231with physicians and learn about terminology, anatomy, disease, surgical instru-
ments, and surgical procedure. A process called “cognitive task analysis” was found
to be optimal for this kind of interaction between developers and physicians. First,
gross task or “procedure” deconstruction into a number of steps is performed, and
cognitive task analysis (CTA) is then performed for each step of the procedure to
clearly describe the specifications and necessity of each step, delineate the visible
and hidden anatomic structures, explain the important cues which lead to correct or
wrong decision, describe the interactions and behaviors of tissues, and enumerate
the errors (commission, omission, or execution) which could be made during each
step. Watching a video of a faculty instructing a trainee would be an appropriate
method for demonstrating critical clinical aspects and the important outcome mea-
sures of the procedure [ 8 ].
Phase II: Translating Physicians’ Requirements to Engineers’
Requirements Clinicians’ perspectives, obtained from the CTA, are then translated
into engineering and art design requirements. During this phase, the characteristics
of the task or the procedure to be simulated should be fully understood. If anatomic
fidelity is a requirement, carefully edited anatomic datasets need to be imported and
edited accordingly. If physiologic fidelity is a requirement, verification of the func-
tion of the system as it relates to other organs critical for a given learning objective is
important. If tissue fidelity is a requirement, tissue behaviors that need to be observed
are identified by collecting tissues and studying its physical and biomechanical prop-
erties. This will lead to creation of more realistic “high- fidelity” tissue samples which
could be later used to obtain the desired organs. Anatomic data are obtained from
DICOM images from computed tomography (CT) and magnetic resonance imaging
(MRI) scans. The CTA also serves to identify and weigh each task, decisions based
on each task, and what needs to be assessed. Furthermore, performance metrics are
delineated and, whenever possible these should be used to give tutoring and feedback
in the form of an exportable performance reports. These performance reports have
pronounced importance with the increasing role of simulators in objective assess-
ment of technical skills to avoid the “halo effect” of subjective evaluation. If there is
a requirement to reproduce the feelings of interacting with the likeness of a real
human (affective domain), then verbal and nonverbal cues need to be carefully
thought out, and presented to elicit this response in the learner [ 9 ].
The development process is guided by a set of specifications which vary accord-
ing to the nature of the simulator and the intended use of the interpretation of simula-
tor scores. These specifications are created by the developers and include a statement
of purpose(s), target users or populations, content frameworks, construct to be mea-
sured, tasks, and scoring. Specifications concerning the intended use should mention
whether the simulator score(s) interpretation will be primarily criterion- referenced,
where absolute interpretations are always used, or norm- referenced, where relative
interpretations are always used. Content specifications should delineate what is to be
included to represent all aspects of the construct to be measured, and this could be
guided by theory or by analyzing the content domain. For example, delineating the
requirements to be credentialed as urologist is an important content specification for
13 Modern Theory for Development of Simulators for Surgical Education