As much as serious games can afford instructional and motivational advantages, they are sometimes seen as rather immature or lacking in serious intent. This is reflected in a widespread, if tacit, sense that the use of games in health professions education does not reflect well on the gravitas of clinical practice and that to use them in this context requires us to clearly differentiate between serious and non-serious games. Unfortunately, this dichotomous perspective obscures the more important issue that “game” is a rather ill-defined aggregate of activity designs and components that can be realized in a multitude of ways, many of which already intersect with mainstream instructional strategies.
A central goal for this paper has been to encourage both a critical engagement with and a more in-depth consideration of games and gaming in the field of health professions education. Rather than listing game types or exploring them from a taxonomic perspective, I have set out a framework of game facets, I have used these facets to differentiate between gaming and simulation, and I have described them in terms of their educational affordances. In doing so, this kind of faceted approach can address the fundamental category problem of asking whether games are educationally effective. Different games employ different game facets in different ways; it is the educational avoidances of the facets that are used in any given instance that confer educational advantage. This reflects pattern-based faceted thinking  associated with other kinds of activity design such as PBL , team-based learning , and simulation . Not only does this approach give more flexibility and precision in considering games for educational purposes, these facets can be understood as part of the broader instructional design repertoire for health professions education. After all, many of these facets are already to be found in health professions education activity designs. For instance, competition, whether with oneself or with others, is intrinsic to most contemporary assessment practices, and simulation is to be found almost everywhere within the field of health professions education .
It might be argued therefore that there is nothing particularly new about games and gaming in health professions education, and it is only the emphasis on certain facets or the particular configurations of facets that differentiates game activities from more mainstream practices in health professions education. However, the novelty of videogame, gamer culture, and the many devices that can be used to play games seems to have blinded us to the true nature of serious games and it has confused the debate over their use in health professional education. As educators, we need to make deliberate and informed use of game facets as part of our instructional design repertoire.
For instance, games are distinct and bound in ways that other health professional education activities are not. Games have clear success and failure criteria, they have specific and somewhat abstract rules, they depend on the use of structured feedback both within and between game instances, and they require participants to engage in the psychosocial moratoria of role-play, competition, and conflict. This suggests that games and game facets involve much larger (and potentially better) use of anisomorphism to create compelling experiences and drive learning than other activity types in the health professions education repertoire. It is an interesting paradox that learning in games can be driven by divergences from practice while mainstream thinking in simulation-based learning is so concerned with its convergence with professional practice.
In focusing on game facets and their instructional uses, I have perforce neglected other issues in and around the use of games in health professional education that are nevertheless deserving of attention. I will consider two of these briefly. Firstly, health professionals, in particular health professions learners, may be less experienced in gaming because of the effort required to build a credible profile to gain entry to a professional school. Because they tend to be relatively inexperienced in video games, they are likely to be less disposed to select them as a preferred modality of learning. It would be wrong therefore to make a generational assumption that younger people are intrinsically positively disposed towards the use of games. Secondly, perhaps the biggest elephant in the room is that of the economics of developing and using games in health professional education: “the time and skills required to set up such environments can still be a barrier to adoption as can the variability in student hardware and connectivity” . However, the faceted approach would suggest that we should not assume that games will cost more in general. Answering economic questions depends on what facets are used, how they are combined, and how they are realized in a game template.
It is also important to note that this paper differs from other theoretical perspectives on serious games that have been proposed in fields outside of health professional education. Indeed, there have been many connections made between serious games and learning theories such as behaviorism, situated learning, transfer theory, and problem-based learning [36–38]. However, these have tended to focus on the alignment and fit between game and theory rather than on the faceted approach I have presented in this paper. Where game facets or elements have been considered, attention has tended to focus on the differences between game and pedagogical elements rather than on their educational affordances .
This reflects a more extensive consideration of educational games in education as a whole than there has in health professions education, with work in the latter tending to focus on particular games and their applications with the assumption that they have intrinsic and beneficial educational affordances [7, 40]. There are some exceptions, for instance, the connections between games and activity theory have been considered within health professions education  as well as in other fields . van Staalduinen’s exposition of game properties is particularly notable as it takes a similar faceted mapping approach to that set out in this paper . While there are similarities between the two models in terms of common facets (such as conflict, rules, and feedback), van Staalduinen’s model concentrated on the more operational aspects of actual games (such as pieces, players, and communication) rather than on the broader principles set out in the typology advanced in this paper. A key difference then is whether we should focus on the specifics of things that are explicitly considered to be games or instead on game-informed principles that can be realized in activities that are not games per se. In the context of exploring the connections between game and simulation in support of health professions education, my argument has been that a game-informed approach is perhaps the more useful of the two.
I acknowledge some limitations to the work presented here. I have taken somewhat hypothetico-deductive approach in synthesizing and shaping key concepts around serious gaming and deriving a framework and set of game-informed principles for health professions education. In doing so, I have not presented an evaluation of this model, nor have I tested it robustly in practice. Indeed, it would be hard to do so in any comprehensive way given its broad reaching scope. I have also not undertaken an exhaustive audit of the literature on serious games from outside of health professions education. The many examples that I have drawn upon indicate a paucity of application to our field and its particular needs and dynamics that may account for the lack of uptake compared with other professional training paradigms. Indeed, taking an instructional design perspective (as presented here) has enabled a critical stance on both the advantages and limitations of different serious game facets that does talk to some of the key concerns within the field.
I started this essay with the observation that, while there have been many calls for, and champions of, games in health professions education, the category of “serious games” was broad and their educational affordances ill-defined. It would be easy then to suggest that the answer to this is more research into particular uses of serious games in training health professionals. However, as I have set out, the catechism of “more research is needed” is too simplistic, not least because there has already been much research in to the educational use of games; the long-running Medicine Meets Virtual Reality conference (www.nextmed.com) and the US military-funded TATRC program (www.tatrc.org) are just two indicators of this effort. Rather, the main lesson here is the need and opportunity to see past the current sturm und drang of video games and gaming to the advantages that game-informed learning can afford health professional education. A key implication of the model I have presented is to connect individual and collections of game facets to educational theory and evidence. I have not done so here as this is in itself a significant task as, while there are links with extant work, it is not in the context of game facets. For instance, topics such as transfer , competition , conflict , shared symbols , complexity , scaffolding , and performance  have been previously explored. A systematic exposition of these connections is nevertheless a logical next step in pursuing this line of inquiry, as is the exploration of those elements that have a less robust evidential basis such as the use of chance.
A judicious use of gaming facets has the potential to extend and enhance the instructional design repertoire in health professions education, and in doing so it can act as a challenge to orthodox thinking that would see the unit of instructional value as the game rather than as its different facets. Moreover, a clearer focus on different game facets allows for the exploration of broader issues such as the educational value of activities that diverge from real world practice as well as those that converge with it.