How Games Can Transform Medical Education

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When you think about a video game, you might imagine it primarily as a form of entertainment — something for enjoyment and diversion. However, in addition to being entertaining, video games can be incredibly challenging and frustrating, requiring iterative practice in order to achieve various tasks after multiple failures. From Mario Cart to Final Fantasy, Halo to Call of Duty, video games have the capacity to make people practice until perfect.


Modern video games have become increasingly complex, involving a wide array of performance levels of gameplay and multiple players simultaneously in a common virtual environment, all engaged in learning how to achieve. Why do we keep trying in the face of failure? What motivates us to continue playing until we achieve mastery?


Video games have tremendous educational potential. They provide a private learning experience that is judgment-free — a “psychological moratorium of practice” as described by psychologist K. A. Ericsson. They provide opportunities for high-frequency deliberate practice and iterative skill development. As a result, serious video games can add significant learning value to almost any educational curriculum.


Serious games can augment an educational experience by engaging learners in active cognitive experiences, providing opportunities for knowledge application and decision-making, helping learners to consolidate and assimilate new knowledge. There is clear evidence of their potential. Serious games such as Gran Turismo (driving/auto racing simulation) and Zwift (cycling simulation) create virtual environments for serious gameplay that have developed individuals who have gone on to become professionals, demonstrating the power of serious gaming when the game design is aligned with real world performance.


The apprenticeship model of clinical learning — more familiarly called “see one, do one, teach one” — has traditionally formed the foundation of learning and competency development in the medical field. This requires a breadth of real world experience in order to accumulate the essential skills and knowledge to practice independently.


Apprenticeship learning is dependent upon exposure — the chance of encountering a specific disease state over a fixed training time. Knowing that the breadth of clinical exposure is a function of both time and serendipity means that a great deal of hours and effort can be spent performing repetitive cognitive skills, waiting for a new learning experience to expand knowledge and skills. Across a cohort of learners, apprenticeship learning leads to inconsistent exposure over a fixed training time, resulting in heterogeneity of knowledge and clinical skills.


Manikin-based simulation creates these learning experiences in a risk-free environment. One can directly observe as individuals learn, practice, and demonstrate their competence managing various disease states and rare high-risk cases. With the addition of a simulation curriculum, one can compress experiences that may take years to come across in the clinical environment to supplement experiences in the clinical learning environment. Engaging clinicians in applied conceptual learning exercises is a cornerstone to effective learning. Following the Kolb Learning Cycle, teaching with simulation can provide invaluable opportunities for active experimentation with new concepts that can be reinforced in the clinical environment through concrete experience. Simulation is an accelerant on the fire of learning.


Simulation-based assessments can provide opportunities to directly observe and assess individual learner performance in specific core competencies as well as milestones in learning with a high degree of specificity and accuracy. However, reliance upon the clinical learning environment and focused simulation-based activities is still limited in several important ways. While manikin-based simulation is highly valuable, it can be very costly in terms of the physical resources needed to create a simulation room or lab as well as the significant time constraints of both teaching faculty and learners to be physically present in the simulation lab for a learning or assessment session. These issues limit the frequency of opportunities for regular focused cognitive practice and the number of observations of individual learners that can be made over the course of training. They also limit our ability to determine competency across a wide array of disease states, rare conditions, and clinical management scenarios.


Direct observation of an individual performing a history and physical examination by a trained faculty member using standardized checklist does not deal with the “sampling issue” — infrequent opportunities to measure an individual’s performance lead to an incomplete picture of their competence in the clinical learning environment. While manikin-based simulation can increase these opportunities, they can be augmented even further using a serious gaming simulation environment (SGSE).


A serious game can provide opportunities for high-frequency practice using “low-dose” simulations, compressing a 30-minute manikin simulation into a 3-minute simulation game that requires the same cognitive skills and applied knowledge. Unlike most manikin-based simulations, SGSE can provide opportunities for repetitive practice and iterative skill development, covering a broad array of diseases, freed from the constraints of physical space and scheduled time. SGSE can motivate performance despite failure because of the privacy of the gaming learning environment, allowing for more challenging cases and complex learning with a low cost of failure and high reward for success. The psychological moratorium that SGSE can provide promotes practice despite failure, as a video game does, to enable practice until successful performance. This can be leveraged to augment performance and prepare learners prior to entering the more high-cost, high-stakes manikin-based simulation environment where the fear of public failure and judgment might impede learning. When used prior to a classroom or simulation training session, a serious video game can calibrate a group of individuals to a common level of performance and understanding prior to engaging in a team simulation exercise.


Ericsson’s concept of deliberate practice relies on four components: a task with a well-defined goal, motivation to improve, feedback on how to improve performance, and the opportunity for repetition, refinement and skill development. A serious game can enable repetitive practice. Situating serious games within the hierarchy of clinical learning, one can envision didactic learning being the foundation of knowledge acquisition, followed by gaming for initial application of knowledge and skills practice. This preparation can then support higher-level manikin-based simulations which, along with repetitive concept reinforcement with gaming, support real world performance in the clinical learning environment.


Deliberate practice is not just for improving performance — it provides evidence of competence. Tracking individual performance improvement over time with a serious game allows the collection of hundreds, if not thousands, of observations over a relatively short period of time, well within the scope of health professions training. These data can provide evidence of skill acquisition from novice to expert, according to Dreyfus & Dreyfus. For example, using a set of 50 simulation cases that can be played repetitively as a serious game, each with specific measurable elements of history, physical, diagnostic testing, and clinical interventions, one can measure thousands of critical actions successfully performed over time through iterative practice to more accurately assess achievement of milestones in training.


In addition to observations from the clinical learning environment and mannequin-based simulations, SGSE can provide a broad and accurate representation of an individual’s clinical competence across a wide array of disease states, from the common to the rare, benign to the critically ill. Put simply, a serious game enables us to measure individual competence at a highly granular way using the principles of deliberate practice while enabling cognitive skills development anytime, anywhere.


This posted is adapted from an article originally published July 9, 2018 on Healthy Simulation

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3. Ericsson KA. “Deliberate practice and acquisition of expert performance: A general overview.” Academic Emergency Medicine, 2008;15:988-994.


4. Gee, JP. What Video Games Have to Teach Us About Learning and Literacy. Palgrave-MacMillan: New York, NY, 2003.


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