Changing the Culture of Medicine

Sometimes things come together, sometimes they fall apart, and sometimes those pieces form new things.

My project has taken a number of twists and turns over the past 18 months. It sprang from a series of projects I had been thinking about, motivated by my interest in training resident physicians (I am a residency program director) in the care of patients with chronic childhood-onset diseases. For example, patients with Juvenile Rheumatoid Arthritis (JRA), our model disease for this project, are often diagnosed in the teenage years and can have the disease for their whole lives. They go through adolescence, college, graduate school, dating, playing sports, making family decisions, having children, working a job or developing a career, and all the while their bodies are exposed to inflammation and the toxicity of long-term use of anti-inflammatories and immune suppressive medications. And they need to do all this while navigating through a health care system that is designed to treat children or adults, but not necessarily children who have grown up to be adults. So, physicians haven’t traditionally been trained to work with this patient population as they transition from childhood to adulthood. I was interested in exploring the role that storytelling might play in training residents, and in the role that technology might play, in creating a resource that addressed the issues specific to the care of this population of patients.

In the summer of 2013, I participated in a three-day workshop on Digital Storytelling to explore for myself the potential for using storytelling as a vehicle for professional development and communication. I used audio equipment I had purchased for the project to tell my story, and the production quality was excellent. A few weeks later, when two of my residents decided they wanted to create a Podcast, I loaned the microphone and recorder to them for the project. This helped to confirm for me that the residents themselves can create and contribute material for an online resource.

My project team was thinking about how to structure the project, doing literature searches, and looking for a technology platform that was flexible, collaborative, and easy to use, not to mention  inexpensive. I, in the meantime, learned a new word at one of our Faculty Fellowship meetings: gamification. I’d played games my whole life, and have learned a great deal from them. The idea that game-like experiences could be used to teach college, graduate, and post-graduate students was a completely new idea to me.

This led me to consider the feasibility of creating an interactive simulation of a patient’s progression through the disease and interactions with the medical system. I spent some time exploring game engines that would allow me to create branching stories where the residents’ decisions affected the “patient’s” story, and found some free interactive-fiction story editors that could be used to create simple text-based games.

Ultimately, our team decided to create a curated and catalogued set of tools and resources, organized in a way that makes sense to primary care clinicians. Our preliminary work already has informed several initiatives in the residency program I direct. Specifically, we have created a “living” intranet that is interactive and useful to our residents. This site has been uniformly praised by them, and is now the administrative center of our program (see below).

Intranet overview.


I still plan on fleshing out the idea of a virtual patient that can be “managed” longitudinally. In the meantime, my experiences with gamification have made their way into the residency program that I direct. Specifically, we’ve created a competitive, team-based monthly curriculum with a prize going to the winning team at the end of the academic year. Additionally, we’ve created a set of “choose-your-own-adventure” style cases which force interaction among team members and require them to make decisions. These text-based cases are built with an interactive-fiction story editor called AXMA Story Maker. These games (see example pages below) allow us to use iPads in the team-based setting, and we publish the games on our intranet, so that residents who can’t attend in-person can still learn the topics.

First page of a “choose-your-own-adventure” game. Clicking Hints will bring up the following page.

Here, students chose to get the Sensitivity hint, but it cost the team a point.

We are steadily working toward our main goal: to create an online repository of resources for the care of patients with childhood-onset conditions. As part of this, we have plans to create resident-generated podcasts, and we are working on a series of branching virtual patient cases. The Fellowship experience of using stories, gamification, audio and video tools, and web technology to drive innovation in education has changed how we approach resident training in the Med-Peds program. I’ve incorporated the lessons and technologies that I experienced in the Faculty Fellowship Program into the residency program.