Card and board game design for medical education: length and complexity considerations

Article information

Korean J Med Educ. 2023;35(3):291-296
Publication date (electronic) : 2023 August 31
doi :
1General Pediatrics, Oregon Health and Science University, Portland, OR, USA
2Division of General Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
Corresponding Author: Michael Joseph Cosimini ( General Pediatrics, Oregon Health and Science University, 707 Sw Gaines St, Portland, OR, USA Tel: +1.503.418.5700 Fax: +1.503.418.5700 email:
Received 2023 February 17; Revised 2023 June 1; Accepted 2023 June 13.



There is growing use of games for health professions education. Card and board games are relatively easy to develop, effective for education, supported by educational theory, and generally well accepted by learners; yet, they remain relatively infrequently described in the medical education literature.


A questionnaire was developed to understand barriers to use of card and board games and to understand user preferences to inform their development. The questionnaire was offered to students and educators downloading a printable antibiotic card game online.


The questionnaire was completed by 335 health professionals primarily by physicians, pharmacists, and their trainees. Participants described preferences for shorter games and games with lower complexity. Player counts in the two to four range were the most commonly desired. The most frequently cited barriers were lack of availability in desired subjects, cost, and concerns about content accuracy.


Educators looking to develop or use serious card and board games should start with shorter, lower-complexity games. Methods to assure and demonstrate content accuracy for educational games should be explored by educators and researchers.


Serious games are games with educational goals that are designed for a purpose other than entertainment [1]. Serious games provide a low stakes environment for learner experimentation and improvement through iterative play. They can modify learner behaviors and attitudes in service of educational goals and directly demonstrate educational content to facilitate learning. Serious games exist in many formats though much of the literature in medical education focuses on digital games; sometimes to the exclusion of tabletop games (card and board games) from the definition of serious games [2]. Board games have evidence for efficacy showing improved longer-term retention compared to traditional educational methods [3]. While the body of literature has grown, publications remain focused on implementations of single games with learner reaction data and immediate learning outcomes. Guidance regarding the ideal format including player counts, length of play, and general preferences of users are yet to be described. The goal of this study is to fill this gap and inform educators to design games to meet the needs of learners.


1. Survey development

The goal of this survey was (1) to learn what game characteristics best meet student and educators needs and (2) to understand barriers for use of games among students and educators. The study received exempt status by the Oregon Health and Science University Institutional Review Board.

Survey questions were developed based on literature of players’ perception of a game for medical education, literature outside of medical education on barriers to implementation of games in the classroom, communication with creators of tabletop games for Health Professions Education (HPE) and with educators in other disciplines who use games for teaching [4,5]. Questions were piloted in social media channels dedicated to educational games and modified based on results of this feedback for content and clarity. They subsequently were piloted on pediatric faculty members and again modified.

Complexity scale was modified from BoardGameGeek weight (complexity) ratings using examples of games falling into different ranges based on lists of popular classic and hobby games ( This scale was refined to assure that users would be familiar with at least one reference game in each category. The lowest complexity category was split into two to better reflect the landscape of current medical education games and the highest complexity range was removed due to lack of universally familiar examples. The full survey is available in Supplement 1 .

2. Survey distribution

The survey was offered to people downloading a printable card game used for medical and pharmacy education from December 13, 2021 to June 13, 2022 with the goal of surveying students and educators already interested in using games for education. This game was promoted on social media channels focused on HPE on Twitter, Facebook, and Reddit. Users who clicked a link to download the game were asked if they would like to participate in this survey prior to accessing the game.

3. Analysis

Response rate is reported as the percentage of users who submitted the survey divided by the total number of users who went to the game files. Responses of those who endorsed health profession roles were analyzed. All questions were optional and submitted surveys with current health care roles were analyzed regardless of the percentage of other questions completed. Results are described divided between those intending to use the game for teaching versus their own learning.


1. Respondents

The questionnaire was submitted by 390 (23%) out of 1,717 people who went to the game files. Of these 55 were excluded as they did not specify a role in healthcare. Most were in the United States (53%) and in the physician (56%) or pharmacy (33%) domain. Most participants were downloading the game for their own education (71%) and most did not have previous experience with games for education (83%). Demographics of participants are displayed in Table 1.

Survey Respondents: Demographics of 335 Survey Respondents Who Met Inclusion Criteria

2. Preferences and barriers

There was a preference for games with shorter play times <20 minutes or 20–39 minutes. There was also better acceptance of low to medium complexity when compared to higher complexity formats. There was not a strong preference between cooperative, competitive, team, or solo formats (Table 2). Two to four players were best accepted (Fig. 1).

Preferences for Format and Barriers to Use of Card and Board Games for Teaching and Learning

Fig. 1.

Player Counts

Player counts that respondents would be most likely to use from 276 respondents who completed this question. Other player counts not captured in this chart (number, %) were 12 (1, <1%), 18 (1, <1%), 20 (8, 3%), 24 (2, <1%), 25 (<2, 1%), 30 (3, 1%), 40 (1, <1%), 60 (1, <1%), 100 (1, <1%), and 120 (1, <1%).

The most commonly endorsed barriers to use of games for medical education were: lack of games to meet educational goals (85%), concerns about games content accuracy (70%), and cost of games (64%). Free text comments included concerns around accessibility includeing language, topic specific availability, awareness of games for education, content concerns including ability of individuals to rely on accuracy of material, and logistical challenges around implementation.

One respondent described the challenges around student confidence when using games for teaching.

“It seems like a wacky idea (although actually is a very good idea), and so I worry that I would lose the confidence of my students if I made up a game like this. A game made by somebody else, however, would look like a legitimate thing and so I would be more confident using.”


This study provides a number of considerations for designers and users of games for HPE. Cost was highlighted by participants in our survey as it has been by others looking at users of games for HPE [6]. With the challenge of cost in mind, there are games available free to print either directly from designers (e.g., or published as journal supplements [5].

Content accuracy is a consideration for any educational resource and was highlighted here as an important concern. Literature on online medical education suggests some strategies that could be applied to games for medical education. These include provision of and consistency with the references, clear disclosures, and the use of a defined editorial process. MedEdPortal ( is one source which provides a defined peer review process for game content.

Tabletop games can be presented in a wide variety of formats, playtimes, player counts, and degrees of complexity. For example, a short low complexity card game “Clinical Coaching Cards” has been used in the setting of workshops for faculty development [5]. A more complex board game “GridlockED” is an hour or longer and is used for two to six players in a wider variety of settings [7].  When designing games length and complexity are important considerations in part driven by particulars of the educational setting. Although learners and educators generally prefer shorter games, games described in the literature are often an hour or longer. As an example, a 90-minute game was felt to be too long by some students [8]. Educators should consider using shorter games based on these findings. Shorter games allow for more time to either present material upfront or debrief after gameplay. Debriefing is important to consolidate learning and address potential misconceptions from the way reality is simplified for the purpose of a game.

Respondents preferred lower complexity games consistent with games described in the literature. Appropriate complexity varies by setting, more complex games may be appropriate in the classroom setting with less extraneous cognitive load compared to games used for teaching in the clinical setting. Additional complexity beyond what is needed to meet the educational goals comes at the cost of germane cognitive load and could be a detriment to learning. This was summarized nicely by a respondent to our survey.

“The game complexity shouldn’t be harder than the information it’s providing. The point is to learn, not to understand the game.”

Regardless of setting it is wise to minimize complexity and choose rules and mechanics that align directly with the educational goals.

There are theoretical considerations regarding the strengths and weaknesses of using competition or cooperative mechanics in educational games. For example, self-determination theory has been used to support team-based competition and raise concerns about the negative effects of individual competition [9]. We found cooperative, competitive, team, and solo games were all acceptable options to respondents.

This survey was administered to a sample of learners and educators interested in a specific free to print game “Empiric” which is a short, lower-complexity game and may have influenced the population surveyed [10]. Although the instrument was piloted among educators both with and without a game design background, no specific testing for reliability was performed.

Serious games are an innovative part of the HPE tool kit. This study describes ideal design considerations for tabletop games. Educators interested in creating their own serious games to incorporate into their teaching should target games to lower complexity and shorter play times to meet both learners’ and other educators’ preferences.  While serious games are a proven way to enhance learning we have identified continued barriers to the implementation of tabletop games in HPE including a lack of games in desired content areas, the cost of existing games, and concerns about content accuracy. This study is the first step in addressing the absence of serious tabletop games for HPE. In order to make serious games a standard educational tool further research is needed to define how to assure and demonstrate content accuracy.

Supplementary materials

Supplementary files are available from

Supplementary 1.

Survey Instrument.



We would like to acknowledge the Games and Medical Education Research (GAMER) Collective members for assistance in question development.



No financial support was received for this study.

Conflicts of interest

Dr. Cosimini is the creator of Empiric and receives a portion of its sales. This survey was offered to people downloading a free version of this game. Dr. Collins has no conflicts of interest relevant to this article to disclose.

Author contributions

Dr. Cosimini performed the initial conception and design of this study, performed data acquisition, analysis of data and drafted initial manuscript. Dr. Collins performed data analysis and interpretation and revised the manuscript for important intellectual content. Both authors have approved of the final version of this manuscript.


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Article information Continued

Fig. 1.

Player Counts

Player counts that respondents would be most likely to use from 276 respondents who completed this question. Other player counts not captured in this chart (number, %) were 12 (1, <1%), 18 (1, <1%), 20 (8, 3%), 24 (2, <1%), 25 (<2, 1%), 30 (3, 1%), 40 (1, <1%), 60 (1, <1%), 100 (1, <1%), and 120 (1, <1%).

Table 1.

Survey Respondents: Demographics of 335 Survey Respondents Who Met Inclusion Criteria

Variable No.(%)
Total 335
 Medical 188 (56)
  Attending 64 (19)
  Resident 51 (15)
  Fellow 23 (7)
  Medical student 50 (15)
 Pharmacy 111 (33)
  Pharmacist 63 (19)
  Pharmacy resident 3 (1)
  Pharmacy student 45 (13)
 Nursing 16 (5)
  Nurse 8 (2)
  Nursing student 2 (1)
  Nurse practitioner 6 (2)
 Physician assistant 6 (2)
  Physician assistant 5 (1)
  Physician assistant student 1 (0)
  Othera) 14 (4)
Prior use of games of HPE
 Yes 56 (17)
 No 278 (83)
Plan to use the game
 To teach 98 (29)
 To learn 236 (71)
 USA 178 (53)
 Australia 19 (6)
 Turkey 14 (4)
 Canada 12 (4)
 UK and Northern Ireland 11 (3)
 India 11 (3)
 Mexico 9 (3)
 Pakistan 6 (2)
 Germany 6 (2)
 Italy 5 (1)
 Brazil 4 (1)
 Saudi Arabia 4 (1)
 Poland 4 (1)
 Colombia 4 (1)
 Chile 3 (1)
 South Africa 3 (1)
 Otherb) 42 (13)

HPE: Health Professions Education.


Other fields included microbiology, paramedics, dental, and other healthcare educators.


Countries with three or more participants are specified.

Table 2.

Preferences for Format and Barriers to Use of Card and Board Games for Teaching and Learning

Preferences Total Using game for teaching Using game for learning
Length (min)
0–19 87 (269/308) 84 (74/88) 89 (194/219)
20–39 72 (216/302) 69 (61/88) 73 (155/213)
40–59 26 (75/289) 19 (16/86) 29 (59/202)
≥60 9 (27/291) 16 (16/97) 11 (23/205)
Low 77 (251/325) 80 (77/96) 76 (174/228)
Low/medium 87 (276/318) 90 (83/92) 86 (193/225)
High/medium 65 (205/315) 55 (50/91) 70 (155/223)
High 37 (114/309) 30 (27/90) 39 (86/218)
Cooperative 81 (263/325) 92 (87/95) 76 (175/229)
Competitive 79 (245/312) 92 (83/90) 73 (162/221)
Team 77 (244/316) 81 (74/91) 75 (169/224)
Solo 77 (244/315) 60 (55/92) 85 (188/222)
Setup time 35 (114/329) 41 (39/96) 32 (75/232)
Length of available games 46 (149/327) 57 (54/95) 41 (95/231)
Lack of games to meet your educational goals 85 (279/329) 93 (89/96) 82 (190/232)
Cost of available games 64 (212/331) 65 (63/97) 64 (149/233)
Difficulty learning rules 36 (120/331) 48 (47/98) 31 (73/232)
Lack of games with appropriate player counts 58 (192/329) 57 (55/97) 59 (137/231)
Student perceptions of games for education 30 (99/327) 33 (32/97) 29 (67/229)
Concern about the accuracy of content in games 70 (229/328) 72 (71/98) 69 (158/229)

Data are presented as % (number/total numbers). For preferences each question is the percent who responded they would prefer to use that length/format/complexity of those who completed that question. For barriers each question is reported as the percentage of those who completed that question with “yes, it is a barrier.”