15. S2 Episode 5: Gamification in Medicine

Dr. Rupeena Purewal invites Dr. Shaqil Peermohamed, Infectious Diseases Physician at Vancouver Coastal Health, to discuss gamification in medicine.

Episode Transcript

(00:00):
Thanks for joining us at the Canadian Breakpoint, a Canadian infectious diseases podcast by

(00:13):
Canadian infectious diseases physicians.
I'm Summer Stewart, here with Dr. Rupeena Purewal, pediatric infectious diseases physician
in Saskatoon.
In this episode, we invite Dr. Shaquille Peermohammad, infectious diseases specialist at
Vancouver Coastal Health to discuss gamification in medicine.
Dr. Purewal.

(00:35):
Welcome everyone.
Thank you for joining us for another episode of our podcast, the Canadian Breakpoint.
So today we have very special guests with us.
Dr. Shaquille Pir Muhammad, who obtained his MD degree in 2011 from the University of Calgary.
He then trained in internal medicine from 2011 to 2014 at the University of Saskatchewan,

(00:56):
and then completed his sub specialty training in infectious diseases at the University of
Toronto in 2016.
He completed his master's of public health through the Harvard T.H. Chan School of Public
Health with a focus in clinical effectiveness.
For the past six years, he has practiced in Saskatoon and his research interests include

(01:17):
antimicrobial stewardship, quality improvement and medical education.
Recently, Dr. Pir Muhammad joined the Division of Infectious Diseases at Vancouver Coastal
Health.
And in his spare time, he enjoys playing tabletop games, escape rooms, stand up paddle boarding
and making his own cold brew.
So awesome.

(01:38):
Thank you so much for joining us today, Dr. Pir Muhammad.
And today we're going to be talking about a really kind of a newer concept and we haven't
really done anything like this on the podcast.
We've had a lot of discussions around medications and we've done a lot around microbiology recently,
but we're going to be talking about gamification.
So I think without further ado, I'm going to let our expert here explain kind of the

(02:03):
concept of gamification.
Great.
Thanks for having me today.
A pleasure to chat on this exciting topic.
So gamification is the idea of using game mechanics, elements and principles of playing
a game, but applying it to a non-game context to engage users in a different way.

(02:29):
So there's lots of different examples of what are called serious games and these are entertaining
games, but more importantly, they're used to promote learning and promote behavioral
change.
And so recently I know that you've implemented this.
Obviously the reason we're talking about this today is because we've implemented some of

(02:50):
these concepts or this concept in medicine and specifically because you're interested
around antimicrobial stewardship.
Can you kind of walk us through like how did it come about or where did this idea kind
of come from?
Sure.
I think we're always looking for new and exciting ways to teach concepts related to infectious
diseases and antimicrobial stewardship.

(03:13):
I think during the pandemic, we were also trying to find new and exciting ways to engage
our learners, especially using virtual platforms.
So that certainly precipitated some ideas related to medical education and using gamification
as a technique.
Personally I love playing tabletop games and escape rooms.

(03:37):
So I was curious about how we can combine a game like an escape room or puzzles to engage
medical students and internal medicine residents to learn more about infectious disease, antimicrobial
stewardship and also help them achieve their learning objectives too.
Got it.
And so while you're out here in Saskatoon, is that kind of when like the initial, like

(04:02):
was there initial pilot project that started?
So we were keen to develop an antimicrobial stewardship themed escape room.
And there's been lots of really great examples of escape rooms published in the medical literature
from a wide array of different disciplines, including radiology, toxicology, dermatology,

(04:25):
anesthesia as well.
And so we wanted to create one for first year internal medicine residents.
And so we started out by looking at what are the key objectives of training from the Royal
College relevant to infectious disease and antimicrobial stewardship for internal medicine.
And we identified 10 key learning objectives.

(04:49):
And from that point, we then built variety of different puzzles that would test those
ideas.
And once we kind of created small beta versions of those puzzles, we pilot tested them with
some second year internal medicine residents to trial them out.
And if it seemed like a good fit, then we got together and built the actual puzzles

(05:12):
and using different arts and craft supplies.
And we were able to collaborate with our simulation labs on campus to use their technology.
So we had access to TV screens and mannequins and a two way mirrors so we could watch students
as they progressed through the escape room.

(05:33):
So then we actually built and designed everything.
And then the next step was probably the most integral part of creating an escape room.
And that was pilot testing.
So testing it out with some second year, second and third year internal medicine residents
and also some friends and colleagues outside of infectious diseases to better understand

(05:53):
the game mechanics, the flow of the game, get a good sense of how many people we wanted
on a team for the escape room, and then make some final tweaks to each of the puzzles before
going live.
And then currently, assuming that the escape room kind of went forward, where was the interface

(06:14):
or how could viewers or other public access the escape room?
The escape room that we built was an in-person escape room using our simulation lab on campus.
But there's been some emerging literature about creating virtual escape room platforms.
And the huge benefit of a virtual platform is that there's more flexibility in terms

(06:38):
of timing for students and learners to participate.
It's easier to reset the escape room by a click of a button rather than spending 10
minutes to reset all the locks and everything.
And so there's greater flexibility and you can also make more easier adjustments to puzzles
and create more variety with a virtual platform.

(06:59):
So I think that would be a cool project to work on next is developing an antimicrobial
stewardship or infectious disease themed virtual platform.
So that way people from all around the world could participate in that type of learning
activity.
That's awesome.
And then after the escape room, were there other projects that you guys already kind
of took on that have gone live?

(07:20):
So one of the other projects that I was involved with was creating a game called microbial
pursuit.
I'm a huge fan of simple, quick games that you can play on your phone.
A good example would be would be Wordle.
I'm guilty of still playing Wordle to this day.
And Wordle is a great example of a serious game that involves a lot of gamification elements

(07:47):
creating rewards for the player by keeping track of your winning streaks to incentivize
you to return back to the game and be motivated to try again.
Also being able to keep track of your kind of player statistics and a histogram that
kind of outlines that and being able to share on social media and share your scores and

(08:09):
your stories with other people.
So we were keen to create a game similar to Wordle and apps like that.
So we wanted to create something that was more trivia based and what discipline opens
itself more to trivia content than infectious disease and microbiology.

(08:32):
There's a huge rich history when we think about all of the different pathogens that
are out there, how they were found and the history behind them, the infections they cause,
the clinical syndromes and the development of different antimicrobials as well.
So we created a game called Microbial Pursuit and I collaborated with a company called Firstline

(08:54):
which creates antimicrobial stewardship mobile apps for healthcare providers and healthcare
systems.
So they were fantastic in collaborating on a game.
And basically each day a new puzzle is presented and you can access Microbial Pursuit online.
It's a web-based platform.

(09:16):
There's a new daily trivia puzzle where you have a series of four clues presented to you.
And as you progress through the four clues, the answer becomes a little bit more easy
to identify.
And you have to guess what the pathogen, whether it's a bacteria, virus, parasite or fungus
or an antimicrobial.

(09:36):
And if you answer correctly on the first guess, you get a hundred points.
If you need to advance to the second guess, you lose 25 points and so on.
And we're keen to work on adding more features and more gamification elements to incentivize
players and also enhance learning.
Another key element that we're looking at would be the concept of spaced repetition,

(09:59):
which is the concept that rather than trying to learn everything at one go, from a learning
perspective, if you spaced out key concepts and learning materials over time, you're more
likely to retain that knowledge.
So for example, from a game point of view, if you were playing today and you got a question
incorrect, maybe that question pops up again a week or two weeks down the road to try and

(10:25):
bring back that knowledge recall.
And so some of these concepts, I think obviously reiterate the facts of how we learn.
So like with repetition and having, especially like some people are visual learners, so having
the ability to kind of synthesize and process that information.
So for me, I think I definitely have played microbial pursuit.

(10:49):
So I don't know if I've done very well on it, even though I'm being an ID doctor, but
some of those questions were pretty hard.
So but it's one of those things that you want to, it kind of motivates you to go back and
I mean, first of all, A, you learn a lot, right?
And you learn about the history because I think all of us in our busy clinical world

(11:10):
life, we're not really focused on that anymore.
And so it's kind of nice because you learn some background information on organisms that
you don't see frequently or commonly in clinical practice either.
So yeah, it was challenging though, I'm not going to lie.
But it was fun in terms of, so those are some of the advantages that I saw, like even, you

(11:31):
know, looking, playing and moving through that interface, the microbial pursuit.
So what are some of the other advantages or any like feedback that learners have given
you guys to see like, is this something that's working?
Like is this a concept that really has made a difference in medicine?
Sure.
So when we first did our, the first iteration of the antimicrobial stewardship escape room,

(11:54):
we did study it and we used a pre post self assessment model based upon those 10 learning
objectives using a five point Likert scale.
And we did find across the board that our first year internal medicine residents perceived
learning through the escape room and their scores for each of those 10 objectives improved

(12:17):
from a statistical significant point of view as well.
And so I think from a gamification point of view in general, I think it's a very exciting
time because there's lots of new games being developed and different ways to try and study
gamification and medical education.
One thing to reflect on would be Kirkpatrick's training evaluation model, which comes up

(12:40):
with medical education.
And so with our project, we were able to get a sense that, that our students liked the
activity and perceived knowledge acquisition through the activity.
Kirkpatrick's training evaluation model has four levels, basically like a pyramid.
The first level is getting that reaction.

(13:02):
Do your students like the activity?
We achieved that.
People liked the escape room and it was fun.
It was engaging.
It was educational.
The second level is learning.
So to what degree do participants acquire the knowledge intended through that activity
or skills or attitudes that you're trying to deliver?

(13:23):
And we did achieve that through the self-assessment tool that we employed.
The third and the fourth levels are sometimes harder to achieve and create studies that
determine whether you're achieving those levels.
The third level is behavior.
So does your learning activity change practice?

(13:43):
Will do students take away key learning messages from your learning activity and then apply
it at the bedside or apply it to real life practice in healthcare?
And the fourth level is those results.
So to what degree does that outcome actually occur?
Does it change clinical practice?
Did your learning activity change how we practice and function and behave and the medicine that

(14:10):
we practice at the bedside?
So those are a little bit harder to achieve and elucidate, but it's definitely a very
exciting time.
There's lots of cool medical education initiatives related to gamification that are coming out
and lots of exciting literature.
I think it's like, I mean, definitely in the era that we're living in where we're using
a lot of technology and I think everybody has like other, like a phone or a device that

(14:36):
they can access at all times.
So I think using all of those and I think we're kind of the generation in our kind of
practice constantly had apps and tools like this to learn.
So I think this seems like definitely even more exciting for the future for all of the

(14:57):
students that are coming through med school and other degrees as well.
So in terms of obviously technology is the key here, right?
We need technological advances that we've seen to help us have these types of games
and apps and all these develop.

(15:18):
So is that kind of the reason why it's taken so long to come up with this?
Because it sounds like a fantastic idea and I'm sure we've known about concepts like this
before, but really like kind of what are the hurdles or challenges that I guess you faced
when implementing this and is that kind of the, was that really the real ending step

(15:40):
for a project like this to come to surface?
I think one of the biggest challenges with gamification and medical education is that
it is fairly new and there has been a surge of games, including tabletop games and apps
and video games in medical education.
I think one of the biggest challenges though that we're still trying to learn more about

(16:04):
is finding that sweet spot where you have a serious game that is entertaining and engaging,
but pushes the learner outside of their competence and a little bit outside of their comfort
zone to push them to learn, but without creating a distressful experience that demotivates

(16:27):
them or discourages them from returning back to the game and participating again.
So I think that's the challenge with gamification medical education is you want to create something
successful and powerful that encourages the user, the player to continuously come back

(16:47):
to the game to support their learning because that ultimately would be the main goal here.
Yeah.
And I mean, I can definitely see like the advantages of having something like this,
right?
Cause it's on your fingertips and you're also like not having to open up a textbook
to learn all this information and not be overwhelmed, right?
Because you're getting small doses of information and then you can go on with the rest of your

(17:11):
day.
And I think in our generation of learners, that's something that I think most of us would
appreciate, right?
To have instead of read a textbook of like 50, 60 pages a night.
So it sounds like something that should be introduced into concepts are like universities

(17:31):
and other workplaces.
Do you know that, are they implementing this or is there something still that's, you know,
you would look at as like a disadvantage in a certain field that you wouldn't implement
this?
I think creating games in medical education is very innovative and very exciting, but
it certainly wouldn't be our only strategy and certainly wouldn't replace our more traditional

(17:56):
approaches to teaching our students.
But it can be an effective way to reinforce concepts and be more stimulating and encourage
learning, especially if it's done in a safe space.
The escape room experience is akin to simulation labs that we still use in medical education,
but using for years when we're teaching how to perform a mock code, for example, or handle

(18:21):
very high stress situations to practice those types of scenarios.
So an escape room is almost similar to that.
And so some of the concepts and ideas behind gamification medical education aren't maybe
as new as we rethink.
I think a lot of these puzzles and games have been around for quite some time.

(18:42):
I think we're just starting to now introduce these concepts into medical education and
push that, especially with a generation of millennial learners.
I think it's also important that we adapt to their learning style and creating more
flexible adaptive platforms for teaching.

(19:03):
In terms of, so if a center or a physician wants to get involved and implement something
like this, what's the starting blocks for this or how would you guide somebody?
I think if you were interested in creating a serious game or whether that's an escape
room experience or tabletop game or a video game or an app, I think a great place to start

(19:29):
would be by contacting your medical school or your PGME office or UGME office.
And I think you'd be surprised by how much may be already there in terms of support and
reciprocity to support these types of initiatives.
When we were developing our escape room, I was pleasantly surprised by how much enthusiasm

(19:52):
was shared by our PGME office to carry out and help bring this idea to fruition and also
how much support there was from the simulation labs on campus that were very keen to collaborate
and help support the project.
So I think a good place to start would be contacting your local institution and see

(20:15):
what kind of feedback you get about the idea and what support might exist.
I think collaboration is also critical to these types of interventions.
You want to involve a good team of people from a variety of different backgrounds that
can give you good insight on your puzzles and your ideas.
When we play tested our escape room, getting feedback from second year internal medicine

(20:40):
residents was very important to know that our content level and difficulty level was
at the right stage.
But it was also important to get feedback from people outside of infectious diseases
to better understand the game mechanics and whether our puzzles flow and make sense from
a logical point of view.
So yeah, that's actually really good information I think for our listeners who are thinking

(21:05):
about introducing a concept or kind of, I think sometimes you just need some like a
starting point and knowing and having those supports and knowing who to reach out to.
So that's really good.
So what are some of the newer, I guess, so you talked about microbial pursuit and then
you talked about your escape room.
Are you currently working on other projects or anything that's recently been released?

(21:27):
Some of our listeners can tune into.
I think it's definitely interesting.
I definitely want to continue to work on creating more antimicrobial stewardship and infectious
disease themed escape rooms.
I think it's also might be interesting to work on escape rooms that are ranging in terms
of difficulty level for different audiences.
Another idea that I don't think has been tapped into yet would be creating an interdisciplinary

(21:54):
escape room because that reflects how often we practice in real life working with providers
from different perspectives, including dietitians, PT, OT, nursing.
So why not create an escape room that reflects those principles and gives us a better sense
of each of our roles and how we work together to support positive patient outcomes.

(22:18):
I think it's also really interesting to look at what other people are doing with medical
education and escape rooms.
Dr. Teresa Chan out of McMaster University developed a really cool tabletop game called
Gridlocked, which helps learners understand triaging skills in the emergency room and

(22:38):
as a tabletop board game.
There's lots of really other cool apps and games out there for infectious diseases.
Barmageddon is a really cool game that I would encourage people to try out.
And Empiric is another kind of cool card game that you can play to learn about antimicrobials
and spectrum of activity in terms of what bacteria different antimicrobials cover.

(23:04):
So yeah, there's lots of really great examples.
From an app point of view, there's a cool company called LevelX, which has a variety
of different games you can play on your phone to learn pattern recognition when it comes
to different rashes and dermatology, practicing how to perform endoscopy.
So if you're in respirology or gastroenterology, you can practice performing an endoscopy on

(23:28):
your phone.
And I think there's also one for cardiac catheterization.
So cool, cool techniques using a gamification theory in serious games to teach those skills
and that knowledge.
Awesome.
I actually didn't know about any of those.
So I mean, it's so neat to see it's so widespread over so many different fields.

(23:52):
And I think definitely our listeners will be excited to tune into some of those.
I'm definitely going to do that.
The LevelX sounds so cool.
And then what about microbial pursuit?
Is that something they can access on Firstline?
It's not available through the app itself, but if you Google microbial pursuit or go
to firstline.org slash microbial dash pursuit, it's a web based platform.

(24:17):
Right now we have over 150 puzzles that are in circulation and you can access all of the
puzzles.
All the previous puzzles are accessible, but a new one is posted every day to play.
So that's free for players to access.
One other idea that I've been kind of toying with in my mind is, I don't know if you've

(24:37):
ever played the game Heads Up that I think was made popular on the Alan DeGeneres show.
Player A would hold their phone in front of them, which would show a clue, maybe a name
of a celebrity or a language or an animal.
And your player B or multiple players would help you give you clues to guess what's on

(25:01):
the phone.
I thought that could maybe be applied to infectious diseases.
So maybe on the screen you have a name of a bacteria or an antimicrobial or a fungus
or a virus that's relevant to your level of training and your colleagues, your peers,
your friends give you clues to guess.
So it's a grand positive cockeying clusters and that might help with a bidirectional feedback

(25:27):
and precipitate learning both from the clue giving perspective and then the clue receiving
perspective.
Well, you have definitely a lot of ideas coming up, so I'm excited to hear some of the future
kind of concepts and really how we're going to implement this into our daily learning.

(25:48):
And I think it's really nice because we have the ability to create apps and do all of this
and work with multiple, there's so many technology-based platforms now that I think this will definitely
come to surface.
So super excited.
We're so grateful to have you on the podcast and talk about gamification.

(26:08):
I mean, it was definitely, when I heard about it, I mean, this is the name itself.
It sounds interesting, right?
So to come into and then thinking about incorporating that into medicine, because historically we
didn't always have such great ideas.
And so I think there's a lot in the future and maybe we'll have you back on when you've

(26:29):
developed a couple more of those games and you can kind of walk us through that.
Thanks for having me.
Thank you, Dr. Pirwal and Dr. Pir Mohamed for the very interesting topic.
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