Beyond the clicker: rethinking student response systems as pedagogical infrastructure for healthcare professions education

Large-group lectures (150 students and upwards) remain a central component of healthcare professions education despite longstanding concerns about passivity, limited interaction, and difficulties in providing formative feedback at scale. These concerns have acquired renewed relevance as educators face digitally connected student cohorts, ubiquitous smartphones, and growing concerns about digital distraction. Student response systems (SRS), initially introduced through dedicated "clickers" and now commonly accessed through students' own digital devices, offer one approach to transforming the large lecture from a predominantly transmission-oriented format into an interactive learning environment. Meta-analytic evidence indicates positive effects of SRS on cognitive and non-cognitive learning outcomes, while research across psychology, nursing, medicine, dentistry, and other higher education settings suggests that their educational value depends less on the technology itself than on the pedagogical processes it enables. In this Perspective, we argue for a shift from viewing SRS primarily as engagement technology towards understanding it as pedagogical infrastructure for retrieval, formative assessment, peer discussion, feedback, self-monitoring, and metacognitive calibration in large lectures. Drawing on nearly two decades of research and educational experience with response technology, we propose an evolution from SRS 1.0, centred on response and participation, through SRS 2.0, centred on formative feedback and dialogue, towards SRS 3.0, where artificial intelligence may enable adaptive questioning, misconception detection, personalised feedback, and instructor decision support. This development creates new opportunities for healthcare professions education, but also requires renewed attention to pedagogy, digital competence, privacy, cognitive offloading, and the role of the educator.