Can games help train future doctors and nurses?

Its addictive mix of education, entertainment and competition proved to be a hit when it debuted in UAB's internal medicine residency program in 2013. The following year, thanks to a grant from the UAB Health System Foundation, the Kaizen team revised its software and purchased dedicated equipment in order to facilitate multiple games. Kaizen quickly spread to several other residency programs at the School of Medicine and the nurse practitioner program at the UAB School of Nursing. This past fall, undergraduates in the nursing school and first-year medical students joined in.

Named for a Japanese phrase meaning "continuous improvement," Kaizen presents players with short, multiple-choice scenarios designed to test their clinical knowledge. The questions are meant to be answered quickly -- in an elevator ride between floors during hospital rounds, for instance. Over the course of a Kaizen "season" (generally one semester), players compete as individuals and in teams, answering weekly batches of questions that follow their curriculum. An online leaderboard allows players to see where they stand in relation to classmates and other teams.

"It's all about using competition -- with themselves or others -- to help students learn," said James Willig, M.D., an associate professor in the UAB Division of Infectious Diseases and a co-developer of the game. Kaizen gives students an opportunity to test their "developing clinical knowledge without the embarrassment of public failure," agreed medical student Russell Marsh. "By making mistakes under the guise of a game, I am able to reinforce clinical techniques before I apply them to a real patient."

A game with real-world implications

Willig and other UAB faculty are closely tracking Kaizen data in ongoing studies to determine its effect on student performance. "Kaizen is a great way for our students to review for the high-stakes tests they are preparing for, and I love that the learner is in control," said Nancy Wingo, Ph.D., an instructor specializing in education innovations at the School of Nursing who has acted as a Kaizen champion at the school. "Students can decide when, and whether, to answer the questions. Besides, it's just fun."

In December 2015, Wingo and other School of Nursing faculty received a grant from the UAB Center for Teaching and Learning to launch a qualitative study of the different factors that motivate students to play. They also plan to examine correlations between Kaizen participation and a student's grades. "This is a pilot project to find out how to better use the Kaizen platform to offer the best possible learning experience to our students," Wingo said.

Ashley Mezzanares is one of more than 140 undergraduate nursing students given the opportunity to try Kaizen in fall 2015 as part of NUR 311, the basic skills course required of all first-year nursing students. Mezzanares compares it to the popular smartphone app Trivia Crack, "which I have played religiously before," she said. But Kaizen offers far more payoff. "If there was ever a question I had trouble answering, I would go back and review," Mezzanares said. "I enjoyed being quizzed on the material before exams as well."

"It's a great way to study," agreed Assistant Professor Cathy Roche, Ph.D., R.N., who led the introduction of Kaizen in NUR 311 and is a part of the CTL grant with Wingo. "The students aren't graded; it's completely voluntary. But since these are the foundational skills all nurses need, this will help them throughout their careers."

Scenarios and stickers

Kaizen made its debut in the first-year Introduction to Clinical Medicine course at the School of Medicine as a replacement for weekly quizzes. "The buzz has been very good," said Victor Sung, M.D., an associate professor in the Department of Neurology and leader of the Learning Outcomes and Assessment Working Group within the ICM course. "Because it's a game, rather than a quiz, students tended to dig into their readings to figure out challenging questions."

"I can use Kaizen as a learning opportunity," said medical student Shenila Lallani. "It allows me to assess my own progress in the course and fill in the gaps in my understanding."

Sung was surprised that some of the more lighthearted aspects of the game -- the option to send other players virtual stickers and badges, for example -- were so popular. "The students have been really enthusiastic about that," he said. "They really like giving each other digital high fives and stars and trophies." "Kaizen captures my interest with the simple concept of achievements," Marsh said. "I want to be a good physician, and for that reason alone I work hard to understand my assignments. But I can use my desire to have an icon beside my name to help prod me along."

Mezzanares says she quickly got into the game's competitive spirit, looking to move herself up the individual leaderboard and cheering on her team, the Aidets. The students "talk smack among themselves," Roche said. "They're competitive and they want to win, but it's also a great team-building exercise too." Students have the option of creating aliases to preserve anonymity and express creativity. One of Roche's favorites: "a gentleman who called himself Florence Nightingmale."

Kaizen has also been popular among graduate-level students in the nursing school, Wingo says. Assistant Professor Natalie Baker, DNP, introduced Kaizen to her adult/gerontology primary nurse practitioner students in the fall 2014 semester. "I was surprised that at least 90 percent of my class played" in the first semester, she said. The following spring, more than 90 percent participated. "Students loved the concept of testing their knowledge while playing a game," said Baker.

"Everyone is pushed for time; students realize that Kaizen is a great way to learn on the fly," added Jared White, M.D., assistant professor in the Department of Surgery and a leader in the department's general surgery residency program, which also introduced Kaizen in fall 2014. "We're eager to see how this affects board scores and pass rates on in-service exams," he said. "It takes just a few minutes to answer some questions on your phone while you're waiting on an elevator, or sitting at home with a tablet."