Not Just Fun and Games: Game-Based Learning in Health Professions Education

Gamification in Biomedical Education

Presenter: Janniko Georgiadis of the University of Groningen in the Netherlands

Dr. Georgiadis began the webinar series with an in-depth discussion of the behavioral and neuroscientific theories linking learning motivation and gaming, and presented the findings of a recent systematic review on using games in health professions education [1]. In his presentation, he discussed the neuroscientific theory of reward-based learning and the role of the brain’s reward system in learning and motivation. He explained how the release of neurotransmitters, like dopamine during pleasurable experiences, can reinforce certain behaviors and increase the likelihood of repeating them in future behaviors. He further stressed that if we enjoy an activity or find it pleasurable, we will be more motivated to engage in it and put in more effort, leading to better learning outcomes. On the other hand, if we do not find an activity enjoyable, our motivation will be decreased, and we may perform poorly.

Dr. Georgiadis pointed out that game-based learning, i.e., acquiring knowledge in a game-like framework, relates to play. This natural learning process can be observed in both young animals and humans. He emphasized that evidence supports the effectiveness of games in engaging learners, citing the example of teenagers playing video games [2]. Dr. Georgiadis then distinguished between serious games, which have education as their primary goal (such as simulations in healthcare education), and gamification, which refers to the use of game elements in a non-game context (such as incorporating gaming elements like competition, story, and rules into an online learning platform). He discussed the nine attributes of game elements, as classified by Bedwell et al. [3] and van Gallen et al. [4]: (1) rules and goals, (2) action language, (3) assessment, (4) environment, (5) conflict/challenge, (6) control/ability to alter the game, (7) game fiction/story/narrative, (8) human interaction among players, and (9) immersion.

Dr. Georgiadis continued by discussing the findings of the systematic review, conducted by his lab and which revealed that the Medical Education Research Study Quality Instrument (MERSQI) scores of the included studies ranged from 5 to 18, with an average score of 9.8 [1]. The MERSQI is a tool designed to assess the quality of experimental, quasi-experimental, and observational research studies in medical education. This average score was considered relatively low due to the descriptive nature of most studies and the limited number of controlled studies on gamification in healthcare professional education. The game attributes most frequently studied were conflict/challenge and assessment, or a combination of these two, indicating a bias towards participant competition and individual scoring in the application of games in medical education, particularly in Western settings. While no negative effects were reported, the outcome measures of the studies primarily focused on knowledge acquisition and student satisfaction. However, Dr. Georgiadis pointed out that it is difficult to determine whether the positive effects observed were due to the use of games or other factors, such as novelty, because of the need for proper controls in the majority of studies. The review concluded that there is limited empirical evidence supporting the effectiveness of games in facilitating learning and that future research should include proper controls to allow for a more definitive conclusion. The systematic review demonstrated that only 18% of the selected studies on gamification in medical education were grounded in a theoretical framework. The reported theories included the Experiential Learning Theory, Reinforcement Learning Theory, Social Comparison Theory, and Self-Directed Learning/Self-Determination Theory. Most of the studies were purely descriptive and did not test a theory, making it difficult to understand the mechanism by which gamification impacts the learning process. Dr. Georgiadis suggested that future studies should be grounded in a solid theoretical framework and consider other gaming attributes and societal values, as well as examine the impact of gamification on knowledge retention and the suitability of different parts of the basic science curriculum.

Trivia Reimagined: Making Questions Fun & Educational

Presenters: Jeremy Walker, MD, of the University of Alabama at Birmingham and Michelle Carroll-Turpin, PhD. of the University of Houston

The second webinar of the series explored the benefits of using games in healthcare education and offered strategies for incorporating different types of games into the basic science curriculum. The presenters reviewed existing literature on the theories behind using games in medical education, the results of recent research studies on the topic, and practical tips for implementing game-based learning in the classroom. Dr. Walker began the webinar by outlining fundamental principles related to the use of games in education. He defined “Gamification” as the integration of game elements into non-game contexts to enhance user engagement and experience. He cited examples such as using games and rewards in language learning Apps like Duolingo and reward systems employed by companies like Starbucks. Dr. Walker highlighted the fitness industry as being particularly close to the concept of gamification in education, as Apps in this space often utilize daily challenges, team-based competition, rewards for goal completion, and other methods to engage users. He distinguished gamification from serious gaming, which refers to games specifically designed for non-entertainment purposes, such as healthcare simulations.

Dr. Walker continued by citing examples of Serious Games from Drexel College of Medicine in microbiology, such as CD4 Hunter, Malaria Invasion, Hep B-ware, and Solve The Outbreak from the CDC, as well as board games such as Empiric Abx. He explained in detail the components common to all educational games, such as the setting, gaming elements, participant instructions (rules), game objective(s), and educational content.

Dr. Walker introduced the Kaizen platform, a widely used tool for continuous improvement in business and manufacturing, first developed in Japan [5]. The Kaizen platform is based on the principle of making small, incremental changes to improve processes, products, and overall performance. He then presented his work in creating a microbiology module for first-year medical students using the Kaizen platform concept. He explained the idea behind the “ID Fellows Cup,” an educational game consisting of a formative question bank for Infectious Disease fellows. He highlighted cognitive science principles employed by the game, such as retrieval-based learning and spaced repetition, which help fellows retain content information in long-term memory, and the anti-stress benefits of the game at the end of the term.

Using formative questions is a valuable tool in the learning process, allowing learners to assess their understanding of a topic and receive immediate reinforcement. Dr. Walker also emphasized the importance of student discussions, which serves to clarify key learning points and provide supplementary context, incorporating visuals and contrasting examples and linking learners to additional digital resources for further exploration of the subject matter. He presented the results of an evaluation study, which indicated a positive correlation between student mean exam scores and engagement with the Kaizen platform [6]. Furthermore, the study found that in a spaced repetition game, players were more likely to correctly answer questions seen months prior, as determined by a two-sample Wilcoxon test He concluded that using the Kaizen platform maximized the game’s educational return on time invested.

Dr. Walker presented a recent study on the use of a formative question bank with game elements, which aligns with several principles of cognitive psychology, such as retrieval practice, elaboration, appropriate context, dual coding, spaced repetition, and interleaving [7]. He explained that retrieval practice is achieved through effortful recall, elaboration by attaching details to concepts and comparing them, appropriate context is provided using clinical vignettes, dual coding is performed using visual aids, spaced repetition is achieved through the repetition of concepts, and interleaving is achieved by switching between content areas. Overall, Dr. Walker highlighted the importance of using games in education and how they can enhance traditional learning practices by providing external incentives and by promoting engagement and retention of content using various cognitive science principles, such as retrieval-based learning, spaced repetition, and interleaving [8].

Dr. Walker next presented best practices in the use of games in education [9]. He emphasized the importance of providing high-quality educational content as the primary priority and highlighted the benefits of incorporating team competition to foster group identity and create a shared experience among learners. He also explained the benefits of implementing a pace feature to enhance the effectiveness of spaced repetition and interleaving strategies, and the use of badges as a reward mechanism for consistent engagement in desired daily practices. Dr. Walker also shared several additional gaming platform examples that can be utilized in the classroom, such as Kahoot, Quizizz, Formative, plus the Kaizen platform. He summarized his presentation by stating that gamification, when implemented in a strategic manner, can enhance traditional learning practices by providing external incentives through the incorporation of game elements. He stressed that it is important to capture data to demonstrate the effectiveness of gamification, and measure the impact of competition, which can be channeled productively through the formation of teams. Finally, he emphasized the importance of ensuring that the game setting is accessible to all learners, and the importance of understanding and engaging with the community in the gamification process.

Dr. Carroll-Turpin continued the session with her presentation, “Gaming in the Classroom: Tips & Tricks from the Trenches” by emphasizing the benefits of incorporating games in active learning environments, as they can change the pace and keep things engaging. She mentioned that for the academic year 2020–2021, medical schools reported that games made up only 0.19% of instructional time. Dr. Carroll-Turpin then discussed the barriers that hinder the utilization of games in the classroom. These barriers include lack of relevance to the curriculum, lack of professional development, varying proficiency among teachers and students, inconsistent development of games, lack of data to support the use and positive outcomes, and the continuous evolution of educational practices and technology. She also highlighted that there are cultural barriers, particularly in the perception of the value of using games in the classroom. To ensure that gaming is a good fit, Dr. Carroll-Turpin recommends asking four questions: (1) How can I tie the activity explicitly to learning objectives? It is important to ensure that the activity is directly relevant to the curriculum and that adult learners can easily understand its value. (2) How much do the students already know? It is important to be aware of the students’ prior knowledge and that games are often better suited to facilitate review rather than introducing new concepts. (3) What are the stakes? The stakes of the game should be considered as winning by itself can be a strong motivator, but grades may introduce unnecessary stress. (4) How engaged will the students be? Teamwork is known to boost motivation and encourage peer teaching and learning; thus, it is important to consider how engaged the students will be in the game.

Dr. Carroll-Turpin went on to discuss the process of planning games in the classroom. She emphasized the importance of keeping it simple when it comes to game rules and managing the cognitive load of students by minimizing frustration and maximizing the connection to content. To ensure a successful gaming session, she recommended providing session instructions in advance, which should include the rules of the game, team assignments (if applicable), material covered, the corresponding learning objectives, and the rules of engagement. This will aid in preparing participants for the session and help them understand the objectives and rules of the game. Furthermore, Dr. Carroll-Turpin stressed the importance of incorporating physical items, such as buzzers, paddles, wheels, and prizes, to optimize opportunities for engagement. This enhances the gaming experience by allowing for more interactive and hands-on activities, and increases participation and engagement among learners, making the experience more memorable. To ensure that the game is used to its fullest potential, Dr. Carroll-Turpin recommended a 3-step process: (1) provide an introduction including instructions and a clear connection to relevant learning objectives, (2) engage in the game activity, (3) debrief on what was learned from the game. This will help to reinforce the learning objectives and allow for reflection on the experience. This process will guarantee that the game is used to its maximum potential and that the learners are getting the most out of the experience.

Escape Rooms: Breaking Away from the Lull of Lackluster Curricula

Presenters: Amy Beresheim, Ph.D. and Adam Wilson, Ph.D. of Rush University, location?

Drs. Beresheim and Wilson began their talk by introducing the concept of escape rooms. They explained that the objective is to escape a themed room by discovering clues and solving puzzles within a specific time frame, usually 60 min. The game starts with a storyline, which provides context for the setting and the reason for escape. Although the initial search for clues may seem random, as more clues are deciphered, it becomes easier to anticipate the next steps required to complete the escape. They also mentioned additional aspects, such as the use of distractors and time pressure.

Both presenters discussed the application of escape room games in medical education. They stated that the primary goal should be to review or practice new educational content through team interaction and collaboration, while the secondary goal is to solve puzzles and escape within the allotted time. The medical education escape room also begins with a storyline to establish context and objectives. However, the key difference from general escape rooms is that the puzzles and clues are designed to test the application of knowledge. Successful application of knowledge will reveal new clues or help solve parallel ones, leading to the eventual escape. The speakers then mentioned that groups typically comprise around five participants and that the ideal environment is fast paced, encouraging a high rate of communication among team members. They noted that older and more educated players tend to speak for longer during the game, and the strength of prior relationships within the group impacts the intensity of collaboration and problem-solving interactions.

The presentation then moved to the differences between in-person and virtual escape rooms in educational settings. While most escape rooms in education are in-person, a smaller percentage are digital or hybrid formats. The speakers acknowledged the limited number of comparative studies on the effectiveness of in-person versus virtual educational escape rooms. They also highlighted the logistical advantages of virtual escape rooms, such as adaptability during COVID-19, space and time savings, reduced resource costs, and reproducibility. They emphasized the importance of considering the dexterity and motor skills required for in-person puzzles and the potential challenges some students may face. Drs. Beresheim and Wilson described various escape room implementations at the University of Alabama at Birmingham and Rush University, including the “Anatomy Escape Room” and “Who am I?” They provided a list of tools and examples for creating virtual escape rooms and shared links to escape room instructor guides for inspiration.

Card and Board Games for Health Professional Education

Presenters: Sarah Edwards and Michael Cosimini

Drs. Edwards and Cosimini began their presentation by discussing gamification, a technique that integrates game-like elements into non-game contexts to influence learning behaviors or attitudes. Gamification utilizes the motivational and engagement factors inherent in games to enhance learning experiences. In medical education, gamification can be used to augment traditional educational methods, making learning more interactive and enjoyable. By incorporating game mechanics such as points, feedback, competition, and storytelling, medical educators can foster greater engagement, motivation, and retention of information in learners. They introduced Landers’ theory of gamified learning, which differentiates gamification from serious games [4]. Gamification uses game attributes in non-game contexts to influence learning-related behaviors or attitudes, which in turn impacts learning either by strengthening the relationship between instructional design quality and outcomes or by directly affecting learning. In contrast, serious games employ game attributes to directly impact learning. The presenters also discussed the Bedwell taxonomy [3] which provides categories of game attributes and examples of their application in gamification, and offered recommendations for conducting rigorous, scientific studies on gamification. Next, they explored Abt’s definition of serious games as games with a specific educational purpose, not primarily designed for entertainment [10]. They also presented Garris’s input-process-output model of instructional games and learning, which addresses the key aspects of games from an educational perspective, the game cycle that defines engagement in gameplay, and the resulting learning outcomes [11]. They emphasized that a game is appropriate for medical education if it enhances learner engagement, changes motivation, allows for low-stakes trial and error, aligns game mechanics with learning goals, and demonstrates how systems work.

The speakers continued by showcasing examples of board games used in health professions education, such as “Cards Against Peds Ortho,” “Game of Stools,” and “Gridlock ED.” They summarized the results of a survey on a card game for antibiotic use education conducted among online groups interested in educational games and healthcare education [12]. Among respondents, the majority (56%) were physicians, residents, or medical students, and 33% were pharmacists, residents, or students. Most participants (53%) were from the USA, and 70% downloaded the game for self-education. The survey suggested that the optimal duration for educational board games is around 20 min, with a recommendation not to exceed 40 min. The most frequently cited barriers to using games in education were the lack of appropriate games, concerns about content accuracy, and cost. The presenters also briefly addressed the potential credibility issues of games in educational contexts. They offered game design tips, emphasizing that game complexity should not exceed the complexity of the information being provided, as the primary goal is learning, not understanding the game. They concluded by highlighting the unique potential of card and board games as a social environment for active learning. While there is currently a limited selection of such games, there is a demand for short, simple 2–4 player games. For those considering creating a game for their specific educational context, the presenters recommended starting by adapting mechanics from known games.

Foresight, Insight, & the Quest: Transforming Learning through Game-Based Learning

Presenters: Teresa Chan and Eric Gantwerker of Hofstra University, and Satid Thammasitboon of Baylor College of Medicine

Drs. Chan, Gantwerker, and Thammasitboon started the fifth and final webinar by sharing their definition of “Gamification,” a term they mean to reflect the use of video game elements to improve user experience and engagement in non-gaming systems. With the rise of “gamified” applications, there is a wealth of research on the heuristics, design patterns and dynamics of games and their positive impact on user experience. They believe that gamification and serious games in education are similar in that both utilize elements of games to improve the learning experience, but they differ in their primary goal. Gamification involves adding game-like elements to non-gaming systems to increase user engagement and motivation, whereas serious games are specifically designed for educational or training purposes, using games as the primary medium to deliver content and achieve learning objectives. In other words, gamification takes a broader approach to using game elements in a variety of contexts, while serious games are specifically designed for educational outcomes [3, 13].

The presenters stated that Game-Based Learning (GBL) has the potential to add to medical science education by offering several benefits, such as providing a more interactive and engaging way to learn complex concepts, allowing for simulation and practice in a safe environment, and promoting problem-solving skills and critical thinking. As technology continues to advance, the possibilities for GBL in medical science education will likely expand, allowing for more immersive and realistic simulations and potentially incorporating virtual and augmented reality elements. Overall, the presenters argue that the future of GBL in medical science education has the potential to greatly enhance the way medical professionals are trained and educated. They also stated that game-based education has the potential to be the most effective way of learning and growing because it taps into our natural desire for interaction and engagement. By incorporating elements of play and competition, game-based learning can create a more dynamic and engaging educational experience. This approach can also foster collaboration, critical thinking, and problem-solving skills. They further offer insight into the evolution of gamification in medical education as GBL becomes more prevalent in medical science education [14]. Challenges include (1) ensuring the quality and accuracy of the educational content within the game, (2) balancing the competitive aspect with the educational goals, (3) the potential for distraction and oversimplification of complex medical concepts, and (4) the need for effective evaluation and assessment of learning outcomes.

Drs. Chan, Gantwerker, and Thammasitboon proposed that teaching the tools of game designers to medical educators who are serious about games is seen as a crucial step in catalyzing personalization, motivation, and engagement in learning. By incorporating cognitive and technological elements used by game designers, educators can enhance the learning experience and foster more active and engaged learners. They believe that to optimize the potential of GBL in advancing medical science education, it is important to capitalize on the opportunities and address the challenges in four key areas: innovation, learning, sustainability, and well-being. This can involve utilizing the latest technology and game design techniques, fostering a learning-centered approach, ensuring sustainability and accessibility, and incorporating considerations for student well-being into the design. By approaching GBL in a strategic and holistic manner, it is possible to improve the overall learning experience for students and advance medical science education.

Declarations

Ethical Approval

N/A.

Informed Consent

N/A.

Conflict of Interest

The authors declare no competing interests.