Assignment 4

20,000 Microfathoms Under the Skin


This game design process would occur no later than one-third of the way into an anatomy and physiology course, and the major subjects covered, would be elements of anatomy and physiology (4), commonly known as “A&P”.

Ideally, the students taking part could begin designing and testing our their mini-games the first and second week of class, and it can be presented as a creative coping method of dealing with a challenging topic, one that many students experience anxiety over (Chace, 2014).

Learners, Subject, and Formal Learning Environment

The target learners (3) are health science learners, particularly those studying either nursing, physician assistant studies, or an allied health field such as physiotherapy, and occupational therapy. The rationale for focusing on non-physician learners is that many students entering nursing, allied health or even the graduate medical field of physician assistant studies, have not already taken common pre-med and science courses during high school or undergraduate programs. Typically, all of these learners would be in a cohort taking lockstep training and classes as a group, even if there are as many as 90 learners in a cohort. That cohort should enjoy a minimum of 3 to 5 hours each week for open-ended “game design” (5), and can be encouraged to participate in additional study sessions with friends during meal periods, and after class. Many, many hours are typically devoted by these same learners to practice of new A&P knowledge; the “game design” period may be welcomed as a break.

Game Design Task and Purpose

Small groups of learners should develop a game that will help the next cohort, as well as their classmates, traverse inside the human body* and use medications or movement to jump-start bodily processes (6). The broad idea for this game is influenced by the movie Fantastic Voyage (David & Fleischer, 1966), which involved a group of doctors and allied health personnel racing the clock to save a patient’s life by being miniaturized, and sent in a vessel that traversed the patient’s bloodstream and organs.

(* Note – this could also be adapted to veterinary students who can design games taking place inside different, living, animal bodies.)

Student groups would have the option of selecting specific body systems that they wish to innovate as a game, from a larger group of options: cells, general tissues, axial skeleton, appendicular skeleton, axial tissues, etc. The game must help the player better memorize and identify anatomical locations, but also the physiological actions that take place in different locations. The game must take place inside these locations and reinforce the player’s ability to identify unique qualities of anatomy and their physiological functions. For instance, a goal of one game might be to turn on the “pacesetter cell” inside the patient’s stomach, to trigger contractions in the stomach’s smooth muscle tissue.

The purpose of the game task (7) is to help reinforce the learning and memorization of anatomy and physiological knowledge, commonly known as the most difficult classes in the health science curriculum. Learners will not only know what areas are difficult to remember, and understand, and can incorporate that into their games, but reinforce their visual-spatial skills, which can make a key difference in their A&P performance (Lufler, Zumwalt, Romney, & Hoagland, 2012; Bogomolova, Hierck, van der Hage, & Hovius, 2019).

Lower spatial ability or practice has been suggested as a reason why some STEM fields have fewer women (Dawson, 2019). In a STEM field like nursing or occupational therapy, which has many women students with less prior STEM training as undergraduates, this could particularly be helpful for bridging a “spatial practice” gap. It will also help learners build on awareness of how the actual physiological processes occur by turning them into games.

If the game is designed from an object-oriented outlook, there may be a parallel between understanding object-oriented programming, or the modification of data inside an object, and understanding the way that physiological functions can be modified inside an anatomical organ or other “object”.

This is a creative way to apply concepts that health science learners must learn in order to succeed in their programs, and problem-solve through health issues through visualization and educational gaming. This task can allow students to start scaffolding the learning of difficult words and processes.

Anatomy and physiology are broadly known to require memorization and repetition before they become part of the learner’s professional knowledge base. Students would benefit from working together rather than individually (9), not only because some may be intimidated by learning a technical task, and feel more supported in trying something outside their comfort zone, but also because teamwork and emotional intelligence is crucial to becoming a successful health care professional. Team learning has specifically been found to aid in anatomy learning and performance (Huitt, Killins, & Brooks, 2015; Isbell, Makeeva, Caruthers, & Brooks, 2016).

Conceivably, advanced learners in practice (such as medical residents, or existing professionals working on doctorate degrees) could design effective games that would teach younger cohorts and also help them creatively visualize new methods of providing medical treatment.

Based on the games I tested out on the platform, and my experience working with medical, nursing, PT, OT, and PA students – my first choice for game design software would be MIT’s Scratch, because of its visual orientation and what appeared to be a very, very low barrier to entry. Students could import graphics and figure out how to use the existing sprites in the program to mimic different states of physiology, and how to get different systems, organs, etc., back to homeostasis.

However, I had difficulty testing out Scratch for myself, thanks to the tutorial getting “stuck” in some kind of feedback loop that never exited “Creating Project”. The two next best choices would be Alice and Kodu. Both of these were developed as educational game development engines that integrate knowledge about object-oriented programming.

While Alice 3 has a powerful set of tools for storytelling, and would be an excellent choice for additional constructivist game development among health science learners, learning anatomy means becoming comfortable with highly visual learning. In order to build a human landscape, through which the avatar of the player can play inside the muscles, organs, or skeleton parts, Kodu’s design package is superior.

Game Development Software




Kodu is a easy to use visual programming language and platform that does not require existing coding skills. Different worlds are built in, and it is easy to change the landscape and properties of the landscape, from grass to water for example. Worlds and games that have been designed by others in the Kodu community can also be loaded in.


Low barrier to entry; learners don’t need to know an existing language or have coding experience. Highly visual.

Utilizes object-oriented programming as part of its underpinning, which may metaphorically help students think critically about the connection between anatomy and physiological processes occurring in specific organs, systems, locations, etc.

Kodu is free and easy to download (~3 minutes on a T1 line at a university; could probably be packaged and deployed to existing computers in a lab). Requires no keys.

Macs are common in the health science classroom; Kodu can be run on an emulator inside a Mac computer.


Ideally in the first week and no later than the third week of a 11 to 13 week course, learners should be introduced to the Kodu program, the purpose of the game design, and shown a sample game that allows a small avatar craft to swim inside a small cut in the epidermis of the arm, into the dermis, where a gland will be stimulated by the avatar to make oil, enough to become a pimple.

In that first class, learners will then be asked to break into groups of no less than four people. They will be encouraged to start playing Kodu games and playing with the tool as the teacher walks through and answers questions. The teacher will pause the practice at the halfway mark, and then suggest that they select one area of the body they would like to design a mini-game around, and at least one function for the body to practice.

Typically, cohorts have one or more classrooms where most of their class time takes place; for example, the teachers might move into the room rather than the students moving into a teacher’s main location. There is typically, in physiotherapy and occupational therapy classrooms, at least one classroom with a lab attached. Each week, at an appropriate time, the students should be given free time to continue working on their game, and to ask questions and share feedback among the cohort.

By the 7th or 8th week of classes, in-progress games should be shown to the group, with additional feedback requested. This may help some students break blocks; some students may have superior visual designs in their games but difficulty with designing the game play; others may have the reverse problem. During the free time from this point on, multiple groups will now be encouraged to work together to resolve the games’ issues and to play through each others’ designs.

During the last weeks of class, when review is of the utmost importance (and all students will expect to take high-stakes testing on this subject), students should be encouraged to bring in visual aids to help with the learning of anatomy and physiological processes, for placing up on a bulletin board or even presenting on an overhead projection screen. Learners can discuss as part of a group what seemed “easy” to understand through the game lens, and what seemed hard, how gaming can help with visualization and practice of both working with a patient and conceiving of what is happening “under the skin”. This information should be collected and shared (along with finished and unfinished games) with the next cohort.

In order to study this game design process formally (12), a qualitative study could be designed to collect information and observe students during the design phase of games, during the “free time” carved out into the regular time spent together in a cohort classroom. Students could also be interviewed individually, and then given an open-ended questionnaire to fill out to describe their experience and sense of self-efficacy with design, approximately a semester later, including their suggestions for improving the practice. A mixed methods study could also incorporate the quantitative study of students’ grades in anatomy and physiology courses, including on high-stakes multiple choice tests.

Proposed Research Questions (11):

R1. Does designing a basic mini-game about anatomy and physiological functions increase self-efficacy among health science learners studying A&P?

R2. Does constructivist design of a mini-game on anatomy and physiological functions increase performance by health science learners on high-stakes A&P tests?


Bogomolova, K., Hierck, B. P., van der Hage, J.A., & Hovius, S. E. R. (2019). Anatomy dissection course improves the initially lower levels of visual-spatial abilities of medical undergraduates. Anatomical Sciences Education, [in press].

Chace, Z. (2014, September 2). The toughest class in nursing school is the first one. All Things Considered. Radio broadcast retrieved from

David, S., & Fleischer, R. (1966, August 24). Fantastic Voyage. [Motion picture]. United States: Twentieth Century Fox.

Dawson, C. (2019). Tackling limited spatial ability: Lowering one barrier into STEM?. European Journal of Science and Mathematics Education, 7(1), 14-31.

Huitt, T. W., Killins, A., & Brooks, W. S. (2015). Team‐based learning in the gross anatomy laboratory improves academic performance and students’ attitudes toward teamwork. Anatomical Sciences Education, 8(2), 95-103.

Isbell, J. A., Makeeva, V., Caruthers, K., & Brooks, W. S. (2016). The impact of team-based learning (TBL) on physician assistant students’ academic performance in gross anatomy. The Journal of Physician Assistant Education, 27(3), 126-130.

Lufler, R. S., Zumwalt, A. C., Romney, C. A., & Hoagland, T. M. (2012). Effect of visual–spatial ability on medical students’ performance in a gross anatomy course. Anatomical Sciences Education, 5(1), 3-9.

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