Round34: Attending-Moderated Tabletop Gameplay to Enhance Resident Team Dynamics During Inpatient Rounds

ABSTRACT

Background

Inpatient medical rounds are central to experiential learning in residency education but are often challenged by high team turnover and hierarchal dynamics, limiting team engagement, comfort in asking questions, and education. Gamification can address these challenges.

Objective

To evaluate the impact of Round34, an investigator-developed cooperative card game designed to improve health care team dynamics on residents’ engagement in rounds, comfort in asking questions, and perceived educational value of rounds.

Methods

In a 22-week prospective randomized trial at a single academic center in 2024, paired inpatient internal medicine teams were randomized to intervention (game) or control (standard rounds) groups. Round34, played during teaching rounds, included prompts ranging from humor to clinical questions to facilitate interaction. Residents completed daily 10-point Likert surveys on perceived educational value of rounds, engagement, and comfort in asking questions (primary outcomes). Weekly surveys measured secondary outcomes of burnout (Maslach Burnout Inventory), well-being (Resident & Fellow Well-Being Index), and loneliness (UCLA Loneliness Scale). Rounding time was recorded daily. Outcomes were analyzed with ordinal regression adjusted for patient volume (total/new), call days, and round duration.

Results

From 274 of 455 possible daily and 54 of 91 possible weekly responses, the intervention group reported higher scores for perceived education (8.0 vs 6.2, P<.0001), engagement (8.5 vs 7.1, P<.0001), and comfort (9.1 vs 8.2, P<.0001). No differences were found in rounding time, burnout, well-being, or loneliness. Regression analysis confirmed gameplay was independently associated with improved outcomes.

Conclusions

Round34 boosted perceived educational value, engagement, and comfort during rounds, without increasing rounding time.

Introduction

Daily inpatient rounds are central to residency education, providing a platform to learn clinical reasoning, communication, and systems-based practice. Effective rounding relies on strong team dynamics, which, like in any field, are built on communication and trust.¹ Frequent turnover of teams means residents may join groups of near strangers, with little time to develop interpersonal comfort and trust before engaging in complex clinical decision-making. Low familiarity teams blunt the impact of effective rounding on medical education and patient care.² Effective teamwork is essential for ensuring better efficiency, team performance, and patient care,^3,4 but current training structures provide no systematic approach for helping new teams develop these qualities early in a rotation. The core gap is the absence of evidence-based strategies that can rapidly foster team familiarity, which would result in improved communication, decision-making, and patient outcomes.^5,6

Gamification is a promising tool to address these challenges. In medical education, it has been shown to enhance teamwork, motivation, and learning.^7-9 Given that rounding serves both patient care and educational purposes, any game introduced during this time must complement, rather than detract from, the learning experience. To our knowledge, no gamification interventions specifically target medical rounds.

We hypothesize that playing Round34, an investigator-developed, health care–related, card-based game, during rounds will improve residents’ engagement with the team, level of comfort in asking questions, and educational experience without impacting duration.

KEY POINTS

What Is Known

Inpatient medical rounds are vital for residency education but often suffer from limited engagement due to team turnover and hierarchical dynamics.

What Is New

A small, randomized trial showed that Round34, a physician-created cooperative card game, significantly improved residents’ engagement, comfort in asking questions, and perceived educational value of rounds, without negatively affecting rounding length of time.

Bottom Line

Gamification of rounds through Round34 enhanced the educational experience of rounds by fostering interaction and comfort, offering a practical tool to strengthen team dynamics.

Methods

Study Design and Data Source

We conducted a prospective randomized trial over 22 weeks (January to June 2024) at an urban academic medical center. Our internal medicine residency program includes 131 residents. Our internal medicine teaching teams consist of an attending physician, 1 to 2 postgraduate year (PGY) 1 residents, and a PGY-2 or PGY-3 resident. Participation was voluntary, and consent was implied through completion of anonymous surveys. Paired medicine teams, which share similar patient types, alternate admitting days, and an even patient load, were randomized to either the intervention or control group. Attendings in the intervention arm were given email instructions on how to play. They were encouraged to play as many days of the week as possible and as many rounds as they see fit.

We designed Round34, a quick, social, cooperative, draw-a-card game, with educational elements to test our hypothesis. We created the content using Microsoft Excel. Cards were designed in Adobe Photoshop version 24.7.1 and were formatted and printed using nanDECK version 1.27.1. The intervention involved playing Round34 during teaching rounds. The game design promoted team engagement by reducing hierarchical barriers, placing all participants on equal footing, and allowing teams to experience wins and losses together. The control group continued standard teaching rounds, maintaining their usual clinical and educational activities.

Game Attributes and Mechanics

Team members complete prompts on drawn cards and collaboratively arrange the cards so that the edges sum to 34 (online supplementary data Figure).

The game begins with all team members gathered, and one member draws a card from the Round34 deck. The drawn card can be one of the following 6 card types.

1. Joke Cards contain one-liner jokes.

2. Action Cards contain a simple one-line action item (eg, “Everyone shows off their socks”).

3. Story Cards prompt participants to share fun facts about themselves.

4. Take Sides Cards pose binary choices (eg, “Crunchy or smooth peanut butter?”) to stimulate lighthearted debates.

5. Medical Cards present clinical questions (eg, “What are the criteria for a lung cancer screening scan?”) to reinforce medical knowledge on the level of an internal medicine resident.

6. Trivia Cards include general and medical trivia to engage residents intellectually.

The player who draws the card reads the prompt to the team. The team then responds based on the type of prompt. Some prompts may require active participation of players, some may require discussion, others may not require responses at all. Once the card prompt is completed, the next team member draws the next card, and this process repeats until at least 4 cards have been drawn. After 4 cards have been drawn, the team works together to arrange the cards in such a way that each of the corners of the cards will numerically add up to 34 (online supplementary data Figure). This can be done with a card in any rotation as the center point between 4 cards forms a circle. Additional cards beyond 4, in multiples of 2, can be added to any free edge of the cards with the goal of continuing the linkage of corners adding up to 34 (online supplementary data Figure). A “game completion” was defined as drawing at least 4 cards, completing their prompts, and arranging them so that adjoining corners summed to 34; this process typically required only a few minutes and was designed to avoid disrupting patient care.

Outcomes

Primary outcomes measured were the residents’ perception of engagement, level of comfort in asking questions, and perception of education. These were assessed using 10-point Likert scale questions in daily anonymous surveys (online supplementary data Table 1). Secondary outcomes included assessments of burnout levels using the Maslach Burnout Inventory (MBI),¹⁰ overall well-being and distress measured by the Resident & Fellow Well-Being Index (RFWBI),¹¹ and feelings of social isolation evaluated by the UCLA Loneliness Scale¹² on a weekly survey (online supplementary data Table 2).

Survey Administration

Data were collected via anonymous surveys from both intervention and control groups. Daily surveys were distributed immediately after rounds to both teams with reminders and accessed by texted link or QR code. Each team of 2 (occasionally 3) residents could submit 10 to 15 daily surveys per week, for maximum totals of 225 (intervention) and 230 (control); variable response rates were expected because control teams did not play, and intervention teams might not play every day. Weekly surveys, offered each Friday, allowed up to 91 potential responses. Participation in gameplay and surveys was voluntary; no demographic or training-level data were collected to promote candor and reduce bias, and anonymity precluded tracking individual participation.

Analysis used IBM SPSS Statistics for Windows, version 25 (IBM Corp); figures were produced in Python (Google Colab). We computed between-group descriptive statistics using independent t tests or Mann-Whitney U tests for continuous variables and chi-square test for categorical variables. Because data distribution was non-normal, we performed multivariate ordinal logistic regression analyses to evaluate the relationship between gameplay and outcomes of interest after adjusting for potential confounders. A P value of less than .05 was considered statistically significant.

The study was approved by the institutional review board (iRISID-2023-1579) at Thomas Jefferson University Hospital.

Results

A total of 274 of 455 (60.2%) possible daily and 54 of 91 (59.3%) weekly surveys were received. The intervention group included 156 of possible 225 (69.3%) compared to 118 of possible 230 (51.3%) responses in the control group. We noted no significant differences in terms of total patient load, new patients, daily teaching rounds duration, or on-call status (Table 1).

Table 1.

Baseline Characteristics Based on Daily Questionnaires

Characteristic	Intervention (N=156)	Control (N=118)	P value
On-call days, n (%)	71 (45.5)	53 (44.9)	.92
No. of patients, mean (SD)	9.3 (2.1)	9.5 (2.0)	.33
No. of new patients, mean (SD)	1.2 (1.3)	1.1 (1.3)	.48
Duration of rounds in minutes, mean (SD)	117 (42)	117 (41)	.90
Games played, n (%)	131 (83.9)	0 (0)
Round34 completions per survey, mean (SD)	2 (1)	0 (0)

Within the intervention arm, Round34 was played on 83.9% (131 of 156) of survey days, with a mean of 2(±1) completions per survey (Table 1). Primary outcomes assessed via daily questionnaires favored the intervention group with significantly better mean (SD) scores across perceived education (8 [1.7] vs 6.2 [1.9], P<.01), level of engagement (8.5 [1.5] vs 7.1 [2.0], P<.01), and perception of level of comfort (9.1 [1.3] vs 8.2 [1.7], P<.01) compared to the control group (Table 2, Figure 1, section 1). Secondary outcomes (Table 2) assessed via weekly questionnaires showed no significant differences between groups in terms of burnout (MBI mean score: 5.6 [2.9] vs 5.5 [3.3], P=.93), well-being (RFWBI mean score: 3.2 [1.7] vs 3.0 [1.8], P=.64), or loneliness (UCLA 3-item scale mean score: 4.3 [1.4] vs 5.1 [1.6], P=.15).

Table 2.

Outcomes Based on Intervention and Control Group

Primary Outcomes (Daily Questionnaire)	Intervention (N=156)	Control (N=118)	P value
Perception of education			<.001
Mean (SD)	8 (1.7)	6.2 (1.9)
Median (IQR)	8 (7-10)	6 (5-8)
Perception of level of engagement			<.001
Mean (SD)	8.5 (1.5)	7.1 (2.0)
Median (IQR)	9 (7-10)	7 (5-9)
Perception of level of comfort			<.001
Mean (SD)	9.1 (1.3)	8.2 (1.7)
Median (IQR)	10 (8-10)	8 (7-10)

Secondary Outcomes (Weekly Questionnaire)	Intervention (N=27)	Control (N=27)	P value
Maslach Burnout Inventory			.93
Mean (SD)	5.6 (2.9)	5.5 (3.3)
Median (IQR)	5 (4-7)	4 (3-7.5)
Resident-Fellow Well-Being Index			.64
Mean (SD)	3.2 (1.7)	3.0 (1.8)
Median (IQR)	3 (2-4)	3 (2-4)
3-Item UCLA Loneliness Scale			.15
Mean (SD)	4.3 (1.4)	5.1 (1.6)
Median (IQR)	4 (3-6)	5 (3.5-6)

Figure 1.

Primary Outcomes Stratified by Intervention vs Control Group and by Game Played vs Not Played

Findings were consistent when comparing days games were played (131 surveys) versus not (143 surveys), with similar advantages for education, engagement, and comfort (online supplementary data Table 3, Figure 1, section 2).

In adjusted multivariate ordinal regression analyses, the intervention remained associated with higher scores across all 3 primary outcomes (Table 3, section 1). For education, the intervention was associated with a β coefficient of 1.60 (P<.01); for engagement, it was β coefficient of 1.43 (P<.01); and for comfort scores, it was a β coefficient of 1.15 (P<.01). Among the baseline variables, the number of patients did negatively impact education (β=-0.19, P<.01) and engagement (β=-0.21, P<.01) scores.

Table 3.

Multivariate Ordinal Logistic Regression

	Coefficient of Effect (β)	95% CI	P value
Intervention vs Control
Outcome 1: Perception of education
Intervention team	1.60	1.12, 2.06	<.001
No. of patients	-0.19	-0.31, -0.70	.002
Outcome 2: Perception of level of engagement
Intervention team	1.43	0.97, 1.89	<.001
No. of patients	-0.21	-0.33, -0.90	.001
Outcome 3: Perception of level of comfort
Intervention team	1.15	0.66, 1.63	<.001
No. of patients	0.11	-0.02, 0.23	.09
Game Played vs Not Played
Outcome 1: Perception of education
Game played	1.50	1.04, 1.96	<.001
No. of patients	-0.17	-0.30, -0.60	.003
Outcome 2: Perception of level of engagement
Game played	1.34	0.89, 1.80	<.001
No. of patients	-0.20	-0.32, -0.80	.001
Outcome 3: Perception of level of comfort
Game played	1.23	0.74, 1.72	<.001
No. of patients	0.12	-0.01, 0.25	.06
No. of Winning Game Rounds’ Impact on Outcomes
Outcome 1: Perception of education	0.51	0.33, 0.70	<.001
Outcome 2: Perception of level of engagement	0.43	0.25, 0.62	<.001
Outcome 3: Perception of level of comfort	0.33	0.12, 0.53	.002

Note: All models adjusted for number of patients, number of new patients, duration of rounds, and on-call days. Statistically significant values are bolded.

Results were similar when the data were stratified by the days when the game was played (Table 3, section 2). Table 3, section 3 shows that each additional winning game round was associated with significant increases in all outcomes. For education, each win was associated with a 0.51-point increase (P<.01), for engagement a 0.43-point increase (P<.01), and for comfort a 0.33-point increase (P<.01). All models were adjusted for baseline variables, including patient load, new patients, rounds duration, and on-call status.

Figure 2 shows the average scores of the primary outcomes stratified by day of the week in both the intervention and control groups.

Figure 2.

Outcomes by Day of the Week

Discussion

Round34 is a pedagogical intervention designed to enhance the inpatient medicine rounding experience through gamification.¹³ Needs assessment of resident feedback underscored the importance of strengthening communication, teamwork, and structured learning. The gamification of rounds can temporarily dissolve hierarchical barriers,¹⁴ promote resident confidence and willingness to ask questions,^15,16 and build a framework of coregulated learning where residents and mentors collaboratively navigate the educational environment.¹⁷ These factors that reinforce familiarity within a medical team can improve the psychological safety for residents and may also improve patient outcomes.^5,18

Rather than prescribing content, Round34 supplies prompts that support teaching while preserving each educator’s teaching style. Requiring no moderators or prior training, the game offers low-stakes opportunities for interaction and teaching and creates an open atmosphere for sharing knowledge, personal experiences, and humor. Our results suggest that the Round34 gamification effect led to comfort and engagement having a more persisting effect throughout the week, while in comparison, perceived educational value is more likely to fluctuate day to day. Our day-by-day analysis suggests that this game-based intervention helps teams connect earlier and build momentum across the week, rather than requiring several days to reach peak function. Importantly, based on the intention-to-play analysis, there was no significant difference in on-call days, number of patients on census, number of new patients on census, or duration of rounding. This informs us that these factors seemed to be well controlled within the randomization aspect between the 2 groups, and their characteristics were similar. We postulate that some of these benefits may be derived from unstructured rest breaks, which have been shown to enhance team performance, decrease fatigue, and boost vigor.^19-22 Incorporating breaks and informal interactions has been shown to mitigate stress and fatigue, while strengthening engagement.²¹ Unlike most medical education games, which are played in separate learning environments, we deployed Round34 in clinical spaces such as on the mobile computer stations, nursing stations, or standing desks outside patient rooms. Round34 is designed for real-time, “in vivo” clinical educational settings, seamlessly integrating into daily inpatient rounds.

Prior medical education tabletop games such as Pulmonopoly, Liver Land, and GridlockED have demonstrated efficacy in conveying knowledge and increasing participant satisfaction.^23-29 Other gamified strategies utilize nontraditional means to enhance team dynamics. For example, the use of “escape rooms” to simulate medical scenarios fosters teamwork, collaboration, and stimulates higher-order critical thinking.^30,31 The strength of these scenario-based games is their ability to immerse learners, challenge their behaviors, and facilitate evaluation at Kirkpatrick level 3 by measuring changes in behavior.

Several limitations of this study should be considered. The evaluation of this intervention was restricted to Kirkpatrick Levels 1 and 2 assessments of reaction and learning.³² The impact of Round34 on team behavior was not quantified. Because the study was conducted at a single center, the generalizability of our results may be limited to institutions with similar rounding structures or educational cultures. In addition, the intervention required access to table space to play the game, which may not be readily available in all rounding situations. Some general limitations of card-based games include the lack of ability to rapidly generate new cards on a frequent basis, and the general lack of platforms for card generation for those not familiar with card generation programs.

Future studies should aim to assess behavioral changes (Kirkpatrick Level 3) through assessment of the attending perceptions, objective measures such as direct observation of communication patterns on rounds, qualitative interviews with participants, or structured surveys assessing changes in team interactions and clinical decision-making. Further research could also explore the long-term impact of Round34 on knowledge retention, clinical reasoning, and team cohesion, as well as whether its use leads to sustained improvements in clinical education beyond single rotations. Beyond its current focus on pulmonology, critical care, and medical oncology, Round34 could be adapted for additional subspecialties, while categories such as Joke, Story, Take-Sides, and Trivia remain broadly applicable across diverse medical settings.

Conclusions

Incorporating Round34 in rounds improves resident engagement, comfort, and perceived educational value without impacting its duration.

Author Notes

Interim analysis was presented at the CHEST Annual Meeting October 6-9, 2024, Boston, Massachusetts, USA.

Funding: This research received internal funding from the Department of Medicine Wellbeing Program at Thomas Jefferson University. No external grant funding was used.

Conflict of interest: Dr Baig consults for Methapharm, Regeneron Pharmaceutical, Verona Pharmaceutical, and GLG expert network solutions.

Editor’s Note

The online supplementary data contains the game cards, outcomes based on days the game was played, and the questionnaires used.