Education Benefits of an Escape Room as a Novel Educational Activity for Radiology Residents Kedar Jambhekar, MD, Rachel P. Pahls, MD, Linda A. Deloney, EdD Rationale and Objectives: We created a radiology Escape Room, a competitive game where a team of players must discover clues and solve a mystery to escape a “locked” room. To succeed, players must collaborate and think critically and creatively. Our objectives were to provide a novel team-building activity, teach interesting content about radiology as a specialty, cultivate grit, and share the game with other programs. Materials and Methods: Escape Rooms were held during orientation (BOOT Camp) for incoming radiology residents and for upper level residents and faculty with advanced content (four teams totaling 20 residents and faculty). We repeated the Escape Room 27 times for 144 residents from more than 10 countries at Radiological Society of North America (RSNA) 2018. Results: Players were engaged and competitive. They were able to connect the activity to their future responsibilities À analyzing knowl- edge under pressure (being on call), communicating effectively (conveying results and recommendations), having the dexterity and motor skills required for physical puzzles (hand-on procedures), being able to multi-task and come up with differential diagnoses under extreme stress and time pressure (being on call). A post-RSNA survey confirmed satisfaction with the activity, with overall enjoyment receiving the highest rating. Conclusion: It is feasible to create a portable, inexpensive Escape Room as a novel educational platform for radiology residents. Combin- ing knowledge-based challenges and technical skills in a live-action game simulated a real-life situation in which vital patient information must be collected and reported concisely and accurately. A Game Guide is available to program directors and medical educators upon request. Keywords: Educational games; Escape room; gamification; millennials; radiology; residents. © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. INTRODUCTION relevance, continuous feedback, transparency, and autonomy (2). We envisioned a radiology-themed Escape Room game he transition from intern to radiology resident is as an innovative approach to meeting these generational stressful and surprisingly challenging. New responsi- preferences. bilities require learning a high volume of complex T Newer teaching methods, especially the flipped class- information while simultaneously adapting to a new peer room, audience response technology, team-based learning, group in a new work environment. We reported previously long-distance teaching, and active/experiential learning, are that including team-building activities during our BOOT recommended to complement the traditional lecture (3). Camp orientation fostered the development of camaraderie Likewise, board and card games have been developed for and support new residents need to meet these challenges (1). teaching medical concepts and specific clinical skills (4À6). Millennial residents crave active engagement, both in and out Playing a game creates a dynamic educational environment of the reading room, and prefer multimedia learning. They that enhances retention of knowledge and reinforces learn- are motivated by achievement and affiliation. They expect ing (7). “Gamification”,defined as the use of game design their educational experiences to include explicit goal-setting, elements in a nongame context, has become a popular instructional method in K-12 and higher education (8À10). Acad Radiol 2020; 27:276–283 Although gamification has been shown to make a positive From the University of Arkansas for Medical Sciences (UAMS), College of Medicine, 4301 W. Markham, #556, Little Rock, AR 72205. Received March impact on the teaching/learning process, medical education 7, 2019; revised April 18, 2019; accepted April 23, 2019. The authors have is in the early stages of embracing it as a teaching method no competing interests and alone are responsible for the content and writ- À ing of this article. Address correspondence to: L.A.D. e-mail: (7,11 14). Well-designed games based on sound adult [email protected] learning theory model the ancient Chinese proverb, “Tell © 2019 The Association of University Radiologists. Published by Elsevier Inc. me and I forget, teach me and I may remember, involve me All rights reserved. and I learn.” https://doi.org/10.1016/j.acra.2019.04.021 276 Academic Radiology, Vol 27, No 2, February 2020 RADIOLOGY ESCAPE ROOM A newer type of gamification with potential educational Small studies of grit among surgical residents demonstrated grit benefits is the Escape Room. An Escape Room is a competi- was predictive of psychological health and suggested that it is tive physical adventure game within a prescribed setting, con- learnable and teachable (16). Resilience is an aspect of grit strained by rules and procedures, where a team of players important in medical school, residency, and as a physician. In must discover clues and solve a mystery to escape a “locked” the face of failure, disappointment or even boredom, the gritty room. They are physical versions of “escape the room” video individual stays the course. games, set in fictional locations. Currently, they are becom- ing popular as team building exercises. Escape Room experi- MATERIALS AND METHODS ences require players to think critically and creatively, making them a good fit for millennial residents who crave We applied for and received the 2018 Jerome Arndt grant active engagement. Learning results from the experience of from the Association of Program Directors in Radiology playing the game, not the academic content (11). (APDR), an award intended to encourage development of When we initiated our project, there was no literature on resources for the membership, including innovative projects the use of Escape Rooms in medical education. Furthermore, in radiology education. This funding allowed us to retain the our collective experience was limited to commercial recrea- services of Wero Creative, a Toronto-based game studio, for tional experiences. We aimed to create a radiology themed their expertise in design, including theme, puzzles, and set up Escape Room game as a novel activity for radiology residents. instructions. Our objectives were to provide a unique team building activ- We built our Escape Room on fundamental adult learning ity targeted to radiology residents, teach interesting content principles. Residents are autonomous, self-directed, and about radiology as a medical specialty, cultivate grit, and share goal-oriented. They are motivated by the need to know and the resource with any program in the country that was inter- their readiness and desire to learn. Learning that is based on ested in replicating the activity for their residents (Fig 1). their life experiences and is relevant to their work environ- It has been suggested that playing an Escape room may cul- ment is most highly valued (17). We designed our room and tivate grit, which research has shown can be a better predictor its challenges around interesting radiology knowledge and of success than standardized tests and has also been associated technical skills. with decreased burnout and increased psychological well- We created four branches of puzzles which, when success- being among residents. Defined as “perseverance and passion fully completed, win the game. Mental puzzles require players for long-term goals,” Duckworth found through her research to use critical thinking skills and logic to decipher clues that grit was an independent predictor of achievement (15). (knowledge). Physical puzzles require the manipulation of objects to overcome a challenge to get the reward (technical skills). Each puzzle uses a simple game loop: a challenge (e.g., a locked box), a solution (e.g., the combination), and a reward (e.g., something inside the box). Every challenge creates a learning experience. Puzzles combine information the player should know (input) with information the player should have acquired by the end of the experience (output). There is no set order in which the puzzles must be finished but all must be completed to reveal the final clue, a meta-puzzle with the final challenge derived from the previous solutions (Fig 2). Examples of educational material and radiology knowl- edge tested in this escape room included matching or naming classic imaging diagnoses based on written description and testable buzzwords, identification of classic imaging diagnoses within the chest on computed tomography or characteristic intra-abdominal pathology. Additionally, identification of neuroanatomy via CT/MRI, identification of bone tumors, soft tissue masses, fractures types, and eponyms was tested. There were also questions about muscle insertion and origin anatomy, tendon and ligament anatomy, and bones or osse- ous structures which utilized the full sized anatomic skeleton prop. Imaging diagnosis questions could be shown on any modality including radiography, CT, MRI, nuclear medicine scintigraphy. Knowledge about radiotracers used in nuclear medicine Figure 1. Promotional poster for radiology Escape Room featuring and their production, or radiation safety dose limits and the Marie Curie. detrimental effects of radiation exposure, or proper handling 277 JAMBHEKAR ET AL Academic Radiology, Vol 27, No 2, February 2020 Players were scheduled in teams of 4 to 6. They were not required to bring any tools or materials to