Background: Between 30 and 40 % of patients with severe injuries receive treatment at non-trauma centers\n(under-triage), largely because of physician decision making. Existing interventions to improve triage by physicians\nignore the role that intuition (heuristics) plays in these decisions. One such heuristic is to form an initial impression\nbased on representativeness (how typical does a patient appear of one with severe injuries). We created a video\ngame (Night Shift) to recalibrate physician�s representativeness heuristic in trauma triage.\nMethods: We developed Night Shift in collaboration with emergency medicine physicians, trauma surgeons, behavioral\nscientists, and game designers. Players take on the persona of Andy Jordan, an emergency medicine physician, who\naccepts a new job in a small town. Through a series of cases that go awry, they gain experience with the contextual\ncues that distinguish patients with minor and severe injuries (based on the theory of analogical encoding) and receive\nemotionally-laden feedback on their performance (based on the theory of narrative engagement). The planned study\nwill compare the effect of Night Shift with that of an educational program on physician triage decisions and on physician\nheuristics. Psychological theory predicts that cognitive load increases reliance on heuristics, thereby increasing\nthe under-triage rate when heuristics are poorly calibrated. We will randomize physicians (n = 366) either to\nplay the game or to review an educational program, and will assess performance using a validated virtual\nsimulation. The validated simulation includes both control and cognitive load conditions. We will compare\nrates of under-triage after exposure to the two interventions (primary outcome) and will compare the effect\nof cognitive load on physicians� under-triage rates (secondary outcome). We hypothesize that: a) physicians\nexposed to Night Shift will have lower rates of under-triage compared to those exposed to the educational\nprogram, and b) cognitive load will not degrade triage performance among physicians exposed to Night\nShift as much as it will among those exposed to the educational program.\nDiscussion: Serious games offer a new approach to the problem of poorly-calibrated heuristics in trauma\ntriage. The results of this trial will contribute to the understanding of physician quality improvement and\nthe efficacy of video games as behavioral interventions
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