Setting and Problem
Teamwork is critical for patient and provider satisfaction; therefore, it is important to consider when interviewing resident applicants. Written applications and one-on-one interviews are unable to fully capture the dynamics of team interaction and interpersonal skills, which according to the National Resident Matching Program (NRMP) survey of program directors, are considered very important when ranking applicants. An escape room allows for observation of applicants engaged in teamwork. However, if poorly designed, it could give applicants a negative impression of the program.
Escape rooms are a form of cooperative, live-action gaming in which teams solve puzzles to successfully escape a “locked” room. Escape rooms are novel, fun, and in the cultural zeitgeist. We therefore hypothesized that a group activity modeled as an escape room would be acceptable to applicants and allow for observation of teamwork.
Intervention
Our escape room was part of a multifactorial interview process that also included one-on-one interviews. The intervention was determined exempt from Institutional Review Board review, because it did not meet the definition of human subject research.
We collaborated with a consultant experienced in the design of escape rooms to create an activity customized to our Mid-Atlantic residency. Program behavioral health faculty who facilitated the operation of the activity also served as the observers and evaluators of interpersonal skills, and their presence was integrated into the storyline of the activity. A standard script read by the faculty explicitly noted that the escape room activity was designed to observe teamwork. The puzzles related to locations, food items, and sports, which were inspired by unique geographical and cultural characteristics of our residency. Clinically themed clues were not part of the activity. This exclusion was intentional so that applicants would not misperceive the activity as an assessment of clinical ability. Applicant teams were tasked with opening 8 locks and solving a master puzzle within 50 minutes.
As a means of quality improvement of the recruiting process, the residency conducted informal, voluntary, anonymous online surveys of applicants following the NRMP Match Week. Among other questions, variations on “Did the group activity have a positive or negative impact on your impression of the program?” were asked in the 3 Match cycles prior to implementation of the escape room (2016–2018) and then again in the year the escape room was implemented.
Outcomes to Date
While some groups required more hints and extra time, all groups successfully completed the escape room. Behavioral health faculty generated scores for each individual. These scores were incorporated into a more expansive scoring rubric that was used to generate the program's preliminary rank order list for the Match, comprising 8% of the total score.
The results of the post-Match survey showed that the escape room was viewed positively by the 19 respondents of the survey (28% response rate, n = 69). It was rated “strongly positive” by 47% of respondents (n = 9), “positive” by 37% of respondents (n = 7), and “neutral” by 16% of respondents (n = 3). By contrast, the previous group activity used from 2016 to 2018 had 66 respondents (36% response rate) and was rated “strongly positive” by 21% (n = 14), “positive” by 17% (n = 11), “neutral” by 33% (n = 22), “negative” by 20% (n = 13), and “strongly negative” by 9% (n = 6) of the respondents. Comments from the free text portion of the survey appear in the Box.
Box Comments From the Free-Text Portion of the Escape Room Survey
Before Escape Room Implementation (2016–2018)
“The team-building survival exercise felt bizarre to me. I didn't understand the purpose of it…the only conclusion I was able to draw from it was that it was some way to psychoanalyze the candidates, which is a conclusion which is very off-putting to me and is not something I experienced this directly at any other programs.”
“I found it off-putting to be placed in a situation with other applicants and be observed by faculty members. It was uncomfortable given the fact that we were all there to interview for a select number of spots.”
“This was interesting—good analysis of group work and group dynamic. This was the only experience like this I had on the interview trail.”
“I loved this portion of the program!”
“I really enjoyed this part of interview day. It was fun and helped provide me with some insight about my communication, leadership, and teamwork skills.”
“This activity was actually a lot of fun, and I appreciated that the program cared about how we worked as a group.”
Representative Comments Regarding Acceptability of Group Activity After Escape Room Implementation (2019)
“I LOVED this activity and I thought it was so unique.”
“So much fun.”
“It just made the whole interview day very long.”
“It was great!”
“This was an excellent way to get a feel for how we would interact as possible co-interns.”
We conclude that a well-designed escape room can be highly acceptable while being an effective means of assessing applicant teamwork. The significant investment of faculty time for facilitation and the $3,000 cost for the initial design may be barriers for replication, although an escape room can be utilized by any residency program in collaboration with a skilled designer.
Footnotes
The authors would like to thank Jessica A. Parascando, MPH, for her work reviewing and preparing the manuscript.