Dr. Brennan Spiegel is the author of VRx: How Virtual Therapeutics Will Revolutionize Medicine. He’s the Director of Health Services Research, Cedars-Sinai Health System.
This is a historic, one-of-a-kind interview. It lays out the digital future for GI from the lens of virtual reality (VR). Dr. Spiegel and his team have seen 3,000 patients via VR. The technology is no more new. FDA is approving solutions. Medicare is due to pay for VR.
The challenge of private practice GI is to diversify from colonoscopy. Could VR be a new ancillary stream? Find out.
Do not miss this one (35+ mins).
◘ “The whole idea of cognitive behavioral therapy is to allow patients to rethink their relationship between pain and their body”
◘ “It was almost as if we gave her a micro dose of psychedelics, so we call it a cyber-delic instead of psychedelic”
◘ “I think it’s important for those of us in digital health to recognize that we’re held by the same scientific standards as any other traditional treatment”
The Transcribed Interview:
Praveen Suthrum: Dr. Brennan Spiegel, author of “VRx: How Virtual Therapeutics Will Revolutionize Medicine” thank you so much for coming on The Scope Forward Show. I want to first warmly welcome you.
Dr. Brennan Spiegel: Thanks for having me.
Praveen Suthrum: Brennan, I want first start by asking you about your author photo. WhenI see your author picture on the book it’s the same as the one that shows up on the website of the Cedar Sinai website for VR and I’msure something happened that day you know, with that patient and that must mean something to you so I wanted to ask you about that.
Dr. Brennan Spiegel: Well, no one has ever asked that question before! Yeah, so, that was taken several years ago when we were first starting to test virtual reality and with patients. You know, for listeners here they may first of all wonder what we’re even talking about? And you know most people think about VR for gaming or entertainment but about six years ago we were beginning to test virtual reality with our patients in the hospital mainly to see if it could help them with their pain management. And that particular day we were using virtual reality with a young woman who had severe recurrent abdominal pain, and had been in the hospital many times… actually six times in one year. And had been on a number of medications – opioids, ketamines, and she was pretty frustrated and so we tried virtual reality. And the moment that that photograph was taken of me… was me responding to her responding to the VR. And she went from being understandably frustrated, upset, and disappointed that the therapies she had been receiving were not working to being kind of swept away into this virtual world reaching out to blue whales that were swimming across her visual field in the middle of a hospital room and laughing and enjoying herself and just seemingly having fun. So, I couldn’t help but smile in response. And it just so happens that moment we had a photographer who was a part of this this event and yeah I’ve used that as my headshot sort of ever since because I think it’s just a genuine reaction to a patient responding to VR.
Praveen Suthrum: Yeah, and that actually comes through you know in that photograph. I want to ask you Brennan, why did you choose to use VR that day? You know this is the first patient… I’m sure around that time you must have come across many people with abdominal pain. Why that day? Why her? What prompted it?
Dr. Brennan Spiegel: Well, we all learn in gastroenterology about the brain–gut axis. We know that the brain and the gut are connected and why wouldn’t they be? That’s just for starters. There’s this old notion that really comes from René Descartes from the mid 1600s – a very old idea of dualism that the brain and the body are separate and distinct and they operate independently. But we know that’s completely false. That the brain is tied in and completely with the gut and the rest of the body and vice versa and they’re connected through all sorts of neurohormonal avenues. So, with that background we’ve always known that cognitive behavioral therapy, psychotherapy, hypnotherapy, talk therapy, and other non–pharmacological treatments that go back thousands of years from the earliest transcendental meditative traditions, can help people with IBS. Not that it’s always the cure. Not that it is in place of traditional medical therapies. But it can support people with IBS.
So, with that background when I learned about virtual reality and recognized the ability it has to nudge the human mind in different directions including positive directions, I thought why don’t we try this with people with IBS specially those who are in the hospital where you know the most severe patients have been admitted and our treatments are so lacking, so wanting. And when I started to see responses that’s when I realized I think we’re on to something here and this is something we need to study and learn more. About and six years later we’ve used VR in over 3000 people at Cedars Sinai and we’ve learned an awful lot. We could talk more about that today.
Praveen Suthrum: Let’s go there then. You know from these 3000 people on whom you’ve used VR what would be you know, three or five takeaways?
Dr. Brennan Spiegel: I’ll start with what is VR doing and how is it working – as you know clinicians want to understand what is sort of the mechanism of action whenever we’re recommending a new treatment. Whether it’s a drug or a non-pharmacological therapy. The first takeaway, I spent quite a bit of time and in the book, I talk about this in VRx – what we think is the mechanism particularly for pain. So, I’ll just address pain for the moment. So, listeners know virtual reality has been used for many conditions not just for pain. It’s been used for eating disorders, for anorexia, for obesity, it has been used for managing dementia, schizophrenia, anxiety, depression, stroke rehabilitation, autism, cerebral palsy, multiple sclerosis, I mean the list is about 50 or 60 conditions at this point where there’s evidence with over 5000 studies! So, that’s one takeaway unto itself. But for pain one question is – how would it help somebody with pain? And so, there’s different mechanisms and one is purely just distraction for starters neuroscientists called that ‘inattentional blindness.’ And the idea is… it’s difficult… we’re not able as humans to concentrate on many things at once although we might think we multitask… But there’s just no way that person is listening to these words, and counting their heartbeats, and thinking about the pressure of the floor on their feet or the pressure of the seat on their bottom. It’s just not something you can do without getting distracted. That’s because we have a spotlight of attention sort of psychologically speaking and neuroscientifically. And so, what virtual reality does is it can draw attention away from neuro–susceptive experiences like pain. So, that’s one but it also seems that it might be able to help the brain fight back.
One reason why people seek calm, and go on a vacation, and meditate is that the brain when it’s in a calm condition can inhibit pain signals through your descending inhibitory pathways. And we think virtual reality probably works by putting the brain in a state of mind, so to speak that rejects pain. In other words, it will inhibit pain using this old ‘gate control’ theory with along the spinal cord. The brain can sort of send inhibitory signals down to close these gates along the spinal cord to disallow the arising pain. And we think that’s how VR is working. And then finally there’s cognitive restructuring – giving people ways to think about their pain in a different way. And this is important not just for acute pain but for chronic pain especially visceral pain like irritable bowel syndrome, functional abdominal pain, functional dyspepsia, where you know our pills fall short. And often we need to allow patients to rethink and re understand their pain and the relationship between their pain, and their body, and their minds and that’s the whole point of cognitive behavioral therapy. So, VR could do all those things.
Praveen Suthrum: Great! I want to ask you what happens to the story of these patients after the first few visits? Like someone has IBS, there is a new sensory experience that going through with dolphins swimming or surreal trip you know from the app Tripp or in any of these experiences. Now, that’s new for the first time but then the mind might get used to that. And I wonder does their reliance on drugs reduce overtime? What happens to this story in three months, six months, one year, two or three years down the line?
Dr. Brennan Spiegel: Yes, so, we’re just now starting to see studies with longer term follow-ups. Not yet in GI, although we intend to begin doing those studies. But outside of GI… for example there was a recent study for people with chronic lower back pain. In that study randomized controlled trial of virtual reality using an 8–week skills–based CBT treatment in VR was compared to what they called ‘sham VR’ where the other group did wear a VR headset but they only watched sort of neutral two-dimensional scenes that do not have any apparent benefit. And they followed those patients for eight weeks. So, you know we don’t have 12 week or one year data for pain but we do have at least 8-week data. And they showed not only a separation pain initially but the separation grew over the course of the eight weeks treatment. So that, by the end the patients in the VR group had considerably, statistically, and clinically meaningful reductions in pain over 8 weeks. It did not show evidence of them getting used to it or sort of a tachyphylaxis, where the therapy starts to wear off like you can see with certain medicines. That was not seen in that study.
And the whole point is of these studies is not to ask people to use VR more and more but actually just using VR less and less. If people learn something about their mind, about their body, learn new skills in VR that they can then take with them outside of VR an enjoy real reality RR even more than they might have otherwise without relying upon virtual reality. So, when we use VR it’s not as an addictive substance like a video game, it is to teach people skills that they can use in their real life and so that’s the really the goal. But we do need more data in in GI and so we’re creating a comprehensive IBS VR program right now and we certainly intend to test it over longer periods to see if this bears out with our patients in GI.
Praveen Suthrum: Excellent. So, in in the book VRx Brennan, I remember the story where you went to see this patient with abdominal pain and she experienced VR and they had tried everything else but nothing worked and then in that moment she realizes that her abdominal pain is linked to her brother’s death due to stomach cancer. Can you talk about some of these examples? I’m sure the GI community keeps seeing similar patients but somehow you know we may not be making these connections like you did in that story.
Dr. Brennan Spiegel: Yes…that is a powerful story and I often tell it. Indeed, there was a patient with recurrent severe abdominal pain of unknown origin. She was in the hospital and had been fully worked up. She had an upper endoscopy, colonoscopy, abdominal imaging, CT scan, laboratory tests for everything, for inflammatory bowel disease, celiac disease, etc. And we’ve all seen patients like this, we were scratching our head, we were perplexed. What are we missing? You know, is this porphyria? Is this Familial Mediterranean fever? Or you know what could this possibly be? Well, this woman was in the hospital with this pain and I really was starting to scratch my head. And they asked us to come in and I decided to use virtual reality. So, I used the headset and put her in a scene where she was swimming with Dolphins. And it’s a scene that we often use because it turns out to be very pleasant. People enjoy Dolphins and they like watching them, listening to their squeaks, and all this sort of thing.
And so, she found herself all of a sudden underwater swimming with Dolphins all around her, and there was some music playing, then she became silent and after about four minutes she started to cry and we’ve seen this a lot with VR and you have to imagine if you’re patient who is just in one moment in a hospital room feeling vulnerable and the next moment your brain accepts that you’re swimming with dolphins, the contrast is so striking that it can lead to sort of emotional responses. And she started crying, I said, “Are you okay?” and she said, “Yeah I am. I think I know why I have this pain.” I said, “Really? Why? Tell me more” she said, “I think it’s my brother” I said, “Your brother? What about your brother?” and she said, “Well my brother died of stomach cancer and I think I’m going to also” and I said, “You know we’ve been in your stomach though and we haven’t seen cancer. There was no sign of cancer” she said, “I know that, you guys keep telling me that, but I haven’t been willing to accept it. But these dolphins… they’re telling me I need to accept this explanation. I need to move on with my life and I’ve got to tell you, my stomach pain is better too! I just don’t have any pain right now” and she said, “I could have been on the couch for a year and I wouldn’t have figured this out but I‘m ready to go home.”
And so, it was just like an incredible experience because I thought to myself, man I’m a gastroenterologist not a psychiatrist! But somehow, she had had this you know incredible turn around. And it’s not like it works like this every single time. So, I don’t want to overstate that this is some kind of miracle but for her it was just the right thing to kind of reboot her brain. And if I had a brain scanner… we actually know a little bit about what’s going on in the brain when people use virtual reality because we’ve had MRI studies, it would have seen that the part of the brain the default mode network that kind of controls our inner voice will power down in the setting of virtual reality allowing the rest of the brain to have lateral thinking. It’s the same thing that meditation does, it’s the same thing that psychedelics do. They all work in the same way. It’s not like… the brain has many different functions or it does but it’s not like it has brand new ways of dealing with this. It‘s the same function in all three cases. So, it’s almost like we gave her a micro dose of psychedelics and then she was ready to go. So, we call this a cyber–delic, instead of a psychedelic. I didn’t make that term up by the way, somebody else did.
Praveen Suthrum: A few years back I was in Peru you know with the native shaman, and I went through this whole ayahuasca ceremony and it was semi psychedelic first-hand experience. And then when I look at some of these apps like… there’s something called Tripp, there’s one called ayahuasca, if I remember correctly or a video that I came across. They are trying to replicate some of these experiences and it’s very interesting. So, to me on the outside it appears that because we’re calling VR as a tech tool or a technology tool and we’re doing all these clinical studies it almost seems to give credibility to all these ancient healing modalities which we have maybe before poo-pooed on and said you know that’s BS and that’s not medicine or that’s not healing and so on. But now we seem to or the health care system seems to be more open to this. I’m curious you know about your comments on this.
Dr. Brennan Spiegel: Oh yeah, I have so much to say I’ll try not to spend the rest of the podcast on just this topic. You’re absolutely right. Particularly in western medicine historically there’s no doubt that there was a bias against behavioral medicine, historically. And this I think still stems from that Descartian notion of dualism. That there’s sort of the mind and that’s what we call super territorial you know, which in medicine is referring to the everything above… basically the brain. And that’s sort of for the psychiatrist. Then there’s the rest of the body… that’s where the real scientists work you know, like where we have enzymes, and we have you know physiologic processes, and we have targets for pharmacotherapies. But you know that’s nonsense. The brain and the body have always been connected and I talked about that at the top. And so, these traditional approaches of meditation, and so–called mind body interventions undoubtedly have effects on the body is just no question about it. Neurohormonal effects of long–term and short–term benefits. So, this is not a new idea whatsoever I think all virtual reality is doing which is which you point out is leveraging those innate abilities we have whether it’s to deploy our own endocannabinoid system, our own endorphins, and intrinsic opioid system whether it’s to trigger changes in cortisol, all the mechanisms that have been identified in that literature.
VR is just making it a little easier to do that. If you think about what it takes to become an expert at meditation… you know Buddhist monks average 30 to 40,000 hours meditating to get to the point where they can basically turn off their default mode network in their brain and that’s what’s happening neurologically. So, what VR is doing is… it’s leveling the playing field a little bit so that you know people like me who have not lived in a cave practicing meditation for 30,000 hours can suddenly get that ability. Especially, if you start adding biosensors to this. So, we can add an EEG and for example is one company called Healium – where you it’s monitoring your brain waves and it’s looking for a particular pattern of asymmetric beta waves over the prefrontal cortex that’s associated with the flow state. And when you achieve that, you’re rewarded in the VR headset.
So, for example use your mind to fly out of the Yosemite Valley, and you can use your brainpower to move yourself around space and just imagine all the other things that you could do when you start connecting brain computer interfaces to wearables and then connect that to the virtual reality headset. So, VR is a way to leverage all of those known benefits. And medicine finally is slowly coming back to recognizing all of that after being in low desert for most of the 1900s from around 1950 to 2000. I have looked historically and actually traced this history in the book and I talk about the sort of pendulum – how it’s gone back and forth. And we’re now at a point where this type of therapy is considered to be reasonable as a mainstream therapy whereas 20 years ago when I was training or 30 years ago, it wouldn’t have been accepted as it is now. So, things have changed now.
Praveen Suthrum: Yeah, I think it’s also got to do with societal shifts in this direction. There are apps for medication. So, I think the market or people or consumers are primed to adapt to something like this and there much more open and because consumers are open, I think the physicians follow. So that’s something that I took away.
Dr. Brennan Spiegel: I would add to that because there’s so much consumer interest it’s very easy to create non-evidence–based kind of stitch in a snake oil and sell it. And I think it’s very important for those of us in digital health to recognize that we’re held by the same scientific standards as any other traditional treatment. And so, that’s why you know we’re funded by the NIH right now to do clinical trials using virtual reality. That‘s why we’ve published randomized controlled trials. And that’s why in the book VRx I’ve cited… Oh God, I don’t even know… well over 300 studies in that book. I know because it took me months just to write the reference section. Because I felt it was very important when I wrote this book that it should not feel like sort of like a snake oil thing but rather it should feel like a real evidence based scientific endeavor. And I’m really pleased that the FDA on the basis of the work that we’re doing and many other people are doing has now recognized this field and is now calling it MXR which stands for medical extended reality. And so, we’re going to see more and more treatments coming through FDA through the regulatory pathway. that’s already happening right now and we’ve started to really truly see this this field expand as a legitimate treatment approach.
Praveen Suthrum: I want to get back to GI and ask you what advice do you have for the private practice gastroenterology that’s largely busy maybe in the procedure room so to take time away from colonoscopy and focusing on something like this… If you could tell them how they could use it and if you can connect it to business benefit.
Dr. Brennan Spiegel: Yeah, absolutely I think this is actually a perfect solution for the busy endoscopist because let’s face it like most of us went into GI because we really liked surgery but maybe we didn’t want to get up in the morning quite that early or wear scrubs all day but we liked using our hands, we like doing procedures, we like stopping a bleeding peptic ulcer, we like clipping a vessel, and screening for colon cancer but yet we found out that the most common condition we manage – irritable bowel syndrome – it’s like we have to sort of be honorary psychologists for part of the day and that’s not what we signed up for. So, I think for some GI doctors there’s this almost like tension between this hands–on, manual, mechanical approach to handling patients and is very cognitive non–procedural approach to managing these very common patients. And then you throw in the fact that the treatments that we have for IBS although many are very effective it’s hard to predict when they’re going to work.
Giving an antibiotic to a patient with IBS is not like giving an antibiotic to somebody within the mode. You know, the relationship you had with your patient and their understanding of the treatment you’re giving, will modify the effectiveness of an antibiotic or any medicine that we give. We know this. So, patients like to go to doctors who feel like they’re giving them something more than just pills, they’re giving them their time but also giving them insights that they may not have had. And so, that’s why we’re creating this IBS VR program right now which takes all the science that goes back years about CBT, the mindful meditation, that packages it all up into a program that patients can use at home. So, they have this ability to build skills and the GI doctor may not even know how to do that, but we’re packaging it up in a VR headset. So, it’s like you have a CBT psychologist with you at home – you can do hypnotherapy, you could do CBT therapy, and you can do mindful meditation around gut health. And all the GI doctor really needs to do is tell the patient about it and send them on their way rather than learn how to do CBT or always send them to another person who may or may not be all that helpful. So, I think that there’s a lot of benefits to private practitioners to learn about this. I think patients are increasingly… I wouldn’t say demanding yet, but are very receptive to it and seeing really positive benefits so it’s something we’re thinking about.
Praveen Suthrum: So, the obvious question is who pays for all this?
Dr. Brennan Spiegel: Yeah so, that’s a great question and it’s one that insurance companies are actively exploring right now. For the most part, insurance companies are not covering VR as a procedure or as a treatment but there are some models emerging. So, at Cedar Sinai where I work, we are soon going to announce… and this is I guess like a little teaser… a clinical VR program that is going to be run by clinical team for both inpatients and out-patients. So, not just a research program like we have right now but a full-fledged consulting service. I mentioned that because the person running that is a psychiatrist who’s trained in virtual reality. And so, he gets paid just like he would in any other day of the week. He’s getting paid to use VR. Because he’s getting paid for delivering psychological treatments it just so happens that it is VR, he doesn’t get paid separately. But some psychiatrists are billing for VR for exposure therapy for example for phobias that’s a very effective use of virtual reality and one in which many doctors are getting paid.
There are some codes being developed for VR for physical therapy. But we’re now at the point with FDA starting to look at these treatments that soon Medicare may actually have to cover VR. This is really interesting. There is a company in LA called Applied VR and Applied VR by the way, came through Cedars Sinai’s accelerator program many years ago and they they’ve been working towards FDA clearance for their chronic pain treatment program and it received what’s called “breakthrough” designation by the FDA. And that’s sort of a rare designation that once approved, requires some level of coverage from CMS. So, CMS may actually have to cover breakthrough VR therapies just from a statutory standpoint. But other insurance companies like – travelers insurance has funded our research. Blue Cross Blue Shield have been looking at this with other groups and are seriously considering supporting it. But in the meantime, patients can also download the stuff. They could just buy a headset for $200 or $300 and download programs for free or for $15 to $20 and off they go. So, we don’t necessarily need insurance to cover this right now. But certainly, for people who can’t afford these headsets it would be great if we had other ways to cover it.
Praveen Suthrum: How have you seen VR being applied in obesity? I’ve read what you wrote in your book but I’m sure things have evolved now. Just your take on weight loss and virtual reality.
Dr. Brennan Spiegel: Right and this idea as you mentioned we have discussed in the book. We haven’t yet seen this go mainstream, but I’ll tell you I before the pandemic I was at one of these VR centers in a local mall here in Los Angeles called Dreamscape. And it’s really amazing if you haven’t been in one of these things. You get in a body pack, and you wear headset, and you look down and you see that you become a different person and, in this case, we were like some Navy seals or something underwater and it was really amazing and immersive. So, I mention it because one of the people in our group was obese, she was overweight and she herself said this, as we were getting on our outfits for this VR experience. But what was amazing to me is when she looked down and she said, “Oh my God, I’m thin!” It was sort of a tongue in cheek joke, I guess, she said it sort of facetiously. But when you look down you see this really fit avatar and you’re embodying that avatar.
So, what she was experiencing at that moment has actually been studied and I talk about that in the book. There’s a guy in northern Italy who’s worked on this program and he’s shown in a randomized control trial over a one year follow up… so we talked about long term follow-up… not over a day or a week or month – a year later people who use VR compared to cognitive behavioral therapy without VR had durable and significant weight loss that was sustained. So, I think there’s an opportunity here probably for private practitioners, for weight loss centers, to actually learn this paradigm to figure out how it works and start applying it as part of a multi component CBT approach. We think about patients with non-alcoholic fatty liver disease and NASH, you know that’s an obvious case. I know you’re interested in gastroenterology where the VR treatments may be affective to help change cognitions about the body.
Praveen Suthrum: How far are we from a timeline standpoint on when all this goes mainstream? You might say it already is but maybe you know it’s not mainstream. I want your outlook on you know the future of VR three to five years from now.
Dr. Brennan Spiegel: Yeah, it’s going to depend upon certain things. As you say VR is not quite mainstream yet but it’s certainly VR in general has become pretty mainstream. You know not in healthcare but in general. You know, two years ago if I said VR most people would know what that means. Now we just say VR, we don’t say virtual reality. So, it’s just… there’s a familiarity with the technology. And you know it’s becoming more mainstream for gaming and entertainment. The question is in healthcare in the next five years, what will be the catalysts? One of them will be insurance coverage, and payment models which we’ve discussed. The other will be more evidence around novel therapeutics and acceptance amongst clinicians that these are worthwhile, I believe that that’s already happening. And it’s going to be you know a bit by bit progressive realization and up some point will hit this sort of threshold of dissemination where enough people know about it and see the benefits that they’re willing to use it as a matter of routine.
In GI I think we’re going to start seeing more effective therapies and there will be a demand from patients to have access to those therapies when they will start to talk about it on social media and talk to one another and I think that’s going to happen. I think we’re going to really see a particularly in IBS and disorders of brain-gut interactions in particular. So, you know, we’ll see. I don’t have a magic ball… just seeing what’s happened over the last two years it’s really been moving quickly and I think if we continue this trajectory, we’re going to see it really penetrating.
Praveen Suthrum: You know this has been fantastic I’ve been greatly inspired by your book. So, Dr. Brennan Spiegel, thank you so much for coming on The Scope Forward Show. Any final words before we go?
Dr. Brennan Spiegel: No, I appreciate the time. If anyone’s left interested the book is called the VRx: How virtual therapy will revolutionize medicine and I just happen to have a copy sitting here on my desk.
Praveen Suthrum: I have one too and I highly recommend it.
Dr. Brennan Spiegel: For those that are listening the book is about VR but it’s really about what is VR teach us about our consciousness about our connection between mind and body what does it teach us about the boundaries of neuroscience and the intersection between neuroscience and psychology, technology, and clinical medicine so it was a blast to write it and to explore all these fields in a way that would be accessible to non-scientists also who are just interested in science in general so hope you take a look and enjoy the book.
Praveen Suthrum: Thank you so much.
Dr. Brennan Spiegel: Thank You.
By Praveen Suthrum, President & Co-Founder, NextServices.