Ever played poker with all the cards face-up?
No bluffing. No strategy. No suspense: poker is not poker when the cards are face-up, and learning is not learning when the path is neatly scripted.
In many of the healthcare simulations I observed, clues were often exposed early and tasks were heavily labelled, reducing opportunities for discovery. Predictable. Neat. Safe. But far from the uncertainty and high stakes of real clinical practice. Research shows that authentic learning comes from navigating uncertainty and making decisions under pressure (1).
10 of Diamonds: reveal your hand - the easy beginning
To students, traditional simulations can appear like a polished gem: tidy, predictable, and quickly solvable. A diamond on the surface, but one that reveals its whole value too quickly, everything transparent, little left to discover. Take, for example, a scenario about Adverse Drug Reactions (ADRs). The scenario is clearly labelled as an ADR case, practically announcing its purpose before it even begins. The prescription lists antibiotics, antihypertensives, and steroids. Students encounter a set of symptoms, and the visible ADR form signals that these symptoms must relate to one of the medications.
Students need not investigate alternatives; the scenario title and supporting materials steer them directly to the culprit. They simply match symptoms to drugs instead of forming differential explanations
It isn’t detective work; it’s box-ticking. Game over. It was safe. Straightforward. And totally unlike the messy, ambiguous reality of healthcare. Students were not rehearsing the thinking required when the stakes are high; they were following the script, not shaping it. Like watching poker with all the cards face-up. When every clue is obvious, we remove the uncertainty that builds professional judgment (2).
That’s where the game needs to change.
Queen of Hearts: the patients who rewrite the rules - the turning point
Welcome o my healthcare simulation…but not as you know it. Here, I introduce a new approach: a Royal Flush of Pedagogy, where each unfolding moment invites critical thinking and decision-making. Students enter the simulation expecting routine. Instead, they meet a patient who calmly declares, ‘I am the Queen.’
I designed the Queen role to specifically reflect steroid-induced psychosis: a character who conceals the scenario’s purpose until students uncover it themselves. The prescription remains unchanged, antibiotics, antihypertensives, steroids, but now offers no easy answers. The patient describes her world with vivid eccentricity:
‘One is to be addressed as Your Majesty.' ‘One’s loyal footman presents one’s medicines upon a golden tray, ever punctually.’
In that instant, the room shifts: the expected script dissolves, and uncertainty takes the stage. Students must piece together what’s happening through observation, questioning, and reasoning. They may consider whether the steroid-induced psychotic symptoms could be related to the medication, while keeping alternative explanations in play. Misdiagnosis lurks unless they actively listen, interpret, and explore. This is no longer tick-box learning; it is clinical detective work.
Authentic simulation should mirror the social and cognitive complexity of real clinical encounters, not merely their surface features (3).
Jack of Clubs: the serial spoilers - the interruption
Every gripping story has its threat. Ours? The serial spoilers. Tutors, trying to make simulations more efficient, would inadvertently reveal details to students waiting nearby for their next simulation:
Tutor: ‘Have you done the ADR scenario?’
Students: ‘Not sure, which one is that?’
Tutor: ‘It’s the Queen one.’
The mystery? Gone; the suspense? Dead.
Rules had to be rewritten. Tutors were briefed to guide without giving away critical details. This preserved engagement, curiosity, and the learning challenge, as excessive guidance can undermine active problem-solving and learner autonomy (4).
King of Spades: the corridor memory phenomenon - the deepening
A new pattern emerged: one that I later conceptualised and termed the ‘corridor memory phenomenon.’ This referred to the spontaneous, informal reasoning students engaged in outside the simulation room. Students were overheard discussing the Queen scenario in the corridors, replaying events and debating clues long after the session had ended. These unplanned discussions became an impromptu poker table: comparing hands, testing hypotheses, interpreting clues. While other scenarios were linear and predictable, the Queen case stayed alive in conversation, becoming the most analysed, debated and remembered. Many later chose the Queen case for their formal reflections, noting that it was ‘so memorable’ and ‘impossible to forget.’
This corridor memory phenomenon highlighted a new layer of learning: students were not just following instructions. They reflected together, shared interpretations, and turned the scenario into a shared cognitive puzzle, where critical thinking, collective intelligence, and off-script learning flourished (5).
Ace of Spades: the Royal Flush - the culmination
Here, everything comes together. Stakes rise. Narrative, suspense, and inquiry intersect. Students are not merely learning what an ADR is. They are rehearsing how to think when outcomes matter.
The Queen, the spoilers, the corridor conversations, all threads weave into a crescendo: a Royal Flush of Pedagogy. Simulation becomes deliberate practice under uncertainty, integrating cognitive, social, and emotional layers of authentic clinical learning (1,4).
The Royal Flush of Pedagogy: my framework
Of course, this is not a literal poker's Royal Flush as the cards do not come from the same suit. That’s intentional. The metaphor is not about poker rules but about pedagogy: each ‘card’ represents a different dimension of cognitive challenge, and together they form the strongest possible hand of learning. Narrative disruption, uncertainty, cognitive load, social reasoning, emotional engagement, and post-simulation reflection combine to create a cumulative learning experience far more powerful than any single scenario alone.
A simulation-design framework I developed to map the learning journey from simple recognition (the 10) to deep, reflective clinical reasoning (the Ace). Each stage reflects rising uncertainty, cognitive load, and complexity, a pattern that parallels the progressively higher stakes typically seen across the rounds of a poker hand. The Queen case exemplifies the framework in action.
Final hand: game on
The Queen isn’t just a patient. The corridor isn’t just a passage. The Royal Flush isn’t just a metaphor; it’s the narrative arc of curiosity, challenge, and mastery. It’s an invitation:
• to design simulations that reflect real clinical practice
• to orchestrate curiosity, suspense, and discovery
• to let students earn their ‘aha’ moments themselves
So here’s the final deal. Are you game enough to:
• call your hand,
• craft your Royal Flush of Pedagogy, and
• create the corridor memory phenomenon that lets students ace their learning?
Thuy Mason (Kingston University) shares how her Royal Flush Pedagogy transforms healthcare simulations into high-stakes, narrative-driven experiences that spark ‘corridor memories’ and deep critical thinking. By blending unpredictability and suspense, the approach builds authentic decision-making skills, preparing students for the realities of practice long before they face them.
References:
1. Hamstra SJ, Brydges R, Hatala R, Zendejas B, Cook DA. Reconsidering fidelity in simulation-based training. Acad Med. 2014 Mar;89(3):387-92. doi: 10.1097/ACM.0000000000000130. PMID: 24448038.
2. Patel P, Hancock J, Rogers M, Pollard SR. Improving uncertainty tolerance in medical students: a scoping review. Med Educ. 2022;56(12):11631173.
3. Dieckmann P, Gaba D, Rall M, et al. Deepening the theoretical foundations of patient simulation as social practice. Simulation in Healthcare. 2007;2(3):183193.
4. Bevis Z, Nestel D, Kumar S, Gibson K, Kavanagh A, Rosado D, Ní Chianáin A, Battista K. Instruction and guidance in healthcare simulation: a scoping review. J Healthc Simul. 2025;1(1):115
5. Sellberg C. Learning from simulation: pedagogical principles and complexities. Med Educ. 2017;51(12):12301239.