Okay, well, good morning, and welcome to the Mark J. Rosen MD Master FCCP Endowed Memorial Lecture. I'm Stephanie Levine. I'm based in San Antonio at UT Health and at the South Texas VA, and I want to tell you a little bit about Mark and our speaker today. So the Mark J. Rosen MD Master FCCP Endowed Memorial Lecture recognizes a chest educator who embodies the educational and leadership passion of Dr. Mark Rosen. This lecture, given in his memory, acknowledges his service as a clinician, educator, faculty, mentor, and leader in the pulmonary and critical care medicine community worldwide. Dr. Rosen's distinguished career in pulmonary and critical care medicine spanned more than four decades, marked by his deep commitment to fostering leaders, medical education, and patient care. And this year, it's my pleasure to present this award to Dr. William Kelly. Dr. Kelly is a professor and clerkship director in the Department of Medicine, Uniformed Services University, and a pulmonary critical care and sleep physician at Walter Reed National Military Medical Center. Dr. Kelly has helped publish numerous peer-reviewed manuscripts, chapters, and abstracts, served as faculty for more than 200 presentations, both national and international, and has received over 40 teaching and military awards. Dr. Kelly has held many national leadership positions, including chair of the education committee, chair of training and transitions, and chair of the CHEST 2019 annual meeting and CHEST Italy 2022. His contributions to CHEST have helped the organization, members, and patients in many different ways. His original live and computer-based learning activities using game-informed learning with CHEST have reached over 15,000 physicians in North America, Spain, India, China, and Italy. To him, Dr. Rosen was a mentor, inspiration for him, and partner in advocating for games. For anyone that knows Dr. Kelly, you know he is passionate about interactive education. He is one of the creators and emcees of the CHEST Challenge, and don't forget about the CHEST Challenge championship tonight at 730. For his overwhelming accomplishments and dedication to CHEST, we honor him today. Please join me in welcoming Dr. Bill Kelly to present the Mark Rosen Master FCCP Lecture. Well, thank you Stephanie, and thank you for your wonderful Dr. Rosen lecture last year. You mentioned CHEST Challenge, and we're going to give the Rosen Cup to the champions tonight. We named the trophy after Mark, totally appropriate, because as mentioned, he was an international educator, a scholar, clinician, mentor, and friend for 40 years. Plus, he also just liked it. He played with it all the time, he would joke around with it, so every time I see that trophy, I of course think of Mark, and it makes me smile. In honor of Mark, I want to start a conversation, share with you some thoughts on games and gamification in medical education. As mentioned, Mark, amazing educator, big on interactive learning, and since he was the lead of international education for CHEST, he literally brought our games around the world. For disclosures, I am from the government, and I'm here to help. I certainly don't speak for the government. And then for CHEST, I'm working even more with them this year, but for 20 years, just like all of you, a member volunteer, creating and delivering games for this organization that all of us love so much. For objectives, I'm going to touch on some of the nomenclature in the games literature, give you some examples, and then summary literature, that's the why, and then I'm going to talk about the limitations, because like Mark, I'm a salesman, but I want to be an honest salesman to you. And then we'll end with seven lessons learned, so you can do some of this back home. But before we do that, just think about play for a little while, okay? Every animal, to our knowledge, like every animal does it, it's an evolutionarily created reward system for learning physical, social, psychosocial skills. Now, this is paedic play, just kind of goofing around, but ludic play, play with rules like board games and sports, that goes back forever too. Royal Game of Ur, from the town of Ur, Mesopotamia, 4,600 years ago. You can still play this game, you can buy it on Amazon, it's like cardboard now, $30, but you can still play this game after all this time. And then just to mention video games, it's not just the teenage boy in the basement, this is a 350, he plays video games? All right, see, case and point. So it's a $350 billion annual industry in the U.S., 215 million players, about half, almost half are female now, and then 42% of baby boomers play an average of two and a half hours a week of games, usually on their phones. So again, it's a broad demographic. But when you study it, it gets tough, because you have to get picky. You know, what is play, what is a game? Since the 1930s, 60 different definitions in hundreds of articles. I'll give you the Lander's definition, externally structured, goal-directed type of play. So again, pretty straightforward. But then you're going to read about serious games, where you make a board game or a video game. Game-informed learning, game-based pedagogy, all these different terms. So I like this graph, I modified it by Kroon, it's really a continuous spectrum. On the far side, you have serious games. You decide to make a video game to teach lung cancer, or a board game for microbiology, and that's great. On this extreme, it's life. Life is a game, right? Aren't there rules to life? We're supposed to be nice to each other? No? All right, all that stuff. And then simulation-based education. I think you all do that, or you're fans of that. That has game elements. Checklists, scoring, timers, and often a narrative story, a scenario. So there's game elements there. But then there's this swath in the middle, gamification. Term goes back to at least before 2008, and these are things you can add to your everyday teaching when you get off the plane back home. Whether it's a structural thing, like a timer, points, rewards, prizes, leaderboard, or content, like an immersive story. These are things you can just embed. As for attributes, probably 52 published game attributes out there. These are the core nine that most people agree on. And the things you add could be assessment, usually in the form of points. A challenge, either with the game or other players, or both. The learner has to have some autonomy. That's part of the power of it. And then interaction among players. This social component is powerful, and I'm going to come back to that. And you have to have rules. And then finally, the other stuff. You know, resources permitting. You can add as much immersion and narrative story as you like. So just a quick activity here. If you could pull up this QR code, it's a single question. And don't answer just yet, because I have to explain the rules. But how many dozens or hundreds of articles do you think, if you were to do a PubMed search on games and medical education? Now, there's two rules. You can't look it up, because that's cheating. And it's closest to the number without going over is the winner. So price is right style. And, you know, I can tell you who is closest, and I can also tell you how much closer you were to everybody else. And while you're doing that, it gives me a chance to show the first of a couple pictures of Dr. Rosen. This is eight years ago. Program committee meeting at Chicago. They're always in February. This fell on Valentine's Day, so we're all wearing red there with Barb Phillips. And what I love about it is the photographer captured an outtake a split second later, where Mark said something inappropriate and funny, and he got the whole room going. And he always does it, but this was captured on film. And I just love that. Gamification, games and education, well-grounded in educational theory. It's experiential learning, it's autonomy. You get to keep playing the game until you get it right, so there's some deliberate practice and mastery learning. Social cognitive theory, Bandura, you get to learn by watching other people's play. Social comparison theory, that's the leader board. We have this drive to see how we compare to others, you know, higher or lower. Here are some video game players, I'm sure. And then reinforcement, simple operant conditioning, positive and negative rewards. And Shulman's not here, but someone in the audience would say, okay, nerd, learning theory, that's great, show me an article. And for that, walk with me, if you will, up and down the Kirkpatrick model for any kind of educational curriculum. Anything you teach, you know, is your teaching, do they like it, learners like it? Do they learn something, does it have an impact? And at the very top, any outcomes. And in our case, has gamification ever helped a patient? Right, that's the top of the pyramid. Do I have you at the bottom, that people like it? Because I might not. Do I have you that learners like it? Maybe? A little bit? All right. Quick anecdote for you, this is the chest virtual pulmonary knowledge escape room, it was virtual, so on Zoom I captured a couple of faces, and this will loop around, but the moment that they make the final diagnosis, solve the puzzle and escape the room, let's see, it's going to cycle back, watch for the moment, boom, right there. Now, that is emotional engagement, that is learning that sticks and they never forget it. And part of the reason they don't forget it is because it's not a typical boring conference. There's a novelty effect with games, and you'll see this when you try this, or try this more back home. So there's a novelty. Quick example from our surgical colleagues, urologists, they had this da Vinci robot simulator, $84,000, and for seven weeks they said, hey residents, go do this, it's good for you, and to the left of the blue line, that's usage. Okay, what happened on day 49? They said, we're going to have a tournament. We're going to keep score of the residents, we're going to email out to the department your scores, you know, so some publicity there, and they also gave I think a couple $50 gift cards, one resident might have got an iPad. And as you see to the right, usage increased 58 times, which makes the cost of the simulator, the educational cost, go from $860 per learner hour to $74 per learner hour. So there's a financial impact there as well. Now when you step back, say go to Cochran, and just look at all the benefits of gamification. This is 2013, and again, like the government, they can neither confirm nor deny that there's a benefit. But this is 2013. Two-thirds of the literature have come out since then, including about 200 articles last year. And some of the games and examples, I'm just going to do a couple. This is touch surgery, it's not one of mine, it's not one of chess. It just goes through how to do chess tubes. And you can see this is a cell phone based screen. And when you make a game like this, you try to show impact. So a lot of the literature, a lot of the studies are simple experiments. You give a lecture, randomized to do the chess tube game, or maybe a control game on thoracentesis. Next day, have them come back into a pig lab, a live porcine model, put in chess tubes. And you can show in the short term that the checklist scores are a little higher in people who play the chess tube game. So again, short term, simple studies like that. And if you take a step back like Gentry did, 2019, and look at all the randomized trials, you see kind of a recurring theme there. And what they did is, again, just randomized trials, compared games to lecture, compared games to digital learning, compared games to other games. This is just games to lecture traditional learning. And you do some forest plots and basically the more the line goes to the left, you know, the greater the impact or the positivity towards games. And for medical knowledge, say on a simple written test, you see a moderate to large effect size. When you look at these, you know, 27 randomized trials and three clustered randomized trials. For procedural skills, kind of a wide range, small to large effect size. And actually one study was neutral, and one study for skills went the other way. The games wasn't as good, but that was not statistically significant. And I didn't plot attitudes there, because that's just one big kind of fat arrow that goes all the way to the left, because repeatedly people love it. And this might scroll up just to show you some of the stuff that's out there. And at the end of the lecture, I'm giving you all these references and slides and stuff. But these are off the shelf and you can take them, and some of these have been studied in those simple ways. Two big problems with this whole bundle. One is there's a high risk of bias in the studies. They're not biased, but there's a risk of bias, because the authors don't really disclose how they allocated people to groups, or don't completely describe the control group, don't have the longer term outcome. So there's potential for bias. Some things aren't reported. And then only two of the 30, say, randomized trials are on gamification. A lot of this are serious games, and if you want to build a game, that's great. I do that too. But I'm interested in the gamification piece where you add fun stuff to your daily teaching. That big chunk in the middle. Oh, I forgot to mention that if you didn't play the game earlier, the quiz, you still can, and the winner gets an Amazon gift card. All right. And few people are reaching for the phones. And the point is, people play the games because they want to, right? You don't even need the prize. But there is a prize for the closest, just today. But people are just motivated to participate. They want to be there. Just like with Mark. You know, people wanted to be in his orbit. They just wanted to be in his educational activities. So again, highly motivating. All right. Back to our model here. Let's skip some levels and go right to the pinnacle. Patient outcomes with a couple examples. Kerfoot, 2017, took about 500 patients with diabetes. They all got education. Diet, medications, lifestyle. But then half were randomized to some spaced education questions. That's the Q stream. That's where you get a question every few days. And if you get it wrong, it comes back later. What were the gamification elements? There were three. An appointment dynamic. If you don't answer the question, it disappears. Limited time offer. That's exciting. There's a progress bar. And you get this on all your training. How much are you almost done? And then there's competition. Not only how much smarter am I than the other patients when you answer the question, but the authors made the teams geographic regions like sports teams. So there was natural competition. The control group got questions on like civics. They did the game for six months and then followed patients for a year. Everyone got better. This is hemoglobin A1C on the Y axis. Lower the better with diabetes. Everyone gets better with education. But the game group out at 12 months had even lower A1C levels. And if you started with worse diabetes control, that's the panel on the right side of the screen, the benefits were even more. So overall, this was equivalent to having started, the game was equivalent to having started another medication for diabetes. And I'm looking for critics in the audience. Someone might say, okay, Kelly, that's a patient playing a game. Show me where a clinician playing a game made somebody better. And Kerfoot did the same thing with high blood pressure. He took 111 primary care clinicians, not all physicians, taught them about education, gave them on hypertension, gave them materials on hypertension, and then randomized them to a similar spaced education game. And then tracked their patients for a year. How good was the patient's blood pressure control? And this is multivariate analysis hazard ratio and more to the right side of the screen means the patients on average got to better blood pressure control. As you can imagine, there's a ton of variables involved. For example, if the baseline test showed the clinician knew more about the hypertension guidelines, their patients got to better blood pressure control faster, as you might expect. But if you were a clinician randomized to the spaced education game, you did a little better. Now maybe that was just 128 days compared to 134 days. Eh, you know, is that a big deal? Phrased another way, for every clinician who played the game, another two patients got to control. And I thought that is pretty good. And then one more example for our nursing colleagues that might be here. Catheter-based, catheter-line infections are a big deal. And you know this. In the ICU in the wards, Orwell 2018 described they were having a big problem with it at their institution. So what they did is they added an app, just a program to the hospital computers outside the computer record, where nurses could assess themselves, self-audit. And that's great. They added what they called micro-learning, little teaching points in the app, which is great. And they had that. But some months they added gamification. Again a leaderboard, comparing units to each other, competition. Donuts for the best ward, you know, nominal food prizes. And when they did that, the use of the app and the kind of self-assessments on the nurse's own time increased an order of magnitude, ten times. The authors were super honest, and I love this. And this is complicated, but I'll describe it. So it's a pre-post study, right? They introduced it, the app. During the study period, they talk about how they moved to a new hospital, and they were so busy that they stopped doing the nursing audits. They were too busy to look over the nurse's shoulders like they're supposed to do. Those are the gray bars that went down. But the black line, the number of line days was the same. And they were able to show a big relative decrease. Their baseline rate was high of infection. But they were able to show a relative decrease in infection. And then through estimation, they say this change, the game change, was associated with a drop, theoretically, in inpatient costs and stays, and maybe even two or three patient deaths. Now, how much is the app? How much is the microlearning? How much is the gamification elements? I don't know. But I do know that the gamification made them use the app. So it was at least part of it. Okay. This is something, 2021, a nice review, Van Galen and Giorgides. And I've had some back and forth and communicated with Giorgides. What I like about it is just gamification. So if you look at his and his article, their article, Prisma Flowchart, look what they got rid of. They got rid of the video games, the medical board games, the Jeopardy you play with your residents, all that stuff, and just focused on adding gamified elements to your teaching. Of the attributes I showed you earlier, which ones are most common? Usually it's a combination of assessment, you know, points with some kind of conflict, competition. And the authors are Dutch, and they point out that this need to be number one on the leaderboard and compete. It's like a Western culture thing. And there's probably something to be said for that. But those are the most common elements. They tried to be rigorous about looking at the quality of the papers using a validated instrument. This instrument has a range of, say, five to 18. It gets at randomization, validity checks, outcomes, and follow-up. And of the 44 studies that looked just at gamification elements, you know, okay, paper quality. There was a range. No negative outcomes. It's important to note that no one was ever harmed by adding gamification. And most of the time, again, it's assessment with a challenge. Papers with better control groups, unconfounded control groups, were obviously of higher quality research. And I'm gonna come back to what an unconfounded group is. And the bottom line from this nice comprehensive work, your learners will interact with the material more, often on their own, when you add gamification. They're gonna like it better. And for medical knowledge, at least, it seems to improve learning outcomes. But they emphasize, you know, larger randomized trials are needed. All right, taking off the salesman hat for a little bit, a couple things to keep in mind. Obviously, some study limitations, and there are two of them. One is confounded comparison. If you make a game, and I hope you will, or do it again, add gamification. And I hope you will, and I wanna help you do it. You're gonna wanna study it. And you can't give one group randomized to your game, and one group gets nothing, and then give them a test later, right? That's cheating. Unconfounded control group has to get some kind of traditional learning, to be fair. The other thing is duration. I found one study that the group randomized the gamification over traditional, at 10 weeks, had more retention for medical knowledge on a written test. Do folks do jeopardy with their residents and fellows? You know, one randomized trial, immediately after, on the test, they were equivalent. 12 weeks later, 12 weeks, the Jeopardy game had better, who had the Jeopardy game had better retention. Three months is pretty good, you know, for learners to remember something, but that's about as far out as I've seen in the literature. Publication bias, if your game stinks, you might not wanna advertise it, I guess, so you might not publish it. And those theoretical frameworks I showed you up front, those should probably be explicitly linked by the researchers better. When your game works, and it will, was it the leaderboard, the timer, the prizes, the social aspects? We don't know, you have to break that up and study it separately. And we have to learn more about qualitative subjects, like what, about play and gaming in general. What subjects work best? You know, learning is intrinsically rewarding. We love to learn. So maybe gamification works best with the boring subjects, you know, get them hooked, and then they learn to do it. Too many bells and whistles can turn people off. Novelty bias, novelty is a good thing, but if you go home and do a game every day at noon conference, every noon conference forever, you know, maybe they don't like it. You do it once a month, every other week, they're gonna like it. For competition, if you have people answer quickly, they might not reflect more on the answers. And then there's an over-justification effect, and this is kind of interesting. Again, people like to learn. If you try to incentivize it too much, they get suspicious and they might be demotivated. That's a small subset of people. You know, people are suspicious. All right, I'd like to transition now just to the, more of the how, you know, seven tips, some from the published literature, some from just my mistakes over the years. This might have been Austin or Texas, I don't know if you remember, Rob, but one of our chess arcades, everyone having fun, vintage arcade boxes there, task trainers, a lot of social learning. And all of you are gonna get to take home this little worksheet where you can design your own game and gamification. It's based on the current six-step model, so it's pretty good. And do stay in touch. I want to help you do gamification at your institution, and maybe we can do some fun stuff for Chess 24 Boston. Here's some, just a snapshot, internal data. Excuse me, so this is 10 years old now, but when people would walk off the arcade floor, we'd make them do an anonymous survey. And I included this year because this was the first year of COPD whack-a-dolph, like whack-a-mole, where you knock down the wrong answers. The piston stroke bothered everyone, so that one got bad reviews, which I like, because when you average that into my other games, look at the yellow column there. Most people learned something, they liked it, they wanted more. 95% picked up something playing the game that they didn't get otherwise during chess week. And then for the past couple years, we've had Chess Player Hub. This is member-donated pulmonary critical care sleep content into kind of a pre-existing game template. And there's pros and cons with that, but it's very practical and feasible. Survey of 500 learners. Everyone agrees they learned something new. And three quarters say that they're gonna change their practice because of the game they played. And I'm not gonna show you much more, because Dr. Adams and Rob, they're gonna publish all this stuff, so I can't disclose too much, but we have to follow up. Did they make the changes? That's the important thing. But this intent to change is powerful. All right, number one, start small. These are first-year medical students learning how to do a medical interview. Chief complaint to social history, what goes in order? You're done, but make sure you correct. Takes two minutes, paper cards. Beginning of the month, or by the end of the month, they can do it in 20 seconds, so it's gratifying. They're literally out of their chairs, so it's active learning. Or with your residents and fellows in the team room, go around the room, you draw a card from the hat. Cross-cover issues. Things that go bump in the night. Hyperkalemia, fall out of bed, whatever it is. Costs nothing to do. For the container, I used a clean bedside commode, just for effect. What are the game elements? Maybe you pull a pass card. Maybe you pull a reverse order. Or maybe, like on a bad call night, you pick a card that says you have to talk out loud about three different patients. So there's a random element there that's exciting. That's starting simple. Here's the other extreme. CHESS 2019, pulmonary nodule escape room. First organization professional society, to our knowledge, ever, to try to pull this off. Here's a peek around the curtain. Talk about immersion. You have x-rays and pathology. Aliens needing ultrasound. Happy players. You get over here, you have robots. Distracting noises, just to kind of make it intense. And then loop around the corner to another learning station. I don't know if June's here. That's June Chang in the red. Faculty member in costume to facilitate. Don't do this your first gamification element. Because it takes a big team, like the faculty and friends and staff that we have here. What about middle ground, if you like escape rooms? Rather than get out of a room, have your trainees get into a box. Something you build in your garage, or a cheap cardboard box. The idea is they make the diagnoses, get the x-rays right, the multiple choice questions right. They get the code, and they get the prize that's in the box. Number two, know your audience. This might have been 2012, end of the night. Some of our colleagues are there, playing games late at night. You couldn't get them out of the chair. Don't assume that it's just a certain demographic, like only young boys. It's a broad demographic. And you know this, you're all teachers. You have to know, is it a mixed group? Is it students, is it fellows? Who's your audience? Never was that more important than when we took our games internationally. I think it was 2012, Mark called and said, hey, we're going on a trip. And I said, great. And then you hear this big sigh on the phone. He's like, Kelly, I gotta teach you to be a better negotiator. Wait till you hear the trip. But this was India, four cities, including some games. And this was just an attendee who reposted this picture every few years. They had such reverence for Mark. They would put like this cloak on, like a faculty cloak after he spoke. I mean, it was such reverence. In Italy, we did a nice lecture for Mark because he had the same effect in Europe. And then 2016, China, there's some leadership. Stephanie, leadership was there. And Mark, who helped put it together to include our chess challenge. Now, here are my participants, didn't know Alex Trebek, didn't know Jeopardy. And then culturally, the yelling at each other and the buzzers, you know, and the trash talk wasn't gonna work. You know, know your audience. So I changed the format of the slides. And it was more like a tennis match. You know, you could pass, you could answer back and forth, and people had fun. All right, remember your learning objectives. Don't get distracted by the game part. This is Pulmonary Adventures. This is one I want to bring back, Rob. But narrative story was fun. You know, Indiana Jones theme. And when you got it wrong, Dr. Contrarian would pop up and make fun of you and make you feel terrible. It was very motivating. And yes, Dr. Contrarian should look a little familiar, you know, anyway, in the back there. But at the end of the day, you stop playing the game, go down to clinic. You had learned about basic x-rays and pathology and clinical cases that were gonna help you. So never forget the underlying assumption. Hmm. Number four, peer review, chess challenge. You know, I always think of that. This was 2014. Tonight's our 22nd anniversary. Here's the fifth anniversary, and there's Lisa there and Kevin and some friends. Was this the night that the system crashed, I think, and the computers might have broke? And then for 20 minutes, Mark just stood there and had to like, you know, work the crowd, stand-up routine, and he pulled it off. He pulled it, until he got the computer back up. I think that's when they named him Seinfeld. And you do this, or you should do this, peer review of your teaching. Whenever you're gonna do teaching, get peer review, especially, you know, this, North American competition, thousands of dollars in prizes, it's a big deal. Which reminds me of another story. At least I might know this. I don't know if I told anyone else. At the chess meeting, early, you know, on the day of the challenge, I'd walk with Mark to a bar, you know, it was light out in the day. He'd have his martini, and he'd hold it. And I'd kind of run through the questions to kind of get his sense of them. Most were fine. Some, if there were stinkers, Mark was good with feedback. He'd say, get rid of it. But every once in a while, when he's holding his martini, I don't know if you remember this, he wouldn't really nod. He just kind of closed his eyes and pursed his lips a little bit if it was a good question. He'd let go. And I lived for that moment, because I knew that night, that question was gonna be perfect, and I loved that one-on-one time, and here's some of the Rosen family, and when they're here, they often will give the trophy to the winning team. Number five, rewards and feedback. This was my aspirated game. You try to remove the foreign body in the shortest amount of time. Did you play it? You played it. It's rewarding to get the foreign body out. It's rewarding to have your name on the leaderboard. You know, again, intrinsically rewarding. The updated Whack-A-Doc, no plungers, more digital. It's rewarding to quickly say, that's a dangerous behavior for a patient, stop it. It's rewarding to do that quickly. So you don't need the prizes. When we first started, you know, 12, 13 years ago, oh, let's get iPads and all this stuff. People still play, even if there's no prizes or it's a $10 gift card. And then feedback. When you leave the escape room, you get this bundle of learning materials to reinforce the learning that happened during the game. Number six, learner protection. This is peer pressure Italy. And again, you never know how something's gonna translate, but this went pretty well. This is Billy on the streets, kind of these ambush interviews we do. I don't know if Saadi is here, but. So learner protection, it's tough. Was that? Ambush is a good term. Approach, we approach. And just for the record, I think it was 2018, I chased someone to the bathroom, not into the bathroom. Because again, you know, standards. But learner protection, you all know about learning climate. Your learners, your students, your residence fellows have to be comfortable. And this is tough. And it's also tough because you have to be able to get the answer wrong. If there's no risk of getting it wrong, then there's no emotional engagement. So how do you work around that? You have a second question that's easier, so they leave on a win. Or a transition, or a consolation prize. And this, again, one of the many articles I can share with you. Ultrasound Pong was the game. But I like the graph. Challenge versus skill. And you know this. If the game is too intense, the question's too hard, people shut down. If it's too easy, and they get every question right, it's boring, and you lose them in about 90 seconds. That flow state, we're always looking for that magical flow state. And then finally, keep it social. Chess Challenge audience, New York Methodists. You know, they were super fans. Pretty rowdy for several years. Here's peer pressure. And we're playing again at 11.45 today. You can see how people kind of go back and forth to answer the questions. That Bandura, Social Cognitive Theory. They're learning by watching others. A lot of smiling, laughing back and forth. Just so much fun. Incorporate the social elements whenever you can. And for me, my social element is getting to work with my friends, and faculty, and staff, and just the most amazing people every chance I get. And it's been so rewarding over these years. Mark, I think, really, in the world, he was the best at understanding the social element. The social element to education, certainly to a professional society, and certainly to life. This is one of the great dinners we had. This might have been after. No, we're not dressed up enough. This isn't Chess Challenge dinner. But every year after Chess Challenge, we'd go out to dinner. And I got to tell you, a long time ago, as a first year fellow, maybe first time at the meeting, not knowing anybody, the game's over. I'm like, all right, great. Back to the hotel, room service for one. Pretty lonely. That was me. But across the hall, you hear Mark's voice. Hey, Kelly, you're coming out with us. He literally and figuratively got me a seat at the table. And he did this for so many people. He mentored so many people. And he included us, which encouraged us to kind of stick around and do more. Like some of you, first time, I'm a first generation physician, and had a lot of stuff getting started. And Mark really treated me well. And he was great about it. This is Mark saying, all right, Kelly, keep it together. And finish on time. All right, good. I'll do that. He was always good about that. So in summary, gamification, serious games, making a video game, million dollar game, that's great if you want to do that. But gamification, adding elements to your everyday teaching is possible. And try to do more of that. You know you're going to increase learner satisfaction. It's pretty clear you're going to increase their engagement with the material. It's not even homework. They do it on their own. Growing, but limited, growing evidence that it's going to improve outcomes, even a couple studies suggesting patient outcomes. And we're trying to add to that literature with outcomes committee, and Rob, and the games team. And really, it's just fun. It's an educational tool and creative outlet for you. And you go from your scratch pad on the airplane after one chess meeting. And then at the next, it's this huge, huge production. This was incentive spirometer. So in closing, I just want to thank the Rosen family for sharing Mark with us all these years. And I think I've given you a taste for the literature. But the literature only goes so far. You really have to follow your heart in these things. And you know there's something here, and it works. And similar to that, I don't know if it'll play, but I wanted to give Mark the last word, if it works. Finally, despite my comments about the health care crisis, death, taxes, you need to love what you do, and you need to have fun. You need to laugh. And you need to laugh a lot. I did a MEDLINE search. This is what we do, a little EBM thing. I did MEDLINE. I did Cochran. The key words were laughter and benefits and no hits. There is not a single randomized placebo-controlled trial to support the statement that laughter is the best medicine. But who are you going to believe, the literature or me? So there it is. Academic rigor is important, and we're doing that. But you have to, you know, you know what's right. And you have to follow your heart. And in the year or two since he said that, there's now 740 hits that came out in terms of that. Again, we're going to play at 11.45. I think we have another game at 9.30. Just come on down. And then with this, I think this should work, a QR code, a bunch of free text articles, my worksheet. That's an email. Because again, I really would like to keep this conversation going. We can maybe incorporate games at your institution, you know, pilot a few things. Open submissions for November for Boston if you have any game ideas. And you can go through the submission channel and or reach out to me separately. And I really encourage you to try it. Because again, it's been a lot of fun for me over the years. So thank you so much for being here. I'm happy to stick around and answer a few questions. Thanks so much for coming by to honor the great Mark Rosen as well. And enjoy the rest of the meeting. Thank you very much. Thanks, Hussain here was asking about burnout and team building. You know, a couple quick examples. Certainly with the escape room, there is a crew resource management component. You know, you're having to come together to solve the puzzles, which is helpful. And then in terms of under the learner satisfaction category, there is some try to report decreased burnout. You know, some editorials talk about, you know, the cure for burnout. That's not, I don't think that's true, but it is part of it. So there is some literature on that. Part of the, you know, when learner satisfaction goes up, resiliency goes up a little bit. And then the team building, they've done it for, I think, palliative care, some nursing studies, pharmacists and dentists, it's interprofessional. And they usually report team building. They call it, you know, that's one of their more softer qualitative outcomes, but I think it's a very important outcome. Absolutely. Absolutely. So, there's stuff off the shelf you take, and then the worksheet we can help you, online and offline, help you build it. You get a feasibility. Some people say, well, let me just do a lecture. It's so much easier. No. The data says to do a brand new one-hour PowerPoint, it's 20 hours, on average, depending on the subject. And then, what good is all that time if your learners aren't engaged and they don't remember the material? So, I think you can make a faculty case that it's worth a slight time investment, especially if you start small, and then you have that kind of contagious, circular, positive feedback. So, I think the worksheet that's in this bundle, or should be in this bundle, can help, and I can also talk to you offline. Yeah, the off-the-shelf stuff is great, sometimes free, but nothing is, you know, more free than some Post-it notes, and you scribble things down and drop them in a hat. And that stuff's pretty easy, and you can add that to a noon conference when you get back home. And for peer pressure, you know, like which I'm doing at 11.45, that you can do at home, too. It's just some masking tape on the floor, you know, four quadrants, A, B, C, D, and it's like a non-anonymous audience response system. People have to commit publicly, and they kind of laugh around. I think that might be good for morale, too, back home. Thanks, Hussain. Anything else for the group? Otherwise, I can stick around. All right. Thanks, everybody. I really appreciate it. Thanks. Thank you.

gamification

medical education

learner engagement

learning objectives

feedback and rewards

teamwork and collaboration

interactive learning activities

teaching tool