HOW TO...
Use Games in Medical Education A H . SHORT arid D.K.'TOMLINSOX
Med Teach Downloaded from informahealthcare.com by V U L Periodicals Rec on 12/29/14 For personal use only.
Anthony Short, B.SC, MD, is Senior Lecturer and David Tomlinson, B.SC, PH.D, is Lecturer in the Department of Physiology and Pharmacology, at the University of Nottingham Medical School, Queen's Medical Centre, Nottingham, NG7 3UH. T h e r e is tremendous scope for greater use of games i n medical education. I n this introductory article, the authors explain what sets games apart from other learning activities, discuss the place of games i n the curriculum, and list sources of information for interested teachers. T h i s paper will be followed, i n the next issue, by a detailed description of three examples of learning through games i n biochemistry, physiology and pharmacology. There is no body of experience in the use of games in medical education which could allow a definitive article with this title to be written. However, a start must be made. Games are absent from the repertoire of most medical teachers. No member of the small band of enthusiasts has the opportunity to use more than one or two games in his teaching, and as with all other forms of learning activity, methods of evaluating educational gaming are poorly developed. I t has been suggested elsewhere (Short, 1978, 1979) that games owe their ubiquity in childhood to the social and survival skills they teach, a proposition which implies that the skills can be successfully transferred to real life. It is so hard to be sure of transfer of learning in general that this feature alone justifies a closer look at games as learning opportunities. This article attempts to outline the main properties of academic games and to offer some examples applicable to medical education. We also propose a strategy for the teacher who wishes to compose and evaluate games for his own students to use. Properties of Academic Games Games are conveniently defined as procedures in which participants play for a payoff permitted by the rules. A game is an academic game if any of its attributes (not necessarily its information content) are deliberately used to attain a learning objective. This means that no operational distinction needs to be made between game types and formats -all could be represented in the class of academic games. Any game's potential as a learning tool itself, or as a kernel for a new academic game, can be divined by an enthusiastic player who happens to notice
116
within the game an analogy with some educational need. What sets games apart from other activities and gives them their special flavour is that they contain a temporary mystery or indeterminacy, the resolution of which ends the game cycle and provides the payoff. The mystery may concern the intentions or resources of an opponent, or the future events such as the turn of cards, roll of dice or speed of horses. The mystery and the search for the payoff powerfully attract the attention and effort of players. In an academic game the teacher seeks to harness these to learning. T h e Place of Games i n the Timetable Guilbert (1977) lists seven types of learning resource, but omits games altogether. When a learning need has been identified and an objective defined, a game is not necessarily the most natural choice. The learning pace in games is probably slower than in the more familiar situations, notably in use of printed didactic text. I t is therefore unlikely to be preferred as a primary source of raw, factual information. A game is almost certain to simplify and isolate the group of concepts with which i t is concerned, so that it is also unlikely to be reliable for cultivating the highest critical and evaluative thought. I f , however, the teacher seeks the review of recently gathered information, its re-ordering and the exercise of associ ations with previous knowledge, the interpretation and problem-solving modes of thought, then his options are assignments (for example, problem solving or essay writing), the playing of games and simulations, and actual practice under supervision. Games appeal when the latter is not available and the former are already well-used. How do I obtain a Game to meet my Particular Need? There exists a Society for Academic Gaming and Simulation in Education and Training (SAGSET) of which the secretariat is situated in the Centre for Extension Studies at the University of Loughborough. This Society publishes a journal containing both stimulating articles and useful reviews and citation lists. l ' h e Handbook by Gibbs
Medical Teacher V o l 2 No 3 1980
Med Teach Downloaded from informahealthcare.com by V U L Periodicals Rec on 12/29/14 For personal use only.
(1974) and the other material listed as ‘further reading’ will direct the interested reader either to an existing game, or to a kernel from which he can develop his own ideas. The field is already rich in games for social, geographical, and mathematical studies, and fairly well supplied for chemical and a number of historical topics. There are a few biological games, but in general the physical sciences have been neglected in this respect. Economics, international relations and warfare have spawned large numbers of (often overlapping) games and simulations. Gibbs’ Handbook is a compendium of sources for all these. It should be possible for medical education to benefit from much of this antecedent work. Indeed, there are a few published examples (and presumably even more unpublished ones than those known to us), of games applied to learning in medicine and health care. Three games concerned with basic physiology which are worth mentioning are ‘Nephron’ and ‘Guts’, which were devised for nurse training, and ‘CVS Rummy’, which has been used for medical students. ‘Nephron’ (Martin and Tremlett, 1978) is a snakes and ladders analogue which rehearses the exchanges along the renal tubule. ‘Guts’ (Lowe, 1975) is a ‘Happy Families’-type of card game which fosters appropriate mental associations of food, substrate, enzyme and absorption site in alimentary physiology. ‘CVS Rummy’ (France, 1978) uses a more complex web of associations to exercise the students’ grasp of control mechanisms of the heart and circulation. We know of three exercises which are concerned with social and management questions, ‘Blood Money’ and ‘Hospitex’. T h e latter (available from Management Games Limited, 38 Bedford Place, London W C l ) , rehearses the tasks of organizing ward work that fall to a nursing sister, and simulates the pressures that typical incidents of the working day can generate. ‘Blood Money’ (Greenblat, 1976) considers the dilemma of the patient and health care and other agencies in a case of haemophilia set in the American context. No doubt many departments of social medicine and community health run simulation exercises related to the delivery of health care, and it would be of great service if some of these were published in detail. An example here is Folmer’s description of a simulation game to teach learners how to allocate health care resources in a rational manner (Folmer , 1980). An article in the next issue of Medical Teacher will provide examples of learning through games in biochemistry, physiology and pharmacology. References Folmer, H. R., The way we teach allocation of resources using a simulationgame, Medtcal Teacher, 1980, 2,lO-17. France, V. M., Department of Physiology, Kings College in the Strand; Personal communication, 1978. Gibbs, G I . , Handbook of Games and Simulation Exercises, E. & F. Spon, London, 1974. Greenblat, C. S., T h e design ofgamingsimulations. Improm’ng H u m a n Petformance Quarterly, 4, 115-125, 1976. Guilbert, J-J., Educatzonal Handbook for Ilenlth Personnel, World Health Organization, Geneva, 1977.
.Medical Teacher V o l 2 No 3 1980
Lowe, J. E., Gamrs and simulations in nurse education, N u ~ s i n g Mirror, 1975, 68-69. Martin, Peggy and Tremlett, R., Physiology at play: The nephron. Nursing Mirror, 1978, 147, 26-29. Short, A . H., Lcarning by game. Medical Education, 1978, 12, 340-343. Short, A. H., Tearhing physiology by games and models, T h e Physiology Teacher, 1979, 22, 27-29.
Further Reading Abt, C., Seriour Games, Viking Press, New York, 1970 Armstrong, R. H. R. and Taylor, J . I.., Instructional Simulafion Systems in Higher Education, Cambridge Monographs on Education, No 2, Cambridge lmtitute of Education, 1970. Armstrong, R. H . R. and Taylor, J . I... Feedback on Instructional Simulation Sjstems, Cambridge Monographs on Eduration. Ko 3 , Cambridge Instituteof Education, 1971. Barrow, H. S . , Simulated Patients (Programmed Patients), Charles C . Thomas, Springfield, Illinois, 1971. Longley, C. (Ed), Games and Simulations, BBC Publications, London, 1972. Tansey, P. J., Educational Aspects of Simulation, McGraw-Hill, Maidenhead, 1971. Taylor, J. L. and Walford, R . , Simulation in the ClasJroom, Pcriguin Education. Harmondsworth, 1972.
AAMC Educational Initiatives Evaluation and accountability continued to be a major thrust of the educational activities of the Association of American Medical Colleges in 1978 to 1979. A plenary session of the AAMC Group on Medical Education focussed attention on the need to formalize the teaching and evaluator role of the resident. Special sessions looked at the relationship between accreditation and quality in continuing medical education, the use of the National Board certifying exams in programme evaluation, and ways of assessing nonacademic aspects of professional development. According to the 1978-79 Annual Report of the AAMC, six of the seven GME-sponsored workshops that year were devoted to enhancing evaluation skills, ranging from the assessment of clinical performance to the use of a needs-based criterion for determining quality in continuing medical education programmes. 11;
Use Games in Medical Education A H . SHORT arid D.K.'TOMLINSOX
Med Teach Downloaded from informahealthcare.com by V U L Periodicals Rec on 12/29/14 For personal use only.
Anthony Short, B.SC, MD, is Senior Lecturer and David Tomlinson, B.SC, PH.D, is Lecturer in the Department of Physiology and Pharmacology, at the University of Nottingham Medical School, Queen's Medical Centre, Nottingham, NG7 3UH. T h e r e is tremendous scope for greater use of games i n medical education. I n this introductory article, the authors explain what sets games apart from other learning activities, discuss the place of games i n the curriculum, and list sources of information for interested teachers. T h i s paper will be followed, i n the next issue, by a detailed description of three examples of learning through games i n biochemistry, physiology and pharmacology. There is no body of experience in the use of games in medical education which could allow a definitive article with this title to be written. However, a start must be made. Games are absent from the repertoire of most medical teachers. No member of the small band of enthusiasts has the opportunity to use more than one or two games in his teaching, and as with all other forms of learning activity, methods of evaluating educational gaming are poorly developed. I t has been suggested elsewhere (Short, 1978, 1979) that games owe their ubiquity in childhood to the social and survival skills they teach, a proposition which implies that the skills can be successfully transferred to real life. It is so hard to be sure of transfer of learning in general that this feature alone justifies a closer look at games as learning opportunities. This article attempts to outline the main properties of academic games and to offer some examples applicable to medical education. We also propose a strategy for the teacher who wishes to compose and evaluate games for his own students to use. Properties of Academic Games Games are conveniently defined as procedures in which participants play for a payoff permitted by the rules. A game is an academic game if any of its attributes (not necessarily its information content) are deliberately used to attain a learning objective. This means that no operational distinction needs to be made between game types and formats -all could be represented in the class of academic games. Any game's potential as a learning tool itself, or as a kernel for a new academic game, can be divined by an enthusiastic player who happens to notice
116
within the game an analogy with some educational need. What sets games apart from other activities and gives them their special flavour is that they contain a temporary mystery or indeterminacy, the resolution of which ends the game cycle and provides the payoff. The mystery may concern the intentions or resources of an opponent, or the future events such as the turn of cards, roll of dice or speed of horses. The mystery and the search for the payoff powerfully attract the attention and effort of players. In an academic game the teacher seeks to harness these to learning. T h e Place of Games i n the Timetable Guilbert (1977) lists seven types of learning resource, but omits games altogether. When a learning need has been identified and an objective defined, a game is not necessarily the most natural choice. The learning pace in games is probably slower than in the more familiar situations, notably in use of printed didactic text. I t is therefore unlikely to be preferred as a primary source of raw, factual information. A game is almost certain to simplify and isolate the group of concepts with which i t is concerned, so that it is also unlikely to be reliable for cultivating the highest critical and evaluative thought. I f , however, the teacher seeks the review of recently gathered information, its re-ordering and the exercise of associ ations with previous knowledge, the interpretation and problem-solving modes of thought, then his options are assignments (for example, problem solving or essay writing), the playing of games and simulations, and actual practice under supervision. Games appeal when the latter is not available and the former are already well-used. How do I obtain a Game to meet my Particular Need? There exists a Society for Academic Gaming and Simulation in Education and Training (SAGSET) of which the secretariat is situated in the Centre for Extension Studies at the University of Loughborough. This Society publishes a journal containing both stimulating articles and useful reviews and citation lists. l ' h e Handbook by Gibbs
Medical Teacher V o l 2 No 3 1980
Med Teach Downloaded from informahealthcare.com by V U L Periodicals Rec on 12/29/14 For personal use only.
(1974) and the other material listed as ‘further reading’ will direct the interested reader either to an existing game, or to a kernel from which he can develop his own ideas. The field is already rich in games for social, geographical, and mathematical studies, and fairly well supplied for chemical and a number of historical topics. There are a few biological games, but in general the physical sciences have been neglected in this respect. Economics, international relations and warfare have spawned large numbers of (often overlapping) games and simulations. Gibbs’ Handbook is a compendium of sources for all these. It should be possible for medical education to benefit from much of this antecedent work. Indeed, there are a few published examples (and presumably even more unpublished ones than those known to us), of games applied to learning in medicine and health care. Three games concerned with basic physiology which are worth mentioning are ‘Nephron’ and ‘Guts’, which were devised for nurse training, and ‘CVS Rummy’, which has been used for medical students. ‘Nephron’ (Martin and Tremlett, 1978) is a snakes and ladders analogue which rehearses the exchanges along the renal tubule. ‘Guts’ (Lowe, 1975) is a ‘Happy Families’-type of card game which fosters appropriate mental associations of food, substrate, enzyme and absorption site in alimentary physiology. ‘CVS Rummy’ (France, 1978) uses a more complex web of associations to exercise the students’ grasp of control mechanisms of the heart and circulation. We know of three exercises which are concerned with social and management questions, ‘Blood Money’ and ‘Hospitex’. T h e latter (available from Management Games Limited, 38 Bedford Place, London W C l ) , rehearses the tasks of organizing ward work that fall to a nursing sister, and simulates the pressures that typical incidents of the working day can generate. ‘Blood Money’ (Greenblat, 1976) considers the dilemma of the patient and health care and other agencies in a case of haemophilia set in the American context. No doubt many departments of social medicine and community health run simulation exercises related to the delivery of health care, and it would be of great service if some of these were published in detail. An example here is Folmer’s description of a simulation game to teach learners how to allocate health care resources in a rational manner (Folmer , 1980). An article in the next issue of Medical Teacher will provide examples of learning through games in biochemistry, physiology and pharmacology. References Folmer, H. R., The way we teach allocation of resources using a simulationgame, Medtcal Teacher, 1980, 2,lO-17. France, V. M., Department of Physiology, Kings College in the Strand; Personal communication, 1978. Gibbs, G I . , Handbook of Games and Simulation Exercises, E. & F. Spon, London, 1974. Greenblat, C. S., T h e design ofgamingsimulations. Improm’ng H u m a n Petformance Quarterly, 4, 115-125, 1976. Guilbert, J-J., Educatzonal Handbook for Ilenlth Personnel, World Health Organization, Geneva, 1977.
.Medical Teacher V o l 2 No 3 1980
Lowe, J. E., Gamrs and simulations in nurse education, N u ~ s i n g Mirror, 1975, 68-69. Martin, Peggy and Tremlett, R., Physiology at play: The nephron. Nursing Mirror, 1978, 147, 26-29. Short, A . H., Lcarning by game. Medical Education, 1978, 12, 340-343. Short, A. H., Tearhing physiology by games and models, T h e Physiology Teacher, 1979, 22, 27-29.
Further Reading Abt, C., Seriour Games, Viking Press, New York, 1970 Armstrong, R. H. R. and Taylor, J . I.., Instructional Simulafion Systems in Higher Education, Cambridge Monographs on Education, No 2, Cambridge lmtitute of Education, 1970. Armstrong, R. H . R. and Taylor, J . I... Feedback on Instructional Simulation Sjstems, Cambridge Monographs on Eduration. Ko 3 , Cambridge Instituteof Education, 1971. Barrow, H. S . , Simulated Patients (Programmed Patients), Charles C . Thomas, Springfield, Illinois, 1971. Longley, C. (Ed), Games and Simulations, BBC Publications, London, 1972. Tansey, P. J., Educational Aspects of Simulation, McGraw-Hill, Maidenhead, 1971. Taylor, J. L. and Walford, R . , Simulation in the ClasJroom, Pcriguin Education. Harmondsworth, 1972.
AAMC Educational Initiatives Evaluation and accountability continued to be a major thrust of the educational activities of the Association of American Medical Colleges in 1978 to 1979. A plenary session of the AAMC Group on Medical Education focussed attention on the need to formalize the teaching and evaluator role of the resident. Special sessions looked at the relationship between accreditation and quality in continuing medical education, the use of the National Board certifying exams in programme evaluation, and ways of assessing nonacademic aspects of professional development. According to the 1978-79 Annual Report of the AAMC, six of the seven GME-sponsored workshops that year were devoted to enhancing evaluation skills, ranging from the assessment of clinical performance to the use of a needs-based criterion for determining quality in continuing medical education programmes. 11;
