Choose Your Own Adventure! – Engaging Learners in Digital, Interactive Patient Stories

By: Morgan P. Stewart, Pharm D, BCACP

Have you recently given a virtual lecture to an audience of blank screens or had learners admit to “Zoom fatigue”? Amidst the COVID-19 pandemic, higher education institutions across the world have rapidly adapted their teaching strategies to a primarily online format. One challenge with online courses lies in optimizing student engagement and interaction.¹ Choose-Your-Own-Adventure (CYOA) books were developed in the 1970s as a popular interactive gamebook for leisure reading, and the concept has since been adapted in educational curricula.² The concept of CYOA is non-linear storytelling where the participant determines their own storyline through a series of choices. Traditional in-class activities have been described utilizing CYOA format, and online unfolding cases have been used to develop clinical reasonings skills.³  However relevant pharmacy literature is limited in delivering a CYOA case in a virtual, synchronous pharmacy education course using Google Forms as the platform of delivery. ^{4, 5}   

As part of an ambulatory care elective for 38 third-year PharmD students in the pharmacy curriculum, a two-hour class session was dedicated to the treatment of hypertension. As a flipped classroom format,  students completed prep-work prior to class and used in-class time to build upon concepts. Students in this elective had already completed 4 hours of hypertension pharmacotherapy in the core curriculum. To apply knowledge to the ambulatory care setting, a CYOA activity was created using the online platform Google Forms. Five hours of preparation work were required to develop the case with multiple story lines, with an additional ten hours of time inputting the scenarios onto the online platform. The form consisted of 148 “sections” to accommodate all of the potential responses students could have selected. Humor in the storylines was incorporated to create a fun and enjoyable environment.  Survey logic (see Picture 1) was utilized to provide feedback on the clinical decision-making. Students navigated the “adventure” together in breakout groups of 2-3 students and talked through their decision making for about thirty minutes; then, all students returned back to the main virtual classroom to discuss their experiences, items for clarification, and lessons learned. Case decisions were not graded and only served as an educational tool. 

Most scenarios in the CYOA activity represented a “grey” area of practice in which there were multiple correct decisions that could have been made, just like a real-life setting. For example, a patient with a compelling indication for a beta-blocker, but the patient’s pulse was on the lower end of normal. However, other responses contained a “most correct” answer that should have been chosen in the patient’s best interest. For example, if a thiazide-diuretic dose was increased, but the labs showed hyponatremia, students were redirected to a section that explained the risks and potential adverse outcomes of this decision.  One objective of the activity was for students to learn how to prevent unnecessary provider encounters when given a patient scenario. Before starting the game, students were briefed about how extra encounters are associated with less efficient care, higher costs to the system, and extra work for all individuals involved. For example, if students chose to wait a month to start an anti-hypertensive, when the best choice was to start pharmacotherapy based on current guideline recommendations, students generated an extra encounter for the patient and were sent to a prompt explaining clinical inertia (see Picture 2). 

Discussion/Limitations:

• 8 students completed activity evaluations and reported the activity: “engaged the class with an extremely helpful and realistic patient case”, “really helped me to discover a new way to study”, and “was a creative way to engage all students while testing our knowledge”
• This activity worked very well for an elective, flipped classroom course, as students generally chose to take this course based on interest in the content and were conditioned to actively participate in class. 
• Google Forms does appear to have a “capacity” for number of sections. After ~100 sections were added, the form was very slow to load content. Duplicative work could be avoided by utilizing a platform with a higher data capacity. 
• Google Forms was not capable of counting the number of encounters generated, and thus relied upon students to keep a manual tally.

Advice and Recommendations:

• For first time creation of an activity, I highly recommend using a platform you are comfortable with in order to troubleshoot the technology easily. Other feasible platform options I could envision being utilized are Microsoft Powerpoint, InkleWriter, or TypeForm. 
• Thirty minutes for breakout rooms was great for groups who actively discussed case options together, whereas some groups finished quickly and were less likely to read the full patient scenarios. For future activities, it may be worthwhile to trial a 2-part activity where time in the breakout rooms is split up. 

To readers, do you teach a topic/course where a CYOA activity could boost engagement?

Picture 1

Picture 2

Acknowledgements

The author would like to acknowledge Drs. Nathan Pope, Kirk Evoy, and Kathryn Litten for their guidance and feedback on this blog post. 

References

1. Darby, Flower and Lang, James. “Chapter Two: Guiding Learning Through Engagement.” Small Teaching Online: Applying Learning Science in Online Classes. Jossey-Bass, 2019, pp. 27-46. 
2. Choose Your Own Adventure®. History of CYOA.
3. Johnson G, Flagler S. Web-Based Unfolding Cases: A Strategy to Enhance and Evaluate Clinical Reasoning Skills. Journal of Nursing Education. 2013;52(10):589-592. 
4. Bechkoff J. Gamification Using a Choose-Your-Own-Adventure Type Platform to Augment Learning and Facilitate Student Engagement in Marketing Education. Journal for Advancement of Marketing Education. 2019; 27(1):13-30.
5. Kiles T. Preliminary Assessment of Choose Your Own Adventure Patient Case Format. [abstract] Am J Pharm Educ. 2020 Jun; 84(6): ajpe8220. 

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Author Bio(s)

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Pulses is a scholarly blog supported by a team of pharmacy education scholars