An Online Spaced-Education Game for Global Continuing Medical Education A Randomized Trial

Objective: To assess the efficacy of a "spaced-education" game as a method of continuing medical education (CME) among physicians across the globe. Background: The efficacy of educational games for the CME has yet to be established. We created a novel online educational game by incorporating game mechanics into "spaced education" (SE), an evidence-based method of online CME. Methods: This 34-week randomized trial enrolled practicing urologists across the globe. The SE game consisted of 40 validated multiple-choice questions and explanations on urology clinical guidelines. Enrollees were randomized to 2 cohorts: cohort A physicians were sent 2 questions via an automated e-mail system every 2 days, and cohort B physicians were sent 4 questions every 4 days. Adaptive game mechanics re-sent the questions in 12 or 24 days if answered incorrectly and correctly, respectively. Questions expired if not answered on time (appointment dynamic). Physicians retired questions by answering each correctly twice-in-a-row (progression dynamic). Competition was fostered by posting relative performance among physicians. Main outcome measures were baseline scores (percentage of questions answered correctly upon initial presentation) and completion scores (percentage of questions retired). Results: A total of 1470 physicians from 63 countries enrolled. Median baseline score was 48% (interquartile range [IQR] 17) and, in multivariate analyses, was found to vary significantly by region (Cohen d(max) = 0.31, P = 0.001) and age (d(max) = 0.41, P < 0.001). Median completion score was 98% (IQR 25) and varied significantly by age (d(max) = 0.21, P < 0.001) and American Board of Urology certification (d = 0.10, P = 0.033) but not by region (multivariate analyses). Question clustering reduced physicians' performance (d = 0.43, P < 0.001). Seventy-six percent of enrollees (1111/1470) requested to participate in future SE games.