March 27, 2019

Teaching Observation Medicine Through a Serious Game

The practice of observation medicine by emergency medicine (EM) providers has spiked over recent years. An increasing number of emergency departments (EDs) across the country are adopting clinical models that incorporate observation units. Consequently, it is essential that EM residency graduates receive proper training on best practices when working in this similar, but different, clinical practice setting. While a model longitudinal curriculum for observation medicine was proposed in 2016,1 there is still a paucity of literature that suggests novel pedagogies that can be applied to effectively teach observation medicine to trainees.

Several characteristics specific to observation medicine continue to challenge educators interested in addressing this educational deficit. Critical challenges include:

  1. Not every EM training program is affiliated with an ED that has an observation unit. The opportunity to learn experientially, while physically practicing observation medicine, is limited if a hospital system does not yet have a functional unit. Other mitigating factors may include: only having a handful of observation unit providers in a department, and/or if learners only spend limited amounts of time in the observation unit over the course of their residency training.
  2. Observation medicine is the new kid on the block. The practice of observation medicine is a new type of practice within EM that requires a specific skillset and knowledge base, inclusive of multiple aspects of patient care that cross several EM milestone domains (ie, patient care, medical knowledge, and systems-based practice).
  3. Significant practice variation. Because observation medicine is in its infancy, clinical practices lack standardization. As a result, teaching best practices to residents may pose a challenge to educators.

To address this challenge, education and observation medicine champions in the Department of Emergency Medicine at Thomas Jefferson University collaborated to create an innovative educational intervention to teach the principles of observation medicine to EM residents. A ‘serious game’ was created and played during EM resident conference for 1 hour. Serious games are increasingly being used for education and training in order to convey important knowledge and concepts that may affect clinical practice and outcomes.2,3 Research on the use of serious games within the realm of education suggests a commensurate effect on health-related knowledge acquisition when compared to other educational methods, with the added benefit of improved learner engagement, motivation, and satisfaction.2-4 Additional research in using serious games for educational endeavors is needed to determine its potential impact, as well as its utility for teaching the topic of observation medicine to various audiences.

The following is a description of the game, “Surviving the Obs Unit”

After a brief didactic lecture on the basic principles of observation medicine, the game was played over a one-hour time period: thirty minutes of game play followed by thirty minutes of discussion. Resident learners were divided into teams of individual observation units competing to ‘disposition’ the most patients in an evidence-based and cost-effective manner. All teams started with the same set of 10 patients and received a ‘sign-out’ that started the game. Players were provided with each patients’ observation admission history and physical examination, pertinent ED diagnostic data and findings, and their respective observation unit plans. Teams were instructed that they had only $1,000 per patient to provide care in the observation unit. The winning team was the team that dispositioned the most patients with a length of stay under 18 hours, and with the most money left in their “observation unit bank.”

A reference sheet was provided to each team that delineated various costs of observation unit services, including, but not limited to: consultation fees; medications; physical therapy evaluation; imaging testing; as well as the duration of time each service would take. Teams were left to decide how to provide the best care for their set of patients, while keeping track of both length of stay and cost. In two-minute intervals, teams drew an “Update Card” that contained either a “Bonus” or a “Slammy” which changed the hospital course of a patient in their observation unit. Bonus cards reduced the length of stay and/or cost of care while Slammy cards increased the length of stay and/or cost of care.

At the end of the game, if a team did not receive an ‘update card’ about a patient in their unit, the team could discharge the patient after an appropriate work-up, which defaulted to normal results. At the end of the game, teams were asked to debate and defend their care plans for each patient. Faculty physicians in attendance moderated the discussion, and assessed for evidence-based, cost-conscious practice, as well as realism of the plans taken by the teams.

Surviving the Obs Unit” was designed to introduce learners to the basic principles of observation medicine; provide education about common observation medicine diagnoses; and coach learners to use evidence-based, cost-effective practices. The game represents a pedagogy rooted in gamification. It provides learners who have not rotated in an observation unit the opportunity to experience observation medicine. It also supports the interplay of teams, sharing of best practices, and the understanding of the impact hospital systems play in the role of patient care. Following the game, the debriefing facilitated by the faculty member(s) captured learning points from the group. The importance of the debriefing cannot be overstated. Discussion points ranged from ED decisions for admission to observation, to evidence-based and systems-based practices. The most significant finding was that this activity has the potential to uncover provider and institutional variability in observation care that diverges from protocol-driven practice models.

Our game represents an innovation that can move forward education and training in observation medicine. This innovation is pending publication with quantitative and qualitative data, with an in-depth description of the experience.


  1. Wheatley M, Baugh C, Osborne A, et al. A model longitudinal observation medicine curriculum for an emergency medicine residency. Acad Emerg Med. 2016;23:482-92.
  2. Gauthier A, Kato PM, Bul KCM, et al. Board games for health: A systematic literature review and meta-analysis. Games Health J. 2019;8(2):1-16.
  3. Sipiyaruk K, Gallagher JE, Hatzipanagos S, et al. A rapid review of serious games: From healthcare education to dental education. Eur J Dent Educ. 2018;22(4):243-57.
  4. Kaczmarczyk J, Davidson R, Bryden D, et al. Learning decision making through serious games. Clin Teach. 2016;13(4):277-82.

Elizabeth Lee, MD;
Dimitrios Papanagnou, MD;
Maria Aini, MD