Simulation
The Human Face of Simulation: Patient-
Focused Simulation Training
Roger Kneebone, PhD, FRCS, Debra Nestel, PhD, Cordula Wetzel, Dipl Psych,
Steven Black, MRCS, Ed, Ros Jacklin, MA, MRCS, Raj Aggarwal, MA, MRCS,
Faranak Yadollahi, MSc, John Wolfe, MS, FRCS, Charles Vincent, MPhil, PhD, and
Ara Darzi, MD, FRCS
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Abstract
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Simulation is firmly established within
health care training but often focuses on
training for technical tasks and can
overlook crucial skills such as
professionalism and physician–patient
communication. The authors locate this
paper within current developments in
health care and relate it to the literature
on simulation. They make the case for
placing real human “patients” (played by
actors) within simulation environments,
thereby ensuring that the training
I n recent years, simulation has shifted to
center stage within health care education
and is now firmly established as a crucial
component of training. Simulations
range from simple benchtop models (for
practicing basic skills such as
venipuncture and urinary
catheterization) to virtual reality
computer systems and highly
sophisticated recreations of clinical
environments (such as the operating
room or intensive care unit). Pressures
from a rapidly changing health care
landscape are hastening the shift to
simulation-based training in many
countries. Shortening of training
programs, reduction of working hours,
and ethical imperatives to protect
patients from harm are having a
profound effect upon traditional
approaches to training. Moreover,
opportunities for training within a
clinical setting are unpredictable, and the
learning needs of the trainee must always
Please see the end of this article for information
about the authors.
Correspondence should be addressed to Dr. Roger
Kneebone, Senior Lecturer in Surgical Education,
Department of Biosurgery & Surgical Technology,
Division of Surgery, Oncology, Reproduction and
Anaesthetics Faculty of Medicine Imperial College
London, Chancellor’s Teaching Centre, second Floor
QEQM Wing, St Mary’s Hospital, Praed Street,
London W2 1NY; telephone: 020 7886 7930; fax:
020 7886 1810; e-mail: (r.kneebone@imperial.ac.uk)
Academic Medicine, Vol. 81, No. 10 / October 2006
experience remains rooted in actual
practice. By practicing repeatedly within
a safe environment, technical skills,
communication with patients and team
members, decision making, and clinical
judgment may all be practiced and
mastered while preserving patient safety.
In elaborating this concept of patient-
focused simulation (PFS), the authors
draw on work already published by their
group and several recent studies that are
in review. These explore PFS in low,
be subordinate to the clinical needs of the
patient. Hospitals provide expert care to
patients who are often extremely ill or
who undergo surgical procedures within
highly specialized units. Rising student
numbers, in conjunction with continual
pressures on bed occupancy, mean that
time-honored educational patterns are
no longer feasible.
These pressures have shifted the focus of
health care education. It is no longer
possible for trainees to gain all necessary
skills simply at the bedside, in the
operating theater, and through
observation during a prolonged
apprenticeship. Simulation offers obvious
benefits.1 By practicing repeatedly within
a safe environment, learners at all stages
can gain necessary skills without placing
real patients in jeopardy. In this setting,
the needs of the learner can be given
priority. Such learners may include
medical students, postgraduate doctors,
nurses, and other health care
practitioners.
Technology and simulation walk hand in
hand. Early experience with resuscitation
mannequins laid the foundations for
simulator-based training.2 Recent
developments in mannequin design offer
high levels of realism within anesthetic
simulation, while virtual reality computer
medium, and high complexity settings.
Important or rare situations can be
recreated and practiced, as well as key
procedures required across a range of
experience levels and clinical specialties.
Finally, the case is made for curriculum
redesign to ensure that simulator-based
technical skills training and assessment
take place within an authentic context
that reflects the wider elements of
clinical practice.
Acad Med. 2006; 81:919–924.
programs address a wide range of surgical
and interventional procedures.3–7
Much innovation in the field of
simulation is prompted by technological
developments, including computer
gaming and other drivers both within
and outside of health care.8 Indeed, such
developments are crucial if the field is to
remain dynamic and evolving. However,
simulation manufacturers’ agendas may
not always be aligned with the
requirements of learners and their
teachers.9,10 Moreover, there is a danger
of creating ever more complex simulators
for their own sake, and of losing sight of
the wider picture. In particular, learners
must integrate a complex set of skills and
behaviors in order to become expert
clinicians. These include technical skill,
communication with patients and team
members, decision making, clinical
judgment, professionalism, and a host of
others.
In this paper we argue for a broader
focus, aligning technology, simulator
development, and educational design to
ensure that simulation-based experiences
achieve the outcomes outlined above. In
particular, we describe the inclusion of
real people (simulated patients, or SPs)
within simulations. As far as we are
aware, our group at the Faculty of
Medicine of Imperial College London is
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 Simulation
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Figure 1 SP combined with arm model for venipuncture.
the only group systematically to explore
and develop the combination of SPs with
inanimate simulators.
Traditional Simulation Training
Part task trainers form the backbone of
simulator-based training. Such trainers
represent isolated procedures or parts of
the body, allowing the individual
components of a practical procedure to
be practiced (e.g., venipuncture,
bowel anastomosis, endoscope
manipulation).10,11 Many are highly
convincing and provide excellent
opportunities for repeated practice.12–21
Yet we have much to discover about the
transferability of isolated technical skills
and the optimum conditions for applying
them in a clinical setting.1,17,22 In order to
make sense, such skills must be applied
within their clinical context.
It may be entirely reasonable to break
each task down into component steps,
each one of which learners must master
before attempting to reassemble them.
On the other hand, it might be that
technical skills are best learned in an
authentic context, mirroring more
traditional conditions of learning at the
Figure 2 Endoscopy setup.
920
bedside or in the operating theater.
Cognitive and constructivist learning
theories emphasize the critical role of
context for learning,23,24 unlike early
behaviorist theories, which were oriented
toward task acquisition.25,26 Given that
technical tasks in clinical practice are
rarely performed in social isolation, we
argue that highly contextualized learning
environments are likely to be more
effective for promoting learning. It seems
probable, however, that there will be
different learning styles, approaches to
learning, and intellectual development
levels. A “one size fits all” philosophy is
likely to fail some learners.27
High-fidelity simulators (as opposed to
task trainers) are now well established in
anesthesia and emergency medicine
training. This field has been led by
anesthetists, who have done outstanding
work in crisis management and in raising
the importance of training for effective
teamwork for safe practice.28 –36 Such
simulations can accurately recreate the
conditions of an operating room, using
authentic equipment (e.g., monitors,
operating lights, anesthetic equipment)
to generate a high degree of realism.
Academic Medicine, Vol. 81, No. 10 / October 2006
Important or rare situations, as well as
crises, can be presented and practiced.
However, surgical practice is a team
effort which involves different
disciplines.37– 41 Although some
simulations are interprofessional, they
seldom address the wider picture by
ensuring that surgical, anesthetic, and
nursing needs are all met during the same
training episode. Moreover, by focusing
on technical tasks, surgeons in particular
can lose sight of the overall perspective
that underpins safe practice. They can
become fixated on what happens in the
operating field, losing track of the need
for continuity (preoperatively,
intraoperatively, and postoperatively).
Patient-Focused Simulation
Training
A crucial element here is the inevitable
artificiality of using simulators (however
sophisticated) to take the place of human
beings. A promising alternative is the
combination of real human beings with
high-fidelity simulated environments, or
patient-focused simulation (PFS).
Relating to a “patient” while performing
a procedural task evokes a range of
professional behaviors in trainees that aid
the suspension of disbelief and encourage
“buy-in” to the simulated experience.
Clinical skills and procedures
Invasive procedures on conscious
patients illustrate this point. From the
patient’s point of view, a successful
intervention requires much more than
technical expertise, although such
expertise is clearly fundamental to a
successful outcome. Effective
communication, clinical judgment,
professionalism, and an ability to
recognize and respond to the unique
features of each individual are some
obvious requirements.42 Yet part-task
trainers, however realistic they may be, can
only address technical aspects of
performance, and other elements of
behavior may be ignored.
Our group has developed the concept of
scenario-based assessment for clinical
procedures.43– 48 By combining a
professional actor (SP) with a simulator
(physical model or virtual reality [VR]
computer), participants are forced to
engage with a real human being while
performing a procedure. In our
experience, this creates a completely

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Figure 3 Endoscopy simulation with simulated patient.
different qualitative experience from
working with an inanimate simulator.
The necessity to relate to a human being
appears to activate a wide range of skills
and behaviors, forcing the technical task
into a clinical context. Over the last five
years we have applied the concept of PFS
to an increasing range of procedures,
exploring its applicability at different
levels of complexity.
Low-complexity procedures
Initial work by our group focused on
relatively straightforward procedures
such as urinary catheterization and
simple wound closure under local
anaesthesia.48 Our preliminary studies
with undergraduate medical students
have been supplemented by further
research with over 300 postgraduate
doctors, nurses, operating room
technicians, and an increasing range of
specialist care practitioners.43,46,48 –51
More recently we have developed a panel
of tasks that samples both technical and
patient interaction skills (judgment,
Figure 4 Laparoscopic cholecystectomy simulation setup.
Academic Medicine, Vol. 81, No. 10 / October 2006
communication, professionalism) by
presenting 12 clinical scenarios (e.g.,
venipuncture, urinary catheterization,
suturing, intravenous infusion). These
represent procedures that newly qualified
doctors are expected by the UK General
Medical Council and other bodies to
perform competently.
In each case, a simulated tissue model or
item of medical equipment is combined
with an SP who plays a predetermined
role, reflecting the breadth of clinical
challenges expected of newly qualified
doctors (Figure 1). Scenarios include
patients who are angry, distressed,
frightened, blind, deaf, or unable to speak
English. In this Integrated Procedural
Performance Instrument, each
participant’s performance is mapped
onto a matrix of complex behaviors to
provide a global picture of that
individual’s practice (paper under
review). We are currently applying this
performance instrument to medical
students and to doctors within the first
year of qualification and are broadening
Simulation
our range of scenarios to cover key
procedures required by health care
professionals across a spectrum of
experience levels and clinical specialties.
Detailed, independent evaluation is key
to this development process.
Mid-complexity procedures
Gastrointestinal endoscopy demands
sophisticated manipulative skills
combined with high levels of patient-
centered awareness. We have combined
VR endoscopy simulators with SPs to
create authentic scenarios.46 The presence
of a conscious patient, who sees the same
screen as the operator, requires
endoscopists to be able to manage
potentially difficult consultations during
a procedure.
The SP lies adjacent to the VR simulator
with his or her knees drawn up beneath a
sheet (Figure 2 and Figure 3). An
audiolink to the VR simulator prompts
the patient to respond authentically to
the endoscopist’s maneuvers, for
example, groaning if there is undue force
or excessive insufflation of air. This
scenario enables the endoscopist to
rehearse the integration of complex sets
of skills, including how to respond if an
abnormality appears.
High-complexity procedures
We have successfully introduced the
combination of SPs and surgical
simulators into complex operations.
Laparoscopic cholecystectomy. We have
used a sophisticated VR minimal access
surgery simulator within the simulated
operating theater (SOT) environment. In
these scenarios the surgeon begins by
encountering the “patient” (SP) in a
preadmission area, with a full set of
clinical notes (i.e., outpatient notes,
results of investigations, and drug chart).
The patient presents an authentic clinical
history, and the surgeon is required to
establish a rapport and then gain consent
for the operation.
The surgeon then enters the SOT and
performs the procedure on the simulator,
dealing with any operative problems that
may arise. A commercially available
simulator (LapMentor) offers numerous
variations of a standard operation
(laparoscopic cholecystectomy, with
anatomical variants), all with force
feedback.14 The realism of the simulator
is augmented by the head and feet of a
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 Simulation
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Figure 5 Laparoscopic cholecystectomy.
resuscitation model, the instrument ports
are covered by a layer of artificial skin,
and the model is covered by surgical
drapes (Figure 4 and Figure 5). The video
feed from the computer is connected to a
standard laparoscopic stack and other
operating team members (anesthetist,
runner nurse, and surgeon’s assistant) are
present. Furthermore, the scenario
enables the surgeon to directly interact
with the assistant, who is controlling the
view from the laparoscopic camera.
At completion of the procedure, the
surgeon must write the operation note,
and then visit the “patient” in the
recovery room. The patient– doctor
interactions are recorded with discreet
web-cams, to be analyzed post hoc. Our
pilot studies (paper in progress) suggest
that contact with the “patient”
preoperatively and postoperatively may
strengthen the surgical illusion by
recreating the conditions of actual
practice. Ideally, however, the patient
would be present throughout the
procedure.
Carotid endarterectomy. Increasingly,
complex surgical procedures are carried
out under local or regional anesthesia, so
Figure 6 Carotid endarterectomy simulation.
922
the patient remains aware throughout the
surgery. Surgeons, interventional
radiologists, and other clinicians must
therefore be able to perform demanding
technical tasks while managing the wider
clinician-patient interaction, even if
something untoward happens. When
carotid endarterectomy (CEA) is
performed under local anesthetic, for
example, the surgeon must remain aware
of the patient’s neurological status
throughout this complex and demanding
operation, in order to recognize incipient
stroke and respond accordingly.
Our group has developed a CEA
simulation, using SPs (trained using a
patient-derived script) in conjunction
with a physical CEA model within a high-
fidelity SOT (paper under review). A full
surgical team accurately recreates the
conditions of actual practice (Figure 6).
Each surgeon begins by interviewing the
“patient” (SP) and gaining consent for
operation. While the surgeon prepares
for the procedure, the SP is positioned on
the operating table, the CEA model is
placed alongside his or her neck, and the
area covered with surgical drapes. The
surgeon, supported by a full team, carries
out the procedure on the model. The SP
Academic Medicine, Vol. 81, No. 10 / October 2006
remains in audio contact with a control
room using an intercom and on a given
signal can simulate an intraoperative
stroke.
Participating surgeons’ performance is
recorded during crisis and noncrisis
scenarios and feedback is given
postoperatively. Their perceived stress
levels are mapped retrospectively after the
simulated operation, using self-report
measures, while physiological stress
markers are measured throughout the
operation. Surgeons receive expert
feedback on their technical and
nontechnical behaviors immediately after
the session. A study of 60 simulated
procedures (paper under review) has
established the feasibility of the scenario
and the high perceived levels of realism it
provides.
Preliminary data from our studies suggest
that evaluating a surgeon’s performance
in the SOT may allow more accurate
discrimination of a wide range of
required skills, compared with benchtop
models that address technical skills
only.52 Data on both are currently being
evaluated.
The Benefits of Patient-Focused
Simulation
From our experience, we believe that the
presence of a real person within a
simulated scenario adds enormously to
the perceived authenticity of the
experience. Involving a human “patient”
creates an anchor to each clinician’s
actual practice, which in turn taps into a
complex web of conscious and
unconscious professional responses.
These include empathy, communication,
clinical judgment, and decision making.
Accessing such responses through
mannequins and computer simulators
alone is not feasible, given the current
state of technology. Indeed, there seems a
danger that practitioners may learn to
“play the simulator.” Yet the ultimate
focus of any health care training must be
the patient.
We suggest a radical alternative to
current curriculum design, using PFS to
enrich and augment task-based training
and to ensure that concerns for patient
safety remain real. At key levels of
training and clinical practice (novice,
intermediate, advanced), realistic
scenarios will allow clinicians to

demonstrate the full range of their skills
within a safe environment. The patient’s
perspective will contribute to a rounded
picture of each clinician’s practice, as will
that of the procedure/operating team,
allowing feedback on all aspects of
trainees’ performance. By examining
behavior under routine as well as crisis
conditions, PFS will hold up a mirror to
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actual practice. This will allow trainees to
map and document their progress, while
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regular validation of established
specialists could confirm excellence or
give early warning of problem areas and
poor performance.
In contrast to clinical experience, PFS
offers “on demand” facilities that can be
tailored to the needs of individual
learners and accessed at any time. Unlike
the current separation between technical
skills training (using benchtop models)
and crisis management (using high-
fidelity simulation), PFS offers a
framework for recreating authentic
clinical experience across a spectrum of
procedures and challenge levels. Each
level can provide formative and/or
summative assessment, meeting the
educational needs of learners and the
regulatory needs of the profession and
society. This may allow areas of weakness
in a clinician’s practice to be identified
and rectified before patient safety is
compromised.
Potential applications include initial
training on invasive procedures for
novice clinicians (e.g., bedside
procedures, central line insertion), high-
level interventional and diagnostic
procedures for specialists in training (e.g.,
coronary stenting, urological
interventions), and case-directed
simulations for team-based work, where
a problematic case is recreated, rewound,
and replayed (e.g., ventilatory failure
requiring intensive care). Effective,
patient-focused training in less complex
procedures is required in primary care
and other areas of clinical practice.
Because procedures are an essential part
of most branches of clinical practice, we
believe that the principles of PFS can be
applied within a wide range of specialties
and can be tailored to address the specific
requirements of each discipline.
Although such a change will have
resource implications, the potential
benefits are enormous. Indeed, rapidly
increasing numbers of medical students
Academic Medicine, Vol. 81, No. 10 / October 2006
and other health care learners coupled
with reduced training trajectories and
decreasing opportunities for learning
on patients make radical changes
inevitable.
We have assembled a body of work that
explores the combination of humans as
SPs within simulations of varying
complexity. These range from simple
bedside procedures to highly demanding
operations, covering a gamut of clinical
situations alongside technical tasks.
Current computer simulations, however
technically sophisticated, cannot begin to
reproduce authentic human behavior.
They are unable to mirror the
unpredictability of actual patient
encounters. Yet it is managing this
human element that characterizes the
expert clinician. Tapping into such
responses seems a sine qua non for
recreating complex, real-world behaviors
that require judgment, communication,
and professionalism.
From our experience it appears that the
presence of a human “patient” within a
simulation can trigger authentic
responses from trainees on a level that
computers or models alone are unable to
achieve. This may be the case even when
a human encounter is separated in time
and space from the simulated procedure,
as in the laparoscopic cholecystectomy
we discuss above.
We believe that the PFS approach has
wide potential applications within many
health care disciplines. We therefore
make the case for an imaginative synergy
between simulated patients and simulator
technology. Neither on its own is
sufficient, but each can enrich the other
to provide a learning experience of great
power. We believe that simulation in the
21st century must embed technical
excellence within a matrix of authentic
professional behavior.
Dr. Kneebone is senior lecturer in surgical
education, Department of Biosurgery and Surgical
Technology, Imperial College London.
Dr. Nestel is senior lecturer in communication,
Department of Biosurgery and Surgical Technology,
Imperial College London.
Ms. Wetzel is research associate, Department of
Biosurgery and Surgical Technology, Imperial College
London.
Dr. Black is registrar, St Mary’s Hospital Regional
Vascular Unit, London; and Department of
Biosurgery and Surgical Technology, Imperial College
London.
Simulation
Dr. Jacklin is clinical research fellow, Department
of Biosurgery and Surgical Technology, Imperial
College London.
Dr. Aggarwal is clinical research fellow,
Department of Biosurgery and Surgical Technology,
Imperial College London.
Ms. Yadohalli is research associate, Department
of Biosurgery and Surgical Technology, Imperial
College London.
Dr. Wolfe is Consultant surgeon. St Mary’s Hospital
Regional Vascular Unit, London.
Dr. Vincent is Professor of Patient Safety
Department of Biosurgery and Surgical Technology,
Imperial College London.
Dr. Darzi is Professor of Surgery and Head of
Department of Biosurgery and Surgical Technology,
Imperial College London.
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