LostKnightsRPG.org

hello LoKni,

I have yet another project under my belt. This one is intended to wait for break before I work on it.

I spoke today with Kal Winston, the overseer of PBL, or problem based learning here at Ross. He is very interested in developing a game theory based approach to presenting students with cases and having them work through it. He is familiar with DnD, and his son plays. He is very interested in my help in putting together essentially a RPG for PBL. We talked about it for a while and he insists that I should not do a whole lot of work on it until after class lets out, and he is perfectly willing for me to get help from other sources. So, I'm looking for brainstorming and ideas.

If a workable model is developed and adopted, it may become a product that Ross markets to other schools. It's not going to be something the general populace is interested in playing, as it will depend on active medical education to play. Ross is a business, and is actively staying on the cutting edge of medical education. Kal also mentioned that a simulation center is opening up here, and that if a good game model is established then it may expand to a new level with essentially live action role play for PBL. I think this would be massive fun, and Kal seemed very excited about the possibility.

Please post any ideas you have. I'll see if anyone who contributes can get a development credit, not sure if that would work or not.

I already started making a character for it.

So, general constraints and objectives.

Right now, PBL is based on presenting us with cases, and having us analyze the case and derive 'learning issues' from it. It's a team building exercise, as well as an opportunity to hone clinical knowledge. We are organized into groups of 8, and are graded on a number of factors, including the quality of research that we do over our learning objectives. Our total grade in PBL is worth 5% of ALL of our other classes, so it is taken seriously by the students, but is generally not 'hard'.

Kal and I both think that as a 'game', it should remain diceless. I proposed that there is some chance that a lab value come back as a false positive, but we feel that at the level we're working at, a lab value should be a fact. We can build in the capacity for dice or random number generators later.

The basic idea we have so far is that a menu of exams and tests can be available, and we have a certain amount of 'time' that we can use to get labs and exams done before a disease progresses.

I reckon that all labs that can be ordered or the whole semester should always be available, so that 'giving away' the diagnosis (dx in medical speak) isn't done by just making a certain lab available.

I guess the tricky part is moderating how simulation happens. Basically initiative and things like that. It should work the same way each time.

So, also, patients can generally be chronic or acute. A chronic patient is often sick, as opposed to an acute patient is suddenly sick. A headache that builds up for weeks is chronic, a sudden mind splitting headache is acute.

Most of you guys don't have a huge medical background, but what I'm working towards is a model for the game, not a specific set of data.

Killing the patient, Kal emphasizes, should result in a loss of points, but finishing the case is still important, and we've looked at the paradigm of an autopsy or court case in which the rest of the case can be examined.

Also I'm thinking about how to modulate the priority of exams, like stat vs urgent and so forth.

So, any input at all would be helpful. I'm going to try very hard not to work on this until class is out. This means that Wushu may be delayed further, but honestly, STAT is going to be simple in comparison to Wushu by far, so it shouldn't take a long time to finish.

So, what factors can you think of to help build a system with? Just because it's diceless, doesn't mean that it can't have point values and things.

i too will be waiting to put in major study for this, but i do have alot to offer i think, as this is more a sociology/education project than a medicine or even a gaming project. Chris, this means your input would be good too.

off the top of my head, things i think are important are, in no particular order:

1> the rules should foster a game mentality, in that it is fun, competitive, and encourages people to get into the character, with very few rules to work with or learn (med students don't need any more to learn)

2. i think this, aside from just learning to diagnose, this should be about learning the roles of doctor and patient, and familiarizing yourself with that interaction. that said, i think someone (possibly on a rotating basis, since you have six people) should take on the roll of patient, and should be given a list of basic rules to follow, personality traits (to increase difficulty/realism) to display, and symptoms to present with. i am absolutely positive that those going through this type of roleplay will have better scores on the portion of med school dealing with interaction (not sure what you call it, for me it is a counseling practicum). Further, i think that the personality flaws will encourage critical thinking and analysis from the "doctors" and extra points could be won for getting past such difficulties. personality traits, symptoms, and pretty much anything else could be listed out.

3. i think that, at least initially, students should interact individually with the "patient", or perhaps pair off in patient/doctor sets. the facilitator person would still provide all the data, and take care of everything, but it would be as the person that hands out the facts, gives test results, and supervises the whole thing, as well as scoring and such. after the initial interview, people could come together to analyze the problem from the perspective of their different angles, the "doctors" listing tests to run, treatments, diagnosis, etc, and the patients listing concerns, potential trouble/setbacks for treatment, etc. for each case, assuming the groups are constant, the patients and doctors could flip, so that everyone gets to play everything.

4. i think theres should be a point system based upon successful completion of goals. not sure how this would/should work until i know more about the setup of the groups, the learning goals, etc.

Well LoKni, I've spoken with Kal Winston again, by email, and he will be joining us in this thread to answer questions and to help brainstorm. Please keep profanity to a dull roar. He can better outline the scope of changes we can make to the existing model. Oh, and he's verified that our names would appear on papers if this works out. And even if not, planning a game is almost as fun as playing one. I think chris already has a tumor-ninja built. Pity there's no character creation. Chris: you fail.

I've asked Mr Winston to introduce himself in this thread. Please greet him warmly and identify yourselves, don't be shy, he's a nice chap and quite thoroughly British.

And a pre-emptive welcome to Mr Winston from me, Gideon, aka Rusty.

So, here's another idea that got kicked around yesterday after studying ceased. Using an HTML platform to access a series of databases, we could have a member of each PBL group access via their laptop a simulated lab and radiology study database.

A patient would have a unique identification number, and this would be entered along with their name, sex, and age. Any labs desired would be entered as well. The database would spit back the lab values in a standard format (we could even vary these between routine and stat, and have routine labs come back by email later). This way, the preparation and background for the game mostly consists of compiling a database of normal values for ages and sexes, using a random component to vary within normal ranges, and the case designers could flag specific values to be abnormal. Also, Radiology studies could be ordered in this way, and the database would reply with a code. The facilitator would have a folder of radiographs, and this code would correspond to an appropriate one for sex age, and normalcy.

To take the web-engaged aspect of the game a slight step further, I thought we could include aspects of treatment such as the venue in which the treatment is occurring. So, if the patient comes into the clinic, you have a limited range of studies and exams you can do. But this doesn't mean that the patient is only sick enough to be seen in the clinic, you could admit them to the general floor, or to intensive care. Knowing when to admit a patient for what disease is a learning issue based decision, so this would probably happen at the outset of a second session on the patient. Of course, in ICU you can do more for the patient, even in wards you can prep a patient for surgery (which procedure to do? can we make a menu of those? I was thinking for consults either a 'no intervention' or a 'specific intervention' answer would be quick, painless, and simple.)

It was only a short step from this to what I thought would be a massively fun expansion. Several people have been very excited about these ideas.

So, the case building committee decides on sort of broad ideas for the learning issues they want the students to answer. We don't really have to give all the learning issues in the same order. We can even mix them up a bit. One case could be about diabetes, and different groups could reach the same learning issue with different patients, so, since we can facilitate the cases with a database and have a more over-arching metagame to work with, maybe every group has a different patient? AND, while we're admitting patients to our simulated bed board, we can have it coordinated with all of the PBL going on in a given semester. So, Ross University Hospital has a certain number of each kind of bed. We can plan it out so that at some point each semester, each level of PBL deals with some more advanced issue involved with overflow in a hospital. So first semester might deal with holding a patient in the ER overnight waiting on a bed, second semester might deal with waiting on an ICU bed from the floor, and third semester might deal with waiting on a surgical theater for their ICU patient.

There should be multiple roads to 'winning'. Ideally, the maximum win is gained by giving the fastest most cost effective treatment and diagnosis to reach the healthiest patient. But suppose we take too long or order too many labs, but don't quite kill our patient. Well, after a certain period of time, a PBL session has to end. But if we wind up chasing a non-optimum pathway we may wind up with a 4th session on a given patient, but why not introduce the next patient anyway? So, this is more 'game' then we have right now, but if we build the cases so that only after all the stated learning objectives are satisfied are we really done with a patient, but the students chase red herrings or need to catch up on a concept they missed along the way, they should still get the full objectives from the case, plus what they superfluously add, but shouldn't slow down the overall flow of PBL. So, theoretically, if the students aren't willing to discharge any patients, they could have four patients admitted to their service by the end of the semester.

This is where the simulated "ross university hospital" comes in. Eventually an administrator is going to notice that you have a telemetry bed with a healthy patient in it. And they'll DC them for you. Lesson learned, but it means that the students need to check themselves and make sure they don't overtreat a patient.

We could use a chronic patient to work on interesting issues, one patient might see two or three PBL groups each semester, little jimmy and his cystic fibrosis. The students would be recording their data on a mock chart, and would consolidate that chart into a report that gets filed into the database. Obviously, mock histories would be needed in advance, but this would mean that each semester the amount of information about a patient slowly increases. Maybe little jimmy makes it three semesters before someone kills him with an inappropriate treatment. The possibilities with using a web based database to keep track of both patient records and lab/radio studies are nearly endless.

By not synchronizing the cases, we eliminate the possibility of students discussing the case with others that may be ahead of them. Also, the same patient might occur with different groups each semester, so an end of semester PBL report might be printed, and we can measure the overall success of all three semesters by looking at a 'morbidity and mortality' report for the patients that we all saw. We could look at stats for all three semesters at once, and also for a given class. Maybe a little competition would help keep people focused on PBL. Try for that 12/12 score with live patients.

One last note. It's almost over the top, but perhaps a PBL extra credit opportunity could exist with 'being on call'. A PBL group would have an 'on call' week that they would be notified of ahead of time. They would be informed that they need to examine the charts and look at conditions for all the patients in critical care. At some point not during class and not after 8pm during call week, the PBL group gets called in. They have 30 minutes to get to campus and get to the room. Then they have 1 hour to manage a crash cart level code blue. Their knowledge from the default learning issue of 'emergency critical care' would be examined in real time, and they would try to save a patient that is crashing. Once done, they would either write a note to the coroner or write a report to the attending (the PBL group in charge of that patient).
Suppose a patient dies under the care of the call group, well, the PBL group attending that patient would not lose points for that, but they could still do an 'autopsy' and follow the patient through their care. (I also think a morbidity & mortality meeting setting works for finishing a case with a dead patient, in these meetings the attendings and department heads hear the cases that didn't work well or at all, and walk the residents through what they should have done. Essentially making learning issues.)

Well, that's it so far. enjoy.

Hi Kal, my name is Paul.

I have a couple of ideas for this game:

1. You have varying levels of difficulty, where the lower levels (for first semester students for example) consist of fairly common and easily diagnosable ailments, and the more experience you gain you see progressively more difficult cases either in regards to the rarity of the ailment or the obscurity of the symptoms. This could include at higher levels multiple ailments that may or may not be linked, such as (not being a medical student I am just throwing out something that I am familiar with as an example) an odd rash on the elbows and painful swollen fingers could possibly be linked as psoriatic arthritis or could possibly just be a coincidence. Also at higher levels you could include adults who are not physically ill at all but suffer from factitious disorders such as Munchausen syndrome or a child who is a victim of Munchausen by proxy. These last two ideas would of course require a patient history mock-up or I would imagine it would be very difficult to diagnose without spending a lot of money and time on labs that will all come back as inconclusive since there is not really any physical ailment at all.

2. There should be roles that are present in each of the groups that students get to play, for example for one case student x has the role of legal adviser for the hospital (I don't know if it would legal aspects would come up with every case, I imagine not, however I would think that students being trained to be doctors would do well to get the experience of thinking from a legal POV so as to learn how to avoid possible malpractice suits). An example of when this might be warranted is in the case of a diabetic that repetitively comes into the hospital but always when it is a crisis situation and always because they have not being following their doctor's orders. The last time this patient came in they had a severe infection in their toe that required amputation, this time they are suffering from extremely high blood sugar levels again, very high ketone levels and this time they have an infection in their entire foot that will require amputation. What are your legal responsibilities and capabilities, this patient is obviously a danger to themselves because they are not caring for themselves possibly, but is it possible to detain then in order to make sure that they receive the treatment and supervision that they require or do you have to release them and just keep on cutting on them every time they allow their disease to get out of control.

3. I think that the cases that are presented to students should include ailments that you would see at a family practitioner's office as well as ailments that you would see in the ER. (that is probably a given but I haven't heard anyone mention it thus far)

I'd just like to mention that my mother, Kitty, will be assisting via email through me. She is an educational psychologist, and is very interested in contributing to the project with her expertise. I'll be copy+pasting to her updates to the forum, and will paste her posts with "from kitty". Feel free to address specific questions to her with "to kitty". She'd rather not directly access the boards.

She and I discussed the project, and she's pointed out some interesting aspects and has some neat ideas. For example, she proposes that ordering the wrong labs should result in directed education towards "when to order that lab, and what it means."

We both came to the conclusion that if a group makes certain mistakes consistently, then they should be directed to a document on the G drive (our school wide network drive) for essentially remediation for some concept that the group has missed/forgotten/ignored. These documents should be available at all times, and would basically be educational packets about aspects of what the students are expected to do, but aren't directly part of any specific course.

Also, students should be able to explain why they performed procedures, interventions, or ordered laboratory and radiological studies. She recommends that they randomly be called upon to explain about 30% of their actions. The groups may actually wind up being able to explain all of them, with learning issues connected to making the decisions in the first place. I added that at some point they should have an entire case audited, in which they explain everything. With an electronic medical records system, like what I proposed before, this could be as simple as "little timmy's parents are suing you, explain everything so our lawyers can fight back." This might be best timed for the end of a session in which there are few if any learning objectives. The group could split up the "medical record" and each explain the reasoning behind their selected procedures. If they made some errors and ordered superfluous labs, then they should explain that as well. There is no 'sorry' in medicine, only settlements.

As an observation, the integrated "Ross University Medical Center" system allows for a lot more assessment of students progress then the current model does. Each student gets a grade in PBL, based on a variety of factors, but as has been observed to me by other students here, the current scheme leaves the opportunity to "fake it". Students can come in give their research, and engage others in conversation, smile and wag their head, but they aren't necessarily learning anything. I've spoken to 5th semester students here that feel that they got a lot out of PBL, even though they didn't think so at the time. So, to help make sure that we know that students are learning the material and not reading verbatim from wikipedia and then forgetting it, we could have them sign off on their charts and orders. If a student doesn't feel that an order is correct, he can choose not to sign off on it. If it's wrong, he wins, if its right, he doesn't necessarily lose. We should determine a percentage that a student needs to choose correctly to earn that 'point'. I'm thinking something like 60-70% ought to do the trick. On the other hand, if he didn't sign off on a bad order, he doesn't have to do whatever remediation is needed for the bad choice.

Oh, I'd like to suggest that when we start determining points and things that we use percentages of another number, because it is really up to the PBL faculty to decide how many of what to throw at us.

I think that an extra and awesome thing that can be learned by our new model for PBL is "what can happen where" and "how do you move from here to there". Things like "what is commonly available in a doctors office" and "Under what circumstances do we admit a patient" are very valuable things to know and currently they don't get learned until 3rd semester at the earliest, and possibly not even until clinical rotations.

In response to the idea of interacting with a human patient,

suppose once a semester each student would be required to join a PBL group for half an hour as 'the patient'. It would not be their own PBL group, so it would not be their own patient. The students would have about half an hour before their patient arrived to go through their learning issues and learn a little about their patient, including primary complain, as they would from their nurse. For unresponsive patients or children the visiting student's role would be as a parent or friend. They would have a briefing ahead of time, and would only be downgraded for giving away information. Bonus for dramatic presentation.

With this model, we get that human interaction and 'what it feels like' but also don't wind up giving away the symptoms that the students are supposed to be picking up. I'm worried that if we just take turns doing it students won't get the point, or would feel really weird. By not breaking roles, the students can ask questions as they occur to them, not just as they hear other students asking them. If the students miss an important question, the facilitator (aka the attending) would ask the question, and possibly mark off it was a question that the students should definitely have thought of. Alternately, if the students forget something, they can send the nurse back in, and again, be counted off if it was something they should have known.

This may stretch out the basic 'getting information' period, so we should provide the students with the basic demographics so as to save time.

A PBL session is typically 2 hours long, and we have about 12 PBL sessions over which we see 4 cases. Taking 30 minutes out of a session to interview the patient might be a little long. Maybe 15-20 minutes. We also don't want to disrupt the visiting student's study schedule by too much.

Now, 70 PBL groups x 4 patients = 280 students. So, a couple follow up visits would allow for the whole class to have a chance to be the patient, and possibly require a few students to do it twice.

One of the very first Doctor, Patient, and Society lectures in first semester is about taking a medical history. If we ensure that if PBL starts before that lecture, the questions are intuitive or don't count against them, then we'll be 'fair' about doing this.

Anyway, what do you guys think?

FROM KITTY:
(I asked her to provide her background)

Credentials and Experience
Kitty J Keith
Degrees
Michigan State University
BA Psychology
MA Educational Psychology
Central State University, Oklahoma
Teaching Credential: English
San Francisco State University
Graduate Level Credential: Reading Specialist

Structure of Learning
Levels
Students should be able to succeed at solving the problem with the knowledge they are accruing during the particular term
Problems that require a stretch should be included but "graded" generously

Reference Materials
Students should have ready access to reference materials upon which they may call to aid in Dx/Rx process
All uses should be cited
This keeps track of dependence on material and wise use of references…continued reference to the same item indicates that the content is not being learned.
Students who use references readily are building research habits and not relying only on memory.

Economics
Unless you have socialized medicine and a real free hand, there are limitations invariably imposed by the patient's income level.
Patients should be assigned a financial limit not known by the doc unless asked. When a patient reaches the limit, the patient stops treatment. Oops

Location
Understanding of differences between availability of tools and possible procedures that differ among facilities, e.g. ER, clinic, ICU, office practice
Dealing with difficulties such as availability of OR, room in ICU or general care wings, etc..

Intuition
Students should be encouraged to consider acting on Intuition and/or feelings. Then requested to support the action from observations and facts: thus training their minds to effectively use materials, connections, and information that may be peripheral to their focus at the moment.

Auditing Student Behaviors
Regular Random checks on understanding of labs and procedures ordered
Randomly request students to explain 20-30% of orders
Why did you order this lab or procedure?
What information will this give you that is pertinent to the presenting symptoms?
When explanations are inappropriate require assignment to review background

Choice of Problems
Students should be exposed to treatment of routine as well as esoteric symptomology.
Illnesses endemic to certain regions should be included, such as might occur when a patient has recently returned from a visit abroad or to a desert or forested area, e.g., deer tick disease from forested areas, plague endemic in American SW desert…

damned professionals and thier good suggestions...

Hi all, Kal here.

I just registered and logged in for the first time. I'm really impressed with the amount of thought going into this, and there are a lot of excellent ideas.
I'm going to take my time over responding to them all - the suggestions deserve no less than very thoughtful consideration.

My only comment at this point is a concern for complexity. The logistics of getting a large number of people (faculty and students) to understand what is required, and to actually agree to participate, to follow the "rules", is no small matter. And faculty are notoriously resistant to change.
So, we need to start simple, introduce ideas one (or very few) at a time, and remember this is a long term project.

Anyway, I just wanted to introduce myself, and let you all know my appreciation for your input.

Much more later (after the footie).

Kal

Welcome!

Well, as far as getting people to learn the 'rules' is concerned, I think I can say with some degree of certainty that we can build the actual game mechanic in such a way as to provide near total transparency. After all, we don't want people to wander into PMH and wonder where the dice roller is. I think as we build the system we would use measurements of time to keep track of things, and we would want the students to be able to say things like "ok, I'll do a full physical and an H&P." The 'controls' for the game should be intuitive, such that if someone didn't read the documentation for the game, they would only once in a while ask for something they can't have.

In essence, the ward of a hospital is very much an interactive simulation. you want labs, you write them down and they go into the computer. you want a physical, you go into the room and do it, you want a consult, you call whoever is on call.

I'm confident that we can build a simulation that is precisely realistic and yet also provides a vehicle for the learning issues that the PBL faculty would like to see happen. And by using a virtual bed-board and a mock lab/radiology tool, we can make that transparency almost automatic.

as far as convincing people goes, suppose we had a playable alpha by the end of the first week of class next semester, do you think we could run a group of PBL facilitators through a sample case? I think in most things like this seeing is believing. Just a thought.

hey Kal, nice to have you. hope this proves productive to you.

Rusty, as far as your suggestion for people roleplaying the patient... that would be good, as long as everyone had their turn. basically, my point is that learning the role of patient, how it feels, the kind of things that come up when you are the one being interveiwed, the things you forget to mention, are all important to being able to give a good examination and present an accurate diagnosis. if only a few do it, then that undermines the purpose. or i guess it could be an extra credit thing. but basically i would suggest the role of patient be important, and one in which the patient does more than just read off a list of symptoms. give a story scenario, that they then have to explain, from memory, to the "doctor", and then they get the joy of going through the trials and tribulations of patientdom.

but i do think the idea of working with a different case/group would be good... hmmm. actually, you could have one group serve as patients to another group working on a different case, thus encouraging class interaction as well as ensuring that everyone gets to play both roles and that the patients don't work on the same case that they are "doctoring" for.

again, not sure on the exact design yet, however i think the most important part at this point is determining the overall goals, ideas, and the flavor of interaction that we are going for. basically, a more top down design paradigm.

edit: so, i keep editing this post as i think of more stuff. one other thing you might look at is goffman and dramaturgy. google or wikipedia them. i think dramaturgy will be at least as valuable as game theory in this particular endeavor.

I've done work designing games and simulations for the classroom. I'll offer some help after my school stuff is done in the next month. There is a lot of good research I've collected regarding such things that would be helpful. This would all be from a purely educational perspective, as I won't even pretend to knopw a lot about medical school. I'll let you guys figure out how to implement my suggestions.