The Problem

idea series teaching residents quality improvementEvery year, emergency medicine (EM) residents take the In-Training Exam (ITE) to test their medical knowledge and predict the likelihood of passing their official written board examination upon completion of residency training. The Accreditation Council for Graduate Medical Education (ACGME) requires all EM residencies to include weekly didactics in order to build the knowledge base of residents and facilitate preparation for the written and oral American Board of Emergency Medicine (ABEM) or American Osteopathic Board of Emergency Medicine (AOBEM) examinations. These didactics, however, often consists of traditional lecture formats. In contrast, according to the testing effect, we know that taking a test on material improves retention more than just passively hearing or reading the information alone.

The Innovation

This innovation incorporated written board review multiple choice questions into weekly didactics through the use of Kahoot!, a free, online multiple-choice platform intended for group settings.  This innovation was implemented at the University of Michigan/St. Joseph Mercy Hospital Emergency Medicine Residency. The residency program has no financial relationship with Kahoot!.

Incorporating multiple-choice questions in a similar format as the written board examination into weekly conference may improve long-term retention of the material and ultimately resident performance on the annual ITE and the ABEM or AOBEM written board exams.

Target Learners

The target learners included all EM residency weekly conference attendees, including PGY-1 through PGY-4 residents as well as faculty in attendance.

Group Size

Target group size:10-50 individuals

Materials Needed

Kahoot! is a free online game-based learning platform intended for group settings. Board review questions can easily be incorporated into the Kahoot! platform.

Kahoot! is a free, online multiple choice platform intended for group settings. A subscription to the program is necessary for this innovation, as is a computer that projects the questions on a screen at the front of the room. All participating residents and faculty must have a wireless-internet capable device with which to select answer choices, such as a mobile phone, laptop, or tablet.

Description of the Innovation

  • Each week, 5 written board review multiple choice questions were entered into the Kahoot! Platform and administered at the end of conference. These questions occasionally included visual stimuli, such as radiology images, visual diagnosis or ECGs.
  • During a Kahoot! game, players answer on their mobile devices while question prompts and choices are displayed on a shared screen at the front of the room. The colorful display and upbeat music creates a fun, social atmosphere that fosters friendly competition.
  • Users receive a score based on both the accuracy and speed of their responses. A streak of correct answers also results in additional points.
  • At the end of a game, the users with the top 5 scores were displayed.
  • Questions were based on material covered during lectures from that day, as well as material previously covered during that academic year.
  • Residents logged in with the same identifiable usernames each time, and results were tracked over all sessions. At the end of the year, each class leader earned a prize.

This figure provides an example of a typical Kahoot! question. The image on the left demonstrates how the question appears on the screen at the front of the room. The image on the right demonstrates how the answer choices appear on the mobile device of those participating.

Outcomes Measured

Data from 13 conference sessions was collected. On average, there were 33 total participants per session. The average percentage correct was 62%. Following each session, satisfaction was measured on a scale of 1 to 5, with 5 being most satisfied. The mean satisfaction following sessions was 4.64.

Theory Behind the Innovation

The testing effect refers to the observed phenomenon that being tested on material improves retention of the information.1 In other words, testing oneself on material during the studying process improves performance versus only passively reading material. The testing effect requires proper feedback (i.e. information on which questions were answered correctly and incorrectly) on the tested material.2

Lessons Learned

The Kahoot! platform provides a novel way to incorporate written board review material of recently covered conference material.  Participants as a whole enjoyed Kahoot! quizzes. Future studies should examine whether or not ITE scores improved following the incorporation of Kahoot!

Read more about the IDEA Series.

Chan J, McDermott K, Roediger H. Retrieval-induced facilitation: initially nontested material can benefit from prior testing of related material. J Exp Psychol Gen. 2006;135(4):553-571. [PubMed]
Chan J, McDermott K. The testing effect in recognition memory: a dual process account. J Exp Psychol Learn Mem Cogn. 2007;33(2):431-437. [PubMed]
Brendan Munzer, MD

Brendan Munzer, MD

Medical Education Fellow
Department of Emergency Medicine
University of Michigan/Saint Joseph Mercy Hospital
Ann Arbor, MI
Rob Huang, MD

Rob Huang, MD

Assistant Program Director
Director, Clinical Ultrasound Fellowship
Associate Director, Clinical Ultrasound
Department of Emergency Medicine
University of Michigan
Ann Arbor, MI
Mary Haas, MD

Mary Haas, MD

Clinical Instructor and Education Fellow
Assistant Program Director
Department of Emergency Medicine
University of Michigan/Saint Joseph Mercy Hospital