Simulation reframed

Roger L. Kneebone

Simulation is firmly established as a mainstay of clinical education, and extensive research has demonstrated its value. Current practice uses inanimate simulators (with a range of complexity, sophistication and cost) to address the patient 'as body' and trained actors or lay people (Simulated Patients) to address the patient 'as person'. These approaches are often separate.Healthcare simulation to date has been largely for the training and assessment of clinical 'insiders', simulating current practices. A close coupling with the clinical world restricts access to the facilities and practices of simulation, often excluding patients, families and publics. Yet such perspectives are an essential component of clinical practice. This paper argues that simulation offers opportunities to move outside a clinical 'insider' frame and create connections with other individuals and groups. Simulation becomes a bridge between experts whose worlds do not usually intersect, inviting an exchange of insights around embodied practices-the 'doing' of medicine-without jeopardising the safety of actual patients.Healthcare practice and education take place within a clinical frame that often conceals parallels with other domains of expert practice. Valuable insights emerge by viewing clinical practice not only as the application of medical science but also as performance and craftsmanship.Such connections require a redefinition of simulation. Its essence is not expensive elaborate facilities. Developments such as hybrid, distributed and sequential simulation offer examples of how simulation can combine 'patient as body' with 'patient as person' at relatively low cost, democratising simulation and exerting traction beyond the clinical sphere.The essence of simulation is a purposeful design, based on an active process ofselectionfrom an originary world,abstractionof what is criterial andre-presentationin another setting for a particular purpose or audience. This may be done within traditional simulation centres, or outside in local communities, public spaces or arts and performance venues. Simulation has established a central role in clinical education but usually focuses on learning to do things as they are already done. Imaginatively designed, simulation offers untapped potential for deep engagement with patients, publics and experts outside medicine.