Crossing the Line: Simulation and Boundary Areas

These are challenging times for the simulation community—times of uncertainty, of ferment, and of rapid growth. This instability reflects the realities of healthcare and healthcare education, where traditional approaches to training are no longer possible. By offering safe, learner-centered training, simulation occupies a central position. If simulation is to be fit for purpose, we need to elaborate an underpinning “theory of simulation.” As well as establishing the scientific basis of our field, this will provide insight into the theoretical frameworks of related disciplines, helping learners and teachers to select the type of simulation which best meets their needs at a given moment. Effective simulation interweaves clinical practice, laboratory science, education, computer design and many other disciplines. This richness and diversity is a key strength, bringing creativity and innovation and presenting teachers and learners with a wide choice. Yet there is a danger that this very diversity may lead to fragmentation and a lack of overall direction. Without a coherent theory, it is easy to get lost in a confusion of beguiling but disparate fields. In this paper, I frame simulation as a conceptual space where many domains come into contact. Drawing on personal experience, observation and my reading of the literature, I argue that better understanding of these diverse realms will strengthen the theory-building process. I argue that the boundaries between domains are where creativity flourishes and where advances are to be found. I examine how such boundary areas may function and identify some difficulties which may be encountered in bridging areas of expertise. I have based this paper on an invited closing address at the IMMS conference in January 2006. I have written from a personal perspective, drawing on my background in clinical practice (as a surgeon and a primary care physician), in education (as a general practitioner trainer and a developer of training programs) and in research (as an academic with a particular interest in surgical simulation). BACKGROUND The landscape of clinical practice is being radically altered by external and internal forces. Changes in established models of healthcare delivery are being driven by changing patterns of care (with increasing emphasis on targets and service outcomes) and reduction in working hours (both in Europe and the United States).1–3 Traditional service-based apprenticeship extending over many years is being supplanted by more focused, learner-centered programs aimed at achieving specific educational objectives in a much shorter time.4–10 The potential benefits of simulation are widely acknowledged, offering opportunities to practice repeatedly and in safety. Anesthesia-based team training and crisis resource management have led the move from task based practice to performing within authentic situations. Now patient-specific simulations are poised to create a whole new level of realism, using imaging and other data to provide authentic recreations of individual people. For many within healthcare, simulation is seen as a means of repeatedly practicing specific clinical tasks. Of course this is an important function, but it represents only a small part of simulation’s potential, and a task-focused philosophy can obscure the wider picture. If simulation is framed as a response to wider changes in the healthcare environment, a logical conclusion is that it should recreate as closely as possible the conditions of actual practice. These will include teamworking, leadership, crisis management, and many other elements. In this way, simulation can offer an alternative universe, where learners may safely experience issues which parallel those in real life. Seen from this viewpoint, simulation must provide not just a series of individual tasks, but rather a canvas upon which the elements of practice can be painted as required. Moreover, such environments should support that construction of professional identity which takes place within the clinical workplace through participation in communities of practice and of learning.11–13 In this sense, simulation is less of a physical reality than a conceptual space within which many activities can occur. To be effective, simulation must parallel its real world counterpart in a functional sense, even if it does not recreate reality in every detail. We must therefore examine the intersecting domains which relate to the various activities which simulation subsumes. These are illustrated by the issue of complexity. LEVELS OF COMPLEXITY Consider an apparently simple procedure such as closing a skin laceration with sutures. Simulation allows a learner to practice the technical aspects of this relatively straightforward task, repeatedly and safely. If these skills are to mean anything, however, they must be applied within a second level, that of clinical context. The clinician must relate to the patient before, during and after the technical procedure and, when the patient is conscious, while performing it. The clinician must take into account the patient’s ideas, concerns, and expectations, managing a holistic consultation at the same time as performing a procedure. In addition, each clinician must interact with other members of the healthcare team. For a novice, this integration of technical with nontechnical skills may be difficult enough even if the case is straightforward. If the patient is challenging (angry, upset, suffering from a disability or unable to speak the clinician’s language), or if there are problems with teamworking, the difficulties increase enormously. Yet it is the ability to perform in this wider and unpredictable context that characterizes the effective clinician. If the clinical task is more advanced (such as anesthesia and surgery), the potential for complexity increases enormously. Thirdly, there are the wider influences which bear on clinical practice, such as policy pressures, workforce design, economic imperatives, healthcare priorities, and the limitations or opportunities of funding. By shaping the care we provide, these exert a profound effect on the choices we make and the constraints under which we work, even if they are not directly involved in simulation-based training. So an awareness of such issues is crucial for effective simulation design, if it is to reflect the realities of our world and not simply create an oversimplified world which works within its own rules. Yet although there must obviously be a close concordance between simulation and its clinical counterpart, there are important differences too. In clinical practice, care of the patient is the overriding imperative. In simulation, although patient care must remain at center stage, the focus is on the learner. Moreover, simulation offers a kaleidoscope of shifting patterns made up of many disciplines. Simulators themselves form part of this space but do not constitute it wholly. When we move towards more authentic recreations of clinical situations, the need for integrating the elements of simulation becomes acute. An effective educational framework is essential to ensure that participants learn and (where appropriate) are assessed. Yet we have much to discover about teaching and learning within simulated environments. It is here that the need for a theory of simulation becomes increasingly compelling. Using the language of complexity theory, we can think of healthcare as a complex adaptive system.14,15 As with other such systems (such as the weather or the environment), there is no simple relationship between cause and effect. Accurate prediction of outcomes can be problematic. A major benefit of simulation is to expose learners to this very complexity, yet without the hazards of real life. Teaching, learning and clinical practice (each a complex system in itself) must therefore take place alongside one another within a simulated universe. REALISM A key issue is a simulation’s fitness for purpose, especially in relation to an overarching educational framework. For example, it is commonly held that the more realistic a simulation, the more effective it will be. Apart from its economic implications, this view privileges the position of complex technology within simulation. Although such technology is obviously essential in some instances (eg, training for procedures requiring advanced manipulative skills), too much emphasis on technology for its own sake may obscure important issues. Moreover, in a resource-limited environment there are opportunity costs in selecting particular elements of simulation at the expense of others. However, the relationship between realism and effectiveness is not a simple one, and surface realism may not always be necessary or even desirable. Moreover, what is perceived as realistic by one clinician may not be so for another. We have much to learn about the effect of experience on personal ways of seeing and of perceiving. It may be, for example, that minimal cues can stimulate a mental representation of clinical practice which is effective for some forms of training, such as urological endoscopy, without requiring expensive and elaborate simulators.16 On closer examination, therefore, fitness for purpose is a complex issue where firm theoretical foundations must underpin everyday judgements. Perhaps a more productive approach is to view realism as a negotiable currency which can be used flexibly in different settings. This requires a balance to be struck between the needs of learners and teachers and the resources that are available. In this way, we can keep sight of the overall aims of simulation rather than striving towards realism for its own sake. Again, a theory of simulation will give focus. BOUNDARY ZONES If we accept that simulation requires contact between disciplines, we must consider how such disciplines relate to one another, especially because no one practitioner will be expert in all the domains which contemporary simulation requires. For example, few clinicians have detailed knowledge of simulator programming and technical design, whereas nonclinical scientists may lack insight into the challenges of patient care and teamworking. It is at the edges of domains that most growth occurs. Of course there is much valuable work in the centers too, but by definition this takes place within an established field. Much of the impetus to change and grow comes from constructive friction between different domains and fields (for example, the combination of clinical imaging techniques with simulator technology to develop patient-specific simulations). It is here that cross fertilization of ideas takes place and that creative energy resides. Boundary zones—where the growing points of different fields intersect—are the most likely places to find these seminal events. This resonates with developments elsewhere in education, where pedagogical techniques that use technologies in constructive ways to teach content are being explored.17 This resonates with Kuhn’s distinction between normal science and scientific revolutions.18 Science, in Kuhn’s view, is not the steady, cumulative acquisition of knowledge that is portrayed in the textbooks. Rather, it is a series of peaceful interludes punctuated by intellectually violent revolutions in each of which one conceptual world view is replaced by another. Kuhn points out myriad examples of this process, from the discoveries of oxygen and x-rays to the convulsive paradigm shift of quantum mechanics. Simulation provides much scope for domains to intersect. Figure 1 is a list based on my personal experience and reading in my fields of research. For others the list may be different but the principles are the same. To illustrate this point I will use as an example the relationship between acting and clinical training, drawing on a scenario-based approach which my colleagues and I have developed for procedural skills.19–21 This example is intended to highlight areas of contact between 2 professions which function largely separately but where each can learn from the other.FIGURE 1.: Domains relevant to simulation. The following list is based on my own experience and is not intended to be exhaustive.Scenario-based assessment combines models or items of medical equipment with Simulated Patients (SPs; professional actors trained to play the part of real patients and then provide feedback), creating a realistic quasi-clinical environment where professional behaviors can be explored in addition to technical skills. In contrast to the isolated benchtop model, this kind of simulation appears to tap into a network of clinical responses activated by a realistic environment. This approach frames clinical procedures as “performance,” drawing heavily on the actors’ professional expertise and experience. From the actors’ point of view, key elements of effective performance include learning a part, managing props, remaining sensitive to their audience’s response and integrating all these elements seamlessly within a convincing performance which, if successful, hardly seems like a performance at all. Our experience has been that the actors’ contribution can far surpass the immediate requirement of creating a realistic encounter through mimicking a patient. A skilful SP performs at another level too, stepping out of role to provide feedback that is grounded in their authentic response to a quasi-clinical experience yet free from the power issues that can inhibit frank feedback between a sick patient and the clinician responsible for their care. At another level still, the professional expertise of the actor is itself a resource which, if skillfully exploited and suitably mediated, can be invaluable to the clinician. Simulation therefore offers opportunities for clinicians to “act” within a safe environment, focusing on performance skills which are commonly taken for granted or not recognized as legitimate components of expert clinical practice. All these are skills which a clinician needs as part of their own expert “performance” with each patient. Yet clinicians seldom see themselves as professional performers. To appreciate the artistry and expertise of the professional actor—the art which conceals art—we need insight into the process of acting. In many cases, this can be provided by the actors themselves, who can articulate their methods rather than simply performing.22 In this way, the learner gains a different level of perception and insight than simply “working on” the SP as a surrogate patient. This process is valuable in the other direction too, and SPs report that working with doctors and patients provides them with a different perspective which enriches their stage performances. If this open-minded engagement with experts from another profession is the case for acting, why should it not be so for the many other domains which bear upon simulation? For example, as clinicians we need an understanding of computer and materials technology, at least so that we can appreciate the possibilities and limitations of the field. Equally, as simulator designers we need an understanding of clinical practice. And such insight is essential in whichever areas we brush up against—not so that we can pretend to expertise in those fields, but so that we are aware of what they can offer us. TOTAL INTERNAL REFLECTION This process of constructive engagement can be easier said than done. If a wider view of simulation requires the integration of domains and effective collaboration at boundary areas, what obstacles might there be? Each of the domains in Figure 1 has its own traditions, its own literature, its own language, its own paradigms. When I was working towards a PhD (examining the application of an innovative approach to surgical skills training from an educational perspective), I initially encountered considerable difficulties in bridging the gap between my surgical background (with its heavy emphasis on a positivist scientific tradition and implicit assumptions about the existence of a single external reality) and the literature of education and the humanities (with its more contested views of truth). I grappled uncomfortably with an unfamiliar paradigm, and it was some time before I could engage effectively with these different domains and integrate their ideas with my own thinking. This was thrown into sharp focus when I came to combine quantitative and qualitative methodologies in my experimental design. From this experience I formulated the notion of total internal reflection as a metaphor for examining relationships between domains.23 Total internal reflection is an analogy from elementary physics and refers to the reflection of light from a surface without penetrating it. A goldfish inside a goldfish bowl would only be able to see within his own bowl and would be unaware of any world outside it. Indeed, he might be unaware that he was in a bowl at all. In my experience, a similar lack of awareness can affect those attempting to make contact with an unfamiliar domain. A creative rapprochement between different intellectual traditions is one simulation’s most attractive benefits. Yet we cannot assume that good will and enthusiasm are all that is required. The very richness and diversity of the fields can mask the effort required to understand where other contributors are coming from. Unless we recognize the dangers of total internal reflection, we may miss opportunities to capitalize on the creative possibilities which boundary areas present. Moreover, awareness of other domains and enthusiasm for their ideas is not enough. As scientists we need to maintain a criticality that assures our rigour and detachment if we are to avoid being swept along by fashion. CONCLUSION Simulation is an exciting area that offers enormous potential for developing innovative approaches to clinical education. Different groups will use it in different ways according to their needs: some with a narrow, task-based focus and other reaching out more widely. Perhaps one of simulation’s most attractive possibilities is the scope to draw creatively on other domains. However, in developing what simulation can offer we must remain critical, maintaining the rigour which defines us as scientists. If we are to draw on other domains yet still keep our sense of balance, we need to understand enough about these domains to assess critically what they can offer. This requires us to have sufficient knowledge to engage with them on their own terms. If we do not make this effort we risk becoming magpies, picking up glittering ideas but remaining ignorant of the philosophies which underpin them. The challenge to us in this evolving field is to reach out and explore other domains, building on the expertise which is out there. But in the process we must forge an identity of healthcare simulation with its own individuality. A “theory of simulation” is key to establishing a science which allows us to formulate and test hypotheses, engaging critically with an evidence base which transcends the accumulation of nuggets of knowledge. In this way, we will establish a creative, challenging yet mutually respectful alignment between our field and the sources of inspiration which must feed it. ACKNOWLEDGMENTS The author thanks the Simulation in Healthcare reviewers for their helpful comments.