It’s not like real life: Simulated patients …. more to offer than we think?

By Victoria Brazil (@SocraticEM)

“But its not like real life… I mean, you can’t tell from the manikin what the patient really looks like…..”

That’s not a real quote, but rather a synthesis of hundreds of comments I’ve heard in simulation debriefings. Many of us have developed fined tuned strategies and responses to this kind of statement and try to reduce its frequency through pre-briefing strategies like establishing a ‘fiction contract’ and undertaking upbeat, chatty familiarisation to a simulation area and manikin.

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There are many advantages to working with simulated patients (SPs) (i.e human actors) in scenarios, and for more cases than generally appreciated. I’m still surprised at the predominance of manikins in simulated scenarios at all levels of medical training, even for cases where there is no intubation or invasive procedures.

There is history here. In the 1990s, David Gaba and others started building (mechanical) human patient simulators to support training in crisis resource management(CRM). The aim was to replicate a physiologic model of a human to challenge anaesthesia trainees with the kind of physiologic crises they dealt with in the operating theatre. Dave Gaba was an ex-engineer – this made sense and worked for the educational objectives.

In parallel, medical educators were working with SPs to train medical students for history taking, physical exam and communication skills, and training them as ‘standardised’ patients for reliability in OSCE exam formats. (thanks to another famous med ed name – Ron Harden) There was little overlap between these ‘sim’ and ‘med ed’ worlds in the 1990s.

Fast forward to 2018. Health professional education and simulation are multifaceted, overlapping disciplines with broad applications. Many educators have responsibilities across domains, disciplines and training level. Working with SPs in simulation is more common, and there are some marvellous resources to guide those interested, as well as courses and conference workshops. For a wonderful illustration of this on stage – look out for Chris Hick’s dasSMACC talk from Berlin last year, soon to be released.

A brief summary: –

Why SPs?

SPs offer better physical realism (obviously), maybe better functional task alignment (scenario/ LO dependent) and can participate in the debriefing process, offering feedback on important domains like patient experience.

Maintenance is much easier (!), and they don’t suffer wireless dropouts, compressor failures or need complicated software to operate.

When SPs?

I think it’s worth considering SPs for any scenario where there are no invasive interventions planned (CPR, advanced airway management i.e. where there would be physical safety risks to the SPs). Its especially important to work with SPs where the learning objectives relate to patient interaction and/or require nonverbal diagnostic cues eg pain, anxiety, delirium, behavioural emergencies, or ‘looks sick’. To use manikins in this situation arguably risks negative training – forcing learners to look only to objective data in the form of monitor cues.

The scope of SP based sim has been broadened thanks to adjunctive technology such as monitor emulators (eg iSimulate) in which our simulated patients can appear to have abnormal cardiac rhythms, hypotension or low oxygen saturations. “Hybrid’ simulation with SPs and ‘wearable trainers’ (eg birthing ‘Mama Natalie’, IDC, IV arms, suturing pads) offers the chance for integrating procedural skills performance with patient communication in a scenario context. This is taken to extreme in the surgical cut suit, which allows laparotomy, surgical cricothytomy and ICC insertion. (seriously.., check out their videos)

Don’t under-estimate acting skills with things like seizures, acute behavioural disturbance, simulated cardioversion, simulated procedural sedation – I have seen SPs do all of these expertly.


It may be easiest to use our clinical colleagues or peers as SPs, mainly due to availability. There are mixed views on this, and definite downsides with engagement as learners struggle to suspend disbelief if they know those people.

There are challenges in recruiting, training and supporting professional SPs. Medical schools will often already have a panel of SPs on staff and dedicated training for them, and postgraduate training programs may be able to access these groups by arrangement. Paediatric SPs may be even more difficult to arrange but don’t rule it out – check out this performance at last year’s Don’t Forget the Bubbles conference by my friend @IanMeducator.

Preparation for SPs role portrayal requires both thoughtful generic training and specific preparation for each role. You’ll need to modify your scenario template from that used for manikins – to include more detailed briefing content for the SPs. However, don’t ‘over-script’ these, as a ‘non-practitioner’ perspective can emerge more authentically in the role portrayal.

The cost of SPs varies according to individual arrangements, but in general hundreds of hours of SPs can be bought for even the yearly maintenance cost of a $100k manikin.

Recognise that SPs have different ‘reality gaps’ – their pupils are reactive, they don’t have crackles on the left like your scenario dictates, and their pulse of 80 doesn’t match your simulated monitor rate of 125. The fiction contract principle is still a good one here, with pre-briefing on specific gaps anticipated and information on part task trainers used in conjunction with the human being. ‘Within scenario’ cues may be required from an embedded confederate (preferably) or – if you must – the voice in ceiling.

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Cautionary tales

Safety is paramount.

Pre-briefing must include explicit ‘don’t hurt the SPs!’. Despite this – expect a level of engagement in the simulation that far exceeds that with a manikin and anticipate reflex responses of experienced practitioners (e.g. putting a bed flat rapidly in response to a rhythm change, performing jaw thrust if a patient is snoring, assessing GCS using sternal rub if ALOC, physically restraining a patient who is trying to leave). Embedded confederates need to be able to intervene rapidly if needed, and SPs themselves being prepared to leave character if any concerns … reminiscent of ‘safe’ words in S&M (so folks tell me)

Ensure SPs know how ‘real’ they need to be in following scenario participant instructions e.g. performing a Valsalva manoeuvre, and ensure everyone involved gets a ‘no duff’ briefing, in case of real emergency.

In summary

So, of course manikins are great for some of our simulation activities and may offer more with emerging augmented reality technology (but that’s another blog post). It’s not a competition.

But consider whether SPs have a bigger place than you’ve previously thought in pursuit of optimally matching modality to objectives.

Further reading

  1. Nestel, D., & Bearman, M. (2014). Simulated patient methodology: theory, evidence and practice. John Wiley & Sons.