BRITISH JOURNAL OF NEUROSURGERY, 2016

VOL. 30, NO. 5, 577–581

http://dx.doi.org/10.1080/02688697.2016.1211252

REVIEW ARTICLE

Simulation in neurosurgical training: a blueprint and national approach to

implementation for initial years trainees
Lihan Zhanga, Ian Kamalyb, Pramod Luthrac and Peter Whitfielda
a
Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK; bCentral Manchester University Hospitals NHS Foundation Trust, Manchester, UK;
c
Health Education North West, Liverpool, UK

ABSTRACT ARTICLE HISTORY

Simulation has played an increasing role in surgical training in recent years, this follows from various Received 2 January 2016
reports such as the Chief Medical Officer annual report and Sir John Temple’s ‘Time for Training’ and also Revised 10 June 2016
from other factors such as increasing focus on efficiency and transparency within the healthcare system. Accepted 3 July 2016
Evidence has shown that simulation can develop and improve technical, clinical, communication and man- Published online 12 August
2016
agement skills. With technological advances, the quality of simulation has also improved with more realistic
models and environment. We have undertaken a review of recent drivers for simulation training in the UK, KEYWORDS
current techniques and have focused on the application of simulation training within the current UK Simulation; training;
Neurosurgical curriculum for newly appointed trainees. education; technology;
neurosurgery

Introduction combined with feedback and performance debriefing to maxi-

Simulation has been used in medical education and training to
learn and practice tasks for over 60 years. Since the early 2000s,
greater emphasis has been placed on supervised and supported
deliberate practice with formative debrief and feedback.
Simulation based education and training is a learning tool that
has gained great support and become mainstream in healthcare.
Safe patient care recommends simulated training before supervised
practicing and learning with patients.
Recent reports and recommendations have driven the change
from the apprentice model practiced previously of ‘see one, do
one’ to a model of ‘see one, simulate one, and do one under
supervision.’ The key reports and recommendations promoting
the development of simulated training are as listed below:
1. The Chief Medical Officer Annual Report (2008)1 by Sir
Liam Donaldson. It is recommended in this report that simu-
lation training should be integrated into the healthcare service
to facilitate the provision of a safe and responsive service.
2. Sir John Temple’s 2010 report ‘Time for Training’,2 which
reported on the impact of Working time Directive on train-
ing, which can be addressed by including simulation based
learning in training programmes.
3. In 2011, the Department of Health ‘A Framework for
Technology Enhanced Learning’3 and Higher Education
England ‘Technology Enhanced Learning Programme’4 rec-
ommended the use of simulation and emerging technology to
support learning, education and training.
4. The General Medical Council publication, ‘The Trainee
Doctor’ (2011)5 Section 8.7 recommended that trainees must
be enabled to develop and improve their clinical and practical
skills through technology enhanced learning.
5. The Joint Committee on Surgical Training (JCST) simulation
group (2012)6 recommended that simulation training can
complement and augment clinical training, especially when
mise training benefits.
Subspecialisation and development of new techniques have led
to different patterns of skills acquisition, resulting in the develop-
ment and increased use of simulation in surgical training.
Recently, the JCST has driven the development of a simulation
curriculum within surgery, including Neurosurgery, which was
approved by the GMC in 2013.
Definition
Simulation in the context of surgical training means any repro-
duction of both common and uncommon real life events, proc-
esses or a set of conditions or problems, e.g. history taking,
performing a procedure, team resource management, and human
factors.7,8 In simulation training, all learners should have the
opportunity to perform deliberate practice in a patient-safe envir-
onment under supervision. This can be used for the development
of individuals and teams in various aspects of clinical practice as
shown in Figure 1.
Experience from military and aviation programmes are often
referred to in support of simulation training in medical practice.
The objective behind simulation is to improve patient safety by
increasing trainee familiarity in managing potentially hazardous
clinical situations. Sackier stated that ‘the first time that a resident
deals with crisis management should not be a situation of true
crisis’.9
In situ simulation, which is integrated into the clinical environ-
ment, through location and participants (actual clinicians) can
help individuals and teams to review and develop their practice
and skills in real life clinical settings.10 This promotes experiential
learning for the individuals within a familiar clinical environ-
ment,10 which facilitates practical application of learnt skills and
behaviour.

CONTACT Lihan Zhang lihan.zhang@nhs.net Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, United Kingdom
ß 2016 The Neurosurgical Foundation
578 L. ZHANG ET AL.

Deliberate practice is a method of learning employed in simu- familiarity with equipment and procedure-based training. Practical
lation training, it has nine elements11: simulation can be classified into three categories:
1. Motivated learners, 1. Biological models – use of cadaveric or animal material;
2. Defined objectives, 2. Synthetic models, including 3D printed models and
3. Set at the appropriate level, 3. Virtual reality models.
4. Focused and repetitive practice, Haptic models are a variant of synthetic and virtual reality
5. Produces reliable measurements, models that provide psychomotor feedback, which can facilitate
6. Informative feedback from supervisors, skills acquisition.7,12–14
7. Promotes learning and corrects errors,
8. Evaluates performance against the final standard but also to Simulation models
ensure completion of minimal outcomes for all trainees and
The ideal simulation model should allow practice of as many pro-
9. Progression in training.
cedures as possible, and be reusable to provide maximum value,15
for example, for cranial surgery simulation, an ideal model should
have15:
Simulation techniques  Complete head and neck anatomy with surface landmarks;
 Compatibilities with imaging modalities;
Several techniques can be used to simulate operative procedures  Ability to be positioned in a three point head clamp
(Table 1). The simplest is a critical verbal assessment. Although it (Figures 2 and 3);
is not a practical task, it includes a viva voce style description of  Realistic scalp, bone and dural layers;
anatomy, findings and potential complications. This approach can  Realistic bone behavior;
improve surgical planning and organisation, and identify areas for  Realistic brain substance including CSF spaces and
further studies. Operative models (Tables 2 and 3) have been  Accurate representation of pathology.
developed to focus on acquisition of practical skills, such as
Categories of simulation7,12,13,16
1. Cadaveric models – used for cranial and spinal procedures,
Systems especially for understanding of cranial surgical approaches.
Usually limited by poor brain preservation.
In-situ Human factors

Table 2. Simulated use of technical equipment.

Equipment Training modality
Clinical and Operative microscope Basic Neurosurgical skills/local training
Simulation
technical skills Manikin Drill techniques Basic Neurosurgical skills/local training
Training
Image guidance system Image guidance workshop
and stereotactic frame
Endoscopic techniques Neurosurgical skills training
CUSA Basic Neurosurgical skills/local training
Intra-operative ultrasound Basic Neurosurgical skills/local training
Simulated patient Assessment Spinal instrumentation Neurosurgical skills/ local training
(procedure specific)
Values Basic instrumentation including Local training
diathermy/suction
Figure 1. How simulation affects clinical practice.

Table 1. Simulation techniques within neurosurgery.

Simulation Comments
Technique
Critical verbal assessment (CVA) Full discussion of a surgical procedure and possible complications with a senior surgeon,
using anatomical models as appropriate. Local delivery.
Basic clinical skill courses BSS, CCrISP, ATLS – these include practical skills, team work and communication skills.
The SAC/TPD supports the provision of a compulsory National Simulation Training
Facility incorporating Clinical Skills in Neurosurgery for Early Years trainees. Local,
regional and national delivery.
Anatomy workshops including 3D materials Covered on Neurosurgical Training courses. National delivery.
E-Brain Over 500 neuroscience topics. Some of these contain video/simulation techniques. Local
delivery of National integrated programme.
Dry bone techniques, use of anatomical models Often industry supported; e.g. Spinal models, MARTYN and ROWENA heads. Local,
regional and national delivery.
Cadaveric workshops Approaches, techniques, dissection skills. Many courses exist, some covering advanced
surgical skills. Combination of regional and national delivery.
Image guidance training Industrial support with phantom set-up. Local, regional and national delivery.
Hardware workshops Industry support. Pumps, stimulators, shunts. National delivery.
High Fidelity Computer simulation models (including VR models) These techniques largely remain aspirational. Developments are occurring in this field and
we envisage that these be phased in as validity and availability are enhanced.
Regional and national introduction.
Human factors training Team working in a stressed environment can be enhanced by engagement with human
factors training. There is an increasing availability of this type of course. Regional and
national delivery.

Table 3. Showing advantages and disadvantages of simulation models.6,10
Biological models (e.g. Cadaveric, animal)
Synthetic models
Virtual reality
Figure 2. MARTYN (Modelled Anatomical Replica for Training Young
Neurosurgeons) model of the skull and brain (Courtesy of the Royal College of
Surgeons of England). Developed using cadaveric specimens to give greater details,
and has been used for patient positioning, burr hole, craniotomy, and ventricular
cannulation training.19,20
2. Animal models – used to develop practical skills, e.g. drilling
technique, microsurgery.
3. Synthetic models – used for cranial and spinal procedures
and surgical approach. 3D printed models of specific path-
ology can be used to develop specific skills, and potentially
aid surgical planning for patients.
4. Virtual reality – can be used for procedure based learning.
5. Simulated patients – for communication skills training.
Existing simulation training programme in Neurosurgery
– USA
In Texas, an intensive programme of simulated activities was
embedded into the Neurosurgical curriculum in 2012/13. This
programme uses a variety of simulation techniques, including 79
physical simulations, 57 cadaveric simulations, and 44 haptic/com-
puterised simulations. The costs associated with this programme
were substantial. Initial set up cost was $4.2 million, $476,000 in
annual expenses, and $12,500 per resident per year. Residents are
required to complete 30 simulated activities appropriate for their
training level each year. Outcome assessments indicate that
BRITISH JOURNAL OF NEUROSURGERY 579
Advantages Disadvantages
 Accurate tissue representation  High cost
 Limited availability
 Difficult to simulate
 Pathology
 Not reusable
 Cannot replicate bleeding
 Portable  Poor tissue
 Pathology simulation  Representation
 (Reusable)  Not always reusable
 Reusable  High costvTechnical maintenance
 Pathology simulation  Software subscription
 Feedback (improving)
Figure 3. ROWENA (Realistic Operative Workstation for Educating Neurosurgical
Apprentices) model – the head is fixed in a Mayfield clamp. Several burr holes
have been drilled during a training workshop (figure courtesy of Mr R. Ashpole).
This model is compatible with image modalities, which allows the use of image
guidance systems.23,24
simulation training has improved residents’ skills across all levels
of post-graduate training. Cadaveric dissection provided the most
benefit, followed by physical and computer models.17
Feedback from 500 residents at the US National Surgeons Boot
Camps indicates that most simulation models are well-rated.
Drilling skills simulation seemed to have had the best feedback.18
There is also a difference in ratings between junior and senior
trainees, where junior trainees found physical models more useful,
whilst senior trainees found virtual reality models more helpful.9
The implementation of Neurosurgical Simulation
Training Programme in the UK
The delivery of simulation training within the Neurosurgical cur-
riculum is a challenge faced by the training community. A recent
survey shows that 85% of UK Neurosurgical trainees have partici-
pated in simulation, but only 65% supports its integration into the
curriculum.19 Cadaveric operating skills training is the commonest
form of simulation training, however it is limited by cost, avail-
ability of cadavers, and limited pathology.19 At present, the avail-
ability of other simulation facilities in the UK is limited 18.
Various factors can affect the implementation of simulation train-
ing, such as availability of appropriate facilities, cost, trainer com-
mitment to the delivery of simulation training, and the resources
required to establish high quality training. This combination of
circumstances has led to the Specialist Advisory Committee (SAC)
in Neurosurgery and the Society of British Neurological Surgeons
580 L. ZHANG ET AL.

Table 5. Feedback from delegates.

Trans-sphenoidal approach, Pterional craniotomy and sulcal dissec-

tion, Trans-callosal approach, Lateral posterior fossa approach.
Cadaveric, covering areas of interest to the trainee, Recommend
Subspecialty
2015 2014

Optional/Desirable: skull base approaches, thoracic spinal

Advanced image guidance techniques (e.g. microscope and
Overall 10 9.75
ST8

attendance at annual National Neurosurgical Simulation

training programme. Optional/ desirable HF Simulation
All stations 8.93 8.60
Human factor stations 9.59 9.08
Simulation Centre facilities 9.79 9.45
Sawbones model 8.89 –
ROWENA model 9.30 –

ultrasound integration); Spinal navigation

supporting the recent development of a nationally delivered
ST7

Specialist Trainee Year 1 (ST1) simulation training programme.

approaches, pineal approach

To effectively deliver structured simulation training, a blueprint
mapping simulation technique to the curriculum at different
Final

stages has been developed (Table 4). This is in keeping with

experience from the SUA, where it has been shown that simula-
tion training should be targeted, so that resources are directed in
a graduated fashion at the appropriate levels for trainees.17 Based
ST6

on this progressive skills acquisition process, plans exist for a

similar programme aimed at senior trainees.
The aim of the National Neurosurgical Simulation Training
Programme has been to deliver simulation training to a high
VP shunt insertion, Stereotactic biopsy with image
Microscope, Ultrasound. Spinal instrumentation,
Dry bone training, Cadaveric course, Recommend

standard for all newly appointed run-through UK Neurosurgical

guidance, lumbar discectomy, lumbar decom-
pression, cervical discectomy, cervical decom-

craniotomy for supratentorial tumour/haema-

pression, midline posterior fossa craniotomy,
attendance at annual National Neurosurgical

trainees at ST1 level. It is a five day programme, and has taken

place in 2014 and 2015, based at the Surgical Skills centre at
ST5

Simulated use of image guidance, CUSA,

University of Manchester. The content of the programme has

been structured to cover the key Early Years component of the
Simulation training programme

Microsurgical instrumentation
Intermediate

curriculum as outlined in the blueprint. This programme provides

toma, third ventriculostomy

a wide range of simulation training experiences including short

plenaries on a range of topics such as patient assessment, profes-
sionalism skills and behaviour, small group workshops on consent,
operative equipment, ward-based procedures, human factors, and
operative skills. The ST1 Simulation Training Programme con-
ST4

cludes with formative assessment that incorporates learning from

the programme. On average, there were eight members of the fac-
ulty present each day, which mostly consists of consultants and
senior trainees from the local Health Education provider.
The SAC in Neurosurgery supports the annual delivery of the
Trainees should continue to develop skills in this field throughout
Skills (Intercollegiate) course, ATLS Course, Basic Neurosurgical

Core basic Neurosurgical procedures to include lumbar puncture,

lumbar drain, burr holes, convexity craniotomy, application of
Skills Course (with cadaveric simulation), Recommend attend-

ST1 Simulation Training Programme, and it is also supported and

training with attendance at one or more formal human factors
Care of the Critically Ill Surgical Patient Course, Basic Surgical

funded by the Society of British Neurological Surgeons and

ance at annual National Neurosurgical Simulation training
ST3

Industrial Partners. The uptake rate for the course has been 100%
Simulated utility of basic instruments: suction, diathermy

for ST1 trainees. In 2014, 26 trainees attended and 29 trainees in

Table 4. A blueprint for implementation of simulation in neurosurgical training.

2015, at a cost of £560.86 per trainee. Course cost covered facility

hire, accommodation, catering, and materials costs.
Feedback from trainees in 2014 and 2015 has been exceptional
in all domains (Table 5). Overall rating improved in 2015 to 10
Initial stage

out of 10 from 9.75 out of 10 in 2014.

ST2

skull traction and halo vest

Discussion
simulated training sessions

Benefits of simulation training extend beyond gaining technical

skills, it provides a safe, immersive environment that allows repeti-
tion, and can be adjusted to suit training requirements (Figures 2
programme

and 3).7,13,16,20 Integration with human factor training enables

ST1

trainees to develop key skills including teamwork, leadership,

communication, decision-making, situational awareness, and appli-
cation of scientific knowledge in addition to the development of
technical skills. These skills and behaviours can be objectively
Key topics – evidence of

assessed using validated rating systems such as Non-Technical

simulation required

Skills for Surgeons (NOTSS) formative assessment tool.21,22 It is

Compulsory Course

evident that trainees welcome simulation training and it is able to

Instrumentation

Human factors
Attendance

maximise training potential when combined with deliberate prac-

tice, debrief and formative feedback.7,12,13
Using simulation to practice safely benefits patient safety, and
cost of errors in both time and money for the healthcare provider

and patients. However, providing simulation training is costly, not
only in equipment and technology, but also trainees’ time in
attendance, training trainers, time and finances to provide trainers
and management of training and materials used. The overall cost
saving needs to be justified against the cost of the training provi-
sion, and this is well demonstrated in fast track learning, safe
patient care, and improved outcomes.
Conclusion
The interplay of various factors in recent years has driven the
development and integration of simulation training into surgical
programmes, including Neurosurgery. It has been shown previ-
ously that simulation training can improve surgical performance
and feedback has shown that it is well received by trainees. The
National Neurosurgical Simulation Training Programme has now
provided excellent value and high quality simulation training for
all UK ST1 trainees. The content has been blueprinted to the
Early Year Training components of the curriculum to provide a
good foundation for application of training into practice. The
SAC supports and encourages the development of higher com-
plexity simulation training for senior Neurosurgical trainees.
Disclosure statement
Mr Lihan Zhang has no conflicts of interests to declare.
Mr Ian Kamaly is a member of the SAC in Neurosurgery, lead for the
delivery of the National Neurosurgical Simulation Training Bootcamp for ST1
trainees, and is involved in local and national simulation training.
Professor Pramod Luthra is the lead Associate Dean for Technology
Enhanced learning for HEE in the North West, core member of the North
West Simulation Education Network, contributor to the Department of Health
‘Technology Enhanced Learning’ framework, member of the JCST Simulation
working group, visiting Professor in simulation based learning and education
and run postgraduate programmes in simulation at Manchester Metropolitan
University and Edge Hill University.
Professor Peter Whitfield is the Secretary to the National Neurosurgery
Selection Board, Vice Chairman of the SAC in Neurosurgery and Training
Programme Director for Health Education England South West, and is
involved in delivery local and national simulation training.
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