"My Body Thinks This is Real": A Qualitative Study of Fourth Year Medical Student Perspectives on Learning and Realism in Complex Simulation.

INTRODUCTION: Simulation-based education is important to medical training, yet the relationship between realism, learner engagement, and learning remains debated. Realism is often equated with technological sophistication, though contemporary frameworks emphasize realism as multifactorial. This qualitative study aimed to explore how graduating medical students perceive realism, characterize engagement, and describe learning in a complex simulation. METHODS: Fourth-year medical students at an academic center participated in The Shift Change, a complex multi-room inpatient simulation during a pediatrics transition-to-residency course in March 2024. Semi-structured individual and group virtual interviews were conducted with 20 students within 3 weeks of the simulation. Verbatim transcripts underwent iterative qualitative analysis using a constant comparative method to identify categories and organize broader themes describing how realism, engagement and learning were experienced. RESULTS: Students described experiences through 4 interrelated themes, summarized as the "5 Ps": preparation, production, presence and participation, and processing. Background experiences prepared students for learning. The production of the simulation through narrative coherence, a physical simulation space, and thoughtful facilitation was described as supporting presence and authentic participation, thereby generating engagement that students perceived as shaping realism and learning. Processing through emotions, observation and debriefing was described as solidifying lessons and extending perceived learning to future practice. CONCLUSIONS: In this study, graduating medical students described experiences of realism and engagement in a complex simulation through the 5 Ps: preparation, production, presence and participation, and processing. The 5 Ps represent an interpretative analysis of student experiences, highlighting perceived realism, engagement, and learning. These findings may help inform future exploration of simulations designed for undergraduate to graduate medical education transitions.