The AR Show: Justin Barad (Osso VR) on Making Surgery as Safe and Reliable as Air Travel (Part 2)

9:22PM Nov 30, 2020

Speakers:

Jason McDowall

Justin Barad

Keywords:

people

technology

vr

haptic feedback

problem

healthcare

world

haptics

solve

procedure

surgeon

training

surgical

assessed

oso

trained

startup

important

surgery

ar

Welcome to the AR show right dive deep into augmented reality, with a focus on the technology and uses of smart glasses and the people behind them. I'm your host Jason McDowall. today's conversation is the second part of my interview with Dr. Justin varad. Justin is the CEO and founder of Oso VR, a fully immersive and scientifically validated surgical training platform. Prior to starting Oso VR, Justin became a board eligible orthopedic surgeon with a bio engineering degree from UC Berkeley, and an MD a medical doctorate from UCLA where he graduated first in his class, he completed his residency at UCLA and his fellowship in pediatric orthopedics at Harvard and Boston Children's Hospital. In this second part of my two part conversation with Justin, we talked about the imperative to improve medical education. He notes our approach to medical education and assessment is still largely based on what worked 100 years ago. But using today's insights and technologies, while not perfect, can dramatically improve and expand the quality of medical education.

Let's say there's this theoretical simulator that is 100% realistic, but there's like one of them in the world. And it's like 100 million dollars, you know, how many people can really use that, and how much value is that providing under the curve. Whereas let's just say, for the sake of argument that you have something that's 80%, the level of realism just slightly less realistic. But now you have millions of people around the world using it, the net benefit, that area under the curve is exponentially by several orders of magnitude much larger. And so that's to me where VR is so powerful, because now you have this, you know, $300 headset that can solve this problem, and you don't need a million dollar piece of technology. And not only that, but it could do it better, you know, based on the existing research

just goes on to describe the opportunity to accelerate the trust curve during in hospital training, the notion that before you can get hands on and work your way up the learning curve, you have to work your way up the trust curve. Justin also talks about startup leadership principles he's learned and his take on virtual reality versus augmented reality. About halfway into this episode, you'll notice we took a break and came back later to finish the interview. Let's dive back in. As somebody who takes evidence very seriously, as a student of medicine, how how do you know that these VR based simulation training sorts of solutions actually work that they actually move the needle in the right direction meaningfully?

I think that's a really important question. And I think this is one of the earliest things that we did as a company is really two things. One is, we need to make sure that this technology works. Like I personally didn't want to quit, you know, full time academic surgical career to just create, like, a novelty. You know, it's Oh, it's cool. It's fun, but it doesn't actually solve the problem. That's That's not what I was in for. And so I'm like, I would like to know, scientifically does this work or doesn't it and then, you know, we'll figure out where to go from there. And secondly, the technology needs to provide value to like, not only does it need to work, but it needs to somehow improve outcomes, drive revenue, or save money for hospitals for the med device industry, otherwise, this this won't be successful long term. So those were two things that were very high priority for us. So one of the first things we set out to do was to get an academic center to do a clinical study. And so UCLA performed a level one randomized clinical trial, where they took 20 trainees 10 were trained in VR and then assessed to a specific proficiency threshold. And then 10, were trained traditionally, so this is didactic materials, text, materials, illustrations, and they were allowed to have as much time as they needed to prepare. And then they came into a test environment where they had to perform the procedure, and they were videotaped. And then they were assessed by a blinded observer, who didn't know what training modality they had done, and evaluated using a scale called Oh sets, which is the object objective structured assessment of technical skill. And what it is, is basically a score of one to five in different categories, like time and motion for the operation, etc. And what that study found that was published in the peer reviewed journal of surgical education was that the OCR trained and assessed individuals performed 230% better than the traditionally trained individuals, which is a difference in about 10 points in terms of the total Oh, SAT score. And what that study told me at the time, is not only does the technology work, it works really, really well. If you look at prior simulation studies, where oftentimes even when you see a study where it's like, Okay, this technology works, but the difference would be so small, it wasn't really clinically significant. So we were seeing a really big clinically significant difference. I think what also really stuck out to me with this study was the traditional trained group could take as much time as they need it. They only needed to come in when they felt ready, whereas the Oso VR group was measured to be ready. And this is, you know, something that I really harp on quite a bit. How we feel and what reality is, are often quite different. And the whole world right now of sort of surgical care is very intuitive and feel based. It's, you know, we feel like this guy's ready, or I feel like I can do this procedure, but there's not really an objective marker of proficiency. And I think this study is sort of an indicator of what a big difference that can actually be. And like, should we really be relying on how we feel in terms of someone's readiness to do something. So that was something that really stuck out to me. And then we had a second level one randomized clinical trial published just a few months ago in a top five orthopedic journal, that showed a 306% improvement in the ability to perform a procedure without supervision when trained and assessed in VR. And this is a very interesting outcome, because not only is once again, a big difference, but there was a study in 2017, that found that after 14 years of education, 31% of graduating residents could not operate without supervision. So to actually make that big of an impact, and that kind of endpoint is a pretty big deal. The final thing I'll say about the evidence is that these technologies that you're talking about looking into like AR and VR, they all get lumped together. It's like saying our books helpful for academics, and just, you know, saying that any book is exactly the same. And so what I point out is that not all VR is created equal. And we need some sort of way to evaluate specific VR platforms to understand what those key differences are. Because I find that it's all getting kind of lumped together where people are like, Oh, I tried Google Cardboard, like VR is not going to work, right? I mean, this kind of extreme example. But that's some of the mindset that's out there. And I think it's just important to understand that, you know, just like a bad website, or a good website, VR is a blank slate in which you can not only present an incredible experience, but also a whole ecosystem platform surrounding it, that can get quite complex in terms of how it all works, and works together. And so that's why I think these studies are not like, hey, VR works. Certainly they show that VR has the potential to work. But these studies are showing that also VR works that the way that also does training and assessment is different and effective. And I think that's just an important delineation.

And also, if you're looking at augmented reality, technology, and anything on mobile, it's in technology in general. And just because something's on a computer is not going to mean it's exactly the same,

you know, so true. I love the analogy between our books helpful to ARV are helpful. It kind of stood out to me, as you're kind of making some question that pops to mind is, how much of the value Have you assessed? Or do you think is related to the assessment versus the type of training that's available within that simulated environment?

I think that's a really good question. I don't know if we've actually evaluated the difference with or without the assessment. But I can definitely say that, to me, that is the biggest differentiator is, even when I do these trainings, you think you know something, and then when you actually put yourself to the test, and you try and run through the steps of the procedure from memory, you realize that you don't, and it doesn't take a lot of work, actually, to kind of get to where you need to get to. But it's that realization that is such a game changer, where you're coming into the operating room, and you feel fully confident when in reality, there are kind of big gaps in your knowledge of the procedure, and you're just not aware of it. So to be able to have that pointed out to you and then to be able to easily address it is a total game changer. So I do feel that just running through a VR experience, even if it's like the most amazing experience ever. It's it's that assessment component that really changes the game, especially how you're assessing people what you're assessing them on. And I think that's where, you know, it's you're talking about product oriented founders and things like that. And you know, there's a new iPhone announced today, and I often think about the iPhone, I often think about the da Vinci two is sort of like, you know, major innovations where someone developed something that nobody really wanted. They're like, Hey, I think we really need this. And someone else is like, I understand actually the core problem you're trying to solve. And I think it actually might look more like this. And it's very controversial and a lot of pushback, then people actually get it in their hands. They're like, Oh, this is amazing. Yeah, this, this solves a problem, right. And so I think that very early on with Oso. There was, like I said, some pushback and this isn't 100% realistic. This doesn't 100% replace, in person surgical training or cadaver training, so it's not going to work. And to me, that wasn't the problem we're trying to solve. We're we're trying to solve what VR does really well the pieces of those components that it does solve for which is knowledge of steps of the procedure, doing certain steps. Well and accurately, and then also getting efficient in those steps. And why I don't want to get ahead. But you know, you asked what book I was reading recently. And, you know, I highly recommend the Checklist Manifesto, if no one's read it, and I really see, you know, sort of like a spiritual kind of follower of that philosophy where healthcare has gotten so incredibly complicated. But if you boil things down to the those steps and checklists, and you can work your way down at just like in aviation, you can change what are complex problems into more simple or complicated problem sets.

Yeah. It's such an insane potential. I just love this analogy that you're painting between how we train and assess the aviation professionals relative to how we're training and assessing surgical professionals. It's definitely a great model here. But as I think about kind of this, this notion of simulation training, not being a doctor, myself, not even being even marginally good at the game operation, I imagine that this notion of using your hands, and in the muscle memory that kind of comes into this. And the haptic feedback you get from interacting with the tools interacting with the human flesh, or the human bone that's kind of as part of the system is part of the benefit of being these sorts of simulation experiences. How How do you think about this notion of haptics? Does it matter? And if so, how do you mix that in? Today's we are relatively limited in the sort of haptic feedback that they that they give?

Well, that's definitely probably the most common question that we get. And I think it's a really interesting one, I often start with defining what is haptic feedback? What are the different kinds, and to me, I think about three different categories. The first and what most people are referring to when they think of like high fidelity haptic feedback is called kinesthetic haptic feedback is is the idea that if you're in a virtual space, and you're pushing on like a virtual wall, that your hand physically stops, there's something pushing back against you, most commonly, like a stylist that, you know, 3d systems makes is, is widely utilized. It comes in, that's what's called grounded kinesthetic haptic feedback. And you can also get ungrounded, which would be like haptics is glove, where it will stop your fingers around a virtual object, right. But it's not tied to a surface, it's it's on your hand, you can move around. Now, kinesthetic haptic feedback has been around for quite some time, well over a decade, and there's quite a bit of research about it in the literature. And what's interesting is that the vast majority of the research seems to find no difference in skill transfer between grounded kinesthetic haptic feedback, and no haptic feedback whatsoever. There are some studies that find an improvement in skill transfer, but like we discussed earlier, not clinically significant, doesn't justify the extra cost and the maintenance. And then there are a small number of studies actually show that it makes people worse, because you're telling them it's 100% realistic, but it's not. So you're kind of leading them down the wrong road, which is kind of interesting. Just a couple of studies. We don't know really how true that is. And I kind of equate it like you're trying to train like an NBA player on a carnival basketball hoop. So that's kinesthetic haptic feedback. And also, a question that you need to ask is, do people like this form of haptics? And so there was actually a really interesting study where they asked a group of surgeons, you know, do you think haptic feedback is the most important component of a simulator and 17 out of 20? said, Yes. And then when they actually tried a kinesthetic haptic simulator to one with no haptics at all, 18 out of 20 preferred the one with no haptics. And people think that this type of haptic feedback suffers from uncanny valley issues, which is why people don't seem to like it very much.

So very interesting there. And then there's a field of cutaneous haptics, which we're all very familiar with. This is like touch vibration temperature. We're familiar with it, because it's in all of our phones, very similar technology. And that's what the Oculus quest and quest two utilizes, which is what we use. And this has some research behind it that cutaneous haptics and simulation studies and robotics studies seems to improve outcomes. It's much lower cost easier to use. And, you know, you mentioned that it's, it's less realistic. And what what I kind of think, is that realism and education are not necessarily the same. Like you can make something very realistic and you can use it for hours. But at the end of it, did you learn anything? Did you obtain some kind of skill transfer? And so for me, the highest priority should be skill transfer, and not realism for the sake of realism. And also, usability is important too, because, you know, if you can you make an incision anywhere and do anything, it can get frustrating, and you get lost, right. And so you always want to make maintain that sort of zone of optimal learning. And so with cutaneous haptics We focus on educational haptic feedback. So like, what are we trying to teach someone with haptic feedback, not just that, oh, hey, if I'm like touching the bone, it feels like this. But we want people to understand that when you're drilling through bone there to kind of surfaces you drill through, and then a hollow center. And we can model that or when you're drilling to the ends of bone, it's not hollow, but it's a lot softer. So we kind of tone down the resistance there. And we can model those differences. So it's, it's less around, hey, how do we make this as realistic as possible? How do we obtain the learning outcomes and objectives that we're trying to achieve, which we can really do quite well with this type of haptic technology. And then there's a third category that is really interesting, where I've seen it called Phantom haptics, cutaneous haptics and sense substitution. It's the idea that our brain has something called tactile memory, that stores kind of haptic data based on our whole life in our experience, and it actually a lot like an optical illusion can fill in the gaps. And so if you've ever used the da Vinci robot, many people report that the haptic feedback on the da Vinci feels amazing like they can feel the resistance when they're like pulling tissue apart, when in reality, there's no haptic feedback whatsoever. I'm not Vinci, none, yet, you're able to peel a grape and do all sorts of very delicate procedures with it. And so this is a phenomenon that's been known for some time in laparoscopic and now with robotic surgery, where it's just this interesting phenomena in the brain. And I've seen this firsthand with our application. Before we had access to the Oculus Touch controllers, we had no haptics at all. But people would take off the headset and be like, wow, how did you get that hammering to feel so good. And I was like, Oh, you know, there's no haptic. So it's really interesting. And I think it's an area of active study in the robotics and simulation world. So at the end of the day, to me, you know, focusing on realism, and fidelity, like we really do go all in when it comes to like visual fidelity, we want things to look really realistic and incredible. But realism for the sake of realism that drives up cost. And not necessarily skill transfer to us is not solving the problem to us solving the problem is a problem of access and scale, we need to make sure that these 30 million healthcare professionals all around the world have access to training and also access to the specific content, and that this content is achieving the learning outcomes that are required to achieve what you know, whatever these people are doing, whether they're putting in a central line, or they're doing complex robotic surgery. And that often revolves around knowing the steps of the procedure, doing critical steps well, and also being efficient. And I often say, you know, let's say there's this theoretical simulator that is 100% realistic, but there's like one of them in the world. And it's like 100 million dollars, you know, how many people can really use that, and how much value is that providing under the curve, whereas let's just say, for the sake of argument, that you have something that's 80%, the level of realism, just slightly less realistic. But now you have millions of people around the world using it, the net benefit, that area under the curve is exponentially by several orders of magnitude much larger. And so that's to me where VR is so powerful, because now you have this, you know, $300 headset that can solve this problem, and you don't need a million dollar piece of technology. And And not only that, but it could do it better, you know, based on the existing research. So it's pretty exciting in terms of solving this problem at scale.

That's really interesting. And then unintuitive, ultimately, also, as an outsider kind of thinking through what would make for a good experience. And it's a delightful, I guess outcome also, right? Because you're able to deliver more value more easily, at least along these levers, then you would have been I would have imagined. So that's, that's really great. Because you now kind of look at the expansion, right of your product offering delivering that product to the broader market to ultimately able to achieve your vision. What are those biggest barriers that you encounter as you're beginning to sell into to integrate into this very complex and messy healthcare system that we have? Yeah, I

think that's a great question, you know, now that we're starting to truly scale the company, you know, we're now more than 50 people. Scaling in itself is a major barrier, you know, making sure that our organization and infrastructure is set up to maintain the speed and the quality of our product as we expand very rapidly in terms of who we work with, where we work, the types of procedures we simulate. These things are our major challenges for any company. I think, also, you know, we are, we have the world's largest VR surgical training library, thanks to the unique technology that we've developed, we're very early on, we recognize that one of the biggest challenges for a technology like this is, whereas if you're building a flight simulator, it's like, you know, you only have one sky and one sort of set of physics rules, and that's it. But here you have, you know, if you look at all the different permutations like millions of different procedures that you can potentially do, it's it and that is one of the major challenges around simulation. So very early on, we built a technical allows us to very rapidly create these procedures. And so starting to apply that into different specialties outside of orthopedics, where we got our start is another interesting kind of challenge that we're solving for, and it's going really well, I think, as you know, you're starting to get a lot of interest given the current environment with COVID, from major educational leaders in various specialties and healthcare institutions. You know, you have to get all these people on the same page when it comes to what are we going to mandate as part of our educational and maintenance of certification pathways. And so I think there's there's some almost like regulatory political elements now that are becoming kind of at play where, you know, you're working with these major professional organizations, and leading academic institutions. And you know, these these key opinion leaders, and everybody has kind of slightly different ideas of how to solve this problem. And you have to work with them to get everybody on the same page and, and be able to paint a picture of what this looks like. So you, you can implement the solution in the first place. And this is a problem for any startup, what you don't want to get sucked into is what they affectionately call like, pilot hell, where every single hospital has their own kind of custom version of what they want this to look like. And you never really create, like a repeatable model that works for everybody. So I think that I see that down the road as being a major challenge. But you know, we're still growing very, very steadily, with, like I said, the current model, which is becoming quite repeatable as we found product market fit. That's good.

So you kind of talked about this, as you as you've been building out the sorts of touch points that have the most potential value, which is really around these these notions of assessment, which is really critical, have an honest, objective assessment of competence across whatever is necessary. And, of course, the right sorts of measures of competence within that surgical activity. But also, of course, the opportunity to train across the wide breadth of training scenarios of surgical procedures that are relevant to a particular target group that you're going after a particular practice for the doctors, is you kind of imagine this ideal end state, where does the VR simulation training fit? Because, you know, we're not trying to necessarily Master 100% realism, not necessarily trying to get rid of the opportunity to operate on or dissect cadavers, or other sorts of maybe more realistic experiences or the existing educational system. But where does it ideally fit in? What can it potentially replace that already exists?

I think it will change over time as the technology both in terms of our software and the hardware that runs on improves, which we've already seen happening at kind of an accelerating pace. And you know, the quest two is really an incredible piece of technology. I think, like you say it is important identify exactly where this technology is best utilized, I think, for certain things this can replace in person training, you know, for example, if you are a high volume joint replacement surgeon, and you do hundreds of joint replacements a year, and you're trying to learn about a new technique or technology, you probably don't need to do that on a cadaver or some kind of in person training at this point, you just need to understand be able to do it and know the steps and, and be able to do the critical steps correctly. So if you're talking about more in residency, or as part of a teaching program, you know, you're wasting a lot of time earning the trust of your teachers in residency, it's, you have very little time to get hands on, especially given how much you need to learn and all of the administrative tasks you need to take care of over 50% of your time in residency is at a computer using electronic medical record system, which is getting really out of hand. So you know, you're having less and less time operating and getting hands on with patients. And what happens is you come into the operating room, you learn in like two month increments two to three month increments on these rotations. So you're rotating between in orthopedics, just as an example you rotate on trauma on foot and ankle joint replacement on spine. And so you come in, and you come into the operating room with your attending surgeon, sometimes there are many of them. Sometimes it could be 30 plus in this one specialty. And they're like, hey, this patient is trusting me with their well being in their life. I don't know this person across the table from me at all. So I'm going to take some time to really understand what they know and what they don't know. So that I can kind of allow them to do parts of the procedure where it's going to be safe for this patient. And that can take some time that can take a couple of weeks. Sometimes it could take a month because maybe you're only operating with the surgeon once every other week. And so I call that the trust curve. I've never really heard of that before, but that's kind of how I describe it. So before you can get hands on and work your way up the learning curve. You need to work your way up the trust curve and in certain programs, where you're getting passed around. So much, you may never get far enough along the trust curve before you have to switch rotations. And then you didn't really get any hands on experience. And that leads to cascading issues, as you're kind of under trained for the level that you're at. So where I see this is really useful for residents is not only to move their way up the learning curve, which we have data that's been published in multiple journals that that shows that that's the case. But also, if I as a supervising surgeon can see that you can demonstrate knowledge of steps of the procedure, you can do those steps well and efficiently, I'm going to feel much more comfortable letting you do more sooner. So I've actually not only moved you further along the learning curve, but I've moved you along the trust curve, so that you're going to get more cases in total. And because you're already equipped to do those cases, better, you're going to, you're further along the learning curve to start and then you're going to move further along on the rotation than if you had never done the simulation at all. So this is an example provide word we're not replacing in person training, but we're facilitating we're even allowing you to do it at all right? Otherwise, it's getting very difficult to do it. So you can just pretty clearly see the picture. And in just that single example, what an incredible differences can make. I think another thing is, as we finish residency, in the US, we have a time based residency system, unfortunately, where you're just in there for like five years, and then you're out, you may have been ready sooner, maybe you need some more time in the oven, but we don't really have a way to check. So one advantage of technology like this is it can be used as a tool to understand if someone is ready to finish maybe even earlier, which is some data from some Canadian residencies that have been experimenting with what's called competency based education. And so we believe very strongly that this technology has a real role in kind of determining your sort of readiness to practice and your ability to graduate from residency. And then finally, on the front end, as we're bringing in new talent, understanding, you know, what are the abilities of these people coming in? What is their potential to learn their aptitude and their ultimate ceiling, if any, and that's an area that is also of great interest to the profession, which I think is probably going to be a later stage thing, frankly, as it's a bit controversial. And also, you know, how do you actually implement that, but that's another area where there's a lot of interest in the community.

Yeah, those are amazing areas, there's really a compounding impact. There's compounding interest sort of concept that plays in here, right, you tweak it here, you create that level of competence that's been properly assessed, you move them for a logo on the trust curve, which then allows them unlocks the opportunity to do more in person hands on sorts of training, which further accelerates them is you can take that through the other steps that you described, right residency experience, etc. It really has some beautiful compounding effects. So that vision ultimately you have for how the technology gets integrated, maybe an important point a leading edge to the round of funding that you recently were able to close, you're able to close $14 million of funding, which is amazing. Congratulations on that is you were working through that process, which happened well, after COVID started and closed here just a month or so back. Right. What were the key points of traction that you had to demonstrate or the sorts of potential that you pointed to he described when making that pitch to investors?

That's an excellent question. You know, as you say, we we just recently closed a $14 million series A led by Kaiser Permanente ventures, and other notable investors like signal fire GSR ventures, OCA ventures, and we're just really excited for institutions like Kaiser to one recognize that this is a major problem. And and to that osoby artists is the company to address it. And it was an interesting road raising the series A for sure, because, you know, we started to have these conversations, what what we felt we brought to the table is that, you know, we have identified this massive problem, space, and problems are often opportunities in the world of technology. And not only did we identify problem, but also a unique pathway in order to build a scalable high margin software business. And we were able to prove this out with our early traction. And, you know, part of it is finding a business model that works and is scalable, which we're able to do. And the other part is to solve critical technological problems. And one of those is how to generate enough content where we're simulating, you know, there are 10s, or hundreds of thousands of different permutations of all of these surgeries that we need to simulate if we want to reach all 30 million healthcare professionals around the world. So you know, how are you able to do that, like, are you building all of these from scratch, there's there's no scalable way to do that. And so we spent years developing technology that allows us to automate the production of these very high fidelity procedures that also incorporate assessment and collaborative training. And so coming to the table with the traction and the unique technology, and also the team that we brought to the table is part of the story that we're telling, and also the vision of what we're trying to Do where we had a very broad vision and a clear mission. And then a focused roadmap on how do we get there? How do we go from zero to one? Now, as we were telling this story COVID, you know, strikes with a fury and everything goes on lockdown. And you know, everything honestly was up in the air, like everyone was just like, hey, like, we just got to put this on pause right now, we're very excited. But we don't know what way the world is going to go. Nobody knew. So that was very interesting to see how those conversations played out. And very quickly, it became clear to people that while obviously, this is a terrible thing that's happened to the world and a huge challenge, that this could be a huge tailwind for a business like this, and many other businesses that drive sort of digital transformation, the ability to improve clinical performance, without needing to be physically present, or, you know, in an automated remote way. And VR was seen as a critical piece of that puzzle. So it went from, you know, this is a very compelling story and a technology that is solving an important problem to we're not having any conversations right now. It's all of a sudden, this is an urgent problem. And this is the technology to solve it all in the span of a few weeks. So it was a real roller coaster. But, you know, we came out of this with incredible support from the world's leading healthcare. Kaiser Permanente is the oldest healthcare institution associated venture capital fund, the world's leading investors, the team continuing to expand so we definitely exited sort of this crisis stronger and better equipped than ever before. But both for the team and myself it was quite the journey. And I think words can we'll ever do it justice, but really an incredible experience. In that moment,

when you thought that you are on the cusp of closing that round. And then COVID strikes and the mindset initially was I everything's going to stop until we really understand what's going on. What was going through your mind. How close were you to the edge

is less of the edge and more of the bottom? I guess whatever it's Murphy's Law in startups applies 100 fold. And then I think is it Hein setters law, I think these are the two things that every startup should factor in where what can go wrong will go wrong. And then also, I think, is Hein setters, ly have to recheck. But it's, you know, everything you do will take longer than you think even when you factor in hindsight. So I think those are the two things that when this happened, I'm like, of course, like something had to have gone wrong at the 11th hour. And, of course, this is going to take longer than we thought it would. So I wouldn't say that I was I was, you know, obviously, everybody was surprised about this whole situation, but I knew something was going to come up. And I think that's what I'm just proud of the team that we put together because it's when things are going well. That's not how you measure like an incredible team, right? It's when things are not going as planned and how you react to it, and how you interact with each other under stress under crisis under what feels like wartime conditions. I think that's what proves the mettle of a person and of a team. And there was really no point where anyone felt worried or not optimistic, or still having a great time on this journey together. And, and that's when I knew that we'd get through it, you know, like, I just knew that our product was incredible. Our customers loved it, the world needed it more than ever, and our team was just loving every day. So even when we were encountering these unprecedented challenges. And you know, we did make it through the other side with an even better outcome than I thought we'd have in the first place, which is what's so crazy about it. So I definitely think that that dynamic. I mean, I was just talking to the team today about it, that it's it's how our team responds to these, you know, there are going to be problems and challenges in the startup. That's what you sign up for. It's like endless challenge, endless micro failures. And it's people that enjoy those kinds of things and enjoy tackling them and enjoy working with the team that also feels the same way. That is the dynamic that we have, and that I hope most people have, because I've definitely been on teams that don't react that way. I think it's something that I brought from the world of surgery that when things aren't going well in a surgical procedure, it's Yes, you have to know what to do. But it's also you know, how you interact with the rest of the team under stress. It's because things can fall apart very easily under those conditions. But if you're optimistic, and you have a plan, and everybody else feels really good about it, they're going to continue to perform at the highest level and you're going to get yourself out of that situation. And I really, in my teachers, the surgeons that trained me that was the one trait that I valued the most that it's I've seen the most horrific things go wrong in surgery and situations that I thought that no one could have ever gotten out of. And we've gotten out of them and partially from knowing what to do. But I felt like it was really that that maintaining the morale and the engagement and the thoughtfulness of the entire team that would get us out of those situations and give the patient the very best outcome that I could possibly get into the circumstances. And I really have tried to embody that element

of curiosity in a situation you've been in industry. surgery room? Have you seen it go the other way? Have you seen the lead surgeon react in the opposite way? And the what sort of outcome came from that?

Yes, quite a bit. You don't you don't know what good looks like until you've seen the opposite, I guess. And so it can get pretty dramatic. I've certainly seen people stormed out of the operating room instruments getting thrown, expletives. Just stomping, like uncontrollable shaking and sweating. So it's, you know, not to make fun of these people in these situations, because these are human reactions, these situations, when you have someone, you know, under the knife, they're, you're responsible for their care, like anything that happens to them ultimately, is going to be your responsibility. Sometimes it's just it can be too much for anybody really, like any normal person would kind of crack under those circumstances. And I think it's, it's so easy to kind of fall into that trap. And sometimes you just need to kind of blow off a little steam in order to kind of recenter yourself. So it's, I don't think it's a flaw to be that way. I think that's kind of how we're wired. But it's the people that are somehow able to that that kind of unflappable mentality that fighter pilot calm as they say that I was so amazed by it, because, you know, some of the situations I've seen, I'm like, Well, I don't know how I'd react under these circumstances, to be honest, because I hadn't yet faced them. And so that's why I was really impressed by it. Because it's not, it doesn't come naturally, I don't think. But yes, it's I mean, anything you see on TV, it's probably even more dramatic in real life. Like it's I mean, these are really the limits of what human stress is capable of, you know, comprehending if someone is, like dying as a result of your actions, or maybe permanently mutilated or disabled, it's, it's a lot to bear responsibility for. And in the moment in which it's happening, it's very difficult to kind of deal with and, and figure out how you're going to make the best of the situation.

Yeah, is incredibly stressful environment. In here, now as CEO, or also a CEO, that happens to be you are dealing with the livelihoods of all of your employees, and setting those expectations and making sure you've taken care of those psyches, those families, all of that is kind of part of this, in your journey as a CEO, kind of this evolution of your leadership style. How have you noticed you've changed so you can reflect on the last four years or so?

Well, I, you know, I, I'm very confident I've changed a lot over the past four years, I think, in many ways, probably, I'm not aware of that, you know, my team members could probably tell you better than me. But some of the things I've noticed, certainly, this concept of, of kind of calm, and you know, always reacting calmly, under pressure under crisis is something that I've tried to embody from day one, and is, I think I've done a good job of that. What was interesting coming into a startup from the world of surgery in the world of surgery is very much you want everybody to speak up and to say something, something's going wrong. But at the end of the day, you're making the shots. And you know, very explicitly all the time, the smallest decisions, you're often like, Hey, we're using this suture, we want this type of gods, like, I want this retractor right here. So it's like, you're very much kind of telling everyone what to do. And when, when you need overtime, etc. and software development companies are not like, you can't just run around telling everyone what to do all the time, right, you're never going to be able to scale a business, that way, you create a lot of churn, it can be very blocking, while people are waiting on your decisions. And then you come in, and you basically make a decision and undo a bunch of work. So you know, finding out how to lead not by sort of direct, like directive, but by influence, right, by being very intentional about how you communicate intentional about your feedback. And if it's working, right, the decisions that get made aren't made by you, but they're the decisions that you would have made. And that's when the system is kind of working, it took me a very long time to get there. And you know, it was hiring people that are much better at their sort of domains than I am so I could learn from them, you know, how how to develop software and how to do these things. So I think, in some ways, surgery really, you know, didn't kind of help me in kind of the way that the surgical world works. But I think it also as physicians, we're always lifetime learners, we're always learning new things. We're constantly educating ourselves. And I think that was very helpful coming into it, because I am constantly learning new things about how best to run the company. And also to know that different stages of the company need to be run in different ways. And being very aware of that, and always trying to evolve and never be stagnant. You know, you have to constantly be moving and be adjusting how you're reacting to things, and that I cannot emphasize size enough. You know, you have to be very careful how you communicate with people because you don't realize when you're sort of the CEO or even a co founder, people listen to everything you say. So if you say something as an aside comment to them. That's like a very strong directive to do something. So you're like, man, it would be great if we had this thing. Tomorrow, you're gonna have that and that doesn't there's nothing for free, right? That's it's not like Wow, this is great. That's awesome that people are kind of doing what I say. That means that someone is up to like 6am. And also that they weren't doing some other work that was actually much more important for the business because you had some offhand comment. So that's also something I've been learning over time as well. And I think the last thing is like, I think a lot of doctors and especially surgeons have a bit of a hero complex, where it's like you want, you want to help everyone, you want to save everyone, any patient that comes to the door, you're going to help them. But you know, when you're on a team, and you're, you know, trying to create a, like a very complex product, run a complicated business in a challenging environment. It's like finding that balance, where it's like, you need to set everybody up for success. But you also need to hold people accountable, ideally, mutually accountable, right? But it's like, you know, where do you draw that line where someone is really not pulling their weight, they're not prioritizing the needs of the whole over the individual. And you know, where you just kind of like, you know, where goodwill and good nature can actually kind of hold hold everybody back. And part of it is just being honest with people and being transparent. And I think in some ways, once again, it's like, there are good things and bad things for medicine, where, you know, the bad things are that it's like, you want to save everybody, you want to help everybody. But it's like, what you're trying to do is solve a very specific problem at the end of the day. But what was helpful about medicine is that I've spent my entire career having hard conversations with people and telling them terrible news, bad news, and just being very transparent about what are we going to do from here. And I think that training has been very helpful for me, because I'm able to have these conversations. And I think people feel like that, it's I'm just communicating very honestly and openly and that there isn't a lot of emotion behind it. So there, there are many ways where i think that you know, especially in health tech, physicians, nurses, anyone who has first hand experience, they have great skills coming in. But I think you also have certain trains, deficiencies are areas that you probably are prepared in not the most optimal way. And it's really it's unlearning those things and also realizing that you don't know everything. And I do see this problem in either sort of healthcare professionals that transition to technology or startups, whether they're working with a startup, or they're running one or part of one that, you know, you think you're amazing, as a physician as a healthcare professional, because we do amazing things. But you do amazing things as part of a very long chain that involves a lot of other people and a lot of complexity, and many interacting pieces. And it's easy to lose sight of that get tunnel vision and think that you are this sort of like genius. And yes, you're very good at a certain element of healthcare delivery. And you know a lot about that problem space, but you are not an expert on marketing, you're not an expert on sales, you're not an expert on product, you're not an expert on program management, or testing or software development, data analytics, right? Like, there's a lot of complicated pieces, and you're not an expert on any one of these areas. And admitting that you are not an expert at all these things and other people are probably much better at it than you is the first step I think to really being successful and technologies sort of letting go. And it's amazing to me, like, you know, those early days of walking into these meetings with investors, they certainly I thought very highly of myself, like, here's a surgeon is willing to sacrifice at all, for a startup, like everyone should just hang on to every word I say. And everyone's like, wow, it's your background is really awesome for like the first 20 seconds. And then they're like, what's, what's your financial model? What's your current burn? What's your gross margin? How do you explain that and they're just like, they're not being nice, and you get no credit for being physician. Like once that and those initial pleasantries are gone. So it's like, you're not going to be able to somehow be held to a different standard, because you're an expert, or highly regarded in society, you still have to just go through the same road that many other founders do and, and learn what you need to do and do the hard work. And I think that's just the little piece of advice I'd share with healthcare professionals because we badly need people to solve problems and create technology or partner with technology companies, but you need to come into it with the right mindset.

Yeah, absolutely. It's amazing. I just trying to picture you walk into the first VC meeting, are you saying, here I am. appreciate me. And they say that is amazing. Now, down to business. Yeah, describe this thing. I

mean, that's like exactly how it when it's like, it's like, Hey, I'm a doctor, and I'm doing doing VR. They're like, okay, like, what's, what's the market size? And like, Oh, yeah. What do you mean, you know, it's, it's amazing, like really starting from zero, you know, so I was humbled very quickly. And it's also interesting, you know, being you back when conferences were a thing, and you're like at a booth and you have other doctors walking up is like, how we, as physicians, treat people who aren't, you know, physicians, like who we feel like are trying to sell us something, you know, and thinking back on how I probably treated people pretty poorly, who are salespeople who are up at two in the morning, not seeing their families so they can support a surgery and make sure that the patient did well. Yeah, they were selling a product but they were doing a lot of other important stuff. And they're being kind of mystery to buy everybody just because they're seen as like a salesperson, you know, are not part of the team. And so that's also just an interesting realization. Once the tables have turned. It's just it's such an amazing experience. Like if, if people in medicine could like do like an externship or something like that, at, like, you know, at a VC or at a technology company or the device company, it's just seeing kind of all of the hard work and the amazing people and everything involved, I think would really broaden your worldview. Because you can really get stuck in a silo and kind of this is tunnel vision when you're just you're taking care of patients every single day. But there's there's a lot going that goes into it that you're not seeing.

Yeah, absolutely. Let's wrap with a few in lightning round questions here. First one is this. What commonly held belief about spatial computing? Do you disagree with

a few. But I think the biggest one, and I'd love to get your take on this is that augmented reality is the natural evolution of virtual reality, where I see them to be two very different technologies that have different optimal use cases, in healthcare, you know, if you're going to be interacting with patients, if you're going to be in the operating room, of course, augmented reality, mobile AR, holographic headset displays, makes a lot of sense applications like navigation planning, telementoring, tele proctoring, these are these amazing stuff happening. But if you don't have access to these things, and which we're in this right now, right, we're in COVID, we can't access facilities as easily, we can't access capital equipment, like x ray machine or surgical robots to train on. Well, those technologies aren't not very useful, you need something that can basically synthesize all of these things. And that's where VR becomes so powerful, and has so many advantages when you don't need to be aware of your surroundings, or you don't have access to real world equipment. And so I think, you know, training and assessment are, like, really the killer application of VR, there are a lot of other VR applications that are very exciting, like, you know, rehab, physical therapy, there's some therapeutic applications in the psychology and the auto space. There's all sorts of exciting stuff. But, you know, often I'm getting questions like, okay, like, when are you guys going to do AR because that's like the next thing. And it's like, I see two very divergent things. Certainly, there's like passthru, and augmented VR and like interesting things, that we're still figuring out the role that those things play, but I see them as just two very separate use cases.

I agree that I see them as two separate use cases, for sure. And I think that if you're getting questions from investment types, we're saying, When are you going to add AR, hopefully, it's from a perspective that there's an additional related opportunity here, we absolutely completely different problems you're trying to solve. You're trying to solve, not the real time, I'm going to assist the surgeon in this moment in the surgery, but I'm going to make sure that they are properly assessed, and they're properly trained going into that surgery before they get there.

Mm hmm. Yeah. For example, like a common thing that comes up is like, well, if you're in the surgery, and you have something that tells you what to grab, and where to put it, that would be really great. And I agree, but would you take a concert pianist, put them in front of music he's never seen in his life. And you know, you have a holographic has a display that highlights what notes to play, like, that's not going to be a great performance, right? Like you still have to practice. And it's still like, there, there are separate problems that are kind of related for a more holistic issue, like how we deliver procedural care, and in medicine. And so it's, I think, the The important thing to understand is how to interact with the different use cases in technology. So how does it make sense for VR to interact with AR? Or how does it make sense for the data produced by VR to interact with the data produced by AR experiences and those use cases? And I think that's the questions that we should be asking is like, how can this ar interoperative technology be better with VR? And how can the VR technology be better from the data produced by the AR technology and not like, hey, like, let's just get one solution to solve every problem magically

agreed, completely agreed. I think the one of the most direct translations potentially to AR is that when that person in front of the injured person is not an expert, and the opportunity is to use all of what you've gathered in terms of training, and make them an instant expert in this moment, right? either because they're being additionally facilitated by a live expert, or they're being facilitated almost primarily by the software that you've created. Maybe there's a scenario there. I'm just trying to brainstorm what what might be going on in some of the people's minds, but it feels to me like there's a gigantic opportunity exactly where you are, without ever needing to go into AR there's not one once we have ubiquitous AR glasses, it's not going to mean that we don't need VR goggles anymore. I'm not a proponent. I don't not a believer that anytime in the foreseeable future, they're gonna have one device the rules them all that's going to seamlessly go between those two experiences, because optimizing for one scenario, means that you are taking away from the other scenario, right? VR is very much about immersion, very large, wide field of view, lots of colors, you know, the whole sort of tracking with all the controllers All these things are really important. Whereas air is all about wearability, at least in the consumer sort of sense. It's really about wearability, it's about being able to have a device that allows you to have some utility, while also looking like a normal person gives you the confidence to wear the thing to be seen wearing the thing in optimizing for those are those in the near term, next 510 years, not gonna deliver a good experience there. And if it does, both,

and and don't get me wrong, I'm very excited about the direction augmented reality is heading in. And it's, you know, it's still very early in that space. So I think it's, you know, we're starting to see the like, Where are the really exciting use cases? At least in healthcare?

Yeah, yeah, absolutely. Let me ask two more here. What book Have you read recently that you found to be deeply insightful or profound?

You know, I'd highly recommend anyone listening in to read the Checklist Manifesto. I refer to it earlier by a tool one day, I think that book was written a while ago, but even then we're still facing an earlier version of the problems we're facing now, which is the runaway complexity of modern medicine. And the way that he proposes dealing with it is through the use of checklists, break down a complex problem to a simpler problem, where you take some kind of problem in medicine, and you're like, Okay, to approach this, I run down basically an algorithm or a checklist. And that's, that's really sort of the the driving fuel of also, which is, we can take these very complicated procedures, and we can break them down to checklist algorithms. And if you know, the recipe, that's 80% of the battle, that's what our research shows. But this is a problem that goes beyond surgery goes beyond procedures, and is, I think it's very important for everyone to understand just how complicated medicine has become in the modern age. And I think this book is a great way for us to start to get a handle on it, and to simplify things so that we can really start to scale healthcare, like we haven't really done a good job of it, it is very bespoke, you know, and you're starting to see it starting to see real healthcare and digital health startups and what's happening in the telemedicine space. It's been amazing. We're finally using technology to solve these problems. But uh, I think this book is was a major catalyst for a lot of transformational change in healthcare. Once everyone really understood what the problem was, which is that it's very complicated.

Yeah, that's a great one. I'll definitely add that to the show notes. If you could sit down and have coffee with your 25 year old self, what advice would you share with 25 year old Justin,

I've gotten like a lot of good advice. And I would probably just give the same advice that that I got, you know, like, maybe I could give it to myself a bit earlier, which is, you know, don't worry about what you think successes, just do what you're passionate about, and successful find you. And, you know, when I was faced with a decision to basically drop out of academic medicine, and the the beaten path and the safe path, I thought about that, because that was advice I got from someone, when I was a bit older, when I was interviewing for fellowship, and it just, it kept repeating itself in my mind. And I'm like, I know what I'm more passionate about. And I'm just going to do that, and not worry about what people think I should be doing or what success is defined as, and it was a huge risk. And you know, it ended up paying off and I'm just so happy. Even if it didn't work out. I'm like, I'm really much happier now. And I would tell myself to, you know, start incorporating that advice at an earlier age. And I would definitely share that with anybody else listening because it completely changed my life. And it's amazing how caught up we get with what we're supposed to be doing. And you know, there is some element, it's not like, you should be doing something that's fun all the time, right, your job, jobs or jobs for a reason. Because they can be hard and very challenging. But it should be something that you are passionate about.

That's a great one. Any closing thoughts you'd like to share?

I think this is a very, obviously challenging time for the world and very hard time in healthcare. But it is been an incredible opportunity. You know, we've never faced problems greater than this. But at the same time, we've never had solutions like what we have today, augmented reality, virtual reality in AI and mobile technology, and then all these other amazing things. So we have the ability to solve these problems now. And now we really have the motivation to do so as well. Like, we understand that we're at the breaking point. And it's amazing that everything's still functioning at the moment. But you know, that can't last. And so it's really the people that are solving these problems are our healthcare professionals that are interested in innovation or technologists that are interested in health care, everybody has some kind of story of, of why, why they want to solve these problems, some personal connection to technology or health care. And I just I just want to tell you guys that you're needed more than ever, you know, like, we're solving a big problem, but there are many, many, many other problems that we need people to try to find some So don't give up. And do you follow your passion and you know, the world needs you more than ever. So I'm very grateful for anybody listening that is an innovator works at a startup works in health care works in technology, even on like the hardware products that are being developed, because they're absolutely amazing. It takes a village and I'm very optimistic about the future if we continue on the track we're on when it comes to utilizing technology within healthcare.

Yeah, it feels like it's time that there hasn't been technology. It's been Of course, it costs an area of innovation. But it feels like it's the right time for us to apply all this great, amazing Information Technology, to healthcare to the benefit of the whole system, and every patient and doctor in it. Where can people go to learn more about you and your efforts? Also,

you can go to Oso VR comm o SS o VR, you can email me Justin at Oso VR, you know, especially if you're a healthcare innovator, one of my lifelong passions is to encourage disruptors and innovators in healthcare and how to balance kind of being in both worlds, which can be very tricky. So please check out the website. Please email me if you're interested. Follow us on LinkedIn, and Twitter. And yeah, thank you so much for having me on the show. This has been an incredibly stimulating conversation. And I just, I love the way that you think about these

things. Justin has been my pleasure. Thank you. Before you go, I'm gonna tell you about the next episode. In it, I speak with Alex hotel. Alex is the former co founder and CEO of experience and currently an inventor at Intuit for he is a director in their futures group. Alex completed his PhD in computer science at the University of Toronto, and is an expert in no code languages, as well as the use of immersive technologies to make the physical world digitally interactive. In this interview, we explore Alex's concept of the world computer, as well as making AR more accessible with a new no code language and his entrepreneurial experiences through to startups. I think you'll really enjoy the conversation. Please subscribe to the podcast. Don't miss this or other great episodes. Until next time,