Gamification Applied To A Surgical Residency: Caught In The Act Of Doing Something Right




You may have heard the term “gamification” (pronounced game-ification) previously.  Gamification is the process of taking certain elements from the world of computer and board games and applying these toward motivational and customer retention strategies for different groups.  Game dynamics may also be applied to other important functions for different companies. Importantly, gamification is a hot topic and is even being taught in some business schools.  It is currently thought that gamification will resonate with the millennial generation (“millennials”) and subsequent generations to a greater degree than, for example, Generation X and the Baby Boom generation.


There are multiple important strategies in gamification that we could discuss in this blog post.  Here, we focus on several important game dynamics as they were applied to a general surgery residency in 2012.  Our group used game dynamics for our section of trauma, emergency surgery, and surgical critical care to assess their impact on resident motivation and perception of quality of learning.  Here, we will discuss the dynamics we used and different outcomes.  Interestingly, we also utilized game dynamics for our team of surgical attendings.  We agreed to participate in a similar strategy so as to demonstrate our support for this new approach.


The set up included the creation of a consensus group of behaviors by the trauma and emergency surgeons that the team wished to reinforce in residents.  Similarly, the resident staff created consensus behaviors they wished to see demonstrated by surgical attendings.  Many behaviors were already present to varying degrees, and the consensus behaviors were not a list of all new behaviors–rather, they were ones that each group wished to reinforce or make more common.  Each group assigned certain point values to the behaviors. The point assignment was arbitrary and was contingent on several factors including the relative scarcity of the event as well as the importance of the event to our trauma and emergency surgery section as a whole.


We then set up an email address and surgeons were able to email from their smartphone each time they caught the resident surgeon doing something correct.  This is a very new concept in residency education:  “catching someone in the act” of doing something correctly.  Interestingly we really focused on catching the resident in the act of doing something good.


Next, residents were given a letter so as anonymize them. Each resident knew his or her letter only. The letters were drawn as part of a leaderboard which was displayed in the trauma and emergency surgery conference room.  Therefore, at each morning report, residents could see their progress and point accumulation relative to the point accumulation of their anonymized colleagues.  Certain threshold levels of points were set and were displayed on the leaderboard.  That is, there were certain thresholds of points at which events took place. Some of these events include obtaining a new skill, such as the ability to clear a cervical spine.  Residents would be educated in cervical spine clearance and the appropriate template cervical spine clearance note.  They were then empowered to clear a cervical spine with the supervision of the trauma surgical attending.  Other events would occur at different levels of achievement including a letter of support to the residency program director for the resident’s file and other important elements.  Unbeknownst to the residents, the overall points leader at year’s end was given a special congratulations and a year end gift at the resident’s award dinner.  This was the only time at which the resident point total was revealed, and each resident except the overall points leader was kept anonymous.


A survey was given to the residents prior to the institution of this motivational pathway.  This was a validated survey which used a visual analogue scale so as to determine job satisfaction.  This is called the Job Satisfaction Survey (JSS) and has been validated among emergency department physicians.  All resident years participated in the system.  All residents received the job satisfaction survey prior to and then after the year long process.


A statistically significant improvement was noted in a proportion of residents (two tailed p < 0.01 by Chi-squared test) who perceived the quality of their education to be excellent.  These data were reported at a trauma and emergency surgery conference at Atlantic City, NJ.


This is one nice case study for how gamification is possible in surgical residency.  This program leverages multiple dynamics including comparison for each individual to a peer group and a focus on positive reinforcements for appropriate behavior.  Experientially, the trauma surgeons involved found this to be highly effective in improving resident behavior and reinforcing positive behavior on the service.  Interestingly, some of the residents originally felt that the gamification may belittle resident eduction or somehow cheapen it.  Instead, by the end of the process, these residents were reporting positive results and were receptive to the process. Again, this type of education is a far cry from typical resident education. The terminology of ‘gamification’ was felt to decrease buy in as some residents felt, as mentioned, initial feedback from a minority of residents included an idea that turning their residency into a game was not appropriate.  However, once residents saw that this was merely an assessment tool that focused on positive behavior and reinforced it while maintaining anonymity, they became much more receptive etc.  There was no ability to remove points from any participant in the system at any time, and, again, focus was placed on what the residents did appropriately according to the defined behaviors.


Experientially, from this, our team learned that gamification is achievable in the inpatient medical education world.  We also learned that this innovative process was a true boon for the human resources portion of our section.  It changed the dynamic and interaction between the surgeons and the residents for the better.  Also, experientially, we learned that  performance seemed to greatly improve.  There was a constancy of expectation of the residents by the trauma and emergency surgeon and vice versa.


As mentioned, the trauma surgeons also participated in the system.  Trauma surgeons were also anonymized and had a leaderboard. Each trauma surgeon was given a letter and each trauma surgeon only knew his or her letter.  Point totals were accumulated as emails were sent from the residents to a third party who was not one of the surgeons who attended.  These were then reflected on the points on the leaderboard.  Many of the dynamics have names in the gamification world.  For example, the system described above incorporates some of the most basic game dynamics including what are called PBL’s.  PBL stands for points, badges and leaderboard.  Points are self explanatory as is the leaderboard.  These leverage positive peer pressure and reinforcement so as to increase performance.  The badges are those things that are achieved to signify an improvement in level. Although we did not give true badges to be put on the physicians coat etc, stickers and other cues maybe options for other programs.


We did use another dynamic, that of “leveling up”, to allow this gamification process to recognize good performance and to increase point accumulation by allowing residents to obtain new skills independent of their year level. Although senior residents had certain skills grandfathered in based on year level, such as PGY-5’s ability to clear c-spines with supervision of an attending surgeon, younger residents were able to attain these and other skills via achieving a certain point total that demonstrated competency in the performance of similar tasks.  This process makes for a competency-based method of advancement and attainment of new skills.


Surgeons and residents were greatly satisfied with this innovative system and it is one you may apply in your educational or motivational process.  Consider applying the process to your team of surgeons, residents, or Advanced Practitioners.


Questions or comments?  As always we invite your thoughts.