surgeons perception of simulation based on their: location, attitude towards the simulation’s usefulness or, attitude towards the inclusion of educational principles.

Senior surgeons were more supportive of surgical simulation’s benefits than junior surgeons.


Barriers to widespread simulation

Every respondent believed that simulation had at least one, and on average three, major barriers to overcome before widespread adoption could be achieved (see figure 2).


1.         Kneebone R. Simulation in surgical training: Educational issues and practical implications. Medical Education. 2003;37(3):267-77.

2.         Aggarwal R, Darzi A. Symposium on surgical simulation for training and certification. World Journal of Surgery. 2008;32(2):139-40.

3.         Sutherland LM, Middleton PF, Anthony A, Hamdorf J, Cregan P, Scott D, et al. Surgical simulation: A systematic review. Annals of Surgery. 2006;243(3):291-300.

4.         Châtenay M, Maguire T, Skakun E, Chang G, Cook D, Warnock GL. Does volume of clinical experience affect performance of clinical clerks on surgery exit examinations? The American Journal of Surgery. 1996;172(4):366-72.

5.         Chalmers CR, Joshi S, Bentley PG, Boyle NH. The Lost Generation: Impact of the 56-hour EWTD on Current Surgical Training. Bulletin of The Royal College of Surgeons of England. 2010;92:102-6.

6.         Maran NJ, Glavin RJ. Low- to high-fidelity simulation – a continuum of medical education? Medical Education. 2003;37:22-8.

7.         Donaldson SI. 150 years of the Annual Report of the Chief Medical Officer: On the state of public health 2008. London: Department of Health2009 16/03/2009. Report No.: 293338.

8          Chikwe J, de Souza AC, Pepper JR. No time to train the surgeons. Bmj. 2004 Feb 21;328(7437):418-9.

Send ePoster Link