Why is simulation insufficiently authentic?

If you’ve read my posts on social media (partially reproduced here) or had a chat with me about simulation, you’ll know that I’m not its biggest fan. Simulation is often used for communication training & assessment for healthcare students & professionals. There is, however, an assumption of authenticity when it comes to how people communicate. This assumption is challenged by research.

Elizabeth Stokoe compared real and simulated police interviews and found that officers produced more exaggerated actions in the simulations (kind of like checking your mirrors on a driving test). In a mystery-shopper setting (calls to a vet clinic), Stokoe and her team also found interactional differences, even though the call taker did not know that the caller was a simulated client.

My own research with Marian Casey shows that simulated patients perform normal consultation activities in different ways as compared to real patients, which make simulations more difficult to manage for the doctor. I have also had the opportunity to contribute to research that has involved semi-simulated recordings, with real clinicians and patients but not in pursuit of diagnosis or treatment. While the focus was not on the simulation component, what was noticeable was just how many more questions patients were asking compared to the hundreds of real consultations I’ve recorded and analysed in other projects.

Why is simulation different? The stakes for the participants involved varies significantly from a real conversation. In a clinical consultations, the patient knows that the clinician is the gatekeeper to care, to validating their illness. An actor does not have the same underlying driver for the visit, no matter how good their acting is. They are still imagining how a conversation might unfold. In an examination setting, the stakes are even more flipped, with the student subject to the judgement of an assessor and the actor still having no clinical stake.

Let's not throw out the baby with the bathwater! This is not to say simulation should not be used, but that there needs to be a stronger relationship between how people really interact and simulations if they are to be used for communication training. Across these articles, the authors discuss why and how this can be done, emphasising the need to engage with conversation analytic research.

There's a lot more work to be done in this space to improve interactional authenticity in simulation. This includes supporting students in learning for clinical practice rather than for assessments by integrating additional authentic assessments & training assessors.