Brain Disorders 1 (2021) 100008

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Brain Disorders
journal homepage: www.elsevier.com/locate/dscb

Gamification and game-based education in neurology and neuroscience:

Applications, challenges, and opportunities
Stefano Sandrone a,∗, Chad Carlson b
a
Department of Brain Sciences, Imperial College London, Du Cane Road, London W120NN, United Kingdom
b
Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA

a r t i c l e i n f o a b s t r a c t

Keywords: The role of games in education continues to evolve. The integration of game-based learning with technology has
Neurologic education become more common and contributed to a growing body of literature promoting the use of game-based learn-
Neurology education ing techniques. However, it is only recently that these approaches have been applied to the realm of medical
Neuroscience education
education. Here, we review the evidence supporting game-based learning in undergraduate and graduate med-
Active learning
ical education and in neurology education. Moreover, we discuss challenges and opportunities for neurologic
Gamification
Gaming curricular implementation and explore applications in clinical settings. The potential for leveraging game-based
Gamebased education learning might represent a chance to seize for neurology and neuroscience.
Curriculum design
Clinical reasoning
Flipped classroom

Introduction rendered by expressions such as ‘game-based learning’ and ‘gamifica-

Playing is an archetypical activity and games of various natures are
part of our life from the very beginning [1]. Within the educational
context, game-based education and gamification of learning are now es-
tablished approaches in several science, technology, engineering, and
math disciplines [2–4]. The concept of gaming and competition being
valuable in learning is not unknown to medical education. However, it
is only recently that these approaches have entered the realm of medical
education. In this manuscript, we review the evidence supporting game-
based learning in undergraduate and graduate medical education and in
neurology education. Moreover, we discuss challenges and opportuni-
ties for neurologic curricular implementation and explore applications
in clinical settings.
Game-based learning and gamification of learning
Definition and theoretical underpinning
According to the Oxford English Dictionary, the word gamifica-
tion refers to ‘the application of typical elements of game playing (e.g.
point scoring, competition with others, rule of play) to other areas of
activity, typically as an online marketing technique to encourage en-
gagement with a product or service’ [5]. A similar concept can also be
tion of learning’. From a mere theoretical perspective, these approaches
can be placed under the umbrella term of active learning, an emerging
educational trend aimed at engaging learners and favouring knowledge
application over knowledge acquisition [6,7]. It indicates the shift from
a traditional teacher-centric approach, where an expert imparts teach-
ing activities ex-cathedra [6,8,9], to a learner-centred approach [7].
Applications in medical education
The use of game-based learning is not entirely new to medical educa-
tion. Many schools and graduate medical education training programs
worldwide organize quiz-show events or similar competitions, although
these are often done on an ad hoc basis. Even a simple neuroscience-
related quiz-show question or poll can be employed to introduce or con-
clude a teaching session [7]. Although many of these informal sessions
have little, if any, data to support their actual benefit nor educational
studies assessing inter-sites validity, there is a growing body of literature
to support the use of game-based learning techniques, as discussed be-
low. As interest in active learning grows [7], game-based learning might
follow a similar trend.
The internal medicine residency program at Birmingham and
Huntsville developed a novel, game-based competitive question-based
program [10]. This web-based software program delivered roughly two
questions per day to residents who chose to participate, and an online

∗
Corresponding author.
E-mail address: sandrone.stefano@gmail.com (S. Sandrone).

https://doi.org/10.1016/j.dscb.2021.100008
Received 24 November 2020; Received in revised form 16 February 2021; Accepted 16 February 2021
Available online 24 February 2021
2666-4593/© 2021 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
S. Sandrone and C. Carlson
leader board showed their progress compared to their peers [10]. This
intervention was assessed based on knowledge retention (through re-
peated questions), participation and acceptance. It has been considered
an enhancement of the educational experience among internal medicine
residents, although they heavily used it during the weekend (28.8% of
questions answered within this time frame) or between 5 pm and 8 am
(when over half of the items answered) [10]. This flexibility might come
at a high price, given the risk of eroding their already limited free time
and potentially negatively impacting the residents’ mental health. Fur-
thermore, overall engagement needs to be sustained over time as the
overall participation went down across the three rounds of competition
(starting with 92 in round 1 and ending with 55 in round 3).
But gamification of learning can also constitute an incentive for par-
ticipation. In a study of urology and surgery residents, only three resi-
dents used the simulator when offered the opportunity for the first seven
weeks of their trial (during which time no game-based elements were
present) [11]. In contrast, twenty-one residents utilized the simulator
after a competition with monetary prizes was announced. Coupling the
simulator with a gamification element and a financial reward boosted
residents’ engagement in relation to the use of the simulator [11].
Gamification has been implemented in the setting of undergradu-
ate medical education. In a small, controlled trial, a gamified module
teaching otorhinolaryngology concepts were tested against a traditional
PowerPoint show [12]. The game-based module involved moving a
character on the screen to obtain learning materials and then collect
relevant information. The investigators found that satisfaction scores
were higher for game-based education. Still, no difference was reported
in the knowledge gain (based upon scores on multiple-choice pre- and
post-tests) between the two learning methods [12]. Performance on a
multimedia-based situational test designed to assess overall competence
was lower in the group that underwent game-based education [12].
Somewhat in contrast, Granger et al. reported successful improvements
in critical appraisal skills for a group of nurses utilizing a web-based,
self-paced educational game aimed at teaching statistical concepts cen-
tered around literature review [13].
Applications in neurologic and neuroscience education
Education in the principles of neurology is necessary for all levels of
health care practitioners. Neurophobia has been discussed as a challenge
in medical student education for decades, and the fear of neurology is
undoubtedly not limited only to physicians and physicians in training
[14,15]. The potential benefits and incentives of gamification, including
peer-support and competition, may even address some of the challenges
surrounding neurophobia.
Gamification does not necessarily require expensive technological
devices. In fact, a low-tech gamified strategy has been piloted with nurs-
ing students at the University of Alabama during the study of the cra-
nial nerves, which are foundational neurological aspects in the broader
curricular economy: learners had to guess the term described by team-
mates without seeing the term to be guessed [16]. Students enjoyed the
experience and the stress-free learning situation, but the retention of
knowledge was not quantified [16]. On a similar low-tech note, a game
called the ‘neurological Hat Game’ has been adopted in Paris to teach
neurological semiology [17]. Intending to guess the highest number of
answers, two teams of medical students (second year) played against
each other with a deck of cards featuring a neurological sign or a symp-
tom to be guessed thanks to a clue-giver member, in a series of rounds
of increasing difficulties [17]. ‘Hat Game’ has been used to complement
lecturer-centred courses to teach neurological semiology to a group of
107 students [17]. They completed multiple-choice questions and a self-
administered survey and described themselves as ‘very satisfied’ with
the new teaching approach. However, randomized work is needed to
replicate this finding [17].
Game-based implementation is not limited to undergraduate and
graduate medical education, but has been piloted for stroke Continu-
2
Brain Disorders 1 (2021) 100008
ous Medical Education (CME). In one of the first studies performed at
the beginning of the past decade, thirty-two family physicians and three
senior family medicine residents were randomly allocated to either a
game-based or case-based group following a presentation on stroke care
[18]. The performance on a knowledge assessment was similar for both
groups; however, participants in the game-based session reported in-
creased satisfaction with the learning experience even three months af-
ter the end of the CME groups. The game-based group had higher num-
bers of ‘strongly agree’ responses for virtually all satisfaction elements
(except for whether it was a useful way to learn material which was the
same for both groups). Based on those responses, the game-based ap-
proach favoured more discussion and interaction at group-level while
generating interest in a future similar CME event [18].
Interactivity can also be promoted via a multiplayer role-playing
game. Mimycx, sponsored by the American Association of Colleges of
Pharmacy, is a recently piloted online, multiplayer role-playing game
with interactive quests featuring ‘avatars engaged in virtual adventures
that are case-based and health-related’ [19]. This platform encourages
social interaction, communication and teamwork via a combination of
chat options and verbal functionalities, and has been used in their Psy-
chiatry/Neurology course and the Healthcare Communication course
[19]. Although the focus of this module was not on primary neurologic
concepts, but rather communication, it nonetheless highlights broad po-
tential applications of gamification even in more substantial learning
circumstances (in this case, seventy-nine pharmacy students). Notably,
between the first “quest” and the second “quest”, attitudes of the stu-
dents worsened, with more students having negative feelings about the
Mimycx system. The authors do note that, at the time of their study,
the system was still in a beta testing stage [19]; therefore, some of the
technical concerns raised by students may be addressed in future itera-
tions. The more negative perceptions of some students reported in this
work are surprisingly in contrast to most investigations analyzing game-
based learning and active learning. However, while this specific aspect
highlights the importance of addressing technical factors in technology-
focused game-based learning, it offers the possibility to discuss how per-
ceived challenges, or difficulties, can be educationally exploited to in-
crease the students’ experience by embracing the flexibility offered by
gamification.
Challenges and opportunities for curricular implementation
Gamification offers a broad range of options to tackle a number of
applications with potential for improved accessibility [20]. Game-based
approaches have the potential to be used both as a training tool and as a
summative or formative assessment in neurology education. In its sim-
plest form, an easily implementable gamification element for the neu-
rology curriculum can be a digital multiple-choice question quiz show
game. This can be played either individually or in teams to assess knowl-
edge and collaborative skills. As the gamification element taps on the
competitive nature of the learners, it can be exploited to ‘put to the test’
the collaborative skills among the team. In more details, a random team-
allocation may favour the development of collaborative skills among
residents and fellows whereas a ‘blind’ topic allocation (i.e. only sec-
onds before the start of the game) can prevent strategic learning of the
tested material. While some data exist to guide the optimal design of
these game-based learning platforms as was discussed above, there is a
wide gap in the optimal approach in neurology education whether at
the undergraduate or graduate medical education level.
Similar to the flipped classroom approach, foundational elements
might be easier to test with a gamification approach [21,22]. As re-
viewed above, procedural learning can benefit from gamification, pro-
vided an alignment between the set of skills to be learnt and the imple-
mentation is in place. In both cases, an educational alignment between
the learning outcomes and the games needs to be established before-
hand, equally for knowledge and skills learning [23]. Sharing this ra-
tionale with the students might maximize their learning experience. As
S. Sandrone and C. Carlson
Fig. 1. Perceived barriers and potential solutions for residents and fellows, faculty and educators.
witnessed by the applications above, technology is not a strictly nec-
essary condition, although it can be used if allowed by the resources
available within a specific teaching context.
In addition to the benefits mentioned above in relation to medical
and neurologic education, gamification and game-based education come
with challenges and opportunities (Fig. 1). Several of these are shared
by active learning approaches, such as the flipped classroom model [7].
Game-based education can support the design and the adoption of tools
allowing the delivery of educational content in time-constrained edu-
cational settings and/or coupled to strategies that can reduce training
costs.
On the learners’ side, poor compliance with expected responsibili-
ties and increased preparation time might be potential barriers. While
the gamification element is designed to engage the students, its flexi-
bility, coupled with the learner-centred nature of this approach, might
erode the already small amount of free time residents and fellows have.
The potential negative impacts of the loss of personal time could con-
tribute to burnout among physicians. Ways to mitigate these effects,
whether through innovative design to minimize time demands, rewards
for completion that “reimburse” time, or curricular designs that build
time in the workday for completing the learning assignments, will need
to be sought and, ultimately, investigated to establish effectiveness. Fur-
thermore, course directors, program directors and educational working
groups have to identify the contents that may be better suited for game-
based approaches while defining protected contexts where traditional
models might be ideal, largely due to external constraints.
On the faculty side, obstacles include the need to train staff and fa-
cilitators, but also the time and resources needed to develop new curric-
ula, or new curricular portions to be ‘gamified’. These challenges may
be further impacted by the possible lack of familiarity with educational
adult learning theories and methods among members of the teaching
team. However, the lack of in-house resources can be compensated by
3
Brain Disorders 1 (2021) 100008
creating training or educational resources and by sharing these (i.e., by
uploading them to existent repositories like MedEdPORTAL). Moreover,
this can offer an unprecedented, multi-centric platform to conduct an
educational study on the effectiveness of games in neurology education
across countries worldwide.
Regarding the evidence substantiating game-based approaches, fur-
ther studies with larger sample size and appropriate control groups need
to be performed. Outcome assessments need to assess not only the re-
action and learning (short term), but also the higher-order outcomes as
described by Kirkpatrick of behaviour and results [24]. Neuroscience-
based approaches to game design are developing [25], but several as-
pects still need to be improved, not only in game design, but also con-
cerning other methodological elements. For example, self-referentiality
can be a significant risk for educational games, as they have a cross-
disciplinary nature, but relies heavily on single-disciplinary contexts for
reports testing the validity and reliability [26]. Game-based approaches
showed great potential to blend the learning process between real world
and game world while promoting problem-solving skills [3]. Still, few
studies exist on knowledge and skill retention in the long term. There-
fore, future works will have to systematically improve shared, replica-
ble game design based on robust research method [3] and define the dy-
namic played by extrinsic vs intrinsic motivation of the learners [27] and
how to sustain this along with the training speciality.
The transdisciplinary potential of gamification
Translating evidence from neuroscience to education
On a neuroscience-related note, one of the most popular results in
several publication repositories is a study at the edge between neuro-
science and medical education, which investigated the impact of gami-
fication of learning on the brain, which seems to ‘deactivate’ the default
S. Sandrone and C. Carlson
mode network, usually active at rest or when not engaged in a cogni-
tive task [28]. This work highlights the importance of applying cogni-
tive neuroscience and neurology findings to education, even for what
concerns technology-enhanced learning [29], to identify biomarkers or
correlates of students’ engagement during learning activity [28,30]. On
a more specific note, this has already been piloted with the oscillatory
EEG, which has been used to ‘track’ attention, motivation and vigilance
during game-based learning [31]. From a more general perspective, this
can bring new research-based input to neurology education [32,33].
Clinical applications
Integration of gamification elements can lead to a range of benefits,
including increased satisfaction, augmented motivation and better en-
gagement for the student [3,34] These observed benefits have, in turn,
led to gamification being applied to rehabilitation. Gamification coupled
with technology provides an opportunity to offer flexible and engaging
therapy treatments with real-time feedback on individual progress. More
than a decade ago, the Wii gaming console started to be piloted within
a rehabilitation setting with a teenager affected by cerebral palsy and
improvements in the three assessed domains (visual-perceptual process-
ing, functional mobility, and postural control) were measured [35]. Af-
ter this, other games (such as Wii Sports and Cooking Mama) for the Wii
were successfully used in stroke rehabilitation: more specifically, partic-
ipants in the Wii-based rehabilitation group showed significant improve-
ments in mean motor function compared to the control group, which had
traditional recreational therapy [36,37]. But tailoring gaming systems
with custom software seems to be a promising strategy [38] and sys-
tems like the Leap Motion optical hand tracking system have been used
to develop further game-based approaches to rehabilitation [39]. While
this remains a nascent field of research, meta-analyses and evaluations
of such approaches have started to emerge [40,41]. Looking forward,
larger sample size, active control groups and new functional outcomes
based on everyday tasks are needed to clarify the full potential of these
technology-assisted, game-based solutions [42].
A discussion of clinical applications of game-based learning would
additionally include the concept of “serious games” and their potential
applications in the rehabilitation setting. Serious games is an expression
that denotes games, typically a computer or console games, which were
developed to accomplish a specific, serious purpose. The use of serious
games has recently expanded into mental health [43] and neurodegen-
erative disorders [44]. Similarly, such expansion is observable in the
world of the exergames, a set of devices enabling virtual reality-based
movement in healthy and pathological populations [45]. Step counters
and reminders, from watches and other devices to move, represent an
increasingly ubiquitous example of gamification in our daily lives. In
parallel, gamification percolated performance-based testing, such as the
neuropsychological profiling: if taken in a gamified-version, issues re-
lated to length and boredom on the patients’ side can, to some extent,
be mitigated [46].
Conclusions
The integration of game-based learning with technology has become
more frequent and contributed to a growing body of literature support-
ing the use of game-based learning techniques. The potential for lever-
aging game-based learning is evident in the literature and represent an
important educational opportunity for the years to come. However, gaps
in its application to learning in neurology and graduate medical educa-
tion persist. The use of quiz games and similar techniques in the learning
setting is not rare in neurology, but the data to support their benefits
are. Therefore, collaboration across programs to assess novel learning
approaches to teaching and learning through gamification and the de-
velopment of successful, shared resources have the potential to fast for-
ward neurologic and neuroscience education.
4
Brain Disorders 1 (2021) 100008
Declaration of Competing Interest
Dr. S Sandrone receives royalties from Oxford University Press
(USA).
Dr. C Carlson has nothing to disclose.
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