Sunday, December 21, 2014


Sometime things take you by surprise. And like embers glowing steadily the logic and thought ignite the spark into a fire. That is exactly what happened when I read this article from the British Medical Journal about Gamification of Graduate Medical Education (1).

I thought well, this seems like a nice idea to enhance education. I read the article and came away with a different impression than was sought by the Authors. “We named our software Kaizen-Internal Medicine (Kaizen-IM). Kaizen, a Japanese word from the quality improvement literature, signifies the need for continuous daily advancement, a concept analogous to the principle of lifelong learning we seek to inculcate in our residents.” Whereas they sought to prove that a Kaizen-IM modelling technique helped ensure educational learning, reading through the article I came away with the tortured use of statistics to prove what they set out to prove. “Analyses focused on acceptance, use, determination of factors associated with loss of players (attrition) and retention of knowledge. Because traditional tests of normality such as the Kolmogorov–Smirnov test, the Anderson–Darling test and the Shapiro–Wilk test are subject to low power, particularly when the sample size is small, continuous outcome measures were graphically assessed for normality by investigating the distributional form of the outcomes using histograms. When normality assumptions were not met, the appropriate rank-based Wilcoxon test was used.”

But here is where it struck a chord and the tumbled notes all fell in a crash of dissonance. “We used the conceptual frameworks of user-centered design and situational relevance to achieve meaningful gamification, including connecting with users in multiple ways and aligning our ‘game’ with our residents’ backgrounds and interests in furthering their education.”

Now why would that bother my internals? Learning by rote in medicine is akin to getting ready for a Multiple Choice Q and A. Now hold on, you power-jockeys of the esteemed elite schools! Think about Medicine as a holistic mechanism for caring for the patient, not as a yes and no binary form of interaction. I need a new paragraph to start that thought, so hold on…

The sheet of paper in front of you has many inked marks on it as the proctor tells you “Start!” And away you go answering all the questions within the bounds of the allotted time. Some, you skip and some you hesitantly answer “C” as a hedge against the limited information in your brain. By the time you are done, the mental exhaustion is replete with multiple rivulets of sweat pouring down your back. You pass your answer sheet back to the examiner and with one last look back at it, you figure, Okay that’s done! Three months later you get a passing grade and you go celebrating till the wee hours of the morning. Loaded with congratulations, inebriated from the slaps on your back and feeling immune to the vicissitudes of mortal life. Ah yes, another conquered!

But then you enter the hospital and there lies a frail, weakened human body, a shadow of its formal self as you can see the skin has since loosened off and hanging on the bones with very little musculature support. “What the…?” your words escape between your teeth. The breath from this shadow comes in slow uneasy cadence, yes there is life but it is struggling to maintain its domain within his shell. There is an odor that you have never encountered before. It isn't obnoxious or anything, just a mousey, old cat litter type, wafting through your senses. His eyes open and the whites of the eyes are patchwork of miniature blood vessels and a hazy dull yellow background affixed onto an equally weak sallow complexion as deep pits on a desert floor. There are some spotty blood marks on his arms that lie above the clean white sheets of his recently made bed. His utterances are feeble and devoid of meaning when you ask him questions. He does nod in affirmance and shakes his head slowly in the negative. Suddenly overcome with the complexity of his person, you open his hospital chart and gaze through the lab reports and his diagnostic x-rays. Ah! You think, here it is, the answers to the riddle. This man has “such and such” and with “Mr. So and So, we will get to the bottom of this,” you stride out of the room as fast as you can only to find that the same tests had been done in this gentleman’s previous admission. Now what?

And there fellow journeyman, reader of these words, lies the problem with gamification of medical education. Our entirety of purpose is not in the hospital rooms, but in the confines of the computer glows where we search for meanings, not in the operating theaters but in the virtual operations conducted within the binary logic of a computer console, not with a patient-understanding the look and feel of a disease but in the memory bank tied to a CPU, where a differential diagnosis is within reach and Sutton’s Law is practiced for the ideals of human care to safeguard finance and limit the use of limited resources. When all you need to do is spend that extra moment in spending with the ones with the ill health and recognize through expediency of critical thinking what the problems are and which ones to fix now and those that can be fixed later. It would limit running through the myriads of differential diagnostics (that cost an arm and a leg and in many cases literally) and it would put the resources to better use.

So here we are stuck in the conundrum of do little to save the limited resources but use the tools that expand their use.

Time to rethink!

Time to reevaluate!

And maybe if we do, we will find the answer that is obvious and time-honored…Spend the time with the flesh not with the automated binary logic. Understand the human body and not the logic of a multiple choice. Draft a memory of experiences that will recognize disease and help patients rather than harming them with a “House MD” type approach of “biopsy the brain” when fifty other things yield negative results in a span of one hour.

And about that EMR, there is nothing meaningful about it, except more population-based algorithms!

No, medicine is and will be for the near future be practiced with an art due in part to the humanness of humans and in part to the connectivity between us humans. A discordant approach between the mind-body and clicks leads to de-coherence, which is futile in healing the sick!

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