Kate Steinbeck: [00:00:01] Hello everyone I'm Kate Steinbeck and welcome to the WH&Y webinar series for March. We've just had a change of platform, and if I look as though I'm confused, I'm just having to see things slightly differently. But I'd love to acknowledge our partners for the NHMRC Centre of Research Excellence into Adolescent Health. We also acknowledge as we are probably listening to this in very many different parts [of Australia], we acknowledge the traditional owners of the country through Australia and recognise their continuing connection to land, waters and culture and pay our respects. 

Kate Steinbeck: [00:00:53] There are a few housekeeping bits and pieces. First of all, we have chat, which appears just with the usual standard chat bubbles on the left top of your screen. Please just use chat for interaction. If you want to ask a question, please, can you move to the next box with the question mark and type your question in. Martin, our presenter, is particularly keen to hear your feedback, and in the chat, we'll put up his email address because he is presenting some very new stuff. 

Kate Steinbeck: [00:01:38] Now, I'd like to introduce our presenter, Martin Brown. Martin is an experienced educator with a background in media and film industry. What I think is really exciting, is he produced Moulin Rouge, one of my favourite movies, and was coproducer of Romeo and Juliet and art director of Strictly Ballroom. He's the director of Award Courses at the Australian Film, Television and Radio School. And now we have him at our very own University of Sydney, where he's Program Manager of Innovative Technologies at the Westmead Precinct. Martin, lovely to have you here and welcome. 

Martin Brown: [00:02:19] Thank you very much for that. I would like to tell you a little bit about what we're doing with this project, because it's very early days, very, very early days. And so, I hope you won't expect that it's in any way a complete picture. That's why I'm very keen to hear what you make of it, because we're exposing it early on, which is sort of part of the way that we like to work. Just a little bit about my role with the University of Sydney, based largely at Westmead, and I lead a group or chair a group of academics from across the campus in all sorts of faculties engineering, I.T., education, e-learning, psychology, science, medicine, a great many, many faculties looking at how we can develop innovative technology environments to support the health sector.

Martin Brown: [00:03:38] So that's sort of our very broad brief, the way that we try to finesse it a little bit, we have a set of prioritisation criteria, I won't read them all out, but basically, we're looking for problems that lend themselves to innovative technology solutions. Innovative technology is not quite the same as doing a PowerPoint on your own laptop at home, it takes a little bit more technology than that and a little bit more development. So, we try to find problems where it's worth investing that bit of development, so therefore, we're looking at problems that lend themselves to this environment, but also hopefully the solution that we provide is scalable. We've been trying to work in this space for a couple of years now, and I'll just give you a bit of a rundown on some of the things that we're doing.

Martin Brown: [00:04:33] Quite often when we're looking at some issues, we love the problem to come to us rather than us to go looking for it. We like the problem to walk in the door because that means that the people who own the problem are very invested and very keen to try to find a way to solve it. And very often the solutions we're developing are virtual realities. We're always putting ourselves under the pressure of saying, is this a problem that needs VR [virtual reality]? Is VR a good way of addressing the circumstances that the person's problem exists in? So, this is sort of how I depict our process. It's pretty much design thinking. This is pretty much our version of the design thinking process. I'll take you through it at top level just to describe how we do it. So basically, we go along we scope, we look for the values, we speculate, we define, we prototype, and then we get into an iterative cycle where we develop and test prototypes and learn from that process and feed that learning back into redefining the parameters that we've set ourselves at the beginning of the process. And we found that this iterative development process has been very valuable in two of the lead projects we're working on. It's been surprising to us how the process of making something has helped us understand what it is we're trying to make. And we try to give ourselves the license to do that in the process. 

Martin Brown: [00:06:04] So, very briefly, we try to scope the problem, and that really just means looking  at where the research is, doing the lit review, looking at the policy and procedures and practices surrounding it, looking at the academic structures. If it's a learning environment, looking at the emotional journey that people have through that, inside the problem. Then we try to make sure that we recruit the right people to be involved in discussing exactly what it is that we're trying to tackle. And that recruitment of the community we're finding is incredibly important and something we have to continually remind ourselves to do thoroughly so that everybody is represented at the table when we're trying to actually pin down what the exact issue is that we're addressing. Then, we try to work out, okay what is the value, the human value that's our endpoint. It's unlike scientific methodology in the sense that we're not putting up a hypothesis and testing it and looking for evidence. We're trying to say what is the value that we're looking for? And in different projects, obviously, they are very different. 

Martin Brown:  [00.07.27] So, I list a couple of examples there. If we're trying to build confidence in the user, that's very different to trying to help them to be competent. If we're trying to develop hope in the person that's using it, that's a very different outcome to just providing comfort. So, once we try to discuss that, that in a way becomes our compass point for the direction we're headed in and we try to hang onto that as we're working through the process. Then we start to get into speculating about what could be potential solutions to that. And then we start to write down a definition, break it down into components, and then if we need ethics approval, we do the ethics work. We put a research framework around that so that we are asking ourselves very precise questions and we are looking for evidence and then we set about building a minimum viable product (MVP). The bits that we work in involve technology, involve equipment. So, we make a thing, we make an app effectively, and that means that it's very precise work. We have to code it. We have to test it. Usability is important. There's a little bit of a threshold to using the technology. If it's a headset, not everybody has had the experience of using a headset, so we have to accommodate all of that. So, because we're building a thing, an app, that disciplines' what we're doing. Somebody said to me, you don't really understand your problem until you have to explain it to a machine. And that's sort of what coding is about. You have to be extremely clear and precise in what you're doing to get the outcome you imagine you're going to get. So, we go through that process. Then we try to get evidence of whether what we thought was going to happen does happen. And then we review that and go back to the values that we put up as our objective target or compass point. We revise that, if necessary, from what we've learned, and then repeat that as often as the funding or the time or the willpower will allow. And when those things run out, then we're finished, and we lock the project and deploy it. We're getting very close to that in a couple of the projects we're working on, and that's trying to work out how to build an app that has a sustainable life. All apps, as we know, are constantly renewed so that's a process that's not free. We need to work out how the things that we develop can have a self-sustaining life and still provide value to the user. 

Martin Brown: [00:10:18] So these are some of the projects that the group is involved in. I won't take you through all of them, but I'll just touch on a couple of them with varying degrees of development. There are some others and there are new ones emerging all the time. So, some of the ones we've touched on such as advanced life support. Some of you may know Nathan Moore, he was running the SIM lab in the adult hospital and did and does the training for the ALS team. So, you would know if there's a heart attack on ward, a flash team is assembled and that team has to maintain life and work out why the person's heart stopped, try to solve that problem and get the heart going again. So, the way that that's done currently is with two expensive plastic dummies in a simulated environment with a couple of clinical educators standing in for a team of five or six people. Nathan found this is a classic example of the problem coming to us. Nathan found that in that environment, an inadequate reproduction of the clinical setting in which people have to perform, and his educational philosophy is that people should be trained in an environment that simulates the conditions under which they need to perform.

Martin Brown: [00:11:44] So, we started work on that project. Many of you would be familiar with the ALS algorithm, and what we did out of that process of analysis is to simulate a virtual reality environment in which all the team leaders are represented by avatars. There's a screen grab of the environment (refer slide on the left) that we've built, and each of the people involved in one of them are represented there by avatars, and the team leader can issue instructions to those people, can monitor their behaviour, can get data back about the heart rate monitor, the labs can come back, all the usual mechanisms of analysis are available. And they get basically to rehearse in a time sensitive environment like under the pressure of time, they have to perform their role as team leader. 

Martin Brown: [00:12:52] I'll just run the video. So, there on the left of the screen is Nathan with the headset on using his hand controllers to run the simulation and he's represented in the larger screen on the right just by the controllers and the headset. So that's where he's positioned in the environment at the foot of the bed, which is as you would know, where the team leader stands. So, the simulation is running here, he can provide guidance on the depth of chest compressions, the frequency. He's getting information there on what drugs have been administered on the cycle. He can make decisions about shock or don't shock and basically run through the whole process of exercising the skills that a team leader needs.

Martin Brown: [00:13:49] So that's one of the projects we've been developing that's coming very close to being ready. Nathan's just about to start clinical trials on that this year. We were, like everybody, affected by COVID last year and it slowed us down a little bit. We're just getting towards a point where we can run that as an alternative or a supplement to the current training regime that exists for training team leaders and re accrediting team leaders for the ALS teams.

Martin Brown: [00:14:27] Another project is Code Black. Everyone knows that violence in the emergency department is a serious and escalating problem and everyone's concerned about this. There's a lot of support for trying to find ways to keep people safe who operate in the emergency department. And so, we were involved at a very early stage trying to work through this problem. You would be familiar with this, it is a bit of CCTV footage of the sorts of events that seem to be occurring almost on a daily basis in EDs these days. From my very superficial knowledge and understanding of what goes on in ED and from people I've spoken to and interviewed and observed, this problem is not decreasing.

Martin Brown: [00:15:22] So we started to investigate how we could add value to the training regime. It's a very intense environment, obviously, in the ED. I did the training course that everybody does for improving your de-escalation skills, the one-day training course and the facilitator of that course said that nothing prepares you for your first day in the ED. And we thought, well, maybe we can try to address that problem in the way that we do it. What I've got on the screen at the moment is a diagram where we started to flesh out some of the modules in virtual reality that we might be able to develop. I'll show you a little snippet of one. We are developing all of these modules, and at the same time that we're developing these environmental experiences in virtual reality, there's also a project on foot to overhaul the training regime around staff practices in the ED to try to minimise the occurrence of violent Code Black events in the ED. So, we're working with that group to provide these VR environments as part of the training package. So, I'll just ask if we could play one clip, his is a little bit of 360 video that we shot. We were lucky enough to get into the CASV just before it was taken. 
Video voice over: [00:16:54] "I'll just get you to stand-up here and observe, you don't have to do anything. Just have a good look around."]

Martin Brown: [00:17:08] So that was a little bit of 360 video that we shot, and that means that you can stand there with the goggles on and you can look around, it's happening all around you. There are clinicians working in the space. We had four actors on the day, and we asked them to exhibit behaviours of concern that were escalating over time into precursor violent behaviours, and then some of them started to act-up pretty noticeably, yelling and occasionally throwing things. So, we've put that environment into a headset, and so a person who's never been in the ED can get a little bit of an experience of what it's like to be in that space. And this is a good example of where VR can reproduce an environment that's otherwise very difficult to reproduce. Obviously, the Eds are open 24/7, so it's not available as a training environment. 

Martin Brown: [00:18:08] As well as that, in that suite of applications we've developed some exemplar videos of veteran practitioners attempting to verbally de-escalate patients so that people can see that. We've also done a 360-video capture of a physical takedown because again, from our research, people who haven't worked in ED before found it confronting, as anybody would, to witness someone being taken down and physically restrained. So, we've captured that, and we can then convey how that is done in an organised, safe manner and how the process is assembled and debriefed. And again, that's a very difficult experience to reproduce in a training environment, but we have captured that in the 360 video. And it's as if you're standing next to that event happening. We're also developing some other components in there that will help supplement the training regime that's being developed. 

Martin Brown: [00:19:23] The one I wanted to talk to you about today, though, and this is the one that's in very early stages, is VR Body Swap. Now, we're not the first people to do this, we were inspired by a group in Barcelona who've been looking at this use of the VR technology for a while. The thing that we got interested in, is that dignified communications or even just clear communications in a clinical setting are difficult to rehearse because the health environment is a hectic environment. It's a stressed environment. It's an underfunded environment. And so, getting up to speed with operating in that environment is difficult to rehearse, again, it's a difficult environment to reproduce in a classroom training environment. So, we were interested in looking at ways that we could produce something that puts people under the similar time-based pressure of human interactions. 

Martin Brown: [00:20:28] And this is something, again, that VR is very good at, it not only gives you the intellectual content, but it does also create an emotional reaction and it does create a physical reaction. So, VR particularly is good at delivering that more overwhelming and complete human experience of the moment rather than just, you know, the intellectual summary of it. So, I'll ask if we could play the clip, which is silent at the beginning, but it picks up. This is what we witnessed from the Barcelona group about how they use this technology.

Video dialogue: [00:21:09] First speaker: "So what is the problem you would like to talk about today?"

Video dialogue: [00:21:38] Second speaker: "The problem is that I'd like to take better care of my health. Usually, I'm sitting for eight hours in my job at work, and I don't get any exercise. And I feel like I should maybe do something about that." 

Video voiceover: [00:22:15] "Please look down towards your body. Raise your right hand. Now look in the mirror to your left. When the light next to you turns green explain the problem to the person in front of you." 

Video dialogue: [00:22:34] Second speaker: "So when I notice that I'm delaying going to the gym after I come back from work, I think that I should go because I want to take care of my health.

Video voiceover: [00:22:55] Now, listen to the person in front of you, and when the light next to you turns green, reply and try to help them find a solution." 
[00:23:06] Second speaker: "So when I notice that I am delaying going to the gym after I come back from work" 

Video dialogue: [00:24:30] Second speaker speaking to avatar of self: " so why do you think you are delaying what seems to be stopping you going to the gym?" 

Martin Brown: [00:24:34] So basically, I'm sorry, that was a bit long, but it's an interesting portrayal of what their experiment was. So, theirs was lab based. They went to great lengths to scan the person so that the avatar they produced was photographically highly, recognisably real as that person. This is an environment in which you talk to yourself from an outsider's point of view. They have a quite neat idea in there, which is that they pitch-change your own voice when it speaks back to you, and that is in the persona of someone who looks a lot like Sigmund Freud. So, this was an environment in which you are basically counselling yourself by swapping from your own position to the position of somebody outside yourself. Their studies demonstrate that you feel better when you've when you've received your own advice, which in itself, I think is very interesting. We got interested in it more to look at, not just self-swapping with self, but self-swapping with someone else. That became very interesting to us. 

Martin Brown: [00:25:54] So we started to rough out a few little tests. I'll just ask to play one. This is a test where we recorded some behaviour and then pressed a button and switched to third-person position and observed yourself talking to the other person. Yourself in this instance was represented by a robot avatar. 

Video dialogue: [00:26:19] I'll just do some hand movements. Hello, how are you today? Head, shoulders, knees, so. You can see the speech synching up with my movements and hit stop. And we should get teleported pretty much after a slight delay straight into our spectator. We have some controls just here. Play and return back to our main character, hit play, recording now. I'll just do some hand movements. Hello, how are you today? Head, shoulders, knees, so. You can see the speech synching up with my movements and hit stop. And we go straight back into our main portal. 

Martin Brown: [00:27:38] OK, so that was interesting to us to see how that could work, but we got more interested, as I mentioned, in swapping into the other person's point of view. So, we started looking at how we could explore this. We had a chance to work with some third-year med students in a meds 388 course. There was a whole bunch of them, but 17 of them opted for our little unit which was about dignity and workplace learning. And we asked them to research dignified communication in a health-care setting, to script a specific workplace interaction that diminished dignity, make an audio recording of the offending comment under 50 words, and then they emailed us that audio file and then we programmed that into an avatar character, an off the shelf game Avatar character that we bought and used, and then we very rapidly developed a VR version of this experience and a flat-screen version of this experience. So, I'll just ask Sharon to play two videos. One is from the students’ own report to us on how the app works. That's the first one. And then the second one is one student's experience of both the VR version and the flat screen version. 

Scenario One: [00:29:11] Video Voiceover: "This is the desktop version of the simulation; I will take you through what the simulation looks like and how to use it. Firstly, you can choose between different scenarios. In this case, we have scenarios one through 4. Once you click on the scenario, an avatar will pop up and you put in an unknown situation, but one you could potentially face in the work environment. Let's work on scenario one and see what the scenario is. 
Scenario One: [00:29:37] Avatar: " You won’t need to worry about all these new medical techniques. I reckon you will be busy pumping out another kid by then."]

Voiceover: [00:29:37] After hearing the avatar scenario, you can click on the record button and practice what you might say in real situations. For example: "I'm not sure if you're aware, but that is an inappropriate thing to say to someone". After this, you can stop the recording and you can actually switch viewpoints with the Avatar and see how you look and sound. "I'm not sure if you're aware that is an inappropriate way to talk to someone?" If you don't like your response and would like to change it, you can repeat the situation again and practice what you think is an appropriate response.

Avatar: [00:30:43] "You're doing it all wrong nurse; you shouldn’t position the patient that way after spinal surgery. Yes, I'm not on the care team, but I've had more experience working in this field than you do. I certainly know what I'm talking about".

Person responding to avatar: [00:30:54] "Yes, it is true you have more experience, but it you're not on the care team, then it is my responsibility not yours. 

Person responding to avatar: [00:31:04] "if you're not on the care team, then it's better not to say anything. I think I know best what's best for the patient. So let me handle this. I learned from my experience that it's better to position the patient in this way if you have anything to say about it, you need to say it in a nicer way, we can discuss it together. But as you said, you're not on the care team, and I am, so please trust me on this."]

Scenario Two: [00:31:40] Avatar: So, I've just finished the urinary examination, but I think it might be beneficial if you perform a rectal examination while she's still asleep. The tumour is very large and is a very good example for you. Don't worry, you won't hurt her in any way. 

Person responding to avatar: [00:31:59] "I think it is important that we have the patient's consent before we do invasive procedures, so it's not wise to do it while she is asleep. Do you think it's a good idea to do this while the patient's asleep because we need patient consent? I don't think the concern here is hurting her. I think the concern here is that we don't have consent and I'm just an intern. It would not be ethical for us to do this examination, especially in this very sensitive area without the patient's consent. 

Video Participant: [00:32:40] "So, the first time I was confronted with the scenarios, it was quite scary, both in the VR version and the flat screen version, I was unable to think of a quick response, and when I did reply, it seemed to be too passive because I was too intimidated. I think it was worse with the VR because it seemed like I was actually talking to the person instead of looking at them through a screen, but there were other people around during the flatscreen version and that made me a little bit more insecure about my answers. I think getting that second chance to reply really helped me, as you just saw, I was able to be more confident and I was able to think of a better response to the scenarios. I think this was a true learning experience, although I'm not sure I'm quite ready to face these challenges in the real world. I would at least be able to assert myself now and be quicker on my feet without sacrificing my own dignity or the dignity of the other person.]

Martin Brown: [00:33:50] So, that little experiment asked us a lot more questions than it answered, which is great. We developed the VR version, as you noticed, and a flat screen version as well, and we're very interested in seeing how scalable we can make this. I think that headsets are not that common, not many people own the headsets yet. If we're talking about issuing them to people as a whole, there’s a lot of logistics around that. And then there's onboarding with using the tech, which is not complicated, but if you're a novice user, there's a little bit of an on ramp. So, there's a small threshold of entry to the VR headsets. And obviously we're all able to use a flat screen version. So, we were interested to look at the differences in the experience between VR and flat screen. And we got some data around that from debriefing the students. We were very interested in the extent to which it is valuable to recognize the person speaking. 

Martin Brown: [00:35:03] When you move to the second person position as yourself. For example, we built it for a standing experience because we felt that a body experience somehow was all joined up to being recognisably you. But to what extent would that be compromised if you're sitting down so that it was more like we are now in this environment? That's another one of the questions. How important is it to identify with the avatar in movement terms? It's actually capturing your own voice so it sounds like you are speaking, but we only had two generic avatars, two off- the-shelf avatars, one white male, one white female. How important is it for the experience that you recognise that person as you, or is that not important? What we worked on in the VR version was a thing called inverse kinematics, which means that the headset and the VR system interpolates where the user's body is by what they're doing with the hand controllers. So, it applies a lot of complicated geometry to guess where your arms are and your elbows and your upper body is, because all it has is where the headset is in space and where the hand controllers are in space. So, there was a little bit of a complicated setup to calibrate the VR system to the person's body height and their distance from the sensors. And that meant that we were able to capture the movements that the person made, and our thinking behind that was that those movements would be important for the sense of recognition. That doesn't work with the flat screen version, and we felt that that wasn't necessarily a negative, that we didn't capture the person's movements. 

Martin Brown: [00:37:05] I've noted in Yamin, the student that you heard reporting on her experience there, when she was holding the controllers, she just held them out in front of her and didn't move them at all. When she was using the flat screen version, she actually used her hands much more, and in a way, I felt that what her hands were doing was showing us how she was feeling. So, the fact that we put all of that work into capturing hand gestures based on the controllers, the fact was she didn't move the hands very much when she was holding the controllers, when she didn't have the controllers, we didn't capture those movements, but she had her hands free to be more expressive with her hands. So that's a whole other area that we're very interested in.

Martin Brown: [00:37:58] One thing we've been talking about is that there is a very simple build-your-own avatar free online app you can build, and you make some decisions about how much hair you've got, what colour it is, what shape your face is, what shape your nose is, what colour your eyes are, what you're wearing. And you can build an avatar, which, having invested those few minutes in making those choices, you might more strongly identify with as being you. Is that a valuable contribution to the experience? Or does it not matter that the person that speaks back what you said is not immediately identifiable or recognisable as yourself? That's a very interesting question to us, which we want to explore.]

Martin Brown: [00:38:46] Another one which came up was and this was a great example of where what we anticipated would happen, didn't happen. We thought that the best plan would be for someone to speak and then immediately have another go and then immediately have a third attempt. But the students themselves, through going through the process, felt that there needed to be time elapsed in order for them to process and reflect on how they had performed in the initial iteration and how they would change it. And I think we've all colloquially had that experience of being in a social context and responding to someone's comment, which we find challenging. And on the way home we go, oh God, I wish I'd said that you come up with a better answer on the way home. So how much time does it take before you are able to go through that process of processing, what you actually did and what you could have done better or differently? That's very interesting to us as a dimension of what we're trying to explore. 

Martin Brown: [00:39:54] Something the students talked to us about was that if the person had been in scrubs and had been in a clinical setting, they would have felt that that added a lot more credibility to what was happening. And that was interesting to us because that was actually really cheap and easy to do and we didn't do it, whereas the inverse kinematics, which is about capturing body movement, was very, very complicated and time consuming and probably didn't make much of a difference in the final product. 

Martin Brown: [00:40:26] Another one that we're interested in is whether it is better to be surprised by the question. The way that we structured the work with the students was that they generated their own provocative statement and then they had to respond to their own, what we called a prompt script, and then had to respond to a script from another group. And they didn't know what that was going to be. And so, they were more recredibly put under the sort of normal workplace pressure that we are put under when someone comes out with something that is surprising and unsettling for us. One of the students, when she experienced another group's prompt script, couldn't speak. She described herself as normally a very garrulous person, an outgoing person, but she was so surprised by the person's question that she couldn't form a response. And that in itself was a tremendously valuable outcome for her. So, there's lots of lots of questions that this project is asking us. 

Martin Brown: [00:41:37] So one of the avenues that we're pursuing at the moment, we received a grant from the State Insurance Regulatory Authority to investigate ways that health-care workers who have had time off work for mental health reasons can get back to work sooner and better. This is very early days at the moment. We're anticipating or we haven't done the research yet, but we are imagining that people returning to work under those circumstances may be concerned about the sorts of questions their colleagues are going to ask them when they get back to work and that they may postpone returning to work until they feel very confident about being able to deal with those questions. And so, there's the potential that if this is this private environment that they can engage with in their own space at home gives them an opportunity to confront those questions, which they may find fearful and rehearse how they're going to deal with them that may help support their confidence in returning to work sooner and better. 

Martin Brown: [00:42:45] We're thinking at the moment with this environment, it's an environment that seems to be adaptable to many different contexts. And one of the things we're thinking about at the moment is whether this environment that we're building needs to be built specifically to each use case or whether there is a way that we could build it so that the person themselves or the person running a training program could populate it with the sorts of questions and environments and exchanges that they themselves or the people that they're working with in the training environment would find useful to engage with and rehearse. So, we're at a little bit of a fork in the road in terms of our production horizon around how we could develop this platform. But we are finding that people find it quite a captivating idea, as we did in the initial stages, and we're looking at a number of different ways that it could be deployed. 

Martin Brown: [00:43:54] So, basically getting back to the process that we like to follow, we've kind of gone through scoping, we've tried to establish the values, we speculated, we've defined we've built a very quick prototype in VR and flat screen. We've tested it. We're just reviewing the qualitative data we got back. And we're now using that to redefine the parameters of the experiment we're conducting and re-establish the basis on which we're trying to explore and digging deeper around the sorts of questions that this really quite simple mechanism is asking us about how valuable an environment it is. That's about it. 
 

Kate Steinbeck: [00:44:55] That has been absolutely fascinating, and we've got a couple of questions to start off with. The first is from Dan Waller, and he says: 
Questioner: Thanks for an interesting presentation, Martin, it would be great to know more about where you think the best, easiest implementation avenues are for this technology.
Kate Steinbeck [xxx] And if I know, Dan, he's thinking about tertiary institutes and health services particularly.
Questioner: And it would be great to know how easy it would be to scale up or drag and drop these approaches across settings.
 

Kate Steinbeck:  I think that's about three questions. 
 

Martin Brown: [00:45:45] No, it's great, and one of the ones that we've been talking about is a very simple piece of communication, which is very common in clinical setting, which is a clinical handover. And it's supposed to be a very prosaic, very precise, very clear verbal transfer of information. And it's taught, you have to learn it, you have to get better at it, and the better you are at it, the better your performance is in the workplace. And so, it's a very important skill, just that basic one. And so, we feel that just that of having a go at a clinical handover then going outside yourself and witnessing how you went, we strongly suspect, and we need to provide an evidence base for this, that observing yourself from outside gives you insights that you can't access from just being inside yourself. That's kind of the fundamental basis of it. And we need to drill into that and test that. If that's true, then this environment, we think, can be quite scalable, even on the flat screen iteration, where just that simple process could be rehearsed, rehearsed, rehearsed. Until you feel that you've done it well. Then you can submit an exemplar to whoever's managing the course. and they can assess you on it.
 

Martin Brown: [00:47:08] A more sophisticated version of that actually came up yesterday, which was a simple interaction. A patient comes to you and makes a statement, and you reply with your best knowledge and training and intention. And then we're investigating whether we can do analytics on what you say. So, we convert a voice to text. We do contextual analysis of that and we grade what you've said according to a number of outcomes. And then we can provide readings or viewings that can help supplement your level of experience. And having consumed those, you can go back in and have another attempt at that exchange so the patient can come up to you again, and you are now are a little bit better informed, maybe you've witnessed other people doing that work, and you can have another attempt. That's something that we're starting to investigate. 
 

Martin Brown: [00:48:10] So, again, we're intrigued by the possibilities. I like the idea that somebody running a training program could say, I want a bank of questions like this, they can just record them all themselves, have them randomly available so the student doesn't know which one’s coming at them, and then the student in real time, and it's the real-time element that I can't stress enough, under the real-time pressure of someone that looks like a person speaking to you, you're put on the spot to respond, that elicits a response that then is valuable for gaining insight. 

Kate Steinbeck: [00:48:47] I think that probably leads quite neatly to the next question from Annabel, who asked: "Were you aware of there've been any trials looking at clinicians pre- and post-VR training, such as in counselling or life-support training, and seeing if there have been any improvements in their skills?" 

Martin Brown: [00:49:18] It's very interesting, VR has been around for a while. It's not new. It's suddenly sort of emerging because the technology is affordable. The very good Quest 2 headsets are only about $400 they are great, technologically they do the job. But from our work in doing lit reviews, there's not an enormous number of papers that demonstrate hard evidence about efficacy. There are papers, but it's still a little bit the Wild West. And so, it's easy to put a headset on people and they go, oh, wow. Like the oh wow is automatic because of the experience of being in a completely new environment. it's more challenging to set out and say, OK, well, what precisely is the behaviour? And this is what we try and do. What precisely is the behaviour we need to change? How will we know that we've changed it? On what basis can we claim that as a result of this experience that has produced that result. 

Martin Brown: [00:50:22] One of the factors that we encountered is that just putting a headset on people means they've had more attention paid to them in a training environment than they would otherwise have had. And so, is that the factor that's improving their performance or is it actually the experience they're having inside the headset? So, there's a lot of precision required to get very stable results. There is quite a lot of evidence that in pain management and pain distraction, it's extremely effective, quite remarkable evidence around burn victims having their dressings changed. You know, even where the most potent pain medications are not working, VR distraction can actually be beneficial in that sort of environment. There's quite a lot of hard evidence around that. In the areas we're dealing with, we're still we still need to do more lit reviews to get to the bottom of that. But compared to other branches, I. think there needs to be more work done, and we're hoping to be doing that obviously. 

Kate Steinbeck: [00:51:19] I must say, I found even on the flat screen that video or that avatar quite confronting the first male. And I'm wondering if any of the students who were working with you found that just the actual stress of being confronted was quite alarming, because you can see that you might create situations inadvertently that have more meaning to people than others. So, I was just surprised how much having an avatar rather than reading the text, has an impact on what you feel. 

Martin Brown: [00:52:07] It is, isn't it? And we were mindful of that going in, that there are very mild to very challenging and confronting statements that are made in the workplace. And no matter what challenging statement we found when we stress tested it with people who work in clinical settings, they said, oh, yeah, that happens all the time. These are not uncommon. So, there's a lot of literature around this issue of dignity in the clinical setting, not just clinical, any workplace. So, no matter how mild our exemplars are, they're bound to encounter worse when they're in the workplace. But that is precisely the important point, is that this sort of technology is real time, and it produces an emotional response. And as we know, there is a lot of evidence around the idea that memories are more indelibly retained if an emotion is attached to them. And so, we believe that emotional learning is likely to produce more enduring change in behaviour than just knowledge learning. 

Kate Steinbeck: [00:53:12] Now we are going right off topic now. Somebody has just asked; how did you get from films to this?

Martin Brown: [00:53:34] That's a good question, I was I was a filmmaker for a while, and then I had a job with the National Film School at AFTRS. I was head of the academic program there for a while. And as part of that, we ran a kind of innovation unit which was looking at the forefront of telling stories with technology. And we tackled a few projects in that space, one of which was a VR project called VR Noir, which you can look up. It's a few years ago now, but it was an attempt answer everybody who said you can't tell a story in VR because the user can look everywhere except where the story’s happening. And we wanted to see if that was true. So, we ran an experiment where we tried to do a noir thriller in VR, and it won some awards and it was quite successful. So that's sort of kindled my interest in this technology as being another way that you can engage people in a very convincing, overwhelming way with technology. So, I guess that's come back around again for me in my current role. 

Kate Steinbeck: [00:54:43] Most of us on this probably have an interest in adolescent health, adolescent medicine. And it's interesting that often I know clinicians find it hard to talk to adolescents. They find it hard to talk to adolescents who are not that willing to share, who need time to develop trust and before they start acting like a patient should, you know, as so many people say to me and do the right thing and answer the questions. I'm wondering, do you see that sort of situation, either helping young people speak to clinicians or helping clinicians to understand some of the particular issues that young people have with communication.

Martin Brown: [00:55:38] I think that idea that you can put yourself in someone else's shoes is a really fertile area. One of our student experiences was that we only had a male speaking and the person speaking back was female. So, inevitably, one of the students was a male, witnessed himself speaking. So, inevitably, one of the students was a male, witnessed himself speaking from the body of a female. And he found that a little confusing to begin with. First of all, he reported that he thought ‘oh I'm with someone who has been treated that way, and I'm hearing how they dealt with it’, even though he said the response. And the second time he did it, he said ‘that's what it must be like to be spoken to as a woman’. And so that was very interesting to us about this idea that not only can swap outside and witness yourself, but you could.swap outside and witness your response as someone different to yourself, different gender, different racial background, being in a wheelchair, all sorts of differences that could be explored around this body swap environment. So I think that that idea too of being very different in age and status between an established clinician and a young person, I think that would be again, there's more questions than answers, would be a very interesting place to examine when you can get outside yourelf and witness what you did, I would love to have a look at that. 

Kate Steinbeck: [00:57:08] So I'm sure we'll have some conversations. But sadly, this conversation is going to have to draw to an end Martin, we have hit our time finishing. And thank you very much for joining us today on the WH&Y webinar series. And I think there'll be a lot of people watching this as well, as well as quite a few people we're going to send the link round to and make sure some people certainly get the chance to hear that. So thank you again very much.