The Digital ENT Surgeon

From the beginning, well — by background, as you know, I'm a clinical doctor. I've been a doctor now for coming on my twelfth year. But TympaHealth was an evolution. Like all of us starting out in medicine and medical school, I didn't really know I was going to end up where I am. When I finished medical school and started my F1 and F2, I actually didn't know what specialty I wanted to go into. You're thrown into F1 and it's a really busy time. And I say this to people — I don't think you need to know in medical school "I'm going to be a surgeon, I'm going to be a cardiologist." That wasn't the case for me. Some people do know, and that's great, but plenty of people who thought like that in medical school have ended up doing something completely different.

It was really when I did my F2 job — my first F2 job was in ENT — that things clicked. I met some really good people; I had a really cool ENT registrar who'd just started, and a really inspiring consultant. My consultant said something that stuck with me: I'd found a specialty that I didn't mind going home to and reading about. I thought, well, if I like doing that, it's obviously a good specialty for me to go into. In that time I also did a couple of projects, one in particular looking at opportunistic screening for hearing loss, and that sparked an interest in how we could bring things to patients more efficiently. But with medicine it doesn't happen overnight — you don't just get an idea and off you go. I ended up jumping through the hoops, because I'd decided I actually wanted to do ENT.

To get into core surgical training I just put my head down for four to six months — got a paper published, did some audits and presentations, ticked those boxes. And fortunately I managed to get a core surgical job in London. I fast-forwarded a few years and became a registrar in London as well. But at that point I hit this thing of: great, okay, I've done that — but what next? And the same issue kept coming back to me. I was seeing patients in my clinic and thinking, this patient is coming in for something as trivial as earwax removal. Why is that coming into the hospital? Surely that can be done somewhere else.

At the same time, smartphones were really coming out, and people were thinking about what more we could do with them. I started to think: we've got this great technology, and we've got a pathway that really doesn't fit. Take a patient who has a problem with their hearing. They go to their GP, the GP says okay, let's send you to the audiologist. The audiologist has a look in the ear — most of the time there might be some wax — and if there is, they have to send them back to the GP, and then from the GP into ENT, because they're no longer offering wax removal in the community. Then the wax gets removed, back to the GP, and finally they get a hearing assessment. I thought, there has to be a way to bring technology into this pathway and make it better for patients.

And fundamentally, the only way I could do that — and we'll probably come on to it later — was to take time out of training. That was to do a PhD, because at the time that was the only thing I could do. That's where the evolution of TympaHealth started: looking at it as a project, seeing how I could make the service and the pathway better, but also bring technology with it. That condensed six or seven years into eventually formalising TympaHealth. But that's where the idea came from. It's been an interesting journey so far, certainly.

The PhD was loosely related. With a PhD you've got to have a defined question, but I needed some bandwidth to evolve the idea. The actual product you see today had a previous concept behind it — a new suction catheter, which we're still planning to bring out — and that was the basis of the PhD, alongside the work on hearing health. As I was doing that, I realised there was another element: you've got this great suction catheter, but what's the interface between that and everything else? That's where TympaHealth evolved.

What it enabled me to do was really valuable. When you're a medic, on call, in those early years as an SHO, you're the engine room of the hospital — it's such a busy time. Having a bit of time and clarity of thought let me evolve the thinking. But I was also getting great experience, because I was evolving my idea while still doing clinical practice. It's great to have an idea — we could all have great ideas — but if you don't know the problem you're trying to solve in real detail, those great ideas don't actually work in practice. I was definitely trying to balance that, because I was doing the PhD part-time while still doing on-calls.

At that time there weren't many ways to take time out of training — it's much easier now. The journey I took was taking that time out and realising there was something I wanted to develop further. I went from ENT, then switched into general practice, then developed TympaHealth. Looking back, maybe I could have done it differently. Finishing the PhD — I had to take a bit of a break to do it — yes, it does distract you. But for me it seemed to work. If you're doing a full-time PhD, though, there's no way you could run a company alongside it.

The idea started evolving, and digital health was becoming big. I thought, how can I, as a clinician — I think I'm onto something here. And what happened was, by stepping out to do that higher degree, people started to say, well, you must be an expert in this field. Obviously I knew about hearing health and changing pathways, but what it enabled me to do was go and talk to really interesting places. I did some talks at the House of Commons and Number 10, looking at a national hearing screening programme for over-65s. That really thrust me into thinking: okay, there's definitely a huge problem here — not just in my locality, my small little bubble of clinical practice, but nationally, and actually globally.

So: one, there's a problem I need to fix. Secondly, now you have to develop the product to do that. Separate to the academic work, the hardest thing is you need money and at least a proof of concept. So I won a couple of prizes — as trainees you can apply for these — I think it was about £10,000 or £20,000, and then another prize, just to build a proof of concept. Then I went to this really small AGM of a charity talking about hearing loss, and I gave a talk. In that room — and this is what made me think there's really something here — was the managing director of Boots Hearing Care, Specsavers, a lot of the big high-street providers. And they all said, if you develop this proof of concept, it would be very interesting. So I built the proof of concept.

The first route I went down was trying to get grant funding, and this was one of the things that opened my eyes to how challenging the system can be. I went for a government-funded grant — a fair bit of money, £850,000. Loads of work went into it, I worked with my colleagues, a big team came together, and we got down to the last five. We had an inclination we were going to get it. So I was going off doing all these great talks, and the hospital I was working at loved that we were building them up. But as soon as they got wind that we might get the grant money, I got an email saying: you need to come speak to us, because we think we own all your intellectual property.

I thought, oh my goodness, this is a big thing. For clinicians trying to innovate within the system, we want to do what's best for our patients, and we really don't know much about this stuff. But I then found myself becoming an intellectual property lawyer. I looked into it and said, well, I've worked on this before I even started here — I've done a lot of it in my own time. To cut a long story short, the way they wanted the grant money to flow, I felt we weren't going to get the true value of it. So in the end I made a really big decision: I said, actually, I don't want to take the money. We declined, we didn't progress with the grant. And those grants are hard to get.

That was a big call. It just didn't work — there was no real incentive, and I don't think the terms were right to even get me to where I am now. So then I thought about it, and I remember speaking to a friend. I said, I really think I'm onto something here, and I think there's some commercial benefit. At the time I'd also just been appointed to the NHS England Clinical Entrepreneur Programme — I think I was one of the first ten in the country to be appointed. So I was starting to learn a bit more about commerciality.

I said to this friend, I think I've got something here. And he said, I know this family office — why don't you go and speak to them? They're looking at social-benefit projects: obviously they want a return on the investment, but something with a good social cause. It was like Dragon's Den. He walked me into the room and then left, and I was there pitching. And they got it — I managed to present what they wanted to hear and where they could see the real value. I got an offer of more than the money I'd have got from the grant. At that point I thought, okay, this is something real now.

I had a really good relationship with the investors, and I said, look, there's real value in me maintaining my clinical background. But on the other hand, you've got a large pot of money and them saying, well, why don't you go and develop it now?

I must have been about ST5 or ST6 in ENT. I remember speaking to my bosses, and it's one of those things — they all said, you're on that trajectory to become the consultant you'd want to become, but you've got this opportunity in life. Would you look back in five years and think, I wish I'd done that? I didn't want to leave medicine, but I took the big decision to switch from ENT. When you're coming to the senior years, you can really only focus on operating and making sure you're a good surgeon, and I felt I wouldn't have been able to do it justice. But I didn't want to leave medicine, so I switched to general practice. They were really helpful, cut down my training, and it was a bit more manageable — but I was trying to run this company, I'd just had my first child, I was finishing writing up my PhD, and trying to be a surgeon at the same time. Something had to give.

As that evolved, the first thing I did was start to outsource a lot of the work. It was about maintaining what I was doing but giving a clear brief to those outsourced companies: this is what I want done. That was the first stage of the evolution — from a big, robust proof-of-concept device that proved what it needed to do, to something much more refined, which became version one of our product.

Yeah. What I felt was that it wasn't fair — and I think things need to be fair. It should be an example of how clinicians can evolve. So when I ended up raising external money, I gave a share to the NHS — the NHS has a stake in the company, and the hospital has a stake in the company. I did it on fair terms, because that's the way it should be done. As the company grows, it incentivises me and the team, but I did some of the work in the NHS — so why should the NHS not benefit? As a principle in life, you've got to be fair to everybody. If someone has done work and contributed — whether in a startup or writing a paper — they should be acknowledged for it.

And it makes me feel better. I could have just gone down the route of, I've got external money, that's it, I'm just going to run with it. But instead I said, let me be fair to where the work was done and how we can all benefit. Because maybe this could be an example of how innovation should happen — you incentivise the clinician. All of us have great ideas, all of us see problems in our clinical practice. You'll have that moment, when you finish your training, of "I wish there were a way of doing this," and you think, well, how do I do that? If there's a way you could be incentivised and supported to do it, that's how innovation will happen. And certainly in the current climate we've seen that accelerate — things having to be done differently.

First of all, as a doctor, we adapt — we're quite good at adapting. But it was a big change: as a senior ENT trainee, I had to go down to ST1 in GP. I had to keep telling myself, it's the long-term aim, it's the long-term goal. And actually it was useful, because our product fits both primary and secondary care, so I could really understand that interface. That helped me nail down what the issues in the pathway are and how it's going to change.

Up until last year it was still only me in the company. So in that two, two-and-a-half-year period, I was outsourcing work. On my days off, and emailing in the evenings, it was: do your day job until five, then five till midnight, do the work in the company. I tried to be really clear to the team I was outsourcing to about exactly what I wanted. On days off, annual leave, days off from on-calls, I'd go down to the design house, test it, make sure it worked, and evolve the product. The product was quite simple but had real nuances — how you hold the device, what the user interface needed to be.

Running a startup like this, it was quite agile: I could leave them a brief, they'd go off and do it, I'd stay in touch, and there'd be an objective at the end we could evaluate. That worked very well, because although I say I was a single person, there was actually a bigger team doing the work outside. I just probably didn't have a team within, at that moment, to share the journey with — it was me telling colleagues and my wife how it was going.

I said, look, we've got this prototype, it works, proof of principle — we need to make it clinically ready. With that team — a software team and an engineering team — we got to version one, which basically let you have a good look inside the ear canal and perform wax removal. That was one of the biggest blockages in the whole system. The way I look at it: yes, you can develop a video otoscope to look in the ear, and yes, you can do a hearing test — but if you look in the ear and there's wax, you can't diagnose anything, and if there's wax, you can't do an accurate hearing test. That's the thing we needed to sort out, and there was no way of delivering that safely in the community.

That was about a year of evolution. We got CE marked on it, and we were trialling it with some sites in the NHS but in the private sector. It was Boots Hearing Care who looked at it, liked it, used it, and said, you know what, this really works. And the key wasn't only unlocking the wax — I wanted it so that you didn't need an ENT surgeon or a GP to use it. We've got this plethora of allied health professionals — why not let them do this, as long as they've had the appropriate training? So I built a training programme, did a train-the-trainer model — very much like how you learn surgery. They used it, they really liked it, and now version one is their go-to assessment tool nationally. The wax-removal part of their service didn't exist two years ago, and it exists now because of TympaHealth version one.

With our device it's interesting, because the hardware and the software had to work together — you can't just pull down the app and start working; it has to work in the cradle. So there was a big element of matching the two: what you see on the screen and what's going through the hardware. Those are really big challenges. The first thing is, if you're developing a new device — and there isn't a device like this in the world — you're bringing all these elements together.

One of the things key for me was to make sure it worked ergonomically. You're taking an otoscope — when I was writing my PhD I read that the first otoscope was described in the 13th century, and the modern-day otoscope hasn't really changed for the last 50 or 60 years. You're building a new digital way of holding it, and it had to be balanced. We had so many mock-up designs. It was literally me going there, testing it, putting it in one hand, getting other people to try it. That was a big design challenge, because you're doing something completely new and there was nothing to mark it up against.

Then, as soon as you nail down your design, you go through the whole CE marking process and manufacturing. For version one we did lower numbers and manufactured in the UK; version two is at much higher volumes and we're manufacturing in Singapore. But you still go through the same CE marking process. There are so many documents to fill out — you do user verification testing, you have to define who it's for, what population it's going to be used for, and it has to pass things like a drop test. You have to find the right team to do that. I'm not experienced in it, but I had a great hardware manufacturing team that walked me through it. All in all, you build the hardware and make sure the software is marrying up — those two had to work together. And what we're really proud of is that with version two, those two elements have been really well recognised: we won a recent UX design award. The previous winners of those awards have been the likes of Samsung and Mercedes-Benz — how have we ended up winning that? I learned a lot about the regulatory side, and now, finishing the regulatory side for version two, it's a little bit clearer. There's a lot of reading I had to manage.

On the phone: it doesn't, because of the way it's been developed. It sits in your left or your right hand, and it's designed to be perfectly ergonomically balanced, so it's really safe to use. I've got one here — you won't be able to see this on the podcast, but it might help me explain. One thing that's been interesting is that with a traditional otoscope you have to be very close up to the patient's face. What's become apparent — and this was always part of our design, but is now more of a need with COVID — is that you can be arm's length away, brace against the patient, and watch what you're doing through the screen. The traditional otoscope you hold like a pen; ours is a slightly different grip, much more robust. You can brace against the patient, so if they move, your hand moves with them.

From a training perspective, we've just published a paper on medical students using it compared to a traditional otoscope — because you guys are the future. You may have had this in your training: you go into clinic and someone says, "have a look in the ear," and then, "did you see the perforation?" and you say, "yeah, yeah, I definitely saw it" — but no one can tell whether you saw it or not. With this, the paper shows it's actually a really good learning tool, because you're learning together. You can say, if you can't see the eardrum you must be hitting the canal — and you can watch it on the screen. That's going to be a bit of a revolution in training. You get about a week of ENT training in medical school anyway. In primary care too, you'll be able to see it on the screen, and then share that image to any specialist anywhere in the world.

You've got to think of the problem. In an ear clinic — even at centres of excellence — you see a patient with a problem with their ear, and the only way you document it is you draw a picture. My drawing is different to someone else's, and the interpretation can differ. What we've done with this otoscope is you can capture it — not only as a static image, but importantly as a video. There are video otoscopes out there, and smartphone clip-ons that can look in the ear. But the thing I thought was needed was: if you look in the ear and there's wax, with those you have to get up, go and get other equipment, and then remove the wax. Whereas here, you look in the ear, there's wax — okay, let me get my suction probe, remove the wax, ah, there's the picture.

The reason digitalisation is key: around 30% of GP consultations are ENT-related. So why would you not have a way to digitalise that image and send it off to a specialist — very much like they do in dermatology? Even in ophthalmology, you go to your optician and you're used to them taking pictures of the back of your eye. It should be the same with your ears. If you could know that your ear health — as I like to call it — may not be quite right, and put that in context with a history and a screening test, someone could do something about it earlier. That's why I've seen the key benefit of Tympa as an all-in-one system: you start by looking in the ear, there's wax, remove it, and then — most people present thinking they've got a problem with their hearing — why not do a quick hearing screen, bundle it all into a digital record, and either give that to the patient or share it with a colleague to review?

Definitely, yeah — and even more so now, with telemedicine, telehealth, taking things out into the community. Tympa's been in evolution for a long time. With the ageing population, I feel there's a big way we could support them — the stigma attached to hearing loss and so on. But this kit can also be used globally, for people to access services from places in the developing world.

What sets us apart? There are loads of video otoscopes, and a video otoscope can look in your ear — but it can't do anything else. What I was really keen on, if we were going to nail this, was making sure the image quality was good enough. If you go to our website, the quality of image we get is endoscopic grade. And to do all the things our kit does — otoscopy, wax removal, hearing screening, sharing it digitally into a back-end system — you'd normally need four or five pieces of equipment alongside your desktop computer. Here, you've got one device. Traditionally those pieces of kit have been used by really highly specialised people; what we've done is taken that and democratised it, so it can be used by an allied health professional, and make the pathway more accessible to patients. That's probably what sets us apart. It's ergonomically easy to use, intuitive, and the software we're building has machine learning built in, so it will tell you: is the eardrum normal or abnormal? It'll look at trends — if you pick up diabetes at year three or four of someone's journey, was there anything we could have picked up earlier?

That's what I wanted to build with the knowledge I had — a complete package. I was one of those people who'd say, "oh, there's wax, you've got to go and wait outside the microscope room." And this is definitely not a microscope — for a microscope you need to go into the hospital. But this lets you do the majority of things in the community, without carrying a whole array of equipment. And now, with domiciliary care, the shielding population — as long as there are the right precautions, why would you not take that service to them? That's the way medicine is going: people want to access their health as easily as possible. We've done a lot of competitive analysis, and there isn't a kit in the world that brings all these elements together at the moment.

You're absolutely right. Our website was only launched at the beginning of this year. We were already being used in Boots Hearing Care, and no one would have known we existed. It's not that we were hiding what we were doing — but I thought, when we do showcase ourselves, I want to show people that this product is here, it's ready, it's available, and it's gone through robust testing. I thought coming to market too soon might be detrimental to us. It may have not — we may have been even further along, I don't know — but I think it served us well. The way we want to market ourselves now is very credible: we've got research papers coming out, we're presenting at academic meetings, and we've got use cases of how it's worked. Boots Hearing Care themselves have seen getting on for 60,000 patients using our kit, which shows it's a safe piece of kit to use.

I feel we now have some noise to make about ourselves. This is only the second podcast I've done, because I wanted to put the message out correctly. Now we'll start making a bit more noise — but doing it in the right tone, the right way, telling people about all the good stuff that's happening while letting them make their own decisions.

Part of what prompted the website was that we'd been involved in some work with Apple. My cousin used to be one of their legal advisors, and she said, this looks like an Apple product — why don't they know about it? I said, well, how am I ever going to reach them? Then it was a Friday, I'd just finished clinic, and I got this email. I saw the title — Vice President of Medical Innovation at Apple in Cupertino — and thought, this has to be one of my friends doing a wind-up. But he said, send me your number and I'll give you a call. I thought, this can't be right. I came up into my spare room, which had my kids' clothes all over the bed, and thought, let me make this look like some kind of office. And meanwhile, Apple being Apple, the guy is trying to FaceTime me. My son is downstairs on my iPad — everything's connected — and he sees the call coming through and declines it four times. I thought, oh my goodness, that's it, I've missed it.

Begrudgingly, he then called me on my phone, and in the end he said, I really like what you're doing — the information and data you're gathering — and I think you should come out and see us. I thought, what is going on? So we met them in Cupertino. A couple of months later they were discussing us in a meeting, and I remember them asking, do you have any other information people can see about Tympa? Because you haven't even got a website. And I thought, okay, maybe now is the time. If we're getting discussed at that level, then we should probably have a website.

It wasn't that I was making noise that we had the product out there — I was quite clear I didn't have it. They just said, if you do develop it, we'd be interested. What I was presenting at that meeting was the vision of how hearing care could be, the pathway change, and some of the research I'd done. So you make noise about what's relevant at the time. I was never trying to tell people I had this product when I didn't; I was always saying, this is where I see it going, I want to develop this.

And I wasn't doing it in big waves — this was a meeting of twelve people. It was just serendipity that they had some big people in the room. I'd done enough to show it was credible, but I didn't use other channels to do it. Maybe that's just me as a person; we could have done more. I just felt I was getting the right messages across, in the right environments, at the right time. And you're right — is that not marketing? Well, it kind of is. You're doing a pitch in your research or whatever you're presenting. But I was quite clear even then that I didn't have it.

What it did do, when I pitched and they said "if you develop this further, we'd be interested," was give me validation. If I'd done that talk and everyone said, "sounds good, but we're not really interested," maybe it would have been a different path. I still believed in what we were doing, but it might not have given the drive — or an investor looking at it and thinking, is that actually a value proposition? Because you're bringing a completely new product to market that's never been developed. Is someone actually going to buy it? So I agree with you. My view of marketing was, let's put it out everywhere — and maybe we were doing it in a small way, and now we're doing it more.

For myself, it's definitely trying to be disciplined and efficient with time. I used to think I was efficient — but it all changed personally when I had my first child. I was no longer able to wake up when I wanted; I was being woken up at five or six in the morning. And I realised there are only so many hours in the day. Because I wanted to spend time with my family, I knew that in the hours when I was working I needed to be ultra-efficient. I'd try to wake up earlier than my son to do a bit of exercise, get him ready for nursery with my wife, go out to do a GP or ENT session, come back, do the whole bath time, have something to eat, and then have that window to do some more work. I was trying to build a routine that was sustainable, with a bit of downtime. Having that structure to the day is probably the best habit I've tried to maintain and instil. And I had to become even more ultra-efficient when I had a second child.

It's all an evolution. Sometimes — you'll know this even when you're studying — you just hit a wall and there's nothing going in; you're not actually being efficient. Having the mindset to say, this is probably the time to take a couple of hours off and do something different — everyone should find their downtime, whatever it is. That's probably the most important thing, because the startup journey is not easy.

I've got a great team behind me now, but it's still a journey, and as the startup founder you might feel you're always doing it in a solo way. But sharing the journey is also very key, because otherwise you can become too laser-focused on certain issues, and sometimes you need someone else to look at it from another angle. So it's finding discipline with your time, but also sharing your problems — which is the case even in medicine: if you have a problematic case, you'd want advice from colleagues. There's been a definite transition in how I like to run the company: everyone has a voice, whether you're the most junior person on the tech side or anywhere else. Everyone should have those open channels of conversation, as you do in your medical teams.

Yes. There were a couple I read along the way. You could read a lot of books about startups and how to set them up, and they're really helpful. But then when you actually have a product and a business and you're trying to create a business model, I think as medics we don't know that intuitively. One of the models for our business is that it's not a transactional sale — it's not a true medical device, because the software is such a big part of it. It's actually a licence. So I wanted to understand how the SaaS model works. There's a book — a friend actually got it for me, he said I'd really like it — called Subscribed by Tien Tzuo). He basically takes you through how his company evolved into becoming a true SaaS model. It's a really easy read. I remember reading it on the Tube every day, thinking, that's how our business could work.

The reason I wanted to go down the licence and SaaS model is what I didn't like in medicine: you'd get all these nice, bright, shiny pieces of kit, and then in a year or two the kit would be redundant. What I like about our model is that every time something evolves, you get the latest and greatest software. It's a really good model that's underpinned some of the business models we use at Tympa now. So I'd recommend it.