By Sara Wykes
Photography by Colin Clark
Jack was sinking fast, his vital signs registering alarming numbers. With every passing second, his doctor, Charles Prober, could see his patient being overwhelmed by sepsis, a deadly complication of infection that plagues hospitals worldwide.
“Jack is the hardest patient,” counsels Prober’s colleague, Lisa Shieh, MD, PhD, the medical director of quality in the Department of Medicine at Stanford Hospital & Clinics. “Give him some fluids.”
Prober, MD, the senior associate dean for education and a professor of pediatrics and of microbiology and immunology at the School of Medicine, clicks in the order. A small group of watching physicians clapped in appreciation as Jack’s health almost immediately improved.
“Has he had his blood cultured yet?” asks Shieh. Prober takes the cue. Then he turns to another patient ailing from sepsis. Just as he finishes ordering fluids for that one, his colleagues shout, in alarmed voices, “Jack, Jack!” — the first patient’s previous gains were rapidly evaporating. “Ah, that’s one thing we want to teach,” Shieh says. “You can’t just give fluids and walk away.”
Prober responds quickly, transferring Jack to the intensive care unit and setting up a surgical procedure to remove infected tissue in Jack’s leg, among other steps. Jack’s status zooms to complete health: Prober is awarded 500 points.
Prober has scored well on a test run of a first-of-its-kind, medical computer game called Septris (named after the popular game Tetris). The idea is to tap into the power of games — an increasingly popular technique, called gamification — to improve clinicians’ skills at recognizing and treating sepsis. Created by Shieh and a team of Stanford physicians, researchers and education technology experts, the game can be played on a mobile phone, a tablet such as an iPad, a laptop or desktop computer.
‘Sepsis is one of those conditions you hear about in med school, but you need to see more of it.’
In real life, sepsis begins as a bacterial infection at a single source, which, if uncontrolled, spreads to become a systemic attack on the body’s kidneys, liver, lungs and central nervous system. It presents as simple sepsis, then moves to severe sepsis and, finally, to septic shock. It can run its entire course within hours. Unless it’s stopped at its earliest stage, sepsis can claim one life in every two it invades. More than 200,000 Americans died last year of sepsis. In the last year, the cost of care for the disease amounted to $2 billion in the United States.
“Sepsis is one of those conditions you hear about in med school, but you need to see more of it,” says Shieh, a clinical associate professor of medicine and director of the group that developed Septris — the Stanford Hospital sepsis performance improvement team. “In some cases, it’s straightforward, and in some cases, it’s not. It takes a lot of clinical sense.”
The game begins with the cartoon image of two patients on the left side of the screen. On the right side are their vital signs. Along the bottom of the screen are diagnostic tests and treatment options. As every second passes, the patients’ images sink down the screen, their vitals deteriorating. It takes less than two minutes for a Septris patient to die, which means decisions must be made quickly. The game’s objective is not just to keep the patients alive, but to cure them.
Coexisting chronic conditions complicate diagnosis of sepsis: They can make a patient more vulnerable to sepsis, but also distract a doctor from identifying it. “Everybody needs to have at least the Septris level of sepsis knowledge,” says Norman Rizk, MD, medical director of the hospital’s intensive care units and professor of pulmonary and critical care medicine. “This simple training tool begins to establish essential knowledge.”
Septris is the result of a $30,000 grant from the medical school’s continuing medical education program to develop a more effective way to teach how to treat sepsis. The team first considered a lecture or workshop format, the typical formats for CME courses. But by the team’s second meeting, people were looking at their phones and losing interest, says Eileen Pummer, RN, a quality manager at Stanford Hospital and the team’s co-director. “I thought, ‘Oh, no, this is falling apart already.’ Then Matt Strehlow said something to the effect of, ‘How about a mobile app? People are always on their phones.’ The energy just turned completely around, and we started brainstorming from there.”
Photo by Colin Clark
Strehlow, MD, is a clinical assistant professor of surgery and an emergency medicine physician. He is also the assistant medical director of the hospital’s emergency medicine department, with a special interest in educational technology and in sepsis. Strehlow is so addicted to computer games that he doesn’t have any on his phone or at home to avoid the disruption it would cause to his life. He’s very aware of the popularity of computer games and of how many medical students and young physicians use their iPhones and iPads as knowledge support tools. During a postdoctoral study in India, Strehlow tested the teaching power of gaming against more traditional simulation methods and reading. In initial comparisons, the simulator-learners performed better than did the gamers. Three months later, however, he retested the group and found the gamers ahead on skills. “They’d been going back into the lab to play the game,” he says.
The clinicians brought the idea to educational technology manager Brian Tobin and instructional technologist Jamie Tsui in the medical school’s Office of Information Resources & Technology. While the team had solid content — best practices and guidelines based on medical literature — there were different questions to be answered for a game format. One of the biggest, Tsui says, was whether to allow the game patients to die. “Players had to be allowed to fail, but also to have a chance to fix their mistakes,” he says. So, patients die once and then reappear with the same symptoms, thus providing the opportunity for knowledge acquired by failure to be applied with success the second time through. The designers also limited the number of patients in play at a time to two, though Tsui noted that more could be added in the future if users are “up for that higher level of play.”
The goal was to keep fun in the experience, despite the gravity of the topic. “You want to let the learner create and play, and you want to offer them choices,” says Tobin, who’s now acting director of educational technology. “It also has to be suitably hard enough so that not anybody can get right through it.”
“At first, we made it way too hard and patients were dying too fast,” Strehlow says. That first version had eight patients on screen at the same time. The group tested the game on several groups of physicians to work out the combination of symptoms and timing that would be challenging without being impossible to beat. There’s also a classic trick: At least one of the patients doesn’t have sepsis, Strehlow says.
They adjusted the speed of the game to accommodate clinicians who “like to take their time reading test results versus those who work very quickly,” Tsui says. They did not include images of CT scans or X-rays, however. “That added a layer of complexity to a game we wanted to keep as simple as possible,” he says.
“We wanted to build something that would work across all platforms,” says Tobin, “whether someone is using a handheld with a touchscreen, or a computer, where you can just click a link and the game displays right then and there.”
The Septris team had to make medical decisions, too. In real life, some antibiotics work better in combination with others; the game awards points if a player understands the possible positive or negative effects of those combinations. They also wanted to reward players with more than points for making good choices. When a good choice is made, a pop-up appears with words of praise and wisdom from “Dr. Sepsis,” whose knowledge-reinforcing tips are meant to be like those from an attending physician to a less experienced physician. The game’s tips section has links to medical journal articles that back up the practice guidelines Septris teaches.
The game is not without a bit of subterranean Stanford medical community humor. The cartoon figure of Dr. Sepsis looks a lot like Rizk, the ICU chief and senior associate dean for clinical affairs. And the pretend patients are quite reminiscent of some other Stanford physicians.
The Septris team knows that some people are uncomfortable with using a game to teach such a serious subject. Even some computer gaming fans were a bit troubled by it. “The comment was that there’s something about the word ‘game’ that doesn’t feel like the right fit when you’re thinking about treating patients,” says Clarence Braddock, MD, associate dean for undergraduate and graduate medical education and a professor of medicine.
But Septris is not conceptually different from the modes of simulation now being used at Stanford and other medical schools to train physicians. “What you’re talking about are ways to activate a learner’s mind to engage and connect,” Braddock says. “You’re trying to mimic the cognitive pressures and drilling around the application of concepts to clinical problems.”
In fact, the team members think the approach could teach many medical topics: This summer they’ll start working with Stanford surgeons to use the same platform to teach about surgery cases.
Braddock and other medical school educators plan to study the game’s effectivenesss. The first large-scale group of subjects will be this summer’s incoming interns.
Already, though, the game has one benefit: People like playing it. Since its release this winter, it’s been played 10,000 times and had 14,000 unique visitors from 54 different countries, more than 1,000 each from Brazil and Australia. Charlie, the patient who’s easiest to help, has been saved 2,300 times; Jack, who’s the toughest, has died 1,400 times.
Anyone can play Septris: It’s available at http://cme.stanford.edu/septris/, and it’s free. Physicians can earn continuing medical education credits by taking a post-game test.
Interest in the game is still growing. Shieh has been invited to speak about it in July at a world conference on using mobile devices in medicine. Officials at the Wake Forest School of Medicine have also asked Stanford’s School of Medicine to set up a one-week competition between the two. “They said they found the game really intriguing,” Shieh says.
“Septris puts people through an increasingly more realistic and challenging simulation and generates adrenaline by having fun and engaging in it,” Braddock adds. “You’re not thinking of it as learning, but as play, which, from a neurochemical standpoint, is a win-win.”
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Playing Septris is free. It runs best on iPad/iPhone or Android. On a desktop computer, it requires a Firefox, Google Chrome or Apple Safari browser. To start the game and to learn about CME credits that are available upon completion, go to http://cme.stanford.edu/septris The $20 fee for the test for the CME certificate is waived for the first 100 learners.