[The following notes were generated by Thomas Thesen, Ph.D.]

Presenter: Sarah Edwards, BMBS FHEA MSc(MedEd) MSc(PEM) (University Hospitals of Derby and Burton NHS Trust, UK) and Michael Cosimini, MD FAAP (Oregon Health and Science University, USA)

Card and Board Games for Health Professionals Education

The Winter 2023 IAMSE Webinar Seminar Series, titled “Not Just Fun & Games: Game-based Learning in Health Professions Education,” had its fourth session on Thursday, January 26. This series explores the benefits of using games in healthcare education and offers strategies for incorporating different types of games into the basic science curriculum. It covers existing literature on the theories behind using games in medical education and the results of recent research studies on the topic. The series also features speakers who will provide practical tips for implementing game-based learning in the classroom. The third session was presented by Dr. Sarah Edwards and Dr. Michael Cosimini and was titled “Card and board games for health professional education”.

Drs. Edwards and Cosimini started by explaining that Gamification is a technique that incorporates game-like elements in non-game contexts to impact learning behaviors or attitudes. It leverages the motivational and engagement factors found in games to drive desired behaviors and improve the learning experience. Researchers in medical education can use gamification to enhance the effectiveness of traditional educational methods and make learning more interactive and enjoyable. By incorporating game mechanics like points, feedback, competition, and storytelling, medical education researchers can increase engagement, motivation, and retention of information in learners.

They then introduced a theory of gamified learning developed by Landers et al., which states that gamified learning defines gamification as the use of game attributes outside of the context of a game to influence learning-related behaviors or attitudes. These behaviors or attitudes then impact learning through either strengthening the relationship between instructional design quality and outcomes or influencing learning directly. This differs from serious games, where game attributes are used to directly affect learning. The Bedwell taxonomy provides categories of game attributes and examples of how they might be applied in gamification. Recommendations are given for conducting rigorous and scientific studies of gamification. Next, the presenters discuss “Serious Games” by Abt CC, published in 1970, which defines serious games as games with a specific educational purpose and not primarily intended for entertainment. Abt asserts that these games have a well-thought-out educational purpose. They also presented an input-process-output model of instructional games and learning (Garris et al., 2022), which covers the crucial aspects of games from an educational viewpoint, the game cycle of user feedback, behavior, and judgments that define engagement in gameplay, and the resulting learning outcomes. They examine the significance of this model for the creation and implementation of effective instructional games. The presenters highlight that a game is a suitable choice for a medical education session when it enhances learner engagement, changes motivation, provides low-stakes trial and error, has game mechanics that align with learning goals, and showcases how systems work.

Drs. Edwards and Cosiminicontinued their presentation by showcasing various examples of board games currently used in health professions education, including ‘Cards Against Peds Ortho’, ‘Game of Stools’, and ‘Gridlock ED’. The presenters then summarized the results of a survey on a card game used to educate on antibiotic use. The survey was conducted among online groups interested in educational games and healthcare education. Of the 390 participants who completed the survey, 55 were excluded as they were not in healthcare. The majority (56%) were physicians, residents, or medical students, 33% were pharmacists, residents, or students. 53% of participants were from the US, and 70% were downloading the game for their own education. In addition, the optimal length of board games for education is recommended to be around 20 minutes and educators are not encouraged to go above 40 minutes based on survey data. The most often cited barriers for using games for education are the lack of appropriate games and the concern for content accuracy, followed by cost.  They also briefly discussed the potential lack of credibility of games in educational contexts. The presenters then offered some game design tips, starting with the maxim that “game complexity game complexity shouldn’t be harder than the information its providing. The point is to learn, not to understand the game.”. The presenters concluded their presentation by highlighting the uniqueness of card and board games as a social environment for active learning. Currently, not many such games are available, but there is a demand for short and simple 2-4 player games. If you think about creating a game for your specific educational setting, they recommend starting by recycling mechanics from known games.

[The following notes were generated by Thomas Thesen, Ph.D.]

Presenter: Amy Beresheim, PhD and Adam WilsonPhD (Rush University, USA)

Escape Rooms: Breaking Away from the Lull of Lackluster Curricula

The Winter 2023 IAMSE Webinar Seminar Series, titled “Not Just Fun & Games: Game-based Learning in Health Professions Education,” had its third session on Thursday, January 19. This series explores the benefits of using games in healthcare education and offers strategies for incorporating different types of games into the basic science curriculum. It covers existing literature on the theories behind using games in medical education and the results of recent research studies on the topic. The series also features speakers who will provide practical tips for implementing game-based learning in the classroom. The third session was presented by Dr. Amy Beresheim, Ph.D. and Dr. Adam Wilson, Ph.D. and was titled “Escape Rooms: Breaking away from the lull of lackluster curricula”.

Drs. Beresheim and Wilson started by explaining that Gamification is a field of educational science that aims to make learning more engaging and motivating using game-related mechanisms. They further highlighted that game-based learning typically includes a system with pre-defined rules, which allows individuals or groups to track their progress and receive incentives as they advance. They also emphasized that immediate incentives could enhance learning and promote engagement with the learning process. The presenters continued by giving an overview of the current literature on gamification in education. They cited several meta-analyses that support the effectiveness of gamification in enhancing student performance. According to one study, students exposed to educational games had higher performance outcomes than non-gaming control groups. Another meta-analysis found that gamification had small positive effects on cognitive, motivational, and behavioral learning outcomes. A third study reported a moderately positive effect of gamification on student achievement.

Drs. Beresheim and Wilson then shifted to the main topic of their talk, the concept of escape rooms, explaining that the goal is to escape a theme room using a series of clues within a specific time frame, usually 60 minutes. They went on to describe the mechanics of an escape room game, saying that it typically begins with a storyline to provide context for the environmental setting and the need for escape. Participants then search for clues and solve puzzles throughout the room in hopes of activating something, such as unlocking a combination device to reveal another clue. At first, the search may feel aimless but as more clues are decoded, it becomes easier to anticipate what additional steps are needed to complete the escape. They also mentioned additional features, such as the common use of distractors and the creation of time pressure to escape the room before the clock runs out.

Next, they discussed how escape rooms can be utilized in a medical education setting. The presenters stated that the primary objective should be to review or practice new educational content through an interactive and collaborative approach. The secondary goal should be to solve the puzzles and escape the room within a given time frame. They mentioned that the medical education escape room still begins with a storyline to establish the context and objectives and tie everything together. They also noted that there are still elements that can distract from the main objective (i.e. distractors), but the key difference in an educational escape room is that the puzzles and clues are designed to test the application of knowledge rather than just finding them. When knowledge is applied correctly, it will either reveal a new clue or help solve parallel ones that will eventually lead to the escape.

Drs. Beresheim and Wilson then delved into the topic of group size and dynamics in escape rooms. They

mentioned that groups can range in size, but generally have around 5 participants. They also emphasized that the ideal environment is usually fast paced, generating a high rate of communication among team members. Additionally, they pointed out that there is evidence that older and more educated players tend to speak for longer during the game. Furthermore, the prior strength of relationships within the group is linked to the intensity of collaboration and problem-solving interactions.

Next, the team discussed the difference between in-person and virtual escape rooms in educational settings. The majority of escape rooms used in education contexts are occurring in-person, and much smaller percentage constitute digital games or hybrid formats. They also mentioned that there are few comparative studies that have examined the effectiveness of in-person vs virtual/digital educational escape rooms. He cited one study that suggests that remote educational escape rooms can be as engaging as their face-to-face counterparts, but their learning effectiveness may be lower. As we now all know, virtual escape rooms offer logistical advantages such as being able to use them in case of COVID-19, saving space and time, reducing resource costs and allowing for reproducibility. The cost of running escape rooms is low and logistical issues are similar to small group sessions already common in medical education. They emphasized that educators must ensure that all participants have the dexterity and motor skills required for in-person puzzles, and think about the overall challenges that some individual students with extra challenges may encounter. They then went on to describe various escape room implementations with a focus on anatomy at the University of Alabama and Rush University, including the ‘Anatomy Escape Room’ and ‘Who am I?’. To make it easier for viewers to implement their own virtual escape rooms, they provided a list of tools and provided an extensive list of other potential examples that could be used in the medical education setting. Lastly, they shared with us links to escape room instructor guides that can be used by the audience as inspiration to build their own educational escape rooms.

After the conclusion of the presentation, the audience had the chance to ask questions from Drs. Beresheim and Wilson. Questions that were discussed included, “Would you consider running a step-by-step course in the future where participants can construct their own escape room games?”, “Do students have a preference between in-person and virtual?”, followed by an ensuing discussion about the use of distractors in medical education escape room games.

[The following notes were generated by Thomas Thesen, Ph.D.]

Presenter: Jeremey Walker, MD (University of Alabama, USA) and Michelle Carroll Turpin, PhD (University of Houston, USA)

Trivia Reimagined: Making Questions Fun & Educational

The Winter 2023 IAMSE Webinar Seminar Series, titled “Not Just Fun & Games: Game-based Learning in Health Professions Education,” had its second session on Thursday, January 12. This series explores the benefits of using games in healthcare education and offers strategies for incorporating different types of games into the basic science curriculum. It covers existing literature on the theories behind using games in medical education and the results of recent research studies on the topic. The series also features speakers who will provide practical tips for implementing game-based learning in the classroom. The second session was co-led by Dr. Jeremy Walker, MD and Dr. Michelle Carroll-Turpin, PhD. And was titled “Trivia Reimagined: Making Questions Fun & Educational”.

Dr. Walker began his presentation by outlining key principles related to the use of games in education. He defined “Gamification” as the integration of game elements into non-game contexts to enhance user engagement and experience. He cited examples such as the use of games and rewards in language learning apps like Duolingo, and reward systems employed by companies like Starbucks. Dr. Walker highlighted the fitness industry as being particularly close to the concept of gamification in education, as apps in this space often utilize daily challenges, team-based competition, rewards for goal completion, and other methods to engage users. He distinguished gamification from “Serious Gaming,” which refers to games specifically designed for non-entertainment purposes, such as healthcare simulations. Dr. Walker cited examples of Serious Games from Drexel College of Medicine in microbiology, such as CD4 Hunter, Malaria Invasion, Hep B-ware, and Solve The Outbreak from the CDC, as well as board games such as Empiric Abx, and the popular Escape Room experiences, which are live-action, immersive scenarios where players must solve puzzles and riddles to escape within a set time limit. He further explained the components common to all educational games, such as the setting, gaming elements, and educational content.

Dr. Walker introduced the Kaizen platform, a widely-used tool for continuous improvement in business and manufacturing. The Kaizen platform is based on the principle of making small, incremental changes to improve processes, products, and overall performance. He then presented his work in creating a microbiology module for first-year medical students using the Kaizen platform concept, highlighting the anti-stress benefits of the game at the end of term. Dr. Walker then discussed the “ID Fellows Cup,” an educational game consisting of a formative question bank for Infectious Disease fellows, which is used by 75 institutions worldwide. He highlighted the cognitive science principles employed by the game, such as retrieval-based learning and spaced repetition, which help fellows retain content information. The use of formative questions is a valuable tool in the learning process, allowing learners to assess their understanding of a topic and receive immediate reinforcement. He also emphasized the importance of discussion, which serves to clarify key learning points and provide supplementary context, as well as incorporating visuals and contrasting examples, and linking learners to additional digital resources for further exploration of the subject matter.

Dr. Walker then presented the results of an evaluation study, which indicated a positive correlation between student mean exam scores and engagement with the Kaizen platform, as determined by a Spearman’s rank correlation coefficient of 0.338 (p-value <0.001). Furthermore, the study found that in a spaced repetition game, players were more likely to correctly answer questions seen months prior, as determined by a two-sample Wilcoxon test (p-value 0.0030). He concluded that the Kaizen platform games maximize the educational return on time invested.

Dr. Walker continued to discuss the use of a formative question bank with game elements, which aligns with several principles of cognitive psychology, such as retrieval practice, elaboration, appropriate context, dual coding, spaced repetition, and interleaving. He explained that retrieval practice is achieved through effortful recall, elaboration by attaching details to concepts and comparing them, appropriate context is provided using clinical vignettes, dual coding is achieved using visual aids, spaced repetition is achieved through the repetition of concepts, and interleaving is achieved by switching between content areas. Overall, Dr. Walker highlighted the importance of using games in education and how they can enhance traditional learning practices by providing external incentives, and by promoting engagement and retention of content using various cognitive science principles, such as retrieval-based learning, spaced repetition, and interleaving.

Dr. Walker then proceeded to discuss best practices in the use of games in education. He emphasized the importance of providing high-quality educational content as the primary priority and highlighted the benefits of incorporating team competition to foster group identity and create a shared experience among learners. He also explained the benefits of implementing a pace feature to enhance the effectiveness of spaced repetition and interleaving strategies, and the use of badges as a reward mechanism for consistent engagement in desired daily practices. Dr. Walker also shared several gaming platforms that can be utilized in the classroom, such as Kahoot, Quizizz, Formative, and the Kaizen platform. He then summarized his presentation by stating that gamification, when implemented in a strategic manner, can enhance traditional learning practices by providing external incentives through the incorporation of game elements. It is important to capture data to demonstrate the effectiveness of gamification, and measure the impact of competition, which can be channeled productively through the formation of teams. He emphasized the importance of ensuring that the game setting is accessible to all learners, and the importance of understanding and engaging with the community in the gamification process.

Next, Dr. Carroll-Turpin continued the session with her presentation, “Gaming in the Classroom: Tips & Tricks from the Trenches.” She began by emphasizing the benefits of incorporating games in active learning environments, as they can change the pace and keep things engaging. She also reported that for the academic year 2020-2021, medical schools reported that games made up 0.19% of instructional time. Dr. Carroll-Turpin then discussed the barriers that hinder the utilization of games in the classroom. These barriers include lack of relevance to the curriculum, lack of professional development, varying proficiency among teachers and students, inconsistent development of games, lack of data to support the use and positive outcomes, and the continuous evolution of educational practices and technology. She also highlighted that there are cultural barriers, particularly in the perception of the value of using games in the classroom.

To ensure that gaming is a good fit, Dr. Carroll-Turpin recommends asking the following questions:

1. Can I tie the activity explicitly to learning objectives? It is important to ensure that the activity is directly relevant to the curriculum and that adult learners can easily understand its value.
2. How much do the students already know? It is important to be aware of the students’ prior knowledge and that games are often better suited to facilitate review rather than introducing new concepts.
3. What are the stakes? The stakes of the game should be considered as winning by itself can be a strong motivator, but grades may introduce unnecessary stress.
4. How engaged will the students be? Teamwork is known to boost motivation and encourage peer teaching and learning, thus it is important to consider how engaged the students will be in the game.

Dr. Carroll-Turpin went on to discuss the process of planning games in the classroom. She emphasized the importance of keeping it simple when it comes to game rules and managing the cognitive load of students, by minimizing frustration and maximizing the connection to content. To ensure a successful gaming session, she recommended providing session instructions in advance, which should include the rules of the game, team assignments (if applicable), material covered and the corresponding learning objectives, and the rules of engagement. This will aid in preparing the participants for the session and help them understand the objectives and rules of the game. Furthermore, Dr. Carroll-Turpin stressed the importance of incorporating physical items, such as buzzers, paddles, wheels, and prizes, to optimize opportunities for engagement. This enhances the gaming experience by allowing for more interactive and hands-on activities, and increases participation and engagement among learners, making the experience more memorable.

To ensure that the game is used to its fullest potential, Dr. Carroll-Turpin recommended a 3-step process: 1. Provide an introduction including instructions and a clear connection to relevant learning objectives. 2. Engage in the game activity. 3. Debrief on what was learned from the game, this will help to reinforce the learning objectives and allow for reflection on the experience. This process will guarantee that the game is used to its maximum potential and that the learners are getting the most out of the experience. At the end of her presentation, Dr. Carroll-Turpin provided some useful links and examples for educators who want to use games in their classroom and that are available to view in the PDF files posted on the IAMSE website under this webinar session.

[The following notes were generated by Thomas Thesen, Ph.D.]

Presenter: JR Georgiadis, PhD, Associate Professor and Section Head at the University Medical Center Groningen in the Netherlands

Gamification in Biomedical Education

The Winter 2023 IAMSE Webinar Seminar Series, titled “Not Just Fun & Games: Game-based Learning in Health Professions Education,” opened on January 5. This series explores the benefits of using games in healthcare education and offers strategies for incorporating different types of games into the basic science curriculum. It covers existing literature on the theories behind using games in medical education and the results of recent research studies on the topic. The series also features speakers who will provide practical tips for implementing game-based learning in the classroom. The first session was led by Dr. Janniko Georgiadis, head of Anatomy & Medical Physiology at the University of Groningen in the Netherlands. In his presentation, “Gamification in Biomedical Education,” Dr. Georgiadis discussed the behavioral and neuroscientific theories linking motivation and gaming and presented the findings of a recent systematic review on the use of games in health professions education.

Dr. Georgiadis began by discussing the neuroscientific theory of reward-based learning and the role of the brain’s reward system in learning and motivation. He explained that the release of neurotransmitters like dopamine during pleasurable experiences can reinforce certain behaviors and increase the likelihood of repeating them in the future. This process can also apply to learning and performance – if we enjoy an activity or find it pleasurable, we may be more motivated to engage in it and put in more effort, leading to better learning outcomes. On the other hand, if we do not find an activity enjoyable, we may lack motivation and perform poorly. Dr. Georgiadis pointed out that game-based learning or receiving instructions or acquiring knowledge in a game-like framework, relates to play, a natural learning process that can be observed in both young animals and humans. He emphasized that the evidence supports the effectiveness of games in engaging learners, citing the example of teenagers playing video games.

Dr. Georgiadis then distinguished between serious games, which have education as their primary goal (such as simulations in healthcare education), and gamification, which refers to the use of game elements in a non-game context (such as incorporating gaming elements like competition, story, and rules into an online learning platform). He discussed the nine attributes of game elements, as classified by Bedwell et al. (2015): 1) rules and goals, 2) action language, 3) assessment, 4) environment, 5) conflict/challenge, 6) control/ability to alter the game, 7) game fiction/story/narrative, 8) human interaction among players, and 9) immersion. He provided an example of a grocery store rewards program, demonstrating how rewards, challenges, goals, and other game-based attributes can create behavioral engagement that can be utilized by medical educators in the classroom.

The findings of the review revealed that the MERSQI scores of the included studies ranged from 5 to 18, with an average score of 9.8. This average score was considered relatively low due to the descriptive nature of most of the studies and the limited number of controlled studies on gamification in healthcare profession education. The game attributes most frequently studied were conflict/challenge and assessment, or a combination of these two, indicating a bias towards competition and scoring in the use of games in medical education, particularly in Western settings. While no negative effects were reported, the outcome measures of the studies primarily focused on knowledge acquisition and student satisfaction. However, Dr. Georgiadis pointed out that it is difficult to determine whether the positive effects observed were due to the use of games or other factors, such as novelty, because of the lack of proper controls in the majority of the studies. The review concluded that there is limited empirical evidence supporting the effectiveness of games in facilitating learning, and that future research should include proper controls to allow for a more definitive conclusion.

The systematic review showed that only 18% of the selected studies on gamification in medical education were grounded in a theoretical framework. The applied theories included Experiential Learning Theory, Reinforcement Learning Theory, Social Comparison Theory, and Self-Directed Learning/Self-Determination Theory. However, the evidence from high-quality studies is mainly at the level of use, and it is unclear how increased use relates to learning and reward. Additionally, the positive effects on knowledge and satisfaction need to be verified through well-controlled studies. Most of the studies were purely descriptive and did not test a theory, making it difficult to understand the mechanism by which gamification impacts the learning process. It was suggested that future studies should be grounded in a solid theoretical framework and consider other gaming attributes and societal values, as well as examine the impact of gamification on knowledge retention and the suitability of different parts of the basic science curriculum. The presentation, which lasted approximately 45 minutes, was followed by a 15-minute question and discussion period. Questions that were raised include: Do low stakes vs high stakes constitute a game attribute, and what do we know about games as part of formative vs summative assessment? Is there any compelling data that looked at knowledge retention and what the results say? What portions of the basic science curriculum are better suited for implementing games than others?