 Welcome to this talk on a project that was launched last year in the acute care surgery unit at Khorotyskir Hospital where I used gamification to entice my students to be a bit more involved in the working of the unit. So in this talk I'll give a bit of a self-introduction that is to myself and to the unit. We'll talk about some definitions of gamification and perhaps a bit of research that is going into gamification in an academic setting, in a professional academic setting for that matter. And then I'll talk about my own experience, the goals that I set for this project and a bit about how I implemented it. So my name is Jean. I'm the head of the acute care surgery unit at Khorotyskir Hospital. I've been a surgeon for 12 years. The acute care surgery unit is quite a new unit, one of the newest or the newest subspeciality to see it that way in surgery. Many of the units are opening in the United States and throughout Europe and what we're really trying to do is to take care of those patients who need urgent surgery. It's not patients that come in and you have time to plan their management, to work them up, to decide how best to treat them. It is patients that require urgent surgery. Now, we do have an undergraduate educational program. We are the academic hospital for the University of Cape Town and in the unit we have final year or six year medical students. They rotate with us for a period of two weeks and they're usually about five or six of them. It forms part of their teaching, preparation for their exams and we are also supposed to provide them with some learning experience and literature. It is a work environment. In other words, the goals of the unit is to see and operate on patients. In amongst doing that, taking care of the patients, the students come along with us and they are supposed to form part of the team of the management of these patients. It must be said though that the actual caring for the patients does not depend upon the presence of these students. The actual management of the patients are taken care of by our interns and registrars and then consultants. What would be termed in America as the attendings. So, what is gamification? It was coined in 2008 and really comes from the digital media industry as opposed to the academic industry. Online, if you read the Oxford Dictionary's website, it says the application of typical elements of game playing. For example, point scoring, competition with others, rules of play, to other areas of activity. Typically as an online marketing technique to encourage engagement with the product or service. So not for academic education really, but of course we can use all of those elements in an academic setting. It ends off by saying gamification is exciting because it promises to make hard stuff in life fun. In eating that makes me a bit nervous in as much as I'm dealing with students in a professional setting where we are taking care of actual sick patients. So making that fun is a bit difficult in as much as I felt that I needed to maintain some form of professionalism in the setting. So could I use it? Just looking at a bit of academic research that is going into gamification at the moment, we can see that a lot still has to be done specifically if I look at the project which I embarked on last year. So there is some research at the moment about society's adoption of gaming and in copying the specific game elements. If we look at society's adoption of gaming, let's just look at Facebook for instance. Facebook is nothing other than gamification. There are rules set for this game. This is how you log onto the system or register with the system. This is how you post these other different pages and things you can do. And then you get scored basically because people respond to you. You get friends and you get likes. There is a scoreboard and it has psychological effect on you. There are some papers looking at what happens if people post something and there is no response. So near deleterious psychological effect has been shown there. I can also think for that matter. Now I am sidetracking this slide a bit. Is academic education a form of gamification in itself? In as much as there are rules, we tell the students what to do, what to read. And in the end they do a test and they get points for that. And there is a leaderboard to those points. In effect there is a form of gamification. Back to the slide. Copying of video games. So there is a lot of research going into how to produce states of desirable experience. We see some city there from electronic arts. There is a lot of elements that go into developing a game like that. And there is research into how to extract desirable states through the mechanics of the game. The motivation that goes into playing these games. What motivates people to pick up the game again and again. And how to look at engagement, intensity and the duration of gameplay. How to improve those, maximize those. These things are not just thumbs up. And we need to do a lot in extrapolating this kind of research into the academic field where we use gamification. So what's my definition of gamification? In my academic setting, well for me it's using game element mechanics. So those are the rules, the badges, the point scores, the leaderboard system. And psychological dynamics, so those would be the enjoyment of it. I'm appealing to the need to perform and the standing amongst their peers in these students. So the psychological dynamics to achieve a learning goal. So these are the things I really wanted to use in this project. Back to the research. I really didn't want to just do this project of gamification. Just to first attain to iron out a few problems before deciding on doing proper implementation and seeing if it's worthwhile. But I need to be scholarly about this as well. And Sydney if we roll this out on a larger scale we really need to think about being scholarly. We need to measure a few effects. And first to measure effects we really have to decide on an ultimate goal and in my mind there are two goals. I can either develop a project of gamification where I improve the actual knowledge of the students and if they have more knowledge perhaps they could pass the exam or get better marks in the exam. Or I could try and design the gamification to make these students better doctors with more critical thinking abilities. So those are two different things. I can do a role playing game and I can have one of the students mimic a patient and the disease and we can have a role playing game and I can test their knowledge. But there's something else I could do. I could really try and alter the way that they perceive the work that they do and go about how they do it and improve their critical thinking abilities. So depending on how I design this and what my ultimate goal is I can then decide what to realise, what effects to measure. Let's also do some research on the game mechanics itself. What platform to use. You'll see later on I just use my private website and wordpress and plugins for wordpress. What must the user experience look like, the design, the actual design of the leaderboards and the point scoring system. What must the bear just look like when someone is in the lead, when they score some points. All sorts of mechanics. Now remember the two slides back I showed you all the research that goes into the game companies themselves. What research goes into designing the best elements into those games to get the most out of their games obviously for making money but to engaging the user. I certainly need to look at the game mechanics and see if I use something else, improve something that has an effect and then probably I also have to do research on the psychological dynamics. What makes students interact with us, what makes them perform better. So a lot of research that we can do on gamification in an academic setting. So the experience of the project in my unit. There's some things to think about before starting. These are the kind of thoughts that ran through my mind before I started. So these will just be some broad statements. I had to understand gamification. It's not long ago that I heard the term for the first time. I had to go read up on gamification specifically in the academic setting. I need to identify the role that gamification can play. Do I need gamification? Can I not just use some form of what I would term hidden gamification to achieve my goals and getting more out of the students in some other way. I could be dictatorial and force them to read more and force them to see more patients and force them to come to theater more. And that I would term some hidden form of gamification or can I do it openly and transparently. And I need to decide do I want to modify behavior or impart knowledge. And I had this in the previous slide and for me that's a big distinction. And I went for modifying behavior. Implementing or designing a game to modify the behavior of the students which I thought was more important than imparting pure knowledge. I had to be cognizant of the setting. I mentioned before this playfulness did not sit well with me. Probably have been in this game too long. And for me the setting is too professional to introduce some sort of playfulness. I'm sure that one can sit and think of doing it in a playful way. While maintaining the professionalism and while we're dealing with extremely sick patients in a very formal setting I thought that I wanted to get away from the playfulness. Really was not the place to do it while we are in the ward in casualty and in the operating theater. But I wanted to use the dynamics of the playfulness. The interaction between the students something to drive them to want to do better. Some more broad statements. You have to decide between an analogue and a digital system. Of course I think the digital was the way to go. And if you decide on digital really have to look at the platform, the design, how to implement these. But reasons for going with a digital platform is of course the ease of use and maintenance. It's not something bored. I have to design and cut out things and paste it on a physical board and keep it somewhere in the ward. It's really much easier I think to do things in the digital domain. There's a variety of products out there that one can use for this smaller project. I just designed my own. There's an air sophistication in the digital world. Of course students could follow this on their tablet devices or on their smartphones. And of course the new generation is always much more familiar with the digital age. In the digital age with this kind of platform. Critical to remember though that you have to even embarking on something new like this. Be a good teacher and a scientist. I always try to remember that students surrender their critical thinking to us. If you tell them to go read that book that's what they'll read. If you tell them to manage a patient in this way that's what they will do. If you tell them about some behaviour that they have to adhere to or listen to. They really do surrender their critical thinking to you. So let's try and not make mistakes in education of students. Specifically in the healthcare setting where most teachers or clinicians just doing a day to day job with sick patients. And I'm not really trained as educationally so we really have to keep that in mind. So the goals that I set I had to identify some problems. If or else there would be no goals to set to improve those problems. There are the three that I went for. I saw that our students had very little patient contact. It's difficult in this day and age. It's difficult for some of the students to get to the ward early in the morning. Transport is an issue. We live in a big city with transport problems. So the patient contact could be improved. So that is some experience for them to get to see more patients. Or at least get to see how more senior people would attend to these patients. Very few of them actually came to theatre to scrub in. They have an enormous workload of lectures that they have to attend. Even in their final year at University of Cape Town in the surgery department. So a lot of formal and informal lecturing takes place. And they have a large schedule. And they have a lot of projects that they have to hand in before the end of their rotation in surgery. And they really skip on coming to theatre. It always somehow falls during some other time that they have to be somewhere else. They tend to get into theatre from their final year. They go on to being interns. And then that's for two years. And then on to community service. And with the healthcare delivery in South Africa. What it is, many of these more non-urban settings, more rural settings. They have very little help from more senior people. And they really need the experience and type of cases that they are going to see regularly. And those would be the emergencies that we do deal with in the emergency setting in the secured care surgery unit. So I needed to improve the experience in theatre. And then what I also found the students hardly ever read outside the prescribed materials. I wanted to entice them somehow to go and look at the surgical literature. To do searches. To read up a bit. And to tell their colleagues about what they read. Those were the three goals I had to improve those three things. And I had to design this gamification project to ultimately improve those three problem areas. So I wanted them to present more rounds. So they would see more patients. And that's really gaining valuable experience. And I needed to measure that somehow. And you'll see the discussions and the little asterisk at the bottom. I needed them to come and assist scrub up in theatre. And again it's an experience thing and I needed to measure it. And how did I do it again through discussions. And you'll see what I mean by that. And then they needed to read at least one good review journal article. And they had to summarize that and tell their colleagues about it. In the discussion I did that via an online forum. So there you go. I just used my website which is basically a blog recently redone. Which has to be populated again. And that is just designed in WordPress. I am not an HTML or website developer. And the forum is easy enough to do with WordPress. You just buy one of the plugins and off you go. So how did I measure or maintain these or measurement of these goals? Did they see more patients? Did they scrub up more and did they talk about stuff they read? Yes indeed. And here is one of the big elements of gamification. They were scored points for doing these things. And they had to talk about what they had done on the forum itself. So they had to log in and say I saw a patient this morning with this and that. And for that they got a point. And I obviously can see what they write on the forum online and I score that. If they saw, if they scrubbed up in a case they could talk about the case. Write about it in the forum and that would get scored. If they ask questions they would get points for that. If one of the other students answered their questions they would get points for that. If they talked about an article they read they would get points for that. And I ranked these scores according to what I thought was important. If they scrubbed up in theatre they got more points. And if they talked about an article that they read they would get more points for that. And if they answered a question, an academic medical question, that one of the colleagues posted they would get more points. Of course I was the moderator and if anything went awry I would also write something on this forum. Interesting to note though that I hardly ever had to correct any mistakes. If they answered each other's questions it was mostly correctly. And I think it was, we've discussed this before, that it was because they probably read up before they answered. They wanted to be sure that when they answered something on the forum where everyone could see that they wanted to be correct. And what was really beautiful about this for me is during war grounds when you ask a question students tend to keep quiet. They won't answer anything and they hardly ever ask questions. But on the online forum it exploded. They asked many questions and they answered each other. I could certainly see the knowledge that they really had which does not come out during war grounds. So there you see just the scoreboard, some of the students there and how they were doing a little star for the one that's in the lead. And once they reached certain thresholds, so there was early, so there was a 50 mark, the 100 mark was coming up. So this was in the blog every morning so they could see where they stood. Lastly just a few of the problems. Initially it's just giving each one a username and password. This was open on the system and very quickly we got some illicit marketing as people from outside somehow got into the system with a username and password. Even though I started buying some extra WordPress plugins to take care of this, this really was never fully under control until such time as I did this as a pen and paper exercise. In other words, every student got a piece of paper and on it I gave them a username and a password so it was not open on the website for them to register on their own. The other thing about it obviously is time consuming, following a forum with so many inputs into the system. In other words, students are typing something on the forum, you have to read it at all times and then at the end of the day count up what type of input was given. Was it a case in theatre? Was it asking a question? Was it answering a question? Was it writing a summary of a journal article? These had to be scored on a daily basis so you really have to read all the posts, that's the word I was looking for, all the posts on the forum and you have to score them and that can be a bit time consuming. In the end though it was very rewarding and we'll do some research on the numbers and try and publish those and of course go on to much bigger projects in the future and really look at the research. But the feedback was enormously positive, the engagement was phenomenal, seeing our students interacted and seeing what their knowledge was and seeing how important it was for them to be in the lead was actually good to see. And in the comments from the more senior staff, suddenly everyone noticed that students were in the war drums presenting in the morning war drums. Students were actually noticed in the wards of the weekends and most definitely it was a lot better in theatre because suddenly there were more hands to help and assist during theatre. So all in all a very positive experience maintaining the air of professionalism and very importantly did not add anything to what is already required of the students. I mentioned they are very busy, they've got a busy schedule, they've got a lot to do so I did not want to add anything to that burden. In other words they have to see patients, they really do have to come to theatre and they do have to read up. I did not add an extra thing for them to do. All of this occurred naturally, it was on their cell phones, smart phones, it was on their tablets and they just took to it like ducks to water. As I suppose they would do to Facebook, Twitter or any such modern forms of interaction. Thank you.