Educational Resource Guide
Eleonora Leopardi and Nara Jones
Introduction: an educational board game
Medical training involves acquisition of a great deal of knowledge and many technical skills, combined with the development of personal qualities and cognitive abilities necessary to apply that knowledge and those skills in clinical settings. In modern medical education programs, typically, a first portion of the educational journey takes place in classrooms, as learners are exposed to clinical reasoning and diagnostic processes. During a later portion of the training, students engage with the clinical environment, gaining progressively more familiarity with the role of the doctor and beginning to contribute to the diagnosis and management of patients.
The transition between these two stages often proves challenging for learners: the health and wellbeing of the patient is the primary interest of their supervisors, who guide the clinical inquiry and step in to prevent errors arising from lack of information or inappropriate testing. In a vast majority of cases, the clinical environment does not enable junior learners to gain confidence in taking decisions with real weight, or experience the consequences of a shortcoming in the diagnostic process.
Game-based learning is an innovative educational strategy that spans a range of applications, from basic gamification of didactic teaching to the development and implementation of serious games, designed to foster specific learning.[1],[2] Serious games, as many other experiential instructional approaches, provide an engaging and relaxed environment to support effective and immersive learning, without risk to patients.[3]
Diagnosis: A medical education game is designed to foster specific skills for medical students transitioning from primarily classroom-based (preclinical) learning to primarily placement-based (clinical) learning. The core skill is clinical reasoning, which is the one most explicitly identifiable in the overarching game design, as players organise their game strategy to obtain appropriate information on their patient to diagnose them. Additionally, the Healthcare token game mechanics foster good resource management, guiding players to privilege free or inexpensive information sources such as history-taking and physical examination, and deterring them from requesting a large amount of tests. The Deterioration Clause mechanic reinforces appropriate prioritisation within the clinical process, providing negative consequences should the players omit to collect basic information. Most commonly, the Deterioration Clause is triggered when basic vital signs aren’t collected or basic examination findings are not elicited. However, this is also an editable element should you wish to emphasise the importance of specific tests or procedures. Lastly, the Spooky Consultant and Tutoring mechanics highlight the value of biomedical sciences, particularly Anatomy, Physiology, and Pathology, which are foundational to good clinical decision making.
In this Resource Guide, we will provide further information on using this game, adapting and integrating it successfully into your curriculum. We offer our session model as an example which has been effective in our medical program, while being cognizant of diversity of curricula and contexts. As mentioned in the Preface, this game is not intended to be a static resource: we would love for you to amend, remove, and integrate anything you wish – and to hear about it, to collectively build on what we have so far produced.
Using this resource
Cases
This edition of Diagnosis: A medical education game contains 10 Cases, which broadly revolve around five common presentations:
- Shortness of breath
- Pain
- Confusion/drowsiness
- Fatigue
- Cough
These presentations occur in combination with each other or with additional symptoms. This allows for discussions of what differences in similar clinical pictures guide the clinician towards a specific diagnosis or a narrower set of differential diagnoses.
The game can be played with all the Cases or with a selection that suits your learners’ needs. Additionally, we have created an editable Case Template to facilitate the creation of additional Cases and the preparation of Case booklets.
Cases summary
Name, Age, Sex |
Presentation |
Diagnosis |
|
| 1 | Geraldine Bridgerton, 28F | Tiredness, anxiety | Graves’ Disease |
| 2 | Lucy Potts, 8F – ED | Drowsiness, confusion | Diabetic Ketoacidosis |
| 3 | Ashley Monroux, 17F | Diarrhoea, weight loss | Coeliac Disease |
| 4 | Kyle Jennar, 57M | Tiredness, SOB | Atrial Fibrillation |
| 5 | Payne Stark, 35F – ED | Chest pain | Pulmonary Embolism |
| 6 | Mike Simpson, 64M | Leg swelling | Heart Failure |
| 7 | John Perkins, 54M – ED | Abdominal pain, confusion | Acute decompensation of chronic liver disease |
| 8 | Olivia Greene, 58F | Cough, fatigue | Pneumonia (CAP) |
| 9 | Bruce Adamski, 52M – ED | Chest pain | STEMI |
| 10 | James Nguyen, 17M – ED | Chest pain, SOB | Spontaneous Pneumothorax |
Question cards
This edition of Diagnosis: A medical education game contains over 250 Question Cards, provided in the Question Cards part of the resource, and in the Diagnosis Supplementary Materials folder at http://bit.ly/NewcastleOER. These cards are required for the Tutoring mechanic, for the Deterioration Clause mechanic (as a knowledge check) and for the Spooky Consultant mechanic. While we don’t intend to encourage rote learning, or memorisation of meaningless facts, these questions target recall of information from biomedical sciences, required for development of more elaborate forms of knowledge and understanding. A small amount of the question cards revolves around niche facts, which are added to the pool of cards to generate an element of unpredictability in the game. It should be clarified to the learners that the format of the Question Cards is not necessarily reflective of formal assessments in the medical program.
As for the Cases, the game can be played with all the Question Cards or with a selection of them. We have created an editable Question Template for the creation of additional Questions.
Question cards summary
Topic |
Number |
| Cardiology | 56 |
| Gastroenterology | 55 |
| Endocrinology | 54 |
| Respiratory medicine | 52 |
| Cellular biology | 42 |
Clinical reasoning development sessions using Diagnosis: A medical education game
The Joint Medical Program, which this game was designed for, is a 5-year undergraduate-entry medical program. Because of the need to assess all students on the same content, harmonising the learning of 22-24 small groups of students, our PBL model is supported by a set of predetermined learning objectives. These are provided to the students in advance, thus the PBL enquiry is often guided by the students’ awareness of the expected learning, which limits the authenticity of the process and limits the development of student-driven learning goals. In substance, our PBL model functions as a basis to encourage contextualised learning, rather than an avenue to foster clinical reasoning and problem solving: a philosophical shift linked to the increase in the amount of necessary knowledge which has been identified within the literature over the course of the past twenty years. [4][5][6]
This pedagogical and philosophical direction ensures we can deliver a knowledge-rich classroom-based curriculum at scale, however it provides less preparation for the uncertainty of the clinical environment. To address this, we have implemented Diagnosis. Our game gives the students a gradual exposure to the undifferentiated presentations they will encounter in clinical settings, where the learning objectives framework does not provide meta-insights into the diagnostic process. We deliver our Game-Based Learning sessions at the conclusion of the classroom-based years, in loosely-structured 2-hour small-group sessions facilitated by a clinician educator.
The ideal group size for the session is 6, giving students the choice of pairing up and forming three teams, or dividing into two teams of three. The competition aspect of the game is largely underemphasised by the session facilitator, but our experience showed that it adds to the engagement of the session. Additionally, working in pairs or in groups of three can avoid disappointment and subsequent loss of motivation in less-prepared learners.
The session facilitator introduces the game and explains the rules, ensuring that students are provided with a copy of the rulebook to refer to. A game session with two or three teams lasts typically between 60 and 90 minutes, leaving then suitable time for debriefing.
The debriefing session is facilitated on the basis of the events occurred in the game, and is often driven by students who want to understand what caused these events. Topics of discussion can vary significantly between groups, which is typically not a challenge for a skilled clinician educator, given their experience and expertise of the clinical environment. A reasonable debriefing session can last 15-30 minutes, and should be concluded with an encouragement to pursue further learning in areas of need.
Supporting self-directed student learning using Diagnosis
Following the facilitated Game-Based Learning sessions, we make the game available to students as a resource for self-directed practice. Students may facilitate an opponent’s Case, or enlist a senior student to play the role of the facilitator. A faculty member’s contact information should be made available to the students using the resource, to allow them to seek clarifications or discuss topics of interest arising from their game session.
Limitations
Diagnosis: A medical education game was created to foster familiarity with the diagnostic process and elements of clinical reasoning, and provide opportunities for learners to apply their knowledge to undifferentiated clinical presentations.
Despite our best efforts, we are aware of several limitations in the game as it is currently designed. Firstly, we have designed the game board and the game mechanics implying that the patient is presenting to the Emergency Department. However, some of the patients present to their General Practitioner, creating a puzzling inconsistency. This decision stemmed from our need to include chronic presentations, while avoiding negative connotations, such as ill feelings towards patients with chronic complaints presenting to hospital rather than primary care. Ultimately, the fictional Emergency Department of Diagnosis is shared between General Practitioners and Emergency Physicians, and care is provided to all patients at the same time.
A further limitation is the relative small window of learning need and geographical setting which the game is designed to be suitable for: the transition from classroom-based learning to placement-based learning for Australian medical students. As a corollary to this, while we have used great care to portray patients realistically, we have needed to simplify some of the Cases to ensure they would be appropriate for our learners.
With the variety of curricula and medical programs worldwide, it is likely that your context, curriculum, and learners are different from ours, and that you will need to tweak the game rules or introduce new elements, for the game to be effective.
For instance, more advanced learners might be prompted towards early stabilisation of the patient, introducing more management tools in the appropriate room. The pacing of investigations (one test per turn rule) and their costs may be altered to allow for diagnosis and management of patients with more severe presentations or lacking sufficient clinical history. Your healthcare system may have different communication tools to replace our ISBAR format, and understandably will need to replace that section in the rulebook and in the cases. These are just some of the decisions you may choose to make to ensure your learners are faced with sufficiently challenging cases, and still find the game enjoyable. We leave this to your creativity, but we are more than happy to be available for discussion and collaboration, should you choose to reach out.
Lastly, the Spooky Consultant mechanic is reminiscent of the practice of “pimping”, i.e. a senior or supervisor clinician asking a learner an on-the-spot question, at times unanswerable or irrelevant. We do not intend in any way to condone this practice or encourage it, and this mechanic can be removed from the game without significant consequences to the gameplay.
The future of Diagnosis
As discussed, we are putting forward Diagnosis: A medical education game as a living resource, which we will continue developing for our learners and which we encourage all adopters to contribute to.
We are also inviting your feedback to drive improvements, corrections, and additions. We are available to engage in continued communication and collaboration, particularly towards the creation of further educational tools and scholarly evaluation of these tools.
Feedback, comments and questions: https://bit.ly/NewcastleOER
References
- Thesen T, Bahner I, Belovich AN, et al. Not Just Fun and Games: Game-Based Learning in Health Professions Education. Medical science educator. 2023;33(5):1301-1306. ↵
- Plass JL, Homer BD, Kinzer CK. Foundations of Game-Based Learning. Educational Psychologist. 2015/10/02 2015;50(4):258-283. doi:10.1080/00461520.2015.1122533 ↵
- Xu M, Luo Y, Zhang Y, Xia R, Qian H, Zou X. Game-based learning in medical education. Mini Review. Frontiers in Public Health. 2023-March-03 2023;11doi:10.3389/fpubh.2023.1113682 ↵
- Epstein RJ. Learning from the problems of problem-based learning. BMC Medical Education. 2004/01/09 2004;4(1):1. doi:10.1186/1472-6920-4-1 ↵
- Taylor D, Miflin B. Problem-based learning: Where are we now? Article. Medical Teacher. 2008;30(8):742-763. doi:10.1080/01421590802217199 ↵
- Neville A, Norman G, White R. McMaster at 50: lessons learned from five decades of PBL. Advances in Health Sciences Education. 2019/12/01 2019;24(5):853-863. doi:10.1007/s10459-019-09908-2 ↵
