84 undergraduate students majoring in clinical medicine were enrolled. By the end of preceding three semesters, all participants had completed the basic medical courses, with comparable academic performance and experimental scores. The baseline academic performance (average score of the experimental group: 78.2 ± 4.5 points; average score of the control group: 77.8 ± 4.8 points) and the experimental assessment scores (average score of the experimental group: 80.1 ± 3.9 points; average score of the control group: 79.7 ± 4.2 points) were comparable. The P values for inter-group comparisons were 0.682 and 0.715 (both P > 0.05). The recruiters were randomly divided into the experimental group (n = 42) and the control group (n = 42). Each group was further divided into 7 study teams, with each team consisting of 5 to 7 students. Each team included at least 2 to 3 female to balance the gender ratio. The study has been approved by the Teaching Management Committee of the School of Medicine at Yangtze University. The chapter on respiratory system diseases in the pathology textbook (People’s Medical Publishing House) was selected as the teaching content. Instruction was conducted in two virtual digital multimedia pathology laboratories equipped with optical microscopes.

Building on the 19 core categories of the traditional TPR model [10][11] and considering pathology teaching characteristics, the GIMM model was developed around three pillars:

Task Design: Twenty typical electronic medical records, jointly reviewed by respiratory clinicians and pathologists, were selected. These covered conditions such as chronic bronchitis, pneumonia, and lung cancer, and included complete medical histories, imaging data, and digital pathological sections (with diagnoses concealed). Tasks were categorized into five difficulty levels (A - E).

Point and Ranking System: Knowledge points were quantitatively scored, with weights assigned based on task difficulty and importance. A hybrid scoring model incorporating both team collaboration and individual contribution was implemented. Effective ideas proposed by individuals and adopted by the team earned extra points for both the individual and the team. Additional rewards were granted for sustained learning (e.g., one-hour continuous study) to encourage extended self-directed learning. No failure mechanism was imposed; students could retry tasks until completion.

Multi-DimensionalReward System:

① Credit Rewards: Be used to redeem course grades or internal assistance services.

② Honorary Rewards: Virtual medals will be awarded to the teams with top-performing and those who complete the tasks the fastest; consistently high achievers gained access to seminars with senior professors.

③ Substantive Rewards: Top three teams were offered internship opportunities in the pathology and respiratory departments of the affiliated hospital; the first-place team member received a pathology atlas.

④ Dynamic Adjustment: Regular feedback was collected to calibrate task difficulty and reward criteria, ensuring fairness and sustained engagement.

Control Group: Teachers mainly conducted one-way knowledge transmission, systematically explaining the pathological mechanism, morphological characteristics and diagnostic key points of respiratory system diseases. Subsequently, they demonstrate pathological section images of typical cases through digital slices, and laboratory observation of pathological organ specimens and microscopic slides was also conducted. After class, experimental reports based on their observation results and class notes were submitted. Teachers provided centralized feedback through grading the reports.

Experimental Group: Accessed hierarchical medical record tasks, digital specimens, and section resources. Groups progressed sequentially through Levels A - E. Upon report review and reward distribution, the subsequent level was unlocked. Uncompleted tasks could be continued post-class. Instructors acted as “NPCs” (non-player characters) to provide guidance with specific responsibilities as follows:

① Clarify the learning objectives, completion standards, and scoring rules at each level, but allow students to control the learning pace independently.

② Center on cases to design interactive activities, provide diagnostic guidance when the progress is lagging, answer questions without directly giving solutions, and follow the “minimum necessary principle” in the intervention process to avoid replacing students’ independent thinking.

③ Real-time track task progress and points, offer prompts or suggestions to groups with different performances, encourage full participation of all members, reward effective contributions, and link with the point/reward system.

④ Collaborate and coordinate to solve issues related to group division and disputes.

⑤ Trigger rewards and advanced resources on demand after the completion of diagnostic tasks to facilitate the development of students’ professional capabilities.

Knowledge Assessment: A unified post-course examination was administered, comprising 40 single-choice questions, 5 terminology explanations, 3 case analyses, and 5 questions each on specimen and section identification (total score: 100). To minimize evaluator bias, subjective questions types such as case analysis and term explanation are scored using a blind evaluation method. Before scoring, students’ personal identification information such as names and IDs are concealed. 2 evaluators conduct independent scoring. A third evaluator is invited to arbitrate if the difference in scores exceeds the preset threshold.

Learning Satisfaction Survey:An anonymous questionnaire survey was used to cover four aspects: perceived learning effectiveness, learning interest, self-directed learning ability, and classroom enjoyment. A 10-point Likert scale was applied (≥9 points = satisfied, 6 - 8 points = basically satisfied, ≤5 points = dissatisfied), and the satisfaction rate was calculated. This questionnaire was revised based on mature scales in the field of medical education. Verified through a pre-survey (n = 30), the Cronbach’s α coefficient was 0.86, indicating good reliability of the scale. Content validity was verified through the expert consultation method, with an expert consistency coefficient of 0.89, ensuring the validity of the questionnaire measurement.

Teaching Satisfaction Evaluation: Covered four dimensions: content delivery, instructional organization, heuristic teaching, and clinical thinking cultivation, using the same scoring system.

Data were analyzed using SPSS 29.0. Normally distributed continuous variables were expressed as mean ± standard deviation and compared via independent samples t-tests. Categorical data were presented as percentages and analyzed using chi-square tests. A P-value < 0.05 was considered statistically significant.

The experimental group outperformed the control group in total score and across key question types, including single-choice questions, specimen identification, and pathological image interpretation (P < 0.05 or P < 0.01) (Table 1).

Table 1. Comparison of practical ability assessment scores between the two groups (mean ± SD).

Note: *P < 0.05, **P < 0.01 versus control group. SCQ = single-choice questions; TE = terminology explanations; CA = case analysis; SI = specimen identification; PII = pathological image interpretation.

The experimental group reported significantly higher satisfaction rates in all surveyed domains: learning effectiveness, interest, self-directed learning, and classroom enjoyment (P < 0.05 or P < 0.01) (Table 2).

Table 2. Learning satisfaction survey results (% satisfied).

Note: *P < 0.05, **P < 0.01 versus control group. SA = Satisfied; BSA = Basically Satisfied; DIS = Dissatisfied; SR= Satisfaction Rate (%).

Overall teaching satisfaction was markedly higher in the experimental group (P < 0.05). Satisfaction rates regarding content, organization, heuristic teaching, and clinical thinking training were all superior to those in the control group (Table 3, Figure 1).

Table 3.Teaching satisfaction evaluation (% satisfied).

Note: *P < 0.05, **P < 0.01 versus control group. SA = Satisfied; BSA = Basically Satisfied; DIS = Dissatisfied; SR= Satisfaction Rate (%).

Note: SA = Satisfied; BSA = Basically Satisfied; DIS = Dissatisfied.

Figure 1.Overall teaching satisfaction distribution.