• R L Kneebone, W Scott, A Darzi, and M Horrocks.
• Department of Surgical Oncology and Technology, Imperial College London, London W2 1NY, UK. r.kneebone@imperial.ac.uk
• Med Educ. 2004 Oct 1; 38 (10): 1095-102.

IntroductionThis discussion paper argues for a creative synthesis between simulation and clinical practice, where an iterative process of continual interaction ensures that skills are learned and reinforced within the context of everyday professional life.BackgroundEvidence is mounting that long-established approaches to surgical training are no longer acceptable in the current ethical and professional climate. This paper considers alternatives to the traditional approach of 'learning by doing' in a clinical context, focusing on recent developments in the technology of simulation and virtual reality. Clinical expertise is a complex phenomenon and no single theory can account for its acquisition. After a brief contextualising overview, Vygotsky's 'zone of proximal development' is proposed as a conceptual framework for task-based surgical learning that takes place within skills laboratories. The discussion is located within a wider context of educational theory, drawing on current thinking about situated learning and apprenticeship. The notion of 'legitimate peripheral participation' in a complex professional environment places technical skill alongside a range of other competencies that are necessary to safe practice.ConclusionsSimulation offers a safe environment within which learners can repeatedly practise a range of clinical skills without endangering patients. Comprehensive simulated environments allow a move away from isolated tasks to more complex clinical situations, recreating many of the challenges of real life. Such simulations, however, can operate in isolation from their clinical context, ignoring the learning needs of individuals within a real health care environment. To realise its full potential as a learning aid, simulation must be used alongside clinical practice and linked closely with it.

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