A conversation with Sam Glassenberg, Founder & CEO of Level Ex
We were honored to be joined by Level Ex CEO Sam Glassenberg, who heads this innovative company that creates industry-leading video games for physicians, for a discussion about the role of games for doctors in the future of medical education. The conversation lead us from the surprising overlaps of game design and medicine to how this type of mobile based learning will continue to shape the landscape of healthcare. Watch the video below or read the transcript for all of his fascinating insights.
Watch the full video
Read the transcript below
Lauren: I am so, so happy to have the founder and CEO of Level Ex, Sam Glassenberg, with us today. Level Ex is an amazing company which creates industry-leading video games for physicians. So, I’m really, really glad and proud to have Sam joining us today to answer some questions. So, I’m gonna jump right off. Sam, you’ve mentioned in previous interviews that Level Ex games capture the challenges of medical practice as video game mechanics, for example, puzzles and hidden object games that are similar to the thought processes involved in diagnosing a patient. So, what are some of the other surprising overlaps that you found between game design and medicine?
Sam Glassenberg: Oh my gosh. So, this is something that we’re discovering constantly, right? So we have this giant toolbox that the video games industry has distilled over the last three decades, right? We really understand and we’ve developed all of these mechanics that, you know, some of what to actually play, you know, on the evolution of the mammalian brain. You know, really like the human brain has certain impulses, right? Like, we want to…you know, the human brain is a simulation machine. We like to predict the future. We like to create order from chaos. We like to create chaos from order. And this is the basis upon which, you know, many video game mechanics across the industry are developed, whether it’s, you know, used in physics puzzles or first-person shooters, or like you in said object games and otherwise. So, you know, what we do with Level Ex is we look at…you know, is we explore a new discipline or a new specialty, right?
We really want to distill, okay, what is the challenge of that discipline? Not just like, what is… And we’re not just focusing on what is difficult for, let’s say, the new surgeon or the new doctor to learn, but what is the thing that is challenging to the practicing physician or the practicing surgeon? The one question we’ll often ask is, like, «What gives you an adrenaline rush in the operating room?» to really try to distill, you know, what are the things that they find difficult or tricky. So, I think diagnosis is a great example. You know, there’ve been a lot of attempts to, you know, «gamify diagnosis,» but inevitably, they all look the same. You know, here’s a bunch of information about the patient, and now here’s a multiple choice quiz. What do you think it is? And this does not truly capture what is the reductive and deductive reasoning challenge of diagnosing, especially a difficult patient. And so, you know, one of the things that we did was, you know, we took a team, we took two of the top puzzle game designers in the country and we put them on the…you know, we basically gave them the challenge of, «All right, can you capture diagnosis as a real video game?»
And what they did is, you know, they followed a game design process. They didn’t just jump to conclusions. They came up with 20 different designs inspired by a wide range of different casual games, whether they were strategy games and even games like Minesweeper. And what they did is they came up with 20 different designs. We evaluated them, prototyped eight of them, and then actually tested them with hundreds of diagnosticians and then converged down to one, which is the rare disease diagnosis mechanic that you’ll actually see in some of our games. So we actually use this for training doctors how to diagnose COVID against other COVID lookalikes. We have diagnostic cases in our cardiology game, for example, and there, what they did is they created a game where we’re not gonna reward you for guessing the right answer. Your patient presents with very little information, just what you would get walking into the clinic. And then now it’s a reductive reasoning puzzle. What questions are you going to ask? What tests are you going to order in what sequence in order to not just figure out what the right answer is, but eliminate the other, what we call 35 differential diagnoses, other diseases that it could be?
So, you have to think about it. It’s a deductive and reductive reasoning puzzle. It’s not just what test is gonna tell me what they have, but what test is gonna tell me what they don’t have and how do I get there? Not just, you know, how do I not just get there, but how do I get there as efficiently as possible, right? Where, you know, asking questions takes fewer points, for example, than, you know, ordering a high-res chest CT.
Lauren: I get it. I get it. That’s actually really interesting that you touched on how it’s like the tapping into the mammalian brain, you know, to kind of really connect those two. I think that’s really fascinating. Okay, cool. So that leads me to my next question. You’ve mentioned that physicians from all over the world will submit case studies which you use to create Level Ex games. So, how does the use of real-life scenarios contribute to the realism of these games?
Sam Glassenberg: Sure. Well, look, real-life scenarios is how doctors learn. So, you know, you attend a medical conference, right, or open up a medical journal. The majority of the content is real cases, right? You know, doctors encounter a once-in-a-lifetime case in the operating room, and they will, you know, take photos, video, grab the scan data, and then write up an abstract and either, you know, submit it to a journal or potentially, you know, get up at a conference and present it to 100 colleagues in the audience. And then, you know, we can all argue about what was the right approach. The advantage of, you know, the technology that we’re building at Level Ex is now doctors can submit a case to us, and then a few weeks later, we’re sending it out to tens of thousands of colleagues who can try, you know, their hand at, you know, achieving a better outcome or trying different approaches.
So, really what this does is, you know, take one of the prime modalities of learning, right, in medicine, which is, you know, understanding the rare and difficult cases, and then just capturing that using video game mechanics. And this is something that exists throughout, you know, continuing medical education, here we’re just making it far more scalable and also more effective because you’re actually…you’re not just reading about the case, you’re actually doing it yourself. So, you know, that creates a lot of value and really sort of accelerates the ability to, you know, disseminate new best practices across an entire specialty. It’s not just the folks that are at the audience in that particular conference session in that hour, but rather anybody at any time can pick up their phone and try their hand at that case.
Lauren: So, well, you know, as you know, medicine is an area that has been slow to adopt the new technology. Do you think that infusing medical education with technology from the faster-paced gaming industry is having an impact on how quickly medicine adopts technology?
Sam Glassenberg: That is, in fact, the entire thesis of Level Ex. So, this is what we see over and over again with, you know, dozens of customers and partners that we work with. Fundamentally, you know, one of the things that has shocked me is the degree to which, you know, it can take years, it can take decades for a new medical device or a new technique that is demonstratively better, right, to gain broad adoption in medicine. Why is that? It’s not because doctors and surgeons are slow or backwards, it’s because we’re not giving them effective modalities of training, right? We can see that the first 100 procedures that a doctor does, the outcomes aren’t as gonna be as good as the next 100. In a lot of cases, you’ve got to do a few 100 cases in order to really experience all those weird, you know, edge cases and complications that can occur, you know, not daily, but on a monthly basis or annual basis in surgery. So, what we really find is the gating factor to adoption is not the value necessarily to the patient or the better outcome, it’s how difficult it is for surgeons and doctors to learn those skills, you know, and be able to achieve, you know, the same level of outcome with the new technique that they would with the old. And this is where, you know, this is something…the ability to recreate virtual humans to, you know, capture the physics of fluids or soft bodies and to really create experiences that, you know, trigger dopamine releases at the brain at the right frequency to maximize learning. You know, this is what we’ve been distilling over the last three decades in the video games industry. We’ve been using it to engage, you know, billions of consumers. But if you can use that technology to train medical professionals, this is an opportunity to drastically accelerate the adoption curve of new techniques and technologies in medicine.
Lauren: Yeah. The dopamine release is really key to, you know, solidifying whatever you’ve learned. So, I think, for me, this whole industry is extremely fascinating, and I think it really does, you know, provide so many new opportunities in the future for medical education, and just I’m very excited to see where it ends up. Okay. So, next question. You said that you had a eureka moment when you discovered the high demand of serious games for education and training in medicine two years after creating your first app in 2012. So what was your most recent eureka moment?
Sam Glassenberg: Oh my goodness. So, yeah, I think the eureka moment that I had in 2014 wasn’t just, you know, the importance of, you know, of using game technology, but what I realized is that was the first time, you know, that I had created a mobile app, basically for my father who’s an anesthesiologist. And I did it for him as a favor and ended up rallying an audience of 100,000 medical professionals who were playing it. And that was the moment I realized doctors and other medical professionals want this content and they want it available on their phones, right? They don’t want to have to travel to, you know, a simulation center in the basement of an academic medical center that costs tens of millions of dollars to set up. They wanna be able to grab their phone and in between cases or on the subway home from work to be able to grab that and practice and train and have this kind of high-quality training and simulation available at their fingertips.
Every day at Level Ex, we are sort of distilling new insights about how doctors learn and not only how they learn, but the differences between different specialties. So, one recent insight that we learned was in the development of Top Derm, so we recently launched in dermatology. And what’s interesting is over the years as we launched in cardiology and gastroenterology and pulmonology, we consistently would get feedback from doctors. Give me more background on the patient, give me more HPI, give me more patient history. I wanna see all the scans. I want to see all the test results. Even if you don’t think it’s not relevant to this case, I wanna see it. I wanna know what I’m getting into. And what’s interesting is the mentality in dermatology specifically is completely different, right? Talk to dermatologists, all that HPI, all that background, that’s a distraction, right? I don’t want to see that…show me skin. Show me skin. This is what I love about my job. I grab my dermatoscope, I wanna look at skin, rapid-fire. I wanna look at it. I wanna quickly be able to make that assessment. Don’t give me all this. I don’t need to know, you know, what trips that this patient took, you know, five years ago. So, this is a big…you know, so we see that there’s even differences in the mentality between, you know, different specialties within medicine and even within individual specialties inside subspecialties.
Lauren: Fascinating. Yeah. I think the fact that you’ve launched into dermatology at this point, I think, is huge because it is really one of those…it is very visual, you know, I mean, obviously, all specialties are visual, but, you know, it is really almost like a game itself just trying to diagnose, you know, a case in dermatology.
Sam Glassenberg: That’s the key insight. It’s all of this, any challenge, right? Dermatology is fairly obvious, right? You look at dermatology, I’m looking at skin, I’m trying to recognize what is it, how far along is it on different colors of skin, different skin tones. So, you know, you really like…there, it’s almost more literal. You can sort of see it. In other areas of medicine, it’s more difficult. So, in other areas of medicine, it may not be as obvious, but when you put some of the top video game designers in the country, you know, who’ve designed everything from, you know, Words with Friends to Call of Duty, now you start getting into some really interesting areas where you start understanding that, you know, managing a ventilator, that’s a rhythm game, right? Or, you know, interventional cardiology, that’s a physics puzzle.
Lauren: Okay. What do doctors cite for them as the most compelling takeaway from playing these games?
Sam Glassenberg: So, the most compelling takeaway from these games…it really depends on the doctor, right? So, for a lot of…you know, for a decent portion of our audience, it’s the ability to earn CME credit, right? So, instead of having to just, you know, watch a lecture and complete a multiple choice quiz, or read an article and complete a multiple choice quiz, which really doesn’t enhance or vet my skills as a surgeon, now I can go in and I can actually do a real case with interesting, rare complications and then be scored, not just on pure knowledge, but also be scored on blood loss and time and the decision-making that I’m making in the moment. So for, you know, a large portion of our audience, it’s being able to earn that CME credit through a much more fun, interesting, challenging, engaging modality. But we also have large portions of our audience that don’t even take the CME credit because maybe, you know, they earn CME through other means. They’re gonna attend the same conference every year and speak at it.
And so, you know, for those doctors, a lot of the benefit comes from, you know, the ability to explore rare and difficult cases, the opportunity to try new devices, right, that they otherwise might only be able to try on a live human being, right? Here, they can go and they can test it out and test it out, not just, you know, on a cadaver or, you know, or on a pig or even on just like a normal presenting patient, but try it out on some of the most rare, difficult, interesting cases where either that device might struggle or that device might offer a unique benefit that you might only encounter on that case.
Lauren: Interesting. So, how do you think the popularity of mobile-based games helps learning for doctors and how does that reflect the changing landscape of medical education?
Sam Glassenberg: So, at Level Ex, our mission is to advance the practice of medicine through play, to use this technology and this design, this neuroscience-based game design to really accelerate the adoption curve of new techniques, new products, new skills in healthcare. So, what does it look like, right, when you achieve that vision, you know, in five years? What happens is, you know, games and play take their place among the other broadly accepted modalities in medicine. So, today, all right, you know, I have a difficult concept that I need to convey. All right, well, maybe I’ll give a lecture or I’ll record a video. Or maybe, you know, if it’s really complex, somebody might make a mannequin or schedule a cadaver lab, right? In five years, it will be broadly accepted that games are just…games take their place among these other modalities as, you know, a solution in the toolbox.
So today, when you say games for doctors, somebody goes…you know, if they haven’t been playing Level Ex games, they might go, «What is that? I don’t understand what that would be.» But in five years, it’s just broadly accepted as, you know, «Oh, yeah, games for doctors, of course. Like, games for doctors has always been a thing.» Because this just becomes another broadly accepted modality of learning. And when do you use it? You know, games are most effective and have the strongest competitive advantage against other modalities of learning when time is limited and when your brain really needs to develop a mental model for a complex system, right? Diagnosing a difficult patient really involves understanding the interactions of multiple systems, dialogue with the patient, different, you know, modalities of testing, different techniques. So, really developing a mental model of what eliminates what in different scenarios, and that gets very complicated. And that’s where games are far more effective, right?
Guideline-based decision-making. Doctors are overwhelmed with these complex flow charts that they essentially have to memorize to really, you know, to be able to, you know, effectively make decisions in surgery or in treating or diagnosing a patient. Games are a far more effective way to explore the solution space, to explore the combinatory space and possibilities from those guidelines than just trying to memorize that flow chart. And we see this. And so, over time, what happens is these modalities become broadly accepted as, you know, whenever we have a scenario where doctors need to learn something and it requires a mental model, we want them to be able to learn quickly, you know, we need to create that environment for them to play in. We need to create a game.
Lauren: Amazing. So final question, your father, who you mentioned is an anesthesiologist, he challenged you to put all this gaming nonsense to good use. Do you feel that you’ve succeeded in that goal at this point?
Sam Glassenberg: Yeah. So, my father has finally given up on the idea of me going to medical school. Mission accomplished in that regard. But joking aside actually, you know, the first app that we launched was actually in anesthesia. And he was instrumental in its development, standing over the artist’s shoulder, you know, helping direct them on, you know, what part of the larynx should be more squishy and how it should react and cough and so forth. You know, there were moments, you know, with my father laying on the floor of the offices at Level Ex holding an iPad because we adjust how we were testing an augmented reality intubation trainer, where basically you have to position yourself correctly relative to the virtual patient to visualize the vocal cords. And my father wasn’t satisfied with just trying it out on the desk. A lot of scenarios they encounter are emergency scenarios where your patient is lying back, is, you know, laying on the floor, and you need to intubate them. And the only way to effectively do it to get a visual on the cords is to lay on your stomach to get a visual on a patient. So, you know, my father was literally, you know, on the floor of our offices providing real-world testing of our augmented reality applications. So, you know, he’s still involved. He’s very passionate about advancing the practice of medicine and anesthesia and exploring new learning modalities, and, you know, so at Level Ex, we love to collaborate with them on it.
Lauren: Yeah. So, he believes that you put it to good use then in the end.
Sam Glassenberg: Yes. The short answer, yes.
Lauren: Great, awesome. Sam, thank you so much for joining us today and for giving all your insights in this incredible world of serious gaming. I mean, as I said, I’m really excited to see where this takes us and how it’s gonna educate doctors in the future. And I agree with you, I do see that serious gaming becoming an integral part of just, you know, the toolbox that a doctor uses in the future. So, thank you so much for joining us, and, yeah, thanks a lot. We’ll talk to you soon.
Sam Glassenberg: Likewise. Great to be here. Thank you.
Lauren: Thank you.