Today we discuss about serious games, and especially the medical serious games.

What the hell is a “serious game”?

Well, serious games is a wide topic which is slowly growing, though more and more during these past years. It is such a vast topic that I actually did not know where to start writing this article. Serious games field is actually quite an old one, but still struggle to thrive to become mainstream.

Wikipedia tells us that serious games are “games designed for a primary purpose other than pure entertainment” [1]. Hence, it encompasses a very wide spectrum of other industries, such as defense, education, science, healthcare etc. It also comprises all the game format available such as video games, escape games, card games, board games etc. I found amusing that in an article, it is highlighted that “the actual problem with the term ‘serious games’ itself is that there appears to be a contradiction between […] the terms ‘serious’ and ‘game’ may seem to be mutually exclusive” [2]. Well, it may not be that exclusive when seeing some online players behave like crap and taking games too seriously…

We then somehow understand that a serious game it a ‘game’ in the first place, which brings an educational side to it. That can be to convey a message, to teach a skill, to advertise a product etc.

Most of serious games are actually not that fun

Which is one (if not the main) issue why serious games have not been that mainstream during their existence. You can fin a list of what was called “educational games” in that time (90s) here. Educational games are actually described as a “Trojan horse for math, history lessons dressed up in blocky ‘90s graphics” and their main purpose was to teach kids lessons.

Few games were actually really fun and memorable and I clearly remember the game “The Incredible Machine” and the game “Lemmings” (Figure 1).

I am not quite sure they were developed with the purpose to teach kids how to think differently, but they are definitely puzzle-solving games. For that reason, I don’t think we can qualify them as “serious game” or “educational games”.

Learning by playing. This is subject I have discussed many times with some friends. Don’t we agree that we all learn better while being playful and joyful? A glimpse at the “Discovery channel” and you’ll see how lion cubs simulate chasing and hunting just for fun, but ultimately develop the required skill for real-life situations. Human kids also learn by playing! Look at your 10 month old niece or nephew, how she/he is always smiling (except when he cries loudly I admit…), trying to walk but fall, then stand up again. It has been reported that good motor development is actually related to a kid’s playfulness [3], [4]. Playing, is thus correlated to our capacity to adapt to the external world.

Serious games, since 1968 (and still ongoing…)

The first educational games reported is named “The Sumerian Game” according thiswebsite, designed by Mabel Addis. As you can see in the previous listof educational games, lots of games have been developed but few have been remembered. One of the most famous one if “The Magic School Bus Series” (Figure 2).

It was a point and click game which tough kids various class topics, spanning from history and geography to biology, human body and solar system (as seen here).

Fun fact
When I was something like 7 years old, my two eldest brothers gave me an educational game for my birthday. I don’t know why but I still clearly remember this. One character of the game asked questions and waited for you to answer. Usually, the question was easy enough for you to answer. Then after answering, the character magically heard you and said “Congratulations! You are right!”. But then I realized I could make an experiment. I thought: “hey, what if I don’t talk?”. And my doubts rapidly uncovered. Indeed, everything was pre-recorded and the gap was only there to make you proud of your performance! Both I and my brothers laugh a lot when I told them that.

There are actually the “serious games”, and “non-serious games” which still teach us stuff

Take the Sid Meier’s Civilization, Age of Empires, Assassin’s Creed and Sim City series (Figure 3).

I still remember playing Civilization 1 as a kid. Of course, I always lost because the game is actually very complex and well developed. It is a turned based video game where you pick up a nation and start the game in the era of -4000 BC. As time passes, you build cities, research technologies such as alphabet, mathematics, pottery and agriculture, declare war to other nations or do coalitions. You can play the game only for the strategic side of it. But if you are curious enough, you can spend hours reading the description of each technology, when it was discovered in real life, the history of each nation etc. And the gamification of it makes it really pleasant to read and “learn lesson” in-game.

Nowadays, serious games are getting more and more attention especially with the development of virtual reality or augmented reality which allow us to immerse ourselves much more and have a deep emotional connection with the game [2]. Serious games industry weighted about 6 billion dollars in 2020 [5]. It has been forecast to reach 30 billion dollars at the end of 2023. We are hence clearly at the dawn of serious gaming.

What about medical serious games?

You might have guessed: serious games are seen as a very serious matter by all industries and by every big organizations of the society (education, military, healthcare etc.), in every country [2], [6], [7].  It has been reported that video games can be beneficial for the person who plays it [8]–[11].

I found there are three main leaders in healthcare serious games: BreakAway Games (USA), Grendel Games(Netherlands), Interaction Healthcare (France).

PULSE!

The first medical serious game was developed by BreakAway Games in 2007 on PC and Sony PSP [12]. We play as a physician in the emergency department (Figure 4).

PULSE! Objective is to simulate the emergency department atmosphere in the most realistic way possible. As you can see in the images, each mission is represented by a patient’s case. As a real doctor, when you make a patient’s admission, you have all his vital signs (heartbeat, respiratory frequency, oxygen saturation etc.). When clicking on the patient, we can perform various tests / clinical examinations. We can also ask our colleague to do specific tasks. When asking for blood sample, you receive the results and must interpret them. When asking for imaging, you read the actual image and have also to interpret that yourself. Everything is set in a stressful environment, with a time countdown before the patient die if you don’t treat him, the “bip bip bip” of the machines, no music, the sound of the respiratory machines etc.

Fun fact
PULSE! Has been developed in collaboration with A&M Texas University. It took 3 years and 14.7 million dollars to be developed [13]. I am not sure if the game made much benefits, but BreakAway Games is still a main actor in the healthcare serious game industry right now!

· Pros: I did not play the game but watched people playing on YouTube. PULSE! Is like a medical book, but involve all your senses at once as well as you emotionally. Indeed, medical students exercise their knowledge by solving clinical cases on books. Basically, the book describes a patient’s case with his symptoms and his history. Then you are asked the diagnosis you think are probable, the test you want to run and the treatment you initiate.

The game is great for clinical analysis because all signs and symptoms are visible/hearable on the patients (for instance, you see the pupilar myosis when illumining patient’s eyes, or can hear patient’s heart and lung by auscultation).

Interpreting all the test you ask yourself is also a very good way to learn the values of certain blood tests, to better learn reading X-ray and CT scan imaging. Indeed, the game directly gives you the image without any written results nor any radiologist conclusion (Figure 5).

As you have a goal, and a time countdown, you essentially want to save your patient because it is the only way to beat the game. So, you are involved emotionally. And I think it is pretty similar to the real life, because in a stressful environment, emotionally involved, with occasionally the necessity to think fast as it is vital, you can sometimes be confused, lose your confidence and forget everything. But here in the game, killing the patient has absolutely no consequence! Therefore, you can repeat the process as long as you want, and start to get comfortable being stressed and thinking fast. It is noteworthy that playing that game is close to medical education by simulations on dummy, which is widely used in medical school all over the world. It has been reported that simulation-based learning increased medical techniques and decreased medical errors [14].

· Cons: PULSE! Is clearly not for people who does not work in the medical field. There is no “fun” playing this game if you don’t understand anything about the medical slang, the tests you can run and why you give this or that treatment.

And that is an interesting question about serious games. Should serious games be developed for a certain population only? Should be serious games used solely as a tool for education? Indeed, “serious games” are games, and a game designer wants to tell a story and give the opportunity for the gamer to hop on a wonderful journey. PULSE! Was released in 2008, the same year at Mirror’s Edge or Metal Gear Solid 4 on PS3. These latest games were wonderful and I personally consider Metal Gear series as a masterpiece.

Vital signs: Emergency department

It is another game developed by BreakAway Games, available on Steam platform here. I think the company suffered from “low return on investment” from the first game because now, there is no more fancy 3D stuff… only non-animated cartoon like image (Figure 6)!

The company released a video here. Recently, a youtuberplayed at the game which is super interesting to watch because is it not medical personnel at all. Hence, he ended up killing all his patients… We actually sees him struggle with the game, not knowing what to do. Indeed, there is absolutely no tutorial and how-to-play intro to the game!

You play the game as a doctor in the emergency department. While chilling at the nurse office (Figure 7).

At the bottom of the screen, there are different missions represented by patient’s cases. When clicking on a patient’s room, you open the case and have the entire symptoms, vital signs and medical history as shown in Figure 6. As you can see, a lots is happing on screen… and no tutorial to tell you where the things are. But you have access to everything medicine have to offer you.

On Steam, gamers wrote some very interesting review. The game had a 60% positive vote. Some people pointed the lack of tutorial and how-to-play the game but find the concept appealing (Figure 8). Other people pointed out that the game was solely developed for medical personnel, and that the user interface lacked clarity and was confusing (Figure 9). In both cases, the game was thus boring (as we previously discussed).

CONCLUSION: well then, what is a “good” healthcare serious game?

That is a pretty good question my dear! There is no good healthcare serious game currently, so there is no standard for the genre.

I since quite some times now, had a little idea bouncing in my head of creating a video games centered around medicine or science. I first had some ideas inspired from the game Phoenix Wright: Ace Attorney (Figure 10).

Fun fact
In Japan, it is said that when you have been accused for a crime, and you have few chances to be proved innocent no matter if you are the real culprit or not. The drama “99.9 Keiji Senmon Bengoshi” actually tells the story of that 0.01 chance of being proven innocent if the lawyer truthfully seeks the truth. I love this drama!
You play the game as a young lawyer, fighting to defend innocent people by delivering logical proofs and facts to the judge. It is a scene-based game where you don’t control a character moving around, but which is closer to a point and click game: you explore different scenes, collect items, discuss with people and select choices when talking with them which influence the outcomes of the game. Designing a medical game in that way appeared easier to me.

When I was younger, I remembered creating some game (only for me) with RPG maker. I recently installed Unity and Unreal Engine on my PC. But it takes time to make games…

Creating a good game is difficult. Then imagine creating a game that is fun, but that also has an educational purpose… it is indeed a high-level challenge! Well, maybe I’ll consider that a bit later…

Take care and see you for the next article!

References

[1]         “Serious game - Wikipedia.” https://en.wikipedia.org/wiki/Serious_game (accessed Mar. 12, 2023).

[2]         F. Laamarti, M. Eid, and A. El Saddik, “An Overview of Serious Games,” 2014, doi: 10.1155/2014/358152.

[3]         E. Trevlas, O. Matsouka, and E. Zachopoulou, “Relationship between playfulness and motor creativity in preschool children,” http://dx.doi.org/10.1080/0300443032000070482, vol. 173, no. 5, pp. 535–543, 2010, doi: 10.1080/0300443032000070482.

[4]         E. Singer, “Play and playfulness, basic features of early childhood education,” https://doi.org/10.1080/1350293X.2013.789198, vol. 21, no. 2, pp. 172–184, Jun. 2013, doi: 10.1080/1350293X.2013.789198.

[5]         “Serious Games Market Size, Share | Industry Forecast - 2030.” https://www.alliedmarketresearch.com/serious-games-market (accessed Mar. 12, 2023).

[6]       P. Caserman et al., “Quality criteria for serious games: Serious part, game part, and balance,” JMIR Serious Games, vol. 8, no. 3, pp. 1–14, 2020, doi: 10.2196/19037.

[7]         F. Almeida and J. Simoes, “The Role of Serious Games, Gamification and Industry 4.0 Tools in the Education 4.0 Paradigm,” Contemp. Educ. Technol., vol. 10, no. 2, pp. 120–136, Apr. 2019, doi: 10.30935/CET.554469.

[8]         “Are Video Games Good For You? Why Games are Beneficial for Brain & Body.” https://www.idtech.com/blog/video-games-are-good-for-you (accessed Mar. 12, 2023).

[9]         I. Granic, A. Lobel, and R. C. M. E. Engels, “The benefits of playing video games,” Am. Psychol., vol. 69, no. 1, pp. 66–78, 2014, doi: 10.1037/A0034857.

[10]      S. Schenk, R. K. Lech, and B. Suchan, “Games people play : How video games improve probabilistic learning,” Behav. Brain Res., vol. 335, no. March, pp. 208–214, 2017, doi: 10.1016/j.bbr.2017.08.027.

[11]      Y. J. Halbrook, A. T. O’Donnell, and R. M. Msetfi, “When and How Video Games Can Be Good: A Review of the Positive Effects of Video Games on Well-Being,” https://doi.org/10.1177/1745691619863807, vol. 14, no. 6, pp. 1096–1104, Nov. 2019, doi: 10.1177/1745691619863807.

[12]      A. Albar, “Toward A Successful Engagement and Use of Educational Video Games,” no. May 2014, 2015, doi: 10.13140/2.1.2722.8484.

[13]      “Serious Games Futuring Medical Training In France.” https://www.seriousgamemarket.com/2009/11/serious-games-futuring-medical-training.html (accessed Mar. 12, 2023).

[14]      L. Sarfati et al., “Human-simulation-based learning to prevent medication error: A systematic review,” J. Eval. Clin. Pract., vol. 25, no. 1, pp. 11–20, Feb. 2019, doi: 10.1111/JEP.12883.