History of Games in Healthcare
People have been playing games for thousands of years to entertain children and adults alike, unintentionally promoting learning about strategy, logic, reasoning, negotiation, and innumerable real-life skills. Senet was one of the first games ever described, in ancient Egypt in 2600 BCE. Latrunculi (also called latrones) was a popular board game played throughout the golden age of the Roman Empire. Terni lapilli, a Greek game, is a predecessor of tic-tac-toe as we know it today. Calculi-ludus calculorum, or “the game of stones,” sometimes is referred to as Roman checkers. The mechanics of these games live on today and inform the design of modern-day games, all the while demonstrating the principles of motivation in games, including competition, competency, achievement, and many others.
Playing and learning games remains the same today as in the past: players must first learn the rules of an entirely new domain and quickly move from rules to strategy in an effort to win the game. This relies on creating new mental models, just as children, and also adults, do to understand the world around us. Learning and game-play alike are sparked by curiosity, the hallmark of intrinsic motivation. Games are an opt-in experience, after all, and if players are not enjoying a game because it is either too boring or too challenging, they will disengage. This is where games have great potential in the learning space, because they keep users moving forward, constantly challenged and engaged.
Our traditional medical education of memorization, regurgitation of data and facts, and the obligation to participate in continuing medical education (CME) created an extrinsically motivated environment that is less likely to create long-lasting, deep understanding of these complex processes. The traditional forms of learning delivery using lectures, slide shows, webinars, and textbooks (often out of date the day the book is published) are a passive style of learning that usually requires more time. In an era focused on more-efficient learning, these time-honored learning methods need to translate into stronger knowledge acquisition, retention, and transfer.
Individuals learning through medical school, residency, and practicing medicine are likely already playing video games.
The idea that video games are only for children and adolescents no longer applies. Recent statistics suggest that more than two billion worldwide people play games, and the average age of a video game player is now 36.(1) Games have become ubiquitous in our lives, and mobile gaming has largely contributed to this massive increase in players and the demographic changes. This means that those individuals learning through medical school, residency, and practicing medicine are likely already playing video games. The potential to tap into these motivating and engaging tools for health professions education is attracting a great deal of interest.
Benefits of Video Games in Medical Education
Traditional video games are built for the primary purpose of entertainment. However, they are based on knowledge and understanding of how to activate and stimulate the brain to enhance learning, allowing players to enter an entirely new domain with its own language and set of rules. The knowledge and skills required to play the game can impart important real-life knowledge and principles, such as when players of Angry Birds learn basic physics, including mass, velocity, inertia, and all of Newton’s three laws of motion, with just a few clicks.
Several other terms closely related to game-based learning deserve a quick mention here. The concept of gamification has made its way into the academic literature, not just in medicine but also in marketing, sales, business training, and any number of other industries. Gamification has many definitions, but the term generally refers to the use of game elements (e.g., scoring, competition, leader boards, trivia) applied to non-game subject matter. In medicine, this application is intended to create greater motivation and engagement with the material. Issues with gamification include that the game elements often are divorced from the core gameplay loops that create that deeper motivation, entertainment, and engagement that traditional video games are built on. Also, not all players/learners are motivated by competition, which often is the main component of gamification. This may lead to less-than-ideal results with the use of this type of application, leading to some of the weak evidence in the literature.
One other area often included is the field of serious games. Serious games is a term that refers to the use of game mechanics on serious subject matter with the main purpose being learning rather than entertainment. The subtle difference here is the objective of the game, which may not translate into a fun or entertaining experience for the player. The principle at work here (or not) is that good game design considers and prioritizes the fun and motivation aspect of video games, with learning as a secondary outcome. This often is difficult to achieve, which is why game designers who are experts in sociology, psychology, behavior, motivation, and feedback are so vital to these experiences and why they are being recruited more and more to the education space.
Game designers are not trying to replace the medical learning process but are using their expertise to create experience-based interactions that can be fun and enhance the learning process. An example is learning how to perform a total knee replacement surgery, where the power of video games is used to create a mental model using 3D spatial manipulation skills.
One of the authors (NB) was learning laparoscopic surgery and had taken a trainer home to practice the hand-eye motor skills. This author’s 11-year-old son, a video gamer, watched his father struggle to suture a hair into a napkin and asked if he could try to suture. The response was, “[Son], this is very difficult, and you won’t be able to do it.” The son prevailed; and to the amazement of the surgeon/father, the young boy could do it faster and better than the adult. The theory is that the hours spent playing video games had improved his hand-eye coordination, which even transferred to an unrelated skill, regardless of his age or experience with the task.
Drawbacks to Using Games for Medical Education
With every benefit of video games come the cons or drawbacks. Most educators need a better understanding that these games aren’t just for kids. There is a widespread negative mindset that video games are associated with brain-numbing and addicting entertainment. We must educate the medical masses that games can be a powerful educational tool and often are more effective than reading a chapter in a textbook or sitting in a boring lecture experiencing death by PowerPoint.
One perceived barrier is that medical video games may require expert game developers and engineers to achieve the full potential of education using games.
Unfortunately, there are games that miss the mark or utilize only very superficial elements of games. These games do not truly transform the learning experience and thus may give game-based learning a bad connotation. This impression convinces conventional educators that games are less powerful than traditional learning methods. The onus is on creators and educators to utilize the power of games and technology well and not just as a hype-engine or gimmick. The level of scholarly rigor and attention should be the same as for any educational intervention.
One perceived barrier is that medical video games may require expert game developers and engineers to achieve the full potential of education using games. This may not be the case, however, as many more consumer level software tools and even non-video games can create amazing learning experiences without a background in computer science. It is true that some high-end games may require more expertise, and, as a result, we see many digital health companies hiring the best game developers to create stellar learning experiences. Additionally, more and more board and card games have become available that create experiential learning with similar outcomes without the cost and expertise required for video games.
Improving Healthcare Professionals’ Skills?
Motivation and engagement are two of the challenges that medical educators face when bringing games into medical education. When participants are motivated and engaged, they enter a state of mind called the flow state. This term is used to describe the experience of people such as elite athletes and musicians who are in a maximal state of intense concentration, which imparts a maximally efficient period of learning that may contribute to more knowledge, retention, and improved skill development.(2) The flow state creates a game environment where fun and entertainment exist, with education becoming the unintended consequence, and players are so tuned in they may lose track of time.
Convincing Bean Counters to Embrace and Invest in Video Games
Ample evidence supports the power of games in learning technical and knowledge-based skills. For example, the 11-year-old child referred to earlier who successfully learned a surgical skill demonstrates that younger video game players will develop visuospatial skills and perform faster than those who do not avail themselves of this exciting technology. It is necessary to explain to those in the C-suite the difference between gamification and actual video games. We need to look at the efficiency of learning and return on investment for these technologies, because they may save money and time and enhance learning outcomes over the lifespan of the intervention. The best advice to those who will invest in educational video games is to start slow, obtain feedback from the students and faculty, and then measure the results of learning and retention as they apply to enhancing skills and even patient care.
We advise anyone going into this area of research to heavily involve subject matter experts with true game designers or players to ensure that the games are medically and scientifically correct and achieve the intended goals. Nothing will turn off a physician faster than finding that the game is inaccurate and not applicable to medicine.
Video games allow healthcare professionals to apply knowledge to medical conditions or procedures. This becomes the secret sauce to creating an effective medical video game. Yet, healthcare-related video games have a lot in common with generic video games, because both are built on the fundamental core of gameplay loops, where a player’s primary set of actions defines the game: a concept that has been tested billions of times. These game mechanics and styles are ubiquitous and can easily be applied to healthcare games.
Perceptions finally are changing, and doctors are realizing the power of game design and this technology’s use to enhance the physician experience. We soon will witness meaningful ways of creating more realistic virtual patients, more natural virtual patient interactions, and a more visually appealing virtual healthcare environment. We also are seeing digital entertainment and the movie industry pushing the boundaries of what computers and AI can do, which also will apply in the gaming industry. More advanced platforms are being developed, including the metaverse and extended reality, that may change the way we work, socialize, and learn. Metaversities already are popping up to embrace the post-pandemic hybrid learning and working environment by creating digital representations of academic centers.
Medical video games can be platform-agnostic given their software-based modality, which makes it possible for them to be played on a smartphone, through a web browser, or with external hardware, such as a virtual reality headset, making them much more accessible. Soon these games will become better, faster, less bulky, less intrusive, and more intuitive for users who are not necessarily tech savvy.
Games will shape the future of medical education in the following ways:
Increase exposure to advances in medicine: Right now, most healthcare professionals rely on existing modalities of education (e.g., live videos, animations, boring PowerPoint lectures) to better understand novel concepts, from using the latest ablation system or understanding the mechanism of action of a new drug. Indeed, these methods are important, but studies show play is highly effective at helping people develop mental models to understand complex concepts.(3) We predict that within the next five years, video games will be the go-to medium for scenarios where a physician needs to understand a complex system deeply.
Engage healthcare professionals across the industry: Much of the latest and exciting tech in healthcare is geared toward doctors, from robotic surgery to virtual reality. However, non-physician healthcare professionals, including nurses, PAs, and NPs, also need more engaging and effective medical training methods.
Create a strong connection with residency and fellowship programs: Healthcare professionals successfully use games to advance their skills and master complex and rare cases throughout their careers, and games also are effective for teaching medical concepts. From the Krebs cycle to common drug interactions, games are a good fit for training programs such as fellowships and residencies and play a critical role in CME. Games can help tackle complex concepts, such as genetics and informed consent. For example, simulation experiences using dummy models to learn CPR are available. Incorporating game technology into medical education at this level builds a consistent and effective foundation for trainees and improves access to high-quality education. With video games, trainees develop lifetime strategies, habits, and approaches to a learning experience. Creating a foundational conceptual understanding and providing exposure to new techniques and devices broadens trainees’ skill sets beyond what they might learn in the classroom.
Break down generational barriers: Nearly all medical educators have the misperception that video games are primarily for children and teenagers. To the contrary—the value of applying game technology to medical education has been recognized as effective and enjoyable for all learners and already is being used by healthcare professionals of all ages. Video games are an opportunity to train physicians in their 50s and 60s too. Short but meaningful experiences are more effective for all learners, because they let trainees learn at their own time and pace. Video game learning is much better than being at a conference for five days or sitting through five hours of lectures, which often is what healthcare professionals—at all phases of their careers—do in the traditional learning system.
Prioritize patient safety: Given the ability to earn CME credit for video game–based content, the steady increase in the number of people who play video games, and ongoing efficacy studies that validate games as a modality for learning, the day is not far off when our patients will see the value of medical professionals who have used games to learn as well. Being able to focus on things that are low risk but allow us to learn skills that otherwise would require live patients to help us is invaluable. Both medical students and physicians require practice over decades to refresh their skills, especially when it comes to rare and challenging cases or new procedures that they may not see on a daily or even yearly basis. With medical training games, healthcare professionals can fine-tune their skills before entering the operating room or touching a patient.
Bottom Line: A well-designed game is better than other learning modalities because it enhances the learning experience and, most importantly, is enjoyable. A well-designed game can go head-to-head with any other learning modality. You will see the advantages in time, enjoyment, and depth of understanding.
References
Number of Gamers Worldwide 2022/2023: Demographics, Statistics, and Predictions. https://financesonline.com/number-of-gamers-worldwide/
Antonini PR, Singer SM, Jaeger JEE, Biasutti M, Sinnett S. Achieving flow: an exploratory investigation of elite college athletes and musicians. Front Psychol. 2022; Mar 30;13:831508.
Hayes A. Using mental models to design for learning: lessons from game development. In: Zaphiris P, Ioannou A, eds. Learning and Collaboration Technologies. Design, Development and Technological Innovation. 5th International Conference, LCT 2018, held as Part of HCI International 2018, Las Vegas, NV. July 15-20, 2018, Proceedings, Part I:433-442.