Hybrid

• Promis-Haptica

• CELTS-Medicalsim

Fig. 7.1 Simulators on the market

Key points and advantages of VR simulation can be summarized as follows:

• Long periods of training without the physical presence of a tutor

• Large number of simulations and exercises

• Repetition of the scenery

• Flexibility of the scenery

• Score system for evaluation and learning assessment

• Network of models: net connections to exchange information for the development of teaching and learning

• New pedagogy and better motivation, representing the meeting point between professional education and the "PlayStation generation," using the positive impact of the so-called videogame effect

When considering simulator design, a complete understanding of several aspects, including human learning, human factors, technology, and the field of simulation in general, is required. Development requires expertise in surgery, education, computer graphics (and possibly haptics), computer programming in general, and in simulation technology. In the pioneering days of surgical simulation in early 1990s, most developers did not apply a comprehensive approach, and it is now clear that simulators created without a thorough knowledge of these areas are unlikely to be useful in today's teaching process.

Moreover, the knowledge of the learning process must be very well interpreted, as learning theories play a determinant role in the transfer of learning on models to the real procedures.

We want to stress here two main points: 1. The most commonly used theories to explain human learning are based on constructivism. A continuous increase in knowledge or change in behavior is brought about through "learning by doing" or "experiential learning" (Kolb). If we speed up this process, a faster and more reliable education can be achieved.

2. It is equally important to remember that surgical simulation is a very reliable application for the model of Rasmussen, who distinguished three levels of human behavior:

a. Skill-based behavior (SBB)

b. Rule-based behavior (RBB)

c. Knowledge-based behavior (KBB)

It indicates that different training simulators need to be developed related to different behavior levels (Fig. 7.2). At the lower level (SBB), simulators are needed to learn basic skills, such as using instruments. For higher-level training (RBB and KBB), surgical skill improvement requires more sophisticated training methods. For example, to enhance patient safety by reducing human errors and critical and unexpected situations (e.g., power failure, instrument breakdown), trainees should be trained at the knowledge-based behavior level.

The potential of learning via multimedia resources must be finally stressed. The commonest form of audiovisual link is a broadband connection that can be easily used between the operating room and the surgical skills center and, with the development of the "intelligent OR," audio-\visual information to and from the operating room can be integrated with the system. Simulation can then be performed on real cases, responding positively to the criticism on the transfer from VR to real practice. Equally important is the chance, thanks to powerful audiovisual requirements, to broadcast simulation sessions from one skills centre to the other, increasing a network of models running on the same digital platform.

Validity and reliability of simulators are key points for their validation as educational tools. This explains why educators and simulation experts must learn and imbed new words in their cultural knowledge, such as

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