The escape box format for teaching chest pain and abdominal pain were predominantly well-received, with the vast majority of learners strongly agreeing with survey questions on engagement, learning, satisfaction, application, and desire for further escape box use. Learners who strongly agreed with incorporating escape boxes in the medical education setting also were most likely to strongly agree with reporting satisfaction as a learner. When stratified by medical school training level (i.e., third- or fourth-year medical student), fourth-year students tended to rate knowledge application, satisfaction, and desire for more escape boxes more highly than third-year students, though not to a significant degree.
In comparing students’ perceptions of didactics quality between escape box and flipped classroom, there were significant increases in rater approval in the escape box group for explaining content clearly and at the appropriate level of complexity, as well as in the category of providing effective lecture materials.
The ratings for the emergency medicine clerkship overall did not differ between academic years to a significant degree in categories relating to quality of conferences, experience, and teaching in the clerkship.
Comparison with Prior Work
Tomaselli et al7 reported introducing a “Price is Right” game to EM residents to teach about healthcare costs and found that 89% of participants indicated they would recommend the session to other learners, similar to our findings. We also found that learners more highly rated effectiveness of learning materials provided in the escape box format compared to the traditional flipped classroom format. Tomaselli et al7 also reported learner preference for gamified formats in their study.
In a gamification study by Gerard et al8, medical students, residents, and attendings were tested via a PediatricSim serious game. Game scores in their study corresponded to level of training. Further studies with our escape box lecture would be needed with a larger group to determine if level of training truly affects perception of these elements. One possibility for this trend is that students at more advanced levels of training may find the activity easier to utilize more of the clinical knowledge developed by exposure on the wards.
Deci and Ryan9 first described the elements of competence, autonomy, and relatedness in the self-determination theory of motivation. Competence describes using challenging goals to promote higher performance; in our virtual escape box, students could demonstrate competence through understanding the pathophysiology underlying the given cases to solve the puzzles. With player autonomy, the game should allow multiple pathways to achieve a target goal; learners therefore have the element of choice in pursuing the subgoals they wish to target. Within our escape box, students were able to choose the order in which they solved cases. Relatedness is met by connecting learners with other learners or facilitators. Rutledge et al3 apply self-determination theory to gamification in an educational setting; learners can collaborate or compete with each other, while comparing learners to other peers also stimulates motivation. Within our game, students worked together as one team to solve the cases, but future implementation of this activity could have two teams compete against each other for escaping in the shortest amount of time. The use of game elements in medical education therefore becomes very nuanced in engaging learners without distracting from the primary purpose of teaching pathophysiology and management of diseases. Furthermore, Gerard et al8 reported in the PediatricSim game that written test scores on subject matter correlated with game scores. Therefore, use of a scoring system within the game may be a positive indicator of knowledge acquisition.
Use of game elements in medical education can also serve as a means to teach processes and more abstract lessons of communication and teamwork. Guckian et al1 examined three examples of escape rooms in medical education, with one involving medical trainees and members of interdisciplinary fields. The learners reported enhanced communication and increased morale during the game. In another case with an obstetrics escape room, the activity was structured in such a way that every participant would need to communicate with each other.1 Additionally, in Stanford’s Ultrasound Games, Lobo et al10 reported a majority of participants (EM interns) strongly agreed that working in a team was an enjoyable experience and that competition helped them feel better acquainted with their peers. Escape rooms provide a method of instruction that can force communication between members or other critical action tasks as part of the game design with beneficial effects beyond didactic material. By incorporating collaboration through gamification in an otherwise mandatory training, learners can have added benefits of abstract lessons such as interprofessional and team communication or multitasking, which are competencies outlined by the Accreditation Council for Graduate Medical Education11 emergency medicine milestones expected of EM residents.
Since the 2020–2021 academic year was the first year in which the escape box was utilized, further studies would be necessary to increase sample size. Additionally, pre- and post-testing could be utilized to assess learners’ knowledge acquisition from the activity. There is also a temporal element that is difficult to control for, in that students participate in the emergency medicine rotation at different times of the year based on scheduling. As students progress through training, they will naturally acquire more knowledge, which can artificially inflate scores later in the year. Similarly, the data included in our study contained evaluations from third- and fourth-year students, and the differing training levels may be confounding variables. Additionally, lecturer availability varies throughout the year, so the variety of lecturers may also be a confounding variable in having different teaching styles; however, to mitigate this effect, the group of lecturers who delivered content for the flipped classroom and escape box was consistent between the two years.