Creating an Inclusive Simulation Lab: It’s Time to Stop Calling Them Confederates

By: Carl Preiksaitis (@CMPreik)

I am in the simulation lab reviewing basic emergency medicine cases with a group of medical students.

I have taken the usual pains with my pre-briefing to create a psychologically safe space where the students can be vulnerable, free of judgement and ideal for learning.

I am assigning roles for the case and need a student to act as a nurse, allied with me to help the other students learn.

“Does anyone want to be a confederate for this case?”

One of the students gave me a look of confusion mixed with something else. I had the sense that the atmosphere in the room changed for a second.

“I need someone to be the nurse for this scenario.”

A student volunteered, we completed our simulations, and the students enjoyed the experience. But that moment of disruption bothered me.

I have since stopped calling them “confederates,” and I believe you should too.


Embedding an individual in league with the simulation facilitator is common practice in medical simulation to help scenarios run smoothly or to enhance the intended educational effect. These participants are often called “confederates,” a term inherited from past psychological experiments used to describe persons allied with the research team to carry out studies, often with a component of deception.1,2

Although different in meaning, the term is identical to “Confederate,” which references The Confederate States of America, associated with ideas of White Supremacy and slavery and now synonymous with hate and racism.3 I suspected my experience with the word “confederate” was not unique and was due to confusion with the term “Confederate.”

This post summarizes an article4 recently published in Simulation in Healthcare that I co-authored, “Creating a Safe Space for Simulation: Is it Time to Stop Calling Them Confederates?”. Given the risk of misinterpretation affecting simulation participants, my co-authors and I were puzzled why this term was still in the simulation lexicon.

The Study

We started with the presumption that jargon terms spoken aloud when conducting simulations would in part be driven by terminology used in the simulation literature. We then sought to determine how often the term “confederate” was used in simulation publications and to see if any reasonable alternatives existed. We completed a rapid review of the healthcare simulation literature between the years 2000 and 2021.

Key Findings

  • The term “confederate” is often used in the simulation literature: We identified 2635 instances in 765 articles.
  • Use of the term appears to be increasing in frequency, even when adjusted for total number of articles published.
  • Alternative terms exist such as “actor,” “embedded participant,” “simulated patient,” “simulated person,” or “standardized patient.”

My Thoughts

The psychological safety of learners in simulation is of paramount importance, and our role as educators is to identify and mitigate any risks to the safety of the simulation environment.5 We must create effective learning environments that are free of re-traumaization, threats to dignity, or acts of discrimination.6 Language is an important factor in creating an inclusive space, so we must choose our words wisely.7

Although “confederate” and “Confederate” have different meanings, they sound identical when spoken aloud and there is potential for confusion or offense. Instances of the word “confederate” in the simulation literature are common, which suggests that the word may be often used with learners. Its use by simulation facilitators carries the risk of undermining the safe space we work hard to create.

Despite referencing an American historical event, members of the simulation community outside of the United States have also questioned whether this term confederate should still be used, as well.8,9 The 2nd edition of the Healthcare Simulation Dictionary no longer recommends its use and suggests alternatives such as “actor,” “simulated patient,” “simulated human,” “standardized patient,” or “embedded participant,” which all can be used in its place.2

The terminology we choose when conducting simulations matters and we must be cognizant of the intended and unintended effects of our language. “Confederate” is a term that carries the potential to be at minimum a distraction and at worst harmful. Alternatives exist that we can use without similar concerns. Let’s leave the confederates in the past.

About the Author: Carl Preiksaitis, MD is a Medical Education Scholarship Fellow in the Department of Emergency Medicine at Stanford University. Twitter: @CMPreik


1. Colman AM. A Dictionary of Psychology. Oxford University Press; 2015. Accessed December 2, 2022.

2. Lioce L, ed. Healthcare Simulation Dictionary. Second. Agency for Healthcare Research and Quality; 2020. doi:10.23970/simulationv2

3. Confederate Flag | Hate Symbols Database | ADL. Accessed October 17, 2022.

4. Preiksaitis CM, MO Lee, K Schertzer. Creating a Safe Space for Simulation: Is it Time to Stop Calling Them Confederates? Simul Healthc.:10.1097/SIH.0000000000000710.

5. Raemer D, A Hannenberg, A Mullen. Simulation Safety First: An Imperative. Simul Healthc J Soc Simul Healthc. 2018;13(6):373-375.

6. Picketts L, MD Warren, C Bohnert. Diversity and inclusion in simulation: addressing ethical and psychological safety concerns when working with simulated participants. BMJ Simul Technol Enhanc Learn. 2021;7(6):590-599.

7. Kolbe M, W Eppich, J Rudolph, et al. Managing psychological safety in debriefings: a dynamic balancing act. BMJ Simul Technol Enhanc Learn. 2020;6(3):164-171.

8. Murphy P, D Nestel. Healthcare simulation terms: promoting critical reflection. Int J Healthc Simul. 00:00:00.0;1(3):45-46.

9. Nestel D, P Murphy, LN Chianain, G Gormley. They’re called what? BMJ Simul Technol Enhanc Learn. 2021;7(4):270-270.

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