Parvesh Konda, Kawtar-Eve Bihmane

Introduction

Gamification refers to the process of incorporating game-design elements into the preparation of teaching sessions to enhance learning outcomes. This may incorporate the use of game mechanics (points, leaderboards, challenges), game dynamics (competition, exploration, collaboration) and narratives such as a compelling story into an educational scenario. In 1990, Csikszentmihalyi proposed the idea of flow theory suggesting that participants develop increased immersion into tasks when the challenges align with their skills and interests (1). Gamification is proposed to improve engagement in this manner. In addition, Skinner (1953) describes that points and rewards can incentivise and motivate desired behaviours – another principle used in gamification (2). Gamification also aligns with Bandura’s social learning theory through the use of team challenges to foster learning through collaboration (3). The essential premise is to incorporate game design elements and principles into non-game contexts, such as education, training, or workplace environments, to increase engagement, motivation, and participation.

Serious games are full-fledged games used for educational purposes such as surgical simulators or the VR-based games described later in the article (4). Simulation-based games are used to mimic real-life scenarios such as “crash call simulations” used in resuscitation or surgical simulators. Structural gamification refers to adding game elements such as points and leaderboards to existing tasks. Competitive gamification refers to using scores and competition to motivate participants.

There is evidence to demonstrate the positive impacts of the use of gamification. Xu et al. have reviewed the literature to show that serious-game based approaches can help to improve clinical reasoning, decision-making skills and collaborative awareness (5). Simulation, a form of gamification, can help to improve patient safety and clinical competence (6). However, not all results are positive. Rondon et al. (2013) demonstrated that traditional learning methods can improve long-term post-test retention when answering Anatomy and Physiology questions (7). Van Gaalen et al. report that most studies on gamification do not have a well-defined control group and underlying processes to explain effects are infrequently explored (8). Another limitation is the time-consuming and resource-intensive nature of this form of education, which can reduce accessibility. Ophthalmology is well suited to gamification due to the blend of theoretical knowledge and technical proficiency needed to be a proficient practitioner. This review discusses the role of gamification in current ophthalmology teaching and appraises its uses so far.

Methods

A literature search was conducted on PubMed to assess articles discussing gamification in ophthalmology education. The following terms were used in the search criteria: gamification, gaming, ophthalmic, ophthalmology, education, and teaching. A general search of Google was also carried out using the above criteria to find other studies on this topic. Inclusion criteria were studies published in journals, using gamification in ophthalmology teaching. The inclusion criteria were purposefully kept broad given the exploratory nature of this review and the relative paucity of studies on the use of gamification in ophthalmology.

Simulators

The Eyesi (VRmagic GmbH, Tübingen, Germany) is the most commonly used surgical simulator and combines a binocular surgical microscope, instruments, and a virtual reality-based interface to mimic real-life surgery. The simulator incorporates gaming elements (such as points and cataract challenges) alongside simulated cataract operation scenarios to maximise improvement in cataract training. A meta-analysis has shown that the Eyesi Surgical Simulator led to an improvement in technical skill scores and a reduction in technical errors (9). Wisse et al. (2017) have reported increased self-efficacy scores on real-life cataract surgery following the completion of cataract training on the simulator (10). In real-world studies, a multi-centre retrospective study showed a 38% reduction in complication rates following the introduction of the simulator into training programs (11).

Many of these studies on the efficacy of Eyesi use either retrospective data or self-reported measures, which may introduce bias. Future studies with standardised protocols could provide additional evidence. The use of randomised controlled trials would be difficult to justify given the current evidence base of reduced complications with the use of simulators. Despite their demonstrated efficacy, these simulators are costly, making them less accessible in resource-limited settings. Comparative cost-benefit analyses are needed to justify their broader adoption.

Escape Room Game

This approach by Akash Dharni is based on the premise of a series of challenges to ‘escape’ from a constructed environment (12). This approach has increasing popularity in the USA, especially in Emergency Department environments (13). The method involves riddles around core conditions, assessment of a practical eye examination, a visual field defect challenge, and logic games. Twenty students trialled the escape room, and feedback was consistently positive.

Increasing sample size and incorporation of a control group can help further similar studies to provide effective comparisons with traditional teaching methods. Future studies should include larger, randomised samples and assess long-term retention of knowledge and skills.

Gamification in Eye Trauma Education

In 2024, used an approach of gamification in eye trauma education (4). Ten ophthalmology residents and 60 medical students were involved in the study comparing a gamification method and a lecture-based method. A 3D gaming environment, based on images and videos of the ophthalmology emergency ward, was developed. Elements such as slit lamps, ampoules, etc., were incorporated into the gaming environment. The teaching goals included the management of eye trauma, prescription of appropriate drugs, performance of surgery, and post-op considerations. Gaming elements included a scoreboard and “shake” to induce a sense of danger.

This scenario was compared to a traditional lecture-based teaching method. Following both interventions, a 45-question MCQ was delivered, and the performance of both groups was compared. The results demonstrated statistically significant better results amongst medical students and ophthalmology residents when using the game-based approach. The satisfaction of the gamification method was also rated highly.

While the study’s results are promising, its resource-intensive nature may limit widespread adoption. Additionally, the study’s design does not assess whether the improved scores translate to better clinical performance. Further studies to assess long-term retention of skills and knowledge may help strengthen the clinical context of this study.

Competition Elements

Malik and Momin use the Eyesi surgical simulator to develop a competitive environment in surgical training (14). Challenges within the Eyesi course software were used, and participants were allowed to aim for the highest score. This was proposed to allow residents to boost their confidence in performing surgery in front of an audience and compete in a safe learning environment.

The competitive nature of this study may appeal to certain individuals and therefore limit inclusivity in engagement. In addition, the audience presence may differ from a surgical environment – hence limiting comparability. Consideration of alternative methods such as collaborative or team-based tasks may help mitigate potential issues.

Discussion

The application of gamification is broad and varied. This review shows some of the approaches that have been used in ophthalmology to date. Simulation consistently shows a positive impact on outcomes in medical education. Most studies focus on short-term benefits like satisfaction and engagement rather than long-term retention and clinical application. Further studies that assess long-term effects and other factors such as understanding basic concepts are crucial. In addition, cost-benefit analyses within these studies may help provide feasibility measures for incorporation into teaching and training programmes.

A review of the literature shows similar trends in other medical and surgical specialities – however, a detailed exploration is not within the scope of this review. For example, based on a systematic review of orthopaedic surgery, technical skill acquisition was enhanced by the use of gamification (13). Echoing the challenges seen in ophthalmology, these benefits come with additional demands such as increased time and resources. The use of hybrid approaches, facilitated by motivated educators, may offer additional merit above traditional approaches alone.

The studies on gamification in ophthalmology, so far, are in their infancy. Further studies on the use of gamification should initially consider the theory behind the proposed intervention – for example, could the game be designed based on the gradual step-wise development of specific skills which would be hypothesised to improve focus and flow as per ‘flow theory’? In addition, the clinical applications of interventions and the short-term effects and long-term effects on knowledge, skills and behaviours need to be investigated before these measures are adopted into widespread medical practice. The eye simulator provides a useful example of a gamified learning model that uses points, challenges and gradual increases in difficulty to improve adherences and learning based on game theory. This has shown effective improvements in practical skills with real-world translatable improvements. Further teaching methods may consider using the Eyesi as an example of an effective approach to the gamification of medical education.

Ethical Considerations

Gamification raises ethical concerns. Given the high cost of simulators or the development of the VR teaching environment, resource provision may not be equitable due to economic inequality. The competitive elements in gamification might lead to unhealthy rivalry or discourage participants with certain learning styles or personality traits. Ensuring inclusivity and designing gamified methods to support diverse learners are important considerations. Some methods to help combat these issues may include the use of cost-benefit analyses and team-based approaches to competitive tasks.

Conclusion

Gamification provides an exciting and engaging addition to traditional medical education. Studies within and outside ophthalmology show strongly positive effects on skill acquisition and participant satisfaction. Nevertheless, challenges such as high costs, resource intensity, and gaps in long-term retention studies remain. Future research should focus on the scalability and cost-effectiveness of interventions. Studies should also analyse long-term effects on knowledge, skills, behaviours and clinical outcomes to ensure translatable integration into medical education.

References

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