The Problem

idea series teaching residents quality improvementPoint of care ultrasound (POCUS) is integral to the practice of emergency medicine (EM) and is a core competency for EM residents. Learning ultrasound requires development of a multi-faceted skill set including image acquisition, image interpretation, and integration into clinical decision making. Utilizing the principles of gamification and competition-based learning provides a more engaging method for teaching POCUS than traditional didactic formats.

The Innovation

The Brigham and Women’s Hospital/Massachusetts General Hospital Harvard Affiliated Emergency Medicine Residency (HAEMR) developed the “HAEMR Games,” an ultrasound curriculum in the format of an inter-resident competition with incentives and prizes. It is modeled after the national SAEM Sonogames® competition.1 The curriculum uses a knowledge quiz and hands-on games to test the learner’s ability to think critically and utilize skills for clinical applications while working in a team setting. The games take 3 hours total.

Target Learners

This curriculum is designed for all EM residents PGY1-4. It can easily be modified for teaching ultrasound skills to other specialties that require ultrasound in their clinical practice.

Group Size

The curriculum involves teams of 3 residents. The groups and games may easily be expanded to fit a specific residency’s needs.

Materials Needed

  • Human Models (3)
  • Moderators (6): Each station will require a moderator comfortable with POCUS. Our ultrasound faculty and fellows served as moderators.
  • Ultrasound machines (4): These may be provided by a simulation center, or can be borrowed machines from your department.
  • Ping-pong balls (30): Write a single item able to be scanned on each (e.g. TAPSE, ulnar nerve, etc.).
  • Plastic cups (10)
  • Tegaderms
  • Surgical marker
  • Lumbar puncture (LP) mannequin and LP needles
  • Tupperware
  • Alphabet letters: The magnetic refrigerator letters work well for this purpose.
  • Gel wax
  • Metamucil
  • Ultrasound journal articles (5-7)

Description of the Innovation

Residents are placed in teams of 3. Each resident will get an individual score which is later combined with their teammates’ scores to form the composite team score.

The curriculum is run in tandem with half of the teams completing the quiz while the other half participates in the games section. After 90 minutes, the groups switch.

QUIZ: The quiz consists of 40 ultrasound-specific questions. These include ultrasound physics, image and clip recognition, and clinical scenarios combined with ultrasound clips to test clinical decision making. Each question is worth 10 points. You can add 10 bonus questions such as funny or little known facts about the ultrasound faculty, worth 5 points each.

GAMES: The games are divided into 5 stations. Each team has 15 minutes per station. Some stations are scored individually, some as a team.

  • Station 1- ABCs: All residents on the team come up with a pertinent object that can be scanned for each letter of the alphabet in order, and then take turns demonstrating this image on the model (ex: X for xiphoid). Each letter/image obtained is worth 5 points. You may skip a letter, but will lose 5 points. This is scored as a team.

    Residents participate in the “ABCs” portion of the competition.

  • Station 2- Ultrasound PongPlace the labeled ping-pong balls in a bowl. A resident will pick one and then must find the anatomy  on the model. Teammates can make verbal suggestions, but can not physically help the resident who is scanning. After the relevant anatomy is located, the next team member picks a new ball. The goal is to find as many items on the labeled balls as possible in 15 minutes. Each correct image is worth 5 points. For 1 bonus point, the resident must land the ball in a plastic cup (remember college?). This is scored as a team.

    In the “Ultrasound Pong” portion of the competition, the resident must find the anatomic landmark written on the ping pong ball using ultrasound, and then land the ball in the plastic cup for an extra bonus point.

  • Station 3- Ultrasound-Guided Lumbar Puncture: Place a tegaderm on the lower back of one of the human models. Each resident has 5 minutes to ultrasound the spine, and correctly mark over the tegaderm with a surgical marking pen the landmarks for a lumbar puncture. They will then perform an LP on a mannequin. Each marking and the LP are worth 50 points each. The tegaderm is replaced between each resident. This station is scored individually.

    Residents first identify the spine with ultrasound on a live model, and then perform a lumbar puncture on a mannequin.

  • Station 4- Gel Letters: Place 4 plastic letters of your choice in the bottom of a tupperware container. Mix Metamucil into melted gel wax to make it opaque, then pour over the letters. Residents each have 5 minutes to scan the block for letters. Each letter correctly identified is worth 50 points. This station is scored individually.

    Residents scan the opaque gel block and attempt to identify letters for points.

  • Station 5- Article Quiz: Pick 5 articles pertaining to POCUS and create 15 questions based on these articles. Send the articles to the residents ahead of time to read prior to the event. They must then answer quiz questions by memory. Each question is worth 10 points. This station is scored individually.

At the end of the games, add up individual and team points. We offered fun prizes for the winning team and the top 3 individuals to further incentivize the residents to perform well. We utilized the games as a tryout for the team that would represent the residency in the national games at SAEM.

Lessons Learned

  • It is difficult to keep on time. Build in additional time to rotate between stations.
  • Use letters that are easy to distinguish in the gel block. For instance, it is almost impossible to distinguish an O from a Q on ultrasound.
  • Validate the quiz questions ahead of time with the ultrasound faculty.
  • The general feedback from the residents who participated was very positive. However, residents scheduled to work during the event were disappointed that they could not compete in the games.
  • The residents who participated shared that the fun nature of the games encouraged them to both attend didactics and to study prior to the event.
  • The event works best when the program offers a prize to the winners, as this further incentivizes and engages the participants.

Theory Behind the Innovation

The curriculum is based on the theories of Gamification and Competition-based learning. Gamification is the use of game like components, in non-game areas.2 It has been shown that the implementation of gamification combined with adding competitive components to a task provides motivation for student learners and improves performance.3

Feedback from our group has revealed that using both competition and a game-like format greatly improved the satisfaction and learning of the residents.

Lewiss R, Hayden G, Murray A, Liu Y, Panebianco N, Liteplo A. SonoGames: an innovative approach to emergency medicine resident ultrasound education. J Ultrasound Med. 2014;33(10):1843-1849. [PubMed]
Robson K, Plangger K, Kietzmann JH, McCarthy I, Pitt L. Is it all a game? Understanding the principles of gamification. Business Horizons. 2015;58(4):411-420. doi: 10.1016/j.bushor.2015.03006
Burguillo JC. Using game theory and Competition-based Learning to stimulate student motivation and performance. Computers & Education. 2010;55(2):566-575. doi: 10.1016/j.compedu.2010.02018
Ashley Gilbert, MD

Ashley Gilbert, MD

EM Resident
Department of Emergency Medicine
Brigham and Women’s Hospital / Massachusetts General Hospital
Harvard Affiliated Emergency Medicine Residency (HAEMR)
Heidi Kimberly, MD

Heidi Kimberly, MD

Assistant Professor
Ultrasound Education Director
Department of Emergency Medicine
Brigham and Women’s Hospital / Massachusetts General Hospital
Harvard Affiliated Emergency Medicine Residency (HAEMR)