HealthScape
By: Alex Gonzalez • @nahitsjustalex
It was the fourth day of SimLand and Dr. Jim Tate had visited every booth in the center except for the one in the back. Truthfully, he had been avoiding it. Not because it made him nervous (although, inscrutably, it did), but because he knew he’d fall for it. From the gossip of the others, the device was everything he had been looking for. It was called HealthScape, and when he said it out loud it sounded like hellscape. Ominous. But funny. Funny enough to diffuse the tension he felt. Funny enough to approach.
The vendor was a pipsqueak. 5 foot flat, skinny as a rail, and with a buzz cut that suggested some sort of military service. Or brain surgery. The brochures were colorful and shiny, and the product itself, Jim was relieved to learn, wasn’t a software. Software meant upkeep, license renewal, and – considering how old UCF’s labs were – new hardware anyway just to run the damn thing. HealthScape was a box.
The pitch was simple if not a little intimidating. Use real DNA to upload avatars to the HealthScape. This will eliminate time spent authoring characters, time spent designing graphics, and with such a robust ‘avatar’ the simulationist can tweak dials and change meters and see how everything cascades. Don’t you want to see what happens if your wife gets pneumonia?
“Let me rephrase that,” the vendor said. “Don’t you want to see what happens if your wife – specifically your wife, not some generic middle-aged woman, not some AACN adjusted patient with committee approved comorbidities, but your specific wife. What’s your wife’s name anyway?”
“Lily.”
“Don’t you want to see what happens if Lily got pneumonia?”
The idea was morbid, inarguably, yet it appealed to the part of healthcare simulation that Jim, personally, always had friction with. To him, because there were so many pearl-clutchers around psychological safety, there were no real stakes in simulation other than a bad grade for the student. If a student screwed up and misdiagnosed a patient, you couldn’t show the patient going into cardiac arrest, screaming in agony, and dying. This would give the student PTSD (they say). It’ll discourage them from trying again (they say). It’s psychologically irresponsible (they say). But to Jim, those things are simply unavoidable in the real world. Wouldn’t it be better to expose them early on to that adrenalizing EKG stutter? To have them run down the bright hallways of an understaffed unit, screaming for a BMV? To utterly shock them with that horrific, flatline of failure? Or should they really pretend that didn’t happen IRL?
The vendor encouraged him to handle one, to get a feel, and Jim did so. It was a silver box the size of a suitcase and on the right side was a series of wet ports that the pipsqueak explained was for DNA samples – spit, hair, urine if necessary. On the left side were buttons and dials ergonomically styled for one’s hand. The back had a power cord, and the top of the box was a screen that lifted up and out. Interacting with it was like playing the biggest Gameboy Advanced he’d ever seen. Oddly nostalgic, Jim considered. And surprisingly light.
He a bought a box and put it in his trunk.
That night, a bunch of them ended up at The Bent Elbow. People were getting petered out with the trip, but Jim’s mind had just started. With each rum and coke, he brought up HealthScape to another professor but none of them had given the squirrely salesman much time.
“Guy gave me the willies,” one of them had said. He was a professor from FAU and had a Looney Tunes wristwatch. “He looked like a mental patient.”
“But the product seems incredible,” Jim argued. “From a time saved standpoint, I won’t have to waste my day authoring scenarios. I won’t have to check off an infinite list of competencies. Or deal with engineers to make a Black woman more Black.”
“I don’t know,” the professor responded. “It sounds like it’d give me an existential crisis. Putting in my hair and seeing myself on the screen? There’s a reason we send shit out to Quest Diagnostics.”
Someone on the edge laughed. Muttered another joke. “Man, fuck Quest Diagnostics.”
“It’s a simulation,” Jim shrugged. “When did we all forget that simulations aren’t real? Isn’t the whole point? How many patients can you make that have the same cookie cutter rubric? I want complexity. I want a challenge. And my students do too.”
“Jim, I promise you. Your students do not want a challenge.”
On the last day of the convention Jim kept one eye on the HealthScape booth to see if anyone else bought a box, but nobody else did. In fact, people gave the booth a wide berth. At first, Jim was dismayed. Had he really been so wrong about this? What was everyone seeing that he wasn’t? However, by the end of the day, he had massaged it into a positive: nobody saw the vision and, thus, UCF would have a leg up the next semester. They would be trailblazers. Innovators. Educators willing to take chances.
The Tate’s lived in a gated community a bit outside of Orlando and, by and large, their health history was mild. Jim had hypertension, his wife had eczema, their eldest IBS, the middle had her adenoids taken out, and their boy broke his arm when he was eight. They had two cars, a cat named Purple, and lived in a Spanish style house that was all the rage in the suburbs of Florida.
When he tucked some of Lily’s hair into the wet port, the box sucked on his fingers. Then the screen whirred to life and asked if he wanted to see her face or just the vitals. He chose the face. What populated the screen was a 3D model of not-quite Lily but pretty damn close. It couldn’t account for her hairstyle, or how she wears her make-up, or the way she slouches to the side, but everything else was there: the eye color, the nose, the height, the way she smirked with the corner of her mouth, even the wear and tear of her cuticles and the scar of her C-section, a faint crescent over her border of pubes. What was shocking was that it had her voice too. Even more shocking than that? It had her coughs, her sneezes, and her groans.
That night he gave his wife pneumonia. Her WBC surged 4.2 over the Mosby Reference Range. The audio clips for her coughing were wet and with coarse crackles, and her vitals self-adjusted to what was more or less expected. Digital recreations of his sick wife were presented in various skits: here is her coughing in bed, here is her with the first symptoms (fatigue), here is her primary symptom (ear pain, interestingly enough, with a secondary ailment of otitis media and packed TM). While all of this was vaguely interesting, Jim did start to feel like he had wasted his money. All of this was technically faster, yes, compared to manually inputting diagnostics and vitals and crafting a scenario ‘off the dome’ but none of this had a wow factor. Until he saw the prompts.
An input bar asked what the learner should do. The simulation could generate a variety of multiple choices, an open response question, and even take voice commands. But the default was a simple white bar. The WBC tipped off that it was likely bacterial pneumonia instead of viral. So, Jim started with a first-line amoxicillin and clicked along to see the avatar improve. Okay. Interesting enough. But next to the prompt was another option: Worsen.
“Now we’re talking,” Jim muttered. This is what it was all about, he thought. Pushing the student into the panic zone. He clicked the button and suddenly Lily was on a ventilator. His stomach dropped. Woof. A little jarring to see. But that was the point wasn’t it? The vitals scattered in all directions. This was advanced level stuff: pulling her back from the vent. The box generated a few multiple-choice quizzes and showed a skit of Lily wheezing, eyes listless in the hospital bed. He clicked worsen again and she got sepsis.
There was a brief moment of hypocrisy when he reconsidered what he was ready to see. It was a simulation yes, not real, a learning tool for Christ’s sake! But the tableau of his wife, intubated, was all too innervating. On the left side of the screen quiz questions populated, and oddly enough, this feature proved reassuring. It was exactly what he wanted. To be confronted with the most horrid, tragic of circumstances and then be asked simple test questions of how to help. Forget med school. Was that not the best way to prepare for life?
He clicked worsen again and Lily died in the hospital.
After that, he turned off the box and got into bed with his healthy wife. He held her closer than he ever had and in the middle of the night he pressed his ear to her back to listen to her lungs.
In the morning, Jim uploaded Karina, his eldest daughter, and he gave her anorexia. A family secret was that she had struggled with an ED back when she was thirteen. Her siblings couldn’t make sense of their big sister wasting away and, fortunately, some well-timed therapy halted its progress. It was a nasty condition, but a really great example of how quickly a chain reaction can break down the body. Plus, now that she was 22, there was more to play around with. More to see. He worsened it a few times right before she needed inpatient treatment and the digital skits were amazing. One of them showed her struggling at work, getting lightheaded. To Jim, this was fantastic because it opened a whole new section of Mental Status Exams, Suicide Risk Assessments, and especially Social Determinants of Health. When one considered the interprofessional teams involved to help, the amount of disciplines this touched on was endless. He worsened it once more and the box showed him another skit. It was Karina, rail thin, crying at the grave of her mother.
“Wait, what?” Jim asked. “They’re related? She’s still dead?” He clicked through some more videos and fiddled with the charts. Lily was still dead in the HealthScape, and the box was able to determine that Karina was her daughter. He was even able to interview her.
“I just wish she was here to help me get through this,” she cried. She bent forward and buried her digital face into her skinny hands. The lanugo on her forearms was dense with pixels.
“Talk about real stakes,” Jim said.
On the last worsen, he set the quiz difficulty to the hardest level:
In 1000 words, explain the relationship between thiamine deficiency and refeeding syndrome in Karina Tate, and calculate the measurement of her remaining electrolytes. Then, outline a plan of care for a weekly weight goal that won’t trigger her nervous system. Use references published within the last 3 years.
Jim got a C-, and his daughter starved to death before lunch.
To this point, Jim had never been a hypochondriac, and he had never been particularly paranoid but now, outside the box, in the real world, he listened to Lily and Karina clatter around the kitchen and squabble over the car keys, and he reminded himself that they were there, still moving, still healthy. But anytime Lily sneezed, he did a double take. And at dinner, he made Karina a second plate.
“Oh, no thanks,” she said. “I’m stuffed.”
She looked it too. Not like that CGI skeleton in the hospital gown.
“I just want to make sure you’re eating,” he said. “I know how you can get.”
“Excuse me?”
“Jim, what the hell?”
“What?”
“Dad!”
“Why did you bring that up?”
“Asshole thing to say.”
“Hey, language.”
“The ED, really?”
“I’m just expressing –”
“Dad!”
“What did I say?”
“Mom!”
“Just eat another plate.”
“Dad!”
“What!”
“I’m gonna be late for practice!”
After he dropped off Jacob at soccer, he came home and put himself in the box. It felt like a point of principle in a way he couldn’t verbalize. He went a step further too and put in his urine, his spit, a blood drop, and also a stool sample (a humiliating activity where he lugged the box to the bathroom because he misplaced the plastic cup). In no surprise, his avatar was a spitting image of himself. Had his blood pressure, his LDL, HDL, the micro-flora report of his bowels, his gut biome, the gravity of his urine, the protein of his urine, the eosinophil of his blood, his MCV, MCHV, his shoe size, sperm count, eyesight, hearing report, and even his grief.
His what?
Jim’s Mental Status Exam was a bright red warning, and his Suicidal Ideation was through the roof. After all, he had lost his wife and eldest daughter to medical negligence.
“You must be joking.”
He clicked WORSEN and he balanced on a stool with a noose around his neck. He was about to kick off, and the quiz that followed was grimly relevant.
“Jim Tate, 48yo male, wants to hang himself. What is the FIRST pathophysiological impact of strangulation?”
- Cessation of oxygen to brain leads to neuro-apathy and subsequent cerebral dark outs.
- Cessation of oxygen to lungs leads to bradycardia and subsequent cerebral dark outs.
- Cessation of oxygenated blood to heart leads to sudden L4 drop and agonist response in the dexmal tissue, dexmal valve, and 3rd chamber.
- Sweet release from all he’s done.
Jim unplugged the box. It was clear that HealthScape had him in a spiral. It was a video game where you kept respawning at the boss battle, no more prepared than when you first got squashed. He had to restart, and his reflection showed bleakly in the loading screen. But it was no use. Digi-Jim still wobbled on the kitchen chair and the ‘What Would You Do’ quizzes came fast. He passed. Not with flying colors but C’s got degrees, and he brought himself back from the brink. Therapy, a long inpatient stay at the Sunrise Clinic, and a cornucopia of anti-depressants had his avatar big bellied, blank behind the eyes, but, goddammit, still alive. Holy shit.
Looking back, he should not have put Eliza into the box at all, but the truth is he didn’t want Digi-Jim to be lonely. He uploaded his 15-year-old daughter and, instantly, the skits were from a domestic drama. She was skipping class, doing drugs, getting in and out trouble. She kept calling Digital Jim a maniac, an evil psycho, she kept accusing him of murder. On a bender, on a rainy night, Eliza got into a car accident and was thrown from the windshield somewhere along I-275. Jim couldn’t let her die. He stayed up in his study, from dusk til’ dawn, bringing her back to health. The tests were the hardest they’d ever been. Open response questions about OR procedures; bio-chemistry hexagons he hadn’t seen since med school; even a long detour with the hospital chaplain talking to him about his daughter’s ‘quality of life.’
There was a part of him that was still impressed with the machine. The fact that it could effortlessly address multiple fields of study really nailed home how inter-connected healthcare was. The OR talks to the ER talks to the Nurse talks to the Social Worker talks to the Police Officer, a digital cop who came around regarding Eliza’s DUI charges. Physical Assessment turned into Pharmacology turned into Med-Surg. Plus, being an American machine, all of this led into quizzes about billing codes and insurance. As a result, Jim was getting a lot of the questions wrong.
In the end, he wheeled Eliza out of the hospital. She was brain damaged, would never walk or talk again, and would need constant in-house support. The HealthScape was quick to generate those quizzes too, and the digital social worker would not get off his ass. A few days later, a detective came around asking a series of questions, interrogating Jim like he had something to do with this, like it was all his fault.
The next morning, Jim cried into his cereal. Lily watched him from their Mr. Coffee and when she realized he was crying she put a hand on his back and asked him what was wrong. He couldn’t explain it though. They were tears of joy. Kinda. His family was happy and healthy. Eliza messed with the TV. Karina fed their cat. Lily breathed with her full chest. But the paranoia in him flourished. He cried with a mix of gratitude and anxiety, a new galaxy of hypochondria that today, yes, today will be the start of the wretchedness. The Tate Family cascade. Incurable pneumonia, anorexia, a DUI. And the cloud of suicide shimmering overhead, its silver lining bright and animated, oh God. Why did he click WORSEN over and over again? Why did he torment Karina with the eating disorder she had already beaten? Why didn’t he brush up on his OR protocol when Eliza was splayed open on the silver table, her pixelated entrails lacerated with glass. He had purchased the box so he could prepare for these scenarios but now it felt like he had authored them into existence.
“Dad, can you take me to practice?”
“Again?”
In the evening, he considered Jacob. What malicious god would he be to upload his son into the HealthScape? For a 12-year-old boy to materialize into a house with a dead mom, dead sister, crippled sister, and evil father? To have no knowledge of anything beyond misery? Jim mulled it over. Philosophically, the subtext was too depressing. In the HealthScape, life was hell. It operated under catastrophe. Of course it did, that was the trade of healthcare. Nobody needed healthcare simulation if everyone is healthy! Nobody opened a textbook for good news. The universe of the box was suffering.
But Jim felt challenged. Could he upload his son and navigate the HealthScape in such a way that his boy lived? That Jacob found happiness? Because Jim felt that he had authored his family’s doom, he felt obligated to author his son’s success. He couldn’t leave it to chance. It would be the greatest test the box could offer. Jacob through the years. From a traumatic, miserable childhood to rich, thriving adulthood. It would cover health scares, procedures, mental health, puberty, poverty, stressors, family drama, insurance, recreation, exercise, jealousy, romance, the goddamn human condition explored through multiple choice and open response. Jim was determined to usher his son to the other side, healthy and happy. And then he would unplug the box for good.
When the sun rose over the Tate house, Jim took his breakfast into his study and he locked the door. The Jacob Challenge would be long and difficult and Jim needed absolute concentration. He brushed off old textbooks from med school. He found a copy of the DSM-5, an Elsevier, a Dains. He kept his laptop nearby for panic searches. And when he uploaded Jacob, the avatar was miserable – red eyes from crying and already malnourished.
The big irony of the HealthScape is that Jim couldn’t not give his son an ailment. Lily got pneumonia, Karina got anorexia, and Eliza was auto-suggested substance disorder, but Jacob’s bar was still empty, begging to be filled with a life-threatening illness. Jim could feel the box breathing. No. Seething. It was ready to play mean. So Jim had to start small.
“COMMON COLD” he entered.
The box gave Jacob a sinus infection and they were off to the races. With each successful diagnosis and efficient plan of care, Jim was able to age up Jacob by a year. It’s true he could’ve turned Jacob’s dial to 25 right from the jump, but Jim didn’t trust the box to let Jacob age gracefully. He had a notion that if he jumped ahead, Jacob would be auto-generated as a homeless alcoholic, or a junkie with HIV. Such were the affinities of an angry simulation. No, Jim had to take his time. He had to be fastidious and diligent with his son. Year by year a new ailment was requested until the box stopped asking Jim for input and had enough data to run on its own.
There was a strip of melancholy to the whole affair. To only know his son through vitals, blood work, and differential diagnoses. The interiority of his son being expressed via Chief Complaint, History of Present Illness, and Psychosocial Behaviors. After each successful quiz, a skit showed Jacob at school, or with friends, a small digital smile slowly forming. But then at home, in the dank, haunted house of the Tate’s, Jacob was morose. His handicapped sister wailed in the dark corner of her room, her monitors blinking in sickly green pixels. His digital father never left his office and raved like a mad scientist behind closed doors, undoubtedly haunted by the ghosts of his wife and eldest daughter. In short, Jacob’s Mental Status Exam was not improving. Nor was his Suicidal Risk Assessment. Even more alarming, Jim noticed his son’s Homicidal Ideation click up a notch. And then another.
When Jacob turned 15, the questions were about gonorrhea and genital lice, and Jim assumed his son was now sexually active. A bit young for Jim’s comfort but the statistics of a ‘distressed nuclear family’ did in fact point towards ‘increased sexual activity among minors.’
Okay. Fine. So be it.
At 16, it’s questions about underage drinking and the impacts of alcohol on the liver.
At 17, it’s a few broken bones and Jim has to re-learn how to read X-rays. The collected evidence (inferred from the quizzes) is that Jacob got into a fight with a bully and more or less got his ass kicked. The bones were set. The cast applied. The Plan of Care is very Education and Follow-Up focused and the subsequent skit showed that awful Tate Home again. Eliza was still brain damaged. And getting worse too. The home aid was asking for more money. The dad still hadn’t left his office. And the Homicide Ideation went up another notch.
On Jacob’s 20th, HealthScape gave him a heart attack. His age and weight and family health history all stood against this, but further inquiry and a drug test revealed cocaine, lack of sleep, and grueling work hours in a high stress ‘manual labor environment.’ Jim prescribed him antiplatelets, beta-blockers, and ACE inhibitors. But he also saw the writing on the wall. He could keep his son physically healthy but if he didn’t figure out the mental component, then Jacob would keep abusing himself. And the older he got, the worse it’d get. He clicked Consult/Referral and referred Jacob to a therapist.
But Jacob refused to go.
“I didn’t know it could do that,” Jim said. But also, despite his fear, he yet again was impressed. “Real People are Bad Patients” was a phrase often tossed around in the sim world. You could click all the boxes and pass all the quizzes when it comes to diagnosing and prescribing, but nothing will make the patient actually take their meds, or start eating better, or stop doing drugs. And Jacob was not going to therapy no matter how much Jim referred him. And once again the Homicide Ideation moved.
In his heart, Jim knew where this was going. No matter how physically fit he kept his son, there was an angry hole inside of him that was worsening. Every time Jacob came home to the Tate House and spoon-fed Eliza or banged on his father’s door, the hole got bigger. Jim wanted to see his son happy but, in a distressing realization, nothing a doctor provided could make that so. The chips were stacked against Jacob from the start. He could possibly be a functional member of society, true. He could find a wife, a career, and start a family, probably. But the foundation of misery would never go away. Unless Jacob got revenge.
Jim went ahead and skipped to 25 and was pleased to see that Jacob was fit as a fiddle. He was sober now, taking sertraline, and keeping up with his running. But behind his veneer of sociability his MSE, SRA, and HI were in the bright red. When Jim watched the skit, it showed Jacob (a very handsome man!) walk into the Tate House and smother his disabled sister with a pillow (crying, saying I’m sorry, saying I love you, saying this is all dad’s fault). And then he took a handgun and kicked down the door of Jim’s office. Jacob accused his father of everything – bizarre delusional allegations that didn’t even make sense within the logic of HealthScape.
“You did this! You did this! I can’t prove it, but I know you did!”
“I’m a victim too!” Jim yelled back. “I’m trapped here just like you!”
And then Jacob shot Jim in the chest five times, and Jim wasn’t sure if the ‘trap’ was the HealthScape or the Tate Home or the frail physical body everyone had to carry around and keep upright. Everyone just sacks of vitals and numbers and quizzes. Fuck Quest Diagnostics.
Later, after real Jim threw the box in the trash he moved through his family with a sense of certainty. He anticipated everything HealthScape showed and knew in his heart that it would all come to pass. Only this time, he’d be ready. He wouldn’t let Lily’s pneumonia worsen. He wouldn’t let Karina’s ED develop. When the tests come in real life, he’d be ready and well-read, and he’d pass them with flying colors. It was feeling more and more like HealthScape wasn’t just a simulation, but a dress rehearsal and opening night was fast approaching. Did he still have time to rewrite his lines?
On the last morning it all started to happen. Or was it just his imagination when Lily coughed. When Karina skipped breakfast. When Eliza snuck out. And when Jim once again forgot about soccer practice, he looked at his son’s sadness and saw the seeds of suffering freshly planted. The test was here. It was finally here and he couldn’t wait to play.