Game-based learning in cardiology: assessing the effect of puzzle games on medical students’ perceptions and clinical reasoning

Abstract

Developing clinical reasoning for diagnosing cardiovascular diseases is a major challenge in undergraduate medical education because learners must integrate fragmented clinical information into coherent diagnostic hypotheses. Puzzle game-based learning (GBL) has the potential to facilitate this process by promoting evidence integration, collaborative reasoning, and illness script development. This study evaluated the effect of a puzzle-based GBL intervention on undergraduate medical students’ learning outcomes and perceptions in cardiovascular disease diagnosis. A quasi-experimental study with a non-equivalent post-test-only control group was conducted among 206 undergraduate medical students undertaking their cardiology clerkship at Shahid Sadoughi University of Medical Sciences, Iran, during the 2024–2025 academic year. Students were recruited through cluster sampling and allocated to intervention and control groups using sequential temporal cohort allocation. The intervention consisted of a collaborative board-based puzzle game in which students reconstructed authentic cardiovascular cases by integrating patient history, physical examination findings, chest radiographs, and electrocardiographic data through stepwise clinical reasoning. The control group received conventional lecture-based instruction supplemented with illustrative clinical cases. Learning outcomes were evaluated using a structured scenario-based clinical reasoning examination, and students’ perceptions were assessed using a validated 10-item questionnaire. Between-group differences were examined using independent-samples t -tests and analysis of covariance (ANCOVA) adjusted for age and gender. Effect sizes were reported using Cohen’s d and partial eta squared. Students receiving puzzle-based GBL achieved significantly higher learning scores than those in the control group (69.21 ± 11.15 vs. 66.07 ± 10.83). After adjustment for age and gender, participation in the puzzle-based GBL intervention remained significantly associated with higher learning outcomes (adjusted mean difference = 3.07, 95% CI: 0.01–6.13; F(1,202) = 3.91, p = 0.04; partial η² = 0.019). The unadjusted effect size was small (Cohen’s d = 0.29). Among intervention participants, formative puzzle performance demonstrated a moderate positive correlation with final examination scores ( r = 0.35, p < 0.001). Overall, 76.2% of students reported positive perceptions of the puzzle-based GBL experience. Puzzle-based GBL was associated with modest but statistically significant improvements in learning outcomes and was well accepted by undergraduate medical students. The findings suggest that its educational benefits may extend beyond learner engagement by supporting the progressive integration of fragmented clinical evidence, collaborative diagnostic reasoning, and the construction of illness scripts. Given the quasi-experimental post-test-only design and the small effect size, these findings should be interpreted with appropriate caution. Nevertheless, puzzle-based GBL may serve as a promising complementary instructional strategy for strengthening clinical reasoning in undergraduate cardiology education.