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As video games continue improving how medicine is learned and practiced, radiology is poised to lead the way across specialties.

She moves the control to the right and the image on screen sharpens, the person’s chest coming into focus.

Another button and the target flips upside down, revealing a small mass glowing bright in the left corner.

Is she a video gamer, uncovering the hidden gems?

Or is she a radiologist, flipping and manipulating a patient’s chest scan to get a better look at a more sinister enemy?

Gaming and radiology—two fields that might seem as different as a CT of the small bowel from an MRI of the prefrontal cortex or as Halo from Animal Crossing—but at a closer look share inherent skills and characteristics. The job of a video gamer is, after all, to play in worlds that exist virtually, while radiologists train for years to interpret and diagnose disease on digital scans.

Now both radiology and gaming experts say that the very foundational similarities that these two groups share may unite them together to change the way medicine is learned and practiced.

“Radiology is ripe for video games,” says Dr. Vikram Sobti, a radiologist and medical entrepreneur in Chicago, IL. “Essentially I sit at a computer, in front of a big video game, and do pattern recognition all day.” 

Evidence from other medical specialties supports this assertion. In the past year alone, half a dozen games have been released or updated dedicated not to topics like destruction and battle royale, but to areas like deductive reasoning diagnosis and bronchoscopies—games for physicians and healthcare professionals to improve their fund of knowledge and procedural skills.

A game created specifically for cardiology, for example, has been helping interventional cardiologists practice complex stenting and angioplasty—scenarios that they would have previously needed to practice in clunky simulators or on actual patients. Today Cardio Ex carries a near 5-star rating on the App Store with reviews that tout it as “astounding” and is the winner of Siggraph’s Real-Time Live! award, the visual effects industry’s largest annual real time graphics competition, for the way the Level Ex engineering team tricked the graphics hardware on the phone to accurately simulate X-ray fluoroscopy and ultrasound, instead of its usual job of drawing video game characters lit by visible light. 

“Now that radiologists are being asked to do more, read faster, and not miss as much, the only way to do that is to make learning fun,” says Dr. Sobti. “Games can help make the pattern recognition you do every day something you’re interested in, so if you see normal so well and so often, abnormal jumps out at you.”

Sam Dreyer, a biomedical engineer and product manager at Level Ex, which in addition to Cardio Ex makes games for dermatologists, anesthesiologists, gastroenterologists, and pulmonologists, says that it has 750,000 medical professionals playing its games—all of them designed by the best developers in the game industry, many of whom have now dedicated their work to pushing the boundaries in creating the most lifelike human soft tissue and simulations of advanced procedures.

“Many of our games use time-based or simulation mechanics, meaning we apply a time limit to decision-making, which is proven to help the brain learn and recall,” Dreyer says. “For radiologists, who are trained to make some of the most high-stakes calls based primarily on an image they see on a screen, learning this way is second nature to them. We believe radiology as a speciality is in a unique position to be some of the first movers and adopters and advance the way medical training happens in the future.”

Research has proven that video games positively impact learning and, specifically in medicine, can enhance confidence in patient care.

Another potential use of video games for radiology: to bring together remote and in-person “players” from all over the globe—say, for example, to learn or practice a procedure at the largest medical event in the world in which a pandemic prevents attendees from being together like they once were. At RSNA, even for the nearly 20,000 radiologists on site in Chicago, a game can be a more effective means to foster community and discussion on new research and technology among such a large group. 

This approach has already been piloted by med tech companies like Brainlab, which used the mechanics and artistry behind video games to create a virtual simulation of its radiotherapy technology. The sophisticated infrastructure and interfaces employed in the delivery of highly integrated radiotherapy can make it difficult to educate users using only standard slide decks and 2D animations.

“Remote Play™  technology then allows us to stream that experience online with multiple users,” says Patrick Murphy, Director, Oncology Portfolio from Brainlab, referring to how multiple medical professionals can practice a procedure or learn together, in real-time, in the same experience.

“What’s cool about the platform is that it’s remote and interactive. Whether you’re on Microsoft Teams or Zoom, you simply send a link, and the clinician enters the shared experience from any device. They say things like, ‘Wow, that’s easy to use and you get a good sense of the clinical benefit. No one else is doing this. I can really see what’s going on now.’”

When asked whether their peers would adopt such platforms, radiology leaders wholeheartedly agree.

“Radiology is a medical specialty residing entirely in the visual space. Innovative technology is the hallmark of medical imaging. As such, radiologists are open to new ways of learning through evolving advances in cutting-edge technology and transformative tools which enhance our ability to provide outstanding patient care,” says Dr. Suzie Bash, Medical Director of Neuroradiology at San Fernando Valley Interventional Radiology & Imaging at RadNet.

So the person manipulating the image on screen, twisting and turning it for sharper focus—is she a video gamer or a radiologist? Maybe she’s both.

The Radiology Society of North America (RSNA) Annual Meeting is where new ideas and technologies that redefine what it means to work as a radiologist will come to life. Glance at the RSNA 2021 agenda, and one thing is clear: change is at hand that will do just that.

The industry is ripe for innovations that make a radiologist’s job more manageable¹ and improve patient care. At least 45% of radiologists are experiencing burnout² due to factors like context switching between different imaging modalities, increased exams using advanced modalities, and the sheer volume of work.³ Artificial intelligence (AI) is one solution that radiologists and vendors are further exploring; it permeates RSNA’s “hot topics” session category, compounded with an AI showcase and 180 exhibitors on AI and machine learning.⁴ Also evident is increased interest in cloud computing and teleradiology, which skyrocketed during the pandemic.⁵

With continuous medical device developments in radiology and work tasks that rely on cutting-edge technologies,⁶ how can radiologists and radiologic technologists keep up with the learning demand? Current trends in radiology point to cloud-based training as an effective tool for convenient continuing education for rapidly emerging radiology technologies and for driving standardized care.

As a product manager at Level Ex, I’ve been working with my teammates for years on how to highlight the critical information a physician needs to know and translating it into a compelling experience. Medical professionals today need to rapidly sift through which new technologies are truly innovative and which are less impactful. To redefine someone’s work, you need to tell a captivating, memorable, convincing story. How? Applied game design and video game technology.

Simulated Radiology Workflows & Devices in the Cloud

Level Ex has developed a medical device and surgical training platform that allows medical professionals to learn on the cloud: Virtual Technique Guides powered by Remote Play™ . This platform uses game-based technology that enables many users to perform the same procedure together in the same digital environment, similar to the seamless interaction you can experience in a multiplayer game. 

Guiding the user through the workflow in an immersive sequence, designed to be both pleasurable and educational, helps medical professionals to internalize learning objectives. Given the specific sequence of workflow processes required in radiology, this learning platform is an ideal fit. Additionally, radiology can be therapeutically agnostic, requiring continuing education across medical specialties.

Video game technology also allows for high-fidelity graphics, critical in a specialty like radiology that is based on imaging. These images can both reflect and defy reality, rendering learning environments that push the limits of what medical professionals can learn. Below are some examples of radiology-adjacent imaging technologies that the Level Ex team has digitally recreated.

Three Examples of Surgical Training Visualizations Beyond Visible Light

• X-ray & Fluoroscopy

Cardio Ex, our cardiology-focused mobile game, simulates fluoroscopy—both reimagined fluoroscopy for captivating gameplay and lifelike for CME-eligible levels. This serves as the striking backdrop as interventional cardiologists try their hand at challenging stenting and angioplasty scenarios. Examples above also include digitized X-ray for breast cancer treatment and radiation therapy* (ExacTrac Dynamic by Brainlab) and spinal surgery (Loop-X by Brainlab). 

Loop-X is the first fully robotic, intraoperative imaging device on the market. At the North American Spine Society 2021 Annual Meeting, Brainlab had the physical robot in the booth, but they couldn’t showcase the full value of its non-isocentric imaging capabilities—also because you can’t irradiate physicians on a showroom floor. Instead, Brainlab was able to take attendees over to the Loop-X experience that we had put on a large screen for people to interact with. This allowed them to show attendees the specific X-ray capabilities that they had no other way of displaying or speaking to as concisely and as crisply without Level Ex’s demo. As said by Sean Clark, President, Brainlab Inc., Level Ex delivered “the visualization and immersion necessary for our customers to quickly recognize the benefits of cutting-edge technologies like Loop-X. This digital experience transcends ordinary sales and education tools, leading customers through an integrated surgical workflow with Loop-X. Subsequent customer conversations about our technologies are more meaningful after they’ve interacted with one of our Virtual Technique Guides.”

• Ultrasound

Medical device companies can also recreate intravascular ultrasound. Above are game levels that focus on educating physicians on intravascular ultrasound (IVUS), Instant Wave-Free Ratio (iFR), plaque morphology, and related medical devices for treating coronary blockages. Recognizing the power of IVUS to improve patient care and treatment plans, the client “sought out Level Ex to help accelerate its education and adoption among peripheral physicians” and interventional cardiologists. Because the IVUS images were generated by Level Ex designers, engineers, and artists, we were able to create hyper-realistic ultrasound images that showed the exact pathologies that our medical device client identified as most important for physicians to learn.

• Mind-blowing Anatomical & Cross-sectional Views

The idea of depicting more than what the eye can see extends to visualizing scenarios that can’t be experienced in real life but help expedite the learning process. A simulation allows you to physically see a radiation beam and safely show how it impacts the human body. You can also see the inside of the body, which you can’t do with videos of procedures or other traditional forms of media. 

The impossible views of the heart, shown above, were used to communicate the changes of both systolic and diastolic heart failure, as well as readouts for various cardiac markers and how they change with the progression of heart failure. This experience was created to support the newest set of American College of Cardiology (ACC) Heart Failure treatment guidelines. Like many of us, physicians have different levels of familiarity with heart failure; that experience shows how cardiac markers can change to indicate disease progression, which is something that is often missed, and is called out in said guidelines. The anatomical views helped physicians to see the potential impact that following the most updated treatment guidelines can help achieve. Cardiologists who playtested the experience also found these memorable visualizations to be useful in explaining heart failure to patients.

Med Device Storytelling Through Virtual Technique Guides 

With game technology and design, we are not constrained by anything—not even realistic physics. We can create nuanced and curated stories because we’re not bound to real patient case stories, anonymized medical reports, or other traditional forms of telling a brand’s story. 

Living and breathing medical device simulation, I’ve recently been reflecting on this personal anecdote and analogy. I was talking to my dad the other day who has been reading a lot of historical fiction. He recapped a recent read and asked, “Who even knows if that’s a true story or not?” After all, this author is writing historical fiction, and he’s not a historian. My response was, “Sometimes historical fiction can, in a sense, be more true than an actual single account that a person has because you’re not constrained by their reality. You can weave multiple stories together to paint a more accurate picture.”

In a similar way, video games are a powerful storytelling medium. We have the ability to tell specific, intricate medical stories, scenarios, and workflows to emphasize a myriad of underlying learning objectives with our end user or our player. We’re recreating their journey and all the things that they see along the way. It’s a fuller picture because it’s a synthesis of the experience. Some topics are difficult to conceptualize through traditional means, but we are able to easily bring learners up to speed because we have the ability to show them anything. 

Radiologists often scrutinize imaging, discerning the complex and obscure. Redefining roles and workflows in a field like radiology is equally as daunting, but it doesn’t have to be. Game-based storytelling makes that process enjoyable and brings the advantages of new innovations into clear view. 

Deliver your radiology medical device training with advanced video game technology and design. Contact us today to learn more or meet with us during RSNA 21 .  

Author Bio

Sam Dreyer is a Product Manager at Level Ex. Previously at Level Ex, he worked as a Biomedical Solutions Specialist, collaborating with clients to tell their story in the most engrossing way to achieve their learning objectives while also maintaining medical accuracy. Sam holds an MS in Bioengineering and has a background as a consultant in medical device development for some of the largest medical device and pharmaceutical companies.

*Works in progress.

References

1.  Radiology Trends and Takeaways: Innovations in the Wake of a Pandemic
2.  Radiology Trends and Takeaways: Innovations in the Wake of a Pandemic
3.  Nine Trends Changing X-ray and the Future of Radiology; Radiology Trends and Takeaways: Innovations in the Wake of a Pandemic
4. RSNA Sessions; RSNA AI Showcase; RSNA Exhibitor Categories
5. Radiology Trends and Takeaways: Innovations in the Wake of a Pandemic; GE Healthcare Brings Radiology Without Walls to Resource-Constrained Small Imaging Centers With AI-Enabled, Cloud Imaging Solution; How 3D Technology Is Transforming Medical Imaging; RSNA Sessions; RSNA Exhibitor Categories; The Evolution of Radiology Services
6. The future role of radiology in healthcare; Emerging Trends Shaping the Future of Radiology; RSNA International Trends: A Global Perspective on the COVID-19 Pandemic and Radiology in Late 2020

When you can’t bring physicians on site to train on a complex medical device, what are the alternatives? We sat down with Patrick Murphy, Director, Oncology Portfolio from Brainlab, to learn how Level Ex addressed this issue and other challenges with cutting-edge video game technologies.

What business challenges did Level Ex solve for Brainlab? 

Level Ex has helped us to address a number of challenges. First, the best way to get clinicians to understand our advanced radiation therapy technologies like ExacTrac Dynamic with our upcoming new technique for Deep Inspiration Breath Hold (DIBH)* is through an on-site visit. Installation of ExacTrac Dynamic is not feasible outside of the clinical environment because of the infrastructure and interfaces required of the highly integrated radiotherapy device itself, so demonstrations at trade shows or hospitals are limited to videos and software screenshots. However, hands-on experience is the best way for our customers to fully understand the benefits of the system. Additionally, from a sales standpoint, it can be challenging to educate customers using only standard sales enablement tools like passive slide decks and 2D animations. Our customers have very busy clinical schedules and limited time so it can be difficult to get them to engage.

What were your goals for this project?

One goal was to have Level Ex replicate a site visit experience without the time and resources required to take customers to a hospital, to our Chicago training center or to our global headquarters in Munich, Germany. The COVID-19 pandemic meant that most site visits were no longer feasible, so the Level Ex solution proved to be even more valuable because it’s globally accessible and virtual. 

We launched our new experience at the American Society for Radiation Oncology (ASTRO) annual meeting, showcasing how ExacTrac Dynamic is used with our new Deep Inspiration Breath Hold technique. 

Excerpt from the Brainlab ExacTrac Dynamic Deep Inspiration Breath Hold Virtual Technique Guide

Why did you choose to work with Level Ex?

Level Ex was the ideal partner to help us create a medical device simulation because of its history creating engaging experiences for physicians. As the President and CEO of Brainlab, Stefan Vilsmeier, said, “We began working with Level Ex in 2019 for several reasons. They are the best at disseminating best practices through video games, and they are unrivaled in their level of ergonomic user interaction, gaming-industry-quality 3D graphics, precise physics models, and game mechanics psychology.” We knew that Level Ex would be able to immerse Brainlab customers in an experience that would engage them in ways that are different from typical animations while educating them on ExacTrac Dynamic, all without the need to travel to another facility. We also wanted something that people would enjoy using as opposed to a dull animation or cliche VR experience that lacks meaningful interaction.

What Level Ex solutions were selected to address your challenges?

As far as Level Ex products, we are primarily using Virtual Technique Guides (VTG) delivered on Remote Play™ . The VTG allows users to engage, step-by-step, with a virtual version of our ExacTrac Dynamic system. Remote Play™  allows us to stream that experience online with multiple users. What’s cool about the VTG platform is that it’s remote and interactive. Whether you’re on Microsoft Teams or Zoom, you simply send a link, and the clinician enters the shared experience from any device. Our customers can use a digitized ExacTrac Dynamic system while the sales reps participate in tandem, coaching them on the benefits of the product, as if they were on a virtual site visit: “Okay, see how you started the patient treatment. Or now the system is monitoring patient position using thermal imaging.” They’re able to talk through the experience together. You don’t sacrifice any quality even though it’s streaming online. VTGs are hyper-realistic, with high-end graphics and realistic anatomy, and there’s definitely a “wow factor” that takes the interaction beyond something like watching a video or reading a PDF and makes it memorable.

Why were those solutions chosen?

One of the best reasons to use the Level Ex solutions is that they not only work as educational tools, but they stand out. Customers are used to getting the same types of sales presentations from every vendor—and here, we send them a link and they’re dropped into an experience, through which they clearly grasp the benefits of the medical device. They say things like, “Wow, that’s easy to use and you get a good sense of the clinical benefit. No one else is doing this. I can really see what’s going on now.” They remember the experience because it’s so unique. They also remember the details of the experience: it digitizes the workflow in a way that makes it easier to internalize information. It’s like you’re actually using the ExacTrac Dynamic system. It’s impossible to not deepen your understanding after you use a Level Ex VTG. 

How did healthcare professionals (HCPs) respond? How did it resonate? 

On the customer side, we’ve seen a lot of success. Healthcare professionals have found it impressive, clear, realistic, and informative. One radiation oncology administrator told me, “I haven’t seen a platform like this that makes you feel like you are controlling the system. It allows you to see the superior benefit of the technology, especially now when you can’t go on site. This is possibly the best training aid and product demo I’ve ever seen. No one has taken a demo to this level to help me understand their technology.” A radiation oncologist shared that he saw the potential to present different clinical scenarios and appreciated the interactive nature of the ExacTrac Dynamic VTG: “The demo gives me a higher degree of confidence in patient safety with the level of detail provided by the software. The real-time animation shows the steps and allows you to play around with the real settings and tools to simulate a true patient workflow.”

How have you integrated VTGs into your sales process, and what has been the return on investment? 

For Brainlab, VTG and Remote Play™  have been a huge help. We’ve linked this experience to a large number of completed deals. In just 6 months, VTGs have become completely integrated into our sales process. We’ve included it in nearly 100 unique customer presentations, which, for capital equipment like this, is significant. The adoption by our sales teams has been dramatic—sales always wants to utilize VTGs because healthcare professionals understand the concepts immediately. Also, the relative ease of use for sales to include VTGs in their process is compelling (they use it independently without needing extra guidance). Then, as I mentioned, we use VTGs for medical device training post sales, providing ample and valuable utility. 

How else do you utilize the Exactrac Dynamic VTG? In what scenarios?

We use it for shorter sales demos as well as for longer, more thorough device training. It’s very versatile. Outside of the remote training, we can take that experience offline to allow people in our conference and trade show booths to try out ExacTrac Dynamic. 

How do you use it at trade show booths specifically?

The goal with our DIBH demo that we debuted at ASTRO is to have someone come to the booth, understand the advantages of using ExacTrac Dynamic for DIBH, and then leave the booth with a complete understanding of our unique workflow; for example, with this VTG they can appreciate the value of X-ray imaging to see internal anatomy while the patient is at the breath-hold level. The ExacTrac Dynamic DIBH booth experience provides the same graphic fidelity and accuracy that I mentioned before, but it uses video game mechanics for added excitement and memorability.

Healthcare professionals using the DIBH ExacTrac Dynamic experience at ASTRO

How do you see others in the medical device industry taking advantage of a product like Virtual Technique Guides with Remote Play™  to engage HCPs?

There’s a wide spectrum of what you can do with a VTG: You can use it for quick demos to generate interest at events, for extended sales demonstrations, or for in-depth medical device training. If your training incorporates interactive tactics, it’s more easily understood by the user when to use the medical device and how to use it, and therefore it would increase adoption. Quick reference guides are another option, during which you could focus on a very specific part of the workflow. Having that wide range of options provides continuity in the way a company messages and communicates.

Do you see applications for audiences beyond HCPs?

Companies could also use VTGs to present to hospital administration. Few CFOs or CEOs at hospital systems are able to take the time to sit through a sales presentation; if you create a link to an experience, they can try it on their own time. You’ve now provided them with something interactive, and they can try it  themselves and really understand the value. The fact that you can use a VTG asynchronously means that someone internally at the hospital who is an advocate for your technology can pass this along so other decision makers can experience it themselves. Similarly, we’ve had large hospital groups ask us if they can deploy our VTG experiences internally. If a hospital system wanted to promote an implant or a device as their preferred tech across a large network, they could internally share a VTG, and it would then help them to drive utilization of that across the network to standardize care. The VTGs could also be great for patient education.

Interested in how Level Ex Virtual Technique Guides can add value and utility to your medical device?  Start a conversation with us today.

*Works in progress.