Much ado about gaming: An educator's guide to serious games and gamification in medical education

Health professions education has introduced elements of games and play into a myriad of educational formats, whether gamifying lecture content into Jeopardy! squares, building sepsis simulations that mimic Tetris with Septris, ¹ or transforming the emergency department (ED) into a board game in GridlockED. ² Play has educational utility. When learners play, they are allowed to explore relationships between real‐world elements in a setting that encourages creativity and flexibility and limits risk. Play can stand alone or be organized by shared rules into a game. When a game is designed explicitly for the purpose of education this is considered a serious game. This can be done in many formats including card, board, and even digital games. ³

GAME‐BASED LEARNING: FROM GAMIFICATION TO SERIOUS GAMES

“Gamification” and “serious game” suffer from considerable conceptual overlap. ⁴ Although there are several means by which to distinguish gamified learning from a serious game, the most straightforward is whether the learning activity would function if the game elements were removed. ⁵ , ⁶ , ⁷ Gamification is the act of adding game elements to a learning activity, such as assigning points or badges to tasks and posting a leaderboard for students to compare their performance to other students. ⁸ Educators use game elements to modify attitudes toward specific tasks (e.g., motivate learners to act professionally or attend lectures), incentivizing behaviors in service of educational goals. Gamified actions are typically external to learning and thus can be added or modified without altering the learning objectives or means by which learning is intended to occur. A serious game, by comparison, is a stand‐alone game with game elements, rules, and objectives that deliberately includes elements of play to support educational objectives. ⁹ , ¹⁰ These are designed to deliver educational content such that optimization and success of in‐game tasks leads to knowledge acquisition or reinforces behaviors outside the game. Empiric ¹¹ employs card matching to reward and reinforce judicious antibiotic use as players clear a deck of cases using available treatments. The cards may be used as a study resource, but gameplay teaches the additional concept of stewardship. Table Rounds ¹² is a simple deck of cards, each with a word or phrase from medicine, which players arrange together based on connections between medical concepts and disease processes. Without gameplay, the cards are simply a list of medical terms—the educational content is provided by the players themselves.

We can further distinguish “serious games” within the broader category of gamified learning based on the relationship between game objectives and learning objectives. Whereas gamification layers game objectives on top of learning objectives to motivate behavior, a serious game unifies learning objectives and game objectives. ⁵ Gamification may be effective when the goal is to motivate learners to perform a behavior that they are not already motivated to perform, for example, to answer board‐style questions or complete administrative tasks. Serious games excel when there is an opportunity to match the mechanics of the game to the learning objective or to have learners practice to a specific goal. Serious games may enable self‐directed and social learning experiences that better align with active learning theories. ¹³ , ¹⁴ In GridlockED, ² success requires an understanding of both enabling and limiting factors to patient flow through the ED but also the ability to problem solve as a team to find strategies for overcoming challenges presented by the game. The flow of patients to final destinations within the game is improved by closed‐loop communication skills, a transferable skill that has been noted to have high relevance outside of the game. ¹⁵ Clinical Coaching Cards ¹⁶ asks players to both provide challenging teaching moments and judge how well techniques on game cards might be used to overcome these challenges for their own teaching. Game objectives of assessing and evaluating active learning techniques are accomplished through discussion, friendly competition, and social judgment. In either game example, the content could be provided outside the framework of a game, but game objectives expand participants' potential to learn. The variability in players and gameplay in each instance of a serious game offers novel interactions to emerge that could not be similarly programmed into a learning activity.

WHAT'S IN A GAME? CORE COMPONENTS OF A SERIOUS GAME

Gamification and serious games apply game elements to different degrees to support learning. Serious game design incorporates educational content with game elements, ⁶ , ¹⁷ , ¹⁸ such that gameplay cycles (rounds or turns) produce learning outcomes. This “input–process–output model” ⁵ is a conceptual framework that can be used to describe how game actions are used to achieve both game and learning objectives. We suggest four components common to all games, useful for developing and evaluating serious games: 1) shared goals that are challenging to accomplish and give players a purpose and orientation through the game, 2) rules that constrain and guide how players may achieve them, 3) feedback to players to guide behavior toward success, and 4) voluntary participation. ¹⁹ , ²⁰ , ²¹ Several educational theories have been used to explain how these game elements contribute to learning ¹⁸ , ¹⁹ , ²² ; in Table 1 we highlight four to show how effective game design, learning design, and learning theory may be mutually supportive.

TABLE 1.

Education theory and components of serious games

Game component 18	Education theory	Theory applied to game‐based learning
Goals ♛ Players work toward specific objectives that direct what they are trying to accomplish while playing.	Self‐efficacy ♜ Players' beliefs that they can accomplish their goals in a specific domain shape their behavior. ♜ Past experience, observations of others' accomplishments, social persuasion, and physical and emotional status influence players' beliefs. 25	♟ Players select games and continue to play based on their belief that they will be able to succeed in the game. 23 ♟ Larger goals may be divided into smaller steps and to incorporate progressive increasing difficulty. ♟ Incremental achievements encourage repetition of play until players have mastered the desired content.
Rules ♛ Available and prohibited actions allow sufficient flexibility for players to innovate and develop strategy.	Experiential learning theory 16, 26, 27 ♜ Experience drives learning through learner reflection, which allows for planning new actions. ♜ Learners identify challenges and incomplete solutions to problems, leading to innovation. ♜ Engagement with other people, artifacts, and contexts shapes experience to enrich learning.	♟ Game cycles reinforce Kolb's four‐stage learning cycle of concrete experience, reflection, abstraction, and active experimentation within the rules and boundaries of the game. 28 ♟ Many games are learned in a “practice round,” as new players are introduced by experienced players, creating a game's community of practice. 29 , 30 ♟ Matching players at similar, but unequal, skill levels overlaps their “zone of proximal development” to drive learning. 31
Feedback ♛ Games must provide immediate response to performance to guide future action.	Deliberate practice 32, 33 ♜ Learners are motivated to improve and repeat performance of a desired skill. ♜ Feedback and corrective critique suggest changes to behavior not achieved through self‐reflection.	♟ Feedback can be built into the game in the form of points, such that higher‐scoring accomplishments indicate higher skill. ♟ Players, in both competitive and collaborative roles, can demonstrate or direct behavior. ♟ Coaching can be provided by peers or a teacher as an adjunct to learning within the game. 34 , 35
Voluntary participation ♛ Players engage in play knowingly and willingly, allowing for challenges that may have been stressful to become safe and enjoyable.	Self‐determination theory 36 ♜ Players have fundamental needs for autonomy, perceived competence, and relatedness or connection to the social environment. ♜ Extrinsic motivators can become intrinsic motivation, in which an experience is sought for its inherent rewards.	♟ Play allows for choice, innovation, and exploration within the rules. ♟ Serious game accomplishments can be constructed to reflect real learning objectives. ♟ Voluntary play in a game setting can support psychological safety and connectedness with other players. 7

LIMITATIONS AND OPPORTUNITIES

Serious games do not currently have broad uptake in medical education. Development of games for publication requires testing and iteration that takes significant time and effort, often over the course of years. As such there is not a wide library of existing published options for educators to choose from. The cost of games and challenges around complexity of rules have also been identified as barriers to uptake. ¹⁰ Game rules or excessive bookkeeping can create extraneous cognitive load. If not relevant to educational content, game complexity and themes are not only a barrier to use but detrimental to learning. ²¹ In our experience, the simplicity of card‐ and board‐based games has allowed for relatively low resource utilization to create serious games. These formats are well accepted by learners, inspire near‐peer teaching, and work well to maintain engagement in small group teaching. Some of the biggest challenges around their use is difficulty in scaling to larger groups, variable response of learners to competition in teaching sessions, and need for facilitation for debriefing especially when used to simulate more complex systems.

Technologically‐rich digital simulations have been developed that are sufficiently accurate to earn professional continuing medical education credits while playing. ²² , ²³ These present an interesting confounder to future research: noneducational video game playing has been independently correlated with improved skill in procedural simulation, ²⁴ so future work may be needed to disentangle the relative benefits of task‐relevant physical training from specific medical content.

CONCLUSIONS

Game‐based learning provides versatile tools to increase motivation through gamification or to build serious games that reinforce desired skills, knowledge, and behaviors. Games provide unique attributes beyond gamification that can support learning through multiple mechanisms. We have shown several educational theories available for use with serious games. While our discussion focuses on how theory is enacted in games, future game development, and evaluation of games as learning tools, would benefit from increased consideration of how game components contribute to learning outcomes.

Watsjold BK, Cosimini M, Mui P, Chan TM. Much ado about gaming: An educator's guide to serious games and gamification in medical education. AEM Educ Train. 2022;6:e10794. doi: 10.1002/aet2.10794