Latest / Show Me The Evidence / Göran Malmberg, Mentice: Why Simulation Without Metrics Falls Short

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Göran Malmberg, Mentice: Why Simulation Without Metrics Falls Short · Show Me The Evidence

0:07
Göran you started with Mentice in 2008, you
0:10
have an engineering background and you came
0:15
really from the high-tech sector from
0:17
automotive and industrial markets. So you came from that
0:22
background into virtual reality simulation
0:26
in medicine, was that really a very big jump?
0:29
I wouldn't say so Tony, I mean I've always
0:33
been working with high-tech or technology and
0:39
selling advanced technology into a B2B
0:42
environment, so that's pretty much the same and the main focus
0:46
is to understand how can new technology
0:49
solve problems for the client and that's the same
0:52
regardless of what you sell really. So from that
0:56
perspective it was known to me, obviously you had
1:00
to learn a new area, application area, so that
1:03
was all new but the basic thing was fairly similar.
1:07
I would say.
1:09
So what did you make of this newish industry?
1:13
I mean, because back in the early 2000s,
1:15
like virtual reality simulation in medicine
1:18
was relatively new, medicine, the Swedish company,
1:21
I'm sorry, Mentice Swedish company was fairly much
1:26
at the forefront of where things were going.
1:28
So what did you make of it
1:29
and what did you think the challenges were?
1:31
I mean, I think my first impression was really,
1:34
I was amazed by the passion among,
1:38
I mean, among our people obviously,
1:41
but also among physicians and the nurses
1:44
that their dedication to provide care for patient
1:48
and to try to make things right.
1:50
I think that that was probably what I first sort of noticed.
1:56
But from a challenge point of view,
1:58
I would say that the difficult thing,
2:01
I mean, we always talked about the big opportunities
2:04
obviously in hospitals and provide structured training
2:08
for doctors, for physicians.
2:11
But what I faced very early on is the fact that
2:13
training is not really connected to return on investment
2:18
or to value.
2:20
In a lot of cases, training is just the cost item.
2:24
So it's really hard to find a structure
2:27
to allocate the right resources, both financial
2:32
and people resources to provide training
2:35
in a structured way.
2:36
And in many situations, I would say that training worked
2:41
just because you had physicians and others
2:44
being passionate about training
2:45
and they investing their own time.
2:47
But in a continuum that just doesn't work.
2:52
So I think that that's one of my biggest challenges
2:55
early on, but in a lot of cases,
2:57
that's still the same really.
3:00
And in 2026, do you think,
3:03
so that was in 2008 there,
3:05
that was a big issue and today,
3:07
do you still think that's a big issue?
3:08
Yeah, yeah, I would say so.
3:10
I mean, of course in a lot of cases,
3:15
simulation is tied to training of fellows in residence
3:20
or a graduate medical education.
3:25
And that's still the same really.
3:28
Obviously we, both you and me believe that
3:31
simulation should be used for practicing physician
3:34
in the continuum and that's different.
3:36
But yeah, I say largely the same.
3:40
I think from an industry point of view,
3:43
simulation has come a long way where we, 20 years ago,
3:49
we're focusing on more basic, basic learning, imaging,
3:55
Catheter & wire techniques things like that.
3:57
Why today, I mean, the simulation can provide
4:01
way more advanced training on a complicated device
4:06
that's in complicated kind of procedures.
4:09
So from that point, I mean,
4:11
simulation have improved quite a bit.
4:17
There was a recent article, I think it was a Jama
4:19
in the New England Journal of Medicine
4:21
where they were complaining that academic medical centres
4:24
in the past were seen as the leaders in education & training
4:29
and now more and more profit.
4:32
And the business ethos is moving into it.
4:35
And the trainees, the residents
4:37
are really seen as service providers.
4:40
But the problem is, okay, they're service providers,
4:44
but the primary duty of the hospital or the university
4:48
is the training of the resident
4:50
and keeping the skills up of the experience
4:54
and attending physicians.
4:56
And the pace of change with medical devices
5:00
is just astonishing.
5:02
I mean, we developed the metrics for a cryo-oblation device
5:05
and it's now in less than two years,
5:08
it's been superseded by another device.
5:12
And physics-based simulation would seem to me
5:15
to be the ideal solution.
5:17
So is the return, the business attitude
5:21
and the return on investment by the hospitals,
5:23
by the training organisations,
5:25
do you think is that distracting from the point of the primary
5:31
business that they should be involved in that's training?
5:33
No, I don't see that as a main problem.
5:38
I think it's actually ultimately good
5:45
to have a commercial drive
5:48
and a commercial push to become better.
5:52
So I think that that should help.
5:55
So I don't think that's an issue.
6:00
But I mean, if it interferes with the training
6:04
and the insistence on the quality assurance
6:06
of the people that work for the organization,
6:09
where training and quality assurance of performance
6:12
is pushed to the side, surely that is an issue.
6:14
I agree with you about the business.
6:16
Okay, it's a harsh world out there
6:18
and organisations do have to make a profit.
6:20
I really don't have an issue with that.
6:22
But what I do have an issue is
6:24
if you've got a responsibility to do something
6:26
such as training, such as quality assurance of performance,
6:29
that has to fit into the scenario somewhere
6:32
and that's gonna cost money, that doesn't come for nothing.
6:35
Yeah, no, I can hear you.
6:38
I can see that.
6:40
So my research has shown that any simulation without metrics
6:45
is a suboptimal tool for procedure-based training.
6:49
What's your view on that conclusion?
6:53
No, I completely agree with that.
6:58
I mean, I would say there are more use cases
7:02
and scenarios for use of simulation
7:04
than learning a specific device or procedure.
7:08
But if we talk about structural learning
7:11
to reach a defined level of skills,
7:16
clearly metrics-based or proficiency-based progression
7:20
is the way to go.
7:22
So with that, I completely agree.
7:26
And so what's the major challenge for simulation companies
7:29
to implement performance metrics?
7:31
Because we've had this conversation many times
7:33
and we've gone all the way from characterisation to procedure
7:37
to building the metrics into one of your simulations.
7:40
And the mechanical thrombectomy for acute stroke
7:43
is probably one of the best examples
7:45
where mentors were pushed to build and subsequently patent
7:50
a new device because the clinicians were unhappy
7:53
with part of the simulation.
7:54
I mean, that was almost a perfect example.
7:57
So what's the issue for the challenges
7:59
for the simulation company to build the metrics
8:02
into the simulation?
8:03
I mean, there are a couple of things connected there,
8:07
but I would say to simplify it,
8:09
I would say that the biggest issue for us
8:12
is the process of defining and validating the metrics.
8:16
I mean, we as a technology provider,
8:20
solutions provider have a hard time pushing that
8:23
onto the device companies.
8:24
So I think that is a fairly complicated process
8:29
to require the device companies
8:30
really think that through properly.
8:33
And if that's not done before we get engaged,
8:37
that I think is the heart of the issue.
8:39
And in a lot of cases when we do that,
8:44
we don't have time enough to,
8:46
or the company doesn't have time enough to make that happen
8:49
or to get taken back by the effort
8:53
or the cost of that process.
8:55
I would say that that is for me
8:58
probably the biggest hurdle.
9:01
But surely it shouldn't just be
9:03
the medical device manufacturers,
9:05
surely it should be professional medicine,
9:08
maybe the departments of health,
9:09
because the evidence shows that somebody that trains
9:12
on a simulation with validated metrics
9:16
with performance benchmarks,
9:18
they perform about 60% better in the clinical environment.
9:23
Surely professional medicine and departments of health
9:26
should have a significant chunk of that cake
9:29
unless they want the industry to own the metrics.
9:32
I absolutely agree with you.
9:35
But if you look at the view of this right now,
9:39
at least if you if you ask me and if you go to US and ask
9:44
hospital and physicians, who do you
9:46
think is responsible for the training?
9:49
They would in my mind at least link it
9:51
to the device and then to say it's the
9:53
company's responsibility.
9:55
So I think it's the question of who owns that responsibility.
10:01
And I agree with you it should be the hospital and the providers of
10:04
of health care.
10:05
But right now, in my mind, it's not the case.
10:09
Yeah, I mean, I agree with you.
10:11
And a lot of medicine complains that the medical device
10:15
manufacturers own the metrics and so on.
10:17
I said to them, OK, if you want the metrics,
10:20
you're going to have to develop and validate them
10:22
and own them and own the benchmarks.
10:24
Otherwise, I think professional medicine
10:27
going to end up being controlled from outside their organisation.
10:30
And that's not a good position to be in.
10:33
But there seems to be a naive understanding of,
10:35
like you just described, about the development
10:38
and who owns it and so on.
10:40
I mean, I think probably we need something
10:43
of an equivalent effort as the genome program,
10:46
where the medicine, professional medicine
10:49
has to develop validate the metrics at the benchmarks
10:52
and then go to the simulation companies and say, OK,
10:55
these are our metrics.
10:56
Can you build these into your simulation?
10:59
And there needs to be some sort of negotiation.
11:01
The negotiation, similar to what we had for the mechanical
11:05
thrombectomy that worked out almost perfectly.
11:08
It wasn't 100% perfect, but it was pretty good.
11:12
So many of my clinical device manufacturer colleagues
11:16
seem to have a very naive understanding of why physics
11:19
based virtual reality simulations are so expensive.
11:23
Why do you think that is?
11:25
I think that there are more and more companies that really
11:35
understand what you're talking about.
11:37
And obviously, I mean, you and your team,
11:40
I've been working with this now for many, many years.
11:43
And I think there is more and more people that really get it
11:46
and understand the value.
11:48
But I think my simple view of this
11:52
is that if you get to the training responsibility
11:57
or the marketing department right now with industry,
12:01
it's not in their body.
12:03
It is not in the scope, but maybe not
12:05
in their responsibility to provide training
12:10
in the way you provide.
12:13
I think if I take a bit of a different approach to that,
12:16
it is also not only for fellows and residents,
12:22
because a lot of the training that we work with
12:25
is related to more advanced devices like heart valves
12:30
and things like that, where you typically start using them
12:35
past your specialisation or maybe in your two, three,
12:41
or four, or five year term after you have graduated
12:45
as a specialist.
12:46
So it's not only really for the graduate medical education
12:53
training.
12:54
It's really much, much longer.
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So I think it's a question really what you relate to.
13:01
I think in hospitals, to relate back to yourself
13:05
initially, they don't really have right now
13:11
a process to define training programs like that.
13:16
We have very few, if any, development initiatives
13:20
with hospitals or with health care providers.
13:23
I mean, all of our discussions on developing new modalities
13:27
or functionalities related to device industry.
13:30
So it just doesn't seem like that have come to that point
13:38
where hospitals actually define a program,
13:40
to define a program specific task.
13:43
Well, actually, your honour, I wasn't actually
13:45
thinking of the residents.
13:46
I was actually thinking of the consultants learning to use
13:48
a new device or a modification of a device because I mean,
13:52
I mean, OK, I do hospitals, but I also do quite a bit of work
13:57
with industry.
13:58
And they complained to me about the price of a physics based
14:01
virtual reality simulation.
14:03
I said, hold on a second.
14:05
This can be used anywhere in this country
14:07
with the same standards, with the same--
14:09
this can be used anywhere in the world with the same metrics.
14:14
And they seem to have a view that a physics based virtual reality
14:18
simulation is something like a video game.
14:21
You just switch the video and that's it.
14:23
They don't seem to understand that it takes programmers
14:27
and engineers like months and months on hours of work.
14:32
That's never mind the physical engineering
14:35
to actually build the simulation, the simulator,
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the mechanical or electromechanical.
14:44
They don't seem to understand that you just
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don't do this in five minutes.
14:48
Yeah, but I also might think--
14:52
sorry, I interrupted.
14:53
I also think, Tony, that it's a question of what
14:57
is the scope for simulation?
14:58
What is the ambition you have?
15:02
How do you calculate that value or the alternative cost
15:07
of not using simulation?
15:10
So I think there's more to that.
15:12
I think if you really look at what you could use simulation for,
15:15
if you have the program you talk about,
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if you have a structured training to provide a defined skill
15:21
set of a group of physicians and you can calculate the value
15:26
or compare with the alternative cost of having people go
15:29
through real cases with proctors over a three or six month period,
15:35
you can easily see that the value of what you provide
15:39
with simulation is very, very high.
15:41
But I don't think we do that comparison in a fair way.
15:46
And so why is that not being done?
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I mean, Stefano Puliati published a paper a few months ago
15:52
that basically demonstrated that with a relatively large group,
15:57
about 500 group trainees, I mean, whatever level,
16:02
that proficiency based progression simulation training
16:05
costs about a third of what it would normally cost.
16:09
I mean, so this wasn't super difficult to collect
16:14
the information and the data.
16:16
So why is medicine not doing that?
16:18
Because we know that suboptimal performance leads to worse outcomes
16:22
and worse outcomes cost money in terms of hospital stay.
16:26
And so why do you think medicine has not,
16:32
the business of medicine has not been collating this information?
16:37
I mean, it's a it's a big question, I think.
16:40
But I mean, my view is what we touched upon earlier on here.
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It's an unclear responsibility, really.
16:50
Who's who's responsible for this?
16:53
I mean, if you look at industry,
16:56
it's it's obviously very hard for industry.
16:59
It's a sensitivity in in measuring the connection
17:03
between providing training
17:07
and the sales of a clinical device, as
17:09
you know, that that's one one sensitivity.
17:15
But but it's also unclear if it's the
17:18
if it's the industry's responsibility.
17:22
And I know you say it's not to to tell a doctor or a group of doctors
17:26
that they are not ready to perform
17:28
that procedure with that with that device.
17:31
But the question is, who who have that responsibility?
17:34
Is it the the regulatory bodies?
17:37
Is it the society's?
17:39
Is it the health, the hospital health providers or is it?
17:42
I mean, I think it's a lot of things there
17:45
in terms of the stakeholder responsibility
17:47
that is not clear.
17:48
So I think that that in my mind need need to be,
17:52
I mean, it needs to be worked out in order for this to be clear.
17:56
How should this be done? You know, but but it hasn't been worked out.
18:00
And we've sort of I mean, even if we
18:03
go back to the Berkman study in 2013,
18:06
we've known that suboptimal performance of experienced clinicians.
18:11
We knew that we're probably going to have bad outcomes.
18:15
What we didn't anticipate was the magnitude of the difference.
18:19
I mean, it was like something like 50 to
18:21
80 percent difference in terms of that.
18:23
I mean, like we're talking more than a decade
18:26
later and it doesn't sound like much has happened.
18:30
Yeah, no, it's it's frustrating.
18:34
I completely agree.
18:35
But I think it's a question of and I probably should have said that
18:39
for the challenge I faced initially.
18:42
But I think that that's really one of the
18:44
challenges that if you come into the group
18:45
group, the hospital or a group of physicians or whatever,
18:49
it's really hard to understand who who have
18:52
the authority to determine who can do what
18:57
or who's who's ready to perform a procedure or not.
19:01
To me, that's that's not clear.
19:03
I think a lot of that is is
19:07
and needs to be worked out and it's clearly not, you know.
19:10
Yeah, I mean, 20 odd years ago,
19:14
the the device manufacturer suspected
19:18
that a lot of their device failures
19:20
wasn't really to do with the device because,
19:23
I mean, for example, the explanted had
19:25
like a pacemaker or CRT that had failed
19:28
and they'd get it back to the production facility to dismantle it.
19:31
There's nothing wrong with the device.
19:33
And they sort of suspected that maybe it was to do with the
19:37
clinician, but they couldn't say that.
19:39
Today, they actually have the metrics to
19:41
say, OK, that procedure wasn't done well.
19:44
I mean, one of the interesting examples was
19:47
Yorio Macheroni published a study in JAMA Open a couple of years ago
19:52
where the training he did proficiency based progression,
19:55
virtual reality simulation in Metronics headquarters in Switzerland,
19:59
and he compared it to the best
20:01
example of what they would normally do.
20:03
Nobody in the their normal training,
20:07
their controlled or their standard training group,
20:09
nobody demonstrated the proficiency benchmark.
20:12
But in the PBP group, it was 93 percent.
20:14
That was a very hard message for Metronic takes.
20:19
I mean, I think they accepted, but
20:21
it was a very hard message for them
20:23
that basically nobody in their best
20:26
example of training that they often,
20:29
nobody demonstrated the proficiency benchmark.
20:32
And I think they get that the skills
20:35
of the operator impacts on outcomes.
20:36
And I think their grappling was, OK, what do we do with that?
20:40
I, as I said, I think the evidence is
20:44
utterly clear that volume and skill
20:49
set have a massive impact on outcome.
20:52
And I think I mean, my view is that I think right now,
20:56
I would probably think that in the industry,
21:01
leaders in the industry need to take the step.
21:04
And I think if you have one or two of
21:07
the of the large medical device companies
21:10
taking the step or providing structured
21:12
training and really providing training
21:14
to to to define skill set, that that will change the perspective.
21:18
And everyone else need to follow.
21:21
You know, that that to me is
21:22
probably the most logical path right now,
21:25
because I don't see any any clear next step for me.
21:30
Yeah, I mean, the device industry,
21:33
they're legally mandated to supply instruction for use.
21:36
There was a I was in Leuven yesterday,
21:39
you know, for PhD, and the Viva was on
21:44
proficiency based progression training
21:45
for a circular stapler circular stapler
21:48
is about 500 euro.
21:49
It has about 27 percent leak and complication rate.
21:53
And a third of the patients that have a leak will die.
21:58
This is a 500 euro device.
22:00
And we had the device manufactured
22:02
train according to the instruction for use.
22:05
The the best trainers that they had in
22:08
comparison to proficiency based progression,
22:10
the standard training, the industry
22:13
training had a one third leak rate.
22:16
The proficiency based progression trained group had none.
22:21
And this is not physics based virtual reality simulation.
22:24
This is simulation on a circular stapler with an animal model tissue.
22:29
And the industry is looking at this and going, her IFU doesn't work.
22:35
And I think they don't know what to do with that level of evidence.
22:40
But I think it's as I said before, it's very sensitive for
22:45
for a device company or their representative to to make the judgment
22:53
or tell physicians that might be
22:56
their friends or at least their clients
22:58
that they are not ready.
22:59
You know, so I think there's there's
23:01
a large degree of sensitivity there.
23:04
So I think that that need to be worked out in a proper way.
23:09
What I've been trying to say to them is
23:11
they're not saying to them that they're not ready.
23:13
What they're saying is you're not ready yet.
23:16
Yeah, the metric, the metrics aren't the
23:18
simulation companies metrics or the device manufacturer.
23:22
They are the metrics that are developed by developed from
23:26
clinicians who are good at the procedure.
23:28
They're validated with clinicians who are good at the procedure.
23:32
So it's not really the device manufacturers saying it's the metrics
23:38
from their peers that are saying they're not ready yet.
23:41
You know, I would agree.
23:43
I think it would be logical that you have.
23:46
I mean, I think more and more, if you
23:47
look at in in the US, you both, you and me,
23:49
have spent quite a bit of time on US hospitals.
23:54
I mean, they move there to more and
23:56
more clinical leadership and hospitals.
23:59
To me, would make it probably more
24:02
simple to find a way where you have a CMO,
24:05
Chief Medical Officer, so able to control that more
24:09
as a team leader and say that this is a structure.
24:12
Here's what we're going to do. Here's the requirement.
24:15
You need to get to this point before you start doing the procedure.
24:18
And then you can work together with
24:19
a device company to make that happen.
24:21
I think that's more logical, where
24:24
maybe in other situations where you have a
24:26
have a clinical leadership and then you
24:28
have a financial leadership of a hospital
24:30
and those who never sort of work together
24:33
and it's and you have a group of physicians
24:35
that everyone makes their own decisions.
24:37
And I think I think I think there's a way
24:40
to get there where you can work together
24:42
between industry and hospitals.
24:44
But that I still think that's today
24:47
still is the is the largest issue.
24:49
That is there is no clear structure there.
24:51
Who who makes those those calls?
24:54
Yeah, I agree with you.
24:56
And I think that article that I mentioned
24:58
earlier on about about the business ethos
25:02
in academic medical centres, I think
25:04
that's attempting to confront that problem
25:07
that you've just characterised. Yeah.
25:10
I mean, I work a fair bit with industry,
25:13
particularly about the rollout in new devices.
25:15
And industry gets that they're going to
25:18
have to, you know, have a simulation for it.
25:22
But the issue that I see is they approach the
25:25
clinical education division about six months
25:28
before they go to market and they say,
25:30
OK, we want you to build a curriculum now
25:32
and get ready for going. I've been very explicit.
25:36
I think that's wrong. I think it's the wrong approach.
25:39
I think that as soon as the device
25:41
manufacturer knows that they're going to market,
25:44
they should go to the education division and
25:46
say, right, I want you to construct us a curriculum.
25:48
I think that the the education
25:51
division should build the metrics and so on.
25:53
And that probably should be about two years in advance.
25:56
How long would Mentice how long
25:59
would you like to be able to, you know,
26:02
build the metrics for a new device
26:05
into the physics based VR simulation?
26:09
I mean, first of all, to say, I think if if there were a structure where
26:13
the device company started much earlier and they created a metrics,
26:19
defined metrics and and validated them prior coming to us,
26:24
I think that will be fantastic, because that
26:27
means that we have clients that is way more
26:29
prepared and have a clear understanding for what you want to achieve.
26:34
And I think at that point, if we are there,
26:36
I think the extra effort for us to implement the metrics
26:40
was not significantly delayed the project.
26:44
I mean, I would say typically depends on
26:46
depending on the complexity of the device
26:49
and the procedure, it will take us three
26:52
to six, maybe sometimes up to nine months
26:54
to to to create the program based on specification.
26:58
And I think if if a customer comes to us
27:01
with already defined metrics, validated metrics,
27:04
I don't think it's going to delay that process significantly.
27:09
We're going to do it in principle in the
27:11
same maybe it's a lay of amounts and so on.
27:13
So I think think to me most important change would be what you said
27:17
that the company take responsibility
27:19
for the definition and the validation
27:21
or the metrics prior to coming to us. That would be fantastic.
27:26
Yeah, I mean, I've had this
27:27
conversation with some of the device manufacturers
27:30
and they're complaining about the simulation company.
27:32
I said, hold on a second.
27:34
What are you complaining about the simulator?
27:35
I mean, your conversation with them is imprecise.
27:40
What you need to do is you need to go
27:42
to the company, the simulation companies.
27:44
These are our metrics. Can you build them into your simulation?
27:47
But if you can't build them in, we're not interested.
27:49
And then it's a negotiation. Which ones can you build them?
27:52
And the device manufacturer needs to have.
27:55
They're not doing that.
27:57
I mean, like I don't think it's the education division.
28:01
I don't think it's necessarily that
28:03
they're given much too short a period of time.
28:05
And they seem to be more wanting the simulation for a marketing tool
28:10
rather than actually, you know, an effective simulation tool.
28:15
I don't think they have they have got
28:18
that it's not not a task they have got initially.
28:22
I mean, they have got the task to define a program
28:26
to provide initial training for advice and so on.
28:29
So I think that if you have have
28:31
the approach that you are suggesting,
28:34
it probably would require people from development
28:38
and other parts of the company to be involved as well,
28:41
because you probably need way more technical understanding for the
28:46
details of the procedure and the
28:48
requirement for the device and so forth.
28:51
And I think that we would have a different dialogue with the client.
28:55
And in a lot of cases today, I mean,
28:58
a lot of our clients are super smart
29:00
and very, very skilled.
29:03
But still, we see many, many situations where the perspective
29:08
or the scope of the of the of a project changes multiple times during
29:14
during the project because they have just
29:16
haven't done that work prior coming to us.
29:19
We are redefining the program as as as we starting the project,
29:25
which I don't think is the right way.
29:27
I mean, but the irony is that the the
29:30
manufacturer has a lot of this information
29:32
inside the company anyway, I mean, with the human factors people.
29:36
I mean, when we met with a
29:38
manufacturer that was producing a new robot,
29:41
we had to have a conversation with the human factor
29:43
and they were uncomfortable with our metrics because they thought
29:46
we were trying to change the human factors,
29:50
you know, benchmarks and information that they did.
29:53
And once they understood we weren't all we were trying to do
29:56
was operationalise it to build into a simulation, they were fine.
30:00
But they have this information anyway, so I'm not really sure why
30:04
they're not actually using this
30:06
information to help build the metrics.
30:09
To go to slightly different tack, I
30:11
mean, everybody's buzzing about A.I.
30:14
at the minute, basically the amount
30:15
of money that's that's been spent on it
30:18
is astronomical. I mean, will A.I.
30:21
in your opinion and do you think it's
30:22
going to help with metric based scoring
30:24
in real time to give feedback on the VR simulation to the trainee?
30:31
And if if it is, is what sort of
30:34
time frame are you going to put on it?
30:36
I think it's probably a bit premature.
30:39
And I'm maybe not the right person to answer that question.
30:43
I certainly think that A.I.
30:45
would have have a big play also there.
30:48
I mean, I can say that I already have
30:51
an important role in our development.
30:54
I mean, we use it for in a speed up code generation.
30:59
We we use it to improve segmentation.
31:02
I mean, the process to convert CT scans
31:05
into 3D graphical models or anatomies.
31:10
I believe we can use A.I.
31:11
much more effectively to create new content like new anatomies
31:15
and areas, things like that.
31:17
So I think it's just a matter of time
31:19
before we can do what you're saying.
31:21
But I can't say if it's one year or three years.
31:24
I don't think it's significant longer than three years.
31:27
Yeah. Yeah. I mean, I agree with you.
31:30
I'm not too sure about the three years.
31:31
I think it might be longer.
31:33
What worries me is that the A.I.
31:36
research that I read in the leading
31:37
journals, unless there's something going on
31:39
in the background, but the the A.I.
31:42
research I read in the leading
31:43
journals, they're making all the same mistakes
31:46
that were made in the laparoscopic generation where they're using
31:50
they're trying to measure process rather
31:52
than actually the quality of performance.
31:55
And I think they're going to have to develop some sort of alphabet
31:58
that allows them or tools that allows them, you know, to to measure
32:03
the actual quality of performance, which
32:05
really means they've got to measure the errors.
32:07
And I don't see anything approximating that.
32:11
And it's certainly not in real time.
32:13
So I agree with you. It's a few years off.
32:15
You say three. I say more like five to ten.
32:19
And that's that's assuming the bubble doesn't burst.
32:21
Yeah, I think it's a question what
32:24
you expect, though, because in my mind,
32:27
you still need to have the underlying
32:29
functionality created in the simulation.
32:33
I mean, both I mean, first, the hardware needs to be able to measure
32:37
what you want to measure in a realistic way.
32:41
But then you have in the software,
32:43
you need to have the software capability
32:45
from the stock. But if you have that,
32:47
then I think I think you can have AI to to
32:53
make it to sort of evaluate it to to
32:57
to assess it and and a lot of that.
33:00
But I think the underlying functionality still need to be created
33:04
and if you say to make it faster, that's
33:07
one thing, but it's still going to be made
33:08
by by man, so to say, you know. Yeah.
33:12
Yeah. And the irony is, I think, I mean,
33:16
the time, the effort that it takes to actually label things
33:20
and then the effort to train it is huge.
33:24
And the quality of the labelling that I
33:26
see in a lot of situations is very poor.
33:29
But if you if you can get something, for example, for the mechanical
33:32
thrombectomy that Mentice built, I
33:35
mean, I think that a lot of the cases
33:38
for training the AI will probably be on a
33:41
simulation because it's more controllable,
33:43
it's more standardized, it's more precise.
33:46
You have the mathematics there and there seems to be very few groups
33:51
actually using the simulation for training the AI,
33:55
which I think probably is the direction that they should travel.
33:59
So the device manufacturers seem to be comfortable
34:03
with using virtual reality simulation for marketing.
34:08
They seem less comfortable with using
34:10
virtual reality simulation as a training tool.
34:14
You've been in the industry for a
34:15
long time and in different contexts.
34:18
So why do you think they're more
34:20
comfortable with marketing rather than
34:23
metric based physics based virtual reality simulation for training?
34:28
I touched upon it before.
34:31
And I think I mean, I think there's there's quite a bit of value
34:37
in what we call marketing tools.
34:38
It's not only marketing, just marketing tools.
34:42
I mean, it's a lot of the work that we do today where we provide
34:46
relevant understanding for a
34:50
complication or the behaviour of the device and so.
34:54
But so there are a lot of use cases, as I said before,
34:57
where you can use simulation with without the metrics
35:02
for the proficiency based progression structure.
35:05
But I really think that it's a mix.
35:08
The reason why it's not more structured, I think it's the mix of
35:14
probably lack of understanding, coupled with what I said before,
35:18
the sensitivity of really assessing
35:22
skills of doctors and clinical staff.
35:27
That's still, I think, in discussion I've had with companies.
35:31
They they tip toeing around that is it really our responsibility?
35:38
Should we really do that?
35:39
What will happen if we do that?
35:42
So I think that that and then maybe a
35:44
third point is what you mentioned before,
35:47
the actual cost and effort of defining that program.
35:50
So those those three would be the reason.
35:53
Really, because I really think, sorry,
35:56
going back to what we talked about before
35:59
I think you need to have a force shaming that perspective.
36:03
Either you have a couple of device
36:05
company taking the lead and demonstrating
36:08
by example the effect of that, or you
36:10
need to have a regulatory change or a
36:13
or a regulatory body of some kind saying that stop with this.
36:20
Now, now we have a different structure.
36:21
Here's the requirement and then you have to live up to that.
36:25
Yeah, I mean, I don't have a problem with marketing.
36:29
I mean, I know that industry they've got to make a profit.
36:32
I really don't have an issue with that.
36:34
But coupled with that, you've got to train
36:36
people to effectively and safely use your device.
36:40
And one of the uncomfortable messages
36:42
that a lot of the manufacturers receiving,
36:44
and this is in published evidence that
36:48
some of the clinicians that they're using
36:50
for their faculty and have been for the
36:52
last 10 years are really not very good
36:55
at what they do when you objectively assess the performance.
36:58
And this has come as a shock to them because
37:01
the irony is if you ask if you want to know
37:04
whether a surgeon's good or not, ask the theatre sister.
37:07
Yeah. If you want to know whether
37:09
somebody's good at training or whatnot,
37:11
ask the device manufacturers
37:14
professional training staff, they know this.
37:17
So I'm not too sure why the hierarchy
37:20
is having difficulty to accept this.
37:23
Because if you have somebody that's not good at doing the procedure,
37:25
they're not going to do good skills training.
37:29
And it seems to me that the device manufacturers, they know it,
37:34
but they really don't want to know it and
37:35
they certainly don't want it quantified.
37:39
But an impact on the sales of their
37:41
device, I think if you train somebody properly,
37:45
they're confident in their capacity to use that.
37:49
You're going to have less complications.
37:51
You're going to have somebody that's
37:52
safer and better at using the device.
37:54
And I think they're going to purchase more devices to implant.
37:58
That's always been, I mean, both you and me
38:01
see many examples of the negative side of that.
38:06
If you run into issues, several of the devices
38:10
both you may work with have had those kind of issues
38:12
and you see the negative impact on
38:14
sales of something like that happening.
38:18
And I think it's clear, I mean, I
38:19
always talk about the speed to volume.
38:23
I mean, in order for you to get a device to sell in volume,
38:29
you need to have a large group of physicians
38:34
properly trained in order to use that device safely.
38:36
And only then you're going to have the sales number going up.
38:40
So it's very clearly linked to that.
38:43
But as I said before, that also makes it a bit sensitive
38:47
because then you can argue that the device
38:49
company only provides training to sell more.
38:52
which is not really the only thing they do.
38:55
You also make sure that when you provide a device,
38:57
you also provide safe care for your saving patients.
39:03
And your experience globally, not just in Europe,
39:06
but in the US, because you spent a long time in the US,
39:08
you think that's an uncomfortable issue
39:12
for the device manufacturers to deal with, to embrace,
39:17
to think about?
39:18
Yeah.
39:19
You do?
39:19
Yeah, yeah.
39:20
Yeah, it's a sensitivity, absolutely.
39:25
I mean, I face that, regardless if it's Europe or US
39:29
or even Asia, but I think in a lot of cases,
39:32
either US or Europe, but no, I really see that
39:36
as one of the big issues.
39:39
Okay, if we move away from industry for a second,
39:43
do you think teaching hospitals should have
39:46
their own simulation suite for trainees to use?
39:50
And what, in your view, would be the optimal approach
39:54
for those hospitals?
39:55
Is it every hospital?
39:56
Is it only teaching hospitals?
39:58
Is it index hospitals?
40:00
What do you think?
40:01
Well, obviously I have to say,
40:02
every hospital should have a Mentice device.
40:05
You know I would say that.
40:06
Okay, let's be sensible now.
40:09
No, but I actually, I've seen since I started
40:16
20 years ago, so that,
40:19
I mean, we're coming from a situation
40:21
where you create big multi-discipline skill centres,
40:27
things like that.
40:28
I mean, you had the US, the Kennedy bill,
40:32
the Kennedy bill back in 05 or 06 or 07,
40:36
that way a lot of hospital got government funding
40:41
to build training centre.
40:43
And you build these massive buildings
40:45
with all kinds of simulation and training equipment.
40:49
And that might have worked for some specialties,
40:53
but if I look to what we work with endovascular space,
40:56
I mean, there's a fairly focused group of people.
41:00
There's four or five or six different specialties
41:03
or groups of physicians
41:05
that have the different requirement.
41:07
So I've really seen all the years that it seemed
41:11
to be way more effective to move the simulation activity
41:14
out to the departments
41:16
and really make sure that you have a structure
41:19
where it's not only, as we talked about before,
41:22
fellows and residents or trainees using simulation,
41:26
maybe just, then it's maybe only a couple of times a year,
41:30
but really find a way to get it integrated
41:32
in their weekly structure.
41:35
I mean, use it for, you know,
41:37
what are the interesting cases during this week?
41:41
I mean, what are we training for?
41:43
What are the new devices procedure we need to train on?
41:46
Really get it integrated so everyone can get used
41:49
as a daily use tool rather,
41:54
because if it's delegated back to something you use
41:57
a couple of times a year,
41:59
eventually it's gonna fade out
42:01
and it's not gonna be used in a structured way.
42:05
So I think that the most effective way we're seeing
42:09
is that it's close to the cath lab.
42:11
It's available, easy to set up.
42:14
You can use it when you have an hour off between cases.
42:17
You have the proctors close that can help you.
42:23
And, you know, that's the way it should be.
42:26
It should be, you should be able to start it up
42:29
in a matter of minutes and you can run a case or two
42:32
or run a session in a structured way
42:34
with a proctor or a mentor close by.
42:39
That is my way, the best way.
42:43
And then I think all these different specialities
42:46
should really have access to a simulator
42:50
with the proper program and the proper structure
42:54
to make that work.
42:57
The endovascular simulators in my view are the best.
43:01
The physics-based endovascular simulators
43:03
are the best virtual reality simulators in medicine.
43:07
That's my, and I've long held that view.
43:10
I mean, I also think, I would pick teaching hospitals
43:14
that, you know, have, you know, a bulk of trainees
43:18
for those disciplines.
43:19
But I also think that physics-based virtual reality
43:22
simulation should be mandatory.
43:25
It should be a non-negotiable part
43:27
of part of the residency's training
43:29
and that they demonstrate the benchmarks and so on.
43:32
I think that should be centrally funded
43:35
because a lot of the hospitals are finding it tight
43:37
and they use that as an excuse to not fund those.
43:41
So I think it needs to be funded
43:43
either by the European Commission or Departments of Health.
43:46
And the hospitals, you know, they would have to compete for it
43:51
but it would also be quality assured
43:53
what they're actually doing.
43:55
Would this, you know, centrally funded simulation units
43:58
in hospitals funded by the Department of Health,
44:01
I'm thinking of Ireland in the UK and in Europe,
44:04
funded by the Departments of Health
44:06
or the European Commission,
44:07
would this be a good investment
44:10
and why do you think it would be a good investment?
44:12
I'm not just thinking, I'm not just thinking residents.
44:14
Okay, I'm thinking primarily residents
44:16
but I'm not just thinking residents.
44:18
No, I think it needs to be,
44:20
I mean, go back to what you just said.
44:23
I think it's important that this is continuous training.
44:25
That this is lifelong training.
44:28
I mean, you keep holding on your skills.
44:31
I mean, you know what you said before.
44:33
It's so much new technology coming out
44:36
and new devices every single year.
44:38
And I mean, everyone needs to train
44:41
throughout the entire career.
44:43
So that's why it needs to be there
44:46
and people need to change their mindset
44:48
that this is just, I train in my other days
44:52
and then I'm done, you know?
44:53
So I think that that's the first point.
44:55
But to answer your question,
44:56
if there would be value for money,
44:58
I certainly think so.
45:01
But I think in order to put that structure,
45:04
you need to have a very clear view
45:06
on who has the responsibility
45:09
and who can make the call of what you're gonna do.
45:12
What is the, I mean,
45:14
if you talk about certification or whatever it is,
45:17
I think that structure is just not in place.
45:21
I mean, I think right now there are,
45:23
as I said initially,
45:24
there are a number of different stakeholders
45:26
between societies, regulatory bodies,
45:29
industry, hospitals and the position organisation.
45:34
And it's not just clear who owns that responsibility.
45:38
So there's been, as you know,
45:40
there've been multiple attempts.
45:43
I worked with American Board of Internal Medicine
45:46
in the US some 10 years ago
45:49
that have a very ambitious program for cardiologists
45:53
to certify them and re-certify them
45:56
and they are implementing a simulation.
45:58
They got massive pushback
46:00
from multiple different directions
46:04
on why they did that
46:06
and how they can impose requirements like that on doctors.
46:11
So I think it just needs to be thought through carefully
46:15
and it should be implemented,
46:17
but I think you need to work out the structure.
46:20
I think just getting the resources or money
46:23
obviously would not help.
46:25
I think there's more things you need to figure out first.
46:30
I mean, I think simulation centres,
46:36
however it's worked out,
46:37
certain index centres in the country
46:39
or in academic medical centres
46:42
whether in Europe and the US,
46:44
I think that's inevitable.
46:46
In the European Commission,
46:47
I'm assuming you know what they're pushing now
46:50
for micro-credentials,
46:52
for technical skilled performance
46:55
and for robotics for endovascular procedures and so on.
46:58
And they don't just want to hear
47:00
that somebody's gone on a course.
47:03
They want to know actually what they can do
47:05
at the end of the course.
47:06
And the fact that the micro-credentials
47:09
are delivered by the universities
47:11
means that there's an agreement across Europe
47:14
that if I get micro-credentials in Germany,
47:16
they'll be accepted in Ireland or in Belgium.
47:21
And I think that's a good,
47:23
but it's gonna have to have teeth
47:25
and it's gonna need money
47:27
because the hospitals that I work with,
47:30
they use that as an excuse not to purchase the simulations.
47:35
But it's more than that.
47:36
And I suppose that leads on to my next question.
47:38
Suppose these centres were funded
47:40
and the simulations were available for the trainees.
47:43
Would you be happy for the trainees
47:46
just to go and play on the simulators
47:47
or would you be hoping that they did something more than that?
47:53
Would that be a trick question, Tony?
47:56
That's not really a trick question.
47:58
No, I know what you're getting.
48:02
No, of course not.
48:05
I think that if you don't provide a structure
48:08
for how the simulation should be used,
48:11
people will lose interest rapidly
48:13
and you will not create any value.
48:15
So obviously it needs to be a structure
48:19
and a required learning and all of that.
48:23
So, I mean, there are some obviously,
48:27
if you go back to the residents and fellows,
48:32
there's some value in sort of market the field
48:36
and make young physicians interested in an area,
48:40
but that's just a small part of it.
48:42
If you're talking about really getting the value
48:45
out of the technology,
48:47
you need to have a really defined structure
48:50
and provide the structure.
48:52
Yeah, I totally agree.
48:53
Well, it wasn't a trick question,
48:55
but I'm curious what you would say.
48:57
I mean, ERIS is a European robotic simulation centre
49:02
for cardiovascular procedures
49:04
and we've just started running our courses.
49:07
And there's two important things have happened.
49:10
One is the European Heart Rhythm Association
49:12
has released a scientific statement from the society
49:16
and the European Society of Cardiology
49:18
that basically says,
49:19
"Okay, simulation is a fundamental part of training."
49:23
And that basically what they've said is,
49:26
it's gotta be proficiency based progression simulation training,
49:29
which is a big deal.
49:30
And the more applied end,
49:32
we've started running the courses where I think
49:34
we're on our third or fourth course now.
49:36
And the trainees, the thing that we're discovering,
49:38
well, I'm not discovering, I was saying it for a while.
49:41
The thing that we're,
49:42
the trainees want more simulation based training.
49:45
And what I'm saying to the faculty is we've got to move
49:48
more of the didactics online
49:50
and we've got to give them the maximum amount of time
49:52
on the simulator.
49:54
Because the trainees understand the value of the simulation.
49:58
It allows them to train on a good simulator
50:01
in a safe space away from the patient.
50:04
And it's safe for them to make mistakes
50:06
because they can learn more from the mistakes
50:08
than they can actually from getting it right.
50:11
But I think that simulation centres in hospitals,
50:16
whether it's probably academic training centres,
50:19
university hospitals,
50:21
I think that's going to be inevitable.
50:23
But I also think you're quite right
50:26
that it's gotta be something structured.
50:27
They can't go, a trainee or faculty who says in front of me,
50:33
well, I'm gonna play on the simulator for a while.
50:35
And I say, no, you're not.
50:36
You're gonna train on the simulator for a while.
50:38
There's no playing on the simulators on this course
50:41
because it's a very significant part of how we train people.
50:47
But I mean, you have every speciality,
50:51
every faculty is their own entity sort of.
50:56
So I think, I mean, if you're gonna work it procedure
51:00
for a procedure or faculty or speciality per speciality,
51:03
it's gonna take a long time.
51:04
So the question is how do you approach it?
51:07
If you manage to do it in one area,
51:10
how do you make it move to the next one?
51:13
So I think that there is a structural element of this here
51:17
you need to figure out.
51:19
Yeah, but I think you as industry and me as an academic,
51:24
I think we're partly at fault as well
51:27
because a young colleague of mine said to me,
51:29
he says, "Tony," he says,
51:31
"proficiency-based progression simulation training."
51:34
He said, "It's not that the evidence is not there."
51:37
He says, "You haven't sold it or we haven't sold it
51:41
to the clinical community."
51:43
And I think he was quite right.
51:45
You look at the amount of evidence there is on simulation,
51:48
the effectiveness of simulation-based training.
51:52
And I mean, I'm still hearing colleagues
51:54
talking about how expensive physics-based simulation is.
51:59
And you match that up against the cost
52:03
or the consequences of the death of our patient.
52:07
I don't know.
52:10
I mean, I think you told me this before,
52:12
but maybe this is the thing,
52:17
that we will lack that evidence,
52:20
that actual evidence to, as you usually say, body count.
52:24
I mean, you need that ultimate study then maybe.
52:28
I'm not sure if that is the case,
52:29
but if you need that study to prove
52:31
that if you use simulation structurally
52:33
with a professional-based progression,
52:35
this is the outcome you're gonna get.
52:36
If you don't do, this is the outcome you're gonna get.
52:40
And maybe that's what needed, but I'm just skeptical.
52:43
I mean, obviously we have not been able
52:47
for financial reason to do that study
52:49
because that's a very costly thing to do.
52:53
Then the question, if that would be done in one area,
52:56
how would that be transferred to other areas?
52:59
Would it have to repeat that in every single faculty
53:02
or every single speciality?
53:04
No, I don't think so.
53:05
I mean, I agree with you that that,
53:07
and it's always been my ambition in that study.
53:09
But I mean, the person who told me
53:13
about not selling proficiency-based progress,
53:16
I think he was right at resonated.
53:18
I mean, I don't think it's gonna be one thing
53:21
that's actually gonna get a simulation over the line.
53:24
I think it's gonna be multiple factors.
53:26
And over the last five years or so,
53:29
I think the evidence has been accumulating.
53:31
Industry, I mean, the fact that they have,
53:34
they have their own published prospect
53:37
of randomised blinded studies published in the leading
53:42
medical that demonstrates their simulation-based training.
53:47
They have the simulators,
53:48
but they're not using them properly.
53:50
And I think there's almost like a cascade building up,
53:55
but you're quite right.
53:56
We do need that ultimate study
53:58
that's prospective randomised, it's squeaky clean,
54:01
and it basically shows a body count,
54:04
where there's no ambiguity, this is the cause and effect.
54:09
So in your opinion, how should VR simulation be used
54:14
and is not currently in the medical device sector
54:20
and in healthcare?
54:23
I mean, it's always, I mean, regardless if we come
54:28
from industry or go directly to hospitals,
54:31
it's always the training of physicians
54:33
that is the end goal here.
54:36
So, I mean, I think that the reason why industry
54:41
has been driving this is because there you have the link
54:45
to value and the ability to actually fund simulation
54:50
that ultimately provided to doctors.
54:52
But if I look at what we do now in hospitals,
54:58
I mean, it's always been said that hospital for us
55:02
is the ultimate opportunity or ultimate target.
55:06
I think that right now we probably target,
55:09
I don't know, less than 5%,
55:11
less than 3% of the opportunity in hospitals,
55:15
since it's just part of a TELOS residency program
55:20
that is used for simulation.
55:23
It's not really providing the structure all the way
55:26
to training them to a specific goal,
55:30
but even less so for the practitioners
55:35
used in their continuum for certification on new devices,
55:40
new procedures also.
55:41
I think that we can use simulation way more,
55:45
way broader.
55:46
I mean, if you look at the process
55:48
of teaching a practicing physician,
55:51
a new procedure like heart valves or a section heart
55:55
and then helping them to use a new complex device,
55:59
like a micro valve or something like that,
56:02
that's today a six to nine months process,
56:06
maybe more in some cases,
56:08
but simulations are only used for the first part of that.
56:12
And I think that if you have a program
56:14
that you're talking about,
56:16
you can use the simulation much, much further
56:22
and in a very cost effective way
56:24
and reduce the time to proficiency
56:27
for those trainees significantly,
56:31
which would obviously lead to better outcome,
56:35
lower cost by industry.
56:37
So I think that there is a lot of opportunities
56:40
to really extend where simulation is used.
56:45
I also see that too, if we provide,
56:49
I mean, we continuously improve the realists of what we do
56:55
and we also work a lot,
56:56
have been working a lot with structures
56:58
to provide a unique patient information
57:05
or a unique cases that we say,
57:07
all the way up to patient specific situation.
57:11
I think that if we can continue to improve that,
57:16
we can provide way more learning capability
57:21
or ability for physicians to really practice
57:26
and learn on every single situation,
57:28
up to a point where you can train
57:30
before and after a procedure.
57:32
I mean, you can prepare for a procedure,
57:34
you can warm up in a proper way,
57:37
but you can also after the procedure,
57:41
work on what went right, what went wrong
57:44
and how can I improve to the next round.
57:46
You can also bring up situations from the week
57:49
as we talked about before
57:50
and train the entire group of people
57:53
on making sure that we always come together,
57:56
improve on what we do.
57:57
If you do all of that,
57:58
I mean, the opportunity for use of simulation in our area,
58:05
could be, I mean, 50, 100 times larger
58:08
and we can provide significant value to healthcare.
58:13
I mean, you know, there's so much challenges around,
58:17
cost are increasing, we're all getting older,
58:20
you can provide very advanced, complicated care,
58:23
you're not getting older, but the rest of us are.
58:27
And you provide very high cost care
58:31
way up in the age spectrum.
58:36
So I think it's just important to use technologies
58:39
like simulation to help improve productivity,
58:43
reduce cost and make sure we provide better care really.
58:48
So it's a lot of opportunities.
58:51
I know I totally agree with you.
58:52
I mean, unfortunately, I think a lot of medicine
58:55
and healthcare looks at simulation
58:56
as some sort of magic bullet and it's not,
58:59
it's a tool, but it's a very powerful tool.
59:02
I mean, there was a friend of mine many, many years ago,
59:05
he'd just come back from three weeks in France
59:08
and I met him in the evening and he said to me
59:11
that he had been operating that day
59:14
and he had felt very de-skilled.
59:16
He'd been away for three weeks
59:17
and that led to a subsequent study
59:19
that we published in Annals of Surgery
59:21
that shows once you're away from the job for about two weeks,
59:24
you significantly decrease.
59:26
And so I use simulation primarily for training,
59:29
for residents or fellows or for a new device,
59:33
but that surgeon could have gone to the simulator
59:37
and could have got their skills back up to a level again.
59:40
I mean, there's so many uses, I totally agree with you.
59:43
So what do you think the future holds
59:45
for physics-based VR simulation in medicine
59:49
and in healthcare?
59:51
Where do you see it going?
59:52
We will be able to provide a situation
59:56
or an environment where clients in hospital
1:00:00
can create their own content
1:00:02
and in a much faster and effective way
1:00:06
to make the information relevant for all kinds of situation.
1:00:11
And if you couple that with structures for metrics
1:00:15
and the proficiency-based learning,
1:00:17
I think we can provide very relevant training
1:00:21
for all levels of expertise of physicians,
1:00:29
but also other clinical staff like nurses and techs.
1:00:35
So, you know, but it needs to be integrated
1:00:38
in the daily clinical practice
1:00:41
and be a natural part of your work.
1:00:45
And people need to get paid to use simulation.
1:00:48
They need to be part of the requirement.
1:00:53
That's not the case.
1:00:54
So it's a lot of things that need to be changed
1:00:56
in the structure and how people are reimbursed
1:01:00
and paid for what to do.
1:01:03
Because today, I mean,
1:01:04
the people have to use their own private time
1:01:07
sort of in other cases to go on a simulator,
1:01:10
which is not right.
1:01:11
Yeah, no, I totally agree with you.
1:01:13
I mean, I think I've always valued simulation
1:01:17
particularly the endovascular Simulations.
1:01:19
I mean, I think I bought the first one
1:01:22
that you produced in Europe.
1:01:24
And I mean, in comparison today, there's a significant,
1:01:29
but even back then I saw the value of it.
1:01:32
And I look around at some of my colleagues in clinical medicine and
1:01:37
in industry and they see it's some sort of magic, but it's not.
1:01:43
It's a tool, but it's a very, very
1:01:44
powerful tool that can be used in many contexts.
1:01:48
And unfortunately at the minute that it's not.
1:01:51
But I'm also cognisant that part of
1:01:53
that may be my fault that I haven't really.
1:01:55
I just assumed people would understand and get it.
1:01:59
And unfortunately, not as many of
1:02:02
them have got it as they would like.
1:02:04
Yeah, I don't think you should take responsibility for that.
1:02:08
I think you have helped a lot.
1:02:09
And we all have tried to move this,
1:02:13
the development of this over the years.
1:02:15
And I think we come a fair bit on the way there,
1:02:20
but certainly a lot, lot more we can do.
1:02:22
So, yeah.
1:02:24
All right, Göran.
1:02:24
Thanks very much.
1:02:25
Always good to talk to you as usual.
1:02:27
Thank you, sir.
1:02:28
All right.
1:02:29
Yeah, sure.