Let’s stop using the ‘F’ word in Simulation

When it comes to simulation speak it can get very confusing now days. But all in all we can agree that the word simulation in the healthcare sense relates to the substitution of something (ie situation, environment, equipment, people, etc.) that we can use to teach and/or assess someone, or some group of people to improve their knowledge and or performance in the patient care environment or a related system. Even as I compose this definition to try and encompass the common forms of simulation I struggle a bit, but feel that I covered the gist of it.

That being said the ‘F’ word in the context of simulation is one of the most overly and misused terms that gets bantered about on the regular basis and introduces not only confusion, but subtle thoughts of “the right way” and the “wrong way” to approach simulation. That word of course is fidelity. Likely coined by industry or the inventors of something or some system that approximates part of a human beings anatomy or a specific environment. I argue here that to properly use the term fidelity we have to define it in context with a rather specific focus and would rather we just eliminate it from our vocabulary.

Recently I was touring a simulation center and was told, “We do our high fidelity simulations in these rooms”. The rooms contained high technology human simulators with no other specific environmental attributes except an overly populated array of video and audio capturing devices. We travelled down the hall and my host told me “We do our low fidelity simulations like task training and SP’s in here.”  This notion was an immediate hair rising response for me representing a gross misuse of the term. Seriously? If fidelity is that by which there is some measure of realness, then how can one ever describe an SP as low fidelity?

Conversely when I touch the pulse of, or perform a needle decompression on a SimMan®  I can appreciate a comparison to those events in real patients, thus suggesting an increased realness or dare I say, fidelity. However take that same simulator in a room and have a conversation with it for 20 minutes and then tell me it was a high fidelity experience? Examine the knee joint of a METI HPS and tell me that you every felt a knee like that on a real patient? I think not. So are these machines both high fidelity and low fidelity? Or is it something in between? I think if it labeled a high technology piece of equipment there would be little argument. But, high fidelity? Seriously? Perhaps in some very focal aspects, but I would argue certainly not in total. Thus the confusion begins. Does it matter?

While the above example focuses on a simulator, the same analogy can be made when we talk about the environment the simulation is conducted in. If the simulation takes place in a room that is decorated or equipped to mimic an actual operating room, the situation may appear highly realistic when compared to live surgery and therefore might be labeled as high fidelity. But we must bear in mind that the reference to fidelity in that sense is to the environment. If we are running a scenario in a highly realistic replica of an operating room with a low technology simulator, is that called high fidelity simulation? If we ran the exact same scenario in the confines of a hotel conference room and were able to accomplish the learning objective, is that lesser fidelity? Does it matter? What is we ran a scenario in a beautifully equipped simulated operating room and didn’t accomplish the learning objectives? Is that still high fidelity?

The same type of descriptive dissection can be used to describe the people involved in a given scenario. If a standardized patient is rendering a convincing performance of crying during a scenario focusing on delivering bad news, what do you call that? Incidentally, I have never been to a theatre production and walked away thinking that was a high fidelity production even though there are elements of the every stage production that may seem realistic and those elements that are clearly not!

The same type of comparative discussions could be used to evaluate the realness of the audio cues, the equipment racks used, the amount of stress caused by the simulation and on and on as compared to life in the real healthcare environment. The bottom line is there are always elements of every scenario that seem very close to reality and those that don’t. The decision by which to include and exclude various elements is complex. Many variables factor in including, budget, resources of equipment, people and environments, and hopefully most importantly consideration for the ability of the scenario to accomplish the learning objectives in the most efficient and effective way possible. After all isn’t that what we are really trying to accomplish?

Thus if you must continue to use the ‘F’ word, please, please, at least apply the context by which you are using it. We even have the editors of healthcare scientific journals confused and believing it means something such as a standard! Talk about confusion? I believe much of this comes from industry terminology evolving from sales speak, as well the creeping danger of the simulation being the focus of the activity. The education and/or assessment outcomes must always be the focus of the activity.

Lets all agree to do high effectiveness simulation and therefore truly think about the outcomes we are trying to achieve as opposed to the show we will put on along the way!