Final Project: Documentation
Motivation
For my final project, I chose to refine my interactive fiction work, “Healthopolice.” When initially crafting the storyline, I aspired to highlight the real-world challenges doctors face when treating patients. I sought to accomplish this by creating a dystopian society where real-world challenges in medicine are exaggerated to the point of ridicule. In the first version of this game, players truly appreciated the theme and storyline. One key area of improvement identified was the visual aesthetic of the game; having the visual design better align with the goals of the game was thus something I aimed to work on. Personally, I also wanted to conduct more extensive secondary research on the psyche of medical professionals and aim to weave my insights into a potentially slightly expanded storyline. Thus, for the second version of “Healthopolice,” I conducted several different types of activities: (1) secondary research on challenges key players in the healthcare ecosystem face, e.g. doctors, patients & weaving these insights into a slightly expanded storyline (2) crafting a new visual aesthetic for “Healthopolice” (3) playtesting and game refinement. Regarding the research component, while I originally sought out to interview both patients/physicians and conduct secondary research, gathering enough people to work with on primary research was challenging. Thus, I decided to instead, playtest on the persons I found with extensive healthcare experience and use their feedback to iterate on my game; in this way, I integrated the research component into that part of the game. Here is the link to the final playable game: http://philome.la/MS93423160/he-althopolice
Research Findings & Storyline Development
I conducted extensive secondary research on the healthcare ecosystem, seeking to better understand the physician/patient relationship. To this end, I decicded to read Dr. Abraham Verghese’s novels Cutting for Stone and The Tennis Partner. Both books provided tremendous insight into how doctors interact with patients on a daily basis and the challenges they face. Key findings and insights from both books are listed as follows:
On Cutting for Stone:
This novel is about conjoined twins who were born to an Indian nun and English doctor in Ethiopia. Two doctors — Hema and Ghosh — at the hospital where the children are born raise the children themselves. The twins are named Marion and Shiva; both go on to become doctors as well. Marion falls in love with a maid’s daughter, Genet, who cheats on Marion with Shiva; Marion and Genet’s relationship is broken, and Marion ends up leaving Africa for New York where he completes his medical training. He meets Genet who comes to the famous Dr. Stone in the United States as she is very sick. Marion unites with Genet and ends up contracting hepatitis B; Shiva attempts to donate his liver to Marion to help him recover but dies in the process.
- Medical education in India at the time Dr. Verghese attended was very much a man’s world — even obstetrics; his classmate, a woman named Hema, had to go to Africa to even be allowed to practice. This is why the story takes place in Ethiopia.
- Societal pressures and norms can be devastating; doctors have to deal with this aspect of medicine in addition to actually prescribing cures. For instance, the stigma the nun and doctor felt about having children resulted in them abandoning their children; Hema and Ghosh then had to bear the brunt of this.
- Doctors face so much stress that they often make unhealthy decisions, despite having a wealth of medical knowledge themselves. For instance, in Ch. 11, Ghosh visits a prostitute and contracts a urinary tract infection.
- The sentiment of being so immersed in business translates to other facets of doctors’ personal lives. For instance, when Ghosh asks Hema to marry him, she agrees to do so for one year — with a “renewable contract” (Ch. 16).
- Human life is intricate and complicated; this is amply demonstrated by the tragic way in which Shiva passes away. During the liver transplant surgery, Shiva’s brain clots because a part comes loose — the part where he was conjoined with Marion. Thus, despite having some of the best medical care available, Shiva still passes away.
On The Tennis Partner:
This novel is about Dr. Verghese’s personal experiences supervising a fourth-year medical student named David in Texas. Though the student is talented, Dr. Verghese observes he is deeply troubled; Dr. Verghese learns the resident is an expert tennis player, and the two start playing after work. David and Dr. Verghese form a very close bond. As Dr. Verghese’s marriage falls apart and he plunges into solitude, David remains one of the individuals whom he continues to have strong interactions with. However, Dr. Verghese also learns David is a recovering drug addict and is addicted to philandering with women; David cheats on both his girlfriends. Ultimately, David’s addiction resurfaces and he commits suicide by overdosing; Dr. Verghese is in the difficult of position of trying to help David overcome his addiction, and deeply feels for David’s passing.
- Observing how doctors attempt to treat other doctors is fascinating. Dr. Verghese approaches David with greater perspective than the typical physician/patient interaction; he looks out for him as diplomatically as he can, taking care to not shame David for his addiction.
- It is intriguing to note the kind of relationship developed when conducting an activity for leisure, i.e. tennis. This is what brings Dr. Verghese and David together, ultimately allowed Dr. Verghese to provide much more solace to David than he otherwise would have been able to.
- Addiction is a ravaging disease; it is hard to treat and requires a strong emotional support system. David suffers the consequences of not having as strong of support system as he could have.
After reading both these novels, I sought to weave some of the insights gleaned into the storyline for Healthopolice. In particular, I found the contrast between the very human side of medicine and the wave of automation fascinating. Because Healthopolice is a dystopian, robotic society, I sought to introduce a component where the human side was better explored. I did this through having a scene where the player plays tennis with the Chief Doctor and through those interactions, realizes the very human side of the Chief Doctor who is struggling with addiction himself. This scene transpires in between patient treatments, as a “break” of sorts, and is not subject to time pressure. Ultimately, I chose for the player to ignore the Chief Doctor’s pleas and proceed with the player’s robotic intuition to highlight the flaws of Healthopolice. I iterated on this storyline through my playtests. And, evidently, the storyline was inspired from The Tennis Partner.
Visual Aesthetic
Another aspect I wanted to improve in this version of the game was the visual aesthetic. Feedback on version 1 had been that the imagery could have been more relevant to the sentiment of the game. To this end, I decided to establish a color scheme for the game: white and red. Red and white are associated with ambulances & emergencies; thus, I thought this scheme would be visually appropriate to convey a sense of urgency and underscore the medical context. During times when the player is unsure of decisions, the text is purple; and green when the player thinks the choice is the “right choice” to make in order to survive. The background becomes grey in especially distressing situations, for instance, when the Chief Doctor announces a patient has died. The aesthetic is quite simple and raw; at times, certain elements appear jarring, for instance the red alert that accompanies the timer. While I realize that these elements may not look “pretty,” I intentionally chose this so; I wanted to highlight how the stressful nature of the patient/physician interactions in this game result in conflict & ugliness.
To emphasize the sense of urgency and timer better, I styled the timer so that it looked more like a digital clock that was counting down.
I also experimented with Twine’s capability to display text character by character, “Typewriter style,” and chose to have both the opening and closing passages adopt this, as well as selected other passages where I wanted to slowly build suspense, for instance, in “please your patient training.”
Another important realization that arose after playtesting was that in order for the images and timer to have maximal impact, it was important to have them interspersed within the passage rather than placed above. I thus followed a structure where I would have a few sentences of description; an image; a few more sentences of description; the timer; and a few sentences enumerating the choices. That way, the player can better match the image with the description and be able to quickly refer to the timer when making choices.
Finally, also based on playtesting feedback, I extended the timer length even more and continued to keep the forward/back buttons so that if the timer length does not work for every reader, players can still see the text passages.
In this way, I was able to improve the visual appeal of the game and better convey the sentiments I sought to evoke with this game.
Playtesting
I conducted two rounds of playtesting with two individuals with diverse backgrounds and experiences with the U.S. healthcare system. I used the same pre/post assessment that I did for my first version of the game as my overall goal has not changed. The pre/post assessment questions were as follows:
Before playing Healthopolice and after playing the game, playtesters were asked the following questions, which employed the Likert scale:
- How much freedom do you think doctors have in making care decisions currently in the U.S. on a scale of 1 to 5? 1 represents: no freedom, other institutions/laws largely determine doctors’ decisions and 5 represents: doctors have very few restrictions imposed on them when delivering care.
- How much do you think the advent of intelligent technology & automation will impact doctors’ freedom in making care decisions in the U.S. on a scale of 1 to 5? 1 represents: intelligent technology & automation will have no impact on doctors’ care decisions and 5 represents: most care decisions will be made by intelligent technology — doctors will have very little control.
Additionally, because my research process had sparked my interest in understanding the patient/doctor relationship and elucidating that in my game, I chose to evaluate this as well. Specifically, I screened my playtesters so that they had had chronic medical conditions they had been dealing with; I wanted them to have had extensive experience with the healthcare system so that they could give me an accurate perspective on how well Healthopolice represented the negative components of healthcare.
Before game-play, I asked them to elaborate on their health experiences. After game-play, I asked them: “How strongly did your own experiences relate with themes present in Healthopolice?” I took notes on their answers and used this as a follow-up interview of sorts.
Round #1 of Playtesting:
Who: This round of playtesting was conducted with a female in her early 20’s and is a college student (not at Stanford University). Other personal details are anonymized as per the participant’s request. This student has had extensive experience with the U.S. healthcare system, having had chronic mental health conditions. She has been seeing a therapist for over a year.
Pre-assessment: Q1- 3/5; Q2–2/5
Post-assessment: Q1–1/5, Q2–4/5
Reactions/Notable Quotes:
“Wow this game is really mean … there’s no way to win!”
“Oh no! If I don’t act in time all the patients will die! And I die too!”
“Yes! I was evil and won!”
Positives:
- Appreciated concept and the choices presented
- Found it very creative and relevant to personal experiences
Suggestions for Change:
- Disliked how images and timer were at the top of the page; could not pair things together
- Wished the timer looked more like an actual clock
- Liked the red & white color scheme
- Thought the tennis-player doctor storyline was a little abrupt and short
Follow-up Interview:
- Especially related to Mary, the patient who comes to seek mental health assistance
- Definitely agrees that primary care doctors are too strapped for time and don’t know how to talk to mental health patients
- Had bad personal experiences with primary care doctors, but had better experiences with expert psychologists — “however, you have to somehow go to an expert. I just wish primary care doctors were better at least hearing me out. They just assume I want a referral. You caught that aspect really well in this game!”
Based on this round of playtesting, I made the suggested visual changes (detailed in the “Visual Aesthetic” section of this post). I also expanded the tennis partner storyline to include more dialogue between the player and doctor. It was encouraging that the patient story around Mary appeared to represent issues on mental health aptly.
Round #2 of Playtesting:
Who: This round of playtesting was conducted with an elderly lady in her early 80’s and is retired (not at Stanford University). Other personal details are anonymized as per the participant’s request. This lady had extensive experience with the U.S. healthcare system as well; she has chronic back pain and diabetes for three decades. Thus, in managing these conditions she has seen several geriatric specialists.
Pre-assessment: Q1- 3/5; Q2–2/5
Post-assessment: Q1–1/5, Q2–4/5
Reactions/Notable Quotes:
“This time is getting urgent, I don’t know I can read all of this in time…”
“Wow, that’s sad that Joe died. The doctor should have known!”
“What a disgusting society — is healthcare really this bad?”
“That’s ridiculous; how can a doctor be addicted to drugs? What has this world come to?”
Positives:
- Strong story and writing — great descriptions helped with visualizing scenes in head
- Appreciate the inter-doctor communication — had no idea doctors faced such problems themselves
- Very creative and has great potential for educating people about the challenges of healthcare
Suggestions for Change:
- Found timer too fast
- Having red text on every screen gets boring — can change colors up
Follow-up Interview:
- Related to Joe — though the patient does not like to use painkillers, they have been in a position where they have been tempted to and where the doctor has not offered sufficient information on consequences
- Has found interactions with doctor robotic even in-person — especially in appointments with non-specialists; “they just run through a script, asking the same questions every time, and don’t really care about getting any more information than an automated system could.” So the auto-med nurse is relevant.
- The time pressure component was also very relevant; doctors never have enough time for their patients, in this playtester’s experiences.
Based on this round of playtesting, I made the suggested visual changes (detailed in the “Visual Aesthetic” section of this post) by adding the green and purple themes. I also extended the time on most passages as detailed in the visual aesthetic section. It was encouraging that the patient story around Joe appeared to represent issues on chronic pain and painkiller addiction appropriately. It was also encouraging that the auto-med-nurse seemed a realistic possibility (in terms of how well the game highlighted challenges in the healthcare system).
Ultimately, before playing the game, on average, playtesters believed that on a scale of 1 to 5 (1 being low, 5 being high) doctors’ freedom in making patient care decisions was 3/5 and after, 1/5. Thus, the game convinced players that the healthcare system has several challenges and can indeed comprise doctors’ freedom to make care decisions, one of the goals of the game.
Additionally, before playing the game, on average, playtesters believed that on a scale of 1 to 5 (1 being low, 5 being high), intelligent technology/automation would have an impact of 2/5 on healthcare. After, on average, playtesters thought such technology would have an impact of 4/5. This game thereby prompted players to realize the possibility that technology can have a tremendous — and possibly negative — impact on shaping healthcare, another goal of the game.
Conclusions
Overall, it was rewarding to refine Healthopolice in this fashion. I enjoyed integrating secondary research, the perspectives of patients with extensive experience in healthcare, and my own creativity to add more dimensions to this game. I hope to continue iterating on Healthopolice and on getting diverse perspectives from medical experts to improve the game.
References
Verghese, Abraham. Cutting for stone. Random House India, 2012.
Verghese, Abraham. The tennis partner. №892.8 V496t. Harper,, 1999.
