Episode 167: Medicine Meets The Metaverse - Brennan M. Spiegel, MD, MSHS

Brennan Spiegel, MD, MSHS, is director of Health Services Research for Cedars-Sinai and Director of the Cedars-Sinai Master's Degree Program in Health Delivery Science. He directs the Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), a multidisciplinary team that investigates how digital health technologies; including wearable biosensors, smartphone applications, virtual reality (VR) and social media; can strengthen the patient-doctor bond, improve outcomes and save money. CS-CORE unites clinicians, computer scientists, engineers, statisticians and health services researchers to invent, test and implement digital innovations, always focusing on the value of technology to patients and their providers.

His team developed one of largest and most widely-documented medical VR programs at Cedars-Sinai, and his work has helped to support a new field of medicine called Medical Extended Reality, in which doctors use immersive technologies like VR to help treat conditions ranging from pain, to anxiety and depression, to irritable bowel syndrome. Spiegel has published numerous best-selling medical textbooks, editorials and more than 230 articles in peer-reviewed journals.

He is listed in the Onalytica "Top 100 Influencer" lists for digital health and virtual reality. His digital health research has been featured by major media outlets, including Bloomberg, CBS News, Forbes, Huffington Post, LA Times, NBC News, Reuters, The Washington Post, and the Wall Street Journal. Dr. Spiegel published the book "VRx: How Virtual Therapeutics Will Revolutionize Medicine" (Basic Books, NY, NY), which was named by Wired Magazine as one of its top 8 science books of 2020. Beyond his focus on digital health innovations, Spiegel conducts psychometric, health-economic, epidemiologic and qualitative research across a wide range of healthcare topics. His research team has received funding from the National Institutes of Health, Robert Wood Johnson Foundation, Hearst Foundation, State of California Precision Medicine Program, PCORI, Veterans Administration and industry sources.

Spiegel is editor-in-chief of the American Journal of Gastroenterology, the leading clinical gastroenterology journal in North America. He was among the first group of clinical researchers to examine the gastrointestinal manifestations of COVID-19. He continues to practice clinical medicine and maintains an academic teaching practice at Cedars-Sinai. A prolific speaker, Spiegel is frequently invited to present on his areas of expertise at national and international events. Dr. Spiegel earned his bachelor's degree from Tufts University, his medical degree from New York Medical College where he received Alpha Omega Alpha honors, and his master's from the University of California, Los Angeles Fielding School of Public Health. He completed his residency in internal medicine at Cedars-Sinai and his fellowship at UCLA Medical Center.

Audio Title: Ep167 - Brennan Spiegel
Audio Duration: 01:11:08
Number of Speakers: 2 

Dr. Spiegel is a gastroenterologist and digital health expert who has conducted extensive research on the use of virtual reality to treat digestive disorders.

• Virtual reality therapy can be a valuable tool for patients with functional gastrointestinal disorders, such as irritable bowel syndrome (IBS), by reducing anxiety and improving symptoms.

• Using VR as part of treatment can also increase patient engagement and adherence to treatment plans, leading to improved outcomes.

• Dr. Spiegel's team at Cedars-Sinai Hospital has developed a VR platform called "Gut-Brain Therapy" that allows patients to explore a virtual world while receiving cognitive behavioral therapy (CBT) to address the psychological factors that contribute to their GI symptoms.

• Virtual reality therapy can also be effective for managing pain, with studies showing a significant reduction in pain intensity and duration in patients who use VR during medical procedures.

• Virtual reality technology is advancing rapidly, and new applications for healthcare are constantly being developed.

• VR therapy is still a relatively new field, and there is much more research to be done to fully understand its potential and how it can best be used in clinical practice.

• There are some potential downsides to VR therapy, such as the possibility of motion sickness or discomfort from wearing a VR headset for an extended period of time.

• VR therapy should always be used as part of a comprehensive treatment plan, and patients should work closely with their healthcare providers to determine if it's a good fit for their needs.

• Overall, VR therapy is a promising new approach to treating a wide range of medical conditions, and it's an exciting time for researchers and healthcare providers who are exploring its potential.

[00:00:00] Intro: Welcome to the Heroes of Reality Podcast, a podcast about the game of life and the hero's journey we all experience. Let's jump in with our host Dylan Watkins, as he introduces today's guest.

[00:00:17] Dylan Watkins: Do you want to know how virtual therapeutics will revolutionize medicine? Well, on today's podcast, I have Brennan Spiegel. He is the Director of Health Services and Research for Cedars-Sinai and director of the Cedars-Sinai Master's Degree Program in Health Delivery Science. He directs the Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), a multidisciplinary team that investigates how digital health technologies, including wearable bio sensors, smartphone applications, virtual reality, and social media can strengthen the patient-doctor bond, improve outcomes and save money. He is also the author of VRx: How Virtual Therapeutics Will Revolutionize Medicine. Without any further delay, I'd like to welcome Dr. Spiegel. Hey.

[00:01:04] Brennan Spiegel: Thanks for having me.

[00:01:05] Dylan Watkins: Yeah, I am so stoked to have you on here, man. I was just telling you before this, I was going through your book again and, you know, there's so many people in my studies of uncovering, discovering modern day heroes that are helping kind of transform who they are and the people around them. I came across so many of these people inside your book that you've put together, and I was just blown away at your ability to take all of these different experts in the space and put it in a comprehensive book that you can explain in layman's term, not, you know, non-doctories, to make it comprehensive and digestible for the average folks. So I'd love to say thank you so much for making that, and it's a pleasure to have you on.

[00:01:50] Brennan Spiegel: Well, thanks so much. I'm glad it was useful.

[00:01:52] Dylan Watkins: Yeah. I'd love to start off just a little bit, if you could kind of just give everybody just a bit of the background that kind of led you up to really creating this VRx book.

[00:02:03] Brennan Spiegel: All right. So I've been working in virtual reality now for about seven years, which is not as long as some people, some people have been working in VR for decades. And, you know, when most people think about VR, they think about a gaming platform, you know, to entertain people, think about, you know, teenagers playing first person shooter games, that kind of thing.

But long before it was a platform for gaming and entertainment, you know, VR was being used in the Department of Defense to train fighter pilots. It was being used in elite psychology laboratories all around the world to understand how it can affect the human mind, for good or for bad. And so I became interested in it. It's used for healthcare. And the book VRx is really my way of telling the stories of what we now call MXR, which is Medical Extended Reality, but it's really a kind of a journey into the boundaries of human knowledge about the brain, about neuroscience and about what happens when we combine technology and psychology, even philosophy and clinical medicine, mix in some neuroscience, and through the lens of virtual reality, almost literally explore what it means when we talk about mind, body medicine. So it's really a lot of things all at once.

[00:03:24] Dylan Watkins: Yeah. I mean, you're trying to encompass the entire human condition all in one go, you know, from the physical to the mental, to the social, to the emotion, all that fun stuff. And so it's a lot to digest and process. Can you talk to me just a little bit about your process of how you actually created the book? Did you gather all the information? Did you throw it on a whiteboard? Can you talk to me just a little bit, how you actually created the book?

[00:03:45] Brennan Spiegel: Yeah, it's a good question. You know, I've written, you know, hundreds of articles for doctors. So I'm comfortable, you know, writing in English, but writing in, you know, outside of, you know, writing for the lay public is a different kind of challenge. And so one of the challenges is just trying to translate all of this science into a digestible kind of user-friendly, you know, resource, but also trying to thread together the thousands of stories, both patient level stories that we've experienced, but also the now 10,000 research studies around medical extended reality and how do I kind of compress those all into one book?

So it took me, you know, a good two years of work, both reading every study I could find at the time on VR and healthcare, categorizing them into kind of major opportunities, mechanisms of action, so on, and then trying to walk through, from my own viewpoint, from stories I experienced myself using VR and patients using VR, sort of create a narrative to work us through where we are now and what the future looks like as medicine meets the metaverse.

[00:05:01] Dylan Watkins: Medicine meets the metaverse. I mean, that is something that we're stepping into right now because right now we are starting to become aware this VR is becoming much more adopted now than ever before. We have what 10 million Quest headsets went out last year. And so this is getting adopted even faster, but I mean, even recently, I still heard, you know, from a local hospital they're like, hey, is this effective? Do doctors even use it? Do they even use it in the facilities? How do we even know? Is this a evidence-based therapy? Can you, you know, for them just speak a little bit about that?

[00:05:35] Brennan Spiegel: Yeah, yeah, for sure. Absolutely evidence-based. In fact, at this point we have more evidence for VR for pain management in particular than we have for some drugs. I mean, literally we have not just some randomized control trials. We have meta analyses of randomized control trials and even multiple meta analyses. So at this point it's really not a scientific issue or debate anymore about whether or not VR can help with pain in particular. Now there are many, many other uses of VR beyond pain, but just focusing on that for a moment, it's really not a scientific issue anymore.

Really the issue is how do we logistically deliver virtual reality into everyday clinical practice? How do we train clinicians who should be administering the VR? Should they get reimbursed? Should insurance be paying for this? These are the real big hurdles at this point. Not so much the science, because we have FDA cleared therapies now, in fact, so, yeah, it's not a scientific issue, although there's still a lot of science to work out for sure.

[00:06:47] Dylan Watkins: Yeah. So, I mean, you're speaking to one of the front runners of saying this mitigates pain. I was actually talking to a friend of mine who just announced that she was pregnant on mother's day and they're trying to figure out if they wanted to do the pregnancy. And I said, well, you, from what I understand can actually wear it on your head while you're giving childbirth to actually mitigate some of that childbirth. And she was a little skeptical to say the least, because I think we have a direct implication that if I can just get a shot, it would be more like how could possibly VR could have an impact if I just put a thing on my – how does that stop pain? And I think it's one of the big – especially when you're going into something that is difficult as childbirth.

[00:07:29] Brennan Spiegel: Yeah. Now of course, here we are two men, talking about childbirth.

[00:07:33] Dylan Watkins: Fair, fair.

[00:07:35] Brennan Spiegel: That caveat. But that said, we've actually conducted a randomized control trial here at Cedars-Sinai in partnership with Melissa Wong and Kim Gregory, who are two obstetricians here at Cedars-Sinai, who took a real interest in virtual reality.

And so we did a randomized control trial that involved use of VR. It was a form of biofeedback enabled VR, where the breathing in and out was tracked by the microphone and the headset. And then there was sort of this metaphorical narrative that people – that these women would see during labor, where they're sort of bringing a tree to life. As they breathe in and out this tree expands and contracts with their breathing and sort of with each expansion, you see more leaves growing on the tree and it starts to become the sort of fantastical, beautiful, almost, you know, iridescent, glowing object over the course of the several hours of labor.

And so there was also a voiceover and some sort of meditative scripts designed specifically by and for women going through labor. And as I said, I haven't been through labor, so I don't know, but when we measured the pain scores, we saw lower perceived pain in the group that received the VR.

Now, this has been reproduced at the University of Michigan where another study found the exact same thing. Yet another study, I think from the Middle East, as I recall, might have been Iran. I can't remember exactly. Looked at episiotomy and episiotomy repair, which sometimes is required after a particularly traumatic delivery. And once again, virtual reality helped reduce the perceived pain from the repair of the episiotomy after labor and delivery.

So we have quite a few studies now. And in fact, Melissa Wong gave a wonderful talk on this topic at our recent virtual medicine conference. And so you can go on her website, virtualmedicine.org to learn more about that. And yeah, I talk about that in the book quite a bit.

[00:09:37] Dylan Watkins: Yeah. And you're right, coming from a male, they're like, oh, do you really know? I'm no, I don't. I really don't know. But the science says …

[00:09:45] Brennan Spiegel: That's fair. Right.

[00:09:48] Dylan Watkins: And one thing you're talking about this, having a clear indicator, right? So we know pain mitigation. You can show that. But you're also talking about, there's also this messy other piece of this psychosocial, emotional aspect of using virtual reality to help people let's say believe that they're heroes of their own story, or be able to transform who they are or shift their identities, their beliefs, their patterns, their behaviors, their habits, whatever it is to actually be able to change that.

And so that's a little bit more messy when you can't necessarily, you know, look at it on metrics, because you're getting in the areas of psychology, which is you've said in the book, primarily doctors are more hesitant to getting into that because they feel like there's a disconnection between the body and the mind. And so can you speak a little bit to the coming up with the data for the messy pieces that is the psychosocial, emotional aspect?

[00:10:38] Brennan Spiegel: Yeah. So messy is an interesting word. I think sometimes what we mean by messy is we don't have, let's say an objective parameter, you know, something like blood pressure, heart rate, or some kind of biomarker. Instead we're relying on some people call psycho markers, which is basically how are you feeling? But that's very objective too.

So we are able to definitely get objective outcomes about how people are feeling, anxiety, depression, even hallucinations in people with schizophrenia. But I think that the sort of messy part is disentangling what we call biopsy psychosocial medicine. And so I talked – I sort of traced the history of this in the book a little bit that back in, I think it was 1948 when the World Health Organization charter was founded. The World Health Organization defined health as not just physical wellbeing, but a complete state of physical, emotional, and social wellbeing.

And so the WHO defined health with this tripartite model of three components of pain – not of pain, of wellbeing. So yeah, I mean there's the physical experience, but there's also psychosocial. And that was quite revolutionary at the time. And so the interesting thing though, is over the course of the mid-century and then into the later part of the century, there were such massive advances in biochemistry, pharmacology, genetics, and multiple other fields like immunology that we started to lose track of the psychosocial because there was this massive new avalanche of information and knowledge about just the biological components of health.

And so psychology and psychiatry started to become kind of pushed aside, like not a real component of medicine. Psychiatrists took care of the brain and the mind, and then like real doctors took care of the rest of the body. Well, it turns out that was dead wrong. And I kind of traced this story because we now know that the brain and the body are completely and totally inexorable. They're connected. They're one and the same. In fact that your body, your muscles, your tendons, your nervous system, your immune, all of it is kind of like the extracranial part of your brain. It's the part of your brain that's not protected in the hard skull, but it's all connected.

So we now have come to sort of full circle and now, and I won't belabor this history too much longer, but in the late 1970s, this idea of biopsychosocial model came out. That's not just a biomedical model. We have to integrate social sciences and psychological sciences into a holistic view of human health.

And so that has really affected the subsequent decades. And I kind of traced that story a bit. And this is where VR shows up because now we recognize both neuroscientifically, psychologically, that we have to think broadly about human health. And this isn't to say, pharmacotherapy that I'm trained in as a Western doctor is not worthwhile. Of course it is, but we can augment many of our treatments through behavioral therapies. And VR just gives us a very efficient way to deliver a wide variety of behavioral interventions that can help augment the care that we provide.

[00:13:54] Dylan Watkins: Yeah. I mean, that makes a ton of sense. So, I mean, just to let you know, on my side of things, I've also produced virtual reality multiplayer experiences. I've facilitated workforce readiness programs where I help them. I've done it in areas where the people are incarcerated and helping kids to see that they hear some story using this VR therapy. And the way that I kind of look at this is we live in three realities and in your book, you do a great example of that. The OG virtual reality is imagination, which I love. I absolutely love that. And I think that we live in three realities, right? We live in the external reality, which I learned a lot from Joseph Riviera on the podcast, right. We live in our own internal reality and then we live in the social reality that we co-create together.

And so using that, really using coaching inside a virtual space, you're leveraging those two realities to then affect the inner reality of the patient or the client or the person to affect change. Is there another dynamic piece to that? Or are there other pieces of that that I'm missing in that overall theory or concept?

[00:14:57] Brennan Spiegel: Yeah, I think there's a few ways to take that. I think that's a nice framework. The way I kind of talk about it in the book is just taking a neuroscience approach for a moment, there's exteroception and there's interoception. So what that means is exteroception is our ability to sense the world around us, to see it, to hear it, to feel it, all the typical senses, to taste it, so on. And that's how we often think about the world as we experience it. These sensations come in from the outer world, and then they're integrated in our body and in our mind, and we actually process information with brain and body together.

But there's also interoception. Interoception is the inner body. We constantly are tracking what's happening inside of our body. We can feel our heart beating or our digestion, and typically you don't really pay a lot of attention to that unless something goes wrong. And for some people, the problem that they experience is really not so much exteroception, but interoception. They have, for example, too little connection with their body or too much connection with their body. And I kind of break those two up in the book and talk about how virtual reality can actually help with interoception and exteroception.

But really what you're bringing up then is the social component, which is virtual reality also can modify how we interact with one another, not just with the world around us or within the world within us, but with one another. And social VR opens up that box. But what complicates all of this is this idea of, you know, where does virtual and real, where do they come together? And what does that really mean?

Because as you kind of think about it, you know, virtual reality in a way is genuine reality. The metaphysics are different. So for example, we're dealing with bits and bytes when I look at a digital forest. As opposed to atoms and quirks and electrons and whatever makes up an actual biological forest, but they both can affect my physiology. They both can affect my cognitions, my emotions. So at what point is one thing become real or not real, that's a really interesting philosophical discussion that people like Chalmers at NYU has written books about.

[00:17:21] Dylan Watkins: Yeah. It doesn't matter what actually happens, it's your interpretation and the story that you tell yourself along the way that actually shapes that reality. Because you talk about how the Buddhist says, you know, pain is inevitable, but suffering is really a choice that we really extend on ourselves. And if you look at people like the gentleman who created the transformational technologies and you talked about enlightenment. Enlightenment, if you look at the patterns of enlightenment, one of the key signs of that is you lose the narrative mind, that thing that tells you that you have these stories inside of yourselves, because that is the thing that creates a lot of suffering because you have that ruminating mind. And the people that are enlightened are pretty much in a blissful state moving through that. It's just very difficult or can be difficult. We feel like we have our ego is attached to that narrative mind. And so really creating that detachment from that and separating that is what I think a lot of people create in that piece.

But do you feel like it's really, you need to have that narrative mind in order to function in society, or can you operate from a place without having that internal narrative mind to able to get things done?

[00:18:29] Brennan Spiegel: Right. Yeah. So we all have – most all of us, not all of us, but most all of us have a sense of self, meaning I can tell that I'm not you. And I don't think I'm you. And I have a very strong belief that I'm not, you. Now that could be violated if I took a psychedelic. You know, if I took psilocybin or LSD, I might actually just lose my sense of self entirely and lose this and enter this non-dual consciousness where I literally believe I'm this computer I'm standing in front of, or this room that I – I just become – I lose myself, literally lose myself.

And so, you know, neurologically the sense of self is determined by a network in the brain that, you know, we call the default mode network or the DMN. And so the idea is that we do need a sense of self, it's pretty important to get through the world. It's important to strategize and to protect one's self and to make decisions that are wise for one's wellbeing. But obviously the ruminating mind is sort of the extreme where there's this rigid sense of self, where the mind is creating stories, often neurotically, predicting a catastrophic future and constantly protecting against that. And that can be very well adapted in certain situations, but can lead to anxiety and depression if it's extreme.

On the other side, if you have too little sense of self, then all sorts of bad things can happen. First of all, you can be taken advantage of and that sort of thing. But at the other extreme, something like schizophrenia, where you might hear voices in your head that you literally believe are not you. So you've lost to some degree, a sense of self in that condition. And so I talk a lot about this in the book because virtual reality has a role to play on both sides of that spectrum. It can help strengthen the sense of self in people with schizophrenia, for example, and it can help loosen the sense of self in people with neuroticism, anxiety or depression. And so there is a Goldilocks zone in the middle. Yeah.

[00:20:49] Dylan Watkins: And as someone who has embodied in plant medicine, I can confirm that you do lose a sense of self and you feel like – it's interesting because as you grow up to that, you feel that that greater sense of unity being one with everything. And when you feel that sense of unity, you have that both terror of letting go of the ego, but also that calmness of being, you know, everything's okay because I am one with everything as Zen Buddha matrixy as that sounds sure, right?

But if you look at that though, and when I – and by the way Dr. Jeffery Martin, was thinking about that, he wrote the book Finders and talks about mapping out the enlightenment paths along the way of losing the narrative mind and what else that means. I just remembered that, so I want to get back to that. But looking at that, I think you're talking about how inside the book you're talking about these seemingly psychedelic experiences that you can have inside of VR.

One of the things that I had to take a pause and I had to read through it and I go through it back, I was like, wait, wait, wait, this is fascinating. One of the things that you brought up was when you had a situation where your consciousness was essentially ripped from your body inside of VR where you felt yourself have that detachment from it, through combinations of haptic and visual experience stacking on top of the phantom arm syndrome and going – can you just talk a little bit about that? Because I found that'd be so fascinating and I think that'd be – I've never actually heard of something actually creating that outside of a psychedelic or plant medicine experience.

[00:22:18] Brennan Spiegel: Yeah. So first off, I do see there's a question about whether it can help deal with dementia. Maybe we'll get to that because that's a really good question. They're popping up on the screen where I am. But before we get to that, yeah, so this example, I actually start the book with this at least the first chapter after the intro and I was in the laboratory of a Mel Slater who's a professor of virtual reality, of virtual environments at the University of Barcelona. He's been studying this for years.

And so when I visited his lab, they put me in this room. It was kind of a nondescript room. You have to just imagine there's like four black walls. It's not particularly appealing. And you sit down. And they asked me to kick my feet out onto a coffee table that was out in front of me. So I did that. And they then put a headset on my face. And all of a sudden that dark dank room turned into this beautiful living space, like a living room. And I saw my legs right out in front of me on that coffee table. But of course they were digital legs.

And so they asked me to start to move your legs. And I moved my legs in real reality. And then these virtual legs moved in a one to one synchrony in virtual reality. So they had put me in this body. I had what he called full body virtual embodiment. And how they did that is we don't have a lot of time to get into the details, but this is what I experienced. And so I'm in this digital body and I'm thinking, wow, this is so realistic, right? But somewhere in this room, there's a computer running thousands of lines of code convincing my brain that I am occupying this digital body, but my brain, you know, just assumed that that was actually my body because we've never evolved to live in multiple realities at once. We accept the reality that we're given. Even intellectually, I understood that I wasn't actually in a living room, I knew I was in a laboratory in Barcelona, my brain didn't really care. It's like, yeah, you're in a living room.

So with all of that, what happened next is really hard to put into words. And I tried to in the book, but what happened next is he separated me from me. I, all of a sudden, my observing eye came apart from my body and I floated up into the ceiling and I looked down and I saw that body that I had just occupied. But what struck me, and I remember it even to this moment, was that that body was motionless and that body was vacated. It was dead. I had just had a complete out of body experience. And so the first part of the book is me trying to understand what just happened there. How did this digital parlor trick basically trick my brain into violating its own sense of self, something as powerful as that, like a psychedelic can do. And even something as essential as my coordinates and space and time were violated with a computer.

And so I kind of break down what that is and how that happens because it's the basis of medical extended reality. That's why I really started with that whole story and the science behind it.

[00:25:29] Dylan Watkins: It's a great hook, man. You got my attention, you know, going through that and really that ability to put someone in place and then separate them out there. I imagine that would be amazing for pain management and perspective. And you're really talking about VR being like the ultimate empathy machine, but the reason why it is, is because it's the ability to change your perspective, shift your perspective and really kind of, you know, put that reality on top of it and put you in different – whether you're going to be a man in a woman's body or you're going to be a child or empathy, or if you want to find out – I heard somebody once said that they put people – in order to find someone's values, they put them into different experiences. Like you're a redwood tree and a lumberjack's cutting you down. You're dolphins from the ocean and it's being polluted. But it's really interesting that that embodied presence and then that ability to shift that presence to really kind of deconnect you from that, I thought was absolutely brilliant along the way, which I guess we can segue into it because it is a topic. I can see some of them, but I have a light and my light kind of covers up some of these things. So thank you for calling that one out.

So dealing with dementia, I'd love to talk about this one for you and we can explain about it and go back and forth in this, and get your thoughts on, can virtual reality help with dementia?

[00:26:42] Brennan Spiegel: Yeah. So dementia of course is a very difficult, challenging condition, heartbreaking to watch people lose their sense of self. And really in a way, going back to this earlier discussion, dementia is the consequence of losing your sense of self. You know, the mechanisms of something like Alzheimer's are of course, different than something like schizophrenia. Although they both do tend to involve the hippocampus to some degree, but the point is that in both cases broadly, you're losing your sense of self. So the idea then is how can virtual reality kind of restore a sense of self? Now I would never claim that VR is going to reverse something like Alzheimer's dementia. Time will tell if these sorts of therapies if implemented earlier can actually slow the trajectory of something like Alzheimer's.

But what we do know, and I talk about this in the book is these really profound examples where virtual reality can be used as reminiscence therapy. So, one thing we do know about dementia particularly Alzheimer's is that although short-term memory is generally lost, dysfunctional, if you tap into the right part of the brain, people can remember with great detail, long-term memories from way back.

And so there's a technique that some therapists use called reminiscence therapy, where you can, you know, give somebody a photograph from decades ago and talk about it, play some music from their childhood and they'll remember it and they'll sing along. But what's really profound is if you use virtual reality. So there are examples where in nursing homes, virtual reality is used using Google Maps and sort of a three dimensional stereoscopic reproduction of somebody's childhood home. And you can put somebody right in front of their home. And they think they're there. I mean, you just feel like you are there and you can just see, like, if you had an MRI scan, you'd see the brain light up, but you can just see the body language. All of a sudden people start telling stories, singing songs, very deep and detailed recollections that it was just a matter of tapping into the right part of the brain and using the leveraging, the benefits of psychological presence that you get from VR, where you feel like you are there. And that's what makes it so powerful more than just looking at a photograph. So virtual reminiscence therapy is one very interesting technique that can be used for people with dementia.

[00:29:27] Dylan Watkins: That's interesting. So you're saying that with dementia and one of things, my grandmother had it, my mom has it, going through this whole process, and you see that they have this long-term memory, right? But they don't have the short-term memory. They lose a lot of nouns, right, person, place and things along the way. And then along that pattern, you're saying that if you can – you're basically creating a bridge from the long-term memory into the immediate, by recreating that, and then basically jump starting that pattern. Has there been anything, any studies around that with the MRI machine, showing that in some sort of way that the brain is compensating or in some – and I know you can't speak and say, it cures Alzheimer's because I'm not saying it does. That's not the point of the compensation, but we do know that the brain is placid and has the ability to compensate in different areas.

So you can lose a chunk of your brain to a degree and it can compensate to a degree. So has there been any MRIs or any types of studies shown by using this type of therapy that the brain is somehow learning a new way to think and a new way to process, very much like the phantom limb syndrome?

[00:30:25] Brennan Spiegel: Right. Yeah. And that's again, why I start with the phantom limb example because it actually helps unpack what happened to me when I had that out of body experience. And you hit the nail in the head that the plasticity of the brain is the key phenomenon that we can leverage in all of these examples. And so the whole idea there is, you know, the brain is not like some block of Play-Doh sitting in our head that never changes. It's a moving, shape shifting part of our body, just like anything else. I mean, this conversation right now is changing my brain and your brain and the brains of anybody who's listening, hopefully for the better, but it's changing, right? It absolutely changes every single millisecond. And the incredible thing is it taken a little bit of a tangential – tangent for a moment is that every cubic centimeter of brain tissue, and we all have, you know, a thousand to 1,300 cubic centimeters of brain tissue, just a tiny little cubic centimeter brain tissue has more neural connections in it than there are stars in the Milky Way Galaxy. Okay, over a hundred billion connections between nerves.

So, you know, just the untapped potential we all have is literally mind blowing. I mean, it's just beyond anything that we can conceive of. And so, yeah, I mean the brain is constantly rerouting, shifting. And so stroke is the classic example where a part of the brain is, you know, is ischemic, it dies. And then the brain starts to work around that, especially that that can be accelerated with virtual reality. That's been shown, there are neural rehabilitation VR programs to help accelerate that ability. That's why VR works for phantom limb pain, for example.

And so dementia is a tougher nut to crack. I don't know offhand of any studies with functional MRIs using VR for dementia. They may exist, I just have not seen them personally. I think that would be a challenging study to do, but it would be an interesting one. I think fundamentally that's what we're trying to achieve is to accelerate sort of, you know – they always say, you know, nerves that, you know, wire together, fire together, and trying to lay down kind of new pathways to work around some of the deficits that we're dealing with. Yeah.

[00:32:48] Dylan Watkins: Wow. So two things on that. One, before I get to the MRI piece, when you talked about the chunk of brain has more neurons in it than the stars in the Milky Way, my mind just kind of blew. And I was like trying to process that. And I have a thing that I've noticed, I've seen a simulator and I don't know, this is what I'm going to call my bro science on things. And you can please fact check me on this. Is that the sense of awe, right? When you see, when you go from the little tunnel into the Yosemite Valley and you see all those ones, or you're inside your tent and you step out and you look up at Joshua Tree and you see all the stars in the sky, I've noticed that the same type of thing happens on a computer or a VR headset when you're trying to render and you're trying to process so much that you over process the system and you basically create a sense of awe.

And so I think, and I don't know if – this is one of my thoughts is, is that awe is a sense of really over trying to render so much beauty at one moment that your brain literally goes, ah, and you're trying to actually process all that. I don't know if you had any thoughts around that, but that's something I've just experienced for myself.

[00:33:57] Brennan Spiegel: Yeah. So the sense of awe actually is a area of scientific inquiry. There's research that is attempting to understand what that is psychologically and physiologically. In fact, in the book, I talked a little bit about this sense of awe and the reproducible ability of virtual reality to achieve a sense of awe under certain circumstances in certain people, not all brains actually are equally capable it appears of experiencing awe. That seems to be, yeah, that is an awe. And so, you know, what is a sense of awe? I mean, psychologically, it's sort of this notion that you're part of something much, much, much bigger.

So astronauts, when they're in, you know, orbiting the earth, will often report a sense of awe. They look out and it hits them that, wow, like that's the Earth. You know, I'm part of something much bigger. And that's profound. And people have goosebumps and physiologic responses. And, you know, there's a really interesting scientific research around that. In fact, there's something called the goose cam, which is a camera that will look at goosebumps as a objective outcome measure in virtual reality studies.

So there's been work done at Simon Fraser University up in Canada using the goose cam, literally putting people in VR and circling the Earth and demonstrating how quickly it can create goosebumps. It tends to be more common in women than men in their research and not everyone gets the willies. But that's kind of an outward marker of awe. And so there's some really interesting work in that area.

[00:35:40] Dylan Watkins: Oh, that's fascinating. And I wonder, I mean, I don't know why it would be men versus women. Maybe men are more familiar with the technologies. And so it has less of an impact, maybe there's that hedonic treadmill kind of thing going on, or maybe there's something that is more of a physiological thing. I don't mean – that's fascinating.

[00:35:56] Brennan Spiegel: Well, I don't want to risk overstepping my area of expertise, but yeah, there of course are biological differences between men and women. And some of that does track with empathy and empathy is sort of the ability to look beyond yourself to those around you. And that can be a mechanism to help open the doors to awe, if you're open to experiencing kind of the world beyond you more broadly than not. And so that's one approach, and yeah, there's quite a bit of research looking at empathy and awe and the biological differences, but it's of course, variable from person to person.

[00:36:38] Dylan Watkins: Sure. That makes sense. I mean, as a survival mechanism, I mean the male-female relationships and women pay attention to more of the social structures and, you know, that makes sense to a degree. I want to circle back to the MRI and people have seen that. Do you know of a woman named Mary Lou Jepsen? Are you familiar with that name?

[00:36:58] Brennan Spiegel: Does not ring a bell.

[00:37:01] Dylan Watkins: Okay. So, years ago I was on Reddit at three in the morning as sometimes I want to do, trolling through the Reddits subreddits, and I saw this title and it says X Head of Research for Oculus Reality Labs invents AR/VR telepathy. Okay. And I was like, hmm, you have my interest, go on. So I went to go watch it. And I went and watching this woman. And she's literally doing the speed of light calculations in her head by doing this. And I'm like, okay, I am way too dumb to know if this is true or not. So I sent it to three of my smartest friends, like AAA developers, MIT people, all that fun stuff. And they came back and said, yes, yes, this a hundred percent true. So essentially she was working the labs and she makes a lot of the face plates and stuff like that, like the Quest and all that stuff. And she since left, but she realized that the cameras are so good right now just as is because of trying to get Pokemon, you know, 2022 out and all those other ones. It's so good that you can actually, if you put it on your brain, you can actually, if you had an array of them, a series of cameras over it, it can operate as if a functional MRI at one one-thousandth the cost, one one-thousandth the price and all that fun stuff.

She has since left Oculus to go pursue a thing called Blue Ocean, I believe it is. And she, or Blue Water, I think is the name of her group. And, it's really, she created a device that can go on your head, that can what she says, operate as a functional MRI. But, so what happens if you have a VR machine that can also be an MRI that can see what you're looking at, hearing, selling and also seeing the way your brain is responding in real time? She goes over time, you're going to be able to have, be able to think a thought, it'll be able to transcribe it, then send to someone and process it as well as a low cost universally adaptable MRI machine that she said four years ago, she's going to work on a prototype two years. And so that's been two years since.

And so now, supposedly she's at the point where she's getting ready to kind of have this go out into the public with everything. And I know she's somewhat local to the area. So when you're talking about that, and you're always in the future tech space, I haven't been able to get her on the podcast yet, but if you get a hold of her, just let me know, because I think you guys would make something really magical together.

[00:39:15] Brennan Spiegel: Yeah, I think broadly we're talking about brain computer interfaces here and the ability to have a feedback loop between neural processing of some sort and the user interface that in this case, the VR is exposing the user to. And so folks like Adam Gazzaley in UCSF have been studying these kind of feed forward feedback loops in VR, and other forms of technology for quite some time. And, you know, we've also been doing more and more work with this, not so much with this kind of portable MRI, FMRI paradigm, but just other measures of physiology.

So for example, we've been using the HP Omnicept headset, which is a headset by HP. It has built in biosensors. It can measure pupil diameter, it measures heart rate and heart rate variability. It measures eye tracking. And it will calculate an integrated metric called the cognitive load, which is kind of basically how hard is your brain working. It's not near as granular as what you're describing in your discussion here, but the idea is still even with a headset right now, we get biofeedback and we can use that to modify in real time dynamically what people are experiencing, plus we can measure it on a computer as our patients are using the virtual reality to get a sense of how effective is the VR. And then we'll debrief with patients afterwards and show them the measurements so they can see firsthand how this psychological experience actually was also a physiological experience that they did modify their nervous system, their autonomic nervous system, for example, with their thoughts, with this experience.

And that's very, very powerful for patients to see that because otherwise it's just kind of us saying talking, but it becomes manifest when you can see how your physiology changed and how you can feed back into yourself with these brain computer interfaces. So this is a very exciting, important area of research.

[00:41:23] Dylan Watkins: Well, that's fantastic because what you're talking about is we're digitizing reality. Reality is the external reality, the social reality and our inner responses. And one of the ways is if you, yeah, I can scan the brain. That's one thing. But eyes are window of the souls because you can look at pupil dilations and all that jazz. I had Adam on the podcast. Fantastic topic, fantastic beard. He looks like the world's most interesting, man, you know.

[00:41:45] Brennan Spiegel: He does. Yeah.

[00:41:46] Dylan Watkins: He does, right? And also, I mean, he talks about, you know, he had a couple different companies, he had a gaming company. He also have, you know, this company that does measurements and feedback and can really, how do you integrate these systems? And I think this is where these studios are going. It's not just a game company anymore, a VR company. It's a combination of these interdisciplinary skills coming together to really digitize a human and create an entire reality, not just the external, but the internal to be able to shift people to where they want to go because ultimately, if you look about people being the heroes of their own story, it's a story of human transformation, a human growth. And it's about getting from one place, you're seeking a goal, but transforming who you are along the way. And so have you seen any companies like this coming out that are really focused on, besides Adams, of these integrations of multiple different disciplines and integrating them in to transform the user?

[00:42:33] Brennan Spiegel: Well, I'll think about the company question in a second, but just to comment on what you're saying that, yeah, I mean, the idea of all this, as I think about it, is not for people to live in virtual reality forever, right, so that we created this almost dystopian metaverse where people are living their lives entirely within digital worlds, which will become increasingly possible as the metaverse evolves, whatever that is we're learning and as the technology improves.

To me, the goal of doing this kind of work in virtual reality is in a practiced, reproducible and safe environment. We could give people the chance to practice managing their physiology, their thoughts, their cognitions, their emotions and their body in a way that they can practice over and over again. And so that they can then go back into real reality, maybe we'll call that RR, and have those skills at the ready and, you know, use them to live a richer, more meaningful life in real reality. So when we talk about the metaverse and all the worrisome dystopian, you know, possibilities, it is inevitable that the metaverse is coming.

So, you know, my role as sort of a clinician, a doctor, and somebody's interested in medical extended reality is how do we kind of, let's call it cultivate some corner of this metaverse so that it is for good and it is to support human health and wellbeing in the real world. What does that look like? Is it regulated? There's lots of interesting questions, regulatory, philosophical, psychological about what's involved in creating that part of the metaverse.

And the companies that are thinking in that way are the ones I'm most interested in, that are thinking about not how do we sort of addict people to VR and gamify it endlessly, but how do we give people hits of VR, let's call it, that will allow them to go back to the real world and not have to continually rely upon these digital metaverses to, you know, to survive and thrive.

So, yeah, I mean, I don't know about any individual companies right now because they're kind of coming here and there and their flashes in the pan, some are more to stay. I have been very impressed with AppliedVR. Applied because they have an FDA cleared, you know, treatment. We've worked with Applied for years. And, you know, I think they've been doing it right. And there are many other companies that are doing it right as well.

[00:45:12] Dylan Watkins: Yeah. Had lead designer for Applied on the podcast as well. And you're talking about one things that I find fascinating here, because we're talking about, they have a breathing device, right, that allows you to be able to track breathing with the headset. And why is that important? Because breath is the window to being able to regulate your autonomic nervous system, right? It's really a connection to the vagus nerve. And if we really look and when you talk about people think that we're thinking machines that feel, but we're really feeling machines that think, and the feeling piece of that is our vagus nerve.

And if you look at the entry points down the system, part of it being is one, you can tap into that, say EMDR therapy in the eyes, you can have the breathwork going in through the lungs, using things like Wim Hof, all the way down to say gut, right, and having a healthy gut. And, you know, if you transplant the – having good food in your system versus bad, it is the second brain, so it can affect you down the line. And those are things about affecting your internal reality so that you can actually show up and actually have an effective change in your social reality or the physical reality around you.

In terms affecting the vagus nerve, going down the lines, what technologies or systems have you seen that have paired up with virtual reality that really stack to have a comprehensive effect on the way we feel?

[00:46:29] Brennan Spiegel: Well, there's a lot built into that question. You know, and you mentioned the vagus nerve, which certainly is an important part of how we integrate our mind and our body. No question about it. Key parasympathetic pathway. But of course there's much more than the vagus nerve, just the spinal cord itself, you know, we have these descending pathways, so descending, inhibitory pathways. So for example, if you, you know, are in pain, either acutely because you twisted your ankle or chronically, because you have, let's say chronic lower back pain, those pain signals are kind of amplifying in the spinal cord and just bombarding the brain constantly. And the brain starts to change how it perceives that pain, changes physically, functionally over time.

But the thing I wanted to point out here is the brain doesn't just sit there, haplessly getting washed over with signals. The brain can fight back. And so the brain does that. One of the ways it does that is not even through the vagus nerve necessarily, just through descending inhibitory pathways from an area called the periaqueductal gray. And it doesn't really matter right now, but it can basically send signals down that will close these virtual gates. So the whole idea behind this gate control theory is we have these like kind of like gates that open and close along the spinal cord.

And if we close those gates, then the pain signals hit the gates and kind of bounce back and don't come up. So how do we do that? Well, if you are anxious, your gates are wide open because it makes sense evolutionarily. I'm like preparing for a threat, so I need to know what's going on down there. I'm wide open in letting everything up into my brain. But if I want to chill by a Palm tree or something, I don't have time for pain. I need to put my mind in the state of ease and calm. And one of the ways we know you're in ease and calm is you're not feeling the pain in the same way because the brain is fighting back and smothering it.

So, you know, it's not just the vagus, there's so many other ways, and that's not even to mention hormones like cortisol and stress hormones and the immune system and all the other ways that the body and the brain are constantly communicating. And that goes back to my earlier point, it's not the body and the brain, it's one integrated system. It's just our way of thinking about it. It makes sense that there's a brain and there's a body. It's all one system.

So VR just kind of plugs into that as one of many different kinds of ways to modify the way our brain is experiencing our body. And when we use haptics and we use peripherals, now we actually are modifying our body. I mean, I could use this sensor right in front of me right now, which goes on the GI tract. It's a sticker and it listens to your intestines and the sounds can actually go into a VR headset. So you can just imagine all the ways we can integrate mind and body.

[00:49:29] Dylan Watkins: Well, that's interesting because, you know, things that get measured, get managed, right? And so if you can take those internal responses and make it – awareness, right? If you look at social, emotional control, the first step of it is awareness and we can – and being able to have those types of biometrics, I've heard of, you know, you can take a look at your breath. You can see your heart rate. You can take a look at the – and if you see it and you can become aware of it, that is the first step to be able to affect that change.

I have one that until I read your book, I didn't know about this GI thing that you put on your stomach to be able to see that. Does that influence like healthy dieting, healthy eating? Because I imagine just people trying to abuse it to see what kind of loud sounds can come out of the body. Can you talk to me just a bit about like how it's applied?

[00:50:09] Brennan Spiegel: Yeah. Well this particular thing is unfortunately not yet available to anyone, but I'm still holding it here. It's FDA cleared device. I happened to have invented it many years ago. It's called AbStats. And this is just one example. I mean this thing actually has a microphone in it. So if you stick it on your belly, it's like a Fitbit for your stomach. So it's measuring the sounds of digestion and it's just like you have a heart rate or respiratory rate, this is the intestinal rate. This is a number of times per minute that your bowels contract. And so it makes a sound and we can simply measure that sound. So that's just an example of one of many different measurements that we could obtain.

Just like you said, you know, you have to be aware of something first to sort of modify it. And that's often very true because it's very hard to count your intestinal rate. You know if you have something like diarrhea or constipation, but you don't necessarily know how quickly intestines are moving, unless you hear it or feel it. But this is something that can give you awareness of it.

Or a totally different example is, you know, anorexia or on the other hand, obesity. And I talk about that in the book. In both of those cases, one of the theories is that we lack the interceptive ability to feel inside of our body. At the beginning of this discussion, I've talked about interoception and exteroception. And so we lose track of what it feels like to be full or to be emaciated. Like your brain just becomes accustomed to that.

And so there's this guy, Giuseppe Riva in Northern Italy, who's used virtual reality to try and reset the mind's map of the body by raising awareness about this, like you said, about this deficit. So he'll put somebody who has, let's say anorexia into a headset, and you look down and you're in a normal sized body. Totally not an anorectic body, but a normal body. And people go, oh my God, like that's what it's supposed to look like. Like literally the awareness right there, that that's what it's supposed to look like. Because somebody could tell you that, but in VR you see it and feel it. And he's literally shown in randomized control trials that that intervention can help with weight gain. I mean when used as part of a broader intervention, but it's really quite fascinating. And it's really true about awareness being one of the first steps and VR can help with that.

[00:52:25] Dylan Watkins: Yeah. I love that. Yeah. And we had, again, Giuseppe on the podcast. We were jamming with that. And he was talking about – and it was one of the things that let me know about the creating physical reality. When you have the mental route and you're thinking about it, it's very loose, but if you actually create it as a digital space, it creates it into a concrete environment. And so, because we're constantly, we're these prediction machines constantly predicting what's going to happen. This is going to be good. This is going to be bad. This is what's going to happen. I'm going to like this. I'm not going to like this. Right? And the thing is, we're good at it, but we're just not nearly as good as it, as we think we are.

And that's one of the biggest challenges that we have going through the process. He actually doesn't want to get into multiplayer VR because it's too hard. So he keeps things pretty single player.

[00:53:03] Brennan Spiegel: Okay.

[00:53:04] Dylan Watkins: But the one thing I think is fascinating is on that same note, I don't think you talked about in there, was the ability to be able to not only see your own body, but be able to see a reflection of yourself as an avatar and say based upon what you do, there is an expedited effect. So if I eat unhealthy, I can see a dramatic effect. Or if I do something, it has it, because one of the things about – the reason why people like to live in a game world versus be in reality is that reality can be messy and unpredictable and games have a quick response and immediate feedback that you can see a consequence.

And often for us, you know, someone smokes cigarettes. They may not see that until 50 years later, right? So that effect, what have you seen with people using being able to see their own avatars and what effects have you seen to be able to shift their behavior patterns?

[00:53:49] Brennan Spiegel: Yeah, this is really important. And it goes back to this benefit of VR to feel different, to literally feel embodied when I see my hands or my body. So for example, you know, somebody who has rheumatoid arthritis, but it hasn't advanced yet. But it's starting to hurt their hands. And they're not sure whether they want to start taking certain medications, which could have risks. Well, one way to help figure that out is to just watch and see what your hands might become. And this isn't to be scary or catastrophic, but like, this is what your hands could look like in 10 years without treatment. And that's an example where you now have a little bit more information to work with.

Another example that we did was for managing high blood pressure and people staying on their medications or staying on a low salt diet. So we exposed them to what could happen to your heart and your brain and your blood vessels and your kidney, if this continues, and the damage that's going to occur. And when people experience that in VR, we actually saw amazingly a reduction in their blood pressure over the subsequent six to eight weeks because they just got back on their medications and tried to change their diet. It was so impactful to get that sense of the future. Like what you say, it's not a short-term game, it's a long term game and VR can kind of accelerate the clock in a way that just a doctor or clinician saying it may not be all that convincing. But when you feel it, there's an emotional valence.

And if you think about what do you remember the most in life, usually both the good and the bad memories were tied to something strongly emotional. That's what steers memories and lessons into our brains. You get married, you remember that. Somebody punches you in the face, you remember that, okay? And so VR has an emotional valence and that's the power of sort of burning in strong lessons using VR if we use it appropriately and not inappropriately. You could see the potential for abuse too.

[00:55:56] Dylan Watkins: Absolutely. Absolutely. I say, you know, experience is a great teacher. It's just not always the kindest. And I think with virtual reality we can kind of shortcut the kindest part because you're like, oh, test run. You, you don't actually have those hands. This is what's going on. Or you're talking about lowering blood pressure. In the book, one of the things that was great, you're talking about doing a thing with pastors and preachers, where they're talking about, hey, a low salt diet. And what you did, which I think was great, being a human-centric designer myself, is you involved this community to co-create this experience and to be able to incentivize that. You didn't just say, hey, I know best, I'm the doctor, eat your medicines, this what you have to do, right, or you're going to die, right? You co-created that together. You had the community go through it. And then you shifted collectively that behavior to be able to lower that salt levels or the, I believe it was blood pressure, like seven points all the way down. Anything above four, I believe was significant.

So what I like about that, you said there was a methodology, a practice, a three phase approach for actually designing and co-creating effective experiences for transformative change, at least in my words. Can you please kind of, if anybody's listing out there for that, want to be able to design these types of effective modalities, can you kind of maybe summarize that to a point?

[00:57:04] Brennan Spiegel: Yeah, absolutely. You're right on, right on target with this. Whether it's VR or any other kind of digital therapeutics or really just anything in healthcare, it makes a lot of sense that you start with the end user in mind, okay? You start by learning from the end users, in this case, generally patients. What are their unmet needs? Knowledge, attitudes, beliefs, preferences. And use human-centered design principles to create an experience that is meaningful to them and that they had a hand in co-creating. And so we call that VR one. So there's VR one, VR two and VR three. And just like the FDA has phase one, two and three trials for pharmaceuticals, we have VR one, two and three trials for immersive therapeutics. And XR might be a better term than VR.

But in short VR one is the human-centered design component. This is where we sit down with patients and find out what do they want? What are they looking for? And obviously it's informed by the literature and by experts also, but we have to have patients involved in storyboarding and developing the idea behind it. VR one ends with some kind of a prototype program that's then used in a VR two study to evaluate if there's any early evidence of clinical benefit and also looking for safety and tolerability. It's not a randomized trial yet, but it is a clinical application and you continue iteratively improve it.

VR three is the full randomized controlled trial. By now you've got a pretty locked in intervention and now you have to actually demonstrate that it makes a clinical difference in somebody's life compared to some other intervention that we might otherwise be using in everyday practice. And that's the most rigorous way to really evaluate these. And that takes time, which not a lot of developers are interested in, you know, in taking let's say, yeah.

[00:58:54] Dylan Watkins: Yeah, we go, isn't that demo cool? Wouldn't that be cool? That's usually the, as far as, as most developers want to take it along the path. So for myself personally, I've been working on this game for like the last 18 months and it's a VR multiplayer shooter. It just got released in AppLab Store and all that stuff. And one of the things that we're looking at is not only just a fun game to play, but also working on combating toxicity in games. And the principle of this is that gamers are the new gang members. And they don't roam the streets anymore, they roam online. If you want to call them metaverses or video games or whatever, terrorizing people, and they're inside their own world.

And inside there, you can have just this traumatic experience because inside there, there is the achievement, there's picking teams, there's shaming, there's blaming, there's rampant toxicity inside these games. And at that point of being triggered is when you want to be able to bring in and have some sort of a pathway or communications that gives them the way to process, or be able to communicate that in a healthy way.

Have you seen anything in that areas or any recommendations you'd have that comes to mind for being able to build, create, or refer to something that's been able to tackle this issue?

[01:00:04] Brennan Spiegel: I haven't. That's a really interesting point. And it also brings up an earlier point, which is that real – virtual experiences are real experiences. Okay. This whole idea that, oh, there's the virtual world and there's the real. Yeah, but like I said before, if you're being shamed in a digital space, it can feel just as bad, maybe worse, who knows, than if you're being shamed in a real space, the shame, the emotions, they're real, the physiologic effects, the emotional and, and cognitive effects are real. So just because it's in a virtual world, doesn't mean it's not a real genuine experience. And I think that's an important insight.

As for best practices for mitigating that, I don't have enough expertise in that particular area, but I will just mention that Jeremy Soule is a famous composer. He's kind of the John Williams of video games. He created all the sound for the Skyrim series, for example, which a lot of people love. And so we've worked with him because he's made some beautiful compositions and he's noticed that people love Skyrim in large part because of the music. And many people have come to him and say, you know what, video games normally amp me up, but the music is so beautiful that it actually calms me down. And I play just for the music. In fact, some people have said such profound things to him that they were suicidal until they heard his music. And I'm not suggesting that music is the solution for suicidality. That's a bigger topic.

But the bigger point here is that there are things that could be done to try to modify emotions and something like music – this is not just an audio – this is not just a visual, it's an audiovisual experience. So there's lots of very interesting ways that I think we can do better, but I'm just not an expert enough to tell you what those all are.

[01:01:59] Dylan Watkins: That's fair. What that brings to mind for me is one of the things that you talked about, I think the next couple of weeks I'm going to have Nanea Reeves from TRIPP VR on the podcast. And you talked about precision medicine, the ability to pick the emotion, pick what you would like, and then have a custom precise experience delivered to you, which was a combination of the auditory and both the virtual inside and immersive environment that was precise to you.

Have you seen other things for precision medicine inside the immersive space that you can kind of, you know, choose your flavor, pick your own journey and be able to get the emotion or the effect or the mindset that you want by going through an experience?

[01:02:37] Brennan Spiegel: Yeah. This is really, I think where we need to move is using the right treatment for the right patient at the right time. I remember my perspective is as a clinician, as a doctor, I'm thinking about this almost like a therapeutic, like if VR is a therapy, we need to VR pharmacy. That's why I call my book VRx. Where is it? It's up here behind me. VRx. So how do we precisely pick the right treatment for the right patient? So you mentioned Nanea Reeves from TRIPP. And one thing that, you know, they've done a trip, really effectively is to try and personalize the experience a little bit.

So one way they do that is you can upload photographs that are meaningful to you from your life let's say, and those images will be embedded within these fantastical beautiful environments. And you'll just be sort of floating along and there's your dog or there's your wife or there's your, you know, family member, parents. And that is alone, a form of precision therapeutics, just that you see something very unique and emotionally valenced to you as an individual.

And you know, we talked earlier about other ways to make it very precise, like using biosensors, the ultimate might be this functional MRI brain hat that, you know, can tell you what you're thinking. But short of that, just having, you know, heart rate variability and pupillometry, and all these other measurements can also be used to more precisely integrate. But then there's a whole other part that, you know, we can spend another hour talking about. And I think we'll probably wrap up soon. But it's the mechanism of action. We call it the MOA. So when I pick up a therapy for a patient, I'm trying to understand how does this pill work? What exactly is it doing? And, you know, that should be aligned with the pathophysiology of the patient.

So here we need to think about what is the mechanism of action of this therapeutic? Is it just relaxation or is there something more specific? And so we're getting much more detailed now. For example, I'm a gastroenterologist. So I treat a lot of irritable bowel syndrome and we're creating a whole new treatment just for IBS called IBS VR. And that's an example of a very tailored, specific intervention that's really designed for the pathophysiology as we understand it of irritable bowel syndrome. So I think we'll see more and more of these examples coming up.

[01:04:46] Dylan Watkins: I love it. Yeah. The pharmacy, right? Precision medicine. Being able to actually say, okay, unique problem, unique, specific solution, and be able to kind of, you know, a what do you need? Okay. Here's a specific slice that solves this specific problem for you specifically, you know? Right technology, right medicine, right person, right time. Brings this towards the end of the podcast here. You've put a lot of time in creating this book and being a evangelist in this space and really promoting it and getting the word out about everything that you've done in this space, what is your Holy Grail for all this effort and all of this work? What is the flag in the sand that you hope to achieve by being able to put in all this time and effort?

[01:05:27] Brennan Spiegel: Yeah. Well, I think there's a philosophical answer and some very pragmatic answers. So I'll just stick with the really pragmatic part. I was a philosophy major, so I spent a lot of time on that side of things. But if we can just get insurance to start paying for this, that is a form of a Holy Grail because at this point we have all this pent up science. There's over 10,000 studies now in the literature, if you go to PubMed type and virtual reality. And as I said in the beginning, it's not a matter of needing like another 10,000 studies. It's a matter of now figuring out how do we use it in whom and when is it appropriate? It's not a panacea. You're not going to cure cancer, we don't think. There's some questions that people have raised about that. You know, we're not going to cure Alzheimer's at this point in time. So we have to be careful about not over promising and underdelivering.

But when used appropriately in the right people at the right time, VR can really make a difference in people's lives. I've seen it first hand over and over again. So we need  insurance companies to recognize that too and to recognize that this is probably a cost effective intervention to use these therapies. Just think about the difference in cost between pharmacotherapies, surgeries. Not that VR is going to always avoid a surgery, but we're using it for chronic lower back pain. Just even a slight benefit of these technologies will pay for themselves. So that's my Holy Grail is to have insurance companies start paying for this, so that that'll really unlock the capacity and the interest and potential of medical extended reality across the US and beyond.

[01:07:04] Dylan Watkins: Yeah, yeah, yeah, yeah. The economics is the lifeblood of any industry and flowing through things. If that is the Holy Grail, this is my second to last question here, what is the dragon? What is the biggest thing preventing these insurance companies from paying these virtual medicines?

[01:07:20] Brennan Spiegel: I mean, I think right now it's simply a lack of knowledge to some degree and that's something we're trying to help with. Also, we need more FDA cleared technologies. So insurance companies are only going to pay for, for the most part, FDA cleared technologies. They're not going to pay for something that's on the Oculus Store that's available at anyone everywhere. So, we need more rigorously developed programs in the way that I just described earlier with that VR one, VR two VR three pathway, FDA cleared, or other regulatory agencies around the world clearing them. And that's kind of going to allow these insurance companies to pay for these and make them much more available so that people don't have to, you know, pay out of pocket for a headset and, you know, and a program like $1,500 for a program. It's just unsustainable.

And the last thing I'll say on this is, you know, if I want to download an app on my phone, I don't need to buy a new phone. I use the phone that I've got and I download the app. It's not like I have a hundred phones sitting around me, one per, you know, per app, but that's kind of the model that is evolving right now. Some of the startup companies like, well, you can purchase our headset with its kiosk with the software on it. So what we also need is a HIPAA compliant, data safe, secure platform where doctors can actually prescribe these therapies into a headset. And right now, Oculus is not that solution, unless Meta decides to play nice with HIPAA. At the moment, data security is not, you know, the strength of that platform. So we have to understand that as well is creating the infrastructure to support medical extended reality and moving forward.

[01:09:08] Dylan Watkins: You want to talk about a dragon man? FDA? Oh yeah. Go, go fight that dragon. That's intense. This has been incredible. Is there any last things you'd like to let people know about before you tell them how to get a hold of you or find your book?

[01:09:24] Brennan Spiegel: Yeah, no, I think we've covered a lot here. It's been comprehensive discussion. The book goes in a lot more detail. So it's VRx. You can check it out, Amazon, wherever you'd like. And you know, I think what I would say as a doctor here is what I sort of started off with is, you know, this idea of the mind and the body being separate and apart is an old and very outdated concept. And I think new doctors are much more open than I've, you know – that have sort of within the digital divide below the digital divide. I don't want to be too prescriptive about this. But I do find that younger doctors coming up at a medical school are much more open. They grew up with the internet, grew up with smartphones, see the value of digital technologies in addition to traditional medical therapies.

And I hope more and more, we're going to start recognizing, appreciating these types of interventions, not as some pseudoscience, but as real neuroscience that can help advance human wellbeing. And we'll see, as medicine meets the metaverse, if this vision can come true, or if it goes sideways and, and blows up on us. I certainly hope not.

[01:10:31] Dylan Watkins: Excellent. Well put. Thank you so much Dr. Spiegel. Thank you so much for coming on the show. I really appreciate jiving with you, going back and forth. This has been a wonderful podcast. And I appreciate your time and thank you so much. I'll see you on the other side.

[01:10:43] Brennan Spiegel: Thanks for having me.

[01:10:45] Dylan Watkins: Bye now.

[01:10:46] Brennan Spiegel: Bye-bye.

[01:10:47] Outro: Thank you for listening to the Heroes of Reality Podcast. Check out HeroesofReality.com for more episodes. While you're there you can also take the hero's quiz to find out what kind of hero you are, or if you have a great story and want to be on the podcast, tell us why your hero's journey will inspire others. Thank you for listening. See you on the other side.