The Augmented Reality Surgeon

Sure. My background is an interesting one. I lived in many different countries as a child. I was born in California — I'm originally Lebanese — so I spent my childhood in the States and then my teens in Beirut. We'd arrived in Beirut in that post-war era, so it was a very stark contrast from what I'd been used to growing up in the States. But it started to show me the importance, the value, of doctors — how they can really play a role in improving patients' lives and the quality of the lives they live. And so I was very inspired from an early age. I was about 13 or 14, and I used to spend time with a family friend who was a plastic surgeon. He would go to poor areas and offer reconstructive surgery for free, to help people restore form and function. That really left a mark on me from that early age.

So from quite early on, I knew I wanted to be a reconstructive plastic surgeon, because I wanted to help improve the quality of people's lives — so they could lead lives with better mobility, better function, and reintegrate into society better. I went on that path: graduated high school in Lebanon, went back to the States for undergrad, and then moved to London for medical school after I met my husband. I've been in the UK now for 18 years. It's a long-winded way of saying I've been exposed to health systems in lots of different parts of the world.

Beyond that, I always felt I wanted to make an impact. So I got really involved in global health initiatives, travelling to different parts of the world — Vietnam, South America, the Middle East — and I started thinking about how I could help device companies and other groups in the industry bring new products to market and deliver them, and the training, safely. I was involved a lot in product launches and training courses. And it all started to culminate around 2013, 2014, when I realised: I'm really passionate about surgery, I want to make a difference, I love the work I do in the NHS. I was also really passionate about the global health work — going into different countries, helping as much as learning from them, understanding how they deal with their health system, and understanding that private–public partnership: how do you work with industry, what are the relationships, how do you support them to bring new products safely to market?

And I started to think — what's the single similarity between all of them? It was really the requirement to be physically co-present to support and deliver that skill, that training, that communication. At some point it became, at least for me personally, quite difficult to be in all those places at the same time. So I started to think about how we could leverage technology to scale expertise — because I knew there were many more like me who were passionate, interested, wanted to be involved and see what different people were doing in different countries. That was really what prompted me to start Proximie: thinking about that intersection of technology for the benefit of our health system, our clinicians and our patients. It's been a great journey. We're almost 45, 50 people on the team now, and we're getting involved in about six to seven hundred procedures a month. So it's really inspiring.

I'd caveat it by saying I'm not an engineer. But what I knew was that I wanted a technology that could do a certain number of things functionally. I wanted to enhance communication — can you and I connect with good audio and good video? — but then take that to the next level, make the interaction much more multi-sensory, so we could bring in images or scans, or so I could almost, in a sci-fi way, virtually reach in and annotate, mark, share suggestions and tips and gestures on how to do things.

So I started to look at what technologies were out there. Telecommunications had been around a long time, but bringing that together with augmented reality seemed to be the way forward. That was my journey into learning about AR. It was around 2014, when Google Glass had just come out, and I was trying to think about how we take that technology but deliver it in a way that's accessible and scalable. So we thought about combining augmented reality and telecommunications — as well as AI, which we can talk about later — and delivering it in a way that's accessible to everyone. Using any device you have: phone, tablet, computer, robot, laparoscopic device, you name it. And it's great to see, a few years later, how it's really adding value in surgery.

What really drives us as a team is the ethos behind what we're doing. We're doing it to bring the best of human expertise together with the most advanced technologies to save lives. We want to scale clinical expertise everywhere — support doctors and nurses and healthcare workers everywhere. The technology is the tool, but ultimately what we're focused on is the value to the end user, the patient. Long-term, we see Proximie being a core component of operating rooms all around the world, supporting clinical collaboration and communication — how we as clinicians prepare, perform and perfect our craft, to the betterment of patients.

What you're describing is often referred to as "parachute missions" — you come in and come out. And there's no doubt — I say this as someone who was involved in a lot of those initiatives — everyone has tried in the past to find ways to support and scale local capacity building. The challenge is that silo, that disconnect: it's a moment in time, you come in, you're involved in that case or that week of training, and then how do you stay connected? Distributed learning, distributed support, can bring far more value than those single bursts.

So I looked back at how we describe surgery. If you speak to any surgeon, they'll often say: "see one, do one, teach one." That was the mantra we were all taught. But to me, "see one, do one, teach one" is very disconnected — very analogue, very siloed. You may go and watch a great surgeon do something, come back to your own practice, try to assimilate all the information to deliver it, and then somehow go on and teach others.

We very much push the narrative that that needs to change — to the three P's: prepare, perform and perfect. Because surgical education and surgical care delivery are a continuum. We're constantly looking at how we can improve, be innovative with new techniques, share best practice among ourselves. You have to go through a cycle. First you prepare — by watching how others are doing it, understanding all the components of a procedure. When you get ready to perform, having a virtual coach, support or mentor walking through the case with you adds so much value. We hear it from so many surgeons: "It was just so great having someone there — even though they're virtual — to guide me through." And then there's the debrief, the "perfect," which we often don't do very well. Today we do it in a very analogue way. It's about going back and reviewing how you did what you did, and how you could have done it better. And it's not just trainee–trainer — it's peers too. How can peers collaborate and drive each other further?

It's all underpinned ultimately by video. To prepare, you need to be able to dial into cases. To perform, you need the interface that allows that virtual support to dial in with you. And that interaction is recorded, so you can go back and watch it for "perfect" — in the same way athletes go back and review their post-game debrief. We've tried to draw a lot of analogies from other industries to see how they can help in surgery. And it was great — a few months ago a paper was published, done independently, measuring Proximie versus being there in person. It was found to be equivalent. That really means we can use these technologies to scale expertise, to support and mentor each other.

Very happy to. And what's great is the technology can be used across the whole world — the global south, the Middle East, the UK, the USA. It's a single technology built not for one part of the world but for the whole world. We're seeing as much value from the NHS and the US as we're seeing in low- and middle-income countries.

At a practical level: I'm sitting here today talking to you on my laptop, looking at a Chrome browser. I could do that with Proximie. I'd go onto Google Chrome, go to www.proximie.com, and dial into a case. I'd go to my dashboard and see the cases I've been invited to. I just click Join, and that case opens up — I can see it in real time as it's happening. I can talk to the doctor, and I can use my hand to annotate and put gestures on their screen, so when they're in the operating room they see that on their screen too.

I can overlay images or anatomical structures — a scan, or an anatomical image from any of the libraries out there. While the case is happening I can also search through the Elsevier content for the most relevant material to that particular procedure. And I can see four screens at the same time — the surgical field, the scrub nurse's table, the haemodynamics, any imaging or scans. So you're bringing together all the components of that operating room and bringing it to life in real time, allowing different people to dial in at once. I could do this from my computer, from the app on my phone, from a tablet. And many others could dial in simultaneously — we've got cases where tens and tens of doctors dial in to engage. So it's really about connection and collaboration at the core. Surgeons are social beasts — we like to communicate, share what we do, give our opinion. What we're doing now is crowdsourcing that surgical expertise virtually into the cloud and letting people share it all around the world.

A really good question. We've built certain mechanisms into the system. First, it works on very low bandwidth — you can 3G or 4G hotspot if you have to. The system also has bandwidth adaptability: if your internet connection drops, it adapts rather than just cutting out — it takes the video from high definition down to 1080 or 720 and drops the quality. We also have warning signs telling you your connection is unstable.

But beyond that, we've put in a very clear and detailed end-user licence agreement. It says Proximie is a communication and collaboration tool that lets you share your ideas and best practice — but ultimately, whoever is in the operating room is responsible for the patient. Whoever is with the patient needs to feel able to maintain or complete that operation safely, without anyone there. That's worked very well for us. As I said, we're now in over 100 institutions globally, doing about six to seven hundred procedures a month, and growing fairly quickly. In Q2 I think we grew about five or six hundred percent.

You're spot on. When you're in that early phase of a company, there's a lot of learning happening. You're trying to adopt an agile approach — understand your user base, not just how they're using it and how you can keep adapting the technology, but also your go-to-market strategy, your business model, how this is going to scale, what resource you need, your execution plan to make sure you can scale beyond ten hospitals. All those things are going through your head as you try to bring a very disruptive product to an industry that doesn't necessarily adapt or evolve very quickly.

So we decided early on to focus on just one or two key areas, because we knew we could learn, adapt, get to a point where we were comfortable, and then scale globally. We started largely in the UK and the Middle East, because we had good links there — good mentors, early-access sites we could test and iterate with. We learned a lot in those 18 months. We commercialised at the end of 2018. 2019 was a really good year. And we also focused on some specialties — we didn't go to every specialty. We focused on colorectal, orthopaedics and cardiology. Even within that focus we were able to quantify growth — in 2019, doubling quarter on quarter in engagement, users and revenue. So we were starting to see reproducibility and scalability in our model.

It was really only in March or April of this year that we decided to scale to the US. This wasn't planned — it coincided. We'd recruited the team and got everything set up just before COVID hit, and in a way we were able to add a lot of value: during COVID, Proximie was supporting hospitals around the world to deliver care. So to summarise: I'd always suggest starting with some key focus areas and a focus geography, iterate, learn, and then scale. And in terms of funding, you'd need enough funds to do that globally.

I'll answer the second question first. In terms of specialties, it wasn't a coincidence we chose the ones we did. We chose specialties used to "head-up" operating, used to video and visualisation in the operating room — colorectal, general, urology, for example. We worked largely with minimally invasive surgical teams. They're familiar with screens, with laparoscopic or robotic head-up operating, and those specialties are naturally driving towards video-based integration. We built a lot of credibility there, with great support from societies like the ACPGBI, ESCP, and now SAGES in the US. Orthopaedics similarly — between arthroscopic and open, all the different kits, they're used to lots of equipment and technology moving quickly. So we started with those, and looking back that was one of the really good decisions we made, rather than trying to do everything. Now we're seeing a huge increase in cardiology too — again there's a big visual element. We've been used across all specialties, but we've focused our depth and breadth within those few.

On culture — does societal culture influence technological adoption? In some industries it can. But we didn't really see a stark difference between, say, a Middle Eastern or APAC surgeon versus a UK or US surgeon. It boiled down to the user themselves. We started to identify our super-users versus our regular users, and those who needed more support, and we adapted our marketing, our outbound, our communication and our support accordingly.

When I think about adoption — and I refer to this book a lot when I'm interviewed — the one I'd recommend is Crossing the Chasm, looking at adoption and adoption groups. That was a global phenomenon for us. We had those really keen to adopt quickly — fantastic, because they were our early testers. Then those who, with a bit of evidence and support, bought into the idea and became our best champions and ambassadors, influencing the clinicians and hospitals around them. And now we're starting to see the later adopters pick it up — partly because COVID has accelerated behaviour change, but also because we've been around a few years and built a fair amount of clinical and published evidence they're more willing to buy into. And it's fair to say you'll find groups that may never be willing to adopt, and that's okay too.

Early on we focused a lot on super-users, because we were iterating and trying to get feedback on the product. If I look back at 2018, there was a lot of that. But then we went a level deeper: what is it about the behaviour, the profile, of the super-user? What could we do to support the medium adopter — I wouldn't say the laggard — to move them towards becoming a super-user, encourage them, help them increase and drive engagement? So we looked a lot at behaviour, skills, character.

We also started thinking about who we should target. Naturally you'd think, "I want the surgeon in this hospital." But is that the best surgeon to go after? Does he fit that medium-adopter-to-super-user profile? Or is he such a laggard that the time and effort mean you're better off waiting until enough momentum is built up to grab them? There's no single answer, but early on we focused on the super-user and understood the depth of that behaviour; now we're seeing a lot of the medium-term users pick up, and we're just starting to work on strategies to support and influence the laggards.

Not at all. Not at all. Some of our best KOLs and advisors are surgeons who are heads of their departments, have been around for many years, and are at the top of their game. And equally we have very junior trainees driving it. That's great, because you don't want it to be age-related — you want it to be value-related. Do they see value in this technology? We don't want anyone using Proximie just for the sake of using technology. We want them using it because they see value at the end of it — that it's going to support the surgical ecosystem and, ultimately, patient care.

A very good question. I'd take you back to Michael Porter's definition of value: value equals outcomes over cost. When you're trying to bring value to a health system, you need to think about the hospital, the patient and the clinician. If we can find a way to improve outcomes, reduce costs, or ideally both, then the value is higher. That's worked very well for us — because sometimes it's very hard, you're managing multiple stakeholders. What a hospital chief exec is thinking about is very different from what a surgeon in the OR, or the scrub nurse, or the patient is thinking about. How do you marry that? That formula works quite well. It's about making sure your messaging and value proposition are relevant to that individual. Me going to a chief exec talking about the value of training my registrars or SHOs — I'm sure they'd appreciate it, but they wouldn't be jumping up and down. If I showed the outcome benefit or the cost benefit, they may well. I don't want to generalise about hospital execs, but it's important to recognise this is multi-channel stakeholder management — making sure whatever you bring adds value to the different stakeholders is key.

A great question. It was a different skillset I had to learn. I'm very lucky I can still practise as a surgeon, but the skills you need as a CEO to take a company from two or three people to fifty or a hundred — I had to recognise very early on the skills I had and those I didn't. So early on I went out and found some great people to join me on the journey. The first lesson, really, is to have the insight and ability to identify the great skills you do have, but also where the gaps are, and bring in great people to work with you.

I was very lucky — when I call it the Proximie family, we were able to bring people together. Of course, I didn't study finance. I didn't do an intercalated master's in finance or business as you have. But I was fortunate that my husband was a banker — an analyst and a trader — so he taught me a lot about business models, financial models, how to put a pitch deck together. It's a really great learning when you look back — the first time you pitch to an investor, the first time you present your business model, it's a lot of learning. I think I've almost learned another career alongside the surgical one. The key things are: making sure everyone is committed to a single mission and vision and driving towards that; building really good culture — that's been a real focus for us, to build and maintain good culture as we grow from ten to twenty to thirty, so the fabric of the Proximie ethos is maintained; and being confident enough to bring in great people, because it's that combination of great skills and the willingness to listen to others that really drives things forward.

If I look back — and this is probably not just my career but my life — it's a lot of micro-incidents that get you to where you are. But grit and perseverance are really important. Maybe it's because I grew up in a difficult environment in Lebanon during that time, where you really had to work hard to get what you wanted. Perhaps it's also that I'm so driven by the desire to leave a legacy or an impact. So: don't give up. I can't tell you how many people said no to me when I was talking about the idea of Proximie. There are numerous people who'll tell you about the 150 pitches they made before the one person said yes. And that's okay — if you really believe in what you're doing, have the grit and perseverance to carry on and see it through.

I'd also say it's really important to balance that well. I've been very lucky to have that balance — I have three wonderful children, an incredibly supportive husband and a great family. Having that combination, along with the grit and perseverance, has got me to where I am today. Every person has their journey, their formula, the way things work for them — but that, with great mentorship along the way, has really supported me.

Some of it can be innate, but I think it's largely influenced by the environments you work in. If you look at people who've grown up in areas where things weren't so easily accessible and affordable, you do see a certain level of drive that's unique — a consistent drive. But at the same time, you see people who've lived fantastic, very privileged lives who are also very driven. I don't know the answer for every single person, but for me it was probably a combination of both: having to work hard to get to a certain place, and then wanting to leave that bigger legacy.

Yeah.

Oh, goodness. There are so many books — I don't know which to pick. I do have a good reading list I'm happy to share at some point. But I often refer to that one because it nicely highlights what we've experienced in terms of people, behaviour and adoption.

I guess what would be interesting, given you're a clinician as well — or soon to be a junior doctor — is to say: it's okay to find a path that works for you. If five years ago someone had told me you could be a successful CEO of a company as well as have a career in plastic surgery, I'm not sure I'd have believed it. But I tried, and I pushed hard. So it's okay to carve out a different journey — it doesn't have to be just what's expected, or what the books or the colleges tell us. You can carve out what works for you. The College of Surgeons and other colleges around the country have been really great at starting to define the new role of the clinician — can you be a clinical innovator, a clinical entrepreneur? It's a really exciting time for all of you coming out now, because those roles have to some extent been accepted, and there are opportunities to do many things that inspire and excite you alongside your clinical practice, delivering care to patients.