Video Game Training Improves Physicians' Skill in RCT

Veronica Hackethal, MD

August 28, 2018

Two types of video games may reduce errors in trauma triage in the emergency department (ED), according to a study published online August 27 in the Proceedings of the National Academy of Sciences.

"In a randomized controlled trial (RCT), both games had positive effects, whereas equivalent exposure to traditional medical education had none. By complementing physicians' natural ways of thinking, such simulated experiences might transfer to actual triage and other high-pressure decisions," write Deepika Mohan, MD, MPH, an assistant professor of surgery and critical care medicine at the University of Pittsburgh in Pennsylvania, and colleagues.

Prior research shows that 55% to 80% of patients with severe injuries seen at nontrauma centers are not appropriately transferred to trauma centers. Such inadequate triage may contribute to about 30,000 preventable hospital deaths each year, Mohan and colleagues note.

Triage decisions often occur under stressful, time-pressured circumstances in which physicians must draw on "heuristic thinking" or mental shortcuts, such as intuitive judgment, often derived from training and clinical experience. Although often correct, such thinking sometimes results in errors, especially in atypical or rare events.

To see whether video games can improve triage, researchers created two video games intended to improve heuristic thinking. They used medical records, guidelines from the American College of Surgeons, an expert panel, and clinical experiences to develop the games.

One was an adventure game, in which players solved a mystery and role-played as physicians required to decide about trauma triage. The other was a puzzle-based game, in which players triaged sets of trauma patients. Both games included feedback on errors and how to improve them.

To test the games' efficacy, Mohan and colleagues enrolled 320 emergency medicine physicians in a RCT. Participants were eligible if they worked at a nontrauma or level III/IV trauma center, and thus made triage transfer decisions. On average, they had 8 years of clinical experience, and nearly all (88.8%) were board-certified in emergency medicine.

The researchers randomly assigned participants to one of four trial groups: the adventure game, the puzzle game, traditional text-based continuing medical education materials (active control), or no intervention. Those in the intervention and active control group participated in 2 hours of training.

In a 45-minute virtual simulation of 10 cases, physicians assigned to the video games undertriaged significantly fewer patients than those in the no-intervention group: (adventure game difference: −18% [95% confidence interval (CI), −30% to −6%; P = .002]; puzzle game difference: −17% [95% CI, −28% to −6%; P = .003]).

In contrast, those assigned to the text-based education group undertriaged a similar proportion of patients as the no-intervention group (difference, +8; 95% CI, −3% to +19%; P = .15). "Although well-tolerated by physicians, this active control showed no performance improvement, suggesting that users may have extracted as much as they could from that material already," the authors wrote.

The authors concluded that video games could supplement existing efforts to improve the quality of care in nontrauma centers.

They note, however, several limitations, including that they recruited participants from a national meeting and may have included a disproportionate number of men and physicians interested in learning. In addition, participants were instructed to use the video games for 2 hours, but use was not objectively verified. Finally, the study could not measure how long the training effect of these video games might last.

The study was supported by grants from the National Institutes of Health, the University of Pittsburgh Medical Center for Clinical Decision Making, and the Swedish Foundation for Humanities and Social Sciences. The authors have disclosed no relevant financial relationships.

Proc Natl Acad Sci. Published online August 27, 2018. Full text

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