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Thanks for joining us at the Canadian Breakpoint, a Canadian infectious diseases podcast by

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Canadian infectious diseases physicians.

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I'm Summer Stewart, here with Dr. Rupeena Purewal, pediatric infectious diseases physician

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in Saskatoon.

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In this episode, we invite Dr. Shaquille Peermohammad, infectious diseases specialist at

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Vancouver Coastal Health to discuss gamification in medicine.

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Dr. Purewal.

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Welcome everyone.

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Thank you for joining us for another episode of our podcast, the Canadian Breakpoint.

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So today we have very special guests with us.

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Dr. Shaquille Pir Muhammad, who obtained his MD degree in 2011 from the University of Calgary.

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He then trained in internal medicine from 2011 to 2014 at the University of Saskatchewan,

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and then completed his sub specialty training in infectious diseases at the University of

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Toronto in 2016.

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He completed his master's of public health through the Harvard T.H. Chan School of Public

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Health with a focus in clinical effectiveness.

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For the past six years, he has practiced in Saskatoon and his research interests include

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antimicrobial stewardship, quality improvement and medical education.

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Recently, Dr. Pir Muhammad joined the Division of Infectious Diseases at Vancouver Coastal

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Health.

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And in his spare time, he enjoys playing tabletop games, escape rooms, stand up paddle boarding

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and making his own cold brew.

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So awesome.

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Thank you so much for joining us today, Dr. Pir Muhammad.

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And today we're going to be talking about a really kind of a newer concept and we haven't

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really done anything like this on the podcast.

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We've had a lot of discussions around medications and we've done a lot around microbiology recently,

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but we're going to be talking about gamification.

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So I think without further ado, I'm going to let our expert here explain kind of the

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concept of gamification.

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Great.

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Thanks for having me today.

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A pleasure to chat on this exciting topic.

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So gamification is the idea of using game mechanics, elements and principles of playing

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a game, but applying it to a non-game context to engage users in a different way.

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So there's lots of different examples of what are called serious games and these are entertaining

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games, but more importantly, they're used to promote learning and promote behavioral

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change.

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And so recently I know that you've implemented this.

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Obviously the reason we're talking about this today is because we've implemented some of

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these concepts or this concept in medicine and specifically because you're interested

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around antimicrobial stewardship.

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Can you kind of walk us through like how did it come about or where did this idea kind

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of come from?

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Sure.

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I think we're always looking for new and exciting ways to teach concepts related to infectious

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diseases and antimicrobial stewardship.

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I think during the pandemic, we were also trying to find new and exciting ways to engage

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our learners, especially using virtual platforms.

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So that certainly precipitated some ideas related to medical education and using gamification

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as a technique.

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Personally I love playing tabletop games and escape rooms.

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So I was curious about how we can combine a game like an escape room or puzzles to engage

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medical students and internal medicine residents to learn more about infectious disease, antimicrobial

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stewardship and also help them achieve their learning objectives too.

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Got it.

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And so while you're out here in Saskatoon, is that kind of when like the initial, like

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was there initial pilot project that started?

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So we were keen to develop an antimicrobial stewardship themed escape room.

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And there's been lots of really great examples of escape rooms published in the medical literature

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from a wide array of different disciplines, including radiology, toxicology, dermatology,

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anesthesia as well.

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And so we wanted to create one for first year internal medicine residents.

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And so we started out by looking at what are the key objectives of training from the Royal

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College relevant to infectious disease and antimicrobial stewardship for internal medicine.

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And we identified 10 key learning objectives.

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And from that point, we then built variety of different puzzles that would test those

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ideas.

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And once we kind of created small beta versions of those puzzles, we pilot tested them with

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some second year internal medicine residents to trial them out.

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And if it seemed like a good fit, then we got together and built the actual puzzles

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and using different arts and craft supplies.

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And we were able to collaborate with our simulation labs on campus to use their technology.

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So we had access to TV screens and mannequins and a two way mirrors so we could watch students

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as they progressed through the escape room.

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So then we actually built and designed everything.

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And then the next step was probably the most integral part of creating an escape room.

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And that was pilot testing.

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So testing it out with some second year, second and third year internal medicine residents

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and also some friends and colleagues outside of infectious diseases to better understand

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the game mechanics, the flow of the game, get a good sense of how many people we wanted

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on a team for the escape room, and then make some final tweaks to each of the puzzles before

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going live.

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And then currently, assuming that the escape room kind of went forward, where was the interface

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or how could viewers or other public access the escape room?

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The escape room that we built was an in-person escape room using our simulation lab on campus.

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But there's been some emerging literature about creating virtual escape room platforms.

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And the huge benefit of a virtual platform is that there's more flexibility in terms

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of timing for students and learners to participate.

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It's easier to reset the escape room by a click of a button rather than spending 10

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minutes to reset all the locks and everything.

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And so there's greater flexibility and you can also make more easier adjustments to puzzles

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and create more variety with a virtual platform.

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So I think that would be a cool project to work on next is developing an antimicrobial

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stewardship or infectious disease themed virtual platform.

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So that way people from all around the world could participate in that type of learning

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activity.

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That's awesome.

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And then after the escape room, were there other projects that you guys already kind

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of took on that have gone live?

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So one of the other projects that I was involved with was creating a game called microbial

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pursuit.

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I'm a huge fan of simple, quick games that you can play on your phone.

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A good example would be would be Wordle.

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I'm guilty of still playing Wordle to this day.

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And Wordle is a great example of a serious game that involves a lot of gamification elements

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creating rewards for the player by keeping track of your winning streaks to incentivize

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you to return back to the game and be motivated to try again.

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Also being able to keep track of your kind of player statistics and a histogram that

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kind of outlines that and being able to share on social media and share your scores and

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your stories with other people.

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So we were keen to create a game similar to Wordle and apps like that.

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So we wanted to create something that was more trivia based and what discipline opens

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itself more to trivia content than infectious disease and microbiology.

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There's a huge rich history when we think about all of the different pathogens that

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are out there, how they were found and the history behind them, the infections they cause,

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the clinical syndromes and the development of different antimicrobials as well.

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So we created a game called Microbial Pursuit and I collaborated with a company called Firstline

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which creates antimicrobial stewardship mobile apps for healthcare providers and healthcare

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systems.

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So they were fantastic in collaborating on a game.

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And basically each day a new puzzle is presented and you can access Microbial Pursuit online.

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It's a web-based platform.

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There's a new daily trivia puzzle where you have a series of four clues presented to you.

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And as you progress through the four clues, the answer becomes a little bit more easy

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to identify.

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And you have to guess what the pathogen, whether it's a bacteria, virus, parasite or fungus

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or an antimicrobial.

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And if you answer correctly on the first guess, you get a hundred points.

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If you need to advance to the second guess, you lose 25 points and so on.

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And we're keen to work on adding more features and more gamification elements to incentivize

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players and also enhance learning.

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Another key element that we're looking at would be the concept of spaced repetition,

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which is the concept that rather than trying to learn everything at one go, from a learning

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perspective, if you spaced out key concepts and learning materials over time, you're more

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likely to retain that knowledge.

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So for example, from a game point of view, if you were playing today and you got a question

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incorrect, maybe that question pops up again a week or two weeks down the road to try and

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bring back that knowledge recall.

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And so some of these concepts, I think obviously reiterate the facts of how we learn.

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So like with repetition and having, especially like some people are visual learners, so having

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the ability to kind of synthesize and process that information.

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So for me, I think I definitely have played microbial pursuit.

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So I don't know if I've done very well on it, even though I'm being an ID doctor, but

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some of those questions were pretty hard.

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So but it's one of those things that you want to, it kind of motivates you to go back and

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I mean, first of all, A, you learn a lot, right?

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And you learn about the history because I think all of us in our busy clinical world

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life, we're not really focused on that anymore.

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And so it's kind of nice because you learn some background information on organisms that

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you don't see frequently or commonly in clinical practice either.

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So yeah, it was challenging though, I'm not going to lie.

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But it was fun in terms of, so those are some of the advantages that I saw, like even, you

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know, looking, playing and moving through that interface, the microbial pursuit.

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So what are some of the other advantages or any like feedback that learners have given

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you guys to see like, is this something that's working?

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Like is this a concept that really has made a difference in medicine?

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Sure.

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So when we first did our, the first iteration of the antimicrobial stewardship escape room,

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we did study it and we used a pre post self assessment model based upon those 10 learning

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objectives using a five point Likert scale.

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And we did find across the board that our first year internal medicine residents perceived

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learning through the escape room and their scores for each of those 10 objectives improved

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from a statistical significant point of view as well.

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And so I think from a gamification point of view in general, I think it's a very exciting

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time because there's lots of new games being developed and different ways to try and study

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gamification and medical education.

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One thing to reflect on would be Kirkpatrick's training evaluation model, which comes up

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with medical education.

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And so with our project, we were able to get a sense that, that our students liked the

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activity and perceived knowledge acquisition through the activity.

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Kirkpatrick's training evaluation model has four levels, basically like a pyramid.

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The first level is getting that reaction.

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Do your students like the activity?

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We achieved that.

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People liked the escape room and it was fun.

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It was engaging.

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It was educational.

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The second level is learning.

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So to what degree do participants acquire the knowledge intended through that activity

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or skills or attitudes that you're trying to deliver?

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And we did achieve that through the self-assessment tool that we employed.

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The third and the fourth levels are sometimes harder to achieve and create studies that

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determine whether you're achieving those levels.

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The third level is behavior.

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So does your learning activity change practice?

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Will do students take away key learning messages from your learning activity and then apply

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it at the bedside or apply it to real life practice in healthcare?

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And the fourth level is those results.

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So to what degree does that outcome actually occur?

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Does it change clinical practice?

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Did your learning activity change how we practice and function and behave and the medicine that

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we practice at the bedside?

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So those are a little bit harder to achieve and elucidate, but it's definitely a very

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exciting time.

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There's lots of cool medical education initiatives related to gamification that are coming out

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and lots of exciting literature.

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I think it's like, I mean, definitely in the era that we're living in where we're using

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a lot of technology and I think everybody has like other, like a phone or a device that

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they can access at all times.

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So I think using all of those and I think we're kind of the generation in our kind of

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practice constantly had apps and tools like this to learn.

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So I think this seems like definitely even more exciting for the future for all of the

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students that are coming through med school and other degrees as well.

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So in terms of obviously technology is the key here, right?

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We need technological advances that we've seen to help us have these types of games

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and apps and all these develop.

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So is that kind of the reason why it's taken so long to come up with this?

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Because it sounds like a fantastic idea and I'm sure we've known about concepts like this

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before, but really like kind of what are the hurdles or challenges that I guess you faced

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when implementing this and is that kind of the, was that really the real ending step

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for a project like this to come to surface?

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I think one of the biggest challenges with gamification and medical education is that

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it is fairly new and there has been a surge of games, including tabletop games and apps

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and video games in medical education.

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I think one of the biggest challenges though that we're still trying to learn more about

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is finding that sweet spot where you have a serious game that is entertaining and engaging,

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but pushes the learner outside of their competence and a little bit outside of their comfort

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zone to push them to learn, but without creating a distressful experience that demotivates

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them or discourages them from returning back to the game and participating again.

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So I think that's the challenge with gamification medical education is you want to create something

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successful and powerful that encourages the user, the player to continuously come back

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to the game to support their learning because that ultimately would be the main goal here.

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Yeah.

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And I mean, I can definitely see like the advantages of having something like this,

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right?

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Cause it's on your fingertips and you're also like not having to open up a textbook

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to learn all this information and not be overwhelmed, right?

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Because you're getting small doses of information and then you can go on with the rest of your

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day.

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And I think in our generation of learners, that's something that I think most of us would

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appreciate, right?

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To have instead of read a textbook of like 50, 60 pages a night.

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So it sounds like something that should be introduced into concepts are like universities

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and other workplaces.

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Do you know that, are they implementing this or is there something still that's, you know,

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you would look at as like a disadvantage in a certain field that you wouldn't implement

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this?

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I think creating games in medical education is very innovative and very exciting, but

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it certainly wouldn't be our only strategy and certainly wouldn't replace our more traditional

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approaches to teaching our students.

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But it can be an effective way to reinforce concepts and be more stimulating and encourage

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learning, especially if it's done in a safe space.

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The escape room experience is akin to simulation labs that we still use in medical education,

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but using for years when we're teaching how to perform a mock code, for example, or handle

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very high stress situations to practice those types of scenarios.

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So an escape room is almost similar to that.

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And so some of the concepts and ideas behind gamification medical education aren't maybe

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as new as we rethink.

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I think a lot of these puzzles and games have been around for quite some time.

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I think we're just starting to now introduce these concepts into medical education and

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push that, especially with a generation of millennial learners.

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I think it's also important that we adapt to their learning style and creating more

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flexible adaptive platforms for teaching.

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In terms of, so if a center or a physician wants to get involved and implement something

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like this, what's the starting blocks for this or how would you guide somebody?

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I think if you were interested in creating a serious game or whether that's an escape

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room experience or tabletop game or a video game or an app, I think a great place to start

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would be by contacting your medical school or your PGME office or UGME office.

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And I think you'd be surprised by how much may be already there in terms of support and

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reciprocity to support these types of initiatives.

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When we were developing our escape room, I was pleasantly surprised by how much enthusiasm

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was shared by our PGME office to carry out and help bring this idea to fruition and also

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how much support there was from the simulation labs on campus that were very keen to collaborate

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and help support the project.

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So I think a good place to start would be contacting your local institution and see

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what kind of feedback you get about the idea and what support might exist.

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I think collaboration is also critical to these types of interventions.

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You want to involve a good team of people from a variety of different backgrounds that

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can give you good insight on your puzzles and your ideas.

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When we play tested our escape room, getting feedback from second year internal medicine

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residents was very important to know that our content level and difficulty level was

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at the right stage.

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But it was also important to get feedback from people outside of infectious diseases

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to better understand the game mechanics and whether our puzzles flow and make sense from

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a logical point of view.

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So yeah, that's actually really good information I think for our listeners who are thinking

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about introducing a concept or kind of, I think sometimes you just need some like a

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starting point and knowing and having those supports and knowing who to reach out to.

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So that's really good.

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So what are some of the newer, I guess, so you talked about microbial pursuit and then

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you talked about your escape room.

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Are you currently working on other projects or anything that's recently been released?

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Some of our listeners can tune into.

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I think it's definitely interesting.

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I definitely want to continue to work on creating more antimicrobial stewardship and infectious

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disease themed escape rooms.

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I think it's also might be interesting to work on escape rooms that are ranging in terms

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of difficulty level for different audiences.

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Another idea that I don't think has been tapped into yet would be creating an interdisciplinary

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escape room because that reflects how often we practice in real life working with providers

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from different perspectives, including dietitians, PT, OT, nursing.

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So why not create an escape room that reflects those principles and gives us a better sense

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of each of our roles and how we work together to support positive patient outcomes.

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I think it's also really interesting to look at what other people are doing with medical

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education and escape rooms.

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Dr. Teresa Chan out of McMaster University developed a really cool tabletop game called

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Gridlocked, which helps learners understand triaging skills in the emergency room and

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as a tabletop board game.

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There's lots of really other cool apps and games out there for infectious diseases.

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Barmageddon is a really cool game that I would encourage people to try out.

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And Empiric is another kind of cool card game that you can play to learn about antimicrobials

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and spectrum of activity in terms of what bacteria different antimicrobials cover.

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So yeah, there's lots of really great examples.

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From an app point of view, there's a cool company called LevelX, which has a variety

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of different games you can play on your phone to learn pattern recognition when it comes

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to different rashes and dermatology, practicing how to perform endoscopy.

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So if you're in respirology or gastroenterology, you can practice performing an endoscopy on

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your phone.

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And I think there's also one for cardiac catheterization.

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So cool, cool techniques using a gamification theory in serious games to teach those skills

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and that knowledge.

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Awesome.

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I actually didn't know about any of those.

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So I mean, it's so neat to see it's so widespread over so many different fields.

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And I think definitely our listeners will be excited to tune into some of those.

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I'm definitely going to do that.

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The LevelX sounds so cool.

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And then what about microbial pursuit?

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Is that something they can access on Firstline?

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It's not available through the app itself, but if you Google microbial pursuit or go

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to firstline.org slash microbial dash pursuit, it's a web based platform.

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Right now we have over 150 puzzles that are in circulation and you can access all of the

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puzzles.

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All the previous puzzles are accessible, but a new one is posted every day to play.

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So that's free for players to access.

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One other idea that I've been kind of toying with in my mind is, I don't know if you've

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ever played the game Heads Up that I think was made popular on the Alan DeGeneres show.

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Player A would hold their phone in front of them, which would show a clue, maybe a name

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of a celebrity or a language or an animal.

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And your player B or multiple players would help you give you clues to guess what's on

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the phone.

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I thought that could maybe be applied to infectious diseases.

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So maybe on the screen you have a name of a bacteria or an antimicrobial or a fungus

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or a virus that's relevant to your level of training and your colleagues, your peers,

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your friends give you clues to guess.

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So it's a grand positive cockeying clusters and that might help with a bidirectional feedback

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and precipitate learning both from the clue giving perspective and then the clue receiving

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perspective.

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Well, you have definitely a lot of ideas coming up, so I'm excited to hear some of the future

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kind of concepts and really how we're going to implement this into our daily learning.

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And I think it's really nice because we have the ability to create apps and do all of this

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and work with multiple, there's so many technology-based platforms now that I think this will definitely

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come to surface.

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So super excited.

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We're so grateful to have you on the podcast and talk about gamification.

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I mean, it was definitely, when I heard about it, I mean, this is the name itself.

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It sounds interesting, right?

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So to come into and then thinking about incorporating that into medicine, because historically we

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didn't always have such great ideas.

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And so I think there's a lot in the future and maybe we'll have you back on when you've

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developed a couple more of those games and you can kind of walk us through that.

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Thanks for having me.

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Thank you, Dr. Pirwal and Dr. Pir Mohamed for the very interesting topic.

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Have a suggestion, email us at thecanadianbreakpoint at gmail.com and be sure to follow us on Twitter

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at CA Breakpoint.

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See you again soon at the Canadian Breakpoint.