—By David Wild
“Fortnite,” not quite, but pitting endoscopy learners against one another may be a good way to train.
Novice endoscopists who underwent simulation-based training with a “gamified” element outperformed their peers who didn’t have the spur of competition during their first two live colonoscopies, the researchers reported.
Samir Grover, MD, an assistant professor of medicine and the director of the gastroenterology program at the University of Toronto, said some clinicians may find the results of the study counterintuitive to what some believe.
“If you play simulators like other games, you may not take them seriously enough to contextually apply skills to the clinical setting,” said Dr. Grover, whose group presented the study at the 2019 Canadian Digestive Diseases Week (abstract A211). “Rather, our findings show that if you play simulators as if they were games, this may potentially be advantageous in acquiring colonoscopy skills.”
Game design elements such as competition, rankings and rewards have been used to enhance procedural learning in other health care professions, including nursing and surgery, but the approach has never been studied in the context of endoscopic skills, Dr. Grover said.
To test the approach, he and his colleagues enrolled 36 endoscopy trainees who had performed fewer than 20 procedures to receive six hours of one-on-one simulation training with an expert using both a benchtop endoscopy model and a virtual reality model (EndoVR, CAE Healthcare). The training included lectures and small group sessions on the theory of endoscopy, focusing on the core curriculum in colonoscopy from the American Society for Gastrointestinal Endoscopy.
In addition, 18 of the participants were randomly assigned to have game design elements, including a leaderboard summarizing their performance and incentives—such as achievement badges and rewards for top performance—woven into their use of the simulation models.
The researchers evaluated participants’ performance using the simulator before and immediately afterward and during two live colonoscopies performed four to six weeks after training. A blinded independent expert endoscopist assessed the examinations.
Dr. Grover’s team used the validated Joint Advisory Group on Gastrointestinal Endoscopy Direct Observation of Procedural Skills (JAG DOPS) measure and the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT) to evaluate endoscopy skills.
According to preliminary data presented at CDDW, those in the gamification group had statistically higher scores during two live colonoscopies when measured on both the JAG DOPS and GiECAT. For example, the average JAG DOPS score during the first procedure was 78 of 100 for the gamification group, compared with 62 of 100 for the conventional training group.
Nontechnical skills, including communication and leadership, were similar between the two groups, Dr. Grover’s team reported.
Rajesh Keswani, MD, an associate professor in the Department of Gastroenterology and Hepatology at Northwestern University Feinberg School of Medicine, in Chicago, called the Toronto approach “an outstanding, structured introduction to colonoscopy.”
The results demonstrate that concepts such as rankings and milestone-based rewards, can improve performance on live colonoscopies after simulator training, Dr. Keswani added. However, the improvements were “fairly modest, and it is unclear whether the additional effort to ‘gamify’ colonoscopy training is worth the benefits.”
Gamification might also backfire for some trainees. Those who lag behind their peers in a competitive model may end up feeling inadequate or “may wonder if they have chosen the wrong profession,” he said. “There is no data to suggest ‘slower’ learning impacts long-term competency, but placing too much emphasis on ranking this early in the learning process may result in unintended consequences, such as trainee burnout.”