“We’ve witnessed ten years of change in a month” is a typical description of how the pandemic is accelerating the use of telemedicine. Before the virus, video appointments made up only 1% of the 350m consultations which Britain’s National Health Service handles each year. Companies like Docly, eConsult and AccuRx are changing that. The latter claims that 90% of primary care clinics in England are now using its video-calling system.
The most dramatic form of telemedicine is remote surgery. It is not new, but it is growing, and it offers enormous benefits. It can help overcome the shortage of doctors in many places around the world, and it can improve training, raise standards, and drive innovation within the medical profession.
One of the leading enablers of remote surgery is Proximie, a four year-old London-based company whose web-based platform allows surgeons to collaborate remotely via audio, video and augmented reality. Its founder is Nadine Hachach-Haram, a reconstructive plastic surgeon, and if you have a strong stomach, you can watch her demonstrate Proximie’s platform in a real operation in a talk filmed at TEDWomen 2017.
Hachach-Haram played video games as a child, and her father was a computer engineer, but the company was started more-or-less accidentally, as a hobby. In 2015, an early version of the platform was tested with a surgeon in California, training colleagues in Peru in a programme run by the Global Smile Foundation, which provides cleft palate surgery for children. The platform was first used during real-time surgery in an operation on a bomb blast victim in Gaza in 2016. In 2019, the UK Ministry of Defence awarded Proximie a multi-year contract to provide access to its AR system to front-line field hospitals, and Royal Navy ships located around the world. Hachach-Haram is now a member of medicine’s good and the great, and one of the authors of a 2019 report on the Future of Surgery by the Royal College of Surgeons (RCS).
Virtual collaboration in surgery is not new. It has been facilitated for some years by robot surgeons like the Da Vinci system, first approved in 2000. This enables the precise and minimally invasive surgery known as laparoscopy, or keyhole surgery, to be carried out by a surgeon who is thousands of miles away from the patient. This system is not without its critics: relatively few surgeons have yet been trained to use it, and patient outcomes are not greatly changed, despite the £2m price tag on each machine.
Proximie is a highly optimised real-time video platform. It requires very low latency – the delay between the capture of an image and its display. This has been reduced to 200 milliseconds, which is around the limit of the period in which the human visual cortex can register movement. The artificial intelligence comes in with advanced augmented reality (AR) features and cutting-edge computer vision. These technologies enable the surgeon to summon up data and images relevant to the procedure, and to see what is going on with unnatural clarity.
Bandwidth is obviously a challenge, and this is just as true in developed countries as in the developing world. Proximie works closely with partners in the telecoms industry, and uses advanced video compression technology.
The platform’s technology is sophisticated, but it is not Proximie’s secret sauce. The company is run and staffed by clinicians, and that is essential in the medical arena, where regulation can be a major hurdle, but even more so, conservatism, and clinical egos. Surgeons do many things the way they have done them for hundreds of years, and if you want them to change, it helps to be an insider. Increasingly, large companies are reaching out to Proximie to help them access medical facilities, as many of them have tripped up on their own, despite their massive resources. IBM Watson is an obvious example.
When you know who to talk to and how to talk to them, progress can be rapid. Proximie is now used by a third of all NHS hospitals, and the goal is to reach 40% penetration by the end of 2020. Surgical innovations are much less tightly regulated and tested than, for instance, new drugs, and Proximie can secure approval for use in a new hospital in as little as a month.
The company is currently enabling 700 procedures per month, in 35 countries. These are mostly in Europe, the US and the wealthier countries in the Middle East, but Hachach-Haram is keen to make the service available worldwide, and recently hired a global development director. Already, she reckons around a million miles of travel by surgeons have been avoided, which might give a few of her colleagues a problem with their air miles accounts.
Perhaps the biggest question facing Proximie is how to scale quickly and safely. There is huge demand for the service: most new contracts start with an inbound call. The business model is software-as-a-service (SaaS), and there are plenty of funders who are keen to invest.
The future for surgeons
It is easy to see how Proximie can do wonders for surgeon training. The old mantra was that in order to learn how to carry out an operation, a surgeon should “see one, do one, teach one”. Hachach-Haram disputes that humans can do something adequately after just one iteration, and prefers an approach she encountered in sports coaching: “prepare, perform, perfect.”
The RCS report on the future of surgery portrays the surgeon of tomorrow as almost superhuman. As well as mastering their craft, they will have to be academics, managers, educators, and above all, innovators and entrepreneurs. But many will still be wondering whether the AI tools they use today will one day get smart enough to replace them in the operating room. The report predicts that twenty years from now, machines will indeed carry out some simple operations on their own, like suturing – stitching up a wound. Twenty years from now, assuming something like Moore’s Law continues, machines will be 8,000 times more capable than they are today, so this does not sound far-fetched. But thirty years from now they will be a million times more capable. It is not hard to imagine that humans will be no match for those machine on quality, cost or speed.
An intriguing future which companies like Proximie could make real is that every operation in every hospital would be captured on video and analysed by machines. Surgeons would receive real-time guidance based on the sum of modern experience, provided by a combination of humans and machines. Machines would constantly review this mass of data to interrogate and improve diagnosis, medical theory, and best practice. Obviously this raises thorny issues regarding privacy and data security. But an important part of the promise of AI and related technologies is that they can make the world intelligible, and by doing so, make it much better than it is today. Hachach-Haram hopes that by being more attuned to the culture and the needs of surgeons, and by being less scary than behemoths like Google / DeepMind and IBM, companies like Proximie can accelerate the delivery of this promise.