It’s all fun and games until someone learns, then it’s education.

( This is it for us in 2015.  We’re taking a 2 week break to recharge the brains and spend time with friends and family.  Have a wonderful holiday.  See you in 2016. -Jonathan (@sherbino))


By Daniel Cabrera (@CabreraERDR)

The gamification of medical education has been a trending idea, but unfulfilled promise for some time. The concept of using elements from ludic games has been adopted by primary and secondary educators for several decades; artifacts like badges of merit, prize oriented tasks and increasing complexity of objectives (i.e. leveling up) are common place in many non-medical education learning settings. (A caution, while these techniques may be common place, they are often poorly understood.)

Gaming, really.

The idea of gaming as a reputable activity became more attractive with the emergence of generations of teachers and learners adept at digital gaming, ranging from the classic consoles (Atari or Nintendo) to massively multiplayer online role-playing games (World of Warcraft). Although the archetype of gamers as geeks drinking mountain dew, eating pizza and living in their parent’s basements is present and pervasive, truth is most gamers are late 30’s with disposable outcome and (questionable) disposable time invested in these alternative worlds, young professionals and blue-collars workers with day time jobs and families but devoted to this activity.

Video games represent a 100 billion US dollar industry with each American spending around 21 minutes per day playing. This industry not only sparks large revenue but also careers in game development as well as scholar activity and game-related science. In case you didn’t know you can get your PhD in “video games” or have a lofty life as a game developer or engineer. Digital games are a legit and respectable area of knowledge.

With increasing understanding of the core neuroscience that underpins gaming, as well as research in related ideas (e.g., non-linear gameplay), allow leveraging of digital games for teaching and training. The availability of personal devices (e.g., phones) with access to the gaming platforms (e.g., Steam) permits a basic anywhere-anytime access to games. Industries such as the military are harnessing this potential at a very rapid rate, off-loading classic face-to-face, face-to-blackboard and face-to-simulator time for these new learning platforms.

Level up, key concepts

Gaming encompasses a spectrum of activities that involve competition, a set of rules and a defined reward. From constructivist perspective games inhabit the Kolb model of learning: concrete experience, reflection, conceptualization and application (experimentation).


Gaming constitutes a model with constant deliberate practice, where there is a clear objective, the observed outcomes from the last action are rapidly analyzed and incorporated in the mental script for the task and implemented in the next round of actions. A game needs to be easy enough to start playing but difficult enough to be interesting. This explains why most games are arranged around discrete tasks (destroy the alien ship), a series of levels (destroy the current alien fleet) and a long term objective (stop the invasion of earth). From a theoretical perspective the parallelism between gaming and learning is very attractive.

In Medical Education

Current evidence does not support the use of gaming in medical education.  More precisely there is no robust data to support that gaming is better than other learning techniques. But it doesn’t have to be. I don’t think anybody would suggest the sole use of gaming as the learning method for medicine. Gaming is probably helpful in some scenarios, but quite inadequate in others.

The big promise of gaming in #MedEd is the facilitation of a learner directed, stealth and asynchronous spaces of learning. Stealth refers to the principle of delivering knowledge and skills within the framework of a game in a manner that is perceived not as an industrial instructional method but instead as a community and personal journey of growth and enjoyment. The learner is in the drivers seat, determining the route and speed. This creates a sentiment of empowerment and control that is key for gaming and advisable for learning.

A few systematic reviews have looked into didactic instruments that used gaming techniques and their impact in outcomes. The source material is not of strong quality and usually small, single center interventions aimed at psychomotor skills (e.g., surgical techniques) or raw medical knowledge (e.g., game-show style quiz). Most instruments reviewed did not impact behavioural outcomes in learners.

There are some practical and conceptual challenges obstacles to use gaming techniques in medical education. The difficulty in creating a game that is engaging, enjoyable, entertaining, educational and scalable is enormous; also we still don’t have a common language and standard gametrics to assess impact, engagement or even enjoyment. Matching the game to the curriculum requires a robust knowledge both of games, learners and content.

What we get wrong and how it dooms gaming

I think the problem with gaming in medical education is we put the label of gaming on a well-crafted, goal oriented, multi-level tool with a clear set of rules and rewards. The pejorative of  “game” disguises a good instructional system tool.

Games must be epic; games need themes, history and cultural clues to make them identifiable and relevant. Part of the attractiveness of games is their function as a cultural myth,  informing the personal identity and narrative that imbues the learner’s life. It is no fun to be the best intern in the Name-Causes-of-Hypomagnemesia game. What people and gamers want to be is Jessica-the-Magnesium-Dragon-Slayer in a hero’s journey narrative.

Jane McGonigal  describes gamers as super empowered hopeful individuals. For a game to fully function as an instructional method, it needs to be affirmative of the players self-aspiring image, create a community for engagement and social interaction and validation, where the activity contained in the game has a group effect and most importantly, the game needs to provide a relevant, even transcendental, meaning. It is lame to be the best at magnesium but is profound to help friends solve difficult cases.

What a good medical education game looks like

It is an epic journey over a solid road

It is an epic journey

  • The games offers the prize of achieving something incredible, worthy of my journey
  • The game provides a meaningfully narrative arch and origin myth
  • The game provides a platform for self-affirmation or creation of an identity
  • The game provides a community of practice (community, domain, practice)
  • The actions of the game have a clear, measurable impact, and I get pride/satisfaction from it

Over a solid road

  • The game needs to be grounded in a clear curriculum of knowledge and skills
  • The game requires a set of rules, clear goal, scoring system and reward system
  • The game needs to be fun, entertaining and engaging
  • The game requires instantaneous, short, mid and long feedback loops
  • The game allows for a trainee-player model, the learning is in control of the experience
  • The game has a clear and explicit evaluation system
  • The game allows for infinite-play (continuous deliberate practice) until expert level is achieved

References and Further Reading

Image 1 from JD Hancock via flickr under Creative Commons License CC2.0

Image 2 from G.B. Kitchen, J. 64 Humphreys / Trends in Anaesthesia and Critical Care 4 (2014) 63e66