Playing Games to Become a Better Pathologist

Years ago, parents everywhere were quick to point out that gaming was a “waste of time.” Now, with a mini-console nestled comfortably in every person’s pocket and a whole industry solidifying an entire generation of professional gamers, the once-frowned-upon pastime has become unmistakably normal.

But can games be more than just a bit of fun? Can they teach us and keep us entertained? Play has been a part of learning for millenia, but digital education games are understandably newer terrain – the first arguable example popping up in 1968 (1). We don’t fully understand the full breadth of skills that gaming can help teach us, but we do know that, generally, people’s learning is enhanced when gamification is introduced (2). Does this still apply when teaching surgery? What about diagnosing rare diseases? 

Eric Gantwerker, Medical Director at Level Ex and practicing pediatric otolaryngologist, says it does. We sat down with Gantweker to discuss how gaming can be used for education – and what the future may hold for medical training.

How did you first get involved in education games?
 

As a grad student, I went through different games and started to figure out the unintentional consequences of fun – and it really crystallized for me how people learn. Have you noticed that decades later you can remember the different spots on the Monopoly board, the names of cards, how much they cost? Though not intended, your memory clings to the game the more you play it. You’re more likely to remember 40 Pokemon characters than 40 US presidents because our education system isn’t Pokemon Go.

During that time, I started to realize there were many crossovers between the psychology of how people learn and how games are designed and developed – everything from board games to video games. 

We started to understand how to harness the power of games for more serious learning, not just in healthcare but in a bunch of other domains. The next step that took me along that route was a book by James Paul Gee about digital literacy and video games – which totally changed my outlook. I started to see the little elements of how people learn and how games were designed and it all just clicked.

Were you much of a gamer prior to Level Ex?
 

I grew up playing video games with my brother. Whenever I messed up in Metroid or something, he’d hit my hand and say something like, “No, don’t do that!” 

When he reached neurosurgery residency, I actually rotated with him for a month. I did something stupid and he smacked my hand just like he used to! I can say the two fields definitely cross over!

Today, I play a lot of games just to figure out some of the design principles and the psychology of how people are playing them.

How can games be used in medical training?
 

Medicine and healthcare has a huge learning gap. A lot of institutions today teach students in the same way they did 100 years ago – but the world has changed a lot since then. Those medical students lived in the hospital, they saw patients who were in-house for two weeks, and they literally had no hours restrictions. Today, they might be there for two hours and so the onus is on the medical health care system to train people faster, better, and at lower cost. And when you look at efficiency, you start to realize that in person experiential training is a hard system to scale.

It’s also a hard system to make efficient because it’s randomly generated; any patient can walk through the door. If you don’t have a patient who shows up with certain conditions throughout your training program, you will never know how to manage that patient. Games, on the other hand, have the ability to present you with problems and give you opportunities to solve them. And they don’t tell you how to solve the problems, they give you an opportunity to discover any number of paths to solve them – great analogy for healthcare because there is rarely just one path for treatment.

You can onboard yourself without reading a book or studying in a lecture. That’s how games can onboard players to a totally new domain, by giving them a different language and chance to present skills. The other thing about games is that they create a state in which you are massively efficient. As your learning increases, so does the difficulty of the game. And that’s why people can play one hour, but also 1000 hours – the game gets harder as their skills go up. Imagine if we did that in healthcare; you don’t get a lecture about something you already know about for five hours but are instead challenged dynamically with material that actually fits your specific skills at that very point.

How do different demographics respond to educational games?
 

Experts are a group that are mostly forgotten about. I see that as an opportunity to train the hardest people to train – to upskill the experts. It is much harder to turn a decent cardiologist into a master than it is to take a novice to an intermediate. We give those experts the opportunity to train on things that are new in their field, so new knowledge is always accessible. To play our games you do require some base knowledge and that is why it’s more fine-tuned for experts and practicing clinicians.

Which of your games would most interest pathologists and lab professionals?
 

Our first game was in the world of anesthesia, but we quickly moved to more knowledge-based mechanics centered about diagnosing disease and treatments. You can see this in our most recent game, Top Derm.

Dermatologists are constantly doing pattern recognition, right? So they’re looking at rashes, they’re looking at very image heavy content. And, of course, many dermatologists are also pathologists, and those image analysis skills cross over between specialities. There’s going to be more opportunities to bring more stuff relevant to pathology; image analysis is going to be a huge area that we expand on.

How do you tackle rare diseases?
 

We do a lot of work in regards to understanding how to deal with the patients with relatively rare diseases. We’ve encountered situations where doctors are not identifying rare diseases early enough when they could intervene; we use trial and error to teach, asking players to manage multiple patients, presenting them with multiple different types of scenarios, and having them pick up on the nuances.

Is there an “end” to your games?
 

Whenever we come out with a game, we always want players to come back and learn more. It’s through all of our partners and clients that we are able to continue to develop that experience. We call these “endless runners,” but we also include little mini games that can be built into those. We have a whole ecosystem with games that sort of interplay with each other; and that’s how we keep it interesting and varied.

Do you use real life cases?
 

One thing I’ve realized is that healthcare professionals love sharing their crazy cases, and so there’s no reason for us to make them up. So, all of our cases are somewhat based on actual cases, and the images are almost always pulled from actual cases; however, we do have some elements that might be altered. Take dermatology, where there is a huge gap when it comes to examples from people of color. We were able to create a whole pipeline of images that show any disease on any type of skin of color – because those kinds of images don’t normally exist. But otherwise we pull from actual cases and we regularly work with a network of more than 150 advisors who make sure that these are credible, authentic, and hit the mark.

When designing games, we ask ourselves things like: What is the problem? Where is the gap? What are people doing wrong? What are they missing? And then our game designers take that and say: “Oh there's a really good game that we could make out of that.” For instance, if you want to teach someone how to manage multiple patients, then you could make a real time strategy game. There’s no reason to create a new game type when these games already exist. Then we design it from the ground up – we create a game that hits on knowledge gaps and that uses mechanics that already exist within the games already enjoyed by millions of people.

What lessons have you learned over the years? 
 

The biggest learning point that we’ve taken away is finding what makes a game fun; it’s surprisingly hard to define. We give our testers things to react to and build the games around their responses. In our cardiology game, we actually had a mechanism where you would pass the wire in the game as they would in real life. But when we presented it to cardiologists, they were like: “Why did you do that?” So to fix it we used a simple drag-and-pull mechanism that exists in a lot of different games – and they loved it!

What is the future of medical video games?
 

There’s a general trend of acceptance and understanding that people can learn through games; the traditional cynicism is starting to erode. To me, success in this space revolves around making games a fundamental part of training – a tool that can help train new clinicians, make people more efficient at learning, and make the knowledge stick longer.