LIVE. DIE. REPEAT: a novel instructional method incorporating recursive objective-based gameplay in an emergency medicine simulation curriculum

Background

Medical educators must develop instructional methods suiting the learning styles of their students. Simulation-based curriculums are popular among resident physicians, and have been shown to improve information recall and diagnostic abilities, and to sustain proficiency of procedural skills.¹ The gamification of learning, a mechanism that engages students by integrating serious-game elements into the educational environment, has recently been explored.² At our emergency medicine residency, we aimed to create a hybrid of the two models that would profit from each method's individual strengths.

Recursive objective-based gameplay (ROBG) is a serious-game scheme in which participants are allowed infinite lives so that they can achieve predetermined criteria for progression through multiple levels of increasing difficulty. The concept resembles time loops, a plot device used in the film Edge of Tomorrow (Warner Bros Pictures 2014). We named our simulation/ROBG hybrid instructional method ‘LIVE. DIE. REPEAT.’(LDR), after the tagline featured on promotional materials for the aforementioned film.

We designed a LDR curriculum targeting critical management concepts in emergent pulmonary conditions. In this manuscript, we describe the LDR concept and design, and present initial evidence supporting the effectiveness of this model in training emergency medicine residents.

Methods

The LDR design and pulmonary scenario was developed and piloted for the Mayo Clinic Emergency Medicine Residency at the Mayo Clinic Multidisciplinary Simulation Center in Rochester, Minnesota, USA. A single-session high fidelity simulation-based intervention was produced and administered four times to provide exposure to available cohort members (postgraduate year 1 through 3 residents) in small groups. Each session lasted 4 hours and was completed with five resident physicians and one emergency nurse. Participants were notified of the novel LDR structure in advance but were blinded to the topic. Residents were encouraged to watch Edge of Tomorrow beforehand to become familiar with the concept and to alleviate any potential stress the new instructional design might create. Participants were given detailed instructions at the start of the day, describing the gameplay, with special focus on the task-oriented and recursive nature of the instrument. The study was deemed exempt by the Mayo Clinic Institutional Review Board.

The LDR case design for the pulmonary educational module is described in figure 1.

Figure 1.

LIVE. DIE. REPEAT. (LDR) pulmonary case design.

A team included two emergency medicine residents and one emergency nurse. Inactive participants observed via live video feed. If the team achieved the indicated task within the designated time frame, the game was paused due to level completion. If the team failed the critical action, the game was declared over due to patient decompensation. Regardless of game pause or game over status, all learners underwent a 20 min debriefing between each level, focusing on self-assessment and critical action performance review. Participants were switched to a new resident/nursing team with each subsequent level. Owing to the ROBG style, each level began with the events of the level immediately preceding it to allow rehearsal of concepts discussed during the prior debriefing.

We administered a modified version of the Simulation Effectiveness Tool (see online supplementary material 1) described by Elfrink et al³ to the emergency medicine residents to assess the LDR concept and pulmonary scenario. Nursing participants were not included.

Results

See online supplementary material 2 for numeric representation of overall Modified Simulation Effectiveness Tool (MSET) results and online supplementary material 3 for verbatim invited free text learner commentary. Of 20 possible respondents, 17 (85%) emergency medicine residents completed the MSET. Satisfaction scores and narrative commentary were positive, with learners unanimously choosing to ‘strongly agree’ with 6 of 13 MSET domains. Learners opted to ‘somewhat agree’ or ‘strongly agree’ with each of the remaining domains, excepting domain 6, for which a single learner indicated disagreement.

Discussion

We found that the LDR format achieved level 1 of the Kirkpatrick Model for evaluation of training methods. This is the reaction stage, or the ‘degree to which participants find the training favourable, engaging and relevant’.⁴ Learners reported placing value in the increasing complexity of the progressive levels given its pertinence to the field of emergency medicine. Previous studies have documented increased learner motivation with gamified educational programmes due to simultaneous competition and collaboration between participants.² This too was demonstrated in learner comments regarding LDR's team-switching component.

Within its ROBG framework, LDR utilises short debriefings in between levels to provide performance feedback and then introduces an immediate opportunity to apply learned concepts with each subsequent level. This incorporates the idea of deliberate practice, an established method to achieve superior performance through recognition of defined measurement standards, rote experience, analysis of behaviours and repetition of skills.⁵

While emotional learning can enhance retention of information, the LDR design strikes a much-desired balance of tension, as demonstrated in the narrative results. Learners reported being less anxious knowing that the LDR format is per definition a Gordian Knot situation, where the case always concludes with patient decompensation. This fatalistic approach allows learners to concentrate on critical actions instead of the unavoidable conclusion. The use of emergent scenarios in this LDR module further provides a form of stress inoculation training in a simulated environment, which can help to quell performance anxiety for future in situ patient encounters.

Limitations

Three residents (15%) forewent completion of the MSET survey, and their perception of LDR is not recognised in the outcomes reported. The results of this small study may not necessarily be reproduced in a larger setting. The applicability of LDR to other learner groups or instruction involving non-emergent medical conditions is unknown. Efficacy of LDR with regard to Kirkpatrick Model levels 2–4 (knowledge acquisition, behaviour change and outcomes) was not evaluated with this project.

Conclusion

A novel simulation-based educational scheme incorporating ROBG has been produced. Our pilot work suggests the LDR format is an acceptable alternative for training emergency medicine residents in the diagnosis and management of emergent pulmonary symptoms in complex decision-making scenarios. The current experience aims to be a proof-of-concept, and further work is needed to determine whether LDR can improve retention of learned concepts, affect future performance and contribute to positive patient-based outcomes.