Courtesy of BreakAway Games

Perhaps the most elegant example of learning while actually having fun came from a real-time strategy game called Emperor: Rise of the Middle Kingdom. But first some gaming history. Strategy games such as Chess, Risk, and Stratego have enjoyed a long heritage. The classic games were turn-based, essentially allowing each player to gather his or her thoughts, devise a strategy, and then move. The transition to the computer added a second exciting prospect – that of games that simulated a seamless flow of events, allowing for the consequences of each move to play out in real time and giving birth to the genre of “real-time strategy” games or RTSs. Developer Bullfrog’s Populus was arguably the first game in the RTS genre, further refined by Westwood Studio’s Dune 2, and then the Command and Conquer series. Emperor: Rise of the Middle Kingdom, developed by Maryland-based BreakAway Games, was this type of game, but also much, much more. In Emperor, the object is to lead a group of people through the process of building a civilization from the humble beginnings of a small rural community. The tutorial missions, which are set during the Neolithic Xia dynasty, very gently encourage you to understand the basics of community-building from the perspective of a 2100 BC farmer – everything from the proper seasons to cultivate soy versus rice to the vitals of repelling invading marauders is covered, as this description from the game would suggest:

“In the northern region, along the banks of the Yellow River (or Huang He), the fertile yellow ‘loess’ soil and cooler climate was well suited for hardier grains such as millet and wheat. Further south, along the meandering Yangzi, the warmer and wetter climate was ideal for rice, which soon became an important staple of the Chinese diet. Far to the north and west, above the Yellow River and in northwestern China’s Tarim River basin, the extremely dry soil and harsher climate made cultivation without irrigation almost impossible.”

As dry as this may seem on paper, this information proved vital to the survival of my township, which gradually grew and prospered – something that gave me a great deal of pride. I recall how attached I became to each of my little subjects. Added to this was the thrill of our repelling invaders successfully, and the decision to embark upon the gargantuan task of building a little-known monument called the Great Wall of China. In total, just a few hours of game play over some weeks had allowed me to experience some 3000 years of ancient Chinese history. I like to think that Ms. Wilcox, my high school world history teacher (and top-drawer pickle-ball player), would have approved.

It was during the autumn of 1999 that I fell in love. She was beautiful, complex, tremendously high maintenance, and from the land of the rising sun. Her name was Gran Turismo, and our relationship was tumultuous, fiery, and a constant struggle for performance and power. Horsepower, that is. In a few short weeks, I developed both admiration and awe for Japanese racing cars. The game gently goaded me into learning about real-world improvements that can be made to a vehicle in order to enhance its performance. I developed a working knowledge of drag coefficients and came to understand the delicate balance that had to be attained between torque and tire traction. Every single one of GT’s 500+ vehicles came with a detailed history of its design and manufacture process, and I soon garnered a deep admiration for the racing pedigrees behind the vehicles I saw on the street every day: Honda, Toyota, Nissan, Mitsubishi, and Mazda, to name but a few. My GT experience highlighted a fundamental principle of education to me: immersion is everything. Easily the most exciting part, though, were the lengthy discussions that would take place with friends also caught up in the world of Japanese touring car racing, bringing together the oddest groups of people. I recall an 11-year-old boy explaining to me how he managed to beat his father’s horrendously powerful Nissan Skyline GT in a less powerful Subaru WRX, simply because he stiffened up the rear suspension and invested heavily in racing tires. The result? A vehicle agile enough to corner at speeds that would cause Daddy to spin out in his horsepower-laden Goliath of a vehicle.

Game designers are constantly raising the bar for applying realism to their interactive digital experiences. Realism implies more that just photo-realistic environments. It implies the use of detailed mathematical algorithms to capture the realistic portrayal of sound, the collision of objects, the movement of a human being, etc. A favorite example of mine occurred to me while looking at a review of an old game I played on the Commodore 64 called Space Rogue. Essentially a space opera, you played a character who happened upon a derelict Scow-class space cruiser while on a routine reconnaissance mission. While exploring the craft, your own ship is destroyed by pirates, leaving you to start from scratch alone in a huge universe. Aside from its beautiful, open-ended game structure (you could choose your own adventures), the spaceflight sequences obeyed true physics principles, including that of gravity. While the rest of the world simply accepted the fact that Voyager Probes 1 and 2 were being slingshotted from planet to planet, I was actually experiencing it thanks to a few lines of code running on a processor with only 64K of random access memory. Vance Hill illustrates this beautifully in his review of Space Rogue:

“My fondest game play memory involved a binary star system where I was getting trashed by an alien, totally wrecked at the worst time. I couldn’t outrun it and I was far, far away from any help. I turned the nose of the ship to face between the two stars and hit full burn. As the gravity started sucking I started flying in faster than the ship could possibly go under its own power. I started to get pulled off course, towards one of the stars, and then… I shot between them and out to the other side, leaving the alien way back in nowheresville.”

…To be continued

I used to feel that humor was one of the most difficult concepts to do well in gaming, and was shortly proven wrong by Ron Gilbert and his Monkey Island games, followed shortly by what I’ll refer to as the “golden age” of LucasArts’ point and click games, citing The Day of the Tentacle and Full Throttle as experiences that got humor right. The evolution of humor has progressed to the point of ultra-satire with the tight writing of Portal 1 and Portal 2, and frankly, I’m loving it.

So no, not humor. How about fear? Well, gaming has fear pretty much licked. From the bizarre polygonal trappings of the first Alone in the Dark game to the schlocky camp of the initial Resident Evil games and the elegance of the Silent Hill and Fatal Frame games, I’d say there are many ways that game devs have to scare the pants off of us.

And speaking of pants . . . (groan) . . . what of love? I definitely remember feeling something for the princess in ICO as I stood yelling into the screen, half dragging her across the crumbling tower in the final stages of the game, controller sweaty with perspiration.

I also thought that the concept of building a game such as Shadow of the Colossus around a young warrior’s love for his lady, scaling truly epic odds in the hopes of offering his one true love a second chance was initially compelling. However, the beauty of that game lay in the eventual love that one gains for each of the hulking Colossuses (Colossi?), which creates a weighty counterpoint to the naiveté of the original premise.

But no, I’m talking about actually being emotionally engaged in that schoolboy crush type of feeling with a videogame character. Probably the first NPC to raise an eyebrow for me was the daughter of Professor Cross in the game Half-Life 2. Her combination of curiosity, playfulness, warmth, and intelligence as a companion through parts of that game certainly made the quieter sections (sans companion) seem quite lonely. I found myself thinking, “I wonder what Alyx is doing right now?” before smiling at the absurdity of it all.

And then Mass Effect happened. Or perhaps more specifically, Liara T’sonis, the Asari scientist seemingly genetically designed to get under my skin. Able to hold a conversation regarding the ethical implications of the genophage unleashed upon the Krogan species? Check. Playful and inquisitive, with a strong sense of moral balance? Check. A beautiful azure-blue complexion with tentacles for hair? You had me at hello. In classic Bioware style, our in-game relationship grew and manifested as a glorious tryst prior to the game’s final battle. So you can imagine my excitement at the thought of saving the universe with her again in the sequel, Mass Effect 2.

During the sequel, it becomes apparent that she, thinking that I had been killed, had moved on. In fact, when we are reunited in the second act of the game, her reaction to me could best be described as, erm, frosty. And I’ll be the first to admit that I was a little upset by this. So much so, that I had to turn to my IRL wife for support and counsel on this matter.

“What changed? I mean, here I am, back for her, and she’s basically giving me the cold shoulder,” I said as we prepared dinner.

“You’re insane,” my wife responded.

“But I feel that the moral center of this game, namely her, has disappeared. I’m feeling a little less interested in the game as a result.”

Silence.

“The only thing that might even be remotely comparable would be if you were suddenly to be so tied up with getting that critical care fellowship that you forgot or started taking for granted us.”

That got her. Was my fascination for Liara a metaphor for my fascination with my wife? Well, duh!

“She’s probably creeped out by the whole ‘reanimated Shepard thing’ and is still trying to figure out her feelings for you.”

And, of course, she was right. And as it turns out, Liara plays an integral part in this backstory, the details of which I won’t divulge for fear of spoilers. Dare I say that in terms of emotional re-engagements, it was one of the most impressive about-faces I have ever made in my feelings for a character? Brava, Bioware, brava!

So what is the point of all this emotional engagement? Well, if you’re reading this blog, you probably don’t need to be told, but it makes perfect sense from a business standpoint. Dare I say that it was because of my persistent relationship with this NPC with all its twists and turns that I purchased Mass Effect 2, in addition to a ton of DLC – especially the epic Lair of the Shadow Broker DLC which seems as if it was created by the developers as a gift to me alone?

Can you feel the love tonight?

They sat in a circle staring into the fire and pondered their impending defeat.  With such limited numbers, the Apothecaries knew that spawning offspring was unlikely.  There had to be another solution.  Then, it happened – like a smooth drink of spring water, the “Ancient One” flowed into their camp like an answer to their prayers.  Princess Hygiena had returned!

At first glance, her unassuming demeanor made her appear fragile.  The Apothecaries, however, knew better and rose to greet her. With humble bows, they praised her return.  She had never really left, she had always been there for them, but it was not in her powers to do battle unless she was summoned.  In order for her magic to work, she had to be called on often.  One missed summon, and her spell would be broken.  Princess Hygiena was the most ancient and powerful of all of the warriors.  She was well versed in the old magic.  She reached into her satchel and produced the ingredients for a powerful potion.  The sacred twin hydrogens were cleaved with the omnipotent oxygen in a blaze of glory.  She retrieved a sprig of Cholorgalum pomeridianum root from the ancient soap plant and carefully mixed the brew.  The Apothecaries looked on while the mixture coalesced in a bubbling iridescent swirl.  A dram of this tonic could indiscriminately wipe out dozens of colonies in mere seconds.  As the sun began to rise, they steeled themselves for another day of battle….To be continued.

“Easy. Just use chaffs to scramble their radars, stay in the corners, and wait until their mouths open to attack – that’s their only weak spot, really.”

“Dude, thanks, Man!”

“You’re welcome. Let me know if you have any trouble. Oh, and if you’re struggling with the Rays, you might need some help with Solidus Snake, the final boss.”

“Don’t be trash talking me, Punk!”

We both beamed, having finally actually connected on something other than his inevitable mortality.

The next day I was in early, eager to share my experiences in this game. It occurred to me that our lives, despite being of similar age, were worlds apart. And yet gaming culture had given us a set of common experiences that we could relate with. There had to be something here. Instead of just pontificating about it, I wanted to ask him directly.

“Warren, what is it about gaming that, you know, just does it for you?” We had just finished a discourse about how to complete the rest of Sons of Liberty, and desperately afraid that we had come to the end of a common experience thread, I opted to find out a little more about what his motivations for playing were.

“Well, the easy answer is an escape, I think. But I think its more than that. I think it has to do with losing myself in another world. Being something different. You know, taking a football team to the Superbowl, leading armies to defeat the Goblin King, piloting a star cruiser – silly stuff, I know, but important to me. It also keeps me from being negative.”

“How so?”

“Well, when I’m playing I don’t have time to be worried about what my other friends are worried about – clothes, girls, cars – but mainly girls.”

“I got 99 problems . . .” I chimed in.

“Tell it, Playa.”

We both laughed at the somewhat lewd inside Jay-Z lyric, as both his mother and the nurse were around and we had pulled off some mad poetry.

“What if you could get on Xbox Live? What if you could game with other folks out there going through something similar?”

“That would be freakin’ sweet.”

“Agree . . . damn! Look, I’m late for rounds. By the way, your infection’s better according to the blood tests.”

“Uhh, thanks for all the info, Doctor”

“You’re welcome, Punk.”

The days came and went, and we continued to build upon our relationship as his infection was treated. Ultimately, with the blood cultures having remained negative the entire time he was there, we opted not to remove his dialysis access. During that time I spoke with the facilities director and managed to get permission to install an Xbox in his room, playing off the television. Unfortunately we couldn’t figure out a way to get access to the internet, meaning that XboxLive was out of the question. Still, I made sure that after rounds I would swing by and we’d have a quick race on Project Gotham Racing before I left for the day.

But the infection wasn’t the only issue he was working against. A repeat CT scan of his abdomen showed that his cancer had returned with a vengeance, almost doubling in size since the last round of chemotherapy. We had had to put the chemotherapy on hold because of this infection, and there was very little we could do to reverse its course. Despite being comfortable now, the oncologist downgraded Warren’s prognosis based on the aggressiveness of his disease. Oncologists are some of the most vivacious and optimistic people I know, and when even they can’t offer hope, things can look pretty bleak.

“You never told me what your favorite game was, Warren.”

“That’s easy – Final Fantasy.” Touche. Most hardcore gamers considered this particular series of games one of their favorites. It was known for its complex narrative, multiple branching storylines, and lengthy, lengthy gameplay experiences. The typical single-player experience could last anywhere from 40 to 80 hours. I recalled playing one of the games, Final Fantasy VII, over one of my med-school summers, and I still couldn’t finish it. And what a fusion of culture – the games epitomized J-culture, or Japanese entertainment / pop culture, with manga-inspired character art and mythology – all processed, synthesized, and analyzed by this young African-American man from downtown Baltimore.

“If you could be any character in the Final Fantasy universe, who or what would it be?”

“Bahamut.” The Dragon King – a supremely empathetic being who would from time to time be summoned by the adventuring party to lend assistance when the party was attacked by foes who were simply too big to face alone.

We discharged Warren to hospice care a few days later, and I remember being asked by Facilities to come and retrieve the Xbox that had been in his room. I remember standing in the empty room, thinking about the experiences we had shared over the past few short days. I thought about what he had said to me regarding shared experiences, about living in other worlds, about the benevolence of the Dragon King. It occurred to me that this concept of enabling patients with the chance to discover the same things that Warren had through online interactive worlds was simply too powerful to ignore. Wrapping the cables haphazardly around the gaming console, I noticed something lying on the floor. It was Warren’s discarded patient ID bracelet. Purple magic marker emblazoned his allergies and room number. To this day I still wear a purple gel band to remind me of this powerful young man who inspired me to put forward his legacy of bringing positive community gaming experiences to patients facing chronic illness. HOPEconnectsKIDS.org

I’ve started listening to the Weekend Confirmed podcast which is run by the folks at Shack News, a gaming news site / blog from back before blogging was even a noun/verb. The podcast is run by game reviewer/illuminati Garnett Lee, and I began listening after the Totally Rad Show’s Jeff Cannata mentioned it as another podcast he did that focuses solely on games and gaming culture.

I enjoy niche podcasts as they tend to represent discussions that would be best described as being like dialog penned by screenwriter Aaron Sorkin – that is, intelligent people speaking quickly about things they are passionate about. Confirmed is no different. The discussion from two weeks ago zeroed in on speculation about the next Grand Theft Auto game – GTA 5. Xav de Matos, one of the show’s other frontrunners, brought up a point detailing the disruptive nature of GTA games in general, highlighting how interesting it might be if this next GTA game had a woman as the central character. It occurred to me how amazing this would have been. (We now know that this is not the case, as a trailer for GTA 5 was recently released.) A further sad realization is that the gaming industry is taking a page from Hollywood with a surprising dearth of gaming experiences driven by strong, complex female characters.

This is a shame, as I believe that Rockstar (makers of the GTA series) does have the talent and audacity to do something like that and do it well. And before you cite the somewhat tired examples of GTA games highlighting violence against women (such as assaulting prostitutes), I would counter that being an open world game means that people can make morally despicable choices, but can just as easily not do those things. Secondly, the strength of supporting female roles in the more recent Rockstar games Red Dead Redemption and LA Noire suggests that this is something that they are giving serious thought to.

Seriously though, other than Faith from DICE’s ambitious but slightly flawed Mirror’s Edge, what other games have had substantial female lead characters?

Your charge, as a father, Sir, is to protect your children from the darkness that exists in this world.

When you calmly took your belt off, turned off the lights so that no one outside could see what you were about to do, and then proceeded to hold down and whip your child as she pleaded for you to stop – you became that darkness.

Then, of course, the behemoth that was X-Men: First Class came out and I got to witness the intensity of James MacElvoy and Fassbender go toe to toe as Professor Xavier and Magneto in their formative years – probably my second favorite film of the summer. And finally, while figuring out which movie to watch next on my Netflix account, the suggestion for a smaller film that had been released three years previously bubbled to the top of my “Recommended for You” films. I decided to give it a whirl. Called Hunger, it told the story of Bobby Sands, the Irish republican prisoner who led a hunger strike in 1981 in protest of the treatment and conditions at the HM Prison Maze in Northern Ireland.

Sands was played by none other than Fassbender, ending the trifecta of amazing performances by this talented young actor. Perhaps highlighting his dedication to the art is a 17-minnute sequence in which Fassbender and supporting actor Liam Cunningham discuss the moral and ethical implications of a hunger strike. Jeff Cannata details instances in which “dialog can be just as powerful as any action sequence” in his review of the film Doubt. This I truly believe to be the case, as the sheer volume of script that both actors passionately convey is a thing of beauty.

It was during this film that I got the “Fassbender is the next Christian Bale” vibe, as in addition to the cerebral mastery involved in “owning” this particular portrayal of Sands, there was the remarkable feat of losing 35 pounds for the role. Truly The Machinist levels of commitment here. So there you have it – by random chance Fassbender has gone from my “meh” list to my “if he’s in it, I’m watching” list along with Ian McShane, Ciaran Hinds, Clooney, and DiCaprio.

I wanted to focus on one of those characters today, Mordin Solus. l suppose it would have been easy for the writing team to have made him the one dimensional “Bones McCoy” type of space-faring physician who occasionally acts as a humanistic counterpoint in discussions about the ethics of certain situations. Fortunately they instead chose to weave a fascinating backstory about a brilliant scientist who is also a warrior monk of sorts – a physician who uses intelligence and logic to explain some of the occasionally ruthless decisions he makes. Perhaps some of the most compelling discussion involves exploring the ethics of modifying the Krogan genophage that essentially resulted in the wide-scale rendering of the belligerent Krogan species largely infertile in the hopes of curtailing their becoming a threat to the galaxy and ultimately being slated for genocide. The ethics here are murky at best, and being a physician myself, I appreciate the inherent complexity of the various viewpoints and how they can change with time.

Despite Dr. Solus’s apparently cool and calculated intelligence, it becomes apparent that the warrior side of him and the physician side of him are at constant odds, as made evident by this quote:

“Have killed many, Shepard. Many methods. Gunfire, knives, drugs, tech attacks, once with farming equipment. But not with medicine.”

This comes to a head when he realizes that his trusted colleague is performing perverse experiments on the Krogan in hopes of justifying a cure for the genophage. In a watershed moment in which he realizes that science and logic can be used to justify both sides of an argument, he opts to make the irrational decision to execute said colleague, requiring an intervention by your character, Commander Shepard.

This certainly struck a chord with me regarding the importance of appreciating the complexities of medical ethics in general.

The six commonly understood pillars of medical ethics (summarized nicely here by the good people of Wikipedia) include:
● Autonomy – the patient has the right to refuse or choose their treatment. (Voluntas aegroti suprema lex.)
● Beneficence – a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.)
● Non-maleficence – “First, do no harm.” (Primum non nocere.)
● Justice – concerns the distribution of scarce health resources and decisions regarding who gets what treatment (fairness and equality).
● Dignity – the patient (and the person treating the patient) have the right to be treated with dignity.
● Truthfulness and honesty – the concept of informed consent.

Adding to the complexity of dealing with these concepts is the understanding that viewpoints can also change with time – something that I (and I only) might refer to as the “Solus Paradox.” This is what adds true grist to the practice of medicine, in my view. I’ve had patients who were at first staunchly opposed to the idea of life-support and resuscitation change their minds at the last moment. Similarly, I’ve had patients who explored all avenues of care in the treatment of conditions with poor prognoses calmly and confidently determine that “enough is enough.” Anticipating that patients can and will change their minds when it comes to difficult decisions equips you to be a better physician.

Thanks, Dr. Solus!