An Escape Room to Teach First- and Second-Year Medical Students Nephrology

Abstract

An escape room is a team-based activity that requires players to solve a series of puzzles to complete a story and “break out” of a room. It has recently gained traction in medical education for its ability to interactively and effectively present learning objectives. This was a prospective educational study that describes the successful application of a nephrology themed escape room for first- and second-year medical students. Compared to pre-escape room participation, the 52 students demonstrated a statistically significant improvement in self-reported knowledge for renal physiology (p < 0.01), pharmacology (p < 0.01), pathology (p < 0.01), and relevant clinical practice guidelines (p < 0.01). A majority of the students also claimed that the escape room was “more effective” than traditional lectures (80.8%) and textbooks (73.1%) and “equally effective” as third-party board preparation resources (69.2%) and their institution’s problem-based learning curriculum (51.9%). The escape room also facilitated a high-level peer-to-peer collaboration with 82.7% and 76.9% of students reporting that they worked with someone in their year and outside of their year for at least half of the game, respectively. Ninety-five percent of the first-years and 84.6% of the second-years believed that the escape room was effective at preparing them for their respective exams, and an overwhelming majority (90.4%) described the escape room as “very enjoyable.” Overall, this nephrology themed escape room was an engaging and well received educational modality and may be an effective supplemental study resource for medical students. Further studies are needed to assess knowledge acquisition.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01917-6.

Introduction

Nephrology represents one of the more difficult subject areas in medical education nationwide [1]. In two separate studies, survey respondents recalled nephology as their most difficult course in medical school and expressed little interest in the subject [2, 3]. Although the complexity of renal physiology and pathology is unavoidable, the quality of preclinical education is likely to significantly influence student perceptions for this topic. A qualitative study demonstrated that a multimodal learning approach using various study tools promoted positive attitudes and greater knowledge for renal physiology [4]. Thus, reevaluating current educational approaches and creating engaging teaching modalities may improve learning outcomes for preclinical students studying nephrology.

Game-based learning (GBL) has gained traction in academia and may be an innovative way to address different medical education subjects, effectively delivering study objectives through tactile, physical, and analog activities [5]. One application of GBL is the escape room — a team-based game that requires players to complete a story by solving puzzles under a time constraint to “break out” of a situation [6]. A unique aspect of escape rooms is the creation of an underlying story that carries the participants through the puzzles. In medical education, the format is similar, but the puzzles focus on different medical education learning objectives. Recent applications across various disciplines such as emergency medicine, internal medicine, and vascular surgery have been successful in promoting learning, knowledge retention, team building, and communication skills [7–11]. They have also functioned as orientation strategies to familiarize medical students with event reporting procedures [9] and simulated medical environments [10]. Some of these escape rooms have employed hands-on activities such as ultrasound readings [11] whereas others were completely virtually using online forums [8]. Ultimately, they all shared the same sequential problem-solving and allowed participants to engage with each other while learning about a topic.

To address the potential challenges of medical student engagement in nephrology education, the application of an escape room may represent a promising, learner-centered approach. At the University of Hawaii, John A. Burns School of Medicine institution, nephrology is taught in the preclinical curriculum through problem-based learning (PBL), didactic lectures, and textbooks. This study designed a nephrology themed escape room for first-year (MS1) medical students preparing for their mid-course exam and for second-year (MS2) medical students preparing for their United States Medical Licensing Exam (USMLE) Step 1 board exam. The key objectives were to evaluate whether the escape room will:

1. Be an effective supplemental study tool

2. Confer similar, if not greater perceived benefit compared to lectures, textbooks, and other traditional study materials

3. Facilitate more inter- and intraclass collaboration

Methods

This prospective educational study was approved by the University of Hawaii Institutional Review Board. MS1 and MS2’s were solicited via university email listserv, and participation was voluntary. Participants were randomized into groups of five to six, with MS2s interspersed among MS1s. The resulting 10 teams were divided into two escape room sessions, each with five moderated rooms running in parallel. The moderators were clinical faculty and members of the study team.

Prior to starting the escape room, all the students attended a 10-min pre-brief in the auditorium to discuss the gameplay logistics, establish the rules, and provide the backstory for the escape room. Following the pre-brief, each team was led to their respective room and given a maximum of 40 min to complete the escape room. The rooms used were the standardized patient rooms in the clinical skills lab at the medical school and contained six total puzzles that covered learning objectives across four subject areas: physiology, pharmacology, pathology, and clinical practice guidelines. Learning objectives for each puzzle were determined by the topics listed in the institution’s course syllabus and by the common themes highlighted across multiple USMLE study materials.

The escape room story started with a group of medical students who are trapped by their preceptor on nephrology rounds. The attending was previously a passionate and caring educator but was recently placed under a “curse” which made him “evil”. To save him and escape nephrology rounds, the students had to find and recite the “secret phrase” that would reverse the curse. This phrase was revealed by solving different puzzles and getting to the final crossword. Some puzzles were connected and required sequential completion to finish (Fig. 1). For instance, solving Puzzle #1 would provide the code to access Puzzle #2. Solutions to Puzzle #2 contributed to the final crossword (Puzzle #6). Puzzles were created by members of the study group and were tested by medical students who did not participate in the study (see Supplementary File 1).

Fig. 1.

Escape room gameplay flow chart

Following the escape room, participants were led by the study team in a 40-min debrief session. All participants were asked to reflect on their experiences and identify key learning points which were shared and expanded on with the larger group. The game moderators also presented a slide presentation to review the solutions for each puzzle and reinforce the learning objectives (see Supplementary File 2). Following the debrief session, all the learners were asked to complete a survey. Survey items using five-point Likert scales queried learners’ retrospective pre- and post-intervention comfort with renal physiology, pharmacology, pathology, and clinical practice guidelines before and after escape room participation. An additional three-point Likert scale also had participants compare the relative efficacy of escape rooms as “more effective,” “equally effective,” or “less effective” compared to lectures, third-party board examination resources, traditional textbooks, and the school’s PBL tutorial sessions. Overall enjoyability, perceived effectiveness, and degree of inter- or intraclass collaboration were assessed.

Data Analysis

Demographic data on class year was obtained. and the Shapiro–Wilk test was used to evaluate the normality of the data. Since the data did not demonstrate normality, a non-parametric Wilcoxon signed-rank test was used to assess if there was a significant difference between the pre- and post-participation responses. A Spearman correlation was performed to compare if working alone or with others correlated with greater scores in enjoyability or perceived effectiveness.

Results

Fifty-two students participated in the activity, including 39 MS1s and 13 MS2s. All teams were able to complete the escape room in under 40 min. Self-reported understanding of renal physiology, pharmacology, pathology, and clinical practice guidelines each improved significantly after escape room participation compared to retrospective baseline (all p < 0.001). Their level of understanding was rated on a five-point Likert scale (1, not knowledgeable; 2, slightly knowledgeable; 3, moderately knowledgeable; 4, very knowledgeable; and 5, extremely knowledgeable), and the medians and interquartile ranges for the responses are displayed in Fig. 2.

Fig. 2.

Self-reported knowledge across learning objectives before and after the escape room (* indicates p-value < 0.01; black bar represents median values)

Overall, 80.8% and 73.1% of participants rated the escape room as more effective than traditional lectures and textbooks, respectively. 69.2% and 51.9% considered the escape room to be equally effective compared to third party board prep resources and the school’s PBL tutorial sessions, respectively (Fig. 3).

Fig. 3.

Escape room effectiveness versus other study tools (N = 52)

Inter- and intraclass collaboration was also evaluated as MS2s were mixed with MS1s on each team. When asked how often they were working alone, 90.4% of the students reported “less than half of the time.” 63.5% reported that they were working with someone in their class “more than half the time” and 36.5% reported working with someone outside their class “more than half the time” (Table 1). In terms of enjoyability, 90.4% reported the escape room to be “very enjoyable,” with 7.7% and 1.9% reporting “somewhat enjoyable” and “neutral,” respectively. No participants rated their experience as “not enjoyable.” Finally, MS1 and MS2s were asked to rate the escape room’s overall effectiveness on a three-point scale (1, not effective; 2, somewhat effective; and 3, very effective). Ninety-five percent of MS1s answered that the escape room was “very effective” in integrating information from all the first-year courses so far. 84.6% of MS2s believed the escape room was “very effective” in helping them identify areas of improvement prior to their upcoming USMLE exam. There was no significant correlation between degree of inter- or intraclass collaboration with enjoyability (p = 0.73 and p = 0.34, respectively) or perceived effectiveness (p = 0.82 and p = 0.07, respectively).

Table 1.

Degree of inter- and intraclass collaboration

	How often during the escape room were you working alone?	How often did you work with someone in your class/year?	How often did you work with someone NOT in your class/year?
Less than half of the time (N)	90.4% (47)	17.3% (9)	23.1% (12)
About half of the time (N)	5.8% (3)	19.2% (10)	40.4% (21)
More than half of the time (N)	3.8% (2)	63.5% (33)	36.5% (19)

Discussion

This study is one of the first to describe a nephrology-themed escape room for pre-clinical medical students. It demonstrated a significant perceived increase in level of understanding on renal physiology, pharmacology, pathology, and clinical guidelines. An overwhelming majority of the participants described the escape room as somewhat-to-very enjoyable, very effective at integrating information, and very effective at identifying personal areas in need of improvement. Furthermore, the escape room was considered as effective or more effective than other more commonplace educational modalities which teach nephrology. Finally, this escape room facilitated peer-to-peer teamwork with 90.4% working in a group more than half the time. As nephrology has historically been a difficult subject, this escape room offers a unique and engaging supplemental educational activity to support peer to peer interaction, increase perceived levels of understanding, and identify areas in need of further review.

Although Zaric and colleagues asserted that gamification does not directly affect learning, they postulated that it increases behaviors and attitudes that stimulate it [12]. While mixing colored vials in this escape room did not require any “learning,” the students needed to apply Winter’s formula and their understanding of metabolic acidosis to choose the correct vials. Anecdotal evidence of positive attitudes was also observed by the study team with students expressing increased enthusiasm and friendly competitiveness as they encouraged each other to recall concepts needed for the puzzles. This was consistent with over 90% of participants reporting the escape room experience as enjoyable. It is possible that positive learner attitudes and increased active recall in the form of GBL facilitated better perceived knowledge following escape room participation.

Additional clues to mitigating factors for escape rooms’ benefits may lie in comparison to the modalities which students deemed as “equally effective,” namely PBL and third-party board review materials. PBL involves small group learning by systematically reviewing a case, developing hypotheses, generating learning issues, and presenting the learning issues in subsequent sessions [13]. This process emphasizes the learner’s role in facilitating their learning and encourages peer-to-peer collaboration in real-time problem-solving [13, 14]. The nephrology escape room activity similarly encouraged collaboration and problem-solving. The reflection and identification of learning objectives during the debrief session also parallels learning issue presentations in PBL. These shared features may point to generalizable components of pedagogical strategies which modern adult medical learners perceive as effective use of their time. Third-party board preparation resources represent a heterogeneous collection of independent study tools and multimedia aides, which lack the commonalities of escape rooms and PBL described above. However, one parallel could be the escape room puzzle contents’ emphasis on “high-yield” learning objectives similar to those found in popular board review material.

In this study, 82% of MS1’s and MS2’s engaged in collaborative learning at least half the time throughout the escape room. Vygotsky’s zone of proximal development theory states that cognitive growth potential is enhanced by the support of a “more knowledgeable person” [15], which in this study was represented by MS2s who had already completed the nephrology course and were revisiting the content in preparation for board exams. However, the degree of peer-to-peer collaboration was not a strong predictor for the escape room’s enjoyability of effectiveness. This is likely due to the overwhelmingly positive student feedback, irrespective of whether they worked alone or together.

Limitations

This study is not without limitations. Many of the escape room’s puzzles were unintentionally able to be accessed out of sequence. Although working on multiple puzzles simultaneously facilitated more gameplay success, it also meant that some participants were not exposed to all the puzzles, forming gaps in their learning. Nevertheless, we believe the debrief session mitigated this concern. The evaluation may also be limited by bias. Because this was not a mandatory event, the students participated on a volunteer basis which may have positively affect our results, especially if they had an affinity to game-based learning. The self-reported data also only reflected the students’ perception but did not demonstrate whether the escape room translates to improved scores on exams. Further research is needed to answer this question.

Conclusion

This study showed that a nephrology-based escape room is well received, encourages peer-to-peer interactions during learning, and improves perceived understanding of nephrology topics. This study adds to the growing literature for the use of escape rooms in medical education as an innovative modality to teach preclinical content. Further studies assessing knowledge acquisition should be completed to best understand the full educational impact of escape rooms on preclinical topics.

Supplementary Information

Below is the link to the electronic supplementary material.

Data Availability

The authors confirm that all the data from the current study are available from the corresponding author on reasonable request.

Declarations

Ethics Approval and Consent

This research project has obtained approval from the University of Hawaii review board and ethics committee. The procedures used in this study adhere to the tenets of the Declaration of Helsinki. All subjects participated in the study on a voluntary basis and were provided informed consent.

Conflict of Interest

The authors declare no competing interests.