Nova Wilson, program coordinator for the UCSF Institute for Global Health Sciences, instructs Dr. Mike Reid on using virtual reality equipment at UCSF offices in San Francisco on Dec. 10, 2021. The VR program is intended to teach doctors to have more empathy for their patients of color. (Beth LaBerge/KQED)
When you slip the virtual reality headset over your eyes and take hold of the hand controls, a middle-aged Black woman appears before you. When you move your hands, she moves hers. When you turn your head to the left, so does she.
“You are Monique Williams,” the VR narrator says. “Take a look at yourself in the mirror.”
You have a short Afro and you’re wearing a blue sweatshirt and jeans. You’ve been experiencing a lot of pain in your right arm, the narrator tells you, but after you went to the doctor two weeks ago, the pain has gotten worse, so you're heading back.
Now you sit on a medical exam table, and a white doctor stands at her computer looking down at you. Her voice brims with contempt.
“Yeah, I can see in these notes that one of the other doctors on my team told you last time that a lot of what you're experiencing is because of your weight and lack of exercise,” she says.
When you try to tell her the pain is really bad and you need help right now, she looks at her cellphone.
“Listen, Monica. Uh, Monique,” she says. “As the professional here, I can say, I really don't think you need anything other than to work on diet and exercise.”
Next, the VR narrator asks you how you feel, giving you a range of emoticons to choose from. The frustration, anger and embarrassment all are feelings behavioral scientist Kelly Taylor, 50, knows well from real life. She’s Black and has gone through the same experience as Monique at the doctor’s office.
“For instance, I've gone in, I had some back pain and they will not prescribe pain meds because there’s a perception of drug-seeking behavior,” she said. “In those instances, I have felt that, ‘You don't believe me.’”
Now Taylor is leading the research team at UCSF to see whether virtual reality might play a part in reversing trends like these, testing the simulation to see whether it can raise awareness of medical mistreatment and mitigate unconscious bias among doctors and nurses.
Using emotion to bypass intellectual defenses
The project is called CULTIVATE, short for Combating Unequal Treatment in Health Care Through Virtual Awareness and Training in Empathy. Researchers hypothesize virtual reality can interrupt the kinds of interactions patients like Monique have and may even do a better job than existing training modules.
“Unconscious bias training is super popular,” Taylor said.
But the law doesn’t specify what training should be used. Research is mixed on the many variations of unconscious bias training that have been developed, and, Taylor says, the jury is still out on how well it works or whether it works at all.
“We also don't know much about dosing — how much it should take, how long we should do it to actually see a change in implicit bias,” she adds. “We do know that in some spaces, if it's not carefully thought through, it can actually do more harm than good.”
Some studies show white men in particular may feel shamed or threatened by diversity training. They argue back or shut down, Taylor says — conversation over. With virtual reality, Taylor’s team thinks they can sidestep some of the brain’s intellectual defenses and trigger an empathy response instead.
"So we're not telling you, 'You're bad,'" Taylor said. “We're saying, this is how someone else is experiencing life, and maybe if you can see it from their perspective, that may change how you engage with them.”
Can you teach empathy?
There is scientific debate around whether empathy is something that can be taught. Some social psychologists believe it's a fixed trait, rooted in genetics, and what we’re born with is what we have for life. But others, including Taylor and her team, believe whatever our innate capacity for empathy is, we can learn to increase it.
Virtual reality, in particular, can be an effective tool for cultivating empathy, with some calling it “the empathy machine.”
A Stanford study showed that people who lost their homes in virtual reality developed long-lasting compassion for unhoused people in real life and were more willing to sign a petition for affordable housing. More than 86% of participants in a Columbia study said VR enhanced their empathy for people of color after they inhabited the experience of a Black man interacting with police and being ignored in a job interview.
“You can intellectually understand something, but when you evoke an emotion, it scientifically interacts with a different part of your brain. It codes in your memory in a different way. It triggers different physiologic processes,” said Dr. Madhavi Dandu, professor of medicine at UCSF and an investigator on the research team.
Hearing stories in the news, seeing movies about how other people live and traveling to different states or countries all are things that allow us to connect with others, she added.
“Seeing people differently, understanding something differently than the way we saw something in the first place is where empathy comes from,” she said. “So I think it is learnable and teachable, and more importantly, it's encode-able: It becomes a part of who we are.”
Other researchers caution that empathy is just one piece of what should be a comprehensive, ongoing approach to training health care providers about racism and bias.
“We have to change hearts and minds,” said Monique Jindal, assistant professor of clinical medicine at the University of Illinois Chicago, who believes individual bias training should be paired with education about the structural and systemic causes of racism.
She equates addressing unconscious bias with quitting smoking, which often involves multiple attempts and strategies.
“Some people need knowledge, some people need to be motivated, some people need to be scared by something,” she said. “There are a lot of things that go into someone being able to change the way that they are and the way that they've operated throughout the world their whole life.”
Can building empathy lead to change in the doctor's office?
UCSF researchers acknowledge that their VR simulation is only a starting point. The study is in its early phases and still needs to be refined and fully tested before it can be scaled and, ultimately, given away for free to whatever institutions wish to use it.
For now, they want to see whether it sparks an empathy response, and whether that might lead to even small changes in how doctors interact with their patients.
That’s what happened for one of the first white doctors who tried it.
When Mike Reid placed the VR headset over his head and became Monique Williams, his breathing quickened almost immediately.
“I’m in the body of a Black woman. I've got boobs and I feel different as I look at myself in the mirror,” said Reid, an infectious disease doctor at UCSF and co-principal investigator on the study, along with Taylor.
After 20 minutes in the virtual clinic, being ignored by the receptionist and failing to get the doctor to take his pain seriously, he’s visibly flustered. He looks like he just ran to catch a bus, but still missed it.
“Viscerally, it was very uncomfortable,” he said. “I felt uncomfortable about the lack of eye contact and what felt like contempt or dismissiveness. I could feel my blood pressure rising.”
Right away, Reid starts reflecting on how he’s made his patients of color feel this way.
“I'm embarrassed to say that I think these kinds of things happen all the time,” he said. “I keep people waiting. I'm not fully attentive to their needs because I'm distracted by a million other things.”
The VR simulation includes what researchers call a “repair vignette,” where Monique goes back to the clinic and this time is treated with respect and kindness. The doctor asks her if she prefers to be called 'Monique' or 'Ms. Williams.' She sits down across from her at eye level. She listens and collaborates with her on finding an immediate solution to her pain.
Reid says these are changes he can make to his practice right away. Before this, seeing a patient was all about his own time and all the things he had to do. Now, he’s thinking about his patients of color and how precious their time is. He believes these adjustments will save time overall, for him and his patients.
“If they feel respected and validated, you are more likely to be a confidante and trusted provider to them,” he said, “and the engagement is more likely to be productive.”
But it’s a long road from building trust and rapport to having a definitive impact on a person’s health, let alone reversing the statistics on racial disparities in disease outcomes and death. A large, long-term study is needed to see whether there’s a causal relationship there.
“So essentially, does our VR reduce health disparities? It’s a huge question,” Kelly Taylor said. “We'd love to be able to say, 10, five years even from now, that yes, it does.”
In the meantime, if doctors say they’re going to do their work differently because of VR, even on a small scale, Taylor says, “We’d be satisfied with that outcome for now.”
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