title: Assessing the validity of using serious game technology to analyze physician decision making.
abstract: BACKGROUND
  Physician non-compliance with clinical practice guidelines remains a critical barrier to high quality care. Serious games (using gaming technology for serious purposes) have emerged as a method of studying physician decision making. However, little is known about their validity.
  
  
  METHODS
  We created a serious game and evaluated its construct validity. We used the decision context of trauma triage in the Emergency Department of non-trauma centers, given widely accepted guidelines that recommend the transfer of severely injured patients to trauma centers. We designed cases with the premise that the representativeness heuristic influences triage (i.e. physicians make transfer decisions based on archetypes of severely injured patients rather than guidelines). We randomized a convenience sample of emergency medicine physicians to a control or cognitive load arm, and compared performance (disposition decisions, number of orders entered, time spent per case). We hypothesized that cognitive load would increase the use of heuristics, increasing the transfer of representative cases and decreasing the transfer of non-representative cases.
  
  
  RESULTS
  We recruited 209 physicians, of whom 168 (79%) began and 142 (68%) completed the task. Physicians transferred 31% of severely injured patients during the game, consistent with rates of transfer for severely injured patients in practice. They entered the same average number of orders in both arms (control (C): 10.9 [SD 4.8] vs. cognitive load (CL):10.7 [SD 5.6], p = 0.74), despite spending less time per case in the control arm (C: 9.7 [SD 7.1] vs. CL: 11.7 [SD 6.7] minutes, p<0.01). Physicians were equally likely to transfer representative cases in the two arms (C: 45% vs. CL: 34%, p = 0.20), but were more likely to transfer non-representative cases in the control arm (C: 38% vs. CL: 26%, p = 0.03).
  
  
  CONCLUSIONS
  We found that physicians made decisions consistent with actual practice, that we could manipulate cognitive load, and that load increased the use of heuristics, as predicted by cognitive theory.
authors.affiliation: Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
authors.forename: Deepika
authors.initials: D
authors.lastname: Mohan
authors.affiliation: Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
authors.forename: Derek C
authors.initials: DC
authors.lastname: Angus
authors.affiliation: Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
authors.forename: Daniel
authors.initials: D
authors.lastname: Ricketts
authors.affiliation: RAND Corporation, Pittsburgh, PA, United States of America.
authors.forename: Coreen
authors.initials: C
authors.lastname: Farris
authors.affiliation: Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA, United States of America.
authors.forename: Baruch
authors.initials: B
authors.lastname: Fischhoff
authors.affiliation: Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Rosengart
authors.affiliation: Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
authors.forename: Donald M
authors.initials: DM
authors.lastname: Yealy
authors.affiliation: Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
authors.forename: Amber E
authors.initials: AE
authors.lastname: Barnato
mesh_terms: D003657:Decision Making; D003658:Decision Making, Computer-Assisted; D004635:Emergency Medicine / Q000379:methods; D004636:Emergency Service, Hospital; D006801:Humans; D010360:Patient Transfer; D010820:Physicians; D014218:Triage / Q000379:methods; D018910:Video Games