Monthly Archives: November 2013

Suspension of Disbelief is So Yesterday – Lets Think About a Great Movie Encounter

The concept of “suspension of disbelief” was orginally attirubuted to a poet/philospher in the 1800’s with regard to creating works of fiction to be interpreted by readers. When I first started in healthcare simulation back in 1997 it was told to me that we needed to create an environment where there is a suspension ofdisbelief so that the participants will believe that they are in the actual health care environment and perform accordingly. I drank the coolaid, I thought that is what we were to do. Today when I reflect on this notion it seems a bit crazy when it is inerpreted to mean that we are designing simulations to make participants forget they are in the simulated environment.

Certainly we don’t want health care professionals to actually think they are in the real clinical environment when they engage in simulation.  We want to create an evironment where they can perform aspects of what they do when they are taking care of real patients so that we can form an opinion to help them improve. This ocurrs through feedback,  assessment and debriefing methods as well as other innovative learning and assessment strategies.  I think we need to think of it more as a “fiction contract” which I believe was a term coined by Peter Dieckmann of Copenhagen which has always resonated with me. (At least he was the first person i heard use it in that concept, shutterstock_130674926and he a brilliant mind in simulation as well as a friend.  So barring any information to the contrary, i’ll leave it attributed to him for the time being 🙂 )

A good metaphor would be to think of it more like the intellectual engagement of going to see a great movie. The movie goer buys a ticket and enters into a contract (of sorts) with the producers of the film and perhaps the movie theater involving a belief  that the money they are spending will allow them to see something that is not quite real, but is a reenactment of something real, and  perhaps they will be participating in it emotionally and psycologically, but they never thought it was real.  However, the value to the participant is in the movie metaphor would be the entertainment provision.  So in essence the “deal” is summarized by the fact that they are entering into an unofficial agreement that says I will provide you $15 to buy the movie ticket, and you will provide me two hours of entertainment. 

I think there are strong analogies between that and the way we should approach healthcare simulation relationship between participants and the simulation providers. We need to create environments where the participants trust us so that they will engage psycologically and emotionally in the simulated environment  in exchange for the valuable use of their time to help them improve as a healthcare provider. 

I think that if we shift the focus so that we are not trying to create a “suspension of disbelief”, it will allow us to better create the environment necessary for effective healthcare simulation. That is that we realize we’re not trying to recreate everything to do with reality in healthcare, we’re just trying to recreate that which allows the participant to engage in a way that they might when they are actually taking care of patients. I think it is particularly important to be direct in letting the participant know that not everything we do in simulation will mimic their realistic practice environment. If we are honest with this orientation and apporach, I believe it causes less constrenation on the part of the participant who is in an environment where some things seem real and some things do not.

Participants are often experiencing a sense of  internal “conflict” when interpreting what the see, hear and experience in the simulation, wondering is this supposed to be part of the simulation or not? I am of the opinion that they are more likely to reconcile this with us if we are frank, open and honest about the intent and expectations of the simulation. This is in contrast to simply asking them to “pretend this is all real” conceptually describing the mantra of suspension of disbelief.

Through this bilateral agreement we enter into a fiction contract or a trust contract that says, on the participant’s side, I will engage in this activity in exchage for the trust that you are making valuable use of my time and helping me become a better healthcare professional.  On the simulation provider side of the agreement it goes something like this: “we will create an educational program using aspects of simulation, which some parts will feel realistic and some will not, but we commit to you that this will be a valuable use of your time with tust, dignity, respect and professionalism. We will attempt to help you get better as a healthcare provider.”  Isn’t that what we’re all trying to accomplish? To me this seems more plausible than asking professionals to suspend the disbelief and interpret the entire simulation as “real”………

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Simulation and the Future of Customized Continuing Education for Practicing Professionals

Click Here to Watch the Video on YouTube

I posted a new video on the WISER You Tube channel describing how simulation can fit into a futuristic model of customizing a pathway of continuing education for practicing healthcare professionals. The model incorporates the utilization of healthcare system quality, safety and risk data. A provocative thought to move us down a road to help imoprove replace the time honored, yet inefficient system of continuing education that exists currently.


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November 13, 2013 · 7:50 pm

Patient Centered Debriefing – The Ultimate Goal

I am growing more and more concerned about the pacifism by which I hear people approaching their debriefing efforts as I travel about the world. The phrase “safe learning environment” is being hijacked into some sort of process during which the only thing that matters in the world is the feelings of the learners participating in the simulations. So much so that some are saying you shouldn’t tell students what they didn’t do correctly and that during debriefing you should only focus on that which went well and then have a group hug at the end. This is being claimed under banners of student centric debriefing, “safe learning environments”.


Do these same educators harbor the fear and trepidation that students might be sad if they perform poorly on a written test? Do these same educators realize what a disservice they are doing for the students when you step back and look at the big picture?  Maybe the educators themselves have a tough time bucking up and delivering the news, doing the HARD WORK of simulation. Perhaps, this shifting or trending is partly evolving because many of the people involved in the teaching and theorizing about simulation feedback don’t see patients on the frontline of the healthcare battlefield.



I am certainly not advocating that we don’t need to be mindful of students emotions and psychological well being during simulation education activities, but come on people, healthcare decisions and actions involving patient care need to be near perfect. Every Time.  We need to be certain that when participants leave our simulations they have a clear understanding of what was right and what was wrong not just do a deep dive into their feelings carefully guarded by the emotions police and find happy things to chat about.



I am sorry to be the bearer of bad news, but providing healthcare is hard work, stressful and requires excellence. We need to develop/reinforce excellence in the participants of our simulations and help them achieve their goal, which is to get better at what they do. Every healthcare professional in the world has this as a goal at some level. How we reach out to them and help them along this journey needs to be PATIENT CENTRIC because the ultimate goal is to continuously improve healthcare throughout the world.


We certainly must develop methods consistent with the levels and abilities of our simulation participants and create environments that are open to participating, learning, exploring and discussion. But we also must provide participants with information on where they are with regards to expected performance on a continuum of the development of competence. We can not hide the truth during a debriefing because the faculty is uncomfortable with delivering critical feedback, or is so concerned that the students emotional fragility will be violated if they receive the feedback. This is a violation of our ultimate relationship with the ultimate beneficiary of healthcare simulation, the patient.



During debriefings it is incumbent upon us to make sure that students are treated fairly, treat each other fairly and help to discover things needed for improvement through creating reflections on the learning activities. We also need to make sure there is crystal clarity on expected outcomes versus perceptions of performance that are reconciled. We also must guide the debriefing process in a way that is mindful of the psychological safety of the involved. I think this can be done with adequate training, re-training and continuing practice with the art of debriefing. When we achieve this, we have arrived at Patient Centered Debriefing, and that’s a place I think we all want be.



I do believe most professionals want to know what they did well as well as what they didn’t. They are the fundamental elements of being able to reflect and improve. We need to be able to have the message delivered by either a process of self-discovery, perhaps through facilitated reflection, or at other times, but just directly providing the information. This doesn’t mean it has to be harsh, or without the feelings of the person involved carefully considered, but it does mean it has to happen with a level of deliberateness that is unequivocal. It is the true art of the debriefing to be able to lead this effort and achieve these goals.


Finally I’ll close with a quote from my twelve-year-old son about one of his baseball coaches, “Dad, why does coach always tell me I did a good job when I know I messed up?” What is the answer? Not sure, but I hope that the coach doesn’t change careers and become a simulation facilitator for healthcare professionals.



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