Gamification in Interprofessional Education: Learning Through Virtual Escape Rooms

Podcast Transcript

Dr. James K. Stoller

Hello and welcome to MedEd Thread, a Cleveland Clinic education podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano

Hello, welcome to today's episode of MedEd Thread, an education podcast exploring how gamification in interprofessional education is enhancing healthcare learning through interactive game-based methods. I'm your host, Dr. Tony Tizzano, Director of Student and Learner Health here at Cleveland Clinic in Cleveland, Ohio. Today, I'm very pleased to have Brian Peacock, Assistant Professor and Program Director in the Department of Physician Assistant Studies at Wake Forest University School of Medicine, here to join us. Brian, welcome to today's podcast.

Brian Peacock

Thank you, Tony. Um, it's a pleasure to be here and, um, an honor to be part of this innovative and creative podcast.

Dr. Tony Tizzano

Well, we're glad to have you, Brian. To get us started, could you please tell us a little bit about yourself, your educational background, and your roles at Wake Forest University?

Brian Peacock

Sure. Prior to attending PA school at Wake Forest, I gained my clinical experience as a phlebotomist and autopsy assistant, which really sparked the motivation and influence to get into medicine. I graduated from the Wake Forest PA program and immediately started working in general surgery here in Winston-Salem at the Wake Forest Baptist Hospital. Early on in clinical practice, I really got involved precepting clinical training students. And shortly after that, I found that I enjoyed the teaching aspect as much as I was enjoying the patient care aspect. So about 10 years ago, I joined faculty here at the Wake Forest PA program. And in 2021, I was named the program director to oversee the curriculum and training of PA students across 2 campuses here in North Carolina.

Dr. Tony Tizzano

So you've had all kinds of interesting experience along the way. So in today's segment, we hope to explore how gamification— and Brian is going to explain this to us— applied to interprofessional education is enhancing healthcare learning through an engaging and interactive game-based method and how one might implement such a program in an in-person virtual escape room for trainees. So Brian, if you would, please help frame the topic by first defining it for our listeners and give some context around the intriguing and growing role of gamification in interprofessional learning.

Brian Peacock

The medical profession accrediting bodies have come to recognize the importance of preparing healthcare teammates to work effectively in collaborative practice. Really to focus on patient-centered care. And so recently the LCME, the ARCPA, the CCNE have put a big focus on interprofessional education with a goal to foster that teammate among healthcare professionals, really once they enter clinical practice versus things that they have to gain over years of clinical practice.

Dr. Tony Tizzano

So what are those bodies? I'm, I'm not familiar with some of those acronyms.

Brian Peacock

Those are the accrediting bodies for medical schools, PA schools, and nursing.

Dr. Tony Tizzano

Okay, perfect. Go ahead.

Brian Peacock

So, as we started to review our curriculum and our interprofessional education events, we just started thinking about different forms of curriculum design and what could be being done out there that was better than sort of the traditional methods. And so we found some publications on gamification, and in those publications they were discussing improved grades, retention of material, and then really the increased motivation of the learners, the engagement. And improved satisfaction as well. So we started thinking, is there a way that we could implement this gamification into these now required curricular components so the students were more than just attending the events, but really engaging, being active learners, and retaining the information from them?

Dr. Tony Tizzano

Yeah, that is really interesting. And when you say this, are you bringing in multiple disciplines into the same room during these interactions?

Brian Peacock

Yes, sir. We brought in 9 different disciplines from 3 different institutions located here in Winston-Salem. You know, we were well aware of those typical IPE simulation formats working through specific patient cases, but we thought if we could bring in as many as 9 disciplines versus the 2 or 3, which were kind of the normal, could we make this more broad, more engaging? The sort of traditional historical IPE events we found really were focused on simulation-based activities or really patient-specific cases. And that tends to limit that discussion on a scope of practice and training area in that specific setting or in that specific case. It's more of a, what would you do next? What would you do next for this patient? Versus a, how are you trained? What other skills do you have? How— what else could you bring to the table in this scenario?

Dr. Tony Tizzano

And do you think by bringing these different groups in and these different disciplines, you start to flatten the hierarchy that exists? I know certainly between physicians and nursing, because really flattening that playing field too me seems such an imperative in education today.

Brian Peacock

That was one of our primary goals, was to see if we could help break down some of those barriers that we find, you know, takes years of clinical practice to realize what everybody else on the team can bring to the table. And so if we could really teach them about others who were in the hospital, in outpatient settings, in the communities, and how to engage them as soon as they enter practice versus that large learning curve that maybe we could have a bigger impact on breaking down some of the hierarchy and showing that you don't have to know everything, but you know who to engage in different situations to improve that patient satisfaction.

Dr. Tony Tizzano

Boy, if that isn't a mouthful. I mean, I think it's not lost on any of us that you can't know everything, and it's not seeing that as a sign of weakness, but a willingness to engage others to help deliver the very best care. And most importantly, know what you don't know. I'm curious about your inspiration. Did you look at what you were doing and say, you know, there has to be something more, or not hitting the marks we want to hit, and we want to look for a more novel, engaging approach? Because when you hear the word gamification, you right away think, oh, that's a lesser, you know, do you bring in the game of Operation and teach surgery this way or no? Tell us what that really is and how you brought that to bear.

Brian Peacock

Yeah, what led us to creating this is we just sat around thinking, could we design this interprofessional education event that allowed for others to hear about the specific training and responsibilities of other healthcare teammates in different patient settings versus that more narrow patient current condition event that we had been doing? And then reflecting back on the research thinking, okay, this gamification idea really enhances motivation. Ensures active participation, maybe improve some knowledge retention. Could we combine these two things and come up with something really unique? Which really led us to this discussion about different rooms and different settings versus that one patient or that one condition. Can we have them travel from this setting to this setting to this setting to really focus on what everybody brings to the table at different points or different contact points of the patient? And then it just all fell into place of, well, for going from different rooms or settings, what if each one was an escape room with its own goals and you had to unlock sort of all the objectives within that room before you can move on to the next one?

Dr. Tony Tizzano

I'm hoping some of our listeners have at least had the opportunity to do one of these escape room exercises for fun because they've cropped up. We even have one in Wooster, Ohio, if you can imagine. And I can see immediately how every person coming into that room brings something to the table that someone else may not have. And if their disciplines vary and their backgrounds also differ, even better to be able to unlock and get out of there in a timely manner. So, you know, I think that embarking upon this is really intriguing and the escape room sounds like a great virtual model. So what were the specific goals and objectives that were essential outcomes to this escape room that you designed?

Brian Peacock

You just said it straight up, Tony, which was You imagine walking in that escape room with a group of people and recognizing that those puzzles take everyone in the room to solve. It's not one that you can easily walk around and figure out the codes and identify the different puzzle pieces. And so was there a way we can make sure we engaged everyone in this room, that they were required to participate, they needed to be there for everybody to be successful? And so while they're in the rooms, our goals were really to make sure that each of the team members' roles and scope of practice based on their training, not just the perception of what they did, but how they were trained, and to gain an appreciation for that purpose and focus for patient-centered care. We really wanted to optimize effective healthcare teams by communication strategies, discussing different ways we communicate amongst the team, whether it's in the patient's chart, whether it's patient handoffs, whether it's just interacting in the room. And working to foster that trust and clarity around communication skills. We've talked about flattening the hierarchy by reducing some of the jargon that goes into our own terminology and things we put into the medical chart.

Brian Peacock

And then recognizing those potential case-related differences in health outcomes that can impact patient outcomes.

Dr. Tony Tizzano

Yeah, I think, you know, you hit upon the jargon thing. I think that's so important. I know that especially earlier in my training, but even still, I meet a new discipline and they use acronyms that they'll say 3 letters and I'm diving, diving, diving. What could that mean? What could that mean? What could that mean? And you can only ask the question, what does that stand for? So many times before it's like, okay, buddy, do you have any idea what's going on? So you feel kind of foolish. So it helps you be more of the team when you get to have this stuff fleshed out. And I think it always probably even brings some of the barriers to care that occur up to a level where they're more understandable. Is that possible as well? As well in healthcare?

Brian Peacock

It is. I think having various disciplines and students from across different backgrounds and experiences really trying to brainstorm in a safe space of what could be a barrier or a social driver of health for a patient in this setting, what could be limiting their ability to be as successful as possible, and allowing them to brainstorm and come up with ideas, knowing that behind these ideas is sort of this puzzle that they have to kind of come up with the correct code to unlock. And so they end up engaging in these deep discussions on what they think it could be or couldn't be and why it would be this or why it wouldn't be that. And it's just, it's really fascinating and fun to watch them sort of break down their own barriers and have these open discussions about what can impact patients at different phases.

Dr. Tony Tizzano

Boy, and you hit that word, a safe space, a psychologically safe space. In this kind of simulation where you don't have a patient in front of you and you're not afraid of making a mistake, you can be honest and transparent. And that transparency shines through. And when people start to see that that group is interacting in a way that is entirely transparent because there's no fear of like, uh-oh, you don't know what you're doing, because no one knows what they're doing in these escape rooms. I mean, it is sometimes a, I'm not finding the next step. Why am I not finding it? And you never know who's going to bring that piece to the table. So let's take a moment to look at this particular model and help understand how implementing this virtual escape room, what does it really look like?

Brian Peacock

So we're taking students from 9 different healthcare disciplines and putting them at a single table with one faculty facilitator. That's where they kind of enter this virtual escape room that's computer-based. They watch a short video about a traumatic spinal cord injury that occurs on a construction site. And this kind of creates the 3 phases they're gonna go through, or the 3 different rooms they have to get through. There's an acute phase after the injury, or acute room. There's an inpatient rehab room. There's a discharge home room or phase.

Dr. Tony Tizzano

And are these individuals at different places? Are they all in one room together, or can I be working with you from home?

Brian Peacock

Currently it's been in person. So they're doing an in-person virtual escape room. That'll get into future aspirations is how do we make this transferable to other institutions all across the country with hopes of really engaging students from other states, other institutions, or being able to pass this along to everybody else. But as they get into these 3 phases, the acute phase, inpatient rehab phase, the discharge home phase, in each room or each setting, there's sort of 3 different codes or keys that they have to unlock before they can get out of that room. One of them is to first off identify different communication barriers in healthcare within that setting. So they start reading this patient note for the acute phase, that first room, and it's really a medical document that we've written and engaged with all of the faculty from the disciplines that are there to say, "Send us your acronyms, send us your jargon, send us your shorthand that you use." We make sure to include from each discipline, as many as we can in this note, almost like an electronic medical record. And so as the students go through and read this medical document, they have a Post-it note that they write down the jargon or acronyms or numbers that they don't really understand what it means, whether they're uncertain, I'm not sure that I know that, or I really have no idea what that is.

Brian Peacock

And then once they've all completed that portion of the reading, they really go through, the facilitator collects them, and pulls it out and says, "What does this mean?" And allows whichever discipline utilizes that to go through and explain, "This is what it means. This is why we use it. It helps us remember, or it's a shorthand for this." But it also starts to highlight the amount of times they see that same acronym come up from other people writing it down that maybe nobody knows what it means when I write that down but me. And so is there a way to really start breaking down some of these barriers to say, These things may help with my time or my understanding, but the other people reading the chart don't know what that means.

Dr. Tony Tizzano

And you've even built in anonymity to this. So the facilitator's gathering the Post-its so you can be honest because no one knows who's submitting what. And all of a sudden you realize everyone but my discipline submitted this. No one knows what I'm talking about.

Brian Peacock

Exactly. And so they go through and you're reading it and you're just like, I, I don't know what this means. And then the physical therapy student speaks up and says, oh, this is why we use it, this is what it means. And they recognize that none of the providers, none of the nurses, none of the people on the team really know what that means, or the stuff that we use as PAs or nurses use. And so as they go around, they really identify this may not be the best way to list it in the chart if other people are supposed to be gaining information from it.

Dr. Tony Tizzano

I love it. So the teamwork and the communication skill, I mean, you hit on all three of those in healthcare. Communication, huge issue for us, and understanding scope of practice of these different specialties that you're not familiar with.

Dr. James K. Stoller

Mm-hmm.

Dr. Tony Tizzano

So I love it. I think this is outstanding. So Brian, once you've gone through the communication portion of this exercise, what comes next?

Brian Peacock

So in these rooms, we have specific hotspots set up. And so the students have to find these. It's— the bed is one of them, and like the vital sign machine is one. There's a little petri dish on the counter is another. And so as they go through the room and click on these objects, It serves as prompt up, and the prompt is, based on this setting and the patient's bed, what is your role or responsibility for this patient? And the goal is to get everybody to talk about, well, what I think of the bed in the acute phase, this is my role for taking care of the patient. I'm thinking about— you have different people talk about pressure wounds and patient positioning and sort of the acute medicine aspects of it. But you get to hear from everybody and learn that there are people who should be involved in the acute phase of a patient's accident that you probably never thought should be involved. They have training and skills in this space. And then they'll go in, once they've uncovered all these, the facilitator has kind of the key to everything they're supposed to talk about.

Brian Peacock

It also highlights areas of redundancy where multiple people are trained to do the same thing. And so is there a space to improve that communication to reduce redundancy? Or make sure there's no gaps in assumptions that, oh, well, they do it as well, so I shouldn't have to do it too. And so working on that space as well. And then once they've solved that puzzle, they move on to the next hotspot. So the Petri dish is when you think about labs and what are you thinking about, and whether it's where was it drawn from, how's the specimen. Different aspects of the care within the room spur different discussions about what are you trained to manage in that space. And then once they've uncovered the scope of care, for each discipline associated with that setting, they're able to move on to the next key, which talks about the barriers to healthcare.

Dr. Tony Tizzano

So it touches on two important factors. One is I may not understand what someone else brings to the table and recognize that it needs to be done and why it's important. So the patient benefits there. And then even though I do this and someone else does it, we can collaborate to maybe bring that up to a higher level in that particular area through collaboration, because everyone has something to bring to the table as long as they have an opportunity to do so. Very well said. So how does this model focus then on building skills related to these factors that determine health outcomes? You mentioned that to me in an earlier conversation. I'd like to hear more about that.

Brian Peacock

Sure. Participants really they have to explore different social factors that impact health outcomes and address personal and systemic biases within the healthcare system. And so as part of the last puzzle in each room, they're thinking about within this hospital setting, so the acute phase when they're first arriving to the hospital and trying to navigate all of the people coming in and out of the room to be evaluated by, or in the rehab phase where everybody's coming in to make formal recommendations before they get discharged. And then they are going home phase, thinking about what the patient's life is going to look like at home, what are the different social factors that can impact their overall health or ability to be successful within their healthcare? What are personal biases that can exist as people walk into a room and make assumptions about patients based on their presentation, their accident, how they ended up in the hospital? And then acknowledging the systemic biases in healthcare. One of the major parts of the puzzle is going through and trying to identify the systemic barriers that exist and then highlighting those to get the correct code before they can unlock the door to get out of that room.

Dr. Tony Tizzano

So as regards to systemic barriers and kind of our stereotypical things, just for our audience to understand, maybe you could expand on those. I think of things like bias related to obesity, or this is a Medicaid patient or a Medicare patient, or this is someone with a disability. Are those the kinds of things we're talking about or something different?

Brian Peacock

Those are the kind of ones that have ageism, ableism, racism, sexism, the things that can really impact somebody's overall experience and assumptions that we make about somebody as we walk into those rooms. The other barriers that aren't necessarily the personal biases are in things like housing instability, access to community resources, job insecurities, disabilities, transportation, workers' compensation, are they going to feel supported or unsupported for discharge, financial limitations. These are the things that are on a list they have to go through and say, in this phase, this is probably something that's going to be a barrier for this patient.

Dr. Tony Tizzano

Boy, and unless you're a social worker, you may not feel those, or you may not think of those right away because you're busy with the modality that you deal with day in and day out and making sure that piece is done. But they've got to leave that setting and go home and continue the plan that you've set forth, and those things could easily be stumbling blocks along the way. I just love this. So you put this all together, you've watched it kind of take its course. You know, have you been able to verify the effectiveness of this approach to ensure that your objectives are being met? And how do you do that?

Brian Peacock

The very last puzzle, and not like kind of the acute knowledge, did you actually learn some stuff from this event in this setting, is a crossword puzzle. So we've designed this extensive crossword puzzle that includes specific medical jargon from the day. It includes some of the barriers, some of the biases, some of the scopes of practice that they've reviewed to make sure that they're able to answer and address some of these things as they go through as kind of a final puzzle on the way out the door. And then we utilize survey-based data to help kind of validate or verify and say, what did they actually get out of this? What do they perceive they got out of this? And so from the 9 different disciplines, we break it out and we complete the Interprofessional Attitude Scale, or the IPASS. And we found that quantitatively, there's a statistically significant improvement in the perceptions of teamwork and the roles and responsibilities subscales. And we thought going into this, doing a pre- and post-survey based on their attitude towards IPE, not a whole lot of things would change, because you understand you're supposed to be engaged. You understand you're supposed to do patient-centered care.

Brian Peacock

But to see really statistically significant improvements in how they view teamwork and the roles and responsibilities was just eye-opening to us. And we're really satisfied with that. 68% felt the experience changed their perception of other teammates' roles. And we had qualitative themes on just how great the experience was and the collaborative nature. They were just really shocked by how collaborative the entire team worked together to solve these puzzles.

Dr. Tony Tizzano

Boy, that really is impressive. How has this very innovative, if not novel, teaching method been received, and has it been adopted across the School of Medicine at Wake Forest, or—

Brian Peacock

It's really been well received, and we've been fascinated to see the amount of administrators that want to come watch and participate in this. We've had provosts from other institutions, deans across the board, wanting to come just watch and observe the students and just be engaged in this event. Which has been really fun to see them there, to see them engaged, and to see their interest in this.

Dr. Tony Tizzano

I missed a meeting that I was hoping to go to a couple days ago because of an issue I had, and I noticed that in the agenda, and it was the first thing I asked to be included in, was a gamification at Case Western Reserve University. So it's front of mind. I think a lot of people are looking at it. What do you see on the horizon for this sort of work to optimize these educational modalities for your students that maybe generations unlike mine are looking at things differently, want to see things and hear things differently? What's next?

Brian Peacock

Really hoping to improve the facilitator guide to allow this to be just more widely disseminated. Is there a way to create this that is across multiple states or additional institutions to host these things virtually in a virtual escape room versus having to be in person. I think the in-person is a limitation on the amount of different universities and disciplines you can get involved. And so is there a way to expand that? The timing of this is, is really ironic. Earlier this week, we had our IPE event, our virtual escape room for this year, and we expanded to create 2 new cases. So there's 3 total cases now and engaged completely new disciplines across other institutions. To see how that was going to go. And so continue to expand the cases to make sure we can include others who are part of the healthcare team we may not even be thinking about. And so how can we grow this if it's going to ensure students are actively participating and retaining and learning from it? Is there a way to include more in this and really disseminate it across the board?

Dr. Tony Tizzano

Is it possible to develop a kind of plug-and-play series of pieces that one might use. For example, you know, we have focused on LGBTQ+ education and recognizing that in the first and second years of medical school, not everyone, not all faculty may have it at the tip of their tongue on how to present this information. So we literally created these slides for each discipline to look at it. Might you find a way to incorporate these into your lecture or into your program or into your syllabus? And It had fabulous success and not a lot of schools do that. Is there a way that something like that could be done with this? So for someone who would hear this for the first time and think gamification, virtual escape room, what? Might be able to look at this toolkit and do it?

Brian Peacock

I think 100%. If you start with that end goal in mind and then think about what kind of discussion needs to take place for others to see and recognize versus just sitting and receiving somebody telling you about a situation or about data or reading it on a slide. Is there a way to create this experience or this game where they're actually interacting with each other and seeing how if I do this or say this, what is the outcome? What if I change it and say this or do this? What is the outcome? And trying to really recognize different strategies to get sort of the keys to these rooms.

Dr. Tony Tizzano

Well, your interest in Passion for this is palpable, and I have to applaud your efforts because I think it's incumbent upon us as educators, especially since there are generational differences, to look at the way different groups learn, how they like to learn, how they want to engage. And if we don't learn to embrace those, embrace those well, our ability to lead those groups is going to be diminished, and our success, our personal and professional success, I think, will be diminished. So is there anything, Brian, that I didn't touch upon or I didn't ask you that you feel is important for our listeners to know?

Brian Peacock

I think there are a lot of really innovative curriculum ideas going on around the country, and you mentioned Case Western and their gamification earlier this week. I just want to encourage everyone out there to share what's going on, what's working well, what's not working well, what have you tried that found just great success, what did you find that didn't go so well, and being transparent with that. We're all out here just trying to train the next generation of healthcare professionals, and we want to be in a space where they are ready upon graduation to make that positive impact on their community. And so we need to work together to talk about these experiences so that we can all improve that outcome for this next generation. I thank you for hosting a podcast like this that allows us to take those positive steps to improve that transparency and hope to continue to listen and engage with others.

Dr. Tony Tizzano

So if they've heard Brian Peacock, Wake Forest University, and they Google you and they obviously will find your email, they could give you a, a buzz and you might share some information with them.

Brian Peacock

I'd be happy to talk to anyone out there who is interested in learning more about this or participating in this event. More than happy to share.

Dr. Tony Tizzano

Fabulous. Well, Brian, thank you so much. This was an intriguing, wonderfully insightful podcast. To our listeners, if you'd like to suggest an education topic to us or comment on an episode, please email us at education@ccf.org. Thank you very much for joining. We look forward to seeing you on our next podcast. Have a wonderful day.

Dr. James K. Stoller

This concludes this episode of MedEd Thread, a Cleveland Clinic Education podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread. Red, and please join us again soon.