Deception and misdirection – Is being “unethical” a bad thing during medical simulation?

This week’s post was prompted from a recent set of articles in the journal Simulation in Healthcare. Until recently, I’ve given little thought to purposeful deception during  simulation scenarios. Often scenarios are designed to be somewhat “tricky” with a key learning point. This often takes place by incorporating a random medical fact/concept that the learner may not pick up. For example, the seizing patient in refractory status epilepticus…if the participants took a proper history from the family they would have found out that patient has recently started treatment for tuberculosis. The diagnosis of INH induced seizures would be clinched  But what about when you purposefully try to mess with the participants and actually challenge their personality, their ability to behave as a physician and arguably break the psychological safety that should exist within a simulation? Is this beneficial or does such a scenario inhibit learning? optical-illusion-man

I’d like to review and comment on the articles and editorials published in the most recent edition Simulation in Healthcare. The article is a description about how simulation was used to test/study medical hierarchy during a medical resuscitation.

The authors (pediatric intensivists) implemented a scenario where a young child was critically ill with hyperkalemia resulting in a dysrhythmia and incidental hypophosphatemia. The team leader (who was a confederate) was scripted to order potassium phosphate to replace the low phosphate, however, this would also result in death of the simulated patient. The learners (ICU residents/fellows) had some idea that a team leader (staff intensivist) would appear part way through the case but were unaware that such hierarchy conflict would emerge. The team leader confederate was instructed to comply by not administering the drug only if the team demonstrated repeated or sustained challenges in giving this potentially deadly medication. The authors describe running the scenario 3 times and reported the following responses:

  1. Appropriate, successful challenge of drug administration and team leader complied
  2. Appropriate challenge but delayed resulting in delayed appropriate management
  3. The order was not challenged and the simulated patient died

What are you thoughts after reading this? Do you have a visceral reaction that this was a good or bad idea?

My opinion is that in the right circumstances with trained educators I think this is extremely powerful, useful and should be part of the educational toolbox. There’s an accompanying editorial where the authors have raise multiple concerns about this approach which I won’t reiterate – all of which are valid. Though interestingly they also provide well written counter arguments in anticipation of how others may respond.

Simulation scenarios that address non-medical aspects that can lead to patient harm should be simulated. While I agree that this type of case probably is best administered by an experienced simulation educator with highly skilled participants, I disagree with the editorial which suggests that such scenarios should be avoided. They were concerned that this may cause the participant to think:

“Am I the kind of person who is unwilling or unable to challenge a respected colleague who I think is making bad medical judgments, even when this may result in serious injury to the patient, or even death”

I would argue (like the study’s authors) that with proper briefing regarding the educational purpose of the simulation and adequate de-briefing to explore the cognitive decision points that resulted in the patient’s outcome, then learning can be achieved. The degree of deception should be related to experience level of the participants since junior learners would unlikely benefit from such a difficult scenario. However, increasingly, we recognize that teamwork and crew resource management (CRM) play an important role in how we care for patients. Our non-technical skills and awareness to our own cognitive biases during critical situations has considerable impact on patient outcomes.  It’s inevitable that during critical situations we may face challenging interpersonal interactions or difficult decisions.  We should train by pushing the limits of the team and the system. I acknowledge there are some who are concerned regarding the disregard for psychological safety during such simulations. I argue that with proper approaches that psychological safety can be managed. Furthermore we can do a much better job controlling the psychological safety of a simulation than we can simply leaving learners to fend for themselves during a real-life situation where not only their psychological safety is at stake, but the medical safety of the patient is at risk.

The argument that we should study this more before widespread use is reasonable but I’m not sure that results from one centre will be applicable to others. The validity of such studies remains challenging to say the least. Certainly larger studies will help, but meanwhile simulations including misdirections or deceptions that challenge not only technical knowledge but interpersonal and team dynamics should be supported.


Abstract from cited article above 

Case & Commentary: Using Simulation to Address Hierarchy Issues During Medical Crises. Calhoun AW et al. Simul Healthc. 2013; 8(1):13-19

Medicine is hierarchical, and both positive and negative effects of this can be exposed and magnified during a crisis. Ideally, hierarchies function in an orderly manner, but when an inappropriate directive is given, the results can be disastrous unless team members are empowered to challenge the order. This article describes a case that uses misdirection and the possibility of simulated ‘‘death’’ to facilitate learning among experienced clinicians about the potentially deadly effects of an unchallenged, inappropriate order. The design of this case, however, raises additional questions regarding both ethics and psychological safety. The ethical concerns that surround the use of misdirection in simulation and the psychological ramifications of incorporating patient death in this context are explored in the commentary. We conclude with a discussion of debriefing strategies that can be used to promote psychological safety during potentially emotionally charged simulations and possible directions for future research. (Sim Healthcare 8:13Y19, 2013)