Management games in internship: what they train

A controlled trial with 91 participants in a multiple-casualty incident management course found that those who trained triage with a serious game triaged casualties more accurately in a live simulation than those who trained with a card exercise (Knight et al., 2010). The time to triage all casualties was similar in both groups (Knight et al., 2010). Results like this draw attention to games that call for a management decision, not just a diagnosis, but studies vary widely from format to format.

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 covers management games and simulations as support for the internship: escape room, serious management games, decision simulators with open cases, and triage and prioritization games. For each format, it shows what the evidence says and how to use it when time is short. The types of diagnostic reasoning game have their own text on clinical reasoning games, and the moment to order a test or choose a management approach is in the text on clinical decision-making.

Key points

• Management games ask you to decide what to do: treat, order, prioritize or refer, with feedback on the choice.
• In a review of games for teaching clinical reasoning, reflection was the least present step (Koelewijn et al., 2024).
• Educational escape rooms increased knowledge in meta-analyses, and most were used to review content (Kakos et al., 2025).
• Serious management games show mixed results: better performance in a simulated scenario in some trials, no difference on exams in others (Perron et al., 2025; Aster et al., 2022).
• More realism does not always help: in a study with students, the most faithful game engaged more without improving skills (Dankbaar et al., 2016).
• When time is short, management games work best as preparation and review, alongside the clerkship.

Summary

• What management games are
• Escape room: reviewing as a team
• Serious management games
• Decision simulators and the weight of realism
• Triage and prioritization
• How to use them when time is short in the internship
• Where NEXO comes in
• Frequently asked questions
• Checklist for using management games

What management games are

A management game is any game or simulation in which the main task is to decide what to do with the patient: choose a treatment, order a test, prioritize who to see first or define the referral. The case responds to the choice, and the feedback shows what happened and why.

The most studied formats

A scoping review found 19 different games created to support the teaching of clinical reasoning in the health professions, most in the simulation and escape room genres (Koelewijn et al., 2024). In this text, they appear in four groups:

Format	What the player does	Where it appears in studies
Escape room	Solves challenges as a team, against the clock, to "escape" the room	Content review in undergraduate education (Kakos et al., 2025)
Serious management game	Treats patients in a virtual hospital or emergency department	Pediatrics and infectious diseases in undergraduate education (Perron et al., 2025; Aster et al., 2022)
Decision simulator with open cases	Manages emergency cases, choosing assessment and treatment	Students and residents before a practical training session (Dankbaar et al., 2016; Dankbaar et al., 2017)
Triage game	Sorts casualties or patients by priority	Multiple-casualty incidents (Knight et al., 2010; Mills et al., 2020)

The steps the games cover

The review by Koelewijn and colleagues compared the games with an eight-step clinical reasoning cycle (Koelewijn et al., 2024). Most included considering the patient, collecting data, intervening and evaluating the outcome (Koelewijn et al., 2024). Setting goals and reflecting were the least integrated steps, and the authors recommend using the games with a reasoning model that has explicit reflection steps (Koelewijn et al., 2024).

As an editorial reading, this suggests that many management games train the "doing", and reflection on what was done is left to the player or the teacher. The section on debriefing in the text on simulation shows how to lead that conversation.

Escape room: reviewing as a team

In the educational escape room, a team solves a sequence of challenges tied to a theme, with limited time, until they "open the door." In health care, the challenges are usually cases, questions or practical tasks.

What the meta-analyses show

A meta-analysis of educational escape rooms in the health sciences included 11 studies with a before-and-after design and 5 studies with a control group (Kakos et al., 2025). In the studies with a control group, the 508 escape room participants performed better than the 555 in the control group, with a standardized mean difference of 0.616 (Kakos et al., 2025). Most escape rooms were used to review content already taught (Kakos et al., 2025).

Another meta-analysis, with studies in English and Chinese on medical education, found a positive effect of the escape room on knowledge compared with traditional teaching, with a standardized mean difference of 0.84 (He et al., 2024). The same review also assessed teamwork, satisfaction and anxiety (He et al., 2024).

What the escape room trains

Kakos and colleagues describe the escape room as a way to exercise teamwork, communication, attention to detail and application of knowledge under time pressure (Kakos et al., 2025). The meta-analyses measure, above all, knowledge. So the safest place for the escape room in the clerkship is group review of a theme, for example before an exam or at the end of a rotation.

Serious management games

Serious management games put the student in a virtual hospital or emergency department, where they see patients, order tests and choose treatments. These are the formats closest to the clerkship routine, and the results vary according to what is measured.

A trial in pediatrics

In a randomized trial with final-year medical students in Australia, 154 participants were assigned to one of three resources for 8 weeks: a role-playing game in a virtual hospital, an interactive online tutorial or paper guidelines (Perron et al., 2025). The content was the assessment and management of acute asthma and seizures in children (Perron et al., 2025).

In the simulated clinical scenario, the game group scored 20.8 out of 30 points, against 18.7 for the paper guidelines group, a moderate effect (Perron et al., 2025). Against the interactive tutorial, the difference was not significant, and on the multiple-choice questions the groups were equal (Perron et al., 2025).

A trial in infectious diseases

In Germany, 100 fifth-year students were assigned to three levels of exposure to virtual patients with infective endocarditis or community-acquired pneumonia in a game that simulated an emergency department (Aster et al., 2022). More exposure to the game did not lead to higher OSCE scores (Aster et al., 2022). The performance recorded in the game, however, had a moderate correlation with OSCE performance, of 0.477 (Aster et al., 2022).

The authors point out as advantages of the format the standardized content, less inhibition to learn and less need for teacher time, compared with small-group teaching (Aster et al., 2022).

A trial before cardiac arrest simulation

In France, 82 second-year students prepared for a cardiac arrest simulation training with a serious game in a 3D environment or with an online slide course (Drummond et al., 2017). The training time needed to reach the minimum score in the scenario was similar: a median of 20.5 minutes in the game group and 23 minutes in the course group (Drummond et al., 2017). The authors conclude that the game was not superior to the online course as preparation (Drummond et al., 2017).

What the three trials have in common

Study	Comparison	Main result
Pediatrics, final year	Game against paper guidelines and against interactive tutorial (Perron et al., 2025)	Better in the simulated scenario than paper guidelines; equal to the tutorial (Perron et al., 2025)
Infectious diseases, fifth year	More or less exposure to the same game (Aster et al., 2022)	Equal OSCE scores; game performance correlated with the OSCE (Aster et al., 2022)
Cardiac arrest, second year	Game against online course (Drummond et al., 2017)	Similar time to the minimum score (Drummond et al., 2017)

The joint reading, as editorial interpretation, is that the management game tends to beat passive materials and tie with other interactive resources. What seems to matter is studying actively, with feedback, more than the game format itself.

Decision simulators and the weight of realism

Decision simulators present open cases, in which the student conducts the assessment and treatment step by step. An important question is how much realism they need to have.

More realism, more engagement, same skill

In a randomized study with 61 students, Dankbaar and colleagues compared three groups: an online module, the module with text patient cases and the module with a high-fidelity simulation game with the same cases (Dankbaar et al., 2016). After 4 weeks, blinded assessors measured emergency cognitive skills in two mannequin scenarios, and the groups did not differ (Dankbaar et al., 2016).

The game group felt more engaged, and the case groups studied 2 hours more than the module group (Dankbaar et al., 2016). The authors suggest that the high-fidelity game, although engaging, probably distracted the students, and recommend adjusting the complexity and realism of the case to the level of the learner (Dankbaar et al., 2016).

With residents, the advantage was temporary

The same group tested a serious game as preparation for residents for an emergency training (Dankbaar et al., 2017). Before the in-person training, those who played studied 2.5 hours more and had higher scores on the clinical competence scales (Dankbaar et al., 2017). After 2 weeks of training, the difference between the groups disappeared (Dankbaar et al., 2017).

What this says for the internship

As an editorial reading, these results match more with the decision simulator as preparation for practical training than as the entire training. For those in the internship, the use that matches them best is playing before a rotation or an in-person simulation, to arrive with the assessment script in mind. Training with people, simulated patient and debriefing is in the text about care simulation.

Triage and prioritization

Triage games ask the player to classify patients or victims by severity and decide who to attend first. It is a type of management decision in which time and the order of decisions matter as much as getting each one right.

Game against cards

In the trial by Knight and colleagues, 44 participants trained with a card exercise and 47 with a serious game, and then each one triaged victims in a live simulation (Knight et al., 2010). The game group got more classifications right, and more participants in this group followed the correct procedure on all victims (Knight et al., 2010).

Virtual reality against live simulation

In a study with 29 paramedic students, each participant did a live mass casualty incident simulation and one in virtual reality, in randomized order (Mills et al., 2020). The number of correct classifications was the same in both formats, and classification was faster in virtual reality (Mills et al., 2020). The authors list, among the resources of live simulation, actors, makeup, staged vehicle and team time (Mills et al., 2020).

Triage in the hospital

There are also trials with serious trauma triage games for emergency physicians, with outcomes measured in patient care; they are described in the text about clinical reasoning games. In the internship, day-to-day prioritization, such as weighing severity and probability when deciding who to see first, is in the text about clinical reasoning in the internship.

How to use it with little time in the internship

Free time in the internship is short, and management games need to fit into it. The general study routine is in the text about how to study in the internship; here are specific suggestions for management games.

Each format at its moment

Format	Best moment (Editorial suggestion)	Why
Escape room	Group review at the end of a rotation	Most were used to review content (Kakos et al., 2025)
Serious management game	Before taking on patients in a new subject area	It beat passive material in a simulated scenario (Perron et al., 2025)
Decision simulator	In the week before a practical training session or simulation	The advantage appeared as preparation (Dankbaar et al., 2017)
Triage game	Before an emergency and urgent care rotation	It improved triage scores in a live simulation (Knight et al., 2010)

After the game, reflection

Since reflection is the least present step in clinical reasoning games (Koelewijn et al., 2024), it is worth adding it on your own. As a practical suggestion, after each game answer in writing:

1. What was the main decision and what led me to it?
2. What did the feedback show that I had not considered?
3. Where does this appear in the rotation: which patient or situation resembles this case?
4. Where does the right management come from: which guideline or protocol of the service supports the answer?

A week with little time

As a practical suggestion, a clerkship week with management games can look like this:

1. During breaks in the shift: a short hypothesis case, with the question "and now, what would I do?" written down at the end.
2. Once a week: a management game case or a simulator case linked to the current rotation, followed by the four reflection questions.
3. At the end of the rotation: an escape room or a group review of the subject, if the medical school or the student league offers one.
4. Always: take the management you chose to the preceptor, as in the presentation model described in the text about clinical reasoning in the clerkship.

The game and the patient of the day

The studies cited measure performance on exams and in simulations. As an editorial guideline, management is decided in supervised care, and the game helps when it prepares you for that and when what you learned comes back to the discussion with the preceptor. The routine of linking games to books, Anki and questions is in the text about how to fit games into your routine.

Where NEXO comes in

Management games train what to do after the hypothesis. NEXO trains the hypothesis, the step that comes before: each case arrives in up to six clues, one at a time, and each guess shows the proximity in ICD-10.

Hypothesis in Daily, time in Adrenaline

Daily brings one case per day, the same for everyone. Adrenaline is a case against the clock: before playing, you choose the dose, and the higher it is, the less time you have. There is one Adrenaline case per day, a training of reasoning under time pressure. Archive gathers the previous daily cases, and Multimedia brings cases with images, audio and other exams.

From the hypothesis to the management question

Choosing exams and management is trained in the formats described above, in the rotation and in simulation. As a practical suggestion, after getting the Daily mode or Adrenaline case right, write in one line what the first management step would be and check it in the guideline, using the questions from the text about clinical decision-making. The streak, the ranking and the achievements follow consistency, and the Anki button turns what you missed into a card, as described in the guide on spaced repetition.

To research, bring to your class and create

If you research games and learning and want to propose studies with NEXO, meet NEXO Researcher. To bring NEXO to your medical school, student league or residency program, there is NEXO Closer. Doctors who review cases in their specialty take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.

Frequently asked questions

What are management games in Medicine?

They are games or simulations in which the main task is to decide what to do with the patient: treat, order tests, prioritize or refer, with feedback on the choice. The most studied formats include simulations and escape rooms (Koelewijn et al., 2024).

Do escape rooms work for studying Medicine?

In meta-analyses, educational escape rooms increased knowledge compared with control groups (Kakos et al., 2025; He et al., 2024). Most were used to review content, which makes it a good format for the end of a rotation.

Do serious games improve clinical management?

The results are mixed. In a pediatrics trial, the game beat the paper guideline in a simulated scenario and tied with an interactive tutorial (Perron et al., 2025). In an infectious diseases trial, more exposure to the game did not improve the OSCE score (Aster et al., 2022).

Is the more realistic the simulator, the better?

It depends on the learner's level. In a study with students, the high-fidelity game engaged more without improving skills, and the authors suggest adjusting realism to the student's level (Dankbaar et al., 2016).

Do triage games help?

In a controlled trial, those who trained with a serious triage game got more victim classifications right in a live simulation than those who trained with cards (Knight et al., 2010). In paramedicine students, virtual reality simulation had the same accuracy as live simulation (Mills et al., 2020).

How can I use management games with little time in the internship?

Use each format at its moment: the simulator before a practical training, the management game before a new topic, the triage game before the emergency room and the escape room to review at the end of the rotation. After each session, set aside a few minutes for written reflection.

Does the management game replace the internship?

The internship remains where management is decided, with supervision. In studies with residents, the advantage of those who played before training disappeared after 2 weeks of practical training (Dankbaar et al., 2017). This result fits with using the game as preparation.

How does NEXO help in the internship?

NEXO trains the guess, with cases in up to six clues and proximity in ICD-10, in the Daily mode and against the clock in Adrenaline. Management is trained in the internship, in management games and in simulation, and a line with the first management step after each case connects the two stages.

Checklist for using management games

1. Do I know which decision the game asks for: treat, order, prioritize or refer?
2. Does the game give feedback explaining the right management and the mistake?
3. Does the topic match the current internship or the next one?
4. Does the realism match my level, without distracting from the content?
5. Did I use the game as preparation before a practical training or a new topic?
6. Did I set aside time to reflect after the session?
7. Did I check the management in the guideline or in the service protocol?
8. Did I take the question to the preceptor the next day?
9. Did I review in a group at the end of the internship, if there was an escape room or discussion?
10. Did I record what changed in the way I decide?

References

1. Koelewijn G, Hennus MP, Kort HSM, Frenkel J, van Houwelingen T. Games to support teaching clinical reasoning in health professions education: a scoping review. Med Educ Online. 2024. https://pubmed.ncbi.nlm.nih.gov/38394053/
2. Kakos NJ, Lufler RS, Cyr B, et al. Unlocking knowledge: a meta-analysis assessing the efficacy of educational escape rooms in health sciences education. Adv Health Sci Educ Theory Pract. 2025. https://pubmed.ncbi.nlm.nih.gov/39266886/
3. He Y, Chen X, Ma H, Zhao R, Zhou H, Yang Y. Effectiveness of escape room in medical education: a systematic review and meta-analysis. Games Health J. 2024. https://pubmed.ncbi.nlm.nih.gov/39093839/
4. Knight JF, Carley S, Tregunna B, et al. Serious gaming technology in major incident triage training: a pragmatic controlled trial. Resuscitation. 2010. https://pubmed.ncbi.nlm.nih.gov/20732609/
5. Mills B, Dykstra P, Hansen S, et al. Virtual reality triage training can provide comparable simulation efficacy for paramedicine students compared to live simulation-based scenarios. Prehosp Emerg Care. 2020. https://pubmed.ncbi.nlm.nih.gov/31580178/
6. Dankbaar ME, Alsma J, Jansen EE, et al. An experimental study on the effects of a simulation game on students' clinical cognitive skills and motivation. Adv Health Sci Educ Theory Pract. 2016. https://pubmed.ncbi.nlm.nih.gov/26433730/
7. Dankbaar ME, Roozeboom MB, Oprins EA, et al. Preparing residents effectively in emergency skills training with a serious game. Simul Healthc. 2017. https://pubmed.ncbi.nlm.nih.gov/27764018/
8. Perron JE, Uther P, Coffey MJ, et al. Are serious games seriously good at preparing students for clinical practice?: a randomized controlled trial. Med Teach. 2025. https://pubmed.ncbi.nlm.nih.gov/38460191/
9. Aster A, Scheithauer S, Middeke AC, et al. Use of a serious game to teach infectious disease management in medical school: effectiveness and transfer to a clinical examination. Front Med (Lausanne). 2022. https://pubmed.ncbi.nlm.nih.gov/35547200/
10. Drummond D, et al. Serious game versus online course for pretraining medical students before a simulation-based mastery learning course on cardiopulmonary resuscitation: a randomised controlled study. Eur J Anaesthesiol. 2017. https://pubmed.ncbi.nlm.nih.gov/28731928/