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Concepts and Commentary

Lack of Diversity in Simulation Technology

An Educational Limitation?

Conigliaro, Rosemarie L. MD; Peterson, Kerstin D. MA-TESL; Stratton, Terry D. PhD

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Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: April 2020 - Volume 15 - Issue 2 - p 112-114
doi: 10.1097/SIH.0000000000000405
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With significant attention focused on diversity in medicine and healthcare, the Liaison Committee on Medical Education, the primary accrediting body for allopathic medical schools in the United States and Canada, introduced in 2008 elements mandating “diversity among its students, faculty, staff and other members of its academic community.”1 Similarly, the Association of American Medical Colleges endorses the widely shared belief that a diverse student body adds to students' educational experience and that medical schools, toward this end, should actively recruit students and faculty of diverse backgrounds.2 As a result, many programs have formal diversity policies that guide admissions procedures, direct instructional strategies, and inform faculty and curricular development. However, if the intent is to expose learners to differing social backgrounds, facilitate understanding across cultural and racial divides, and, ultimately, challenge cultural stereotypes, attaining a diverse faculty and student body may be insufficient; achieving true appreciation and understanding of diversity may require that the educational environment is itself diverse.

One means of providing realistic, “hands-on” cultural awareness training involves the use of simulation,3 including standardized patients (SPs), virtual patients (VPs), and mixed and high-fidelity simulators. (The term high-fidelity describes full-body human simulators with programmable software used to create a more physically, physiologically accurate patient scenario. Conversely, low-fidelity models are partial-body or body parts that may or may not have a software component). As surrogates for actual patients, these modalities offer the primary advantage of control and standardization. From a diversity standpoint—representing variations of race, ethnicity, age, and sex—each has limitations: SPs are typically drawn from the local community, which may be homogenous in terms of race, ethnicity, socioeconomic status, or sexual orientation; VPs and other simulation-based learning experiences may unconsciously reflect the cultural framework of those who develop them; and manikin-based simulators are often limited in their physical scope.

Human and virtual simulation are perhaps the most “locally adaptable” as they are selectable by race, age, sex, etc4 and may be cosmetically enhanced, for example, to mimic certain dermatologic diseases5 or mixed haptic types (ie, adding tactile sensation into simulation technology) for honing sensitive physical examination skills (eg, breast, pelvic examinations). Props and apparel have been used in cultural competency training for doctors-in-training to enhance the authenticity of the encounter6 and to effectively represent different social classes.7 In addition, portrayal of non-English–speaking patients8 and other specifically designed observed structured clinical examinations have been used to provide culturally specific training experiences. However, although the authenticity of a VP has been identified as an important component of the learning process,9 efforts to mimic certain patient characteristics can also reinforce common stereotypes.

Although the feedback they provide is largely physiological, high-fidelity manikin-based simulators offer the highest level of complexity and technology. In skilled hands, these simulators can be made to realistically react to various drugs, procedures, or treatments. However, they too are restricted in their abilities to reflect subtle but relevant variations (eg, race, age, or physical stature) often crucial to a condition, treatment, or diagnosis. Ultimately, these limitations may restrict students' exposure to and preparation for diverse clinical situations.


In 2018, we reviewed product offerings from major simulation technology suppliers to assess the physical diversity of patient simulator models available for educational use. Catalogs were chosen based on an Internet search of online companies; entries returned in the top search results were reviewed. Items listed for purchase were counted toward the total number of products offered. Items with skin components included manikins, simulators, replacement skin or body parts with skin, and skin pads. We use the term “light skin” to represent the skin tone options offered by suppliers, which include “Caucasian,” “fair,” “light,” “white,” and “Asian.” We also included here items that were designated “standard” and “tan,” as these items were light skinned. We use the term “dark skin” to represent skin tone options offered by suppliers, which include “African American,” “beige,” “black,” “brown,” “dark,” “darker,” “ethnic,” and “medium.” Items offered with geriatric and obese options include manikins, body parts, replacement parts, and computer simulation options. We use the term geriatric to represent options listed as “elder,” “elderly,” “geriatric,” and “senior,” and the obese products represent those options denoted as “bariatric,” “obese,” “obesity,” and “overweight.”

We also reviewed related medical education Web sites commonly accessed by medical educators as sources for VPs and online educational modules.


The results of our review of 8 major simulation catalogs are summarized in Table 1.

Results of Review of 8 Major Simulation Catalogs

Full- or half-body human simulators available for purchase tended to be younger, light skinned, and anatomically “ideal” (ie, muscular build, full head of hair, no obvious physical abnormalities), although many companies offered specific body parts, skin patches, gunshot wounds, and female genital mutilation models in dark skin tones. Five of the 8 companies reviewed offered dark skin tone body parts for emergency settings, trauma, parenting skills, breast milk training, sex education/contraceptive training, gunshot wounds, female genital mutilation, and cervical pap training.

Limited diversity was also apparent in online demonstrations of procedures using SPs or actual patients.10 With few exceptions, both standardized and real patients portrayed were ideally proportioned, well-muscled, white males. Similarly, female-specific procedures were demonstrated almost exclusively on white patients. Few deviations were found from this ideal type; for example, in one video tutorial on internal jugular placement, an obese patient is only briefly shown with the caveat that “following these landmarks can be challenging in the obese patient,”11 with no further commentary or guidance provided.

In the VP world, where computer simulation allows for almost infinite patient varieties, a wider array of racial types is possible. One vendor has a case bank of various simulations from which to choose.12 Other companies take this a step further, allowing users to create a truly custom virtual case (including patient race and age) for online simulation.13 Similarly, another company also features patients of varying skin tones, ages, body mass index, and cultural/ethnic practices and beliefs.14


In reviewing the inventories of major simulation vendors, we noted that models available for educational use generally lacked diversity in skin tone, age, or weight. Limitations in manikins and videos also exist, with most options presenting a fit, “well-developed” physique. Offerings available in dark skin tones are typically limited to lower fidelity options often used to portray trauma, wounding, or sexually related themes. The diversity of virtual and online simulation products tended to be greater.

Despite the relative paucity of available products, educators wishing to incorporate a wider range of simulation in their teaching or assessment are not without options. Our literature search identified several examples where educators have been successful at incorporating diversity in their teaching endeavors. For example, in comparing residents' abilities to diagnose obstructive sleep apnea, The Virtual Experiences Research Group altered the VP's body habitus to more closely mimic a patient with this condition (ie, obese with large neck circumference).15 In the clinical setting, Silk and McTigue16 describe adjustments for teaching physical examination skills when the “typical” patient is no longer 70 kg. The American Heart Association, in their Basic Life Support Course video on assisting a choking victim,17 demonstrates additional maneuvers for victims too large for the Heimlich maneuver. Future educational modifications should further reflect patients who are culturally, physically, and/or physiologically diverse.

For manikin-based simulators, comparatively fewer choices exist for institutions to diversify their cache of models. Most companies use similar prototypes—the young, fit, white male—likely reflecting the initial prototype and subsequent costs of expanding product lines. Typically, these models do not allow for adjustment for anatomical sex, which may lead to difficulty translating simulated actions to female patients with different anatomical landmarks.

The availability of racially, ethnically, and anatomically diverse simulation technology is hardly a panacea for accommodating all possible training and assessment applications, and it is unrealistic, given the costs, to expect programs to make the added investment without an economic impetus to do so. As a result, educators should be sensitive to applications, which may inadvertently reinforce “normality” rather than highlight uniqueness.18

Our analysis has several limitations. First, as a nonsystematic review, we did not have specific inclusion or exclusion criteria in our selection of vendors. Though nonexhaustive, we believe that the catalogs chosen represent a reasonable cross-section of simulation technology suppliers. Second, because identical products may appear in multiple catalogs, product counts should be considered estimates. Lastly, our review did not include representations of disability—an important component of cultural competency education.

Clearly, to optimize care, providers must understand, empathize, and relate to patients regardless of variations in race, ethnicity, or physical appearance.19 As health professions educators, we must be empowered to reinforce the value of diversity while also recognizing that our educational environments and tools may not accurately represent the wide range of patient diversity students are likely to see. Although educational tools should reflect the educational goals and objectives for which they are used, simulation may never completely replicate the broad range of patient diversity practitioners will encounter.20 However, as a supplement to verifying physiological accuracy, it may be prudent to consider cultural factors when assessing the validity of simulation technology.21

Although research is needed to empirically examine the relationship between simulation diversity and educational outcomes,22 educators should be cognizant of inconsistencies and challenge those aspects of the “hidden curriculum,” which serve as latent microaggressions toward multicultural patient care.23 Indeed, a heightened awareness of these subtle biases may encourage more innovative adaptations of simulation technology presently available. Only with continued attention will learners receive a consistent message that diversity, even if not always obtainable, is important and that even limited simulator-based experiences can provide useful opportunities to recognize and internalize the relevance of diversity in patient care.


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Simulation; Diversity; Standardized patients; Cultural competency; Diverse educational environment

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