Point of care ultrasound (POCUS) is integral to many health professions and a requirement in the training of emergency medicine resident physicians (Bahner et al., 2012). The use of POCUS improves patient care by allowing for prompt diagnosis and management of frequently time-sensitive pathologies and more accurate performance of procedures with fewer complications (Bahner et al., 2012). In emergency medicine, POCUS is traditionally taught through formal didactics, bedside teaching, and the repeated practice of imaging protocols. Becoming competent in POCUS requires attention to medical knowledge, psychomotor skills for image acquisition, image interpretation, and integration of the information gained into clinical decisions (Nicholls et al., 2014). While traditional didactics can address medical knowledge, image interpretation, and clinical applications, this multifaceted skill set demands a more complex curriculum to better address all its components. 

In addition, keeping learners engaged in developing POCUS skills throughout their three years of residency can be difficult. We have found that many residents are excited early on and are engaged with educational sessions during their intern year. However, as they move on in their residency, they have increasing clinical demands and requirements in other areas, and start to put continuing ultrasound education to the side. In order to address these concerns we turned to game based education to maintain our residents’ interest in POCUS education.

Game-based education aims to maintain learners’ intrinsic motivation to learn by providing educational content that fits within their Zone of Proximal Development (Singhal et al., 2019). The Zone of Proximal Development, described by Vygotsky, suggests that there are tasks that learners cannot yet complete because they are too challenging which can cause anxiety, and tasks that learners have already mastered which can evoke boredom (Groot et al., 2020). Vygotsky argues that being able to teach at a level between these two zones, known as the Zone of Proximal Development, allows for enhanced engagement and in turn can promote improvement and growth in the learner (Groot et al., 2020).

Over the last decade, gamification of learning has increased in health professions education (van Gaalen et al., 2021). For definition purposes, a game can be described as an interactive experience (with or without a significant hardware/software component) that has a challenging goal, is fun to play, incorporates some scoring mechanism, and is expected to provide the user with skills, knowledge, or attitudes that are useful in real life (van Gaalen et al., 2021). Several game design elements, the taxonomy of which was first developed by Wilson et al. and subsequently adjusted by Landers et al., can be utilized to augment education including that of “action language,” “assessment,” “conflict and challenge”, “human interaction”, and importantly “rules and goals” (Wilson et al., 2009; Landers et al., 2014).

Action language is the way that the game interfaces with the learner. Assessment is the real time feedback the game provides based on learner performance. Conflict and challenge address both the problems the learner faces and acknowledge the nature and difficulty of these problems as the learner progresses through a game. Human interaction allows learners to work as a team and interface with other players. The rules and goals element requires clear definitions so that the learner understands how to progress through the game. The incorporation of these gamification elements not only engages the learners but also has the ultimate goal of addressing the learners’ skills, knowledge, and/or attitude toward the topic being taught, in this case POCUS.

Our residency program includes class-specific teaching days, an optimal time to incorporate a game-based POCUS curriculum to better target the learners’ Zone of Proximal Development. The objectives for curriculum include learning more advanced ultrasound protocols, reviewing pathologic images, and focusing more on clinical integration. Over the last few years, we have incorporated multiple different game structures, from team-based contests to modified board games.

One recent intervention involved an ultrasound-adapted escape room, which was held virtually in 2021 when social distancing demanded virtual didactics, and again in 2022 in-person once social distancing mandates were lifted. In the in-person session, the theme was inspired by the 1990s Nickelodeon children’s game show, “Legends of the Hidden Temple.”  Residents from the second-year class were divided into three teams. Teams received pieces of a statue at different stations after solving a problem, answering questions, or performing ultrasound scanning techniques or skills. Once all the pieces were obtained, they were able to build the statue and unlock the final room where they completed a final clinically-based scanning task to win the game.