Before starting Level Ex, Sam Glassenberg had made Star Wars games for LucasArts and Hollywood movies, headed up Microsoft's DirectX team, and picked up a technical Emmy.
By his own account, however, he was still "sort of the disgrace of the family, because I come from a long line of doctors... and I'm the first one who didn't go to medical school".
Level Ex, which makes medical simulation games for iOS and Android, essentially got its start by accident, Glassenberg told ZDNet.
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He started the business after his father -- one of the family's many doctors -- asked him "to put all this videogame nonsense to good use, and make me something to train my colleagues to do a fibre-optic intubation".
The technique, used to open up the airways of tricky patients, is a procedure that needs a deal of practice to perfect. Glassenberg built a simulation for iPad, uploaded it to the App Store, and forgot about it. Two years later, he checked in on his creation -- and found he'd made one of the most popular medical simulation tools then available.
Fast forward a couple of years, and Level Ex now has a suite of four training tools for different areas of medicine: cardiology, gastroenterology, respiratory, and airway management. Each has a number of levels that medics can play through, choosing their surgical tools and medications, and practising the techniques that they'll later use with their patients. Each level is played against a clock, with a set number of attempts possible, and with high scores awarded on completion. One in three US surgeons are signed up to the service.
The games are built with the input of both numerous medical professionals and games designers. Part of translating the medical experience into a game is really trying to understand what is the challenging portion of the case, and to interpret that into the game mechanics says Dr Eric Gantwerker, a paediatric ENT surgeon and Level Ex's medical director.
"If it's a really challenging decision about how to remove [a foreign body], there are ways we can create a puzzle game to try and recreate that," he says.
"The doctors don't really have the game side in their brain," he explains. The doctors and designers explore together what's the real challenge of the case -- whether that's position the doctor has to hold themselves in, the force or direction they use for a procedure, or how to manage unexpected bleeding while removing an object from a patient's airway at the same time. Once the doctors have nailed down the real challenge for the designers, then they can work out the right mechanics to translate the case into a game. "There's this, 'boom, OK, this is a puzzle mechanic, a real-time strategy game', and all these things pop into the game designer's head."
The company has 150 physician advisors, who help the company emulate the realities of medicine, as well as contributors who test the products and share their feedback. "Those are the advisors that we're working with across the specialities that we're in and specialities we're going into, giving us the information we need to build these games -- understanding what the challenges are, understanding what the skills are, understanding what's fun about their speciality and going into the cases -- [telling us] this should be squishier, this should swell more, this should be redder," Glassenberg said.
As well as offering an entertaining way to pass a few minutes between patients, Level Ex's games are useful professionally, too: doctors can get continuing medical education (CME) credit for playing certain levels, helping them fulfil the mandatory training requirements needed to renew their licences. Glassenberg cites efficacy studies by third parties that found playing that fibre-optic intubation simulator helped improve physician performance. The company is doing its own efficacy studies, though it's yet to release its data.
"We send cases out to individuals at CME providers to review the objectives and play through the levels, and then they decide if they're going to certify. We get almost everything certified, but we don't CME certify every case for several reasons. One is we really feel like CME there should be a challenge, those should be the 'boss' cases in video games -- those should be the CME cases where there should really be something difficult," Gantwerker said.
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Like a lot of other CME efforts, Level Ex's games are free for doctors that use them, and paid for by sponsorship from medical companies. For example, physicians can play levels using virtual instruments sponsored by the companies that make the real-life versions. The company does make some content using virtual and augmented reality, typically for clients that particularly want it, and for conferences, but currently remains focused on mobile due to the relatively rarity of VR tech in medical education. "Our model is mobile, accessible in your pocket at all time, and free. The second you have to have a physical device, it limits all of those things," Gantwerker said.
Currently, Level Ex's cases are aimed at senior doctors such as attending physicians, but the company has had requests for material aimed at more junior members of the team, including residents, fellows, and student doctors. Gantwerker said that content aimed at those earlier in their medical careers would need to be created as part of a curriculum, but the company is in discussions with medical institutions, societies, and hospitals around adapting their existing content, as well as creating new material.
Glassenberg also says Level Ex plans to add to its roster of medical disciplines in future and already has hundreds of cases for other specialities. The existing four apps are regularly updated with new cases submitted by doctors encountering interesting or rare cases in their practice. These can be like the case of a carpenter who accidentally inhaled one of the nails he was holding in his mouth. His airways are now recreated in the Airway Ex game, teaching doctors to approach the foreign body from an unusual angle to grasp and remove it.
"We start with real cases, this is how doctors learn… now when you encounter a difficult or interesting case, you can submit it to a journal or conference, or you can submit it to us and, within weeks, hundreds of thousands of your colleagues can be playing it and competing to get the best outcomes," Glassenberg said.