The final concept I mentioned was the use of Scripts and Heuristics. This is a very big area in medical education just now and follows on the work of Kahneman and Twersky . Heuristics are rules of thumb that we have developed which allow us make better use of our subconscious mind – described as fast thinking. I think of scripts as a subset of heuristics. The key features of a script are firstly that actors know what they are supposed to do and say and secondly that there are cues letting the actors know when they are expected to respond or react. Social Psychologists often use the restaurant script as an example. A typical example may go like this.
Customer – “we have a table booked for 7 pm under the name of Smith”
Restaurant staff – having checked bookings list “Come this way, here are the menus, the waiter will tell you about the specials”
Front of House Staff – “Can I get you something to drink”
Customer – “Can I see the wine list?”
The above script may win no prizes for literary merit but it contains those two concepts of firstly, knowing what to expect from the occasion and secondly, how to respond to the actions of the restaurant staff. Two other driving forces – minimising ambiguity and reducing cognitive work load  come into play here. We reduce cognitive load by making the process automatic; that is, the pattern and the specifics of the script are transferred from our conscious working memory to our long term memory and can be recalled when appropriate. We reduce ambiguity by remembering how the sequence is supposed to play out. Of course, there are different kinds of restaurants with different patterns of expected behaviour – buffet, self service etc. and so we build up a repertoire of scripts that we can use for these different circumstances and cues will determine which script we call upon to use. Formica tables, plastic tables and cutlery and several queues at a serving counter will evoke one script, smart furniture, linen napery and the presence of a sommelier will evoke an entirely different script but they are still part of the set of restaurant scripts.
I find this model, in which a person builds up a repertoire of scripts related to professional encounters, very helpful because it expands on the Novice to Expert model described by the Dreyfus Brothers . The Novice to Expert model describes changes that take place in the cognitive processes as a professional moves from being a novice (relying heavily on rules) to becoming an expert (making extensive use of cognition). The relevance of this model to healthcare was described by Benner . Interestingly, Social Psychologists argue that the ‘fast thinking’ associated with scripts and heuristics is also connected with our willingness as humans to ascribe stereotypes to other people and this may be a contributing factor to the Fundamental Attribution Error.
We can experience something similar in a clinical setting. Let us imagine a medical student with no personal experience of asthma learning the management of someone suffering an acute asthma attack. The student will probably learn guidelines as a basic script but the more patients the student meets and the greater their involvement in the management then the richer the repertoire of scripts for managing a patient with asthma will become. At the most basic level the student learns an algorithm, which can be thought of as set of rules, and like all sets of rules are helpful to learners by reducing ambiguity. However the guidelines only provide one version of a script and it is only through clinical experience that the scripts become richer and the repertoire of scripts builds up. Some interactions will be common to the majority of these scripts – administer high inspired concentration oxygen, give bronchodilators and so on. Different types of clinicians will have acquired different ranges of scripts for the management of patients with acute asthma – family doctors will acquire a lot of experience of managing patients with asthma and their families and carers but may not see so many severe acute attacks; whereas, intensivists will have a lot of experience of patients with very severe attacks of asthma but much less experience of mild attacks.
This model – the development of scripts – can help us in our design of scenarios in simulation based education. At the level of the novice, where rules are dictating the interactions in a very basic script, strong cues may be helpful. If our wish as educators is to help the learners establish a basic script in long term memory then knowing when to intervene may be helpful. Certain models of simulator have features such as LEDs that are intended to represent the blue of cyanotic peripheries or the red dots of an allergic rash. I am conscious that in my own centre we have often exaggerated physiological values to act as cues to bring out a response from the participants. We have made the heart rate is a bit faster than it probably would be, the blood pressure is a bit lower, SpO2 is a bit lower and so on. I have always held concerns that we may be promoting a behaviourist model of conditioning. I think it is less important if learners are exposed to such experiences infrequently but if we wish to reinforce the place of such algorithms in long term memory and choose to delineate the intervention points, the points at which the learner is expected to initiate an action, we may reinforce an inappropriate pattern.
Another model that may help explain my concern is that of signal to noise ratio. What we are attempting to do in our scenarios is to make the signal so loud so that it stands out above the background ‘noise’ and so becomes less ambiguous. This may be acceptable for novices who are learning a script that is based on rules. However, when we are delivering scenario based courses for more experienced health care professionals then the scripts that we seek to create in our simulated environment may not be faithful to the repertoire of scripts residing in the long term memories of our participants. Such learners are likely to have acquired the ability to discern more subtle signals from the noise. In some cases I suspect that the cues that would activate a particular script in real life may not be able to be recreated in the simulated environment. In some cases this may be down to limitations of the hardware or even the simulated actors, simulated patients or confederates in the scenario. These issues by themselves are not new but maybe we have to add ‘script fidelity’ to our ever burgeoning dimensions of fidelity as yet another factor to consider when developing courses. As a former obstetric anaesthetist there would be subtle signs but important cues from women undergoing caesarean section under regional anaesthesia that a manikin or even a simulated patient would struggle to replicate. I have no simple solutions for this challenge although I have used the limitations of the manikin and simulated environment as a way of setting an agenda for discussion in courses with experienced clinicians. By asking a group what they would expect to observe, and when they would intervene one can help these clinicians explore their own scripts and so reflect upon them.
Our scripts are unique to us because they are built from our own experiences. I think that one of the ways of learning from others is to make aspects of their scripts more explicit and I think that one of the strengths of scenario based simulation is to use the scenario as a way of bringing scripts from long term memory into the working space of short term memory. I wrote earlier that this also has the advantage of moving the focus away from that of the performance of the individual learner in a scenario and putting the focus on the discussion generated from the performance. This helps with the self-esteem of the learner but the script / heuristic model also helps me reflect on why some discussions went particularly well and other did not. The use of the script / heuristic model may help the facilitator concentrate on some of the more salient components of scripts, such as the way in which clinicians anticipate that the course of an event will follow and how and when they would intervene, update their model and so in. I find this especially interesting because it links this model with the cognitive non-technical skills of situation awareness and decision making. I think that simulation-based education can help with continuing professional development and maintenance of competence by helping healthcare professionals learn aspects of practical management from their peers as well as helping individual practitioners reflect upon their own strengths and weaknesses.
I explore this further in the Vignette in Additional file 1.