Walter Greenleaf, PhD, Distinguished Visiting Scholar at Stanford University: Improving Care with Virtual Environments

Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future focused education, health care and workforce leaders explore new education to work approaches and innovations. I’m your host Van Ton-Quinlivan, CEO of Futuro Health, and today I’m very happy to welcome Dr. Walter Greenleaf, a pioneer in the development of clinical virtual reality technology for surgical simulation, rehabilitation and treatment of PTSD and other mental health issues. I’m going to ask him to provide an overview of his illustrious career because there’s too many titles and accomplishments to list. But currently, he is a visiting scholar at Stanford University’s mediaX program and its virtual Human Interaction Lab and senior executive at several medical device and digital health product companies, as well as editor of a leading journal in the field. I’m really looking forward to asking him about advances in digital medicine and the impact on patient care and the workforce. Thank you so much for being with us here today. Walter, welcome.

Walter Greenleaf: Well, thank you. It’s very good to be here with you too.

Van Ton-Quinlivan: So, Walter, with over three decades of research and development experience, you are considered a leading authority in the field of digital medicine and medical virtual reality technology. Tell us what drew you into medicine in the first place and why you saw Virtual Reality technologies as an opportunity so early on?

Walter Greenleaf: [00:01:40] Well, I became interested in clinical medicine as an outreach of my work as a research scientist in the physiology department at Stanford University. I was studying how hormones affected mood in people and was part of a psychophysiology research lab. And I became very interested in how we can use computer technology to score the signals that we were collecting in our research lab. We didn’t have digital scoring of the data back in those days and I found that to be very frustrating. So from there, I moved on to develop some algorithms and some interface technology to hook our instruments into a computer. Back in the day it was an Apple II Computer. And then I realized, and other people came knocking on my door saying, “what you’re doing in terms of scoring this data with a computer is very appropriate and needed in the clinical arena”. So that’s what sort of dragged me. I moved from basic bench research on human psychophysiology into clinical care through the pathway of analytics of my information. So it’s been it’s been a really fun ride since then, since the mid 80s, using computers as part of clinical research and clinical care has really grown. And now, especially in today’s world, with the Internet and all of us being so interconnected and also the compelling need to reach people through telemedicine, it’s become all the more important to be able to have ways to capture information, score information and process information as part of the health care process.

Van Ton-Quinlivan: Well, Walter, you’ve talked about a range of technologies and you’ve seen so much evolve in your 30 plus years in this field. Before we get into the details on the implications of the technology and what it can do now, can you touch on a few career highlights so that our listeners can get a sense of the breadth of your experience?

Walter Greenleaf: Well, I guess I’ve been fortunate in that I’ve been able to stay both inside the academic arena and also to be a participant in not only the technology development arena, but also in the medical product arena. It’s three different ecosystems, three different languages and three different opportunities to have both wonderful peak experiences and sometimes some exhausting experiences. In the academic arena, I spent a year as director of the Mind Division for the Stanford Center on Longevity, and that was exciting for me because I had an opportunity to learn about the looming issue of an aging population and how it’s going to be straining our health care system, not just in the US, but really worldwide. I became acutely aware of the looming problem of neurodegenerative disease. As we get up into our 70s, 80s and 90s, two out of every seven of us right now are destined to develop a problem like Alzheimer’s. So that academic experience sensitized me to the acute need to work hard to come up with interventions to support all the problems that happen as we age. You know, chronic pain, mobility restrictions, chronic diseases like diabetes, stroke. So many problems accumulate as we get older and the only way out is for us to come up with new technologies to support living independently. So that academic experience resonated with some of my other experiences. I’ve had the opportunity to start and bring through to a successful exit several medical product companies on the digital health arena. And I really like making contributions in that manner. I feel that when I was a scientist publishing papers on basic research, that was important, but in many ways, translating those findings out into clinical care is really extremely important and personally extremely rewarding. So to address your question, one of the other peak experiences I’ve had is the pleasure of developing medical products and bringing them out and seeing them in use and that always makes me very happy. And I guess currently, this current chapter of my life, what I’m enjoying doing is working with some of the academic groups and some of the early stage startup groups. And there’s quite a few of them out there doing just really amazing things. And I’m doing my best to connect them to the larger entities that are more established — some of the public medical device companies, some of the pharmaceutical companies, some of the health care networks. I think that’s really what helps grow the ecosystem is having the more established groups reach out and team with some of the academic groups at early stage companies. So I’m having great fun making those connections. And I guess the third arm, to answer your question is I got involved in the field of Virtual Reality technology back in the late 80s. And it’s a field that back in those days was nascent. It was very expensive to use virtual reality technology.  You needed to have an expensive computer, a five hundred thousand dollar silicon graphics machine, and some very expensive head-mounted displays. Now we can do things a thousand times better for a head-mounted display of a VR system that costs a third of the cost of a smartphone. And the good news is the work of my colleagues over the last three decades exploring the clinical applications of virtual reality technology and also how it can be used for training, that’s all been under development. So now that we finally have affordable, comfortable technology, we also have hand in hand with that the momentum that all the hard work of people who have been working with more expensive and more cumbersome systems. But people have been working on it for decades and we now finally have the platform to reach people and leverage this very powerful technology.

Van Ton-Quinlivan: Well, I feel so fortunate that we got connected through the Stanford Distinguished Visiting Fellow program with mediaX. I mean, it’s a rare individual like yourself who can travel all these worlds, the world of academia, medical products, and then also the medical clinical technology applications. I wonder, Walter, you’re really in a good position to tell us what you think are the most promising advances in virtual medicine in terms of the potential for having a positive impact on patient care. What are some of those areas that you would highlight?

Walter Greenleaf: I think some of the most compelling and important examples are using virtual environments to treat issues of mental health care. Heretofore, we’ve relied upon our imaginations to treat some difficult problems like post-traumatic stress, like helping people who have a problem with substance abuse or problems with managing their diet or managing their moods. We’ve said “imagine you’re in this situation” or “imagine something that is unpleasant or fearful for you” and that is hard to do. It’s really hard to get your brain to think about something that’s painful or uncomfortable or terrifying. However, with the use of virtual environments, we can gradually do exposure therapy and take people to a place where they may feel some anxiety, may feel some discomfort and teach them how to manage and face those feelings of discomfort and anxiety. So we’ve had great progress of addressing post-traumatic stress, learned fear reactions, addressing fears and phobias and we’ve also, in the same way, been able to use virtual environments to teach people situational confidence and refusal skills involving things such as learning how to resist peer pressure in a bar when your friends are encouraging you to have another drink and you’ve made a decision that you don’t want to drink or managing cravings for a substance of abuse or also managing anger, if someone has an anger management issue we can put them in a virtual environment in a way to evoke that type of response and teach them how to manage their behavior. It’s also very powerful in that we can do better assessments. Heretofore, we’ve had to rely on self-report. I might say to you, “how did that medication affect your mood” or “how are you feeling today” or “how did you feel last week?” And it’s very hard to report that. It’s very hard to recall that. It’s very hard to describe that. But if I use virtual environments, I can challenge you. I can evoke a emotional response, and I can also measure your response and not just by what you say, but also what you do and also your psychophysiology. We can capture your heart rate, your eye gaze, your pupil dilation, your facial expressions, and we can use those as biomarkers of your cognitive and emotional state. So finally, we have some new tools to help improve mental health care and also do research. If we’re trying to come up with new medications, we can use virtual environments as a way to do much more robust assessments of people for neuropsychological.  But the list goes on, helping with autism and Asperger’s, teaching social skills, helping people deal with pain, dealing with depression — we’ve been able to use virtual environments as new tools to have better measurements and better feedback systems to improve that part of clinical care.

Van Ton-Quinlivan: You know, I’m glad you brought up the domain of mental health and wellbeing. Here at Futuro Health, with our board, we’ve been looking at whether the pandemic is going to create a rise in mental health issues, in essence, a crisis of mental health issues and how we can supply workers to be of help in this area. What we’ve discovered is that mental health issues and behavioral health issues are intersecting rather than remaining apart. And so in 2021 we will be investing a lot in occupations at the sub-baccalaureate level that could be of help in the behavioral health area. So I wonder — you’re giving these examples focused in behavioral health like PTSD, anxiety disorders, addictions and other difficult problems — I wonder if you can talk a little bit about maybe the workforce implications of these technologies and what it would take to bring these technologies out into more pervasive use by patients.

Walter Greenleaf: Well, one of the workforce implications is that I think as people start returning to work from working from home soon, hopefully, there will be times where we’re going back to the office and virtual environments can help us develop the confidence of how to return and how to return safely. I mean, there will be times where we’re returning, but we’re still fearful of exposure. And so people will be worried about keeping social distances and also how to deal with someone who confronts them, who may not be abiding by the rules and doing things the way we’d like them to. So I think virtual environments can be used to help…the term is stress inoculation…we can help people be prepared for stressful situations, have them rehearse going through a stressful situation. And in terms of workforce training, we can also train people how to handle a difficult situation with someone else. If somebody is being angry, if somebody is being defiant, if somebody is being really sad and they need help and encouragement, or recognizing signs of stress in other people and learning how to do emotional first aid, how to support someone who’s upset or angry or distressed or perhaps suicidal. So I think teaching people skills on how to manage their own emotions and how to manage other people who are having emotional challenges is really key. Same thing for everybody in the health care ecosystem as we need to be prepared.  Both trained on how to handle an emergency and also how to manage our moods when that happens in order to be able to keep calm and do the right thing. The other thing that’s very powerful about simulations as a way of learning is that we can slow down the speed, we can speed things up, we can watch things from another point of view, from a third person point of view, for example, and that allows us to have more individualized learning. We can match the individual’s learning style.

Van Ton-Quinlivan: So Walter, in 2020 Futuro Health is putting through and underwriting tuition for twelve hundred individuals from the community to be able to get their training to become Medical Assistants, and what we hear from the employers is that it’s not the technical skills. They agree with you that it is their soft skills, their ability to deal with distressed patients who are walking in or patients who are in homeless situations and are coming in with all sorts of issues. So it’s being able to expose the graduates to these types of scenarios in advance that could better prepare them to be productive on day one in inpatient care.

Walter Greenleaf: I think it’s so important.

Van Ton-Quinlivan: And we’ve been so fortunate that you’ve been advising us on potential technologies that we could take advantage of in order to create these simulations for students.

Walter Greenleaf: Well, I think what you’re doing is incredibly important. And I do think that people are very social animals and it’s one thing to learn mechanically how to do a process but if we also don’t know how to do it as a member of a team or to do it in collaboration with the patient, it’s not going to go very well. So learning how to interact and manage a process in a way that’s sensitive to people’s situation and being, again, knowing what to say and how they handle it is so important and it’s the extra layer of knowledge that often people don’t get. You know, one of the things we can do in a simulation is we can exaggerate the nonverbal communications. So often there’s a cultural gap between somebody who’s grown up in one culture trying to understand what’s going on in somebody who’s had a different cultural upbringing. And that cultural competency isn’t just learning the language. It’s learning the nonverbal communication that might signal different moods. So I’m so glad that Futuro is, and with your efforts, are looking at not just how to train people on a process or how to use a certain device or how to use a certain part of equipment, but you’re also.. part of that is teaching the soft skills, how to recognize behavioral issues in other people and also how to be the most effective person in that situation. You want to be engaging. You want to be charming, you want to be attentive, you want to be supportive. And those are all part of skills that can that can be improved as people gain confidence.  I think that’s the core thing that you’re teaching people in order to do any any job, is to how to be confident.

Van Ton-Quinlivan: So, Walter, you’ve been involved on the academic side, and so you’ve seen students come out with MDs and PhDs as well as go down to the bachelors and sub-bachelorette level. Do you think these skills are sufficiently developed at any of these levels in current programs?

Walter Greenleaf: No. Sad to say I think often we focus on the pedagogy of what’s in the book or what are the sort of checkmarks that we can check off on a list of knowledge that is brought forward and I think often what’s missed is sort of the human factor, the having empathy, having the ability to understand somebody else’s state and how and again, how to help them. It used to be there was the phrase, “the bedside manner”, but that was never really attended to. And that nonverbal, that non-textbook part of the education was often ignored. Now, I think we’re getting better at that, but really at the whole stack of training in clinical care, we need to pay attention to that because that’s what makes a good experience for for the patients. Yes, we all want to have a great result. We want to get discharged from the hospital or we want to go home from the clinic. But whether we know what to do is a matter of how much rapport we have with who’s telling us, giving us discharge instructions, and whether we feel like we’ve had a good patient experience is really… I think the foundation is how we interacted with other people. Medicine is so hard, you know, as a patient, it’s a scary process. It’s a painful process sometimes. It’s a confusing process all the time and if the people that we’re interacting with can help us feel confident and if they’re attentive to our needs, then it’s so much better. So the more we’re talking about this Van, the more I’m energized by the idea that this is such an important area of training that we must get right. All too often people get sent home from a clinical experience with a stack of papers and they’re not clear on what they’re supposed to do and they’re still scared. And so if we can help people feel more comfortable that they’re being attended to and understand what’s going on and in order to understand, you have to have good rapport. So I think there’s all aspects of it that could be improved.  Let me let me ask you a question, Van. How do you bake into your curriculum some of the skill training and you know what can we do to make it even more robust?

Van Ton-Quinlivan: We’re putting a lot of investments into a curriculum called Human Touch Healthcare that we pair with whatever technical program that our students are taking because we actually need to decode for the students what are these skills, and also engage them in practicing these skills and getting coaching and feedback. So we’re augmenting their normal education journey with additional coursework and scenario simulations, essentially. I definitely agree with you that there’s going to be a need to do more in order for students to come out with them.

Walter Greenleaf: Yeah, well, I think you’re doing the most important thing, which is teaching people to have situational confidence. If you’re feeling prepared, if you’re feeling self-confident, that gives you the foundation to do the rest.

Van Ton-Quinlivan: That is a great point. So you have more insights than others into the future of care. What career advice, Walter, would you have for someone who is just starting out or wanting to pursue a career in medicine or health care?

Walter Greenleaf: Well, to me, getting back to the earlier part of our conversation, I think in 10 to 15 to 20 years, our health care system is going to be strained by the need to address the challenges of an aging population and the elderly. I would say to anyone who is entering into the workforce now and has interest in anything involving clinical care: master technology, make sure you feel comfortable with technology because it’s going to be part of part of your career path is just learning how to master it and be very proficient and love it. And then also, I think looking at how one could be prepared to address and feel comfortable working with seniors. There’s often a big cultural gap, not just between different ethnic groups and different linguistic groups and different cultural backgrounds, but between the young and the old and often it’s harder to relate to someone who is a senior. And often there’s a little bit of tension and anxiety to just deal with an older person. I think the more you can be comfortable working with people who are who are seniors, that’s going to open up more and more career paths.

Van Ton-Quinlivan: I’m going to sneak in one last question here, Walter. The pandemic has created a great concern for all individuals who have their parents in nursing homes. Naturally then you would want to move your parents into your home. That would also argue that care moves into the home. Do you see that as a part of the future of care, a more prevalent part of the future of care?

Walter Greenleaf: Oh, absolutely. For two reasons. Number one, as we get older, no one wants to be in a skilled nursing facility or in a senior care facility, assisted living facility, they’re no fun. So people are going to do what we call “aging in place”. And there’s already a large movement in that direction to support people, even when they’re not as healthy as they could be, to allow them to stay at home longer. And again, technology is going to allow us to help do that in a better way. But we’re going to need caregivers and people who can bring medicine to the individual as opposed to having the individual live in an assisted living facility. I think also that it’s not just aging in place that is going to be a shift in all of this, I think it’s also going to be the need to provide support for families too. People don’t age in isolation and family members get burnt out, get stressed, too.

Van Ton-Quinlivan: That’s an excellent point. I mean, when we have children, there’s a lot of books and a lot of processes and a lot of rituals for transitioning into parenthood. But you don’t have the same processes and rituals and support structures, to transition into caring for parents, for example. So thank you very much, Walter, for being with us today. It’s such a delight.

Walter Greenleaf: Thank you for the wonderful questions. I’ve enjoyed our conversation.

Van Ton-Quinlivan: Oh, very much so here. I’m Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future focused workforce in America.