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thebmj.com Should doctors ЖЖNews: Digital offer new ways to tackle mental problems be prescribing (BMJ 2012;345:e5163) games to patients? ЖЖNews: US heart association endorses active video games (BMJ 2010; 340:c2802) In 2013, NHS Choices launched its health apps library—essentially a list VIDEO GAMES ON of health related smartphone and tablet apps that have been reviewed by clinicians to ensure they are clinically safe (http://apps.nhs.uk ). PRESCRIPTION For Charles Lowe, director of the Digital Health and Care Alliance, Computer games are being designed as healthcare tools because of part of the government’s delivering assisted lifestyles at scale programme, their power to engage, motivate, and inspire. Stephen Armstrong this doesn’t go far enough. Lowe is lobbying for NICE to assess the safety considers the potential and the dangers of using games to inform and effectiveness of medical apps and or treat patients and, overleaf, looks at games for doctors

s this the future of ? Little positive things—using puzzles that they have Artie has been left at the doorstep of his focus on—and ignore threats. They learn by grandma’s house—a spooky mansion practice over and over.” filled with shadows. His grandma has MindLight is at the leading edge of the so been taken, and only he can save her. called gamification of healthcare—Silicon IAs he moves through corridors and darkened Valley’s attempt to join the medical profession. rooms, terrifying shapes loom above him. His The theory of gamification—using game only friend is Teru the Magical Hat, who shines mechanics to help people solve real world more brightly the calmer Artie becomes. If Artie problems—is gaining credence as a motivation MindLight teaches techniques to relax patients panics, however, Teru dims and the darkness tool for everything from to grows. wear an electroencephalogram monitoring terror groups such as Hamas. The potential is This is MindLight, a haunted house computer headset and as brain activity slows, the player’s obvious: in 2011, people spent roughly three game aimed at teaching relaxation techniques light shines brighter. Granic hopes the game billion hours a week gaming, and the number to anxious children. Currently undergoing trials will train anxious children to conquer their of hours that gamers worldwide have spent with Dutch primary school children, it’s the fears. playing the online sword and sorcery game result of a collaboration between Isabela Granic “We know when people are anxious that World of Warcraft since its launch in 2004 adds and Rutger Engels, professors at Radboud they’re very absorbed by threats and they can’t up to over six million years.1 The possibility of psychopathology department, and focus on their own goals,” she explains. “So you using this immense amount of engaged time in Dutch computer games studio Gain Play. Kids train the cognitive control system to focus on a productive way has been exciting academics researching so called serious gaming for almost two decades. There are already more than 300 health related games available as well as some 13 000 apps professing to give medical advice, according to the NHS Commissioning Board.2 There are games designed to help cancer patients stick with drug therapy, games aimed at allowing patients to receive physiotherapy at home, and games that claim to treat Alzheimer’s. Yet this is a market in its infancy and as yet not formally regulated. “We think healthcare games are currently at between 5% and 15% of their total potential market,” says Brian Burke, research vice president at leading US tech consultancy Gartner. “These games are still strongest in the US, although there’s a strong presence in the UK, Holland, Spain, and India.” So far, although some evidence suggests games could be hugely useful in certain areas of healthcare, few scientific studies have been flagship game Re-Mission for young cancer patients has delivered impressive results published. So should patients be using them?

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arrival of new technology but it’s only just coming them with confidence. And there is a growing to terms with the arrival of email.”7 need to distinguish between healthcare games Some GPs are already experimenting with for keeping people well and healthcare games the use of gaming tricks to help change patient for serious medical conditions. Debate is behaviour. In 2013, a group of west Oxfordshire ongoing in the US over the need to regulate GPs, led by David Brodie, Emma Doyle, Jey mobile medical apps for serious conditions. 9 Radhakrishnan, and David Shaw, offered obese “There are standards for patient safety and IT, patients access to information from diet to and rules for software suppliers to the NHS,” she exercise based around an anonymous online explains, “but something like Fitbit [a game (left) league table where patients reported weight to encourage fitness] or an obesity game falls games to give general practitioners a list of changes. 8 One of the most striking outcomes, between all of these stools. The whole process options to prescribe to patients. the GPs found, was that almost 90% of the male of regulation needs to be overhauled. Double “Right now, serious games aren’t generally patients lost weight—with men typically the most blind randomly controlled trials very well used by GPs,” explains Maureen Baker, chair reluctant to join a weight loss programme. for drugs but they’re seen by many as the gold of council at the Royal College of General Although there are games and apps with standard for any aspect of clinical care, and Practitioners. “We have a health informatics similar possibilities, Baker suggests the UK’s many of these wellbeing boosting games and working group that’s aimed at addressing the regulatory system makes it difficult for GPs to use apps simply don’t require that level of scrutiny.”

Huge potential “We found that playing Re-Mission need some serious and expensive academic For advocates like Olivier Oullier, professor led to more consistent treatment research to understand the eff ects of these of behavioural and brain sciences at Aix- adherence, faster rate of increase interventions.” Marseille University and adviser to the World in cancer knowledge, and faster Without an evidence base, the idea that Economic Forum on neuroscience and games could help people manage their behaviour, the benefi ts are clear. “When kids rate of increase in self efficacy in illness—or even treat it—is facing some don’t concentrate in school we tend to rely on young cancer patients,” resistance. Controversy abounds over a possible pharmacology,” he argues. “But pills are not relation between video game addiction and the only solution—cognitive brain therapy is a positive impact on health behavior in young attention defi cit hyperactivity disorder, and as eff ective. The games industry is as big as people with chronic illness.” there is general concern that computer games the pharma industry and it can develop new Its follow-up, Re-Mission 2 Nanobots encourage a sedentary lifestyle and bad eating games in months rather than the years it takes Revenge, launched last year, is based on Cat habits. Early healthcare games pioneer Willem- to develop new drugs. Developing new ways God vs Sun King, a non-healthcare game Jan Renger, head of applied game at the for kids to learn through gamifi cation has to be in which players rain fi reballs on the Sun University of Arts in the Netherlands, points better for society than another prescription for King’s attempts to build a tower. Nanobot, to an early game designed to help diabetic Ritalin.” conversely, sees players raining drugs down on children understand their condition. Certainly the industry fl agship games a mass of cancer cells as they grow towards a “The game had a diabetic avatar whose Re-Mission and Re-Mission 2, both from patient’s blood stream. The graphics are more blood sugar you had to control,” Renger HopeLabs in California, have delivered sophisticated than in the fi rst Re-Mission, explains. “Kids were great at keeping their impressive results. The game, launched in but the key diff erence is in . avatar healthy. What we found, though, was 2006 with the Teen Cancer Trust, pits players Re-Mission came on a DVD and shipped to that while playing the game they were sitting against cancer cells in the blood, fi ring drugs 250 000 patients worldwide. Re-Mission 2 is on their sofa eating chocolate—which did their at the mutating cells to keep them in check. downloadable as an app. own diabetes no good at all.” “The biggest problem in adolescent and teen Some fear drug companies might use cancer patients is getting them to stick to their Lack of evidence games to manipulate patients into buying chemo treatment,” explains HopeLabs head There is, so far, no available research on the their products. There are also concerns over of communications and , Richard effi cacy of the new version. Indeed, this could healthcare games and data following Tate. “The drugs make them feel awful and look be said for the entire healthcare games industry. awful.” “Healthcare games have been around for Aft er the game’s release, HopeLabs tested a long time, but they’re still in their infancy, its effi cacy on 375 patients with cancer aged which is unusual in technology,” says 13-29 at in the US, Canada, and Christos Gatzidis, who works in the creative Australia. Patients received either an off the technology department at Bournemouth shelf computer game or the same game plus University devising therapeutic uses for Re-Mission. The results were published in game techniques such as “fi rst person Pediatrics in August 2008.3 “We found that shoot-’em-ups”—games where the player playing Re-Mission led to more consistent is inside a character’s head and shares treatment adherence, faster rate of increase in their point of view. “I think the pervasive cancer knowledge, and faster rate of increase presence of smartphones and tablets is in self effi cacy in young cancer patients,” Tate going to change that. What’s lacking is a says. “A carefully designed video game can have proper evidence base for the outcomes—we NEIL WEBB NEIL the bmj | 20 September 2014 15 HEALTHDRUGS FOR AND NEGLECTED TECHNOLOGY DISEASES

recent attacks on sites like iCloud.4 And with controversy over computer guided disability checks for welfare claimants in GAMES FOR DOCTORS the UK still rumbling,5 there is reluctance to allow games—and technology in general—to Stephen Armstrong looks at how the computer games industry is replace face to face contact between patients turning its attention to helping doctors improve their performance and doctors. The Wellcome Trust is already supporting ow would you feel if you were fac- scored 26% better overall than surgeons who several game based therapy projects with ing an invasive operation and, on never played video games,” Rosser told The BMJ . the aim to gather some scientifi c evidence. the way to the theatre, you passed “I can see a day when we have a video games con- It has given a £1.3m translation award to your surgeon playing Super Mon- sole in the corner of every operating theatre.” King’s College London Institute of Psychiatry key Ball on a Nintendo games con- In one sense, of course, elements of what’s to follow up on a small project that allowed Hsole? According to James Rosser, general surgeon now called gaming have been used by surgeons patients with schizophrenia to create avatars at Florida Celebration Health in Kissim- for thousands of years—ancient Babylonians for the voices in their heads and eff ectively mee, you should be delighted. used clay models of organs to teach doctors and battle them. In a pilot study with six patients, In September 2012, Rosser asked half of the priests. But video games add extra dimensions almost all reported a reduction in the surgeons at the hospital to play computer games, such as levels, point scoring, and rewards to frequency and severity of the voices.6 Three including Super Monkey Ball, for six minutes increase motivation. Multiple meta-analyses have patients stopped hearing voices completely before performing simulated laparoscopic sur- suggested that, in the right circumstances, games aft er experiencing them for 16, 13, and 3.5 gery; the remaining 150 surgeons did the surgery can be more eff ective than traditional methods of years, respectively. without playing games. teaching in areas as diverse as military skills to The Trust’s Centre for Neuroimaging Surgeons who had done the computer game understanding ecosystems.3 4 at UCL has been running the Great Brain warm-up completed 10 simple manipula- From this comes the idea of serious games— Experiment based on a freely available game tion trials using surgical graspers in 649 sec- essentially computer games with a purpose, app that investigates memory, impulsivity, onds compared with 712 seconds in the control usually to train or teach. “The use of games tech- risk taking, and happiness in a bid to group—a statistically valid time difference. 1 nology is now becoming recognised as a key tool understand if mobile games can be reliable The number of errors in suturing tests was also to drive down costs and increase effi ciency across tools for conducting psychology experiments. fewer—133 errors versus 192.1 A similar study the medical sector,” according to Tim Luft , opera- More than 60 000 people have taken part at the University of Rome produced comparable tions director for Coventry University’s Serious so far, and the study’s fi rst results were results, concluding that video gaming enhances Games Institute. published in July—successfully reproducing spatial attention and eye-hand coordination.2 The big boost in spending to develop these well known fi ndings from laboratory studies “The surgeons who had played video games games has come from the US. “Gamification and demonstrating, says Iain Dodgeon, made 37% fewer errors, were 27% faster, and is moving into healthcare in the US, largely creative partners manager at the Wellcome Serious games add story, as a result of the Aff ordable Care Act,” argues Trust, “that mobile games can be used to challenges, missions, and time Phaedra Boinodiris, head of IBM’s gamifi cation reliably conduct research in psychology and pressure to traditional simulator and s erious games programmes. The act has neuroscience. We can now investigate how models, making training on made remuneration more dependent on patient factors such as age and aff ect outcomes than number of procedures, so it’s cognitive functions.” routine procedures more attractive boosting US money So far, HopeLabs and Wellcome are the only major backers of healthcare games research to publish in reputable journals. In some cases, game designers are experimenting with apps and games designed to aff ect the player’s brain without any academic work supporting their intervention. The benefi ts of gamifi cation might be immense, if HopeLabs and Wellcome’s research is replicated. Unless well conducted studies are forthcoming, however, the risk is of a new market in Clockwise from unlicensed digital supplements installed top left: Nintendo’s on the two billion smartphones already in Super Monkey Ball; circulation. It’s in everyone’s interests that Human Sim, for Artie gets out of the mansion safely. first responders at terrorist attacks; Competing interests: None declared. Air Medic Sky 1, for Provenance and peer review: Commissioned; not emergency trainees externally peer reviewed. References are in the version on thebmj.com

Cite this as: BMJ 2014;349:g5615

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“When I was a pilot, I was evaluated every year on a flight simulator to check I was still good to fly. I don’t see why that shouldn’t be compulsory for surgeons as well.”

ing hospital that travels the world, allowing play- ers 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 imag- ined,” says Cor J Kalkman, professor of anaesthe- siology 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 indi- cated where we should go with the next update.” NEIL WEBB NEIL Ahmed suspects slow uptake is the result of into preventative medicine, she says. “Gamifica- and HS Critical Decisions tests nurses on deci- resistance from doctors suspicious of gaming. tion is a good motivating tool. The next big expan- sions for patients at risk of pressure ulcers. Serious games publishers fear costs may be too sion we see on the way is in serious games for Heneghan believes the games could be used high to enter a market that’s too small. He pre- healthcare professionals.” for assessment as well as training. “When I was dicts this resistance will diminish as pressure on In surgery, perhaps the most obvious spe- an Apache pilot, I was evaluated every year on a budgets increases. cialty where games can be useful, simulators flight simulator to check I was still good to fly,” Developers of serious games are persisting, have been around in various forms since the he points out. “I don’t see why that shouldn’t be and their ambitions extend way beyond surgery. 1980s. But it was not until 2009, when neuro- compulsory for surgeons as well.” Bournemouth University’s Dementia Institute surgeon David Clarke at the Queen Elizabeth II But Shafi Ahmed, consultant general laparo- is developing a game to train student nurses to Health Sciences Centre in Halifax used a simula- scopic and colorectal surgeon at Barts and The deal with patients with Alzheimer’s disease, tor to dummy run the removal of a brain tumour London NHS Trust, is cautious. Ahmed is no lud- which would allow high risk scenarios to be before successfully carrying out the operation, dite—in May he became the first British surgeon played out in safety. that simulators really took off. Serious games to broadcast a live surgical procedure online Gaming techniques are also poised to enter add story, challenges, missions, and time pres- using Google glasses. However, although he diagnosis. US start-up CogCubed is developing sure to traditional simulator models, making agrees that the games are good at teaching deci- a game aimed at diagnosing a range of disor- training on routine procedures more attractive sion making, he argues that “they won’t make ders, including attention deficit hyperactivity as well as being able to model situations that are you a good surgeon, and they can’t measure the disorder, autism, anxiety, depression, traumatic hard to replicate in the real world. quality of your surgery. There’s an enormous brain injury, and even Alzheimer’s disease. The Human Sim, a spin-off of US based gaming amount of intuition and fingertip feedback that game—Groundskeeper—is a variant of the end company Virtual Heroes, for instance, offers Zero these games can’t reproduce.” of the pier classic Whac-A-Mole, using a series of Hour for desktop computers. The game is aimed The advantage computer game simulators small cubic screens that the patient moves with at training emergency first responders to deal with have, he believes is cost. Higher end surgical his or her hands. One screen holds a digitised incidents such as earthquakes or terrorist attacks. simulators cost at least £100 000 (€125 000; hammer while three others show a grass covered Set in the fictional city of St Lillo, the player begins $160 000) but games are considerably cheaper— field from which moles pop up, with the added each mission in an ambulance approaching the the SimPraxis Nissen iPad interactive, profes- distraction of a boy pushing a lawn mower across scene of the disaster and has to choose equipment sional level, surgical simulation trainer costs at random times. The cube edges hold sensors and deal with the situation against a ticking clock. just £20.99, for example. They can also be used that record 70 variables related to movement, Jerry Heneghan, director of product develop- to help patients understand forthcoming proce- reaction, and response patterns—designed to ment for Human Sim, served as an Apache heli- dures, which can help quell anxiety. measure a patient’s attention span and distracta- copter pilot in the US Army before launching this bility. Pfizer is developing a similar game, Project medical equivalent of flight simulators. The com- Slow uptake EVO, with game company Akili Interactive Labs. pany worked with Duke Medical Centre to build Human Sim’s in the UK penetration is low Stephen Armstrong journalist, London, UK software that mimics the responses of the human and rivals are also struggling. Coventry University [email protected] body, a so called physiology engine. The com- professor Pam Kato helped develop the game Air Competing interests: None declared. pany now sells situation games to the military Medic Sky 1 (AMS1) with Visionshift Studios and Provenance and peer review: Commissioned; not externally and the . HS Anesthesia, for the University Medical Center, Utrecht. The game peer reviewed. example, contains a range of critical situations is aimed at young doctors preparing to work in References are in the version on thebmj.com and reflects patient responses to various drugs, emergency departments. AMS1 is a fictional fly- Cite this as: BMJ 2014;349:g5642

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