I like video games, but they're really violent. I'd like to play a video game where you help the people who were shot in all the other games. It'd be called ‘Really Busy Hospital’
– Demetri Martin

What’s in a Game?

When I was a kid, my friends and I would seclude ourselves in the basement of my house and stay up into the late hours of the night playing video games. I’m talking about the classics: Zelda, Final Fantasy, Mario Kart, GoldenEye 007, and other greats. I distinctly recall my mom yelling down to the basement saying, “Those video games will rot your brain…don’t stay up too late.” Fat chance.

OK.  So, perhaps it wasn’t the healthiest thing to stay up all night guzzling liters of Coke with our eyes glued to the television. I accept the argument that our time might have been spent in a more productive manner. But, would video games really rot my brain? I don’t think so. In fact, there is evidence to the contrary.

As it turns out, a great deal of science has gone into the development, design, and construction of various gaming platforms. There is a substantial amount of psychology, cognitive science, and performance theory that goes into building a great game.¹ The thriving gaming industry has taught us a lot about how our brains work and interact with electronic media.^2-8 For example, Daphne Bavelier, a cognitive neuroscientist at the University of Geneva, has demonstrated even popular ideas about the detrimental effects of video games such as “too much time staring at a screen is detrimental to one’s vision” or “video games cause decreased attention and focus” are simply incorrect. The effect of games on various sensory cortices and cognitive mechanism is quite the opposite. Her research demonstrates gamers demonstrate increased visual acuity and enhanced ability to focus (see her TED Talk for more).

Perhaps what’s most interesting is that we can now apply what we’ve learned from the gaming industry to improve health. The application of game mechanics can be used to help fan the flames of intrinsic motivation and engage people using digital media. This process has been dubbed “gamification”.⁹ Some psychologists and computer scientists have been able to gamify^10,11,12 forms of cognitive behavioral therapy and positive psychology to augment the clinical treatment of anxiety and depression^13-19 as well prevent cognitive decline in adults.^20,21 Although more rigorous academic exploration of these modalities is needed, preliminary investigations are promising and show benefit.

But what about less purposefully “gameful” things, like the aspect of Free Open Access Medical Education (FOAM) that utilizes online social media? It is not normally thought of as a game, per se. However, as it has evolved, it seems to meet many of the criteria for what designers consider a game to be. How people interact with FOAM adheres to the  psychological framework of what make games pleasurable, stimulating, and attractive. I submit that social media, in general, and FOAM, in particular, adhere to proposed psychological constructs of games, which may explain their popularity and effectiveness at sharing medical information.

Getting SuperBetter

Jane McGonigal is all about games. She has a PhD in performance science from the University of California at Berkley and has been doggedly studying the science of games since 2001. In fact, her thesis work focused on the psychological strengths of gamers and how some of these qualities could be translated to help solve problems in the real world. She is also the author of two New York Times best-selling books: Reality is Broken²² and SuperBetter.²³ Her passion is bringing together different findings from psychology, cognitive science, sociology, economics, and political science to improve game design. Her goal is not simply to make better games, but to make games better for you.

In 2009, McGonigal experienced a head injury that left her with bothersome and relatively debilitating symptoms. She was unable to function at work as she was always confused, had difficulty articulating her thoughts, could not focus her attention, and was always (as she described) in a “mental fog”²². Constantly plagued by headaches, nausea, and vertigo she sought medical attention. But, as she learned, treatment options for postconcussive syndrome were limited and dealing with the long, slow road to recovery was difficult and depressing.

In an inspiring turn of events, McGonigal decided it was time for her to win back some semblance of control and normalcy. So, she turned to what she knew best: games. She knew, from her research, that dealing with challenges often helped people grow, develop resilience, and build coping skills that helped them lead happier lives. McGonigal realized that a number of cognitive behavioral skills that correlated with the concept of post-traumatic growth^24-29 were also ways that she discovered individuals think and act when they are playing challenging games.^30,31,32 She took seven of these evidence-based skills and came up with gaming correlates. Using these seven “rules” she developed a game she called SuperBetter²² which played an integral role in her recovery.

1. Adopt a challenge mindset —> Challenge yourself: actively pursue anything that provokes your desire to test your strengths and abilities. Accept any opportunity to take on adversity to further develop these abilities.
2. Seek out whatever makes you stronger and happier —> Collect and activate “power-ups”: identify and complete simple actions that create moments of pleasure, strength, courage or connection. Doing these little things can elevate mood, stimulate positive emotions and increase motivation.
3. Strive for psychological flexibility —> Find and battle bad guys: recognize the major hurdles and antagonists that prevent you from reaching your goals. Cultivate healthy strategies for dealing with these people, places, or things and don’t let them stop you from progressing to your goals.
4. Take committed action —> Seek out and complete quests: engage in long-term, longitudinal committed action toward achieving major life goals.
5. Cultivate connectedness —> Recruit your allies: build a network of colleagues, friends and family that you can speak to honesty about your stresses, fears, hopes, and dreams. Ensure the people in the network can be reliably called upon to help you serious problems.
6. Find the heroic story (times you’ve been strong/successful) —> Adopt a secret identity: Focus on your signature character strengths, the heroic qualities that form the cornerstone of your character. Draw on these strengths to address challenges and in times of difficulty.
7. Learn the skill of “benefit finding” —> Go for epic wins: Take on reasonable, calculated risks that can result in awe-inspiring outcome and help you become more motivated as well as less afraid of failure.

McGonigal attributes her recovery (in a large part) to the development and application of SuperBetter. She makes it very clear that the gamification of healing and recovery is not a substitute for seeking clinical care, but it can often supplement conventional treatments. To date, anecdotal reports from people around the world suggests SuperBetter has been helpful for patients.²³   An investigation into the use of a SuperBetter smartphone application at the University of Pennsylvania suggests that it can reduce subjective symptoms of anxiety and depression.¹⁸ However, these results should be interpreted with caution given methodological issues (small sample size, self-reporting, demographics not generalizable, and significant participant attrition) and notable conflict of interest (McGonigal is one of the investigators and also the owner of SuperBetter, LLC). A more robust investigation has been completed at Ohio State University with the help of an NIH grant.³³ Their results were submitted in September 2017 and are pending review at this time.

A Game by Any Other Name…

So, what do we really mean when we call something a game? While various definitions exist, there seem to be four fundamental characteristics that define a game:²²

1. A goal – Every game has a particular objective that imbues a sense of purpose. This motivates and drives players. It focuses their attention and provides orientation for their participation.
2. Rules – Rules provide structure for how the goal is to be accomplished. In limiting the ways a participant can achieve the goal, participants are pushed to apply novel, creative techniques. They actually promote ingenuity and foster strategic thinking.
3. A Feedback System – Whether it be points, leveling up, or rank compared to other players, games all have a quantitative or qualitative feedback. This system keeps participants informed of how close they are to achieving a goal or how well they performed once a goal is achieved. The feedback system provides reinforcement and motivation. It shows progress and promotes participants to persist in goal-directed behavior.
4. Voluntary Participation – Participants knowingly and willingly join a game. In so doing, they accept the goals, rules, and feedback system as it exists. They are free to enter or leave a game at will which ensures that any challenging or stressful aspects of the game are experienced in a safe and pleasurable manner.

The Game of FOAM

Thinking about the general ethos, philosophy, and characteristics of FOAM³⁴ reveal that it adheres, albeit somewhat loosely, to these principles of gaming.

It is voluntary.   Producers of FOAM spend their time freely producing material for consumption and distribution. Likewise, patrons read and listen to podcasts at their leisure and of their own volition.

The goal of the FOAM, simply stated, is to disseminate and discuss medical information in a clear, easily accessible, and free manner.

The feedback system is both intrinsic and extrinsic to the content: consumers can provide direct feedback to the authors and the number people reading or downloading material can be analyzed using the website software which supports them. Furthermore, as a strict consumer, you can track what material you’ve listened to or read.

The rules of FOAM are somewhat less defined, but none-the-less present. I would submit that there is an understanding in the FOAM community that the material shared should be truthful. It should contain proper attribution and recognition of the information and ideas presented. As consumers, there is an understanding that feedback and comments should maintain professional decorum. Discussions should be helpful and statements should be kind, made with the intent of furthering understanding through academic discourse and not degrading individuals. Again, while not formally codified, these guiding ethical principles act like the rules of the game.

Less Overt Parallels Between FOAM and Games

Like games, FOAM presents us with distinct challenges. There are all sorts of clinical, logistical, interdepartmental, and interpersonal hurtles to clear in our careers. There are a host of educational challenges as well; the search for better ways of teaching material is never-ending. For the intellectually curious, these challenges require thorough research, creative thinking, and tenacity. Often, finding solutions is not easy, we fail, and it’s necessary to go back to the drawing board. Like the levels or quests in a game, these challenges provide us with discrete obstacles to overcome.

In the struggle to find solutions to healthcare problems, as with many games, we push our intellectual limits and we find enjoyment. As it turns out, when people engage in variety of challenging activities they report high levels of interest and positive mood during and after the activity is complete. These activities, including games and puzzles, are fun. This is true despite any reported “eustress” associated with the activity.³⁵ Interestingly, mood reported after participating in challenging games is higher than after things many consider relaxing such as watching TV or shopping.^36,37 We can even become so happily immersed in pursuit of these challenges that we loose track of time and become joyfully lost in our activities, as in a state of “flow.”^38,39 So, whether you are struggling to conquer the last level of a video game or wrestling with a novel way of presenting clinical information, it can be enthralling and pleasurable.

In the FOAM world, when we uncover solutions to problems, overcome some challenge, develop a novel interpretation of data, debunk a myth, or publish something that provides solutions for others we generally feel good about it. Just like when we win a game of poker or complete a level in a video game, there is a sense of pride and emotional activation. We feel good. In fact, research demonstrates that these triumphs activate the reward circuitry in our brains.⁴⁰ Repeated successful involvement encourages us to keep participating and maintain engagement.^41,42

Some of these challenges are much bigger than we can handle alone. A game, or FOAM, can help us tackle them. Take, for instance, the movement to improve medication packaging and safety. The EZDrugID campaign linked patient safety advocates in Austalia, New Zealand, United Kingdom, United States, and South Africa.⁴³ The campaign has utilized the internet and social media to access a broad audience. Furthermore, its efforts have been promoted by numerous people in the FOAM community. In a sense, EZDrugID acts as a massive multiplayer online game (like World of Warcraft or Halo): motivated clinicians from around the word collaborate and engage in a voluntary, asynchronous movement with the intention of enhancing patient safety. In the gaming world, these missions are often called “epic quests.” This allusion to the mythology and literature deeply engrained in the fabric of our culture calls to mind such adventures as The Odyssey, The Aeneid, or more recently The Hobbit. We are drawn (in a strange, yet-to-be-completely-explained way) to these epic quests. Both games and FOAM help us undertake them.

Games make us part of something larger than ourselves and our self-interests. Service, whether its local volunteer work, military service, or even educating others can give larger meaning to our individual actions and improve our behavior. It leads to happiness and fulfillment.⁴⁴ I would suggest that, in the case of FOAM, developing and spreading educational material that helps the healthcare community provide better, more efficient, or safer medical care is included under this umbrella. Evidence seems to suggest that, even through electronic media, when we do something in service to our community, we feel better about ourselves.⁴⁵ Furthermore, service, even through electronic media, seems to beget altruistic behavioral change. In an interesting multinational, multicenter investigation of more than 3,000 young men and women up to college age, Gentile et al found that participants were more likely to help friends, neighbors, and even strangers in real life when they played games that involved helping other players.⁴⁶

Like games, FOAM can help develop stronger social connectivity. In The Ties That Bind I discussed the concept of Social Capital: the idea that through small, seemingly insignificant interactions (such as liking a tweet, or commenting on a blog), we actually develop social bonds. In fact, just being in the virtual world where people are reading, commenting, posting, and tweeting seems to provide some semblance of ambient sociability.^47,48 Research conducted at Stanford demonstrates that when people are involved in a massive multiplayer game, even if they don’t directly interact with one another, they still consider themselves in virtual company. The researches dubbed this “playing alone together.”⁴⁹ Although it may appear to be a very dilute form of interaction, it can still generate beneficial positive thoughts and feelings.

Learning and the Game of FOAM

Games are more than just past times that provide stimulation and pleasure, they are an integral part of the learning process. In his landmark publication Experiential Learning: Experience as the Source of Learning and Development⁵⁰, David Kolb suggests that learning is essentially our ability to process and acquire abstract concepts such that they can be broadly adapted and applied to a range of situations. What drives learning, Kolb proposes, is experience.

A concrete experience, such as a practical experience, a game, or reading something online, stimulates a cycle of events. After the experience, there is a period of reflection where we step back and review information. This is followed by abstract conceptualization. During this phase of the cycle new information is put into context of what we already know and concepts we understand. The final stage, called active experimentation, is where we plan how we are going to put the new information into action moving forward and even try it out.

So, put in the specific context of FOAM, one might read a blog post or listen to a podcast regarding ketamine for analgesia (concrete experience). They might then go back and review the key points of the blog or podcast, note the references, and reflect on patients they have seen who may have benefited from ketamine (reflective observation). Then, they might think about the underlying physiology: putting the concept of NDMA antagonism within the greater context of neurophysiology and pain. At this point, they might also do a thorough review of the primary literature and talk to experienced clinicians about how, if at all, to safely incorporate this new information into practice (abstract conceptualization). Finally, one could then go on to considering using ketamine in a simulation or actually administering the drug to a patient (active experimentation).

Games might play an important role in medical education beyond learning theory. In fact, many programs are using games to teach medical information and skills.^51,52 Wang et al conducted a systematic review of games in health care training.⁵³ They examined what they called “serious” games: “interactive computer applications…created for the purpose of imparting knowledge or skills, and which incorporate an element of scoring as well as challenging goals and engaging design.” They evaluated 33 publications describing serious games as an intervention for clinical teaching. Of these, 19 studies reported a metric quantifying skills or knowledge gained. Only 2 of these 19 did not report a significant improvement using games. The authors suggested that games were used across many fields to facilitate learning objectives and may be effective at improving clinical skills and knowledge acquisition. The authors note, however, that the concept of implementing games as effective teaching modalities is still in its nascent stage. Best practices remain unclear and many programs are still in developmental or experimental stages.

Limitations

I have suggested that FOAM might meet or adhere to the theoretical architecture of how cognitive psychologists and neuroscientists describe games. Understanding what make games so engaging and how games can facilitate learning may provide clues as to the appeal, popularity, and effectiveness of FOAM. This idea, however, some marked limitations.

The foundation of my argument was that FOAM meets the definition of a game as discussed in the academic literature. By and large this is true. However, FOAM doesn’t fit perfectly within this conceptual framework. For example, unlike games, the definition and goal of FOAM is, perhaps, slightly less rigid and concrete as I have proposed.

As Chris Nickson points out, FOAM may be conceived of differently by different people. Some may see it as means of academic promotion, others may use it to spread new ideas, still others may learn use it strictly as a tool for clinical education.   Another example is that the feedback systems in games (points, “life meters”, etc.) are generally very clear, timely, objective feedback metrics. In the FOAM world they are more variable in quantity and quality. That is, the same people may always like or criticize an author or specific subject material. Furthermore, the feedback can be stretched out over a long period of time. Some comments are posted weeks, months, or years after a work is published. Also, as I mentioned previously, the “rules” that govern FOAM are far from explicit. Even if they were more clearly defined, there is no formal structure for teaching them (like the instructions for a game) or enforcing them.

Even if FOAM did, in fact, more closely meet the definition of a game, the evidence demonstrating the benefits of games in clinical skills and knowledge development is far from definitive.⁵⁴ The evidence surrounding serious games in medicine is evolving and still in its academic infancy. Even in areas where games have been used to successfully provide education or change behavioral patterns, authors have made it clear there are many challenges and pitfalls to gamification.^9,10,11

In addition, there may be more to FOAM than the gaming psychological construct. Chris Nickson makes a note to point out that the knowledge dissemination and learning material of FOAM is built around “an ethos and inspiring community.” Even though games seem to promote social connectivity, perhaps the connectivity functions outside the confines of the gaming architecture.

Finally, games, in and of themselves, are not completely benign. Games can be excessively engaging. In fact, numerous authors have discussed the concept of gaming addiction.^55,56 The distinct possibility exists that the very psychological architecture that makes FOAM attractive could also cause pathology.⁵⁷ In fact, disorders associated with the overuse of social media have been described.⁵⁸ While addiction to FOAM has not yet been formally described in the literature, excessive attention to, use of, and/or production of it could, theoretically, cause problems.

In summary, my intent here is to simply act as an idea broker: to shed light on interesting, unconventional concepts from disparate fields and draw parallels between them. These concepts are not concrete. Rather, they are part of a dynamic hypothesis that may help us better understand how we think and learn. I hope that these thoughts spark discussion and generate further academic exploration.

Conclusion

FOAM appears to follow the structure of serious games as they are discussed in the literature, which may explain the marked success and rapid expansion of FOAM as both an educational modality and global community of individuals. Through blogs and podcasts, as well as other more traditional mechanisms, such as academic publications and formal conferences, it has become stronger and more influential. FOAM lies at the crossroads of electronic media, education, and gaming. Understanding the unique psychology and the cognitive science that emerges at this transformative intersection provides some insight into its development. As it evolves, perhaps we should consider with more intention the nuanced psychological phenomenon that remain at play. Understanding this could lead us to further enhance the way we learn and spread valuable information.

So go ahead…play on.

 Acknowledgements

Special thanks to Chris Nickson (@precordialthump), Daniel Cabrera (@CabreraERDR), and Damian Roland (@Damian_Roland) for their helpful input, insight, and editorial assistance with this post.

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Mike Lauria

Regular Contributor at EMCrit.org

Emergency Medicine Resident
University of New Mexico Health Sciences Center
Former US Air Force Pararescue and Critical Care/Flight Paramedic

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