These data provide insight into medical student attitudes towards various instructional styles and methods, and towards the role that serious games and related new media technologies could play in enhancing medical education. They also reveal some important differences with regard to gender and characteristics of video games.
While students reported a variety of favorite game genres, the most popular were puzzle, strategy, and role-playing games. This result suggests that students may have an affinity for cognitively challenging games. Role-playing games may have special educational utility to help students envision what their life would be like in different types of professional practice. Allowing students to step into the shoes of practitioners in different specialties, healthcare settings and economic systems, in an immersive and authentic way, could help to prospectively inform their decisions regarding which career choices would be the best fit with their values and personal characteristics[30, 31].
It is important to recognize that favorite game genres can also be blended together in the creation of serious games for medical education. Very challenging abstract concepts--for example, how the nephron works or how a patient-centered medical professional works--can be made amenable to reification through hybrid systems drawn from any number of game-related new media technologies.
Serious Game Design
Independent of genre, the design imperative of any serious medical game is that it should both teach and be fun . Some might question whether medical teaching can simultaneously be fun and still convey the appropriate degree of gravitas. However, consider the argument of media expert Marshal McLuhan:
"It's misleading to suppose there's any basic difference between education and entertainment. This distinction merely relieves people of the responsibility of looking into the matter. It's like setting up a distinction between didactic and lyric poetry, on the grounds that one teaches, the other pleases. However, it's always been true that whatever pleases teaches more effectively.".
Perhaps the most compelling testimony to "fun" as an indispensible quality of serious games comes from the failure of "Arden: The World of William Shakespeare," a multiplayer game designed to teach students about Elizabethan England while serving as a place for social-science experiments. According to the game's creator, Arden was scuttled a week after its much-heralded release principally because "It's not fun."[34–36]. That fully 97% of respondents chose "fun" as the quality that would most interest them in a multiplayer online healthcare simulation further supports this argument.
Games, Genres and Gender
According to the Pew Internet & American Life Project, a majority of American adults age 18 and older (53%) play video games, and men (55%) are slightly more likely than women (50%) to play a digital game. The fact that more males than females play video games is also supported by other research. Our data shows that 53% of respondents play video games, but there is a far more pronounced male-female difference, with males being 4.4 times more likely than females to play video games. This may represent a distinct feature of the medical student demographic and should be explored further in future research.
Within the group of medical students who identified themselves as playing games, the strong female preference was for puzzle games. Other favored games also showed a male-female rift that was the greatest with respect to first person shooters and narrowed progressively for strategy games, sports games and role-playing games. In part, these data may be a function of neural sex differences between men and women. For example, males are better at such tasks as mental rotation of three-dimensional objects, navigation through a route or maze, and target-directed motor skills (such as guiding or intercepting projectiles). Females are better at landmark memory (remembering details of objects seen along a route), object displacement (identifying if an object is missing or has been moved), and perceptual speed (rapidly identifying matching items based on visual cues). In puzzle games, the primary objective is figuring out a solution, which often involves solving enigmas, navigation, learning how to use different tools, and the manipulating or reconfiguring of objects[40, 41]. Thus, it would appear that females gravitate away from games that are biased towards male cognitive strengths, such as first person shooter games, but that they are drawn to games that allow them to exercise control and elicit gratification through an optimal challenge based on their own cognitive strengths. It is also possible that female game play predilections may stem from an aversion to games that are sexualized, or games that feature violence, which is often the case with first person shooters.
Whereas both men and women enjoy video games that challenge them, women prefer games emphasizing personal challenge, whereas men are more motivated by competition. This conforms to our finding that females were about 35% as likely as males to enjoy the competitive aspects of the video games. One might expect that women self-selected for the rigors of medical training would somehow be different, perhaps more inured to competition than women at large. The fact that this does not appear to be the case may explain the high prevalence of stress and depression among women as compared with men in medical school, and the high negative impact on Health Related Quality of Life scores exhibited by female students transitioning into clinical training[43–46].
It is heartening to note that one of the features that students would like to have situated into digital domains is skill and comfort in patient interactions. This is the foundation of ethical and professional medical practice. Fortunately, these educational needs align perfectly with current technological capabilities. MMOGs combine several new media technologies that provide sophisticated educational capabilities to help students master communication skills and professionalism through first-person experience. In "Tactical Iraqi" and "Darwars Ambush," the U.S. military employed these capabilities to train "non-kinetic engagement," helping soldiers who are deployed to hostile and culturally unfamiliar areas to become better thinkers and communicators while under stress."[47, 48]. One sees here a compelling similarity to medical practice, where physicians' professional skills are regularly tested as they venture into culturally unfamiliar and high-stress, high-stakes situations. Medically themed MMOGs may have similar training utility for medical students.
Medical Education Game Development
Our data indicate that medical students, overall, are interested in serious games and MMOs as pedagogical vehicles and specifically as epistemic constructs to help them develop ethical and professional ways of knowing, being, acting and interacting in the medical community. This information is heartening in view of both recent calls for higher quality medical education and the known difficulties that educators face in imparting ethical and professional values to medical students[49–52]. Blended learning that incorporates new media technologies with traditional approaches, e.g., didactic, small group discussions or standardized patients, can help overcome the limitations of traditional teaching environments and help meet this critical mandate.
However, the task of innovating change falls to mainstream groups of medical education policy makers who are generationally distanced from game-based and other new media technologies[53, 54]. They may find fortitude by recognizing that Millennial students are very education-oriented, and that their bent towards digital media, interactivity, social environments, and hands-on, experiential learning actually offers medical educators a fantastic opportunity to create new, more powerful educational paradigms than ever before possible. Our data further demonstrate that some medical students wish to participate in this creative process. Encouraging this inclination through a combination of institutional will and financial support will not only help to train today's learners, but will also cultivate tomorrow's medical educators.
As a non-random sample, it is possible that students who participated were self-selected individuals with an interest in gaming and new media; so the extent these data can be extrapolated to other medical students is uncertain. Since the survey was conducted near the end of the academic year, we do not know how many students received the invitation, as seniors may have already graduated, and others may have left for the summer. Thus, calculating an accurate response rate is difficult. As both host universities are research-focused, the respondents might have heightened interest in research and academics. Even considering these limitations, the results describe attitudes about new media in medical education for a substantial number of medical students.
Duplicating this work with medical students in other settings and countries is needed to determine if our findings generalize to a larger, more ethnically and culturally diverse medical student group. It would also be interesting to further break out game preferences according to platform (e.g., PC, console, handheld), and to correlate game attitudes and preferences with academic/clinical performance and career choice. Also useful would be to expand the inquiry to see whether games (such as MMOGs) that include social dimensions have an effect on stress and/or health-related quality of life, and if they can build social capital in medical student communities. As serious medical games (not merely simulations) are developed, it will be important to see how they correlate with current "gold standard" educational methods, and whether they are capable of creating shifts in perspective that affect how students regard and process educational experiences. Finally, further investigation into gender and game play may provide additional, important insights into women's experiences in medicine.