Here's my shot at recapping the recent issues, using a video game analogy (because you can never have enough analogies
I've always played RPGs like a 1st person shooter. I imagine the rules as a HUD interface (with a health bar, etc.) between me as a player and the POV of the character.
In classic D&D, the HUD is obvious around the periphery but it doesn't have to be immersion-wrecking -- because players can choose to reference the in-game world instead of the HUD.
After all, in a conversation with an ally NPC, I could choose "I'm exhausted and bleeding, we need a defensible or safe place to rest and bandage our wounds" instead of "my health bar is low, we need a safe zone with no monsters on the mini-map". Honestly, I'm frequently lazy and say "I'm low on health, we need to rest" -- which isn't entirely in-character but not entirely immersion-breaking either. Once near full hit points, I can say "I feel perfectly fine now, let's head out!" instead of "My health bar is 100%, I'm ready now!".
So I know how to fluff an abstraction like hit points, and I know how to reference it in-character as a double entendre, and this helps to maintain immersion.
Then comes 4E, and two things happen...
Firstly, gameplay changed from 1st person perspective to a bird's eye view or 3/4 perspective
and someone forgot to tell me! It wasn't until a few years ago I suppose that I learned about non-Actor stance on Enworld. Maybe other people were always playing with a 3/4 perspective pre-4E and I was clueless otherwise. Why this focus on narrativist playstyle wasn't even mentioned in the 4E preview I have
no idea.
Secondly, abstractions like bloodied appear on the HUD. What does the specificity and timing of the occurence of a 50% full health bar mean, in the fiction? IMO absolutely nothing. There's nothing that can be said in-character that conveys the phenomenon of bloodied for PCs and monsters and all the in-game expectations and various associated triggers and effects. Unlike referencing hit points and other "pretend" simulationist mechanics in which you have a choice to use in-character or out-of-character language, trying to reference a condition like bloodied almost always has the player speaking in metagame and out-of-character. Pile on too many pure metagame interfaces like this and the HUD feels more referential and more important (and IMO too obtrusive) vs the character POV.
I guess I should have a conclusion now. I guess the importance of a "nod to realism" depends on your value on immersion. I guess that your value on immersion at least partially depends on whether you're roleplaying 1st person perspective or 3/4 perspective or top-down view. I suppose that "realism" attached to cause-and-effect and narrativist mechanics also depends on your perspective (pun intended).