Stephen C. Shannon, DO, MPH
Gamification: Harnessing New Technologies to Optimize the Medical School Learning Experience
As I have written previously on the new strategic plan that AACOM established July 1 of this year, I thought I would take this opportunity to discuss in more depth one of these new strategic goals and an initiative that has grown out of its pursuit: GAMIFICATION or ‘educational gaming.’
With its new strategic plan, AACOM seeks to "Support member schools in preparing osteopathic physicians who are ready to meet the evolving health care needs of America by promoting excellence, innovation, and a culture of lifelong learning throughout medical education." We identified gamification as an area of exploration that could act as a springboard for innovation and help our colleges deliver state-of-the art medical/clinical training in an efficient and effective way.
What is "Gamification?"
"Gamification is the use of game thinking and game mechanics in non-game contexts to engage users in solving problems. Gamification has been studied and applied in several domains, with some of the main purposes being to engage (improve user engagement, physical exercise, return on investment, flow, data quality, timeliness); teach (in classrooms, the public or at work); entertain; and to improve the perceived ease of use of information systems. A review of research on gamification shows that a majority of studies on gamification find positive effects from gamification." - Wikipedia
In the context of medical education, gamification includes training using simulation tools, video game representations, and other modern electronic gaming modalities to supplement the learning of educational objectives toward clinical competency. In the health care system of the future, both patients and physicians will be playing more games in the pursuit of higher learning and health care awareness, discovering that “play is not a waste of time.”
Video Games Can Improve Medical Training
Gamification is one of the newest approaches to learning that has found its place among classroom lectures, laboratory exercises, TBL, PBL, flipped-classroom and many other well-tested models of teaching and learning. The various topics in medical education covered by current gaming products are extensive and include anatomy, physiology, pharmacology, radiology, pathology, cardiology, patient literacy, surgery, patient encounter skills, and many more. Learning through gaming is not new but applying it to medical education and practice is a relatively novel idea due to the complexity of the field of medicine and the fidelity required to approach the ‘reality’ required to enrich the clinical experience. There are several recent examples that point to the potential efficacy of the format as well as a place for this mode of learning throughout the medical education continuum. For instance, a quiz-based clinical neurophysiology game has been shown to significantly improve scores residency in-service exams.  General surgical residents showed similar gains with the use of quiz-based learning games. In fact, video game skill appears to correlate positively with laparoscopic surgical skills. Heavy video game users made 37 percent fewer errors and were 27 percent faster than non-gamer residents were at actual laparoscopic procedures.
Medical Games are Preferred Over Lectures
The current generation of learners – now in or approaching medical school – are adept gamers. So it’s not surprising that game-based learning is a preferred mode of learning that drives engagement at a higher and more meaningful level than lectures. In a 2013 presentation by researchers at A.T. Still University of Health Sciences School of Osteopathic Medicine in Arizona (ATSU-SOMA), gaming strategy in learning is identified as different from other approaches, in that it allows for expression of competition, rules, and procedures as well as rewards. In the investigators’ experience with a patient safety gaming instrument, the learners were able to integrate fun and excitement into the learning process, possibly contributing to a reduction in stress and anxiety while enhancing motivation through competition, social interaction, communication, teamwork, reinforcement of existing knowledge, as well as the encouraging of complementary and formative feedback.  Common responses of learners to educational learning experiences include: “enjoyable”; “stimulating”; “engaging”; “increased my content knowledge”; and “helped me retain information.”
In a survey of 434 residency program directors, more than 90 percent supported the use of games in residency education. Approximately 80 percent supported quiz-based exercises to supplement learning, which not only improved learning outcomes among medical students, but also improved the students’ opinion of medical microbiology as a field. Levels of engagement appeared particularly high, with a geriatric house call video game and, as a group, those students strongly supported the inclusion of the game in training. Such positive attitudes toward video games are not restricted to video game users. Eighty percent of medical students surveyed felt that video games have educational value. More than three-quarters of respondents would use a video game on their own time if it would help them improve their medical knowledge or patient management skills.
The inherent properties of most video games, such as goal-directed challenges and real-time feedback, coincide with ideal approaches to science education. Users are highly motivated to perform tasks within a video game environment for digital, rather than tangible gains. There are numerous examples in which video games, especially quiz-based games, improve medical and science learning outcomes. Moreover, most students and educators involved in medical education endorse the premise of video game-based exercises. It is conceivable that video game learning may soon become a more mainstream and significant component of medical education.
Fidelity - Simulation Increases Learners’ Abilities in Reality
Hands-on learning experiences are critical to osteopathic medical education. Looking at the use of sensory and data acquisition technology to measure and characterize the sense of touch, one physician recently developed the “E-Pelvis” - an electronic pelvic mannequin. Students practice pelvic exams on the device, and instructors can see the location and intensity of the students’ touch. It’s a far cry from merely reading about how to do a pelvic exam, as in most pedagogical circles, it is generally accepted that “doing” fosters more effective learning than just “seeing.”
There is more, much more, to come from the use of gamification in medical school, as both learners, educators, and physicians explore what’s possible in this new paradigm of learning. A 2011 AACOM Osteopathic Health Policy Intern, Dr. Cole Zanetti exemplifies this growing trend in educational gaming engagement with his academic research presentation entitled "Virtual Reality as a Supplemental Tool for the Advancement of Medical Education." Here are just a few other emerging ideas for future exploration:
- Mental health patients are using games to confront phobias, such as a fear of spiders, by placing patients into virtual situations with their fears. [Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. Thomas D. Parsons, Albert A. Rizzo. Journal of Behavior Therapy and Experimental Psychiatry 39 (2008) 250–261]
- Patients with severe burns can play a therapeutic game that immerses them in a snowy, cold environment. [Virtual-reality Video Game To Help Burn Patients Play Their Way To Pain Relief." ScienceDaily, 22 March 2008.]
- Immersive simulations, such as a game set in Iraq, lets veterans return to virtual battle to reduce post-traumatic stress disorder. [Effect of Virtual Reality PTSD Treatment on Mood and Neurocognitive Outcomes. McLay Robert, Ram Vasudha, Murphy Jennifer, Spira James, Wood Dennis P., Wiederhold Mark D., Wiederhold Brenda K., Johnston Scott, and Reeves Dennis. Cyberpsychology, Behavior, and Social Networking. July 2014, 17(7): 439-446.]
- Reduction of drug prescribing for chronic pain and other health issues by use of use of virtual reality games to build resilience, bring relief and change health habits. [Virtual reality and pain management: current trends and future directions. Angela Li, Zorash Montaño, Vincent J Chen, and Jeffrey I Gold. Pain Management, Vol. 1, No. 2 , Pages 147-157]
Is any of this really possible? At AACOM, we believe that the future is wide open, and it is our goal to act as a facilitator and thought leader in developing research around and future uses for gamification in medical education.
List of Gamification Resources:
- 21st Century Skills: Mishra, P. (2012). Rethinking technology & creativity in the 21st century: Crayons are the future. TechTrends, (September/October), 13–16.
- Barab, S., Gresalfi, M., & Ingram-Goble, A. (2010). Transformational Play: Using Games to Position Person, Content, and Context. Educational Researcher, 39(7), 525–536.
- Brain: Zull, J. E. (2004). The Art of Changing the Brain. Educational Leadership, September.
- Brain: Green, C. S., & Bavelier, D. (2003). Action video game modifies visual selective attention. Nature, 423(6939), 534–7.
- Brain: CNN (2012) Gaming Reality, http://www.cnn.com/
- Flow: Schiefele, U., & Raab, A. (2011). Skills demands compatibility as a determinant of flow experience in an inductive reasoning task. Psychological Reports, 109(2).
- Engagement: Gee, J. P. (2005). Pleasure, Learning, Video Games, and Life: the projective stance. E-Learning, 2(3), 211.
- Psychosocial Moratorium: Deterding, S., & Dixon, D. (2011). Gamification : Using Game Design Elements in Non-Gaming Contexts. Sociology The Journal Of The British Sociological Association, May, 5–8.
- Social Collaboration: Brown, J. S., Collins, A., & Duguid, P. (2007). Situated cognition and the culture of learning. Educational Researcher, 18(1), 32–42.
- Schema: Anderson J. The Architecture of Cognition. Cambridge, MA: Harvard University Press; 1983.
- Scaffolding Connections: Bransford J, Brown A, Cocking R. (2000). Mind and Brain. In: How People Learn: Brain, Mind, Experience, and School. Washington, D.C.: New Academy Press.
- Social Interaction: Aufschnaiter, C. (2003). Interactive processes between university students: Structures of interactions and related cognitive development. Research in Science Education. 233:341– 374.
- Inquiry Episodes: Duckworth E. The Having of Wonderful Ideas and Other Ideas on Teaching and Learning. New York, NY: Teachers College, Columbia University; 2006.
- Time to Reflect: Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Advances in Health Sciences Education. 2009;14(4):595–621.
- Constructivism: Bronack S, Riedl R, Tashner J. (2006). Learning in the zone: A social constructivist framework for distance education in a 3-dimensional virtual world. Interactive Learning Environments. 14(3):219–232.
- Cognitive Learning: Patel VL, Arocha JF, Zhang J. (2004). Thinking and Reasoning in Medicine. In: Cambridge Handbook of Thinking and Reasoning. Cambridge, UK: Cambridge University Press; 1–34.
- Game Learning: Kebritchi M, Hirumi A. (2008). Examining the pedagogical foundations of modern educational computer games. Computers & Education. 51(4):1729–1743.
- Fun: Prensky M. (2001). Fun, Play and Games: What Makes Games Engaging. In: Digital Game Based Learning. McGraw-Hill. 1–31.
- Deterding, S., & Dixon, D. (2011). Gamification : Using Game Design Elements in Non-Gaming Contexts. Sociology The Journal Of The British Sociological Association.
- Affordances: Dalgarno, B., & Lee, M. (2010). What are the learning affordances of 3-D virtual environments? British Journal of Educational Technology, 41(1), 10–32.
- Non-linear learning: Poulton, T., Conradi, E., Kavia, S., Round, J., & Hilton, S. (2009). The replacement of “ paper ” cases by interactive online virtual patients in problem-based learning. Academic Medicine, 31, 752– 758.
- Perspectival Framing: Van de Sande, C., & Greeno, J. G. (2012). Achieving Alignment of Perspectival Framings in Problem-Solving Discourse. Journal of the Learning Sciences, (November 2012), 37–41.
- Legitimate Peripheral Participation: Lave, J., & Wenger, E. (1991). Situated learning: Legitimate peripheral participation (p. 123). New York, NY: Cambridge University Press.
Watch these speakers give their talks at TEDMED 2014: Visit the TEDMED 2014 website (http://tedmed.com/event/tedmedlive?ref=about-tedmedlive) and login with Affiliate ID: L94281.” Once you’ve logged in to the on-demand streaming, find the appropriate video:
For the beginning of Dr. Pugh’s talk, find the “Play is not a waste of time” video and go to 32:59.
For the beginning of Rose’s talk, find the “Play is not a waste of time” video and go to 1:28:47.
For the beginning of Dr. Primack’s talk, find the “Stealing smart – San Francisco stage” video and go to 02:24.
 “Gaming as a tool to teach patient safety,” Fred Schwartz, DO; Tom Bennett, DO; Rupal Vora, MD; Noel Carrasco, MD; Inder Makin, MD; Robin Pettit, PhD; Stan Brysacz DO; and Lise McCoy, MTESL, A.T. Still University