Three Things True Simulationists Should NEVER Say Again

From Wiktionary: Noun. simulationist (plural simulationists) An artist involved in the simulationism art movement. One who designs or uses a simulation. One who believes in the simulation hypothesis.

Woman taping-up mans mouth


After attending, viewing or being involved in hundreds if not thousands of simulation lectures, webinars, workshops, briefings and conversations there are a few things that I hear that make me cringe more than others. In this post I am trying to simmer it down to the top three things that I think we should ban from the conversations and vocabularies of simulationists around the globe!

1. Simulation will never replace learning from real patients!: Of course it wont! That’s not the goal. In fact, in some aspects simulation offers some advantages over learning on real patients. And doubly in fact, real patients have some advantages too! STOP being apologetic for simulation as a methodology. When this is said it is essentially deferring to real patients as some sort of holy grail or gold standard against which to measure. CRAAAAAAAZY……   Learning on real patients is but one methodology by which to attack the complex journey of teaching, learning and assessing the competence of a person or a team of people who are engaged in healthcare.  All the methodologies associated with this goal of education have their own advantages, disadvantages, capabilities and limitations. When we agree with people and say simulation will never replace learning from real patients, or allow that notion to go unchallenged, we are doing a short service to the big picture of creating a holistic education program for learners. See previous blog post on learning on real patients. 

2. In simulation, debriefing is where all of the learning occurs!: You know you have heard this baloney before. Ahhhhhhhhhhhhh such statements are purely misinformed, not backed up by a shred of evidence, kind of contrary to COMMON SENSE, as well as demeaning to the participants as well as the staff and faculty that construct such simulations. The people who still make this statement are still stuck in a world of instructor centricity. In other words, “They are saying go experience all of that…… and then when I run the debriefing the learning will commence.” The other group of people are trying to hard sell you some training on debriefing and then make you think it is some mystical power held by only a certain few people on the planet. Kinda cra’ cra’ (slang for crazy) if you think about it.

When one says something to articulate learning cannot occur during the simulation is confirming that they are quite unthoughtful about how they construct the entire learning encounter. It also hints at the fact that they don’t take the construct of the simulation itself very seriously. The immersive experience that people are exposed to during the simulation and before the debriefing can be and should be constructed in a way that provides built in feedback, observations, as well as experiences that contribute to a feeling of success and/or recognition of the need for improvement. See previous blog post  on learning beyond debriefing

3. Recreation of reality provides the best simulation! [or some variant of this statement]: When I hear this concept even eluded to, I get tachycardic, diaphoretic, and dilated pupils. My fight or flight nervous system gets fully engaged and trust me, I don’t have any planning on running. 😊

[disclaimer on this one: I’m not talking about the type of simulation that is designed for human factors, and/or critical environmental design decisions or packaging/marketing etc. which depend upon a close replication to reality.]

This is one of the signs of a complete novice and/or misinformed person or sometimes groups of people! If you think it through it is a rather ludicrous position. Further, I believe trying to conform to this principle is one of the biggest barriers to success of many simulation endeavors. People spent inordinate amounts of time trying to put their best theatrical foot forward to try to re-create reality. Often what is actually occurring is expanding the time to set up the simulation, expanding the time to reset the simulation and dramatically increasing the time to clean up from the simulation. (All of the after mentioned time intervals increase the overall cost of the individual simulation, thereby reducing the efficiency.) While I am a huge fan of loosely modeling scenarios off of real cases in an attempt to create an environment with some sense of familiarity to the clinical analog, I frequently see people going to extremes trying to re-create details of reality.

We have hundreds and thousands of design decisions to make for even moderately complex scenarios. Every decision we make to include something to try to imitate reality has the potential to potentially cause confusion if not carefully thought out. It is easy to introduce confusion in the attempts to re-create reality since learners engage in simulation with a sense of hyper-vigilance that likely does not occur in the same fashion when they are in the real clinical learning environment. See previous blog post on cognitive third space.

If you really think about it the simulation is designed to have people perform something to allow them to learn, as well as to allow observers to form opinions about the things that the learner(s) did well, and those areas that can be improved upon. Carefully selecting how a scenario unfolds, and/or the equipment that is used to allow this performance to occur is part of the complex decision-making associated with creating simulations. The scenario should be engineered to exploit the areas, actions, situations or time frames that are desired focal points of the learning and assessment objectives.  Attention should be paid to the specifics of the learning and assessment objectives to ensure that the included cache of equipment and/or environmental accoutrements are selected to minimize the potential of confusion, create the most efficient pathway that allows the occurrence of the assessment that contributes improving the learning.

Lastly, lets put stock into the learning contract we are engaging in with our learners. We need to treat them like adult learners. (After all everybody wants to throw in the phrase adult learning principles…. Haha).

Let’s face it: A half amputated leg of a trauma patient with other signs and symptoms of hemorrhagic shock that has a blood-soaked towel under it is probably good enough for our adult learners to get the picture and we don’t actually need blood shooting out of the wound and all over the room. While the former might not be as theatrically sexy, the latter certainly contributes to the overall cost (time and resource) of the simulation. We all need to realistically ask, “what’s the value?”

While my time is up for this post, and I promised to limit my comments to only three, I cannot resist to share with you two other statements or concepts that were in the running for the top three. The first is “If you are not video recording your scenarios you cannot do adequate debriefing”, and the second one is “The simulator should never die.” (Maybe I’ll expand the rant about these and others in the future 😉).

Well… That’s a wrap. I’m off to a week of skiing with family and friends in Colorado!

Until next time,

Happy Simulating!


Filed under Curriculum, debriefing, scenario design, simulation

6 responses to “Three Things True Simulationists Should NEVER Say Again

  1. Joe

    Great blog! I totally agree with what you said – (although if one of the objectives is to deal with squirting blood, you can’t blame someone for requesting that 🙂

    Will be checking out your previous writings!

    • Thanks for your feedback! Completely agree on responding to the fundamental objectives of a case! It’s the honest appraisal that I believe folks struggle with.

  2. Loved you’re points. Waiting for a debrief leaves alot of learning on the table.(literally!) I would hope the learner would show up eager to try and get things right in the scenario and able to improvise to some degree. Both of which would inspire learning. Thanks for great thoughts.

  3. Grace

    I totally agree with your points and am glad someone finally had the courage to express them. I’m waiting for the blog on video recording scenarios. Could someone provide me with some hard, creditable evidence the using scenario video recordings in debriefing is “best practice” or is it the invention of vendors who want to sell expensive video equipment? Just because the NFL does it for professional football players doesn’t mean it’s best for medical learners. In general, I find students open up more and conversations/reflections are much deeper when we don’t use the video. Am I alone in this?

  4. I certainly agree with your comments, Dr. Phrampas, and thank you for having the courage to speak them out. I’m anxiously awaiting the comments on the value of scenario video recording for debriefing. Would someone please provide me with some solid, authoritative evidence that using video for debriefing is really a “best practice” and not just a vendor ploy to sell expensive equipment? Am I alone in finding that the deepest, most reflective/constructive debriefing sessions occur when video is not used?
    Grace Durham, Skills and Sim Director, Fresno, CA

    • Agree Grace! Routine use of video in any simulations has not been shown to be superior in any way. Video is a tool that has use like any other tool. To think you need to video and replay every video is often a barrier to productivity and deep conversation in my opinion!

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