Gaming infectious diseases – an interview with Salam Abbara

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Could board games be used as an educational tool to help teach and raise awareness around some of the major challenges in infectious diseases? In this interview we speak to Salam Abbara following her presentation at the European Congress of Clinical Microbiology and Infectious Diseases (11–16 April, Amsterdam, the Netherlands) about the game she has helped develop with Liem Binh Luong Nguyen, which aims to help medical students learn and understand antibiotic prescribing.

First, could you introduce yourself and give a brief summary your career to date?

My name is Salam Abbara and I am a resident in internal medicine and infectious diseases in Paris (France). I am now doing my last year of residency. During my curriculum, I also did my master’s degree in interdisciplinary research biology and once I finish my residency, I will do a PhD in epidemiology.

Could you outline the research you’re presenting here?

So, the game we are presenting is a table game. The main audience is students and residents – so primarily prescribers – and the main objective is for the game to teach them the prescribing reasoning for antibiotics. We saw during our practice that it is quite difficult for students and residents to be able to merge all the information needed to decide on which antibiotic is appropriate, so we created the game to educate people on these factors – taking into account patients, bacteria etc. – but to do this learning via a fun process.

The main interactions in the game are a combination of three things. First, within teams you must collaborate to infect the patient of another team. So, you have to consider the patient background, is it an immunocompromised patient? What is the site of infection? What are the infecting bacteria and their resistance profile? Because the game is played within teams, we hope that no one will feel stigmatized, if they don’t know they can collaborate with teammates to find a good answer.

The second level of interaction in the game is between teams: each team infects patients of the other team and then the other team has to find the appropriate treatment. The third level of interaction is with a mentor. You are supposed to have a specialist on the table to guide players on, for example, whether the treatments are appropriate, whether the drug combinations exist in real life etc., and this is more for the educative process. However, we are also working on a companion app that will allow people to play without a senior physician or mentor present, they could just scan QR codes and then the app would give them information.

Finally, there is this process of infecting people and there are also special cards that can make things a bit more exciting, for example, there is septic shock, which gives the opposing team only one turn to treat the patients. And to add a final level of complexity there is a resistance scale, each patient has a resistance scale and each antibiotic has a specific penalty linked to how broad-spectrum the antibiotic is and whether it is thought to impact the microbiota of the patient – so that makes the game more exciting!

What are the current issues surrounding antibiotic prescribing?

The main problem that we encounter is that antibiotic prescribing is quite difficult to access because the reasoning is very complex and depends on lots of factors at the same time; the patient background, site of infection; clinical presentation, presence of sepsis or hemodynamic dysfunction, the infecting bacteria and the possibility of resistance. If you want to teach this to a medical student or resident, it is quite hard to address this easily. At the same time, it is very important to understand this because nowadays we really have a problem with superbugs emerging and we know that a key way to address it is to master antibiotic consumption and reasoning in order to promote good use of antibiotics. This is what we wanted to work on but with a different and more fun process than the usual one!

You have talked about your app – How do you think gaming technologies can help improve clinical practice with regards to antibiotic prescribing?

There are a lot of possibilities. Our game is mainly a table game, as we thought that for the educational process it would be much more interesting to discuss things and that’s why we chose this format as opposed to a computer game you play alone. However, it is becoming more frequent in table games to have companion apps, which will in our case allow the players to play the game without an infectious disease specialist.

There are other ways game technology has been paired with targeting antimicrobial resistance, for example, there are other games being developed that are virtual reality games. You can play games on your computer (e.g. On call: antibiotics) where you have to diagnose patients and decide on the antibiotic treatment. In addition, virtual reality games have been developed for headsets where you are immersed into the game. In the future perhaps we could imagine a game where you can target infections and kill them with appropriate antibiotics. There is really a whole spectrum of games that could be appropriate to target antibiotic resistance and I think what is nice is that people are exploring them little by little.

Do you think this ‘gaming’ approach could be applicable to other issues? E.g. ensuring infection prevention and control measures?

In infectious diseases the gaming approach could be applied to any objective you want to target.  However, you would have to consider whether you needed to target more of a general audience or practitioners. For example, the e-Bug project developed games raising awareness on antibiotics, useful and harmful microbes, and hand washing that have been designed for children. They are working with teachers to teach good practice from the very beginning, which is actually the most effective way to teach people – it is better to target students than physicians and it is better to target children than adults.

Do you have any other comments you’d like to add?

With regards to turning an idea into a game the most complex thing for us was that as medical doctors, we are not game specialists, so we didn’t know how to turn our idea into reality. When we first began thinking about the game we wanted to put too much scientific content in it and we had to simplify this.

During my master’s degree I was in the Center for Research and Interdisciplinarity in Paris, and there were lots of students from other fields, so we had the opportunity to discuss and set the game rules with the help of students from video and game design schools. I think it is very important for anyone who wants to design a game to turn to game specialists because they will help you ensure that you have a good game play, which is not too complex and has a really clear pedagogic objective. Then you can add other levels of complexity if you want, but the main game should be very easy to understand and to play.

So, we had to drop lots of things that we wanted to add to the game because yes, part of it has to be educational but also it is a game so it must be fun. Sometimes elements of the game are a bit farther from reality, but they are there to make it funny; finding this balance is difficult but essential to make the game succeed.

Finally, creating this game was an interdisciplinary process and we couldn’t have made it without the help of game design students, friends, beta testers, colleagues, designers, infectious disease experts, etc. so we want to thank them all.  For the moment, our game has been endorsed by the French Society of Infectious Diseases and the College of Professors of Infectious and Tropical Diseases in France. They are helping us greatly by validating the scientific content, giving us financial help, and plan the spread of the game. We also received financial help from the Network of Young French Infectiologists and the MACSF Foundation.  We plan to launch the game in September, and distribute it to universities, infectious disease units, and individuals, then evaluate it. If anyone is interested to use or distribute it in its country, please contact us at dawaa.thegame@gmail.com.

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