Technologies such as virtual reality and distance medicine are changing healthcare delivery and medical education. Industry analyst, Michael Krigsman, speaks with a medical technology and innovation pioneer on this special episode of CXOTalk.

Professor Shafi Ahmed is a multi award winning surgeon, teacher, futurist, innovator, entrepreneur and an evangelist in augmented and virtual reality. He is a 3x TEDx and an international keynote speaker and is a faculty at Singularity University.

He is a cancer surgeon at The Royal London and St Bartholomew’s Hospitals and has been awarded the accolade of the most watched surgeon in human history. As a dedicated trainer, educator, and Associate Dean of Bart’s Medical School, he was awarded the Silver Scalpel award in 2015 as the best national trainer in surgery by the Association of Surgeons in Training. He is currently serving as an elected member of council of the Royal College of Surgeons of England where he is the Director of the International Surgical Training Programme. He is an honorary visiting professor at The University of Bradford where he delivered the Cantor Lecture of Technology in 2017 and the public lecture to open the Digital Health Enterprise Zone.

In 2017 he was the top Top British Asian star in Tech and received this award from HRH Duke of York.

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Transcript

Michael Krigsman: We all go to the doctor. Sometimes we even have surgery. But, what about using virtual reality to do telemedicine and to teach future doctors? Today, on Episode #281 of CxOTalk, we are speaking with a pioneer in using virtual reality for just these purposes.

I'm Michael Krigsman. I'm an industry analyst and the host of CxOTalk. I want to say a sincere thank you to Livestream for supporting CxOTalk low these many years. If you go to Livestream.com/CxOTalk, in fact, they will give you a discount on their plans.

Our guest today is Dr. Shafi Ahmed, who is a practicing surgeon in London. Shafi Ahmed, thank you so much for taking time in your evening to be with us today.

Dr. Shafi Ahmed: Thank you very much for the invitation. It's a pleasure to be here, Michael.

Michael Krigsman: Shafi, please tell us about your work.

Dr. Shafi Ahmed: Yeah, as you've said earlier, I'm a practicing surgeon. I'm a cancer specialist, and I specialize in what's called laparoscopic of keyhole colorectal surgery. That's kind of my day job. I also have a medical school. I'm an associate dean at Barts Medical School, and I've been there for a number of years teaching undergraduate medical students as well as being a trainer for postgraduate students.

Outside of medical world, I tend to run some tech companies and do a lot of speaking, especially on the future of medicine. I play around with technology, I guess, and see how we can influence clinical practice and education.

Michael Krigsman: It's pretty extraordinary to hear you say that you play around with technology. Would you share with us some of that playing around with technology that you've done?

Dr. Shafi Ahmed: Okay. If we go back a few years ago, I initially was one of the Google Glass explorers. We used the Google Glass to live stream, using Livestream, actually, the software and the app to live stream an operation around the world. I taught about 14,000 students across the globe in a single operation. They could see what I was watching, and they could text me during the operation, which would come off the Google Glass. I could answer is real time. It was a way of connecting people around the world in a way that hadn't been done before.

That further forwards with the virtual reality, and we created our own kind of live stream using 360 cameras. Then we could bring people into the OR with me in virtual reality using a smartphone and a Google Cardboard. That was a different way of teaching the art of surgery. On that day, I taught 55,000 people in 142 countries in 4,000 cities. It just shows the impact that people have.

More recently, I've been working around with holograms, avatars to connect doctors around the world to discuss patients, to perhaps educate people and to kind of reshape the way that human traction is forming in medicine. I've also used social media, Facebook, Instagram, and Snapchat, which kind of had a lot of interest around the world, teaching millions of people using this media because they're free [and] they're accessible.

Students these days, who are much younger than we are, they're using social media in a way that we haven't seen before. It empowers them, and you can teach 1,000 people in a single day across the globe just by the power of connectivity, Michael.

Michael Krigsman: Shafi, it seems like there is tremendous interest and demand for exposing surgery in this way to a wider audience, both among medical practitioners, medical students, as well as the general public.  Is that the sense that you have as well?

Dr. Shafi Ahmed: I think so. One thing I've been kind of troubled with for a long time is the fact that surgery is often suspended and mystique. It's almost that secret society we're in. We go into the operating theater. We wear masks. No one knows what happens, for example. We want to be more open and transparent so that the public can see what we do. We're only human. They can share our kind of work and look

Michael Krigsman: We all go to the doctor. Sometimes we even have surgery. But, what about using virtual reality to do telemedicine and to teach future doctors? Today, on Episode #281 of CxOTalk, we are speaking with a pioneer in using virtual reality for just these purposes.

I'm Michael Krigsman. I'm an industry analyst and the host of CxOTalk. I want to say a sincere thank you to Livestream for supporting CxOTalk low these many years. If you go to Livestream.com/CxOTalk, in fact, they will give you a discount on their plans.

Our guest today is Dr. Shafi Ahmed, who is a practicing surgeon in London. Shafi Ahmed, thank you so much for taking time in your evening to be with us today.

Dr. Shafi Ahmed: Thank you very much for the invitation. It's a pleasure to be here, Michael.

Michael Krigsman: Shafi, please tell us about your work.

Dr. Shafi Ahmed: Yeah, as you've said earlier, I'm a practicing surgeon. I'm a cancer specialist, and I specialize in what's called laparoscopic of keyhole colorectal surgery. That's kind of my day job. I also have a medical school. I'm an associate dean at Barts Medical School, and I've been there for a number of years teaching undergraduate medical students as well as being a trainer for postgraduate students.

Outside of medical world, I tend to run some tech companies and do a lot of speaking, especially on the future of medicine. I play around with technology, I guess, and see how we can influence clinical practice and education.

Michael Krigsman: It's pretty extraordinary to hear you say that you play around with technology. Would you share with us some of that playing around with technology that you've done?

Dr. Shafi Ahmed: Okay. If we go back a few years ago, I initially was one of the Google Glass explorers. We used the Google Glass to live stream, using Livestream, actually, the software and the app to live stream an operation around the world. I taught about 14,000 students across the globe in a single operation. They could see what I was watching, and they could text me during the operation, which would come off the Google Glass. I could answer is real time. It was a way of connecting people around the world in a way that hadn't been done before.

That further forwards with the virtual reality, and we created our own kind of live stream using 360 cameras. Then we could bring people into the OR with me in virtual reality using a smartphone and a Google Cardboard. That was a different way of teaching the art of surgery. On that day, I taught 55,000 people in 142 countries in 4,000 cities. It just shows the impact that people have.

More recently, I've been working around with holograms, avatars to connect doctors around the world to discuss patients, to perhaps educate people and to kind of reshape the way that human traction is forming in medicine. I've also used social media, Facebook, Instagram, and Snapchat, which kind of had a lot of interest around the world, teaching millions of people using this media because they're free [and] they're accessible.

Students these days, who are much younger than we are, they're using social media in a way that we haven't seen before. It empowers them, and you can teach 1,000 people in a single day across the globe just by the power of connectivity, Michael.

Michael Krigsman: Shafi, it seems like there is tremendous interest and demand for exposing surgery in this way to a wider audience, both among medical practitioners, medical students, as well as the general public.  Is that the sense that you have as well?

Dr. Shafi Ahmed: I think so. One thing I've been kind of troubled with for a long time is the fact that surgery is often suspended and mystique. It's almost that secret society we're in. We go into the operating theater. We wear masks. No one knows what happens, for example. We want to be more open and transparent so that the public can see what we do. We're only human. They can share our kind of work and look in to see not just the operation, but how the team works in the operating theater.

Also remember, in terms of the students, they've been taught surgery for hundreds of years, in the same way, all crammed in together into the operating theater. For example, our medical school. We have six, eight, maybe ten medical students at a time who sit in the OR. Often, they don't get a chance to see what's going on because it's busy and, obviously, the team are around the patient in the OR.

If you look very carefully, the students in the back of the room are on their smartphones, on Instagram, on the Net going other things, not really learning or engaging. They spend six to eight hours a day in that environment learning, so we've got to challenge that and say, "How can we teach it better? How do we use these technologies so that we allow you to get a good value for your training and teaching?" That's been the kind of remit of my work.

Michael Krigsman: I want to remind everybody that we're talking with Dr. Shafi Ahmed right now, and there is a tweet chat taking place on Twitter using the hashtag #CxOTalk. You can ask Dr. Ahmed your questions, jump in, and participate. Shafi, tell us more about training doctors and the kind of mindset, the digital mindset that you're involved with and using virtual reality to help the medical education.

Dr. Shafi Ahmed: Yeah, let's go back, Michael, a few thousand years, probably. If we look at education, we've come from a period many, many years ago where we're using stone and carving on stones, depict pictures, et cetera. Then we moved on to papyrus and then paper came out and the printing press. The words were quite important in text.

In fact, we go back to a guy one of the surgeons called Abu Qasim, who was based in Andalusia. This was back in 1000 A.D. He wrote the first textbook on surgery, Michael. That textbook became the only textbook on surgery for about 600 years because it hadn't been changed very much. It was very innovative of its time, but we go through incremental changes in the learning medium.

We've now moved on to, of course, online platforms, e-learning platforms. People are now using the Web Internet to learn themselves. I see both augmented reality and virtual reality just as an extension, as a continuum of platforms. We've got to figure out where AR and VR, for example, will allow us to teach people in a way that is validated, makes sense, and that adds something to their educational experience. That's kind of where we are in terms of the platforms.

Where I think virtual reality has an advantage, of course, is that because when you put your headset on, whether it's a smartphone and a headset, or a tethered or a large device, more powerful devices, we're immediately immersed in a 360 environment. Most of the time we've been training on videos and 2D interfaces. You can literally imagine having a cup of coffee, watching what's going on on YouTube, trying to learn the fundamentals of a video operation. Video has moved on. Now it's going to be VR where you can see yourself in 360 degrees. You can see the whole team working and see what's going on. We very rarely have been concerned with the soft skills, they call it, how the team is working, how the communications are going in the operating theater. What are you doing?

Rather than having the points of view, you're seeing a total immersive area of learning. You know what? That's quite important in surgery. People forget surgery is not all about the actual operation and doing it immediately in front of you. It's how you're communicating with the team to give the best outcome for the patient. If things are going wrong, how are you dealing with it? How is that team behaving? I think all of those things add more of an intellectual stimulation for kind of learning in that platform. That's where VR is an advantage.

We've been playing around with virtual reality. We've played around with 360-degree video, and that's been quite interesting. A lot of people now are thinking about storytelling, VR, and 360. Very early on, this was going back, Michael, about three years ago, we actually made our own 360 cameras and 3D printed some kind of platform for a few cameras like GoPro and things to stick together. We then produced some images and videos we stitched together ourselves because that wasn't available at the time.

Very quickly, I learned that the 360 videos are one element of learning. It's great. You can add other things like hotspots, like learning material. Make it into a learning package rather than just the operation. That's what I've been working really hard on the last two and a half years with my team, Medical Realities, to create a learning platform, content that is powerful and that is kind of validated so that it becomes the way of learning in the future.

Michael Krigsman: You have, shall we say, the technique of surgery, then you have the teamwork and communication, and then you have the virtual reality dimension. Given the technique of surgery and given these other pieces, where are the primary advantages of virtual reality?

Dr. Shafi Ahmed: Okay. I think, first of all, it's very much a visual platform. You may remember most of learning now is very visual. Video content is what we use now to drive our learning pathway. Video has become such a powerful medium now, whether it's YouTube or something else.

In fact, look at the Internet as a whole, Michael. People are now going away from pictures and video is the main way of people learning knowledge, either on YouTube or other platforms. Videos are very powerful, no question.

Then we're looking at, okay, what's the real advantage of virtual reality? It is immersive. When you are in the headset, you do feel as though you're there, which is different to watching a 2D interface on television, for example, or on a computer. That element of immersion where you feel that you're physically in the same room or as close as possible, kind of, that adds a different dimension. You're suddenly concentrating on the environment, looking around, and there's more pressure on you. If you're replicating operations or simulation, for example, there's more realism attached to it rather than the traditional method of learning on a video screen maybe using traditional simulation models where literally it doesn't feel as real. I think the realism certainly is an added value to this.

I think also figuring out, Michael, where virtual reality is going in the future, I guess we don't know. It's still new for all of us. I think it's only been around for the last few years in a way that it's been shaping with lots of tech companies coming into the equation. But, we're just figuring out about where that content should be driven, how the content should be supported, and we're still figuring it out.

Virtual reality, sadly at the moment, is hardware driven. A lot of companies out there are bringing headsets out one after the other. Actually, that's not the answer. We have to find compelling content in virtual reality to drive the industry and also to drive the headsets to people's houses and homes. In some ways, I feel it's the content that has to be compelling. It has to be validated and reliable, which needs to be shown in trials and projects to make the whole virtual reality kind of pathway more helpful to people.

Michael Krigsman: You say that the content needs to be validated and reliable. I have to assume that, in the case of medicine, that is of profound importance, especially for teaching. And so, this raises the issue of the acceptance of this type of content in the medical establishment and, at the same time, the ability of medical training and the medical establishment to be open to change and using these new technologies. What are your thoughts on that, the adoption of technology in the medical establishment?

Dr. Shafi Ahmed: That's a really good question. We could talk for hours on this one. I've got a couple of thoughts about all of this. The first one is around you mentioned about driving innovation and the adoption of innovation. The problem we have in medicine is, historically, we're fairly risk-adverse. We try to ensure that we have robust data before we implement change.

Currently, in this whole area of exponential medicine and rapid change, innovation is moving quite rapidly. Yet, validation is quite slow. Say, for example, you're designing a new learning medium--virtual reality, for example--people are waiting for the validation to do the clinical trials, the randomized trials, and make sure you compare this with the next best item, et cetera. That takes time, Michael. It takes maybe one, two, three, four, five years to accrue enough data to showcase this is the right [way] going forward.

But if you do that, of course, you lose momentum. It's moved on. Virtual reality would change to something completely different within five years. The concept for me now in medicine, we've got to change. We've got to innovate. We've got to mitigate risk as fast as possible, make sure we understand what we're doing, and take the whole hospital and medical field with us on that journey, but we accept the kind of limitations of where we are and then validate as we go along. But, to change validation slightly to trials that are much more quicker, much faster that will give you answers. That's one area where innovation and validation are at a crossroads. We've got to figure out how that moves forward.

The second one is about healthcare on the whole. As I alluded to earlier, healthcare professionals generally don't want to change. I use this kind of saying that I often say at my talks at conferences is that medicine is kind of steeped in dogma and tradition. It's who we are. We're still very traditional people.

My answer to that is if we accept dogma and tradition, then we become mediocre. I always ask my audience, "How many people in the audience want to be mediocre?" Not surprisingly, no one puts their hands up, right? [Laughter] But, by the same token, unless you're challenging, on a daily basis, every pathway, every outcome, you're accepting mediocrity because things are changing, evolving so rapidly. That's the other thought around adoption.

There's always going to be the inventors. There's always going to be the early adopters. They're self-selected. It's the rest of the healthcare professional that you have to drive change. I've been thinking about how to do that. It has to be transformative. It takes a lot of energy, of course, to persuade people. But, I think it requires a different way of managing individuals and taking them on a journey with you to show that the new technologies might be beneficial, for example. I fear that we need to work on that a bit more to drive the change through the entire industry. It's not easy.

Michael Krigsman: You're Associate Dean of a medical school, and so what is your experience in terms of the practical acceptance and adoption? I know we're in the very early days, but where exactly are we in those early days? Where along the process of adoption are we?

Dr. Shafi Ahmed: It's quite early on. All this is new. Remember, even medical schools sadly don't change very quickly either, Michael, and I've been at a medical school for almost 20 years now. If you think about the curriculum, let's take the medical school curriculum, Michael. This is an interest that I have, of course. I'm Associate Dean at Barts Medical School, which have run a long time. That hospital has been around since 1273, so a long time we've been around as an institution.

But actually, if you look at the kind of curriculum, it hasn't changed an awful lot, Michael, in all those years. We're still running a five- or six-year program. I would say to people, why are we still running a five- or six-year program? Could we teach medicine in three years? Why are we still existing to run the same program?

Often, when you're at medical school with other specialists and other areas of interest like physiology, pathology, and biochemistry, all those subspecialties are competing for a slice of the medical school curriculum. All have an interest to make sure their subject still has importance. But my thing is, is it going to change? We are still practicing medicine like it was 50 years ago with the same disciplines of anatomy, physiology, biochemistry, and then clinical sciences, sometimes integrated, sometimes separate two and three years or three and three years, for example. That's going to change.

Why does it have to change? Because a lot of learning we do is unnecessary. We don't need to learn every muscle of everybody, for example. I think it's irrelevant. We can teach the muscles in different ways. We can teach in AR and VR in the future, so I think that will change.

The curriculum takes a while for things to move on. Remember, you have to go through various regulatory bodies to evoke change. Even if it's just an exam question, it takes a two- or three-year cycle. That's the problem.

What I've done at our medical school, Michael, and I'll share that with the audience with you, is I've talked about this. We are trying to create doctors of the future. If you look at where technology is heading towards, I call the future doctor the digital doctor or the connected doctor. We are looking at individuals in the next five to ten years who will practice medicine differently to we practice with the onslaught of all these technologies I described like blockchain, like artificial intelligence, like wearable sensors, big data, pharmacogenomics, nanobiotechnology, and VR and AR. All of these are coming together at the same time to impact healthcare, but we haven't taught our medical students what's going to happen or how to deal with these changes.

We've never been in a position where there's been such richness in technology. I often say this is the most exciting time to be alive as a medical student. It really is so amazing.

I have thought about this. How do we do this together? What I've done at our medical school, I run something called the Barts X Medicine program. I'll tell you a bit about it very quickly. About two years ago, I approached the medical school saying, "Look. We need different leaders. The doctors of tomorrow need to be flexible. They need to be innovative. They should be entrepreneurs. They need to figure out how technology is going to impact healthcare. They need to be really different in mindset.

If that's the case, how do we create the future leaders? We go back to square one and redesign the curriculum. We now teach our medical students not using anatomy, physiology, biochemists. At Barts X Medicine, we teach them about app design, coding, developing, and we teach them about all the future technologies. We talk about venture capitalist funding, how to go to market, run business cases, because that's the way healthcare is going to shape the future, and these people will be inspired to change that and to know what it's like. The students go through a whole course. They get a mentorship with groups of mentors from the tech industry. They decide on a product, maybe, or a solution to a healthcare problem. They go to a Dragon's Den. They go to a hackathon.

Really different words now. We use a different dictionary on medical terminology, and the winners are given a placement with a tech company to see if their idea can be taken to market to impact change. Now, for the first year, this year, Michael, we can say we're, I think, probably the first medical school in the world to embed it into the curriculum. There's no choice. All 300 students go through the same program. We're the first, I think, to do this.

I just think it's the beginning of changing the way we teach our medical students of the future. You know something? They're really different to us. Doctors now don't want the careers that we had before, the 120 hours of work every week, for example, for X number of years training hard. They want flexibility. They want to see the world. They want to travel. They want to be entrepreneurs. They want to challenge healthcare in different ways.

I often call them portfolio doctors now. It's a new term again based on the career pathway. You can do more than one thing in medicine. That's where we are at the moment, and that's where I think we need to drive medical school education to produce the doctor of tomorrow, Michael.

Michael Krigsman: We have a very interesting question from Twitter, but let me just do a quick follow-up, if I may. To play devil's advocate for a moment, you're describing training doctors who have a range of skills and interest, but are you injecting distraction into their careers, pulling them away from the central focus of honing the technical craft of, say, surgery, for example?

Dr. Shafi Ahmed: That's a really good question. I like to answer that, of course. No, of course not; the fundamental part of being a doctor is being a doctor. It's treating people and making them better, having the knowledge. That's always the fundamental part of any medical school curriculum, and we shouldn't distract from that at all.

I say to you this. It's very interesting. If you ask medical students, okay, you come into medical school. For us, we call them undergraduates. I know it's postgraduate in America, for example. They'll come in and you ask them, "Okay, what skills do you have?" We never ask them. We never say, "Oh, you can code or you run a business," or, "Oh, also you do music lessons," or you do this. We never ask those questions, Michael. We say, "You come in day one. We will make you into a one-dimensional human being after five or six years. You'll come out with that skill set," and they get frustrated. They have skills that we have never seen, Michael.

Medicine is not just about this one-dimensional human being. It's about art. It's about music. It's about the human psyche. It's about all the things you add that you can add value to as individuals, and we never see that.

Why I did this program, I asked my students, "What else do you do?" It's extraordinary. Some are running businesses. Some are making money. Some were doing amazing things on the backend. They have skill sets we never use. What I'm saying is that those skill sets can be used in a way to shape healthcare.

The other thing, of course, Michael, a lot of doctors are leaving medicine. They're disenfranchised and not everyone is happy at the end of the day in the medical practice. Some have left. Some are unhappy. They do other jobs. Some go into management consultancy. Some go into the tech industry. They're going anyway.

What we're saying is let's give you the skillsets as a group of people to shape healthcare because healthcare has got a problem, Michael, in the big scheme of things. There's no more money in the world. Everyone is struggling to find more cash. We all know we need more cash. There's no more money in healthcare. That's not just the U.K. It's every country.

Therefore, you've got to say, "Look. Okay. How do we redefine healthcare? Tell us what your views are, your thoughts to make healthcare more efficient, more equitable, using the same kind of money." That might mean some guys going away, forming an app with an AI interface or chatbots or whatever, to away the burden of healthcare. But, unless you teach more of these skillsets, they won't be able to do that.

I really think this is where we are. It's just a unique position we're in. We never faced it before in hundreds of years, but we shouldn't shy away from the challenge. Yes, you're right to ask the right questions about what we're trying to create. By the same token, the way the tech has been driven, we have to adapt to these new solutions.

Michael Krigsman: Certainly, some of the most extraordinary doctors I know are multitalented. They are hardly one-dimensional individuals, as the cookie cutter training would typically end up resulting in. We have some interesting questions from Twitter. Michael DePalma--who works at IQVIA, which is a large healthcare-related company, as many people know--asks, "How do we get patients to adjust to this new world of medicine, and what about the healthcare industry as a whole?

Dr. Shafi Ahmed: Okay, so a really interesting question. Thanks, Michael, for the question. Yeah, so one of the things that somehow often miss in these discussions is the patient, the end user. Michael, one of the frustrating things I find in healthcare, all the conferences I go to, and look at the tech industry is that often patients aren't involved in anything. I go to a lot of conferences where you won't see a single patient, but yet we're discussing healthcare and the future of healthcare. Yet, we haven't engaged the end user.

We need to strive to make sure the patients are the center of that discussion, always. There's no question. I have certainly made sure that when we do this work that I'm trying to do to engage learning, training, and changing clinical practice, it's taking the patient on the journey with you. I think, with the technology, which can be scary for some patients, and the evolution of technology and its inception and use in clinical practice, it is scary for patients. There's no question. They're scared of AI. They're scared of robots. They're scared. I mean I would be too if I didn't have the information.

We have a moral duty to ensure that that journey is taken together with patients. How do we do that? We engage them. We talk to them and say, "Look. This is what we're trying to do."

When I'm doing these live operations, Michael, around the world, I have patients who are very supportive. When you're trying to do good, when you're trying to help people learn and teach around the globe, you'd be surprised at how patients are so supportive and generous with their time, with their surgery, with having to improve health outcomes. It's incredible how generous our patients are to us as doctors. We mustn't underestimate what they can achieve.

One of the thoughts that recently we had around the discussion around X Med last year was that all these tech companies, we have, for example, the CEO and the chief medical officer, the CFO, and perhaps what we should be incorporating is the CPO, the Chief Patient Officer, in every company to ensure we don't forget them in that equation. I feel that we should do more of that to ensure that they're part of that bigger discussion. They shape us, and they also restrain us from doing things that aren't right or can be dangerous. They are our thought process for us so that we do it together.

Also, we need to encourage them to innovate. They are the best people to know how to innovate their own healthcare conditions, almost, because they live through conditions. We assume when they're better, but I'm not sure we do.

I have a couple friends like Michael Saris (phonetic), for example. Michael--I can share his story with you--is a wonderful patient who has had surgery before many years ago as transplanted intestines. He had a bowel transplant for inflammatory bowel disease. He's gone away now and formed a tech company to measure the fluid in the ileostomy that people have for surgery to allow you to have an app to tell you when it's going to leak or what the electrolytes are.

He is engaged. He's worked out the problem. We need to encourage more of that to happen to go to the patients to help us design the healthcare solutions that they need. We're not doing that enough.

Every time I go to a conference now or wherever, I just say, "Where are the patients? Where is their voice? We need to hear it. It needs to be loud and clear."

The third part of the question was around the big corporates and the healthcare system. That's more tricky about how we engage the healthcare systems work together, Michael.

Michael Krigsman: We have another question from Twitter, another great question from Arsalan Khan. He is asking again about acceptance of change. He's asking about the cultural transformations that are needed to enable the acceptance of this kind of change that you've been describing.

Dr. Shafi Ahmed: Yeah. That's a really good question. Thank you, Arsalan. Absolutely. This is really going to the crux of the kind of philosophy and the practice of medicine for many years. I look at that sometimes.

Let's go back and look at the doctor/patient relationship. I often talk about the hypocritic oath, the oath that we had been given for hundreds of years about our pledge to our patients and our degree of professionalism, et cetera. It becomes a bond with us and the patient, and now it's been superseded by the Declaration of Geneva from the hypocritic oath.

Also, if you look at the pictures around the doctor/patient relationship, it's very maternalistic. The patient is often below. You're either standing. You're talking. There's a connection there. There's the human interface of touch, sound, and site. We often see that as a way to empathize and teach people, for example.

If you think about what's going to happen in the next two to five years, Michael, that's going to transform entirely. Patients won't be seeing a real doctor, i.e. a human being. The first point of contact for most people, within a very short time, will be an AI chatbot. It'll be asking questions to a smartphone, and get responses back depending on your answers, et cetera, and algorithms to give you a diagnosis, and possibly even a prescription to go to the pharmacy or chemists because medicines maybe completely maybe completely embedded in AI. You may see avatars. You might see holograms because the way we're going to connect with people is going to be different.

Already, we're using telephone triage. We're speaking to patients on the telephone or Skype, so the whole concept of that doctor/patient relationship of handholding, touch, and kind of breaking news or bad news sometimes, it's been disrupted. Sure, that's reasonably relevant for some patients, but not all of them. I think we've got to manage it differently.

That goes back to the question that often says we have to social condition people differently. If you're a patient expecting to see a doctor for half an hour, yet we are soon going to be asking you to go to a chatbot for two minutes with your problems before you see anybody, that requires social condition, a cultural change from the profession and also from society. Actually, you're not going to see a doctor for half an hour, 40 minutes. You don't need to. If you have a cough and cold, you can access a chatbot. It'll give you the information you need and perhaps that's the kind of situation we're facing fairly soon.

Yes, there'll be a lot of resistance. But, I've seen areas now in London and other places we're already now embracing either telephone consultations or Skype consultations, and now AI chatbots for … (indiscernible, 0:31:44) populations to show healthcare is changing. What's interesting about those experiments, Michael, is they seem to be working. Already in the U.K., we have Babylon Health, Ada Healthcare, and others who are now actually using this in real time for real patients and seeing thousands of people.

I was at a conference just yesterday at Wyatt Health. I was speaking, and Ada, which is a kind of AI interface, are getting an inquiry into their chatbot by a patient every four seconds of every day. You can see already we're changing the way we're practicing.

Michael Krigsman: I'm thinking now in terms of the AI that's associated with this and the kind of data sets that need to be enabled to make that AI work because you've got the technology, and there has to be a certain level of efficacy. That needs to be there before adoption can take place. You were just talking about resistance to adoption and the cultural change needed for adoption, but the technology has to work. What I'm wondering is where are we in the technology lifecycle of that today?

Dr. Shafi Ahmed: Yeah, so that's a really good question. Where are we? Look; if you look at the technologies that we've been discussing before that I often talk about at various conferences and things, there's the whole AI kind of discussion. That includes the machine learning and also robotics as kind of a consequence of AI. There are the blockchain and cybersecurity areas in data. That's another area of huge interest. Then there's the whole wearable sensors and monitoring of people, including pharmacogenomics and the access to profiling. VR and AR are slightly separate to that kind of environment. Those are the areas that people are really driving hard towards.

You're quite right. They're not as good as we think they are. That's the first thing. They're very early, still, in inception and, more importantly, in practical applications. But, they're accelerating quite rapidly. We're not sure, so AI itself is in already. It's being used today with algorithms. We use it all the time. We just don't realize we're using it. Within two to five years, it'll power most of healthcare, I'm pretty sure, so that's going to be really fast. We're going to adjust to the changes of that happening.

Robots themselves, if you look at robots, it's fascinating. At the moment, they just augment surgical practice. They take away some of the tremor and the error and make it much more precise for most surgeons to work in. They're very expensive. They became better. In general surgery, for example, my own specialty, over the next 18 months there'll be 8 to 10 robots on the market.

We only have one at the moment that's Intuitive Surgical with their system of da Vinci. Another eight are coming to market fairly soon, including a collaboration between Google and Johnson & Johnson called The Verb. Medtronic has gone one. TransEnterix has got one. We've already got a new company in Cambridge in the U.K. called Cambridge Medical Robotics, all again coming into this area. What will happen, that will drive change, reduce costs, making it more accessible? Suddenly, the prohibitive cost before will be fairly cheap in the next two to five years.

The problem with this, though, Michael, it produces a lot of data. All this that we do with sensors, AI, and robotics, it's going to generate a huge amount of data. People now call this kind of area having what's called a quantified self, i.e. having so much data you become a quantified person. What we haven't figured out is what to do with that data. No one knows.

It's going to come through, it's going to amass, and that is going to be the difficult part. How do you access the data? What bits are important? How much control does the patient have? We have the new regulations in Europe, the GBDR, which will come out next month, which will regulate much more of the data regulation across all channels. We've got to figure that one out as well.

What's been disappointing, I think, overall is the wearable and sensors. About three, four, or five years ago, there was huge interest in wearables, sensors, and your Fitbits and whatever. They've actually largely disappeared from actual practical use because they were treating the well people, not looking at chronic diseases properly, not looking at the patients, how they're going to utilize that. Because we can't catch the data and know what to do with it, they haven't really transpired. There'll be another circle of life for wearables in about two to five years when we've figured out what the data means [and] how to use it. We'll go back and start using them again in a way that we haven't used before.

All of this is still quite a bit confusing for a lot of people, confusing for us healthcare professionals because there are so many things coming together at the same time. I think we're quite mature. I think we are, as humans, as healthcare professionals, very mature about whether it may have a role. I think time will be the most important thing for us to figure out how all these things come together and what has an impact, more than anything else.

Michael Krigsman: You mentioned this accumulation of data. Obviously, if we can use that data, it can bring great benefits to healthcare. Then there are privacy issues that you also raised and ethical issues. The CMO of Aetna Insurance has been a guest on CxOTalk, and I know they have an interest in this data. But, what about those privacy and ethical implications? Where does that come into play? That's of keen interest to many people today.

Dr. Shafi Ahmed: I certainly agree with you, and that's one that we have to figure out fairly quickly because that data will start to be produced fairly soon from all these things we described. This is where, I guess, if you think about what that data means, there's the hospital, the healthcare system, insurance companies, for example, but also the patient and the access they have to that data record. Ideally, we'd like to be in a position where all of that data could be shared securely. The patient will have ownership, and they can easily allow their data to be shared if necessary.

People talk about this whole blockchain kind of technology, which will probably form the fulcrum of data sharing because it becomes more secure and it's the most secure form that we have at the moment. Blockchain itself is exciting, but again, at the moment, people still haven't figured out where it stands in a global context of healthcare.

If you put that into a position so you create a secure pathway with ledgers, with controls at both the patient and healthcare end, at least you can build up the ecosystem securely. That would help us obviate some issues around privacy and problems. I think the technology is out there that would help to actually overcome some issues that we may have assumed would happen. Then that comes full circle around autonomous kind of practice.

If you look this whole AI data, for example, say we can predict on a chest x-ray with quite a good reliability index, about 98%, the outcome of the chest x-ray that people take, and that makes sense to me. It means that you get results fairly quickly. But, what about if that goes wrong? What if the AI machine or the chat, whatever it is, gets the wrong diagnosis? What are we going to do? Who is to blame? Where is the caution going on? Is it the software engineer? Is it the data that's been put in by somebody else? That's very interesting.

What I look at as an analogy of that, Michael, is the autonomous vehicle. When we look at Tesla and all these cars now where you can get a car and go around the best parts of the world with no drivers. For me, that's really important because that will ask the right questions about data, about ownership, about who is at fault. In some ways, it will help us shape healthcare in the future by asking the questions already in a different industry. It's really funny how these other industries and other verticals will help support healthcare in the future. I find it fascinating.

Michael Krigsman: In a way, would it be correct to say that for you, as a medical educator, as Associate Dean of a medical school, it's these ethical and governance issues that are slowing adoption equally as much as technology advancement?

Dr. Shafi Ahmed: Yeah, I think you're right. There is a balance there. People, as I said before, are risk adverse. They don't want to change. I can understand why. The legal framework, remember, runs behind, so legal framework is another one when you talk about governance. Legal framework runs two, five, ten years behind where, at the moment, is nowhere near quick enough or sophisticated enough to change very quickly. This is where, again, we have to take the legal system with us.

Okay. When I was doing these live operations, Michael, and we're thinking about the impact and issues around ethics and confidentiality, we're very careful with what we did, and we actually approached the governance team in the hospital. We approached the legal team. We had a big discussion with all the teams involved and all the stakeholders to say, "Look. We're trying to push innovation either using AR, VR, whatever it is for education. What are the risks here? How do we … (indiscernible, 0:41:22) as possible? Where is that legal framework taking us? How do we use that to support us?

We were very mature in the sense that the hospital itself said, "Look; let's innovate together. It makes sense. Let's get all the people together to ensure that we are safe, and we are taking as little risk as possible and to put in safety measures if necessary." That's how you're going to drive change because you can't wait for things to change for you to make that happen. You have to take the whole system with you, including patients, including the governance team, including the legal team as well, and say, "Let's do this together."

My experience has always been about that journey. How do you take a healthcare system with you? I work in the biggest healthcare system in the U.K. Barts NHS Trust is the biggest hospital, the biggest organization, et cetera. My view is, how does the biggest trust accept change and move on? If we can bring this big system with us, it makes a difference. I've learned a lot from how to engage with the right stakeholders.

Michael Krigsman: We're almost out of time, but we have a very interesting question from Twitter. This is from the @CxOTalk Twitter account who is asking, "If we take the human out of the doctor, does that really benefit the patient?" I guess it gets right to the heart of that ethical/efficacy issue, as well as comfort with change.

Dr. Shafi Ahmed: A brilliant question. Thank you very much for that one. I think we've got to change. Look; we're kind of obsessed with having a human being at the interface. Now, yes, I can see the importance of that. I can see the fact that we need to see someone eye-to-eye, making contact, et cetera. I get that, of course. That's what I've been doing for 25 years. I break bad news every week, Michael, to my patients who have cancer. Sometimes I break good news because they get better and they're cured.

I know what it feels like. I know what that means to patients. That can't be replaced, and I don't think it should be replaced. But my question really is around a lot of healthcare where you don't need that physical connection or contact. Can you replace it in other ways?

I've used Beam Systems to go around the wards, Michael, to see my patients. I've used Google Glass to interact with my patients remotely. I don't think you need to be there physically to be able to see a patient. They see you on a 2D interface, on a TV screen or on a smartphone or on a phone itself, to interact with you to ensure that you're helping to support them. They just want to know that you're there.

I've asked them questions. Would you be happy with me not being there, but being remotely, but using telemedicine or something? They've happy. They just want to make sure that you're looking after them and you know what's going on with them on a day-to-day basis.

You then move on from that point and then decide we're going to an AI interface, the chatbots, and also around avatars and holograms that I've been working with recently thinking, okay, if we recreate a human being in real life. You might have seen the picture. I created my own virtual surgeon using a process of photogrammetry, 104 cameras around me creating this volumetric person that was me.

Now imagine if you add a kind of motion to that, i.e. facial expressions and also add voice that speaks like me, talks like me with my intonation. Then add Google in the backend with all the knowledge around the world. That thing, whatever you call it--humanoid, avatar, or virtual person--can then teach a lot of people around the world. It could support and treat people as well.

We have a mission now. How do we incorporate that? How do we persuade patients that they're still being looked after properly? This is the whole bit about social reconditioning, how to change the framework. We can't carry on as we are, Michael. It can't carry on. We don't have the resources available for an aging population, for more chronic diseases to manage in the same way. We've got to think outside the box. This is not working.

For me, healthcare is not working, not in the U.S., not in the U.K. anywhere. We keep doing the same thing over and over again, Michael. We wonder why it's not working. We've got every challenge, and it isn't different.

Michael Krigsman: I know what my medical bills and insurance cost, and I can tell you for sure it's not working over here. We're out of time, but we have a few comments from Twitter that I just have to share because there are some really good ones.

John Nosta makes two comments. He said earlier, he wants to know when you're going to win the Nobel Prize for your work. We hope that that's very soon. He also points out that the reality is that chatbots will become better than humans. That's from John Nosta.

Then Michael DePalma very emphatically makes the comment, "No, you do not take the human out of the doctor. It's human and tech. It's not zero-sum either." It's a very common misconception.

Any final thoughts on that aspect?

Dr. Shafi Ahmed: I agree with Michael, absolutely. I think the two have to go together. We have to be sensible when we're pushing the boundaries. We have to think about how that interface would work better. It's not one or the other. I agree; it's a mixture. I think tech augments clinical practice, as it will do. At what point it will make a big difference, we're not quite sure.

John is quite right. I think the chatbots and AI at some point will supersede human behavior. That's what they call singularity, of course, but I also believe that's going to happen at some stage. I already answered John's first question, I think.

[Laughter]

Michael Krigsman: Then I will just ask you very quickly and finally, what advice do you have to other medical practitioners or administrators, professors in medical education who are looking at this and saying, "All of this is interesting, maybe it's inevitable, but I haven't the foggiest clue how to start implementing this in my medical school"? Any advice for those folks?

Dr. Shafi Ahmed: The word is collaboration. We live in a world where you can't do everything on your own. People do things differently in different places in the world. It's about the collaborative effort for everybody.

At the moment, if you look at tech and healthcare, there's so much going on. There are so many interesting conferences. There are so many startups happening. There are so many meetups. It's almost that you can't go a day without seeing something going on.

My advice to people on getting involved and to implement change is to immerse themselves with the people around them in that environment. Go see them. Don't go to a medical conference. Go to a tech conference for a change. See what's going on out there. It'll help you open your minds, develop your own kind of thought processes, and so don't feel that you can't change. You can.

There are other people out there working with you to make that change. Big tech companies, remember, need doctors. They need us more than anybody else to help shape the change for them. I would encourage every doctor to think about that as a whole and, every day, make a little practice about how they're going to effect change and not be mediocre, but be the best that they can be.

Michael Krigsman: Okay. What inspiring words. I would like to thank Dr. Shafi Ahmed so much for taking time out of an insanely busy schedule to be with us here on CxOTalk. Thank you so much, Dr. Ahmed.

Everybody, I want to thank you for watching. Go to CxOTalk.com, and don't forget. Be sure to subscribe on YouTube. There are more shows coming up next week, so tune in. Thanks so much, everybody. Have a great day. Bye-bye.