A Clinic in a Headset? The Exciting New World of VR

Show Notes

In the first of a 2-part episode on Healthy Conversations, Dr. Brennan Spiegel, a professor of medicine and public health at Cedars-Sinai Health System, gastroenterologist, and VR pioneer, discusses the exciting possibilities of virtual reality in terms of its affecting the human mind, as well as chronic diseases. As he puts it, "Rather than always bringing patients to the clinic, what if we can bring the clinic to the patient?"

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Speaker 1:
I often say, rather than always bringing patients to the clinic, what if we can bring the clinic to the patient?

Speaker 2:
Welcome to Healthy Conversations. I'm Dr. Daniel Kraft, and today I'm thrilled to be in healthy conversation with Dr. Brennan Spiegel. He is a professor of medicine and public health at Cedars-Sinai Health System, the director of health services research, and a practicing gastroenterologist as well as my friend and a leading pioneer in the world of virtual reality, extended reality, augmented reality as it applies to the world of health care. Maybe for our listeners who are mostly health care providers, how will you sort of summarize the field in general?

Speaker 1:
When most people in medicine and in general think about, let's say, VR for starters, they might think about kids playing first-person shooter games, but not necessarily as a treatment for chronic conditions or for any condition for that matter. But it turns out in elite psychology labs all around the world, there's been this sort of small cohort of investigators going back decades now who have been studying the effect of VR in particular, but increasingly, mixed reality, extended reality in general, AR, on the human mind and on its effects on chronic diseases.
Until recently, we just haven't had access to really high quality, low-cost headsets that we can bring into a hospital or into a clinic. And over the past seven years or so in our hospital, we've been experimenting with how to use VR, and now we're at the point where we are almost daily called to the floor to use VR for a wide variety of applications we can discuss. And now even the FDA has a name for this field. They call it medical extended reality or MXR. And I could even announce today that we are now establishing a new medical society called the AMXRA or the American Medical Extended Reality Association. So there's a lot to talk about.

Speaker 2:
Fantastic. That's super exciting. Cedars-Sinai runs one of the biggest academic medical centers using VR. What's your sort of favorite cutting edge example, how VR is entering the clinical space?

Speaker 1:
As a gastroenterologist, the most common GI condition that we manage is irritable bowel syndrome or IBS, which affects about 10% of the world's population. And to this day, we're not entirely sure what causes this, but we think of it as a disorder of brain-gut interaction. And this old idea that the mind and the body are separate and distinct goes all the way back to René Descartes in the mid-1600s. And it turns out that's wrong. It's one continuous system. This is a good example of a model condition where the mind and the body are sort of talking to one another. And so we need to think holistically about managing our patients beyond just medications.
Long answer to your question, we've been developing a treatment specifically for IBS. We call it IBS/VR, and we've actually actually published one paper on this and are entering some clinical trials and seeing really positive results to augment traditional therapies using VR to help support cognitive behavioral therapy, biofeedback therapy, mindful meditation with a focus on the gut, even gut-directed hypnotherapy in virtual reality.

Speaker 2:
What used to be a $2 million lab now fits on a $200 headset. What's that experience like for the patient?

Speaker 1:
I often say rather than always bringing patients to the clinic, what if we can bring the clinic to the patient? This isn't meant to replace doctors or traditional therapies, but 99% of people's lives are spent far away from the clinic. And so what we are doing is giving people headsets that they take home. And in their headset, they experience a clinic. Literally, there are hallways and rooms and doors, and we periodically unlock treatment rooms over the course of a protocolized eight-week treatment period.
It starts with just learning about IBS and seeing firsthand this connection between the brain and the body and putting into context the bacteria. Then we graduate into various behavioral interventions. We put people in a public restroom, which can be a very stressful experience for many people with IBS. And you can hear people, and you can see their feet as they're waiting for you, and you're running late for a meeting. And we freeze that moment, and then we conduct cognitive behavioral therapy in the stall. Literally on the back of the door that you're staring at, we start an interactive CBT experience so that the next time a patient is in that environment, they've already rehearsed how they're going to manage that moment.

Speaker 2:
It really is experience on demand. Even at Stanford Packard Children's Hospital, they can take children before they go in for a procedure and they can experience going into the waiting room, anesthesia, post-op care. But you're also pioneering the work as sort of, I think you described VR, XR, et cetera, almost as the new syringe. It can be used for many different applications. Some of your pioneering work goes to pain. How does that work? Because that's a bit different than cognitive behavior therapy. That's really putting folks in a whole new space.

Speaker 1:
That's right. Pain comes in different forms, and it can be acute, which is an expected response to tissue injury that's short-lived, or it can become chronic, where now even if the tissue injury has subsided, there's still persistent feeling of pain. And the location of that pain generation can migrate from the source of the tissue damage into the brain itself. It's called nociplastic pain, where the brain itself is generating an experience of pain. And that pain is not just a physical experience. It's emotional, it's cognitive, which is why opioids maybe can reduce the physical experience of pain for some period, but don't necessarily address the emotional drivers. And so this is where VR can step in, both for acute pain, which is really just mainly distraction, and for chronic pain where it's a 56-day at-home treatment course using an FDA-cleared software-hardware combination to manage chronic pain through various forms, again, of cognitive behavioral therapy. We've seen really positive results there.

Speaker 2:
And that can be used in a pain crisis, but also like a burn injury. And the one I'm familiar with, I think it's called SnowWorld, where you're literally in the Antarctic and you're throwing snowballs at penguins. And it's partly distracting you. But also, every time I even see a picture of that platform, I kind of get the chills.

Speaker 1:
You're referring to really innovative, pioneering work from Hunter Hoffman at the University of Washington who years ago now, long before I'd even heard of VR, he created, as you said, SnowWorld. In that instance, it's for burn injuries. So rather than the searing hot pain of a burn injury, you experience cool blue, white, snowy scenes, sort of a metaphorical counter-narrative. Really incredible results, not just with the reports of pain, but also with functional MRI scanners where he demonstrated that the effect of VR is equivalent to hydromorphone, if not maybe a little bit better, than using an opioid for acute pain. Whereas for other types of pain, let's say IBS, again, the metaphors are different.
So for example, we're developing a program using biofeedback where we have a sensor on the abdominal wall called AbStats that actually measures the intestinal activity. And that data can be put right into a headset where you can then almost see metaphorically what's happening in your belly. It could be if it's slow like a swamp or if it's fast like a river, and you need to try and change your own motility through biofeedback enabled by VR connected to a biosensor.

Speaker 2:
Is that something that can continue when you're not connected to the technology?

Speaker 1:
Absolutely. One of the easy critiques is to say, "Oh, well, it's great that they feel better while they're being distracted. But we live in RR. We live in real reality." We don't live in virtual reality, which is why when we develop programs like IBS/VR, towards the end of the eight weeks, they spend less and less time in VR. And the idea of the VR is not to live in this forever, but to take advantage of the presence that is achieved in VR. We can trigger emotional experience that lead to robust skills so people can throw the VR headset away as far as I'm concerned. You don't stay in CBT forever. That's an eight to 12-week treatment that literally changes the brain, which is a shape-shifting organ like any other organ in the body.

Speaker 2:
Speaking of changing the brain, another major area of interest I think with VR XR and beyond is mental health. You can see the impact of VR lighting up certain elements of the brain, and now you're seeing a lot of work with maps and other actual psychedelics, and everything from MDMA to psilocybin. Where's that starting to blend with the ability to shift folks with, everything to optimize your mental health, all the way to dealing with very severe, high morbidity, mortality mental health challenges?

Speaker 1:
You're absolutely right, and this gets at the heart of what is driving many mental health conditions. Part of it has to do with what's called the default mode network of the brain or the DMN, which was discovered in the early 2000s, I think at the University of Washington. Simply put, the part of your brain that is that inner voice that we all hear chattering and scheming, and the executive CEO in the brain that's telling you what to do, when to do it. And this is a very human experience that we all have and allows us to survive and thrive in the world. But it also can become an overbearing companion, a chattering monkey.
We look at Buddhist monks, for example, who meditate and practice for on average 40,000 hours to be able to shut down their default mode network. That's what they're actually doing on functional MRI scans, is they shut down the DMN, which allows them to have what's called non-dual consciousness. And what that means is they literally feel as if their sense of self has dissipated, and they've become one, almost literally, with the world around them. And that's exactly what psychedelics do. Psychedelics inhibit the default mode network of the brain that is pharmacologic. So the question is VR like a cyber-delic? The answer is, it turns out, yes. There have been head-to-head studies of VR versus psilocybin and other psychedelics, and the felt experience for the user is almost equivalent. And we see this all the time with our patients.

Speaker 2:
It's really fascinating. And of course, you can blend other modalities. I think you once described to me a bit of a out-of-body experience, almost like a near-death element that's also been approached with psychedelics for end of life care. What are some examples of where the VR element, the headset, the visual part, integrates with other sensorium?

Speaker 1:
So you mentioned that out-of-body experience. This was one of the most profound VR experiences or any experience that I've ever had. It was at the University of Barcelona where I traveled out there to visit Mel Slater, who's been studying VR. He's created this really fascinating VR experience where you separate from your body, and then you float up to the ceiling and look down upon yourself. And there's this moment where you realize that you've passed away. It stuck with me. I often show that video, as you mentioned, for some of my talks, just to demonstrate the impact it has on the mind. And what's so powerful to me about that is it was five years ago, but I still remember it acutely, and it's even changed how I think about the process of dying.
I'm not ready to die, God forbid, anything happens to me prematurely. But I do at least now have this idea that the actual process of dying itself does not need to be catastrophic, necessarily. And that's an important insight that came from a 10-minute experience in the lab in Barcelona, in a VR headset. So you think if we can do that with people who are well, what role might it have for people towards the end of their life who need to maybe practice dying in a comfortable and powerful way? What about other conditions like schizophrenia, which is an area VR is being used for now to help people confront their inner demons through virtual reality? There's really innovative uses of VR that are exploding, and we talk about all of these in this course that we put on every year at Cedars-Sinai. It's called Virtual Medicine every March. You can go to virtualmedicine.org. And in a book I wrote too, I talk a lot about these examples.

Speaker 2:
Yeah, I've been to your Virtual Medicine conference. It's incredible because it's really at this convergence of technologists, artists, gamers, patients, clinicians. And as you mentioned, I think the FDA is now getting into VR and digital therapeutics so that you can actually prescribe and even get reimbursed for some of these technologies.

Speaker 1:
In fact, I was just talking to Medicare last week. There are ongoing discussions right now to develop codes so that providers can be reimbursed both for the use of VR in a clinical environment and even as a durable medical equipment in the outpatient environment. And yeah, you're right. The FDA has now been approving and regulating programs, and there are really interesting new evolving paradigms, and there's really interesting conversation about whether to go through the FDA or not, and how do we keep updating programs that are FDA cleared, especially since we're going to hear from Apple probably in the next year or less about its new XR ecosystem, and how do we keep up with all that while also looking at the regulatory pathways. So that's a whole other interesting set of discussions.

Speaker 2:
We're going to stop here on this part one of our Healthy Conversation with Brennan Spiegel. There's so much to cover. Hope you'll join us for part two as we look further into the future of virtual augmented and extended reality in health care.