What’s your simulation hidden curriculum?

By Victoria Brazil (@SocraticEM)

The ‘neurosurgery resident’ had just entered the simulation. He was rude and arrogant, and oblivious to the other trauma care priorities for the patient. The emergency team continued with their intubation. Meanwhile, the simulation team thought it was hilarious. Laughing behind the one-way mirror, they thought their colleague’s portrayal of the arrogant neurosurgeon was his best yet.

As the laughing died down…one of the team quietly suggested it might be a bit of a stereotype…?

The others quickly chimed in. “Our trainees have to know how to deal with this stuff. There are idiots who come down to ED everyday and we have to know how to handle them…..”

Simulation can be an effective training tool for a broad range of clinical skills and teamwork training. Simulation educators dutifully write clear learning objectives and design their simulation process carefully to achieve those.

But what do our learners really take away?

Like most learning experiences, there is often a powerful hidden curriculum – the “unspoken or implicit academic, social, and cultural messages that are communicated to learners”.

Sometimes this is positive, and adds value to the formal learning objectives. If we have regular team training involving doctors and nurses – whatever the clinical content of your sim – there is a message about your unit’s commitment to teamwork. If we work with simulated patients and include their feedback in our debriefing, it can send a powerful message about the value of patient experience and perspective. Positive values and beliefs about patient care can be transmitted through simulation.(1)

But these powerful implicit messages can also be negative and/or unintended.

Using mannikins in simulation can reinforce messages that sick patients are identified through looking at vital signs on monitors, rather than patient appearance and behaviour cues.(2) Simulation scenarios with universally Caucasian names, heterosexual partners, and male ‘surgeons’ can inadvertently reinforce implicit bias. Debriefings always led by a doctor in interprofessional simulations can reinforce discipline hierarchies within the team.  I have been guilty of all of these.

Stereotypes can be particularly problematic in simulation, including those of both our professional colleagues and our patients and families, as described by Ben Symon in a recent post. I raised this issue at the smacc conference in Sydney in March and sparked a lively and interesting Twitter conversation.

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I’ve been guilty of this too, and witnessed many more.

I believe we can and should explore important learning objectives related conflict within and between teams. High performing teams are not without conflict, and develop strategies for using divergent views positively(3).

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Two recent experiences have given me reason for optimism.

  1. A medical student ‘resilience’ program using simulation. Final year medical students participated in scenario-based simulation – learning to deal with difficult patient interaction and difficult nursing staff interactions. These were stressful for participants and debriefing focused on coping strategies – short and long term.
  2. An #EMwellnessweek initiative in our emergency department. A teamwork scenario where the ED team had to deal with a stressed and unhelpful emergency medicine consultant (played by me), who actively derailed the perfectly good clinical care that was being provided for a young patient with sepsis.

In both cases, learners reported powerful and useful experiences, and (as far as I know) without traumatisation, or harm to the reputation of others. I don’t think these experiences were perfect, but a few principles I might suggest from reflection: –

  1. Make any learning objectives related to professional interactions clear and explicit.
  2. Communicate this clarity in pre-reading and pre-briefing for simulation participants.
  3. Design the roles away from lazy stereotypes, and safest to make the ‘target’ your own speciality or role.

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  1. Invite patients and/or practitioners from other specialities/ professions to your simulations to discuss/ participate. Simply discussing how ‘we’ deal with ‘them’ misses an opportunity to explore why our perspectives and behaviours may diverge.
  2. Prepare actors, confederates/ embedded simulated persons to portray these roles in a nuanced way, aligned with the learning objectives. Lazy gags purely for humour value can be especially destructive – e.g. radiologists on golf courses, anaesthetists checking share portfolios… etc etc

6, Name any potential perceived stereotypes in debriefing discussions. We can actively support mutual interprofessional and patient respect while still openly discussing lapses or even patterns of behaviour, including our own. Exploring reasons why can be even more interesting than simply admonishing bad behaviour

  1. Think about ‘de-roling’. I found it very stressful to play an unhelpful, demanding ED consultant 😊. The nurses involved in the challenging student simulations felt the same. The psychological impact of performance, and how to ‘de-role’ is better described in acting, but also worth considering here.

Ultimately, we don’t really know what out learners take away from our simulations, even if we ask them, but being aware of unintended consequences is useful.


  1. Purdy E, Alexander C, Caughley M, Bassett S, Brazil V. Identifying and Transmitting the Culture of Emergency Medicine Through Simulation. AEM Education and Training.0(0).
  2. Alsaba N BV. Medical Students’ Recognition and Response to Clinical Deterioration in Simulated Patient Scenarios. MedEdPublish. 2018;7(2).
  3. Greer LL, Saygi O, Aaldering H, de Dreu CKW. Conflict in medical teams: opportunity or danger? Medical Education. 2012;46(10):935-42.