key: cord-0715084-p0r5xx85 authors: Wu, Xin; Peterson, Ryan B.; Gadde, Judith A.; Baugnon, Kristen L.; Mullins, Mark E.; Allen, Jason W. title: Winter Is Here: A Case Study in Updating the Neuroradiology Didactic Curriculum Through a Gamification of Thrones Solution date: 2020-07-04 journal: J Am Coll Radiol DOI: 10.1016/j.jacr.2020.05.028 sha: 67bc6db3bbadc5c02668414c1e50f07e4fe2f52f doc_id: 715084 cord_uid: p0r5xx85 nan Engaging and effectively educating learners is a long-standing issue in graduate medical education [1] . We noted a decrease in resident attendance and focus during our daily traditional didactic curriculum. Although there is protected resident conference time, attendance is difficult to verify due to videoconferencing. Trainees are motivated to learn by a variety of factors, including intrinsic intellectual curiosity, desire to excel, examinations, and clinical rotations [1] . However, these can be undermined by competing clinical or research demands, learners' variable interests in the subject, and perception of its relevance for clinical practice or examinations [1] . Even if trainees recognize value in the curriculum, presentation styles may affect effective learning. Passive learning, in which knowledge is gained purely through listening and watching without instructor feedback, is limited in efficacy [2] . Active learning, in which learners participate in the discovery process, can increase information retention [2] . However, it may be difficult to implement active learning in residency curricula [1] . A major barrier is lack of "buy-in" (ie, learners are not motivated by active learning methods and view them as pointless) [1] . There is increasing interest in gamification and its effect on engagement and buy-in [3] . Theoretically, gamification increases participant motivation by endowing them with "epic purpose" [3] . By framing educational goals as a contest, gamification offers immediately attainable challenges and consistent rules against which accomplishments are rewarded through positive feedback [4] . Gamification encourages teamwork, as players have implicitly agreed to the same rules and goals [4] . For medical education, gamification has shown promising results in participant acceptance and knowledge retention [5] . Mindful of increasing engagement, we redesigned our resident neuroradiology curriculum by updating lecture contents and gamifying the delivery method. Our main objectives were to increase resident awareness, attendance, and participation by redefining high-yield didactic topics and encouraging healthy competition. A major determinant of participant buy-in of a gamified system is align-ment of participant and game-designer goals [3] . Given changes in the ABR Initial Certification, we redesigned our current curriculum based on neuroradiology topics within the ABR "Diagnostic Radiology CORE Examination Study Guide" [6] . Main study guide topics were divided into conferences to be repeated on a 2year cycle to ensure redundancy. Advanced topics, considered beneficial by faculty but not part of the study guide, were repeated every 4 years (Table 1) . Each faculty member was asked to participate by teaching at least one conference yearly. We made the curriculum available to residents, highlighting correlations with the study guide [6] to alleviate concerns that chosen topics were solely centered around faculty interest. Curriculum gamification was based on the popular HBO television show Game of Thrones, in which powerful families vied for political and military dominance [7] . Residents were divided into four houses (Lannisters, Targaryens, Starks, and the Night's Watch [7] ), balanced across different postgraduate-year levels, subspecialty interest, and gender ( Table 2) . House assignments were made by a Clinical Competency Committee faculty member familiar with 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 residents' clinical interests. Each house elected a leader (king or queen), who encouraged team members to respond to questions and online campaigns and arbitrated differing responses. Teams sat together during each conference. Each conference lecturer divided 20 points among the houses as they liked, based on attendance, multiplechoice responses, free response, anatomic drawing, and individual or group problem-solving. Faculty were encouraged to use creative challenges to maximize active learning and supported with resources including interactive slide deck templates (such as Jeopardy!), active learning ideas (including reversed-classroom teaching or drawing exercises), and polling software (including Poll Everywhere [8] , Kahoot! [9] , and RSNA Diagnosis Live Q5 [10] ), which were accessible on a dedicated intranet site. Administrative support was provided for the translation of existing lectures into interactive formats. Faculty were familiarized with the gamified curriculum before implementation with collaborative discussions facilitated by the sectional education committee and received regular e-mail reminders throughout the year to sustain utilization of gamification techniques. Twice a year, residents participated in "campaigns" worth 50 points each. These were open-book, online case-based challenges coupled with questions regarding imaging findings, diagnosis, and management. Each king or queen solicited and submitted a consensus response for their house, and the 50 points were divided by the faculty organizer among the houses based on accuracy of their responses. Each house's score was periodically posted on a highly trafficked, secure resident website to remind learners of their progress. At graduation, the winning house was honored with a "crowning ceremony," and their 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 Table 3 . Institutional review board-exempt, anonymized survey questions assessing self-reported resident attitudes toward the old, as well as redesigned neuroradiology curricula n Not enough-I hear things once and do not remember it well enough n Barely enough -I vaguely remember hearing something before, but could probably use more repetition (continued) banner was hung in the residency conference room as a visual challenge to motivate residents during the following academic year. Before and after the first year of the gamified curriculum's implementation, we performed an anonymized, voluntary, institutional review board-exempt online survey to assess resident attitudes and their attendance habits (Table 3 ). All 61 residents (residency years 1-4 Q6 ) were surveyed, and questions were predominantly phrased using 5-point Likert scale or true-or-false formats. Results were compared across the two time points with statistical significance assessed by the Mann-Whitney U test. Before implementation, 22 of 61 (36%) residents responded to the survey and 25 of 61 (41%) responded afterward. Significant differences were found in awareness of the existence of a neuroradiology curriculum (increasing from 18% to 76%, P ¼ .0007), and the number of residents who thought the curriculum was "organized" or "very well organized" (P ¼ .005). No significant differences were found in how well residents believed the curriculum prepared them for rotations, call, or CORE examination. However, a greater percentage of learners believed that the redesigned curriculum prepared them "well" or "very well" as compared with before. None of the other questions yielded statistically different results. An informal evaluation of neuroradiology in-service examination results from 2016 to 2020 did not show significant differences in performance trends before and after curriculum gamification, although this assessment may be underpowered given high individual and postgraduate-year class variability. Our intervention altered both content and delivery method of the curriculum, making it difficult to distill the impact of each of these changes. However, because there was no change in residents' awareness of the ABR study guide [6] or their perception of how closely the curriculum mimicked it, it is likely that these outcomes are at least partly attributable to gamification. We refrained from asking leading questions regarding self-perceived engagement and enjoyment of the curriculum. However, marketing research suggests that increasing awareness forms the baseline step toward increasing customer engagement. Thus, improved awareness of the gamified curriculum and perception of its organization may pave way for better engagement. A challenge of gamifying the curriculum is the ability and willingness of faculty members to alter lecture styles toward active learning. We were fortunate to have a faculty with high levels of interest in educational improvement, and we easily filled the schedule with teachers eager to give multiple conferences. Informal faculty feedback indicated that the centralized intranet resource with applications and templates encouraged creativity, and administrative support helped decrease associated technological challenges. Though regular reminders were necessary to encourage uniform utilization of gamification techniques (such as appropriate point assignments), most faculty successfully adopted active learning techniques. This questionnaire is limited by the subjectivity of self-reporting and self-selection, in which attendance and information retention can be overreported. Our sample size is limited by voluntary participation from a single year of residents. The nonindependent, unpaired sample population may have also undermined statistical power, limiting ability to detect significant changes in resident attitudes. In the future, we plan to improve objective tracking of resident engagement, including attendance. Because the recent coronavirus disease 2019 pandemic necessitated remote learning, it has become easier to monitor attendance and participation as residents now individually log in. The gamified curriculum can also be brought out of the lecture 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 hall by allowing teams to earn points during the clinical workday. Through innovative approaches to educational strategy including gamification, we hope to continue improving the quality of radiology education . 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 Understanding the challenges to facilitating active learning in the resident conferences Hybrid interactive and didactic teaching format improves resident retention and attention compared to traditional lectures The maturing of gamification research Gamification in higher education and STEM: a systematic review of literature Gamification as a tool for enhancing graduate medical education Diagnostic Radiology CORE Examination Study Guide Game of Thrones. Home Box Office Home Entertainment The authors state that they have no conflict of interest related to the material discussed in this article Q4 . Dr Wu, Dr Peterson, Dr Gadde, Dr Baugnon Peterson contributed equally to this publication Grady Memorial Hospital