Thomas Caruso: VR for Childhood Anxiety Reduction (CHARIOT Program)
Kim Bullock and Faaizah Arshad speak with Dr. Thomas Caruso, Clinical Professor of Pediatric Anesthesia at Lucile Packard Children's Hospital at Stanford and co-director of the CHARIOT Program. They discuss virtual reality solutions for reducing anxiety in pediatric patients perioperatively, and ways in which the Invincikids nonprofit is supporting immersive technology programs in clinical settings worldwide. Please note: Stanford University has no affiliation with Invincikids, which is an independent, federal, tax exempt non profit entity.
BIO
Dr. Caruso is a Clinical Professor of Pediatric Anesthesiology at Lucile Packard Children’s Hospital Stanford. He is the co-director of the Chariot Program, which aims to reduce pediatric patients’ anxiety and pain by utilizing immersive technologies, including mixed spatial and virtual reality. Software developed by the Chariot Program can be found in hundreds of hospitals and their customized VR hardware solutions are widely used by researchers in the field. He is also founder and board chair of Invincikids, a global non-profit that distributes immersive technologies to pediatric patients around the world.
The following is a transcript of the episode:
Kim Bullock
So welcome back to Psychiatry XR, where we aim to inspire worldwide conversations about the use of extended reality and psychiatric care. I'm your host for this episode, Kim Bullock, and I'm joined by my co host Faaizah Arshad. We're happy to have Dr. Thomas Caruso as our guest on the podcast today. Tom has both an MD and a Master's of Education and is a clinical professor of pediatric anesthesia at Stanford University's Lucile Packard Children's Hospital. He is the co-director of the Chariot program, which aims to reduce pediatric patients’ anxiety and pain by utilizing immersive technologies including mixed spatial and virtual reality. Software developed by the Chariot program can be found in hundreds of hospitals and their customized VR hardware solutions are widely used by researchers in the field. He is also the founder and Board Chair of Invincikids, a global nonprofit that distributes immersive technologies to pediatric patients around the world. Dr. Caruso, thank you so much for joining us today.
Thomas Caruso
Thank you for having me, Kim.
Kim Bullock
Thank you for your generosity and your time. And I've personally known you now for several years. And it seems like we both started kind of innovating clinically VR at Stanford around the same time, but you and your group have really taken off now to a whole ‘nother stratosphere. And I'm really excited to have you here and selfishly I personally want to learn for your secrets for being so impactful and effective while simultaneously working as a clinician, which I think is quite a feat. So maybe we could start off just by hearing your story about how you ended up being interested in immersive technology, especially because we've got a lot of pre-med and medical students who listen to this podcast. And yeah, how your career kind of pivoted to include extended realities?
Thomas Caruso
Sure. That's an excellent question. I like you mentioned am a pediatric anesthesiologist, and one of the core components of my profession is to take children's anxiety perioperatively, mostly preoperatively and reduce that. This is a very, very sensitive moment for children prior to their surgery, maybe the first and only surgery they'll ever have. Their parents and the patient are under understandably very anxious. And we have traditionally treated that anxiety with a mix of pharmacologic solutions, and non-pharmacologic solutions. Some of the non-pharmacologic solutions historically have included storytelling, jokes, and more recently distraction with tablet devices. About five, six years ago or so, my colleague, Dr. Sam Rodriguez, and I realized that tablets are becoming pretty much omnipresent in the perioperative space to try and distract children prior to surgery. So much so that the novelty had sort of worn off. And very organically, we didn't set out to become immersive technology researchers, we were just trying to improve patient care. And we started to use a projector. And we'd shoot that projector on the, on the bed and the children thought totally got a kick out of it. They're sort of like trying to touch it. And it's so funny. An old technology used again, right? For people like yourself, and you know, when I was in elementary school, we use projectors to display images. Now, I suppose they have smart boards and whatnot. But using these projectors, the kids really loved them. But they only worked on certain age group, the older children not so much. They weren't as impressed by him. And as we developed the program more, we went from projectors to virtual reality to augmented reality, and just trying to find different types of technologies that are on the cutting edge of what's mainstream right now to try to engage children prior to their surgery in a way that's fun, and distracting without having to reach for more medicines.
Kim Bullock
So it just kind of there was a need, and you are filling it and getting creative.
Thomas Caruso
Yeah, I think it's important for, like I, am very almost embarrassed at how much I love my job. If you can call it a job. I have lots of people shadow me and they think that this is just a laugh riot what I'm doing, you know. I'm playing with applications as therapeutic adjuncts in the operating room and now throughout the entire hospital, and I still provide pediatric anesthesia care. And it's just a lot of fun. And what we did at the time is what we continue to do today. And that's following a passion, that is not just fun, but also aimed at improving patient experience. And the combination of those two values really play off itself. And as long as we've been, you know, we stick to that true north of, ‘Is this still fun’? The answer is obviously, yes. And ‘Are we improving patient care’? The answer is yes. Then we're just having a great time while we're doing it. I certainly am not one of those people who thinks about like, when I'm going to retire, and someday, that sort of stuff. I just come to work every day extremely excited about everything that we're doing, and that excitement is fueled by the change in patients that we see every single day that utilize our technologies, not just at Lucile Packard, but other hospitals as well around the country.
Kim Bullock
I love that— the value of fun. I think we, we don't value or think about that enough. And yeah, it can do tremendous things. I love to hear that. And so the other thing that's so unique about you, and your projects, is the structure. I'm still trying to get my head around a talk you gave to our hubinar last month, where you talked about having the startup and Invincikids inside the CHARIOT program— and how you're able to do that that like the structural, how you created a structure that's so effective. And how did you straddle startup within an academic institution? Still blowing my mind.
Thomas Caruso
That's a really excellent, excellent question there, Kim. There's an old quote, I don't remember who said it, but it was, it was along the lines of you, you'll never believe how much you can accomplish if you stop caring about who gets the credit. And one of our core tenants within the Stanford CHARIOT program was that we wanted to make the technology and software that we are creating available for anyone to use. So in some of the listeners may not know this, but in academic medicine, unfortunately, sometimes people, other practitioners, they want to kind of create their own, their own playground, and they want to be king or queen of that playground. And what we wanted to do is not create something that we just had our hands around, but to help empower other physicians and providers throughout our hospital to run with this stuff. Because although we knew how to use it in the perioperative space, we did not know how to use it, for example, in ENT clinic, or in general surgery clinic, or in orthopedics clinics. And there's about, there's over a dozen different divisions where providers are using our technologies. And we very openly and willingly have outfitted these providers with the power and know-how to use these technologies. And we asked for nothing in return. Quickly as we spread throughout Lucile Packard and we've spoken on the topic and spoken to other people at different institute's about the technologies we're using. We found that that same need was, was out there in the country and in the world. And so we said to ourselves, ‘How can we get these technologies out there’? And there's two main ways to do it. It turns out, and some people may know this, but anything you develop at an academic institution is actually owned by that academic institution. So the software that we were creating, were all owned by Stanford, which was fine by us. So we went to Stanford, and we said, ‘How can we get these technologies out there’? And they said, ‘You have to find a distributor’. And all the distributors of immersive technologies that we could find, or I should say almost all of them, not every single one, but the majority of distributors were for-profit. And we have been very fortunate to have very generous philanthropic donations fund our program. And we felt that to be good stewards of those philanthropic donations, it was only right to pass these technologies on to patients at other hospitals with that same philanthropic idea. So instead of choosing a for-profit distributor, we decided to go with a nonprofit distributor. But there wasn't a nonprofit distributor that really filled all of our needs. So we started one. And this is where Invincikids, our nonprofit was born. So I know nothing about nonprofits starting companies. I'm a pediatric anesthesiologist, like I said, and neither does Sam Rodriguez or Ellen Wang. Dr. Ellen Wang is another pediatric anesthesiologist, who has been fundamentally crucial in the Stanford CHARIOT program and in funding Invincikids. And we said, ‘Well, what do we need to know?’ And so we shook our Rolodex, which I guess some of our listeners may not know what that means, but it's sort of a listing of contacts, and we found a couple of core contacts in the business world. We put together a little team, and we told them our vision, and we started a nonprofit called Invincikids. This was a couple years ago. Now at Invincikids kids, our executive directors named Andre’, he's doing an excellent job at fulfilling our mission at Invincikids, which is providing immersive technologies to children everywhere to improve their lives. And we distribute directly to hospitals domestically, and through domestic NGOs, we actually distribute our technologies, through domestic NGOs, on mission trips, to help those in limited resource settings who are in critical need of some therapeutic adjuncts. It's been a journey. And we intentionally wanted, wanted to make a nonprofit that was distinct from Stanford University, so that people from other universities and within Stanford could feel like they could all have skin in the game. Some people may not know this, but there's no ownership of nonprofits. So no one owns it. And it sort of just goes along with our main purpose with what we started here in the ORs of Lucile Packard several years ago. And we've now spread through many hospitals, domestically, and in certain countries around the world, of trying to give back to those who are in need. And, you know, we'll see if we're here in five years. We started this organically, we started this not like, ‘Hey, we are going to set out and do this. And if we fail, we're going to consider ourselves failures.’ We are doing this because it's fun and improving patients’ lives. As long as those two buckets are fulfilled, we'll keep plugging away. We're successful today. I don't know if we'll be as successful in five years, I'd like to have grand visions of us being the, you know, a premier hospital immersive tech program at the Stanford CHARIOT program. And Invincikids being the go-to nonprofit for health care, pediatric health care providers looking for therapeutic adjuncts for their children. That's rad. I'd love to, I'd love to see that vision realized. But we can only go one day at a time. And I still, you know, tomorrow, I'm in the operating room. So this isn't, you know, this is my side job, if you will, though, it feels like sometimes it takes up as much time as my clinical job. And it keeps us very happy and keeps us motivated and really adds a lot of meaning to life.
Kim Bullock
Yeah, yeah. Did you have any hurdles like with Office of Technology and licensing at Stanford, or any bureaucratic hurdles, or challenges doing this? Anyone that was trying to replicate this in their own university might, any advice you have for them?
Thomas Caruso
Sell your vision— would be probably the best advice I could give somebody. What we have done here at the Stanford CHARIOT program, like I said, did not exist. And we had to create it. And it continues to be iterated upon. It continues to be improved. It's really easy for people to look back, by people I mean, whether it be administrators or people coming into the program later in the game, to be like ‘Well, why did you do that? Why didn’t you say set it up like this? That doesn't make any sense?’ And it's like, well, you have to remember four years ago, we had a budget of X, and didn't think we're going to last another six months. So, you know, hindsight is 2020. Same thing with the nonprofit, you know, we have a vision, and we just keep going back to that. It's unusual arrangement for Stanford to license something they owned to a nonprofit. It appears to be. But I think that they understand what the vision is and so we're fortunate that they are willing to have that license agreement. But, you know, at the end of the day, this, they own this software, and you know, that license agreement could go away someday. I mean, I don't, you know, that's, these are not decisions that I make. These are decisions that the university makes, on a one individual basis. So we have seemingly sort of found our way through an obstacle course, without too many cuts or scrapes. But it certainly requires a lot of patience. And if anyone who knows me knows that I can be very impatient at times, and I have to reel it in, when I start to get frustrated by how slow things move, when everyone else around me is telling me that we're moving very fast. And I feel like this is taking forever. So I need to always keep that perspective. And make sure I don't get too emotionally caught up in things. Because there is red tape in any institute that you work with.
Kim Bullock
Yeah. Yeah.
Thomas Caruso
And you just have to be mentally prepared for that red tape.
Kim Bullock
Yeah, that sounds like you have a team of people you're working with too though. So that helps that you trust.
Thomas Caruso
Yeah, and I have, you know, some people's, some people's roles, I feel like are just to talk me down.
Kim Bullock
Right.
Thomas Caruso
I wouldn’t say just, but that's, that's certainly part of their job.
Kim Bullock
You outsourced your emotion regulation. Yeah.
Thomas Caruso
Like, ‘Okay, I just got to like, get this out, in an unprofessional way behind closed doors.’
Kim Bullock
Yeah, it's nice to be able to have that honesty. Well, I'm going to turn over the questions to Faaizah. So who said up and coming pre-med?
Faaizah Arshad
Yeah. Thanks, Kim. And thanks, Tom, all of the sounds so, so fascinating, especially the whole journey to even building Invincikids. And I love the fact that it just everything seems so organic, and like you're really just trying to do this to help patients and improve patient care. I think one thing that I'm curious to know, because it seems like now that you are working on like distributing the immersive technologies to other hospitals, and in generally getting more involved with technology, in addition to health care. What are the, have you seen any conflicts between industry, academia, and like patient care? And I guess, what are those conflicts? Or barriers? And how do you think that we can address those to really get patients access to VR treatment when they need it?
Thomas Caruso
Sure. So conflicts are extremely important aspect of what we do. And that's another secondary benefit of having a nonprofit. My disclosures are that I received no funding. As a nonprofit board member, I actually donate to the nonprofit. And that's actually been beneficial, I think, in my workings between academia and invents the kids being able not to have a financially, a financial conflict of interest. I have always spoken to our, the highest people in our conflicts office at Stanford. And I feel that in general, and maybe this is me giving advice, but we have stayed as aboveboard to a fault. If not, you know, like we are so aboveboard, an open book with Stanford with our Office of Technology licensing within InvinciKids. I speak about it plainly, candidly, and honestly. Being aboveboard really helps with those conflicts. And I say this, because, you know, there are some people who do navigate those conflicts and they do it well. And I can't speak to it as well as those folks who may be getting paid by different businesses to do stuff for their, for those businesses, while also being an academic physician working on similar stuff in academics. There are people who have disclosures and I find that I personally would find that challenging, which has been a motivating factor for remaining sort of nonconflicted in terms of receiving industry funding myself. So it's an excellent question. My solution to your question has been for me to just back away from it, much to the chagrin of my wife, who sometimes sees me putting in a ton of work. And she's like, ‘I don't understand how much work you're putting into this, and there's like, no return.’ But I'm like, the return is in smiles, okay.
Kim Bullock
Yeah.
Thomas Caruso
And I find that to be very, very helpful.
Kim Bullock
And it keeps the fun, it must keep the fun there. And it's a currency in itself. To have no conflicts of interest, it probably allows you to overcome some bureaucracies that you'd be in otherwise. So in a sense, it is a currency.
Thomas Caruso
It keeps it fun, because you're able to say, like, at the end of the day, if a hospital or somebody does not want to engage with Invincikids, like I say: I'm not a salesman, I'm not selling you anything. You don't need to. It means, I mean, I wouldn’t say it means nothing to me, I believe my mission, but if you guys choose not to sign our license agreement, or whatever it may be, it's not like I have a secondary financial gain from this. And, and for me to be on that side of the fence has been very helpful for me personally. Now, that's not to say that other people have not been able to successfully navigate that. And this is not a dig on them in any sense of the word. Just for me personally, that's the route I've gone and, you know, maybe 10 years from now I'll be a different person. But right now, that's, that makes it makes my life stay a little simpler. And Stanford has been so supportive of the Stanford CHARIOT program. And just, you know, whenever you start something novel in an academic institution, like, there's always, you know, it's going to be some eyebrows raised, and what are you doing, and how are you doing it? And I people asked me, like, why are you at Lucile Packard and why are you at Stanford? It's because they have been just so supportive every step of the way. And they've been open to different ideas. And I know, I have friends at other institutes who have not faced red tape— they've just faced walls that could not be broken down. And it's expected in my mind, like, there's going to be some things you have to navigate around when doing something unique. But Stanford. I mean, my family is back on the East Coast, cost of living here is through the roof. But they have been just so supportive every step of the way that I can't even fathom having even half the support at another institute. I'd like to think that's not true. But I just can't picture it someplace else. So I've been, I feel like I've been blessed with a high degree of serendipity to have landed in such a supporting system.
Kim Bullock
Yeah, and having fun at work and being energized at work is priceless. Yeah. How do you pick the projects to work on? And also what role? Sorry, this kind of two questions. What role do you see psychiatry playing in the field of VR and behavioral health, or VR in general, since we're kind of late to the game? Psychologists have kind of developed this, but yeah, do you see any role for psychiatrists, and when you're picking projects, what stands out to you?
Thomas Caruso
Sure, we, we design projects based on patient need / clinician-identified patient need. We don't know everything that patients need. But sometimes clinicians do, sometimes patients do. We, when we weigh different projects, we look at two things. One is scale. And one is impact. There may be an application that will have, maybe a relatively speaking, minor impact — something where it's a distracting application prior to like IV placement. And I know IV placement can be very traumatic. I'm someone with needle phobia. But on the broader scale of things, you might say that that application has a very large scale. It can be used lots of places, but the impact is like, you know, maybe not that high, but because there's such a high scale, is worthwhile. The other side of the coin would be something with a very high impact but maybe smaller scale. That would be something similar to our pediatric chronic pain VR applications. So there are not that many patients who have pediatric pain conditions. However, those patients who do is, it is a very traumatizing and acutely and chronically impacting their day-to-day and longitudinal livelihood. And so in that situation, it's kind of the other end, where it's a very impactful application, even though the scale might not be as big as let's say, patients having IVs placed, and then things in between that sort of fall somewhere in the middle. In terms of psychiatry, we feel that almost everything, we, not everything, but the majority of what we do is actually rooted in the psychiatric field. We know that attention is a limited resource. And perhaps you guys can identify in yourself that you may, at the end of the day, see a bruise on your leg when you're like taking a shower, let's say, and have no idea where that bruise came from. However, if I were to sit you down and be like, ‘Hey, I'm about to take this bruise and whack your leg’, you're going to say ‘Ow’. I guarantee you, and you're going to identify that that perception, you perceive that perception as painful. And you know, exactly when it happened and how it happened. Nevertheless, if it happened in the middle of the day, where you're rushing from, like the grocery store back into your car, you had no perception that that even occurred, but you know it did because you see the bruise later in the day. So we can all agree that attention is a limited resource. And attention and pain perception are directly related. So when you ask, you know, what are the psychiatric implications of virtual reality, from a pain perspective, being able to, for lack of better words, exploit the psychiatric processes associated around pain perceptions, attention, and emotion, the implications are very large. Then you can get take one step further, and say, you know, how can we use these VR to help with, how would you say this, it's almost patient education. Right. We try to because we're dealing, we're working with a lot of children, we try to almost game-ify some psychiatric care. So for example, children with chronic abdominal pain. A lot of times children, children's chronic abdominal pain, there is no organic cause that's identifiable. So it's not that the children do not feel abdominal pain, it's just that we don't have a pill or a drug or a treatment that can treat the pain directly. Instead, we need to treat their brain. And we can and have developed applications in partnership with some of our psychiatric with, well, I guess, their GI colleagues, but working in the GI clinic, using VR applications to help people better, you know, for lack of better words, redefine that chronic pain in their abdomen to be something that they can live with. So psychiatry as a field, when it comes to virtual reality is, is right there at the underpinnings of most, a lot of what we do. So it makes a lot of sense that we would have strong ties with psychiatrists, and just try to understand how we can use VR to better heal and help patients who have ways in which we can, you know, help their brain better cope with the conditions they face.
Kim Bullock
Thank you so much for sharing all your valuable insights into what's happening in medical XR. Is there anything else you'd like to share with our listeners today?
Thomas Caruso
You know, I would say that a lot of people will tell you no. And sometimes you got to listen to them. But you don't always have to listen to them. And I have this joke with Ellen, one of my colleagues that when I hear no, if I ask at least three more times, usually they'll say yes. We have a lot of human-made constraints that we work around. And a lot of noes are related to policies and other procedures that were just created by humans. And sometimes it takes, you got to be the one to sort of step back and say, ‘Does it have to be that way? I know it says that on that piece of paper. But do we have to proceed that way? Can we think about, can we just take three steps back and think about maybe there's another route forward?’ And I would tell any listeners to you know, just follow your heart, follow your compassion, and you'll be definitely on the road to like a very fulfilling career and profession no matter what you choose.
Kim Bullock
I love that. Yeah. And no is just the beginning of negotiation.
Thomas Caruso
Exactly.
Kim Bullock
Well, thank you so much. So that's it for this episode of Psychiatry XR and we hope you've gained a new perspective on the use of extended reality in health care and thanks so much for listening.
Thomas Caruso
Thank you guys.
Kim Bullock
This episode was brought to you by Psychiatry XR, the psychiatry podcast about immersive technology and mental health. For more information about Psychiatry XR, visit our website at www.psychiatry xr.com. Kim Bullock produced this podcast with the help of Faaizah Arshad and Jessica Hagen, and we credit and are grateful to Austin Hagen for music and audio production. See you next time.
Again please note: Stanford University has no affiliation with Invincikids, which is an independent, federal, tax exempt non profit entity.