Ready, Set, Derm: Advancing Dermatology Through Video Games Part 1

View part two here.

Eric Gantwerker, MD, MMSc, FACS, AFAMEE, is a pediatric otolaryngologist. He is also the vice president, medical director at Level Ex, Inc., the world's leading medical video game studio. Dermatology Times® recently spoke with Gantwerker to discuss the company's dermatology video game, Top Derm, and its role, as well as the role of medical video games, in advancing the future of dermatology.

"Games have this trial and error, this doing it over and over and over again. And we can introduce these different disease entities that normally you wouldn't think about," Gantwerker said. "Games really instill that pattern recognition, that ability to remember things long term."

Eric Gantwerker, MD, MMSc, FACS, AFAMEE: So I'm a pediatric otolaryngologist in academic practice in New York, about 60% of the time, and then 40% of the time, I work with Level Ex. So I'm the vice president, medical director, and my sort of role here, I've been with the company since the very beginning, initially as a subject matter expert, and then been the medical director since 2018. And essentially, in that role, oversee everything from a medical and educational standpoint across the company.

Dermatology Times: What are Level Ex and Top Derm?

Gantwerker: So Level Ex is essentially a medical video game company using the technology and psychology of video games and bring it to health professions education. We do that through multiple ways: through mobile games, through cloud gaming platforms, and a bunch of other specialties including dermatology. Top Derm is specifically for dermatologists, and it's essentially a knowledge-based challenge game to look at all different kinds of diseases and all the stuff that dermatologists do every day, focused on practicing dermatologists to keep them updated on new treatments, new diseases, new mechanisms of action, mechanisms of disease, and such.

Dermatology Times: How widely used is Top Derm?

Gantwerker: We have about a million users, health care professionals, in all of our games. TopDerm is still active, we're releasing new packs. It's significant numbers, and we have good idea of how many players are playing, how active they're playing, how long they're playing, which is really, really near and dear to all the work that our teams have done.

Dermatology Times: What is the significance of Top Derm for dermatologists are care for patients of special populations/with rare conditions?

Gantwerker: So I mean, I think the really big thing for us and what we see in the games industry, is essentially that people learn so well through games, just through action. And traditionally, the way that especially practicing clinicians learned, was going through conferences, sitting in a lecture, now sitting over Zoom for hours on end, which is very passive, which we know from the literature: that's not how best people learn. Best people learn through activity, through action, through active learning. And that's literally how games have been working for 1000s of years, and so video games and using that technology and the psychology of video games to deliberately design an experience for dermatologists was no small undertaking. But essentially what we're trying to do is instead of sitting and reading about that case, why don't you play through it? Why don't you be the person in charge of this rare case, this rare disease? And there are a lot of gaps that we saw in dermatology; specifically, there was a lot of news around the skin of color, and how the atlases and all of the different dermatology textbooks didn't have representations of skin of color with certain diseases. And so people just didn't recognize them in practice, and so that was an immediate area that we thought, okay, we can use video game technology, and that's how we built this game engine that literally showcases any disease entity on any color of skin to help fill that gap. And that was really something that I was very proud of, our team was very proud of, and something that skin of color, was introducing that to dermatologists who normally didn't have access to those types of materials.

Dermatology Times: What are the benefits of learning through video games as opposed to in real life?

Gantwerker: So the biggest thing we see in the experiential learning model is what medicine has been modeled after. The problem with it is that it's relatively sporadic, and it's not evenly split, so if you're a dermatologist in, let's say, Australia, you're going to see a ton of melanoma. If you're a dermatologist in Montana, you're not going to see as much melanoma. So that differential of experience, and exposure to those diseases, and the chance that a patient comes in, is not the greatest way to learn. And so we know that even accessing patient-specific cases, really the only way to fill that gap is to read about it. And there is a place for that, and there's a place for sitting in a lecture. But we do think that knowledge retention is much, much better. The example I always give is, imagine Monopoly in your head. If you've ever played Monopoly, it's probably been years since you've played Monopoly, but if I asked you to list any of the properties, any of the colors, the order any of the cards, or any of the money amounts on the board, you probably can name a fair number of those items, even though you haven't played the game in forever, maybe decades, for some people. That is how games just create a fun environment, and learning is the unintended consequences of fun. And that's where games have really special magic for people to learn. Our CEO says always says that kids remember 40 Pokemon characters, but not 40 US presidents, and there's a reason why that happens, is just because games are built on the understanding of the deep neuroscience of play and the psychology of how people learn, and just hit on it to hit it really hard so that people remember stuff, and they remember it for long term.

Dermatology Times: How can medical video games like Top Derm be used for awareness and recognition of conditions?

Gantwerker: So I think awareness is a huge component of what we do, because if you don't see something every day, and especially with that experiential learning, rare things are rare: you're not going to see them that often. And maybe 1 person may see it, they may present it at a conference. If you don't go to that conference, guess what? You're not going to hear from that expert on this extremely rare disease unless you read about it, and again, you're not going to remember it because you don't see it that often. Games have this trial and error, this doing it over and over and over again. And we can introduce these different disease entities that normally you wouldn't think about, without creating, in some sense, a recency bias. You actually want to create a recency bias, because if you see that rare disease again, you're like, 'oh, my god, I remember that,' and remember that games really instill that pattern recognition, that ability to remember things long term. And if there's rare diseases and patients who present with those diseases, who've seen 10 doctors and [say], 'I just don't know what this is, no doctor's been able to answer this for me,' then keeping that in the top of mind and be able to present those disease. Again, rare diseases, in rare instances, in rare patients, is something that games can do very, very well, and that awareness we've done in a bunch of different rare disease areas. And obviously, where there's therapeutic options that are coming out to the market, making it aware, like, 'hey, this was a disease, you couldn't treat for a really long time. There might be a treatment coming down the pipeline. Let's refresh your memory about what this disease was because now we have options.' And that is not something that is in their day-to-day workflow that they can learn about because they're not going to read about that rare disease unless somebody else presents it to them.

Dermatology Times: What is the role of medical video games in advancing dermatology?

Gantwerker: The world of dermatology is very interesting. They're [dermatologists] very, very good at pattern recognition, and they see a lot of very common things, and sort of pass it off. But the rare things are always very difficult. And everybody needs a dermatologist. If you go on to any physician forum, there's always posts about rashes. There's all these Facebook communities that I see nothing about, 'What's this rash? What's this rash?' Dermatologists literally do that every day, and so I think that ability to represent some of these rare things that they may not see, or some of the community dermatologists who don't have access to academics, that is really a gap that games can fill, especially with our games, which are mobile and accessible anywhere. Like I said, if there's a disease in Australia, getting it to somebody in Seattle isn't always in real time. And so we can represent those diseases and educate at a distance, something that conferences can't do very well. And so that is something that we think is a huge advantage for video games because of the ability to disseminate information, as well as the technology of video games, because we can make skin renders that look extremely real. You actually can't even tell the difference between the 2 of them, and that is from the games industry. And that is, I think, something that people don't realize, like, 'oh my god,' it's not just the psychology, but this technology is cutting edge. And that's where you're seeing it across the board in health professions education, but specifically in dermatology, because skin is king. I mean, skin is the biggest organ of the body, right? And so if we can educate health care professionals to recognize rare diseases, get deadly diseases earlier, which is some of the projects we're working on, getting even primary care doctors to recognize very deadly diseases early on, or even dermatologists who don't always see some of these conditions early on, we can really make a huge impact on patient outcomes.

[Transcript edited for clarity]