Gamification in medical education: the evidence

Points, medals and rankings teach nothing on their own. What research in health education observes is something else: challenge with assessment makes the student return to the material. It is the most repeated finding of the main systematic review on gamification in the health professions, in which almost all studies used some type of assessment, usually combined with challenge, and eight of them showed that this combination increased the use of study material (van Gaalen et al., 2021). You have probably felt this: the app's medal does not explain pathophysiology, but the question you got wrong yesterday makes you open the book again.

NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.

This text brings together what reviews and meta-analyses say about gamification in medical education, with the tone of someone who reads the studies before believing the marketing. It separates serious games from gamification, shows the effect sizes that meta-analyses have found, explains why testing memory is at the center of almost every game that works, discusses when points and rankings help or get in the way, and ends with criteria for you to evaluate any medical game before putting it into your routine.

Key points

• Gamification is using game elements, such as points, levels, rankings and challenges, in activities that are not games. A serious game is a complete game, made to teach. The two are studied together, but they work in different ways.
• Meta-analyses find effects from small to medium in favor of gamification on learning, more stable for knowledge than for motivation and behavior.
• Much of the effect seems to come from what the game asks you to do: remember, answer and receive correction. Testing memory with feedback has its own consistent evidence.
• Expected rewards can reduce intrinsic motivation, and pure competition can discourage. Competition combined with collaboration had better results in a meta-analysis.
• The average quality of studies on games and gamification is low or moderate. A good medical game makes the learning objective clear, demands active response, gives informative feedback and invites research on its own format.

Summary

• Serious games and gamification are different things
• What the reviews say
• Why testing yourself teaches
• Points, rankings and rewards: when they help
• Where the evidence is still weak
• How to evaluate a medical game
• Frequently asked questions
• Checklist before adopting a game

Serious games and gamification are different things

The word "gamification" has become an umbrella for almost everything that has a scoreboard. In the literature, it has a narrower definition, and the difference matters for reading the studies.

Gamification: game elements outside the game

Gamification is the application of game design elements to contexts that traditionally are not games, such as a class, a question bank or a study plan (Rutledge et al., 2018). Points per question answered, levels per module completed and class ranking in a course are examples. The theory of gamified learning proposes that these elements act indirectly: they change behaviors and attitudes linked to studying, such as time dedicated or frequency of return, and these behaviors are what influence learning (Landers, 2014). According to this theory, gamifying weak material does not make it good; gamification amplifies the effect of good instructional design.

Serious game: a whole game made to teach

A serious game is a complete game, with its own rules, challenge and environment, created with the goal of training. A systematic review on serious games in medical education and surgical skills training identified 30 games in 25 articles, divided between games made with an educational purpose and commercial games used to train skills, such as the psychomotor skills of laparoscopy (Graafland et al., 2012). In Landers' theory, in a serious game the game elements are manipulated to affect learning directly, without going through this behavior change (Landers, 2014).

Why the distinction changes how studies are read

Many reviews lump the two things together. In the systematic review of randomized trials on serious games and gamification in the health professions, only two of the 30 studies evaluated gamification; the others evaluated serious games (Gentry et al., 2019). When you read "games work" or "games don't work", it is worth asking: which game, compared with what, measuring what? A diagnosis game based on clues, a surgical simulator and a ranking in a question bank fit into the same word and train different things. If you want to see how a diagnosis game based on clues works from the inside, the post What NEXO is and how the diagnosis game works shows a match step by step.

What the reviews say

There are reviews on gamification in the health professions, on serious games in medical education and meta-analyses on gamification in education in general. They point in the same direction, with different effect sizes and similar caveats.

In the health professions

The systematic review on gamification in the health professions included 44 studies and concluded that it is possible to improve learning with gamification, especially with elements that improve behavior and attitude toward studying (van Gaalen et al., 2021). The review of randomized trials gathered 30 studies with 3,634 participants and concluded that serious games and gamification were at least as effective as the controls, and in many studies more effective, for knowledge, skills and satisfaction (Gentry et al., 2019). A scoping review on serious games found 25 studies; in 14 of the 18 studies with a control group, the score after the game was higher than with conventional teaching, and the authors speak of effectiveness for short-term learning (Haoran et al., 2019).

For clinical reasoning, which is what matters most to those who study diagnosis, a 2026 meta-analysis combined 10 studies and associated gamified learning with better clinical reasoning than traditional teaching, with a standardized difference of 1.11 and low certainty of evidence (Lee et al., 2026).

In education in general

Outside health, a meta-analysis on gamification of learning found small and significant effects on cognitive (g = 0.49), motivational (g = 0.36) and behavioral (g = 0.25) outcomes; the effect on knowledge held up in the more rigorous studies, and the other two were less stable (Sailer and Homner, 2019). Another meta-analysis, with 30 interventions and 3,202 participants, found a medium effect in favor of gamification on academic performance (g = 0.504) (Bai et al., 2020). An earlier review of empirical studies concluded that gamification has positive effects, but that they depend heavily on the context and on who uses it (Hamari et al., 2014).

The reviews side by side

Review	What it gathered	What it found	Caveat from the authors
van Gaalen, 2021	44 studies of gamification in the health professions	Assessment with challenge increased use of the material in 8 studies	Well-defined control groups are lacking
Gentry, 2019	30 randomized trials, 3,634 participants	At least as effective as the controls	Low or very low quality evidence
Haoran, 2019	25 studies of serious games (scoping review)	Higher score than conventional teaching in 14 of 18 controlled studies	Research still emerging, short term
Lee, 2026	26 studies, 10 in the meta-analysis	Better clinical reasoning, standardized difference of 1.11	Low certainty, possible publication bias
Sailer and Homner, 2019	Gamification in education in general	g = 0.49 in knowledge, stable in the rigorous studies	Motivation and behavior less stable
Akl, 2013	Educational games for health professionals (Cochrane)	Two randomized trials included	Search up to January 2012; calls for high-quality studies

Why testing yourself teaches

Almost every educational game that works has a common core: it makes you answer. That core has evidence of its own, more solid than that of gamification itself.

The testing effect

In cognitive psychology, testing memory on something you studied is a learning event, not just an assessment. A meta-analysis that compared testing with restudying found support for the role of effortful recall: recall tests, in which you produce the answer, yielded more than recognition tests, in which you choose among options (Rowland, 2014). The basis of this meta-analysis comes mostly from laboratory studies.

A review applied to medical education gathered the practical recommendations: frequent tests spaced over time, questions that require effortful recall, such as short-answer ones, and feedback, which helps correct errors and confirm correct answers (Larsen et al., 2008). The authors suggest that learning by testing can strengthen the clinical knowledge on which expertise rests (Larsen et al., 2008).

Spaced question games

Spaced education games combine the testing effect with game elements. In a trial with 1,470 urologists from 63 countries, an email question game, with a relative leaderboard among participants, compared two delivery paces; 76% of enrollees asked to take part in future games (Kerfoot and Baker, 2012). In a randomized trial with 111 primary care clinicians, the same type of game, on hypertension management, was compared with the same content published online and modestly reduced the time until patients' blood pressure reached target (hazard ratio of 1.043) (Kerfoot et al., 2014). It is a small effect, in physicians, in a question game about hypertension, and one of the few educational game studies with an outcome measured in patients.

What this says about games

If the core that teaches is answering with effort and receiving correction, the useful question about a game is how much of it is that core and how much is decoration. A game in which you produce the answer, get it wrong, receive informative correction and return to the topic days later is aligned with what the studies on testing show. A game in which you collect points for opening content uses another mechanism, less studied.

Points, ranking and rewards: when they help

The visible elements of gamification, such as points, badges and ranking, have the most discussed and most variable effect. They can help or hinder, depending on the design and who plays.

Expected reward and motivation

A meta-analysis of 128 experiments on external rewards showed that rewards for taking part, for finishing or for performance reduced intrinsic motivation measured by free choice to continue the activity (d = -0.40, -0.36 and -0.28, respectively) (Deci et al., 1999). In the same work, positive feedback increased free-choice behavior (d = 0.33) and reported interest (d = 0.31) (Deci et al., 1999). For those who design or choose a game, the difference is practical: telling the student what they did well tends to sustain interest; promising a prize for studying can have the opposite effect.

Competition and collaboration

In medical education, gamification is explained by self-determination theory: well-chosen game elements reinforce autonomy, competence and belonging, and thus intrinsic motivation. Poorly applied, the same elements can undermine these needs through the overjustification effect or the negative effects of competition (Rutledge et al., 2018). In the meta-analysis on gamification of learning, combining competition with collaboration was particularly effective for behavior outcomes, and the inclusion of game narrative also helped (Sailer and Homner, 2019).

In practice

To use points and ranking in your favor, treat the scoreboard as a reminder and the error as content. A group ranking with your class, in which everyone discusses the case afterward, combines competition and collaboration. A streak of days that becomes an anxious obligation, or a global ranking in which you never appear, can weigh more than it helps. In these cases, look only at your own progress. The review of health professions did not record negative outcomes of gamification in the included studies (van Gaalen et al., 2021), and the theory calls for attention to them anyway (Rutledge et al., 2018).

Where the evidence is still weak

The reviews that show positive effects are the same ones that call for caution. The limits below apply to studies on games and gamification in general, and help you read any promise of "learning by playing".

Quality of the studies

The Cochrane review on educational games for health professionals, with a search up to January 2012, included two randomized trials and concluded that the findings neither confirm nor refute the usefulness of games as a teaching strategy (Akl et al., 2013). In the following reviews, quality remained the weak point: moderate evidence by the MERSQI score (Gorbanev et al., 2018), average methodological quality of 10.5 out of 18 points, considered modest (Wang et al., 2016), and low or very low quality evidence for all outcomes (Gentry et al., 2019).

Control group, heterogeneity and publication bias

Most gamification studies in the health professions had no well-defined control group and did not use a theory to explain why the game element would work (van Gaalen et al., 2021). In the meta-analysis on clinical reasoning, heterogeneity was high (I² of 85%), and the publication bias analysis suggested that the effect may be overestimated: adjusted, it fell from 1.11 to 0.75 (Lee et al., 2026). Outside health, the effects on motivation and behavior lost stability when only the most rigorous studies were considered (Sailer and Homner, 2019).

Validation and long term

In the review on serious games in medical and surgical education, six of the 30 games had gone through some validation process, and none had completed it for the intended use (Graafland et al., 2012). The scoping review on serious games mentions short-term learning and calls for studies covering more competencies and more stages of training before general conclusions (Haoran et al., 2019). Patient outcomes remain rare, and the hypertension study cited above is one of the exceptions (Kerfoot et al., 2014).

How NEXO contributes to this research

These limits are a research agenda. NEXO maintains the NEXO Researcher program, open to researchers and institutions that want to propose studies with a control group, diagnostic reasoning outcomes and follow-up over time. Medical schools, academic leagues and residency programs that want to include the game in teaching can learn about the NEXO Closer program.

How to evaluate a medical game

With the reviews in mind, you can look at any medical game with a short set of questions. They apply to apps, gamified question banks and medical school activities.

Six questions to ask

1. Is the learning objective clear? Selective gamification aligned with learning objectives is the one with the potential to increase motivation and learning (Rutledge et al., 2018).
2. Does the game make you produce the answer? Recall tests yielded more than recognition tests (Rowland, 2014).
3. Does the feedback explain the error? Feedback is decisive for learning from tests (Larsen et al., 2008), and positive feedback sustained interest (Deci et al., 1999).
4. Does the game bring you back to the topic with spacing? Tests spaced over time are one of the practical recommendations for medical education (Larsen et al., 2008).
5. Does competition come with collaboration? The combination had the best behavior results (Sailer and Homner, 2019).
6. Who reviews the content and how is the game studied? Validation is the weakest point of serious games (Graafland et al., 2012), so it is worth looking for who signs the content and whether the game opens space for research.

Warning signs in a game promise

Some sentences require a second reading. "Increases your score by X%" without a link to a study with a control group is one of them, since most gamification studies in health did not have that group (van Gaalen et al., 2021). "Scientifically proven" supported only by student satisfaction is another: liking the game is a valid outcome, but different from learning. A large effect coming from few heterogeneous studies also deserves caution, because it can shrink when publication bias is considered, as in the meta-analysis on clinical reasoning (Lee et al., 2026). The positive sign is the opposite of all that: the game says what it trains, cites the studies on the methods it uses and leaves room to be studied.

How NEXO applies these criteria

In NEXO, assessment is the center of the match. You read up to six clues, one at a time, write the diagnosis by searching ICD-10 and receive the proximity of the guess in five levels, a feedback that says where the error fell. Streak, ranking and achievements follow the pace, and groups take the case of the day to the class or the league, combining competition and conversation. The Anki button creates the card straight from NEXO and opens it in the Anki app, searches the cards you already have and, when the case has an image, takes the image to the card. Physicians from each specialty review the cases in their area through the NEXO Curator program, and researchers can propose studies on the format through NEXO Researcher. To see a full match, read What NEXO is and how the diagnosis game works.

How to use a game in your routine

The game works best as a complement. Classes and the book provide the base; the game tests whether you can remember and use that base; preceptorship and case sessions discuss management, priority and communication. If you want to go deeper into studying with cases, the post on case-based learning in clinical practice shows how to study cases alone and in a group.

Frequently asked questions

Does gamification work in medical education?

Reviews find positive effects, from small to medium in education in general (Sailer and Homner, 2019) and at least equivalent to controls in the health professions (Gentry et al., 2019), with low to moderate quality of evidence. The effect depends on the design and the context (Hamari et al., 2014): games that require active response and give feedback are closer to what the testing research supports.

What is the difference between gamification and serious game?

Gamification is using game elements, such as points and ranking, in activities that are not games (Rutledge et al., 2018). Serious game is a complete game created to train (Graafland et al., 2012). In Landers' theory, gamification acts by changing study behaviors, and the serious game tries to act directly on learning (Landers, 2014).

Do ranking and points get in the way of motivation?

They can get in the way when they become a reward for the simple fact of studying: expected rewards reduced intrinsic motivation in a meta-analysis of 128 experiments, while positive feedback increased it (Deci et al., 1999). Competition combined with collaboration had better results than competition alone (Sailer and Homner, 2019).

How can NEXO help with studying with games?

NEXO focuses the match on what the testing research supports: you produce the diagnosis and receive feedback that shows the distance of the error in ICD-10. Use the daily case as a test of what you studied and take the diagnosis to your review. To study the effect of the format, check out NEXO Researcher; to bring NEXO to your medical school, league or residency, NEXO Closer.

How to combine games with a question bank and Anki?

Each tool covers one part of studying. The question bank trains the exam format; spaced repetition cards bring the content back with an interval; the diagnosis game trains reaching the name of the condition from the clues. All three rely on the same principle, testing memory with feedback and with an interval (Larsen et al., 2008). A simple division is to play the case of the day, write down the diagnosis you missed or got right by guessing and take it to your cards and to the questions on that topic during the week.

How can teachers and leagues use games with the class?

Choose a game with a clear learning objective, combine the ranking with group discussion and use mistakes as the topic of conversation (Rutledge et al., 2018; Sailer and Homner, 2019). If your league or medical school wants to measure the effect, plan a control group from the start, which is what studies lack most (van Gaalen et al., 2021).

Checklist before adopting a game

1. Define the learning objective before choosing the game.
2. Prefer games in which you produce the answer, instead of just recognizing it.
3. Check whether the feedback explains the mistake, and read the explanation even when you get it right.
4. Return to the topic with spacing, instead of playing everything at once.
5. Use the ranking with your group and discuss the cases afterward.
6. Watch your interest: if the scoreboard has become an anxious obligation, look only at your progress.
7. See who reviews the content and whether the game leaves room for research.
8. Keep the game as a complement to class, textbook, questions and preceptorship.

Want to try a diagnostic game with these criteria? Play today's case on NEXO.

References

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