Simulcast Journal Club August 2019

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. 

Title :  “The Uncanny Valley 

The Case :  

Nimali hung up her phone and hyperventilated for a moment in the dark of the simulation storage room. As she breathed in the darkness the light of her phone swung temporarily across a shadow in the corner.  It was Snythe’s body, stored carefully by Nitin and Brad an hour ago to minimise the distress to her staff. 

She hesitantly walked over and stared at the pale and lifeless face of her colleague.  He’d been many things to her, a thorn in her side, a bitter clinician, but lately he’d been a stranger mix : a previous sceptic who’d suddenly become very enthusiastic about simulation education.  They weren’t close, but the impact of his death would potentially destroy her centre and lose her friends their jobs.  Getting to the bottom of this murder was vital to their survival as a unit, but who could she trust? 

She marvelled at how lifelike Snythe still looked on the bench.  In the pitch black of the room, you could have mistaken him for being asleep, a hole in his side where the trochar had pierced his chest was all that suggested anything was wrong. 

Everything was so confusing right now… Her ex-husband had just phoned to make claims that didn’t make sense.  That Nitin wasn’t registered with the medical board, that he’d been listed as a person of interest in the case of a simulation educator who’d disappeared during a conference in Malaysia 18 months ago. 

She gently placed her hand on Snythe’s with the intent of a warm farewell gesture, but his hand felt odd somehow.  Firmer, less textured, somehow less human; maybe it was the rigor mortis.  She froze suddenly at the sound of the door opening and the light being turned on.  Nitin was in the doorway, looking concerned. “Nimali, what are you doing here?  Everyone’s worried.”. 

Nimali blinked in the sudden bright light and stared instead at the sight of Snythe’s body below her, confused.  She grasped Snythe’s hand again and ran her fingers firmly down his chest and deeply into the wound.  Thick syrupy fluid dripped out on her fingers.  She sniffed it cautiously. 

“Nimali, don’t’…” said Nitin, but he paused at her expression. 

“I’ve always admired good moulage.” Nimali stated, detached. “I never had the knack for it, and the conversation afterwards always seemed more important than the sim itself, but I’ve watched Louise do it a few times and it’s a real art.  The engagement it can create is impressive, but this?  This, Nitin, is next level stuff.  If I hadn’t touched… well I would’ve believed….” she frowned and held up her hand.  Her tan fingers soaked in vivid red.  “I guess sometimes physical fidelity is important after all?”.  She grasped her face in grief. 

“This isn’t blood, Nitin.  And this isn’t even Snythe.  It’s a Lifecast mannequin and some very impressive effects work.  What the hell is going on?  Is he even dead?” 

She folded her arms and stared at him fearlessly, daring him to explain.  He held her gaze for a moment, his facial muscles held tight and expressionless.  He reached behind him and locked the door. 

“It’s never about fidelity, Nimali.  It’s about functional task alignment.”. 

The Article : 

Stokes-Parish, J., Duvivier, R. and Jolly, B. (2019). Expert opinions on the authenticity of moulage in simulation: a Delphi study. Advances in Simulation, 4(1). 

Discussion :  

As described in our salacious case study, moulage is often considered important for realism or fidelity.  In this new article from Stokes-Parish et al, the authors describe a synthesis of expert opinions on moulage through a delphi study. 

We look forward to your reflections on their findings, the process, and any of your own misadventures into ‘the uncanny valley’. 

References : 

Stokes-Parish, J., Duvivier, R. and Jolly, B. (2019). Expert opinions on the authenticity of moulage in simulation: a Delphi study. Advances in Simulation, 4(1). 

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.

26 thoughts on “Simulcast Journal Club August 2019

  • Robbert Duvivier

    Great post Ben, such a creative way to discuss research! Looking forward to reading more thoughts from around the globe!

  • David Halliwell

    We love this…, all of our lifecast bodies are real people who are very much alive … and I guess that is so important to us as we try and explain our journey it’s inportant for us to let people know who our bodies are and why they chose to allow us to copy their body and turn it into a manikin.

    Vivien our older lady (84) is an actor in Star Wars, a dancer and a psychologist – she went sky diving aged 80 and challenges perception of older people. Vivien is our hero and our favourite manikin for challenging words like Geriatric or Elderly – we would argue that Vivien has a More active life than many of us.

    Pete our older man (82) is a lovely guy – if my body looks like his at his age I will be very happy!

    Carl / Karl works at Elstree – he is a draper and a lovely man- we see him most days and his body is good for his age…

    Megan – Megan is actually a Goth – but her body is that of a 24 year old lady – a complete lifecast and 3D scan

    Alice – Alice is a lifecast and scan of a lady aged 22 called Alice –

  • Noel Roberts

    Hi Ben,
    You’re wasted in medicine! I’d certainly buy a “Simulation Romantic Thriller” category novel.
    I’ve always thought the best piece of moulage was a falling oximetry tone with a bradycardia. Maybe I’ll need to rethink after this article but hard to concentrate when wondering about Nitin ☺
    Looking forward to the next instalment.

    • Ben Symon Post author

      Cheers Noel! It seems to have backfired this month though, 3 comments on the case study and nothing yet on Jess’ article!!!

  • Susan Eller

    Hello Ben,

    A little late in responding this month, sorry about that – I do have several thoughts.

    I appreciate the rigor of their Delphi technique, and loved that they wrote about the challenges of administration involved in gathering opinions of the experts. As a budding researcher, also really appreciated the group exploring a topic that is not prevalent in simulation literature. In reading the article, I found myself going back to some of the works cited in order to facilitate my own reflection.

    It was enlightening for me to go back and read the Dieckman, Gaba & Rall article with a different filter – as I had always associated it with the social aspects of simulation practice. Since I had only skimmed it as background content in the past, I then had to check out the reference to Uwe Laucken and the physical, semantic, and phenomenal thinking modes – and follow that rabbit hole just a little ( Since one of my peeves as a PhD student is the amount of simulation research that is a-theoretical, I appreciated the use of Dieckman’s adaptation of Laucken’s work as the guiding theory for the moulage article.

    I would agree with the top five elements as generated by the group: likeness to real world, anatomical correctness, position, detail, and color. I am interested to see how the instrument development goes with this topic. I could imagine that the instrument would first be used by simulation facilitators, and then perhaps to the participants. One of the things that I wonder is how the perceptions of those two groups would differ – and what degree of the three different types of realism in moulage is needed in order for the learners to feel fully engaged. It is a great scientific start to several questions.

    Another article or concept that I needed to revisit after reading this article was that of the Uncanny Valley. My initial impressions of that concept was that as simulators or moulage approached physical realism, there was a point in which the likeness to the actual made it distracting for the participant. Jess mentioned this in the article, that sometimes it can cause fear instead of engagement. It suggested further research to me: when is the moulage’s physical properties so close to reality that it causes distraction from the semantic and phenomenal realism?

    So – thank you for the article. And thank you for the story as well. Maybe your phenomenal realism of the murder mystery was so good, that it distracted from the physical and semantic of the article ;). I will let you – or Jess – tell me if I have used those terms appropriately.


    • Benjamin Symon

      Hi Susan, thankyou so much for getting the conversation started, and in particular for your in depth response. I love that your reflections share that the article highlighted some new concepts and questions for you, but also prompted you to reflect on previous literature with a different lens as well.
      I’m familiar with the uncanny valley term primarily from my previous degree in Animation, (we were studying at a time when CGI was taking over the beloved handdrawn method, and the uncanny valley was seen as something of a warning against photorealistic CGI compared to drawings). I was wondering given your question “When is the moulage’s physical properties so close to reality that it causes distraction from the semantic and phenomenal realism?”, did you have an opinion on that yourself yet? I’d love to hear it if you did,

      Many thanks my friend,
      Ben Symon

      • Susan Eller

        Hello Ben,

        Hmm…I think that in my own experience, we keep moulage minimalistic – just enough to give the idea, but not enough to distract. The one thing that is very realistic is a trainer that one of our ENT surgeons developed for a carotid blow out exercise. Lots of blood – and that is part of the challenge of dealing with the airway issues IRL. But it hasn’t been distracting thus far.

        I don’t want to go too far off topic, but Ann’s comments about not knowing that it is not a real patient resonated with a recent in situ sim event. One of our cherished simulation colleagues was portraying a stroke patient in the ED. The resident on duty knew her well, and had an emotional response to her being the “patient”. There are obviously pros and cons to practicing taking care of a colleague, but that was not the intention of the simulation. In this case, her acting and the moulage, combined with her familiarity to the team caused a very Uncanny Valley.

        • Benjamin Symon

          How interesting! I hadn’t considered people having emotional reactions to a colleague appearing unwell. I think one thing that your post highlights is that contextually the moulage needs to hit the learning needs, and some themes that seem to be coming out specifically is the importance for surgical simulations. I’ve got some anaesthetic colleagues who do team training in theatres, but they’re often concerned specifically about giving the surgeons enough to physically do with their hands that it’s actually relevant to them. Just standing there miming cutting stuff doesn’t seem to do it for them ;p

  • Komal Bajaj

    Congratulations @j_stokesparish and team on this rigorous work and for digging deeper into an area of simulation where there is much to be learned! As someone who has been in a “front of the house” facilitator role since my beginnings in simulation (both center-based and insitu), I am mediocre at best at SimOps/moulage/etc. I have a healthy respect for those that do it well and try to avoid falling into the “uncanny valley” :).

    I’m looking forward to seeing how the tool evolves and it’s application to faculty development.

    • Benjamin Symon

      Thanks Komal! Looking forward to seeing you soon in Oz.
      I wish my moulage efforts were at risk of approaching the uncanny valley, my moulage efforts are barely at risk of being seen as interpretable.

  • Ann Mullen

    Thanks Ben for an intriguing subject. Like Susan, I found my self following the links to dive into the references. This is an important subject as we aim for the right dosage of moulage.
    I had never heard the term “uncanny valley” but I have definitely witnessed it! Some participants describe their reaction to the “creepy” appearance of the mannikin, and they use a lot of energy trying to deal with that. They feel like they are acting in a play, rather than engaging in a clinical case, which adds to their cognitive load.
    At the risk of sounding like Johnny One Note, I will add a few comments about moulage and sim safety. Mannikins can create unexpected responses. For example, most sim educators have had the awkward experience of transporting the mannikin to an in situ sim. The reactions range from amusement to discomfort, and I am highly aware that the sight of a lifeless body could cause distress to a patient or visitor. The strategies for minimizing the risk vary; I like to take a less travelled hallway, go with a buddy to clear the way, calmly tell people that it is a training mannikin etc.
    I was fascinated by the extremely realistic mannikins. When I saw them at the exhibit hall at IMSH, I thought that I was looking at an actor! At the same time, there are risks to consider. Imagine the sim education team sets up an in situ sim and proceeds to another room for the pre briefing. Imagine what might happen if a clinician encountered the mannikin without knowing that it is not a real patient!
    I am impressed with the advances in realistic moulage and mannikins, and these comments are not intended to discourage innovation. I propose that we include safety considerations in our planning and implementation processes.

    • Benjamin Symon

      Hi Ann, Thanks so much for coming along! It’s always great to hear your considered perspectives.
      Interesting that you mention the risks of realism. A recent hospital I know recently had a bit of distress when a latex bleeding limb kept in an education centre’s refrigerator was found by a highly concerned cleaner working in the kitchenette. It didn’t go down well.
      I also have mixed feelings about photorealistic mannequins, and to be honest I have found myself moving from a high fidelity mind set to having instead a focus on functional task alignment and departmental skills rehearsal. Does it really matter if I can’t fake urticaria? Shouldn’t I just tell them the kid has anaphylaxis and they can work out how to administer adrenaline safely? If the moulage isn’t intimately related to the specific learning objectives (e.g. dermatology assessment) , then is my realism time well spent?
      Would love to hear your thoughts,

      • Ann Mullen

        Yikes! I can just imagine the distress caused by the leaking blood. In my previous job, I made sure to meet the cleaning staff and explain our work, including the use of fake blood etc. I did worry that there might be a substitute cleaner and that we would alarm someone!

        The photorealistic mannikins are a creative innovation, yet they can have unintended effects. I agree that functional task alignment is the key; the concept of uncanny valley helps me think about this more clearly. Spending lots of time on realism can waste time and resources, and can be a distraction to the learners. We want our learners to be thinking about the clinical issue, not wondering “how did they make that look so real?”

        When I was involved in postpartum hemorrhage sims, I realized that no matter how much blood we used, the clinicians would not recognize that it was a hemorrhage. They were accustomed seeing a lot of blood in their daily work! We started covering this in the prebrief; today we will practice managing PPH. We also had scripting for the ESP : “This is a lot of blood, this patient is hemorrhaging, this is not normal.” If our learning objectives were to diagnose PPH we would have had a different approach.

  • Ian Summers


    Many thanks for putting this article onto my radar after so much time anticipating it, and thanks Jessica and others for its writing.

    Some thoughts:

    The use of highly realistic mannequins puzzles me. I get the strangest sensation of wanting to hold Vivian’s hand (Lifecast, congratulations) yet in sim design I can’t work out how I would use this powerful emotional trigger in a scenario in a way that would benefit learners more than having a real human being/SP that talked back. So, I end up admiring her like a great piece of art, and appreciate the emotional response it triggers, again like a great piece of art. I suspect this might apply to the limits of my creativity as much as anything because I am sure that people are creating great learning using them. What I have also noticed is the power conveyed to a mannequin by the way in which it is treated as a person by confederates around it, and again an emotional response and genuine tears generated by faculty as they interact.

    Within the discussion of this paper I am always troubled by who gets to be the judge of realism. Is it the expert creators of moulage who were polled here, or the intended audience who are learners? Who’s views of reality or functional task alignment do we actually care about? And is it individual components of reality that matters, or just the overall effect?

    And then my brain starts to hurt.

    Interestingly the uncanny valley effect is mentioned from a mannequin or animation being made to look eerily like a human, when special effects, make up, bad cosmetic surgery or Instagram filters/Photoshop can go the other way and make a real human being or SP look uncomfortably half real/half fake too.

    Congratulations on your writing Ben I am engrossed with whatever happens next in the romantic serial killer cognitive detective genre you have made your own.



    • Ian Summers

      For a demonstration of what I was trying to suggest that confederates and actors treat mannequins to make them real and give learners or audiences an emotional response to them, watch video of sim at DFTB in withdrawal of ALS/CPR at about 38 minutes for the next 90 seconds or so (and hang around for Liz Crowe/Damian Roland/Katherine Lorenz comments too). As the scenario ended we had to be careful that the set-up team carried the “body” off the set in a respectful way. While the scenario ended the audience emotion and buy-in had a carry over effect. The mannequin was a Resus Annie or equivalent, and actors were clinicians ad-libbing their response and the way they interacted with their “daughter”. In terms of moulage, and physical realism there was absolutely nothing. But it had power.

    • Ann Mullen

      I admit that I held Vivian’s hand while speaking with the Lifecast representative! Glad that I am not the only one. High engagement has benefits and risks. The realistic manikin could remind a student of a beloved grandmother or aunt, which could be upsetting and derail the learning.

      • Benjamin Symon

        I feel similarly with paediatric mannequins. The sight of a sick, still child is unsettling. I suppose that could be considered stress dose resilience training, but in particular with the lifecast one of our big interests is actually their ability to be put on a ventilator (as opposed to our normal paeds ones which leak so much the exercise becomes pointless). The visual interest and engagement is in some ways a nice bonus.

  • Janine Kane

    To moulage or not moulage! Did the course, bought the kit, and only use my small makeup kit instead. Time constraints for me have a big impact on using moulage to its full potential. I think it also depends on the level of the learner, where the scenario is taking place and what scenario you are using. As we are reducing clinical hours, specifically in nursing, I feel we should be using more simulation. Not just for the unusual or infrequent scenarios that may occur, but for the every day situations that nurses in particular have to deal with. Using students, dressing them up as pts, using a bit of creativity with make up wigs etc can give a real authenticity to scenarios which transfer well into the clinical arena. (Based on student feedback)

    • Benjamin Symon

      G’day Janine, so lovely to have you here. It sounds like as a group we are somewhat moulage skeptics : admirers of the artistry, concerned about the resources required if not benefiting the scenario. To me this sounds like a good thing, a sign that as an industry we are reaching a level of maturity where we’re asking ‘when is this useful, when is it not’. I think that’s why to me this article is important, because it’s an academic evaluation and documentation of us learning together about the nuances of this practice.

  • Sarah Janssens

    Hi Ben, we at the Mater Sim Team discussed the paper over coffee today (no time for curry this month!!!!)

    Thanks for bringing this paper to our attention – it was a great selection and brought some of our “back of house” team to our journal club! Firstly Steph Barwick expressed the opinions of the whole team about how easy to read the methods were and a great example to follow for those wanting to do a Delphi Study – thanks Jess!

    Michael Blunt (Simco) led the discussion about the role of moulage in participant engagement, and we agree with comments of others that the balance needs to be right with respect to buy in vs distraction. We debated the role of moulage in buy in with respect to the “cool factor”. To explain, when participants are leaving the sim room commenting on how “awesome” the blood felt/looked etc some argued that this is engagement with the “sim” not the “case”. The counter argument was “does it matter?” as often if engaged in the sim then will engage in the debriefing and perhaps this is where most of the learning takes place. We’d be interested in others thoughts on this!

    We spoke of confusion regarding the scope of the term moulage when seeing in the final tool the “simulation orientation” item. Does moulage extend to the include other things we do to facilitate engagement or are these separate?

    There was one item we considered could be important in moulage authenticity that perhaps didn’t make it into the Delphi and that was (for want of a better word) consistency of authenticity within the moulage. When using sim mum with her plastic face and lack of real eyelashes and anatomically unrealistic genitals, it would sim incongruous to have a highly authentic baby pop out. Conversely, a life cast manikin or simulated patient with a simulated wound that was simply a piece of plastic with a cut in it might lower overall authenticity!

    Overall the team was keen to see how this tool evolves with further validation – I’m sure we’ll see some more great studies coming out soon.

    Thanks for the opportunity to discuss signing off – Mel Barlow, Kate Strawson, Robyn Dickie, Michael Blunt, Steph Barwick and Sarah Janssens

  • louise dodson

    Hi Ben, thanks for the great story, what a twist!
    I have learnt over time that you don’t always need to go all out on your moulage to elicit engagement. Although, I do think authenticity in moulage has its place, given the objectives of the simulation. Insitu operating theatre simulations are an example where engagement of the surgeons is an important consideration.
    I do feel even I, as a simulation provider, buy in more emotively when human’s role play adolescents or adult patients. Working in paediatrics, I find myself constantly looking out for the their physical safety, as mannequins are the norm. I can understand how a colleague may respond emotionally when one of their own appears to be unwell. Observing how the participants follow the response a confederate parent or embedded clinician implanting the notion of the unseen change in the mannequin’s colour or level of consciousness is also a curiosity and requires a carefully considered script.
    There is one element of the Moulage authenticity score sheet that I am somewhat perplexed as to how I would apply a score – “the moulage is at a sufficient level so as not to distract / confuse the participant” – I think I would need some criterion to gauge what a ‘sufficient level’ is. There is much to be considered with this research and hope that the next stage involves investigating participants perceptions.
    I must admit the leg did look great! And perhaps it was an indulgence for myself, but having gone all out on creating such a moulage masterpiece to not having it revealed in the scenario because in real life one would not remove the bandage from a bleeding foot, did seem like a waste of time – & yes, it ended up in the bin, replaced by a much simpler, more easily applied silicone model of tubing! & we now have a special fridge clearly labelled simulation only.
    Cheers Louise

    • Benjamin Symon

      Louise! You don’t know how happy it makes me to have you come along and comment, thanks for all your work and I hope you appreciated the little tribute ;p
      I think you’ve highlighted some important points both regards to getting the fidelity right for the educational task, but also with regards to challenges interpreting the moulage authenticity score sheet.
      Looking forward to exploring this more with Jess on Wednesday!

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