Introduction
High-fidelity simulation (HFS) is a burgeoning tool gaining widespread acceptance in medical education across multiple health fields.Footnote 1,Footnote 2,Footnote 3,Footnote 4,Footnote 5,Footnote 6 Although many studies have analyzed the utility of simulation as a teaching technique, very few have actually investigated why simulation works. A recent study has shown that permissive failure, leading to simulated mortality, is one method by which HFS can increase long-term performance.Footnote 7 Some critics, however, believe that simulated mortality should only be used as an educational tool for breaking bad news; they argue that other uses are unethical because the experience can be emotionally troubling.Footnote 8 By accepting this conclusion and not utilizing simulated death to optimize learning objectives, we believe that these educators are diminishing the value of their HFS educational efforts. In this article we explore the hypothetical implications of exposing learners to HFS simulated patient death, with the aim of ultimately promoting its use and, therefore, the development of more effective HFS curricula.
Currently, simulation is utilized in nearly every branch of medicine.Footnote 9 Simulation-based training can provide a wide array of learning experiences with varying degrees of fidelity. The most basic simulators are part-task trainers. These body part models are each designed to teach one specific hands-on task. For example, a simulated arm is used to teach IV placement or a head is used to teach basic airway maneuvers. These tools create a very low-risk environment for students to practice a task with little consequence resulting from failure. As the simulated environment becomes more complex, the stress of the learning environment increases.
The next step in increasing complexity is employing low-fidelity simulators, tools that may have more than one moving piece. These devices are used to integrate learning principles and teach multiple hands-on tasks. The most familiar low-fidelity trainer is Resusci-Anne, a mainstay of hundreds of institutions around the country for teaching cardiopulmonary resuscitation (CPR).Footnote 10 Resusci-Anne allows the practitioner to learn mouth-to-mouth resuscitation, simple airway maneuvers, chest compressions, and intubation. Low-fidelity simulators provide only limited approximation of physiologic and anatomic feedback, such as lungs that inflate when provided with air or a chest that indents and recoils with compressions. Although low-fidelity simulators provide a more immersive learning environment than part-task trainers do, their response to errors is minimal.
The gold standard of simulation technology is high-fidelity simulation (HFS), which most closely mimics reality. In medicine, high-fidelity simulators fully interact with monitoring devices, thereby enabling accurate real-time depiction of physiological responses such as accurate heart rate, blood pressure, pulse oximetry, capnography, and invasive monitoring measurements. Simulators respond physiologically to drugs that are administered, chest compressions, and defibrillation. HFS is typically employed in recreated environments that look like operating rooms, intensive care units, emergency departments, or patient rooms. Many HFS laboratories use actors to portray nurses, physicians, patients, family members, or technicians who are part of the medical environment. Thus, HFS provides a learning environment that closely emulates the environmental, psychological, and physiological parameters of real life.
Clearly, simulation-based training can provide a wide array of learning experiences with varying degrees of fidelity. As the simulated environment becomes more complex, the stress of the learning environment increases. By creating realistic environments, educators improve trainees’ recall and long-term performance.Footnote 11 Increasing the fidelity of the experience to enhance education also has other consequences. When the proper treatment is not administered, simulated morbidity or mortality may ensue, which increases stress. Simulated death is the most extreme consequence of an error in the simulated environment. There is a growing body of literature that reflects a concern with regard to how death and deceptionFootnote 12 are used in simulation scenarios, and the possibility that this negatively affects learners.Footnote 13 There are those who believe that simulated death places learners at risk.Footnote 14 We believe these assertions are mistaken, based on our experience and current evidence. Although some have argued that pushing the learner to this degree can be counterproductive,Footnote 15 this article will clarify why the introduction of realistic outcomes such as death can lead to enhanced learning. Ideally this will lead to stronger clinicians, and, therefore, better patient care.
In medicine, many clinical environments can be stressful, as practitioners are frequently confronted with morbidity and mortality. High-stress, life-on-the-line situations occur daily in many branches of medicine. Even common tasks (e.g., medication administration) can lead to dangerous life-threatening consequences. If real life exposes medical professionals to stress, they need to train in similar situations so that they learn to function effectively when they are stressed.Footnote 16 We believe that the simulated environment is low risk because the patient is merely a plastic mannequin. Critics believe simulated mortality can be unsafe for learners because these learners may not feel that they are able to speak openly about their self-reflections without being humiliated. With that said, however, the potential stress of embarrassment is also an issue when the simulator does not die or when a student displays a knowledge gap in a classroom or problem-based learning discussion. We believe that the learner’s concerns include lack of knowledge or skills, an inability to perform in front or others, or simply embarrassment in front of colleagues. In other words, whether the mannequin dies or not, performing in front of colleagues is what is stressful and potentially psychologically unsafe for fear of learner embarrassment. Why, then, are these risks acceptable in classroom or group discussions but not those associated with simulated mortality?
Stress has been defined as any real or imagined homeostasis-threatening situation that impacts one’s well-being and causes anxiety.Footnote 17 Once the body recognizes a homeostasis-threatening event, certain biochemical reactions occur. The brain releases norepinephrine and cortisol. Norepinephrine peaks within 30 minutes. This physiological response increases attentiveness and vigilance.Footnote 18 Cortisol peaks in 30–60 minutes and primes the brain’s encoding (receiving, processing, and combining of events) and consolidation (creation of a permanent record) of material.Footnote 19 The physiological timeline can be exploited to improve learning and long-term retention.Footnote 20,Footnote 21
Multiple studies have demonstrated that stress at the time of learning enhances consolidation of material and future recall.Footnote 22,Footnote 23,Footnote 24,Footnote 25 When a hyperaware state is initially created, the learner is primed to be vigilant during the simulation. Priming of the brain with cortisol improves the encoding and consolidation of the experience, and the material taught during the debriefing that follows the stressful scenario. It has been shown that stressors must be appropriate and applicable to the context of the learning environment.Footnote 26 Shocking learners with electrodes would produce stress. Nevertheless, if the electric shocks are unrelated to the lessons, they would likely not promote learning.
In the context of an HFS, stress can come from a crying family member or gasping patient. We hypothesized that such experiences would optimally increase stress, and thereby facilitate learning. Therefore, some HFS scenarios have been designed to exploit normal physiological responses in order to increase memory.Footnote 27,Footnote 28,Footnote 29,Footnote 30 Our group has worked to design scenarios aimed at exploiting the principle of stress in order to induce learning and enhance memory of what was learned.
Study 1
Our first experiment evaluated whether adding emotionally charged stressors to the environment would enhance learning.Footnote 31 By specifically targeting emotions, we attempted to improve education by utilizing the amygdalar pathways for learning. The amygdala is the portion of the brain where emotions are created and processed. Memories stored there are the most resistant to extinction as compared with the more common memory pathways.Footnote 32 One example illustrating the power of amygdala-charged memories is the “9/11 test.” Most people remember exactly where they were on 9/11/2001, but would be hard pressed to remember where they were on 9/10/2001. The stress and emotional charge of the experience enhanced encoding and consolidation of mundane details and made the memory resistant to extinction, even after many years.
To test the effect of emotional stressors, we designed a study utilizing two groups of 12 medical students each performing an HFS scenario of CPR. In preparation, both groups received the same instructions on how to perform adequate CPR. The first “placebo” group then experienced a simulated cardiac arrest with actors calmly playing family members, nurses, and interns. In the second “emotionally charged group,” all of the simulated circumstances were kept the same, but all three actors played their parts with exacerbated emotional reactions. The family member tearfully screamed for her father, the nurse repeatedly cried out that the patient would die, and the intern repeatedly yelled that it was his patient and everyone had to save him. Obviously, all three performances delivered emotionally charged reactions that could produce stress in the learner. Both groups were brought back to the facility 6 months later and asked to perform CPR again. The students in the emotionally charged group had enhanced recall and performed much better than the placebo group did.Footnote 33
Reaction to Study 1
This work was initially met with apprehension. One group of critics wrote: “Using patient death in simulation as an incidental emotional stressor potentially introduces a fear-based motivation for improving one’s clinical practice and, hence, represents a backwards step in efforts to promote a non-punitive culture around medical error and critical incidents in the health care setting.”Footnote 34
As a retort, however, we believe that death and dying are an intrinsic part of the medical community experience. The need to prepare our students to work effectively in situations in which death is a real possibility is integral to the profession, and we believe that simulated mortality can help prepare for this inevitability. Simulated “bad” outcomes should be utilized to teach learners in a low-risk environment before they inevitably experience these events in real life.
In addition to the potential physiological priming for improved learning that occurs through stress, its use in simulation may also help students to develop psychological resilience to bad outcomes. By encountering adverse medical events in a low-risk environment, learners can become “stress inoculated,” that is, more resistant to the negative effects of stress.Footnote 35 Students and residents can learn stress-coping mechanisms that will help them when they confront similar contextual stressors in the future.Footnote 36 By experiencing stress in a simulated environment, students can learn to overcome it or deal with it constructively.Footnote 37,Footnote 38 Death can be the most stressful event that physicians face, and it is inevitable that they will encounter patient death at some point in their careers. For this reason, we concur with others who have argued that students should be exposed to it in order to learn to deal with deaths related to medical care.Footnote 39,Footnote 40
Study 2
To respond to the critics of utilizing simulated death who are concerned about causing harm, we designed another educational experiment.Footnote 41 This second experiment aimed at assessing the emotional effect of simulated death. We hypothesized that learners in the simulator laboratory are not as negatively affected by death as some may believe. In this study, we again used two groups of medical students, each receiving the same preparation for performing CPR in an HFS scenario. One group had patient survival as the end result; the second group had patient death as an end result. Patient survival was independent of group performance. Both groups then returned to the simulation laboratory 6 months later and were evaluated for knowledge and performance in advanced cardiopulmonary life support (ACLS). The results indicated a trend toward improved performance in the group that experienced simulated mortality, but the findings were not statistically significant. Although the data only indicated a trend toward improved knowledge and performance, the subjective questionnaire that was administered to both groups after their simulation experience did, however, reveal an important conclusion. In both the simulated death group and the survival group only 8 percent had any negative feelings toward the simulation. Furthermore, 92 percent of the students in the patient death group rated the overall learning experience as a positive one. Therefore, in contrast to what critics had presumed, this study showed that simulated mortality was considered a positive, rather than a negative, experience by students. Based on these findings, we created another study to test whether performance-dependent simulated death could impact learning.
Study 3
In our most definitive study,Footnote 42 we utilized two groups of residents, both provided with a simulation concerning contamination of the oxygen supply to the operating rooms. Given the difficult nature of diagnosing this contamination, most junior residents are not experienced enough to properly treat the condition. Failure to identify and respond appropriately to the situation would, ultimately, result in patient death. In the first group, the residents were given a chance to properly treat the problem, but as the patient approached a critical state, a simulated attending intervened to prevent death. The second group did not receive the attending intervention, and invariably, the HFS patient died. Both groups received identical debriefing that focused on the appropriate treatment to correct and treat the contamination. Six months later, all participants returned to the simulation laboratory to experience a different scenario with the same problem (oxygen pipeline contamination). The group that originally experienced the simulated death performed overwhelmingly better than the group that did not experience the simulated death: 67 percent provided correct treatment as compared with only 17 percent in the group that was not allowed to fail. Based on this finding, we concluded that permissive failure leading to simulated death improves future performance.
In order to examine why this study was successful and refute the claims of those who declare simulated death to be impermissible, it is necessary to analyze the keys to a successful simulation. What follows is a framework in which we believe successful simulation can occur and why, under this format, unexpected simulated mortality should be permissible and encouraged.
Successful Simulation
We believe that effective simulation scenarios should include four elements that must be optimized to provide effective education: pre-simulation, intra-simulation, post-simulation and participant-related factors. Pre-simulation factors identify specific, achievable learning objectives. All successful lessons start with clear aims. Without specific objectives, simulations would not be able to demonstrate measurable educational value. Pre-simulation planning involves building a scenario in which something specific happens to the simulated patient. The scenario has to enable the learner to experience a clinical condition, learn how to react appropriately, and absorb concepts to guide future practice.
Once specific objectives are created, it is the educator’s responsibility to maintain the authenticity of the scenario by manipulating intra-simulation factors. This is important in order to optimize the students’ perception and experience so as to facilitate sensory replication. Accurate sensory replication enables students faced with similar real-life situations to quickly recognize the circumstance. By creating an environment that closely mimics “real-life,” (including authentic patient portrayal, confederate acting, high-fidelity environment, and multiple possible outcomes based on physiologic response to student interventions), the educator who employs HFS technology can immerse the learner in the experience and optimize memory creation to quickly trigger future recall. Increasing intra-simulation fidelity has proven to improve future performance,Footnote 43 and should continue to be used as a critical tool in the simulation armamentarium.
The third key to a successful simulation is post-simulation debriefing. As we mentioned earlier, the increased hormone levels caused by stress (specifically cortisol) lead to a priming effect 30–60 minutes after the inciting event, which optimizes the ability to imprint learning and create long-term memories.Footnote 44 This time frame perfectly overlaps with the debriefing that occurs immediately after the HFS scenario ends. During this period, the educator should ideally have the student recall each step of the scenario and what happened at each decision point throughout. Each branch point of the simulation serves as an instance in which the teacher can encourage learners to reflect on the specific action taken, consider whether it was appropriate, explore other options, and evaluate the likely consequences. The insights gained from this step-by-step debrief can then be synthesized into an appropriate course of action for similar circumstances. During the post-simulation debriefing, pre-simulation learning objectives can be reiterated and the appropriate measures needed to optimize future clinical practice can be explained. The pre-, intra-, and post-simulation factors are variables that the educator can control to optimize HFS so as to improve situational awareness and appropriate intervention.
Imagination is the final factor in creating a successful simulation. Imagination refers to the learners’ ability to place themselves within the scenario, “buy into” its realism, and respond as they would in a real-life encounter. The entire simulation can be derailed if the educator does not maintain appropriate physiologic responses in an appropriate environment with accuracy and authenticity. When a learner does not “buy into” what the educator is attempting to create, and responds to a piece of plastic rather than a “real” patient, the simulation is no more valuable than a lecture. Once students regard the simulated patient as an inanimate object, they no longer have an emotional investment in the clinical fate of the simulated patient. Although imagination is a variable that the educator cannot entirely control, it can be primed by maintaining authenticity throughout the HFS scenario. Stimulating learners’ imaginations is critical to enabling memory encoding, in order to impact future clinical decisions. Because simulated mortality contributes to authenticity, we recommend that it be employed.
Simulated Mortality
Currently, the use of simulated mortality is a controversial topic.Footnote 45 Although there are some uses that can be agreed upon by most; for example, it is generally acknowledged that an educator may employ simulated mortality when the goal of a scenario is to teach how to break bad news to a patient’s family. However, there are instances in which critics believe that simulated mortality may detract from learning objectives.Footnote 46 In these instances, critics of simulated mortality maintain that learning objectives could likely be achieved by using the “brink of death” technique.Footnote 47 In other words, detractors believe that the same pre-simulation learning objectives can be achieved without risking potential negative consequences, if the simulated patient is brought to the brink of death without actually being allowed to die. We disagree with this presumption.
The stress of the simulation can vary based on the educator, the center, and the learners. In simulations in which learners are protected from negative outcomes regardless of their action (or inaction), we believe that the value (and possibly the fidelity) of the exercise is diminished. Furthermore, learners need to learn to handle exposure to morbidity and mortality because they are factors in real medical care.Footnote 48 However, some educators believe that simulation should be more psychologically safe.Footnote 49 They maintain that realistic HFS scenarios with bad outcomes can perpetuate negative stereotypes about healthcare, and may cause posttraumatic stress disorder.Footnote 50 Our concern with this thought process is that medicine is a high-risk field, in which death abounds. Patients’ lives are constantly affected by clinician’s decisions, and learners at all levels should be aware that mistakes can directly affect outcomes. We believe this is best encountered in a low-risk situation, such as a simulation. If a learner shows a complete inability to handle poor outcomes in a simulation, it may help parse out those who may not be suited for medicine at an early point in their careers.
By curtailing simulated mortality, educators do not adequately engage learner imagination. When learners are not allowed to experience a particular outcome that results from their action (or inaction), they are less likely to buy into the seriousness with which every decision should be made. Death occurs in the hospital daily. Simulations should not be restricted so as to distort that reality. If students are never allowed to experience the risk of directly causing death when a mistake is made, there will always be a disconnect between the HFS encounter and real life; and hence, a loss of authenticity. Simulation is unique, as the death of the simulator can evoke close-to-real feelings of loss and responsibility.Footnote 51 Hence, it would appear that HFS is the perfect venue in which to explore these feelings without the stress of a true clinical outcome.
Educators who fail to maximize the potential of the simulator also fail to optimize retention of learning. Although we do not advocate for allowing simulated patients to die needlessly or inappropriately, we maintain that simulated death can serve legitimate learning objectives. Educators must always have the well-being of their students in mind, but they must also have future patients’ best interests in mind as well. Simulation is esteemed for its ability to protect patients from practitioners who may be developing their technical skills.Footnote 52 Why should that not apply to the practioner’s emotional development? That goal is not accomplished by preventing them from experiencing what will be an almost certain clinical outcome.
The main counterpoint to our argument is that without warning learners in advance that death is a possible outcome, they may be too shocked or emotionally vulnerable to be able to effectively integrate the simulation’s learning objectives. However, as of the writing of this article, the authors note only six prospective studies evaluating the use of death or deception in simulation.Footnote 53,Footnote 54,Footnote 55,Footnote 56,Footnote 57,Footnote 58 Of these six articles, five noted benefits to learners, such as perceived improved competency, and multiple articles reported that learners requested more exposure to such simulations, reflecting a strong desire for such scenarios.
Conclusion
Edmund Pellegrino has argued that physicians have a fiduciary responsibility to their patients.Footnote 59 The doctor–patient and teacher–student relationships are similar in multiple respects. In both relationships there is a dominant and a vulnerable party. The dominant party has expertise and decisionmaking authority. Therefore, the dominant party has a fiduciary responsibility to the vulnerable one, and should always have the well-being and interest of the other as a goal. The death of the simulator creates an ethical quandary: Is it fair to put any learner at risk, if most learners will benefit? Is it fair to treat practitioners this way to help future patients? It is clear that this field is young, and that more research is necessary. However, in this discussion, we have argued that exposing learners to simulated death enhances learning.Footnote 60,Footnote 61 Furthermore, given that simulating death has been proven to be an effective and useful learning tool, this makes it obligatory for medical educators to benefit future patients through optimal training of future practitioners.
Critics have maintained that the utilization of simulated mortality may cause undue harm to students and, therefore, should potentially be avoided. In contrast, based on our study findings, we conclude that utilization of simulated mortality increases learning with no perceivable downside. Although we recognize the theoretical risks of simulated death and offer counseling to all students who come through the laboratory, we have yet to have anyone utilize these services. By adopting a restrictive attitude toward simulated mortality, educators are shortchanging their students’ learning and thereby compromising future clinical performance. Without evidence to support the critics’ recommended restrictions on simulated mortality, and with evidence of benefit from employing simulated mortality, we recommend instead that simulated mortality be employed in HFS encounters when doing so serves important goals of medical education.
