Context, curriculum and competence.

Abstract

As I sat down to write this editorial, I found myself staring intently at the corner of my office ceiling. Actually, I wasn’t looking at the office ceiling at all—I was staring intently at the inside of my mind, and focusing (actually not focusing) on the office ceiling so I would not be distracted by the contextual cues in my environment. I was reflecting on a recent event. A few days ago, I was in Hamburg at the meeting of the German Medical Education Association, where I had the honour of being invited as a keynote speaker. During my talk, I showed a graph comparing high fidelity to low fidelity simulations, showing a minimal and not significant advantage for the high fidelity (Norman et al. 2012). One of the domains I looked at was auscultation, where all the studies compared Harvey to a much lower fidelity simulation, typically a CD recording. After the talk, I was approached by a colleague who counseled me that comparisons using Harvey were not really appropriate as there were much higher fidelity simulations available now. He apparently did not accept the notion that, if Harvey showed no empirical advantage over something as simple as a CD, it was unlikely that a more sophisticated simulation would show an effect. Of course he may be right. Perhaps with a simulation that blinked, cried out, or panted, the context may be sufficiently more realistic that it would enhance learning. Or perhaps not. Indeed, an implicit assumption of many high fidelity simulations is that the more the plastic patient resembles a real patient, the better the transfer to the ‘‘real’’ world. That is, it is assumed that learning to listen to a heart in an almost-real plastic chest will make it easier for students to recognize an abnormal heart sound in an actual patient situation. A bit like presuming that watching and listening to a Beethoven symphony on YouTube will enable you to recognize it better than just hearing it on an iPod. Perhaps. But perhaps not. However, this editorial is not about simulation, for a very good reason. Simulation is only one of very many places in health sciences education where we presume that the