Have you ever created a simulation case with hidden objectives that the learners were not aware of? Would you ever purposefully try to trick or deceive learners in a simulation case?

Simulation can be used to reinforce clinical and procedural knowledge. It can teach important teamwork skills. It can also be used to learn about ourselves in morally and ethically challenging situations.

But maybe if the learners knew that they were about to be morally and ethically challenged, they would always elect the high road. Perhaps to truly challenge the learners, these types of cases might have to involve deception in order to really see what will unfold when challenged. (Great example of human behavior was demonstrated during the Stanford Prison Experiment.)

With the cloak of deception, educators can actually challenge the learner’s psychology, leadership skills, and crisis management skills.

Examples of purposeful deception:

  1. Nurse confederate administers the wrong medication that leads to significant adverse outcome, and then lies about it.
  2. Confederate leader who gives wrong and harmful directions to the team, and expects it to be done.
  3.  Confederate team member has adverse outcome during procedure and attempts to cover it up (e.g. guidewire left in the body)

These are simulation cases where the learners are not pre-debriefed about the real objectives of the case and are not aware confederates are purposefully deceiving them. The real objectives would be handling of unforeseen, ethical dilemmas that evolve.

Unfortunately our good side does not always come out when we are challenged. Remember Lord of the Flies? Imagine what happens to the learners in the post-debriefing when asked by the facilitator about knowingly allowing the confederate leader to execute the wrong decision. We all want to imagine ourselves always doing the right thing, no matter the situation, for the patient’s best interest. Leaders are courageous and always battle for the right; they are not weak.

This type of debriefing session would have to be handled with extreme caution in order to maintain a safe learning environment, stay productive, and develop effective learning take away points. Deterioration into guilt by perceived inadequate leadership skills should be prevented.

Bottom Line

Ultimately I feel that this type of situation is appropriate for a simulation session and a necessary topic. Medicine is full of examples of bad outcomes from mortally questionable behavior such as billing fraud and falsifying of charts to cover up errors. Educators must teach their learners how to handle these real-life situations so that in the real world, the learners always land on top and can be the shining leaders that they can be.

Please share your thoughts and experiences.  

Additional Reading
  • Corvetto M, Taekman J. To die or not to die?  A review of simulated death. Simul Healthc2013;8:8-12. PMID: 22960702
  • Gaba DM. Simulation that are challenging to the psyche of participants: how much should we worry and about what? Simul Healthc 2013;8:4-7. PMID: 23380693
  • Truog RD, Meyer EC. Deception and death in medical simulation. Simul Healthc 2013;8:1-3. PMID:  23380692
Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University
Nikita Joshi, MD


Emergency Medicine Doctor Associate Editor of ALiEM Gun Sense Advocate #FOAMed #Docs4GunSense #MomsDemandAction Tweets represent my own views and opinions