Ep 302 - Inner Logic CEO Porras explains how autonomous surgery can save us from looming surgeon shortage

0:00Hi, everyone. Tom Salemi here. Welcome back to the Device Talks weekly podcast. We're going to talk about autonomous surgery today, both with surgical robotic systems, but also with medical devices. So I talked with Dr. Tito Porras. He's the CEO and co-founder of a company called InnerLogic. And InnerLogic is working with medical device companies of all kinds to sort of help develop autonomous functioning. And Dr. Portis will get into why he moved on from being a neurosurgery resident to an entrepreneur and startup founder. He'll explain that he saw a need to find a faster way to pass on the training and knowledge of experienced surgeons.

0:45And listen to what they're up to at Interlogic. I'm sure you'll see the reason he got excited and diverted his path from medicine to medtech. MedTech. So happy to have Dr. Porters on the podcast. And just before that, Chris Newmarker of MassDevice will join us for the Newmarker's Newsmakers. So make sure you listen to the Newsmakers of the Week. Before we begin the podcast though, I want to invite you to join us on Tuesday at 4 p.m. Managing Editor Kayleen Brown will be leading a conversation called Building the Strongest Clinical Evidence in Biocompatibility Strategy for High-Risk Implantable and interventional devices.

1:25She has two great experts from RQM Plus on the panel, Caitlin Lerner. She's vice president of biocompatibility and scientific excellence at Geordi Labs, which is an RQM Plus company. And Dr. Deborah Morley, she's director of cardiovascular center of excellence and CV strategy and delivery at RQM Plus. So go to device docs.com register for the upcoming device talks Tuesdays. Join us live at 4pm Eastern for this conversation. Get your questions answered right there. And then if you're unable to join us live, make sure you register and watch on demand. You'll still be able to get your questions answered.

2:03Might take a little bit longer, but RQM plus will still respond to questions. So make sure you're part of that conversation. However, you can fit it in. All right, without any further delay, let's get this podcast started. Are you ready for this? Ready.

2:39Chris Newmarker. How are you, sir? Doing well, Tom. Doing well. Sorry I had to drag you in from the back porch. That was quite the... Chris had cicadas going crazy in the background. It was... You're like, what's that hissing sound? What's that? I was like, cicadas, man. It's like, there's cicadas. All I needed was for a hawk to fly across the lawn. Like... Very, you call it. Very, very lovely setting. Just doesn't quite fit the motif for a high med tech technical podcast like this one. That is true. So it's like, but yes, being very lucky to work in a home office here in Minneapolis and the heat bubble, at least we're talking on Thursday and the heat bubble isn't here.

3:22So, you know, it's nice outside right now. So I got to take advantage of that while I can before, you know, winter, you know, undoubtedly slams the door on us, though. Though I don't know. I know we have a Super El Nino, so maybe, who knows, maybe we won't have a winter this year. We'll find out. Like, I hope we get snow. That'd be nice. I'm sure. I'm sure you'll get snow. I don't know, man. This part of the podcast. I think Minnesota will get snow. Boston likely will get snow. So speaking of working from home, do you have any neighbors and or friends who have been called back to the office from some of the medtechs that have called people back to the office as of late?

4:02You know, I would say like, I mean, I've got, you know, people all up and down the street who work at corporations, including medtechs. And yeah, it's like it's been a story. all up and down the street. You know, it's like people, people talk about having to get into the office now. So do they hate you because you don't get called back to the office? They giving you side eye? I try to dial it down. You know, I'm not going to, I'm not going to show up at the bus stop with my kids in pajamas. You know, like, you know, I could just wait another 20 minutes, man. I'm just hanging out, you know. I was trying to record a podcast and the cicadas were going.

4:38It was just so beautiful outside. I hated to go inside, but, you know, I had to, but isn't it great working from home? Yeah, no, probably good to tone that down. Yeah, I'm toning that down. Yeah, like make sure to don't show up in exercise clothes or something like, you know, I'm going to get a little workout done first before I start here. You know, like, oh, you guys are driving in. Okay, I'm sorry.

5:04Are any of them listening to this podcast? I hope not. They probably. all right we should get into our jobs what do you say that's always been fun actually like on my street there's like some of them do are like like you've got a podcast really like a podcast every week like a real podcast i was like yeah i sit down and record stuff i mean like like we have like little gatherings at the bonfire like oh i got 30 000 linkedin followers you got 30 000 linkedin followers you're kind of a big deal yeah big deal chris newmarker sure there you go yeah all right well mr big deal let's go to new markers newsmaker let's go yes number five chris newmark number five as i said we're talking on thursday and uh wednesday actually but yeah oh yeah you're right recording this early because i'm taking friday off you messed me up man

6:00it's wednesday tom what are we doing

6:05I'm so used to it. It's Wednesday and like the the president has put out something on a post on Truth Social because that's how we get our news from this administration. Yes, that he's nominated his, you know, his White House domestic policy official, Dr. Heidi Overton, to be FDA commissioner. So, you know, referred to Heidi as a rock star who will deliver on my priorities of fast. Can I do a Trump? No, I won't do a Trump. No, don't do a Trump. your priorities I don't want to deliver on my priorities of faster cures increased American innovation major clinical trial reforms lower drug prices and even more Maha wins so that's that's what we got so we'll we'll follow how this this whole nomination process plays out yeah and I think yeah I don't have a lot I mean I think I read somewhere she was the third choice that two other folks turned it down really yeah Yeah.

7:09So. You know, of course, the previous FDA Commissioner Martin Macri left months ago. Yeah. Reportedly because he was against approving flavored e-cigarettes because that could make them something that children might want to use. So, yeah, well, it's interesting times, but at the very least, it seems like the device industry has been really good at kind of not getting a ton of attention. Like a lot of the stuff, big changes and talk out of this administration has involved pharma and vaccines. Yeah, I don't know. I get nothing. I mean, I don't know. I don't know what she's going to do. I don't know what the priority is going to be.

7:58we could say oh well it'll be great for for medtech because there'll be less regulation but that might not happen i'm not sure yeah i don't know what the stated preferences are other than the maha reference um i don't know so i'm not even going to pretend to predict um we'll see what the i'm sure that i'm sure the nomination uh hearings will be centered around uh non-medtech things. So, but we'll see what happens. I mean, moving on to number four. Yeah. I don't have anything to offer. I'm sorry. But I mean, there, there we are. We got somebody who's, who's been nominated. Who's, you know, at least the president, the person, the president would like to be the new FDA commissioner.

8:42So keep on following that. And, you know, maybe we'll get some, some more information on what, you know, Dr. Overton, you know, like what kind of priority she could have for, for medical devices. So it'd be fantastic. Sounds good. Let's roll into number four. Hey, number four. This is from, you know, like what, you know, our senior editor, Sean Hooley, left now just a few weeks ago. But we have, you know, we've been using some different freelancers on MassDevice and we have one Connor Hale like just today. Yes. You need to let Sean go. I know. Sean who? That guy? Last reference of Sean. Sean Hooley, enjoy your, enjoy your next stage best wishes man godspeed anyway so continue who wrote this story connor hale connor hale wrote this connor hale all right yes and this was a news out of haymanetics um that they've they're reconnecting with a cl cell plasma with a new deal to a supply uh like you know this plasma donation collection operator with its latest hardware for plasma collection And, you know, they used to supply to CSL, expired back in 2022, wasn't renewed.

9:58But, I mean, this was like, you know, over$100 million of business for them in the past. And, you know, and right now they're not changing their financial guidance. I mean, this isn't, you know, there isn't a minimum amount that CSL has to buy from them. But, you know, the analysts are thinking like this could be another, you know, this could be$183 to$223 million a year potentially for them. So some good news for Hamanetics. Yeah, apparently it's a good kind of razor blade sort of business. Like there's a lot of money to be made in the resupplies. So it's not a space I know of. I've never donated plasma.

10:32Obviously I've donated blood and I've donated the red blood cells, like the, I forget what they call it, the power red or something like that, where you're there for two hours and kind of having your blood removed and then the plasma reinserted. But I have not done plasma directly, have you? You know, yeah, I grew up poor, Tom. so when I was in college I was also poor but I did not donate plasma I didn't realize that was required for poor people to donate plasma I mean yeah when I was at Ohio State I'd head off of campus and go to a plasma donation center to sell my plasma sometimes I just waited tables I did that too whenever it took you made dryers too I believe I did I spent the year making clothing dryers Or as I said, in the Whirlpool plant in my hometown, like shooting screws into dryers.

11:28I did that for him. There you go. All right. I can't wait for the Netflix documentary about Chris Newmarket. I know. It's going to be a real tear jerker. But actually, I looked at CSL, looked for local plasma donations. And the closest ones are probably about an hour from me in Providence. So I just don't, I don't, can't say if I've ever been driven by a place that said, we'll buy your plasma or anything like that. Maybe it's a little less, a little obvious, a little less obvious than that. But yeah, like that's true. It's not, it seems to be something you see more in the, like, yeah, yeah, yeah.

12:00I don't, definitely not something you see very easily. They don't like the Northeast blood. That's right. We don't want any of that Harvard blood. Harvard blood. Harvard plasma. stuff's garbage alright let's let's roll on to number good good corn fed midwestern plasma you know

12:25rolling to number three oh goodness alright next up people are like what is up with these guys let's just never do this on a Wednesday again alright I'll do my best not to take days off I'll take Fridays off yes so you know number three on the list this is from yours truly I caught an SEC filing that Setsionics was an activist investor at Sessa Capital. They've taken a pretty sizable stake. It's giving them basically right up to the limit that they would have with their

13:05basically they have a percentage of voting rights now up to 9.9%, which is kind of where we hit that blocker provision that companies had to prevent investors from owning 10 % or more without being subject to SEC insider rules. So yeah, that's just very interesting news. So this activist investor now coming in and buying a portion here of Senseonics. Didn't get any response. I messaged some of the top people over at CESA on LinkedIn asking if anything they'd to say about what their plans are there and nothing from them yet. It'll be interesting to see what happens there. Senseionics did. They had their second quarter results.

13:50Their CEO described it as the strongest quarter in the company's history. Q2 revenue more than doubled to$14.5 million. Clearly Senseionics is doing something right. Maybe the activist investors, and this is totally guessing, maybe this is more of a case where it's like, hey, we think, you know, we can see some ways they could even, you know, choose this even more and do better perhaps, you know. Yeah. I know we want to kind of sound the alarms, activist investor, but maybe it's just a passive activist, passive aggressive activist investor. They're just betting heavily on the CGM space. You know, Senseonics has had success and maybe they're just going along for the ride to write the stock up.

14:34So I'm sure they have their ideas for efficiencies and things like that. And really interesting technology. I mean, we even held an editorial webinar earlier this year on it. I mean, just this really interesting idea that you can have a, you know, Sensionics has a mostly implantable sensor that, you know, is going to measure, you know, glucose for, you know, for a full year for you, you know, like versus, you know, like something like Dexcom or whatnot, where you have to like, you know, be changing charges all the time, you know, and like swapping out sensors on the skin. So it's, yeah, it's kind of, it's a cool technology.

15:11Sounds great. All right. Well, welcome, is it Sessa? Sessa. Welcome, Sessa, to MedTech. Well, I'm sure they have other MedTech properties as well. Sure, yeah. All right, let's roll into number two. Yeah, and our next one up is from freelancer Sophie Kurit. And this is, you know, Johnson & Johnson winning FDA clearance for new robotic bronchostics-based software. You know, they're now launching their Monarch Quest 3, you know, software for their Monarch system. And this news comes just like a week after, you know, competitor Noah Medical announced, you know, the launch of its Galaxy 2 software.

15:48And, you know, just late last year, we had Intuitive winning clearance for software advancements with its Ion platform, including a system-wide AI. So like we're just bringing in more and more, you know, software capabilities into this kind of like exciting, exciting space. Like, you know, there seems to be a lot of promise with using robotic systems to perform bronchoscopies and intuitives even talk about taking it to the next level and getting ablations done as well to, you know, you find the cancer in there, you just take care of it right away. absolutely and i think it's just an opportunity for companies like j &j to really use software as sort of uh their killer app so to speak to with these constant regular upgrades making the system better and better you know once they get the system in place they can they can really just keep upgrading and amping up and um and making it more of a software story than a hardware story.

16:43So interesting, interesting news. Yeah, absolutely. All right. What's the big number one, Chris Newmarker? Yeah, this is also from Sophia. This is Medtronic's now facing a potential injunction in the antitrust lawsuit that Applied Medical filed against it in, you know, federal court in Central California. Medtronic lost this case earlier this year with the federal jury saying they needed to pay$382 million in damages to Applied Medical. And now Applied Medical is asking the court for injunction to basically halt a lot of the activities that they say Medtronic has been engaged in. kind of using its, they've claimed all along that Medtronic's been using its size, you know, to kind of push through illegal bundling practices to, you know, like to monopolize U.S.

17:46market competition for, you know, advanced bipolar devices, you know, that seriously cut tissue, sealed blood vessels. So, you know, they're now seeking injunctions again. So it looks like there's going to be a federal court hearing in October in regard to this push for an injunction. So we'll see what happens next. And Medtronic says as soon as this gets wrapped up in the U.S. District Court in Central California, they want to appeal this. Yeah. So it says here, Sophie Wright said, Applied Medical asks that hospitals and health systems be able to purchase ABDs from Applied Medical and other suppliers without triggering higher prices, lost rebates, or worse contractual terms when purchasing other products from Medtronic.

18:29So in Medtronic contracts, if a hospital or a customer tries another product, then it can trigger higher prices and lose rebates from Medtronic. So, yeah. I mean, it all hinges upon whether the original finding holds up. but it seems like Applied is really trying to correct some inequities that they see. And, you know, as you and I have always said, we're in favor of competition here. Absolutely. In MedTech. It's only good for everybody. So we'll see how things sort out and how, where is this being, where was this submitted? This was. This is in a U.S. district court in Central California. So, like, yeah, Playa itself is based over in, you know, Rancho Santa, Margarita, California.

19:23Oh, really? And they're also, you know, I mean, they're a privately held company, but, you know,$954 million. So, this is, you know, so they are tiny, you know, but, you know, Medtronic, most recent fiscal year,$36 billion. million dollars. So Medtronic's 36 times larger than them. And they've been arguing that, you know, hey, we have better, we really work in innovating surgical tools. This is our business. Yeah. You know, but, you know, we can't get these sold because, you know, Medtronic's using these bundling practices. So, and then, you know, Medtronic's had its own arguments against that.

20:01It looks like the jury found for applied in this case, but yeah, we'll see what happens on appeal. And it's interesting. I mean, we've seen a number of these cases over the years, There's like this argument's kind of been growing, like some of these really large med techs, like kind of smaller companies saying, hey, we're getting shut out of markets because you're, you know, engaging in unfair bundling practices. So, you know, I mean, I think, I mean, other cases that might be out there, I mean, seeing the supplied medical case would, you know, probably like hearten those smaller companies making those lawsuits or who knows, we'll see if it encourages more of those types of lawsuits as well.

20:37Yeah. No, I mean, clearly if someone develops a better mousetrap, then I think the established players need to either develop their better mousetrap, that's better than the better mousetrap, or they just need to acquire the better mousetrap company and sell it themselves. That's part of our ecosystem. That's right. But again, that's how ideally things work. We'll see what the court finds with applied medicals, regarding to applied medicals requests. Yeah. All right, Chris Neumarker, great stuff as always. Hey, always fun, Tom. Catch you again soon. All right. Thanks, Chris Newmarker. Now it's time for our keynote conversation.

21:13Once again, I spoke with Dr. Tito Portis. He is CEO and co-founder of InnerLogic. Let's listen. Well, Tito Portis, welcome to the podcast. Thanks for having me. My pleasure. This is an area within med tech and surgical robotics that I find fascinating and difficult to comprehend. So I'm glad you're sort of here to walk us through the powers and potential of autonomous surgery and what inner logic is up to. But before we get into that story, let's unpack your story. You were training as a neurosurgeon. I don't know how far you went in that, but you're a physician. How did you find your way into the medical industry?

21:57What made you want to be a doctor? Okay, so great question. Big question, I know. That's right. A lot to unpack here. Take a sip of water. Yeah, that's right. Yeah, you'll want to be seated for this. You know, so I actually come from a very medical family. My grandfather was a obstetrician who later became a family physician. My own father is a practicing internal medicine physician. and my mom was a registered nurse. And so medicine was what I grew up living and breathing in many ways. And, um, there was really never anything else. And, and, uh, that, that was often, you know, that was just in my DNA, not something forced on me by any means, but, you know, I think the big question to me was what I was going to do within medicine.

22:50Um, you know, and this, this is a bit of context here, but it's important because it really did inform a lot of my personality and what I enjoy doing. I grew up in the desert in El Paso, Texas, and I spent a lot of time actually riding and racing dirt bikes. And this is relevant because it instilled in me two things. One is a love for calculated risk and adrenaline. And the second was a true enjoyment of using my hands. And that was instilled via, for example, working in the garage on my bike and maintaining and things like that. And so I had this natural gravitation towards something procedural, something where I could use my hands.

23:39And then in high school, I took a psychology class. And that's really where for the first time in my life, I've learned a little bit about brain science. And in hindsight, this was very simplistic and this would evolve. But, you know, in those early days, I just put two and two together. I said, well, I know I'm going to be a doctor. I know I like to use my hands. And I know now that, you know, the brain is the most interesting thing that exists. And so why not put those things together and pursue neurosurgery? And, you know, the rest sort of took care of itself from there. That's amazing. So what did that path look like?

24:16Where did you go to school. I know you ultimately went to medical school up here in New England. You were up at Dartmouth, right? Found your way into the Northeast. That's correct. So I got my start with my undergraduate in Texas at the University of Texas at Austin. I was on the pre-med track there. Spent a little bit of time doing some research, learning about what it's like to work in a lab as well. And then ultimately was very fortunate to get into med school at Dartmouth and so moved to New England. And I spent four years there. But during my med school training, I actually took a gap year to do research.

24:57And that was done in Baltimore at Johns Hopkins. And that was really my first introduction to that institution. I was doing basically neuronal development research. But during that time, I also pursued clinical research with the Department of Neurosurgery. And that's really what set a foundation for my relationship and ultimately my matching into residency at Johns Hopkins. So let's follow your journey. So you're on the train headed toward being a neurosurgeon. Obviously, at some point, the track switched and you became an entrepreneur and a CEO. Take us to that moment. What convinced you to take a different direction?

25:38Um, so, so I'll get another drink of water. It sounds like a big story. This is indeed, yes. So, you know, I spent seven years total in my neurosurgery training, which is actually the intended duration of neurosurgery training. And it started with, you know, the typical clinical exposure. I was very much boots on the ground in the trenches, learning how to be a surgeon. And during that path, you know, something that I saw was the limit of how we train surgeons. And there's something about that because Johns Hopkins is really where modern surgery training was born from William Halstead. He is the one who actually created this residency training model that we still use to this day.

26:36But as I mentioned, I did experience firsthand both the elegance and how well that training works and how artisanal and historic it is, but also the fact that it has its limitations. You know, and there's something about having to transmit knowledge and experience to surgeons, one surgeon at a time over the course of several years. And it's a very anecdotal process filled with, you know, bias and other factors that ultimately just leave room for improvement. Give us a time stamp, if you would, just so our listeners know, what period of, what years are we talking about? A lot of this is really coming to bear in, I would say, especially my third and fourth years of training.

27:28So, you know, the first year of training, internship, you're rotating through many different specialties, non-surgical and surgical. And so your goal in life is just to truly understand and practice the language of medicine, but you're not yet being honed into a surgeon. And then at Hopkins, you know, your second and your third years are really where you start to get into the operating room, but you're a junior resident at that time. and you start um as as a junior in a much more let me say a much less um hands-on surgical position and you're really the person taking care of the patients manning the pager things like that but that that balance starts to shift as you become more and more senior and you get toward that end of your third year and as i progress toward the end of my third year that's that's really where you start to earn the trust of your attending surgeons and where you start to see those early glimpses of your coming into your own as a surgical trainee.

28:36And then in the fourth year at Hopkins, that's where you get your first chief resident experiences, where you go to Hopkins sister hospital called Bayview Hospital, and you are the chief resident. And so it was really this point where a lot of these concepts came to really crystallize in my mind that there was this incredible opportunity and need to think a little bit more about how we train and improve surgeons. Now I want to get to the moment, but calendar-wise, what year were we looking at? Just 10 years ago, five years ago? What time frame? Let's see. So I started in 2018 as an intern. And so I would say, you know, the rough, you know, these thoughts, all of these concepts are starting to coalesce somewhere around 2023, 2024.

29:28So very recent. Okay, great. Not too long ago. Exactly. So take us to the moment. You were, again, on the track to be a very successful surgeon, I'm sure, in a very distinguished field. and you decided on doing something different. Yep. So, you know, here's the thing is I saw this exciting opportunity to think about surgeon training. And really there was, I was at Hopkins, right? And I was incredibly fortunate to be there because I was a part of a huge ecosystem with a myriad of resources that I could tap into. And I thought to myself, okay, well, you know, If I'm interested in surgeon education as a research topic, I should think about leveraging the Hopkins ecosystem to study that.

30:18And what better way than to consider, for example, collaborating with the Department of Computer Science, where if I'm interested in objectivity, then they will help me to study and measure surgeon performance, codify that, and then figure out ways to disseminate that. And the idea was you could actually improve training, make it less subjective, and really like democratize access to excellent education. And so I pursued that during the research phase of my residency as a NIH-funded postdoctorate in the lab of my now co-founder, Matthias Umberoth. and in that process two things became clear one is that an individual can only do so much and and so even perfect training if you were to actually measure and and codify and transmit that to surgeons it doesn't change the fact that you're not creating more surgeons and you're also not changing access to those surgeons and so there was there was this interesting problem where the training piece of all this was downstream of something much bigger, which was effectively access.

31:30And this is where that moment starts to occur, where the realization was our research that we were doing was building effectively AI that could watch a procedure and give surgeons objective feedback. But if the software could start to actually judge an operation, then in spirit, That was halfway to software that could actually help perform a procedure. And that same intelligence that we were looking to measure and capture could not only be transmitted and live within individuals, but it could even start to live within systems. And the idea there was that now suddenly these limits around surgeon training, surgeon access could stop being locked behind a decades long training pipeline and geography, but rather you could almost start to shift it into infrastructure.

32:33Something that you could actually build and solve for on a much nearer timeline. And that really became the impetus for a lot of the thinking behind EnerLogic and part of what drove me to make my career decisions. And just to sort of underline the state of today, you're not, analogic is not just a hammer with no nail. You've identified there's, how would you define or how would you characterize the state of surgeon training today? Do we have a problem? Could it just be better? Is it a dire situation? How would you, when you're talking to folks, how do you describe it? I think that, you know, there's many ways that you can approach this.

33:17You can look to the literature to find the total number of procedures performed every year, but the gap in access to procedures. You can also look at, you know, surgeon shortage numbers and all of these things put together tell you one story, which is that we have demand and excess of supply. And so what I want to say is that I think that there is nothing wrong with the surgeons that we graduate, to be clear. Like, like these are highly trained professionals who, you know, are, are training on the body of a training corpus that has existed for, you know, a century and, and they're very good at what they do.

34:02But the issue just is that we cannot produce enough surgeons to reach all of the patients who need help. And I mean, if you think about this, right, like to bring a little color to this, even outside of conventional surgery, think of a patient who lives in a rural environment and has, for example, a stroke. that stroke might be managed by medication, but often it can't be. And the best decision at that point is some kind of procedure that is done through blood vessels by an interventionalist. And often the issue is that that patient does not live within proximity to a qualified interventionalist to get that done.

34:43So you must now transfer the patient from one hospital to another. And with stroke, you know, time is brain. And, and so the question here is how can we think about that? That is just one example of demand, not having requisite supply. And, and that is like, like that is the big gap where yes, like training is, is fine. It's well, there's many things to improve. Um, but, but there's, there's just these downstream aspects that are, that are broken and, and need creative solutions. No, that's great. And it's something we hear frequently at industry meetings and such that the surgeon's shortage, this is a problem that medical device companies, surgical robotics companies are seeking to alleviate.

35:33Well, let's, and I love the fact you brought up stroke. We talk about that problem a lot on the podcast. One solution has been the rise of telesurgery, have the expertise in Boston and deliver it. in bangor maine the other that we've talked about is is transferring the knowledge to bangor maine and having a system in place that can assist someone up there and perform the procedure up there there's some companies that are doing that let's talk about inner logic though i don't want to get too far down what we've talked about previously let's talk about what your how did you come to the company was previously called semaphore i don't know if that was the company that you started or, but now it's in a larger talk about the creation of the company and what your mission was or is.

36:20Great. So, so Semaphore is a company that, that I had started. And for a bit of history, you know, I mentioned that I was doing this research in the lab of Matthias Umberoth, who is now a co-founder. There are three total co-founders there. There is myself, Matthias, and then Axel Krieger. Now, in the very early days, it was Matthias and myself, and we had not yet settled on what would ultimately become the final company thesis, so to speak. And so the first name we had was Semaphore, which was a play on the protein that was discovered by my PI when I did neuronal development research in med school.

37:07So it was a bit of a homage. It had some relevance in that the name means hand signaling for trains, basically. And there was some thought that, hey, we're building intelligence that can provide some guidance to the operating room in some capacity. And so, you know, initially Matias and I were thinking more about the operational use of the intelligence that we were building. Matias is very much an expert in computer vision and perception. And so we were very good at taking surgical video, whether that's point of view or even ambient level, and extracting insights either at the surgeon level or even more, as I mentioned, at the operational level, thinking about what was happening around the surgeon.

37:58And this is a concept that is not new and has been well-tread by companies like Artisite, Theater, Surgical Safety Technologies, etc. etc. And ultimately, you know, we decided that our expertise and the opportunity, you know, was elsewhere. And there was this very exciting grant that had come up with the individual who would become our third co-founder, Axel Krieger, where we were basically thinking about autonomy concepts. And, um, you know, that, that was when we realized that actually the very interesting opportunity was not just to think about the operational aspects and, and not just to think about, you know, surgeon performance measurement, but rather to think of, again, how do you back up all these concepts and, and get them into systems?

38:52And very simply, you know, the initial thought was, can we effectively productize the intelligence layer that would eventually lead to autonomy on surgical devices? And that effectively became the core thesis from which the current company expanded. And the name change effectively, I think, we moved from Semaphore to Interlogic for several reasons, But we also just felt that inner logic ended up better capturing the essence of what we do, which is, you know, within the machine, we support by providing really something that is core and underlying the devices intelligence, whatever it is that the OEM that is in question is productizing.

39:46we help provide a layer underneath all of that that is truly within. And I could talk a little bit more about, of course, what inner logic is, but that's some of that historical context for you. Yeah, no, let's unpack that. But just for the sake of listeners' understanding, define, we know what autonomy means, but what does it mean in the context of autonomous surgery? What does that look like? What are we ultimately talking about this being? So, autonomy in surgery isn't necessarily new. If you think about it, LASIK, for example, is ablating corneas by a machine. We have radiation systems and orthopedic robots that execute plans every day.

40:36And so there's a distinction to be made here. Today, by and large, the surgeon makes the plan, and then you have a machine that executes deterministically. And that's really automation. now the the gap that we have to think about here is is automation versus autonomy and what we mean there is instead of just executing a surgeon driven plan can the machine get to a point where it perceives it reasons and and then adapts and acts to what it finds and and that's that's this big next inflection point that we have to think about um and and today you know pretty much almost 100 so you know surgeons are the ones who are are controlling you know the show so to speak and to be clear you know this this path to the latter point this this true autonomy is going to be very much a staged process where we will have to crawl we will have to walk we will have to run And so you will go through, you know, things like assistance and then you will have subtasks and each step must earn, you know, the next.

41:50There's a tremendous burden of proof, of course, within medicine. But that is this autonomy that we think about. Great. And how is Interlogic going to help the industry get there? Okay. So, so our company, you know, we sit at the intersection of, of physical AI and medicine. And I think one thing that we should get across up front is the fact that we are not a hardware company, you know, so we are not building a surgical robot. We're not building an imaging device, nothing like that. Rather, we are building computational development infrastructure for procedural devices. And so the idea is that manufacturers, they design, they test, and they prove their devices across thousands of virtual patients using our technology all before ever reaching a real patient.

42:45And there's something important here, which is, yes, surgical robots get a lot of attention, and autonomy is a huge part of this. That is our long-term crown jewel application. But the mission here is really procedural devices in general, whether we're talking about a full self-driving surgical robot or even something like a conventional heart valve or catheter. So what that means is that anywhere a device meets a patient from cerebrovascular to cardiovascular, from orthopedics to general surgery, we are supporting OEMs today with a development loop underneath all of those clinical domains, all of those product types, so that they can really build this next generation of devices in a more cost-efficient, time-efficient, and safe manner.

43:41so what is it that inner logic is providing to the the oems and i mean that physically are you are you is this a place where their robots are sent to be tested is it is it a box of software or a download that that is being shared something on the cloud what are you what are you providing them yep so so it's really more of of the latter uh so um the idea is that manufacturers bring their device, they bring their data and we give them effectively three things. So there's the concept of a virtual patient and that patient is derived effectively from two things. One is real data. So if you as a device manufacturer have a body of real data, we can support by structuring it into a usable, searchable form.

44:35But that data alone is not sufficient to generate and test safe clinical devices. You need to extend it. And the extension occurs through synthetic data. That way, you get these edge cases, these failures, these rare scenarios that just a traditional clinical archive by definition won't provide you at least reliably. So that's the first thing is virtual patients as derived from the combination of real and synthetic data. The next is an environment within which you can have your device run against those patients. And that's this concept of a simulation environment. And so you've got thousands of cases basically that you can test against that you would otherwise never be able to stage, certainly in a time or cost-effective manner physically.

45:33And then underneath all of that effectively is evidence. So you need a record that is always building and accumulating so that you understand at each step what was done, what data was used, the lineage and the provenance attached to that, et cetera, et cetera. So are you working exclusively with surgical robotics companies or are you working with other devices as well who uses your service? We work with multiple strategic types within the medtech ecosystem. And so conventional surgical robotics, absolutely, that's a big part of it. But the reality actually is that the technology that we have is most mature in an endovascular and an orthopedic context.

46:25And so what that means is that we are working with MedTech OEMs who span, for example, imaging devices, you know, so C-arms, for example, all the way to those who are building catheters for endovascular use or screws and implants for orthopedics. we really are able to span the gamut of medtech customer. It's just that the technology is more mature, more ready to deploy in these endovascular and orthopedic contexts. Whereas in soft tissue surgery, for example, there is still science that needs development before that becomes as mature and capable as what we have in these other clinical domains.

47:12But the autonomy only applies to the surgical robotic systems or is there a degree of autonomy with the orthopedic and endovascular devices as well? Absolutely. This idea of autonomy actually is applicable across all of these clinical domains. And so, you know, this is actually where it's effectively the imagination that constrains you because regardless of device form factor, if it can be automated, that's something that we can support with. And so, for example, you know, Axel Krieger's lab has automated not only a conventional soft tissue robot to perform live gallbladder removal in a pig model, but he's also been able to show that you can leverage a similar framework to advance a catheter in blood vessels, for example.

48:04And in Matias's lab, a C-arm device, an imaging device used intraoperatively, has been actually programmed and controlled entirely through natural language, trained entirely on synthetic data to assist with pelvic fixation workflows in an orthopedic context. So there really is a myriad of devices that can be automated. And of course, I know this is a topic that is increasingly of intrigue in the ecosystem, which is, for example, even humanoids. In what role will that device form factor play? um you know they are also of course you know in in play uh and and capable of being automated need to be automated uh so so really really we we touch multiple device types is the bottom line it's it's interesting you bring that up yeah that's something else we've been talking about frequently humanoid robotics and i've been in the camp that it seems to be unnecessary to have a humanoid a surgical robotic system doesn't need to be shaped like a surgeon it just needs to be able to perform surgery is is is the shape is it does this does this technology does this capability make humanoid robotics suddenly i guess more more sensible and more having their that form factor more necessary do you see that um i think ultimately in the long run it's it's difficult to speculate exactly um all the spaces within which humanoids will find a home Obviously, there are people who very verbally and within their spheres of influence will declare that humanoids will outperform human surgeons, you know, on a shockingly close timeline.

49:57And, you know, I think this sentiment is shared with my co-founders that actually, you know, a humanoid form factor may not be the best way to, you know, perform all surgeries. And the reality is that humanoids are very good at tasks like, for example, supply chain management and general operating room management. And increasingly, you have device manufacturers building incredibly sophisticated surgical robotic form factors that once automated, you know, I think will not require, for example, a humanoid form factor to drive them necessarily. And so it may be that in the future, humanoid form factors will absolutely play a role in the actual performing of surgery.

50:51But I think in the nearer term, to us at least, use the same infrastructure that we're talking about for surgical automation development, but don't try to fit a square peg into a round hole necessarily and allow the humanoid to function more elegantly in a different context where it can actually provide some impact in a much more ready fashion. forgive me humanoid robotics has become one of my favorite rabbit holes so so thanks for indulging me but we don't need to go too much further down there sure let's look to the future what what this may be so you set out to sort of uh revisit redesign uh surgeon training to make it more efficient uh you you started this company you've raised some capital recently so you have a vision for the future you have a sense of where you'd like in a logic to be and where you'd like the field to be in, I'll say 10 years, because this is a big project.

51:47What does that look like? What does autonomous surgery look like? Where are we headed? Okay. So another sip of water question. So I actually think that if we're thinking about a 10-year timeline, for the most part, the operating room is going to look approximately, it's going to look very familiar. And you're going to have a patient, you're going to have a team, and you're going to have a responsible surgeon. And underneath that, though, things will be interesting because every device in that room will have been developed differently. So you will have leveraged technology like that being developed and in a logic to test those devices across thousands of virtual patients.

52:40And effectively, what you'll have is this crash simulation that thought a lot about how cars are made, for example, being applied within a surgical procedural context. And so what that means is that you will have all of these devices that we think of, you know, expanding on the roles that they can play today. And this is interesting because you'll have intelligence that is very capable of doing many things, but it'll be largely bounded. But that's okay because we will be using it to support surgeons in very exciting ways. And I think one of the biggest things to think about is, of course, the fact that, you know, computer perception will never get tired.

53:27And you'll have concepts like guidance just very intrinsically woven into surgeon workflows and and there will be certain subtasks that run under supervision and a lot of this is going to happen in increments and so you know yes if you peer 10 10 years down the line from our vantage point today things things will look similar but but they'll be very different but that shift is going to happen very incrementally. So it won't feel as dramatic as perhaps the imagination conjures today. And I think the biggest place where all of this can impact is going to be what we started our discussion with, which is this access question.

54:15Today, a lot of excellent surgical capability lives within a handful of centers of excellence. And now suddenly, because we will be taking a lot of the intelligence and moving it into a systems level, we will be able to benefit, for example, those rural community hospitals with technologies that really help the surgeon do a better job or perform for longer democratized access, et cetera. And the biggest reason for this shift is just that development itself, development of procedural devices will start to increasingly move at software speed. And the distance from a good idea to something being proven and device capable will not be measured in at times decades, but rather a matter of an evening even.

55:14fascinating final question a bit of a personal one how does your family take your your departure from the traditional medicine track uh do they see the wisdom of what you're doing or do they sort of roll their eyes and say oh god tito's on talking about autonomous care again um i would say that that uh i've been very fortunate to have you know a family that um supported you know my decision-making at every step and has always known that what I choose to do is generally well thought out and comes from a place of conviction. And so I think when you speak to, for example, my parents, they realize that this is all the same personality, that this is who I am, just manifest as the next logical stage which is you know um always trying to think of of what comes next and how to to really take things to the next level and i i you know i i miss my surgical training dearly i i miss being a doctor i miss my colleagues i miss patients um but then again i also know that this this company and this idea you know it's it's mission driven and the whole point is taking the academic potential within my technical co-founders and trying to get that to a point where it can actually be scaled and made accessible to the masses.

56:51And if we succeed in even doing a fraction of that, then I think from just an impact perspective, You know, it really, for me at a personal level, it becomes deeply meaningful. And because of that, I am able to sleep at night with, you know, the decisions I've made and I feel, you know, confident in the path that I'm pursuing, even if it took me a long time to come to the realization that this was the best thing for me to do. And it's still something that I think about every single day. that's great and no i didn't mean to fit your script but i think um final final question i always have a second final question your your former classmates your colleagues other surgeons or do they see do they hear what you're doing and say yes please we need this right away or they do they not see what you do not do they not share your vision yet and they and they don't i'm just curious as to how the medical world views this movement i think that if you asked that question five years ago, people would have been stuck a little bit more on, for example, the anxiety around even being recorded and measured in any capacity.

58:02And these questions of replacement of the workforce, I think we would have been asking them without the benefit of having seen how these technologies are playing out in other contexts. And so I think that For example, the automotive industry has created an excellent precedent where there's a realization that just because we say the word autonomy does not mean that you're having a Waymo moment in surgery tomorrow. And we're not going to have a surgical robot performing cholecystectomies A to Z by themselves for a very long time. And so we as a society, we as surgeons, device manufacturers, patients, all the stakeholders have the opportunity to walk that path in a very iterative fashion and to find for ourselves what the burden of proof at each stage is and what we're comfortable with and how best it does improve things like access to that care.

59:03I think that that has made a lot of this a lot more palatable and also inevitable. People realize that you can't continue doing things the way we've always done it because you have an aging population. You're never going to solve the question of geography, for example, by just trying to train more surgeons. We have to get more creative. We have to be more pragmatic. And so as long as we walk that path thoughtfully and responsibly, then, you know, people get it. And with that realization, I think they've been incredibly supportive, which has been really humbling, you know, and really validating of what we're up to.

59:48that's great my brothers and cousins are on a text line where we've been they've been arguing about autonomous cars for probably 15 years now and i've always been one of the holdouts but i enjoyed my first waymo ride in san francisco uh earlier this year so i'm i'm on board so uh it's it's scary to be early sometimes but uh it's a good it's it's sweet when you're right and uh i think you're right this seems like five years ago this would have been uh this would have raised a lot more eyebrows than it does today for sure. So, well, excellent conversation. Great view of the future. Tito Potos, thank you for joining us on the podcast.

1:00:25Thank you so much. And I'm looking forward to talking more as the future unravels here. All right, well, that is a wrap. Thanks so much for joining us on this episode of the Device Talks Weekly Podcast. Please remember to register for the upcoming Device Talks Tuesdays sponsored by RQM+. Please also remember to subscribe to the Device Talks Podcast Network so you don't miss a future episode of the Device Talks Weekly Podcast or our other great podcasts. And finally, please connect with me. Please connect with Chris Neumarker. Please connect with Kayleen Brown on LinkedIn. Make sure you follow Device Talks and MassDevice as well.

1:01:04All right, folks, thanks again for joining us on this episode of the Device Talks Weekly Podcast.

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