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Amanda Wilde (Host): Welcome to the Healthcare Executive Podcast, providing you with insightful commentary and developments in the world of healthcare leadership. To learn more, visit ache.org. I'm your host today, Amanda Wilde. In this podcast episode, I am joined by Dr. Brian E. Miller, Executive Vice President and Chief Digital Officer at Intuitive. Thank you to Intuitive for being an ACHE Premier corporate partner and advancing ACHE members and healthcare leadership excellence. And thank you for being here on the podcast, Dr. Miller.

Brian E. Miller, PhD: Happy to be here.

Host: We're focusing on a very timely topic, uses and perceptions of artificial intelligence in surgical practice. Now, Intuitive was founded back in 1995, which was centuries ago in AI time. Right. But from the perspective of having been involved in this technology for over two decades, how would you say perceptions and applications of AI in healthcare have evolved?

Brian E. Miller, PhD: It hard to believe, but if you think back, the origins of AI actually traced back to 1950. And so if you look at the technology and some of the building blocks, it's been around for a while. We then saw in the seventies, there was some applications in the healthcare domain.

There was the first artificial medical consultant in the early seventies. And so it does have a history even though we've just heard about it the past two or three years where it really had amplified it. And I would say as far as perception, and as with most new and developing technologies, and we've seen that evolve over the last 30 years.

Even with Da Vinci, I think opinions in, comfort level, they differ. Some people are more used to polling technology and experiencing it and seeing the value, and, others are a little bit more apprehensive of about doing it and adopting the technology and with AI, I think because it's been around for a while, it's probably evolved and, there's been certain times where it's probably been more positive and, maybe there have been times where, uh, people have been a little bit more concerned.

But I think now, and you look at the past several years, with the introduction of generative AI, people are starting to integrate it into their everyday life. And they're using it for a range of things, throughout their day. And so with that, I think people get more comfortable with the technology.

So, so I think that's how it's evolving, although at least my experience is that, even with being more comfortable with it, people still prefer when there's a physician in the loop, making the final decision and just using it for input.

Host: Yeah. I mean, we like to think AI will never replace the human element.

Brian E. Miller, PhD: I, agree. And, I think our approach, when you look at it, and this is, similar to how we approach the design with Da Vinci is, refer to human in the loop, it's really augmenting what a surgeon can do. And, with Da Vinci, we did it through kind of a vision, precision and, dexterity.

And with AI, you're starting to bring in context and intelligence.

Host: And so should we think of AI as a tool or standing on its own intelligence as its own player?

Brian E. Miller, PhD: Yeah, it's a good question. I think, when we look at how do we develop products and the value to customers, we first start with how can we help improve patient care? What are the needs of the users and in this case, the surgeon? We start with that, and then once we've clearly identified where we can add value, then you start to look at how do you do it.

And sometimes AI is the right thing. Other times, there's other technology. And so I guess I would say I do view it as a tool. I do think it's a powerful tool that you will start to see more and more, as time continues to go, but it has to be applied to something that matters.

Host: Now Intuitive, since 1995, has been involved with robotic assisted surgery and innovations in that area. What are the transformative aspects of integrating AI with robotic assisted surgery?

Brian E. Miller, PhD: Yeah, I would view it as something where if you start off and just look at it and say, all right, if you take AI and start applying it to surgery, I'm excited just with that general direction. When you think about surgery, it involves many variables, in the patient and in the surgeon, that influences the outcomes of what's going to occur.

And so, I do think that AI is well suited, to be applied to really understand, how do you control those variables, to get the best outcome possible? And our focus now is really using the data. And so we get data from the robot during the procedure. You then connect that to the outcomes that are accomplished. And you can start to describe, what good surgery looks like. And, once you can describe it through data, then there's a range of things that you can use it for.

Host: Can you go a little deeper into surgical data science and how that differs from traditional surgical practices?

Brian E. Miller, PhD: Absolutely. And so Surgical Data Science is an emerging field. It's been around for a bit, but really what it's focused on is improving the quality of surgery, but doing it through in a data-driven way. And so through the capture and analysis of data, you can start to see, what things are influencing outcomes.

And so it takes into account things that occur preoperatively. Because we know how the types of characteristics of patients, if they've had prior operations, things of that nature, that, that matters. Clearly what happens during the procedure, so, interoperatively, it takes that data into account and the robot and Da Vinci is, well positioned because through that platform, we're able to capture the types of things that are occurring during surgery.

And these are things that did not exist in prior modalities. So that's an exciting piece. And then clearly postoperative, you need to know what was done. Did it result in a good outcome? So surgical data science looks across that continuum and it analyzes the information to try to understand how to deliver the best outcomes possible.

Host: And during a surgical procedure, does AI also play a role in clinical decision making?

Brian E. Miller, PhD: It can. I think when we start to look at, where AI will come, I do think we will find traces of AI throughout many applications that help inform surgeons. And I think as we talked about before, it's one piece information. It doesn't give them everything, but it can be an important one, for them to use it for clinical decision.

I'll give you an example. There is, uh, use of preoperative imaging, so, certain procedures have as part of the pre-procedure prep is a preoperative image, MRI or, CT and utilizing, machine learning, which is a form of artificial intelligence, we go in and segment the preoperative scan, into the organs and critical structures, and then create a 3D model of that. The surgeon then uses that both preoperatively for decision making. What's the right approach for this patient? And then interoperatively, it helps them navigate during a procedure because they can see structures that are underneath the tissue through this scan.

And that's, one example of how the use of AI in, this case, machine learning algorithms to segment preoperative scans is helping with clinical decisions.

Amanda Wilde (Host): And related to that, how can AI and robot assisted systems improve surgeons in training and education for new surgeons?

Brian E. Miller, PhD: This is a really great question and it's, one of the topics that I enjoy discussing and talking about because I'm a strong believer that AI in surgical training and education as a, as a surgeon learns throughout their career, will significantly improve patient care.

And so, if you think about an elite athlete, let's just take a comparison for a moment. When they train and continuously improve, they've got game tapes, right? So when they're out performing or they're in a contest, they have a game tape that they can review. And then during training, there is a wide range of physiological parameters, that they measure and optimize as they're going through.

And so, if you take Da Vinci as a platform and take the analogy of a surgeon to an elite athlete, you have the same opportunity. So you have clinical video that can be reviewed for benefit, you combine that with data from Da Vinci where you can get motions, of the instruments, you can get forces that are being applied to tissue, and all of that can be captured together for analysis.

So as you take that through and analyze it, you can start to identify how a surgeon is performing relative to an expert. And those differences and those patterns that can be pulled out can then be used to create a personalized training plan, giving a surgeon a really purposeful way, that they can continue to improve.

I think as that continues to grow, and surgeons continue to grow and improve, I think that will have a direct impact on better outcomes.

Host: Yes. And the education doesn't stop with new surgeons. This is truly the cutting edge of medicine. We talked earlier though, about people's comfort with AI, and you mentioned slow adopters. What are some common misconceptions about using AI with robotic surgery?

Brian E. Miller, PhD: Yeah, it's interesting. My experience in this actually kind of the other end of the spectrum, meaning there are certain people that will jump all the way to saying, okay, if it's AI and robotics, when will the robot perform the procedure and the surgeon is no longer required. So they kind of take that big leap, all the way to full automation.

And, AI is a powerful technology. But we view it as something where it collaborates with surgeons. It provides information for clinical decision making and, so all of the approach is really understanding how can it be valuable with the surgeon in the loop?

And so, that's one aspect. Now this still does leave open, the possibility for autonomous subtasks. Things that the robot and Da Vinci is, better and more precise to do. And you leave the surgeon with the ability to, spend their time thinking about more complex tasks or other decisions.

And so I think pretty powerful. And in fact, today with Da Vinci, our robotic stapler, there is a method where it auto adjusts, to optimize the compression in the jaws, to improve the staple formation. And so, I think that's the way to think about it. But it is interesting that some people jump to that conclusion of fully automated surgery.

Host: Well, when you look ahead, what excites you about the future of AI in healthcare, particularly in surgical practices?

Brian E. Miller, PhD: Yeah, for me, it, really is, and you said it, it really is in the intersection of AI and surgical robotics. And so when you look at what AI can provide, I talked earlier about providing context, but if you imagine that AI is able to help identify and automatically track sensitive anatomy, as an example, and so you're in a procedure where there's certain anatomy that you don't want to come in contact with, and in fact, if you accidentally do, it can create surgical complications. And so if you bring that knowledge and context with robotics, you can imagine an implementation where the robotic system then stops the instruments from coming in contact with that piece of anatomy.

And so, not only as we've seen over the past 30 years, does robotics help to reduce variability in surgery and reduce complications, you can imagine that AI plus robotics can eliminate certain complications, based on the technology. And to me that, that's just exciting and very powerful.

Host: It is, because the fact that AI can reduce risk, make things safer, makes me look forward to future developments in this evolving field. Thank you so much for sharing your insights, Dr. Miller.

Brian E. Miller, PhD: Appreciate it and thank you for having me here today.

Amanda Wilde (Host): Thank you to Intuitive for being an ACHE Premier corporate partner and advancing ACHE members and healthcare leadership excellence. To learn more, visit ache.org/intuitive. For additional podcasts, please visit healthcareexecutive.org/podcast. And for more information about the American College of Healthcare Executives, please visit ache.org. Subscribe so you won't miss an episode. And stay tuned for our next discussion. This is Healthcare Executive Podcast from the American College of Healthcare Executives.