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The Sim Cafe~
Discussions on innovative ideas for simulation and reimagining the use of simulation in clinical education. We discuss current trends in simulation with amazing guests from across the globe. Sit back, grab your favorite beverage and tune in to The Sim Cafe~
The Sim Cafe~
Beyond the Headset: Revolutionizing Medical Education with VR- Dr. Ryan Ribeira
What if healthcare professionals could practice high-stakes procedures hundreds of times before ever touching a real patient? Dr. Ryan Ribeira is making this vision a reality through virtual reality medical simulation.
As both an emergency physician and the founder of SimX, Ribeira bridges the worlds of clinical practice and technological innovation. His journey began in quality improvement and patient safety, where he recognized that traditional approaches weren't creating the dramatic safety improvements healthcare needed. Looking to aviation's remarkable safety record achieved through simulation, he saw an opportunity to transform medical education using virtual reality.
Traditional medical simulation centers face significant limitations – they're expensive, require dedicated space, and offer limited availability that typically restricts training to quarterly sessions. Mannequins can't display neurological symptoms or traumatic injuries, and capturing the psychosocial complexity of real patient interactions is nearly impossible. Ribiera's solution? Create virtual patients and environments that can be deployed anywhere in minutes.
The impact has been transformative. Healthcare organizations using VR simulation have increased training frequency from quarterly to several times weekly. Modern headsets with improved refresh rates have largely eliminated motion sickness concerns, making the technology accessible to virtually everyone. The technology allows learners to experience rare but critical scenarios repeatedly, building muscle memory and decision-making skills without risking patient harm.
Looking forward, Ribiera envisions AI-generated training scenarios, mixed reality combining physical task trainers with virtual overlays, and biometric monitoring that keeps learners in the optimal stress zone for skill acquisition. These innovations represent a fundamental paradigm shift from "see one, do one, teach one" to "see one, sim a hundred, then do one."
For healthcare educators, administrators, and practitioners facing increasing patient volumes and staffing challenges, VR simulation offers a powerful solution for rapid, effective training. Join us as Dr. Ribiera shares his insights on this revolutionary approach to medical education and his vision for a future where patients never have to be someone's first attempt at a procedure.
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The views and opinions expressed in this program are those of the speakers and do not necessarily reflect the opinions or positions of anyone at Innovative Sim Solutions or our sponsors. Thanks to Innovative Sim Solutions for sponsoring this week's podcast. With over 50 years of experience, they'll bring your next simulation center to life with ease, confidence, while saving you time and money. Contact them today. Welcome to The Sim Cafe, a podcast produced by the team at Innovative Sim Solutions, edited by Shelly Houser. Join our host, Deb Tauber, and co-host, Jerrod Jeffries, as they sit down with subject matter experts from across the globe to reimagine clinical education and the use of simulation. So pour yourself a cup of relaxation, sit back, tune in and learn something new from the Sim Cafe, from The Sim Cafe.
Deb Tauber:Welcome to another episode of The Sim Cafe, and today we're here with Dr Ryan Rivera. He is a prominent emergency medicine physician, health technology interviewer and educator based in California. He currently serves as the medical director of the Sanford Adult Emergency Department and holds a clinical assistant professorship at Stanford University School of Medicine. In addition to that, beyond its clinical roles, Dr A is the founder and CEO of Cimex, which is a leading provider of virtual reality medical simulation software. So thank you so much, and we already talked. You said I could call you Ryan. So, ryan, do you want to add anything to your introduction?
Dr. Ryan Riberia:Maybe the only other thing to add. I appreciate that introduction. I think maybe the only other thing to add is you know, prior to founding Cimex and maybe we'll get into this as we go along I was pretty involved in quality improvement, patient safety work. So I worked for CMS and AHRQ like building packages of quality metrics, and I also was on the board of trustees of the American Medical Association working on like public health work to try to make healthcare safer, and that's actually the kind of the thing that brought me into the SIM community. I came from the angle of not technology actually, but from patient safety, quality improvement and how can we use SIM to make care safer?
Deb Tauber:Wow, you certainly have your hands full and have done so many things, and I thank you for all the things that you've contributed to.
Dr. Ryan Riberia:Why don't you tell us a little bit about your current emergency department experience and some of your challenges, since you're still currently yeah, yeah no, yeah, I do actively practice and, as you mentioned, I kind of work as a medical director and I think we face probably a lot of the challenges same challenges that people do across the country in emergency departments right now, which is more and more people coming in the door needing emergency care and often not enough places to put them. And so you know that's a lot of my work as a you know operations lead at Stanford is trying to figure out how we can make sure that we're able to safely care for the increasing number of patients that come into our doors. And I say, you know, one of the other challenges that we face a little bit less at Stanford but we still do face and many other hospitals are facing is how do you make sure that you have sufficient staff that are adequately trained right as volumes go up and, as you know, I think post COVID we've continued to suffer a bit from a nursing shortage especially. You know how do you make sure you get people in and you train them up for you know the skills that they sure you get people in and you train them up for. You know the skills that they need for their role and how you do that quickly. So that's something that we deal with as well.
Dr. Ryan Riberia:And then you know, on a personal note, emergency medicine requires you to do days and afternoons and I did a night shift last week and then I did a 5 pm to 1 am yesterday. And how do I navigate that with the 9 to 5 or you know, more like 7 to 7 job of running a tech company? You know that's some of the things that I face every day, but you know I love it, emergency medicine. You really get to see new things all the time. You really get the satisfaction of helping people who have an acute need and getting to help them through that. So I wouldn't trade it for anything.
Deb Tauber:Thank you, thanks. Now, what inspired you to start Cimex and how do you see virtual reality transforming medical education and training?
Dr. Ryan Riberia:Yeah well, so, yeah, big question there. And I, you know, gave you some of the background, I guess, already, which is that I came from the world of quality improvement, patient safety and trying to think about, you know, how can we, how can we improve the quality of the care that we provide? And, after spending years in metric development and sepsis, bundle compliance programs and things like that, I mean that's really important stuff. But I started to feel like, well, you know, we really we need to do more than just reduce this one certain part of medical errors by 7%. We need to be, you know, decreasing all of our medical errors by 80%. And how can we do that? And I really got interested in simulation because it was such a big part of how the airline industry has become so safe and I see a lot of analogies between the airline industry and medicine. I mean, we both have a lot, a large number of low frequency but high consequence events that we need to be prepared for, and that's exactly what sim is good at. So that was kind of the grist for it. And then, as I was going through medical school, I was going through sim training myself and you know I noticed that there were a couple flaws that prevented us from being able to achieve the same success they've had in the airline industry.
Dr. Ryan Riberia:Airline industry, they've got these hyper-realistic simulators that are like a perfect one-to-one matchup with real life. We don't have that. We had mannequins, which are great but can't really have traumatic injuries. They can't really have neurologic symptoms. There's not a lot of psychosocial interaction there, and then we really weren't simming all that often. I mean, the sim centers are very expensive, the time is hard to get, the equipment is pretty limited and so, you know, when you're at a big academic center, that's sharing between your nursing program and your MD training programs and your APP training programs and all this stuff. We ended up simming like once a quarter.
Dr. Ryan Riberia:I was going through my own training and thinking, well, you know how can we resolve this? You know how can we resolve this, and I had a background in technology and entrepreneurship already and was looking at the kind of upcoming VR, AR world. This was back in 2013 and thought, you know, this might be the solution. Right, it was a virtual patient. They can have neurologic symptoms, they can have traumatic injuries. You can have any demographic that you need and you don't need to buy a bunch of equipment to make a multimillion dollar sim center. You can just, you know, be in an OR or in the PACU or, you know, in the back of an ambulance and all it takes is kind of software development.
Dr. Ryan Riberia:So it seemed like there was a lot of potential there to solve those issues. And, you know, back in those days there weren't really any VR headsets available for an average consumer. So we just started building the software, knowing that one day someone would make the hardware, and we were doing that for many years and then eventually, 2018, 2019, our headsets started to become released and we started to have customers. And then 2020 is when the Oculus Quest came out, which really made it dramatically easier for people to use VR, and that's things kind of took off from there.
Dr. Ryan Riberia:And you know, I do think when we talk about the benefits of VR, that is really where a lot of the power is the fact that you can pop up a high fidelity sim experience in any empty space in less than five minutes. Right, and there's obviously pros and cons. You're not going to get the tactile element with VR that you get with traditional simulation training, but you are getting a lot of great psychosocial complexity. You are getting a lot of great environmental complexity. The visible physiology that you can portray on a patient is really flexible and awesome. And, again, many of our customers have gone from simming once a quarter to three or four times a week because it's something that they can just pull out back to the classroom, pop up their sim center and go, and so that that's our hope is that what vr lets you do is sim more realistically and sim way, way, way more frequently, and therefore we can, you know, improve the quality of the care that we provide and save more lives.
Deb Tauber:Absolutely, and we know repetition right and I think, especially with your, you know people who are more experienced to be able to use it. And you know we talked a little bit before the podcast about the myth of the nausea. Why don't you talk a little bit about? You know, repeat that to our listeners.
Dr. Ryan Riberia:Sure, yeah, yeah, V VR as as come a long way. You know, in the very early days of VR technologies, headsets weren't particularly powerful, and so I think you had a lot of challenges with frame rates and refresh rates and people were still learning how to use VR well and they were using things like warping and using joysticks to move around the virtual world. And all those things we now know cause nausea, right, and it makes sense. If there's a discrepancy between what your eyes see and what your body feels, that's what causes motion sickness. And so if you're in a headset and you're moving around and the refresh rate is not good and so, like, what you see is delayed compared to what your body feels, that makes you sick. Now the newer headsets even I'd say the last three years, but you know they keep getting better it lasts one year and the headsets are so much more powerful. The frame rates, the refresh rates are much, much easier to keep sufficiently high. That you know you don't see that disconnect between what you see and what you feel. And then you know some of it is software design too.
Dr. Ryan Riberia:I think at SimX we don't really use warping navigation, you just if you want to walk to the other side of the room.
Dr. Ryan Riberia:In VR, you just walk, and so that maintains this. You know synchronicity between what you see and what you feel, and if you do all those things, it doesn't need to be nausea. Actually, I don't think nausea and VR are not inherent to each other. It really is. It really is a matter of how you design the software, and so for us, we've had customers do specific studies on user acceptance and nausea with SimX, and one of them in particular I think it was University of Nebraska who ran a study that where they found only 4% of their students I believe it was I'm quoting this off the top of my head, so there's little discrepancies here 4% of their students, I believe it was. I'm putting this off the top of my head, so there's little discrepancies here. Forgive me, but it was low single digits that experienced meaningful nausea when they were using the product, and again, I think that's attributable to the more powerful headsets these days and also careful software design.
Deb Tauber:Excellent. Now, how do you evaluate real world impact of emerging technologies like AI and VR in the clinical setting?
Dr. Ryan Riberia:Yeah, this is, I think, an exciting area where there is a lot of opportunity that is yet to be untapped. Now there's tons of studies out there on the efficacy of VR medical training. I think we recently did a lit review and there were over 4,000 studies in PubMed on XR in medical training. I think we recently did a lit review and there were over 4,000 studies in PubMed on XR in medical training and the large majority of them show very positive impact, especially, you know, even in head-to-heads, compared to other simulation modalities. Though usually those studies are looking at, you know, things like pre-post performance on you know, structured exams, or they're looking at individual user evaluations of the efficacy, or they're looking at learning retention or things like that. Those are meaningful endpoints for research, but they don't really speak all the way to clinical performance.
Dr. Ryan Riberia:Now, it is not a problem that's particular to VR. I think all of us who are kind of in the education community know that it is very hard to be able to demonstrate that an educational initiative translates all the way to better clinical care. There's just so many things that happen along the way. But we are looking at a few collaborations that I think could do it, and part of it is that there's more sim being done now in the in-practice space, you know, especially in nursing when they're doing like cross-training, and there's more large hospital systems that are developing simulation programs and so I think because of that there's opportunity to do stuff like CAUTI, like you can say let's do a simulation training program and see if we can reduce catheter urinary tract infections pre-post by training people through VR on the proper insertion and cleaning and maintenance mechanisms.
Dr. Ryan Riberia:And you know that's an endpoint that hospitals care about. That is real clinical practice as meaningful patient safety impact and where you can kind of do a pre-post analysis. And so we're looking at things like that. And so we're looking at things like that. And then back to my roots with SIFSIS bundle compliance as well. Yeah, I think that's where the opportunity is is to do these studies for in-practice nursing in hospital systems. On those subjects where it is, hospitals are incentivized and they also are meaningful from a patient safety perspective. So I think there's a big opportunity there. I don't think there's a lot of research out there yet, but we're in the midst of finalizing some partnerships to do that type of research.
Deb Tauber:You have come so far. I remember meeting you at NASCIL when it was in Milwaukee when it was in. Milwaukee yeah, and it's just been really fun to watch how far you've come and how many people have adopted your work.
Dr. Ryan Riberia:Believe it or not, we were already years in. At that point there were five years or so before that many of which were just me and two other people just working on it.
Deb Tauber:And how many people are there now?
Dr. Ryan Riberia:We're closing in on 100 employees actually. So yeah, it's grown a lot.
Deb Tauber:That is just great. That's just fantastic. What do you see in the future?
Dr. Ryan Riberia:So, yeah, I mean, I think there's a lot of opportunities in the future and there's probably a few categories that I would point to.
Dr. Ryan Riberia:One is obviously AI. I think AI is going to have a big impact on a lot of aspects of education. Ai is something that we've kind of cared a lot about, and from the beginning, one of our co-founders is an expert in AI actually, and we've got a number of other team members that have really true exceptional expertise in this space. And I think with the advent of LLMs and you know, I think with the advent of LLMs, there is the kind of obvious low hanging fruit of being able to have conversations with virtual patients. You know, the LLMs just make that way way better, and definitely that's something that we are in the process of integrating, but there's actually more opportunity there too. So, simx, we build our platform in a very. The platform is very structured in such a way that environments and patients and tools can kind of be intermixed, and so that lends itself to a world where you know, if you've ever used generative AI to make a photo or a video or something you know you can type in a paragraph format hey, can you make me a picture of a cute cat wearing a birthday hat or something, and it will put that together. Now imagine a world where you could type in and say, hey, make me a virtual reality medical training scenario suitable for second year nursing students that teaches them the importance of five rights of medication administration five rights of medication administration and it generates that you put on a headset and then you can run it, and that is. That might sound very sci fi, but it is actually very achievable with LLM technology and with a platform like ours, where everything is kind of carefully segmented because it's really just piecing those components together, live, and so it's really just a matter of training the AI agent and how to put that together. So that is something that I think is definitely coming down the pipeline and is going to be very exciting.
Dr. Ryan Riberia:I think mixed reality is another category that is quite exciting. If you've seen some of the newer headsets from Apple or even from Oculus or HTC, they're all really making a big push towards mixed reality, where the real world and the virtual world are kind of intertwined, and I think there's a big opportunity there for us to kind of get the best of both worlds right. You can imagine a really high fidelity task trainer that has a virtual patient projected over it and so you can have the conversation with them, that can be rolling around in pain and you can have that kind of psychosocial and environmental complexity from the virtual component. But then you can still use the task trainer to get really high tactile fidelity. And that is, I think, in some ways probably going to be the gold standard of training and there's going to be a big opportunity there as the mixed reality headsets start coming out. We expect them from Oculus this year and HTC probably shortly after that. So I think there's going to be a lot of opportunity there.
Dr. Ryan Riberia:And then, finally, I would say something that excites me a lot as an educator myself, is the opportunity that mixed reality and VR give us for assessments. Right, because you know right now, very often, if you're doing traditional sim, you're standing behind a one-way mirror and you're kind of watching the students and you're furiously writing down okay, they gave this dose, they probably should have given this dose, or maybe they should have asked this first, and then you're doing your debriefs and it's a lot of cognitive load for you as an instructor. But VR already kind of takes a lot of that away, because it can tell here's the dose that they gave, here's how long it took them to put the patient on the monitor. All that's already pre-recorded. But we can actually take that a step further. In VR, we can tell where people are looking. So you can imagine a world where we say, hey, you were only looking your patient in the eyes 41% of the time that you were talking to them and you know, average for your level of training is 76%. So maybe let's talk about the personal touch that you can add to these encounters or the other thing. So there's just the sheer amount of information that we have available in these virtual trainings about what people are actually doing, I think is still mostly untapped. So there's a lot of opportunity there.
Dr. Ryan Riberia:And the other thing is biometric sensing. So you can already buy third party biometric sensors and they basically use minute changes in, like skin temperature and sweat, to evaluate your levels of physiologic stress. And, as we all know, there's kind of a sweet spot in stress for learning. If you're not stressed enough, then obviously you're not being pushed. If you're too stressed, you're freaking out, you're crying, you don't, you're not going to remember anything from this sim, and so you really got to keep your students kind of like right at the edge, but not overwhelmed. And so we have some customers already that are using these third party biometric sensors in conjunction with VR to kind of like modify the scenario in real time and really keep them in that sweet spot.
Dr. Ryan Riberia:But some of the headset manufacturers are looking to build that into the headsets in the coming years, and so you can imagine a world where you're running a sim and you have like a running graph of their physiologic stress and whether they're in the sweet spot or not, and you can either intentionally or automatically through the software make the scenario harder or easier to keep them in that sweet spot. And that, I think, is really exciting, because when we talk about the need to cross train and quickly train up nurses and things, how do you quickly train someone up? You do it by making sure every single minute of sim counts right, that they are always in that sweet spot. They're always being pushed right to the edge. I mean, that's how they train Olympic athletes, right. They're always staying in their sweet spot, and so I think the prospect of being able to do that with medical training is really, really exciting.
Deb Tauber:Yeah, yeah, I love that. Wow, very, very fascinating.
Dr. Ryan Riberia:We've really come a long way in the last five years, but really on the precipice of a lot of exciting changes, I think, in medical education.
Deb Tauber:Now, how do you stay grounded with everything that you do between you know, an ER physician, a CEO, a dad? How do you hold it all together?
Dr. Ryan Riberia:an ER physician, a CEO, a dad how do you hold it all together? Yeah, that's a good question. I mean I would say these things aren't completely disparate, like there's definitely a lot of synergy here, right? When I go on clinical shifts, I get new ideas for things that we should build in SimEx, and or when I'm training residents you know, and I still do traditional sim with residents all the time it gives me new ideas for how we can make it easier for our instructors. And when we're doing things in SimX, sometimes I myself get in headsets and run cases and I build up my own skills along the way, as we're kind of getting things ready to ship, and so they're really very synergistic and I think that is key.
Dr. Ryan Riberia:If I was doing things that are completely unrelated, it'd be quite a bit more overwhelming, but you mentioned a couple of things there. Obviously, if your life is all work in one form or another, even if it's fun work, that's a little too much. I've got four kids and they just keep me grounded every time I interact with them. Right, the age is 16, all the way down to five, and so we really got the spread and going to all the tennis matches and piano recitals and everything that comes with those age groups is a ton of fun.
Dr. Ryan Riberia:We live out here, right next to the Santa Cruz mountains actually too, and so I've taken a mountain biking recently, which maybe it doesn't sound that relaxing to some people, but it is very relaxing actually. You get out into the woods and we've got a lot of beautiful redwoods out here. Spend some time in nature, I think that's really key. And then I've also I've taken up meditation over the last several years, which has been really helpful. You know, even just a few minutes a day, I think, of that kind of centering and being in the moment has been really key for me when things are going crazy, wow.
Deb Tauber:What do your kids think about all this virtual reality?
Dr. Ryan Riberia:They think it's pretty cool. I would say they thought it was pretty cool. It's kind of old hat for them. Now we have videos of them, you know, 10 years ago not quite 10 years ago, maybe eight years ago wearing like the backpack computers and like the big old headsets, when they were very young and so they were exposed to VR before most people even knew it was a thing. And you know, we've always had probably a minimum of 10 VR headsets around the house for one reason or another. So I think I think my son for his eighth or ninth birthday. So again, this was very early in the VR world. We had a Minecraft themed birthday party and we brought a bunch of VR headsets and all the kids did VR Minecraft together and blew their nine year old minds.
Dr. Ryan Riberia:So oh my gosh side benefits, I guess, of having a dad who's in the VR industry.
Deb Tauber:Yeah, I do a little bit with my grandsons. I play a little bit of VR games, some kind of squirrel game where you catch it.
Dr. Ryan Riberia:Oh yeah, akron, we play that one at home all the time. That's my five-year-old's favorite. He loves to be the tree and throw the acorn at people.
Deb Tauber:Yep, yep, yeah. Now, do you have any final words that you'd like to leave our listeners with today?
Dr. Ryan Riberia:Yeah, you know, I think we've talked about a lot of different things. For me, and probably for most of us, what it really does come down to is patient safety. So I think you're kind of right on the nose asking, like, how do we make sure this translates into a clinical setting? And you know, you asked a little bit about what prompted me to go into this space and I shared a couple of those experiences. There was another experience I think that is was a part of what pushed me over the edge, and that was, you know, when you're going through medical school, they teach you things, and they teach you a little bit about the history too, and like all the things we did wrong in the past and everything from bloodletting and things to like Tuskegee experiments, and you know that all the mistakes that the medicine has made along the way, and they also tell you. Fortunately, a certain percentage of the things that we're teaching you now are also going to turn out to be wrong. And the problem is we don't know which parts right, like what are the things that generations from now they'll look back and say I can't believe that they did that, Like that was nuts. And as I was going through training. It struck me that obviously we don't know what the future will hold, but certainly it's plausible that what that thing will be for us is the fact that we practiced on real people like that.
Dr. Ryan Riberia:We, you basically go and you listen to a bunch of lectures and you maybe do like one or two sim cases and then you just go out and start working with patients and you know of course we do do a lot in in health care to try to make that a safe transition, but still, you know, at some point you're sticking needles in people with very little experience and you're cutting on people with very little experience.
Dr. Ryan Riberia:And you know there's that whole saying see one, do one, teach one in healthcare, which you know you kind of got to do out of necessity. But is that really the best way to do it? If we had other options it would not be, and I think as SIM becomes more realistic and more accessible, it doesn't have to be that way. Right, like this is perhaps, in my view, the key to changing that, so that it's not see one, do one, teach one. It's, you know, see one, SIM a hundred, then do one right and then teach. And I think that really is the future and I do think people will look back on us and say, like that was so barbaric that they just send you out into the world without putting you in a headset and having you do 100 first. So hopefully we can be part of creating that better future for our healthcare system and for our patients.
Deb Tauber:That better future for our healthcare system and for our patients. I love that. That is amazing. Now do you guys use the headsets for hiring decisions?
Dr. Ryan Riberia:Oh, put people into VR interviews. Yeah, you know we haven't yet, but that would be interesting. Pop people in a headset and kind of see their decision making process along the way. We have had some people approach us though about vr for motivational interviewing or for de-escalation, like for front desk staff in an er and having to do de-escalations and things. So it's, it can be used for that kind of stuff. But we have we haven't used it at simx for that purpose not yet not yet yeah right, I think that's.
Deb Tauber:And if our listeners want to get a hold of you, what, uh? How can they do that?
Dr. Ryan Riberia:you know simxvrcom. They can head there. They could probably message me through Linkedin too, and it's probably the best way to get a hold of me. But yeah, either of those sources and I'm happy to connect.
Deb Tauber:And I thank you so much for taking your time today and meeting with me, and fortunately, Jerrod couldn't be here today. He's going to be disappointed. He missed such an interesting conversation. Thank you for everything that you've done. It's just an honor to get to speak with you today.
Dr. Ryan Riberia:Yeah, no, thanks so much for having me. It's been a great conversation and it's been great.
Deb Tauber:Thank you and happy simulating.
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