This cross-sectional, quasi-experimental study assessed the learning outcomes of an interdisciplinary medical escape room and compared the differences in knowledge gain and student satisfaction between GBL group and a control group. The study was approved by the ethics committee of Heidelberg University Medical Faculty (S-840/2024) and conducted in accordance with the Declaration of Helsinki [22].

The escape room was repeated eight times between March and July 2025. Using pre- and post-intervention questionnaires, we assessed the learning outcomes and feedback (evaluation) from medical students to determine perceived benefits of an innovative teaching approach over traditional teaching. One post-test questionnaire was completed by participants immediately after the interventions to assess short-term outcome (knowledge gain). Another post-test was implemented one-month later to assess long-term knowledge gain (knowledge retention). The questionnaires were administered online on the SoSci Survey platform and in paper format. Students who agreed to participate in the study completed the online pre- and post-tests under supervision before/after the intervention. The one-month follow-up test was completed online by students without supervision.

The experimental group participated in the escape room while the control group participated in a post-mortem teaching session, complemented with handout material on the escape room learning goals. The post-mortem inspection is an obligatory part of the medical curriculum, therefore all participants had to attend it. Participants of the experimental group could take part in the post-mortem inspection only after attending the escape room and completing the first post-test. To minimize group differences, students were recruited from the one-week clinical module of forensic medicine, whereby all students must take an obligatory exam in forensic medicine and therefore have studied the same material up to that point.

Students enrolled in clinical semesters (semester 8 and above) and registered for compulsory forensic medicine module were invited to participate in the study. The activity was promoted using social media, official teaching platform (Moodle), onsite recruitment and via social contacts. Interested students could freely decide whether they wanted to participate in the control or intervention group. No randomization took place. Participation was voluntary and students were not graded for the activity.

Exclusion criteria were no enrollment in the forensic medicine module, lack of legal age (< 18 years) or lack of consent to the scientific use of data. Students had to confirm they participated only once in the escape room.

Since all students were registered for the compulsory forensic medicine module, they had the same access to lectures and took part in the mandatory postmortem teaching session.

Before the intervention, the participants received an information leaflet and provided their informed consent, agreeing to the data privacy policy to start the pre-test questionnaire.

The escape room teaching session comprised 60-minute gameplay inside a simulated crime scene with students tasked with solving the mystery using medical knowledge puzzles, tasks and clues. The gameplay was followed by a 45-minute debriefing session with experts from different medical specialties and two police officers specialized in securing evidence at crime scenes. The debriefing session was used for giving feedback to students and allowing them to reflect on their learning experience [15, 23]. Students from the experimental group were only allowed to take part in the obligatory post-mortem inspection after having completed the escape room and the first post-test.

The control group only took part in a 60-minute postmortem inspection, which is a mandatory part of the regular medical curriculum. In addition, the control group received lecture slides covering psychiatric and infectiology topics that were covered in the escape room.

Figures 1 and 2 illustrate the study sequence and setup of the escape room session, respectively. In Appendix A, we have described the escape room design, medical puzzles and learning goals. Further design details and the storyline are provided in Appendix B.

Study sequence. CN= Control Group, EX= Experimental Group. 1on-site MCQ, the test for the CN included 14 lecture slides at the end; 2on-site post-test right after learning module; 3 one month later, online

Sketch of the set-up of the escape room and surrounding facilities

Pre-and post-test questionnaires consisted of the same 20 multiple-choice questions (MCQs) with five answer options each to measure objective knowledge before and after the interventions. Students scored one point for choosing each correct answer and one point for not choosing each incorrect answer, corresponding to a total score of 100 points.

Each question was derived from a specific learning goal described in the NKLM [18] (see Appendix A) and mainly referred to subjects taught in the clinical semesters. The MCQs were formulated after Delphi group discussions [24], involving two infectious diseases experts, one psychiatrist, two forensic doctors and two medical students. After two rounds of discussions, comments and adaptions, the MCQs were finalized with 100% consensus. The same knowledge-based questions were repeated in the two post-test questionnaires, one immediately after the intervention and one 30 days later.

Boxplot depicting total test scores for the control group (CN) and experimental group (EX) over time

Another 20 questions were used to evaluate the two pedagogical interventions related to communication skills, perceived competency and teamwork skills. These evaluation questions were derived from instruments used in similar studies [25,26,27]. Each question was rated on a six-point Likert-like scale, ranging from 1 = strongly agree/very good to 6 = strongly disagree/very bad, corresponding to a score between 1 and 6 for each item.

To assess student satisfaction, three open-ended questions were used to obtain brief qualitative feedback on “suitable subjects”, “best aspects” and “improvements” for the escape room.

Data obtained on SoSci Survey and in paper format were combined for experimental and control groups and analyzed as one dataset in R. The paper-based questionnaires and the full code are available on request.

For pre-post knowledge assessment, the difference between scores of the pre- and first post-test was defined as “short-term knowledge gain”, expressed as means and standard deviations for each group. The “long-term knowledge gain” (retention) was assessed using the difference between the pre-test score and the one-month post-test score. We use the terms “knowledge gain” and “knowledge retention” as defined above throughout the paper.

Inferential statistics were used to measure differences in the experimental and control group scores related to gender, age and semester distribution. The knowledge gain for each group and the overall mean differences between the control and experimental groups were analyzed using Repeated Measures ANCOVA. To check the assumption of linearity between the covariates, they were plotted against the total score of the second follow-up post-test. Multicollinearity was tested by correlating all covariates. Normality was assessed using the Shapiro-Wilk-test and by visually inspecting the histogram of residuals.

As participants responded at different times to the one-month post-test, this resulted in an inter-individual time difference between the first and second post-test. This delay was defined as the number of days between the due date of the post-test (one-month) and the timestamp when the post-test was submitted. As this delay could influence the recall capacity [28], we included the pre-test scores and delay as covariates for correction. In addition to group assignment, pre-test scores as a baseline measure, semester and delay were included as covariates. Eta-square was used as a measure of effect size. The results were considered significant at p < 0.05.

Exploratory t-tests were performed to measure the in-group score differences between the different timepoints of the tests to better understand the dynamic of the test scores over time. A Bonferroni correction was done to adjust the significance level for exploratory t-tests.

For the 20 Likert-scaled evaluation questions, the responses between 1 and 6 were summed up for individual items to calculate means and standard deviations, offering an overview of satisfaction among participants and groups.

After an internal discussion, evaluation questions were also sent out to the control group. The evaluation survey, consisting of the same 20 evaluation questions and three open-ended questions, was sent out after all data had been collected. The control group was asked to evaluate the standard post-mortem inspection module to enable direct comparison between groups. The control group evaluation served as a baseline for the evaluation results of the experimental group. Mean evaluation scores of the experimental and control group were compared to identify possible benefits of the escape room approach over traditional teaching.

Responses to the three open-ended questions were qualitatively analyzed to obtain feedback on “suitable subjects for GBL”, “best aspects of escape room learning” and “improvements in game design”. Two authors (LS & FB) evaluated the responses from students and independently coded them to generate thematic categories via content analysis [29]. For intercoder agreement, the authors discussed their coding systems after the first round. The final categories were agreed upon through consensus building between the two coders. Only relevant categories and quotes were then translated to English to be included in this manuscript.