BMJ 2014;349:g5642 doi: 10.1136/bmj.g5642 (Published 16 September 2014)
Page 1 of 2
Feature
FEATURE HEALTH AND TECHNOLOGY
Games for doctors Stephen Armstrong looks at how the computer games industry is turning its attention to helping doctors improve their performance Stephen Armstrong journalist, London, UK How would you feel if you were facing an invasive operation and, on the way to the theatre, you passed your surgeon playing Super Monkey Ball on a Nintendo games console? According to James Rosser, general surgeon at Florida Hospital Celebration Health in Kissimmee, you should be delighted. In September 2012, Rosser asked half of the surgeons at the hospital to play computer games, including Super Monkey Ball, for six minutes before performing simulated laparoscopic surgery; the remaining 150 surgeons did the surgery without playing games.
Surgeons who had done the computer game warm-up completed 10 simple rope manipulation trials using surgical graspers in 649 seconds compared with 712 seconds in the control group—a statistically valid time difference.1 The number of errors in suturing tests was also fewer—133 errors versus 192.1 A similar study at the University of Rome produced comparable results, concluding that video gaming enhances spatial attention and eye-hand coordination.2 “The surgeons who had played video games made 37% fewer errors, were 27% faster, and scored 26% better overall than surgeons who never played video games,” Rosser told The BMJ. “I can see a day when we have a video games console in the corner of every operating theatre.”
In one sense, of course, elements of what’s now called gaming have been used by surgeons for thousands of years—ancient Babylonians used clay models of organs to teach doctors and priests. But video games add extra dimensions such as levels, point scoring, and rewards to increase motivation. Multiple meta-analyses have suggested that, in the right circumstances, games can be more effective than traditional methods of teaching in areas as diverse as military skills to understanding ecosystems.3 4 From this comes the idea of serious games—essentially computer games with a purpose, usually to train or teach. “The use of games technology is now becoming recognised as a key tool to drive down costs and increase efficiency across the medical sector,” according to Tim Luft, operations director for Coventry University’s Serious Games Institute.
The big boost in spending to develop these games has come from the US. “Gamification is moving into healthcare in the US, largely as a result of the Affordable Care Act,” argues Phaedra Boinodiris, head of IBM’s gamification and serious games programmes. The act has made remuneration more dependent on patient outcomes than number of procedures, so it’s boosting US research and development money into preventive medicine, she says. “Gamification is a good motivating tool. The next big expansion we see on the way is in serious games for healthcare professionals.”
In surgery, perhaps the most obvious specialty where games can be useful, simulators have been around in various forms since the 1980s. But it was not until 2009, when neurosurgeon David Clarke at the Queen Elizabeth II Health Sciences Centre in Halifax used a simulator to dummy run the removal of a brain tumour before successfully carrying out the operation, that simulators really took off. Serious games add story, challenges, missions, and time pressure to traditional simulator models, making training on routine procedures more attractive as well as being able to model situations that are hard to replicate in the real world.
Human Sim, a spin-off of US based gaming company Virtual Heroes, for instance, offers Zero Hour for desktop computers. The game is aimed at training emergency first responders to deal with incidents such as earthquakes or terrorist attacks. Set in the fictional city of St Lillo, the player begins each mission in an ambulance approaching the scene of the disaster and has to choose equipment and deal with the situation against a ticking clock. Jerry Heneghan, director of product development for Human Sim, served as an Apache helicopter pilot in the US Army before launching this medical equivalent of flight simulators. The company worked with Duke Medical Centre to build software that mimics the responses of the human body, a so called physiology engine. The company now sells situation games to the military and the healthcare industry. HS Anesthesia, for example, contains a range of critical situations and reflects patient responses to various drugs, and HS Critical Decisions tests nurses on decisions for patients at risk of pressure ulcers.
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BMJ 2014;349:g5642 doi: 10.1136/bmj.g5642 (Published 16 September 2014)
Page 2 of 2
FEATURE
Heneghan believes the games could be used for assessment as well as training. “When I was an Apache pilot, I was evaluated every year on a flight simulator to check I was still good to fly,” he points out. “I don’t see why that shouldn’t be compulsory for surgeons as well.”
Ahmed suspects slow uptake is the result of resistance from doctors suspicious of gaming. Serious games publishers fear costs may be too high to enter a market that’s too small. He predicts this resistance will diminish as pressure on budgets increases.
The advantage computer game simulators have, he believes is cost. Higher end surgical simulators cost at least £100 000 (€125 000; $160 000) but games are considerably cheaper—the SimPraxis Nissen iPad interactive, professional level, surgical simulation trainer costs just £20.99, for example. They can also be used to help patients understand forthcoming procedures, which can help quell anxiety.
Gaming techniques are also poised to enter diagnosis. US start-up CogCubed is developing a game aimed at diagnosing a range of disorders, including attention deficit hyperactivity disorder, autism, anxiety, depression, traumatic brain injury, and even Alzheimer’s disease. The game—Groundskeeper—is a variant of the end of the pier classic Whac-A-Mole, using a series of small cubic screens that the patient moves with his or her hands. One screen holds a digitised hammer while three others show a grass covered field from which moles pop up, with the added distraction of a boy pushing a lawn mower across at random times. The cube edges hold sensors that record 70 variables related to movement, reaction, and response patterns—designed to measure a patient’s attention span and distractability. Pfizer is developing a similar game, Project EVO, with game company Akili Interactive Labs.
But Shafi Ahmed, consultant general laparoscopic and colorectal surgeon at Barts and The London NHS Trust, is cautious. Ahmed is no luddite—in May he became the first British surgeon to broadcast a live surgical procedure online using Google glasses. However, although he agrees that the games are good at teaching decision making, he argues that “they won’t make you a good surgeon, and they can’t measure the quality of your surgery. There’s an enormous amount of intuition and fingertip feedback that these games can’t reproduce.”
Slow uptake
Human Sim’s sales in the UK penetration is low and rivals are also struggling. Coventry University professor Pam Kato helped develop the game Air Medic Sky 1 (AMS1) with Visionshift Studios and the University Medical Center, Utrecht. The game is aimed at young doctors preparing to work in emergency departments. AMS1 is a fictional flying hospital that travels the world, allowing players to train in a variety of scenarios. Players are wired up to biofeedback monitors that measure heart rate. As the patients mount up, the doctors must learn to stay calm to avoid losing points.
Despite winning two US prizes for best serious game, AMS1 is still in search of a publisher. “This has been more difficult than I had ever imagined,” says Cor J Kalkman, professor of anaesthesiology at the University Medical Center, Utrecht. “We have recently been doing research with the game in groups of medical students. The results of these studies were quite positive and clearly indicated where we should go with the next update.”
Developers of serious games are persisting, and their ambitions extend way beyond surgery. Bournemouth University’s Dementia Institute is developing a game to train student nurses to deal with patients with Alzheimer’s disease, which would allow high risk scenarios to be played out in safety.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3 4
Rosser JC Jr, Gentile D, Hanigan K, Danner OK. The effect of video game “warm-up” on performance of laparoscopic surgery tasks. J Soc Laparoendoscop Surg 2012;16:3-9. Giannotti D1, Patrizi G, Di Rocco G, Vestri AR, Semproni CP, Fiengo L, et al. Play to become a surgeon: impact of Nintendo Wii training on laparoscopic skills. PLoS One 2013;8:e57372. De Freitas S, Griffiths MD. The convergence of gaming practices with other media forms: what potential for learning? A review of the literature. Learning, Media Technology 2008;33:11-20. Egenfeldt-Nielsen S. Third generation educational use of computer games. J Educ Multimedia Hypermedia 2007;16:263-81.
Cite this as: BMJ 2014;349:g5642 © BMJ Publishing Group Ltd 2014
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Feature
FEATURE HEALTH AND TECHNOLOGY
Games for doctors Stephen Armstrong looks at how the computer games industry is turning its attention to helping doctors improve their performance Stephen Armstrong journalist, London, UK How would you feel if you were facing an invasive operation and, on the way to the theatre, you passed your surgeon playing Super Monkey Ball on a Nintendo games console? According to James Rosser, general surgeon at Florida Hospital Celebration Health in Kissimmee, you should be delighted. In September 2012, Rosser asked half of the surgeons at the hospital to play computer games, including Super Monkey Ball, for six minutes before performing simulated laparoscopic surgery; the remaining 150 surgeons did the surgery without playing games.
Surgeons who had done the computer game warm-up completed 10 simple rope manipulation trials using surgical graspers in 649 seconds compared with 712 seconds in the control group—a statistically valid time difference.1 The number of errors in suturing tests was also fewer—133 errors versus 192.1 A similar study at the University of Rome produced comparable results, concluding that video gaming enhances spatial attention and eye-hand coordination.2 “The surgeons who had played video games made 37% fewer errors, were 27% faster, and scored 26% better overall than surgeons who never played video games,” Rosser told The BMJ. “I can see a day when we have a video games console in the corner of every operating theatre.”
In one sense, of course, elements of what’s now called gaming have been used by surgeons for thousands of years—ancient Babylonians used clay models of organs to teach doctors and priests. But video games add extra dimensions such as levels, point scoring, and rewards to increase motivation. Multiple meta-analyses have suggested that, in the right circumstances, games can be more effective than traditional methods of teaching in areas as diverse as military skills to understanding ecosystems.3 4 From this comes the idea of serious games—essentially computer games with a purpose, usually to train or teach. “The use of games technology is now becoming recognised as a key tool to drive down costs and increase efficiency across the medical sector,” according to Tim Luft, operations director for Coventry University’s Serious Games Institute.
The big boost in spending to develop these games has come from the US. “Gamification is moving into healthcare in the US, largely as a result of the Affordable Care Act,” argues Phaedra Boinodiris, head of IBM’s gamification and serious games programmes. The act has made remuneration more dependent on patient outcomes than number of procedures, so it’s boosting US research and development money into preventive medicine, she says. “Gamification is a good motivating tool. The next big expansion we see on the way is in serious games for healthcare professionals.”
In surgery, perhaps the most obvious specialty where games can be useful, simulators have been around in various forms since the 1980s. But it was not until 2009, when neurosurgeon David Clarke at the Queen Elizabeth II Health Sciences Centre in Halifax used a simulator to dummy run the removal of a brain tumour before successfully carrying out the operation, that simulators really took off. Serious games add story, challenges, missions, and time pressure to traditional simulator models, making training on routine procedures more attractive as well as being able to model situations that are hard to replicate in the real world.
Human Sim, a spin-off of US based gaming company Virtual Heroes, for instance, offers Zero Hour for desktop computers. The game is aimed at training emergency first responders to deal with incidents such as earthquakes or terrorist attacks. Set in the fictional city of St Lillo, the player begins each mission in an ambulance approaching the scene of the disaster and has to choose equipment and deal with the situation against a ticking clock. Jerry Heneghan, director of product development for Human Sim, served as an Apache helicopter pilot in the US Army before launching this medical equivalent of flight simulators. The company worked with Duke Medical Centre to build software that mimics the responses of the human body, a so called physiology engine. The company now sells situation games to the military and the healthcare industry. HS Anesthesia, for example, contains a range of critical situations and reflects patient responses to various drugs, and HS Critical Decisions tests nurses on decisions for patients at risk of pressure ulcers.
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;349:g5642 doi: 10.1136/bmj.g5642 (Published 16 September 2014)
Page 2 of 2
FEATURE
Heneghan believes the games could be used for assessment as well as training. “When I was an Apache pilot, I was evaluated every year on a flight simulator to check I was still good to fly,” he points out. “I don’t see why that shouldn’t be compulsory for surgeons as well.”
Ahmed suspects slow uptake is the result of resistance from doctors suspicious of gaming. Serious games publishers fear costs may be too high to enter a market that’s too small. He predicts this resistance will diminish as pressure on budgets increases.
The advantage computer game simulators have, he believes is cost. Higher end surgical simulators cost at least £100 000 (€125 000; $160 000) but games are considerably cheaper—the SimPraxis Nissen iPad interactive, professional level, surgical simulation trainer costs just £20.99, for example. They can also be used to help patients understand forthcoming procedures, which can help quell anxiety.
Gaming techniques are also poised to enter diagnosis. US start-up CogCubed is developing a game aimed at diagnosing a range of disorders, including attention deficit hyperactivity disorder, autism, anxiety, depression, traumatic brain injury, and even Alzheimer’s disease. The game—Groundskeeper—is a variant of the end of the pier classic Whac-A-Mole, using a series of small cubic screens that the patient moves with his or her hands. One screen holds a digitised hammer while three others show a grass covered field from which moles pop up, with the added distraction of a boy pushing a lawn mower across at random times. The cube edges hold sensors that record 70 variables related to movement, reaction, and response patterns—designed to measure a patient’s attention span and distractability. Pfizer is developing a similar game, Project EVO, with game company Akili Interactive Labs.
But Shafi Ahmed, consultant general laparoscopic and colorectal surgeon at Barts and The London NHS Trust, is cautious. Ahmed is no luddite—in May he became the first British surgeon to broadcast a live surgical procedure online using Google glasses. However, although he agrees that the games are good at teaching decision making, he argues that “they won’t make you a good surgeon, and they can’t measure the quality of your surgery. There’s an enormous amount of intuition and fingertip feedback that these games can’t reproduce.”
Slow uptake
Human Sim’s sales in the UK penetration is low and rivals are also struggling. Coventry University professor Pam Kato helped develop the game Air Medic Sky 1 (AMS1) with Visionshift Studios and the University Medical Center, Utrecht. The game is aimed at young doctors preparing to work in emergency departments. AMS1 is a fictional flying hospital that travels the world, allowing players to train in a variety of scenarios. Players are wired up to biofeedback monitors that measure heart rate. As the patients mount up, the doctors must learn to stay calm to avoid losing points.
Despite winning two US prizes for best serious game, AMS1 is still in search of a publisher. “This has been more difficult than I had ever imagined,” says Cor J Kalkman, professor of anaesthesiology at the University Medical Center, Utrecht. “We have recently been doing research with the game in groups of medical students. The results of these studies were quite positive and clearly indicated where we should go with the next update.”
Developers of serious games are persisting, and their ambitions extend way beyond surgery. Bournemouth University’s Dementia Institute is developing a game to train student nurses to deal with patients with Alzheimer’s disease, which would allow high risk scenarios to be played out in safety.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3 4
Rosser JC Jr, Gentile D, Hanigan K, Danner OK. The effect of video game “warm-up” on performance of laparoscopic surgery tasks. J Soc Laparoendoscop Surg 2012;16:3-9. Giannotti D1, Patrizi G, Di Rocco G, Vestri AR, Semproni CP, Fiengo L, et al. Play to become a surgeon: impact of Nintendo Wii training on laparoscopic skills. PLoS One 2013;8:e57372. De Freitas S, Griffiths MD. The convergence of gaming practices with other media forms: what potential for learning? A review of the literature. Learning, Media Technology 2008;33:11-20. Egenfeldt-Nielsen S. Third generation educational use of computer games. J Educ Multimedia Hypermedia 2007;16:263-81.
Cite this as: BMJ 2014;349:g5642 © BMJ Publishing Group Ltd 2014
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
