Simulcast Journal Club June 2020 – Diversity in Simulation

Introduction :  

Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education.  Each month we publish a case and link a paper with associated questions for discussion.  Inspired by the ALiEM MEdIC series, we moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field. 

The journal club relies heavily on your participation and comments and while it can be confronting to post your opinions on an article online, we hope we can generate a sense of “online psychological safety” enough to empower you to post!  Your thoughts are highly valued and appreciated, however in depth or whatever your level of experience.  We look forward to hearing from you. 

The Article : 

Conigliaro, R., Peterson, K. and Stratton, T., 2020. Lack of Diversity in Simulation Technology. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 15(2), pp.112-114. 

Discussion :  

This month on Simulcast journal club we discuss diversity in simulation.  The article up for discussion by Conigliaro et al presents data from a non systematic technological review on the proportion of mannequins and associated apparatus that are made with a range of skin tones. 

In the context of current events we ask readers for your thoughts and experiences with both the paper and diversity within simulation in general :  What concerns you?  What can we do about it? And how have you seen it done well? 

We look forward to the discussion! 

About Ben Symon

Ben is a Paediatric Emergency Physician at The Prince Charles Hospital in Brisbane and a Simulation Educator at Lady Cilento Children's Hospital. He currently teaches on a variety of paediatric simulation based courses on paediatric resuscitation, trauma and CRM principles. Ben has a growing interest in encouraging clinical educators to be more familiar with simulation research.

33 thoughts on “Simulcast Journal Club June 2020 – Diversity in Simulation

  • Eve Purdy

    Hi Ben,

    Thanks to you + the team for starting a conversation as we all move towards creating practices and places that are anti-racist. I do feel that there really is an urgent need to evaluate and transform our practices as they relate to racism. I have a one main concern.

    The misconception that diversity in mannequins = an antiracist simulation program.

    I’ve been in medical training for nine years and involved in simulation for most of those. Until this fall, I had never worked with a Black simulation mannequin. Is this a problem? Absolutely. A bigger problem however, was that this fall when our lab purchased a Black mannequin (and pointed to this of evidence of inclusion and diversity) that the first case that was run (during which I was a participant) was a patient found outside of street health unconscious having overdosed on methadone and when he woke up spoke with a Jamaican accent (played by a white sim tech). You honestly can’t make this shit up. I spoke with the facilitator after the session about my concerns around stereotyping, and overt racism in the design of this case. He was very receptive and reflective. I still grapple with understanding what prevented me from broaching this issue in the debrief with all the participants present which would have been an appropriate way to start a critical discussion about the systemic racism in medicine that allowed us to get to the point of this seeming like a good decision – and frankly would have been way more interesting, fruitful, and impactful than discussing whether to overdrive pace or use isoproterenol for Torsades….. I’ve since crafted the words I’d use in a similar situation in the future but recognize my failure to be true ally in that moment.

    Anyhow, I think what we see from this situation is that just bringing in a Black mannequin to a sim program without any other efforts to consider anti-racist practices has the potential disastrous effect of propagating stereotypes and actually fostering/teaching racism (imagine a similar case being run for hundreds of medical students). So, as we appropriately diversify our simulation tools we must also build in anti-racist practices related to their use (review of all cases in a sim program through the lens of anti-racism, anti-racist training of facilitators/techs, regular review and reflection of sim program as it relates to diversity, commitment to inclusion and mentorship of BIPOC simulation faculty and many more).

    We know that simulation is a moment of cultural compression. With that comes the reality that it is a tool that has propagated structural racism in medicine. It also means that simulation is a place that tells us an awful lot about the culture of medicine as it is….and can be used thoughtfully as a reflective lens to understand our own values, beliefs, and shortcomings…just as the situation above overtly highlighted some serious issues with racism that may not otherwise come to the surface. Perhaps more hopefully, understanding simulation as a moment of cultural compression means that it comes with the real opportunity to facilitate deliberate, meaningful, cultural change….we can use it to move towards a version of ourselves we most hope to become. Let’s make it happen.

    • Ben Symon

      Eve! Thank you so much for posting, it means a lot to me that you’re first here given how much your work has impacted my perspectives on the hidden curriculum and cultural compression and how central they are to simulation training. I can imagine many people may be a little nervous about posting this month on a complex and challenging issue that’s emotional and heated at the moment, so I’m grateful to you for taking the first dip into a spicier journal club than usual. It can be easy to not comment because we worry about saying the ‘wrong thing’ too. So thank you for sharing both your experience and vulnerability in that moment.

      I feel like I could just sit here and highlight the important points you make one after the other, but I wanted to focus on your opening statement : that diversity in mannequins doesn’t equal an antiracist simulation program.

      I’m going to go downstairs to our metropolitan hospital’s lab when I’m back at work, but I’m confident I’ll find an almost exclusively light skinned storage room consistent with the article’s report. The consequences of that purchasing/supply issue is that (as described in your case) a darkened skin tone mannequin is used for ‘a very special episode’ type simulation where the skin tone itself is utilised to signal : otherness + ethnicity specific social or medical vulnerabilities. It’s hard enough to balance mannequin cues sometimes when learners are hyper-attuned to interpreting every signal in the room as ‘the clue to crack the case’, and even if the skin colour is used to reinforce a teaching point (e.g. indigenous australian’s increased risk of rheumatic fever) the take can be clumsy but it also repeatedly reinforces the ‘othering’ of the skin tone.

      One challenging reflection I had was that when (many months ago) I placed an infographic on explicit communication during a resuscitation on twitter and intentionally chose to feature a doctor wearing a head scarf, I was rapidly called out for having a conscious or unconscious agenda in the image. While my personal perspective was that I was trying to be mindful of some simple representation (particularly after google searching ‘professor’ on google image search), instead I was repeatedly asked by multiple people what my purpose was, that I must have included that headscarf for a reason and in private tweets politely asked to justify my choice. A colleague of islamic heritage was asked to comment (and in some ways adjudicate) on an image that she had not been involved in, in ways that made me uncomfortable people were being asked in some ways to represent their race without them self nominating to do that. These comments were from colleagues I respect and admire, but the signal to me was clear, this image of a doctor in a headscarf was somehow ‘out of place’.

      One unfortunate take away for me was that in featuring a non-white, female doctor in the infographic, my intended message on communication in resuscitation had been dampened by learners instead focusing on the colour and cultural dress of the doctor in the image. She registered as an other, and therefore there must be a more complex reason for her existence. In trying to include the most minor element of diversity, my intended message was somewhat lost. So from an educationist perspective, the inclusion of cultural diversity made my infographic less successful at its intended intervention. Which in some ways gave me less motivation to do it again.

      I remember our sim fellow Sonia mentioning that at Sim Health in Australia last year, Komal Bajaj spoke about the inherent ‘cultural dominance’ in establishing one set of mannequin skin tones as ‘normal’, but I heard it second hand so hopefully we’ll be able to tempt her here to elaborate in more detail.

      • Jessica Stokes-Parish

        Great thoughts @Eve and @Ben

        I’m wondering, too, if we should move away from this idea that we need to suddenly upskill in anti-racism education. Don’t misinterpret – I do not mean that we shouldn’t be anti-racist. What I mean is, there are plenty of people out there that ARE experts in embedding anti-racism education into curriculum, there ARE experts out there that understand the underlying concepts of bias and culture. Should we consider bringing experts as consultants to guide us to best practice and hold us accountable in measurable ways? This to me addresses two things:
        1. We are honouring expertise and paying for the labour involved, and
        2. No excuses for good intentions without action (external accountability means honesty and no kind pats on the back!)

        • Samantha Davis


          You make valid points here – and I agree completely.

          It’s wonderful to hear racism and bias becoming topics of everyday discussion in health professions education, however expertise does not appear overnight. Planning for ways to properly engage and educate our current simulation folks is an ambitious long-term project (which no doubt will impact the future of simulation). In the meantime, experts should be sought out and compensated to foster accountability, action, and safety.

  • Ian Summers

    Ben, thanks so much for posting this journal club.

    You and Eve raise some important issues, as do the authors when they talk about the costs and justification for purchase of mannequins. I would certainly want to run all potential scenarios on any mannequin I purchased, which means that I can’t elect to have skin tones I swap in and out depending on the potential sensitivity of the scenario objective and the possible link between any “centre generic” skin colour and any racial overtones and bias perceived. In summary: it’s even more of a minefield than I had imagined! We have responsibilities to promote diversity in staff and learning and mannequins, and to make sure that our scenarios are respectful to all. There are a number of scenarios I can reflect on over the years that wouldn’t pass this test. We should do better.

    There are sentences here written and rewritten to try not to cause offense. Hopefully I have added to the debate but will sit back and listen!

    This from the article sounds like a good way to go forward:

    “educators should be cognizant of inconsistencies and
    challenge those aspects of the “hidden curriculum,” which
    serve as latent microaggressions toward multicultural patient
    care.23 Indeed, a heightened awareness of these subtle biases
    may encourage more innovative adaptations of simulation
    technology presently available. Only with continued attention
    will learners receive a consistent message that diversity, even if
    not always obtainable, is important and that even limited
    simulator-based experiences can provide useful opportunities to recognize and internalize the relevance of diversity in patient care”.

    • Ian Summers

      Pondering this article and discussion a little further it pursues thoughts based around mannequins where I would see expanded opportunities for cultural competency and the interaction of culture, race and health as working with a diverse group of simulated patients. Pushing the learning of culturally appropriate communication and its intersection and de-biasing skills with the aid, insights and feedback of a diverse group of SP’s seems to offer much more potential. It also eliminates the cost implication of being locked into a limited numbers of mannequins. This would be “as well as” rather than “instead of”….but expands the opportunities. I suspect lots of centres and SP’s are already doing this. Would love to hear their thoughts.

      • Ben Symon

        Hi ian,
        Thanks so much for your comments, and I agree that in some ways recruiting a diverse group of SP’s offers a lot of potential in that it allows for some cultural authenticity and perspective sharing, rather than just nominating the inclusion of a specifically coloured mannequin to identify diversity.

  • Susan Eller

    Hello all,

    Some great points raised thus far, and perhaps Eve’s succinct statement sums it up best: diversity in mannequins = an antiracist simulation program.

    We wanted to increase the diversity of our mannequin population, however cost and turnover does play a part as well. Our first need was to buy a new baby, and two years ago we waited three extra months in order to get the medium skin toned baby instead of light. Last year we needed to purchase a new adult mannequin. We did have some thought about dark skin tones, but opted for the medium skin tone. Our rationale was that it could be used for more scenarios – as it approximates (not exact) coloring for Hispanic, Indian, and Native American. It was a somewhat of a pragmatic choice, as it gave us more options for use. Due to the nature of our tech, we have to hard wire our mannequins in the sim lab, as opposed to wireless. So swapping them out becomes cumbersome, and hard to do between scenarios. There was another less pragmatic component to our choice, as we thought then we would have the potential to run family scenarios with the medium skin baby and adult. Reflecting back now, that choice reflected our implicit bias – that we should have the skin tones match in order to have a “family”. I need to take accountability for encouraging that stereotypical sense of family when discussing the issue with our team.

    We celebrated the fact that we had diversified our mannequin population over the course of two years. Yet when all the protests started, it caused me to reflect on why we had not purchased a black skin mannequin. It is true that in our local geographic area, the medium skin mannequin would better reflect our population. So although it was a conscious attempt to diversify based on our demographics, was there unconscious bias in not purchasing the dark skin mannequin? My angst took the form of wondering if that potential unconscious bias meant that I have no right to participate in anti-racist demonstrations or discussions. I chose to discuss my thought process in the purchase with my black academic colleagues, acknowledge my regret, and participate.

    We have not used our mannequins in stereo-typical scenarios such as Eve describes. But I have heard from medical education colleagues that there is lack of black representation in cases for the course work, and that one of the few cases use an example of a poor, under-educated black male. Some of the other challenges are cases with Mexican Hispanics or Asians who do not speak English. I imagine some of these cases were written to highlight health disparities, so probably with the best of intent. But they are not offset with cases of successful persons of color.

    Thank you Eve for this statement – I am going to share with our team as it highlights the direction we all should think of taking: “…understanding simulation as a moment of cultural compression means that it comes with the real opportunity to facilitate deliberate, meaningful, cultural change….we can use it to move towards a version of ourselves we most hope to become. Let’s make it happen.”

    • Susan Eller

      Oops – I meant to quote from Eve’s statement that diversity in mannequins DOES NOT equal an anti-racist simulation program – but I copied that poorly

  • Sonia Twigg

    At the Australasian Sim Congress last year – my first sim conference, I was standing in line waiting to enter the market place chatting with a respected, senior colleague. She encouraged to me to look around the marketplace, and asked me “what colour are the mannikins?” I realised all of the manikins were white. I had never had to think about it before.

    Ben – as a white, middle-class woman in Australia who does not have to think about race every day, I I have a lot to learn on this subject and carry some shame. But I can say that I am listening. I can find ways to be a better ally.

    The talk about diversity reminds of my time spent in Central Australia – as a medical student for a couple of months in a remote aboriginal community and then a few years in Alice Springs – where Aboriginal Australians make up 25% of a very diverse population. I went through – and saw other new health staff go through a predictable mental upheaval trying to comprehend the differences in living conditions and health consequences, and trying to learn – reading books, watching documentaries, talking to locals and starting to learn some language. I am forever grateful to my Pitjantjatjara teacher – a proud elder who tried to teach us language, but more importantly shared her experience of being in the world and helped us to start to understand.

    The finding in this article that most mannikins are white, male and able bodied underscores that this viewpoint is still dominant in our discourse. This resonates Ben with your story – where the mere act of including an image that was not white, male and able-bodied took the discussion away from your intended message. I agree that the colour of a mannikin does not necessarily result in decreasing stereotyping but I do think it prompts us to think and talk about race and diversity – and hopefully to recognise that a stereotype is present. Like any change process, we need a range of strategies to combat racism in our society and increasing diversity in the skin colour of our mannikins is one of those strategies.

    I have been thinking about what practical steps I can take to contribute to anti-racist medical education;

    I can build a better relationship with our aboriginal liaison service and invite their service to review sim scenarios, attend and participate in our simulation training.
    I can engage with community groups in my area and discuss how these consumers could guide and participate in simulation training.
    I can ask for comment about race and diversity from colleagues before running the sim and from participants afterward.
    I can have the courage to bring up race and diversity in the debrief and encourage us to talk about it openly – displaying my own vulnerability as an example of learning to have these discussions.

    Small steps.

    • Ben symon

      Thanks Sonia!
      What a lovely set of pragmatic steps you plan to take, hopefully I can follow your example.

  • Sarah Beebe

    Thank you everyone for your thought-provoking comments. This is an area that has been on my mind for a while now as I look through our sim center, we only have 1 black mannequin. While all of the rest are white. I have found what others mention, it takes longer to get the mannequin with dark skin tone versus white and may cost more money. However, we need to diversify our “patients.” I think a lot of it comes down to our mission of suspending disbelief and meeting the objectives of the simulation. If we are describing a patient that doesn’t actually look like the patient our learners are taking care of, how can they suspend that disbelief and practice as they actually should and do. If we’re running a sim that involves objectives surrounding social determinants of health that include race, does it make sense to use a white mannequin. Nope. How can we begin to address our unconscious bias if we’re not practicing it at every step in the learning process, including the simulated setting. Thank you for being this article to light and I hope there are more like this.

    • Benjamin Symon

      Thanks so much for your comments Sarah, I appreciate that you highlight that addressing our biases has to extend into every step of the learning process. Have you seen any examples of it being done well?

  • Amy Lannen

    It appears that many of those commenting here are from Australia so I hope it is OK if I add a little comment from America. My comment is this- We have the same issues! I am working toward some research to help address this but I’m so happy to see that I am not alone in this pursuit. It is difficult to deal with the shame of having allowed stereotypes to permeate our education. It is especially hard to accept that I have participated in these microaggressions simply because I was unaware and uneducated about particular topics surrounding race and stereotypes. I’m learning and trying to listen to voices that belong to people who don’t look like me. Eve is completely correct in saying that diversity in mannequins does NOT equal an anti-racist simulation program. An anti-racist simulation program is created by anti-racist educators and it sounds like this group is moving in that direction while realizing the journey is not short or comfortable. Thank you all for sharing.

    • Ben Symon Post author

      Hi Amy, apologies for my slow reply this month but I wanted to thank you for joining us! I agree that acknowledging this and reflecting on our own hour it’s through this is uncomfortable. So thanks for sharing your perspective!

  • Ben Symon

    I want to take a moment to just acknowledge that while the posts we’ve had have been enlightening and engaging, overall there has been less discussion than usual this month. (And that most people who feel comfortable posting appear to be my personal friends). Some people have emailed me privately expressing concern their statements might somehow be wrong or offensive and requesting input before posting. While we have discussed some moderately controversial subjects before, this month there appears to be a lot more hesitation to engage in discussion out of fear of saying the wrong thing.

    To respond to that I would like to highlight that if there are genuinely offensive comments I would edit/remove them and privately notify the poster of my specific concerns. This has happened once in the 3 years we’ve been running journal club.

    From a meta perspective though, I would also like to challenge us, in that I’m worried that if we can’t even have a genuine discussion on diversity in simulation in a small journal club setting, how on earth will we actually change in the sim lab? I guess I’m sensing a tendency towards avoidance here. Better to say nothing than to engage in the conversation and cause offense. I think this comes from a good, caring place, but in the process we risk not talking about something important.

    Permit me to move to some personal reflections :
    I think this issue of diversity is a very personally important one to me. And I want to comment specifically on the fact that while we have highlighted the importance of truly diverse programs with appropriate curricula, we have downplayed the simple dignity of having a mannequin that represents someone like you. Sometimes simple gestures of inclusivity can seem token, but sometimes they can also have a strong impact on the marginalised, and we can’t predict how each person will respond. When we respectfully include others in our stories, we advocate that they have value.

    Being white in a predominantly white country, I can’t reflect on racism personally, but while I don’t want to equate the discrimination I receive as a white gay male as at all equivalent to discrimination based on race, which is very different, I do have thoughts about the impact of seeing oneself represented in shared narratives. As a heavily internally repressed, very young, closeted teenager, I remember with crystal clarity the time my English teacher off handedly mentioned an author was homosexual without a hint of judgement or scorn. While that simple comment wasn’t life changing, it was clearly impactful enough that I remember it 25 years later. The simple acknowledgement that somebody like me existed and had cultural value was helpful to me at the time. In similar fashion I remember on my med student elective driving through San Francisco and seeing a huge crowd of gay men walking out of a cinema in the Castro. I had never seen a group of people, en masse, like me. They walked hand in hand, without shame, expressing affection and warmth. I remember TV shows that showed minor moments of representation be hailed as revolutionary, and finding it revolutionary at the time as well. These experiences helped me validate my own life experience and combated the daily degradation that comes from exclusion from the narrative.

    I think in some ways it’s a privilege of a dominant race or culture to worry about the impact minor elements of inclusivity can have on the experience of that majority. When that majority already maintains omnipresence within our cultural stories and group narratives, diversity can be seen as a distraction. But my experience is that while tokenistic representation can feel insufficient or half hearted, there is also sometimes a simple dignity in demonstrating to a group of people : this person’s experience is less common, but we value it & we are going to share their story.

    I hope to do better.

    • Victoria Brazil

      Hey Ben
      Great conversation, and I understand the hesitation from others to engage. As you say – it comes from a caring place, and I totally get the desire not to offend. So thank you for the repeated challenge and encouragement
      The balance between representation/ validation versus tokenism extends way beyond simulation and health professional education. I remember writing and critiquing PBL cases and there was this very fine line between ‘trying too hard’ (and risking lack of authenticity and tokenism) versus genuinely reflecting diversity. And of course, that ‘line’ was different for everyone, and no doubt said more about us than the case!
      I think is important to have patient cases where for e.g. the motor vehicle accident patient just happens to be indigenous, or where the chronic hypertension case just happens to have a Korean name, without that being some sort of ‘clue’. Hence, I agree the simple act of having different skin colour manikins can be a good idea, albeit with the thoughtfulness to avoid experiences like Eve’s.
      I think scenarios names should also reflect our community – not always ‘John Williams’ or ‘Sue Smith’, and that maybe ‘Farhan’ is a 6 yo old than just broke his arm, without it needing to be ‘the interpreter case’. It may be that the expectations of learners are still to be culturally curious and sensitive, but not stereotype. This can then complement those simulation/ educational cases that are more specifically designed to highlight the very real disparities that are associated with race, gender and other factors.
      The rubber is going to hit the road for our ED sim program soon – as we are planning to design and deliver some simulations during NAIOC week, in collaboration with our Indigenous liaison unit. We’ll probably get it a bit wrong, but we’ll do our best, work with the right people, take advice, and give it a go.

      • Jessica Stokes-Parish

        Vic, I want to pick up on this idea of ethnicity being some sort of clue. This is really interesting to me, because it suggests or reinforces the idea that there are “hidden meanings” in simulations that participants look for. This was certainly echoed in my PhD work, where students repeatedly highlighted that they were looking hidden meanings behind any sort of clue or patient signal. I wonder, does this reflect our approach to scenario and simulation design being flawed in the first instance?

        When considering this aspect and Black, Indigenous and People of Colour representation, are they are core component of our curricular agenda, or are they an after-thought? Where is the balance between weaving in cultural diversity into our design and actually including as a deliberate agenda?

        • Victoria Brazil

          Hey Jess
          I thought a bit about your question…
          Not sure its ‘hidden meanings’ … its just that many simulations are designed as problem solving exercises – whether clinical reasoning or application of knowledge to clinical or team based situations. Hence we make design choices about signal and noise. eg we want to focus on management of STEMI so we make it very clear that the pain is ‘typical’ of cardiac pain, has appropriate ECG changes and is on in age group where that diagnosis is likely. That means learners are less likely to be ‘distracted’ by other differentials such as PE/ aortic dissection when we really want them to practice calling and getting to cath lab. So we RELY on them using pieces of information (clues) to proceed.
          Unfortunately the flip side of sensible clinical reasoning (with providers putting appropriate weight on pieces of information) can be unconscious bias.
          e.g. as the paramedic i might have rarely seen female medical team leaders in resuscitations, so my reasoning is to look for the tall white male ( and i might be most often rewarded/ ‘right’ with this bias)
          Now i am not suggesting this is a good thing! ……but it just underscores the significance of the design choices we make. and sometimes sims might be a chance to work on ‘debiasing’ , but not always…?

    • Samantha Davis

      Ben, I appreciate you sharing your story. Living authentically, and sharing those stories, means being incredibly vulnerable more often than is “comfortable”.

  • Jessica Stokes-Parish

    Thanks Ben for continuing on this conversation and exploring the complexities of anti-racism in a moment of global reflection.

    In answer to your questions

    What concerns me?
    What concerns me is our complacency with shortcutting in our simulation designs and delivery. Whilst largely informed by our time and resourcing restraints, I think that we do not truly understand the impact of inadvertently perpetuating microaggressions or stereotypes in our learning. I think we have had a focus on task outcomes, as opposed to culture development, which may create a bias for these stereotypes. Let’s face it – stereotypes are easy and comfortable. The key identifying feature of a stereotype is that it is a common character or case with negative connotations. An archetype is a common character or case with positive connotations. But what we should be working towards is individual character design – which we can consider the individual as a human.

    What can we do about it?
    This of course feels like the hardest part – as you point out, many of us are feeling uncomfortable right now. However, I strongly feel that we cannot allow ourselves to become trapped in fear. This mission is way too important. We have countless stories of patients receiving poorer care due to the colour of their skin (e.g. maternal deaths, pain etc) – we have a really wonderful opportunity in simulation to change this narrative. I would love to see simulations utilised to unpack racism (whether unconscious, conscious, deliberate) – these would need to be designed well with high-level psychological safety practices and well-trained debriefers. This would be hard work. It would be emotional work.

    How have you seen it done well?
    At one simulation centre I used to work, there was an amazing program for exploring Indigenous antenatal care. Undergraduate medical students were given the opportunity to interact with an Aboriginal Simulated Patient (who was a co-teacher) in a number of communication skills classes – they explored stereotypes, unconscious bias and more. The key point, I think, was that it was not “using” an SP, this woman was an equal contributor to the design, implementation and review of the simulation. We didn’t simply design it and ask her to join. I wonder if this is perhaps what is missing?

    • Susan Eller

      “Whilst largely informed by our time and resourcing restraints, I think that we do not truly understand the impact of inadvertently perpetuating microaggressions or stereotypes in our learning. I think we have had a focus on task outcomes, as opposed to culture development, which may create a bias for these stereotypes.”

      This is just brilliant Jess – I so appreciate you sharing your insights and affirming that we cannot become trapped in fear. As Vic said, we are bound to make mistakes occasionally, but will still need to persevere and try. Thank you Ben for sharing the Try Anything message with me about making new mistakes. Hopefully I will learn and grow from these, and make fewer of them. Thank you Komal for advocating for change on the prompt simulator! I am grateful to be part of this learning community that fosters self-reflection and community growth.

  • Komal Bajaj

    Hello all. Cruising by to support @Sim_Podcast. Thank you to @symon_ben and @LankyTwigg for cuing me into this important discussion (and I didn’t realize that my comment during @SimAustralasia had been a cause for reflection, @LankyTwigg. Thank you for the generosity of sharing that).

    In 2018, our New York City-based health system was awarded a hefty grant to improve maternal morbidity/mortality among women of color (spoiler – the program has in fact moved the needle on the intended outcome – more to come on that another time). A substantial portion of the grant was to support simulation-based activities. During the launch of the program, we held an obstetric simulation for a senior government official, which came with all sorts of media attention. It was upon review of the photos that we were first struck by an immediate gap that needed to be addressed:

    We lobbied the simulation company that made the part task trainer we were using to develop a simulator to help us do the important work that needed to be done. It took quite a while for the company’s engineers to develop the product and we became the first health system in the planet to have Black PROMPTs. Simply having these plastic pelvi does not make us an anti-racist simulation program(agree wholeheartedly with @purdy_eve, @LankyTwigg, @AmyLannen & @s_eller), but it is one component of many as we continually strive to get there.

    For starters, I’d love to see tools to perform an anti-racist needs assessment for simulation programs – from sim content (Do Words matter? Stigmatizing Language and the Transmission of Bias in the Medical Record, sim design (you’re so right, @SocraticEM, we do need more Farhan), sim modalities (@IanMeducator – great point about SPs) including moulage (What does a Lyme disease rash look like on darker skin?, who is facilitating the simulations, and are the metrics being tracked informed by a solid equity framework.

    We can and will do better, together.

  • Samantha Davis

    I appreciate the discussion here and enjoyed reading. Discussion of racial diversity in simulation was a large part of this article and is where many of the comments have focused; I will try to expand on this a bit.

    Diverse representation in health professions education is incredibly important to the future of healthcare. We cannot teach learners to care for others well if we are not preparing them to actively seek and recognize the nuances of their patients. The authors suggest that the educational environment itself should be diverse, yet the results of their analysis demonstrate how out-of-reach this ideal is. Foronda, Baptiste et al. (2017) highlighted the lack of diverse representation several years ago, yet the simulation products available remain largely unchanged today. Foronda, Prather et al. (2020) completed an international survey of racial diversity in simulation which revealed that, in addition to a lack of product diversity, there is also a substantial lack of diversity in simulation personnel.

    Racial diversity is often the first that comes to mind when we think of “diversity”, but it is just the first step. In addition to the considerable lack of racial diversity in simulation, we lack authentic representation for sexual and gender minorities, body size, cultural and religious beliefs and practices, varying physical abilities, and more.

    Two ideas are most concerning to me right now. The first is that we are subjecting learners to harmful and traumatic educational experiences when they are based in stereotypes or are otherwise inaccurately representative of a particular demographic. An abstract by Seckman and Ahearn (2011) describes the use of cultural relics and enhancements in a simulation to prepare nursing students to care for diverse groups. It is unclear from this abstract what the enhancements are, who selected them, and who is debriefing on cultural norms of the patient represented in the scenario. Regardless, the concern is that far too often in simulation we default to creating scenarios we think are representative of a particular population, when in fact they perpetuate stereotypes.

    The second idea is that many simulation educators are not prepared to address racism, transphobia, or other common forms of discrimination. Discussions often circle back to implicit bias, but that is the *lowest* bar. We can do so much more than simply recognize our implicit biases, yet that is where many choose to stop. The most diverse – in every sense of the word – suite of simulation products will never be enough if we are not prepared to interrogate our structures, policies, hiring practices, recruitment and retention initiatives, and ourselves.

    Foronda, C. L., Baptiste, D.-L., & Ockimey, J. (2017). As simple as black and white: the presence of racial diversity in simulation product advertisements. Clinical Simulation in Nursing, 13(1), 24–27.

    Foronda, C., Prather, S. L., Baptiste, D., Townsend-Chambers, C., Mays, L., & Graham, C. (2020). Underrepresentation of racial diversity in simulation: an international study. Nursing Education Perspectives, 41(3), 152–156.

    Seckman, C., & Ahearn, B. (2011). Simulation: dressed for diversity. Clinical Simulation in Nursing, 7(6), 262.

    • Ben Symon Post author

      Hi Samantha.
      Thankyou so much for your posts this month and the links to additional reading which continue to highlight the problem, but I think also more effectively than the article we’re discussing this month, point towards strategies to actually act on the problem.
      As you’ve described, acknowledging our implicit bias should be considered the lowest bar rather than ‘objective complete’.

      Komal points us towards considering tools for measurement and accountability in sim representation, while I note the articles you’ve linked propose that international sim guidelines include benchmarks or values that highlight diversity as an expected part of simulation practice.

      Really enjoyed your comments this month, Thankyou!

    • Cynthia Foronda

      Hi Samantha,

      Thank you for mentioning our work in this area. This type of discussion is so needed during this time. Initially, we noticed that there was a lack of racial diversity in manikins in simulation centers globally as well as displayed at conference exhibition booths. However, when we brought up the lack of diversity, we were told, “show me the data” and “how do you know that is not just your perception?” This is what inspired the first study. In our study, after examining 2035 body parts and 395 manikins, we found that 94% of manikins and body parts were white. In the US, this does not represent our demographics and demonstrates an underrepresentation of black simulators. This was not just our perception – there were data to support it.

      In our 2020 study, we found that simulation educators felt differently about the need for racial diversity based on the region they lived. If they lived in a predominantly white area, then they did not think it was necessary. However, do we not need to educate learners to care for the global community? We found that 2/3 of simulation educators thought diversity should be part of the best practices/ international standards of simulation. However, current simulation standards still do not address the need for a simulation curriculum comprised of diverse patients.

      My current work is focusing on cultural humility. Through development of a theory and instrument to measure cultural humility, I am hopeful that we can test and refine interventions to better prepare learners to be embracing of diversity and differing perspectives/lifeways. The way that makes sense to me to promote this type of learning in the simulated setting is through debriefing.

      Thank you all for your interest in this important work. Let’s keep working to change the world!

      Foronda, C. (2020). A theory of cultural humility. Journal of Transcultural Nursing, 31(1), 7-12.

      • Ben Symon

        Hi Cynthia!
        Thanks so much for coming along and sharing your work, I really look forward to reading your work on cultural humility.

  • Maybelle Kou

    Beyond the colour of mannequins ( and I feel if we are to have more available colours then facial features must also be authentic) we need to think about the authenticity of the vignettes we provide when teaching. In North America racial stereotyping is pervasive in simulation stems, usually well intentioned but these contribute to the persistence of implicit biases. Standardized patient scenarios are very helpful to address racism, and must include ethnic groups for validation of communication and realism.

  • marc auerbach

    Great thread- I am catching up on this thread. As a white male I would like to explore other thoughts on how to engage experts on this topic. I am NOT an expert in bias and antiracism. I am trying to read and learn as I would about other topics that I have gaps in my KSA. We need to educate ourselves and consider augmenting our curricula on this topic by inviting experts to collaborate during the sim/curriculum development, case facilitation’s and debriefings. We have an “expert in the room” for many clinical topics and can reach out to experts locally on this topic in the same way. We need to leverage the evidence based approaches in this area through curricular integration into our existing programs through explicit objectives and ongoing efforts to allow the time/space for these discussions in our reflections/debriefings. Simulation is a tool and technique that must be used to address this gap in our current education/training created by systemic racism. Lets learn from and with each other in sim and outside of sim as we embark on this work.

    • Andrew Jacques

      This thread has been so helpful to me in both developing and expanding my own thinking and practice. I am teaching on a Post Graduate certificate in Healthcare Education next week with a focus on equality, diversity and inclusivity. This thread and the references within have been very valuable in informing my preparation. It has also made me realise how much we need to do back at our hospital with representation and in our debriefing. Thank you for giving me a greater insight into such an important area.

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