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We have uh Professor Bajad Patel, a professor of Surgery and Director of Robotic and laparoscopic surgical Skills at Queen Mary Hospital. Uh sorry. Um Queen Mary University and consultant Upper Gi and laparoscopic surgeon at Barts Health NHS Trust. He is a leading figure in surgical education and innovation. Today, he will discuss about the surgical training and technological innovations for humanitarian crisis. Please welcome Professor Patel. I think. Thank you everyone and especially the organizing committee and the college for hosting this and for inviting us, it has been a real learning experience for me, understanding the conflict and the challenges and uh II knew but not to the uh depth and intensity. What so what I'm going to talk and present about uh as I just sort of mentioned earlier, we we, you know, when you talk about humanity and surgery and conflicts and all it, it's a very, very complex situation in a scenario. It's not just sort of one thing, one size that could fit all um and different challenges, different uh levels of skill and support on the ground and each one of it is unique and um uh it requires a lot of effort, motivation locally, nationally, internationally, you know, so what I'm going to talk about is uh perhaps more relevant um in the rebuilding phase, as I said, you know, uh when, when you, when you uh when you are recovering from the World War, so to say, so these are the hospitals where I work. And uh in the presentation, I'll just take you through some of the topics actually you already covered and we've discussed. Uh So I'll be quick talk about uh uh focusing on the Royal College Humanitarian Surgery Initiative, which is sort of uh build around the research and evidence based practice and building sustainable local capacity. So my key message and my uh uh uh the, the theme of the presentation is how do we build a sustainable local capacity. We talk about technology but it comes at a cost and everything that I do uh in education and training nationally and globally is about capacity building sustainable uh solutions um and not uh high tech expensive uh things even though that can benefit and help us. Uh in many different ways, we talk about surgical education and see what we can learn from other industry. I always like to focus and look at other people, other areas, other specialty, to see what can as doctors, as surgeons, we can learn and we touch upon sort of what the people in the elite sports do, what sort of psychological training and support they get. Uh what uh we can learn from video data analysis and my focus on training the next generation. And then I'll finish a bit with my story in Gaza. So starting with the sort of the first topic. Uh Actually, thanks to the previous speakers, we've got a lot about telemedicine remote diagnostics. So I won't dwell into that all this technology. We are the fourth industrial revolution. So we have everything at our fingertips, drones and unmanned aerial vehicles which are currently being used only to destroy things rather than building things. Yeah, uh A I 3D printing uh adaptive manufacturing Blockchain and all that. So, uh as we heard from the previous presentation uh with telemedicine remote uh uh diagnostics uh using mobile phone technology, a lot you can do to support uh the patients, the community, the healthcare providers, consultation, diagnostics, et cetera. Uh This is uh uh the global internet usage sort of penetration what you see on the why there is uh everything which is yellow and blue. More than 50% of the population has access to mobile or internet, this thing. And these are the data uh figures from Myanmar uh from World Bank uh uh International Telecommunication Union and CIA has this data uh which is from 2021. So uh before coming here today, I assumed that more than 50% of the population has access to internet and mobile phone. I didn't think of the challenges and the uh you know the blocking of the services which the uh uh the military does. I mean, if you were to just simply assume that more than 50% have, you could set up a fantastic telemedicine, teleconsultation services in remote areas and all but clearly, that is not the case apart from telemedicine. What A I does is uh mobile health. Uh If you all had stable mobile internet connection and mobile phone, all these uh these are multimillion dollar uh apps and companies that have evolved uh uh K Ey AAA and all, and most of the features are free to use and consultation with A I is better than an average GP I can tell you that. And that has been shown in the literature that has been proven. This is all evidence based practice. So I don't give opinion especially in conflict zone where we were discussing how, you know, you, you need uh skilled workforces. So this is sort of skilled workforce behind the scene. This is an example of one of the apps which is a A, I've used it myself. It uh you know, it, it's a symptom checker gives you diagnosis, gives you treatment, gives you instruction information and you can even um have an account to get an online consultation with a doctor to take it further. So uh ii, it, it's free to use you just download the app and it, it has a uh each step is like an algorithm because it's a I and computer generated. So, before coming here, today, I presented with acute appendicitis and I see I saw and I thought I'll see if it comes up with the first diagnosis. And a ad I came up with that said, you've got acute appendicitis. So I just simply presented as a patient to the app and that's the output you get and that gives you instruction and you can sort of go dive into further into that. This is another similar app, do we? So that that's uh application of technology for a consultation for diagnosis. Now, coming to training, education and training. Um This is another app which some of you might know, uh it's uh building your confidence before entering operating theater. So this is the modern textbook of surgery. Uh It's called touch surgery is done by some medical students. It started which this was designed many years ago by medical students. Now it's a multibillion dollar company bought by Metronic. It helps you prepare for surgery anytime anywhere using your mobile phone, that's all you need. And touch surgery is sort of been referred to as Uber of Surgical education. It's a platform which is now used by 2 million users all over the world. 100 and 60 global surgical residency programs of which 100 residency programs are based in us. It is endorsed by the Royal College of Surgeons of England for learning and uh preparing yourself. It's, it's a textbook of surgery essentially. But a digital textbook of surgery, uh the advantage of technology and technology enhanced education is that it helps you fast track surgical training and education. Again, these are all evidence based. Uh uh in information, it's a platform which is free to use. You can scale it, you can use it anywhere. Obviously, you need internet connections for that. It requires active user participation. I mean, I know from my days in medical school, what used to happen before exam, sitting in the library trying to read you just fall asleep. But over here now it requires active user participation. So you've got your mobile phone in your hand. Uh You have to engage, you have to immerse yourself in the learning process as a result, your knowledge retention is superior and uh better, you can mental, you can use it for mental rehearsal before going into operating theater or even as a student or a trainee. When you're in the operating theater, there's an operation going on. You can log on to your touch surgery platform and go through and uh do it yourself on the touch untouched surgery because a lot of the time students hanging around in operating theater don't necessarily get the teaching and attention they deserve. So from touch surgery to actual uh o operating theater proximity, this is uh a cloud based solution that allows uh uh live uh uh surgical coaching or mentoring. So you can be in operating theater anyway. So somebody, the doctors performing surgery. N I can be over here, I could be the coach and take them through uh the procedure and support, provide intraoperative life support to the surgeon. Not only surgeon, you could just sort of translate this into a knee, it, wherever you want to place it. Industry over here have invested in mobile training solutions. Johnson and Johnson Ethicon, Boston, scientific big industries, even colleges have now mobile simulation centers and lab. This is sort of low cost because you don't need fixed infrastructure and maintenance of fixed in infrastructure. You can adapt, you can scale, you can change the room as and when you want and the training can go to the community rather than the community coming over to center for training. So you can reach much wider audience places where you cannot necessarily travel and have those equipment and facilities. The bus can go and provide that sort of a training drones, unmanned vehicles. They have been used even in NHS now to deliver blood blood products. And in future, you can see even transporting patients in and out of conflict zone. So these are all futuristic technology and difficult to use during conflict because I'm sure if you try using drones to deliver blood of vaccines and Myanmar will be shot down by the military A I, you can go on and on and on about A I in healthcare and medicine A I is gonna feature in many different aspects of the presentation. So I won't stay on this slide. Similarly, 3D printing uh and the application of 3D printing has been very well established for surgical instruments, for implants, for simulation, for training models where you could customize, you could even rehearse, preoperatively, patient specific models and plan your surgery for surgical rehearsal. So a lot of evidence in the literature talking about 3D printing its application in surgery, et cetera. Similarly, the Blockchain Blockchain technology, which sort of can uh decentralize uh record keeping and add security to everything that we do ties in very well with mobile health, medical management, medical records, et cetera, et cetera. But again, in the middle of the crisis during crisis, all this is just complete waste of time and not affordable. We've discussed several challenges during uh uh for uh uh in crisis and in humanitarian surgery, there are lots of non surgical issues that get attention priority that affect the overall health service. We've seen the Lancet Commission's report, neglecting surgery and the effect of that and providing safe surgery. What is lacking is a collaborative or coordinated approach during and post crisis. Often you see duplication of resources uh and wastage as a result of that uh assessment. Most important, we spend a lot of time, energy effort, money. Uh but during and after crisis, but how effective the interventions are, how useful the interventions are are are we don't know there's no data uh on that. Um and challenges in the system, non adherence to the International Humanitarian law, et cetera, et cetera. So, in the ideal world, uh with the political stability, growth and funding and uh everything else, if we would not be here on a Sunday afternoon, we would be sitting somewhere nice, enjoying sunshine and watching, looking at the sunset, but that's not the reality. So, um coming to our topic of humanitarian surgery, it is sort of a situation where circumstances are far from ideal uh people on the ground we have seen in Myanmar and elsewhere are dealing with incredibly difficult situation and very, very difficult conditions and circumstances, very or no resources. Local response is always first on the scene because you are there in the middle of the crisis dealing with emergency and life threatening situation. And then the international response comes days weeks, months later, what I want to focus on and emphasize is the importance and need for international coordinated approach and partnership with local uh bodies uh to ensure uh capacity and uh sustainable uh solution for building services. There are several projects similar to what we discussed in Gaza going on and have taken place in Myanmar. These are some of the examples, these are again individuals or organizations uh with networks and contacts in Myanmar who've gone there and provided services, education and training uh uh for surgeons in the Myanmar. Uh What I was most impressed about is a program by the Royal Austral College uh from 2009, which is in partnership with the Myanmar Ministry of Health. In 2009, they started with the primary trauma care training program, PTC. Following that, the Australia New Zealand Surgical Skills Education program, which the college does. And then they have moved on to management of surgical emergencies as a uh and non technical skills training that have changed culture and building confidence and teamwork and all that. And uh not so long ago, Asset program, which is a my instructor course. They train the trainer course. Yeah. So I think this is a very good example and um you know, uh endeavor from the Royal College, this is the Moses program on the train, the trainer provided by them. So what are we doing over here in London? The College of Surgeons over here has a Global Affairs uh unit. You may be aware of. Um they have uh I mean, we have a lot of international collaboration opportunities for training surgeons, grants and fellowships as well as other service for the international uh surgeons, the colleges um Humanitarian Surgery Initiative uh has a slightly different approach compared to what you saw from the role of serv college. Uh you know, it's evident based competency based uh model. Uh The humanitarian surgery initiative at the college is a collaboration. It's an international collaboration which is focused around uh uh technology and engaging partners uh locally and internationally to provide capacity building uh in a more sustainable long term way, which is, uh going to be evidence based. As I said, the humanitarian surgery could, you know, from global surgery to emergency surgery surgery along with several players, as you see, from local response to national local region in uh response, it's quite a complex uh uh endeavor. So the first thing that the college did over here, this paper was published in 2024 February, uh a project uh with the London School of Economics, which is just sort of next door was an online Delphi process to actually defined what is humanitarian surgery. We have seen definition and we have understanding of what is humanitarian surgery. But this was in by the college with London School of Economics through an international process. And the human surgery is an area of study research and practice that focuses on the coordinated provision of the surgical care in conflict and post conflict zone in areas of sudden onset disasters. And when the local health system is overwhelmed. Now, why did the college decide to do this and define it is because when you have data, when you have uh a definition, uh and information, it becomes clear, you can have clarity on the terminology will help you identify the capabilities, experience and qualification that is required for the team, for the individuals to be effective interventions in a very demanding environment, surgical voice from the global South this is a series of webinar which was organized by the college. Uh over here, this is again, not the college telling you what to do. This was initiated by uh doctors and surgeons from low and middle income countries. They decided what topic they wanted to discuss, invited experts. You can access the webinar. It's still there on the line, you can listen to them. I would strongly recommend you do that. So rather than college telling you it is we are we are engaging with the local bodies to define and identify what are the needs to understand those needs. Yeah. So how can we build sustainable humanitarian, uh surgical capacity, capability and preparedness in resource limited setting? And what role can technology play in widening and improving access to training, learning and uh mentoring now, just like global surgery and uh uh global surgery and uh humanity and surgery providers, strategies for and methods of sustainable capacity is fairly complex. We to sort of well on every aspect of this uh what you see on the screen. Uh Basically the core and the sustainable capacity, you could sort of put it down and divide into three levels. One is personal, organizational and institutional. So we're going to focus more on what we individually as a surgeon, as doctors can do. Uh And then we'll also uh look at some ideas for improving institutional organizational structure. So without uh uh any uh saying that capacity building will involve training, learning knowledge, skill transfer, coaching, support for development. So this is going to be the road to a sustainable development. Uh The path that we can take to achieve and go through that road of sustainable capacity development is listed over here. Uh which is what uh I believe. Uh and the college uh uh supports is to establish and validate, validate humanitarian surgery as such, uh expand res research and build evidence and build accessible egalitarian sustainable community practices and then enhance workforce education and access to resources. So we'll go through each briefly now, one by one. What do we mean by establish and validate humanitarian surgery? We want to do this with the point of view of local surgical workforce. What issues they face on the ground on day to day basis in dealing with and dealing during crisis situation and the incoming humanitarian uh and the global response, is it really helping or is it hindering? Have seen that sort of it can be helped as well as a hinder because we come in with a different mindset with a different idea, with a different expectation. Uh having worked under a completely different environment and circumstances. So we need training before we can go and train somebody else to uh the the process of validating humanitarian surgery would involve outcome measures, looking at the short term and long term outcome measures that you have in the country, quality assurance, uh implement standardized protocols and checklists to maintain surgical standards. So no matter what you are, but these standards have to be designed and adapted to the local setting. We don't have all the checklists, all the standards that you see have been designed and developed in the Western world. And you can't just simply say that, ok, you have to do this as well in Gaza or Myanmar or Afghanistan, it doesn't work that way. So all this information is lacking. We have no defined standards, checklist guidelines in crisis situation or even in uh location A will be different from location B, competency based proficiency based training, establishing standards. We saw it was quite impressive to see one surgeon do everything uh over there. But that is not a sustainable model. That is not something that you can provide a good, safe, effective service uh for a population of nearly 60 million ethical consideration and then publishing the research. The second is having an evidence based approach which is uh why, why do we need data? Why do we need evidence? Because research can help us paint a picture, a true picture of strength and limitations of implemented changes and support the community in in future, develop strategies and policies to obtain funding money flows. If there is data, if there is evidence, it will help us plan for future resources, which is necessary to build its future, to move forward. Eventually we have to move forward. Uh and things hopefully will always get better reflect and evaluate each incident separately and see what we can learn from it, what happened subsequently after a disaster, you know, we spoke about mental illnesses, mental support, uh et cetera and building capacity capacity. We are not suddenly going to have many medical colleges and doctors. We we struggle with healthcare workforce in UK. So I can't imagine what uh would be the uh workforce and resource constrained areas. We briefly mentioned about role of physician associates, nurses, pharmacists, nonmedically qualified doctors, how we can use each and every person who can provide resource. But at the same time, like a Blockchain supports centrally uh uh I and decentralize that and support locally within a community based practice, integrating mobile health and telemedicine to support those individuals. The third thing is I just mentioned building a community of practice which requires a complete shift in mindset, empower the local community, local people, whatever they are, whatever their skills that are because each geographic area has its own challenges. Uh And um uh uh unique features. So we need to have a community based practice, not only just in surgery, but uh across the healthcare sector. This again requires a good interdisciplinary collaboration, not just doctors, nurses, paramedics, physiologists, and uh any studies in itu whatever. And along with that, then you have active support from regional National International Bodies to support that. And the last thing is uh how do enhancing local workforce education and access to resources with technology. Yes, you can access online education and uh everything else. But again, it comes to not having the right internet and infrastructure. Eventually, what you want to uh uh achieve is sort of made in man now made locally provided locally because uh training the current workforce as well as the future workforce is important. And the college, this is where the Royal college uh and uh organizations and associations such as this can help develop local standards, which may be internationally recognized, build local capacities, evidence based, it's not practical to fly doctors in or out to build capacity and scale uh at a scalable level even though that is happening in crisis and even in post crisis situation, because we are not, we don't have a coordinated approach internationally. There's no one single international body that is responsible for coordinating care in crisis. And you have several actors from different sides, different location, providing care. Uh coming to the top simulation which I'm all passionate about and how simulation and low cost simulation uh can help us uh develop uh sustainable capacity and uh practice. Uh sim similar to the three levels that I've listed over there. Personal uh organization and institutional. We have micro meso and macro simulation, which macro simulation focuses on organizational and institutional skills, uh meso simulation. We mean by sort of your team, your department uh and more of non technical skills supporting each other, not blaming each other. And micro simulation is focused around your own individual, basic skill, cognitive as well as technical uh skills. So we'll give you some examples of uh each uh macro simulation, which is, as I said is an institutional simulation. The model uh hospital exercise hosp this is a predeployment training program used by the UK Defense uh medical services. The military use clinical simulation to train large number of personnel, standardized patient pathway and sustain specific skills to um ensure medical uh persons are prepared to be deployed in clinical roles. So this is sort of a mass institutional simulation. What it means is on the ground. If you follow the and understand the aspect program, there are 21 is a tent based aspect and a table based aspect. The tent bed is just slightly more fancy in the sense we have separate cubicles and tents, but essentially it is exactly the same as you see a table, a top aspect program. On each table, you have a different station as you see on the side, you got ward one theater x-ray resuscitation area, itu lab and on each station you have uh uh experts with a clinical scenario and it's, it's almost like a uh exam VR but it's not a yr, it's a training, the whole institution uh and preparing and you could design and develop scenarios which are fit for your purpose. Locally, MESA simulation is sort of focusing more on um uh institute non technical skills when surgery as surgeons, it's important to uh um uh not only acquire skill but to maintain your skills as well. Strategies for improving uh procedure techniques and skill among practicing surgeons are rare. Once you become surgeons, we just sort of become surgeons. And there's very little in terms of doing things to maintain your skill. And how do you maintain your skill? And when do you know that you are descaling unless you have insight on that? So the two things that have been uh used in this situation is surgical coaching, which was popularized by you probably will all know at one day, doctor at one who designed the wh checklist that you use in operating theater every day. And the Wisconsin Surgical Coaching program, which was partnered by uh Caprese Greenberg has demonstrated that video based peer coaching could potentially be effective in surgery including improvement of surgical skills. So I'm looking at non technical ways of maintaining and assessing performance and improving your surgical skills. Briefly, the Wisconsin Surgical coaching program uh II is based on individual of the units you set your goals. Uh you encourage design uh uh system around that and get feedback and evaluate your performance. And then it's just like an audit to re re audit and uh repeat the cycle. It's video based. And uh in the next few slides, I want to focus on how we can use surgical videos to improve technique and surgical skills and looking at psychological training, mental imagery, mental rehearsal and surgical video analysis. So they start by saying, I like to look at other specialty, other uh uh industry and see what we can learn. So uh using uh surgical videos, what do surgeons and elite athletes have in common? Anyone? What is that we have in common with the e elite athletes? We all need training. Yeah. Anything else? Yes. Yes, there are a lot of similarity. You could, you, you, you could draw whether you're playing football or cycling or whatever we perform in a team environment, you know, uh hours of practice to become a elite. And if you are the surgeon, you have to be elite in the operating theater. Uh they did, they discuss strategies how they're going to perform on the day. They are racing similarly, before you go to the theater, you prepare the patient, you have your MDT, all sorts of preparation are going on discussions taking place as to what you're going to do on the day. So there's a lot of similarity. However, obviously sports and the money they get and the money that is invested is completely different compared to healthcare because they're dealing with small number of individuals, they get a lot of motivation, support, psychological training for managing anxiety, mood, emotion, confidence, et cetera, et cetera. But one of the things that I want to just uh draw your attention to is uh mental uh imaging. Uh and what we mean by that, it is, uh unfortunately, this video is not working. We were trying to use this video, play this video, but for some reason, it's not working, it's just showing him kicking um a rugby ball to the goal and uh uh you should observe his action you'll see in the next video, a different sport. Uh It is a neuromuscular training to enhance the brain control of muscle functions and movements. So you may not be operating. But you have to sort of imagine as if you are operating and rehearse. And again, literature is full of mental imagery and mental rehearsal in surgery and looking at the surgical performance before and after training. So let's play this, this should work. Clo was I think 19 or 21 year old uh uh skateboarder and this is Winter Olympics 2022 one of the youngest person to win gold medal and just observe, see what she's doing. Every sport like surgery is a, it's, it's a motor sport. We use our fingers or arms or legs or whatever. You need to build your motor skills, whether you're a surgeon or as a sports person, she's not stretching her back. She has just visualized herself to the finish line, strap yourself in. Pick you up with that beautiful method. 15, 10, 88, these are motor skills like doing a vehicle's operation or that to me. Ok? But you have to be precise. You don't want an anastomotic leak or a bleed anywhere. So these are very precise action that she rehearsed before starting out. She won the gold medal over there from that performance. Um I do that before doing complex operation to sit and watch one of my video that I've performed to see on a different patient uh just to rehearse mentally and prepare yourself enough. So if you look at elite surgical performance, what is it that they do? And we don't do is we don't reflect, we never reflect. Once you operate out of the operating theater, you're on to the next patient where once the match is over, you can see when you're watching a football match or cricket or rugby. All the data, the information you get about position and where he should have been. And why did we get this not, why did we not get this goal? All this data, this is all video data analysis that is taking place live on the spot. Why? Because again, it's a multimillion dollar billion dollar industry. There are professional uh front end video analysis system available to them to give you that information live on the spot. But each team will sit down and watch their video to do a post match analysis, whether you win or lose to see, you know what was happening at the time. You cannot see what's happening at the time when you're in the match. It is similar to this next video we know that you have to be safe while using the diathermy. Thanks. That is cholecystectomy and duodenal injury. See that. So when you are in operating theater or in the middle of your football pitch, your mindset is very different even though you know what you should be doing and what you should not be doing and that's why you win and lose. So, a surgical video for the computer, it is a binary zero and one. So this is a gastrectomy video for the computer or A R. It is gonna be a series of zeros and one which will eventually look like uh a digital image, um surgical video of the cornerstone of uh uh A I in surgery. They can help you uh surgical workflow analysis, instrument detection and tracking seam segmentation and reconstruction uh and intraoperative uh uh A R uh with critical structure identification to sort of minimize uh uh complication and improve safety intraoperatively. But without data, without the videos you can have uh all this uh surgical video analysis um you know, can benefit preoperative debriefing, surgical education, co coaching and uh skills improvement. We are starting to see emergence of this in surgery. Now, this is one such platform proximity you saw uh for intra in theater consultation. The proximate platform also does this but this is a uh a different platform. Uh DS one, it's called uh uh again, this is an advanced version of touch surgery which is connected to your uh operating theater laparoscopy start every video is captured, recorded, it's stored in the cloud and it's immediately available to you on your mobile phone. Uh You can segment the video and you can review rehearse play back and see, especially if you had a complication. You can look back as to why did you get an anastomotic leak or bleeding if you had to. This is uh a data driven insight. This is laparoscopic gastric bypass data from 10 different surgeons. And each row represents 24 different steps of laparoscopic gastric bypass which is broken down. And you can see over here starts with port entry. So everybody has to do the same thing port entry to start the operation. But as you progress, things start to move up and down and then again in the end port closure the brown column. So there is no there is lack of standardization. So what we learn is even among experts when you look at the data and the video analysis is lack of standardization and lack of standardization means um AAA different performance every time. So this is what surgical video data analysis can do. Um They give us data driven insight where we are at the moment is here where one another spectrum fuzzy. But if you have not 10 laparoscopic gastric bypass video, but if you had 1 million over here, which we will have one day, then you will have good decision making as to what you should do when you should do both intraoperatively, preoperatively and postoperatively. So surgical videos are the cornerstone of A I. And at the moment, we are just simply bleeding video data because we don't capture them the hemorrhaging data. And you know the value of data, we know little bit about data because when it comes to data, when it comes to research, small data versus big data, we know about randomized controlled trial. And then you ask, what is the sample size? Your sample size is there? So your data is small. So analysis interpretation is going to be very, very subjective. And currently a lot of our decisions are based on randomized controlled trial where you have recruited perhaps 500 patients, not 5 million. So imagine if you had data from 5 million and not 500 patients, what would be the quality of that information? So if you look at the learning process, how do we human versus machines learn? We learn by what's defined as heuristic technique? It's a bit of trial and error, you know, it's knowledge, skill, judgment experience. So when you come to my age and say, oh, this is how I always do it. I heard my bosses do it. This is how I'm gonna do it. That is level five evidence. OK? If you go back to the previous slide opinions, case, expert opinion, yeah, this is expert opinion. So next time when your boss says something you talking about expert opinion. And if you argue with your boss, you should be able to pull the paper for meals. If you cannot put the paper for me, if you are not prepared, you don't know the subject. So you simply have to accept whatever he or she is telling you and take it as face value and then you will call it as evidence based medicine that is not evidence based medicine. The reason is because we just learn by knowledge, judgment and experience and we just stay over there. We stagnate. Why are we scared of artificial intelligence? Because they don't learn by experience, they learn by data or facts. Machine learning is better because machine, they follow an algorithm and an algorithm is a process, a set of rules to follow in order to solve a problem, which is what we are all trying to do as a human or as machines. So computer coding is a set of rules telling the computer what you want to do. We are designing the A R we are telling the computer to analyze, extracting the data, manipulating the data and design the data. But when we do it physically, we can only do handful of data handling like a randomized controlled trial with 200 patients or 500 patients. We cannot do data handling and data analysis at the scale which a computer can do. But we've, we have done it and we do it and we call it good practice. This is sort of an algorithm. This is a human algorithm which Atul Gawande has designed and we follow this. OK. It's a very simple human algorithm of your checklist. We have an algorithm for colonic polypectomy management. After what happens if somebody gets. So this is how we standardize education training. We have algorithm in stroke. So we have several algorithms preoperative. These are all applicable preoperatively or postoperatively intraoperatively. We have no algorithm. We are just one man show, we like to say that we work in a team, but it's just one man show one woman show the surgeon himself without any teamwork without any knowledge, understanding or limitations of when he or she should stop or not or continue when in crisis. So standardizing and using video for teaching and surgical skill again, a lot has been written over there and the benefit of standardizing the standardizing will come from um either randomized controlled trial with small data or with big data. The benefit of standardizing is um improve patient safety, consistent quality of care, increase efficiency and clearly there is cost saving. So here are two digital twin. I just came up with this, the Eagle project and the Safe Cholecystectomy program are digital twins. They were designed one in Europe, one in America, independent of each other, completely different uh time scale and period for improving performance in operating theater. This is sort of measles simulation, non technical skill education and training. Nothing to do with how you should do cholecystectomy or how you should do a bowel anastomosis. This is sort of a one week lecture. So feel free to go educate yourself. It's free education online to access. What is safe cholecystectomy? What is the Eagle project? What did they teach you and what the research has shown from the output from this to improving safety efficiency and outcome. Finally coming to micro simulation, we spoke about a bit of micro simulation, video analysis, video feedback, self reflection, deliberate practice. As adults, we learn best as active participants in learning. You identify your own goals, you practice deliberate practice, not force fact, practice self self reflection with constructive feedback, you integrate all that to learn as an adult because as a doctor it is continues medical education, you never stop learning. But how do you address your learning need? This is how you do with this. This is again based on or uh the Wisconsin surgical coaching program draws on that. You identify goals, get training, get feedback and support, you do things in isolation, it won't work. This is again one of my favorite line not engaging leads to plateau in a state of proficiency. So you have to engage at every level, at every stage of your life of your career, elite professionals and other disciplines use coaches to facilitate deliberate practice and continue performance improvement, just lecturing and reading and all the knowledge retention. You can see is very poor unless you engage in discussion, teaching, practicing uh you, you'll pick up wrong and big habits. We heard a bit about frugal uh innovation that are high tech and technology available, which is not necessarily applicable uh and useful in prices and in conflict uh situation. One of the reason is even if you had money, it's not worth having investing in high tech technology. Simply because uh II, in resource constrained areas, you don't have infrastructure facilities to support machine breakdown. For example, a lot of it, labs have been jumped. One of the things that I've heard from big companies who donate um uh machines, scanners, ct scanners, they can donate CT scanners to Myanmar. But once it goes over there, if it breaks down, it just lies, takes up a space and it's like a junk of metal over there. So you need the whole infrastructure to sustain and support technology, which itself comes at a cost. Again, there's a lot of frugal innovation that you can use at low cost for improving patient care in resource constrained areas come to. Next is training the next generation, future generation of surgeons. When I started my journey sort of over 20 years ago at Queen Mary University. Uh we, we started with this master's program and surgical skills using simulation. Our two aim was to just sort of get young students, trainees like you develop their research skills and surgical skills in open laparoscopic and robotic surgery. That's where we are based in London and Charterhouse Square. Every student gets a box trainer. This is cheap. You can make it yourself for learning laparoscopy skills. The curriculum we have designed is a proficiency based curriculum, uh, which is internationally recognized. We also have the benefit of being in London and, uh, uh Russell Group University access to virtual reality simulators where the students, uh, get to learn laparoscopy uh laparoscopic surgery and perform a laparoscopic cholecystectomy on the virtual reality simulators. We are the first university in the country to offer robotic training now uh to a master's program uh through a master's program uh including uh uh uh undergraduate students who enrolled finally in the last few minutes. I just want to share uh some of the things which a touched upon uh with her um experience in Gaza, uh the Royal College of Surgeons and Medical Aid for Palestine started this uh uh project. Uh So they are going back 2015, 16 and three surgeons from the college, which is my uh Professor Shafi with myself and uh Mr Nick Markham, they were from the College Council three of us uh went to Gaza on the first mission to establish what is, what was locally required. So the first mission was just simply to go uh to see what is it that they have and what is it that is required at that point in time? The situation was stable. So you go to go through this horrible metal cage to come to the other side. The minute you come to the other side, we straight go to the hospital and we, we have an MDT type of a meeting. We see the patients see the X rays pathology, discuss the management, go see the patients and then uh operate. We have seen some interesting cases over a period of time. This is you can see a metal rod going straight through coming out of the other end. We survived. It missed all the vital structures. We started this project of building capacity in Gaza and this was one of the successful project of building uh laparoscopic surgical capacity in Gaza. At that time, they were not doing laparoscopic surgery, but it was a risk to sort of uh take that up. They had some basic instrument, they had one tower. So the first few missions I went there with Shafi and we used to operate together and then you can see all all the surgeon, surgical colleagues coming over watching. Then we went on to sort of video analysis while life surgery is going on, we are moderating a meeting with the surgeons you can see on the top corner stuff is operating. Then we are doing like a video analysis, tips and tricks, troubleshooting or whatever procedure is going on. Once that's finished, the next couple of days, we spend training local uh medical students, trainees and surgeons, basic surgical skills scores, basic laparoscopy scores. That's sort of the set up we had. And in the end they get draw college certificate of completion of basic surgical skills and course with the laparoscopic surgery, this required for us to deliver six courses over three years to train the some of the faculty over there to a point that from year four onwards, they were doing the delivery of the course they were operating. And over a period of time, we built capacity, we would get together in the evening again to discuss cases like symposium and they had conferences as well. This was my last visit last year. Just before the uh uh escalation, there's a new triage unit they had built over the marble floor, fancy place, everything is destroyed now. And uh this is while I was there, we could see from my hotel fireworks and the Iron Domain Action. Another example, I want to just sort of uh draw you to his uh college of uh uh East Central and Southern Africa and West African College sex and wax in Africa. They have come together and have made great strides in the last couple of decades in building a local capacity. Each college represents a conglomeration of about 11 or 12 countries for standardizing surgical education and training for Africa. I've had the pleasure of now getting involved with the cos ESA and University of Zimbabwe and similar to Gaza. I have set up a surgical skills and training center in uh Zimbabwe. Uh I'm going to Zimbabwe back next week. These are my colleagues. Uh one of the middle is he's a professor of surgery. Uh These two colleagues are from uh USA Stanford University. We do, we don't operate, but we, we deliver training courses and program and proficiency based training, setting standards for surgical education and training in Africa. So in conclusion, I think pathway to strengthen humanitarian surgery is to establish and validate humanitarian surgery, expand the surgery and build evidence, build accessible egalitarian, sustainable community practice and enhance workforce through educational access to sort of resources. We need uh innovative funding models for this and um involving young healthcare professionals and students in humanitarian affairs is essential for future innovation and their participation can lead to new perspective and approaches to solving complex challenges because hopefully it is your generation who will see a more stable environment and the need for building capacity and resources there. As uh JFK said, our problems are manmade. Therefore, they may be solved by man. No problem of human destiny, beyond human being. So we put our effort and minds together. I'm sure we can achieve this. Thank you. You can reach out so feel free to reach out for any discussion, support ideas, sharing, especially the next generation. And I said I'm only focusing on next generation simply because you can't train adults. It's very hard to train others. It's very hard to change their habits. They are gone, young, young is on this side, young is over it. It's very hard to unlearn. You should remember that if you can't learn, don't learn wrong things because it's very hard to unlearn, it's impossible to unlearn incredible. Uh So your name? Any questions from the audience? I I'm not asking a question about this. Uh OK, I just like to hear your opinion. So you listen to the whole thing. I listen from my colleague about our challenges and uh provide care for these people. So uh in those as an expert in the surgery in different part of the world to be your advice for. What is that? Um I think, let me, let me start by uh just telling me a little bit about Gaza. When we went there, we had no idea similar to that. I have very little idea and understanding of what's going on in my, what they have. Uh Was I, you know, you, you can't imagine the energy and the passion they had in the hunger, they had to learn it. It was which I'm sure existed in Myanmar as well. So it was you can only feel it once you interact and then minute you support them, provide better structure, evidence guidance, they are willing to follow, learn and adapt and they could very quickly integrate that into the practice. First thing for us was to understand what is it that you want it was very challenging for the 1st 23 missions when we were operating and there were 50 people in the operating theater trying to look and when you go to such places, you are only faced and given the most challenging cases which they cannot manage or they are not sure what to do. So, uh you obviously, you need to be very, very experienced as a team that's that's going in. So what I would say is again, looking at uh this slide, having uh an good understanding locally that yes, we have been, we've been doing a certain thing in a certain way, but there is a different way of doing it and how can we adapt that to our circumstances. So, designing a model working in partnership that are you and me together to say fine, this is what we want to do. We wanted to start laparoscopic surgery if we want to start laparoscopy, how can we do that safely? And we managed to sort of establish that working in partnership. And this is just one small example. It is sort of understanding the local need, then designing the curriculum around that based on our experience in the West and then integrating that into your system. If I just tell you, this is exactly the conversation that I'm going to have in Zimbabwe next week with the American College with COS ESA and uh with the University of Zimbabwe, they want to standardize laparoscopic training the American College SAGES has fundamental lasic surgery course, which is free online to access alone, but it costs $5000 to get the certification training. It is exactly the same as what we have a G laparoscopy pass over here. But the point I'm trying to make is a resident in UK or USA has access to laparoscopic surgery in theater. They watch, they know what it is where a resident in Africa will probably never see or has never seen laparoscopic surgery or has very limited, even in big cities, very, very limited exposure to tell them to do this competency based program, as described by the association of uh Great Britain and Ireland or the American College of Surgeons is not going to work. So we have to, I have to adapt, change the curriculum method of teaching delivery to the local you. So, you know, it, it, it has to be a partnership to first for us to understand what is it that you need. And then what is it that you have? It's like you're in a forest, you want those sort of lighter fires. You cannot see that. Bring my lighter over here, you sit with two rocks and start grinding it to make us to get a spark. So, so first when you know, you started with the basic surgical skills, then, so, you know, like uh in the first surgeons to me and then we came back to a meeting and then they were doing independent uh rectal resections all. So we talk them that you have to work together, you have to work collaboratively. It's not one person doing it. It's yeah, operations like it's not, but they, they did the trainees get the first everything I said the presentation about digital surgery, surgical coaching, uh video analysis, video based learning group discussion. We've, we had integrated that into our uh learning pathway in building capacity and making sure that it is uh sustainable. Uh you know, we used to not go with a lot of money and funding. Uh This was funded by the Royal College and by the uh uh map, charity, medical aid for Palestine. Um we, we could uh some carry some staplers and instruments from here. Uh and whatever you could carry in a suitcase. Uh but then you have to improvise, use local resources. Yeah. Yeah, you have to adapt and that, that requires a different train, the trainer. OK. I have a question. Um So you talk about A I medicine and so um my question was a little bit debatable subject. So do you think a I would develop to a certain point where it can like uh replace some of the medical professionals eventually, eventually? Yes, it will, it can. And it will. Yeah, if you, if you ask somebody about autonomous car 100 years ago, what would have, what they would have say would have laughed at you. Thank you very much and you, now you have autonomous car and you drive autonomous car and they take you there and you don't know that, uh, most of the landing and takeoff is autonomous. When you are flying, the pilot is sitting there, the takeoff and landing is the, just have a question to what's medical specialty should I, should I choose to make sure that my specialty is not replaced by the, er, so this is a very good question. And the first thing that you have to understand is that you are in charge of A I, so you have to change and adapt and your job and role will change if you think, like, I'm gonna keep doing open surgery. So I have to be good at open surgery. I'm gonna keep doing it. Then when laparoscopic surgery came, you'll be thrown aside if you did not adapt to open to laparoscopic, laparoscopic to robotic, robotic to A I. So these are just changes. Your job is not at, at risk, no matter what you do, you may think you will perceive it that way. But unless you change your thinking, you will always be scared of the machine. I mean, your career and I think is going to change. So you just have to be willing. You will not be in, you know, I've been in this hospital for 20 years and, you know, my generation is gone. You're not gonna be one job, one surgeon. One unit, you will be mobile, you will be moving and you will be doing all sorts of things and adapt your skill, everything will change and you will learn. So that is part of your continuous education, how you control the robot will be up to you to decide. You know, another one of my favorite slide is like, you know, top guns, you saw the movie, top guns, Tom Cruise. We don't have those fighter pilots like top guns anymore because there are unmanned drones and pilots. So the top gun is actually sitting somewhere in USA controlling the plane and not actually flying over Gaza or Afghanistan. So if you are the top surgeon or the top gun pilot in thinking of what's going to happen to my job, you know, I'm gonna stop flying all this fancy F-16 jet and all. Yes, you will stop flying F-16. You will just do it in training and you know, go for a spin and come back when you actually need, you'll be sitting in a room controlling so and those jobs did not exist before. So how we train doctors and how we design our healthcare system will evolve. You can't stay static and you have questions. Um um not all the patients come with that. If the data in A I is from 10 patients, then it will not have. But if it's A I have the data from a million patients, there will be a lot more than any single surgeon present in that hospital because I have seen 5000 patients, but A I would have seen 5 million patients. So what is near is data? Once you give data, it's like if you have fuel in your car, you can run, you can go the minute your tank gets empty, you'll start struggling. So when, when A I becomes that intelligent, once you start centralizing data and that's the Blockchain technology comes sort of even though it's, it's safe, it's decentralized, but it can capture data, gather, data, manage data, the apps that you saw a ab uh symptom checker, they are very accurate. So they are just diagnostic apps which is medical consultation. So you don't need to see a doctor. So that is already there. But the app will tell you you need to go to A&E now or go and see a doctor now or click this button for an online consultation. So the A I will guide you read and not only that and once you have variable devices. So now you have your BP, monitor your pulse, heart rate. All that is gonna be straight into your mobile phone and all the basic parameters can be uploaded will be integrated into the software. And the A I will say actually you're hypertensive, your BP is this and that and all the things you've got an ectopic pregnancy or your bleeding inside, go go to A&E and then eventually you will have just like you have washing machine, you will have your medical pod that you can lie down over there and the robot will do the operation for you and then you can get up and have a coffee. You. Mhm. It will happen. What you see in all the Hollywood movies are, the science fiction is not fiction. It's reality. What you see in Star Trek is because we've just lived for how many years on this planet consciously, about 5000 years out of our existence of 5 billion years. So we just far fo fast forward 5 million years. But the good thing is it's not gonna affect you and me. So we are safe as far as the job is concerned, you focus on your training. We don't have to worry about what happens after 100 years. Yeah. You know, Max might be 100 years, I think.