Games as teaching tools in a surgical residency

Abstract

Background: Didactic lectures have been the mainstay of core teaching in the surgical residency program at our school. Our concerns about the educational impact of these passive activities led us to consider more interactive teaching approaches.

Methods: We developed an interactive games-based approach to learning. One set of games was labeled “Who wants to be a Surgeon” (WS) and the other was called “Senior Face-off” (SF). We evaluated the impact of this innovation using an end-of-year questionnaire.

Results: Enjoyment, teaching quality and preference over lectures were high for both games. However, the WS sparked interest significantly more in junior residents (4.3 ± 0.21 vs 3.3 ± 0.31, p = 0.015) and senior residents found both games more stressful than did junior residents (WS: 2.88 ± 0.32 vs 2.00 ± 0.21, p = 0.038, and SF: 3.54 ± 0.29 vs 1.80 ± 0.33, p = 0.001).

Conclusions: This innovative teaching technique promoted learner interest and was regarded as a worthwhile educational activity. Games with a competitive emphasis may unduly stress senior residents.

Introduction

In 2000 the General Surgery Residency Program at McGill University instituted an Academic Half-Day of three hours in order to formalize the teaching of its residents. Initially didactic lectures were given but, although the material was covered, residents complained that the lectures were not sufficiently interactive. In addition, junior residents complained that the lecturers directed their messages at senior residents, often neglecting the juniors during the lecture. We decided that one approach to improving the learning would be to devise educational games with the hope of increasing the interactivity and enjoyment. We devised one game specific for junior residents and another for senior residents. Educational gaming has had a long history in other fields such as in business and management (Wolfe 1993) but very little has been written in the medical education (Henry 1997; Hartmann & Cruz 1998) literature and even less explored in surgery (Fukuchi et al. 2000). The purpose of this study was to devise 2 educational games for surgical residents and to determine residents’ impression of their quality and usefulness. Our hypothesis was that residents’ would enjoy learning in a game format.

Methods

Game development

Teaching during our Academic Half-Days is structured by subject with 2–4 week blocks devoted to a single surgery content area (i.e. Esophagus, Stomach, etc). Traditionally didactic lectures have been given using Powerpoint presentations by Attending Staff. The games we developed were centered around the content area being addressed in each block. During Academic Half-Day all residents (senior and junior) are required to attend and participate in all the teaching activities. There are 40 residents in the McGill General Surgery Program (this a five-year program with 8 residents/year) and all were exposed to both games and evaluated them (100% return of the questionnaires). The first game, directed to junior residents (R1, R2) was called “Who wants to be a surgeon?” patterned after the popular game show of a similar name. Twenty topic-specific multiple-choice questions were prepared by a surgeon assigned to the content area as a PowerPoint presentation. The junior residents were divided into first-year and second-year teams and pitted against each other. For each question the junior resident (chosen in alphabetical order) had the option of answering without help or asking for a lifeline. Lifelines included polling the audience, asking a senior resident or having 2 answers eliminated (known as a 50 : 50). Each team could use 5 lifelines during each game after which they were forced to answer the questions on their own. Each resident had the opportunity to answer up to 4 questions and the game was concluded after the 20th question. After each question was presented the attending staff member who prepared the game discussed the question in detail and residents were allowed to ask questions before moving on.

Table

Practice points

Educational games can be an important part of a surgical educator's toolbox. Games provide interaction and stimulate interest in the topic. Games may be stressful.

The second game, directed to senior residents (R4, R5) was called Senior Face-off since 2 seniors competed against one another on a particular topic in front of the entire group of residents in the program. A staff member prepared 2 or 3 clinical scenarios that again revolved around the topic being discussed that month. Two seniors were picked at random, given transparencies and a pen for writing down their answers. At a critical junction in the clinical scenario the seniors were asked a question and given 1–2 minutes to write their answers on transparencies. This method was chosen since we did not want the answer of one resident to influence his/her competitor (eliminating statements such as: “I agree with him/her”). The residents then presented their answers for evaluation by the staff and the audience. After a clinical scenario was completed, the audience voted to determine which resident performed the best. The winning resident continued in the game. Residents tended to try to outdo each other hoping to continue playing indefinitely. Of the Academic Half-Day teaching, 80% was in the traditional lecture format and 20% in this innovative “Games” format.

Evaluation of teaching

After implementation of the games for one full academic year, we gave the residents a questionnaire (validated internally by McGill's Center for Medical Evaluation) evaluating 5 specific areas on a 5 point Likert scale (1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree). Questions asked for each game included:

• Do you enjoy the game?

• Do you prefer didactic lectures to the game?

• Assessment of teaching (learning) quality, (as defined by transmission of important concepts)?

• Did the game spark interest to go read about the subject?

• Was the game stressful?

We calculated the means and standard errors for each question. Differences between groups were assessed using the student's t-test. A p-value of < 0.05 was considered significant. Analysis was done using SPSS version 12.0® for windows.

Results

Who wants to be a surgeon?

Table 1 summarizes residents’ opinions of this game. Juniors, for whom the game was intended, found it sparked interest significantly more than did seniors. Seniors found this game to be significantly more stressful than the juniors. Overall the game was well liked by both juniors and seniors and both groups felt that the quality of the teaching was good.

Table 1.  Who Wants to be a surgeon?

	Enjoy game	Lectures preferred to millionaire	Teaching quality	Sparking interest	Stressful
Juniors	4.30 ± 0.396	2.60 ± 0.267	4.20 ± 0.249	4.30 ± 0.213	2.00 ± 0.211
Seniors	3.92 ± 0.239	3.08 ± 0.288	3.69 ± 0.175	3.31 ± 0.308	2.88 ± 0.317
p-value	0.428	0.238	0.114	0.015	0.038

1 = strongly disagree; 5 = strongly agree.

Senior Face-off

Table 2 summarizes residents’ opinions of this game. Seniors found this game to be very stressful (although juniors only observe this game and do not actively participate). Nevertheless they both enjoyed it. Seniors in particular found that the teaching quality and ability to spark interest exceeded the junior-level game.

Table 2.  Senior faceoff

	Enjoy game	Lectures preferred to senior faceoff	Teaching quality	Sparking interest	Stressful
Juniors	4.30 ± 0.153	2.20 ± 0.200	4.10 ± 0.100	3.70 ± 0.335	1.80 ± 0.327
Seniors	3.92 ± 0.309	3.00 ± 0.340	4.15 ± 0.274	4.15 ± 0.222	3.54 ± 0.291
p-value	0.290	0.057	0.856	0.275	0.001

1 = strongly disagree; 5 = strongly agree.

Discussion

Very little has been published in the area of gaming as a teaching tool in general surgery. This study demonstrates that surgical residents enjoy this approach to teaching. Fukuchi et al. (2000) used an Interactive Board Game to teach a multidisciplinary approach to cancer treatment during surgical clerkship. Their study showed improved test scores and a better appreciation of the multidisciplinary approach to oncology care in students who used the interactive computer-assisted board game. Recently Ogershok & Cottrell (2004) and Eckert et al. (2004) and colleagues showed that gaming can engage and stimulate learning in pediatrics and immunology respectively. Similarly DaRosa et al. (2006) showed that an innovative game on viral hepatitis was well-received and well-liked by students. Allery (2004), in an editorial in Medical Teacher, recently defined and distinguished the terms: game, simulation, simulation-game and exercise. Based on her definitions, the approaches presented here are simulation–games which are “reality-based games where learning results from the subject matter” while a game is a competitive activity with a prescribed setting constrained by rules and procedures where the learning does not come from the academic content of the subject matter. These simulation games were surprisingly well liked by our residents. Interestingly residents liked the games that were devised for their level much more, with juniors enjoying the Who Wants to be a Surgeon? game and seniors preferring the Senior Face-off. The games were fun, interactional and sparked interest to read. We believe that it is crucial to incorporate the games into a structured curriculum to maximally enhance the learning experience. O’Leary et al. (2005) showed that a Jeopardy style game on ectopic pregnancy not only was well-liked but also enhanced learning (as measured by a pre- and post-test) of third-year medical students. If the game addresses the topic being addressed during that block, we believe that surgical residents will be more inclined to prepare for the game. Informed feedback indicates that residents prepare for the games since they do not want to be embarrassed in front of their colleagues. This is in keeping with the other important finding of this study, that is, that games can be stressful. In fact seniors found both games stressful with the Senior Face-off, which is really a “mock oral” exam, extremely stressful as expected. The “stress” was related to the fact that they were placed “on the spot” but they otherwise enjoyed the Senior Face-off as a format for teaching. The residents felt that the stress was manageable and, in fact, because of the anticipated stress they prepared for the sessions actively. The limitations of this study are two-fold: we did not demonstrate that the Games actually improved the acquisition of medical knowledge, although this was not our primary aim, and we evaluated the residents’ impressions at only one time-point, the end of the Academic year. We decided to evaluate the results only at the end of the year because we wanted them to be exposed to multiple sessions of the games with different staff so as to ensure that their impressions would be more reflective of the games rather than the teaching styles of individual staff.

Conclusion

Gaming is a useful and not often used educational strategy that is well-liked by residents and may make formal surgical teaching curricula more interactive. In future studies we will look at whether gaming improves learning.

Additional information

Notes on contributors

Sarkis Meterissian

SARKIS METERISSIAN is the Associate Dean of Postgraduate Medical Education Core Faculty Member of the Center for Medical Education. He is interested in innovative new approaches in surgical education.

Moishe Liberman

MOISHE LIBERMAN is presently interested in Outcomes Research and completing a Fellowship in Thoracic Surgery at the Massachusetts General Hospital.

Peter McLeod

PETER MCLEOD is an Internist and Pharmacologist and past Director of the Center for Medical Education. He is also past President of the Canadian Association for Medical Education and his research interests are in assessment of the acquisition of educational expertise.