Simulations are becoming a more and more common training method for medical students. In a typical simulation, students resolve a medical case presented by an actor, and then participate in debriefing sessions led by a supervisor to analyze and critically review their experience and performance. This process commonly follows the “Promoting Excellence And Reflective Learning in Simulation” (PEARLS) framework, developed by Adam Cheng and Walter Eppich in 2015. While this protocol has been effective in safely preparing medical students for interactions with real patients, work remains to be done on incorporating diversity, equity, and inclusion into the trainings. 

In a recent paper published in the journal Advances in Simulation, Niki Soilis, a doctoral student at McGill’s Institute of Health Sciences Education, presents an altered version of the PEARLS protocol which examines the impact of social structures on healthcare and explores ways to mitigate systemic inequalities.

Soilis, now completing her doctoral studies, previously worked as the education manager at McGill’s Steinberg Centre for Simulation and Interactive Learning at the Faculty of Medicine and Health Sciences for eight years. During that time, she noticed a significant underrepresentation of marginalized communities in medical training—an issue she is now tackling through her research.

“That became kind of the driver of, ‘How do we, as a program, start to integrate more inclusive and diverse perspectives in our curriculum?’ I started to look at the ways we can go more mainstream and make it into the culture of our programs,” Soilis said in an interview with The Tribune.

To address this gap, Soilis collaborated with other professionals to incorporate the Community Links Evidence to Action Research (CLEAR) toolkit into medical simulations. Developed at McGill, the CLEAR toolkit helps healthcare practitioners integrate advocacy and awareness of social determinants of health into their daily practice. 

Initially tested by frontline healthcare workers who attested to its efficacy, the toolkit was subsequently integrated into the PEARLS approach to debriefing, ultimately leading to the creation of the PEARLS Debriefing for Social Justice and Equity (DSJE) tool. Implementing the PEARLS DSJE tool is more cost-effective as compared to creating separate simulations programs specifically for diversity and inclusion.

“So we kind of merged two worlds, hoping that they would be more accessible,” Soilis said. “It was a way of allowing people to really have dialogue on a consistent basis, rather than making programs that are just dedicated to that. Simulation is one of the most expensive educational modalities—it’s known as highly effective, but it’s much more expensive than classroom-based teaching—so this became a way of making [diversity, equity, and inclusion] more incorporated.”

The PEARLS protocol underwent further refinement after consultations with Cheng and Eppich, its original creators. One of the key additions was an “Activism” phase, which encourages discussions on how systemic inequalities affect patient care and how practitioners can address these barriers.

This phase prompts medical trainees to consider how follow-up care should be handled while recognizing the complex intersectional realities of medical treatment.

“My research is specifically in [houselessness], and one of the interventions that we’ve discussed in groups is, when a person comes in, doing an analysis of their psychosocial profile and understanding their context,” Soilis said. “Where do they get to sleep? Are they on a substance? So sometimes it’s not these grand changes: It’s just having an awareness of a bigger picture, not just the person.” 

Another key update to the PEARLS DSJE framework is its emphasis on community engagement. In practice, this means incorporating discussions about systemic inequalities within healthcare, the marginalization of certain communities, and strategies for fostering a more supportive and inclusive medical environment.

Soilis and her team hope that by implementing this new version of the framework, healthcare professionals can actively work towards reducing harmful biases in medical practice.

“It shouldn’t be the only way. It should still [be part of] a better-integrated curriculum, but this is one way, and we’re hoping that through our experience in implementing it, others will see its value,” Soilis said.

Soilis offered some advice for current and future medical students at McGill. “Just stay open, in practice, to reflecting on [yourself] continuously,” Soilis said. “Look at why we are the way we are, with a nonjudgmental stance, and reflect on how it affects how we deliver care.”