Hidden Levels: Surgical Precision (Side Quest)

Dr. James "Butch" Rosser was a pioneer in minimally invasive surgery in the 1990s. When he credited his surgical skills to video games, people dismissed him. The prevailing narrative was that kids who played video games became killers, not doctors. So Butch set out on quest: to show how video games can help make better doctors. Show notes: The impact of video games on training surgeons in the 21st century (JAMA Surgery https://jamanetwork.com/journals/jamasurgery/fullarticle/399740#27476034) Study: High-School Video Gamers Match Physicians at Robotic-Surgery Simulation (Slate https://slate.com/technology/2012/11/teenage-video-game-players-match-physicians-at-robotic-surgery-simulation-study.html) We Have to Operate, but Let's Play First (The New York Times https://www.nytimes.com/2005/02/24/technology/circuits/we-have-to-operate-but-lets-play-first.html) He’s really on his game (Orlando Sentinel https://www.orlandosentinel.com/2006/01/28/hes-really-on-his-game-2/) Credits This episode was written and produced by Grace Tatter and edited by Meg Cramer. Mix, sound design and music composition by Emily Jankowski. "Hidden Levels" https://99pi.org/hl is a production of 99% Invisible https://99percentinvisible.org and WBUR's Endless Thread https://link.mgln.ai/99percentinvisible. The Managing Producer for Hidden Levels is Chris Berube. The series was created by Ben Brock Johnson. Series theme by Swan Real and Paul Vaitkus. Series art by Aaron Nestor.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Speaker 00

  Support for this podcast comes from Is Business Broken?, a podcast from the Marotra Institute at BU Questram School of Business. A recent episode explores how AI is reshaping our schools. Stick around until the end of this podcast to preview the episode.

• 0:17Amory Sivertson?

  Support for Endless Thread comes from MathWorks, creator of MATLAB and Simulink software to design and develop engineered systems, accelerating the pace of discovery in engineering and science. Learn more at mathworks.com.

• 0:33Speaker 02

  Hey Spotify listeners. When you travel with American Airlines, you'll enjoy comfort and convenience at every altitude. Before takeoff, unwind in the Admirals Club Lounge with curated self-serve offerings of hearty bites and refreshments. In flight, stay connected with high-speed Wi-Fi, sponsored by AT&T. Your journey is designed to feel easy from the moment you check in to the moment you arrive. No matter where you're going, American gets you there. Book now at aa.com.

• 0:59Speaker 03

  WBUAR Podcasts, Boston.

• 1:12Amory Sivertson?

  Ben Brock Johnson.

• 1:13Ben Brock Johnson?

  Uh huh. Anne Marie Seibertson, yeah.

• 1:15Amory Sivertson?

  Are your fingers magic? Are your hands your greatest asset?

• 1:24Ben Brock Johnson?

  I think, I mean, I can tie a, I could tie a double knot, no problem. But if, but, and I do have a double-jointed thumb. So that's a thing that's cool about my hands.

• 1:37Amory Sivertson?

  Oh yeah, you like crack your thumb sometimes, right?

• 1:40Ben Brock Johnson?

  Yeah, I crack my fingers.

• 1:42Amory Sivertson?

  You do like a weird like thumb roll?

• 1:44Ben Brock Johnson?

  No, I can just, I got a double-jointed thumb. It just like kind of pops in and out. But like if you ask me to do anything with a needle and thread, I'm worthless.

• 1:53Amory Sivertson?

  You're not even getting the thread through the needle.

• 1:56Ben Brock Johnson?

  No, it's tough. It's tough. Tough to thread that needle for these sausage fingers, for sure.

• 2:01Amory Sivertson?

  Okay, well, our next exclusive side quest from Hidden Levels, our series with 99% Invisible about how the video game world has changed the world beyond video games, is about a surprising connection that one man has been trying to get the medical community to accept and celebrate for decades now.

• 2:21Ben Brock Johnson?

  And he's got scientific studies to back it up. Next up in our series, Grace Tatter brings us an episode that should make you think twice about the concept that video games rot your brain. This one's called Surgical Precision.

• 2:37Amory Sivertson?

  Grace, we are in your hands.

• 2:48Speaker 05

  Butch Rossers quest started before he even set eyes on a video game in the small town where he grew up, Morehead, Mississippi.

• 2:58Speaker 06

  I wanted to be a doctor ever since I was five years old.

• 3:01Speaker 05

  When he was a kid, Butch's mom got really sick.

• 3:05Speaker 06

  My mother had a terrible attack of abdominal pain. She was writhing around. I thought she was going to die.

• 3:16Speaker 05

  This was the 1950s. Butch's dad, who was black, called the local doctor, who was white, and asked him to come over. This was a bold thing to do in Jim Crow-era Mississippi.

• 3:29Speaker 06

  But on this instance, God somehow touched his heart to come and do a house call on my mom. And he examined her, and I was watching it just attentively. Everything he went through with her in the exam and everything. And he said, "Marjorie, I think you have a gallbladder attack. I have this concoction I've put together for you that should get you better in the next two to three hours." He gave her that, and in an hour, she was like nothing had happened. The fact Dr. Philip Kane impressed me, and the fact that he knew what to do and helped my mom, it was a miracle to me.

• 4:14Speaker 05

  So Butch knew what he wanted to do when he grew up. He also knew where he wanted to learn how to do it.

• 4:20Speaker 06

  All of my life, I wanted to go to the University of Mississippi, Ole Miss.

• 4:27Speaker 05

  Mississippi's flagship university is in Oxford, about 100 miles northeast from Warhead. When Butch was still a kid, James Meredith became the first Black student to enroll at the University of Mississippi. Butch remembered hearing about the racism-fueled chaos that met Meredith. The riots were so violent, President Kennedy deployed more than 30,000 troops. Butch enrolled there as a full-time student 10 years after that, in 1972. And there still weren't many Black students. But he knew he had the grades to succeed, and he came from a family of trailblazers. He was even willing to give up a football scholarship at the University of Florida to become a Mississippi Rebel.

• 5:13Speaker 06

  Coming from a family that's always broken the barrier, whether it be my father in the Marines, the most segregated branch of the armed forces, to my grandfather, who was a butcher on his plantation and was the first Black butcher there. I'm surrounded by people who have a legacy at first and a legacy of believing in more than themselves.

• 5:44Speaker 05

  That didn't mean it was easy.

• 5:46Speaker 06

  It's really weird sitting in a chemistry class with 300 people and you're the only person of color in the room. You need a maximum effort all the time to be able to get through that.

• 6:00Speaker 05

  Only one person in his organic chemistry class even acknowledged his existence.

• 6:06Speaker 06

  Everybody else, you know, just ostracized me. They saw me, but they didn't see me, if that makes any sense.

• 6:19Speaker 05

  Butch was often totally alone. But then, one day, he was in the student union.

• 6:25Speaker 06

  And I heard this sound. Boop, boop, boop, boop. I said, "What is that sound?" And I went over, and it was the Pong game.

• 6:36Speaker 07

  You're watching the most exciting game you will ever see on your TV set.

• 6:40Speaker 05

  When Pong was released by Atari in 1972, it became the first commercially successful video game because it could be played on an at-home gaming console. If you play video games, you've probably heard of Pong. It's essentially virtual table tennis. A white square bounces back and forth across a black void. A white line represents your paddle. Miss the ball, and it disappears off your side of the screen. Your opponent scores. Keep hitting the ball, and you rack up points. Turns out Butch was really good at Pong.

• 7:18Speaker 06

  Oh, my God, I started playing, and I couldn't quit. And I just fell in love with video games. Asteroids, Tech Trust, and so on, and so on, and so on. I played all the time, and that was my relief.

• 7:31Speaker 05

  When Butch was killing it at the gaming console, his white classmates stopped pretending he wasn't visible.

• 7:37Speaker 06

  I had white people actually talk to me. I had white people to understand I was intelligent. I had white people to know that I liked the same things as them.

• 7:49Speaker 05

  Butch achieved one objective: graduating from Ole Miss. And now, he was advancing to the next level. He moved down to Jackson to attend the University of Mississippi's medical school. Once again, he was one of the first Black students to do so. And he thought he was doing really well. But one day, he got called up by the chief of surgery. And he was nervous because surgeons have a reputation in medicine for being kind of high-strung.

• 8:22Speaker 06

  I thought I was in trouble.

• 8:23Speaker 05

  The chief of surgery told Butch that he'd heard he had particularly nimble hands.

• 8:29Speaker 06

  He said, "Did you ever think about going into surgery?" I paused, and I was looking up at the ceiling. And finally, I got the gumption to utter these words. "Well, sir, permission to speak freely?"

• 8:46Speaker 06

  And he said, "By all means, please speak freely." I said, "Don't you have to be an asshole to be a surgeon?"

• 8:58Speaker 05

  The dean told him that the decision to be an asshole, much like the decision to be a surgeon, was a personal one. So, in part because of those nimble hands, Butch started a general surgery residency in Ohio. And he brought his video games. He introduced his fellow doctors to not just Pong, but newer games like B-17 Bomber.

• 9:20Speaker 07

  Fighters, nine o'clock!

• 9:24Speaker 07

  Fighters, nine o'clock!

• 9:26Speaker 06

  We would have tournaments in the residence lounge, and I'd be beating everybody, making them cry, you know, because surgeons, surgeons are so competitive.

• 9:36Speaker 07

  Fighters, twelve o'clock!

• 9:40Speaker 05

  Video game consoles were becoming more portable, small enough to tuck under a hospital TV. Meanwhile, surgery was undergoing its own miniaturization shift. For centuries, surgery meant cutting patients wide open, exposing their organs by making long, deep incisions that left jagged scars and required weeks of recovery. But this new procedure called laparoscopy was just starting to catch on. It worked like this. The surgeon made a tiny incision in the patient's body. Through that small opening, they inserted a laparoscope, a thin, rigid tube containing a tiny camera and light source. Next came a couple of other little incisions

• 10:26Speaker 05

  for the surgical instruments, which were slender tools, nearly a foot long. There were graspers to hold tissue, scissors to cut, and cautery devices to burn blood vessels shut. Because the surgeons couldn't see directly inside the patient's body, they had to peer through the thin tube of the laparoscope. The first time Butch remembers seeing this kind of surgery, the patient was a young woman who had pain in her lower right abdomen.

• 10:53Speaker 06

  The ER physician thought it was appendicitis. When I did my exam, I thought it was appendicitis.

• 10:58Speaker 05

  So Butch told the attending surgeon that they should do an appendectomy. At the time, a typical appendectomy required an incision of 2 to 4 inches and several days in the hospital to recover.

• 11:11Speaker 06

  He said, "Wait, wait one moment, young one. Wait one moment."

• 11:15Speaker 05

  He thought they could operate laparoscopically. And when they looked into the laparoscope, they realized it wasn't appendicitis after all. The woman had a twisted ovarian cyst.

• 11:26Speaker 06

  And he got a needle, put the needle in, sucked the cyst out. That girl got up and ran off the table and went home in three hours.

• 11:36Speaker 05

  Butch's own mom eventually had laparoscopic surgery. She had her gallbladder removed. Had she undergone this procedure earlier, she might have been spared years of pain. By the late 1980s, laparoscopic surgery had advanced. Instead of peering directly into that tiny laparoscope, surgeons could look at a screen to see inside the patient's body. Butch's career had advanced, too. He finished residency and became one of the faces of this new multimedia medical practice. He and a colleague performed the first laparoscopic gallbladder removal at his Ohio hospital. He also operated on the youngest child to undergo a laparoscopic gallbladder removal ever. The patient was less than 2 years old. Other doctors, and even journalists,

• 12:21Speaker 05

  regularly dropped in to see Butch work. And it was while talking to a journalist that Butch made a connection he hadn't before. This was around 1990, and he had just completed one of his historic surgeries.

• 12:34Speaker 06

  There's just press hanging off the rafters. And after, it's a plain dealer reporter asked me, "Dr. Rosser, you look so comfortable doing that. And this is a new procedure. Why do you think that is?"

• 12:48Speaker 05

  And that's when it clicked, like stumbling into a side quest he hadn't even known existed.

• 12:54Speaker 06

  I said, "Because I play video games and I fly radio-controlled airplanes."

• 13:04Speaker 00

  Join us as Dr. James C. Rosser and patient Candace Wynden take us on a fantastic voyage of the operation.

• 13:12Speaker 05

  You can see the connection between Butch the gamer and Butch the surgeon in a 1993 episode of a documentary series from the Learning Channel. In it, Butch calmly narrates what he's doing as he removes the patient's gallbladder.

• 13:26Speaker 07

  And we're gonna open the tummy, make a small hole.

• 13:29Speaker 05

  Both of his hands are moving swiftly, but he isn't looking down at them. His eyes are fixed on the screen.

• 13:35Speaker 07

  Now that beautiful red structure looking like mountains in the background, that's the liver. And against the liver...

• 13:43Speaker 05

  Instead of the CGI scenery of a video game, he's seeing the landscape of his patient's organs.

• 13:50Speaker 07

  That is the tip of the gallbladder. That robin's egg blue structure in the middle of your screen. Now let's take a look.

• 13:58Speaker 05

  He's fluently translating how he manipulates the surgical instruments to what he sees on the monitor.

• 14:03Speaker 07

  See, we just go and it's just like, in a lot of ways Nintendo, and just grab and pull, voila.

• 14:11Speaker 05

  Eventually, he pulls the gallbladder out through the patient's belly button.

• 14:15Speaker 07

  Alright, we got it. I tell you, every time I do this surgery and just witness this modern day miracle, you know, and I see people come in with their lives not as disrupted and they're not in as much pain, I am just so happy.

• 14:30Speaker 05

  Butch wanted more patients to have access to this kind of surgery. But that required training more surgeons. Because most surgeons had never operated looking at a screen.

• 14:40Speaker 07

  So that's when I said, hmm, I wonder could playing video games help me in my educational program to get these surgeons up to speed? If it helped me, could it help them?

• 14:53Speaker 05

  Butch believed video games had made him one of the top laparoscopic surgeons in the country. And now, he was on a mission to get other doctors on his level. More after a break.

• 15:23Speaker 00

  Support for this podcast comes from Is Business Broken?, a podcast from the Marotra Institute at BU Questram School of Business. How should employers measure real skills in the age of AI?

• 15:35Speaker 07

  Instead of observing the final artifact, instead of observing the final essay or the final program, observe the entire process of creation.

• 15:44Speaker 00

  Follow Is Business Broken? wherever you get your podcasts. And stick around until the end of this podcast for a preview of a recent episode on rethinking academic and job assessment when AI can do the work.

• 16:03Speaker 02

  Hey Spotify listeners! When you travel with American Airlines, you'll enjoy comfort and convenience at every altitude. Before takeoff, unwind in the Admirals Club Lounge with curated self-serve offerings of hearty bites and refreshments. In flight, stay connected with high-speed Wi-Fi, sponsored by AT&T. Your journey is designed to feel easy from the moment you check in to the moment you arrive. No matter where you're going, American gets you there. Book now at aa.com.

• 16:29Speaker 02

  This episode is brought to you by State Farm. Football has a play for just about everything. You can go deep, keep it on the ground, or draw up something nobody sees coming. And whether you want to run a flea flicker or the tush push, you need a plan to fit your unique situation.

• 16:44Speaker 05

  That's why State Farm takes the time to get to know you so they can help personalize coverage for your life and budget. Now that's a solid game plan. Like a good neighbor, State Farm is there.

• 17:02Speaker 05

  Butch wanted to get more surgeons performing these minimally invasive surgeries that are less painful for patients. And he wanted to use video games to do it.

• 17:14Speaker 07

  Now, it had been theorized that it takes 350 hours for anyone to learn how to do this. So my goal was to actually see if I could come up with a program that could actually reduce it to 8 to 12 hours.

• 17:35Speaker 05

  He called the program Top Gun, after the elite program where Navy fighter pilots level up their skills. As Butch told that plane dealer journalist, he is also an avid aviation enthusiast. And Top Gun: The Movie is his all-time favorite.

• 17:52Speaker 07

  Is this your idea of fun, man?

• 17:54Speaker 05

  You can hear how much he loves this movie in this ad he made for the course.

• 18:02Speaker 05

  With its theatrical music and the sound of planes flying overhead.

• 18:08Speaker 07

  Hi, I'm Dr. Butch Rosser, the creator of a Top Gun laparoscopic skills and suturing program. And I have just one question for you. Are you the advanced laparoscopic surgeon that you know you ought to be?

• 18:23Speaker 05

  Top Gun: The Surgical Program focused on drills requiring manual dexterity.

• 18:29Speaker 07

  Two-hand choreography, 3D depth perception compensation. All of these are needed attributes of a frontline 21st century surgeon.

• 18:40Speaker 05

  And here's where the gaming came in, at least at first. Butch remembered those video game battles he'd had with his co-residents. The competition had been fun and motivating. So he assigned points to every Top Gun drill based on speed and accuracy. And he made it a competition with a leaderboard so doctors could see how they stacked up against each other. Once Butch was able to show that the skills he taught in Top Gun translated to skills in real surgical settings, he added actual video games. Fun ones, like Star Wars Racer Revenge and the shoot-'em-up video game Silent Scope.

• 19:22Speaker 05

  By now, it was the early 2000s. And video games had a bad rap. In the public imagination, a kid who loved video games was more likely to be a killer than a surgeon, as exemplified by Joe Lieberman's remarks at a 1993 congressional hearing. Instead of enriching a child's mind, these games teach a child to enjoy inflicting torture. And Butch says he had other doctors telling him that video games were just frivolous, a way to blow off steam, not to train surgeons.

• 19:57Speaker 06

  I was sensitive to that because, you know, I came up where they looked at black people as, you know, not acceptable, not as smart, they can't do this, they can't do that. Came up all my life hearing that. So it didn't faze me. I just kept putting the work in.

• 20:14Speaker 05

  If Top Gun: The Surgery Course was Top Gun: The Movie, Butch was Maverick, doing things his own way, just like he always had. He partnered with other researchers to evaluate the course with the video games included. And they found that the better doctors were at playing video games, the better they were at the drills, which again simulated actual surgeries. The video game with the strongest connection to surgical skills? Super Monkey Ball 2.

• 20:47Speaker 06

  You have to push the little monkey forward, and then you have to not hit the walls. It's trying to kill the monkey. And you have to collect so many bananas, which are dodging you, okay? That is an eventful exercise, where your fine motor movement, video spatial compensation, non-dumb hand dexterity, all of that is challenged at once.

• 21:14Speaker 05

  So in Super Monkey Ball, you're learning to save the monkey so you can save the patient?

• 21:19Speaker 06

  Yeah, don't kill the monkey. And that's what we holler, do not kill the monkey. That's right.

• 21:30Speaker 05

  Butch and his fellow researchers were excited about this connection. And the idea that maybe if you could get better at a video game like Super Monkey Ball 2, you could become a better surgeon.

• 21:42Speaker 06

  You could have doctors being faster with fewer errors if you introduced video games into the curriculum.

• 21:52Speaker 05

  When Butch and his fellow researchers published their findings in 2004, the public was also really excited. The idea that playing video games could correlate with something good was breaking news.

• 22:04Amory Sivertson?

  Dr. Rossiter is considered one of the best at this in the world. And it's all because he figured out something no one else had thought of.

• 22:13Speaker 06

  That was a big breakthrough. You know, it's like, oh, Mom, you know, look, I played Donkey Kong and it still could help me save lives.

• 22:26Speaker 05

  Today, there are lots of studies suggesting a link between gaming and minimally invasive surgery. In 2012, researchers in Texas showed that high school sophomores who played video games performed surgery simulations better than surgical residents who didn't. And a Japanese study published earlier this year showed that medical students with gaming experience had better spatial awareness and more skills associated with laparoscopic surgery. What once was breaking news now seems almost like common sense.

• 23:06Speaker 05

  Butch still loves video games, but his goal was never to give them a PR boost. It was always to increase access to potentially life-saving surgeries.

• 23:16Speaker 06

  Our biggest challenge now is not the technology. Our biggest challenge now is how to get more people to go into surgery because we have a surgeon shortage. And it's shown that depending on your color and location, you may or may not Be blessed to have these laparoscopic or minimally invasive procedures available to you. And that cannot be allowed to stand.

• 23:44Speaker 05

  Butch has now run the Top Gun courses at colleges and even in high schools. The high schoolers play the same games and run the same drills as doctors who take the course. And in some cases, they perform the drills faster. Butch believes that if these young people make the choice that he did, to pursue surgery as a career, they could potentially start training at an advantage.

• 24:07Speaker 06

  You can make the whole surgeon training process more efficient because they come in skill ready.

• 24:13Speaker 05

  Butch has even done work with students not much older than he was when he set his sights on a medical career. Can learning techniques used to train surgeons help elementary schoolers too? A Central Florida surgeon thinks so. A few years ago, a local news station in Florida, where Butch was practicing at the time, covered his efforts to help young people see video game skills and themselves in a new light.

• 24:38Speaker 06

  I believe people, if they're trained in the right way, if you're approaching the right way, they can do anything. Do you feel like he could be a scientist now?

• 24:47Speaker 05

  Yes. Right now, Butch is working on more games for kids. He wants them to be able to picture themselves in the OR and for the journey there to be enjoyable.

• 24:59Speaker 06

  With all these kids playing for fun, we're going to have some surgeons shake out.

• 25:03Speaker 05

  He still has lots of ideas about games and medical education that he wants to test. Board games, mobile games. Butch wants to know how else he can invert our expectations about how to save lives.

• 25:18Speaker 06

  Because I'm going to shake it up, sugar, as we say it out south. And I'll be doing that until the day I'm not here anymore.

• 25:32Ben Brock Johnson?

  That was Grace Tatter coming right up in our series, Hidden Levels. Another step along our larger quest. Endless Threads' Dean Russell helps us touch grass digitally.

• 25:44Amory Sivertson?

  Coming out like right now in our feed and the feed of 99% Invisible. Listening is its own video game. Try and keep up.

• 26:03Amory Sivertson?

  This episode was written and produced by Grace Tatter. It was edited by Meg Cramer, mix and sound design by Emily Jankowski. Shout out to Hidden Levels managing producer Chris Berube for his input on this episode.

• 26:14Ben Brock Johnson?

  The rest of our team at Endless Thread is Franny Monahan, Dean Russell, Amory Sivertson, myself, managing producer Sumit Joshi, and production manager Paul Vikas.

• 26:25Amory Sivertson?

  Who also wrote a bunch of the music for the series.

• 26:27Ben Brock Johnson?

  Heck, yeah.

• 26:28Amory Sivertson?

  And our theme music was composed by Swan Real and Paul Vikas. Hidden Levels is our series co-produced with 99% Invisible about how the video game world has changed the world beyond video games. Jump over to that feed or keep listening here to go to the next level.

• 26:44Ben Brock Johnson?

  And Endless Thread is a podcast about the blurred lines between Super Monkey Ball 2 and Surgery. Have an online mystery, untold history, another wild story from the internet? Hit us up. You can email us at [email protected].

• 27:09Speaker 00

  Support for this podcast comes from Is Business Broken?, a podcast from the Marotra Institute at BU Questrom School of Business. Follow Is Business Broken? wherever you get your podcasts and listen on for a preview of a recent episode featuring Janet Kang, executive director of the Just Horizons Alliance, on who stands to benefit from AI in education.

• 27:32Speaker 05

  I am absolutely in favor of AI in learning in the right context. And just to explain why you're excited about it. Oh, my gosh, individualized support, right? Personalization and to be able to scale quality education in places where it was historically impossible. So for certain kinds of learners with different kinds of learning styles and disabilities, for example, speakers of different languages. There are amazing ways AI can boost learning. It just has to be with the right context. And age appropriateness is something we do a lot of work in because it is very different depending on where in that maturity cycle you are in terms of how your brain develops.

• 28:10Speaker 00

  Find the full episode by searching for Is Business Broken wherever you get your podcasts and learn more about the Marotra Institute for Business Markets and Society at ibms.bu.edu.

• 28:29Speaker 06

  This episode is brought to you by State Farm. Football has a play for just about everything. You can go deep, keep it on the ground, or draw up something nobody sees coming. And whether you want to run a flea flicker or the tush push, you need a plan to fit your unique situation. That's why State Farm takes the time to get to know you so they can help personalize coverage for your life and budget. Now that's a solid game plan. Like a good neighbor, State Farm is there.

• 28:57Amory Sivertson?

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