The Many Ways VR is Getting Real - er

Show Notes

In Part 2 of the Healthy Conversations discussion with Dr. Brennan Spiegel, professor of medicine and public health at Cedar Sinai Health System, gastroenterologist, and VR pioneer, lets us peak into the future, and see some of the many ways VR is getting “real-er” – as he puts it: “You can experience life as someone with a disability, or as a different race, or with certain physical or visual handicaps. And that can give clinicians a bit of insight to what their patients are experiencing continuously.”

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Dr. Brennan Spiegel:
I've had cervical arthritis for a long time in my neck from a whiplash injury early on, and I did use one of the VR headsets for neck pain that really has you go through a range of motion that might extend you beyond what you normally can do. But do it in a graded way and you don't realize that you're moving your neck that far because you're busy following a butterfly or something.

Daniel:
Welcome back to Healthy Conversations for part two of our conversation with Dr. Brennan Spiegel. He is a Professor at Cedars-Sinai Health System, a gastroenterologist and the Director of Health Services Research and a real pioneer and virtual reality. And I've been lucky to know Brennan, for several years and we're really exploring the potential for virtual reality, augmented reality, extended reality across the healthcare continuum. So welcome Brennan Spiegel.
With Apple and clearly Facebook are now Meta, getting into the space that technologies are becoming commercialized. I visited Jeremy Bailenson, who runs the Virtual Reality lab at Stanford, I think 12 years ago, and what was literally a 3 million setup now fits in your $300 headset or you go into the VR lab there when you put on a headset and you cut down a huge tree and you feel the tree falling. And they did this with thousands of people and found that afterwards they were much more environmentally friendly and used less paper and waste. Or they were Superman and they were saving people in the VR experience and then they had better empathy and they were more likely to be helpful.

Dr. Brennan Spiegel:
You're referring to the really pioneering work of Jeremy Bailenson, at Stanford, whose also written a terrific book called, Experience on Demand. So he described the proteus effect, I believe it's called. The Superman Effect, where if you become Superman, literally you feel like Superman. In general, we know if you stand up straight, you feel more confident, literally just the physical embodiment of smiling makes you feel happy.
VR allows people to embody these positive roles and carry out responsibilities that give them a different perception about their own powers. And also flying out in the outer space and looking back upon the world, it literally gives you goosebumps. There's research out of Canada and elsewhere demonstrating this sense of awe. I know you're a NASA guy and some of the astronauts in the International Space Station talk about this sense of empathy that they achieve for others and for the world when they look back upon the earth. And we can even do that in VR.

Daniel:
Recently, NASA flew astronauts with VR cameras and you can now literally be on a spacewalk outside the space station and have the experience without the Gs or the zero Gs as the case may be. So I imagine when we land on the moon, hopefully with Artemis III in a couple of years, we'll be there virtually with the astronauts. Let's circle back to some of the other use cases again as a therapeutic and then touch on medical education and even the social elements.
Clearly one area that none of us do well as patients or prescribing as clinicians is physical therapy, and that's another area where folks can gamify that.

Dr. Brennan Spiegel:
And this is a really well established use of virtual reality is to standardize and augment physical therapy, particularly at home. There's one company, XR Health, you can get access to a remote physical therapist. And you get a VR headset sent to your home, which allows the patient to, on a daily basis, go through different physical skills that are titrated to their level of ability. And when you're in VR, you can do Tai Chi, you can do different specific maneuvers that the headset will guide you through.
I know you, Daniel, have been using some of the VR gyms, for example, which engages you three-dimensionally, spatially to feel like you're doing it in a way that's empowering, I guess, in ways they might not otherwise, if they were just given, let's say a black and white piece of paper that said, "Here's your exercise to do at home." But in VR, it's literally in your face.
There's now research using this for everything from movement disorders, and Parkinson's, and cerebral palsy, neck pain. I've had cervical arthritis for a long time, my neck from a whiplash injury early on, and I did use one of the VR headsets for neck pain that really has you go through a range of motion that might extend you beyond what you normally can do. But do it in a graded way and you don't realize that you're moving your neck that far because you're busy following a butterfly. So lots of really fantastic examples in that space.

Daniel:
For the first three months of the pandemic when the gyms were closed, I booted up my Oculus, tried a then new platform called Supernatural where you're on a mountain, or on a beach, or on Mars hitting balls with bats and get my heart rate to 160, 170 for 30 plus minutes and it's got the music. And as I could track on my Apple Watch wearable, my resting heart rate went down by eight points and the three months I was doing it.
So one application that's getting exciting for those of us who are healthcare professionals is maybe to do a little better job on CME than our standard formats or even medical education. Where are we now with VR and medical education?

Dr. Brennan Spiegel:
There's been some efforts within medical schools, for example, to start using virtual reality in the anatomy lab, or potentially even instead of the anatomy lab. I think those of us that trained with cadavers might wonder for a second, "Is that a good idea?" But I have to admit, as powerful as cadaver based anatomy was, I think most of the learning I did was looking at the diagrams and reading the books. It's powerful to see it, but in virtual reality, you can see it too dissected out so precisely that there may be some real benefits of using VR for anatomy compared to a cadaver, without getting too technical here or grotesque for that matter.
I worked in the anatomy lab, saw things that probably would've been better in VR than in real life. But that aside, can we engage people in different ways? So there's a company called Confideo that's been really pioneering CME in VR and even live mixed reality, CME. So in that case, the speaker is actually on a stage and there could still be a live audience. But rather than a traditional PowerPoint slide that's two-dimensional, you actually enter a three-dimensional slide and the speaker is within a three-dimensional world interacting with the components.
And that can be very powerful for spatial learning if there's some anatomical component or some three-dimensional model or molecules. And so those are areas I think people are trying to explore.

Daniel:
A startup called Osso VR, started for orthopedic surgeons. They could literally put the headset on, be in the operating room, have the different orthopedic set, have a difficult knee case, or hip replacement, or the patient you're about to see simulated. And they can go through the entire procedure or learn a new one. And I think the data suggests they learn faster and retain longer and certainly don't need to practice on humans or an animal lab.
So I think that we learn to see one, do one, teach one, but I always think the future might be see one, sim one, sim one. And that will be more virtual as well as with your colleagues because maybe we could touch on the fact that VR and beyond is becoming social.

Dr. Brennan Spiegel:
Well, Daniel, you're always great at coming up with the next catchphrase, and I haven't heard that one yet, but you're absolutely right. See one, sim one, do one. And Osso is a great example. Justin Barad, runs that company and he is an orthopedic surgeon who saw firsthand the opportunity of developing simulations.
What's great about that story is it was developed by a physician who saw the unmet need and developed a simulation that's realistic, in really precise ways that he talks about. He's demonstrated in a randomized trial, as you mentioned, that he can improve the time to learning and the efficiency and timing and ideally outcomes of the procedure itself from those who practiced in the sim.

Daniel:
Yeah, my favorite analogy since I'm a pilot also is this flight simulator are pilots who fly 777s and others they practice those very acute challenges, which are very rare in real flight, but very important to practice. And I think for almost every medical application, from a procedure all the way to even interacting with their team, or running a code, or dealing with a patient with a mental health crisis can be simulated in VR.

Dr. Brennan Spiegel:
We can learn a lot from flight simulators. In fact, the origins of much of the VR work comes from the Department of Defense. As early as the 1950s and '60s when very primitive forms of VR were being developed to train fighter pilots, helicopter pilots, to go through simulations and war games. And it wasn't until many years later that we started recognizing the other opportunities. You've hit it on the head. Many of the origins of what we're now talking about go back half a century or more.

Daniel:
You helped lay that out, we're both accidental futurists. You have a terrific book, VRX. How Virtual Therapies will Revolutionize Medicine. They're already starting to do it. Let's take our futurist hats and let's look at three to five years. Where do you think we'll be then? And what are some of the challenges and opportunities?

Dr. Brennan Spiegel:
The last chapter of the book, I lay out a day in the life of the medical virtualist and what that looks like. What kinds of patients are they seeing and what kinds of interventions are they using? And we already have all of the technologies that I describe in that last chapter. And so what my hope is in the next three to five years, it has more to do with finding the infrastructure, the reimbursement, the staffing, the training, and just the will of healthcare systems, hospitals and so on, to stand up these types of services.
I think as we start seeing Apple enter this space and seeing more and more, maybe not low cost initially, but high quality headsets in everyone's homes, and as the metaverse starts to expand, as you like to call it the Medaverse, M-E-D verse, we need to protect some corner of this Medaverse so that it's not some dystopian, strange, Ready Player I world that people don't want to go to. But rather a corner of that world that is supporting human health and allowing people to live richer, real realities.
We'll continue to see incredible advances in the technology. We need to get it into the hands of users and train doctors how to talk with their patients and use it appropriately and have insurance pay for it. So that's my hope.

Daniel:
Let's shift to some of the now blended and mixed and augmented side of the equation. You mentioned Apple's probably hanging out with their augmented reality headset. We're seeing AR play a role in everything with medical education, to the ability to guide surgeons to procedures. Where do you see that right now and what might clinicians out there expect next?

Dr. Brennan Spiegel:
AR has been a fascinating technology that we all learned about during the Pokemon Go era. As people were running around chasing cartoon characters along sidewalks with their smartphone. And for those that aren't exactly sure what the differences between VR and AR, VR, you have essentially a blindfold on, you can't see anything, but you see everything at the same time. You're completely surrounded by these virtual worlds. Whereas in AR, you're experiencing the real world, but there's some overlaid computer graphic that's augmenting that real reality.
If somebody is operating on the brain where it may be difficult to see through tissues and around tissues, you want to know, "Am I targeting the right area to get to a brain tumor?" Well, that could all be reconstructed in advance with MRI scans that could be put into VR, but potentially AR as well so that you can have a target to help guide the operation.
And so there are really interesting opportunities and we're seeing it evolve these live surgical applications. Folks like Rafael Grossman, have been studying this and we're using this for years personally and still a little skeptical because I don't do operations, but I do endoscopies. I'm still on the see one, do one, teach one. Not the see one, sim one. Until they get maybe a little bit better the simulations but I think it depends on the application.

Daniel:
Even without a headset, even in your world of gastroenterology where the AI is looking at your image and suggesting a lesion you might want to go biopsy because it might have some subtle signs of cancer that you might have missed. So that's an idea of AI coaching. But now there are platforms for, let's say, surgeons out of UK called Proximie, started by a surgeon where if I'm doing an open case, a surgeon from somewhere around the world can help be my eyes and ears and point things out.

Dr. Brennan Spiegel:
Yes.

Daniel:
So continually coaching.

Dr. Brennan Spiegel:
Shafi Ahmed, in the UK has been doing a lot of that as well. And I think it's a fascinating opportunity for centers of excellence to beam out their own operations, not just on a video screen, but in the three-dimensional experience, may very well be able to enhance the skills. Maybe there's a way to help guide somebody who's trained in doing those procedures, those are all possibilities.

Daniel:
Where it extends further, I was recently in Long Beach for the XPRIZE finals for the Avatar XPRIZE where the user would put themself into a robot and go through a series of tasks, and the future may be literally porter there. You are in a virtual environment with the VR headset.
And in the near future you might just draw a line and the robot sutures up or does the anastomosis. So I think the blend of not just the robotics, the AR, VR, the haptics, but adding in the insights and maybe the crowdsourced AI big data elements from seeing thousands of procedures will up-level everybody across healthcare.

Dr. Brennan Spiegel:
That's right.

Daniel:
We touched on medical education, but part of the question now is who do we select and how do we train them for this new age? Any thoughts on changing the medical curriculum? How are you getting VR into your own medical schools and compatriots toolkit?

Dr. Brennan Spiegel:
Well, slow and steady. But you're right, there's so many other opportunities here. We know that there's this history of a paternalistic mindset amongst the biomedical industry and doctors in general. We know the answers, and here we're bringing down the tablets from Mount Sinai to tell you what medication to use or to get an operation or not.
But we know, of course, that patients are the experts in their own wellbeing. They also have vital knowledge that we need to tap into. That's all well and good to say, but how do we actually train our doctors to really learn how to do that? There's really interesting examples using virtual reality.
Once again, where you simulate exchanges with patients in virtual clinic and over and over again, the student doctor has to manage very, very difficult situations. And using various forms of AI, the patient can actually respond and might get upset in a way that might very well be appropriate by the way. And so there's been some studies showing that when doctors repeatedly rehearse these sorts of exchanges, they get better and in a way more empathic.
And so this is particularly important as we're talking to more people through zoom screens and remotely where it's harder to read body language. So that's one direction that VR is helping us take medical education.

Daniel:
Another one I'm aware of is VR is an empathy machine. You can experience life as someone with a disability, or as a different race, or with certain physical or visual handicaps, and that can give clinicians a bit of insight to what their patients are experiencing continuously.

Dr. Brennan Spiegel:
All those examples are exactly right on. We talk about walking in the shoes of another. But in VR, you literally can do this. There's been examples with Syrian refugee camps and experiencing it that can change people's perceptions about what that means to be a refugee without a family, or to feel what it's like to be homeless.
I often, in lectures I give, will show a video of myself at the University of Barcelona lab with Mel Slater, where he put me into a woman's body and I looked in the mirror and I saw myself as a woman. Then I find myself in an apartment and a man comes busting in, gets right in my face, is yelling and screaming and throwing things at me, and he's taller than me. And I'm telling you, I was scared.
And since that time, I think a little bit differently about domestic violence in a way that really changes fundamentally what I think when I see an ICD 10 code for domestic violence on an electronic health record, the visceral experience of what that must be like.

Daniel:
I think that's a very powerful example. So we have a lot of clinicians and caregivers of different sorts listening. Let's just close with what might be an early approach to get folks into experiencing or trying VR in their clinical practice or for their own medical education?

Dr. Brennan Spiegel:
We have this website, virtualmedicine.org. On the website we have this one little section called Programs we Like. And so that's a place to look. Patients with anxiety, with pain, you can "Prescribe" that they get a headset. They may already have one, and they can download from the Oculus store software like Trip VR is one example. There are many others, and it's really quite shocking that some patients have tremendous responses, others less so. And part of what we're doing with our research funded by the NIH, by the way, is to try and distinguish what predicts whose going to respond and what makes them so different?

Daniel:
There's at least 100 different VR and another 50 XR and AR type platforms already available that you can put in your digital formulary and use for your clinical practice or maybe your patient. And thanks to all your great work pulling this community together. In closing, anything we've missed touching upon?

Dr. Brennan Spiegel:
I think it's important as clinicians that we be open to other ways of thinking about what we do. We all learn from a textbook, we learn from the same textbooks. And often the way we learn something is how it sticks with us for the rest of our career. And I think it's very important for all of us to think about new paradigms and actively think about how to implement these paradigms into our everyday practice of medicine.
Millions and millions of people have these headsets sitting around like a toaster they use occasionally, but they're not always going to use every day. And there may be some really incredible therapeutic opportunities sitting at their fingertips that you can leverage as part of your practice.

Daniel:
Great. Well, thank you so much, Dr. Brennan Spiegel for being on Healthy Conversations. And I will see you in the Medaverse or in the real verse soon.