Diabetes 2013 July-5


InsuOnline, a Serious Game to Teach Insulin Therapy to Primary Care Physicians: Design of the Game and a Randomized Controlled Trial for Educational Validation

Leandro Arthur Diehl, Rodrigo Martins Souza, Juliano Barbosa Alves, Pedro Alejandro Gordan, Roberto Zonato Esteves, Maria Lúcia Silva Germano Jorge, Izabel Cristina Meister Coelho. Faculdades Pequeno Príncipe, Curitiba, PR, Brazil. drgaucho@yahoo.com

JMIR Res Protoc. 2013 Jan;2(1):e5



Background: Physicians´ lack of knowledge contributes to underuse of insulin and poor glycemic control in adults with diabetes mellitus (DM). Traditional continuing medical education have limited efficacy, and new approaches are required.

Objective: We report the design of a trial to assess the educational efficacy of InsuOnline, a game for education of primary care physicians (PCPs). The goal of InsuOnline was to improve appropriate initiation and adjustment of insulin for the treatment of DM. InsuOnline was designed to be educationally adequate, self-motivating, and attractive.

Methods: A multidisciplinary team of endocrinologists, experts in medical education, and programmers, was assembled for the design and development of InsuOnline. Currently, we are conducting usability and playability tests, with PCPs and medical students playing the game on a desktop computer. Adjustments will be made based on these results. An unblinded randomized controlled trial with PCPs who work in the city of Londrina, Brazil, will be conducted to assess the educational validity of InsuOnline on the Web. In this trial, 64 PCPs will play InsuOnline, and 64 PCPs will undergo traditional instructional activities (lecture and group discussion). Knowledge on how to initiate and adjust insulin will be assessed by a Web-based multiple choice questionnaire, and attitudes regarding diabetes/insulin will be assessed by Diabetes Attitude Scale 3 at 3 time points—before, immediately after, and 6 months after the intervention. Subjects´ general impressions on the interventions will be assessed by a questionnaire. Software logs will be reviewed.

Results: To our knowledge, this is the first research with the aim of assessing the educational efficacy of a computer game for teaching PCPs about insulin therapy in DM. We describe the development criteria used for creating InsuOnline. Evaluation of the game using a randomized controlled trial design will be done in future studies.

Conclusions: We demonstrated that the design and development of a game for PCPs education on insulin is possible with a multidisciplinary team. InsuOnline can be an attractive option for large-scale continuous medical education to help improving PCPs´ knowledge on insulin therapy and potentially improving DM patients´ care.

Trial Registration: Clinicaltrials.gov: NCT01759953; http://clinicaltrials.gov/show/NCT01759953 (Archived by WebCite at http://www.webcitation.org/6Dq8Vc7a6).



Worldwide, most diabetic patients are treated by medical doctors who are not specialist in diabetes, and these professionals tipically lack knowledge and confidence regarding insulin therapy for diabetes. However, most diabetic patients will need insulin at some point, but general practitioners´ and primary care physicians´ difficulties regarding insulin contribute to clinical inertia (the lack of intensification of medical therapy when it is necessary) and poor glycemic control, increasing the risk of diabetes chronic complications. In Brazil, only 24% of diabetic patients studied in a nationwide survey were considered well-controlled.

As the current undergraduate and postgraduate medical education is deficient for preparing physicians to correctly use insulin in the treatment of diabetes, our group developed InsuOnLine, a serious game to complement primary care physicians´ competence to prescribe insulin for diabetic patients (Figure 1). Our objective was to create a game that could be played either on computers or on tablets or smartphones, and which could be useful as an educational tool for medical doctors as well as fun.

The game was designed by a multidisciplinary team, including diabetes experts, medical teachers, and game designers, and the programming was made in the Unity game engine, while characters´ modeling and animation was performed in 3D-Suite Blender. The Figures 2 and 3 show some screenshots from the game.

In the game, the player takes on the role of a young doctor, in a primary health care unit, where he must see a series of diabetic patients who need initiation or adjustment of insulin in order to reach a better glycemic control. During the game, the player must make the best decisions on how to use insulin for each case. The game gives immediate feedback, comparing player´s decisions with the recommendations from current published guidelines on diabetes treatment.

We will perform usability and playability tests, with a group of medical doctors and students of both genders, with varied degrees of computer and game expertise. The results of those tests will guide further adjustments in the game.

Finally, we will perform a randomized controlled trial, where a group of primary care physicians will play InsuOnLine, while the control group will take part on a traditional instructional activity (lectures and discussion). We will assess if our game can be as effective for teaching insulin therapy basics as the traditional approach. In our paper, we describe in detail the rational and the design of our research protocol.

We expect, with this study, to demonstrate that a well-designed serious game can be an effective and attractive option for large-scale continuing medical education (CME) on insulin therapy for diabetes. Besides that, InsuOnLine includes game elements in order to make it fun and self-motivating, which we know can improve players´ learning and content retention. Another advantage of a serious game like ours is that it can be used in flexible time schedules and in any location, making it a much more convenient (and, possibly, less expensive) option for the target audience, compared to today´s most commonly used CME modalities: medical conferences or symposia, or postgraduate medical courses. The medical doctors can be exposed to a great number of different virtual patients or clinical scenarios, and they can learn how to best manage them without exposing real patients to the risk of eventual error and injuries.

We hope that our work can contribute to improve the quality of medical care given to diabetic patients, reducing their risk of serious long-term diabetes complications, and also to stimulate and support the development of new serious games and simulators for the education of health professionals on many other fields.

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Figure 1 – InsuOnLine logo.


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Figure 2 – The player´s avatar is a young doctor – who is a gamer, too!


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Figure 3 – Screenshot of the physical examination of the virtual diabetic patient.



leandro_diehlThe author:

Leandro Diehl was lead author in this paper and thanks his co-authors for all their invaluable help and support. He is a clinical endocrinologist, medical teacher at Londrina State University (UEL), and also a games enthusiast. He is currently developing his PhD thesis on the assessment of InsuOnLine as an educational tool for primary care physicians, together with the Health Education research group at Faculdades Pequeno Príncipe (FPP), in Curitiba, Brazil. The game was developed in collaboration with Oniria Software, located in Londrina, Brazil.

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