Three Decades of Medical VR, with Stanford’s Dr. Walter Greenleaf

XR has come a long way, baby – and we have one of the technology’s earliest pioneer’s on today’s episode. Dr. Walter Greenleaf has been working in the field for 33 years, since the days when VR was little more than a twinkle in research scientists’ eyes. Now, he and Alan chat about how far the technology has come, and how far it still has to go.

Alan: Welcome to the XR for Business Podcast with your host, Alan Smithson. Today’s guest is Dr. Walter Greenleaf, a behavioral neuroscientist and medical technology developer working at Stanford University. With over three decades of research and development experience in the field of digital medicine and medical virtual reality technology, Walter is considered the leading authority in the field of working in this industry, and he’s been doing this for 33 years. Unbelievable experience. Dr. Greenleaf has designed and developed numerous clinical systems over the last 33 years, including products in the fields of surgical simulation, 3D medical visualization, telerehabilitation, clinical informatics, clinical decision support, point of care, clinical data collection, ergonomic evaluation technology, automatic sleep staging systems, psycho-physiological assessment and simulation assisted rehabilitation technologies, as well as products for behavioral medicine. Dr. Greenleaf’s focus has always been on computer supported clinical products, with a specific focus on virtual reality and digital health technologies to treat post-traumatic stress disorder, anxiety disorders, traumatic brain injury, stroke, addictions, autism and other difficult problems, and behavioral and physical medicine. He’s currently a distinguished visiting scholar at Stanford University’s Media X program at Stanford University’s Virtual Human Interaction Lab and the Director of Technology Strategy at the University of Colorado National Mental Health Institute Center. To learn more about the work that Dr. Greenleaf and his team are doing, you can visit the Human Interaction Lab at Stanford at vhil.stanford.edu and a new organization that he’s formed called the International VR Health Association at ivrha.org.

Welcome to the show, Dr. Walter Greenleaf. So great to have you.

Walter: Thanks, Alan. I’m pleased to be here with you.

Alan: That’s an honor. You are considered one of the godfathers of this technology. You’ve been working in it your whole life. And I want to personally say thank you for laying the groundwork that allows people like myself — the new people getting involved here — to really pick up where you left off, and where you’ve driven this whole industry forward to, and let us really build upon your lifetimes of knowledge. So thank you very much for paving the way for us.

Walter: Well, thank you, Alan. And really, without everybody else’s and my colleagues work and your work and other people who are helping the trends position from something that for a long time was a research lab curiosity and something that really hadn’t escaped the confines of academia. Now we have it out there in the world. And I’m particularly excited about all the progress has been made in applying VR and AR technology to difficult problems in healthcare. For me, it’s a very exciting time.

Alan: I’ve been keeping track of all of the different things that come up in my news feed and I have a health and medical folder. And it’s interesting, because last year I actually had to break it apart into a mental health folder, in addition to the traditional health and medical. So there is an enormous amount of, not just research, but real practical applications being created for this. You know, one of them, one that stands out the most to me is being able to use virtual reality to treat lazy eye or strabismus. I thought that was just amazing. Within a few sessions, people are seeing complete reduction and elimination of their lazy eye using virtual reality. And that’s just one of a thousand use cases in this technology. So maybe walk us through the work you’re doing at the Virtual Human Interaction Lab, and what are the some of the great use cases that you’re seeing now?

Walter: OK, well, sure. Jeremy Bailenson is the director of the Stanford Virtual Human Interaction Lab, and I help out there as the medical advisor and expert. The Stanford Virtual Human Interaction Lab has a focus on exploring and studying how VR technology can promote pro-social behavior, such as helping us better understand how our behavior affects the world’s ecology, how our behavior affects other people, and studying how we can shift attitudes and shift behavior using virtual reality technology. The lab is really one of the pioneering research groups in the field of VR and behavior change. And I encourage you and your listeners to check out the website. There’s a lot of really amazing research material that’s been accumulated there. But my role is sort of translating that research and the research of other groups from the academic arena out into the medical product arena. So in addition to my work at Stanford and at the University of Colorado National Mental Health Innovation Center, I’m doing a lot of work advising some of the early stage and some later stage medical VR startups, those that have received investment funding to build and bring to market products. Then also helping those groups connect with the healthcare ecosystem, the pharmaceutical industry, the medical device industry, the health services industry, and the insurance providers, making sure that everyone in the healthcare ecosystem is aware of the power of VR and AR technology and how it can make a big difference in healthcare.

And as you mentioned earlier, it really spans the spectrum. We see some really amazing products are being developed to in the education arena to help train people to not just do surgical procedures, but also to work as a team on difficult problem, how to deliver distressing news to a family or to a patient, how to interview a patient in an effective way. A large selection of training applications. But beyond training, we also have a whole new wave of systems — like you described, for strabismus — that help therapeutically with clinical problems. And those range from– well, you listed a few of them, treating stroke and traumatic brain injury, treating anxiety and depression, post-traumatic stress disorder, helping with addictions, helping with autism. There’s a very long list of interventions. And one of the things I’m really excited about is VR allows us also to do a better job of assessing people, to measure how they move, measure their mood and their behavior in ways that we really didn’t have tools for before. We can now do better objective assessments, instead of subjective measurements. And that gives us some very powerful tools.

Alan: One of the tools that I think we’re just starting to see come online is eye tracking and motion tracking, where we’re really able to get data points about humans that we’ve never had before. Is that some of the things you’re working on?

Walter: Absolutely. And what I find very exciting is that because we can measure how people move, because we can measure where they’re looking, what they’re paying attention to, things that before we’re collected in a subjective and analog way, we now are able to collect in a reproducible and objective way, and that gives us both new tools for research, but also new tools for assessment. Let me give you a few examples. If we’re trying to understand, let’s say, a neurodegenerative disease like Alzheimer’s or Lewy body disease or perhaps Parkinson’s. And we are asking people subjectively — or their family members — to subjectively give a report on how someone’s doing cognitively. It’s very, very hard to measure. And that means that developing new pharmaceutical interventions, new behavioral therapy interventions are all limited by the fact that we don’t have very precise tools. But if we can measure how people move, if we can measure what people are looking at, if we can measure what people are attending to, if we can measure behavior, then we can do a better job of coming up with new interventions that — either pharmaceutical or through cognitive behavioral therapy — that can help with whatever problem is that they’re dealing with. And it’s really putting us in a better position to move forward in terms of both research and product development.

Alan: It’s incredible. The work you were doing 30 years ago, how has it progressed? How has it changed, from where you were starting out in this technology, to where it is today, and where you think it will go in the next five to ten years?

Walter: Boy, what a big question. In terms of the progress we’ve made, we knew back decades ago that VR could be an effective tool to help with some very difficult problems, for example, treating phobias or post-traumatic stress. We can use a simulation to help do what’s called exposure therapy. So, for example, someone who might have a fear of flying, we can develop a simulator that allows him to go through the experience, or fear of heights, or fear of spiders, or really anything that there is a fear reaction to. The counselor or commission can gradually, in a controlled manner, expose a patient to what they are afraid of, and teach them the skills to manage those fears and to habituate sometimes what’s a learned fear response. And we were able to do that, for example, with– there was a– Larry Hodges and Barbara Rothbaum developed a virtual Vietnam — back in the early 90s — that was very effective at treating post-traumatic stress disorder for Vietnam vets, some of who had been suffering from PTSD for decades. And with the help of this method of exposure therapy, it was able to make a big difference.

So to answer your question, we’ve known for a long time that we can treat problems like addiction, problems like post-traumatic stress, problems like phobias, a whole selection of clinical problems using VR, but it really wasn’t affordable. And it also wasn’t very comfortable to wear. Spending a lot of time in VR would sometimes cause simulator sickness. And it was so expensive, and a head-mounted display could cost $70,000. A computer that was used in the research could cost four or five hundred thousand dollars. But now we have better systems that I can order on Amazon. It’s just amazing. What’s happened is some of the paths that were plowed back in the early days showing what works, what doesn’t work, what’s a fruitful path of endeavor, what’s not. We know that. And we can go deeper now with the technology. We can do larger scale studies. We can reproduce the original research that was done with small sample sizes and with what appears now to be very crude equipment. We can really go out and build it up better and probably more importantly, get it to people who need it.

Alan: So we’ve seen a reduction in the cost, reduction in the time to make these things. The one thing that we’re not seeing — and maybe you can speak to this — is a massive adoption across all the industries. And medical is really adopting this technology more so than in the other one. What do you think are still the underlying reasons for the hesitation? And it might– I have a theory on this. And my theory is that we’ve been crying wolf for so long. “VR is going to be great!” Another five years, “VR is going to be great!” Another five years. People are just like “Yeah, yeah, whatever. VR, sure.” How do we break through that?

Walter: I think that’s part of it. I think part of it also has been that VR is somewhat of a glib phrase. I think it’s a very descriptive phrase. But it’s also a phrase that causes some people to think, as you described, that it maybe it’s a little too light-duty and not an effective tool for addressing large problems. But it’s changed. We now say VR or AR, and people know what we mean, much like when we say AI. Whereas five years ago, if somebody said VR, you wouldn’t necessarily know what that stood for. So we’re getting used to that phrase. And in my opinion, what the problem is — yes, what you described — but also, it’s the fact that it’s sort of what we call a virality factor of one. You almost have to see it and try it before you really get it. And that means it’s not as contagious as some other things that catch fire really fast. And I think it is going to really take off very fast. But what we have to do is build the practical applications for the enterprise. We’re in the process of doing that in architecture and finance and skilled labor force training, soft skill training and medicine. Now, medicine in particular, though, has a little bit of a very appropriate barrier. We need to show what’s effective and we need to show what’s safe. It takes a little bit time to do the studies to demonstrate safety and efficacy, but we’re in the process of doing that. And there’s a lot of early adopters out there who have brought VR into their clinics, into their hospitals, and are doing very good work with it. So I think things will catch fire very soon. But I think we’re on schedule, now that the prices are reasonable. And what’s slowing things down, I think, is we just need more people to build out the practical tools that can be used in the enterprise.

Alan: So there is some massive opportunities for enterprising students coming out of universities like Stanford who are– I think they’re kind of benefiting from the three decades of work that you and your colleagues have put in, because in my opinion, what I’m seeing in the market is that now it seems to be just ripe for explosion. It looks like we’ve got, the rocket is on the track and all thrusters are going. And is that the kind of sentiment that you’re feeling in the market right now?

Walter: I think it’s a good analogy. I think that because the groundwork has been laid and because the infrastructure is already in place. VR and AR technology leverages the Internet and broadband that’s in place. 5G is on its way. We’re leveraging distribution mechanisms. And also keep in mind that at least in the medical arena, a big part of what we’re doing relies upon other technologies such as machine learning. I mean, we collect a lot data, but we need to have the tools to analyze it. It relies upon avatar technology that look much more realistic and have facial expressions and nonverbal communication aspects to them, so that they look much more realistic than what we’ve been able to generate in the past. So I think things are poised to take off because there’s a convergence of technology. AR and VR technology is going to leverage AI technology, it’s going to leverage simulation technology that’s being used in a variety of other arenas other than healthcare. And it’s all converging into one spot. So, yes, I think it is poised– and I use the term poised, but I don’t mean poised for taking off in ten years, and I don’t mean even five years. I think it is in the process taking off now, and it’s going to move really fast.

Alan: I couldn’t agree more, to be honest. I’ve been studying this industry inside and out and I subscribe to Google Alerts for virtual and augmented reality. And five years ago, I’d maybe get one alert every two days and have a couple of things in it. I’m getting three alerts a day and they’re packed. Let me read something. I think this is interesting:

“Medical practitioners should suit the virtual reality application to the patient, not the patient to the technology. The VR technology agenda in medicine. All organizations face the problem of dramatic increases in volume of data that they must manage to conduct their daily affairs. Increasingly, this data is in a variety of media formats, particularly in medicine, where data formats include CAT, MRI, EEG and X-ray images, as well as real time communication with consultants. Many technologies have been offered over the past 40 years to help with this escalating information resource management problem. And now we have virtual reality.”

That is from Virtual Reality Magazine, from 1993.

Walter: [laughs] That doesn’t surprise me.

Alan: [laughs] I happen to have three copies of this magazine. It’s just mindblowing that the promise was there and it was 20 years too early. And now with the advent of Oculus Quest and these really inexpensive headsets, I think it’s just opened up the world to developers, and clinicians, and medical practitioners.

Walter: Well, let me mention, to snap on top of that point. I think there’s another trend that’s worthy of paying attention to which is, at least in medicine, the continents are colliding. The consumer electronics companies like Apple and Samsung and to some extent Google and Microsoft, along with companies like Amazon, are jumping nto healthcare. And that’s really changing the game. The fact that with their speed of product development and they’re savvy about good user interface design, to have these groups jump in and team up with pharmaceutical companies like Novartis and Sunovion and others, and to team up with medical device companies like Penumbra, it’s really a wonderful time to see the confluence of speed and savvy that is coming from the consumer electronics company, combined with the experience of the medical product development and distribution channel. It’s like a tidal wave roaring down a racetrack. So I think things are going take off faster than any of us will expect.

Alan: I’m going to read something else. This is from a different magazine:

“Virtual Interface Technology offers many applications for assisting disabled persons: augmenting reality in rehabilitation medicine.”

By Walter J. Greenleaf and Maria A. Tovar, from Spring 1995, Virtual Reality Magazine Special Report.

Walter: Uh-huh. That’s right, that’s right. And finally, the things that we were excited about back then are now affordable. We’ve been able to do it in research laboratories for decades. But now we can start moving it out into clinical care.

Alan: So, people listening… let’s say, for example, hospitals or clinicians or– what is the practical first steps for them to start applying these technologies? What would you recommend? I know you founded the IVRHA, so maybe you can talk about that and how these hospitals and clinicians and medical practitioners can– how can they get into this and start using it right away?

Walter: Well, first of all, I’m glad you asked about practical applications as opposed to asking for “the killer app,” because we don’t use that phrase in medicine. You’d be amazed at how many startups coming from the technology.

Alan: [laughs] Probably the worst phrase ever for medicine. [laughs]

Walter: Yeah, but you know, people still are talking about the killer app for medicine. But to talk about how people can get started, I think going to the IVRHA website is a good spot. You’ll see many of the medical product companies and startups and service providers that are teaming to explore the applications of the technology, it’s a great, great starting spot. We also put on a yearly conference on medical VR and that’s a great spot to come and meet other people that are working the arena and try out demos.

Alan: Where’s that going to be?

Walter: It’s going to be in Nashville. There’s a link to the website for it at the IVRHA website. I think another way really for clinical groups to get started is to well, I think take a look at some of the startups out there that are doing pioneering work. You described how VR is being used to help treat strabismus and amblyopia. For example, I would think for really whatever indication that you’re interested in, be it depression, be it anxiety, be it stroke rehabilitation, be it pain distraction, a good way to get services, to just, of course, do a simple web search to find the principal groups that are out there doing research, and then see which product development companies are basing their products on a research backed initiative and see who is citing and using as part of their advisory group established research groups. There are a lot of people that are jumping into the clinical VR arena by translating their skills in game development or their skills in sensor development into products. But not all of them understand the medical ecosystem. Not all of them understand the ergonomics of how to bring a product into a clinical environment, so that it doesn’t slow down the process, so it doesn’t create additional burden and work for the clinicians and the ancillary care staff.

So I would say as my filter, I would look for those product development companies that have either brought onboard research scientists and experts who know the medical ecosystem to help them advise their technology direction and probably more importantly, conduct validation studies. And I would also look for those that have formed alliances with some of the existing experts in the medical ecosystem, like some of the pharmaceutical companies or medical device companies. They’re very selective. And of course, the ultimate criteria is if somebody has made the effort to go and receive FDA certification, has a product to demonstrate their safety and their efficacy. That’s really the main watchword I would look forward to, to see where to start is to find those companies that address the problem you’re interested in that have gone down that pathway.

Alan: Absolutely. You touched on a couple of use cases, one of them being pain distraction. One of the studies I read, it was something like 25 percent reduction in opioid usage in debridement of wounds. And if you think about that, that’s a massive reduction in medications that have detrimental effects on people, and can lead to addictions and other things, just by using VR.

Walter: It is very exciting. You’re you’re talking about Hunter Hoffman’s work. And Hunter has done a great job of demonstrating not only how we can use VR to reduce the need for narcotics in a burn treatment clinic, for example. But how the reduction in the need for narcotics translates out into less possibility for addiction after people are discharged. And that’s a really significant thing. A large proportion of the problems we have with opiate addiction in our country right now are because people get caught up in using narcotics as a result of being in a hospital and appropriately getting pain reduction medication. But if we can augment the pain medication and reduce the need for it by using virtual environments as a gating distraction from the pain, then all the better. And also VR been used for helping people with chronic pain learn through cognitive behavioral therapy and other approaches how to manage the chronic pain. So it’s not just during the acute phase of a painful process, but also for the post discharge, post acute phase.

Alan: When people are thinking about this, what kind of, in business terms we’d say key performance indicators. How do you measure the success of something over another modality? What are the typical measurements if you’re going to start using VR versus something else used in your clinic? How would you measure that success? What does that look like?

Walter: That’s a very good question. I would say for a medical product, it really depends if we’re teaching a procedure that’s very different than if we have a clinical assessment, and that’s very different than if we have a clinical intervention. They all have different metrics. If you’re measuring the ability to use VR to improve a training process, one thing you would look at is not just how much more proficient the training process is in terms of mastering a skill — such as maybe a surgical skill or how to diagnose a patient — but you also would want to know comparing it to the traditional methods. Is it less expensive? By and large, it would be. Often medical schools have to employ actors and actresses to help in part of the training process or use very expensive simulating machines. You’d also want to know what the retention is. Do people retain the lessons learned in a more experiental matter with VR compared to other ways of learning, such as looking at a videotape or reading a textbook or dissecting a cadaver? And by the way, there are some medical schools that are switching over to all electronic cadavers now, which is not only less expensive, but in many ways more dynamic, they can overlay the image of the cadaver with extra information and have a more structured way of training. So for training, we would have those metrics.

For diagnosis, it would be are we able to do a less expensive, more efficient, more accurate diagnosis to a better differential diagnosis, maybe come up with less false positives and false negatives as a diagnostic criteria? We would use that. And also in all these things, we need to look at the cost. Does the extra cost of deploying a VR system– and not just the cost of buying the equipment, but the cost of putting it into the hospital ecosystem, maintaining it, supporting it. Maybe there’s a need for extra personnel to keep the batteries charged. So you really have to look at the whole effect of bringing new technology into the medical ecosystem. So that needs to be part of it. And same thing when for when we use VR as a clinical intervention, does it save us money? Does it save in the long run? Does it produce better healthcare results? And you know, I have to tell you, Alan, when I’ve looked at the metrics on all three of these things, training, assessments and interventions, VR really can make a big difference. It really is cost effective. But again, it has to be positioned the right way and not brought into the clinical ecosystem in such a way that it produces an undue burden. You want the clinicians to be able go home earlier, not have to say a little bit later to do more paperwork.

Alan: It’s interesting you say that because one of the things that came up at LiveWorx was device management. We’re used to managing cell phones and iPads and stuff, but this adds a whole new element of device management. It’s something that people don’t consider until they have 50 of them to deal with, or 500 of them to deal with.

Walter: Exactly the issue. But I think the savvy product developers will appreciate that and that they are building into their systems ways to reduce the paperwork burden, improve the workflow of the clinic along with having a new tool.

Alan: It’s worth the investment, in my opinion. From the numbers that you’re seeing, what are some of the expected outcomes? Let’s say, for example, using this for autism, it’s very hard to say with a number that this was more efficient or something. It’s almost anecdotal, but there’s got to be numbers there that prove that this technology far outpaces anything else we’ve ever created.

Walter: Well, part of the way we do that in medicine is by doing long term follow up. If, for example, we use virtual reality to help with stroke rehabilitation, both during the acute phase after a stroke and then the post acute, when people are coming into a clinic for follow-up or doing home rehabilitation, if we look at how they’re doing a few years later and compare that to people who had standard treatment, if there’s less permanent disability, if people are returning to work sooner, if people are able to be more functional and take care of activities — daily living is the phrase that we use — more effectively after they’ve used VR and AR enabled interventions as opposed to the standard, then that tells us something and we can put a number on that in terms of dollars saved by preventing permanent disability and helping people get back to work sooner. Same thing for– well, let’s use the example of treating someone who has fear of heights or fear of flying. We can compare those people who used a VR system to master those problems and see how they’re doing a few years later. How many of them are still flying? How many of them need to use maybe anti-anxiety drug in order to get on a plane, versus those who don’t? If the ones who had the VR treatment are doing better, then that tells us a lot and we can quantify the value of that.

Alan: Let me ask you another question from a different angle. Have you ever seen a time where VR wasn’t more impactful or better than the traditional way of doing things?

Walter: That’s a good question, Alan. We’re still in a phase where we’re mapping VR to the problems, and I think– Nothing is really coming to mind. I’m sure there have been situations where we thought that VR would be a better way of approaching this problem, and it turned out to not really be cost effective. But I have to say, I’m really at a loss to come up with a good example. I think mostly because, again, for many years the technology was so expensive, we were very careful to really think through how to apply the technology the right way. Now, I should say I’ve seen a lot of where I think it’s not necessarily always the best use. A lot of VR technology to help people learn to relax. And some of those VR environments I think are not that much different than listening to an audio tape or just closing your eyes and imagining that you’re sitting at a peaceful spot. I think that there are very amazing mindfulness training programs that promote an active engagement, where you’re not just at a beach listening to the waves. And those are very exciting. But I think there are some where the incremental value of just having a VR environment is not as amazing as it could be, but it’s still a learning phase. We’re learning how to leverage the technology in the best way.

Alan: One of the things I saw was — and I think it was the Cubicle Ninjas VR meditation, it might have been them or another one — you actually connected your smartwatch to the VR headset so it could read your pulse. You were able to go through these deep breathing exercises guided, it is like a guided meditation, deep breathing and you could actually watch your heart rate go down as you controlled your breathing.

Walter: That is a good example of a good use case, where we’re leveraging not just the display technology, but incorporating the measurement of psycho-physiological signals and using it to dynamically change the environment. So like anything, there’s a spectrum of innovation that can be applied. And I think when you asked me where VR isn’t really that effective, all I’m really finding is to think of our times where, it’s effective but not as effective as it could be. If we add extra layers of analytics, or extra layers of social connection, or extra layers of leveraging game technology to make things more rewarding and exciting. So but again, we’re really just getting started now. Now that the products are more affordable, I think you’ll see a surge of people applying them to clinical issues. And we probably will see some that are sort of poorly designed and lame, but I’m sure we’re going to see some that are just incredible, too.

Alan: Yeah. I would have to say that we’ve kind of passed the point where we know which VR techniques make people sick. So I get really, really bad motion sickness.

Walter: Uh-huh.

Alan: I’m the guinea pig for the office. But yeah, there are still some companies out there making things that make people sick.

Walter: Yeah, and I think that’s a matter of poor design, if you moved the world around someone, it’s bound to make them sick. But if you give them agency to move through the world, it’s very different. Let me tell you about one way we’re applaying VR and AR technology to medicine that I’m particularly excited about. There’s a focus now in medicine to move towards more what we call precision medicine, where instead of a one-size-fits-all approach for treatments — where you go down a clinical pathway and say, well, let’s try this and see if it works, and if it doesn’t work, we’ll try something else — where we leverage the genomic information about individual, the measurements we can get about their behavior and their physiology. And we challenge them with virtual environments, for example, to see how they react. And we come up with a precision pathway for treatment that is based on their specific biotype.

One of the projects we are in the midst of doing at Stanford University is a project headed up by B Williams called the Engage Project, where we’re looking at people who have comorbid depression and weight management issues. And we’re following them over a multi-year period of time, as they learn to manage their weight and manage the moods. And they have a variety of different interventions. But as they go down that treatment pathway, we’re imaging their brains using a functional medical imaging device. And we’re also measuring their behavior using data collected by– they opt-in to allowing us to collect data on their smartphones about how fast they’re typing, and how fast they’re swiping, and their general activity levels. And then we’re also using virtual reality as a way of challenging their neural circuits to see– we have a challenge, much like Beat Saber, where they have to learn to react the right way and maybe some other times control their reaction. And the idea here is to come up with a VR based system that can be used to identify different neuro circuit biotypes, and that can be used to come up with a more precise approach for treating depression, for example. So for biotype A, we might recommend that they try this treatment for depression, and a different biotype — again, identified by how they react to a stimulus in a virtual environment — might be recommended to go down treatment pathway B and a third person might go down treatment pathway C, all based on their assessment that we’re able to do using virtual reality. So it’s a research project, but it harkens to the vision that we can leverage not just VR technology, but also sensor technology, biosensor technology, and machine learning technology to really come up with a better way of adapting our medical interventions to the specific individual.

Alan: It’s incredible. You talk about the three pillars: training, assessment and intervention. But one of the things that I think must be under the assessment side of things is being able to visualize your data. As a physician, being able to take an MRI data and blow it up and get right in there, I think we’re only scratching the surface of that. Have you seen any real world applications of visualizing medical data in unique ways in VR and AR?

Walter: Oh, absolutely. For example, there’s some groups doing virtual colonoscopies where they collect the colonoscopy data, but sometimes it collected just using an imaging machine as opposed to doing the actual physical colonoscopy and then allows a clinician sort of fly through the colon looking for polyps. Or same thing for pre-surgical planning. We can take CAT scan data, fuse it with ultrasound data, fuse it with other data, and then plan a complex surgical procedure in advance. So allowing the clinicians to– not just the radiologist but also the surgeons, to visualize in three dimensions the complex process that they need to go through in their operation and rehearse it in advance.

I’d like to add to those pillars that you mentioned, too, though. It’s not just training and assessments and interventions. I think the AR technology is also going to be very helpful for promoting health and wellness, showing us the effect of our behavior and promoting us to do what we really should do to be healthy. It’s a very difficult thing to get yourself to exercise, get yourself to eat the right way, to remember to take your medications, especially if they have maybe side effects that you don’t like, and to understand the consequences of not adhering to what you should be doing to keep yourself healthy. One technique that was pioneered at the Stanford Virtual Human Interaction Lab was to create an image of your future self, an avatar of your future self that you could talk to and who could talk to you, and show you in a shortened timeframe the consequences of your decision. So if, for example, your smartphone is sensing that you’re going into a bar and you’ve already decided that really you want to cut back on your alcohol use, your phone can ring, and there on your phone is your future self. Someone who looks like you, sounds like you, but 20 years older saying, “Hey, I thought we talked about this. Look at what you’re doing to me.” Or maybe if you’re not exercising enough or if you’re not eating the right way, it could show up in your future self looking very unhealthy. Same problem for managing addictions.

So I think prevention wellness is another pillar. I think another thing to keep in mind is I think VR and AR technology is going to allow us to reach underserved populations. I think the focus of care will shift from the clinic to wherever the individual is. There’s some things, of course, we have to do at a specialized treatment center where there’s specialized equipment. But I think for a lot of things, especially in terms of behavioral medicine and psychology and psychiatry, I think we’ll be able to start doing a lot more reaching underserved populations and be able to provide effective treatments by leveraging the telemedicine nature of VR and AR technology.

Alan: Well, that’s wonderful. It’s a nice close to this conversation, because if we can use these technologies to democratize wellness and health, not just medicine, not treating people when they’re sick, but really just keeping people healthy, I think that is the fundamental shift that we need to make as a society. And I think VR and AR lends a very good hand to that.

Walter: Well, and especially if we can follow the pathways that our colleagues in the computer gaming arena have pioneered. They know how to grab people’s attention and keep them involved in a process. So if we can look at how they have learned to do that in the gaming arena and apply that to some of the interventions we’re doing in the medical arena, I think we can make medicine not just more effective, but also more engaging and more palatable.

Alan: And fun. Let’s not take away the fun. I want to say, on behalf of all the listeners and myself included. Thank you so much, Dr. Greenleaf, for taking the time to be on this podcast. It’s been really amazing.

Walter: Well, thank you, Alan. Thanks for all the good work you do. Getting the word out and for the good questions today.