The simulation theater: A theoretical discussion of concepts and constructs that enhance learning Ethan Oliver Bryson MD ⁎ , Adam I. Levine MD Department of Anesthesia, Mount Sinai Hospital, New York, NY 10029, USA Keywords: Full environment simulation (FES); Memory; Emotional content; Anesthesia simulator Abstract The increasing role of simulation in medical education has paralleled the advancement of this technology. Full environment simulation (FES) can be used to effectively replicate rare medical catastrophes with exacting realism. It has been suggested that emotion can significantly enhance learning by producing memories that are processed and stored via the amygdaloid complex, which are relatively impervious to extinction and thus forgetting. Theoretically, the addition of emotional content to simulated crises during FES can be used to affect emotional changes in the participants and thus facilitate learning. Here, we discuss the theoretical benefit and the use of FES with emotional enhancement as it relates to improved memory and learning. © 2008 Elsevier Inc. All rights reserved. 1. Introduction Full environment simulation (FES) is a popular adjunct to medical education that has been extensively developed by anesthesiologists. Full environment simulation is a replica of the clinical environment which includes patient, other health care professionals, and ancillary equipment and supplies. Current mannequin-based simulator designs are computer and model–driven, full-sized infant, child, or adult patient replicas that are purported to be capable of delivering “true- to-life” scenarios that simulate reality. Incorporating the simulated patient into a simulated operating room environ- ment, complete with an anesthesia machine, monitors, and adjuncts commonly found in real operating rooms, allows participants the ability to suspend disbelief, thus creating a highly effective learning environment. In this environment, the lessons learned could be more real when compared to simpler screen-based simulators. Many reports have dis- cussed the efficacy of simulation-based education for teaching basic and advanced skills in anesthesiology, management of rare and critical events including Advanced Cardiac Life Support (ACLS) protocols, and team training through crisis resource management. Full environment simulation provides the unique opportunity to not only practice procedures but to allow educators the ability to stage realistic scenarios in which the principal focus can be human behavior and interaction. In this environment, participants can be allowed to make mistakes and experience bad outcomes without actual patient harm. These adverse outcomes can facilitate the generation of negative emotions among the participants; no health care professional wants to be responsible for contributing to patient harm through a bad clinical outcome. One of the major manufacturers alleges that their device “exhibits clinical signals so lifelike that students have been known to cry when it “dies.” We theorize that the effectiveness of the simulator as an educational tool ⁎ Corresponding author. E-mail address: ethan.bryson@mountsinai.org (E.O. Bryson). 0883-9441/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jcrc.2007.12.003 Journal of Critical Care (2008) 23, 185–187