Robodoc

Doctors learn from their experience with patients. As if you didn’t know. It starts by observing and assisting other practitioners. It expands with supervised diagnosis and treatment. It peaks in autonomous encounters with patients over the entire course of a medical career.

Some of those encounters with patients are routine. Many are unique, exploratory, to some extent baffling. A doctor in those thorny encounters is an investigator, a clue finder, a person who doesn’t know but needs to find out. The patient is ideally there to help. A patient in those encounters is a witness, a fellow pathfinder and problem-solver, maybe even a coach.

I don’t know the proportion of medical education that is face-to-face with patients, but it’s a safe bet that learning from practical experience with patients far exceeds learning that occurs in lecture halls and libraries. Learning with patients is so valuable that it’s been boilerplated in technologies known as a simulated patient and a virtual patient.

The simulated (aka standardized) patient emerged in medical schools during the 1960s, around the time that healthcare started morphing into the wondrous industrial process that we have today. A simulated patient is an improvisational actor (professional or amateur) who performs the role of a real patient with certain knotty health issues.

The actor may have personal experience as a patient with the issues that are simulated, but is also well prepared to make a contrived performance seem real. Like audience members called up to the stage in a comedy club, doctors role-play diagnosis and treatment of the simulated patient.

And it works! So well that role-plays with simulated patients are required for getting a medical license in the United States. Doctors must play to practice. In addition to sharpening clinical skills, the role-play helps doctors improve their social and communication skills and polish their comportment for awkward or embarrassing moments in the office or clinic.

The downside with simulated patients is cost. The simulations are expensive to run, even for an industry that hemorrhages billions in carefree ways. Hence the introduction, starting in the 1990s, of the more economical and scalable virtual patient.

A virtual patient is a digital replicant, like a special-effects monster in a movie. Just kidding, the virtual patient is not like a monster in a movie, but like an avatar in a video game. The avatar is programmed to have health and other issues that must be recognized, understood and treated by the real doctor who plays with it.

The virtual patient is a computer simulation, unlike a live simulated patient, but the purpose is the same: learning medicine by means of role-play. A virtual patient is endlessly replayable and easily modified to simulate different clinical scenarios and produce different outcomes. Virtual patients are much less expensive to run than simulated patients, much more accessible, convenient and versatile to use, and may be just as capable of increasing medical competence.

Which brings me to the question I’m here to ask. If simulated and virtual patients are so good at increasing the medical competence of doctors, why haven’t simulated and virtual doctors been used to increase the health competence of patients? There are one million doctors in the United States receiving the benefits of this lavish educational technology. There are over 300 million patients in the United States who don’t have a clue.

Why not offer this powerful, effective educational technology to patients? Wrong question, because there isn’t a good reason. Better to ask what for, and when.

I call virtual doctors robodocs, which I am entitled to do because I invented them. Before you came to this blog, you probably never heard of simulated or virtual doctors, so don’t argue. We can call them robodocs from now on.

On the other hand… one sec… here it comes… Robodoc™. Now I can charge you to use the term! That would make me feel more like a medical device or drug maker. (Pass the Milk of Magnesia, please.)

What would patients do with a robodoc if one existed for them? They would role-play being a patient to learn how it’s done. They would learn simple things, like how to participate in their medical treatment, how to discuss their condition and needs with a doctor, how to seek the right care in the labyrinthine health marketplace, how to pay as little as possible for care that is needed, how to avoid and prevent the care that is not wanted.

Simple things that must be learned from experience. There is no better way. Doctors know that and so should you.

I gave a name to patient learning from experience — Constructive Health Competence™ — and Humaginarium is building video game simulations to promote it. Video games for adults with chronic illness who depend on the medical industrial complex much more than others have to.

And yes, robodocs will be present in our video games. Helping real patients find their way.

Robodocs are virtual doctors that make role-play for patients feasible, both technically and economically. Playing with them lets patients safely practice their performances in the doctor’s office, lab, ER, ambulance, clinic, hospital and assisted care facility where the gold-plated meters are running and ordinary life and well-being are on the line.

Please don’t say that it can’t work. Simulated and virtual patients are already working for a million doctors including yours. Don’t say that it won’t work. Entertaining video game sims are already working for hundreds of millions of consumers including your coworkers, friends and family.

Instead ask what difference we can make if it does work. The answers are pretty straightforward: happier, healthier patients and fewer, smaller medical bills.

These are fruits of patient empowerment that is no longer the first priority of providers, payers and candlestick makers. To hell with that, let’s get it on.

“You’ll need to sign these forms and get labs before the doctor can see you.“

Determinants

Humaginarium addresses the problem of health incompetence, and we do it in a new way.

Not by telling folks how to avoid, prevent and control chronic illness, but letting them figure it out by themselves.

Not by imparting sterile medical information, but empowering them to make choices and decisions that satisfy underlying needs.

Not by picking apart symptoms and treatments, but nudging folks to understand and deal with causes.

Those causes are called determinants of health. According to Humaginarium, the determinants of health fall into four categories:

• Physical
• Psychological
• Social
• Environmental

Physical determinants are tangible properties of the body. Physiology, biochemistry, the tissues that give it shape and weight, the growth and decay manifest in them. Physical determinants can be seen under a microscope, on an x-ray and CT scan, in a DNA sequence. They’re as tiny as molecules swarming the mitochondria, as large as 25 feet of neatly folded intestines hosting trillions of symbiotic bacteria.

Psychological determinants are properties of the mind — conscious and subconscious, voluntary and reflexive, rational and emotional, learned and instinctive. Psychological determinants can’t be seen, yet they can be felt and measured. They’re as fleeting as appetite and rooted as depression. As a professional focus of mind-body medicine, and having biochemical agency, they are psychic fluff that both augurs and stymies disease.

Social determinants of health are properties of lifestyle. Extrinsic, situational, interpersonal rather than organic and evolved, they manifest in customs, culture, class and community as behavioral norms, relationships and traditions that organize and regulate the tribe. Social determinants of health include wealth and poverty, education, race, religion, vocation, zip code and lately ideology. Sex and violence are also big among them.

Environmental determinants of health are both naturally occurring and built — in biosphere and atmosphere, urban sprawls and outback. The water we drink, the air we breathe, the weather that rains on our parade, the ground we frack, the mountains we strip and decapitate, the rivers we pollute, the trees we incinerate. Environmental determinants are palpable yet easy to ignore. They not only cause sickness, but also extinction!

There we have it, four determinants of health by category. There’s a fifth one I haven’t mentioned, the secret sauce of Humaginarium: it’s the determinant of self.

As in, self-determination. An individual’s firm intention to achieve a desired end. Self-determination theory explains out how it works and what it means; conation gives it linguistic pedigree; motivation, grit and ambition haul it into common parlance.

Self-determination is what a person exercises to assert cause, rather than be wrangled by the causes of others. Self-determination can be positive as with Laurence of Arabia, or negative as with Billy Budd. Either way, it is the single most potent counterweight to the other determinants of health that I listed. And of course, it is largely ignored by healthcare and biomedicine as we know them.

As players in Humaginarium develop their own firm intention to prevent, avoid and control the chronic illnesses they meet in our fantasies, it shall happen, they will win, both in game and real life.

But as long as they lack the gumption and inspiration and wherewithal to stand up and fight, it will not happen. I believe that as surely as I believe the sun also rises.

That Humaginarium has found a way to operationalize self determinants at scale, quickly and easily, simply means that the days of the other determinants of health may be numbered. They have ruled and tortured folks with chronic illness enough. Shut the back door. Game on!

From The Little Engine That Could

Suprematism

Suprematism, or constructivism; is that a question? It is, when we come to designing video games. Each is a pillar of design thinking. Each is a buttress holding up the walls of our visual program. They don’t really go together; in fact, each yearns to cancel the other. I want to make opposites attract with a bold new visual style that few seem to have mastered.

Suprematism is the most abstract of arts. It springs from an ideological rejection of objectivity and representation. A suprematist doesn’t mirror nature, or any aspect of the real world. Nor does a suprematist idealize by probing objects for mathematical properties that reveal and convey meaning. Suprematism reports, and cares only for, feelings: immediate, nonverbal, ineffable emotion, triggered by visual perception and expanding into lofty, unmapped spheres of intimation and sensibility and enlightenment.

Thus a suprematist, unlike most artists, is neither magician nor pretender. A suprematist doesn’t wear a mask or dupe people into seeing what isn’t there, or believing that an artifice has physical power. Suprematism is pure sensation and feeling. Feeling about.. what? Desire, valor, truth, fulfillment? No, nothing like that. Suprematism causes feelings about nothing at all: feelings that are a wordless projection of the human condition.

If you’re bored or repelled by feelings that are not for or about something, then suprematism is not for you. On the other hand, if you prefer art that you can use, then constructivism may work better. I think it works well.

I often mention constructivism as a pedagogy. In that sense of the word, constructivism is an offshoot of heuristics and untrammeled learning from experience; the ways children learn when playing and adults learn at work. Both learn by doing things, their own way, alone and with others, discovering what satisfies and turning that into competence. Diabetes Agonistes is a video game simulation, Metabolic Genii is a video game role-play. Therefore, each facilitates constructivist learning experience. But learning and visualization are different things.

Suprematist and constructivist art emerged in Russia in the early 20th Century. Both were revolutionary at the time, became very influential, and remain so today, mainly because they epitomize the morally courageous act of shrugging off tradition and authority, and placing all bets on creative freedom. Suprematists shrug to evince the human condition, constructivists shrug to improve it.

Constructivist art, in theory at least, is utilitarian. It wants not to be viewed, but interrogated. It wants not to be admired, but engaged. It wants not to be hung, but applied. It wants not to be pretty, but unsettling and useful. The most notable constructivist working today is the street artist Banksy. Fracturing rather than mirroring or adorning reality, forcing sudden openings for invention and reform. Not in the artist, but in people who experience art.

There you have two opposites, of sorts, and both are central to the mission of Humaginarium. We are creating interactive art and entertainment that epitomizes the human condition and generates intense sensations, without recourse to narrative, without telling people what to think or how to behave. Just keeping our philosophical mouths shut while they enjoy the playground. And yet, their enjoyment doesn’t stop in the playground. It continues in the imagination and transfers to the real world as a mindset, a frame of reference, a sense of morality, a habit of informed thinking.

Is the question suprematism, or constructivism? No, not in our project, and not at a time when tradition and authority are grinding to a stop on the train tracks to nowhere. We need all the resources of resistance we can get! Because work does not make us free; the act of shrugging might.

Suprematism and constructivism, feeling and empowering: each in full flower, in the same visual program, for the benefit of many people who couldn’t care less, but should.

Suprematist logo art of Humaginarium.

Experience

Video game entertainment is a process more than a product; moreover one that people control to their advantage. For example, as they play Diabetes Agonistes, their personal experience of discovery, invention, synthesis and resolution is paramount. They, not the game, make individual choices and meaning that bring the game to life. They learn from their experience in a process known as heuristics.

Unlike pure play (epitomized by Johan Huizinga and Bernie De Koven), a video game is structural and ordained. It imposes rules on performance; meets out punishments and rewards; tells a story or at least has a narrative arc; occupies virtual space that seams realistic or at least familiar. A video game has personality or involves characters whose personalities have to be dealt with. One of those personalities belongs to the player who participates as an actor: performing a role that is directed if not scripted by the game.

Diabetes Agonistes has five complementary dimensions of experience that enrich lives. By enrich I mean amuse and edify, make them happier, smarter, healthier. These are the takeaways and reasons for coming back for more.

The first dimension of experience is art. Just looking at Diabetes Agonistes gives pleasure and satisfaction. Enjoyment doesn’t depend on understanding or using what’s visible. Drawing, painting, modeling render all subject matter beautiful no matter how it actually appears in nature, if at all. We use a hybrid style of hyperrealism and romanticism to achieve this effect, because the blend is perfect for rendering science and fantasy from the same perspective.

The second dimension is entertainment and it surprises me. Diabetes Agonistes is funny, though I haven’t thought about it that way. It wants to be liked though it’s morbid, difficult, obnoxious. It mocks itself and makes fun of others, and seems to have neither center of gravity nor gravitas: dancing when told to march, joking when asked for help, by turns Harpo, Groucho or Chico and willing to do anything to earn people’s trust — not to make subject matter easy but to make it fun.

The third dimension is fantasy. Our scientific subject matter is not imaginary, not invented, not theoretical, not in doubt. It’s real in every cell of the body; and it’s faithfully represented in Diabetes Agonistes: modeled, simulated, rendered before cast as art and entertainment. Yet the experience we make of science is perversely unrealistic. After taking much trouble to get it right, we rig it in fantasy. We let folks pretend that illness is no threat, but a competitor. Rather than retreating in fear, anger, denial as folks do in life, fantasists tackle illness curiously, deliberately, with chutzpah.

The fourth dimension is plaything or toy. Diabetes Agonistes has unconstrained elements that are not justified by game rules, mechanics, theory, objectives. Pictorial embellishments, challenging diversions, anecdotal pockets that randomly delight for no logical reason. Our proper game about metabolism gains nothing from playthings, while people enjoy the silly distractions. They are occasions for lallygagging.

The fifth dimension is game. It immerses people in conflicts they’ve never consciously had and would avoid if presented another way. Life and death conflicts that erupt in their imagination, involving mysterious dynamics that are scary and difficult to understand, and that most folks are unfit to learn by any pedagogical means. Gaming not only makes it possible to learn, but more importantly desirable. People get to vanquish pernicious drivers of their illness.

Indeed our video game is a process more than a product. A process involving perception, cognition, emotional engagement, self-determination. Each one of the five dimensions is a way of experiencing the process, a way for players to deposit themselves in a virtual world of endless opportunities, and later take themselves out with gifts of amazing insight.

Outcomes

WHO states that “health promotion enables people to increase control over their own health.” I unpacked their statement for Humaginarium like this: Diabetes Agonistes enables naive adults to increase control over their chronic illness.

Notice the use of that subtle word “enable.” It means that health promotion itself doesn’t control anything. It’s neither a drug nor a dictate. It merely qualifies people to exercise control, on their own, under certain circumstances, if they choose to, until they don’t. Qualifications may be conceptual, rhetorical, even technical skills, fired by greater knowledge and resolve that promotion may catalyze, but not deliver fully baked and ready to use.

In other words, people themselves increase control over their own health; health promotion only gets them started.

This makes isolating the outcomes of health promotion a bit more complicated. Outcomes are changes brought about, differences made, measurable results and impact accomplished. As a program of health promotion, what are the outcomes of Diabetes Agonistes?

They are, in a word, competence. That’s the ability to make and stick to healthy choices. But hold on, how can anybody make healthy choices unless they first understand them? Must they study, randomly guess or even delegate them to others? And how can they stick with choices they made unless they understand consequences? Must they follow rules, be nudged, form habits? None of these sounds like an option for highly effective people.

Stephen Covey famously wrote that highly effective people “Seek First to Understand, Then to Be Understood.” That’s both a rule and a habit, so maybe it’s not an appropriate reference here, but people who don’t sport an orange hue generally agree that no problem can be solved before it’s understood. That ain’t rocket science but it is a foundation of laboratory science and clinical medicine. Seek first to understand chronic illness, then be understood as an individual who has one. Axiomatic.

Still, understanding gets only lip service in health promotion I’ve looked at — and why not? It may seem impossible for regular folks to understand physiology, biochemistry, molecular biology, genetics and other aspects of human metabolism involved in Diabetes Agonistes; but understand they must in order to be highly effective people. Even language that describes metabolism sounds and looks like totemic argot. Can Joe and Ms Sixpack ever become interested in such an obscure and erudite process inside the body, even though the process makes them healthy or sick or ends life prematurely, depending on things the Sixpacks can’t see or touch or make any sense of? Better not to try; just nudge the simple folks to their purportedly healthy choices.

That’s a terrible idea and not because it’s never been tried. It’s always tried. Most health promotion treats understanding as optional, even superfluous, while favoring compliance and adherence. Tell ‘em what you’re gonna to tell ‘em. Tell ‘em. Then tell ‘em what you just told ‘em. If patients with poorly controlled blood pressure or diabetes type 2 got a nickel for every time they’ve been told to eat fewer carbs, get plenty of exercise and take their medicine, they (instead of their physicians) would be seriously rich by now! And yet morbid metabolism is still rampant and there are no signs of abatement.

The reason for that is obvious: instructing and nudging are not replacements for understanding. Seek first to understand means delay those healthy choices until you really know what they mean and then make one that you can — nay will, desire to live with.

The outcomes of Diabetes Agonistes are, in a word, competence. Ours is health promotion that doesn’t look down on people, but looks up to them for thought leadership; that doesn’t ask them to learn stuff they can’t understand, but makes them understand before they realize they’re learning; that doesn’t tell them what to do with their body to be healthy, but asks them what they want to do with their sovereign body and what they actually will do; that doesn’t define physical reality as a biometric paradigm, but kicks physical reality down the stairs and replaces it with wholesale shameless fantasy (wish fulfillment); that doesn’t portray patients as victims, but honors them as warriors and heroes; that doesn’t reward them for passivity, but compliments them for chutzpah; that doesn’t coddle them as though they were morons renting space in their body, but challenges them because it knows they are the smart owners of their body; that replaces nescience with scientific health literacy for actually making healthy choices that also make perfect sense; that allows them to ask why instead of always showing them how, even if it takes a lot longer to get there and the final destination is less than ideally perfect.

I can say this about Diabetes Agonistes because my words are consistent with what WHO recommends: that people themselves (not their delegates) may be able to control their own health better, but nobody nobody nobody can do it for them. Exercising more control without being forced or pinged or supervised or digitally assisted is their responsibility. They can fulfill it only one way: with competence.

As health promotion, Diabetes Agonistes works in the interstices between professional domains of practice, policy and education. This is a no man’s land of nescience. The gap there between knowledge and actual behavior may be infinitesimally small, as it is with virtuoso musicians and professional athletes. They almost always perform well and there is little noticeable difference between what they know, what skills they have, and how they perform. But most of us are not virtuosos of the body. We require tons of practice to get it right even some of the time. Diabetes Agonistes provides hours of opportunities to practice.

WHO continues: “People need to acquire the knowledge, skills and information to make healthy choices.” That’s true, I agree, and Diabetes Agonistes does grow knowledge and skills while presenting information in a phenomenal computer model. That said, WHO left out something very important when it comes to health promotion for people with chronic illness.

What’s missing goes by various names: ambition, conation, motivation, self-determination, drive, grit, passion, courage, resilience. No matter what we call this thing, if we don’t make it a priority, then health promotion is bound to fail (as most of it already does, demonstratively).

Diabetes Agonistes will probably succeed because it never tells people what to do or think. It lets them figure that out for themselves, in playful activities that are utterly, indubitably enchanting.

Mechanics Redux

Mind Mapper. Experience in the morbid frontier is enchanting, intriguing, dangerous, bewildering. As a meaning maker, your job there is to filter experience for things that matter – things you can use – and relate them to an obscure metabolic condition that is ominously unfolding in the shadows. Like an archeologist, you interrogate each shard you pull from the biomuck for the story of what it is, how it works, where it came from, what it wants and why. The shards are tangible things with familiar, physical properties; moreover they are metaphors for other tangible things that were beyond your ken before Humaginarium: atoms, molecules, cells, tissues, fluids, organs, mechanisms. You capture their stories with the aid of dynamic mind mapping. This is the visual equivalent of “mapping sentences” that distill coherence from a churning chaos.

Dorian Gray. Users in the morbid frontier are not told what to do or forced to do anything. They do what they want in light of self-interest; which means, whatever it takes to win. Most users will do anything to win, yet their moral and intellectual lights are dim to begin with; and they lack wisdom to make good choices intuitively. So they wind up making and having to cope with bad decisions and failures. How does that affect them? The way crime affects Dorian Gray in Oscar Wilde’s novel: by scourging the alter ego. Users who do bad things for the sake of quick wins – such as skirting or accommodating rather than confronting and controlling morbidity – may appear outwardly heroic, but they are wounded warriors in Diabetes Agonistes. They can eventually heal their wounds by atoning (changing, compensating) before it’s too late; or allow wounds to fester and settle into disability.

Monsterography. Maybe the worst thing about chronic morbidity in real life is transparency. You can’t see, hear or touch this disgusting thing that’s inside you, but is not you. You feel it when it flares, but even when that happens all you can see and hear and touch is not disease, but the tracks that disease leaves on your flesh and psyche after the ravages. The physical evidence indicates that your body itself is the disease: the perpetrator rather than the victim. You blame the victim for your pain and suffering. You’re revolted by your own body that is relentlessly harming you. You fear, you’re angry and you deny the body the way a prisoner despises a jail cell. “What have I done to deserve this? My body hates me.” But unlike life, in Diabetes Agonistes morbidity is not transparent. It appears as it feels: monsters in the body, but not of the body. Horrible monsters that you can more than revile: you can, if you’re clever, destroy them without ever mistaking them for the world they occupy. Monsters here are personified, parasitic, repulsive chronic diseases that users capture and kill while the godlike body lives on.

Combat. My game mechanics stress cognitive and emotional affordances. I want users to perceive and think their ways through challenges, not randomly shoot them down like snipers in a carnival booth. “Nice shot, lad! Here, have this worthless trinket as your reward.” I daresay I’m bored by meaningless kinesis in play of any kind including video games; and I believe that many adult players feel the same way. We want adventure much more than effects; and adventure by definition is purposeful risk-taking. In most play and in Diabetes Agonistes in particular, adventure is experienced as agon. Not merely fighting, but fighting for something that matters. That something – here and now – is wellness. The fighting that wins wellness is tense, noisy, horrifying, vicious, calamitous, brutal, raw, hopeless, heroic. Fun for its own sake, yes, but these many fights accrete into an epic struggle, a true adventure. Humaginarium rewards wins not with trinkets but with tokens that reinforce users for later, harder, nobler existential challenges.

I have a few other core mechanics for this post, but instead I will end with a reminder about context. Diabetes Agonistes is a simulation. It’s a system simulation of physiology and biochemistry; it’s also an experiential simulation of health literacy tempering medical self-efficacy. As a game simulation, interactivity is maximal; passive displays are minimal. Several times a minute during hours of play, users must ask themselves and the game tech: “What is this? What does it mean? How can I use this? What should I do?” Simulation then is our ultimate game mechanic. The faithful, behavioral representation of how chronic illness manifests inside the human body. Damn hard to get your head around, and incredibly fun to try.

Mechanics

Users cross the morbid frontier with a plan, a map, a wallet, provisions and a cache of clues. They have a tough job ahead in Diabetes Agonistes. Seize the minions of chronic illness! Reclaim the birthrights of strength and safety! End the pain; end the suffering; end the fear of your own body!

Whoa, whoa, not so fast. Everything you try in this godforsaken fantasy will be challenged or opposed. What you see and feel is a fraction of what’s actually there; and much of that is out to get you. So be careful.

The minions you’re chasing are feral, ugly, numerous, devious, nuanced, complicated and uncannily intelligent. They’re thriving like a nest of vipers while you gingerly probe their squirming skins. When you grasp one it may throttle or bite, or emit begging sighs that lure you inward or downward, but probably not onward. After all, you want to live strong but the minions of chronic illness frankly want you to die. They might go so far as to kill you! It’s not hopeless though. Their crushing powers to confuse and depress may yield eventually, but not to chemical or nuclear weapons. Only to insight tempered with rare, gemlike passion you store in your heart for this quest. Health may be a human right for others, but you’re going to fight for it.

There are structural mechanics in the morbid frontier. By that I mean programmatic activities. Remember you’re in a video game now where NOTHING happens unless you trigger it. The good news is that your path is packed full of affordances. They are the logical, functional, evocative, riveting means to your ends. They’re also symbolic and deeply disturbing. Purpose-built to ignite learning and motivation. In the morbid frontier, everything you’ll do to overcome The Problem inflames your own personal desire to learn and go farther, and accomplish more.

Let’s begin to envision the game mechanics of Diabetes Agonistes.

Trusted Advisor. You may traipse solo through the morbid frontier, if that’s your style; or bond with a droid who has special powers. To interpret clues, weigh choices, fabricate tools, detour into branches, avoid pitfalls, barter, negotiate, interrogate, assassinate. All handy services, but beware of friends. Droid talents and loyalties are time and place dependent, devilishly restricted. You won’t know their limits until you test them; and you won’t be able to test a droid until you badly need it. You must learn when to fire and replace trusted advisors before they steer you into deep shit.

Meaning Maker. You may journey through the morbid frontier for the fun of it, as though it were some grotesque carnival. That would be thrilling and satisfying, but not winning. To win you must continuously make meaning from your experience. The meaning you make guides you onward, makes you more resilient. Emerging knowledge gradually transforms you into a master of fate. Take note of this. Diabetes Agonistes doesn’t teach you; it teaches you nothing. You force the quest to reveal truths that you can use. Making meaning is like fetching the key that turns the lock, from a ring of glittering duds.

Highways and Byways. You enter the morbid frontier with a map. Unfortunately, the map is a character with a quirky personality, a hidden agenda, and is somewhat unreliable. It doesn’t show you which way to go; doesn’t show all the ways to go; it merely indicates topography and suggests possibilities. You interpret the map, filling in gaps with your intuition and discoveries. You treat the map as a data store rather than a bundle of insight. You filter it for wisdom while suspecting it may be lying to you or mistaken. By improving the map in time you will gradually become a skilled cartographer for higher, more difficult levels of the morbid frontier.

Profit and Loss. You carry a digital wallet, starting in the Arcade and throughout Diabetes Agonistes. The wallet is initially stocked with enough capital to float your quest; but not enough to complete it. The wallet holds identity cards, credit cards, biocurrency and tokens that have specialized uses and surprising half-lives. In the morbid frontier you draw down this capital to pay for provisions and clues, bail, gadgets, services like protection, ferries and contract kills, healing balms and magic incantations. You may replenish your capital by earning rewards, trading objects, robbing minions and their bosses, ransacking their troves, trading on the Metabolic Exchange. The wallet is your permanent and personal property. It goes with you when the game is over and you’re on to a new quest in Humaginarium.

Are there more mechanics than these I’ve just shared? Indubitably. I want to keep writing about them. I’ll resume in my next post.

Morbid Frontier

The exposition of Diabetes Agonistes turns on goal-setting, surveillance, and discovery of The Problem – by users who are going to experience and try solving it. In the real world The Problem is called metabolic syndrome – a nexus of chronic illness including diabetes mellitus type 2. In the fantasy of Diabetes Agonistes The Problem has no name. It’s an ominous presence, an irresistible force that manifests metaphorically, visually, dramatically as a vague, existential threat. More suicide bomber than complex medical condition.

Up to this point, users have glimpsed and probed the borders of a frontier full of hazards and portentous implications. They’ve observed and gathered biological phenomena that eerily materialized before their eyes – each unpacking different clues and warnings about what lies ahead in a quest. The clues suggest where and how The Problem may be found, observed, engaged. Warnings promise enrichment and fun to “all ye who enter here,” while darkly insinuating ambush and horror for hapless adventurers.

The frontier I’m talking about is a new transubstantiation of the human body. Rather than body into wafer, this is body into earth and sea. The frontier is underpinned by computational models of physiology and biochemistry that we’ve exploded and reorganized, reshaped and robed as a chronological, three-dimensional space like Eä and Arda and Middle-earth. Those dreamscapes are symbols of nature at every level and civilization in every moment. They are make-believe geography and history that were created to be explored, claimed and defended by questers pursuing salvation and truth along with victory and peace. Somewhat like the mythos of yesteryear, our new biological fantasy evokes metabolic structures, forms, content, mechanics and processes of a diseased human body; not as a body per se, but as a world that users bravely traverse and strive to master.

A typical user enters this frontier by choosing among three trails that present different perspectives on The Problem. Each trail attracts a different kind of user, but all lead precariously to the same endgame.

The first trail is elemental. It winds through the biochemistry of a metabolically disordered body at its least visible and experiential; its most enigmatic and elusive. From the elemental perspective, the constituents of metabolism have existed for billions of years – since life on earth began in the primal slime – and will continue long after their human hosts have departed. They are like the Valar. They make human life possible; they can sustain or end it in a snap; but all the same they are woefully indifferent to it. Their concern is all life, not human life in particular; and their fate is not bound to ours. This is a molecular agon.

The second trail is combinative. It makes its way among microbial tribes of the afflicted body, populated by wholly formed and determined agents who have unique personalities and life stories. Some tiny organisms are virtuous, others malevolent; some are brilliant, others mechanical; some are empathetic, resilient, capable of serving the greater good; others selfish and moronic, having little on their minds beyond the next meal and procreation. Neither immortal nor transcendent, they persist as long and as well as their tribe does; causing or enduring metabolic disorders and maybe overcoming them alone or with help; but rarely able to survive far from home. The whole of their population is equal to the sum of its parts. This is a cellular agon.

The third trail is civic. It cuts across the anatomy of an unwell body in which relations between tribes are modulated by rules, authorities, competing interests and economic pressures. The actors encountered here are systems rather than molecules or cells. When they are not disoriented by morbidity, they rest in balance and harmony: the endgame of homeostasis. However they are extremely vulnerable to attack, and in defending themselves these organs, tissues and fluids may spiral into conflict and chaos that end badly. This is a physiological agon.

Three trails through one frontier, with discrete beginnings but myriad links, dependencies and interferences. No matter where users begin, their quest ranges through all, interweaving their bewildering and frightful perspectives. What will it be like to play on and in them? That’s for my next post.

Quick Wins

I’m observing a typical user of Diabetes Agonistes: a woman in her mid-30s, perched on the lower rungs of the middle class; a little large she is with high blood pressure and sugar. She’s attractive, gregarious, restless when she isn’t busy, dreamy when she has time for herself. Years ago she finished high school and landed a sales job in the local mall; now she’s a merchant. A single mother whose days are stretched to the breaking point; but to her it feels heroic. She works hard, plays nice, is conscientious about her family and customers. She reads little for pleasure, but has her favorite shows and podcasts. She tries to do the right thing even when that isn’t easy or obvious or cheap, and she counts on quick wins to hold it all together. Quick wins are also why she plays video games, most days for an hour or less; in the train on the phone, at home on the computer. Her favorite kinds of games stymie her as much as life sometimes does, but they also throw off hot sparkling bursts of light, the crackling noise of walls collapsing, the thrill of snatching well-earned victories from the jaws of near defeat.

She heard about Humaginarium from a boyfriend. He said it’s pretty cool, “but you might not go for it because it’s gory.” Pretty cool as in really nice looking, gory as in bloody; yet no gratuitous violence, and that detail got her attention. She’s bored by dumbass shooters and bosomy warriors. It’s free, he added; it streams so it starts right up, no downloads, hardly any latency. “It’s different from anything I’ve ever played,” he allowed, so maybe she’ll have a look? He got into it two weeks ago and he’s still working through the first level. “Damn thing reminds me of Jules Verne” – 3D science fiction fantasy, clue-finding and brainy calculation, mysteries locked in enigmas that are supposedly true – TRUE – “as the human body itself.”

Her eyebrows went up when she heard that. “The human body? Is it a sex game?” He pondered, “actually more sensuous than sensual.” She wasn’t sure what that meant and neither was he. “Rated M, not A.” Okay, good enough!

One night after brushing her teeth she entered Humaginarium in a browser on her laptop and soon found herself wandering a fabulous Arcade. It was confusing and disorienting, yet funny. “Like I’m Alice in Wonderland,” she mused, “or Spirited Away” as she watched and touched things that seemed to have minds of their own. Lots of colors and movement, fractal images and eerie sound effects, curious linkages that eventually made her suspect something was going on: it wasn’t just random game mechanics. She was witnessing the “miracles” of birth, growth, decay and death of the body as though they were magic shows. They helped her form mental models of wellness that are religion in Humaginarium: things to adore and believe in. A firm grasp of wellness finally unlocked a portal into a different and strangely hidden world, one fraught with danger and mystery yet irresistibly beautiful; the hidden world of morbidity.

She wanted to stop right there, not because she wasn’t curious; she was actually intrigued. But over an hour had passed as she explored the Arcade and turned that lock in the portal. It was past midnight now and her alarm clock was set for 6:00 AM. She wondered, “what will happen if I just stop?” Would she lose everything and have to start over? “This is ridiculous, it’s just a game,” and she decided to exit. Before closing the app asked, Do you want to keep your Humaginarium Key? “Sure, why not? What for?”

The next day on the commute to work she had a few minutes to spare, so she started Humaginarium on an iPad. “This won’t work,” she murmured. Wrong! It worked just fine. The app retrieved her Key from Dropbox, authenticated her identity, and transported her right back through the gates of … what … Heaven? Hell? It’s fun is not knowing which. On the other side of the portal she learned she has to quest. She can start right away and collect greater honors and rewards for speed. Or she can slow down a bit and learn before she leaps. She didn’t have time to decide. As the train approached her stop she had to exit.

Sadly she didn’t return to the game until the end of the week, for reasons that have nothing to do with this history. When she regained her previous position in Humaginarium she watched a quick replay of everything that previously happened to her. Now she was ready to forge ahead. She spent an hour collecting raw intelligence about her adversaries and allies in this weird biological fantasy. When she had enough of that, she entered a path that led to…. We’ll find out where in my next post.

Scientific entertainment. La Baigneuse Valpinçon (1808), by Jean-Auguste-Dominique Ingres; pictured with microbiota in the human alimentary canal.

Provisioning

This is the game objective of Diabetes Agonistes:

• Seize the causes of metabolic disorders
• Confound their powers to harm
• Claim the birthright of homeostasis

Reminder: this serious objective is met with play, not with study. It’s pursued in a fantasy; not real life. Users solve tough problems on a personal quest through the make-believe. Yes, they will eventually do similar things in their own real life; and they will do it better because they practiced first in Diabetes Agonistes. But I’m not concerned with that now. Right now I’m thinking only about how to play a really good game.

Each of the three jobs I mentioned – seize, confound, claim – is an agon. Each is beautiful and magical, yet difficult and messy. Users who don’t carefully prepare before questing will fail fast and often.

Players who are MDs and RNs – there will be plenty (real and aspiring) among our play testers – may opt to ‘damn the torpedoes’ because they’re confident of their scientific and clinical acumen; they may plunge headlong into the fight to prove they can beat this silly game sim in record time. By design though, they’ll get plastered by adversaries who have even more confidence, and with good reason.

Preparation for questing is necessary and also voluntary. Like everything else in Diabetes Agonistes, success here depends not on what users know but what they choose to discover and then use. It depends on clue finding and strategy. Diabetes Agonistes does not leverage motor skills like an arcade game.

Users who earnestly examine their surroundings for clues soon find a checklist that helps them prepare. The checklist is for provisioning. It helps them acquire and create things they’ll need to survive an agon. A checklist guides individual discovery of things like:

• Who are my adversaries?
• Why are they adversaries?
• What are their powers?
• Where are they now?
• Do they morph and mutate or always stay the same?
• Are they immortal or can they be killed?
• Who are my allies?
• What can they do for me now and later?
• Why should I join this quest; what’s my purpose here?
• What do I win; what larger difference may I make?

Our principal mechanic for clue finding in Diabetes Agonistes is a metaphor for geolocation. Users can (if they wish) lease a dirigible airship with credits stored in their key. They can steer this airship above a phantasmagoric terrain that elegantly symbolizes human biology and physiology. This landscape is not a funky realistic model of the human body as in most healthcare simulations; it’s not like Lemuel Gulliver in Brobdingnag, or Frankenstein’s cadaver, or a Russian scientist in the movie Fantastic Voyage. Instead it’s an experiential metaphor that showcases metabolism in the human body as a fabulous, habitable world.

Users survey this world from high and low altitudes. They probe it for insights that can be used when pursuing the game objective, but they don’t do that peacefully. Adversaries who dominate the terrain have radar; they sense when their empire is being scrutinized and they don’t like it. The knowledge of others inflames them! Once detected, they do everything they can to capture or kill users who spy on them, knowing that those who escape may come back to haunt them.

In addition to geolocation, users may discover clues in curious containers. Some containers explode when touched inappropriately, others open when gently coaxed; some open freely, others unlock with credits stored in a key; some are unique and can’t be shared, others can be traded. Some are useful and endow users with powers to heal or cure, others are evil and extremely dangerous.

When users guess they have all the clues they need for what comes next, their questing may begin. I’ll describe that beginning in my next post.