Psychiatric Case Scenarios As Visual Novels

An anime woman hiding a part of her face with a hand fan. Underneath her picture there is text saying "I understand that you've been referred to me by your GP because you're concerned about your appearance, specifically your nose. Is that correct?"

In the past two years, I have been supervising the educational activities at the hospital. Basically, the clinical case presentation and the journal club. I also provide one hour of teaching every week for registrars, psychologists and psychology interns.

Recently, I have been presenting short fictional clinical scenarios to supplement the case presentations as this exposes the trainees to cases that aren't seen often (since it is a private inpatient hospital with no child services). Registrars don't routinely attend the outpatient clinics and outpatient cases are seldom presented.

I think what these short clinical scenarios do is increase the confidence of registrars, test their understanding of conditions they rarely see, and expose them to management options that may not be available at their disposal in Egypt (e.g. opiate substitution for addiction).

I quickly found out that preparing these cases as a static slideshow creates a dry and boring experience. No one really likes reading text blocks on a screen in a large room at 9 am in the morning. I try reading out loud the scenario twice to help. Following each case we have a brief discussion on the diagnosis and management.

A slide with a white background showing a cartoon drawing of a woman holding her two children. A boy and a girl, both oblivious to her distress. The following text appears underneath the drawing "She is a single unemployed mother of two young children living in a two-bedroom flat. She has a history of short-term jobs and volatile relationships with abusive partners. She has no contact with her family."

I tried adding some clip art to help make things a little bit more engaging but it looked like a presentation for third graders.

Lately, on a personal level, I have been revisiting the experience of immersing myself in video games. The Legend of Zelda Breath of the Wild brought back a favourite pastime of mine, while offering me a fresh perspective on gaming. In my rediscovery, I found that games aren't just fast-paced action shooters or puzzles, they transport you to an immersive world full of rich characters and narrative. I may have been slow to realise this but video games really sit at the top of the pyramid as an art form. They combine so many arts and skills (storytelling, visual arts, cinematography, music and programming). A top achievement for human culture.

In my journey of rediscovering games, I learned that the experience doesn't have to be visually stunning. Sure the latest AAA games have amazing 3D graphics but the are lots of games that can be enjoyed with far simpler visual element (e.g. Stardew Valley) or none at all such as text-based adventure games1.

Two weeks ago, I wondered if it is possible to have psychiatric case scenarios as games. I thought it could increase the engagement of the highly burnt out trainees. Also, it could be fun.

Games have been used in medical training for some time. They call them serious games. I remember a game I played while in medical school that simulated the management of DKA patients. Besides, surgeons often receive training on laparoscopic simulators.

Visual Novels

Visual Novels are a form of interactive fiction with minimal game play. A story is explored through text with static character models and background. There can be few animated cut scenes or none at all. The player progresses the story and the story line branches according to the player choices (similar to choose-your-own-adventure books). Some don't have any interactivity and the story is linear. This genre originated in Japan and the vast majority of them have anime style characters and backgrounds. Even the ones not produced in Japan continue to emulate the style. Some of the games in this genre can be a little risqué or contain explicit material.

There are game engines that simplify the process of development. Mainstream general purpose game engines like Godot or engines that are dedicated to very specific type of game and needs very little programming knowledge. For example there are engines that create retro 8-bit games or retro RPG similar to an old Zelda.

General purpose game engines like Godot are very capable but have a steep learning curve. An 8-bit game or a retro Zelda-like adventure won't be suitable for psychiatric learning, unless it is too metaphorical and that may open interesting discussions but may not help me reach my teaching goals. I just want to hack something up that is a little more effort than a slideshow presentation.

In my search, I found a Visual Novel development engine called Ren'Py which is a Free/Open Source software that makes their creation quite easy. You write the novel script and then add graphic assets for your characters and background. You can also add some music to enhance the experience. You can draw your own characters but that may need more time and skill than preparing a presentation. Fortunately, there are free or reasonably priced video game assets on These artist-created graphics and music are commonly used by hobbyists in building their own video games or visual novels.

My First Video Game!

Acting on my impulse and thanks to a brief introductory tutorial on Youtube by Zeil Learnings, high level advice by Mathew Vimislik and excellent Ren'Py documentation. I downloaded Ren'Py and built my first video game!

You can try my first clinical scenario visual novel on by clicking on the button above. It is about a woman who has been referred to you by her GP as she is seeking plastic surgery on her nose. It is very short and amateurish, so forgive me and please don't dismiss the entire genre based on my attempt.

I don't want to spoil the game but I will list some of the educational elements that I tried to include:

  1. Patient-centered communication: This is throughout the game. But can also be seen during the process of establishing rapport with the patient at the beginning.
  2. History taking: The game demonstrates the type of questions asked to illustrates the symptoms of the patient's condition and her concerns.
  3. Recognising non-verbal cues The patient hides part of her face and nose with a hand fan.
  4. Empathy: is given an important role in the transition of the story. The player collects empathy points throughout the game (although these points are not displayed on the screen or mentioned anywhere as I don't know how to do that yet). If the player has enough empathy points, the patient will listen to the psychiatrist when they explain the diagnosis and receive treatment. If the player does not have enough empathy points, the patient's condition will continue and she returns with more complaints later on.
  5. Information-giving: The game demonstrates how to give information to patients in a clear and concise way. The condition is explained to the patient in lay terms in bite-size chunks and then her understanding is checked.
  6. Management: At the end the treatment of choice is highlighted.

A usual clinical case scenario would typically address points 2, 5, and 6. However, this mini-game tries to expand the learning potential by integrating clinical skills that can be seen in a clinic or during simulation-based learning. While scenarios have benefits, whether in their original form or as visual novels, they are no substitute to actual clinical experience and professional training. Nonetheless, I think it made that hour a little more fun.

It was a lot of effort, but I believe it was worthwhile. I learned a lot while making this visual novel. It included tasks such as writing the dialogue, designing characters, finding Creative Commons content, selecting music, and programming the branching storyline. It is also impressive the amount of FOSS tools, resources, and helpful people ready to help. Perhaps formal training or working with skilled scriptwriters and artists would certainly enhance the quality of these games.

  1. One of the earliest video games was a text-based adventure called Colossal Cave Adventure, developed in 1976. It was a form of interactive fiction where you get to explore a network of caves and try to find treasures. If you are interested in the history of video games, I recommend the excellent Digital Antiquarian blog or the Advent of Computing podcast

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