To the Editor,I am writing to you in response to an editorial by Pankaj Kundra and Anusha Cherian entitled, “Simulation Based Learning — An Indian Perspective.”[1] I would like to start off by stating that I could not agree more with what the authors have to say with regard to the resistance faced in India in incorporating simulation-based learning in the training curriculum as the thought process has always been “let's do a bunch of simulations for resident × as he seems to have a knowledge gap.”The real value of simulation is in fostering adult learning as the authors point out. Adult learning is a very different and distinct form of learning and the medical community at large has to accept this before simulation-based learning is accepted whole heartedly. I make reference here to Malcolm Shepherd Knowles,[2] a famous American educator who was also very well known for using the term andragogy as synonymous to adult learning. He proposed the five assumptions of adult learning as below:Self-concept: As a person matures his/her self-concept moves from one of being a dependent personality toward one of being a self-directed human being.Adult learner experience: As a person matures he/she accumulates a growing reservoir of experience that becomes an increasing resource for learning.Readiness to learn: As a person matures his/her readiness to learn becomes oriented increasingly to the developmental tasks of his/her social roles.Orientation to learning: As a person matures his/her time perspective changes from one of postponed application of knowledge to immediacy of application, and accordingly his/her orientation toward learning shifts from one of subject-centeredness to one of problem-centeredness.Motivation to learn: As a person matures the motivation to learn is internal.Based on these assumptions, he also suggested four principles that are applied to adult learning as below:Adults need to be involved in the planning and evaluation of their instruction.Experience (including mistakes) provides the basis for the learning activities.Adults are most interested in learning subjects that have immediate relevance and impact to their job or personal life.Adult learning is problem-centered rather than content-oriented.[3]If the medical community wants to really educate the adult learners and wants to incorporate simulation based learning, we need buy in — not only from the educators and program directors but more importantly from the trainees themselves, and this is a bigger challenge facing simulation-based learning in my opinion. One way of making this happen more consistently is to educate our trainees that when they come in for a simulation-based learning experience, we all work with a basic assumption that all personnel visiting the simulation center are intelligent, knowledgeable and genuinely have a desire to improve and keep getting better at what they do. This brings us to the question, what really are we trying to teach with simulation-based learning?The answer to this question is not simple. Most simulation centers and simulation-based activities in the field of anesthesiology are focused around creating scenarios of rare but serious events in the operating room (OR) like malignant hyperthermia, cardiac arrest in the OR, local anesthetic systemic toxicity and so on. This is done with the intent that the trainee will have been exposed to this complication in the simulation setting with the aim that they will be able to deal with this better when a situation similar to this presents in real life. The further questions that remain unanswered with this approach are if this approach really works and how many sessions do we need — is one exposure early in training to one of these scenarios enough to foster adequate memory and judgment for the future or do we need to do repeated sessions at regular intervals?Bloom[4] described a continuum of stages of learning from the lower order thinking skills to higher order thinking skills as follows: Knowledge, comprehension, analysis, application, synthesis, and evaluation. Anderson et al.[5] revised this taxonomy in 2001 using the following stages: Remembering, understanding, analyzing, applying, evaluating and creating. Also, specific scenarios and testing if the trainee knows how to manage a particular complication is working at a low level per Bloom's taxonomy. If we work with the basic assumption as mentioned above, there is not much point in scenarios of this kind for an individual trainee as they tend to test the knowledge base working at the lower end of the thinking skills spectrum. Simulation should ideally be used to foster the analyzing/applying skills because if we can help trainees/practitioners get better at this level, it will foster appropriate skill sets to ensure that we could reach the higher levels of thinking skills like synthesis and evaluation.I also agree to a great extent on the fact that the debriefing after simulation is really the most important aspect of simulation-based education and this offers a very unique atmosphere wherein the participants can discuss without fear of retaliation as well as without any potential harm to one of our patients. And the beauty of this is that you really do not need the most advanced simulation equipment or dummy to accomplish the goals of simulation-based learning effectively even though we wrongly think that we can’t incorporate simulation-based training in our curriculum because we don’t have a big enough simulation center or our simulation equipment is a little dated. As one of my teachers during a simulation instructor course put it “the meat is in the content dummy, not the dummy, dummy!”