Steady Hands Save Lives

I’ve always wondered why, among all the people who grew up in the PlayStation era, so few who spent their time obsessively playing games ended up in medical school. The answer may be that the ones who made it just don’t want to fess up to the hobby. Some aren’t ashamed, of course: A classmate of mine who chose neurology as a specialty once had a long talk with me about Warcraft III tactics. But for most, the process of becoming a surgeon goes hand in hand with the process of distancing yourself from videogames.

Surgeons are different, or at least that’s what we tell ourselves, and too close an association with videogames might be unseemly – make a mistake in the operating room, and an attending surgeon familiar with your fondness for Rayman might tag you with that nickname for all eternity. “You going to screw up in my O.R. today, Rayman?” Every error can be attributed to slackery, every question answered wrongly the result of too much time spent playing with your Wii. (In surgeon humor, that’s high-class punnery.)

Which is why I find the state of videogame research when applied to surgery so amusing. Videogame advocates eager to show how Rise of Nations makes you less senile should be eager to dissect the current literature on surgical skills and gaming, because it doesn’t resort to tenuous links between knowing when to Age up and knowing when to refinance your mortgage. Instead, it examines a form of surgery called laparoscopy that has several elements of gaming to it.

Laparoscopy, or the use of small abdominal incisions to introduce instruments and a camera into the abdominal space without the need for open exposure, requires the real-time translation of a two-dimensional representation (the camera image on the monitor) of a three-dimensional space (the patient’s abdomen) through the use of vaguely gamepad-like controls. A standard camera is angled at 30 degrees, introducing yet another spatial reasoning hurdle. My first attempts at laparoscopy were ridiculously clumsy, but they were fortunately performed on a pig in junior resident training lab. That was about one month after I had impressed a roomful of my fellow residents by performing a series of ball retrieval maneuvers on a virtual reality machine. When they turned up the difficulty, though, I fell flat on my face.

Which is exactly what Albert Einstein College of Medicine researchers found when they assessed medical students for “previously acquired skills.” Advantages gained from gaming manifest in a surgical simulator’s novice mode vanished when they turned up the difficulty. I guess videogames really aren’t that hard. Pitt researchers found a few years ago when they chose Top Spin, Project Gotham Racing 2 and Amped 2 to assess students’ skills, that while performance in the games seemed to correlate with performance on the laparoscopic simulator, actually practicing with the games didn’t improve performance at all. This suggests that maybe people who are good at games just happen to be good at laparoscopy … err … simulators.

Unfortunately, that’s what current surgical videogame research focuses on: simulating surgery. Some even ask whether a variety of skills requiring manual dexterity, including gaming, playing a musical instrument or sewing, improve performance on surgical simulators. The best outcomes? Those with previous chopstick use (although subsequent research from the same group fails to bear out the chopstick correlation). Their conclusion? “It is difficult to predict baseline laparoscopic surgery skills.” One hilarious paper deduces that prior exposure to an endoscopic simulator improves performance on endoscopic simulators. None of this research seems to consider that potential patients are unlikely to be interested in how a surgeon performed on his most recent endoscopic simulation.

A more relevant question for videogame researchers (and potential patients) is, “Do surgeons who played a lot of videogames have better laparoscopic surgery outcomes than surgeons who didn’t?” Given that college freshmen who played the PlayStation upon its introduction in 1995 graduated from medical school in 2003 at the earliest, there isn’t yet a cohort of practicing surgeons who have put in significant time with a gamepad (given the five-year duration of a general surgery residency) to qualify as a “videogame surgeon” generation. (High school freshmen who got a PlayStation in 1995 are in their second year of residency this year.) You can move the timeline back further to include Amiga fetishism or even ’80s arcade gaming. But while I spent enough time playing Seven Cities of Gold and M.U.L.E. to potentially endanger my acceptance into medical school, these games are so far removed from the surgical skill set that it’s doubtful they would make a surgeon any less likely to lacerate your spleen when trying to resect your colon.

In fact, you could make the argument that only with the widespread release of truly 3-D games did potential surgeons get exposed to laparoscopy-like entertainment, which pushes the start date further forward from 1995. Still, at some point there will be a significant population of surgeons who played a lot of Spyro the Dragon and Psychonauts. It would be instructive to find out if that extra time people spent studying instead of playing Ape Escape translates into better outcomes.

There is, of course, a practical reason to ask about the utility of laparoscopic video simulators, and that is to find out whether it makes sense for surgery departments to invest a lot of money in expensive equipment rather than just getting their residents more laparoscopic cases. But that doesn’t address the underlying issue of whether simulator performance is in any way correlated to actual outcomes. The real question is not whether games are a worthwhile mainstream occupation or a giant waste of time, but how to get surgical residents better training so they don’t kill people. Those hoping for more ammunition in the culture wars are out of luck.

The attractive part of this research for gamers is that maybe someone will secretly validate all of our time playing the Call of Duty series because it makes us better at being surgeons or investment bankers or jet fighter pilots. I have to say that – given the number of times gaming has been derided in my presence, sometimes in the O.R. – that it might be amusing for someone to conclusively prove that it makes for better surgeons. Or gets us lots of hot chicks. (I think you can disprove that last point empirically without rigorous statistical analysis.)

In the end, I’m growing weary of these relentless attempts to justify ex post facto my leisure time. Reflecting on my residency so far, gaming’s ultimate appeal is that the complete attention it requires precludes interaction with the rest of the world (unlike watching TV or eating). The ability to completely disconnect from all the awful things that may have happened in the hospital, from all the emotional energy expended in patient care, to instead walk around a post-apocalyptic wasteland with a dog companion, is one of my most jealously guarded pleasures. I don’t care if it makes me a better surgeon; I am just glad it keeps me sane. The “better surgeon” part I can work on.

Although it is not his actual name, Rich Retractor, MD, PhD, is a surgical resident at a large U.S. academic medical center.