The VR Surgeon

Well, that's a really big question. Let me see if I can go back in time — which is a long time ago now, so it'll take a while to remember what happened.

I went to King's College Medical School from 1988 to 1993, in South London. I enjoyed my time greatly. It was a great experience, a new journey for me — an unexpected journey. We didn't imagine ever being at medical school, or even becoming a doctor. At medical school I was very interested in leadership. I was the student union president for a year. I did a lot of work bringing different parts of the curriculum in, like ethics — we introduced that as part of my remit. I worked closely with the leadership at the medical school at the time, and I enjoyed that whole year of doing something different.

The other part of my life at medical school was sports. I used to be very sporty. I played football for the first team for five years, and for ULU, the University of London Union, and United Hospitals — the intercollegiate side of the medical schools. I was also captain of the first eleven cricket team for those five years. We had a lot of success, both in London and nationally.

So I spent a lot of my time doing other things. And during my clinical years, the only thing I really enjoyed, in hindsight, was surgery. In fact there were two things I enjoyed: surgery and neurology, which sounds a strange mix. I think it's about the experience you get — who your teachers are, who inspires you at the time. I loved surgery. I had great teachers at King's. I'd never thought about surgery as a career before that. I didn't think I was good enough, number one. And secondly, coming from our background — a fairly average East End background — aspirations were quite limited. We didn't think we'd get to medical school; and once we got there, we didn't think we'd ever reach the heights of becoming a surgeon. It just wasn't in your mindset.

So I went through, enjoyed it, qualified, passed, and started working as a junior doctor. I did my house jobs — one in Bromley, South London, and the other at King's. My surgical job was first, at Bromley and Farnborough Hospitals. In those days it was a different kettle of fish. You were one of only four house officers on the firm. It was a lovely environment: the chief nurse would look after you, and the consultants were part of your life much more than they are now, because it was a tight, small team. I really enjoyed that. And I learned that I quite enjoyed the job — because when you suddenly qualify, you're never sure you're going to be able to do it properly, whether you're good enough, whether you're going to sink or swim. Remember, in those days we were working over 100 hours a week.

There were lots of on-calls, and you're on your own making decisions. It's a huge jump into clinical work. It's less so now. But once you'd coped with the hours, and the lack of sleep, you enjoyed the job. And in that first year I realised, actually, surgery — I really enjoyed it. I went to the operating theatre, assisted many operations, and I was allowed to have my own minor ops list as a houseman, which isn't really possible now. All those experiences told me: this is what I want to do. I coped with the job, it reflected well on me, surgery made sense to me.

So I decided to crack on and push really hard at that career, and I haven't stopped since. Surgery is one of those professions — it's all or nothing. When you go for your exams and fellowships, it's full on. I went on to do a demonstrator job to pass my part one FRCS, then a surgical rotation to get my part two FRCS, then surgical education jobs going forward. My career was quite smooth in that sense. But the fellowship was a real eye-opener — I'll share the story with your followers.

In those days the primary FRCS was the acid test. If you got through that exam, you were more or less assured of a career in surgery. The pass rate was between 5% and 10%. I remember my first exam, in Ireland — about 400 people did it, and only 35 passed. So you imagine: if you get through that barrier, suddenly you think, actually, I can probably make it. And then you just work really hard, learn your skills, learn your profession.

I never thought I'd be more than a consultant surgeon. Never thought I'd be at an academic teaching hospital. Never thought I'd become a professor of surgery. But what happens is, as you progress, as you're more successful, you push through the boundaries, you break the glass ceiling, and you keep reaching new heights — things you didn't think you'd achieve at a young age. If you'd told me at 23, when I qualified, that I'd be doing this in my career, I'd never have believed you. I was very happy at that stage just to be a jobbing doctor with no other aspirations, because that was enough for me at the time.

But it's about pushing hard, trying to be inspiring, and doing the best you possibly can with the opportunities you have. That's what I'd say to all your viewers: it's about having the opportunity, driving hard, working hard. And if you work hard and you're good enough, you'll succeed. It's as simple as that.

As surgeons, we've always been interested in technology. Surgery is one of those areas that's been innovating constantly over hundreds of years. Even during my training we were doing open operations at the beginning — I never had a laparoscope in my hand until quite a senior stage of training. Then laparoscopic surgery came in: new technology, new instruments, new devices. And now robotics is coming in. There's always an interest in innovation in surgery. It's who you are; it's what defines you.

I used to work with companies like Johnson & Johnson, being flown around the world to look at equipment, test out new devices, give advice about products they were building with people at MIT and other research centres across America and Europe. That fuelled my interest. And when I was teaching as a consultant — I was associated with the medical school for 10 years — I was thinking: how does technology help us? Where do we innovate? How do we teach people in different ways?

At the same time, around 2013 and 2014, suddenly the technology we were after became available. We were looking for ways of disrupting medical education and our own surgical profession, and we didn't have the tools until then. Then there was an explosion. When Google Glass came out, when AR and VR were coming out, I was at the very forefront, saying: how do I use this? What's the clinical application? How can I make this better for somebody? I was always looking for something, and it was just the right time, right place. The right position in my life, the right time, and the right mindset to use the technology in that fashion. I haven't looked back since. I've really enjoyed that journey over the last six years.

That's a really good question. Whenever you're innovating, you're going to be in a very small category. Historically, medicine has been risk averse. Most people don't want to change — they're quite stuck with what I call dogma and tradition. As you've seen through your own medical school years, people say to you: this is how I do this, this is how I was taught to do this. They're not saying, what's better than this? How do I move on? You're always looking behind you, which is the wrong message.

So there are always going to be a few people like me who are the early inventors and adopters, and then a large proportion of people who are slow to change. I was always one of those people who'd look for different things, new things, drive change. And once I started on that pathway there was no looking back, because we'd created useful devices, useful applications. There were clear benefits. There was a lot of coverage, nationally and internationally, about what I was doing. And then it became a snowball effect. I was having more and more ideas. More companies were coming to me saying, you're one of the change makers — how can we help you, how do we work together? I was helping them shape the future, design their products, navigate the bureaucracy around the NHS. Once you've got that reputation, and it's been safe and productive, you end up doing more and more.

My vision has always been: yes, I'm one of those few people trying to make change, but how do I take everyone with me on that journey? It's not about me — it's about everybody else, and ultimately about patients who need to benefit across the piece. So how do I persuade people? That's why I do a lot of talks around the world, work in different groups and committees, to help the digital transformation of healthcare. It's engagement, education, and implementation — showing the good data that comes out of it.

Let me tell you the story about the Google Glass. In 2014, when the Google Glass came out, I got one of the devices — one of the earliest people to get it. In those days the early doctors were called "glassholes", because Google Glass wasn't particularly attractive and there were issues around confidentiality. People were scared of the whole device; it was too early in its inception. But we got there early, and I persuaded my medical students at the time, Ollie and Ali, to configure it. They were very much into software and computer design, and they configured it so it would stream very quickly, which wasn't really available to a lot of people.

I saw the utility straight away: we could stream live and teach people around the world. I was troubled by what I saw in our operating theatre — sometimes you get six or eight medical students in there for eight hours a day and they're not engaged. They're in the back of the room, on social media, on their smartphones, trying to plan their weekend. They're not learning anything. And we've assumed for decades, if not centuries, that this is the right way to train people. We've never challenged it. Even now it still happens. I thought we could always do better — how do I teach better in the OR, and push that out to more people?

So we configured the Glass, and started practising on patients just to see whether it was working — could I stream, was it reliable, was it stable? It worked. So very quickly I approached the hospital and said, I'd love to do a live operation, streaming. And luckily my trust, Barts Health, were very supportive. They didn't say no, let's think about this. They didn't say, let's form a working party and think about it over the next few months. They said: fine, we trust you — what do we need to make it work? That's the right message. Delaying just delays everything.

So very quickly we got a team together — someone from the governance team, the data person, people from IT, the medical director, the legal team. Within a matter of days: what do we need to do, what are the issues, what could go wrong, how do we prevent it? We were very sensible, using common sense: if this happens, we'll do that. And the legal issues — there were none, because the legal framework runs behind technology by a number of years. The most important thing was getting patient consent, and patients were wonderful. I asked whether they'd do this for me, and they were more than happy, because it was training, teaching, trying to improve standards across the world. Our patients are very much our partners; they're very supportive of teaching and training.

Then the hospital decided to send out a press release, and it went viral very quickly. All the news stations picked up on it and wanted to come to our operating theatre for the first live one — Al Jazeera, BBC, Channel 4, ITN. In the end we chose the ITN News at Ten team, and they were in theatre live at the time. Thankfully it all worked. We took precautions, we rehearsed it properly, we made sure it was working, and we pushed it out one Thursday evening back in 2014. On that day, around 14,000 students, doctors and healthcare people logged on from 118 countries and about 4,000 cities. Every part of the world was involved. They were engaging, they were learning, and it worked. The proof of concept worked.

It seemed the world was ready to be connected. These demonstrations showed we're a much smaller world than we think. And if we can democratise health and education, why shouldn't someone in a low-to-middle-income country get access to world-class education? There's no reason why they shouldn't. We've always had these barriers of education that are geopolitical — based on geography, where you're born, how much money and resources you have access to. I think we can do better than that.

The patient had cancer. I did a right hemicolectomy for him laparoscopically, and it went well. The Glass worked well, the views were good, there was good engagement. Overall we had over 95% satisfaction from the student population. They loved it — it was a great way of learning. On that day my students were away on electives, watching from a beach in Bali, from Jamaica, from Tanzania, all just texting me: thank you so much, we're learning.

And here's the thing I did afterwards that people don't realise: I reflect quite a bit on my innovation. I said, OK, what could I have done better? Let's pause and think. What went wrong? What went well? How could we improve? I always do a peer reflection on every innovation, and I listen to the criticism. Although 95% of people were really happy, my interest was in the other 5%. Why weren't they happy? Was I doing something wrong? Were they worried about the patient, about safety? I reflect on that, and then I improve everything as I go forward. It's important to learn from the criticism you get, especially when you're at the forefront.

Now, some of my colleagues are great — they want to get on and innovate with me. The vast majority require some persuading; it's taken years for them to get to my level. But now, in the last three months of the pandemic, suddenly everyone's saying: oh yes, that work you did was good, can you do it again now, we need it for training, you were so ahead of your time. We kind of predicted the future, and now the future is here. And I'm really glad that, in hindsight, I was right. I always felt it was the right thing to do — teach globally, educate people, connect people, offer free education to everybody. And that was the first example of many.

Because they're the people you need to take on the journey. If you compare that to healthcare — you mentioned people not being ready for change — how do we understand that? How do we help them understand this is the future we want to be part of? Because that will define the future of healthcare. In the pandemic we're seeing more adoption, more translation of technology into clinical practice, whether it's telemedicine or remote monitoring. It's all becoming more obvious now, and many more people are engaging.

The other thing is that people are scared. They're worried about technology, about innovation, about new things. So how do you change that mindset? That's always been an ambition of mine. How do you change people's mindsets so they're like you? How do you bring innovation into the heart of every organisation? Innovation isn't technology. Innovation is about having ideas, not being afraid of change, looking at different ways and different models of working. That's what's encouraging in the health service. People like you are already in that mould — you're always thinking ahead, you have a much wider remit than we had before. It's not tunnel vision. You're not going to be a single professional for the rest of your life; you're going to have dual careers, three careers, portfolio careers. You're thinking about technology, about podcasts. You're much more versatile.

My responsibility with all this is to make sure I leave a legacy, but also that we move forward — and that comes back to education. One of the things I've been pushing hard on is: how do you fundamentally change the medical school curriculum? For me, it's not fit for purpose, and hasn't been for a long while. It's squeezed into lots of specialties, still based on basic sciences and clinical sciences with some integration, but fundamentally it hasn't changed. Are the doctors coming out of medical school now ready for digital transformation? Do they understand the language of AI, VR, AR, telemedicine, different ways of working? We're not training them. We're still teaching old-fashioned systems.

We haven't moved on, because everyone's got skin in the game. To disrupt a medical school takes years. To change one MCQ for one exam takes a three-year cycle — imagine that. So how are they going to disrupt a whole curriculum? That's why we introduced something called the Barts X programme, back in 2016 — about four years now — where we embedded digital health, innovation, entrepreneurship and technology into the curriculum for everybody. This wasn't a student-selected component or module; it was for everybody. I'm not doing it unless everyone's engaged. It's part of the curriculum, so everyone's pulled along on the journey.

Which comes back to your question — why do you worry about the 5%? Well, you have to. They're going to be the future doctors of tomorrow. So why not take them with you, find out what their concerns are, and hopefully reassure them? Barts X has been great. We've had great teaching, not just from the UK but from Stanford, from Singularity University, from Harvard. My colleagues join us live with the medical students, teach them about the future. The students go away, form groups of four or five, try to understand the future, create ideas, come up with a business case, get mentorship. Then we pull them in for a Dragons' Den-style pitch and ask: can we support you with crowdsourced funding? Is there a hackathon we can arrange so you can use that as a product design? They spend time in a tech company over the summer. It's been really popular.

I'm surprised no one else has taken this on as a medical-school-wide phenomenon. We've seen it in small patches — modules, master's programmes — but never embedded. I think that vertical integration of medical schools needs to put digital transformation right through the spine. It has to be part and parcel of the fundamental requirements of adopting the future.

You're right about the optimism I have about sharing knowledge. I always say this one quote: it's not about one-to-one or one-to-two, it's one-to-many. How do you leave a legacy? How do you share knowledge on a much more global scale? Most people want to share knowledge — that's what we're here for. As a surgeon with 27 years of experience, I have experience I like to share. I've made mistakes, I've learned from different operations. Why not share that with as many people as possible, and leave that kind of legacy? The technology has allowed me to democratise it on a global scale.

But it's not for everybody — that's the first thing. Not everyone can do this. You have to be a good teacher, first and foremost. You have to understand teaching, and understand your own abilities in the operating theatre. You can't compromise on patient care; that's ultimately about patient outcome. Not every person could put on a Google Glass and livestream, teach, train and perform an operation. I'm not saying I'm any better than anybody else — I've been teaching and training for a long time, so I know what's required.

And it's not for newfangled operations. These are ideal, routine operations — a right hemicolectomy for cancer, a hernia operation. These aren't new operations I'm experimenting with to showcase my talents. These are standard operations I've done over and over again, that need to be shared on a global level. I wouldn't push out a new operation globally — that has risks, because it's new. Obviously you make sure you get consent, you do it properly, you put in safety mechanisms in case things go wrong: if the camera stops, if the patient bleeds more than normal, if there's a complication.

You've got to be very careful about how you manage the optics. When you're live-streaming, people are watching the whole theatre with you. You've got to be careful about patient data being visualised, about the patient's face being visible, about who's coming into the operating theatre, about the experience students around the world are having watching an OR in the Royal London Hospital. You're managing the whole ecosystem — making sure it looks proper and professional, that you're doing a good job, and that at the heart of it is patient care and outcome, with confidentiality. There's a lot of thinking involved when you're doing an operation at the same time. So it's not for everybody. There's a certain kind of person — good teachers and trainers who do it regularly and routinely, who've learned how to use it properly and how to interact with people around the world in a way that's beneficial. That takes a bit of practice.

It's a really good point, and I'm glad you said that — I like to think I'm a good storyteller too. I've done a lot of talks now, so I know what works and what doesn't. First, you've got to know your audience. Who are you speaking to? What level are they? Are they medical students? C-level executives? Government officials? Then you build the story — the why, the what, the how, the when — describing it carefully, making it funny when you need to, adding passion. Passion always comes across. And you do it in a way that people engage: pausing at certain points, going fast when you need to go fast, using images and videos, sharing the emotion of people.

I'd say my talks are like a rollercoaster ride. I try to bring the audience with me. I stand close to them. I break the barrier between me and them. I look them in the eye. Because to get 100,000, 200,000 people all engaged for half an hour, 40 minutes, isn't easy. You've got to make sure the narrative works, that it's the right language — sometimes non-medical, sometimes medical, depending on the audience. You build a story that makes sense and bring them with you, like a film: a beginning, a middle, and you leave them with an end, and you try to inspire. At the heart of it is: what is the story I'm sharing? How do I inspire people? How do I make it emotive enough for people to understand my thoughts, my views? At the end of the day, we should all share the same common vision. It works well for me, but it's very personal — it's a personal journey, it means a lot to you, and you're passionate about it.

Then I see my role as being to inspire others. From my background, where I've come from, the achievements I've had — thankfully, and God willing — how do I now help the next generation do similar things and say: look, it's possible for anybody. This is not about me. I'm just another human being. I've been lucky and fortunate to come out at the right time. But this is exactly what you should be thinking about, and leaving a legacy behind. I really think about that legacy — the reason we're here on the planet over a certain period of time. As doctors we're in a unique position: we help people, we support people, it's very empathic, we can give globally and we're respected. So you have to give something back to society. What I give back is teaching, my legacy, my experience, and inspiring others to make sure we look after humanity better. That's the kind of storytelling that works. Some of it is innate, some of it is my experiences, and some of it is just the passion I have for the work I do.

Of course. So listen — I came to the UK from Bangladesh when I was four years of age, in 1973, following the War of Independence. We lived in London, in the East End, all my life in essence. I still live in East London; I haven't moved very far in the last 47 years. I'm a creature of comfort, I think. I'm a British citizen and I'm very happy with that. So what I do is help the community here a lot. I decided to work locally. I was offered many consultant jobs elsewhere, but I took the one in London because it was close to my community, where I grew up, where I'm from — to give something back.

The benefit is that a third of my patients are Bengali, so I speak Bengali to them. I understand the culture and the religion, and a lot of decision-making is around that. If you have a cancer operation, for example, my patients who require stomas are worried about praying five times a day, about being clean — so I have insight into exactly what matters to them and how to approach them. Some may not want surgery; some will decide they want to go to Saudi Arabia, to Umrah or Hajj, and ask if it's okay. You understand intimately what they're going through, because you understand the culture, the behaviour, the mindset. I also do a lot of charity work in Bangladesh, and locally with the community, so they see me as one of their inspiring leaders in the sense that I'm happy to support them.

When we came to medical school back in the 80s, there were very few Asian people there — hardly any. I was one of a handful of people in the entire country who made it to medical school at the time. So we always had that challenge ahead of us, and I've always felt a sense of responsibility and duty — to show others that this can be achieved, that we can break the glass barriers and keep driving hard. I still have my Bangladeshi heritage; although I've been here all my life, it's still there, it still defines me to a certain extent, and I'll help and support as much as possible.

The benefits have been huge working in the East End of London. It's my community — I work with them, I help them with community work, with charity work, and clinical work has been really supportive in that sense too. In my clinic I don't need any interpreters; I can speak to all of them, and it offers a different sense of consultation and satisfaction for both of us. If you go back from the 80s to now, 2020, that area has changed so dramatically — the health of the nation, the wealth, understanding of public health, communication, it's all moved on tremendously. I've seen the changes and I'm really pleased where they are now. There's still much work to be done, of course.

As a family — my brothers and sisters and people here — we've always pushed hard. We've always had to work really hard to get where we are, we never shied away from hard work, knowing full well that we have to be better than most people to make it. We know where the barriers are. And it's just saying to myself: okay, what's next? What's next? Never settling for what you have already, always saying, what's the next level for me?

We stopped very quickly just being a doctor. I'm happy to be a doctor, I've got that under my belt — okay, then I want to be a surgeon. You qualify, you practise, you become a surgeon. Okay, then I want to be an academic surgeon, I want to do my PhD, I want to be in a teaching hospital. Fine — what's next? I want to be a professor, I want to do some global health work, I want to innovate, I want to be on the RCS council. So you're constantly driving yourself: okay, what's next, how can I impact society as a whole? It's not about me — it's about how do I help shape the future of my profession, and can I be a role model and a leader? And the harder you work, the more opportunities come, and the more success you have going forward.

So I'd say there are no barriers. The barriers are really in your own mind. If you look at my Twitter profile, you might see a quote I use all the time as part of my mission: your future is limited only by your own sense of wonder and your own sense of imagination. If you can confront that, then you can redefine what that future could look like for you.

My book that I recommend is coming out soon — so that's what I recommend to people. I'm writing a book at the moment on digital health and transformation, for medical students and doctors, because it's a language people don't understand. It should be out in the next couple of months. The working title is Advances in Medical Technology and Digital Health. It's aimed at everybody — your audience who don't understand this, and my Barts X medical students who do understand the language of VR, AR, AI, tech, innovation. It's to make it easier for them to understand all that terminology, engage in discussions, and know where to go afterwards to find the relevant information. That's what's missing in the medical curriculum, and it's coming out fairly soon.

The other book I'd recommend is my favourite book of all time, which people find strange. In fact this Sunday coming, they're dramatising the whole series for the first time. It's a book by Vikram Seth called A Suitable Boy. It's one of the longest books you can ever find — over a thousand pages. I remember when it first came out; it's beautifully written. It's set around the partition of India, a love story at heart, but it shows all the frailties of humanity against the backdrop of conflict and partition. It's a beautiful story. I just hope the series does it justice. I have vivid memories of the images in my mind about what it means. I'm half tempted not to watch it, because it might spoil my depiction of what I saw when I read the book. So — A Suitable Boy, very recommended, if you have a few months spare. It's a heavy book, a long book, but it's beautifully written. You'd really enjoy it. That's one people didn't expect me to say.