Simulation: the need for a balanced view

Dear Editor:

Wang et al. should be congratulated for giving a comprehensive review of simulation training in healthcare[1]. Whilst all the points they make are correct, they concentrate on the benefits of simulation whilst largely ignoring the downsides of this new modality of medical education. The advantages of simulation by and large outweigh the disadvantages; however, the disadvantages are worth examining also - if only to get a balanced view.

First of all, the authors ignore the costs of simulation. When the costs of hardware, software, facilities, faculty, and administrative and technology staff are all added up, such costs will be substantial.[2]

Practising on real patients (although it has many advantages) is essentially free, whereas simulation is relatively expensive. There are ways to reduce costs and maintain quality in simulation-delivered medical education (for example, by concentrating on fidelity rather than technology and by ensuring that simulators are used to their maximum capacity); however, high costs still cannot be discounted totally.

Secondly, simulation, even though it can mimic very closely the clinical environment, is still not a real experience. Medical students and junior doctors in postgraduate training ultimately need to spend time with real patients and real colleagues in real wards-only then will they be fit for autonomous practice. In simulated learning, the trainee ultimately knows that their actions in the simulator will not harm patients. On one hand, this is good as it results in a safe learning environment; however, on the other hand, it can result in some students not taking the simulation experience as seriously as they should.

Thirdly and lastly, there is no guarantee that learning in a simulated environment will be transferred to the clinical environment. There are ways to encourage such transfer (for example, once again by ensuring high fidelity); however, transfer can still not be guaranteed.