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LIVE. DIE. REPEAT: a novel instructional method incorporating recursive objective-based gameplay in an emergency medicine simulation curriculum
  1. Kharmene Sunga1,
  2. Benjamin Sandefur1,
  3. Usha Asirvatham2,
  4. Daniel Cabrera1
  1. 1Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Mayo Clinic Multidisciplinary Simulation Center, Rochester, Minnesota, USA
  1. Correspondence to Dr Kharmene Sunga, Department of Emergency Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA; Sunga.Kharmene{at}

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Medical educators must develop instructional methods suiting the learning styles of their students. Simulation-based curriculums are popular among resident physicians, and have been shown to improve information recall and diagnostic abilities, and to sustain proficiency of procedural skills.1 The gamification of learning, a mechanism that engages students by integrating serious-game elements into the educational environment, has recently been explored.2 At our emergency medicine residency, we aimed to create a hybrid of the two models that would profit from each method's individual strengths.

Recursive objective-based gameplay (ROBG) is a serious-game scheme in which participants are allowed infinite lives so that they can achieve predetermined criteria for progression through multiple levels of increasing difficulty. The concept resembles time loops, a plot device used in the film Edge of Tomorrow (Warner Bros Pictures 2014). We named our simulation/ROBG hybrid instructional method ‘LIVE. DIE. REPEAT.’(LDR), after the tagline featured on promotional materials for the aforementioned film.

We designed a LDR curriculum targeting critical management concepts in emergent pulmonary conditions. In this manuscript, we describe the LDR concept and design, and present initial evidence supporting the effectiveness of this model in training emergency medicine residents.


The LDR design and pulmonary scenario was developed and piloted for the Mayo Clinic Emergency Medicine Residency at the Mayo Clinic Multidisciplinary Simulation Center in Rochester, Minnesota, USA. …

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  • Contributors DC conceived and led the study, and supervised the write-up. BS and UA supported the design, led the delivery of the intervention and co-drafted the manuscript. KS supported the design, aided analysis and drafted the manuscript.

  • Competing interests None declared.

  • Ethics approval Mayo Clinic Institutional Review Board.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data sharing statement The pertinent results of the study are examined in the discussion section of the paper. Detailed survey results and learner commentary regarding the LDR case design for a pulmonary module are available on request to the corresponding author at

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