An educational game is defined as a competitive activity with a prescribed setting constrained by rules and procedures [3]. Learning results from peer interaction and feedback in an entertaining and low risk environment. By allowing active learning experiences, educational games stimulate higher thinking such as analysis, synthesis, and evaluation [4]. They make the learning process fun and exciting and reduce stress and anxiety, which in turn may increase retention [5]. They also can generate useful points of departure for discussion [6]. In a national survey of internal medicine program directors, 90% supported the use of educational games as an educational strategy while 78% reported already using educational games (unpublished data).

Thus, educational games represent an educational strategy of growing interest and has the potential to improve adherence to CPGs [7,8]. Indeed, these games could be used in multifaceted interventions, could be tailored to the particular setting of residency training, and would address two of the major barriers to adherence to CPGs [9]: the lack of awareness of CPGs and the lack of familiarity with their recommendations. Formal and informal discussions with internal medicine residency program directors and chief residents at the national and local level revealed a need for additional strategies for teaching CPGs with an interest in educational games as a potential strategy.

The Guide-O-Game^© has a number of shortcomings. First, it requires frequent updates as new guidelines or updates of guidelines are published. Second, because only two teams compete, there might be too many participants per team which could negatively affect the learning experience of some of these participants. Third, the Guide-O-Game^© addresses only 2 of the 7 general categories of barriers to physicians' adherence to CPG (i.e., lack of awareness and lack of familiarity). Consequently it would be ideal to implement it as part of a multifaceted interventions [1]. Finally, educational games in general can be expensive to implement, and time consuming to develop [13]. The evaluation of the acceptability of the game was limited by our use of a convenience sample of residents. Also because of the qualitative nature of the evaluation, we used a non-standardized non-validated measurement tool.

The Guide-O-Game^© has a number of strengths. First, it requires less faculty preparation than other educational interventions because it could be made available with ready-to-use questions. This is advantageous for teaching evidence based medicine in general [14], and particularly because time constraints on faculty is reportedly the major barriers to teaching CPGs in Internal Medicine residency programs (unpublished data). Second, the tool can be used by 2 competing single users (instead of teams) or as a tutorial for individual review of CPGs questions. Third, the Guide-O-Game^© tool can be adapted for teaching in other specialty residency programs, in countries other than the United States and other content than CPGs. However, this type of educational game is probably most effective for teaching factual information. Indeed, when we initially got interested in exploring the value of educational games in residency training, we focused on guidelines that intended to make clear-cut recommendations and selected strong recommendations based on a clear balance of benefits-downsides.

Other relatively simpler tools, such as Microsoft PowerPoint slide sets with hyperlinks from questions to answer slides, are available on the Internet for adaptation for educational games. The developed interface is superior to those simpler tools for managing the game as it simplifies question creation and editing, allows automated data collection, and produces usage reports. It is also superior for running the game considering the automated scoring, the entertaining sounds, and the imbedded countdown clock.

We are currently developing a web-enabled version of the Guide-O-Game^©. From the user point of view, the web-enabled version would allow players of different geographical locations to play together (e.g., in a national competition). From the manager point of view, the web-enabled version would allow question developers to upload questions on the Internet and Guide-O-Game^© users to download them in a timely and efficient manner. It would also allow centralized collection of performance data (e.g., answers to question) for multicenter research purposes and for validating questions.