Why it Works
The Problem: A Summary of Burnout in Medical Students in the Literature
Physicians in training have a higher rate of burnout and related symptoms, especially depression and anxiety, than the general population. The burnout triad includes emotional exhaustion, interpersonal disengagement, and a low sense of personal accomplishment1
Burnout impacts half of all medical students2, and persists, although contributing factors shift as medical students go from pre-clinical to clinical training, residency, and early practice3. The COVID-19 pandemic added further stressors and is expected to increase the problem, especially if it is not adequately addressed. Interpersonal disengagement interferes with social support and hinders proper treatment of patients4–6. Burnout continues to be a problem in medical students despite the addition of wellness programs by many medical schools and medical centers.
Burnout correlates with alcohol and substance use problems7,8. Overall use of alcohol in medical students (91%9) is substantially higher than that seen in the general population (56%) as measured by the 2017 National Survey on Drug Use and Health (NSDUH) data on young adults aged 18 to 25 with past month alcohol use10. In a 2016 study, ⅓ of medical students had symptoms of alcohol abuse/dependence and that use correlated with the burnout domains of emotional exhaustion and depersonalization2. A separate study found that ⅓ of medical students fit criteria for binge drinking and over ¼ used cannabis in the past year9.
Burnout and depressive symptoms overlap11. In a cross-sectional analysis of studies by Rothenstein et al., the rate of depression in medical students averaged 27%12. The rate of depression increased slightly as training progressed13. The linkage of depression and suicide is well-established in general as well as in physicians14. As many as 11% of medical students expressed suicidal ideation and ~16% sought psychiatric treatment12. Given the common reluctance of individuals to admit to symptoms of suicide or seek psychiatric treatment these figures are likely even higher.
Burnout also correlates with higher BMI15,16, poor sleep17,18, and increased motor vehicle accidents19. In addition to the common use of alcohol as a coping mechanism, medical students often utilize ineffective coping responses to stress, such as unhealthy self-indulgence or self-criticism20–22.
How Medical Students Cope
Students may employ coping skills in order to decrease stress or learn to tolerate it. These skills play an important role in preventing and reducing burnout in medical students. Coping mechanisms may be beneficial, harmful, or some combination of the two. Some less healthy coping mechanisms may offer short-term gains, but later become harmful. Sometimes associated harms may not be recognized.
Medical students’ most common positive (effective) coping strategies include better time management, respecting their limits, setting priorities, gaining emotional support, talking to family members or friends, seeking advice and help from others, getting a good night’s rest, and participating in leisure activities20,21,23. However, medical students also may employ negative (less effective) coping strategies. The most common of this type include blaming themselves, being self-critical, and using escape/avoidance to deal with problems20,24.
In order to focus on healthy coping strategies instead of less-effective ones, students may benefit from being reminded to call on or develop personal strengths that may help them endure the more difficult challenges in medical school. Examples of strengths that are useful for medical students include supporting each other and the ability to delay gratification or to see the big picture. In addition, some students may reduce their stress loads by learning to be more assertive, improve communication skills, or use better anger management skills. Learning to recognize and correct cognitive errors25, such as over-generalization or black-or-white thinking, may also reduce stress levels for students who tend to make them. Similarly, students may benefit from recognizing common defense mechanisms they may use, such as denial or procrastination, which tend to relieve stress at the moment but not in the long run. The healthy alternative is intentionally selecting healthier coping strategies.
Using Simulation Technology To Effect Change
Through Step 2 preparation, medical students in the pre-clinical years of medical school are familiar with simulations and comfortable with the experience. A computer-based simulation is available on their schedule and need not compete with their typically very busy schedule.
Simulation technology can expose students to the challenge of clinical care in a realistic and safe environment where strategies can be tested and outcomes assessed. Of the 80% of medical students who positively described their real-life clinical experiences, most credited supportive learning environments (35%) and hands-on experiences (32%)26. A simulation provides such a supportive experience. In a simulation, a student can comfortably identify and adapt to stress and make forward-looking changes that build longer-term resilience, an essential component of avoiding burnout.
The individual focus of simulations supports attention, exploration, and confidence in asking questions. In contrast, learning in teams may not always be optimal. In fact, team size negatively affected students’ learning experiences27. Students in larger groups were less able or willing to ask questions or share opinions on cases, potentially due to time constraints and traditional hierarchy issues seen in groups26.
Skill training simulations successfully impart health behavior change28–31. Simulations support positive emotions, engagement, social integration, and connectedness28–30. A meta-analysis found that simulations increased self-efficacy in a variety of clinical skills by 20%, declarative knowledge by 11%, procedural knowledge by 14%, and retention by 9% more than control approaches32. Increased self-efficacy is a key component of decreasing the stress of real-world clerkship experiences and preparedness33. In sum, a simulation can provide an individualized, scalable, reproducible, comprehensive, and standardized experience offering preparatory guidance to the clinical care challenges that await the medical student.
The Lift Experience Can Help
Our unique immersive role-playing sim utilizes evidence-based interventions, an engaging narrative, and an attractive environment to provide:
- an experience tailored to the general and specific needs and capability of the future or current medical student in clinical training
- choice, exploration, challenge, reflection, and intrinsic motivation
- decision-making opportunities with clear consequences
- collaboration and practice building teams
- feedback on choices made by a simulated mentor
To deepen understanding, medical students explore and navigate the learning environment to identify factors and strategies relevant to them, which is an effective pedagogical approach34. Being in control is a key element in the effectiveness of this pedagogical approach35–39. Exploration puts the user in control of the Lift experience and leads to increased learning and understanding. Control, self-expression, and creativity support a focus on intrinsic motivation40. In our role-playing narrative, the medical student navigates spaces, including clinical settings. The experience components (challenges, communication skills, strength, feedback, and development) mirror elements of an entertainment-focused game. Similarly, users struggle with and conquer challenges and master skills.
As users progress in a simulated clinic, they experience causes of success and frustration (e.g., challenges, ethical dilemmas, demands, frustration, sleep disturbance, work-life balance, negative feedback from supervisors). The sim enhances longer-term decisions, required for behavioral change by letting medical students:
- identify attitudes and perspectives that impact poor choices (e.g., unrealistic expectations)
- prioritize activities that establish balance (leaving aside time for rewarding aspects of life)
- examine decisions and their impact (e.g, substance misuse)
- practice peer support skills
Theories Supporting The Lift Approach
Simulations and games for the purpose of learning, or “serious games” capitalize on the engaging and reinforcing nature of games and simulations and are gaining prominence due to a cultural shift toward visual, interactive, and entertainment-based learning41. They heighten enthusiasm42 and engagement, are effective teaching tools43–47, and increase motivation48. Available for a variety of medical topics43,44,49–51, they improve knowledge, retention, and confidence in clinical skills45–48.
The approach is supported by a combination of social cognitive theory (SCT)69,70, the experiential learning model based on Dewey54 and Kolb55, self-determination theory56, and cognitive load theory57. These models provide theoretical underpinnings for our simulation and guide our use of tailored exploration, reflection, and social learning in an engaging design.
Social Cognitive Theory: The processes central to learning in Social Cognitive Theory of self-observation, self-evaluation, self-reaction, and self-efficacy and their role in motivation and goal attainment are achieved in the Lift simulation via exploration, facing challenges, experiencing the outcomes of choices, and reflecting during debriefing52.
In keeping with the social cognitive theory’s understanding that individuals differ and play an active role in how they learn, including differences in motivation, behavior, and experience52,58, Clinical Encounters: Medical School offers a variety of scenarios; students select scenarios to meet their needs. Variations we will consider include stage of training, introversion vs. extroversion59, and learning styles60. A wide range of common coping strategies will be included61,62. Students may benefit from trying both familiar and new coping strategies20,21,63.
Experiential Learning: The benefit of mirroring real-world experiences and learning from model experiences is described in the experiential learning model of Dewey54 and Kolb55. Lift offers an opportunity to gain from experiential learning54,55,55. Role-playing engages the participant in a cycle of practicing change by initial self-reflection64,65, taking action, post-action reflection66, concluding, and planning that promotes longer-term real-world behavioral change67–72. Student transformation can occur during the simulation or via contemplation afterward, during a debriefing73. Reflection is encouraged during brief pauses to decrease cognitive load temporarily without disengagement and task switching74,75.
Learner Control and Self Determination56: Medical students explore and navigate the simulation learning environment34 to identify factors and strategies relevant to them with respect to burnout. Exploration puts the user in control of the Lift experience and leads to increased learning and understanding35–39. Giving the students control of their experience and self-expression in the simulation supports the development of intrinsic motivation40,76,77. That is, it is an experience perceived as useful in and of itself.
Cognitive Load Theory57 holds that cognitive challenges support efficient and rewarding task attainment, but too much challenge feels overwhelming78–81. Immersion or heightened engagement adds value by enhancing interest, enthusiasm, and emotional involvement, and engaging both affective and cognitive processes82. Research has shown that achieving engagement through an enjoyable level of challenge is important in determining the success of medical simulations83,84. High fidelity elements (accuracy, realism) are valuable if they raise the complexity of the experience sufficiently to yield engagement without overwhelming the learner. At the same time, familiar and announced low-stakes practice employing positive feedback and encouragement also contributes to success.
- Bohman, Bryan, Dyrbye, Liselotte, Sinsky, Christine A., et al. Physician Well-Being: The Reciprocity of Efficiency, Resilience, Wellness Culture. NEJM Catalyst. August 7, 2017.
- Peckham C. Medscape National Physician Burnout & Depression Report 2018. MedScape. January 17, 2018.
- West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. June 2018;283(6):516-529. doi:10.1111/joim.12752. PMID: 29505159.
- Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. June 2010;251(6):995-1000. doi:10.1097/SLA.0b013e3181bfdab3. PMID: 19934755.
- Klein J, Grosse Frie K, Blum K, von dem Knesebeck O. Burnout and perceived quality of care among German clinicians in surgery. Int J Qual Health Care. December 2010;22(6):525-530. doi:10.1093/intqhc/mzq056. PMID: 20935011.
- Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev. September 2007;32(3):203-212. doi:10.1097/01.HMR.0000281626.28363.59. PMID: 17666991.
- Oreskovich MR, Shanafelt T, Dyrbye LN, et al. The prevalence of substance use disorders in American physicians. Am J Addict. January 2015;24(1):30-38. doi:10.1111/ajad.12173. PMID: 25823633.
- Jackson ER, Shanafelt TD, Hasan O, Satele DV, Dyrbye LN. Burnout and Alcohol Abuse/Dependence Among U.S. Medical Students. Acad Med. March 1, 2016. doi:10.1097/ACM.0000000000001138. PMID: 26934693.
- Ayala EE, Roseman D, Winseman JS, Mason HRC. Prevalence, perceptions, and consequences of substance use in medical students. Med Educ Online. October 26, 2017;22(1). doi:10.1080/10872981.2017.1392824. PMCID: PMC5678442. PMID: 29072119.
- Center for Behavioral Health Statistics and Quality. Reports and Detailed Tables From the 2017 National Survey on Drug Use and Health (NSDUH) | CBHSQ. United States Department of Health and Human Services. Substance Abuse and Mental Health Services Administration.; 2018.
- Wurm W, Vogel K, Holl A, et al. Depression-Burnout Overlap in Physicians. PLoS One. March 1, 2016;11(3). doi:10.1371/journal.pone.0149913. PMCID: PMC4773131. PMID: 26930395.
- Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. JAMA. December 6, 2016;316(21):2214-2236. doi:10.1001/jama.2016.17324.
- Mata DA, Ramos MA, Bansal N, et al. Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis. JAMA. December 8, 2015;314(22):2373. doi:10.1001/jama.2015.15845.
- Loas G, Lefebvre G, Rotsaert M, Englert Y. Relationships between anhedonia, suicidal ideation and suicide attempts in a large sample of physicians. PLoS One. March 27, 2018;13(3). doi:10.1371/journal.pone.0193619. PMCID: PMC5870971. PMID: 29584785.
- Peckham C. Physician Burnout and Weight. Medscape Physician Lifestyle Report. 2015.
- Mota MC, De-Souza DA, Rossato LT, et al. Dietary Patterns, Metabolic Markers and Subjective Sleep Measures in Resident Physicians. Chronobiology International. October 1, 2013;30(8):1032-1041. doi:10.3109/07420528.2013.796966.
- McLuckie A, Matheson KM, Landers AL, et al. The Relationship Between Psychological Distress and Perception of Emotional Support in Medical Students and Residents and Implications for Educational Institutions. Acad Psychiatry. February 2018;42(1):41-47. doi:10.1007/s40596-017-0800-7. PMID: 29124715.
- Johnson KM, Simon N, Wicks M, Barr K, O’Connor K, Schaad D. Amount of Sleep, Daytime Sleepiness, Hazardous Driving, and Quality of Life of Second Year Medical Students. Acad Psychiatry. October 2017;41(5):669-673. doi:10.1007/s40596-017-0668-6. PMID: 28421480.
- West CP, Tan AD, Shanafelt TD. Association of resident fatigue and distress with occupational blood and body fluid exposures and motor vehicle incidents. Mayo Clin Proc. December 2012;87(12):1138-1144. doi:10.1016/j.mayocp.2012.07.021. PMCID: PMC3541922. PMID: 23218084.
- Bamuhair SS, Al Farhan AI, Althubaiti A, Agha S, Rahman S ur, Ibrahim NO. Sources of Stress and Coping Strategies among Undergraduate Medical Students Enrolled in a Problem-Based Learning Curriculum. September 8, 2015.
- Pereira M, Barbosa M. Teaching strategies for coping with stress – the perceptions of medical students. BMC Med Educ. 2013;13:50. PMCID: PMC3627623. PMID: 23565944.
- Fares J, Al Tabosh H, Saadeddin Z, El Mouhayyar C, Aridi H. Stress, Burnout and Coping Strategies in Preclinical Medical Students. N Am J Med Sci. February 2016;8(2):75-81. doi:10.4103/1947-2714.177299. PMCID: PMC4791902. PMID: 27042604.
- Jahan F, Siddiqui M, Mitwally M, Said N, Al Zubidi J, Said H. Perception of Stress, Anxiety, Depression and Coping Strategies among Medical Students at Oman Medical College. Middle East J of Family Medicine. September 1, 2016;14.
- Bassols AMS, Carneiro BB, Guimarães GC, et al. Stress and coping in a sample of medical students in Brazil. Archives of Clinical Psychiatry (São Paulo). February 2015;42(1):1-5. doi:10.1590/0101-60830000000038.
- Grohol JM. 15 Common Cognitive Distortions. Psych Central. May 17, 2016.
- Ofei-Dodoo S, Goerl K, Moser S. Exploring the Impact of Group Size on Medical Students’ Perception of Learning and Professional Development During Clinical Rotations. Kans J Med. August 30, 2018;11(3):70-75. PMCID: PMC6122880. PMID: 30206466.
- Kandiah DA. Perception of educational value in clinical rotations by medical students. Adv Med Educ Pract. February 9, 2017;8:149-162. doi:10.2147/AMEP.S129183. PMCID: PMC5308474. PMID: 28223855.
- Riva G. What is Positive Technology and its impact on cyberpsychology. Stud Health Technol Inform. 2012;181:37-41. PMID: 22954824.
- Riva G, Baños RM, Botella C, Wiederhold BK, Gaggioli A. Positive Technology: Using Interactive Technologies to Promote Positive Functioning. Cyberpsychology, Behavior, and Social Networking. February 2012;15(2):69-77. doi:10.1089/cyber.2011.0139.
- Argenton L, Triberti S, Serino S, Muzio M, Riva G. Serious Games as Positive Technologies for Individual and Group Flourishing. In: In: Brooks AL, Brahnam S, Jain LC, editors. Technologies of Inclusive Well-Being. Vol 536. Berlin, Heidelberg: Springer Berlin Heidelberg; 2014:221-244.
- Baranowski T. Games and childhood obesity. Games for Health Journal. 2013;2(3):113-115. doi:https://doi.org/10.1089/g4h.2013.1502.
- Sitzmann T. A Meta-Analytic Examination of the Instructional Effectiveness of Computer-Based Simulation Games. Personnel Psychology. June 1, 2011;64(2):489-528. doi:10.1111/j.1744-6570.2011.01190.x.
- Bosch J, Maaz A, Hitzblech T, Holzhausen Y, Peters H. Medical students’ preparedness for professional activities in early clerkships. BMC Med Educ. August 22, 2017;17. doi:10.1186/s12909-017-0971-7. PMCID: PMC5568232. PMID: 28830418.
- Fowler C. Virtual reality and learning: Where is the pedagogy?. Br J Educ Technol. March 1, 2015;46(2):412-422. doi:10.1111/bjet.12135.
- Khan S, Black J. Surrogate embodied learning in MUVEs: Enhancing memory and motivation through embodiment. 2014.
- Nicholson DT, Chalk C, Funnell WRJ, Daniel SJ. Can virtual reality improve anatomy education? A randomised controlled study of a computer-generated three-dimensional anatomical ear model. Medical Education. November 1, 2006;40(11):1081-1087. doi:10.1111/j.1365-2929.2006.02611.x. PMID: 17054617.
- James KH, Humphrey GK, Vilis T, Corrie B, Baddour R, Goodale MA. “Active” and “passive” learning of three-dimensional object structure within an immersive virtual reality environment. Behavior Research Methods, Instruments, & Computers. August 1, 2002;34(3):383-390. doi:10.3758/BF03195466. PMID: 12395554.
- Zhao YC, Kennedy G, Yukawa K, Pyman B, O’Leary S. Improving Temporal Bone Dissection Using Self-Directed Virtual Reality Simulation Results of a Randomized Blinded Control Trial. Otolaryngology — Head and Neck Surgery. March 1, 2011;144(3):357-364. doi:10.1177/0194599810391624. PMID: 21493196.
- Jonassen D, Land S. Theoretical Foundations of Learning Environments. Routledge; March 22, 2012.
- Lepper MR. Motivational Considerations in the Study of Instruction. Cognition and Instruction. 1988;5(4):289-309.
- Johnson L, Adams S, Cummins M. The NMC horizon report: 2012 higher education edition. Austin, Texas; 2012.
- Lujan HL, DiCarlo SE. Too much teaching, not enough learning: what is the solution?. Advances in Physiology Education. March 1, 2006;30(1):17-22. doi:10.1152/advan.00061.2005. PMID: 16481604.
- Wiecha J, Heyden R, Sternthal E, Merialdi M. Learning in a Virtual World: Experience With Using Second Life for Medical Education. J Med Internet Res. January 23, 2010;12(1). doi:10.2196/jmir.1337. PMCID: PMC2821584. PMID: 20097652.
- Papadopoulos L, Pentzou A-E, Louloudiadis K, Tsiatsos T-K. Design and Evaluation of a Simulation for Pediatric Dentistry in Virtual Worlds. J Med Internet Res. October 29, 2013;15(10). doi:10.2196/jmir.2651. PMCID: PMC3841347. PMID: 24168820.
- Buttussi F, Pellis T, Cabas Vidani A, Pausler D, Carchietti E, Chittaro L. Evaluation of a 3D serious game for advanced life support retraining. Int J Med Inform. September 2013;82(9):798-809. doi:10.1016/j.ijmedinf.2013.05.007. PMID: 23763908.
- Graafland M, Schraagen JM, Schijven MP. Systematic review of serious games for medical education and surgical skills training. Br J Surg. October 2012;99(10):1322-1330. doi:10.1002/bjs.8819. PMID: 22961509.
- Yang B, Zhao X, Ou Y, Zhang J, Li Q, Liu Z. Design and implementation of virtual reality software with psychological treatment for drug-dependent patients. Sheng Wu Yi Xue Gong Cheng Xue Za Zhi. December 2012;29(6):1174-1177. PMID: 23469551.
- Diehl LA, Souza RM, Alves JB, et al. InsuOnline, a Serious Game to Teach Insulin Therapy to Primary Care Physicians: Design of the Game and a Randomized Controlled Trial for Educational Validation. JMIR Research Protocols. January 21, 2013;2(1):e5. doi:10.2196/resprot.2431. PMCID: PMC3628160. PMID: 23612462.
- Miller J. Tacoma Community College. Evergreen Island Second Life. Games & Simulation for Healthcare. 2014.
- Gorbanev I, Agudelo-Londoño S, González RA, et al. A systematic review of serious games in medical education: quality of evidence and pedagogical strategy. Med Educ Online. February 19, 2018;23(1). doi:10.1080/10872981.2018.1438718. PMCID: PMC5827764. PMID: 29457760.
- Ribeiro C, Antunes T, Monteiro M, Pereira J. Serious Games in Formal Medical Education: An Experimental Study. In: 2013 5th International Conference on Games and Virtual Worlds for Serious Applications (VS-GAMES). Vol ; 2013:1-8. doi:10.1109/VS-GAMES.2013.6624240. PMCID: PMC6423463. PMID: 30835239.
- Bandura A. Social Foundations of Thought and Action : A Social Cognitive Theory.. Englewood Cliffs, NJ: Prentice-Hall; 1986.
- Kreuter MW, Oswald DL, Bull FC, Clark EM. Are Tailored Health Education Materials Always More Effective than Non-Tailored Materials?. Health Educ Res. June 2000;15(3):305-315. PMID: 10977378.
- Dewey J. Experience and education. New York: Macmillan; 1938.
- Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. Vol 1 edition. Englewood Cliffs, N.J: Prentice Hall; October 11, 1983.
- Ryan RM, Deci EL. Self-Determination Theory and the Facilitation of Intrinsic Motivation, Social Development, and Well-Being. Am Psychol. January 2000;55(1):68-78. PMID: 11392867.
- Sweller J. Cognitive Load During Problem Solving: Effects on Learning. Cognitive Science. April 1, 1988;12(2):257-285. doi:10.1207/s15516709cog1202_4.
- Redmond B. Self-Efficacy Theory: Do I Think That I Can Succeed in My Work. Work Attitudes and Motivation. 2010.
- Myers IB, McCaulley MH, Quenk NL, Hammer AL. MBTI Manual: A Guide to the Development and Use of the Myers-Briggs Type Indicator, 3rd Edition. Vol 3rd edition. Palo Alto, Calif: Consulting Psychologists Press; 1998.
- Becker K. Games and Learning Styles. ResearchGate. January 1, 2005;2005.
- Vitaliano PP, Russo J, Carr JE, Maiuro RD, Becker J. The Ways of Coping Checklist: Revision and Psychometric Properties. Multivariate Behavioral Research. January 1, 1985;20(1):3-26. doi:10.1207/s15327906mbr2001_1. PMID: 26776273.
- Carver CS. You want to measure coping but your protocol’ too long: Consider the brief cope. Int J Behav Med. March 1, 1997;4(1):92. doi:10.1207/s15327558ijbm0401_6.
- Schiller JH, Stansfield RB, Belmonte DC, et al. Medical Students’ Use of Different Coping Strategies and Relationship With Academic Performance in Preclinical and Clinical Years. Teaching and Learning in Medicine. January 2, 2018;30(1):15-21. doi:10.1080/10401334.2017.1347046. PMID: 28753049.
- Roberts C, Stark P. Readiness for Self-Directed Change in Professional Behaviours: Factorial Validation of the Self-Reflection and Insight Scale. Med Educ. November 2008;42(11):1054-1063. doi:10.1111/j.1365-2923.2008.03156.x. PMID: 19141007.
- Grant AM, Franklin J, Langford P. The Self-Reflection and Insight Scale: A new measure of private self-consciousness. Social Behavior and Personality. January 12, 2002;30(8):821-836. doi:10.2224/sbp.2002.30.8.821.
- Bauman EBR PhD. Game-Based Teaching and Simulation in Nursing and Health Care. Vol 1 edition. New York: Springer Publishing Company; July 27, 2012.
- Olusegun Agboola Sogunro. Efficacy of role‐playing pedagogy in training leaders: some reflections. Journal of Mgmt Development. April 1, 2004;23(4):355-371. doi:10.1108/02621710410529802.
- Meyers C, Jones TB. Promoting Active Learning. Strategies for the College Classroom.. Jossey-Bass Inc., Publishers, 350 Sansome Street, San Francisco, CA 94104 ($24.95).; 1993.
- Comer SK. Patient care simulations: role playing to enhance clinical understanding. Nurs Educ Perspect. December 2005;26(6):357-361. PMID: 16430003.
- Mariais C, Michau F, Pernin J-P. The use of Game Principles in the Design of Learning RolePlaying Game Scenarios. In: ECGBL2009- 4th European Conference on Games-Based Learning: ECGBL 2009. Vol Academic Conferences Limited; 2010.
- Lee B, Yanicki S, Solowoniuk J. Value of a health behavior change reflection assignment for health promotion learning. Education for health (Abingdon, England). August 1, 2011;24:509.
- Kuehlein T, Goetz K, Laux G, Gutscher A, Szecsenyi J, Joos S. Antibiotics in Urinary-Tract Infections. Sustained Change in Prescribing Habits by Practice Test and Self-Reflection: A Mixed Methods before-after Study. BMJ Qual Saf. June 2011;20(6):522-526. doi:10.1136/bmjqs.2010.047357. PMID: 21262789.
- Schon DA. The Reflective Practitioner: How Professionals Think In Action. Vol 1 edition. New York: Basic Books; September 23, 1984.
- Longman CS, Lavric A, Munteanu C, Monsell S. Attentional inertia and delayed orienting of spatial attention in task-switching. J Exp Psychol Hum Percept Perform. August 2014;40(4):1580-1602. doi:10.1037/a0036552. PMID: 24842065.
- Iqbal ST, Horvitz E. Disruption and Recovery of Computing Tasks: Field Study, Analysis, and Directions. In: Proceedings of the SIGCHI Conference on Human Factors in Computing Systems. Vol CHI ’07. New York, NY, USA: ACM; 2007:677–686. doi:10.1145/1240624.1240730.
- Malone TW. Toward a Theory of Intrinsically Motivating Instruction*. Cognitive Science. October 1, 1981;5(4):333-369. doi:10.1207/s15516709cog0504_2.
- Ryan RM, Deci EL. Intrinsic and Extrinsic Motivations: Classic Definitions and New Directions. Contemporary Educational Psychology. January 1, 2000;25(1):54-67. doi:10.1006/ceps.1999.1020. PMID: 10620381.
- Csikszentmihalyi M. Flow: The Psychology of Optimal Experience. Vol 1 edition. HarperCollins e-books; August 18, 2008.
- Schmidt, J.A. Flow in Education. In: In: Peterson P, Baker E, McGaw B, editors. International Encyclopedia of Education, Third Edition. Vol 3 edition. Oxford: Elsevier Science; 2010.
- Murphy C, Chertoff D, Guerrero M, Moffitt K. Design Better Games! Flow, Motivation, & Fun. In: In: Hussain TS, Coleman SL, editors. Design and Development of Training Games: Practical Guidelines from a Multidisciplinary Perspective. Vol 1 edition. New York, NY: Cambridge University Press; 2014.
- Sharek D. The Influence of Flow in the Measure of Engagement. February 19, 2010.
- Bereiter C, Scardamalia M. Cognition and Curriculum. New York; Toronto; New York: Macmillan Pub. Co. ; Maxwell Macmillan Canada ; Maxwell Macmillan International; 1992.
- Haji FA. Advancing Theory in Healthcare Simulation Instructional Design: The Effect of Task Complexity on Novice Learning and Cognitive Load. November 2015.
- Fraser KL, Ayres P, Sweller J. Cognitive Load Theory for the Design of Medical Simulations. Simul Healthc. October 2015;10(5):295-307. doi:10.1097/SIH.0000000000000097. PMID: 26154251.
Our Formative Research with Medical Students Informed Lift Development
In Phase I development of Lift, we completed an extensive critical review of the research literature about burnout in medical students and the most effective interventions (See Lift’s Blogs). From this literature review, we planned a curriculum, and started developing the simulation and cases as interventions, testing them iteratively with the target audience for usability, preferences, and later, effectiveness. We responded to each round of testing by improving the prototype until scores on quantitative evaluations were in a satisfactory range on a Likert agreement scale (4 out of 5) for positive evaluations of the experience. Read a Formative Research Summary to learn about medical student needs and preferences that were identified in this testing.
Summary of Summative Evaluation of Lift Role Playing Simulation for Medical Students
The summative evaluation of this intervention for medical students was completed in May-June 2022. 63 medical students completed the evaluation. The results are summarized in the following image: