The Better Real Thing

This is a bit of an update of a previous thing which was originally a talk for SPANZA 2018. This time around the thing was a pre-conference workshop for the SMACC 2019 shindig and the focus moves a little into principles for choosing VR for your procedural needs. 

This is actually a talk about old concepts. It’s maybe about not quite so old technology. The concepts are old though.


Really, it’s all old news.

This makes life a lot easier really, because the basic idea is something we all believe. It’s pretty simple:

“An experience, even one that is an illusion, can change how we think, or feel, or behave.”

It looks even more special when you put it in quotes, right?

The classics already tell us how much we buy into this idea. It’s easy to remind you of a story about a really miserable rich guy, the sort of chap who would walk across the street to kick a dog and then shave the eyebrows off the kid that is walking the dog. Well, maybe tell a servant to do the shaving. And you’ll immediately remember that this particular individual only needed one night and three not-so-real experiences with the ghosts of Christmas Past, Present, and Future, to change entirely.

Just one night to turn into an entirely cheery philanthrope that is probably now best friends with the dog and the kid who had to glue their own eyebrow hair back on.

But we don’t need to look as far back as ‘A Muppet Christmas Carol’ to accept this broad concept. We use it everyday when we try to engage kids in a story to distract them from a procedure. Every time we create whatever new world we’ll explore this day, we rely on that same concept – an illusion we create can change how we feel.

Virtual reality (VR) is just a different way of doing this – an entirely digitally created world to create that illusion. Augmented Reality (AR) is a bit of the world we know, with digital bits added. And the mushy world we’re all used to touching? I guess we’ll call that organic reality now. Maybe organic isn’t better.

Before, During and Forever After…

So is this any different? Well how about starting with a quick tour of what seems to work. We can tour through what helps us in the ‘before’ stage, what helps during an experience and what might the effect be forever after. Sort of a VR version of those Christmas ghosts – Past, Present and Future.


Think for a minute about something you found a bit confronting. Maybe anxiety-provoking. It could be your first day of work, that time you did something to get the adrenaline going, or maybe just the anxiety that comes with seeing a new barista at the cafe when you really need caffeine. The unknown can be scary.

It stands to reason that if you could experience it beforehand, some of that anxiety would recede.

This idea forms the basis of VR as a preparation tool before an experience. Ryu et al recently published their RCT where 34 kids checked out a VR video of the operating suite preoperatively and 35 just did their standard routine. The video was complete with giant but well known cartoon penguin Pororo, which I guess is a little unrealistic. We are not qualified to anaesthetise penguins.

The kids were 4-10 and the total exposure was for 4 minutes, 1 hour prior to surgery. They then measured anxiety using the modified Yale Preoperative Anxiety Scale (which runs from 22.33 to 100). The results? From a control group of 51.7 down to a treatment group of 31.7. That’s a big change. That’s a lot less anxiety.

Subsequently they have also looked at whether that translated to less emergence delirium. No luck there but this is a developing area.

Similar work is emerging from Toronto Sick Kids with Clyde Matava and crew. It’s also the basis of work happening at The Children’s Hospital at Westmead. At 4 minutes to produce a response, it’s certainly worth a look.


There are lots of groups looking at versions of this. The most well established is in burns though. Use of VR in burns dressings has been shown in plenty of trials, mostly not large, to reduce pain sensation (and need for analgesia). It seems like anxiety isn’t an issue the researchers have looked at as much.

The treatment effects are big though. Jeffs et al looked at 28 adolescents and showed a 23.7 mm shift on a pain scale from 0-100 mm when compared to distraction with a movie. It dropped the result by 9.7 mm vs standard care. They showed use of the tech for a long time too. The dressings went from as little as 5 minutes right out to 100 minutes.

The trials aren’t necessarily big but the consistency is there. Hoffman et al describe a 35-50% reduction in procedural pain during burns dressings with VR. This also correlates with a drop in pain-related activity of around 50% in the areas of the brain you usually expect to light up on fMRI. 50% is a big change any which way you slice it. The basic idea seems to be that the brain can only spare so much attention, and distraction with VR means your neurones just can’t wail about that pain bit.

The other interesting point is that there is at least some evidence that the effect stays about the same, without seeing a decay as the kids get familiar with it. A treatment with big effects in a tricky situation that doesn’t display ‘digital tachyphylaxis’? Big win.

Forever after…

Now you might still be unconvinced but how about something that is hard to treat and where you need to produce long-lasting impacts?

Phobias are the perfect model. Very annoying and very hard to treat. Now at this stage in the talk version, I violated what I thought was a pretty firm personal rule – I showed a spider.

I did offer some compromise and you can see what compromise looks like here (I promise it’s OK).

Garcia-Palacios and crew showed way back in 2002 that you could produce an 83% response rate (83%!!!) in 23 folks with very significant arachnophobia. The average requirement for the ‘fake spider sessions’ was just 4.

It was no small feat either. ‘Success’ meant improving their grading 2 points on an 8 point scale. They hadn’t completed the VR bit until they’d picked up a virtual Tarantula while wearing a haptic feedback glove. They then had to touch an actual jar with an actual Tarantula.


More recently Freeman et al have shown substantial decreases in anxiety behaviour in people with phobias around heights. All it took was a virtual coach and a few weeks. The NNT to produce a 75% decrease in heights anxiety in 51% of the participants in the active treatment group was only 2.2.

How many other drugs do you know with those sorts of numbers? Well, apart from anaesthesia.

So that’s a tool you can use to decrease anxiety for induction with 4 minutes of exposure, 1 hour before surgery. A tool you can use to drop pain by around 50% during pretty painful things. And as a bonus it can stop you being scared of crawling things?

So what’s holding us back?

The Hollow Bit

The thing is other promises with tech have either not been that great or they aren’t great for clinicians. Tablet computers do probably have a role in distraction for induction, but the way we use them sort of seems wrong.

What we tend to do is use an off-the-shelf game and hope that the kid is so engrossed they pretty much ignore us. That link as we create the illusory world is gone.

And that feels not particularly great.

We can fix that, and at the same time we should probably be wanting to get on board because the ability to fundamentally change how we think or act with VR/AR makes it a potential game changer.

How much can it change things?

Well, think “I am now no longer associated with my own body but maybe I’m entirely that other thing and maybe also I have a tail that I am controlling” scale.

A New Body

The astonishing thing with VR is that not only can you create an alternate world, you can change how the participant perceives their physical body.

Welcome to virtual embodiment. It’s weird.

How about an example?

In 2013 Peck et al published work where all the subjects did was move in a virtual environment. In front of them was a virtual avatar, and they had control over it (meaning when the participant moved the avatar moved).

Before long you just come to accept “oh, that is a part of me and I’m over there doing things”. Weird.

What this crew did that was different was they also conducted Implicit Association Testing (basically a test of implicit racial bias). And they’d made those avatars very specifically.

Some were black-skinned, some white-skinned, some were purple and some weren’t really linked as “alternate bodies”.

What they found was that after just 12 minutes of hanging out with this avatar, implicit racial bias dropped. And before you get all #AllLivesMatter this work has been echoed in other experiment settings, and more recent evidence shows that this alteration lasts at least a week. It hasn’t been checked beyond that.

A week of effect on something deeply profound, with only 12 minutes exposure required.

Virtual embodiment also underpins work where placing someone in the avatar of a tall person changes their negotiating style to more aggressive later. You can make people understand a child’s perspective. There’s even some work suggesting that domestic violence perpetrators placed in a setting where they have someone towering over them will be less likely to re-offend, and will even read facial expressions better.

These are changes altering your whole interaction with the world, how you behave and how you think . That sort of potency also suggests we better get in on designing the use of this technology very well.

The Big Questions

Of course by now you will have noticed that there are big concepts here. Those concepts open up huge pits of jumbling questions that need an answer.

The most pressing are really about the size of the effect and how long it lasts. As outlined by Metzinger, we may well need specific guidelines for this type of work. Right now, for example, you couldn’t say how long a behavioural change might occur. So how do you discuss that with a kid and their family?

I am pretty sure commercial groups aren’t going to answer that question.

Following on from that, who has it offered and who doesn’t? Why? Should everyone have access or is it only to be brought out for specific scenarios.

Most pressingly, is there an argument that being offered this on almost every occasion is sort of wrong for development? A lot of what we do is not that confronting. Is it more developmentally appropriate to be able to manage that with your own resources, rather than retreat into a digital world?

These are questions that need answers, and paeds anaesthetists are as good a group as any to ask.


How do you choose?

So assuming you’ve reached this bit and you are thinking “well my reality sort of sucks anyway so I might as well get a bit virtual but I just don’t know where to start” then maybe we should get to the making choices bit.

Well I am not here to recommend the hardware. Honestly it doesn’t matter what I recommend because 7.8 minutes after you read this bit there’ll be a better system that relies on bioluminescent algae that live in the anterior chamber of your eye or something.

What we can think about are the principles of an appropriate VR experience if you want to use it for procedural distraction. These principles won’t change any time soon so if you’re looking for a specific medical app you should definitely see them. And if you’re trying to figure out if some non-medical thing will do the job it should still work.

So here’s a quick list of design principles to look out for:

1. Direction of Action

This might seem simple but can easily be forgotten in the general appeal of “look I can do everything!”

For most procedures you actually want to direct the attention of the person in the space within a limited frame of vision. You do not want the target kidlet trying to climb backwards over the bed to chase that small puffball with the nose that is also a car horn.

The snow world thing is a good example of this – the action is all in front of the viewer and within a limited frame. They don’t need to move their head much and they don’t need to swing an arm around (there is no requirement to slice the snow people with a light sabre for example).

If a designer of an experience for a particular bit of procedural distraction hasn’t figured out what the clinician needs to be able to get done then send in the bin chickens to work over the entrails of that wretched bit of kit.

And if you’re choosing an off the shelf system, think seriously about how engagement happens within that space and whether it will stop you getting your job done.

2. Start with Kids

It should be obvious from the design that said designer either asked kids or gets kids. Asking is better of course. In the work we’ve done with kids who are vaccination phobic they taught us some pretty clever things (the research write up for this is under way). In fact the whole experience is one of having some of our assumptions completely blown apart. Even some of the ones that are close to right might be right for the wrong reasons.

So if you don’t put the kids at the centre of things, you might just miss the point. And if your commercial, off-the-shelf thing you’re looking to use just feels like it … doesn’t get kids, then maybe give it a miss.

Another interesting point is that kids don’t necessarily need us to do all the work. There is at least some evidence that they engage more with an experience if it’s not quite finished. They want to complete the world a bit themselves.

So you don’t actually need to look for super high definition animation in the experience. Ugly is OK. Ugly might even be better. I find that quite reassuring. For no reason. No reason at all.

3. Clinicians are onboard

I don’t mean that clinicians are spruiking it. What I do mean that the needs of the clinician are not just considered, they are integral. In our focus group work with health professionals a recurrent theme was that technology used poorly creates a barrier between the kid and the person trying to do the proceduralising. This sucks on all of the levels that you could progress through on the game with the noble ape linked to a donkey. What health professionals seem to want, unsurprisingly, is a system that lets them share the VR space with the kid and be part of creating that world with them.

There’s a good example of that in this vaccination thing from Brazil. Not only is it pretty excellent that the kid gets to save the planet, the clinician can see the action. The cold swab to clean the skin becomes the very important ice pollen. And then of course you need the fire fruit for a bit of strength I guess, just as that needle bit happens. Gain both of them and you get to protect everyone. Bonus.

Having the clinician see the action is useful for another reason – the default response from kids in the virtual space seems to be to share it. Even if you’re not directly in their world as an avatar, they’ll often seek to draw people into it.

So setting up a system where you can see the action and interact on that level with the kids would be one way to really set yourself up for excellent experiences.

4. A Bit More Spark

Ultimately what we’re all after is something that has a bit of something different. You could do this heaps of ways I guess. What our own group is aiming for is a system that lets kids rapidly design or illustrate the VR or AR experience they’d like to see. That way we’d be learning from them constantly and really letting them be agents of their own care.

Good agents, not the scary unsmiling-as-I-wear-these-sunglasses kind. Maybe still scary I guess.

That technology surely can’t be that far away. One of the underlying programs that came out of Oculus, Quill, is now out there and you can go and look at the work of Goro Fujita and marvel at what a person can do in 30 minutes. And yes he’s a pro but this is something that is looking very real.

If we can get kids showing us the worlds they want that can only be an excellent thing for us understanding our patients while getting to have fun at the same time. Plus we can explore all sorts of fascinating ideas. One we’ll probably look into is the results when you get one kid to plan something for the *next kid* who is having something done. Does the option of stepping outside your own needs to look after that next kid produce something a bit different?

Imagine if you’re the kid who gets to choose which star the astronaut paints. What’s the feeling like after that?

This sort of design is what we’re talking about in interviews like this thing here.

Design used to empower kids a little while enhancing the therapeutic relationship with anaesthetists. I don’t think that’s what they’ll sell at K-Mart.


Shared Worlds

If, after all that, you’re still unconvinced then there’s another key thing to remember. VR and AR aren’t future technologies. They’re here.

When we create the rocket story or whatever else it is, we start by being able to lean on things we know so that we are on the same page as our patient. We rely on making a link to a world the kids already understand.

Well kids will very soon expect that organic reality with a few bits added on is just status quo. They’ll just be using it.

So if you haven’t kept on board with any of this then just ponder this – how are you going to set up a space to share with a kid so your distraction starts in the world you share? How will you do it if you don’t understand anything about AR and VR?

So we’d better get involved, because it’s hard to say what’s next, but there are better ways of saying it if we choose to design truly collaborative experiences with the kids.


We don’t need to rely on white rabbits to take us to other worlds. We can be part of building new ways of doing things, and really influence the experience for our patients. Or at least make a grumpy old man turn into a happy philanthropist and save a few kids’ eyebrows along the way.



A bunch of help for this came from the crew at The University of Sydney working in the OpenVR lab. That’s particularly Dr Hamish McDougall and Dr Elodie Chiarovano.

The design crew we’re working with are primarily the brilliant Dr Naseem Ahmadpour and very excellent Dr Crystal Yoo.

I also had help from the excellent Dr Clyde Matava at Toronto Sick Kids. You should check out the amazing work they are doing here.

Heaps of papers went into this but the most useful ones were these:

Ryu JH, Park SJ, Park JW, et al. Randomised clinical trial of immersive virtual reality tour of the operating theatre in children before anaesthesia. B J Surg, 2017;1628-33.

The follow-up looking at post-anaesthetic emergence delirium and the total lack of effect of VR is here:

Ryu JH, Oh AY, You HJ, et al. The effect of an immersive virtual reality tour of the operating theatre on emergence delirium in children undergoing general anaesthesia: A randomised controlled trial. Pediatr Anesth. 2019;29:98-105. 

Now, how about the burns bit.

Jeffs D, Dorman D, Brown S, et al. Effect of Virtual Reality on Adolescent Pain During Burn Wound Care. J Burn Care Res. 2014;35:395-408. 

Hoffman HG, Chambers GT, Mayer WJ, et al. Virtual Reality as an Adjunctive Non-Pharmacologic Analgesic for Acute Pain During Medical Procedures. Ann Behav. med. 2011;41:183-91. 

And now the fears bit…

Garcia-Palacios A, Hoffman H, Carlin A, et al. Virtual reality in the treatment of spider phobia: a controlled study. Behav Res Ther. 2002;40:983-93. 

Freeman D, Haselton P, Freeman J, et al. Automated psychological therapy using immersive virtual reality for treatment fo fear of heights: a single-blind parallel-group randomised control trial. Lancet Psych. 2018;5:725-32. 

Virtual embodiment is picked up in these:

Slater M, Sanchez-Vives MV. Enhancing Our Lives with Immersive Virtual Reality. Front. Robot. AI. 2016. 3:74.

Bailey JO, Bailenson JN. When Does Virtual Embodiment Change Our Minds? Presence. 2016;3:222-33.

That ethics thing is this one:

Madary M, Metzinger TK. Real Virtuality: A Code of Ethical Conduct. Recommendations for Good Scientific Practice and the Consumers of VR-Technology. Front. Robot. 2016. AI. 3:3. 

That report from the day at BAFTA when clever people looked at kids and using VR can be found here.

Do you want to look at the full example of that Brazilian vaccination thing? It’s here.

What about Goro Fujita? Go nuts here.

And did you get this far? Then really, it’s time you went and looked at this.

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