Design
This observational prospective study was conducted between November 2018 and March 2019 in the Faculty of Medicine Sorbonne Paris Nord. The study was approved by the internal review board of the Faculty of Medicine Sorbonne Paris Nord,authorising this gamified teaching to be included in the medical curriculum for third-year students. Moreover, this work was in accordance with the declaration of Helsinki and al participants gave their oral informed consent to participate.
Students
The « Psychiatric Hat Game » (PHG) has been integrated into third-year[1] medical students’ curriculum for Psychiatry (Faculty of Medicine Sorbonne Paris Nord), concomitantly to their first internship in a Psychiatry department. PHG could therefore intervene as a complementary tool to clinical supervising. All the 166 third-year students were included.
In collaboration with the Officer for Healthcare Simulation (LJ), the person in charge of the second cycle of the Medical Studies (SB) and the vice-dean in charge of Pedagogy (JRZ), an online interactive board was generated to propose to all third-year medical students to participate in this teaching. Questionnaires were filled out on tablets. This has been integrated into a revision period of the psychiatric semiology in addition to their usual lecture courses.
Groups of 12-15 students were scheduled to form two teams of 6-7 students. Each group was supervised by a psychiatrist (RD).
The Psychiatric Hat Game
We used a deck of 63 cards (see Additional File 1). A psychiatric symptom or sign was written on each card. No definition was mentioned on the card. Explanations were given at any time in case of misunderstanding or misinterpretation. This card game was designed by RD and all words were reviewed and validated by one colleague (TB). The task of the game was to guess as many words as possible in a short period (i.e. less than 90 seconds). The entire game session lasted between 90 and 120 minutes.
There were three rounds:
- In the first round, a member of one of the two teams (the clue-giver) had to make his team-mates guess the maximum number of words using any and as many descriptive terms as s/he wanted in less than 90 seconds. Once this time was elapsed, a member of the opposing team started trying to make his team guess the remaining cards of the deck for another 90 seconds. Teams alternated until no cards were left or until the end of the dedicated time. The team that won the most cards won the first round.
- During the second round, the same deck of cards was used and students proceeded in the same way but the clue-giver could give only one word to make his team-mates guess which word was on the card. The team that won the most cards won the second round.
- The third and final round was similar in principle, but students had to guess the words through a mime. Twenty-two out of the 63 cards were considered too difficult to guess by mime (for instance delusion of filiation or devaluation ideas) and students were allowed to use a small scenario to contextualise the symptom.
Assessment
As a first step, the benefit of this teaching was assessed through 20 Multiple Choice Questions (MCQs) about psychiatric semiology (questionnaires available in Additional File 2). This questionnaire was designed by RD and TB to assess symptoms and diagnosis knowledge. Before the beginning of the game, students had to answer the MCQs. Then, at the end of the day of the game, they were given the same 20 MCQs again, but in a different order. Only fully correct MCQs were counted as valid (1 point per MCQ), and students were given a limited time of 15 minutes to complete the MCQs. Possible knowledge scores ranged from 0 to 20.
A satisfaction survey (Additional File 3) was completed after the second MCQs session (right after the game). This satisfaction survey is a homemade questionnaire comprising several questions about the interest (positive or negative) of the PHG. It was already used in a recent study [8]. This survey included 8 questions and responses were given according to a 5 choices scale of Likert (1. Strongly agree, 2. Agree, 3. Neutral, 4. Disagree, 5. Strongly disagree). The whole session including the two MCQs’ sessions, the game itself, the teaching period and the satisfaction questionnaire completion lasted about 150 minutes.
Finally, in order to assess the long-term benefit of such teaching, MCQs were proposed to the same students three months later, at the same time as an annual exam. Online interactive board allowed students to answer MCQs and questionnaires on tablets, to avoid missing data and to limit errors when analyzing data.
Statistical analysis
The data are expressed as mean ± standard deviation (SD) and percentage. We chose to use non parametric tests as data did not follow a normal distribution because of a ceiling effect (20 is the maximum score for the MCQs). The three dependent values of the three times measured were compared with Friedman analaysis. Wilcoxon test for paired samples was used for comparisons between two values. Analyses were performed on IBM SPSS Statistics 23 software (https://www.ibm.com/fr-fr/analytics/spss-statistics-software).
[1] In France, the first two years of medical studies are dedicated to the learning of anatomy, physiology and biology. The third year focuses on medical semiology. Students are taught to perform a clinical exam, recognize different symptoms, and organize them into syndromes.