Applying Game Design to a Medical Study Aid

Ward Round is a new application which experiments with utilising video game design methodology within an academic discipline, in this case, medicine. The project, aimed at medical professionals, integrates the study of medicine with the enjoyable spirit of video games, and is the first commercial project for new Dundee based game development company, Guerilla Tea.

By introducing game design elements such as risk and reward, experience tracking and a heavily competitive edge, Ward Round seeks to innovate in the field of medical study. It utilises a question bank which covers nine discrete specialities and involves the user tackling medical cases in the form of real life scenarios, rather than single, unrelated questions. 

For each case, questions take the player through potential diagnoses, initial investigations, interpretation of results, treatment and knowledge of pathophysiology. These allow the user to deal with medical/surgical pathologies in a more natural, holistic way.

The Ward Round project was a ‘slow burn’ and something which was introduced to me before I had really started on the long career road of video game design although I always aspired to work in that field. The concept had arisen in casual discussions, some years ago, with my client and good friend, Dr Adrian Raudaschl, during our time at the University of Glasgow, where I was studying for a BSc in Mathematics. He was a medical student at that time, but had always been interested in the video game industry, specifically in combining his career in medicine with video games in some fashion.

With the formation of Guerilla Tea earlier in 2011, myself and three colleagues in the company, all graduates of Abertay University’s excellent MProf in Video Game Development course, were on the lookout for commercial projects. We share a common ambition in that we are interested in finding innovative methods for utilising the video game medium within other disciplines. The Ward Round project conformed to the proposed ethos of the company, and - of course - the eventual aims of both Guerilla Tea and Dr Raudaschl.

Upon the project receiving the green light, we were given a design brief detailing a quiz application which would serve as a medical study aid. It would present textual information on interesting, real life, medical cases, the idea being for the player to answer a series of questions on each case, effectively carrying out clinical deductions. The brief also required the integration of video game elements into the project, creating a fun and absorbing educational game while retaining a serious, professional, study application feel.

Extensive medical information was presented to Guerilla Tea with the brief being to utilise it as effectively as possible, in an interactive product. Due to the highly specialised nature of the project, and the fact that no member of Guerilla Tea has medical knowledge, regular and effective communication between ourselves as developers and the client, at all stages, was imperative. One of our main aims, as a small developer, is to function effectively through good verbal communication between team members – something which can (in my experience so far) be lost within larger companies. We were always aware that the need to work closely with each other and to communicate with our client at all times, through our producer Mark Hastings, was vital to the success or otherwise of this project.

Concept Design and Art Style

Early concept design for Ward Round involved identifying an over-riding theme and art style for the game. During this stage, I liaised closely with our artist, Matt Zanetti, working through a number of early iterations. The game was intended to be a loose representation of a virtual tour of the hospital wards, governed by specific textual information. The medical content was presented in the form of ‘cases’ containing detailed descriptions, along with questions and answers, taking the player through individual diagnostic processes.

The original concept involved a stylised hospital setting for the game, where the main menu consisted of a representation of a reception area. In this iteration, the game would effectively move through the various departments of the hospital as the player proceeded through the game. But game development naturally involves a degree of trial and error, over a number of iterations. Although this concept seemed to match our brief, we felt that it was ultimately going to become very art heavy and did not quite fit the slick feel we were trying to achieve, a reservation with which our client agreed. We therefore focused on a certain amount of simplification, formulating a style themed around basic (almost stereotypical) medical items such as pens, clipboards, and stethoscopes. This moved the app closer to our desired outcome, but further experimentation was clearly required.

We ultimately decided on a more minimalist style, which played heavily on a clear, medical blue colour, and would make use of transitions between screens, alternating between screens with greater blue areas, and greater white areas.

Ultimately it was agreed that this art heavy approach with its pseudo-realistic elements threatened to cheapen the overall experience by becoming kitsch or even worse still overshadowing the primary focus of the app, the vast question bank. In response to this we decided to strip everything back to a far more minimalist style focusing on bold colours reminiscent of medicine, strong graphic design elements and simple motion graphics animations. This helped to elevate the app to its intended age limit without becoming dry when being observed for long periods of time or through multiple visits.  

Gameflow

Working closely with our client, we divided Ward Round gameplay into three modes:

Specialities. The player has the opportunity to choose a speciality and play through all the scenarios in no particular order. This acts as a free play mode, providing access to the full content of the game. The lack of constraints presented in this mode allow it the greatest amount of versatility in terms of studying and it may be approached in either a linear or random fashion.

Practice Mode. Much medical learning involves memorising, but the challenge lies in applying that rote learning in any given situation. This is intended as a ‘mock test’ for the player, where he/she can test knowledge gained through five different scenarios picked from the main information bank. This mode essentially presents a challenge to the player.

Big Medical Quiz. This mode was designed to function in the same way as the Practice Mode in terms of gameplay, but is more representative of the ‘real thing’. Attempts are limited to one per twelve hour time period. This mode demands a certain level of confidence from the player, and utilises a risk/reward mechanism, whereby limited opportunities are given, but evidence of good performance (and practice) can be shared with others, worldwide, thereby giving it more significance.

The inclusion of a competitive element was important for this project for two reasons: one was that even with such a practical professional subject as medicine, an element of competition would provoke enjoyment (and consequently engagement) in the player. The other, arguably even more important, was that the examination system in the world of academia has a certain competitive edge. In developing Ward Round, we were always aware of the need to achieve an even balance between a valuable personal study aid and an enjoyable and stimulating experience.

Mentor Character

It is my belief that the video game medium still has a great deal of untapped potential in terms of story-telling, and indeed many mobile and casual games do not require any overt storyline in order to achieve success. However, this largely comes down to one’s definition of ‘story’. Many casual games have an engaging persona and absorbing environment, created through a vibrant art style.  It would also be true to say that video games of all kinds require the presence (and control) of one or more characters, with some objective which will encourage gameplay. The above could be regarded as going some way towards creating a story of sorts, even if it is largely in the mind of the gamer.

With Ward Round, I very much wanted the player, in essence, to play as him or herself, throughout the game. This is an app aimed at trainee doctors, and the player, already part of the medical profession, had to become totally absorbed in the sense of learning and achievement for themselves. With regard to design, there is a loose but interesting parallel to the RPG genre, where the player is given freedom to create his or her own persona. But since Ward Round is also indisputably a teaching aid, this inspired the decision to include a mentor character, who would be known simply as ‘The Professor’ - suggestion from Dr Raudaschl. 

This character was used to introduce the game to the player, appearing as part of a pop-up message tutorial. The character was also used on a general help screen accessed separately. To maintain a professional, serious application feel it was important not to over-use this mentor character. The idea of a non-player character guiding the user through the challenges had to remain subtle at all times. The Professor would appear with speech bubbles at distinct benchmark points within the gameplay, such as advancing in experience level, and for score submission forms, after completing playthroughs of Big Medical Quiz and Practice modes.

Experience and Levelling-Up

Player progress tracking and rewards could be considered a video gaming constant, used across many different genres and within contemporary gaming. This key game design element clearly had to be an important feature of Ward Round. The Experience system in Ward Round was inspired by the RPG genre, but somewhat simplified to facilitate quick learning, for the mobile platform. The experience summary screen would contain all progress information on a single non-interactive screen accessed from the main menu.

The experience system is composed of three elements:

Progress Bar. An empty bar which fills gradually as the player answers questions correctly, akin to vitality bars within action and combat games. This bar is designed as a general completion bar, tied in solely to individual questions answered correctly. This provides a graphical representation of progress covering the main content, holistically.

Ranking Titles.  Linked to the progress bar are rank titles. The player begins at the rank of ‘High School Student’, and progresses through various rankings, all the way to ‘Doctor Demi-God’. Rank names were introduced to provide a more engaging benchmark of progress. Decisions on the exact number of required correctly answered questions were made as a result of extensive playtesting during development.

Speciality Complete Medals. Medals are awarded for the individual specialist categories, once the player has answered all the questions within that speciality, correctly. This provides the player with a different form of achievement, in effect, rewarding a greater concentration of knowledge.

Like most academic disciplines, medicine can be studied in a number of ways, with individuals specialising in a single area or spreading their knowledge more evenly. To some degree – and while remaining aware of the need for a student to absorb a significant body of general medical knowledge - the Ward Round design encompasses this idea within the experience system while the mentor character is called upon to reveal these progression highlights such as Speciality Complete medals, as and when they occur.

Scoring System

An area of design in which mathematics played a large part was the scoring system applied to the Big Medical Quiz and Practice modes. I devised a specific formula to process gameplay information obtained during a playthrough of either of these modes. The actual details of the formula are beyond the scope of this article, but it had to take into account the number of questions answered correctly, along with the overall time taken during the play of the mode. An interesting aspect to this formula is that it actually rewards the player for answering all questions correctly, in any particular individual case. In other words, for a Big Medical Quiz playthrough, the player may answer, on average, 25 questions. If the player answers 5 questions correctly from a single case, this will score higher than answering 5 correct questions spread throughout the 25. Medical professionals do tend to specialise and will be stronger in certain areas than others. To a certain degree, this will have an impact on Big Medical Quiz performance. On balance, therefore, I felt that it was more important to reward full completion of a single case from initial diagnosis through to treatments, than for a player to answer random questions correctly during a playthrough, especially since random questions may be answered correctly solely through the element of chance. The actual values of each score, utilising gameplay data, are fairly low, so to conform to the convention of using high values for the scores within video games, multiplication constants were used to drive scores into the thousands.

Development Design – The Question Bank

Games do not need to be ‘perfect’ and never will be. Even the most high-end, AAA titles feature bugs, animation and gameplay problems. However, there are some imperfections which are ‘acceptable’ among players, and some which are not.  A significant challenge of game development lies in knowing (largely through testing) which imperfections can be waived, and which must certainly be fixed. This idea was particularly relevant during the development of Ward Round, as it was clear from the outset that the factual medical content needed to be absolutely accurate and it was indeed supplied and checked by professionals.

The extensive medical content was provided in spreadsheet form, which was then translated from this to the game. This was achieved via Guerilla Tea’s proprietary database software, which was used to save out a database file of the full question bank, for simple input into the game. The real challenge involved manually creating the database from the information contained in the spreadsheet files. Thanks to our programmer, Alex Zeitler, this approach allowed myself, as the designer, to check each item of information individually,  place it into the correct field of the database, and assign the solutions provided by the client to each question. In effect, my work could be completed and checked independently of the main game engineering and art. This is not to say that mistakes were not present after many hours of database building, but our testing phase was utilised to iron out any minor errors.

During the development process, many other minor development and design decisions arose for the team, including how the game would handle questions with multiple correct answers, and the methods for information display during the timed case questions. Because the questions for each medical case are inter-related, the idea of giving instant right/wrong feedback was rejected, since we believed that this would damage player motivation. The idea would be to let the player play the game, and allow him/her to review performance at the end of a case – thus facilitating the desired learning process. Another design element aimed at limiting player frustration was the ability for the player to review the case scenario descriptions as necessary.

Minor design tweaks contributed towards the final product to create an attractive, high level, professional educational application.

Conclusion

All in all, Ward Round has been a successful and enjoyable debut project for Guerilla Tea, and as the game has only recently been released worldwide as an iPhone app, its full potential is yet to be seen. Updates, and supplementary projects are currently in the works, and we have had a degree of interest from medical organisations and universities, especially from the US. We aim to continue to find innovative concepts and projects for future work, especially those where we can apply video game design methodology, and ideas of fun and absorption to other disciplines.

Charlie Czerkawski