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Proc Natl Acad Sci U S A. 2018 Sep 11;115(37):9204-9209. doi: 10.1073/pnas.1805450115. Epub 2018 Aug 27.

Serious games may improve physician heuristics in trauma triage.

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Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261.
Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213.
Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA 15213;
Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, PA 15213.
Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA 15213.
RAND Corporation, Pittsburgh, PA 15213.
The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, NH 03766.


Trauma triage depends on fallible human judgment. We created two "serious" video game training interventions to improve that judgment. The interventions' central theoretical construct was the representativeness heuristic, which, in trauma triage, would mean judging the severity of an injury by how well it captures (or "represents") the key features of archetypes of cases requiring transfer to a trauma center. Drawing on clinical experience, medical records, and an expert panel, we identified features characteristic of representative and nonrepresentative cases. The two interventions instantiated both kinds of cases. One was an adventure game, seeking narrative engagement; the second was a puzzle-based game, emphasizing analogical reasoning. Both incorporated feedback on diagnostic errors, explaining their sources and consequences. In a four-arm study, they were compared with an intervention using traditional text-based continuing medical education materials (active control) and a no-intervention (passive control) condition. A sample of 320 physicians working at nontrauma centers in the United States was recruited and randomized to a study arm. The primary outcome was performance on a validated virtual simulation, measured as the proportion of undertriaged patients, defined as ones who had severe injuries (according to American College of Surgeons guidelines) but were not transferred. Compared with the control group, physicians exposed to either game undertriaged fewer such patients [difference = -18%, 95% CI: -30 to -6%, P = 0.002 (adventure game); -17%, 95% CI: -28 to -6%, P = 0.003 (puzzle game)]; those exposed to the text-based education undertriaged similar proportions (difference = +8%, 95% CI: -3 to +19%, P = 0.15).


decision making; heuristics; judgment; serious games; triage

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