Crossword Puzzles: Active Learning in Undergraduate Pathology and Medical Education

A growing body of research has indicated that incorporating active learning strategies improves understanding and learning.1,2 The major benefits include fostering development of critical thinking, communication, and cooperative learning skills and attitudes and values3; promoting concept formation; providing an avenue for discovering misconceptions2; and increasing motivation.4 Games and puzzles, forms of active learning, are helpful to review, summarize, practice, find out gaps in knowledge, and develop new relationships among concepts.5 Games are considered valuable for the acquisition and application of cognitive, affective, and psychomotor knowledge and skills.6 Various formats of games and puzzles have been used to supplement traditional teaching, for example, jeopardy-style game in obstetrics,7 card games for gastrointestinal physiology,8 frame game in psychiatry,9 panel board games in immunology,10 and puzzles for gastrointestinal physiology.11 

Crossword puzzles, with a history dating back to word squares of Pompeii and 300 ad Egypt, are commonly found today in magazines, newspapers, and trade journals. Arthur Wynne is credited with creating the first “modern” crossword that appeared in the December 21, 1913, Sunday “Fun” section of the New York World as a “word-cross.”12 There are many forms of this game including the US style symmetrical crossword, cryptic crosswords, and others.13 Crossword puzzles have been used by others in medical and nursing education11,14–17 and staff development.18 Crosswords have also appeared in medical and nursing journals19,20 to review and summarize information in an engaging manner. An extended matching crossword puzzle has been used to assess students' diagnostic thinking and clinical reasoning.21 It is claimed that crosswords expand the vocabulary, stimulate the mind, and help develop healthy skepticism.12 

In the hematology system and the neoplasia section of undergraduate pathology courses for second-year medical students at the University of Saskatchewan, Saskatoon, Canada, students are introduced to many new terms and concepts in a short time. This has posed a challenge in providing adequate practice and necessary repetition to reinforce key concepts. The hematology system is also the first clinical system in the second year (phase B) and students have not yet become proficient in organizing thought processes around clinical problem solving or fluent in system-specific vocabulary. Various active learning methods including crossword puzzles have been incorporated into these courses in an attempt to increase understanding, learning, and retention. Crossword puzzles were introduced as a quick and effective way to reinforce critical concepts and essential vocabulary with the hope that the students would be better able to recall essential concepts. In addition, the puzzles were intended to be engaging while providing an opportunity for discussion and reasonable appropriate humor.

Herein, we report the utility of crosswords for reviewing and reinforcing concepts and vocabulary, student responses for evaluating their usefulness, and a review of relevant literature.

Permission to conduct student surveys was obtained from the undergraduate dean's office; the University of Saskatchewan Behavioral Ethics Committee ruled the study exempt from formal ethics review.

Crossword puzzles were made online at the Discovery School's puzzlemaker Web site (http://puzzlemaker.school.discovery.com, accessed February 26, 2008). These were used for review during the last of the 5 sessions in neoplasia in the undergraduate pathology course and toward the end of the course in the hematology system. The puzzles (Figure) had both vertical and horizontal columns with words in the vertical columns running from top to bottom and in the horizontal columns running from left to right. There were no words that ran diagonally or that were inverted. Both short and long words were included to keep the puzzle at a moderate difficulty level as puzzles with long words are difficult to solve.13 The clues ranged from easy to hard. The level of difficulty was established by referring to the levels of understanding. Simple rote learning and recall were considered easy and problem solving and application of knowledge were considered difficult and more relevant to the ultimate goals of the courses. Unlike some of the common crossword puzzles in newspapers and professional competitions, we did not use misleading clues, anagrams (rearranging letters of a word to create another word), or telescoped words (words telescoped inside 2 adjacent words)13 because trickery or sending the students on a wild goose chase was not the purpose of the exercise. There were generally 20 to 26 clues with 10 minutes allotted for the exercise. Students were asked to complete this exercise in class time in a collaborative and cooperative manner in groups of 6 or 7. There was a certain element of competition; a reward was offered to the first group that finished the puzzle correctly. When the group that finished first had any wrong answer, the group that finished next was considered.

The clues were constructed accurately around key words signifying essential concepts and linkages (eg, disease management and prognosis), facts and terms that need memorizing (eg, the operational definition of acute leukemia being more than 20% blasts in the marrow), and common and classic clinical scenarios. Content validity was ensured by linking the clues and answers to specific learning objectives. One example is given in the Figure; this crossword on neoplasia was used to review and reinforce vocabulary and concepts of (1) differences between benign and malignant tumors (1, 11 across; 13, 22 down); (2) molecular biology and genetics of neoplasia (3, 12, 19 across; 4 down); (3) clinical symptoms and signs of neoplasia (10 across); (4) basic tumor biology (5, 6, 17, 21 across; 8, 9 down); (5) detection/diagnosis, prognosis, and management of neoplasms (15, 20, 25 across; 2, 7, 18, 23, 24 down); and (6) tumor nomenclature and epidemiology and carcinogenesis (26 across; 14, 16, 21 down). In addition, the content and the format were reviewed by 2 faculty members.

Data were collected from 2 different classes of students on 2 occasions (2003 and 2004) through surveys that included specific questions dealing with crossword puzzles. In 2003 the students were asked to respond with yes or no to a series of questions, and in 2004 a 5-point Likert scale was used (Table). The surveys were developed based on the overall educational objective of assessing the usefulness of this learning intervention. The questions were developed to assess 5 broad areas of students' perceptions of crosswords for usefulness in identifying key concepts and vocabulary, usefulness in learning, collaborative aspects, competitive aspects, and student satisfaction. The questionnaire was developed to address these aspects while avoiding common wording problems, minimizing bias, and keeping the overall survey length within acceptable limits; the content validity was ensured by asking an expert to evaluate the relevance of the items and both surveys were pretested on a group of medical students who had completed these courses.22 Informal student comments were also noted. One formal and 2 informal peer evaluations were recorded; the formal evaluation was part of the regular peer evaluation program of teaching, whereas the informal evaluations were by other instructors made aware of this intervention and who offered their comments on the use of this intervention.

In 2003 the yes or no responses were tabulated and the Likert scale data from 2004 were analyzed for individual questions by descriptive statistics (mean and standard deviation).

In general, about 3 (of a total of 6–7 groups, each with 6–7 students) groups finished the exercise in 7 to 8 minutes of the allotted 10 minutes. Generally the group to finish first also solved the puzzle correctly and was awarded the prize (dinner at a restaurant of their choice).

Data from 2 different surveys of different classes (2003 and 2004) indicated that many students (37 of 39 in 2003 and 24 of 41 in 2004) indicated that crosswords were useful and contributed to their learning (Table).

Most of the students (88.5% versus 11.5%) found crosswords a useful learning tool (Q 2; 94.8% versus 5.2%) helpful in identifying important areas and connections (Q 1 and 3; 88.5% versus 11.5%). Whereas the collaborative aspect was considered useful by most (Q 6; 92.3% versus 7.7%), the competitive aspect was less favorably evaluated (Q 7; 74.3% versus 25.7%). Most students were in favor of continuing this exercise (Q 4 and 5; 93.5% versus 6.5%). Most believed that it was neither a gimmick nor a waste of their time and that the level of difficulty was appropriate for their learning (Q 8–11; 95.5% versus 4.5%).

Slightly more than half the responders considered crosswords a useful learning tool (Q 6a, c, d; mean Likert scores: 3.27, 3.63, and 3.66, respectively), found both collaborative and competitive aspects useful in their learning (Q 6g and 6f; mean Likert scores: 3.66 and 3.58, respectively), enjoyed the exercise (Q 6b; mean Likert score: 3.71), and were in favor of continuation of crosswords as a component of the course (Q 6e; mean Likert score: 3.61). A greater proportion of students enjoyed the crosswords (27 of 41 with strongly agree and agree in question 6a) than reported finding the crosswords helpful for learning (21 of 41 with strongly agree or agree ratings in question 6b).

Written and informal comments indicated student enthusiasm and a desire to participate in more of these exercises. Approximately 3% of students considered this exercise a time waster. One student comment was, “The interactive nature of the large group sessions (where crossword is one of the tools) keeps the energy levels high in the class; the sessions are relevant and students look forward to these even though it is pathology and it is at the end of the day.” None of the students found the puzzles unreasonable, too difficult, or constructed with misleading clues. Many students are now using this exercise in other classes in which active learning strategies are used for reviews (L. F. Qualliere, oral communication, November 2004). Some of the students, after having heard about this tool from their senior-year colleagues, asked when will the crosswords be used in their course (current second-year class).

Peer evaluations have also favorably evaluated this exercise including narrative comments in a formal peer evaluation and positive comments by other instructors, some of who have expressed a desire to include crosswords as one of the active learning teaching methods.

The time required to plan a content-valid crossword at a moderate level of difficulty was around 3 to 4 hours. Actual construction using a public Web site took less than 15 minutes. Because the purpose of using crosswords was review and reinforcement, we used this tool toward the end of the course or specific sections. The students had to be “prepared” for expecting a “gaming” exercise and their favorable and a large number of neutral responses (to questions 6c–6g in 2004 survey) were considered an indication of “willingness to try.” It took about 20 minutes to hand out the exercise, allowing students time to complete it and discussing the answers.

Overall the crosswords were a useful ancillary learning tool; students reported these to be of benefit in identifying key concepts, contributing to their learning, and engaging them in collaborative practice.

Crossword puzzles in groups of 6 to 7 would fall within the broad domain of small group learning and are representative of a more student-oriented rather than teacher-oriented approach requiring student participation and interaction.23 Small group activities promote deeper understanding; encourage problem solving, participation, and personal responsibility for learning; and develop interpersonal and social team working skills.24 And students who learn in small groups generally demonstrate greater academic achievement, are more favorably inclined toward learning, and are more positive in general.25 Crosswords are likely to have similar benefits and we found that students were more positive about the class and the topics. Because there are many different types of small group learning activities with various forms of teacher and student participation and feedback to the students,24 it is difficult to pinpoint specific benefits of crosswords in a setting, such as ours, in which crosswords are one of many small group activities.

However, the following are likely to be relatively specific for crosswords. The answers to the clues are key words centered on concepts and help reinforce the vocabulary. Crossword puzzles quickly evaluate the current state of understanding in an informal way that provides immediate feedback (there is only one correct answer) to students and the instructor about misconceptions or misunderstandings. This parallels the findings of other researchers on active learning1–4 and games and puzzles.5,26–30 As the students progress with this exercise, already completed words provide additional information (in addition to the clues for unfilled words) for remaining incomplete entries. This permits the students to integrate information from completed and new (clues to unfilled words) sources and helps establish their understanding of various pieces of data; some already completed entries may be challenged. In an elegant essay, Susan Haack31 has actually drawn the crossword analogy for accounting for subjectivity in the evaluation of scientific evidence: “the clues providing experiential evidence and the already-completed entries the analogue of background information.” The students have an opportunity to test if something is correct when it is crossreferenced and correct from a variety of paradigms.31 This is a form of bayesian approach that is advocated in decision making in medicine32 and crossword exercises provide a contextual and logical framework for critical and perhaps creative thinking, logic and pattern-forming skills, deductive reasoning, problem-solving skills, and decision making. The proponents of crosswords claim that these puzzles help develop healthy skepticism toward accepting things as these first appear to be.12 

The crosswords offer opportunities for immediate team-building—trust and camaraderie—(students depend on each other to draw from and contribute to a partially solved puzzle). This motivates and stimulates student learning by serving as a vehicle for the construction of further understanding and practice of interpersonal skills through a discussion cooperating in a team situation. It is well established that learning is enhanced when students engage in team or group games in the classroom that fosters cooperation.26–30 The competitive aspect, with a prize that is substantial and socially engaging, provides for a battle of wits in a nonthreatening environment. It should be noted that approximately 20% of the students were not in favor of this aspect; it may have to do with learning styles and unnecessary pressures. The competitive aspect of this exercise provided an atmosphere of excitement, challenge, and performing and relying on team members in demanding conditions; this may help to build students' confidence. This aligns with our philosophy that knowledge and skills are important and that one should also acquire the ability to successfully use these skills in a demanding situation.

Although crosswords have been used in classroom teaching,11,14–17 professional journal quizzes,19,20 and student assessment,21 it is surprising that this tool is not reported to be more widely used and studied. This may be partly because some individuals find the use of games frivolous and inadequately evaluated33 and the relatively large amount of time required to develop topic-specific relevant crosswords. Some other disadvantages may include poor suitability for some learning styles and perception of threat (with the competitive element) and boredom.34 The small percentage of negative comments in our study might be attributed to a dislike of crosswords, perceiving it to be trivial or noneducational because it doesn't look like traditional teaching and may be considered an inappropriate use of class time. We believe that some of the reasons for student acceptance and popularity of this uncommonly used tool may be that puzzles lighten the class atmosphere by providing fun and humor, intellectual stimulation, satisfaction with successful completion, and relevance of the exercise to overall learning. Of note is the transferability of the use of crosswords from our classes to other classes by the students. One of the authors (A.S.) was informed that news of this strategy traveled to other instructors in the department via the students.

There are many perceived advantages to including crosswords in the medical teaching repertoire. Crosswords, which are easily constructed and quickly completed, are also self-correcting; if the word fits it fits, if it doesn't fit it is wrong. The challenge for us has been to keep these puzzles at a level of difficulty where the students find these to be just a little beyond their grasp allowing them to “stretch.” Simple and easy puzzles would be only for fun and most students would consider these a waste of their time. On the other hand, extremely difficult puzzles will disengage the learners and turn them off this exercise. Students expand their understanding of concepts, recall and work with “buzzwords” or key words in the discipline that are necessary for the understanding of more difficult or complex concepts, and use a little bit of imagination.

Effectiveness of teaching programs and learning interventions can be assessed at different levels—reactions, learning, behavior, and results—according to Kirkpatrick's model.35 The impact of learning interventions in individual courses on behavior (level 3, positive changes in participants' job performance; eg, when these students are on wards and in near-practice settings) and results (organizational performance, level 4; eg, the overall performance of the medical school) is difficult to assess without an overall organization plan for such assessments; this was not the intent of this study. Although the assessment of the learning experience (level 1, the focus of this study) is not the ultimate determinant of learning and is subjective, it is an important first step in assessing student engagement, which does enhance active learning, the benefits of which are well known and referred to in this article. Student satisfaction with the crossword as distinct from other small group learning activities can be assessed by focused questions on different small group and active learning interventions and our findings are based on questions specifically assessing crossword puzzle “intervention.”

Assessing gains in learning (level 2) is more helpful in determining the effectiveness of a learning intervention; however, in a setting of various active learning interventions (eg, small group cases, weekly assignments requiring literature review, quizzes), it is very difficult to assign improvement in learning to one activity alone. Although recall of essential concepts cannot be assessed by student satisfaction data, it somewhat comes across in the correct solutions to the puzzles by half the class (3–4 groups of 6–7 students each correctly solving the puzzle in less than 10 minutes) within allotted time. The assessment of learning, which has built on existing knowledge (ie, advanced knowledge acquisition), can be done by assessing the ability to transfer knowledge to a different context, task, or domain. Near transfer is called for when students encounter problems very similar to the problems they worked on during the learning stage, whereas far transfer is called for when students encounter problems that are new to them in both content and context. Crosswords, by their very nature, are useful for assessing near transfer. The student performance in these courses (data not presented) has improved since the introduction of this intervention (along with other active learning interventions) as measured by increasing class average and the narrowing gap between the highest and lowest mark. In view of this general improvement in student performance, it is perhaps safe to claim that crosswords are a useful tool in expanding the repertoire of active learning methods. Although we have not linked crossword items specifically to exam questions, other researchers have noted a positive correlation between exam questions and concepts reviewed in puzzles and games.5 An extended matching crossword puzzle has been used to assess students' diagnostic thinking and clinical reasoning.21 In this model acceptable to both students and teachers when the puzzles are completed the horizontal rows reflect integrative ability and the vertical columns measure students' ability to interpret specific data sets.

Our data collection tool is a survey, which has inherent limitations of subjectivity (self-report bias). However, the pretesting, face validity, and high response rate attest to the validity of the findings. Some of the other limitations of our study include not determining the effect of group size and the instructor's enthusiasm or a detailed evaluation of interactive and affective components.

Future research in this area may be directed at determining the impact of crossword puzzles on retention of vocabulary and concepts in undergraduate medical education, development of teams and critical-thinking skills, and a controlled experiment to identify the key contributory aspects of this intervention.

Crosswords provided students with an opportunity to think critically, collaborate, compete, and recall and discuss salient concepts by using essential vocabulary associated with these concepts. The judicious use of crossword puzzles in a collaborative/friendly competitive environment is a useful adjunct to the repertoire of active learning strategies. Crosswords are useful for near transfer content and are best used for review and may be used for assessment. This study provides insight into (1) the utility of crossword puzzles in undergraduate medical education to reinforce concepts and vocabulary in an interactive learning atmosphere, (2) the response of students and other instructors to the inclusion of crosswords, and (3) evidence of its feasibility in a large class setting.

We thank Todd Reichert, ACE, ChemTech, for assistance with preparing the illustration.