Medical Systems – an initial examination

I have long held that there is fun to be had in roleplaying games outside of physical confrontation and violent conflict. I believe many gamers actually agree with me in that, and would say that they indeed do have fun with non-violent aspects in their games. Yet, as long as we concentrate on ‘classic games’ at least, the actual rules we see deal with physical combat mostly, sometimes supplemented by social combat, while other situations are at best relegated to very generalist skill systems, are captured by a ‘one-for-all’ mechanism that does not differentiate between types of action or situation, or fall outside the game rules at all.

Obviously, there is nothing wrong with that. I still maintain, though, that this is a different kind of fun than what we experience in the all pervasive combat scenes (social or otherwise), and that it should be perfectly possible to craft rules which will bring the same sort of enjoyment we get from beating up orcs and shooting nazis to other situations.

This is generally speaking. More to the point, ‘medicine’, or let’s say the work of medics, doctors, healers and whomever else in helping and treating people, makes a wonderful topic for this kind of gaming, yet it is woefully and strangely under-supported.

I believe some if not most of us have watched hospital series or read medical-themed techno-thrillers. So we already know that open heart surgery can be just as dramatic, action-packed, and suspense-laden as a running gun-battle in a secret military complex. We do not need convincing for that. We need a way to make it a reality at the game table, just as it is on the silver screen. But how can we do that?

First, I would like to take a look at what makes the ‘combat experience’ possible in the first place.

I believe there are four main factors involved in this:
1) There has to be the possibility to make meaningful decisions within the rules. What the player decides to do has to make a difference, it has to have an impact on the eventual outcome.

2) The actions taken have to be imaginable. A decision between option ‘A’ and option ‘B’, however meaningful it may be in terms of the abstract rules, brings nothing to the table if I cannot imagine what ‘A’ and ‘B’ actually are. A sub-point of this is that I should be able to judge at least some of the relative worth of ‘A’ and ‘B’ based on my own general knowledge, and not just on rules-savvy or ultra-specific setting knowledge.

3) There should be a certain amount of uncertainty and pressure involved. The player needs to make his decisions in the here and now, and while he surely may (should) plan ahead, he will also need to adjust his plans dependent on the actions of others as well as the yet-unknown results of his initial choices.

4) The last point is the question of scale, and it interrelates with the idea of pressure above. The problem should be one of immediacy, not only for the player, but also for the character, and the situation should directly involve and affect him.

Combat obviously fulfils all four of these points.

Most combat systems offer plenty of options to choose from, from different weapons and armours to a plethora of manoeuvres, which both affect the outcome and are also easily imagined (disarming a foe or directly hitting him can change the whole flow of a fight, while it is very easy to picture the difference between a knight in platemail wielding a two-handed sword and a leather-clad rogue armed with a pair of daggers). Both the mental picture and the rules effect are also easy to relate to one another, and even without in-depth knowledge of the specific rules, I will grasp almost instinctively that the knight is probably going to be better at resisting damage and that the disarming move might be a good idea against an opponent who is both hard to take down and armed with a dangerous weapon. I get all of this instantly, and do not have to spend time ‘learning’ it first (though I may well have to learn more subtle differences, e.g. that in one game the two-handed sword is going to deal more damage, while in another the two daggers might pose more of a threat).

Combat is also a dynamic affair, where I have to make decisions on the spot – do I attack again? – and cannot be sure of my success – will I really cause enough damage to drop him? – and any plans I have made might be thwarted by unexpected actions from my opponent (or sheer bad luck). Combat in roleplaying games is also generally a very immediate and personal affair – it is about you and your buddies trading fire with the goons across the street – not about a general making command decisions back at headquarters. The former is the terrain of roleplaying, the latter (though it can be interesting to roleplay) strays in the territory of true wargaming, being removed in both time and distance scale from what happens to the individual character.

So, what about medicine? You ask me, it could also fulfil all four criteria.

The options in a rules-sense would obviously have to be created, but imagining different options (which could be cast into rules) is more than easy – there is a reason we talk about ‘treatment options’ in real life after all. Making them synch with ‘common knowledge’ is also easy. Sure, as a lay person I won’t probably recognize the difference between tamoxifen and trastuzumab, but I will have a rough idea what it means to just pump someone full of painkillers versus setting a bone (same as I might not instantly know a bardiche from a glaive, but will get the difference between knocking somebody out and killing him). In short, I can break a ‘medical encounter’ into a series of possible component decisions, which can be digested by a player without earning an MD first and which could be converted to mean different things in a rules context.

Uncertainty is present in medical situations as well. There is no guaranteed success, neither with drugs nor with surgical intervention or other therapeutic measures. Correspondingly, a lot of illnesses and injuries can put immense pressure on the treating personnel who need to make the decisions on how to proceed in light of earlier results. Outside the large scope management of hospitals, health systems, and programs for combating specific diseases medicine gets personal in a very similar way to combat, though obviously the actual risks are often carried not by the acting characters but by others – namely their patients. Timing as well is critical but the actions and dynamics can be less immediate than in a combat situation. During first aid and emergency surgery the same split-second decisions characteristic of intense combat scenes may be called for, but in many other cases chosen treatment actions may actually take hours or days and their results may become apparent only much later. When dealing with chronic illness, where a therapeutic course may last months of time, we thus begin to leave the area of dynamic roleplaying situations the same way we do when switching to the general staff’s perspective regarding battles and wars.

These still are pretty vague, ‘high level’ concepts. So, in theory this should work out, but how can we actually realise such a set of medical rules in a game?

As usual, there are countless options one could go about this, resulting in any number of sometimes similar sometimes very different games – the same as with combat, really.

But precisely due to the combat analogy, which brought us here, the general direction I would set out in – whether in creating add-on house rules for an existing game or crafting an entirely new ‘medical rpg’ from scratch – is to take this analogy one step further, and introduce the fifth combat factor, the one that is implied by the others, but not spelled out: An enemy to fight.

By representing medical conditions – from severe trauma to virulent disease – with a profile including statistics and abilities like what is used to represent opponents in combat, everything else quickly falls into place.

Options in a rules-sense become easy to handle, via different interactions with the profile (same as for weapons, armour or combat manoeuvres –a two-handed sword dealing a great amount of damage, but giving a penalty to initiative, while a very effective drug might have a delayed onset). Depending on how exactly the profiles are handled, this might also serve to help with imagination, if, as in the sword and drug example above, the statistics can be used to link to imaginable concepts.

The main advantage of this approach, though, lies in the area of pressure and scale. By giving the disease a ‘face’ – that is, an opponent profile – the conflict to overcome it moves even further into the personal and immediate sphere. By giving it ‘active’ abilities it is transformed from a predictable condition to be removed, into an unpredictable dynamic foe, fit to keep the characters on their toes.

And finally, it gives a good in-road into existing systems, making a medical add-on mesh more smoothly with the established rules. Especially as it largely precludes completely revamping the way damage is handled – the medical conditions not having to be integrated into the way injury and death are modelled, but rather using the same mechanisms to cause (further) damage via their abilities.

And here I let off, for now.