In the timely and important article by Vora et al,1 the authors note that simulation-based education (SBE) is a relevant strategy for addressing racism and call for the application of a diversity, equity, and inclusion lens across the spectrum of SBE. The authors propose the use of Mezirow's transformational learning theory as a guide to designing implicit bias (IB) simulation curriculum, emphasizing “self-reflective debriefings and functions via a guided movement from dissonance through critical reflection and dialogue and then to skill acquisition and behavior change.”1

The authors provide recommendations for addressing racism and/or implicit bias in simulation, emphasizing a well-constructed prebriefing (creating an identity-safe space to protect learners of color), purposeful selection and training of facilitators for debriefing, and the engagement of “subject matter experts” for scenario development and facilitation. Finally, the authors recommend the following tactics for mitigating racism and IB:

Leaving race out of clinical scenarios “if it is not relevant” Using Black mannequins and task trainers for any type of scenario, not only those where the racial identification of the patient is intended to be a teaching point Counter stereotyping (where role players specifically display behaviors contrary to the stereotypes associated with that identity group)

Although these strategies are laudable, acknowledging and surfacing systemic racism in SBE require systemic change grounded in critical race theory and intersectionality. “Leaving out race” is tantamount to color-blind casting, and ultimately, race can never be irrelevant. Although these strategies may create opportunities for representation, they do not necessarily change what is represented. Even the use of the term “implicit bias” risks decentering the experience of a person on the receiving end, for whom the bias may be explicit. Suggesting that a Black father present himself as calm when he should rightfully be angry compromises his full humanity and limits the degree to which participants are able to confront and dismantle racial judgment. The authors suggested that exercise of perspective taking (asking “What might the patient/family be feeling right now?”) may promote cognitive empathy.2 However, perspective taking is limited by the degree to which one can imagine each other's lived experience and could threaten safety by asking a marginalized person to, in return, take the perspective of the person of privilege. Rather, it is essential to model best practices in simulation by listening deeply, acknowledging, and reflecting on future action.

We suggest that simulation professionals consider strategies that not only make simulation scenarios nonracist but also incorporate an antiracist approach to simulation as a profession and as a methodology. Indeed, the Healthcare Simulation Code of Ethics, globally authored and multiprofessionally inclusive, calls for it.3 As antiracists, simulation professionals will address not only the functional aspects of simulation, such as the scenarios, debriefings, and mannequins, but also achieve substantive results in recruitment and hiring practices; training and professionalization of simulation staff; authentic and action-driven diversity, equity, and inclusion committees and taskforces; and fostering cultures of belonging and solidarity within simulation teams.

As educators for the future of healthcare, we have an obligation to provide learners with the tools needed to address their own implicit biases, identify discrimination in the healthcare system, and advocate for health equity. Education should include antibias mitigation strategies, such as encouraging self-reflection of our own biases, techniques for deconstructing our bias, being intentional about diversifying our networks by creating and reinforcing community relationships, and being upstanders against racism. Disrupting racism in action (by calling attention to racist actions and speech and supporting colleagues and learners who are people of color) is essential. In addition, educators have a responsibility to create an inclusive and antiracist learning environment. This includes avoiding use of stigmatized scenarios/cases, calling out racist behaviors, using up-to-date terminology, discussing the impact of social determinants of health versus focusing on an individual's race, and moving from the security of “safe spaces” to the risk of creating “brave spaces.”4

Using simulation ethically and purposefully requires acknowledging that the healthcare system itself is racially biased. Consider the interview with Prof Ibram X. Kendi on the podcast, America Dissected.5 Dr Kendi, who is director and founder of the Center for Antiracist Research at Boston University, is also an African American man who has experienced treatment for metastatic colon cancer and is married to an emergency medicine physician. In the interview, he calls for greater disparity awareness in healthcare delivery, where patients are treated for their individual health concern (eg, obesity) as well as the systemic inequities that led to the health concern in the first place (eg, poverty, food insecurity). In the context of simulation, one might imagine a scenario that includes not only a nonracist approach to obesity (eg, not blaming the patient for “poor self-control” or “noncompliance”) but also an antiracist approach to collaborative practice with a social worker and/or community activist addressing food insecurity. Rather than scenario development including a “subject matter expert” (akin to the specialist/referral model of 20th century US medicine), we advocate for collaboration with a community member whose lived experience involves obesity and/or food insecurity.

The witnessed murder of George Floyd retraumatized some, while awakening others. It focused attention in a new way on endemic racial violence that 4 centuries of US history have not, including that done by healthcare and healthcare education institutions to people of color. Furthermore, the COVID-19 pandemic, with its devastation to people and communities of color, has exposed how deeply systemic health disparities are in US healthcare. Our very healthcare education system is historically predicated on the perpetuation of inequity, and simulation can be a powerful tool in challenging and transforming that inequity. Simulation affords us not only a reflection of how things are but also how things can be. We advocate that all simulation professionals read the article by Vora et al1 through the lens of a truly transformational, antiracist vision of healthcare education and practice. As Prof Kendi challenges us to consider, “The interpersonal decisions and the lack of accountability of individual medical providers is literally leading to people dying, day in and day out… I think it's important for the medical community themselves to get ahead of this, because once we revolutionize American policing, American medicine will be next.”

1. Vora S, Dahlen B, Adler M, et al. Recommendations and guidelines for the use of simulation to address structural racism and implicit bias. Simul Healthcare 2021. 2. Zaki J. The War for Kindness: Empathy Building in a Fractured World. New York: Random House; 2020:178. 3. Park CS, Murphy TF; the Code of Ethics Working Group. Healthcare simulationist code of ethics. Society for Simulation in Healthcare. Available at: http://www.ssih.org/Code-of-Ethics. Accessed June 3, 2021. 4. Arao B, Clemens K. From safe spaces to brave spaces: a new way to frame dialogue around diversity and social justice.In: The Art of Effective Facilitation. Lisa M. Landreman, ed. Sterling, Virginia: Stylus Publications. 2013. 5. El-Sayed A. Anti-racist healthcare? With Prof. Ibram X. Kendi. America Dissected, Crooked Media. Available at: https://crooked.com/podcast/antiracist-healthcare-w-prof-ibram-x-kendi/. Accessed May 25, 2021.