The landscape of medical education continues to evolve as the demographics of our learners diversify and technological capabilities rapidly expand. Gamification has increasingly grown in popularity in medical education as an adjunct to conventional teaching approaches by applying game design elements to traditionally nongame phenomena [1–4]. Game-based learning is intended to strengthen learning behaviors and attitudes to augment the interests of learners and optimize learning outcomes [5].

The incorporation of game design elements, such as leaderboards, scores or points, prizes, and social collaboration, is meant to promote active learning and educational engagement [1, 6–8]. The present literature on gamification in medical education has largely focused on improving learner motivation, confidence, knowledge retention, and the enjoyment of educational experiences [8–10]. However, less attention has been directed at how gamification models can be used within other educational contexts such as feedback—an essential yet notoriously problematic educational process to operationalize.

Providing actionable and impactful feedback to surgical residents remains an ongoing challenge. Multiple barriers to delivering feedback exist, including the time and effort warranted to provide meaningful feedback, the potential for uncomfortable or negative emotions, and the presence of competing priorities [11–16]. Furthermore, the fast-paced, dynamic climate of the operating room (OR) creates a uniquely complex learning environment that contributes to difficulties surrounding feedback for surgical residents [17–18]. Although the value of feedback is universally acknowledged, it remains variable, inconsistent, and thus, often suboptimal, largely due to challenges with overcoming these barriers associated with feedback. As a result, learners remain discontent and risk missing out on meaningful opportunities to effectively develop and advance their skills. Although extensive investigations and different approaches to improve operative feedback have been undertaken, dissatisfaction with feedback remains common among trainees [19–22].

Targeted and innovative strategies to refine specific aspects of feedback practices have the potential to enhance feedback delivery. Given the overall positive trend seen in gamification in medical education, it would be worthwhile to explore how the theoretical framework of gamification can be employed to boost participant motivation and engagement with feedback. We aimed to evaluate how competition as a gamification strategy impacts the implementation of a new feedback framework among surgical faculty and residents.

A new feedback framework was designed and adapted from a validated operative teaching model—the briefing, intraoperative teaching, and debriefing (BID) model [23]. Our framework was introduced to all faculty and residents rotating on the TACS and MIS services at the start of the study period. Participants were instructed on the different components of the framework, how to utilize it, and the importance of completing postoperative surveys. Weekly emails were sent to all participants and provided reminders of the framework components and its utilization. Posters of the framework were displayed as visual cues in the ORs and scrub sinks (Fig. 1).

Several strategies based on gamification tactics were employed to promote engagement and use of the feedback framework. Regular competitions were held between the two services’ faculty and residents throughout the study period. Competitions ranged between two to four weeks in duration, and the timing of residents rotating on and off services was considered when scheduling competition periods. Competitions were announced over email, and the weekly emails provided updates on the services’ progress and also highlighted top performers. At the end of each competition, the service that had the highest participation and use of the feedback framework was awarded a free lunch.

Data were collected from pre- and post-intervention surveys and postoperative surveys that were created on a secure web application, REDCap. Pre- and post-intervention surveys included data on participant characteristics. Postoperative surveys were presented as quick response (QR) codes on the framework posters for participants to access. Electronic links to the postoperative surveys were also included in the weekly reminder emails to participants. Participants were asked to complete the survey after their operative cases. Surveys recorded whether feedback was shared, and responses were monitored weekly.

There were no differences in average responses per week between the TACS service and the MIS service (4.52 ± 3.60 responses vs 6.41 ± 5.70 responses, p = 0.15) (Table 2). When the participants were organized by role, residents had a higher average response rate than faculty (6.67 ± 5.26 responses vs 4.26 ± 2.85 responses, p = 0.04).

There was a significantly higher response rate per week from the TACS service during competition weeks compared to non-competition weeks (6.21 ± 3.93 responses vs 2.69 ± 2.10 responses, p < 0.01) (Table 3). This remained consistent after separating responses by role for TACs faculty (3.21 ± 2.39 responses vs 1.38 ± 1.04 responses, p = 0.02) and TACS residents (3.00 ± 2.32 responses vs 1.31 ± 1.49 responses, p = 0.03) in comparing competition to non-competition weeks. Similarly, regardless of surgical service, the average weekly response rates for all faculty (5.57 ± 3.11 responses vs 2.85 ± 1.72 responses, p = 0.01) and all residents (8.57 ± 6.05 responses vs 4.62 ± 3.40 responses, p = 0.05) were higher during competition weeks than non-competition weeks. There were no significant differences identified with the MIS service.

Our study incorporated a gamification approach with the introduction of a new feedback framework for surgical faculty and residents. Overall, we found that faculty and residents responded positively to gamification, as demonstrated by increased utilization of the framework during times of competition. While feedback remains a complex process with multiple barriers contributing to its impact, targeted strategies can be employed to overcome specific challenges. Purposeful gamification can be a strong motivating factor in increasing engagement and drive to enhance surgical feedback.

The surgical learning environment presents unique challenges to perioperative teaching and feedback delivery. Extensive efforts have been taken to seek out effective and efficient approaches to assess, teach, and provide feedback to residents in these settings [19–22, 24–27]. Much of the current literature has strived to improve the culture of feedback by trialing different initiatives, though no gold standard method exists for perioperative feedback. Despite universal recognition of the value of feedback, its delivery, effectiveness, and impact remain variable. Successful implementation of new feedback initiatives, and thus, the subsequent ideal cultivation of an optimal feedback culture, requires an understanding of barriers to implementation that can be addressed. Furthermore, based on the complexity of the feedback process, tackling specific barriers one at a time may be more impactful in producing effective and sustainable change.

Given the multitude of barriers to feedback from both educators and learners, it is apparent why the motivation to initiate the feedback process may feel insurmountable at times. To address this, our study focused on utilizing gamification as a guiding scaffold for implementing a new feedback framework, aiming to increase motivation to deliver and seek feedback. Gamification is an emerging approach in medical education, with game elements increasingly recognized for improving educational experiences [1–4]. From gamified anatomy and radiology curricula for medical students to featuring resident skills competitions in emergency medicine and thoracic surgery, game-based learning has demonstrated elevated interest and engagement across learners of diverse levels and specialties [9, 28–30]. Our study builds on the present literature by demonstrating that gamification can also promote the use of a feedback framework among surgical faculty and residents.

Specifically in surgical fields, where surgical personalities are traditionally known to be competitive, extroverted, task-focused, and results-oriented, gamification has the potential to be particularly effective [31–33]. Our findings demonstrated that faculty and residents, especially from the TACS service, were responsive to organized, team-based competition. We surmise that incorporating gamification into the feedback process may have sparked the competitive nature of surgeons, yielding increased feedback exchanges. Framing feedback in a gamified way may also make the process feel more playful than evaluative, thereby mitigating the perceived intensity of feedback exchanges for both giver and receiver. Both faculty and residents reacted favorably to our gamification approach, thus notably demonstrating its ability to captivate both cohorts involved in the feedback process. Further investigations on participants’ attitudes and perceptions, specifically surrounding gamification, may provide deeper insight into the broader impact of gamification on the feedback culture within surgical training.

Actively engaging educators and learners through competition draws upon the extrinsic motivation of competition to stimulate the intrinsic motivation of self-directed learning [4, 34]. Although surgical faculty and residents often possess strong internal drive and discipline, the demands and pressures of the surgical learning environment can still be overwhelmingly difficult to overcome to sustain high-quality feedback. Incorporating game design elements, such as team-based competition, can serve as both an extrinsic motivator and a regular prompt to encourage participation in effective feedback practices, thus making this a less burdensome challenge. Various game-based learning strategies have been applied in surgical education to boost learners’ internal motivation and educational engagement. Positive effects of gamification have been reported in areas such as robotic simulation training and preparing for the American Board of Surgery In-Training Examination (ABSITE) and American Board of Surgery (ABS) qualifying exam [35–37]. Conversely, other investigations have shown no improvement in assessment scores and even negative effects, including learner fatigue, demotivation, and attrition [4, 38–39]. Thus, research on gamification in medical education remains variable and context-dependent, with a paucity of literature and underutilization of gamification tactics specific to the surgical environment. Future efforts can explore the conditions under which gamification is most effective.

The landscape of surgical training and education continues to evolve. The transition to competency-based medical education and implementation of entrustable professional activities (EPAs) is a transformative movement in graduate medical education that will require time, buy-in, and motivation from faculty and residents to be carried out meaningfully. Promoting cross-specialty competition, creating short-term wins, and recognizing high and low performers are all gamification processes employed in the successful EPA implementation at an academic institution [40]. Adopting gamified models in educational curricula has the potential to stimulate learning-related behavior, augment learner engagement and motivation, and subsequently, accelerate skills training and mastery compared to traditional pedagogical methods. The effective integration of feedback and EPAs can generate valuable opportunities for both educators and learners. While our study showed that competition enhanced the use of a feedback framework, additional work is needed to examine how gamified models influence resident knowledge, skills, and satisfaction. Gamified learning in today’s surgical environment remains a promising area for exploration with significant opportunities to enrich the educational experience for all.

This study should be interpreted in light of several limitations. Firstly, we acknowledge the sample size from a single academic institution may restrict the generalizability of our findings. Further work can expand across specialties and learners of varying structural and cultural contexts. Additionally, although the postoperative surveys were intended to capture use of the feedback framework and represent instances of feedback delivery, responses may not have always reflected actual feedback delivery. It will be worthwhile for future research to distinguish framework utilization from feedback encounters. Moreover, it is important to note that competition itself may shift motivation away from feedback and learning, thus diverting the focus from the educational value to be gained from feedback interactions. Identifying the appropriate balance between intrinsic and extrinsic motivators, as well as the optimal timing of game-based strategies, will be essential to ensure the meaningful adoption of gamified learning for its intended outcomes. Despite these limitations, our study provides a foundation for further exploration of gamification in surgical education, including its effects on knowledge retention, skills development, sustainability, and culture. It will be of paramount importance to understand which game elements best align with specific audiences, environments, objectives, and outcomes in the education community.

Providing formative feedback for surgical residents remains an ongoing challenge. Many surrounding pressures of the surgical learning environment can impede effective feedback encounters. Gamification offers a practical approach to promote both educator and learner engagement with more impactful feedback. Targeted game-based initiatives, much like ours, have the potential to transform the culture of feedback in meaningful ways and support the advancement of residents into confident and competent practice-ready surgeons.

Table 1. Participant Characteristics