Gamificación como estrategia de aprendizaje activo a través de casos clínicos: impacto en la formación médica J. Adv. Educ. Sci. Humanit. (January - June 2024) 2(1): 34-39 https://doi.org/10.5281/zenodo.14602327 ISSN: XXXX-XXXX REVIEW ARTICLE Gamification as an active learning strategy through clinical cases: impact on medical training  Mayda Beltrán labaut0515@gmail.com Received: 8 November 2023 / Accepted: 12 January 2024 / Published online: 31 January 2024 © The Author(s) 2024 Mayda Beltrán 1 · Denise Vega 2 Abstract Gamification has become an innovative educa- tional strategy, especially in medical training because it pro- motes active learning and student engagement. This review article aims to analyze the impact of gamification in med- ical education, identifying its benefits, limitations, and the challenges associated with its implementation. Recent stud- ies evaluating the use of gamified elements, such as serious games, interactive applications, and clinical simulations, in teaching theoretical and practical skills were reviewed. The results indicated that gamification enhances motivation and enjoyment of learning, promotes critical thinking develop- ment, and facilitates knowledge retention, even in complex clinical scenarios. However, barriers such as resistance to change from teaching staff and the need for adequate techno- logical resources were also identified. Keywords gamification, active learning, interactive teach- ing, medical training, barriers in education, pedagogical strategies. Resumen La gamificación se ha consolidado como una es- trategia educativa innovadora, especialmente en el ámbito de la formación médica, debido a su capacidad para fomentar el aprendizaje activo y el compromiso estudiantil. Este artículo de revisión tiene como objetivo analizar el impacto de la ga- mificación en la educación médica, identificando sus benefi- cios, limitaciones y los desafíos asociados con su implemen- tación. Se revisaron estudios recientes que evalúan el uso de elementos gamificados, como juegos serios, aplicaciones interactivas y simulaciones clínicas, en la enseñanza de habi- lidades teóricas y prácticas. Los resultados indicaron que la gamificación mejora la motivación y disfrute del aprendiza- je, promueve el desarrollo del pensamiento crítico y facilita la retención de conocimientos, incluso en escenarios clínicos complejos. Sin embargo, también se identificaron barreras como la resistencia al cambio por parte del personal docente y la necesidad de recursos tecnológicos adecuados. Palabras clave gamificación, aprendizaje activo, enseñanza interactiva, formación médica, barreras en educación, estra- tegias pedagógicas. How to cite Beltrán, M., & Vega, D. (2024). Gamification as an active learning strategy through clinical cases: impact on medical training. Journal of Advances in Education, Sciences and Humanities, 2(1), 34-41. https://doi.org/10.5281/zenodo.14602327 1 Instituto de la Visión, Portoviejo, Manabí, Ecuador. 2 Hospital de Especialidades, Portoviejo, Manabí, Ecuador.

J. Adv. Educ. Sci. Humanit. (January - June 2024) 2(1): 34-39 35 Introduction In the last decade, gamification has emerged as one of the most innovative and effective pedagogical strategies across various fields of education, particularly in medical training. This approach leverages game principles and elements like rewards, challenges, and instant feedback to create a more engaging, interactive, and motivating learning environment. In medical education, gamification facilitates theoretical content teaching and enhances practical training through cli- nical simulations and interactive cases. These methodologies allow students to confront real or hypothetical scenarios in a controlled manner, promoting the development of clinical skills such as diagnosis, decision-making, and teamwork (Cascella et al., 2023). Gamification has gained prominence in medical education as an innovative tool to improve learning and the training of healthcare professionals. Its roots lie in using game te- chniques to foster motivation and engagement in non-game educational settings. This strategy has been implemented in medical education to improve knowledge retention, critical thinking, and practical skills through simulations and inte- ractive clinical cases (Xu et al., 2023). Several studies have shown that gamification can trans- form the educational experience by promoting more dyna- mic and autonomous learning while improving students’ perception of the teaching-learning process. In particular, incorporating serious games and interactive platforms in me- dical training programs has allowed students to face complex clinical scenarios safely, encouraging decision-making and problem-solving in real time (Dorado & Chamosa, 2019; Smiderle et al., 2020). Active learning focused on direct student participation, has been significantly strengthened with the integration of gami- fication, allowing for better knowledge retention and more effective autonomous learning. However, despite its benefits, the implementation of gamification in medical education fa- ces challenges, such as resistance from some faculty to adopt new technologies and the need for adequate infrastructure for successful implementation. This review article analyzes the impact of gamification in medical education, evaluating its benefits, limitations, and the challenges that persist in its adoption (Hellín et al., 2023). Methodology This article is based on a systematic review of the scien- tific literature related to the topic of interest. To collect and analyze previous studies, a descriptive and qualitative approach was employed. Articles were searched in widely recognized academic databases such as PubMed, Scopus, Web of Science, and Google Scholar to obtain relevant and up-to-date studies. The following inclusion and exclusion criteria were defi- ned for the collection of studies. The inclusion criteria were: (1) studies published in the last ten years, (2) articles in English and Spanish, (3) research addressing the main topic of the review, and (4) articles with full-text access. Exclusion criteria included irrelevant studies, conference abstracts, and articles without peer review. Boolean operators were used to optimize the search. Com- binations of terms were made using AND, OR, and NOT to include or exclude specific concepts. The keywords used included gamification, medical education, educational tech- nologies, and innovative medical training (Kalogiannakis et al., 2021). The searches were expanded to several databases, and references were managed with the Zotero tool to ensure proper organization (Khan et al., 2022). Results and discussion A total of 39 articles were retrieved through the search in several academic databases. After applying the inclusion/ exclusion criteria, 23 articles that did not meet the require- ments were removed. In the end, 16 articles were selected for analysis in the review. Table 1 overviews various studies exploring gamification in medical education, particularly in resolving clinical cases. For the analysis, the studies were grouped into three main areas: diagnostic decision-making, improvement of clinical skills, and motivation and learning. Ishizuka et al. (2023) and Pawar & Pawar (2024) highli- ghted the use of decision-making cards (DMC) in improving diagnostic decision-making, with a particular focus on awa- reness of medical costs and clinical thinking. Both studies demonstrated how this gamified tool helps students improve clinical judgment in practical scenarios. Gamified clinical simulations in the United Kingdom (Gajardo et al., 2023) and Chile (Alzghoul, 2024) enhance clinical judgment and decision-making under pressure, espe- cially in emergencies. Gamification allows for the simulation of realistic scenarios where students develop practical and problem-solving skills under stress. Research in the United States (Gajardo et al., 2023) and Australia (XXV National Congress and I International Con- gress of the Spanish Society of Medical Education, 2023) highlighted that online gamification improves clinical rea- soning and increases motivation and knowledge retention.

J. Adv. Educ. Sci. Humanit. (January - June 2024) 2(1): 34-39 36 Table 1. Gamification in clinical case resolution in Medicine Reference Type of gamification Country Main result Ishizuka et al. (2023) Decision-making cards (DMC) Japan Gamification improves diagnostic decision- making and increases awareness of medical costs Huang et al. (2024) Online gamification methods United States Improves students' clinical reasoning ability Wang et al. (2024) Key gamification elements China Identifies key elements for effectively applying gamification in medical education Xu et al. (2023) Game-Based Learning (GBL) China GBL methods provide immersive experiences and improve learning outcomes Do et al. (2023) Gamified vs. non- gamified online educational modules Australia Gamification improves student motivation and knowledge Huang et al. (2024) Gamified clinical simulations United Kingdom Gamified clinical simulations contribute to better clinical judgment and decision-making Ishizuka et al. (2023) DMCs for diagnostic decision-making Japan Increases cost awareness and improves decision- making Fica et al. (2023) Medical emergency simulation Chile Significant improvement in decision-making ability and stress management in emergencies Yu et al. (2023) Virtual role- playing games Spain Increased student motivation and a better understanding of doctor-patient interactions Aldalur & Alain (2023) Points, levels, and rewards Mexico Students showed greater retention of clinical knowledge and diagnostic skills Leon & Peña (2022) Educational escape room Argentina Stimulates critical thinking and problem-solving under pressure, especially in complex diagnostic situations Salazar et al. (2019) Interactive simulators Chile Effective use for evaluating the development of clinical skills, emphasizing cohort practice Sánchez et al. (2008) Strategy games with clear goals Mexico Participants showed increased adherence to ethical and practical principles in managing critical situations Wang et al. (2024) China Identifies key elements for effectively applying gamification in medical education Do et al. (2023) Key gamification elements Australia Gamification improves student motivation and knowledge Gamified vs. non- gamified online educational modules

J. Adv. Educ. Sci. Humanit. (January - June 2024) 2(1): 34-39 37 This gamification is applied through interactive educational platforms, promoting a better understanding of clinical con- cepts and improving learning outcomes. Other approaches, such as virtual role-playing games in Spain (Pons & Sonsoles, 2020), educational escape rooms in Argentina (Padilla et al., 2024), and interactive simulators (Fica et al., 2023), focus on critical thinking, problem-sol- ving, and teamwork. These modalities help students better understand doctor-patient interactions and tackle complex diagnostic situations. Table 2 summarizes the leading countries in using gami- fication as an active learning strategy through clinical cases in medical training. It highlights the main conclusions from recent research on the impact of gamification in medical edu- cation. These countries lead the implementation of gamified stra- tegies for medical education, adapting them to their specific educational needs. Japan uses decision-making cards (DMC) to improve diagnostic decision-making, while in the United States, game-based learning (GBL) predominates to develop clinical reasoning. In the United Kingdom, gamified clinical simulations are key to optimizing clinical judgment and de- cision-making in realistic scenarios. Spain employs virtual role-playing games to foster doctor-patient interaction and intrinsic student motivation, and Mexico focuses on point, level, and reward systems to strengthen clinical knowledge retention. These strategies demonstrate how gamification can enhance essential skills in medical training, promoting motivation, active interaction, and meaningful learning. In the context of medical education, each gamified strategy Tabla 2. Leading countries in the use of gamification as an active learning strategy Country Gamification approach Reference Japan Use of decision-making cards (DMC) to improve diagnostic decision-making. Xu et al. (2023) United States Game-based learning (GBL) to improve clinical reasoning. Xu et al. (2023) United Kingdom Gamified clinical simulations to improve clinical judgment and decision-making. Ishizuka et al. (2023) Spain Virtual role-playing games to improve doctor-patient interaction and motivation. McLean (2016) Mexico Use of points, levels, and rewards to improve retention of clinical knowledge. Chans et al. (2021) has unique strengths. As used in the United Kingdom, ga- mified clinical simulation is highly effective for developing practical skills and decision-making in environments that mimic real medical scenarios, which is critical in medical training. This approach promotes experiential learning and the direct application of knowledge in practical situations. However, in Ecuador, a context with limited resources in certain institutions, it might be more feasible to implement strategies requiring less infrastructure, such as using points, levels, and rewards, as applied in Mexico. This approach is adaptable, cost-effective, and can incentivize active partici- pation and clinical knowledge retention without relying on advanced technology. Therefore, a combination of clinical simulations in institutions with greater resources and more accessible techniques, such as points and rewards, could be the most effective strategy to address the diverse needs of the medical education system in Ecuador. The impact of gamification in education varies depending on the regions studied, which are influenced by sociocultu- ral factors and the availability of technological resources. In developed countries, such as the United States and the United Kingdom, gamification has shown a significant posi- tive impact, primarily due to advanced infrastructure, trained faculty, and greater cultural acceptance of innovative educa- tional technologies. For example, in these regions, gamified clinical simulations have optimized the development of cli- nical skills and decision-making in controlled and realistic environments. In contrast, although similar benefits in terms of motiva- tion and learning have been documented in developing coun- tries, the implementation of these strategies faces significant barriers. These include limited technological infrastructure, resistance to change from faculty, and budget constraints. Studies conducted in the Ecuadorian context, for instance, highlight that, despite the growing adoption of ICTs and ga- mification, challenges related to connectivity and access to

J. Adv. Educ. Sci. Humanit. (January - June 2024) 2(1): 34-39 38 proper tools persist. Additionally, Hellín et al. (2023) and Gajardo et al. (2023) reported that, in developing countries, the effectiveness of gamification largely depends on the adaptability of strate- gies to available resources. For example, using low-cost ga- mified approaches, such as point and reward systems, has proven effective in overcoming technological barriers and promoting learning in resource-limited environments. This highlights the need to design contextualized educational in- terventions that align with local capabilities and promote the sustainable development of medical education. Conclusions Gamification in medical education has proven to be an effective tool for improving students’ diagnostic skills and clinical decision-making. By implementing games and simu- lations, students can experience medical situations in a con- trolled environment, strengthening their ability to face re- al-life challenges. Various studies indicate that gamification increases student interest and motivation, leading to more interactive and participatory learning. Furthermore, it has been shown that serious video games and gamified platforms enhance knowledge retention and its application in emer- gency medical contexts. This is because it combines playful elements with teaching, facilitating theoretical and practi- cal content absorption. Additionally, gamification has been shown to contribute to the development of specific skills for emergency medicine, improving students’ speed and effecti- veness in responding to critical situations. Gamification op- timizes the educational process and allows future healthcare professionals to gain experience in solving complex cases, better preparing them for their professional practice. References Aldalur, I. & Perez, A. (2023). Gamification and discovery learning: Motivating and involving students in the learning process. Heliyon, 9(1), e13135. https://doi.or- g/10.1016/j.heliyon.2023.e13135 Alzghoul, B. (2024). The Effectiveness of Gamification in Changing Health-related Behaviors: A Systematic Re- view and Meta-analysis. Open Public Health Journal, 17, e18749445234806. https://doi.org/10.2174/011874 9445234806240206094335 Cascella, M., Cascella, A., Monaco, F., & Shariff, M.N. (2023). Envisioning gamification in anesthesia, pain management, and critical care: basic principles, inte- gration of artificial intelligence, and simulation stra- tegies. Journal of Anesthesia, Analgesia and Critical Care, 3(1), 33. https://doi.org/10.1186/44158-023-00118 -22 Chans, G.M., & Portuguez, M. (2021). Gamification a s a Strategy to Increase Motivation and Engagement in Hi- gher Education Chemistry Students. Computers, 10(10), 132. https://doi.org/10.3390/computers10100132 Do, M., Sanford, K., Roseff, S., Hovaguimian, A., Besche, H., & Fischer, K. (2023). Gamified versus non-gamified online educational modules for teaching clinical labo- ratory medicine to first-year medical students at a large allopathic medical school in the United States. BMC Medical Education, 23, 959. https://doi.org/10.1186/ s12909-023-04951-5 Dorado, C., & Chamosa, M.E. (2019). Gamificación como estrategia pedagógica para los estudiantes de Medi- cina nativos digitales. Investigación en educación médica, 8(32), 61-68. https://doi.org/10.22201/fac- med.20075057e.2019.32.18147 Fica, A., Burgess, V., González, T., & Rojas, M. (2022). Ga- mificación en Medicina de Urgencia. Revista Española de Educación Médica, 3, 58-68. https://doi.org/10.6018/ edumed.531501 Gajardo, A.D., Murillo-Zamorano, L.R., López-Sánchez, J., & Bueno-Muñoz, C. (2023). Gamification in Health Care Management: Systematic Review of the Literatu- re and Research Agenda. Sage Open, 13(4). https://doi. org/10.1177/21582440231218834 Hellín, C.J., Calles-Esteban, F., Valledor, A., Gómez, J., Otón-Tortosa, S., & Tayebi, A. (2023). Enhancing Stu- dent Motivation and Engagement through a Gamified Learning Environment. Sustainability, 15(19), 14119. https://doi.org/10.3390/su151914119 Huang, W.D., Loid, V., & Sung, J.S. Reflecting on gamified learning in medical education: a systematic literature review grounded in the Structure of Observed Lear- ning Outcomes (SOLO) taxonomy 2012-2022. BMC Medical Education, 24(1), 20. https://doi.org/10.1186/ s12909-023-04955-1 Ishizuka, K., Shikino, K., Kasai, H., Hoshina, Y., Miura, S., Tsukamoto, T., Yamauchi, K., Ito, S., & Ikusaka, M. (2023). The influence of Gamification on medical students’ diagnostic decision making and awareness of medical cost: a mixed-method study. BMC Medical Education, 23, 813. https://doi.org/10.1186/s12909- 023-04808-x Kalogiannakis, M., Papadakis, S., & Zourmpakis, A.I. (2021). Gamification in Science Education. A Systema- tic Review of the Literature. Education Sciences, 11(1), 22. https://doi.org/10.3390/educsci11010022

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