Walter Greenleaf: Virtual Reality and AI in Healthcare

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0:49I'm Guy Kawasaki and this is Remarkable People. We're on a mission to make you remarkable. And today we have with us the remarkable Walter Greenleaf. Walter is a neuroscientist and medical technology developer. He works at Stanford University. He's a leading authority in digital medicine and medical virtual reality technology. He has designed and developed clinical systems including products for surgical simulation, 3D medical visualization, clinical informatics, and simulation-assisted rehabilitation techniques. He is the co-founder and board chair for the International Virtual Reality Health Association.

1:33He has served as the principal investigator for research projects funded by the National Institutes of Health and NASA. I'm Guy Kawasaki. This is Remarkable People. And now, here is the remarkable Walter Greenleaf. do you know about the meta ray-ban partnership where they have sunglasses with a camera and ai built in yes i i do and i've run across a few friends who are wearing them okay reminds me of the google glass of course is it reality right now because with that you could just say what am i looking at what's the history of this city what's the history of this building what am i seeing so So it's a combination of this visual representation plus AI.

2:20So is that reality now? It's getting there. And I think the other layer that's on top of that is not only will we have visual representations of extra information overlaid upon what we're seeing. I think we will also, and this is an interesting issue, there's a lot of work going on with capturing eye gaze, facial expressions, body language, voice tone. to come up with scores related to our mood, our emotional state, and how alert we are, how grumpy we are. And that'll be overlaid too and filtered. So I could be filtering my interactions with you right now, both visually and auditorily. I can say I want to look a little more friendly or I want to look a little bit more savvy.

3:07And that's what you would be seeing. So as we interact with the built environment and with each other, there's going to be a layer of technology between us and each other. And that's going to be an interesting change. I saw that you re-shared an article about tracking eye movements to use in diagnosis. So you're telling me that someday in the future we could have this kind of virtual conference. And at the end, you say, Guy, by the way, I think you have Parkinson's. I think we're there. I think there's ways to do that right now. Now, the quote by William Gibson, of course, the future is already here.

3:41It's just unevenly distributed. And I think using eye gaze and voice tone as a way of diagnosing neurodegenerative disease like Parkinson's, we can do that. But it's mostly the research zone hasn't been translated out. And I'm sure people are listening to this and their heads are exploding and they're saying maybe Mark Zuckerberg knows my moods because he's watching my eye movements and he knows if I have Parkinson's. Parkinson's and that's a little scary, no? Oh, I think it's both exciting and scary. It's exciting because, hey, with an aging population, as the boomers get up into their 80s and 90s and longer, and we're all going to live a lot longer, there's some challenges that we will have.

4:26We want to keep our brains healthy. We want to keep our bodies healthy. We want to age in place. We want to expand our health span instead of having a long, slow decline. we won't have to be fantastic until we're not. But the technologies we have right now will help us with that. But again, there haven't been position to scale. So it's exciting to have these new breakthroughs that will help us with not just better diagnosis, understanding if you have Parkinson's, but new therapeutics and ways to do it more precisely for you, because we're all different. There should be different prescriptions for interventions.

5:00The scary part is exactly what we were looking at earlier, that this is very personal, very private information. It's right now available publicly. When you're on an online game and playing with other players and speaking, your impulsiveness could be scored, your abilities as a leader or a follower, your voice tone can indicate your mood. And so there's a lot that can already be extracted publicly and even more so privately, that we just have to find ways to lock down and protect. And so, yeah, people should be worried about as the tech titans move into this zone, and especially as they move into health care, it's exciting.

5:43We need it. We need better technology. We have an aging population. It's going to be extremely expensive to address worldwide. How to support people living so much longer could be more expensive than dealing with climate change. but there's also a very sensitive issues we have to address.

6:06I think we should just hook this up to J.D. Vance right now and get insights into his head, but that's a different subject. You opened the door here for me. So can you just describe the state of the art of the neurology of getting old, brain health as you get old? What's the latest, greatest insights into that? I think the first thing we should remind everyone is that what's good for the body is what's good for the brain. So if people say, what can I do now to help my brain be healthier when I'm in my 70s, 80s, or 90s? It's sleep, exercise, diet, stress, reduce stress, all the things that keep our body healthy, we know keep our brain healthy.

6:51So that's one thing you can do to mitigate the risk. That said, those things may or may not make a big difference if genetically you're on the pathway to develop Alzheimer's or Parkinson's or some of the other neurodegenerative diseases. Invest in research would be one thing I would say is that there's some great potential therapeutics, both as molecules and pharmaceutical interventions, but other technologies that can help us intervene. And we need to move forward with them as best we can. Because again, three out of every seven of us will, when we get up into the age zone, that's the way things are, develop Alzheimer's or Parkinson's or Lewy body disease or some other things that we don't want to have happen.

7:36So yeah, keep your brain healthy now by doing what keeps your body healthy. But we need to move forward with an aging population. We've got maybe 10 years before that tidal wave hits, but we do need to move forward. So is the corollary also true that good for the body, good for the brain? Does that mean bad for the body, bad for the brain? Yes. I'm guilty of not getting as much sleep as I should or exercising as much as I should. And I'm very conscious that this is a trade-off versus keeping my brain healthy. Yeah, that's our current thinking. Okay, good for the body, good for the brain, but are there things that are good for the brain?

8:14Is it like playing Sudoku or is it playing chess or are those things just a fad from these influencers and thought leaders who want to sell stuff? Or do these kind of mental things really help? We're getting into a zone where there's controversy and I'll tell you what my opinion and my beliefs are. And I'm sure I'm going to get some pushback from my esteemed colleagues who disagree. But here goes. We do know that it used to be viewed that many of the things that were being brought out there by some of the companies that had games for brain health, for example, the claims were exaggerated. That groups would say this will prevent the possibility of having Alzheimer's or this will address or cure attention deficit disorder.

8:58And a lot of the research did not really back the claims that were being made. That was the past. Now we know that there are some things that we can do that are impactful and make a big difference and can help. There's recently been products that, for example, games you can play that you can get a prescription from for a doctor. You can get a prescription for something that helps with attention deficit disorder. We know that there's some interventions that can be used that will help you with what we call executive functions. some of the decision-making and navigation skills, etc. Very interesting work by Adam Ghazali's group at UCSF looking at how we can play a game.

9:43They have one called NeuroRacer that Noah Feldstein helped design that improves the scores that people in their 60s have that normally are very low compared to people in their 20s and certain executive functions. But if you play this game, not only can you raise your scores up to what you would have had in your 20s, they've gone back years later to see if it persists, and it does. Now, the evidence, in my opinion, is that, yes, there are things that we can do in terms of exercising our brain that make a difference in terms of cognitive decline. I am really interested in this topic in two regards.

10:22First of all, I'm 70, so I would like to know exactly what to do, not just conceptually, but just tell Tell me, if you and I were best friends and I asked you, come on, Walter, just tell me, what do I do? Will you just tell me the game or what do I eat or what should I do, Walter? Guy, come back to me in a week and I'll have a more refined answer to that because there's a lot of different options. And also, I would want to know a little bit more about you. I think one of the challenges we have in health care is that we have sort of a one size fits all. This is what everyone should do. And I would need to know a little bit more about you.

10:56and I would also want to know your goals. Is your goal to live as long as possible or is your goal to have the highest quality in the next 30 or 40 years? Is your goal to continue to work or is your goal to continue to enjoy leisure? So there's more I would need to know before I could give you a good answer. But I'll think about it and maybe if we talk further, I can understand what I could recommend. Okay. But I'm not a clinician. I'm an activating enzyme helping the clinicians and the healthcare providers and the scientists and the healthcare networks understand what's new and what they should look at.

11:30I'm not the person who writes the prescription. I actually have great respect for that answer because it shows it's not a flippant answer that you're just talking shit, basically. A slightly related thing. Now, you mentioned that there are games that can help kids with executive function what's the game for that i i want to hear that i'm taking notes there's a company that i have great respect for akili that developed two games one that is available over the counter meaning you can download it from an app store and that's endeavor e-n-d-e-v-o-u-r And then there's Endeavor RX. Endeavor is for adults with ADHD, and Endeavor RX is positioned for children who have ADHD.

12:23Endeavor RX requires a prescription to get, but the other form of Endeavor for adults can be downloaded from an app store. and these validated interventions. Wait, I'm trying to wrap my head around this. If a parent is listening to this and they're part of Kaiser, they call up Kaiser, they call up the Palo Alto Medical Foundation and they speak to their pediatrician. They say, give me a prescription for Endeavor RX. I'm actually not sure if you need to go see a specialist. You probably need to go to see who's familiar with this intervention. But yes, that's the basic concept is that these are validated interventions, prescribed video game for treatment for children with ADHD.

13:09And I just went to their website, endeavorx.com. There's a tab for getting a prescription. Wow. For people to follow up. Wow. Oh, my God. So are you saying that this thing went through FDA trials? Guy, you are partially responsible for this. What you did back in the 80s and 90s to help move forward to digital technology has helped put us in a position to be able to have things like this. Thank you for that. Okay. Here's to reaping what you sow. So now, getting out of this particular topic here, I want to move back up to virtual reality and medicine. So what is the current cutting edge of virtual reality and medicine?

13:55We're using VR right now for better training of clinicians, of surgical skills or understanding neuroanatomy in three dimensions. We're using it for better assessments, a better way of doing a differential diagnosis for anxiety, depression, attention deficit disorder, different aspects of stroke or traumatic brain injury. And we're using it for better therapeutics, ways to promote better recovery from an injury or ways to address addictions or ways to help people who are on the autism spectrum learn how to recognize body language and facial expressions and others. So really, the full stack of health care has been impacted by the technology.

14:43The Veterans Health Administration has done an amazing job of rolling it out, and they're our largest health care network. They've trained more than 3 ,000 clinicians. I think they're using it for more than 30 different clinical indications throughout their network. And again, still at an early stage in many ways. It's been held back because new technology and medicine very appropriately takes a while to get established, and especially because of our business model of needing to establish a code for reimbursement. And that's why the VA has been able to move forward faster than other groups, because they don't rely on reimbursement codes.

15:20They'll roll something out and use it if it's impactful. So it's happening. I'd say, though, we're at that transition point from early adopters and the people that are willing to try new things and for better results. It's now starting to move over into just how we do things and get beyond that early adopter threshold, especially for pain. There's some fantastic ways to both address acute pain and chronic pain using virtual reality and augmented reality technology that's been well validated and it's starting to be used throughout the healthcare system. Wait, so how can doing something online with virtual reality relieve pain?

16:02Isn't pain at a chemical level? It doesn't have to be done online. It could be. But two ways. For an acute aspect of pain, it can distract you. If you're getting a lumbar puncture, for example, or they're debriding your skin, which is very painful for a burn injury, or if you have back pain. For chronic pain, we teach skills. We use virtual reality as a medium to people to learn mindfulness, relaxation skills, to learn how to mitigate their pain, to reframe the way our brain reacts to a pain signal. And it works. It's been validated. And where does AI come into this? Is it people in India who have MDs or is it AI scanning x-rays and looking at results and giving you recommendations?

16:51Well, AI is really empowering everything. All these new digital health applications we've been talking about, not just the VR and AR, require very sophisticated analytics. And we now can extract more from the signals that we have to do more. And then also because of generative AI, we can take the analytics and we can use it in the case of virtual reality or augmented reality, for example, dynamically change the user's experience based on those signals. So AI is empowering us both to do better diagnostics, to identify a lesion that might be seen on an x-ray that might not be able to be captured easily by the clinician to support the clinicians to do that, or to help us look through some data and find the key features, both on a research level and on an individual level, that we need to have.

17:45So remember I mentioned earlier that in order to answer your question about what helps you, I would need to know you a little bit better. AI is helping us look at the data from an individual, understand them a little bit better compared to the larger population, and make recommendations as to what would be a precision way to help you with your health care problems. And these treatments, they're being tested scientifically, double-blind, placebo effect, all of that kind of stuff. It's not just Donald Trump saying, drink Clorox. This is FDA, everything, the whole shooting match. We've had more than 30 years worth of research on specifically for VR technology, for healthcare, decades of research.

18:30And that's just in that zone, the other zones we're talking about even longer. But the technology hasn't been affordable until recently. So we're now in the process. That's why it's the process of moving it out of the research labs into clinical care, doing the validation studies. But yes, we've done double-blind, placebo-controlled studies on the impact of these digital health interventions, and the FDA reviews them. I was part of a team at a company named Paratherapeutics, which was the first company to establish software as a medical device. so that the FDA will review and regulate these interventions and make sure they're healthy and safe and effective, just like they do any other pharmaceutical pill or any sort of other device.

19:17And here's the cool thing, guys, is we're also now starting to see combination therapy, where it might not just be a pill to manage depression or anxiety or pain, but a pill that is used in combination with the digital health app that can help you again adjust it for you individually see what's working what's not working by measuring the impact of the therapy and then maybe doing something combination and for anxiety maybe not just taking a medication but also learning relaxation skills mindfulness skills etc so it's not just either or it can be together combination. And that means we can leverage the established distribution channels that the pharmaceutical companies and the medical device companies have to bring out these very powerful digital health applications.

20:08Now, can you just give us an idea of a specific treatment? I read that, and I think you mentioned that there's software as a medical device to help people with PTSD. So let's say you are undergoing this treatment. Exactly what happens? For post-traumatic stress and also for addictions and anxiety disorders in general, we use an approach called exposure therapy, where what's happened with post-traumatic stress, and I'm being very simplistic here for the sake of not spending 20 hours going over it with you. What happens with a learned fear reaction, like post-traumatic stress, where you've had some trauma and your brain has very appropriately learned to fear what almost killed you or what was uncomfortable for you.

20:58But that's useful when we were evolving. But now in today's world, some things that can be traumatic might be something that happened to you in combat or something that happened to you one time, but you're having an overreaction. reaction. You're being triggered and you're having challenges. So we use exposure therapy to address that. Same thing with addictions. You may get beyond the metabolic aspect of an addiction, but you still are triggered by cravings. When you go into a bar and your friends are drinking a beer or you go by some place where your dealer used to sell you meth. So in both situations, what we use is to gradually teach people to understand what is triggering their reaction and to gradually habituate that reaction, to take what's a learned fear reaction or perhaps a learned craving and turn it into something that your forebrain is reacting to and saying, oh, there's a pile of trash on the side of the road, but I'm driving on Interstate 280 in California, I'm not over in Iraq, that a pile of trash is not necessarily a threat.

22:08So I don't need to get really upset when I see a pile of trash on the side of the road. And we use virtual reality, for example, to gradually expose you to what is triggering those reactions and under the supervision of a clinician and teach you how to manage your learned fear reaction and to habituate the response. And it works. We get great results. Now, when you say you're using virtual reality, are the people wearing headsets, is it like an Apple Vision Pro? Is it that level? They really think they are in this. For exposure therapy, you don't have to wear a head-mounted display. For a long time, people have taken people with fear of flying to an airport and having them go up.

22:52But if you're doing it in vivo, in real time, it's expensive. So the advantage of using a VR system is we can do it in a clinic. And in some cases, we can do it online, like teaching people who have a fear of public speaking, for example. We can rehearse online with a virtual audience and practice. But for a learned fear reaction, post-traumatic stress from an IED explosion in Iraq, we really do want to use a VR system because then we can block out the outside world. The brain doesn't want to go there. If it's something you're traumatized by and you're scared of, and I start talking to you about it and say, Guy, remember that horrible thing that happened to you?

23:35You're going to be triggered. But I can gradually take you there if I have a way of blocking out the rest of the world and say, let's start by walking up to the ticket counter at the airport. So it's not just post-traumatic stress. It's also phobias that we can treat using exposure therapy. And then I can gradually evoke the learned fear response and without re-traumatizing you. And because I have control of how the level of reality, the level of exposure you have and teach you the skills and habituate your learned fear response. Wow. Walter, I got to say, if anybody else was telling me this, I would be saying this guy is full of shit.

24:17I'm telling you about what other people have done research on. There's been decades of people working behind the scenes developing this new wave of technology. And it's finally coming out, which is great because we need it. My head is exploding. here. Until I prepared for this interview, I never heard of this concept of software as a medical device.

24:49So what's the career path? Let's say somebody's listening to this and saying, man, this is the coolest stuff. I want to do this. I don't necessarily want to be a general practitioner or a pathologist, but I just love this application of software. So what's this person's career path today? Do you go to medical school? What's the whole thing you do? I think if you'd asked me this five years ago, I would have said find an academic research center that is studying how to use digital health and virtual reality technology and other technologies for pediatric care, for example. I'd say, go find a group that has an indication that you're interested in.

25:27Maybe you're interested in helping children who have had stress from the pandemic learn to manage to help with their mental health issues and work at that academic center. That would have been a while ago. Now, I think I could say that's one option and that would be great. We could use your help on the academic research side. But now we're starting to see the technology move. And there are companies, public companies, Penumbra, for example, is one. They're selling virtual reality products to treat traumatic brain injury, to treat post-traumatic stress, to treat mental health issues, to help with neurorehabilitation.

26:06That's one of their fortes. It would be more go to a center, continue with your career as a clinician, but make sure you're aware of what's possible and get your hospital, get your clinic to up their game by bringing these new technologies in. So that would be one way. Another way is to get involved, not necessarily as the clinical or research side, but also on the tech side. We need to put additional layers of technology on top of what we're doing so that we can do more. We can leverage machine learning to look at the data a little bit better and come up with, again, a precision approach to fine-tuning the intervention to match what the individual needs.

26:45So do you think this is going to take longer or in five years, we're going to just be amazed at what has happened? Because Bill Gates has this theory that things happen faster than you think they are, but not as fast as these visionaries say. I guess it depends. I think we have the technologies that can make a big difference. The tech titans are moving into health care. Apple, Google, Samsung, Amazon, Meta are all starting with consumer health and wellness, which is fantastic. But some are moving into the clinical zone, too. I think as that happens, the speed will pick up because the tech titans know how to design for scale.

27:31And they know how to design good user interfaces, which, frankly, the medical device and the pharma companies have not had that skill set before. and their business model has been more slow and careful, which is appropriate for medicine. But I think now that there's new players coming into the game. Also, the other thing that gives me a reason to say things will happen faster than otherwise. So we have some acute needs. We're dealing with three major problems right now. One is an aging population, which will cripple our economy worldwide if we don't do something about it. If three out of every seven of us has Alzheimer's in our 70s, 80s, or 90s, there's smaller families, and there's a wavefront of people getting older, especially in Asia.

28:15That's going to be more expensive unless we get on top of it, extremely expensive unless we get on top of it. At the other end, we have a whole strata of youngsters who went through the pandemic with seeing their parents completely fearful, not able to go to kindergarten and learn social emotional learning skills, learning a lot of fear and stress. And so if you talk to our colleagues in pediatric care at the children's hospitals, they're seeing an avalanche of new problems in mental health. And also our society in general, I think, is challenging our mental health issues for so many reasons. And then meanwhile, the overburdened health care system with so many burnt out clinicians who have been really working so hard.