Through the Looking Glass 10 Years On

It's been 10 years since I donned a Google Glass and transmitted a live cancer operation across the world. People often ask me how I embraced the new world of digital innovation and exponential technologies, and I can say that this changed my career trajectory. Here I share that story and the reasons why I decided to disrupt education:

The Past

In 1993, having freshly graduated from medical school, wearing a new white coat with large deep pockets full of books with all of the knowledge that I never knew or learnt but would carry me through internship but, creating a false sense of professionalism, a stethoscope around my neck that I could barely use, I decided that a surgical career in surgery was beckoning. At least I could get rid of the heavy white coat and wear cool blues with fewer pockets.

Surgical training was accessed by a mixture of learning from textbooks, spending up to 120 hours working per week, obtaining clinical experience on the wards and the emergency room and then juggling to try to get to the operating theatre as much as possible. Those rare moments where I could get to assist at an operation were not as glamorous as one may think. The junior most person in the food chain had the responsibility of holding a large retractor that the most medieval torture tool maker made to inflict as much pain as possible on the user. I used to call these instruments "retractorum tormentorum", as a lot of medical terminology was derived from ancient Latin. Having been tucked under the armpit of the senior surgeon for many hours at a time, craning my neck and manipulating every sinew to try and get an occasional look at what was going on, I developed the skills of a contortionist by trying to retract and avoid obscuring the critical view of the operative field for the surgeons. I indeed became good at counting the hairs on the back of the surgeon's neck. It is no wonder that surgeons and barbers share a common ancestry. (Mr Williams, the first consultant that I worked for, had precisely ten hairs separate from the central hairline. 2 were curly and brown, and the others had become white)

Then there were the medical students. The plankton of this seamless food chain were occasionally asked to "scrub up" for an operation. The problem was that the operating theatre environment was so tense and new for them, and by the time they figured out how to scrub up after several failed attempts, the operation was usually over. Still, they gained valuable experience in washing their hands. It was a shame, as I always looked forward to handing over the retractor to allow valuable circulation back into my fingers.

As I moved up this ladder from second assistant to first assistant and then that much-coveted role of the main surgeon, I always reflected back on my days as a student and trainee. I have spent the rest of my life figuring out how to change this. My questions were posed around what kind of learning we were creating and how we could improve this.

Surgical teaching in the operating room has not changed for centuries. Although the description above is light-hearted, it isn't terribly far from the truth. We have never really engaged our students in the operating room by trying to improve their whole experience. Pictures from history show many students trying to learn in the operating room, often forming a scrum around patients with poor views.

I have concluded that students learn by a process of diffusion and osmosis by breathing in the history and majesty of the operating room with occasional nuggets of actual information. Students in 2024 are more savvy, of course, having learnt valuable lessons from the experiences of their predecessors. They are now paying significant tuition fees and spending 8 hours in the operating room. They no longer watch the paint dry on the walls of the operating theatre but realign their gaze and attention to their smartphones. Interrogation of Dr Google during the operation allows them to predict the usual and condescending questions that the surgeons may ask, and watching operations on YouTube helps them understand better the blood and guts that bear no relation to the accurate and beautifully drawn anatomy in books or formaldehyde infused cadavers that they have dissected. More often than not, I see them now engaged in deep conversations (an oxymoron) on social media via WhatsApp, TikTok, Facebook, Instagram, Twitter, Snapchat, etc.

Fast forward to 2014.

We have a global problem to address in surgery. The Lancet Commission highlighted that we must train 1.2 million surgeons, anaesthetists and obstetricians to carry out an extra 143 million basic operations, as 5 billion people cannot access safe and affordable surgery. This is an enormous challenge as it takes 5/6 years to train as a doctor and at least another 4-6 years to train as a specialist. It is estimated by 2030, we will be 15 million health workers short across the globe, according to the World Health Organisation report on the global strategy for human resources for health. The target metrics for 2030 are that all countries will have made progress towards halving inequalities in access to health workers and improving the course completion rates in medical, nursing and allied health professionals training institutions. However, this doesn't deal with the preparedness of the workforce for digital transformation, which requires a radical rethink of how we teach, educate and dissipate the knowledge and skills to create the digital health worker, which I will be covering in another blog.

We haven't addressed this shortfall in increasing the numbers required in that short period of time. It isn't possible to do this in the conventional manner. Workforce planning is wholly inadequate at local and national levels. This serious dichotomy has grave consequences: increasing healthcare costs versus not having enough healthcare workers to deliver this by 2030. This demands a radical rethink.

In 2014, I was elected as a member of the council of the Royal College of Surgeons of England and directed the International Surgical Training Programme. One of the solutions to this global shortage of surgeons would be targeting and empowering the next generation to leave a sustainable solution utilising the NHS's resources for training. Over four years, the team and I travelled to meet surgeons from different countries, including Gaza, West Bank, Kenya, Malawi, Bangladesh, Sri Lanka, India, Egypt, Qatar, Bahrain, Dubai, Japan and China. We created collaborations with over 40 Ministries of Health, surgical colleges, universities and hospitals. We highlighted areas of surgical practice that were either deficient or needed support. We appointed 300 surgeons to the UK for two years and trained them in different specialities depending upon the host country's needs. Most are back, already helping to support their health systems. One trainee can now help a population of 1 million with urology services and can help train more local surgeons.

The Launch of Google Glass

The Google Glass was launched at the Google I/0 in 2012 and was one of the most jaw-dropping, scene-stealing demos I have ever seen. It involved hosting a live Hangout between skydivers, all wearing the Glass and streaming live video from their point of view while simultaneously parachuting from the sky to the Moscone Centre Earth. After landing, they abseiled the building, cycled, and ran indoors to join Sergey Brin, Google's co-founder, on stage. The whole journey was captured live by the Glass. Having seen this, I started thinking about the utility of the Glass to solve some of the issues in healthcare and education. 2014, I applied to be a Glass Explorer, but applications were only valid for US citizens. I wanted to use them for training. Undeterred by geographical boundaries, I decided to do the next best thing. I went on eBay. The website had a Google Glass for sale at the exact cost of the Explorer version. The owner was a VC from Silicon Valley who had relocated to London and was given a pair by Google and couldn't find a use for it. Twenty-four years later, having met in a coffee shop in Highgate, London, I was wearing the glasses and figuring out how to use them. After spending a few days with them attached firmly to my face, I travelled on the trains, buses and the streets. The public can be divided into three groups: the first noticed me wearing the Glass but looked the other way, consistent with their impeccable British values. The second group just stared and offered no other emotion. The third group was super interested and not only noticed this strange contraption but also came and asked about the Glass and wanted to know what it does, and of course, they ended up with that prized selfie.

They could be used for teaching and telemedicine, but with a bit of work on the software. I was probably one of the first people in London to walk around with them.

Sadly, there were many poor use cases, and the public was not ready to embrace smart glasses because it was considered to be an intrusion into people's lives. The Google Glass was essentially a smartphone on your head, which allowed all of the same features as a phone, for example, taking pictures, taking videos and answering phone calls. The bad press allowed the term "glassholes" to be directed at the early explorers.

On the other hand, my friend Raphael Grossman, a trauma surgeon in Maine, USA, showed the potential of this technology by performing the world's first operation using Google Glass in 2014 to students close to his operating theatre.

After I obtained the Google Glass, I asked my two tech-savvy medical students, Oliver Trampleasure and Ali Jawad, to reconfigure and reprogram the smart Glass so that I could livestream an operation. They managed to get it working within a week and linked it to the Livestream app. I tested this out in the OR and on a minor procedure to ensure that it worked and, more importantly, that it was safe without affecting my surgical ability. I was reassured and confident that we could use this for teaching.

I then approached the hospital as I was planning on operating that same week on a patient with colorectal cancer and streamed this to my medical students to see if this could be used in this way. We approached this sensibly. We worked with the legal, IT and governance teams to ensure we mitigated all risks as far as possible. The latency in the system was around 30 seconds, which was important. If I had a significant problem, we could stop the recording. I then approached a patient who I was due to operate on with a diagnosis of colorectal cancer and explained honestly what I wanted to do. He and his family gave me his full consent, and one of the things that fills me with so much faith in humanity is the generosity of my patients and the trust they have in me as a surgeon and as a teacher to help share knowledge globally. Initially, I was planning on just teaching a few students, but the hospital sent out a media note, and before I knew it, there was a media frenzy. Several TV channels wanted to come and record this live as it was the first time the Glass would have been used in this manner.

A few days later, I performed the "live" operation and streamed the video to medical students and trainees worldwide to showcase how we could democratise surgery using innovative technology. Students worldwide could watch an operation from my point of view on a smartphone, tablet, or personal computer while I was wearing the Glass. We also allowed them to text messages onto their smartphone which would appear in the corner of the Google Glass as I was operating and allowed me to interact with them and teach them. It worked. The operation was watched by 14,000 students in 118 countries, who demonstrated the power of connectivity to help transfer skills and knowledge. The solution was simple. A wearable headset. A smartphone. A free app. High tech, low cost. This has to be one of the ways to make education accessible for all.

Most importantly, the patient recovered well. This project gained a lot of interest worldwide with plenty of media coverage. Our team then set up an entire education platform using Glass for teaching, and we streamed many operations and other clinical scenarios for training. After the initial event, I spent much time analysing and reflecting on the project. I asked myself many questions. I wondered what I would have done differently. What did I learn? What was the value? Did I put my patient at any undue risk? Was it safe? Did we compromise on asepsis with TV cameras (from ITN News at Ten) within a few inches of the operating field? I reviewed the thousands of messages, emails, tweets, etc, and 99% were very supportive and saw the value. Over 90% of students favoured this kind of surgical teaching. However, I concentrated on the critical reviews as they had the most value for me and ensured that I would take valuable learnings forward.

The livestream went viral and was covered by virtually many countries. Here are a few from different countries.

At the Digital Health Forum in Dubai in 2015, I taught John Scully, the ex-CEO of Apple, to perform surgery remotely using Google Glass. He had 30 minutes to learn how to suture a piece of artificial skin using my direction via Glass. He performed very well, and I am sure he would have made a great surgeon if he hadn't chosen to build the world's first trillion-dollar company with Steve Jobs!

For a while, I was known as the Google Glass surgeon, and the tag remained until I transformed and became the virtual surgeon, which is a story for another day.

Fast forward to 2024

The technology has greatly improved with newer and more advanced smart glasses, some even powered by AI. We now have 5G connectivity, allowing for better streaming capabilities, and remote training has become more widespread and almost routine.

One quote stands out after being dubbed as the "Tony Stark" of surgery on social media. It came from a high school teacher from the US who followed my work and said simply this of the first global transmission:

“To reach those that few can reach. We need to teach in ways that few can teach”