Surgical Training in Virtual Reality - Dr. Justin Barad, CEO of Osso VR

JANNAH AMIEL:Hi, I'm Jannah Amiel and today on Raise the Line, I'm happy to be joined by Dr. Justin Barad, a pediatric orthopedic surgeon who is also founder and CEO of Osso VR, a surgical training platform using the latest in virtual reality technology. The company has seen a spike in business during the pandemic and this fall, it announced a $14 million round of funding led by the investment arm of Kaiser Permanente. Dr. Barad has a degree in bioengineering from UC Berkeley and earned his MD at UCLA. He also spent 12 years as an editor at Medgadget. Thank you so much for being with us today, Dr. Barad.

DR JUSTIN BARAD:Thank you so much for having me.

JANNAH AMIEL:Absolutely. So could you start us off by just telling us about your background and what led to your interest in pediatric orthopedic surgery. I'd love to hear about that.

DR JUSTIN BARAD:It's been an interesting road. I didn't always plan on being a physician, actually. I started out my career in video games, so I've been programming my whole life. I've always been very passionate about video games and how they're made. I even had the opportunity to work at Activision when I was in high school and have a game credit with them. But I have a family member with a chronic illness, autoimmune illness, and they got very sick as I was finishing up high school. I started to wonder if there was a way to use software and technology, not necessarily for entertainment, but to help people, especially ones with medical issues. So I actually discovered a major at UC Berkeley called biomedical engineering, where you use technology to help people. I pivoted from computer science to bio, which I studied at Berkeley with this goal to invent healthcare technology.

As I was nearing graduation from college, I still didn't really know how to get started with that. I sought advice from a mentor, Henry Lin, who's a gastroenterologist. He told me that, "If you want to invent something, you simply need to understand what the problem you're trying to solve is." It's pretty simple advice, but I think people often lose sight of that. He strongly felt that a great way to understand medical problems was to be a physician. So I was like, "Oh, I don't know if I want to do that." And he kind of did a Jedi mind trick on me and somehow convinced me to go to medical school. So I spent a year doing research on rat intestines, and I actually collected rat flatulence for my research. So if you ever have any questions on rat farts, I'm your guy.

I was ultimately able to get into med school at UCLA and then I stayed there to do my orthopedic surgery training. That's really where I started to experience the problem that we're tackling in Osso VR firsthand, which is how we train and assess our healthcare professionals with their technical skills. I'll get into exactly what I was seeing a bit later. But one of my other observations is that adult medicine is a bit messy. There are a lot of competing priorities. I love it, but you have patients' money, competition, egos, everyone seems like they're trying to do something different.

Then I stumbled on pediatric orthopedics. When you're taking care of children, it's a mission-driven endeavor. At the end of the day, everybody's highest priority is taking care of kids. I found that to be completely exhilarating. Waking up in the morning, knowing exactly what you wanted to do and everybody you're working with on the same page, all they care about is helping children. I ended up training and specializing in pediatric orthopedics at Harvard and Boston Children's Hospital, which is an incredible experience, and then ultimately coming out to Stanford to do their bio-design medical innovation fellowship. It was really throughout this whole journey that I encountered VR very early in its development with the Oculus DK1 and was able to combine my passions of healthcare and video games and actually co-found Osso VR, and I started in October 2016. On weekends, I do pediatric orthopedic trauma at UC Davis Medical Center.

JANNAH AMIEL:That's awesome. So clinically, my background is pediatrics. I've worked in pediatric ER and trauma and urgent care, PICU as well. So you already have a special place in my heart being a pediatric.

DR JUSTIN BARAD:Right back at you. We should do the secret handshake.

JANNAH AMIEL:I know, but nobody could see it. It does exist, everybody! I would love to hear what you were mentioning about this creation of Osso VR and where this came from. What was the spark to create this? I'm really curious to hear what problem this solves and how were we doing it before.

DR JUSTIN BARAD:Yes. I'm really curious to hear your own experience. It wasn't any one thing, but a series of repetitive experiences where I really started to realize that there was a major gap when it comes to training and assessment for technical skills in healthcare -- procedures and surgery. I was incredibly fortunate at the opportunity to work at some of the top hospitals in the world. Yet I would be in the operating room with a patient under anesthesia and we would get stuck in a procedure, and I would be asked to scrub out and go to the computer and Google what to do, basically. Finding an instruction manual or YouTube video even, or video on a service called VuMedi, or find a sales rep to help us. It was happening a fair amount, obviously not all the time, as surgeons are incredible at what they do. But enough that I thought that there was a growing problem.

I started to look into it and I found some key trends and then some data to back that up. I really was seeing three core problems. The first is, there's simply too much to learn. So in a way we're victims of our own success, accelerating science and technology, which has been an incredible accomplishment is actually creating a unique challenge where it's expanding the library of procedures that healthcare professionals are expected to know how to do at a moment's notice. I always tell this story; it's become famous now. I was just eating lunch one day when I was paged and called to the zoo to operate on a gorilla, which, I cannot emphasize how unprepared I was for that!

JANNAH AMIEL:Is that true, Dr. Barad?

DR JUSTIN BARAD:The only surgery where we had to evacuate a few times, because the gorillas wake up very violently from anesthesia. But that is 100% true. Obviously that only happens like once in a career. But it's a spectrum and on some level, every day, people are experiencing their own gorilla experience where it's, "Hey, this is a surgery I've never seen before and never done before. And now I have not that much time to prepare for it."

The second part of the problem is modern surgery is a lot more complicated than surgery and procedures of the past. Technology which has made surgeries safer, more minimally invasive, more repeatable and consistent, tend to be more complicated and have longer learning curves. So in general, newer procedures like robotics, navigation, patient-specific implant and guides and minimally invasive techniques, would have learning curves in the range of 50 to 100 cases,  whereas traditional surgery might be more like 10 to 20 cases. So an order of magnitude, potentially increasing length and the learning curve, but the way that we train hadn't changed to keep up.

Then the final piece of the puzzle is an almost complete lack of assessment of technical skills in healthcare, pretty much across the board. In my whole career, up to this point, the only time I've been objectively evaluated. Now, we're constantly evaluated subjectively, right? Like how do people feel about our ability to perform. But objective, consistent evaluation. There was one time where I was interviewing for a position and they had me play the board game Operation, and they asked me to remove a plastic piece without buzzing, which I was able to do and I'm very proud of that. But I think we can do better.

On the nursing side or the mid-level side, in-servicing is the main thing we have, right? We know how those go. You show up, you grab a slice of pizza, you sign in, maybe you touch a needle or something like that, and walk out of the room. It's not a very comprehensive training experience and you have to be there physically. So what is the effect of all of these dynamics? Is it like, okay, I was seeing these things firsthand, but how is this affecting our healthcare system and patients? I started looking at some of the data behind it. One of the first questions I wondered is, will the surgical skill even matter? You would assume a better surgeon will have better results, but there's not actually a lot of research on that.

There was a groundbreaking study in the New England Journal of Medicine in 2013 that is frequently cited in the simulation in surgical education world that showed that not only do better surgeons have pretty much every single outcome or metric is better, but the difference between outcomes for low skilled or high skilled surgeons can be quite large. So one of the metrics they saw is that lower-skilled surgeons had a five-times-higher mortality rate than their higher-skilled counterparts. So how is this affecting patients? Pretty significantly.

The other thing I looked at is, well, how good are we doing right now at training surgeons? And so there's a really incredible study in 2017 that came out of University of Michigan, from a surgeon named Brian George. He looked at after 14 years of education, college, med school, internship, residency, how are we doing? What is the ability of these people through this whole pathway to operate on their own? What they found is that for even the most common procedures, 31% of residency graduates still could not operate without some kind of supervision or assistance. Which is a massive number and is getting worse over time.

We're seeing all of that. Now you throw COVID in the mix and now everything is just gone off the rails where we've lost a significant amount of training time for surgeons in training and surgeons in practice because you haven't been able to operate on as many cases. You can't go to remote courses anymore, and you can't go to these large conferences which is another training opportunity for us.

So seeing all of that, that I encountered virtual reality very early on. When I tried the technology, I was like, "Oh my God, this can solve this problem." You can use it anytime and anywhere. You can use your hands in a realistic way, you can for the first time get objective, consistent assessment and you can train as a team and train remotely. I think this is something that people often forget. I was just talking to my surgical team the other day. There's a lot of talk about surgeons and, you know, how amazing my surgeon is. They're doing a piece of the puzzle, but it's a team sport and you have on average, nine people in the room: anesthesiologist, anesthesiology resident, surgeon, first assist, surgical tech. You have the circulator, you have the radiology techs, a lot of people that it takes to get a surgery done, and you all have to coordinate and work together.

That ability to train as a team is something that we just really haven't had the ability to do up until now, and you can do that with this technology. So I came up with this concept for Osso VR, built a prototype myself because of my gaming background, then I met my co-founder on the Internet and I had some money saved up from my bar mitzvah. I was able to pay him to spruce up what we built and that generated some investor interest. We founded the company officially in October of 2016 and it's been a wild ride.

JANNAH AMIEL:Congratulations! That's fantastic. So if I was the end user in Osso VR, how does that work? What would I experience?

DR JUSTIN BARAD:Well, I think the first part of the experience when it comes to Osso VR you'd have to understand is that a lot like pediatrics, we're a mission-driven organization. I wanted to bring that same kind of energy. So what you're experiencing is being a part of that mission, which is to improve patient outcomes with better education and assessment, increase the adoption of higher value medical technology like robotics, and then democratizing access to surgical education all around the world. Tactically, what you're doing is you're taking a headset like the Oculus Quest 2, and you're putting it on your head. I have it right here, I could show it to you. Suddenly you're in a virtual environment where you could select from a number of different procedures or parts of procedures or troubleshooting scenarios and complications that you'd like to train on. You can view your performance and also get guidance on how to improve that performance. There's some automated coaching in there as well. You also have the opportunity to train with your team or train with a coach from anywhere in the world.

You basically select the piece of content that you'd like to train in, and then you're in a virtual operating room. You have your hands in there and you have your instruments or your surgical trays and the patient and all of your capital equipment and everything and you're running through these procedures. So it could be an orthopedic trauma procedure, it could be aortic aneurysm repair endovascularly. It could be a total joint replacement, could be a thoracic surgical procedure with navigated lung technology.

We have somewhere nearly 100 different surgical training modules currently that you could train on, and our goal is to be producing anywhere from over 100 by the end of the year at once. Part of what we bring to the table is a scale, since there are so many different kinds of procedures that we need to train people on. Anything from putting an IV to complex robotic surgery. We want there to just be a centralized repository where you can go to for all of your training and assessment needs.

JANNAH AMIEL: How have those outcomes been for you? What have you observed and collected? Now that you've got, I assume, lots of surgeons that have gone through this  training, are they performing better? What's the effectiveness that you were able to see?

DR JUSTIN BARAD:That's a really great question because I effectively walked away from a full-time career as an academic surgeon to start this company. Which was a really big deal for me and a difficult decision. But I continue to be so passionate about solving this problem. I think this is one of the existential problems facing healthcare today around the world. That being said, I didn't want to take such a leap for a technology that didn't actually work. VR is very cool, there's a lot of novelty to it and wow factor. But that's not enough; it needs to, as you say, improve surgical performance and ultimately improve how patients do, which is our goal and our mission.

We've been commissioning a number of independent studies from academic medical centers. The first published study came out of UCLA, which was published in the Journal of Surgical Education in January, 2020, where they looked at 20 trainees. Half were trained in Osso VR and then assessed and then half were trained traditionally. Then they went on to a tested surgical procedure. What they found is that the individuals that trained with Osso VR had performance scores that were 230% higher than those in the traditional training group. There was a 10 point difference so pretty massive boost.

The second level-one randomized clinical trial was published, came out of University of Illinois in Chicago and published in a top five orthopedic journal called Core. And that looked at the ability to perform a surgery without supervision. Which is, like I said, one of those metrics that is quite high right now for residency graduates. What they found is that traditionally trained residents, about 25% of those could get through a procedure without meaningful supervision. But when you instituted Osso VR for training assessment, that went up to 78%. So it was a 306% improvement in the ability to perform procedure without supervision.

We have a number of other studies that are currently being submitted for publication. Everything has shown a significant improvement when training with this technology, which is really exciting. Some of the studies are even really a little science fiction to me where they're putting motion trackers on surgeons, doing surgery and then surgeons training in VR. What they found is you can't tell the difference, which one's which — the fidelity of the experiences is getting quite high. So that's some pretty cool stuff that's out there. I think what's important at this point and we have enough data that we can say confidently that Osso VR works to improve surgical performance. And we are making an assumption based on the data in the New England Journal of Medicine that performance will tie to better patient outcomes and surgical efficiencies.

But that is the next stage of our research where we really want to understand, okay, how is this technology actually affecting patients, which is something we're looking at now, which is really exciting. But I think another important thing to point out is that the results of these studies are not just that, hey, VR works. Certainly, VR has the potential to work, but it's the way that simulation is done at Osso VR and the unique group of experts we've been able to put together. That is the reason why you're seeing such positive impact in these published studies.

JANNAH AMIEL:Great outcomes. That's something you've got to be really proud of.

DR JUSTIN BARAD:Yes. I mean, it's incredible. It's very interesting. I've never really been in a position where there's a technology that I was involved in creating and then an independent group is going to go study it. And in the back of my head, I'm like, "Well, what if it doesn't work?" I feel very confident about it, but it was amazing to see the results come in and I won't lie, I teared up a little bit as it was very exciting.

JANNAH AMIEL:That is very exciting. You went out and it did work, right? We've always got to think about the other side of the coin. What do you think then about VR in medical training and its use? More specifically, one thing I think about, because I hear VR a lot more and I'm hearing a lot more about simulations largely because of COVID, and how that's affected how we practice in healthcare. Do you imagine that we will be seeing a lot more of VR? Or is that just a symptom of, COVID happened and we had to find another way, but we wouldn't have been here this year doing this.

DR JUSTIN BARAD:I think that's an excellent question. From a macro point view, there are still open questions around what COVID-related behaviors are here to stay, and in what areas are we going to return to pre-COVID era. That's what's described as the so-called “new normal.” That being said, when it comes to training and assessment as we discussed, we were already in crisis mode before COVID. This has just accelerated that transformation. If you look at the papers in the literature like Brian George's paper, what he said is that we were heading towards an unsustainable future for surgical education, and that simulation is the only way to break this vicious cycle and create what is called a virtuous cycle. There's been a lot of research out of Canada as well, and what's called competency-based training. So I strongly believe that VR training and assessment is here to stay, and this is just accelerating the adoption, but it was already a very big need.

That being said, it's still not like, "Oh, hey, VR is here." You need to actually execute to make sure that this is a successful kind of distribution of this new technology. Part of that is the ability to generate the content. That's the biggest challenge. That's where our underlying technology, which we've spent millions of dollars developing, and years, is the ability to automate this content creation in a way that is clinically validated, like we just discussed, and also incredibly high fidelity that also can run on standalone VR, which is the Oculus Quest and Quest 2.

This is a really non-trivial thing that we've put together a team consisting of Oscar and Emmy winners from leading studios like Industrial Light & Magic, Apple, Microsoft, and many more, that rivals that of gaming and movie studios, that has built this technology that allows us to create this content at scale. Because if you're working at say, Kaiser Permanente or Geisinger or Northwell, every hospital is going to use a different central line system, or they're going to have a different technique for how to minimize line-related infections.

You need to be able to create thousands and millions of different modules to service all of the different kind of institutions and providers and what their particular practice is and how they like to train. So that is ultimately what Osso VR is, is VR surgical training content at scale, where we're going to have every procedure available, where you can train at any time and also get assessed. That's one of the powers of our team of now 70 people. And we're going to hit 100 by the summer.

JANNAH AMIEL:Congratulations on that. Earlier, you mentioned you had a mentor and you talked about this idea simply but powerfully: we have to identify the problem that we're trying to solve. Our audience, largely we have students, we have people that are early in their healthcare profession. What would be your advice to them about meeting the challenges of this moment now, even any challenge that they feel like they're encountering in their profession. How do they approach that? They could be the ones right now thinking, "This problem exists, and I have an idea, but I don't know." How do we do that? What would be your advice to that person listening now?

DR JUSTIN BARAD:Well, I'll share two pieces of inspirational advice that was shared with me, and then one piece of practical advice. The first is, I had a fellowship interview in Toronto, at the Hospital for SickKids. I sat down with the director there and he looked at my application and he looked at me. He's like, "Okay, clearly you're a different kind of applicant, you're kind of odd. So I'm not even going to interview. I'm just going to give you some advice.” I was like, "Oh, I have no idea where this is going." He told me not to worry about what I thought success was classically or what other people's expectations were for me, but to just pursue my passion. And if I did that, success would eventually find me.

There was a moment when I was doing this program that I'd dreamt about being at for a long time at Stanford, and I had this decision I had to make between dropping out of Stanford and running with Osso or staying with that full-time academic career. That advice is what led to my decision. I decided what I was truly passionate about was solving this problem, despite it being a huge risk and not what an expectation would be for normal success. Ultimately, I couldn't be happier with how that's turned out.

The second piece of advice I'll give was an activity I did as a leadership development for my fraternity, actually in college, funny enough. It was called the tap of leadership. In this exercise, you're asked to sit down on the ground, close your eyes, and when you feel a tap on your shoulder, you stand up. I was waiting there for some time, and someone taps me on my shoulder, finally I stand up, and they had you guess which instructor was the person who tapped someone first.

Then they said, "Will the person who got tapped first raise your hand." Some guy raised his hand. They asked him, "Who tapped you?" And this guy said, "I did." And my mind was completely blown. This guy realized that no one was going to tap him unless he did something about it and just tapped himself on the shoulder and had that kind of realization. When it comes to innovation, there's no degree or permission slip that someone's going to give you to go out and try and solve a problem. It's something that you need to decide that you're just going to try and do it and see what happens and create something from nothing. But it is, especially when you're in engineering or medicine, these very academic tracks, where there are hoops you jump through and steps you go through, and very prescribed journeys, it's very unintuitive for people. They're just waiting. It's like, "What's the degree or the program I need to do so that I can be an entrepreneur an innovator?" So, don't be afraid to just stand up and try and solve a problem.

Now, these are kind of like inspirational motivational things that were incredibly helpful to me, but what do I actually do, right? How do I execute on that? So while I did drop out of Stanford Biodesign, I learned a lot from my time there. They have created a process around innovation where, it certainly is still a bit of an art form and it is a lifelong discipline, but it is a great way to get started. They have a lot of material on the website and they have an amazing textbook with a lot of anecdotes of some of the great breakthroughs in healthcare and how need-based innovation are the underlying drivers and how you can practice that methodology too.

You may have 1,000 ideas, right? You need to somehow filter through them to decide which one is the one you're going to dedicate potentially five to 10 years of your life to. That's a very big deal to make that kind of decision. I highly recommend checking out the Stanford biodesign program website. There are also other biodesign programs popping up at UCLA and Texas Medical Center that are also very interesting and exciting and have some content as well.

JANNAH AMIEL:Dr. Barad, that was amazing. Thank you so much for joining us and for the information. Osso VR sounds exciting; that advice was amazing. Thank you a million times.

DR JUSTIN BARAD:Oh, thank you guys. I am inspired on a daily basis by what Osmosis does and also this podcast in getting the word out about innovation in healthcare and education especially. Education and communication have never been more important than they are now. I think that's all too obvious to us all on a daily basis. I thank you for the work that you do.

JANNAH AMIEL:I agree. Thank you. I'm Jannah Amiel, thanks for checking out our show today. Remember to do your part to flatten the curve and raise the line; we're all in this together.