Increase complexity
It is noticeable that most studies investigating competitive e-learning interventions in medical education produce an outcome favouring competitive programmes. Publication bias may explain the lack of studies with negative outcome. Simple gamification could be particularly affected: We found fewer studies in this category, even though their lower development effort may suggest that more were originally conducted. It seems possible that complex applications are better at motivating students. The findings of our evaluation survey also indicate students’ wish for increased complexity. Some of the surveyed suggested adding in-game explanations. In literature, complex gamification shows positive influence on students’ engagement and collaborative exchange: Janssen et al. inserted anatomy-dependent MC-questions into a team-based competitive strategy game [