Visually Enhanced Mental Simulation (VEMS) – an alternative simulation delivery format?

By Victoria Brazil (@SocraticEM)

The technology for simulation-based education (SBE) in 2022 is impressive but can represent a barrier to practical scenario delivery. Heavy mannikins, fickle wireless connectivity, audio-visual gear, and clinical consumables (drugs and equipment) can be daunting challenges for even experienced simulation faculty. Do we really need all that? Are there alternatives that can still achieve our educational objectives?

Visually Enhanced Mental Simulation (VEMS) is “a combination of mental simulation and think-aloud with external representations of a patient and the treatments applied by the participants.”(1) The educational basis for this design is the well documented benefits of mental rehearsal and of ‘think-aloud’ approaches to explore cognitive processes. Describing this technique in the International Journal of Healthcare Simulation (IJOHS), Dogan and colleagues explain – “It differs from the mental simulation which solely occurs in the minds of participants because they are expected to collectively verbalize their thinking and actions, including equipment setting and communication with the patient.”(1)

What does this actually look like?  A flat plastic visual representation of a patient is laid on a table. Staff are given the scenario details – “Dragan is an older male has just presented with chest pain, here’s his ECG”. Staff have a variety of options for information gathering (ECGs, Xrays, blood results, monitor emulators) and for treatment (plastic representations of IV lines, infusion bags, drug syringes, oral medications). Staff have to write their treatments on the relevant plastic card (e.g. aspirin on the oral medication card, fentanyl 25mcg on the syringe) and place it next to the patient for it to be ‘given’. Staff need to allocate roles and communicate effectively to coordinate their assessment and management. One option is to have a ‘patient’ actor sitting at the head of the bed if there is an important element of patient communication (e.g. “it looks like you’re having a heart attack…”). Facilitators provide real time information and cues to move the scenario along.

The effectiveness of so called ‘low fidelity’ approaches to healthcare simulation have been well described, and doubtless experienced by most simulation faculty. Likewise, tabletop simulations have a long history in disaster simulations ( e.g. EmergoTrain), or for exploring emergency department function (e.g. ‘Gridlocked’). Clarity on learning objectives is critical; if we are training recognition and response to high airway pressures in an anaesthesia scenario, we’ll need that fancy 3G mannikin. But if we are looking to explore teamwork, communication, and shared mental models in the management of a patient who has a cardiac arrythmia, VEMS might suffice.

That said, I admit to scepticism when I first read about VEMS; surely it was a bit ‘gimmicky’ and our healthcare teams wouldn’t truly engage in a tabletop game? But after delivering multiple sessions to emergency department and maternity teams, I have been impressed by the engagement, simplicity, and effectiveness of the approach.

In deconstructing this with our faculty, I suggest the following principles: –

  1. Think about what you are trying to achieve. VEMS won’t match many of our procedural or patient communication learning objectives but has suited our sessions where the objectives are acute care team coordination and communication.    
  2. Consider this for teams who already have a mental picture of the process on which to draw. This was easy for our experienced teams who had been in major trauma cases or cord prolapse encounters in the real world. I think it might not be effective for students who have no comprehension of what we are ‘rehearsing’.
  3. Consider this for teams already engaged in a simulation program; they will be used to embracing reality gaps and habituated to exploring and reflecting on their teamwork.   
  4. Resist the temptation to ‘add more’ for realism. Will it really add to task fidelity?
  5. Do an effective pre-briefing to shape the expectations of realism for participants. Consider a short scenario demonstration by faculty to illustrate the process. This might only take 5 minutes, unlike many prolonged familiarisations I have seen (and conducted myself) in simulation rooms.
  6. Consider scenario delivery formats like pause and discuss or ‘Live Die Repeat’. The minimalist technology and equipment set up makes it easy to go back and redo segments of a scenario, supporting deliberate practice.
  7. Conduct debriefings in a similar way to other scenarios – with an effective structure and conversational techniques that support team-based reflection.
  8. Consider a VEMS exercise at the start of shift or team huddle (2) – it might be 5-10 minutes well spent in fostering team familiarity and psychological safety in readiness for the first real resus of the day!

Our team plans to develop resources and videos to support faculty interested in this approach. We would love to hear others experience and thank Dogan and team for their work in this area.


1. Dogan B, Pattison N, Alinier G. A form of mental simulation with significant enhancements enabling teamwork training. International Journal of Healthcare Simulation. 2021;1(1):56-60.

2. Lorello G, Hicks C, Ahmed S, Unger Z, Chandra D, & Hayter M. (2016). Mental practice: A simple tool to enhance team-based trauma resuscitation. CJEM, 18(2), 136-142.

The views and opinions expressed in this post are those of the author(s) and do not necessarily reflect the official policy or position of The Royal College of Physicians and Surgeons of Canada. For more details on our site disclaimers, please see our ‘About’ page