Pathologic 3 Review : The Video Game Adaptation of "House, M.D."

The Pathologic series, is considered one of the pillars of arthouse video games, where gameplay mechanics are built around a single core idea and offer an unconventional gaming experience rarely found in the "sterile" projects of major publishers. Few studios can afford to create an extremely dark, complex, deep, yet well-written game that doesn't hold the player's hand and provides incredible room for experimentation. Largely because of this, Pathologic has never enjoyed mass popularity, remaining a "project for aesthetes" until the release of the third installment.

Unlike the second part, Pathologic 3 is primarily a psychological thriller with nonlinear storytelling in the spirit of Disco Elysium. Now, you don't have to survive in a plague-ridden town; instead, your task is to help the remaining citizens make it to the next morning. And trust me: this is much harder than just searching for food and shelter, as the protagonist will be burdened with a mountain of responsibilities that will drive not only him but you as well crazy. In this review, we’ll discuss whether it’s worth playing Pathologic 3 if you’re new to the series, how difficult its gameplay is, and how Ice-Pick Lodge addressed the mistakes after the unsuccessful launch of the second game.

Like the second part, Pathologic 3 is an expanded remake of one of the three storylines from the original Pathologic. Initially, the developers planned to release it as a major DLC, but after evaluating the scope of work ahead, they decided there was enough content for a full-fledged numbered entry. And that's for the best, as the threequel is strikingly different from the previous game, both in terms of gameplay and storytelling. It’s no longer a survival simulator with resource scavenging and a clunky combat system, but something between a detective quest and a role-playing game. Surprisingly, this gameplay formula suits Pathologic perfectly.

The main character of the threequel is Daniil Dankovsky, better known to fans as the Bachelor. He travels to the small Town-on-Gorkhon, where, according to rumors, the immortal Simon Kain lives. However, on the day of his arrival, the protagonist learns that the long-liver has suddenly died, and a deadly plague is raging in the settlement with no cure in sight. Thus, the player becomes the only qualified medic conveniently present at the scene, and it’s up to him to treat the sick, enforce quarantine decrees, search for a cure, and keep the Bachelor sane.

The story of the third part, while repeating the tropes of the original Pathologic, is presented in a rather unusual way — by jumping from one timeline to another. After the prologue, where the Bachelor tries to find a stolen microscope, the narrative abruptly cuts off, and the player is thrown into an interrogation with an inspector who suddenly starts accusing him of things he hasn't yet committed. Immediately after, the fifth day begins, with the protagonist already burdened by a set of past events whose consequences must be dealt with as the story progresses. The most interesting part is that all the choices Daniil made without our knowledge are entirely negative, so all possible paths are simply blocked, leaving the protagonist with no choice but to finish his story with the worst possible ending.

Of course, in reality, this is just a creative tutorial in which Ice-Pick Lodge clearly demonstrates the most anticipated feature for fans — the ability to replay events with the knowledge already gained. That is, you don’t need to replay the entire game to get the best ending and see all the content. Naturally, you can’t jump back and forth through time endlessly due to a special resource—amalgam, which must be extracted from broken mirrors in the open world. But with careful use, you can easily fix most events that lead to bad outcomes.

The nonlinear story of Pathologic 3 is the project's main strength, and the ability to move through time allows you to view in-game events from different angles, thus getting more answers to the questions that will constantly arise in your head. As in the sequel, you’ll have a huge number of tasks and requests to fulfill in a short time, and since time in the game never stops, it’s almost impossible to do everything in one go without hints or guides.

Moreover, despite his arrogant nature, Dankovsky suffers from a "hero syndrome": he tries to save everyone, sacrificing his own interests and health. Although you can play Pathologic 3 as either a positive or negative character, the game, through the Bachelor's thoughts, still nudges you toward the good side. And the most interesting thing: being a good guy in the game is much more difficult due to the unpredictability of the consequences of your decisions. Not every "right" action from a logical point of view leads to the desired result. For example, I, the author of this text, had to rewind time several times because seemingly positive decisions led to the deaths of several key characters.

There are 12 days in Pathologic 3 during which the Bachelor must deal with the epidemic and find answers to his pressing questions. Each day has its own list of events that can be influenced, so that the next day (or perhaps later) you can see the consequences. All of these are recorded on a separate "Thoughts" screen, which is a branching mental map. With its help, you can navigate the intricate plot and plan your routes in advance to collect all the pieces of the puzzle before nightfall.

The Pathologic series can be criticized for many aspects, but it has always excelled in its skillfully written lore and plot twists. The writing, no joke, is no worse than in Disco Elysium. Every character has their own personality and manner of communication, so you need to choose every line carefully. No one will be polite with the Bachelor, so don’t throw your words around carelessly. In addition, dialogues are influenced by Daniil’s mental state, which is determined by the mania and apathy meters — but more on that in the next section.

Finding himself at the epicenter of a plague outbreak and being the only sane doctor around, Daniil becomes the head of the infection control department. He is burdened with a pile of responsibilities that he must somehow fulfill while also progressing through story objectives. And all this under strict time constraints, where any delay is punished by negative consequences. Over the course of 12 days, you not only have to uncover the mystery of the long-liver Simon's death, but also examine dozens of infected patients, create a vaccine, and, of course, save as many lives as possible.

First and foremost, the Bachelor must issue decrees that are theoretically meant to reduce the spread of infection and the number of sudden deaths on the city streets. Why "theoretically"? Because every decision you make has its pitfalls. For example, if you install disinfectant lamps at building entrances, townsfolk may start burning furniture, mistakenly believing you ordered them to "sterilize everything made of wood." Since you can rewind time in the game, you can test each decree and see its consequences. Additionally, by exploring locations and visiting quest spots at certain times, you can unlock new quarantine rules that are not only more effective at containing the plague but can even literally "forbid dying from the disease" at certain times.

Managing resource distribution, growing public discontent, and the spread of the plague is only a tiny part of Dankovsky's duties. Examining patients and searching for a vaccine is the top priority. This is where gameplay in the spirit of the "House, M.D." TV series begins. In addition to the main infection, townspeople have a host of other diseases that somehow suppress the plague's symptoms. But not every resident is willing to say what ails them or how they got it. This is where several diagnostic methods come into play. During the initial checkup, you can closely examine the patient's body for pathologies. Then you can conduct an interview to get more information. If the townsfolk's statements don't match your observations, laboratory research comes into play.

If that's still not enough to make a diagnosis, you'll have to visit the patient's home. Rummage through their belongings, question friends and relatives, collect all sorts of clues — the main thing is to gather as much information as possible to solve the mystery. Yes, each such patient takes a lot of time, which could be spent on story quests, but investigating medical cases is not a randomly generated activity with a repetitive set of actions. Each mini-detective story of searching for a specific disease is a carefully crafted narrative with an unexpected twist and resolution. At least, I never encountered identical situations or simple cases where you could diagnose by just guessing.

The survival system with basic needs from the second game is a thing of the past — you no longer need to rummage through trash cans in search of useful items. Instead, the Bachelor now has a stress meter with two variables: apathy and mania. When the apathy meter fills, the protagonist first starts moving slower, and then completely loses it, grabs a pistol, and tries to shoot himself. At this point, a mini-game starts where you need to choose the right sequence of lines to talk the protagonist out of making an irreversible mistake.

Mania makes Daniil move faster, but he starts responding aggressively in dialogue, and if the meter goes above halfway, he loses health as if from bleeding. You need to manage mood swings by interacting with objects and using medicines. For example, to reduce apathy, you can kick a trash can or look at an ugly piece of art, while mania is reduced by calming sights or touching a swing. The more often you use stress-relieving medicines, the faster your addiction level rises, reducing their effectiveness.

In the first few hours, keeping track of the Bachelor's mental state isn't too difficult. All the stress-relief items are always at hand. But as soon as you enter a closed space and pick a few emotional responses in dialogue, Daniil can quickly go from a calm and reasonable doctor to a hysteric, rushing across town to the nearest playground to touch a carousel or pop a couple of morphine ampoules. And this is a real problem, since it's almost impossible to tell which dialogue lines are emotional. You simply get apathy or mania points after closing the dialogue window. So it's best not to start conversations with townsfolk unless your mental health meter is centered.

Unlike the second game, Pathologic 3 does not have an open world. The city is now divided into sectors, which you can travel between using a fast travel system. The locations themselves are still large, so there's always somewhere to walk and something to see. However, each map now has a clear role. In safe areas, you can stroll, talk to locals, and trade with kids. The barter system isn’t as important as in the second game, so you can buy all useful items for shiny pebbles or bugs without much trouble.

In plague-ridden districts, a monster roams, and you'll have to run from it while dispersing fog with an experimental prototype. Being in such locations affects your apathy meter, so staying too long is very dangerous. Fortunately, there are campfires everywhere that can be lit with consumables and help scare off the plague creature for a while. In special situations, you can use the prototype to slow the monster, but it has a limited number of charges, and replenishing them requires rare reagents and precious time, which is spent during mixing.

In the sector with rioters, you have to sneak through alleys without attracting attention. Unlike the Haruspex, the Bachelor can't fight and only has a revolver with a tiny supply of bullets, which he mostly uses to threaten enemies. While you keep bandits at gunpoint, they stand still, but as soon as you lower your weapon, they attack. There's no point in fighting in Pathologic 3, since the protagonist immediately starts going insane from every kill, and escaping from a crowd of rioters is quite easy, especially if your mania meter is slightly filled.

To sum up, it's important to repeat that all the mechanics in Pathologic 3 are carefully distributed throughout the story and alternate smoothly, never descending into monotonous routine. With emotional swings and time limits, you won’t have time for aimless wandering in a plague-ridden city. The game constantly throws new conditions and tasks at you, which you need to complete not only quickly but as efficiently as possible. Unlike the first game, the threequel isn’t as "stuffy" and is more friendly in terms of difficulty. The action in the sequel was clunky, and the survival system was annoying with its restrictions. By getting rid of those remnants, Pathologic 3 offers the best the series has: the story, multifaceted dialogues, and the unraveling of mysteries. With the time travel mechanic, you can experiment with alternative paths and choose the most suitable ones for your playstyle.

On the other hand, some fans might dislike the game precisely because of the simplified gameplay. Some will surely say, "They made the game for casuals." Although in fact, Pathologic 3 isn't all that easy, especially closer to the finale. In any case, we’re looking forward to the final chapter of the story with the Changeling, for which Ice-Pick Lodge will surely come up with another gameplay formula that might become the best in the entire remake trilogy. Or not. Time will tell.

The graphical execution of Pathologic 3 is rather modest. Yes, the art is excellent, with a well-crafted style, and the location design is decent, but due to low detail, a lack of memorable objects, and poor lighting, the game looks outdated. The plague-infected areas are atmospheric, but the division of the city into districts ruins things — the world feels static and decorative.

Character design is also a mixed bag. In dialogues, the models are attractive and pleasant to look at. But in the actual game, the characters are too low in detail. The city is mostly populated by identical residents who differ only in minor ways. This somewhat undermines the overall perception of the world. Additionally, the animations are unnatural and outdated even by indie game standards.

The soundtrack was clearly created as an homage to the first game. Some tracks fit the atmosphere perfectly and add emotional depth to story scenes. However, in a couple of locations, there are melodies that break the immersion and are unpleasant to the ear. The track by Akira Yamaoka sounds wonderful. It’s a shame the composer wasn’t invited to create the entire soundtrack.

Pathologic 3’s technical state, surprisingly, wasn’t as disappointing as after the release of the second game. Bugs did occur—not critical, but still annoying. Animation glitches happened fairly often, with characters freezing in T-poses. However, there were no softlocks or broken quests. In terms of performance, Pathologic 3 runs well. There were no frame drops during playthrough, and the framerate always remained stable. Perhaps the division of the city into districts played a role here.

Pathologic 3 is the best game in the series, with an amazing story, excellent dialogue, interesting characters, and a well-thought-out setting. Yes, the gameplay isn’t perfect, but unlike the second game, it doesn’t descend into routine or suffocate you with poorly designed hardcore mechanics. The time travel mechanic opens up room for experimentation and lets you play the game the way you want, not just the way you can. While the game isn’t perfect visually and its technical state leaves something to be desired, compared to the previous installment it’s a huge step forward. For newcomers unfamiliar with the series, it’s the best entry point.