The Five Ways of Clinical Virtual Reality – Dr Keith Grimes & VR Doctors

 

Hello world!

I’m back from a digital detox and ready to rejoin the world of Social Media again. This first blog post is a transcript of the second episode of Curistica, which I posted today. There will be more blogging, tweeting, and podcasting ahead, but for now I’m dropping the same content three ways. Do let me know if that works for you!


Welcome to episode two of Curistica – adventures in digital health!

My name is Dr Keith Grimes, I’m a GP, Geek, Gamer, and your host for this podcast which looks at the fascinating world of Digital Health. If you’re wondering what Digital Health is, you might want to listen to Episode one, but if you’re as time-pressured and excitable as me, let’s re-up the definition. Paul Sonnier, curator of the Digital Health group on LinkedIN, defines Digtial Health as:

“…the convergence of the digital and genomic revolutions with health, healthcare, living, and society”

That’s a broad and interesting view, particularly as it includes genomics. Why genomics? Simply put, DNA is a digital molecule – instead of the base-2 of computers, life is written in the base-4 of Adenosine, Guanine, Thymine and Cytosine.

My more practical, applied definition of Digital Health is taking the  existing technologies I use in everyday life, and not leaving them at the door when I get to work. Technologies such as smart phones, voice interfaces, machine learning and chat-bots, and virtual and augmented reality.

Today, I’ll be talking Virtual Reality, or VR. VR is the use of computer technology to create a simulated environment and placing the user into the experience, allowing them to interact with it (You know, you’ve probably seen it already. Headsets and headphones on, people gazing around them open mouthed and grabbing at objects that aren’t there)

I’ve been excited by the potential of VR since I first experienced it in the early 1990’s. As you’ll hear in this podcast, many people were, but it’s taken the best part of 25 years to practically realise this vision

The talk you’re about to hear is one that I’ve given to Digital Health:London, and Health XL in San Diego. In it I describe the five ways of clinical VR ;The five main categories which I think VR can be used in healthcare.

I developed this idea from my exploration of the field, and through discussion with members of my facebook group ‘VR Doctors’. If you want to know more and perhaps join the community, I’d be delighted to see you online.

I’ll be giving the links to VR Doctors, as well as many of the people and companies I mention on this podcast, in the shownotes.

Without further delay, lets get going with episode 2 of Curistica – Adventures in Digital Health. Lets hear about the five ways of clinical VR.


25 years ago I fell in love with Virtual Reality.

I wasn’t the only one.

I have a book from the time, written by Howard Rheingold, and the cover quotes give a good idea about the state of the hype. Douglas Adams – Author of Hitch Hikers Guide to the Galaxy said:

“There are those who think that ‘VR’ may be the most important development since man first chipped flint, and there are those who don’t know what it is yet”

If you look at the back, we have Arthur C Clarke – Author of 2001, creator of HAL, and the mind behind geostationary comms satellite:

“VR won’t merely replace. TV, it will eat it alive”

I felt the same, and I wasn’t the only one. Many people believed this hype, and there was an explosion of ideas about how VR could change the world – entertainment, industry, the arts, education and medicine.

There was a huge interest, but it turns out that VR was writing cheques it couldn’t cash. It was actually kind of awful. So, shortly after being seduced by the idea of VR…the reality broke my heart.

But the revolutionary IDEA of VR remained, and people continued to work on it over the intervening quarter century. And here we are, 25 years later. In a world has changed beyond recognition.We have the internet, smart phones,  processors thousands of times faster, and powered by those changes, VR has come back, and its come back in a big way.

When delivered correctly, with modern technology, VR does an astonishing job of immersing the user in an alternative reality. It is this immersion that gives VR some of the remarkable applications in patient care.

The Five Ways of Clinical Virtual Reality
The Five Ways of Clinical Virtual Reality

I believe there are FIVE main ways in which VR can be applied to patient care. We’ll start with the first, and how I got into using VR with my patients. VR can make existing treatment more comfortable or effective

I’m a geek and a gamer. So I have all the gadgets, nice and early, but I’m also a General Practitioner, and so I have patients who see me about all kinds of things. I’d like to introduce you to one

In the middle of 2016, I met someone I’ll call Eve. Eve needed help with managing pain. She had a large wound that required frequent, painful dressings. She was really struggling with the dressing changes, but she was also a new mother, and breast feeding, so taking pain relief was difficult. We both felt stuck as to what to do.

I was, however, aware of the research, some of which showed how VR can be an effective way of reducing pain and distress during dressing changes. I had my Samsung mobile phone, and Gear VR. I also had a patient with pain during dressing changes.

So…we just….did it

Over the following week I was amazed by the transformation. She went from a lady anxious and distressed by her care to one who was laughing through the procedure. On one occasion, she was so engrossed we had to tell her that we’d finished. The nurse was delighted too, because she got her job done more quickly

I’ve since used VR with many other patients in my own practice for wound care, joint injections, blood tests.

So I started to talk about it, sharing what I’d found online and at presentations. Through this, I was introduced to Mr Sunil Bhudia, a cardiothoracic surgeon based in London, and he had an idea. Because of the nature of his work, his patients almost always require a stay in intensive care after their operations. Patients who visit ICU have a high rate of POST OPERATIVE DELIRIUM – a period of cognitive impairment that can lengthen their stay and delay recovery

Studies have shown that taking a patient to ICU before their operation can reduce post operative delirium, but this is simply impractical for all patients. Sunil asked me whether VR could replace this?

We think it can.

We believe that by allowing patients to experience the journey in immersive 360 before their operation, finding out more about the equipment and surroundings we can reduce anxiety, reduce Post operative delirium, and maybe even reduce the Post Traumatic Stress Disorder that some experience after their stay. We’ve worked together using Gear VR, 360 cameras, and we’re developing an app with a company called Medical Realities which we’re taking to a small scale study later this year, with support from Digital Health.London.

Psychological Resilience through VR Exposure as a Novel Therapy in ICU Delirium -We’re calling it PREVENT ICU DELIRIUM. This is VR AS A NOVEL THERAPEUTIC MODALITY.

The more you use VR, the more you find out about how it could be used. For example, did you know that VR CAN BE USED TO IMPROVE DIAGNOSTICS?

In 2015 two surgeons from Florida, Dr Redmond Burke & Dr Juan Carlos Muniz, used Google Cardboard, their smartphone, and a freely downloadable app to visualise the damaged heart of a baby in their care to pre-plan an operation.

Closer to my home, in Bournemouth, I visited a company called VitaeVR use VR to simulate a trip to the grocery store. Why, when you could use VR to go anywhere, would you go to the supermarket? It turns out the replicating real world tasks is potentially very sensitive way of detecting the early changes present in dementia. Could VR help identify changes much earlier than other methods?

VR ALSO APPEARS TO BE EXCELLENT FOR EDUCATION AND TRAINING.

Some of you will know about Mr Shafi Ahmed, an innovative and energetic surgeon based at Barts in London. On April 14th 2016, I watched him broadcast the world’s first live 360 stream of an operation to people around the globe.

His aim? To radically transform and democratise surgical training by delivering world class education to low-cost smartphones and cardboard headsets, helping meet the demand of the estimated 5 BILLION people who have limited access to safe surgical treatment.

With VR you don’t just have the opportunity to step into the shoes of a world renowned surgeon like Shafi – you get to take the place of the patient themselves and see healthcare from their eyes.

Nick Peres, a PhD student based in Torbay Hospital, has been using 360 cameras and cheap headsets to help teach the humanistic aspects of care provision, so often neglected in the rush to develop technical skills. As a result, Doctors and Nurses often transform how they treat patients once they see what it’s like on the receiving end.

And it’s this ability for VR to deliver empathy, leads to its fifth and final use:

VR CAN BREAK DOWN BARRIERS, AND ALLOW US TO EXPERIENCE NEW PERSPECTIVES.

Again, this needn’t be something fantastical. It can be something simple, and personal.VR Doctors member Alex Smale, at Tribemix, has been developing a VR experience which can be used in care homes to allow older people with memory impairment to digitally reminisce.This reduces agitation and brings calm into their troubled and confusing world.

Dr Brennan Spiegel, Professor of Medicine & Public Health at UCLA, talks about using VR to help patients escape the BioPsychoSocial Jail cell of their illness, taking them out of the hospital and to the beach, or canyons, or lakesides.

All using cell phones and headsets.

Back in Eastbourne, where I work, I’m now looking at how we might use VR to help at the end of our lives, in my local hospice. In the coming year we’ll explore what value there might be in seeing the street we grew up on one more time, or our home, or favourite park, or places that we always promised to visit?

VR has many applications in patient care.

I’ve illustrated just a small number today, some of which are being built, some which are already out there. Unlike the early 90s, the technology is already good enough, and its only getting better.

I’ve clearly fallen in love with VR again. I hope I’ve given you enough reason to suspend your judgement and give it a try as well.


There you have it. The five ways of clinical VR. Do you agree with my categories? Have I missed any? Are there too many? I’d love to hear from you about this, especially if you are using VR or Augmented reality in healthcare, or if you’re someone who has been using VR for your own health and wellness. Share your story! My invitation to you to join VR Doctors is still open. The link is in the shownotes, or you can simply type ‘VR Doctors’ into the Facebook searchbox and join.

You can also get in touch via twitter: I’m @keithgrimes , or you can visit my website: www.drgrimes.co.uk

Over the coming episodes I’ll be speaking to a whole host of incredible personalities from the world of Digital Health and bringing their stories to you. If you’d like to join me, please subscribe to the podcast. If you’ve enjoyed it, then you can show your support by rating me and sharing the show with friends and colleagues.

With that, it’s goodbye for now. I’ll see you next time, for episode three of Curistica – Adventures in Digital Health.


SHOWNOTES

 

The Multiple Realities of Pain

Kate Fleetwood (Jess) in Ugly Lies The Bone at the National Theatre (Photo: Mark Douet)
PAIN IS COMPLEX. When we talk about pain, we can’t help but draw from our own experience. Think about a time you might have been in pain. For me, it’s a recurrent low back pain which emerges every so often to remind me that being tall isn’t always a great thing. For you, it might be something different.Whilst you may not be able to summon up the actual sensation again, I’m sure you can recall the fear and anxiety,  the worry about the implications to your personal and social life. Pain might fade over time, but the emotional and social impact often remains.
As a result, when you try and treat pain, you neglect the whole person at your peril. While drugs can ease the physical suffering, the effect of that pain on the person’s life, relationships, and their standing in the world may go neglected.
This complex interrelationship was strikingly laid bare at ‘Ugly Lies the Bone’, which I saw at the National Theatre last week.
This is the second revival of the Lindsey Ferrentino‘s play, set in the heart of Florida’s Space Coast in 2011 at the time of NASA’s last shuttle flight. It focuses on the return of Jess, a veteran of the conflict in Afghansitan, horribly injured in an IED explosion. As part of her treatment she takes part in revolutionary new Virtual Reality therapy that helps her to escape her pain. As the play progresses, just what form that pain takes becomes clearer – the physical pain of her scars, the emotional and social pain of her return to her home and the effect this has on her friends and family, and how Post Traumatic Stress Disorder never lets her fully escape
It’s not really my role to act as a critic of the play, so I’ll keep that bit short – it’s brilliant, go and see it before it closes on the 6th of June. 
Olivia Darnley (Kacie) in Ugly Lies The Bone at the National Theatre (Photo: Mark Douet
Olivia Darnley (Kacie) in Ugly Lies The Bone at the National Theatre (Photo: Mark Douet
One of the characters in the play is simply listed as ‘Voice’ – the verbal presence of the therapist during Jess’ sessions in VR. Being a therapist myself I was particularly affected by her role, and it served to reflect the rather shallow focus that I’ve been guilty of in the past. Concentrating on the numerical rating of the pain, and the short-term goals of the treatment, the disembodied clinician seems to drift away from the other components of her patient’s pain, leaving her stranded once  the game is complete.

VIRTUAL REALITY HOLDS REAL PROMISE FOR MANAGING PAIN. From distraction and manipulation of the senses, to the respite from reality, and the freedom from physical limitation, we’re seeing examples every day of how this new technology can help people.
Two days after the trip to the National Theatre, I was able to explore this in much more detail in a meeting held at Digital Health: London. There I met with Howard Rose, CEO of Deepstream VR, and leader in the field for over 20 years. In attendance we also had Nick Peres, creator of PatientVR.co.uk and champion of immersive VR. Richard Dolan, Innovation lead at NHS Dorset CCG.
(LtoR) Keith, Richard, Howard and Nick – Clinical VR Aficionados
 We spent two hours experiencing COOL! and GLOW!, both Firsthand VR products used for the management of acute and chronic pain, and anxiety. Cool! was of particular relevance, as it is the direct ‘descendent’ of SnowWorld – the VR experience that played a part in inspiring the story of ‘Ugly Lies the Bone’. As with all VR, it’s a little difficult to convey the experience without it sounding daft – after all, I was throwing iridescent trout and glowing orbs at otters playing on the riverbank – but it did work to reduce my back pain.
GLOW! was particularly beguiling. In this I found myself sitting next to a stone totem with my heart rate illuminated on the rock face. A Leap Motion controller, attached to the front of the headset, meant I could see glowing outlines of my hands, which would summon and dispel fireflies as I opened and closed my hands. The stars above, the cicadas, and the babbling water, all conveyed through stereoscopic images and binaural sound had a remarkable effect on my pulse, leaving me calm and comfortable for hours afterwards.
Glowing hands, fireflies, and a soothing biofeedback experience in the world of GLOW! c Firsthand Technology
We then moved on the PSIOUS VR, which was demo’d by Richard Dolan. Psious is a Gear VR/Laptop based mental health application used to help treat mental health problems, particularly phobias and anxiety. Linked to a stress measuring wearable, the therapist is able to tailor a variety of scenarios to expose the patient in a safe and graduated way to their fears. Accordingly, I sweated my way up a construction lift bolted to the outside of a skyscraper, whilst Nick was taken through a personal fear – preparing for take-off in a commercial jet. Whilst the graphics were more basic than those of COOL! and GLOW!, it was astonishing how they nevertheless generated that familiar discomfort. The level at which VR can deliver benefit – at which point the immersion is ‘good enough’, is a question for researchers and those evaluating VR in healthcare.
Richard works as Innovation Lead at Dorset Clinical Commissioning Group, and it was great to see such a passion for innovation, especially within the NHS. I meet many CCG staff in the Digital Health sphere, and it’s encouraging to find everyone reaching out to each other and beginning to develop networks to share learning and opportunities. Similarly, Nick Peres at Torbay NHS Trust is doing amazing work with 360 video in highlighting the important of human touch in healthcare – patientvr.co.uk. You can find out more about his story on my podcast, CURISTICA.
Being on the receiving end of healthcare can transform your perspective! (Pic Nick Peres, PatientVR.co.uk)

WE’RE ALL AFFECTED BY PAIN IN DIFFERENT WAYS. Some, like Jess, suffer the full spectrum of misery. Others have a thankfully more fleeting acquaintance. For each person, Virtual Reality has a potential role to play. What was made clear in the play, and at the meeting, was how this role could be across every facet of pain – the physical, emotional, cognitive and social.  Given that VR is also not the sole preserve of the clinician, it suddenly becomes a much more interesting proposition. Unlike prescribed drugs, the tools for relief and recovery are now in the hands of the patient.
We need to work carefully to understand what evidence there is for benefit in acute and chronic pain. Are there potential risks or harms? Will VR work only while the user is immersed, or does it persist afterwards? We already have published evidence supporting VR analgesia, but precious little about how it can be scaled, and provided equitably.
For now, I go back to my day job a little wiser and more optimistic than I was before. As a Doctor,I need to step back and always consider the wider implications that pain has on an patient’s life. Maybe I can bring new hope to some of my more troubled patients, for those that have found conventional medicine lacking or limited by side effects. Maybe next time my back seizes up, I’ll reach for the headset before the tablets.

 Links & Declarations

I’d like to thank Nick, Rebekah, and Yinka at Digital Health: London for their kind assistance in providing a room for the meeting. All of the participants are colleagues I’ve met through meetings and on my voyage of Digital Health discovery through Social Media. I have no financial interest in any of the companies mentioned, although I am an NHS GP and CCG governing body member (Eastbourne Hailsham and Seaford).

All costs for these events, including travel and tickets, were paid for personally. My back pain is sadly provided for free.

Howard Rose – firsthand.comLinkedIn @deepstreamVR
Richard Dolan – Dorset CCGLinkedIN @RichPDolan
National Theatre – Ugly Lies the Bone – Lindsey Ferrentino @LindsFerrentino

360 video in Healthcare – Nick Peres & PatientVR.co.uk

Digital technology is radically transforming how we deliver healthcare. Join me, Dr Keith Grimes – Geek, Gamer, and General Practitioner, as I share the stories of the people I’ve met as I explore this incredible and vibrant new discipline in Medicine.

This first episode features Nick Peres, founder of PatientVR.co.uk. Nick is using 360 video and low-cost headsets to deliver radically new perspectives for healthcare workers learning their trade, by putting them in the shoes of their patients.

The Digital Delphi – Artificial Intelligence & Medicine

The Oracle at Delphi , image taken from '300' the movie.

If knowledge is power, then from 7th century BC to the 4th century AD, the most powerful women of the classical world were undoubtedly the Oracles of Delphi.

Supplicants would travel far to seek the Pythia’s wisdom, delivered in ecstatic frenzy after inhaling the spirit of Apollo. Such was the cryptic nature of their utterances that prophets would be employed to help travelers make sense of their revelations.

Important decisions in matters of war, trade, marriage, and business, all made with reference to the divine knowledge imparted by the Oracle.

In matters of medicine, doctors have been the gateway to knowledge. With that, doctors have significant power in the war against disease.


On the afternoon of 22nd February I went to Digital Health.London’s ‘Collaborate’ event. It was a celebration of the programme’s first year’s work, an award ceremony, and innovation event all rolled into one. They were kind enough to let me speak about Virtual Reality in patient care as well.

Molly Watt & Dr Keith Grimes
Molly Watt & Dr Keith Grimes

There was a fantastic, diverse audience in attendance too, from the cutting-edge 360 live-streaming surgeon Shafi Ahmed, to my colleague Sunil Bhudia (with whom I’m working on the PREVENT-ICU-Delirium project), and the inspirational Molly Watt, who took part in a panel discussion about accessibility and digital participation. It’s also brilliant to meet people I know from twitter face-to-face, like Victoria Betton, who led a session on hacking STPs), and Dr Robert Lloyd, who skillfully MC’d the proceedings

So why the Delphi reference? Of all the talks, the most fascinating for me was the panel discussion on Artificial Intelligence.

Patients should use Artificial Intelligence to reduce the amount of time they need to spend with healthcare professionals

The panel comprised of three heavyweights in the Digital Health field:

  • Dr Ameet Bakhai Consultant Cardiologist Royal Free Foundation NHS Trust
  • Professor Nicholas Peters – Professor of Cardiology & Electrophysiologist at Imperial College London

Entertainingly and insightfully chaired by Dr Jordan Schlain , a fellow US based GP and Founder of HealthLoop, the debate fell nicely into those for, against, and balanced on the fence.

The AI Panel @ DH:L Collaborate
The AI Panel @ DH:L Collaborate – notice the #PinkSocks!

Ali Parsa began with a blistering defense of clinical AI, delivering an impassioned argument for how it can meet the yawning gap in healthcare provision around the globe. His team at Babylon have seen an 80% reduction in conversion of clinical inquiries to video consultations since the introduction of their triage AI. As far as he is concerned, there is a moral duty to implement AI to meet the care divide, and augment the diagnostic capabilities of clinicians.

It’s difficult to come back against that kind of rhetoric, although I would posit that Babylon’s UK business deals with a small proportion of range of presentations seen in General Practice, and from a significantly healthier and wealthier cohort. It might be difficult to extrapolate the 80% reduction in demand. With an ongoing trial front-ending GP in North London though, I guess time will tell.

The progress in developing world is also laudable, but I wonder whether it can ever cover the totality of care needs? Perhaps 10% of something better than 100% of nothing.

Next up, and taking an opposing view, was Dr Bakhai. He apologised for playing ‘devil’s advocate’, perhaps a Freudian slip given the perception that some have of the 5 year deal Royal Free London made in sharing data with Google Deepmind. For the sake of clarity, I think it’s a wonderful thing. Ameet worried about the loss of empathy in healthcare, and that AI had no ‘base case’ – no ‘first law of robotics’ akin to the principle of  ‘First, do no harm’

The issue of AI treating humans well and not turning them into batteries comes up time and again, and from my own point of view I swing between optimism and existential dread. It’s not unique to patient care, but does have an interesting twist in that should AI be successful in helping the patient, it may harm the doctor.

As for empathy, this is stronger ground. I certainly believe that humans need contact with other humans, particularly when it comes to the ritual of the consultation. Who’s to say that empathy is a uniquely human property though? Any pet owner will attest to the ability of their loved companions to deliver comfort without words. In time, empathy may well be better delivered by machine, especially to those raised in the post-millennial world – Homo Digitalis .

Professor Peters was left to adopt the middle ground, adding nuance to the preceding statements. I was particularly taken by his observation that the addiction that doctors have to treating patients, felt as a need deeper than simply a method of paying the bills, coloured their opinion. AI and the fear of being replaced and made worthless affect us all.

The framing of the debate made this last point ironic – there were no patients on the panel discussion the proposition. I raised this point, which was countered with an anecdote about Henry Ford who was quoted as saying that if he’d given the public what they wanted, he’d have made a faster horse. Professor Peters also referenced Molly Watts’ support of Apple’s commitment to user interface excellence & accessibility, which comes despite their famous lack of user input. All good points, but I’d still want to hear a patient make them.


The concept of Artificial Intelligence has been around since the 1950s, and we’ve seen this level of enthusiasm before. We’ve also had our hopes dashed before. I believe we’re entering a time when some of that promise will be realised, especially in narrow specialist areas. For this reason, I see the generalist physician outliving the specialist when it comes to head-to-head performance against AI in terms of patient care. Before my GP colleagues get too comfortable, even that advantage will pass in time, leaving the nurses as the most valuable humans in the healthcare system.

It may be that we will co-exist as providers of healthcare, but surely there will come a time when AI will be superior to human in a number of areas. When this happens, if we truly respect tradition of medicine, and believe we must first do no harm, maybe doctors should stop diagnosing patients?

And with that, is the best that doctors can wish for is to become gatekeepers of the knowledge – prophets at Delphi helping the patient understand the superhuman wisdom of the AI oracle? Or will this knowledge by available to the patients directly, leaving doctors shorn of their power?

It’s no surprise that our excitement is tinged with fear.


A STORIFY of my tweets from the day is also available

Virtual Reality in use in the NHS: Primary Care

How is Virtual Reality currently being used in the NHS? Dr Keith Grimes presents to the North West London Critical Care Network about Virtual Reality and how it is being used in General Practice.

This is a narrated presentation, first given to the North West London Critical Care Network on Wednesday 14th December, 2016

A STORIFY of the slides is also available – https://t.co/JR9V01FRiL

Healing & Caring in Virtual Worlds

“Whilst research into the use of VR for healthcare dates back to the 1980s, recent advances in high quality/low cost equipment have seen an explosion of interest in the practical applications in health and social care.

By sharing his experience of using VR with patients, Dr Keith Grimes will explore the history of Medical VR, share current projects, and discuss the future of the field, where the consulting room might very well be a co-created space in Minecraft.”

This is slide & audio recording of the presentation I made at Develop VR in London on Thursday 1st December, 2016.

Please make contact via www.facebook.com/groups/VRDocs