Abstract
Medical schools are moving away from traditional lectures in favor of small-group learning. Here we present a game-based activity designed to improve student engagement while serving as a course review. The activity incorporated 32 questions submitted by eleven discipline directors. The 133 student participants reviewed the session positively, rating it highest of the 11 course sessions with an overall quality of a 4.68 (± 0.84) out of a 6-point Likert scale. The students remarked that the activity was fun and engaging, yet long. It reviewed a breadth of content over several specialties in a format that encouraged active, team-based learning.
Keywords: Flipped classroom, Small group, Game-based activity, Medical education
Background
Many health institutions are moving away from the traditional lecture-based approach in favor of active learning and flipped-classroom strategies [1–4]. One challenge for flipped-classroom educators is to deliver in-class activities that (1) are new, (2) are engaging for students across disciplines and backgrounds, (3) effectively target course objectives, (4) are appropriately challenging, and (5) are an efficient use of class time. Frequently scheduled sessions throughout curriculum contribute to student and faculty burnout [5]. Implementing game activities is an exciting way to mitigate student disengagement and review material in close proximity to assessment during a preclinical curriculum. In recent years, game-based activities have been developed to assuage the above challenges posed by the flipped-classroom model [6–8].
The core of our pre-clerkship curriculum is case-based sessions accompanied by prerecorded video lectures. Students are provided asynchronous learning materials which include prerecorded lectures and course notes. A standard in-class session has small groups of students participate in activities designed by both basic scientist and clinician faculty revolved around a particular disease process. For example, in our gastrointestinal “Food to Fuel” course, students receive a case of abdominal pain and in their small groups are asked to interpret historical, physical exam, laboratory, and imaging data to come up with a differential diagnosis. Subsequently, the pathophysiology and basic sciences surrounding these disease processes are reviewed. This format exposes students to clinical context for more engaged students.
Activity
“Gut Games” is a learning activity developed for a flipped-classroom session during the gastrointestinal block of the preclinical curriculum in a 4-year medical college. Designed to be played in 1 to 2 h, our game session lasted for 90 min and was played by a medical student body of 133 first-year medical students divided into eight groups of 15–17 students. Each group was further subdivided into 4 subgroups of 4–5 students and led by one clinician faculty facilitator. Basic scientists, who design elements of the activity, rotate between groups to assist clinician faculty facilitators, which is standard in our curriculum.
Prework: One week prior to the class session, students were issued self-study materials that were estimated to take 3 h to complete, which is standard in our curriculum [9]. The materials included seven lecture recordings of approximately 10 min each, 25 pages of lecture notes, and 75 presentation slides. Students must complete and understand the material in order to effectively apply the content to the activity.
Flipped-classroom session: Attendance for classroom sessions is mandatory. Content experts, including basic science and clinical educators, developed questions on the most common conditions associated with the digestive system. These varied in format including multiple choice, free response, concept mapping, and matching. An approximately equal proportion of the questions were first-order recall (e.g., multiple choice), knowledge application (e.g., build a differential diagnosis), or higher-order questioning (e.g., interpreting lab data or imaging). An example of one such question showed an image of a normal proximal duodenum taken by endogastroduodenoscopy (EGD) and read, “Where am I?”
Digital presentation slides containing the questions served as an outline for the facilitator to guide the students through the session. The game had 8 sequential rounds progressing through seven locations in the gastrointestinal tract and one round of miscellaneous questions, starting at the mouth and finishing at the rectum (Fig. 1). Each location contained 3–5 questions for a total of 32 questions. Collaboration between subgroup members was encouraged, and consensus was required for an answer to be submitted. All groups progressed simultaneously through each location in the gastrointestinal tract, with the goal of acquiring the most points by successfully answering questions. The point value and time allotted to submit an answer varied for each question and were proportional to the difficulty of the question, pre-determined by the faculty. At the beginning of each question, the facilitator revealed the question prompt, the time limit (30 s to 2 min), and possible points. When the time limit for the question expired, the subgroups rejoined as a larger group to share and discuss their answers with the clinical facilitator. At the end of each gastrointestinal tract location, the points of all the questions for the round were tallied up and a single round leader was declared. At the end of the final, 8th round through the gastrointestinal tract, points were tallied and the subgroup with the most points won the game.
Fig. 1.
Game board and summary of questions by topic. The game was played using a standard game board and game pieces which students could move from location to location in the GI tract as they successfully completed questions at each location. Each location contained questions based on content that correlated with the location in the GI tract. For example, Barrett’s esophagus was included in a question at the oral and esophageal location while anal fissures were included in a question at the rectum/anus location
Session evaluation: After the session, students completed an anonymous electronic evaluation form that included six questions on a 6-point Likert scale aimed at assessing the pre-session materials, the facilitators, and the overall quality of the session. An empty box allowed students the opportunity to provide comments regarding the session. This is a standard form that has been used for every session during the curriculum.
Results
Of the 136 students enrolled as first-year students, 133 participated in the activity and completed a post-session evaluation (Table 1). Respondents rated the quality of the session a 4.68 (± 0.84) out of a 6-point Likert scale. This session achieved the highest rating out of the 11 sessions in the “Food to Fuel” course. Other sessions in the course had the following ratings: 4.27, 4.33, 4.43, 3.33, 4.14, 4.63, 4.33, 4.01, 4.58, and 4.37 (mean 4.23 ± 0.35). On the Gut Games session, 84% of respondents either “agreed” (58%) or “strongly agreed” (26%) that the learning objectives for this module were met. Eighty-one percent of respondents “agreed” (48%) or “strongly agreed” (33%) that the overall quality of this session was excellent. The student’s experience with the session was impacted by engagement by other students within their large group and the facilitator, as seen in the group variability in responses to the post-session evaluation (Table 1). The lowest satisfaction seen was in group 1, where the facilitator was noted by students to not seem as prepared for the session as the facilitators in the other 7 groups. The highest satisfaction with the activity was seen in group 2, where the facilitator was noted to be well prepared for the session.
Table 1.
Summary of survey responses
| Group number* | Number | I had sufficient time to review the independent learning materials† | The independent learning materials for this module were excellent† | The facilitators created a positive learning environment† | The facilitators was/were well prepared† | The learning objectives for this module were met† | The overall quality of this session was excellent† |
|---|---|---|---|---|---|---|---|
| 1 | 16 | 3.81 | 3.44 | 3.06 | 2.94 | 3.44 | 2.69 |
| 2 | 17 | 4.71 | 4.24 | 5.41 | 5.47 | 5.06 | 5.29 |
| 3 | 17 | 4.35 | 3.71 | 5.47 | 5.59 | 4.94 | 5.00 |
| 4 | 17 | 3.94 | 3.59 | 5.18 | 5.35 | 4.59 | 4.53 |
| 5 | 15 | 4.53 | 3.93 | 5.80 | 5.80 | 5.20 | 5.40 |
| 6 | 17 | 4.94 | 3.47 | 5.71 | 5.65 | 4.71 | 4.82 |
| 7 | 17 | 4.82 | 4.65 | 4.88 | 4.88 | 5.06 | 5.06 |
| 8 | 17 | 4.82 | 4.18 | 5.18 | 5.35 | 4.35 | 4.47 |
*The 133 students were broken into 8 groups of 12–17 students
†The survey responses provided by the 8 groups are based on a 6-point Likert scale, where 1 indicated that a student strongly disagreed with the statement and 6 indicated that a student strongly agreed with the statement
To qualitatively assess the session, the student comments were analyzed for themes. Of the 75 comments submitted by students that were directly related to the activity, 34 wrote that the activity was “awesome,” “good,” or “best of the year so far”; 12 wrote that the activity was highly engaging and/or interactive; and 11 wrote that the activity was fun. The most common negative comment was that the activity was too long, indicated in 33 comments.
Discussion
The increased popularity of flipped-classroom has created a need for new, engaging, and validated activities that are both enjoyable and effective. The game activity described here was developed to address student comments stating that activities were becoming dull and monotonous. When designing this novel game activity, the primary objectives were to deliver a unique yet effective instructional activity that not only kept a clinical context but was also innovative, fun, and thought provoking. The session scored very highly, with 4 out of 5 students indicating that the quality of the session was excellent. The activity met 19 pre-session objectives covering content in anatomy, microbiology, embryology, and pathology through the entire gastrointestinal system in under 2 hours (Table 2). This session was delivered a few days prior to the summative assessment; it served as a high-yield review, thereby meeting another major objective, which was acknowledged by several students in their qualitative evaluation remarks. Although this session scored highly compared to other sessions in the “Food to Fuel” course, a future study could be designed to evaluate whether this novel game activity affects ultimate performance on assessments.
Table 2.
Distribution of questions by discipline
| Discipline | Percent of total questions (%) |
|---|---|
| Anatomy/surgery | 28 |
| Biochemistry | 6 |
| Histology | 6 |
| Immunology/microbiology | 20 |
| Pathology | 9 |
| Physiology | 13 |
| Pediatrics | 6 |
| Pharmacology | 3 |
| Pathophysiology | 13 |
Game questions were categorized by discipline and written by content experts in their respective fields. The frequency of questions aligned with approximately the overall distribution in the pre-session materials and represent all disciplines except for genetics in the “Food to Fuel” course
Activities such as “Gut Games” heavily rely on consistency and effective engagement by clinician facilitators. A limitation noted in all sessions throughout the curriculum was that different facilitators provided very different experiences for the student groups. Therefore, instructor training prior to the activity is important for consistent delivery, to ensure consistent experience among groups. This could provide an explanation for the low session outcome scores from group 1, as this group responded negatively to the question “the facilitator(s) was/were well prepared” (Table 1). It is important to note that all facilitators had similar training in normal and abnormal gastrointestinal processes and therefore did not have any overt advantages which could have affected student evaluations. Because “Gut Games” covers many gastrointestinal topics, diseases, and physiologic processes, clinician facilitators may require a significant amount of time to prepare to lead the activity. Since the rules and processes of the game are unique, it is recommended that facilitators for this session play the game themselves prior to conducting the session so that they have a full understanding of game play rules and the activities that will occur at each location.
Overall, the desire to conduct flipped-classroom activities has provided opportunity to rethink the classical approach to teaching preclinical medicine topics. “Gut Games” is a small-group activity that encourages teamwork and review prior to assessment. This type of activity can be scaled and used for a wide variety of health science curricula that utilize small-group session learning.
Acknowledgements
The authors would like to thank Virginia Ferrante-Iqbal for her illustration. We would also like to thank Anne Carroll for her assistance in reviewing session evaluations.
Author Contribution
All authors contributed equally to the inception, design, and implementation of the work as well as data collection and evaluation and creation of the manuscript, tables, and figure.
Declarations
Conflicts of Interest
The authors declare no competing interests
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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