"The goal is surgeons who have the
world's best expert surgeon virtually at their side in every case and the
experience of thousands of cases," says University of Washington's Dr. Sam
Browd.、
Dr. Sam Browd is a Seattle neurosurgeon who
is taking telemedicine and virtual reality technology to a different,
unexpected place – the operating room.
Browd is professor of neurological surgery
at the University of Washington, an attending neurosurgeon at Seattle
Children's Hospital, and cofounder and chief medical officer at health IT
vendor Proprio. He has spent the last few years working with engineers and other
surgeons to bring the operating room out of the analog world and into the
digital.
What they've created is a new technology
that provides surgeons a 360-view of surgery by combining virtual reality and
artificial intelligence, enabling surgeons to integrate information in new
ways. Out of this, too, comes work on telesurgery – the ability to do live
surgery in different locations or mentorship and proctorship.
Browd believes this will democratize
surgery across the world, including training medical students from thousands of
miles away.
Healthcare IT News tapped Browd's expertise
in this interview to discuss these technological breakthroughs and how they
will help clinicians and patients alike.
Q. Where is the healthcare industry
today with regard to telesurgery? Also, please describe your work in creating
the ability to do live surgery, mentorship and proctorship.
A. While the healthcare industry at large
has gone through many key transitions and iterations, telemedicine is still in
its infancy, albeit in a hyper-accelerated mode due to the necessities of
providing care during the pandemic. Our thesis from years back was that
technology is now positioned to fundamentally take what has been a largely
analog space and make it fully digital in terms of the tools used to assist the
surgeon and expand their abilities.
Our goal is to use technology to elevate
the performance and competency of every surgeon, and capture, analyze and share
nuanced knowledge and technical aspects of surgery for training, simulation and
eventually clinical decision support that is immediate, relevant and contextual
to the case. To make the leap from today to the "Super Surgeons" of
tomorrow – that requires the increased use and adoption of technology.
As we look around the world, there are a
number of small companies that have started to look at telesurgery. Current
technological approaches focus on extending the consumer video conferencing
paradigm to use in the operating room. These methods of 2-D display will enable
a first pass at telementoring and teleproctorship, but these are fundamentally
limited because they solely leverage common RGB cameras placed over or near the
operative field.
These are validating approaches relative to
our thesis and are a step in the right direction, but it's only the beginning.
I have done this in practice recently, remote proctoring a colleague in
Australia through a highly technical procedure for the first time. Through this
integration, we were able to live-stream the video from the operative microscope,
and we communicated live throughout the six-hour operation while I was in my
Seattle office.
The challenge is that currently these types
of technologies lack the richness, depth and overall context that is obtained
by seeing the depth of field, and the immersive experience is lacking. That
said, my experience – and the companies emerging in this space – indicate
there's a clear interest and need to do virtual mentorship and proctorship.
At Proprio, we believe telesurgery is the
ability to take detailed, in-depth data in the operative room and share it in
real time, anywhere, and with imperceptible latency, so assisting surgeons can
have the experience of depth perception and immersion as if they were in the
operative room next to the lead surgeon.
We think this type of experience will
provide a myriad of opportunities for education and outreach – and,
importantly, facilitate the essential democratization of surgical training and
knowledge-sharing to build, grow and foster the next generation of surgeons
around the world – importantly positively impacting areas that are underserved
and lack access to high-quality surgical care.
Longer term, being able to operate remotely
and provide mentor-proctorship, regardless of location, time zone or surgical
capabilities, is going to drastically amplify the ability for specialists to
more broadly share their skills and provide surgical guidance creating the next
generation "Super Surgeons."
Beyond just the betterment of human
performance, it is only a matter of time before companies such as Proprio will
facilitate the integration and ability of surgical robotics. The success of
robotics in surgery is integrally tied to knowing the location, changes and
complexity of the anatomy which is operated upon.
Our overarching vision is to take the
performance of surgery into the digital age, improving human performance and
ultimately facilitating the transfer of knowledge into robotics for the
betterment of human care. This unified approach will bring in a whole new
generation of immersive, intelligent surgical capabilities for enhancing
surgical skills, outcomes, and workflows.
Q. You've said telesurgery democratizes
surgery across the world, and training medical students from thousands of miles
away. Please elaborate.
A. Right now in the world of surgical
training, luck has a factor in who you become as a surgeon. Beyond just innate
physical skills, which country you reside in, who you learn from, and what
institution you are associated with can drastically influence opportunities for
learning, training and gaining experience with the most modern surgical
technologies.
It is unfortunate that location can
fundamentally drive how good of a surgeon you will become – and that's
absolutely unacceptable and fails millions of people who should be demanding
high-quality surgery every year around the world.
Training opportunities are limited by the
number of mentors and the ability to scale knowledge. To scale that knowledge
requires a different way of thinking. The traditional proctorship/apprenticeship
only allows a linear scaling of knowledge. To be able to teach more surgeons
and scale that knowledge around the world requires a different approach.
Telesurgery/mentorship/proctorship allows a
single expert surgeon to teach multiple people either individually or as a
group at any location around the world. The ability to scale this knowledge
transfer means that the best surgeons in the world can get away from this
linear apprenticeship model and share their knowledge with hundreds as many trainees.
This shift could be an industry-definer and
game-changer. A further step beyond this approach would be to archive cases,
looking at every procedure, every variation and every complication and distill
those elements into a structured teaching regimen for surgeons that can be
shared, access on-demand and incorporated learnings that today can only be
obtained through direct, one-to-one, in-person surgical training.
What makes a surgeon exceptional is not
just skill but experience, number of repetitions, variety of surgery pathology,
and the complications they have witnessed, experienced and/or gotten their
patient in or out of. Beyond innate skill, experience, education and repetition
informs how good a surgeon is. It is the classic nature-versus-nurture problem.
Innate ability can only be amplified by
experience, teaching, and the ability to safely make mistakes and transform
movement, thought and behavior.
Today we train one-to-one, even while in
surgery, so you have to either be present for that particular case or relayed
to you by a surgeon that's teaching it. This is an unsustainable model and
results in a massive bottleneck of skill distillation and empowerment for the
next generation, which is already anticipated to suffer from significant, global
surgeon shortages despite ongoing population growth.
Other industries have long ago utilized
simulation to achieve repetition and ultimately competency. Learning and
adopting lessons from fields like aviation are just coming to surgery.
What we'd like to do is to not only have
these expert surgeons teach as many people around the world as possible, but
also capture and archive their pearls of knowledge that allow them to reach a
level of exceptionalism in the operating room. We must strive to create the
super surgeons of tomorrow through technology innovation – and bring the
digital world, and all that enables, to the operating theater.
Q. What role does virtual reality
technology play in telesurgery?
A. Surgery is a tactile, immersive event.
It utilizes all of your senses – vision, touch, all of your proprioceptive
skills – to see, feel and navigate a case. Virtual reality allows an observer
anywhere in the world to experience operations as if they were physically
present. Starting with the visual experience of the surgeon, VR creates an
opportunity to participate in a surgery with the full breadth and experience
one would have if they were physically present.
For example, the ability to look at the
surgical field remotely with stereoscopic vision, deep perception and the
freedom to move independently around the visual scene of the surgical field is
mind-blowing, but achievable. Virtual reality creates an opportunity for more
realistic depth perception that is completely different from the current experience
of looking at 2-D images or rendered from a microscope.
Depending on the view that's taken, you can
learn what's happening across the entire operating room – whether that's the
workflow, what the scrub tech or nurse is doing, etc. Whatever is happening in
and around the operation, there's a breadth of nuanced and particular in-person
knowledge that can come from VR and be translated to broader audiences via the
operating surgeon. Workflow, team dynamics, the integration of additive
technologies, aside from the visual of the surgery itself, are instructive and
part of the overall learning objectives of trainees.
It's much more of an engaging experience to
feel like you are present, versus feeling like you are watching a movie. You
are transposed to be an active observer versus passive observer. VR places you
in the situation and allows you to discover the intricacies and inherent
reactions specialists spend years trying to convey – all in that one immersive
experience.
I cannot stress enough the difference in
recollection and understanding between experiential, active learning versus
passive learning. For a resident to experience a surgery and make their own
observations in real time, versus memorizing case studies from a flat textbook,
the retention abilities are night and day. Contextual learning moments lead to
better retention of facts, details and patterns of learning, which ultimately
must be retained by the learner to achieve proficiency and competency, but
ideally mastery.
Virtual reality creates the ability to see
the operating room in a 3-D environment where you can move, manipulate and see
it rendered as a volume rather than looking at a static image. It's more
enjoyable. It changes the dynamics of the engagement and, ultimately, the
effectiveness of the educational experience.
Q. What role does artificial
intelligence technology play in telesurgery?
A. Just as immersive technology is
drastically impacting industries, artificial intelligence is going to shift the
world of medicine in a couple areas, particularly around the concept of data
collection, processing and analysis.
There's data and image capture. The
technology that allows us to capture images requires securing extremely large
data sets in 3-D with low/no latency. There's a lot of work going on in the
background with AI on how these extremely large data sets can be manipulated
and condensed so that latency happens at a rate that does not create a lag.
You can imagine assisting remotely during a
critical portion of the case, you don't want to be sending comments or
suggestions that arrive beyond the moment the information is needed to engage
or change the course of the operation.
Immersive telesurgery will require AI
solutions to improve the speed and efficiency of data transfer, image processing
and reconstruction. Additionally, the ideal situation is an untethered headset,
so the ability to connect via 5G or other enabling technologies will require
thoughtful data techniques that will be driven by AI.
Then there's data and educational advancement.
AI allows us to acquire and process significantly more data, this can also
translate to increased opportunities for learning and evaluation
post-operatively. By combining machine learning and computer vision in the OR,
surgeons can evaluate performance and assess opportunities for improvement
through more intuitively designed data capture, visualization and, importantly,
analysis.
As we acquire data and archive it, we open
the ability to not only play back the surgery in an immersive way, it also gives
us an opportunity to aggregate, learn and extract what we think recurring
features relates to improved performance and workflow. As the operating room
becomes digital, this immense aggregated data set will lead to clinical
decision making tools that will be brought to the surgeon during a case in a
timely, relevant and contextual way to enable the surgeon to see and make
decisions based on the world's surgical knowledge and not just their own.
Imagine information that is generated and
presented as an operation unfolds to bring suggestions, warnings or other
information to the surgeon as the case progresses with contextual relevance.
These digital tools will most certainly improve both the safety and efficiency
of surgery in the future.
And then there's data and surgical
performance. AI creates the opportunity to take robust surgical data collected
digitally in the operating room, process and compare moments in that unique
case against data obtained over hundreds or thousands of cases to inform the
surgeon of information relevant to the anatomy, process and/or outcome of the
surgery.
Data sets will inform decision-making
during the operation. The more data we have, the more we can learn and share.
The goal is surgeons who have the world's best expert surgeon virtually at
their side in every case and the experience of thousands of cases, infinite
anatomical variation and the outcome metrics to rank-order decision-making
surgical support presented in real time to effect the most optimal outcome.
