The present study demonstrated the transferability and replicability of the Hat Game to another medical discipline (Neurology but also Psychiatry) and another institution (Sorbonne University but also Sorbonne Paris Nord) [8]. As expected, the successful application of the Hat Game to psychiatric semiology confirms that the Hat Game is an effective setting for gamified training and that it is easy to create and implement in a teaching or working day. There is no constraint except a sufficient number of student-players.
Here, we applied the Hat Game to teach the psychiatric semiology at the Faculty of Medicine of Sorbonne Paris Nord. The PHG is associated with increased knowledge just after and 3-months after completion. As for the neurological semiology, a satisfaction survey demonstrated that medical students found that the Hat Game is an appreciated tool for teaching semiology such as psychiatric semiology. Compared to the Neurological Hat Game (NHG), almost all the group of the third-year medical students participated in this teaching game. The high participation rate (77.7% completed the whole program) in third year student cohort does not allow for a comparison group. Furthermore, high scores at pre-test may also relate to the university teaching. A further research could involve several universities cohort with control groups and assess both academic performance in psychiatry exam and PHG scores. Further studies could also assess the efficiency of the PHG, indeed, three or four sessions of a 2 h gamified training could be a cost-efficient fast-track training, integrated into university curricula and medical staff routine. Team work is also documented as a way to facilitate competitiveness and protect those who perform less under pressure.
As shown for the NHG, gamified teaching is a facilitative method for learning that probably involves mesocorticolimbic circuits [14, 15]. Teaching and learning in a nice and not stressful environment appear to improve learning and memorization [8, 16–19]. In addition to short-term memory benefits, our results suggest that this playful method could facilitate long-term retention, regarding the MCQs results at 3 months. Yet the benefit persists compared to pre-PHG, the slow MCQs score decrease observed at 3-months follow up indicates the potential need for booster session or regular PHG to maintain knowledge acquisition. Similar enthusiastic teaching was already applied by Roze et al., demonstrating its efficiency in facilitating long term memory [20].
Despite positive results, our open-labeled study presented limitations. A randomised controlled study should be carried out with two arms, some of the students benefiting from this method and the other not. However, this kind of study is difficult to achieve because it implies that one of the arms will be penalised in its university curriculum if a difference occurs. An interesting point would also be to apply again at 3 months the satisfaction survey to verify the students found this educational approach is really useful. Booster sessions could also help enhance the benefit of the game. It would be interesting to perform a multicenter study to confirm the external validity of our findings but differences in the organization of the medical studies between faculties could be a problem. Finally, further studies are needed to confirm the effects on short-term and long-term memory retention. An other way to validate this training could be to show that this increase in knowledge translate in other assessments, such as Objective Structured Clinical Exams (OSCE).
These results are consistent with the literature data suggesting that serious games are useful when associated with standard lecturing [18]. Other playful methods have been proven efficient to increase students’ knowledge in psychosis or dementia [9, 12]. Techniques, such as simulation, could enable students to be more confident in diagnosing and managing psychiatric disorders [22,23]. Developing such educational materials seem all the more important as learning Psychiatry plays an important role in destigmatising this discipline with future health professionals. Moreover, it would encourage "person-centered" approaches to medical practice [24–26].
A further challenge with the PHG relies on stereotypes formation and the development of mental health stigma in young medical students [27–29]. Service users, researchers and health professionals have highlighted the deleterious impact of stigma and caricatured portrayal might contribute to erroneous and stigmatizing representations [30, 31]. To address these concerns, two strategies have been considered: including mental health stigma questionnaire in the pre/post evaluation design [32, 33] and adapting and piloting efficient interventions retrieved from the stigma-reducing literature. The PHG could be co-facilitated with a person living with a mental health difficulty or complemented with a testimony as direct (in-person) and indirect contact (video) have been documented and proven to be efficient in medical students [34, 35]; include perspective-taking exercises and/or debriefs and anti-stigma training in the medical curriculum [36, 37]; include reflexive exercises to encourage medical students to identify self-stigma and seek help when appropriate, as medical students are vulnerable to mental health difficulties and related stigma [38, 39]. Since mental health stigma in medical professions is under-researched in France, both medical students and service users would benefit from further research about integrative training addressing stigma, participants’ concerns and ensuring knowledge acquisition.
In conclusion, the Hat Game seems to be a very interesting educational tool which could be developed worldwide. An international study would be of interest to test the transferability of this easy, playful and promising method of teaching.