• Roger Kneebone.
• Department of Surgery and Cancer, Imperial College London, 2nd Floor, Paterson Centre, St Mary's Hospital, Praed Street, London W2 1NY, UK. r.kneebone@imperial.ac.uk
• Qual Saf Health Care. 2010 Oct 1; 19 Suppl 3: i47-52.

ObjectivesThis paper explores the place of simulation in contemporary healthcare education and training, highlighting the challenges of recreating complex clinical settings which can support the development of competent, rounded and caring practitioners, and address issues around human factors as well as technical skill. It frames the relationship between clinical and simulation-based practice as a mutually dependent, two-way process.DiscussionAccording to this view, simulation is less like a photograph of clinical care than a painting of it-a process that requires selection and interpretation. The paper presents simulation as a canvas on which to paint this picture. To be effective, simulation must mirror the essentials of a clinical setting without reproducing every detail. After highlighting key issues with current approaches to simulation, the paper considers how authenticity and perceived realism can be heightened through innovative uses of technology and design, putting forward a conceptual framework based on the notion of 'circles of focus.' The paper then outlines the concept of Distributed Simulation, using low-cost, portable yet immersive environments to address limitations of access to dedicated facilities.ConclusionThe paper concludes by considering theoretical and practical implications of these innovations, focussing especially on surgery and other craft specialties.

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