How (and Why) we developed CARDiph?

Anyone can play CARDiph and you don’t need any specialist knowledge or skills to play it, but for those who are interested in such matters, we thought you might like to know how educational theory played a part in the design of the game.

The first thing to say is that, as medical educators, we all have a variety of different methods and teaching techniques that we can use depending on the context, what is to be taught, and the specific learning needs and preferences of the learners. CARDiph was not developed with any type of ‘teaching orthodoxy’ in mind, but to allow players to use the methods and approaches with which they feel most comfortable. Sometimes a more interactive approach will be most effective; at other times and with different groups of learners a very traditional didactic, directive approach works equally well.

But we would be disingenuous if we did not point out that every single time we have played the game, not one group has ever suggested using a lecture-based or similarly passive teaching approach. Quite the contrary.

Over the years we have been developing CARDiph the groups who have played it with us have devised a huge variety of active and interactive teaching and learning activities that have included, for example, sorting and matching exercises, discussion, simulations, artwork, photography and video-making, escape rooms, role plays, treasure hunts, props, toys and craft materials. Participating groups have gone on to propose opening up their sessions to a wider variety of teachers and learners, especially patients (including simulated patients, expert patients, social groupings and health charities, families and friends). Many have suggested introducing interprofessional activities with other professionals, including other health and social care professions but also academics, police, social services, lawyers, armed forces and clergy. Assessment and evaluation methods proposed by those playing CARDiph have been equally diverse but always focussed on offering the best possible feedback to learners: quizzes, multiple choice questions, game outcomes, reflective exercises, debriefs, written and verbal, peer and patient feedback, phased assessment methods and adaptive assessment. An interesting output is that within the proposed sessions the teaching is always done in teams, making the most of the talents of all the people in the group.

It would also be a bit disingenuous of us not to admit that promoting this incredibly creative, interactive, team-based approach to producing active learning opportunities through playing our game is precisely what we had in mind. Permit us to explain our standpoint.

Many healthcare educators have little or no training in teaching, even though all healthcare professionals are expected to teach their peers and junior colleagues. It is perfectly natural, therefore, that when an individual first starts to teach, they fall back on what they know. Since most healthcare education courses still rely on single-teacher didactic lectures (either in huge lecture theatres or online) this type of teaching is what everyone knows. It’s therefore self-perpetuating.

We have each been involved in teaching undergraduate and postgraduate healthcare students for decades. Over that time, we have observed that, although our student teachers understand perfectly well that there are a multitude of different ways to teach, each informed by a particular philosophy about how people learn, when push comes to shove and they first start teaching, they prefer to stay in their educational comfort zones and immediately reach for the slide design software to start planning a lecture.

We therefore wanted to develop an activity that would be interactive, that would prompt learners to think differently about teaching, yet would be non-judgmental. As we have mentioned, the habitual fallback position where teaching is concerned can be predominantly passive and unattractive to learners. We liked the idea of using gamification as way of circumventing habitual barriers and generating engagement. We therefore implemented the idea of serious games (1) though privileging the face-to-face collaborative approach to create an entertaining learning event that draws upon educational and learning theory and fosters originality and innovation.

CARDiph is therefore based on the following educational principles:

  1. It is played in teams. Increasingly, it is recognised that healthcare students need to learn to work together in teams and teams that learn together work more effectively together. But there is also a recognition that people often learn better in teams because learning is a social activity, where people work and play together to generate new knowledge through conversation and discussion. (2) Students, even school leavers on their first year of a healthcare degree, do not start from the same basic level of knowledge and experience; it therefore makes sense to encourage dialogue around a task so that everyone, whatever their level, can contribute. (3,4) We have found that the hierarchy between medical students and professors can melt away when both are engaged in trying to devise a teaching app, develop a scenario or design a scavenger hunt.
  2. It is only mildly competitive. While competition can be an effective motivator, it can cause an unhealthy degree of stress (5). Too often it is used in healthcare education to make artificial comparisons that may lead students to adopt maladaptive strategies simply in order to stay ahead in high-stakes assessments. But the low-stakes game format, where winning and losing have no consequences (especially where, if there is a prize, it is only the pleasure of sharing one’s team’s victory with others) is ideal for creating excitement and motivation without any sense that losing carries a penalty.
  3. It is focussed on real-world teaching – that is to say, it is a reasonably faithful simulation of the types of challenges faced by healthcare educators, who regularly have to design interesting, engaging and useful learning opportunities for a wide range of groups and professions, on diverse topics, in various different venues and settings, with a whole host of complexities and considerations. People learn effectively by practising an authentic task (and sometimes by failing), reflecting on the experience, thinking about what the experience means for them, and then trying again. (6) CARDiph can be played again and again, but the experience will always be unique so that learning is maximised.
  4. It is focussed on positive feedback (what did we do well?) rather than summative judgement (who passed, who failed?). (6) This is also a deliberate decision, aimed to increase confidence in players and ensure that nobody need feel that they are not good enough to plan a teaching session. After a collective 50 years or so of teaching, we ourselves are still learning; nobody has a monopoly on excellence in teaching.

A final thought: to ‘win’ the game, you have to design the teaching session that most people in the room would like to attend. There is a deliberate ‘informal curriculum’ in this. (5) Participants can learn from each other and share ideas and insights about what makes a session fun, engaging, and what maximises learning. It is therefore hardly surprising that few participants ever think about creating a didactic lecture – even when they draw the cards that inform them they have a large group in a lecture theatre for two hours. There’s something to be learned from that.

Julie Browne and Katie Webb
Cardiff, May 2023

  • R. Wang, S. DeMaria, A. Goldberg, D. Katz, A systematic review of serious games in training health care professionals, Simul. Healthc. 11 (2016) 41–51, https://doi. org/10.1097/SIH.0000000000000118
  • Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall.
  • Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press.
  • Bleakley, A., Bligh, J., Browne, J. (2011) Medical Education for the Future: Identity, Power and Location. Dordrecht: Springer.
  • Cook, C. J., & Crewther, B. T. (2019). The impact of a competitive learning environment on hormonal and emotional stress responses and skill acquisition and expression in a medical student domain. Physiology & Behavior, 199, 252-257. doi: 10.1016/j.physbeh.2018.11.027
  • Hafferty, F. W. (1998). Beyond curriculum reform: confronting medicine's hidden curriculum. Academic medicine : journal of the Association of American Medical Colleges, 73(4), 403-407. doi:10.1097/00001888-199804000-00013
  • Bligh, J. G., & Browne, J. (2011). Course design. In P. Cantillon & D. F. Wood (Eds.), ABC of Learning and Teaching in Medicine, 2nd Edn. London: BMJ Books and Wiley Blackwell.

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