- Email: [email protected]
The “Neurological Hat Game”: A fun way to learn the neurological semiology
NEUROL-2043; No. of Pages 6 revue neurologique xxx (2018) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original article
The ‘‘Neurological Hat Game’’: A fun way to learn the neurological semiology B. Garcin a,e,1,*, L. Mariani c,d, A. Me´neret c,d, M. Mongin a,d, C. Delorme c,d, F. Cormier c,d, M.-C. Renaud d, E. Roze a,c,d,e, B. Degos a,b a Service de Neurologie, hoˆpital Avicenne, hoˆpitaux universitaires de Paris–Seine Saint-Denis, AP–HP, 93000 Bobigny, France b UMR CNRS 7241/Inserm U1050, Center for Interdisciplinary Research in Biology (CIRB), colle`ge de France, 75005 Paris, France c De´partement de Neurologie, groupe hospitalier Pitie´-Salpeˆtrie`re, AP–HP, 75013 Paris, France d Faculte´ de me´decine, Sorbonne universite´s, universite´ Pierre-et-Marie-Curie (UPMC), 91, boulevard de l’hoˆpital, 75013 Paris, France e Sorbonne universite´s, UPMC universite´ Paris 6 UMR S 1127, Inserm U 1127, CNRS UMR 722, institut du cerveau et de la moelle e´pinie`re, 75013 Paris, France
info article
abstract
Article history:
Introduction. – In-class courses are deserted by medical students who tend to find it more
Received 30 November 2018
beneficial to study in books and through online material. New interactive teaching methods,
Received in revised form
such as serious games increase both performance and motivation. We developed and
17 January 2019
assessed a new teaching method for neurological semiology using the ‘‘Hat Game’’ as a
Accepted 24 January 2019
basis.
Available online xxx
Methods. – In this game, two teams of second-year medical students are playing against one
Keywords:
on each card. Each team gets a predefined period of time to guess as many words as possible.
Teaching
One member is the clue-giver and the others are the guessers. There are three rounds:
another. The game is played with a deck of cards. A neurological symptom or sign is written
Hat game
during the first round, the clue-giver uses any descriptive term he wants and as many as he
Learning
wants to make his team guess the maximum number of words within the allocated time.
Memorization
During the second round, the clue-giver can only choose one clue-word and, during the third
Mesocorticolimbic pathway
round, he mimes the symptom or sign. The team that has guessed the most cards wins the game. To assess the efficacy of this learning procedure, multiple choices questions (MCQs) were asked before and after the game. Exam results of second-year students on their final
* Corresponding author at: Service de Neurologie, hoˆpital Avicenne, 125, route de Stalingrad, 93009 Bobigny, France. E-mail address: [email protected] (B. Garcin). 1 B.D.: study concept and design, analysis and interpretation of data, drafting and revising the manuscript for intellectual content, study supervision. LL.M.: acquisition of data, interpretation of data, critical revision of the manuscript for intellectual content. A.M., F.C., M.M, C.D.: acquisition of data. M.C.R.: study concept and design, analysis and interpretation of data, critical revision of manuscript for intellectual content. E.R., B.G.: study concept and design, analysis and interpretation of data, critical revision of manuscript for intellectual content. Abbreviations: NHG, Neurology Hat Game; MCQ, Multiple Choices Questions; SD, Standard Deviation. https://doi.org/10.1016/j.neurol.2019.01.395 0035-3787/# 2019 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Garcin B, et al. The ‘‘Neurological Hat Game’’: A fun way to learn the neurological semiology. Revue neurologique (2019), https://doi.org/10.1016/j.neurol.2019.01.395
NEUROL-2043; No. of Pages 6
2
revue neurologique xxx (2018) xxx–xxx
university Neurology exam were analyzed. A satisfaction survey was proposed to all participating students. Results. – Among 373 students, 121 volunteers (32.4%) were enrolled in the ‘‘Neurology Hat Game’’ and 112 attended the game. One hundred and seven of the 112 students completed the MCQs with a significant improvement in their responses after the game (P < 0.001). The 112 students who completed the satisfaction self-administered questionnaire were very satisfied with this funny new teaching method. Conclusions. – Teaching neurological semiology via the ‘‘Hat Game’’ is an interesting method because it is student-centered, playful and complementary to the lecturer-centered courses. A randomized controlled study would be necessary to confirm these preliminary results. # 2019 Elsevier Masson SAS. All rights reserved.
1.
Introduction
Classical lecturing, which is teacher-centered, mainly involves passive auditory and visual memorization and lacks interactivity. For this reason, in-class courses are deserted by medical students who tend to find it more beneficial to study in books and through online material. However, many studies have highlighted the positive value of innovative teaching methods that are interactive and student-centered. A recent meta-analysis compared 158 studies of student performance under active learning with 67 studies under traditional lecturing. It demonstrated that active learning increases both performance and motivation, and decreases failures [1]. For this reason, innovative and interactive teaching methods should be developed. Various interaction tools are available to improve students’ learning performances and motivation such as mime, simulation, and games. Amongst them, gaming is of particular interest because it induces a pleasant and friendly emotional context that improves motivational attention [2] and academic achievements [3]. Additionally gaming allows the teacher who supervises the sessions to immediately catch the errors and correct them. Memorization can be increased by a positive emotional context, but also by the repetition of the information to be acquired, and by the use of different sensory inputs. Four main sensory inputs are involved in learning:
visual (graphs, diagrams, figures etc.); oral/hearing (speech, presentation, discussion); reading/writing; kinesthetic (by the realization of an action) [4].
Each individual, and therefore each student, develops a learning preference [4]. Offering different learning modalities can increase the probability of reaching the greatest number of students. Moreover, combining various sensory inputs is particularly interesting, since people learn 10% of what they read, 20% of what they hear, 30% of what is shown and 90% when what is said and done are combined [5,6]. The ‘‘Hat Game’’ is a traditional game, which most people know, notably because various versions have been marketed. We thought that the ‘‘Hat Game’’ would be an interesting tool to learn neurological semiology since it involves speech,
hearing, sight and kinesthesia through reading and mime. All these various modalities reinforce the encoding of information in an active way since the students themselves are the protagonists [7–10]. Hence, we developed a neurological version of the ‘‘Hat Game’’ and assessed how it influences learning and memorization of neurological semiology in second-year medical students.
2.
Material and Method
2.1.
Students
We proposed the ‘‘Neurology Hat Game’’ to second-year medical students (Faculty of Medicine of Sorbonne University) who are learning neurological semiology. Neurological semiology can be easily described and mimed and is therefore suitable for this kind of game. Dr. M-C Renaud (senior advisor to the Dean and vice-dean at the Coordination of Studies and Internships) generated an online interactive board to propose to all second-year medical students to participate in this teaching. This has been integrated in a revision period of the neurological semiology in addition to their usual lecture courses. Groups of 12–14 students were scheduled every morning for one week in March 2017 to form teams of 6–7 students per group. Each group was supervised by a neurologist (B.D., M.M., L.L.M., A.M., F.C. and C.D.).
2.2.
The Neurological Hat Game
We used a deck of 67 cards (see Video 1). A neurological symptom or sign was written on each card (see Appendix 1). This card game was designed by B.D. and all words were reviewed and validated by two colleagues (E.R. and B.G.). The objective of the game was to guess as many words as possible in a short period (i.e. less than 1.5 minutes). There are three rounds:
in the first round, a member of one of the two teams (the clue-giver) has to make his team-mates guess the maximum number of words using any and as many descriptive terms
Please cite this article in press as: Garcin B, et al. The ‘‘Neurological Hat Game’’: A fun way to learn the neurological semiology. Revue neurologique (2019), https://doi.org/10.1016/j.neurol.2019.01.395
NEUROL-2043; No. of Pages 6 revue neurologique xxx (2018) xxx–xxx
as he wants in less than 1.5 min. Once this time is elapsed, a member of the opposing team starts trying to make his team guess the remaining cards of the deck, and so on, until there are no more cards left. The team that wins the most cards wins the first round; during the second round, the same deck of cards is used and students proceed in the same way but the clue-giver can give only one word to make his teammates guess which word is on the card. The team that wins the most cards wins the second round; the third and final round is similar in principle, but students have to guess the words through a mime. At the end of the three rounds, the team that has guessed the most words wins; to complete this playful revision of semiology, there was an open discussion about the symptoms or signs that remained problematic to some students between the first and second rounds. At the end of the game, there was a quick review of all semiology words that were on the cards. The whole session lasted approximately 120 minutes, including the debriefing session that lasted for 20 to 40 minutes depending on the students’ level of knowledge.
2.3.
Assessment
We obtained the authorization from the Council of Studies of the Faculty of Medicine Paris 6 to propose this teaching. In addition, all students received an information about the teaching, and all gave their informed written consent to participate in the study. As a first step, we assessed the benefit of this teaching through 43 Multiple Choice Questions (MCQs) about neurological semiology. MCQs were proposed in two sessions. First, before the game, students had to answer to MCQs. Then, after the game, they were given the 43 MCQs again, but in a different order (see Appendices 2 and 3). Only fully correct MCQs were counted as valid (1 point per MCQ), and students were given a limited time of 15 minutes to complete the MCQs. In order to assess the value of such teaching, we also proceeded to a satisfaction survey that was completed after the second MCQs session (see Appendix 4). This survey included 8 questions, and responses were given according to a 5 choices scale of Likert (1. Strongly agree, 2. Agree, 3. Neutral, 4. Disagree, 5. Strongly disagree). The whole session including the two MCQs’ sessions, the game itself, the teaching period and the satisfaction questionnaire completion lasted about 2.5 hours. Finally, we compared the neurological semiology exam’s scores obtained by the 112 students who participated in the Neurological Hat Game (NHG) to the non-participating students. The exam took place two weeks after completing the NHG.
2.4.
3.
Results
3.1.
Students
3
Out of 373 second-year medical students, 121 (32.4%) registered to the Neurological Hat Game teaching. Of those, 112 students took part in the teaching (9 were absent). Eightytwo participants were women (73%). Ten sets of 9 to 13 students were formed and each group was divided into two teams.
3.2.
MCQs results
Of the 112 students, 107 completed the MCQs before and after the game. Four students did not complete the MCQs because they arrived late (after the completion of the MCQs before the game) and one student had to leave before completing the MCQs after the game. Before the game, the mean ( SD) MCQs score was 8.44 ( 4.34). The mean ( SD) MCQs score after the game significantly increased to 15.56 ( 5.8) points (P < 0.001, N = 107, Fig. 1). Only seven students had a mark greater than or equal to 15 before the game as compared to 55 students after the game. All students improved except one student who regressed and two students with steady marks.
3.3.
Satisfaction survey
All of the 112 attending students completed the satisfaction survey immediately after the game except for the student who had to leave before the end of the session and who sent his evaluation later by email. This corresponded to a total of 896 responses. All eight questions obtained a median response of 1, with mean responses below 1.4 for all questions (see Table 1). Only 21 out of 896 responses were given a score above 2 by 10 students. Amongst these 21 responses, 18 were a score of 3 (neutral), and only one student responded above 3 to questions. Notably, all students agreed that the exercise was playful (3 agreed, and 109 strongly agreed).
3.3.1.
Grades on the Neurology exam
The final exam scores of the 112 students (group 1) who participated in the NHG were compared to those obtained by the 259 students (group 2) who did not participate in the NHG (in this group, two students were not included because they missed the final exam). None of the group 1 students scored less than 10 (out of 20) while 10 students scored less than 10 in group 2. The average neurology exam score was significantly higher in group 1 than in group 2 (13.65 1.4 vs. 13.21 1.7, t-test bivariate, P = 0.016).
4.
Discussion
Statistical analysis
The data are expressed as mean standard deviation (SD), percentage. T-tests or paired t-tests were used for statistical analysis. Analyses were performed on Sigmastat software (https://systatsoftware.com/products/sigmastat/).
This study shows that the neurological hat game can be used to teach neurological semiology. This playful method allows an overview of the main neurological signs, symptoms, and syndromes in a short period and in a fun way. Students who played the NHG increased their marks on the day of the game
Please cite this article in press as: Garcin B, et al. The ‘‘Neurological Hat Game’’: A fun way to learn the neurological semiology. Revue neurologique (2019), https://doi.org/10.1016/j.neurol.2019.01.395
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e:floats>Fig. 1 – Distribution of students’ marks before (red) and after (blue) the Neurological Hat Game (NHG). There was a significant improvement in performances after the NHG. X axis: subsets of scores obtained in MCQs; Y axis: absolute number of students within each subset.
Table 1 – Assessment of students’ satisfaction regarding the Neurological Hat Game. Propositions About the neurology hat game:
Mean SD From 1: strongly agree to 5 strongly disagree
It is playful Helped to better understand Helped to better remember Was helpful for reviewing your upcoming exam Increased your motivation to learn neurological semiology Terms are appropriate Should be repeated in the future Should be extended to other medical specialties
1.03 0.16 1.17 0.44 1.30 0.64 1.24 0.51 1.34 0.63 1.32 0.56 1.07 0.29 1.17 0.40
Abbreviations: SD: standard deviation; Med: median. Responses ranged from 1. Strongly agree, to 5. Strongly disagree. Abbreviations: SD: standard deviation; Med: median. Responses ranged from 1. Strongly agree, to 5. Strongly disagree.
but also a few weeks later at the final neurological semiology exam as compared to students who did not participate in the NHG. Neurological semiology is considered by a majority of students as difficult to master, and medical students are considerably neurophobic [11]. Anxiety has a negative impact on attention, memory and metacognition [12]. On the contrary, it has been shown that positive mood is associated with better memorization [13], and students who have a high interest in and enthusiasm for a subject have better grades [14,15]. Playful teaching methods are of particular interest for neurological semiology to remove the anxiety associated with this discipline, and to increase motivation [16,17]. In this study, the satisfaction survey showed that students were very satisfied with the teaching approach. All students agreed that the teaching method was playful. The playful aspect induces a positive emotional context that stimulates memorization [18], possibly through the involvement of mesocorticolimbic emotional circuits [19,20]. The hat game involves four learning modalities: reading, hearing, gesture and vision. This multimodal learning is also of particular interest for students who have a predominantly multimodal learning preference, especially of the oral and
kinesthetic types [4]. It is also in agreement with the hub-andspoke model of semantic cognition, which suggests that multimodal, sensorimotor, cognitive and emotional engagement are the core ‘ingredients’ for constructing concepts [21]. Additionally, the hat game requires the repetition and categorization of information through two different modalities (language and sight). The mime (gesture), as practiced during the third round of the hat game, previously showed effectiveness on memorization not only in the short term but also in the long term [22,23]. Here, we showed that students who participated in the NHG had better results in the final exam compared to those who just completed the faculty courses. This indicates a benefit of this teaching on short-term memorization [16], but possibly also on longer term memorization. The hat game has practical advantages. First, it requires very little material since it is only based on the use of cards. Second, most people already know the rules of the game. Third, it can be played anywhere (faculty or ward room, outdoors, or at home). Therefore, this low-cost interactive teaching could easily be implemented in any University worldwide, even in resource-constrained teaching environments.
Please cite this article in press as: Garcin B, et al. The ‘‘Neurological Hat Game’’: A fun way to learn the neurological semiology. Revue neurologique (2019), https://doi.org/10.1016/j.neurol.2019.01.395
NEUROL-2043; No. of Pages 6 revue neurologique xxx (2018) xxx–xxx
Despite the positive results, there are some limitations to our study. First, participation was based on volunteering, which could represent a major selection bias. Motivated and hard-working students may have been more likely to participate, which might eventually account–at least in part–for group difference in the performance at the final examination. Alternatively, the students having difficulties with learning neurology and seeking a way to overcome it may have been more prone to participate. A randomized study on a whole year group of students would be necessary to answer this question. Second, the control group did not have an additional lecture in order to compare the NHG to a classical supplementary teaching. Additionally, the neurological semiology exam was performed only two weeks after the teaching. An assessment of knowledge at a longer term would be necessary to determine the impact of the NHG on long-term memorization. It would also be useful to determine how this improved knowledge is converted into practical proficiency. In conclusion, the neurological hat game seems to be an interesting educational approach considering both the improvement of students’ performances after the course and their feedback from the satisfaction survey. These promising results require confirmation via a randomized controlled study conducted on an entire school year.
Consent for participation and publication Oral information on the purpose and the course of this study was given to the students and .all the students gave their informed written consent to participate. They all gave their consent for publication of the data.
Availability of data and material The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Ethical Statement We performed this study with the authorization from the Council of Studies of the Faculty of Medicine Paris 6.
Disclosure of interest The authors declare that they have no competing interest. This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Acknowledgements We thank Olivier Steichen and Alexandre Duguet for their help in the organization of the study, and Se´bastien Balverde for English edition of the manuscript. We thank Arlette Welaratne and Marta Ruiz for their help in video-editing.
5
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j. neurol.2019.01.395.
references
[1] Freeman S, Eddy SL, McDonough M, Smith MK, Okoroafor N, Jordt H, et al. Active learning increases student performance in science, engineering, and mathematics. Proc Natl Acad Sci U S A 2014;111:8410–5. [2] Bourgeois A, Chelazzi L, Vuilleumier P. How motivation and reward learning modulate selective attention. Prog Brain Res 2016;229:325–42. [3] Pekrun R, Lichtenfeld S, Marsh HW, Murayama K, Goetz T. Achievement emotions and academic performance: longitudinal models of reciprocal effects. Child Dev 2017;88:1653–70. [4] Urval RP, Kamath A, Ullal S, Shenoy AK, Shenoy N, Udupa LA. Assessment of learning styles of undergraduate medical students using the VARK questionnaire and the influence of sex and academic performance. Adv Physiol Educ 2014;38:216–20. [5] Dale E. Audiovisual methods in teaching. Third edition. New York: Dryden Press; Holt, Rinehart & Winston; 1969. [6] Kennedy L. PD trivia: making learning fun. CANNT J J ACITN 2006;16:46–8. [7] Bays CL, Hermann CP. Gaming versus lecture discussion: effects on students’ test performance. J Nurs Educ 1997;36:292–4. [8] Gurpinar E, Kulac E, Tetik C, Akdogan I, Mamakli S. Do learning approaches of medical students affect their satisfaction with problem-based learning? Adv Physiol Educ 2013;37:85–8. [9] Kedge S, Appleby B. Promoting a culture of curiosity within nursing practice. Br J Nurs Mark Allen Publ 2009;18:635–7. [10] Konopka CL, Adaime MB, Mosele PH. Active teaching and learning methodologies: some considerations. Creat Educ 2015;06:1536. [11] Pakpoor J, Handel AE, Disanto G, Davenport RJ, Giovannoni G, Ramagopalan SV, et al. National survey of UK medical students on the perception of neurology. BMC Med Educ 2014;14:225. [12] Arnsten AFT. Stress weakens prefrontal networks: molecular insults to higher cognition. Nat Neurosci 2015;18:1376–85. [13] Ba¨uml K-H, Kuhbandner C. Positive moods can eliminate intentional forgetting. Psychon Bull Rev 2009;16:93–8. [14] Augustyniak RA, Ables AZ, Guilford P, Lujan HL, Cortright RN, DiCarlo SE. Intrinsic motivation: an overlooked component for student success. Adv Physiol Educ 2016;40:465–6. [15] Cortright RN, Lujan HL, Blumberg AJ, Cox JH, DiCarlo SE. Higher levels of intrinsic motivation are related to higher levels of class performance for male but not female students. Adv Physiol Educ 2013;37:227–32. [16] Roze E, Flamand-Roze C, Me´neret A, Ruiz M, Le Liepvre H, Duguet A, et al. The Move’’, an innovative simulation-based medical education program using roleplay to teach neurological semiology: students’ and teachers’ perceptions. Rev Neurol (Paris) 2016;172:289–94.
Please cite this article in press as: Garcin B, et al. The ‘‘Neurological Hat Game’’: A fun way to learn the neurological semiology. Revue neurologique (2019), https://doi.org/10.1016/j.neurol.2019.01.395
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[17] Ve´rin M, Benquet P. The move: when neurosciences teach us to better teach neurosciences. J Neurol Sci 2018;391:149–50. [18] Giannakos MN. Enjoy and learn with educational games: examining factors affecting learning performance. Comput Educ 2013;68:429–39. [19] Adcock RA, Thangavel A, Whitfield-Gabrieli S, Knutson B, Gabrieli JDE. Reward-motivated learning: mesolimbic activation precedes memory formation. Neuron 2006;50:507–17. [20] Wittmann BC, Schott BH, Guderian S, Frey JU, Heinze H-J, Du¨zel E. Reward-related FMRI activation of dopaminergic
midbrain is associated with enhanced hippocampusdependent long-term memory formation. Neuron 2005;45:459–67. [21] Ralph MAL, Jefferies E, Patterson K, Rogers TT. The neural and computational bases of semantic cognition. Nat Rev Neurosci 2017;18:42–55. [22] Cook SW, Mitchell Z, Goldin-Meadow S. Gesturing makes learning last. Cognition 2008;106:1047–58. [23] Roze E, Worbe Y, Louapre C, Me´neret A, Delorme C, McGovern E, et al. Miming neurological syndromes improves medical student’s long-term retention and delayed recall of neurology. J Neurol Sci 2018;391:143–8.
Please cite this article in press as: Garcin B, et al. The ‘‘Neurological Hat Game’’: A fun way to learn the neurological semiology. Revue neurologique (2019), https://doi.org/10.1016/j.neurol.2019.01.395
Available online at
ScienceDirect www.sciencedirect.com
Original article
The ‘‘Neurological Hat Game’’: A fun way to learn the neurological semiology B. Garcin a,e,1,*, L. Mariani c,d, A. Me´neret c,d, M. Mongin a,d, C. Delorme c,d, F. Cormier c,d, M.-C. Renaud d, E. Roze a,c,d,e, B. Degos a,b a Service de Neurologie, hoˆpital Avicenne, hoˆpitaux universitaires de Paris–Seine Saint-Denis, AP–HP, 93000 Bobigny, France b UMR CNRS 7241/Inserm U1050, Center for Interdisciplinary Research in Biology (CIRB), colle`ge de France, 75005 Paris, France c De´partement de Neurologie, groupe hospitalier Pitie´-Salpeˆtrie`re, AP–HP, 75013 Paris, France d Faculte´ de me´decine, Sorbonne universite´s, universite´ Pierre-et-Marie-Curie (UPMC), 91, boulevard de l’hoˆpital, 75013 Paris, France e Sorbonne universite´s, UPMC universite´ Paris 6 UMR S 1127, Inserm U 1127, CNRS UMR 722, institut du cerveau et de la moelle e´pinie`re, 75013 Paris, France
info article
abstract
Article history:
Introduction. – In-class courses are deserted by medical students who tend to find it more
Received 30 November 2018
beneficial to study in books and through online material. New interactive teaching methods,
Received in revised form
such as serious games increase both performance and motivation. We developed and
17 January 2019
assessed a new teaching method for neurological semiology using the ‘‘Hat Game’’ as a
Accepted 24 January 2019
basis.
Available online xxx
Methods. – In this game, two teams of second-year medical students are playing against one
Keywords:
on each card. Each team gets a predefined period of time to guess as many words as possible.
Teaching
One member is the clue-giver and the others are the guessers. There are three rounds:
another. The game is played with a deck of cards. A neurological symptom or sign is written
Hat game
during the first round, the clue-giver uses any descriptive term he wants and as many as he
Learning
wants to make his team guess the maximum number of words within the allocated time.
Memorization
During the second round, the clue-giver can only choose one clue-word and, during the third
Mesocorticolimbic pathway
round, he mimes the symptom or sign. The team that has guessed the most cards wins the game. To assess the efficacy of this learning procedure, multiple choices questions (MCQs) were asked before and after the game. Exam results of second-year students on their final
* Corresponding author at: Service de Neurologie, hoˆpital Avicenne, 125, route de Stalingrad, 93009 Bobigny, France. E-mail address: [email protected] (B. Garcin). 1 B.D.: study concept and design, analysis and interpretation of data, drafting and revising the manuscript for intellectual content, study supervision. LL.M.: acquisition of data, interpretation of data, critical revision of the manuscript for intellectual content. A.M., F.C., M.M, C.D.: acquisition of data. M.C.R.: study concept and design, analysis and interpretation of data, critical revision of manuscript for intellectual content. E.R., B.G.: study concept and design, analysis and interpretation of data, critical revision of manuscript for intellectual content. Abbreviations: NHG, Neurology Hat Game; MCQ, Multiple Choices Questions; SD, Standard Deviation. https://doi.org/10.1016/j.neurol.2019.01.395 0035-3787/# 2019 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Garcin B, et al. The ‘‘Neurological Hat Game’’: A fun way to learn the neurological semiology. Revue neurologique (2019), https://doi.org/10.1016/j.neurol.2019.01.395
NEUROL-2043; No. of Pages 6
2
revue neurologique xxx (2018) xxx–xxx
university Neurology exam were analyzed. A satisfaction survey was proposed to all participating students. Results. – Among 373 students, 121 volunteers (32.4%) were enrolled in the ‘‘Neurology Hat Game’’ and 112 attended the game. One hundred and seven of the 112 students completed the MCQs with a significant improvement in their responses after the game (P < 0.001). The 112 students who completed the satisfaction self-administered questionnaire were very satisfied with this funny new teaching method. Conclusions. – Teaching neurological semiology via the ‘‘Hat Game’’ is an interesting method because it is student-centered, playful and complementary to the lecturer-centered courses. A randomized controlled study would be necessary to confirm these preliminary results. # 2019 Elsevier Masson SAS. All rights reserved.
1.
Introduction
Classical lecturing, which is teacher-centered, mainly involves passive auditory and visual memorization and lacks interactivity. For this reason, in-class courses are deserted by medical students who tend to find it more beneficial to study in books and through online material. However, many studies have highlighted the positive value of innovative teaching methods that are interactive and student-centered. A recent meta-analysis compared 158 studies of student performance under active learning with 67 studies under traditional lecturing. It demonstrated that active learning increases both performance and motivation, and decreases failures [1]. For this reason, innovative and interactive teaching methods should be developed. Various interaction tools are available to improve students’ learning performances and motivation such as mime, simulation, and games. Amongst them, gaming is of particular interest because it induces a pleasant and friendly emotional context that improves motivational attention [2] and academic achievements [3]. Additionally gaming allows the teacher who supervises the sessions to immediately catch the errors and correct them. Memorization can be increased by a positive emotional context, but also by the repetition of the information to be acquired, and by the use of different sensory inputs. Four main sensory inputs are involved in learning:
visual (graphs, diagrams, figures etc.); oral/hearing (speech, presentation, discussion); reading/writing; kinesthetic (by the realization of an action) [4].
Each individual, and therefore each student, develops a learning preference [4]. Offering different learning modalities can increase the probability of reaching the greatest number of students. Moreover, combining various sensory inputs is particularly interesting, since people learn 10% of what they read, 20% of what they hear, 30% of what is shown and 90% when what is said and done are combined [5,6]. The ‘‘Hat Game’’ is a traditional game, which most people know, notably because various versions have been marketed. We thought that the ‘‘Hat Game’’ would be an interesting tool to learn neurological semiology since it involves speech,
hearing, sight and kinesthesia through reading and mime. All these various modalities reinforce the encoding of information in an active way since the students themselves are the protagonists [7–10]. Hence, we developed a neurological version of the ‘‘Hat Game’’ and assessed how it influences learning and memorization of neurological semiology in second-year medical students.
2.
Material and Method
2.1.
Students
We proposed the ‘‘Neurology Hat Game’’ to second-year medical students (Faculty of Medicine of Sorbonne University) who are learning neurological semiology. Neurological semiology can be easily described and mimed and is therefore suitable for this kind of game. Dr. M-C Renaud (senior advisor to the Dean and vice-dean at the Coordination of Studies and Internships) generated an online interactive board to propose to all second-year medical students to participate in this teaching. This has been integrated in a revision period of the neurological semiology in addition to their usual lecture courses. Groups of 12–14 students were scheduled every morning for one week in March 2017 to form teams of 6–7 students per group. Each group was supervised by a neurologist (B.D., M.M., L.L.M., A.M., F.C. and C.D.).
2.2.
The Neurological Hat Game
We used a deck of 67 cards (see Video 1). A neurological symptom or sign was written on each card (see Appendix 1). This card game was designed by B.D. and all words were reviewed and validated by two colleagues (E.R. and B.G.). The objective of the game was to guess as many words as possible in a short period (i.e. less than 1.5 minutes). There are three rounds:
in the first round, a member of one of the two teams (the clue-giver) has to make his team-mates guess the maximum number of words using any and as many descriptive terms
Please cite this article in press as: Garcin B, et al. The ‘‘Neurological Hat Game’’: A fun way to learn the neurological semiology. Revue neurologique (2019), https://doi.org/10.1016/j.neurol.2019.01.395
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as he wants in less than 1.5 min. Once this time is elapsed, a member of the opposing team starts trying to make his team guess the remaining cards of the deck, and so on, until there are no more cards left. The team that wins the most cards wins the first round; during the second round, the same deck of cards is used and students proceed in the same way but the clue-giver can give only one word to make his teammates guess which word is on the card. The team that wins the most cards wins the second round; the third and final round is similar in principle, but students have to guess the words through a mime. At the end of the three rounds, the team that has guessed the most words wins; to complete this playful revision of semiology, there was an open discussion about the symptoms or signs that remained problematic to some students between the first and second rounds. At the end of the game, there was a quick review of all semiology words that were on the cards. The whole session lasted approximately 120 minutes, including the debriefing session that lasted for 20 to 40 minutes depending on the students’ level of knowledge.
2.3.
Assessment
We obtained the authorization from the Council of Studies of the Faculty of Medicine Paris 6 to propose this teaching. In addition, all students received an information about the teaching, and all gave their informed written consent to participate in the study. As a first step, we assessed the benefit of this teaching through 43 Multiple Choice Questions (MCQs) about neurological semiology. MCQs were proposed in two sessions. First, before the game, students had to answer to MCQs. Then, after the game, they were given the 43 MCQs again, but in a different order (see Appendices 2 and 3). Only fully correct MCQs were counted as valid (1 point per MCQ), and students were given a limited time of 15 minutes to complete the MCQs. In order to assess the value of such teaching, we also proceeded to a satisfaction survey that was completed after the second MCQs session (see Appendix 4). This survey included 8 questions, and responses were given according to a 5 choices scale of Likert (1. Strongly agree, 2. Agree, 3. Neutral, 4. Disagree, 5. Strongly disagree). The whole session including the two MCQs’ sessions, the game itself, the teaching period and the satisfaction questionnaire completion lasted about 2.5 hours. Finally, we compared the neurological semiology exam’s scores obtained by the 112 students who participated in the Neurological Hat Game (NHG) to the non-participating students. The exam took place two weeks after completing the NHG.
2.4.
3.
Results
3.1.
Students
3
Out of 373 second-year medical students, 121 (32.4%) registered to the Neurological Hat Game teaching. Of those, 112 students took part in the teaching (9 were absent). Eightytwo participants were women (73%). Ten sets of 9 to 13 students were formed and each group was divided into two teams.
3.2.
MCQs results
Of the 112 students, 107 completed the MCQs before and after the game. Four students did not complete the MCQs because they arrived late (after the completion of the MCQs before the game) and one student had to leave before completing the MCQs after the game. Before the game, the mean ( SD) MCQs score was 8.44 ( 4.34). The mean ( SD) MCQs score after the game significantly increased to 15.56 ( 5.8) points (P < 0.001, N = 107, Fig. 1). Only seven students had a mark greater than or equal to 15 before the game as compared to 55 students after the game. All students improved except one student who regressed and two students with steady marks.
3.3.
Satisfaction survey
All of the 112 attending students completed the satisfaction survey immediately after the game except for the student who had to leave before the end of the session and who sent his evaluation later by email. This corresponded to a total of 896 responses. All eight questions obtained a median response of 1, with mean responses below 1.4 for all questions (see Table 1). Only 21 out of 896 responses were given a score above 2 by 10 students. Amongst these 21 responses, 18 were a score of 3 (neutral), and only one student responded above 3 to questions. Notably, all students agreed that the exercise was playful (3 agreed, and 109 strongly agreed).
3.3.1.
Grades on the Neurology exam
The final exam scores of the 112 students (group 1) who participated in the NHG were compared to those obtained by the 259 students (group 2) who did not participate in the NHG (in this group, two students were not included because they missed the final exam). None of the group 1 students scored less than 10 (out of 20) while 10 students scored less than 10 in group 2. The average neurology exam score was significantly higher in group 1 than in group 2 (13.65 1.4 vs. 13.21 1.7, t-test bivariate, P = 0.016).
4.
Discussion
Statistical analysis
The data are expressed as mean standard deviation (SD), percentage. T-tests or paired t-tests were used for statistical analysis. Analyses were performed on Sigmastat software (https://systatsoftware.com/products/sigmastat/).
This study shows that the neurological hat game can be used to teach neurological semiology. This playful method allows an overview of the main neurological signs, symptoms, and syndromes in a short period and in a fun way. Students who played the NHG increased their marks on the day of the game
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e:floats>Fig. 1 – Distribution of students’ marks before (red) and after (blue) the Neurological Hat Game (NHG). There was a significant improvement in performances after the NHG. X axis: subsets of scores obtained in MCQs; Y axis: absolute number of students within each subset.
Table 1 – Assessment of students’ satisfaction regarding the Neurological Hat Game. Propositions About the neurology hat game:
Mean SD From 1: strongly agree to 5 strongly disagree
It is playful Helped to better understand Helped to better remember Was helpful for reviewing your upcoming exam Increased your motivation to learn neurological semiology Terms are appropriate Should be repeated in the future Should be extended to other medical specialties
1.03 0.16 1.17 0.44 1.30 0.64 1.24 0.51 1.34 0.63 1.32 0.56 1.07 0.29 1.17 0.40
Abbreviations: SD: standard deviation; Med: median. Responses ranged from 1. Strongly agree, to 5. Strongly disagree. Abbreviations: SD: standard deviation; Med: median. Responses ranged from 1. Strongly agree, to 5. Strongly disagree.
but also a few weeks later at the final neurological semiology exam as compared to students who did not participate in the NHG. Neurological semiology is considered by a majority of students as difficult to master, and medical students are considerably neurophobic [11]. Anxiety has a negative impact on attention, memory and metacognition [12]. On the contrary, it has been shown that positive mood is associated with better memorization [13], and students who have a high interest in and enthusiasm for a subject have better grades [14,15]. Playful teaching methods are of particular interest for neurological semiology to remove the anxiety associated with this discipline, and to increase motivation [16,17]. In this study, the satisfaction survey showed that students were very satisfied with the teaching approach. All students agreed that the teaching method was playful. The playful aspect induces a positive emotional context that stimulates memorization [18], possibly through the involvement of mesocorticolimbic emotional circuits [19,20]. The hat game involves four learning modalities: reading, hearing, gesture and vision. This multimodal learning is also of particular interest for students who have a predominantly multimodal learning preference, especially of the oral and
kinesthetic types [4]. It is also in agreement with the hub-andspoke model of semantic cognition, which suggests that multimodal, sensorimotor, cognitive and emotional engagement are the core ‘ingredients’ for constructing concepts [21]. Additionally, the hat game requires the repetition and categorization of information through two different modalities (language and sight). The mime (gesture), as practiced during the third round of the hat game, previously showed effectiveness on memorization not only in the short term but also in the long term [22,23]. Here, we showed that students who participated in the NHG had better results in the final exam compared to those who just completed the faculty courses. This indicates a benefit of this teaching on short-term memorization [16], but possibly also on longer term memorization. The hat game has practical advantages. First, it requires very little material since it is only based on the use of cards. Second, most people already know the rules of the game. Third, it can be played anywhere (faculty or ward room, outdoors, or at home). Therefore, this low-cost interactive teaching could easily be implemented in any University worldwide, even in resource-constrained teaching environments.
Please cite this article in press as: Garcin B, et al. The ‘‘Neurological Hat Game’’: A fun way to learn the neurological semiology. Revue neurologique (2019), https://doi.org/10.1016/j.neurol.2019.01.395
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Despite the positive results, there are some limitations to our study. First, participation was based on volunteering, which could represent a major selection bias. Motivated and hard-working students may have been more likely to participate, which might eventually account–at least in part–for group difference in the performance at the final examination. Alternatively, the students having difficulties with learning neurology and seeking a way to overcome it may have been more prone to participate. A randomized study on a whole year group of students would be necessary to answer this question. Second, the control group did not have an additional lecture in order to compare the NHG to a classical supplementary teaching. Additionally, the neurological semiology exam was performed only two weeks after the teaching. An assessment of knowledge at a longer term would be necessary to determine the impact of the NHG on long-term memorization. It would also be useful to determine how this improved knowledge is converted into practical proficiency. In conclusion, the neurological hat game seems to be an interesting educational approach considering both the improvement of students’ performances after the course and their feedback from the satisfaction survey. These promising results require confirmation via a randomized controlled study conducted on an entire school year.
Consent for participation and publication Oral information on the purpose and the course of this study was given to the students and .all the students gave their informed written consent to participate. They all gave their consent for publication of the data.
Availability of data and material The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Ethical Statement We performed this study with the authorization from the Council of Studies of the Faculty of Medicine Paris 6.
Disclosure of interest The authors declare that they have no competing interest. This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Acknowledgements We thank Olivier Steichen and Alexandre Duguet for their help in the organization of the study, and Se´bastien Balverde for English edition of the manuscript. We thank Arlette Welaratne and Marta Ruiz for their help in video-editing.
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Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j. neurol.2019.01.395.
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