Serious games

Medical schools and health care trainers are using advanced gaming technologies to convey what it’s like to practice high-pressure, critical-care medicine

The Serious Games Initiative

In 1972, the big medical stories included the surgeon general’s warning that exposure to secondhand smoke was a serious risk to public health. The development of durable lithium batteries dramatically increased the popularity of pacemakers. And the U.S. government stopped requiring people to receive smallpox vaccinations.

But the most significant medical development of the year — in terms of its long-term implications — might have been the introduction of Pong.

Atari’s video arcade game was an instant hit. A paragon of simplicity, Pong consisted of a long line representing a net, two shorter lines for paddles, a square ball and digital numbers for keeping score. Players manipulated knobs that controlled the up and down motion of virtual paddles, which batted a blip of light across a crude, low-definition video screen.

The game had the right combination of graphics, plausible physics and difficulty — not too hard or too easy — to engage users in a new and powerful way. And although no one knew it at the time, Pong was a harbinger of a significant technological shift in the way certain professionals today are trained.

Since then, the potential for electronic games to radically change the nature of teaching — for the medical profession in particular — has reached critical mass.

Today, medical schools are experimenting with multimillion-dollar game-based software systems that simulate the working conditions and decision-making skills required at some of the biggest hospitals in the world.

Until recently, tinkerers and game enthusiasts typically developed games for medical education. The games’ sophistication varies from simple applications such as online crossword puzzles and “Jeopardy”-type quiz shows to games that — in the spirit of the TV series “Survivor” — rate players according to how well they perform challenging tasks relative to their peers.

“Over the past two or three years, it has become a very active area,” said Parvati Dev, director of the Stanford University Medical Media and Information Technologies lab, which seeks to advance medical education by using information technology in innovative ways.

“People are realizing that a lot of learning requires you to experience a situation before you touch a real patient,” Dev said. “Today, we do book learning and learning in the hospital. Simulation, games and virtual reality provide an intermediate learning experience that can be very realistic, very safe for you and the patient, and which gives you a lot of practice.”

The use of games in medical education might also be one of the best ways to spark learning in a generation of digital natives — students for whom cell phones, video games and iPods are indispensable tools of daily life. William Brescia, the newly appointed director of instructional technology at the University of Tennessee Health Science Center, said he had barely unpacked when students began arriving at his office.

“I had 10 students knocking on my door saying, ‘How can we do this or that with technology?’ ” he said. “They have to pass the boards. They have to remember a lot of stuff. Wouldn’t it be great if we had a game to take them through this stuff over and over so that they could practice?”

Sweat and fear
The most sophisticated medical education games are now multimillion-dollar, graphic-intensive, first-person applications created by the commercial gaming industry. At the leading edge of this category is Pulse, a $10 million virtual learning lab developed by Texas A&M University-Corpus Christi and game developer BreakAway.

The Yale University School of Medicine, the Johns Hopkins School of Medicine and the National Naval Medical Center are testing the game, which replicates in minute detail the operations of the National Naval Medical Center’s intensive care unit. Like other sophisticated electronic learning systems, the game seeks to maximize the time students spend on specific tasks by engaging them with compelling story lines and believable virtual environments.

“The Pulse project represents an important convergence of gaming technology, educational theory and clinical need,” said Dr. Kirk Shelley, associate professor of anesthesiology and medical director of ambulatory surgery at Yale. “The increasing complexity of the critical-care environment mandates that we find innovative ways to rapidly train health care providers.”

A key innovation is the games’ ability to convey the intense atmosphere of the medical theater. Writing in an online forum, Tim Holt, a research assistant at Oregon State University who worked on the Pulse project, vouched for its emotional realism. “We want people to sweat, be scared, feel challenged, get pissed, but try again when the patient dies,” he said.

Immune Attack, developed by Brown University and the University of Southern California under the auspices of the Federation of American Scientists, also reminds its players that medicine is a matter of life or death. The game teaches immunology by placing learners on an electronic playing field where a teenage prodigy with a rare immunodeficiency disorder must teach his immune system how to function “or die trying.”

Virtual field hospital
Duke University hosts one of the more sophisticated projects to simulate serious medical situations. The university’s Human Simulation and Patient Safety Center functions like a flight simulator for doctors-in-training. Using computer-controlled mannequins that exhibit the symptoms of medical emergencies — a patient whose airway is swelling shut, for example — the simulations force students to make decisions before they face such situations in the real world.

The center has partnered with Virtual Heroes, a gaming company best known for creating the America’s Army game the military uses as a recruitment tool, to explore adding 3-D and virtual reality solutions. Virtual Heroes is also developing HumanSim, a medical training tool that will integrate advanced game technology.

Duke’s new game is set in a field hospital’s emergency room, and the situations that arise will have relevance to military and civilian medical teams. The game will connect players via a network that allows them to interact in the virtual environment.

“We focused on team training because [poor communication] has such a huge impact on injury and death caused by health care workers,” said Dr. Jeffrey Taekman, the center’s director.

The Defense Department also faces its share of mistakes with deadly consequences. To minimize risks, DOD uses game technology to train military employees to respond to a range of events, from soldiers reacting to a woman and child approaching a military checkpoint in Afghanistan to military doctors dealing with a critically injured soldier.

“DOD is the only [arena] where every day your job is to train. They know mistakes are costly,” said Kay Howell, vice president of information technologies at the Federation of American Scientists. “Similarly, the medical field spends a lot of money on education and training — and mistakes are costly. The return on investment in gaming could be extremely high” for medical education.

When designing such games, developers must maintain a careful balance between entertainment and seriousness, experts say.

“If you don’t do it right, somebody might die,” Brescia said. “You don’t want a fun game that gives out faulty information.”

Health business games

Not all health-related games are about treatment. Some developers are using games to help health care professionals learn to make business and management decisions. At the University of Virginia, for example, doctors and technologists have come together to create a game that teaches the economic implications — for doctors, patients and society — of various treatment options. The game has several disease scenarios, including gastroesophageal reflux disease, chronic high blood pressure and emphysema.

For each one, doctors choose from among several courses of treatment that vary in terms of direct costs, recuperation time, insurance coverage, out-of-pocket expenses and physician payment.

“The treatment options are a tossup in terms of efficacy, but there are big differences in the economic outcomes to physicians, patients and society as a whole,” said John Jackson, director of educational technology at the University of Virginia’s Office of Medical Education.

The game runs on open knowledgeware that users can customize to suit their needs. To date, the University of Colorado, the University of California at San Francisco and Temple University have adopted the game. Dr. John Voss, an associate professor of medicine at the University of Virginia, wrote the game’s algorithms. “People really like the interactive graphics,” Voss said. “The quickest way to put medical students to sleep is to lecture them about health care economics.”

Pedantic pushback
Of course, not everyone is enthusiastic about games — even serious ones — having a prominent place in medical education. Sophisticated new applications can be expensive to develop, and it’s not clear who will pay those costs.

In addition, the medical community has a reputation for adopting IT at a glacial pace, in marked contrast to its willingness to embrace sophisticated tools for diagnosing and treating diseases.

And although promising, most medical education games lag far behind commercial ones in their ability to engage players on a deep level. “The medical games I’ve seen so far have what I call a very short story,” Brescia said. “We need to think about realistic medical stories. The story is what drives the player to finish the games.”

“My impression of medical education is that they are struggling, like lots of education people, with issues of how new media affect them,” said Ben Sawyer, co-founder of the software development firm Digitalmill. “You add gaming and you get even more pushback because to say that a game would be a serious tool for something like cutting open a human body may sound like anathema to some.”

Such resistance notwithstanding, Sawyer said he is encouraged that universities are bringing together medical professionals and game designers.

He was pleased to hear a doctor at a medical conference express his desire to have Sam Fisher as a virtual patient. If you haven’t met Fisher, a field agent for the super-secret government agency Third Echelon, you can make his acquaintance in the virtual world of Tom Clancy’s Splinter Cell computer game.

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