"The mannequins have been pink for a very long time." Navigating whiteness and realness in simulation

Simulation training provides health professions learners access to training not readily available to them and in a manner that does not harm patients. Simulation also supports learners to develop dispositions and professional communication and reflect on their biases. This study examines how learners, clinical education faculty, and simulation professionals reflect on diversity and antiracism in simulation and contextualize these reflections with their lived experience. We undertook interviews and focus group discussions with medical students, simulation professionals, and clinical education faculty (n = 47) at a public medical school in the U.S. Midwest with three campuses. Students, faculty, and simulation professionals recognized the importance of simulation as a safe and judgment free zone where they could build rapport with patients with a variety of health conditions and medical histories. Moreover, students recognized how simulation professionals created environments where they could ask questions, practice techniques, and feel more prepared for their future clinical encounters. Students, faculty, and simulation professionals recognized how cases written by faculty, simulation professionals and equipment were insufficiently inclusive of the patient populations that students would eventually see, in terms of race, language, disability, body size, and age. Simulation reproduced biases and posed challenges to the perceived realness of encounters with simulated patients. Students who were visible minorities found it harder to relate to simulated patients and found these patients to be biased towards them. The ways faculty wrote cases and the inability to relate to standardized patients reinforced perceptions that the simulation did not feel real enough. While simulation has the potential to address the dimensions of medical training and practice that harm students and patients, it can also inadvertently reproduce these dimensions. We contend that these harmful products of simulation hinder the very efforts to create cultures of belonging and solidarity that antiracist practices in simulation seek to achieve.