A broad collection of fields was represented in the serious games, from surgery and obstetrics to radiology and primary care. The number of serious games published grew from 4 in 2007 to 42 in 2014, and the number of genres grew from 2 to 8 (see Graph, Supplemental Digital Content 2, http://links.lww.com/SIH/A249, which illustrates the growth of published serious games).
An assortment of game genres was compatible with a range of learning goals. The development team members and technical resources used were heterogeneous (Table 2). There were too many serious games to describe every one individually; however, we will discuss an effective representative from each genre.
The pediatric board game is an example of the board game genre. Gameplay occurs in the setting of a game board with a 100-tile path. The first player to reach the end wins. Players answer pediatric knowledge questions to advance. Additional game elements include special tiles that act as shortcuts or award “consult cards,” which allow players to skip questions they do not know.49
An example of the adaptation and quiz genres is Bronx Jeopardy, an adaptation of the TV game show but for pediatrics.22 Players compete by earning points for correctly answering questions on the psychosocial aspects of pediatric care. Points are lost for incorrect answers. Similar PowerPoint (Microsoft Corporation) templates are available online.83
Underground is an example of the puzzle and platform genres. The player interacts with the game using Nintendo Wii (Nintendo Co, Ltd, Kyoto, Japan) controllers that have been repurposed as laparoscopic tools. The player’s objective is to assist robots in escaping a mine, represented as a series of platforms, by reshaping the environment to allow their egress. The player must build and place elements such as elevators and bridges in appropriate positions for the robots to move toward the exit. To do so, the player must perform a number of actions, which replicate laparoscopic actions in the operating room, such as grasping and cutting.68,69
Elderquest is an adventure game set in a medieval fantasy world, through which the player can navigate freely from a first person perspective. The game narrative asks the player to complete a series of quests, all of which require the player to practice various Association of American Medical Colleges (AAMC) geriatric competencies. For instance, to advance in the game, the player must care for an apothecary who becomes delirious, an exercise in the behavioral and cognitive disorders competency.76,77
eMedOffice, a medical practice management training tool, demonstrated trainee satisfaction (Kirkpatrick level 1). It was evaluated by a usability survey completed by medical students after exposure to the serious game. It was rated as having high overall usability. Self-reported knowledge surveys were completed before and after use of the serious game. Self-reported knowledge significantly increased after the intervention.25
The Blood Pressure (BP) Management Game was associated with increased trainee knowledge (Kirkpatrick level 2) and improved patient outcomes (Kirkpatrick level 4). Attending physicians were randomized to 1 of 2 groups: the intervention arm received the serious game, whereas the control group received an online posting of the same educational content. Multiple-choice pretests and posttests were administered to both groups. Both groups scored similarly in the pretest, whereas the intervention group scored significantly higher in the posttest. Patient outcome data, gathered from the electronic medical record, was the time to target BP (<140/90 mmHg) of a hypertensive episode (predefined by the authors) during the study period. A multivariate-adjusted analysis of patients already taking antihypertensive medications showed a significantly reduced time to target BP in patients treated by the intervention cohort.32
No level 3 Kirkpatrick outcomes (ie, transfer of learning to the workplace) were assessed by the included studies.
Serious games have the potential to be a disruptive innovation, one that alters the existing market for training modalities,90 because they enjoy many of the same advantages as other forms of simulation2,91 (eg, enhances patient safety, adapts to specific learning objectives, standardizes training) while allowing for reduced operating costs and wider accessibility.92 Before any such potential is realized, an understanding of the present state of serious games is necessary. To that end, this systematic review describes several findings. First, 42 unique serious games for medical education were identified in the literature. Second, serious games were used for training by many medical fields, to facilitate a wide range of learning objectives. As such, this study identified growth in the number of games and genres. Third, the methodological quality of the included studies was heterogeneous, as were the associated study designs. Overall, the findings depict serious gaming in medical education as a modality that continues to grow and establish itself; best practices for its development, evaluation, and use are still being defined. For this reason, educators can be guided by reviews such as this and others15,18 as well as development and assessment frameworks, either those specific to serious gaming14,15 or those addressing simulation at large.93–95
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