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The rise of the surgical machines

The man billed as ‘the most watched surgeon in human history’ recently addressed the 2018 RCSI Charter Day in Dublin and engaged the audi­ence with his vision of unstoppable revolutionary change in medicine.

Prof Shafi Ahmed is a Colorectal Cancer Surgeon at the Royal Lon­don and St Bartholomew’s Hospi­tals and co-founder of the compa­nies Virtual Medics and Medical Realities. His Twitter biography describes him as “Professor, vir­tual surgeon, global citizen, can­cer surgeon, futurist… ” and fea­tures a photo of Prof Ahmed in the­atre, wearing a virtual reality (VR) headset.

It is clear that this is not your average surgeon.

Speaking to the Medical Inde­pendent (MI) following his John­son & Johnson lecture on the ‘Fu­ture of Surgery’, Prof Ahmed exud­ed excitement about the increasing potential of technology in surgery.

‘Digital natives’

Does he notice differing reac­tions among surgeons to his mes­sage of digital disruption?

“I think so, yes. I think young­er doctors and people in general are ‘digital natives’, understanda­bly. They are more aware around the issues of technology. So, cer­tainly, I get positive feedback from them,” Prof Ahmed told MI.

But more seasoned surgeons can often be a little more sceptical.

“I think, and rightly so, senior surgeons are obviously more cau­tious; that’s the right way of doing things of course,” he said.

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Prof Shafi Ahmed, Consultant Surgeon and co-founder of Virtual Medics and Medical Realities

“So they would balance the ar­guments against and for, and are more cautious in their adoption [of technology]. The problem I guess with more senior people is that sometimes they are not as amenable to change. That’s always the way in every speciality. So you have a kind of problem here be­cause you want to innovate. For healthcare to evolve and actually work better, it has to embrace in­novation; not necessarily technol­ogy, but innovation. But people can just get comfortable.

“Technology is an enabler. It allows us to do things that we couldn’t do before.”

Prof Ahmed is billed as the ‘most watched surgeon in histo­ry’ because in May 2014, using the Google Glass device, he per­formed and streamed a live inter­active operation to an estimated live audience of 14,000 students and trainees across 132 countries and 1,100 cities.

Two years later, in collaboration with Barts Health, Medical Real­ities and Mativision, Prof Ahmed performed the “world’s first virtu­al reality operation recorded and streamed live in 360 degrees” and in December 2016, he performed the world’s first live operation using Snapchat Spectacles. Last year, he was chosen to curate the official NHS Twitter account for a week and live-tweeted an opera­tion via this account.

Passion

The passion that Prof Ahmed has about the growing role of technology in surgery is obvious, which begs the question of wheth­er it is now digital innovation and business that excites him more than scheduled surgery?

“I am still a surgeon,” he said, nodding. “That is my day job, that is what I trained for, it is what I have been doing for 25 years and it’s still the thing that defines me. It is who I am.

“But I have always been inter­ested in technology and innova­tion. But I think only over the last three or four years when [this level of] tech has been available, it has interested me much more.

“I am 48 now; this technology was not available 20 years ago. So I am in a fortunate position, in that I am a senior clinician, I can look at things and see what has changed and influence it in a bet­ter way. I can influence change because I am a bit older — I have some more years at clinical work.

“So yes, I have got a lot of pas­sion for innovation and technol­ogy — it’s what drives me at the moment. I’ve spent many years in hospital working on innova­tion and plans for change and it has been a bit frustrating because hospitals don’t always embrace change, whether because of fi­nancial [considerations], resourc­es, etc. Here, I can do some ‘blue sky’ thinking in my own work with tech companies.”

Surgeons

But Prof Ahmed is confident that surgeons in particular have a professional culture that should keep them open to rapid change.

“Many surgeons are usually inno­vative anyway,” he said. “They are coming from a background where they want to do new operations, new techniques — many of them are al­ways thinking about evolving.

“They are kind of a good brood in that sense for innovation. I think at the moment, it’s the space between what’s out there coming really rap­idly and as a profession, not engag­ing as much as we should.

“It’s almost like sometimes they are not aware of it. So we need to break that barrier down so it’s more obvious, more transparent [and] people can see it, can dis­cuss it.”

When it comes to robotic-assisted surgery, Prof Ahmed says patents are ending and “prices are coming down and there will be more demo­crat access” to the technology.

“Robots with artificial intelli­gence (AI) as well — incredible,” he said. “Imagine a robot with AI, also with a virtual reality platform — that’s the kind of thing we are looking at.

“So I have knowledge of a cer­tain amount of patients in my life­time. If you programme a machine with information about every pa­tient on the earth, they will have an infinite amount of knowledge about patients.”

While there are certain “kinds of clinical skills involved” in phys­ically examining patients, Prof Ahmed sees an increasing role for AI and VR in analysing x-rays and other areas.

“Surgery itself will change. We will have robots coming in; they will somewhat become ‘intelli­gent’ and replace some of us.

“The question then is, as a pa­tient, would you prefer a system where you have an x-ray and you walk away, then somebody looks at it later or the day after, types it out? That then is given to a prima­ry care physician, that has to go back, etc.

“Or do you want an AI machine that can report instantaneous­ly and send a text message saying ‘what is going on?’ That is the re­ality. We are in the phase where that stuff happens. We are going to have to redesign our jobs along those lines.

“AI is going to be big. I think it is going to be the main driver of change in the system. But it will be invisible. It will be in the back-end. You won’t see it. It will be be­hind a chat box or the CR system, but it will be there.”

Change

But there may be a problem, in that technological change in med­icine may be moving much quick­er than the validation process.

“It is getting better. When I first started this a few years ago, there was more reluctance. People are now seeing it and implementing it,” Prof Ahmed said.

“Doctors of course need vali­dation before they can do some­thing differently. But here, there is a problem with that, because if you wait for validation, that might take years, clinical trials or what­ever it is, and therefore innova­tion in medicine has moved on to the next level and you are trying to catch up. So innovation needs to happen and validation needs to happen alongside it to make those changes more effective.

“The current way doesn’t work because the minute you decide to go for research trials, and there is three or four years [to wait], the world has moved on. So that is more tricky.”

Positive

With so much doom and gloom around the medical profession when it comes to the recruitment and retention crisis in Ireland and globally, Prof Ahmed has a very positive message for young sur­geons and doctors generally.

“I always say to trainees, ‘this is the best time to be alive in med­icine ever because there are so many amazing things happening at the same time.

“The technology and capabili­ties are improving; we never had this. What we had before is a ste­reoscope, CT scan and an x-ray. Now you have got multiple tools at your disposal that you can use. You can be involved in the chang­ing environment in healthcare on your own. Young people have the skill sets; they are digital natives. They are already there, they al­ready know what’s going on.”

Indeed, Prof Ahmed believes the adoption of innovative technology can actually encourage young doc­tors to stay in the profession.

“Doctors are leaving the pro­fession. A lot of them don’t like it. Why is that? What can we do better to keep them? They want to have a varied life, they want to be portfolio doctors, they want to have a balance of life,” he said.

“So what is it we need to do for them to keep them attract­ed? What you need to do is teach them about the skill sets that are changing healthcare — not being afraid of change, rather than being a one-dimensional doctor.”

Education

Prof Ahmed believes training in­stitutions have an important role here too.“When a doctor comes to medical school at age 18 or 22, they have other skills sets,” he said.

“Some of them can do coding or run businesses, some are artists; they have got talents. We never see that. All we say is ‘here is anatomy, physiology, chemistry etc, off you go, this is your remit’. 

“Actually, that is not medicine. Humanity has much more depth. It is music, it is fashion, art, it is engineering and computer science. So what about those skill sets? What are they, why aren’t we using them? How do we support them more?

“So we have to be sure that the doctor of the future is trained in a way that supports them. At the moment, the doctor’s forté is clinical targets; ‘how many patients are you seeing, what is the outcome of that, how many outpatients?’ etc. Target, target — it hasn’t changed. There is a failure because we often don’t think of the human behind the targets.”

Historical 

Prof Ahmed is evangelical when it comes to the changes that have been seen with technology and medicine, but stepping back and taking a wider view, is this any different from other major developments in the history of medicine? 

“This is the most significant time ever, I think,” replied Prof Ahmed confidently. 

“If you look at the big changes that have happened before, the (onset) of the antibiotic era, sterilisation that allowed us do more surgery, anaesthesia — there have been big changes that each time [they happen] allow you do more things. But the issue is that it is just one change at a time. 

“But this is a whole load of technologies. We have never been in this position before where so many things have impacted.”

Challenges 

Prof Ahmed accepts there are ethical, legal and other potential challenges in this area. 

Will a surgical robot have to face a fitness to practise tribunal, for instance? 

“I guess we will have to be sensible when we are approaching this problem. There is no surprise that the legal framework normally runs two or three years behind technology innovation. I guess with AI, as long as you are kind of sensible about it and physicians are also involved in the innovation, and issues around morality, we are going to be sensible.

“I’m not saying that AI will replace everything — not at all, it will be supportive, it will add and improve. So I am not worried about that per se. I think it is inevitable in terms of implementation. 

“When you think of the autonomous kind of doctor which people mention… but there will be autonomous vehicles [before that]. We are lucky in the sense that there are companies around the world who are creating driverless cars because that makes the pathway easier for us, because they are going to ask the question about who is responsible, who is in charge? 

“So already these questions are in place. It’s forcing us to think about this new way of working.”

The end of human-performed surgery as we know it?

So how far could things go if rapid developments in AI and VR continue at this pace? Well, Prof Ahmed thinks maybe we could be reaching something he calls the “surgical singularity”.

“Singularity is the point that computers overtake human behaviour and power. So this would be where computers would be doing our job for us in a way that we can’t do it, or better than we can,” said Prof Ahmed, referencing a noted 2005 book by futurist Ray Kurzweil called The Singularity Is Near: When Humans Transcend Biology

“So I was thinking about surgical matters and at what point are we going to accept that a robot or a computer, or whatever you like to call it, will be better or as good as a normal surgeon. 

“That is the kind of the discussion we need to have. Can we recognise structures, can we get our AI machines to figure out and manage things, can we get to the point where they can do an operation based on just intelligence, machine learning? We don’t know that answer. I suspect it will happen, maybe within my lifetime, but I think it will happen. 

“I think initially what you get is AI supporting surgeons and kind of replacing lots of what we do and making our job a bit easier. So I think that is the element initially, and they will get more and more powerful.”

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