Contributed by Baruch Fischhoff, July 11, 2018 (sent for review March 29, 2018; reviewed by Arthur S. Elstein and Avery Nathens)
Americans can expect to experience at least one meaningful diagnostic medical error in their lifetime. One plausible source of those errors is physicians’ reliance on heuristics that are generally useful but can fail in diagnostically challenging situations. Based on previous research and clinical experience, we identified heuristics that might cause diagnostic errors in trauma triage. We sought to improve physicians’ heuristic judgment by providing simulated experience with two “serious” video games. In a randomized controlled trial, both games had positive effects, whereas equivalent exposure to traditional medical education had none. By complementing physicians’ natural ways of thinking, such simulated experiences might transfer to actual triage and other high-pressure decisions.
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).
Author contributions: D.M., B.F., D.C.A., M.R.R., D.M.Y., C.F., and A.E.B. designed research; D.M., D.C.A., M.R.R., D.J.W., D.M.Y., C.F., and A.E.B. performed research; C.-C.H.C. and S.K. contributed new reagents/analytic tools; D.M., B.F., D.C.A., M.R.R., D.J.W., D.M.Y., C.F., C.-C.H.C., S.K., and A.E.B. analyzed data; and D.M., B.F., D.C.A., M.R.R., D.J.W., D.M.Y., C.F., C.-C.H.C., S.K., and A.E.B. wrote the paper.
Reviewers: A.S.E., University of Illinois, Chicago; and A.N., University of Toronto.
The authors declare no conflict of interest.
This article contains supporting information online at www.pnas.org/lookup/suppl/doi:10.1073/pnas.1805450115/-/DCSupplemental.
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