Simulation in an online setting still makes a huge difference

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This article was exclusively written for The European Sting by Dr. Yannick G. Eller MD, simulationalist from the University of Dundee and Ms. Lisa-Christin Wetzlmair, educationalist from the University of St Andrews (UK). They are affiliated with the International Federation of Medical Students Associations (IFMSA), cordial partner of The Sting. The opinions expressed in this piece belong strictly to the writers and do not necessarily reflect IFMSA’s view on the topic, nor The European Sting’s one.

In general, medical juniors in German-speaking countries mostly make contact with simulation as a curriculum innovation enveloping simulation-based education (SBE). During times of COVID-19-related lockdowns and social distancing, syllabi could be adapted as online teleconference versions (Musits & Mannix, 2020). These adaptations require a stable internet connection from participants, however, they have been shown to be feasible online, which therefore led to such a thing as virtually simulating the simulation itself. The online SBE can be used to simulate telemedicine visit encounters with patients or other health care professionals. As telemedicine visits require different skills than face-to-face visits (Health Education England, 2018), online SBE can support the development of both communication skills and required skills for telemedicine (Vitto et al., 2021).

Nevertheless, it is most essential to understand underlying educational theories in order to implement SBE. These theories include cognitivism, constructivism, and the theory of reflective practice. Informed by considerations of cognitivism a learner needs to reassemble the pre-existent knowledge after new experiences are made (Paleeri, 2011). Constructivists like Prawat (1996) constitute the learner’s accountability for own progress. As self-efficacious learners (Bandura, 1986) students are being encouraged to work on practical problems and adopt an active role in gathering new and relevant experiences, while teachers take a step back in order to facilitate progress in training (Kaufman, 2003). Thus, as to Kaufman & Mann (2014) an educator’s assignment turns out to be

  1. bringing the learner and his store of knowledge into action, 
  2. facilitating a detailed analysis of newly gained experience and
  3. guiding to coalesce hands-on with theoretical background as well as purposefully enriching learning-by-doing experience.

Rudolph et al. (2007) raise the educational theory of reflective practice. In this theory learners subconsciously and consciously interpret extrinsic input with pre-acquired values in medical practice. So in the instance these values prove to be susceptible to producing errors in practice, the authors suggest breaking this faulty internal framework by using their “debriefing with good judgment” assuming the learner wants to proactively learn and there are no cultural authority gradients in the way of learning. A short note: to help rearrange constructive frames they recommend the approach of advocacy-inquiry (Rudolph et al., 2007), which is to be encouraged by the facilitator.

McGaghie et al.’s (2016) asserted conservative tendencies of faculty correspond to the rare implementation of SBE at many institutions, whereas designing a curriculum innovation is supported by scientific evidence (Ker & Bradley, 2010) showing SBE’s usefulness even if it needs to be online (Cheng et al., 2020). Actually, student feedback acknowledges online SBE to have additionally enabled forming a productive Community of Inquiry  (Cheng et al., 2020). So according to the best evidence practical guide (Motola et al., 2013) having not enough time and personnel can probably prevent an SBE from affecting optimal learning experience.

Concludingly, we hope experiences with online SBE during lockdown times are a major step in the direction of more implementation of SBE. Students’ feedback will hopefully have an encouraging effect on future curriculum development.


Bandura, A. (1986). Social cognitive theory: social foundations of thought and action. Pearson Education. 

Cheng, A., Kolbe, M., Grant, V., Eller, S., Hales, R., Symon, B., Griswold, S., & Eppich, W. (2020). A practical guide to virtual debriefings: communities of inquiry perspective. Advances in Simulation, 5(1), 1-9.    

Health Education England. (2018). The Topol Review: Preparing the healthcare workforce to deliver the digital future.

Kaufman, D., & Mann, K. V. (2014). Teaching and learning in medical education: how theory can inform practice. In: T. Swanwick (2014). Understanding Medical Education: Evidence, Theory and Practice [2nd ed.]. Wiley-Blackwell. 

Kaufman, D. M. (2003). Applying educational theory in practice. British Medical Journal, 326(7382), 213-216.   

Ker, J., & Bradley, P. (2010). Simulation in Medical Education. In: T. Swanwick (2014). Understanding Medical Education: Evidence, Theory and Practice [2nd ed.]. Wiley-Blackwell. 

McGaghie, W. C., Issenberg, S. B., Petrusa, E. R., & Scalese, R. J. (2016). Revisiting ‘A critical review of simulation-based medical education research: 2003–2009’. Medical Education, 50(10), 986-991.      

Motola, I., Devine, L. A., Chung, H. S., Sullivan, J. E., & Issenberg, S. B. (2013). Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82. Medical Teacher, 35(10), e1511-e1530.   

Musits, A. N., & Mannix, A. L. (2020). Synchronous Online Journal Club to Connect Subspecialty Trainees across Geographic Barriers. Western Journal of Emergency Medicine, 21(1), 33.    

Paleeri, S. (2011). Chomskyan Cognitivism and Linguistic: Irreproachable Ideals for Educational Psychology and Designing Learning. Journal on Educational Psychology, 4(3), 21-25.  

Prawat, R. S. (1996). Constructivisms, modern and postmodern. Educational Psychologist, 31(3-4), 215-225.      

Rudolph, J. W., Simon, R., Rivard, P., Dufresne, R. L., & Raemer, D. B. (2007). Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiology Clinics, 25(2), 361-376.    

Vitto, C., Del Buono, B., Daniel, L., Rivet, E., Cholyway, R., & Santen, S. A. (2021). Teaching Toolbox: Breaking Bad News with Virtual Technology in the Time of COVID. J Cancer Educ, 1-4.

About the authors

Yannick G. Eller MD works as Senior Lecturer and physician-scientist of Medical Education Research conducting postgraduate MMEd-studies at the University of Dundee (UK) in parallel. He originates from Chicago IL (US), used to work clinically as a consultant within areas of expertise Clinical Oncology, imaging diagnostics and General Medicine and holds interprofessionality in high regard.

Lisa-Christin Wetzlmair is currently a PhD candidate at the University of St Andrews (UK). She used to work as an occupational therapist and a diversity advocate in Austria and the USA. Her current areas of interest are interprofessional education and telehealth training in medical education.

YG Eller:, Centre for Medical Education, University of Dundee, UK

LC Wetzlmair:, School of Medicine, Education Division, University of St Andrews, UK

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