Emergency Medicine (EM) physicians care for anyone, with anything, at any time. This includes pediatric patients as well as adults. For those without advanced pediatric training, “sick kids” can be quite intimidating. Rashes in the pediatric population are often benign, but in rare cases they portend significant illness. Rashes are also frequent chief complaints; In 2015, there were 1,452,300 pediatric ED visits for “skin and subcutaneous tissue disorders” [1]. We sought to improve the teaching of pediatric rashes in our residency curriculum.

The Innovation

We developed a one-hour workshop inspired by the 1948 board game Clue and titled it “Clue: Pediatric Rash Edition.” During this game, residents must diagnose various pediatric rashes after they listen to an oral boards-style case presentation. Following the game, participants listen to a didactic in order to review the cases and important features of each.

Target Learners

The workshop targets all post-graduate year (PGY) levels in EM, but can be applied to family medicine or pediatric residents as well.

Group Size

The entire residency program, including interested medical students, can participate in this activity. Although originally designed as a competition for individuals, the activity can be easily modified to incorporate teams of two to four participants.

Required Materials

  • Oral boards-style cases incorporating several different etiologies of rashes in pediatric patients. Example cases include hand, foot, and mouth disease, impetigo, Kawasaki disease, measles, meningococcal meningitis, pityriasis rosea, scarlet fever, and tinea capitis.
  • Visual stimulus for each case
  • One faculty facilitators per case to present the case oral boards-style
  • One additional faculty member to facilitate overall flow and accept answers to the “final diagnosis”
  • “Room” signs, one per case. Examples include the billiard room, the conservatory, the ballroom, etc.
  • Clues to the “final diagnosis” (one discrete clue per case, but enough copies to provide to all learners). Note that this step is the most time-consuming component of preparation. For instance, 8 cases for 50 learners requires 400 clues!
  • Pads and pens for participants to use
  • Prizes for those who correctly answered all cases – our iteration used three prizes, decreasing in value after the first-place prize.

Figure 1: A faculty facilitator delivers an oral boards-style case in “the dining room.”

Description of the activity

Faculty facilitators are seated, one per table, in a conference room. Each facilitator is provided with the case, the visual stimulus, and copies of a specific clue to the final diagnosis.

Clue pediatric rash game

Figure 2: Participants run through oral boards cases incorporating pediatric rashes.

The participants then receive the rules of the game:

  • Around the conference area are eight “rooms.” Each room has a “parent” (the faculty facilitator), who will tell the participant about their child’s condition in an oral boards-style case format.
    • For example, the Kawaski case:

  • In each room, the participant will submit a written answer containing three elements:
    • The diagnosis
    • The most likely causative agent (if known)
    • The treatment
  • If incorrect, the participant may try again. If correct, the participant will receive a clue to the final diagnosis.
  • When ready to submit a final diagnosis, the participant comes to the lead facilitator with his or her answer
  • The first participant with a correct answer to all final diagnoses wins a prize. Any participants with incorrect answers will be excluded from winning a prize, but may continue with other cases.
  • While multiple participants may be at a table at any given time, this is not a group activity.
  • You may proceed to another table at any time, whether or not you have gotten the correct answer at your current table.
  • Cases may be done in any order.

The person facilitating the overall activity circulates around the room to answer any questions that arise and to observe areas of difficulty in order to facilitate discussion after the activity concludes. This facilitator will also accept answers to the final diagnosis.

Those running the activity can choose to end the game once all prizes have been distributed or when a certain number of participants have finished. The workshop is followed by a group-wide discussion of the specific cases. The key features of each case were identified, along with the diagnosis and treatment options.

Figure 3: An example of key identifying features of the case and the diagnosis presented during the post-workshop didactics.

Outcomes Measured

Out of the total participants, 31/40 (77.5%) submitted post-workshop surveys. The vast majority of survey respondents (27/31, 87%) indicated that the workshop enhanced learning more than traditional lectures and reading alone, while 30/31 (97%) responded that it was more enjoyable than traditional lectures and reading alone. In one-on-one debriefings with participants, most stated that they would want to continue with similar activities for learning various components of the curriculum.

Figure 4: The majority of participants responded that the session enhanced learning more than traditional lectures and reading alone.

 

Figure 5: The majority of participants responded that the session was more enjoyable than traditional lectures and reading alone.

Lessons Learned

  • Participants found the directions confusing initially, as they did not understand that they would be circulating from table to table. Clarifying this during the initial introduction could reduce confusion during future iterations.
  • The visual stimuli occasionally provided adequate information to make the diagnosis. Eventually, participants trying to “game” the workshop would ask for the visual stimulus immediately from the faculty facilitator.
  • The game ended sooner than anticipated due to a participant guessing the final diagnosis after only one small case for the following reasons:
    • He received a key clue after his first case.
    • He was more risk-tolerant than others and decided to guess the diagnosis early on for strategic reasons.
  • Based on the above observations, we recommend that learners must take a minimum amount of history to obtain the visual stimulus for each case, and must achieve a minimum number of correct diagnoses in order to submit a guess for the final diagnosis.
  • Participants found the group discussions of the cases helpful in consolidating their knowledge and clarifying areas of confusion.

Theory behind the innovation

Gamification has become increasingly popular in medical education [2]. Gamification incorporates adult learning theory by focusing on the relevant subject material, making it problem-oriented, engaging participants, and allowing them to learn from experience [3].

Gamification also incorporates aspects of self-determination theory, which describes a spectrum of motivation, from amotivation to intrinsic motivation [4]. Amotivation implies that the learner has no interest or engagement in the material. Extrinsic motivation may derive from a reward or punishment, or from social or professional gain without a personal connection to the material. Intrinsic motivation, which is typically the most effective, draws on the learner’s interest or fulfillment in learning the information [5]. When used appropriately, gamification can help to shift learners towards intrinsic motivation and drive them towards further learning and retention [4].

Please feel free to reach out to Dr. Peter Tomaselli on twitter for a complete zip drive of the materials required for this session!

Interested in gamification as a teaching tool? Check out gamification for toxicology, gamification for ultrasound, and gamification for team building.

References:

  1. McDermott KW, Stocks C, Freeman WJ. Overview of Pediatric Emergency Department Visits, 2015: Statistical Brief #242. 2018 Aug 7. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb. PMID: 30277692.
  2. Ohn, M H, et al. Effectiveness of Innovative Gamified Learning among Undergraduate Medical Students. Journal of Physics: Conference Series, vol. 1358, 2019, p. 012060.,
  3. Merriam, Sharan B., and Laura L. Bierema. Adult Learning: Linking Theory and Practice. Langara College, 2018.
  4. Rutledge C, Walsh CM, Swinger N et al. Gamification in Action: Theoretical and Practical Considerations for Medical Educators. Acad Med. 2018 Jul;93(7):1014-1020. PMID: 29465450.
  5. van Roy R, Zaman B. Why gamification fails in education—And how to make it successful. Introducing 9 gamification heuristics based on self-determination theory. In: Serious Games and Edutainment Applications. 2017:Vol II. Cham, Switzerland: Springer; 485509.

 

 

Peter Tomaselli, MD

Peter Tomaselli, MD

Medical Education Fellow, Clinical Instructor
Department of Emergency Medicine
Thomas Jefferson University Hospital
Philadelphia, PA
Peter Tomaselli, MD

@pjtomaselli

EM physician/MedEd fellow in Philadelphia. Tweets and retweets not medical advice or endorsement. He/him/his. 🏳️‍🌈 NNJ native, Miami alum. #goCanes 🙌🏻
Peter Tomaselli, MD

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Meryl Abrams, MD

Meryl Abrams, MD

Chief Resident
Department of Emergency Medicine
Thomas Jefferson University Hospital, Philadelphia, PA
Meryl Abrams, MD

@MerylAbrams4

jefferson em resident finally convinced to get a Twitter
Meryl Abrams, MD

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Megan Stobart-Gallagher, DO

Megan Stobart-Gallagher, DO

Undergraduate Medical Director
Department of Emergency Medicine
Einstein Healthcare Network
Philadelphia, PA
Dimitrios Papanagnou, MD, MPH, EdD(c)

Dimitrios Papanagnou, MD, MPH, EdD(c)

Vice Chair for Education
Department of Emergency Medicine
Assistant Dean, Faculty Development
Department of Emergency Medicine
Thomas Jefferson University Hospital
Philadelphia, PA
Dimitrios Papanagnou, MD, MPH, EdD(c)

@dmitripapa

em doc @jeffersonuniv. associate dean, #facultydevelopment. vice chair of #education. #simulation and #MedEd nerd. student for life. opinions my own.