1. The Rule of 4s: A Theory-Driven Approach to Implementing Simulation into Surgical Training
Sonal Arora PhD MBBS MRCS BSc(hons)
Academic Clinical Lecturer/General Surgeon SpR

2. Simulation Works BUT…. Not always grounded in educational theory
Ad-hoc & Expensive
Disconnect from practice
Failure to realise full potential

3. Simulator-based practice
CLINICAL ENVIRONMENT
Patients
Clinical practice
Clinical supervision
Tutor support
Simulator-based practice
Simulators
SIMULATED ENVIRONMENT

4. SIMULATED ENVIRONMENT
CLINICAL ENVIRONMENT
Patients
Identify learning need
Reapply skill
Review
Continue
Clinical supervision
Tutor support
Simulator based practice
Further practice as needed
Simulators
SIMULATED ENVIRONMENT

5. Aims To establish a 4-step training programme:
Based upon sound educational principles
Delivered according to Kolb’s cycle of experiential learning
Incorporating simulation
Demonstrating transfer at multiple iterations of programme

6. Kolb’s Learning Cycle: The Theory…..
2. Active Experimentation
3. Concrete Experience
4. Reflective
Observation
1. Abstract Conceptualization

7. ABSTRACT CONCEPTUALIZATION ACTIVE EXPERIMENTATION REFLECTIVE
OBSERVATION
CONCRETE
EXPERIENCE .

8. Setting Study Design Participants Test Procedures Outcome Measures
Methods
Single Community Hospital UK
Setting
Prospective cohort study
Baseline skills assessment in OR
Study Design
Total n=16 residents (PGY2-4)
Each iteration; 4 residents
Participants
Open Hernia
Lap Chole
Test Procedures
OSATS (hernia)
GOALS (lap chole)
Outcome Measures

9. Rule of 4s Iterations Days Stages 4 Trainers 4 Trainees
Mentoring & Feedback
Distributed Learning
Replication

10. Study Procedure: Each trainee-trainer pair completes….
CORE LAPAROSCOPY
SKILLS,
KNOWLEDGE & COGNITIVE SKILLS
VIDEOS OF EXPERT PERFORMANCE
Active Experimentation
Concrete Experience
Reflective Observation
Abstract Conceptualization
Day 1: Didactic & Video
Day 2: Skills Lab*
Day 4: Debriefing
Day 3: Real OR Practice*
* Video-based performance assessment

11. Results: Technical performance – Open Hernia (ICC = 0.74 -0.92)
TRANSFER
LEARNING
P= 0.08
P= 0.001

12. Results consistent at all 4 Iterations of Programme
TRANSFER
LEARNING

13. Technical Performance Lap Chole (ICC=0.72-0.88)
TRANSFER
LEARNING
P= 0.35
P= 0.01

14. Results consistent at all 4 Iterations of Programme

15. Discussion: Strengths, Limitations & Future Study
Educational Theory into practice
Single theory, technical skills
Compare models, teamwork skills
Immediate benefits of simulation
Small Group, Single Centre
Retention,
Multi-Centre
In-situ Training
Costs
Resources
Transfer Effectiveness Ratio

16. Summary – Towards best practice with the Rule of 4s
Developed a simulation-based training programme
4 trainees, 4 trainers, 4 stages, 4 days, 4 iterations
Incorporated educational principles of mentoring, distributed learning
Delivered according to Kolb’s cycle of experiential learning
Blended learning with theory, skills lab training, debriefing and transfer
Replication through multiple iterations of programme