Score Your Way to Clinical Reasoning Excellence: SCALENEo Online Serious Game in Physiotherapy Education

Round 1

Reviewer 1 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

The authors have improved the quality of the work. They have taken into account the comments made in the previous review. They posed a single research question that is then addressed in the results, although not directly.
The conceptual part has been improved, as they now present a definition of serious games in the introduction, although the definition of gamification is only presented on page 13, in the results section. It should have been presented in the introductory part where the conceptual aspects are addressed.
I believe that the work has improved.

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

I appreciate the effort the authors have put into improving the paper, and I thank you for addressing my suggestions and concerns. With the applied changes, I can accept the paper in its current form.

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report (New Reviewer)

Comments and Suggestions for Authors

This is a very unique and fascinating approach to education and I applaud the authors and everyone involved in the project for their hard work and dedication to coming up with creative and effective educational methods, and then being able to adapt it into an online environment. Please find my comments below. 

In your abstract, you state that, the game is, "designed to improve clinical reasoning in musculoskeletal physiotherapy education."

Then in your article, in line 111, you state that, "Evaluating CR, which stems from complex internal cognitive processes that are not directly observable, is inherently problematic." In lines 173 - 175 you state,  "The research question was therefore: To what extent does the adapted SCT scoring differentiate performance (i.e., agreement with expert item categorization) across simulated error patterns, and can it support formative feedback in training contexts?" Finally, in line 359 - 361, you state, "While the study does not directly measure, improvements in learning outcomes, the ability to identify cognitive errors and provide score-based feedback suggests a strong potential for formative use in physiotherapy education." 

While I understand the purpose of the game is to improve clinical reasoning, it appears that your paper does not directly show evidence that it does indeed improve clinical reasoning. Unless, of course, your results do indicate this, but the way that the information is presented makes it difficult to understand this fact. 

Perhaps beyond the scope of this paper, but what is the intended purpose of this game in physiotherapy education and how would it be incorporated? When do you propose this be utilized, would a first year get the same benefit from it as a third year? 

Author Response

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Author Response File: Author Response.pdf

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The article presents a game-based assessment tool which is, if I understand correctly, the first serious game developed in the field of physiotherapy education. The level of innovation and creativity involved in constructing the tool is highly commendable. Nevertheless, I have some concerns regarding the overall concept, particularly in light of the study’s stated aim: to provide interactive and adaptive learning opportunities tailored to diverse student needs.

In my view, genuine interaction requires that a student’s reasoning be interpreted, analyzed, and evaluated in depth. Providing feedback after each step—when that feedback merely consists of comparing the student’s response to a predetermined script—does not constitute real interaction. As the authors note, there is currently no gold standard for assessing clinical reasoning (CR), and understandably so. I am not convinced that objective methods—such as the Script Concordance Test (SCT) appears to be—can yield valid results in evaluating such highly context-dependent reasoning processes involving ill-defined, open-ended problems.

Moreover, if I understood correctly, students are not required to generate hypotheses independently; instead, they must choose from a set of predefined options. This means they are not engaged in answer generation, which I would consider a core component of clinical reasoning. This fact should be also discussed mong the limitations. I was also missing the research questions of the study.

I believe it would be highly valuable to collect data on students’ perceptions—specifically whether they find it frustrating that the items are close-ended and that they lack opportunities to reason openly.

One final thought: in my opinion, the future of providing formative, in-depth feedback on clinical reasoning—especially in fields like medicine—lies more in the use of AI than in serious games. AI holds greater potential for personalizing the learning process in a meaningful way.

Reviewer 2 Report

Comments and Suggestions for Authors

The work is interesting since it presents a serious game designed to promote clinical reasoning and decision-making.

The authors focus on describing the game's potential for these objectives and on how the game is evaluated and feedback is provided. The results are based on the generation of plays, but do not describe whether the game has been played with real people. It is unclear whether they have already applied it.

The introduction does not present research questions or hypotheses to be analysed in the article, so it is not clear what is being studied or what the work contributes beyond the description of the game. This should be clarified.

At the same time, the background discusses gamification and serious games interchangeably. It is recommended to present a definition of each and differentiate between them. The authors should then review the article to refer to this terminology appropriately.

The topic of feedback, which is important for the rest of the article, should be presented with more analysis in the background. Only Larsen (2008) is cited. As this is an important topic, it is suggested that more current references be incorporated.

The results should be consistent in answering the research questions or hypotheses posed. 
It is also recommended that the Discussion section be separated and that there be a Conclusions and Future Work section, where the limitations of the study can also be indicated.
In terms of formal aspects, it is recommended that the presentation of figures and tables be improved. First, the description of each figure/table results in an explanatory text. It is suggested that the more detailed description be left as part of the text and only a brief description be left as a figure caption or table header. Second, it is recommended that the justification of figures and tables be reviewed, as it varies. In the appendix, the tables are split between pages, and it is suggested that the table header be repeated for better readability.

At the same time, at the end of the Introduction section, it is recommended that a paragraph be included explaining how the article is organised.

Some typing errors have also been found, such as on page 4, where it says: ‘he players can...’, when it should say: ‘The players...’.
On page 11, there appears to be a comment that is internal to the authors: ‘This can be explained by two reasons: 1) the feeling of competence and 2) the feeling of control over the task to be performed (Viau, 2009). I have placed it as a comment in the document. Honestly, check if you want to add it or not.’ Please, review and analyse that this issue of competence and control over the task was not addressed in the background and is only presented in the discussion.