More than five billion people lack access to relatively simple surgical procedures that could dramatically improve their quality of life, and even save their lives. In this episode of Connected & Ready, host Gemma Milne joins Dr. Michael Marin, Chairman of the Department of Surgery and Surgeon-in-Chief for the Mount Sinai Health System, about developing a remote surgery program to help address this enormous gap in access to health care. Just one year old, this groundbreaking pilot program uses a shared surgery model and mixed reality technologies like Microsoft Dynamics 365 Remote Assist and HoloLens so that surgeons at Mount Sinai can guide their counterparts at Kyabirwa Surgical Center in Uganda through new procedures and train them in new skills, in real time, thus expanding the capabilities of local medical care. Microsoft Dynamics 365 Remote Assist leverages mixed reality to enable remote teams to work with experts and solve problems in real time. Request a live demo today: https://aka.ms/AA8kzgj Thank you for listening to Connected & Ready! Do you have ideas of how we can improve the show? Want to recommend a guest for us to interview? We value your partnership and participation. Please drop us a note at email@example.com. We would love to hear from you.
Gemma Milne talks with Dr. Michael Marin, of the Mount Sinai Health System, about his role developing a shared surgery model as part of a pilot program to expand delivery of same-day surgery and surgical training, the key technologies that make the program possible, and the impact that this sort of program could have globally in medicine and other industries.
About Michael Marin, MD:
Dr. Michael L. Marin is the Chairman of the Department of Surgery and Surgeon-in-Chief for the Mount Sinai health system in New York City. He has revolutionized modern vascular surgery and sparked the rapid development of new treatments with other physicians around the world for minimally invasive treatment of vascular disease. Dr. Marin is an active clinician, teacher, and contributor to medical literature.
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Gemma [00:00:05] Hello and welcome. You're listening to Connected and Ready, an ongoing conversation about innovation, resilience, and our capacity to succeed brought to you by Microsoft. I'm Gemma Milne. I'm a technology journalist and author. And I'm going to be exploring trends around how companies are adapting to a disrupted world and preparing for tomorrow. We're going to speak to the innovators who are bringing products, operations, and people together in new ways. In today's episode, I'm chatting with Dr. Michael Marin, Chairman of the Department of Surgery and Surgeon in Chief at Mt. Sinai, New York, who walks us through how the lack of global surgical care inspires an innovative approach with Mt. Sinai, New York and Kyabirwa Surgical Center in Uganda. We chat about the shared surgery model, how the right technologies enable this model to work in real-time over 7,000 miles, and the impact that the shared expertise is having globally. We also explore what the future holds and how other industries can apply a new model of virtual collaboration to share expertise worldwide. Before we start, I want to thank all of you listeners out there. If you have a topic or a person you'd love to hear on the show. Please send us an email at firstname.lastname@example.org. We're so thankful for you all. Now on with the episode. Michael, thank you so much for coming and joining us on the show. We're absolutely thrilled to have you with us today. Let's start with some introductions. Tell us a bit about who you are and what you're currently working on.
Michael [00:01:30] All right. My name is Michael Marin and I'm the chairman of the Department of Surgery here at the Mount Sinai Health System. And I serve as surgeon in chief for our health systems, seven hospitals for surgery. I work on many things. I certainly am a practicing surgeon and I have a large practice in vascular surgery. I've been interested in education and global health for many years. And one of the projects I'm particularly interested in is our program focused on global surgery and the program built in our department around that.
Gemma [00:02:04] Amazing. So yeah, before we kind of really dive into what you've been doing to share this life saving expertise globally, let's first start by getting a bit of an understanding of what started all of - what got you interested. Talk to me a little bit about why you set out to find a new way to start to tackle this lack of global surgical care.
Michael [00:02:22] Well, surgery is one of those complex tasks that many people don't understand completely. And it goes for a whole host of different reasons. But in general, people think of surgery as being something that's incredibly complicated and something that's incredibly expensive. And those two obstructers, if you would, tend to stop people from thinking about surgery and getting surgery to reach out to communities around the world. As such, if we look at the world as one entity, over five billion people in this planet do not have access to relatively simple surgical interventions, things that might change the quality of their life as well as the existence of their lives. Many lives are lost each year because people can't get access to a simple and safe surgical intervention. And if you think about our planet being filled with about seven and a half billion people, and if five billion people can't get access to surgery, that means the lion's share of people on our planet can't get an operation that might save their lives. So those numbers are quite daunting. And those are the things that we've been focused on in our project as to how we can bend the curve of that large number to get us to a different space.
Gemma [00:03:39] And so tell us a little bit then about how this project, this collaboration came up, both in the sense of working with a rural community but as well, thinking about it from the perspective of tech solutions.
Michael [00:03:51] So to start off with, we know that a good percentage of those out there who need our surgical interventions are living in rural communities. They're living in societies where they're mostly agrarian, active people where they farm their land, they produce a crop that is basically the supporting element for their families and themselves. And these communities are particularly the ones that have limited access to health care in general, but specifically, have very little access to surgical care. So our first target was how do we get surgical services into these communities to provide the services where they're needed? And as we looked at this, there are many challenges and many obstacles. Some of them are very obvious things like power and water that we take for granted in many of our own societies, in our own communities are not things that you can expect to be present in many of these villages that are somewhat remote from major cities. So our facilities had to begin by thinking about the very simple things that are necessary in order to create an environment which would constitute safe and reproducibly affordable surgery.
Gemma [00:05:11] And how did the collaboration specifically with Kyabirwa Surgical Center come about? Was this, you know, somebody there that you worked with before or was it that, you know, it was a good, I guess, pilot or a good collaborative opportunity based on these limitations that you describe? How did that come about?
Michael [00:05:29] What brought us here is somewhat serendipity from the standpoint that we could have set up shop to test this concept anywhere in the world. And I often like to use the analogy. If you took one of those globes that we all had as children that you had on your desk and you spun that globe and you threw a dart at that globe, almost anywhere that dart hit, you'd probably hit a site, provided it was land, that could use or would benefit from a facility like this, given the fact that so many people, again, five billion people are without surgical services. So we ended up in this village, this community, mostly because we had a donor who was interested in participating in a program in Africa. And after a careful look throughout multiple communities and multiple countries in Africa, we settled on this one because it was convenient.
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Gemma [00:06:46] So let's get into the meat of this shared surgical program that you have. You use a mix of technologies from Teams to HoloLens to Remote Assist. Walk us through how you sort of determined the right mix of technologies and how on earth you got all to work from seven thousand miles away?
Michael [00:07:03] Well, I guess it all begins with the concept of shared surgery, the model of that. And that gets to the idea that if we look throughout this community and many other communities around the world, there's a tremendous paucity of surgeons, a paucity of knowledge, and experience related to surgical interventions. Yet if you come to a place like New York City, we have more surgeons than we could possibly need in this very compact area on this little island of Manhattan. We have as many surgeons as you could imagine would be needed to take care of our population. And then many more on top of that. So all this mix together becomes this concept of how do we take the experienced surgeons, put them together with the less experienced surgeons and do so using technology. So no one has to be physically displaced, that we could actually keep people in their geographic locations and then have them available all the time, not just in a one-week or a two-week visit. To do this, it all begins with what we would consider low tech, but would be high tech in many of these communities, and that is an Internet connection. You need to be able to supply connectivity sufficient enough in quality that you don't experience meaningful delays between the two sites. So it can't be a cell phone, if you would, providing the lion's share of that connectivity. It has to be something with a high speed broadband capacity, like what would be present, as we have with a fiber-optic connection to one of the main Internet trunks. And we accomplish this by using what is called RENU. RENU is Research Education Network of Uganda, which is an enterprise partially government-sponsored and partially NGO sponsored, which is focused on the mission of supplying Internet and educational services throughout the country of Uganda. Their whole focus is getting connectivity and education building that will allow the communication between different sites within that country. So with our connectivity to this organization, which has access to high-speed Internet, the next goal was to run an underground fiber optic cable quite a few miles to get out to our village out in Uganda. And whilst that might seem very complicated and difficult, it actually was quite easy to accomplish. The cost wasn't prohibitive because a lot of the capacity to do that is the physical ability to dig the trenches and lay the cable. And there are a fair amount of physical resources available at reasonable cost in that country. So we buried our cable and the next thing we did was we had high-speed Internet with exactly what I'm describing to no physical delays, even though we're 7,000 miles away. Then came the idea of looking at different technologies that would allow us to actually load that Internet communication with the best imagery and the best communication channels. We knew we wanted to share knowledge. We wanted to take knowledge and experience that comes with training a surgeon in this country for 15 years and share it with someone who trained for only three years in Uganda and the systems that we use allow us to actually not only communicate information and digital information in a facile way, but allow us to way communication between surgeon at one part of the world and surgeon in another part of the world participating together in an operative activity. We cannot only watch the operation that's going on in Kyabirwa, in Uganda, from New York, but we can participate in it. We could point to things we could and circle things in the operative field in a very active, precise way and do so dynamically without delay so that we could literally interface with where the next cut will be, where the next stroke of the scissor will be. All these things can happen in a dynamic fashion between a surgeon who's separated many thousands of miles. And this is a game-changer because it allows us to take an operation that might be a little bit out of the wheelhouse of a surgeon in one part of the world and say, let me couple you with someone who does this operation five or six times a week. And give that knowledge to that person who doesn't have that experience and they'll do one case and then one case becomes five cases together, becomes 10 cases, and with this repetitious experience and exchange of knowledge between surgeon here and surgeon there, they suddenly upload that knowledge so that they no longer need the surgeon here guiding that operation. And you've permanently implanted a skill set into that village, into that community that didn't exist before.
Gemma [00:12:07] That sounds like an absolutely incredible achievement, really. And, you know, I think it's interesting that you're saying the part laying the cable was actually the easy part and getting things sort of set up from a logistics perspective was perhaps not as expected. And I think sometimes you can have this perception that getting things off the ground can be really, really hard when in fact there might be other kinds of challenges. So walk us through perhaps what has been the most challenging part of getting the solution to where it is today?
Michael [00:12:35] The most challenging part is getting everybody on board with the concept that we're sharing knowledge. We're not moving into a community and providing services. This isn't an American-based program, moving it to Uganda and showing and taking over and building and running a hospital. This is about Ugandans taking care of Ugandans and building that philosophy from the very first day we started this project. This begins with using Ugandan architects and Ugandan construction people and Ugandan builders and people from the village in the community coming in and laying the bricks, pouring the cement, creating the foundation, and raising the walls on this facility. There were no companies coming from outside of that country coming in there to provide the building of the facility. It was people from the village. So they walked to work with their lunch pails. They walked to work and walked home at the end of the day after completing. And there's a sense of ownership of the community with the program from the very first part that we're involved in. We engaged with local health care and community leaders to help think about the design and what we were going to accomplish. If you would visit this facility, you don't see the United States of America, you don't see American flag. You don't see the Mt. Sinai Hospital logo or anything. You see Kyabirwa Surgical Center. It is a village-based and village function and run facility. And when you visit it, you only see Ugandans because it's Ugandan people who maintain the grounds. It's Ugandan people who turn over the operating rooms after the cases. It's Ugandan surgeons, Ugandan nurses, Ugandan administrative people who manage the purchasing and all the in sundry things that go along with a facility of this type. It's all Ugandans taking care of Ugandans. And that philosophy to get everybody on board with that, both on this side of the world as well as that was an important learning lesson for everyone, but an important accomplishment that we were able to achieve.
Gemma [00:14:47] Yeah, I can imagine as well from a perspective of culture, too, right. You have two very different, I guess, histories as well in terms of what you're saying, in terms of experience of surgeons and the way that health care is run, but also, of course, combating the kind of historical precedents around countries coming in and taking over and projects that really should be local. So I think it's one of those things that we talk about a lot in this show that a lot of the time it's not really the technology that's the problem. It's not trying to teach people how to use a new tool, but rather mindset shifting that can sometimes be part of the challenge. I wonder if you could talk then about benefits then? I mean, it seems like perhaps an obvious question. What are the benefits of having better surgery worldwide? But maybe you could take us through from patients, from surgeons, but also from those who are part of the program at Mt Sinai. What have been the benefits from this project?
Michael [00:15:38] Well, there are some very definable benefits and I would elucidate them in the following way. First, we introduced into this community the concept of same-day surgery. That is that you can actually get an operation, get a problem fixed, and then go home at the end of the day, from that operation, you needn't stay in the hospital. Now, this has become the standard of practice in many parts of the world. And I would say anywhere between 60 and 65 percent of all surgeries we do worldwide can be done what's called an ambulatory platform, or same day surgery. This is not the culture or the commonality in this community. And teaching that idea and getting everybody from the physicians to the patients comfortable with that was a very important part of moving this needle forward and changing the paradigm of how care is done. The next part is the ability to do operations, surgical interventions on people that desperately need them, that not only changed their lives, but in some instances saved their lives. So let's look at the spectrum of that. On one hand, you have patient number one, who has what's called an inguinal hernia, which is a weakness of the abdominal wall. It's when the muscles of your belly become weak. And in so doing, it allows portions of the internal contents to push into the skin. And this causes tremendous pain. It causes disability and if left untreated, can actually contain and squeeze off the blood supply of internal organs and portions of the intestine, resulting in death of that piece of intestine and the loss of life. Left untreated this can cause disability such that people can no longer work, can't tend their fields, can't work in factories, can't provide for their families. And this is an operation which is not hugely challenging to do. So bringing this hernia surgery to this community as a regularly available resource changes all of these people's lives who have been living with these problems for what may be anywhere between a few years to many decades. So right there, we've changed the spectrum of that disease in that community. Other things that are often benign but can be very which means that they don't cause immediate loss of life but can severely compromise lives are all surgically correctable, but people live with them because they don't have opportunity to access these sources. These include things like wounds, large areas of the of the skin which have been lost because of burns or other injuries. These can all immediately be repaired with a simple skin graft and the patient can go home at the end of the day. Another example of where Microsoft Dynamics 365 Remote Assist and HoloLens really was uniquely instrumental was a young woman who came in who had a massively distended abdomen, a huge belly, and this was all caused by a giant ovarian cyst. The cyst was benign, but it had grown to be so large that it looked like she was twice the size of a woman of her size who would have been pregnant at the end of nine months. Can imagine the disability of having a double pregnancy and walking around with that all the time, consistently, week after week, month after month, year after year. To fix this problem we brought it to the operating room in our facility and the first thing we did was we removed all the fluid out of the cyst and it removed over twenty five liters of fluid came out of this cyst. Twenty-five liters. Can you imagine how much fluid that is carrying around this all the time. Then we remove the cyst, which would ensure that this could never come back again. And after completing that through a four-inch incision, she was cured. Never to have this problem again. Imagine the change in her life, how she can take care of herself, her family, her children, work in the field, become part of her community in a more meaningful way, go to her place of worship. All these things could take place in a way that changes her life forever. Now, this may be just one life, but that one life is forever changed by an operation which wasn't that complicated. Each of these examples changes the course of these lives forever.
Gemma [00:20:11] And what about on the New York end, what have been perhaps the benefits for the participating surgeons at Mount Sinai?
Michael [00:20:19] It's funny you mention that, because I never actually thought about that before we started this program. And I'm always thinking about how our surgeons here would impact on the lives of people in another country and on the activities of surgeons in another country. But I never anticipated the positive impact it's had on our surgeons here. The sense of well-being, the sense of participation, the sense that you're doing good for others around the world, the sense that you're participating in a program that could actually set a new standard in sharing knowledge. It's had enormously positive impact on our surgeons and physicians here. And I might accelerate this to say it's not just surgeons. So our facility has a diagnostic component. So we have x ray and ultrasound. So we pair our X-ray and ultrasound team in Uganda with radiologists in this country who are experienced with ultra scenography and X-ray interpretation and help with those interpretations. So suddenly we have radiologists involved. We do biopsies of tissue on masses and problems that are detected in Uganda and because of our remote tele pathology program where we can take a specimen, put it in a microscope in our village in Uganda, and that microscope can be controlled using a Teams integration platform by a pathologist here in New York. We could have all of our specimens diagnosed and reviewed by a pathologist here in New York by specimens that are sitting and never leave that village. So we have pathologists involved. We have radiologists involved. We have gynecologists involved who are helping manage the gynecological problems that we see. General surgeons. We have plastic surgeons involved who are helping conceptualize how we take care of these difficult wounds and so forth. So, so many different specialties. All are able to participate through this remote access program and the incredible reward they get from being part of this has been something I wouldn't have anticipated. And the line to be part of this project here in my own medical center is quite long.
Gemma [00:22:31] I can imagine. And speaking of people queuing up to do something similar, let's speak a little bit about - thinking about scale, not just in health care, but thinking about many different industries that could benefit from this, I guess, shared surgery model, as you put it. What would be your advice for others looking for ways to share knowledge and expertise across distance and in underserved communities? I mean, should they do first to begin to build their own solution?
Michael [00:22:58] I guess the most important thing is to recognize that it can be done. This is very doable. This isn't, you know, how do we get to the planet Venus and come back again? This is a very accomplishable task that could be happening today with this technology and happening at a very high level. The biggest focus is for people to think about the technologies that are associated with power. Our facility is existing in a community where power is not something that is accessible. So we produce all of our power using solar based panels. And prior to this, I had never actually seen a facility that was completely independently functioning on solar. And with all the challenges that might exist in different parts of the world, particularly in sub-Saharan Africa, I can tell you that the sun is one very reliable resource. It comes up even when it's raining. We acquire power with our solar panels. And this facility is completely independent and off the grid. It provides all its own power with its underground fiber optic cable it has continuous access and connectivity to any place in the world. And these things are not high-tech things if you think about it. They're very achievable in today's world and this can be used in anything. It could be used in manufacturing, obviously in health care, but it could be used in virtually any area where knowledge needs to be extended from one part of the world to the other, where you don't need the physical presence to do it, and the depth by which this information could be communicated, particularly with the HoloLens. I mean, the imagery that our physicians and our surgeons are experiencing in that site, sharing that knowledge with people from New York is quite dramatic.
Gemma [00:24:51] What about advice in terms of this, I guess this mindset challenge that you brought up earlier, thinking about people who might be tuning into the show, who are probably based in the US, probably already working with what we think of as basic advanced technologies and wanting to be of help that might not have considered these mindsets or these different sorts of ideas that both have to be considered both from the American side as well as the other side that you're wanting to work with.
Michael [00:25:17] Well, I think one of the key things here is, is our ability to share our knowledge not just on medicine, but to share our knowledge on development. I've been very keen on how we build this thing from day one. How do we make this? And I look at this as a pilot plan or a prototype of what a surgical hospital in a rural village could be like. So we spent an enormous amount of time trying to figure out what were our power needs. We studied the equipment, the anesthesia machines, the electrical cautery machines, the lighting, the air conditioning, the air exchange. We looked at all the devices we would need and we did a huge calculation to figure out how much power we would need. But to be very frank with you, we were off. We were off by about 30 percent. That being said, we learned. And the next one we would build, we could use the knowledge because we keep all this information available and every bit of it is cataloged on the day-to-day basis so we can figure out how much power we use in a day-to-day basis, week-to-week basis, month-to-month basis. We catalog exactly how much water we harvest from rain and store and how much water we use and purify. All these things could be used to feed into additional developments of facilities like this, so when we scale this, which is the vision of this scaling and building other ones like this, we can do so with the knowledge of this one pilot plant, which has given us a tremendous wealth of information. Similarly, we developed an electronic medical record. So everything we do at this facility in the care of our patients is stored in an electronic medical record, which is cloud-based. It sits in Microsoft cloud. And this cloud-based enterprise allows us to have physicians in other parts of the world analyzing our outcomes. What are the results of our care? Everything from how far can someone travel to get a hernia operation and then go home? We think we know this, but with this data, we'll be able to say it's reasonable for someone in a rural village to travel 20 miles, 30 miles, whatever that distance may be, and be able to safely achieve and have these operations. Why is this data so important? Well, it gives us a perspective of what we've done. But it also says to me, if I want to build another one of these, how far if I would draw a circle around our place, how big should that circle be before we consider the location of another facility that could partner with this one but could reach another community in another rural village? All this kind of data gets acquired through our electronic medical record and our cloud-based analysis tool so that we can really be smarter about the next thing we build, both physically, how much water we need, how much power we need, how much bandwidth we need to run this facility. All of those things could be done in a more effective and a facile and an economic way using the data coming from this pilot plant or this trial facility.
Gemma [00:28:19] And I guess in lieu of having a pilot, it goes back to that point you made earlier around engaging local leaders and people who understand how these communities work from things like how far can people travel in a day or what is the usual, I guess, assumptions about how care is delivered and so on and so forth, and taking all that into account before you kick things off. And you mentioned, of course, you're excited about scaling up and seeing what you can do next. And for my last question, I kind of want to put that to you. What is happening, where are you at? What are you most looking forward to doing next?
Michael [00:28:51] So I look at what we've done now, and frankly speaking, I'm completely blown away. If that's a real term to use in this context with how successful this has been. We're into this into just in excess of a year and we've treated over a thousand patients. The ability to scale this and to be successful so quickly was not something I expected. So now, as we complete our first year and change from this pilot, we're beginning to think about phase two, which is how do we scale this to more broader types of operations. While we limit ourselves to things we can comfortably operate upon and send people home? How about broadening that out, the things that require one to two-day hospital stay? So we're looking at adding a addition on to our facility that would be a short stay unit, we'll call it, where patients can stay several days in the recovery phase, things that really are not quite ready to go home immediately after an operation. Which opens the door to much more complex surgeries that we can again share in this shared model as we scale it up. So we start off with relatively I don't want to say that their simple operations, but very defined operations and evolve our 360 assist program and a HoloLens program and our overall global shared model. And now we take it to the next level with more complex surgeries and get into that. So we've got pretty far along the way. We're just about going into design freeze on an addition which will add this short stay unit onto our program. This addition will add other things that we've discovered that we think will be necessary to begin to scale this. And they include things like a unit built into this facility for education. To target it around just education. Using our connectivity and some AI based enterprises and simulation programs. We could begin to train surgeons from other parts of the country in some of the technologies that we have brought into this village community and use it as a mechanism to train people from the community and from elsewhere that could either go back to their hospitals to practice or potentially move to some of the new facilities which we hope to build in the near future. In addition, we built the laboratory in our main facility and as we've used it, we've discovered that we really could supply an enormous resource to the community by scaling that a little bit. So whilst we need certain laboratory tests, they're also needed in a small health care facilities that surround us. NGOs that are providing health care. Nonsurgical based health care, the community very much needs a lot of the resources we have here and with a little bit of infusion of both concept, idea, and capital, we can enhance those laboratories. So this is the next phase which we hope to get underway with within the next six months.
Gemma [00:31:52] Amazing, Michael, is I could keep chatting to you for much longer and hear all the details of this incredibly inspiring project. But, you know, I think you've already given us ample inspiration and hopefully concrete ideas and real motivation for those who are considering maybe not even such ambitious projects, but even just the idea of sharing knowledge in new ways and powering that with technology and doing it with that sort of can-do attitude that you talk about. So, Michael, thank you so much for coming in and joining us on the show today.
Michael [00:32:20] It's been a pleasure and I enjoyed talking with you as well.
Gemma [00:32:26] That's it for this week. Thank you so much for tuning in. You can find out more about Michael's work and indeed some of the broader themes we discussed today in the show notes. If you enjoy the episode, please do take a few moments to rate and review the podcast. It really helps other people discover the show. And don't forget to subscribe and tune in next time to continue our conversation about innovation, resilience, and our capacity to succeed.
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