“Can a flat paper patient on a table sometimes outperform a high-tech manikin?” And has realism been a false idol? I talked with leading simulation expert, emergency physician and medical educator Dr. Victoria Brazil about Visually Enhanced Mental Simulation (VEMS). Also see my podcasts with Dr. Brazil.
The current use of simulation technology in education is often complex, costly, and technically demanding. While high-fidelity simulation offers many possibilities, it raises the question of whether such resources are always necessary for effective learning.
First my summary of the study and after that a Q and A with Dr. Victoria Brazil.
The study in one sentence.
This qualitative study explores how healthcare participants and facilitators experience Visually Enhanced Mental Simulation (VEMS), finding it to be a flexible, feasible, and highly engaging simulation modality that sharpens team-based learning and challenges assumptions about the necessity of manikin-based realism in healthcare simulation.
The study in more detail
What is this study about?
This study examines a training approach in healthcare called Visually Enhanced Mental Simulation (VEMS). VEMS is a way of practising clinical situations in which healthcare professionals work through a scenario together without lifelike manikins, but instead using flat, simple visual representations of a patient and equipment placed on a table. Participants speak out loud about what they think and do, collectively imagining the situation.
The central questions of the study were:
- How do healthcare professionals and facilitators experience this way of training?
- What works well, what does not, and what should be taken into account when designing and facilitating VEMS?
What exactly is VEMS?
In VEMS, there is no manikin lying in a hospital bed. Instead, there might be a drawn human figure on the table, with cards representing oxygen, IV lines, medications, or monitoring equipment.
Healthcare professionals imagine that this is a real patient and speak out loud about:
- what they see,
- what they think,
- what decisions they make,
- who is going to do what.
The goal is collective thinking, decision-making, and collaboration, not the technical practice of procedures.
How was the study conducted?
The researchers conducted 13 in-depth interviews with:
- healthcare professionals who participated in VEMS sessions,
- facilitators who led VEMS sessions.
This took place within a single large healthcare system in Australia, where VEMS is now used across many settings (emergency department, intensive care, maternity, community care, etc.).
The study is qualitative in nature. This means it did not focus on numbers or test scores, but on experiences, meanings, and perceived effects, asking questions such as:
- What do participants experience as learning?
- What supports learning?
- What gets in the way?
The five key insights
1. VEMS is flexible and creates space
Because VEMS is not constrained by what a manikin can or cannot do:
- it is easier to practise a wide range of scenarios,
- teams can pause and discuss,
- facilitators can quickly adapt to what a team needs.
At the same time, facilitators caution that this flexibility requires clear learning objectives; otherwise, training risks becoming too vague or unrealistic.
2. People are surprisingly engaged
Many facilitators initially expected participants to find VEMS “too simple.”
In practice, the opposite was true.
Participants:
- became engaged quickly,
- experienced less stress than in high-tech simulations,
- were less preoccupied with doubts about what was “real” or “fake.”
Precisely because everyone knows the setup is symbolic, there is often greater focus on the learning goal.
3. Greater focus on teamwork
With technical procedures removed from the equation, attention shifts to:
- communication,
- leadership,
- task allocation,
- shared decision-making.
Participants were more likely to think out loud, allowing facilitators to better observe how decisions were made. This led to richer and more meaningful debriefings.
4. Is there a learning effect?
Yes — but in a specific way.
This study did not measure objective learning gains using tests, scores, or pre- and post-measurements. It is therefore not an effectiveness study in the classical sense.
What the study does show is that:
- participants and facilitators report clear learning benefits, particularly in:
- teamwork,
- communication,
- decision-making,
- leadership;
- participants describe changes in how they think and act in clinical practice;
- facilitators observe that VEMS makes thinking processes more visible, which deepens learning and reflection.
The learning effect in this study is therefore qualitative, experiential, and self-reported, rather than objectively measured — a deliberate choice by the authors.
They were not seeking to prove the effectiveness of VEMS. According to Victoria Brazil: ” We assume it works for some people in some situations under some circumstances. What we really were trying to do was illustrate the way that you could identify those situations where it would be of benefit, and if you are using it, how you can use it to best effect. So I think we even wrote those words in the paper, “We are seeking to improve rather than prove.”
5. Practical and feasible in busy healthcare settings
VEMS is:
- less expensive,
- quicker to organise,
- less technically fragile,
- less stressful for facilitators.
This makes it easier for more teams to train, and allows facilitators without extensive technical simulation expertise to deliver effective education.
VEMS is often used as an intermediate step, bridging basic skills training and more complex simulations.
6. Manikins can actually be confusing
A striking finding is that participants sometimes find high-tech manikins more confusing than simple VEMS setups.
With manikins, participants often wonder:
- “Am I seeing this correctly?”
- “Is this a fault of the manikin or of me?”
- “Is this intentionally designed this way?”
In VEMS, facilitators provide immediate and clear information, which increases trust and reduces cognitive noise.
Conclusion
VEMS is not a replacement for all forms of simulation, but it is a powerful, low-threshold, and educationally meaningful way for teams to practise together.
It is particularly well suited for:
- teamwork,
- communication,
- decision-making,
- leadership,
- preparation for complex situations.
The core message of the article is:
Do not automatically choose the most realistic simulation format.
Choose the format that best fits what you want people to learn.
Q and A with Dr. Brazil
1. Boundaries of claims
EH: Are there any explicit conclusions or claims that you feel readers should not draw from this study (for example regarding effectiveness, superiority over manikins, or clinical performance outcomes)?
VB: I think any claims about the effectiveness of a simulation modality are inherently flawed. The modality is just a tiny part of the experience of the participants in any simulation, and effectiveness is such a multifaceted term that is highly contextual. I would never seek to answer that ‘superiority/ inferiority research question because I don’t think it’s a very good question. So, in that same vein, I wouldn’t say there’s a superiority over mannequins. What I would happily say is that VEMS is far less confusing than mannequins across the board. I would also say, quite happily, although this wasn’t tested in our study, that it is far more feasible than using mannequins. Certainly, we got that feedback from our educators.
As to clinical performance outcomes, I think that wasn’t in the scope of what we’re trying to do. It is really a much more complex issue.
2. Context and transferability
EH: To what extent do you think the positive experiences with VEMS are related to the specific context in which the study was conducted (a well-embedded simulation program, experienced facilitators, an established learning culture)? In other words, what is context-dependent and what is likely to be more broadly transferable?
VB: Yes, this is a great question and one that wasn’t sought to be answered by the study. I do think, and I think research supports the idea, that immersion and engagement are easier if it’s a habit, i.e., if you have a well-established simulation programme and your learners have been engaged in similar experiential learning over a long period of time, they understand and are able to engage with the modality more easily. That said, a number of our facilitators felt this was a modality that was easier for novices to engage with and was less overwhelming than mannequins. I don’t entirely understand why that is, as one who’s probably used mannequins over many years, but it certainly was a strong signal in our findings.
3. Learning mechanisms
EH: What do you yourselves see as the primary learning mechanism underlying VEMS?
Is it mainly thinking aloud, shared mental models, reduced cognitive noise, psychological safety — or a combination of these?
Yes, this question has both a simple and a more complex answer.
VB: The simple answer is that this is like any other experiential learning. People immerse themselves in an activity that has:
Task realism and Team realism
They draw upon their own mental scripts of patience to be able to learn from that experience and then obviously reflect upon it in the debrief.
The more complex answer to that about specific to VEMS I think really does lie in the brain’s ability to draw upon prior experience to create mental simulations that in a team who share a patient profile is easy to make a shared mental rehearsal as well. Those things you list like shared mental models, reduced cognitive noise and psychological safety are probably all relevant as well.
4. Limits of VEMS
EH: For which types of learning objectives or skills do you consider VEMS to be explicitly less suitable or unsuitable?
VB: Well, obviously it’s not much good for technical skills practise. For that, I think we need to go to many of the skills/procedural skills instructional models that are out there.
I think we should be doing basic work, even virtually, on correct sequencing. Then, obviously, moving on to tactile-type training with part-task trainers. And then it may come together in a more immersive way if we’re seeking to prioritise and make choices about procedures.
So, obviously, VEMS is not much good if you’re actually trying to practise the tactile and psychomotor aspects of a procedure.
For us, these are really the things that challenge our teams. They are much more related to the interdependent activities of the team members rather than the core skills themselves.
That said, I appreciate these need work, but I’m not sure that it’s efficient to work on those psychomotor skills in the midst of a focus on team training, prioritisation, decision-making, and communication.
5. The finding “manikins are confusing”
EH: Do you see this primarily as a limitation of manikins as a technology, or rather as a didactic issue — how manikins are used and facilitated?
VB: I think this is an inherent limitation of something that is a little bit like physically realistic but really not close enough for people to be able to suspend disbelief. The lack of facial expression interactivity, the colour and feel of skin, everything about mannequins is actually unrealistic. When we try to match that with our pre-formed ideas about what this patient would look like, that is when it starts to get confusing and sap cognitive load as we seek to think “is this what I’m supposed to see? Is this what they’re trying to tell me?”
I think these are the things that we’ve underestimated in the past.
6. Immersion versus realism
EH: Could it be that we systematically overestimate realism as a prerequisite for learning, and underestimate immersion? And was this a surprising finding for you personally?
VB: I think this is a complex question that’s confounded the simulation community for the last 20 years. Definitely immersion, engagement, and learning – what we’re trying to achieve. And yes, I do think as Ben Symon put it, realism has been a false idol. We made the assumption that if we achieved that, we would achieve those things mentioned earlier, but I don’t think that’s necessarily the case.
7. Transfer to practice
EH: What would you consider a logical next research step to more robustly explore transfer from VEMS to clinical practice (for example observation in practice, longitudinal designs, or mixed-methods research)?
VB: I think any of those things you suggest are a possibility, but I am actually really interested in getting into learners’ heads, either using techniques based on neuroscience or a bit of work that one of my colleagues is leading at the moment, which is video stimulated recall of trying to really understand what is the experience of the learners in VEMS?
8. Positioning within a learning trajectory
EH: How do you ideally see VEMS positioned within a broader learning pathway (for example skills training → VEMS → immersive simulation → clinical practice)?
VB: I think that really depends on context, in something like a busy emergency department. I see it as a standalone brief opportunity for teams to come together, practise something in their work that’s meaningful, and then reflect on it together. Whether that takes 10 minutes or two hours.
But certainly, I think, as you indicate, you could see it as part of a circle of learning, such as skills practise followed by VEMS. I don’t know that there is more to be gained by what you call immersive simulation than VEMS. I think that’s where the tension point is.
EH: What do you hope educators or simulation programs will concretely do differently after reading this article?
VB: I hope they will make or buy a VEMS kit and do lots more simulation.
EH: Once again, thank you for your work and for any time you may be willing to spend responding. Your feedback will help me ensure that this blog is both accessible and intellectually rigorous.
VB: Thank you for your interest.