The paper: Sunga K, Sandefur B, Asirvatham U, Cabrera D. LIVE. DIE. REPEAT: a novel instructional method incorporating recursive objective-based gameplay in an emergency medicine simulation curriculum. BMJ STEL. 2016 Jun 10;bmjstel-2016-000128.

LIVE.DIE.REPEAT Starter pack. Documents necessary to implement medical simulation cases using this methodology. License under Creative Commons BY NC 4.0. Please attribute to Kharmene L. Sunga, Benjamin J. Sandefur and Daniel Cabrera. (Downloads a .zip file)

Simulcast episode about LDR. ep. 8 – Live. Die. Repeat. Gamification of simulation trainingSimulcast episode about LDR.

The History

In 2015, I was taking to one of our residents about how to improve the simulation activities at our residency, while she had a lot of ideas about the curriculum her main request was to develop a way to incorporate the nuanced presentations of complex patients. She felt that sim cases usually concentrate in discrete topics with just a few critical actions and they sometimes failed to be a good representation of the increasing difficulty and unexpected situations that arise from real clinical encounters.

Around the same time, by chance, I watched “The Edge of Tomorrow”, a movie about a soldier of the future trapped in a time loop battling against aliens; the movie had the tagline LIVE.DIE.REPEAT. The main character was condemned to live the particular day of a major battle against aliens (resulting in humankind defeat) and every time he died, the loop will start again from zero. After a few iterations of the loop, he realizes that the only way to scape is to become better, by the way of practicing, and to defeat the alien invaders. This plot is similar, without the war component, to one of my favorite movies of all time, “Groundhog day”

Here comes the idea, why not incorporating the concept of the time-loop into a Simulation case? After all, the idea of practicing, and practicing, with a clear goal and curriculum while having a teacher expert on the task providing feedback are the core components of deliberate practice. So we did and we called it LDR (for LIVE.DIE.REPEAT)

We developed a simulation scenario based on a serious game scheme called Recursive objective-based gameplay (ROBG) where participants are allowed infinite lives so that they may have the opportunity to achieve specific predetermined criteria for progression through multiple levels of increasing difficulty. This was like playing Super Mario or Halo or Wolfenstein (for people my age).

First we create a team of residents and nurses who start the clinical encounter with a particular task to be achieved in a short period of time. If the team achieved the critical task within the time frame, the game was paused due to level completion (success). If the team failed the critical action, the game was declared over due to patient decompensation or death. Regardless of game pause or game over status, players participated in a 20-minute debriefing between each level focused on self-assessment and critical action performance review. Then players  were switched to a new resident/nursing team before the start of each subsequent level. Following to the ROBG style, each level began with the events of the level immediately preceding it to allow rehearsal of concepts learned during the preceding debriefing discussion.

LDR utilizes debriefings in between levels to provide performance feedback and then introduces an immediate opportunity for rehearsal of proper actions or correction of prior mistakes with each subsequent level. This is the core of deliberate practice. 

The critical high acuity nature of the scenario presented in this LDR module takes advantage of stress inoculation in which information is better retained when learned under stress versus under less tense conditions. The players felt a lower level of anxiety in knowing that the LDR module was per definition a no-win scenario, where the case will always conclude with the simulated patient dying, independently of the performance.

BONUS: Groundhog Day Trailer