In this episode of "Mutual Connections," we, had the honor of speaking with Dr. David G. Armstrong, a globally recognized leader in diabetic foot care and the President of the American Limb Preservation Society (ALPS). While Dr. Armstrong’s pivotal work in podiatry and limb preservation is well-known, our conversation took a deep dive into a different yet equally impactful area: the innovation process in healthcare and the critical role of technology in transforming patient outcomes.

Throughout our discussion, Dr. Armstrong shared his unique insights on fostering innovation, integrating emerging technologies, and overcoming the complexities of adoption within the medical field. We explored how collaboration across disciplines—connecting clinicians, engineers, innovators, and investors—can bridge gaps and accelerate progress. Dr. Armstrong discussed his experiences with cutting-edge advancements, such as wearable robotics, implantable neurostimulation, and AI-driven tools, emphasizing their potential to reshape healthcare delivery.

The conversation also delved into building trust with patients, ensuring equitable access to new solutions, and how global health systems can learn from one another to optimize innovation adoption. Dr. Armstrong’s perspective offered a fascinating look at how groundbreaking technology and a collaborative approach can drive change and enhance care for patients worldwide.

We hope this episode inspires a fresh understanding of the innovation journey in healthcare and the importance of bringing together diverse voices to make a lasting, meaningful impact.

Listen to Mutual Connections on your favorite podcast platform

Transcript

Shayan Mashatian (00:01.291)

Hello, my name is Shayan.

Thank you for...

Akifa Khattak (00:07.858)

Hi, my name is Akifah Katak.

Shayan Mashatian (00:10.585)

and welcome to the next episode of mutual connections. Today we have Dr. David Armstrong, the president of American Limb Preservation Society and I would say the most famous figure in diabetic food care and podiatrists. Welcome David.

David G. Armstrong (00:30.062)

Well, listen, it's a total pleasure to be here. My goal, as we said before, in the preamble, is to try to bring the quality down so that you guys look even more fancy. So here we go. Let's check that off the list.

Shayan Mashatian (00:44.321)

I think it will fail on that goal very soon, shortly.

David G. Armstrong (00:47.054)

We should quit while we're ahead It's great to be here. Great to see you guys Akifa really great to meet you FYI If you guys haven't met Akifa yet, holy cow She's had her ticket punched everywhere. This is great. I look forward to meeting her and learning

Akifa Khattak (00:56.51)

me.

Akifa Khattak (01:06.334)

Thank you so much. And I have a lot of questions to ask about you, about diabetes innovation. I you also wrote a book about Crohn, so there's a lot to dive into.

Shayan Mashatian (01:06.558)

Absolutely.

David G. Armstrong (01:17.55)

Holy cow, yeah, let's do it.

Shayan Mashatian (01:19.637)

Wonderful. So David, you know, I met you at C2Ship conference two, three years ago. And as a physician, I saw you a lot of entrepreneurship in what you do more than, you know, physician side of you. And it was fascinating to me how a physician is so much into innovation. So how about we start with

As you know, we are startups. We always start with the problem and then we take it from there. And we would love to share with our audience or listeners what is the problem you are trying to solve and what is the challenge. Let's start there.

David G. Armstrong (02:03.852)

Yeah, sure. So the big idea for us is that this is a problem that is like the biggest problem that no one ever talks about. And it's not just diabetes, which a lot of people blow off, but and but it's actually the what happens to the end of the body in diabetes, which is people getting wounds and people ultimately getting amputations right now every second around the world. Someone with diabetes develops a wound that's called a diabetic foot ulcer.

It happens in silence because people don't have painful feedback. And so they can literally wear a hole in their foot. Like we'd wear a hole in a shoe or a sock. And that hole, that diabetic foot ulcer gets infected about 50 % of the time, which, and about 20 % of those end up at hospital, which is why it's a lottery in that now there's an amputation happening every 20 seconds around the world. And I said it's a lottery because depending on where you live, your zip code,

there's a tenfold variation in whether you're going to get your leg off or whether you're not. And a lot of that mandates that we marry kind of the team with technology and I guess a little tenacity. And that's why you mentioned this not-for-profit Alps or the American Lymph Preservation Society. That's why it was developed. There's now more than a thousand people in Alps and only it was developed during the

during the pandemic, but it just shows that there's a real unmet need in this area for putting teams together, but also the technology part of it fits perfectly in that. I mean, our team right now and our group are working on everything from spread on and spray on skin to wearable robots and no kidding implantable neuro stim and brain computer interfaces. It's crazy.

Such a fun time to be a foot doctor, man. I'll tell you what.

Shayan Mashatian (04:06.443)

Great. So, you know, as health innovators, me and Akifah, we would love to see whatever we make happens goes into the world. Everyone starts using it, right? But when I think about it as a patient, I have mixed feelings. On one side, I don't want my doctor try whatever comes out on me.

But at the same time, I don't want to live like someone who was living 100 years ago. I want my doctor to use the latest and greatest science and technology in my treatment.

We would love to have a bit of deeper dive into this process because you are working with an ecosystem of innovators on all fronts from advancement in medical knowledge to technology and everything in between, which we would love to hear what you see is in between those. So would you please share a bit with us? First of all, how do you see the status of innovation in solving the problem that you see?

you explained. And then we can go into the process of adoption of these innovations.

David G. Armstrong (05:17.612)

Yeah, so I think that a lot of this, and this sounds trite, and it's easy to say on a podcast, and it's hard to implement in real life, but so much of this happens at the bedside, at the chair side in the clinic, or in the operating room, but especially at the chair side in the clinic. Because I always tell my patients, especially ours who are at

super high risk, not only for amputation, for early death. I want to do something with you and not to you. And I think when they've been bounced around, I don't know, like a pachinko ball, getting from doc to nurse to doc to doc to doc, insurance to this, this, and then they end up kind of in our sort of collecting bowl at the end.

in our clinic, I think they're just, it's so hard. But that kind of thing is where all of this starts. And I think you identify, meaning kind of collectively, a lot of unmet needs. And Cheyenne, I know we talk about this constantly within our center to stream healthcare in place, these unmet needs and helping our patients do what they know that they're supposed to do.

but really can't do because of all kinds of other problems getting in the way. There's ways that technology can intervene there, but there's also ways that technology can interfere. And a lot of times folks are just confused. think clinicians are confused. We're all confused and there's a little bit of paralysis of analysis. The goal though is to bring people together, the patient, the doc, the engineer.

with the patient and even with an investor to identify those unmet needs. And you'd be amazed at if you try to do this as much as possible, how much you can identify and solve tomorrow's problems today instead of yesterday's problems tomorrow, right? Because that's what tends to happen when everyone's in their own.

David G. Armstrong (07:43.446)

Again, I'm gonna use the word silo, but when everyone is, it's just, yeah, it's just a lot harder. And this transcends specialty in medicine or surgery or nursing. But look, it takes energy. And like I said, it's easy to talk about here. I just left, I'm back at home now. I just left rounding over in clinic, but over in clinic.

I had one of my colleagues who's an engineer come over from Caltech because we're enrolling people in an epidermal electronics project. But he was there with his postdoc in our clinic. And again, that's easy to talk about, but getting everything set up and timing right is hard to do. So this is just another example of these sorts of things.

Akifa Khattak (08:39.636)

That's amazing. So it seems like you got so much going on. What is one thing that you see could aid in educating patients to build trust for these new technologies so that they know it's an option and it's a safe option as opposed to meeting it with skepticism?

David G. Armstrong (09:01.048)

Yeah, think a lot of this happens. The trust is, you I think is earned. And, you know, my father, who is a foot doctor, and I'm a foot doctor, my oldest daughter is going to be a third generation. She is a third generation foot doctor. But my dad used to tell me back when I was working in his clinic in his office, you know, 30, 40 years ago, he said, son, folks don't care how much you know.

until they know how much you care. And I thought, I sort of rolled my eyes when he said it back then, I thought that was something that belonged on a poster or something, but I didn't think, I thought it was just words. I know what that means now. And I think our patients really know that. They know when you, as the clinician, are kind of dialing it in, and they know when you mean it, and they know when you're there for them. And when you are there, even if it may not be for,

You know a two-hour visit maybe just for a few minutes with them They know that you are there for them and that bill that kind of trust happens and it happens instantaneously sometimes if you're fortunate or it happens over time But it's consistent and then when they see that then the world opens up For them and for you and you can talk about hey Look, I have this This tool that might help Heal your wound

It's going to be a pain in the butt for you at first because we're have to do this and this and this. But if you were my sister, for sure, I would offer this to you. And they see that and they understand. They understand that. And some will go with you. Most will. Some won't. But all of them are with you. Right? You you're not there. They're along for the ride. And that kind of thing builds trust. And it's a family.

And you see this and and you know, I think a lot of engineers and innovators with whom we work see this happening, especially if they're with us in clinic and it totally changes them because they don't they're often sort of siloed away thinking about their own thing and then they see the problem in real life and then they often will chime in and then they get into that whole trust thing and you start to see some

David G. Armstrong (11:29.036)

really great things happening. This happens to us regularly.

Shayan Mashatian (11:35.574)

I love the question if I ask because it goes to the heart of the solution which is patient and being patient-centric, right? And starting with the trust. I guess that's what we always talk about, how to gain trust of, I would say everyone in the ecosystem, right? And starting with patience is great. But David, how do you, let's say, let's take a use case. Let's say I'm an innovator. I build a solution, I think it solves a problem. I come to you.

and I offer that to you. We would love to know how do you think about it, how you evaluate it, what happens in your mind. Open that to us. How you see the process to see if this is really delivering on the promise or not.

David G. Armstrong (12:21.966)

Yeah, wow. So I guess different people, I guess, react differently when they're in, and sometimes even different specialties react differently when they are offered a technology or so-called solution. There are some people that are a little more closed off to this sort of thing. There are some that are a little more open and

you know, wanting to sort of adopt this. I, if it's not abundantly clear, I am what you might call a hyper early adopter. I, I, it's astonishing. You know, I, ever since, you know, I've mowed lawns to buy my first Timex Sinclair 1000 computer out of Popular Mechanics in the, in the seventies, I think I, what was like seven or eight. So I, and ever since then, you know, I have all these different gadgets bricked.

in different closets and cupboards around. So that's different because I enjoy these, I'm an alpha or beta tester for everything. But there are most people, I think, in medicine. Medicine is, although I love it with every fiber of my being, I'm often frustrated with it because it's extremely parochial, it's extremely conservative. But then,

When I get frustrated about that, realize that it has to be because you don't want to be some yehu, go and try and everything on everyone because then what will end up happening is you'll end up hurting people. My father, again, I bring him up, he used to say, son, there are two kinds of people in this world. I would think there are more than two, but let's just use this as an academic exercise. And he said, son, there's the kind of person where if you give them a job, they figure out a way to say,

No, and there's people who wouldn't give him a job. They figure out a way to say yes. And he said, son, there's nothing wrong with either of those people. You need both to make the world go round. You can't have people that are always saying no, because that would be like a, it would be Purgatoria, not Paradiso, right? You can't have, that would just be the most dull, horrible place to live. You can't have someone that's just, yeah, sure, let's,

David G. Armstrong (14:51.334)

Because then that's just a cowboy or a cowgirl and they're just all they're doing is They're gonna get themselves in trouble or they're do the wrong thing ultimately so you have to have a Combination of people that are figuring out this kind of implementation that are working but but all of that is surrounded by sort of trust but if someone comes to you with this and They've already done a little bit of this background about you

the clinician and know a little bit about you already, maybe they can steer that sort of, people use that term in tech pitch. They can steer your pitch to you, but I don't think of it as a pitch. That's kind of a, I think of it as just, you mentioned a use case and how can this help? And if you talk about, if you start from there, identifying the problem and saying, here's how this could potentially help.

Here are the problems with it now, but here's where we want to be in one, three, five, 10 years. Then I think that's the best way to go. But you've got to identify who that person is. Is she or is he a no person, kind of are they a yes person? Where are they on that coefficient or that continuum? And kind of adapt from there, because it takes all kinds to make a difference.

Akifa Khattak (16:18.554)

That's awesome. So I loved everything you said so far. one thing I always tend to talk about when I'm in these kind of scenarios is that healthcare does sometimes going backtracking a little bit, addressing the mistrust portion of it or how do patients, you know, gain that trust. It's almost like a...

you need to have a rebranding, I would say, of everything in healthcare, especially when you're dealing now with younger generation too. They want to know exactly what you said that you're doing things with them and it's for their best interest. So that was really awesome that you touched upon that. And then as for getting different technologies into, let's say, the market, you have a great idea. Now you've...

David G. Armstrong (16:49.059)

No doubt.

Akifa Khattak (17:10.344)

got your MVP sorted out, clinical trials, I mean there's a lot of red tape with regulations in healthcare anyway, as you said it is quite conservative, rightfully so, you're dealing with people's lives, but at the same time, now you have entrepreneurs that go, okay, I got through all of this, now how do I get it into the healthcare system, what are the steps for that, and then how can it be adopted? So could you touch on, you know, what does,

a medical or a physician champion look like or how do I reach out to an innovation department, anything about reimbursement? you have anything to say in that regard?

David G. Armstrong (17:53.558)

Absolutely. And I think that, you know, often as a clinician and I guess I'm a podiatric surgeon, you know, scientist, I guess you'd say, whenever I hear things like reimbursement or all of this kind of green eye shade wearing kind of stuff, often my instinct is to feel like I want to go take a shower, you know.

But because I think that somehow that is somehow lesser or somehow is going to make the work that I'm doing research-wise somehow lesser. But that's just not true. I always tell my trainees, in fact, I told one of them today about this, that there's a

There's a coefficient, of a, I call it a missionary, mercenary coefficient. But you can't be on one or the other. You have to be somewhere. You have to know where you are and understand that. But don't be the person that is so commercial that she or he is like a race car, is like a Formula One or a NASCAR driver and they're wearing all those patches on their sleeve or on their car. No way. That's entirely just the wrong place to be living.

You have zero credibility, but don't be the woman or don't be the man that is always figuring out a way to say no and say, no, there's no way that I could do that because that would somehow jeopardize my credibility academically. I could never work with industry. That's ridiculous. This is a balance. The key is you have this balance. You disclose that you disclose it, you manage it, and then that

relationship between industry, academia, between innovators on both sides can flower. That was something that I think early on in my career was there wasn't a lot of that happening in that I think there were a lot of folks that were just figuring out ways to say no in that area. That has changed a lot now. think that there is now around in public

David G. Armstrong (20:15.834)

institutions, private institutions throughout the United States and around the world. I think now you're starting to see real industry academia collaborations. As a perfect example, Cheyenne had mentioned earlier, maybe in the preamble or maybe in the show notes, Cheyenne, you could put it in there. We have this really cool National Science Foundation NSF program. It's actually my first big NSF.

of funding, I've always just had continuous NIH funding, but it's called the Center to Stream Healthcare in Place or C2Ship.org and it is an industry university collaborative research center, or IUCRC, and it's focusing on extending what we would call kind of hospital-free, activity-rich, dignity-filled days. And there's like more than 20 companies.

Six universities, it's now the biggest, I guess, IUCRC ever in the 40 year history of the IUCRC. It's going great, but it starts with this idea about, like you said, about trying to figure out how to develop an environment where you can have industry interacting efficiently and appropriately with academics and with clinicians.

than for us in the clinic, which is really, really unique. But you're starting to see this become less unique now. And you had mentioned all of these different academic units and innovation units around the United States, around the world.

Shayan Mashatian (21:57.025)

This is fascinating. We started with topic of trust, guess, trust between patient and physician. Now we are talking about how we can foster trust between innovators and medical community and physicians, which might take some effort like centers like C2Ship to make it happen. Let's change gear a bit, still stay on the line of trust. And I guess when you talk about health care these days, the elephant

in the room is AI and how we can trust it. We would love to hear your thoughts on that. Do you see AI as another new component in technology or you think it is so big that it is its own entity that needs to be trusted and incorporated in this ecosystem? What are your thoughts on that?

David G. Armstrong (22:51.17)

Yeah, so I'm probably the wrong person to be asking this question about this again, being sort of a, I'm so excited about this. know, I, people always ask on the, you know, to AI folks and I have so many friends and, you know, in around along Sand Hill Road and stuff. And they say, what's your P doom? You know, what's your, what's your, your, your, your assessment for how AI is going to overtake us and create a doomsday scenario. Mine is.

I am very much a bit of an evangelist on this, but I also still have to marry this with an element of skepticism. Obviously, these things are still, there's still quite a lot of hallucinations that are happening regularly with different tools. this is a, it's like having a really good buddy of yours.

that is really, really talented, really enthusiastic next to you. But who's going to make a mistake every now and then and who you can't entirely trust, but they're sort of your wing person. that has been really effective. And on my browser right now, I have the recording for this podcast on the open browser, but right next to it, I'm not going to say any trade names, but I have an AI-based

Scribe now for our clinic. No joke. We've been using that I was an alpha tester and now they tester with that It's it's it's astonishing. It's it's doing amazingly. Well, but of course I have to read right now. I have to read these Notes that it creates for me while I'm in the patient when I'm in the room with the patient my patients love it I put it on the thing and they're they're they're seeing this but you see it's it's that trust That you build up with this and they want to see what the note

looks like afterwards and they'll say, no, no, no, that's not right. That's not right. And I'm like doing it with them. But it's you make these modifications, but it's wonderful. And then right next to that, I have the what do call it? L.M. Notebook L.M. opened up because I'm writing a talk from the American Heart Association on coming up and I dragged all kinds of stuff. If you guys haven't used notebook L.M. Cheyenne has. We're writing a paper on that, aren't we? That's amazing, man.

Shayan Mashatian (25:16.986)

We are, we are.

David G. Armstrong (25:17.972)

Yeah, that's just so boy, you want to talk about a wow factor. those are just two things that I have right next to yours. So I believe strongly that we collectively it's inevitable now. So much has changed just in the last couple of years. We've been working with so called deep learning and for a good decade now on different kinds of things, especially with computer vision and things along those lines.

but and human motion analysis. One of my friends had worked with at DARPA on this about a decade ago or more, but now there's so much happening and this is all just a part of our lives. And it's such an exciting time. I I can't even begin to tell you how enthusiastic I am about what the future holds. I think it's gonna fundamentally change everything that we're doing, but what is it that it's going to fundamentally change?

I don't even know. That's what's so exciting. And I think that just depends on your overall affect on life and how you sort of react to that kind of thing. But it's a fun time to be a toe doctor. I'll just tell you that.

Shayan Mashatian (26:35.264)

I mean, definitely generative AI is new and still, guess the winning use cases are emerging. Which one is good? But how about when it goes to the device side or

Akifa Khattak (26:35.805)

You.

Shayan Mashatian (26:48.657)

areas that you can practically use in the operating room. Can you tell us a bit what do you see in terms of industry trends? I heard about, for instance, the socks that measure temperature of the food or the pad. Can you please tell us how do you see the trend and when you think industry is going with those kind of innovations?

David G. Armstrong (26:52.396)

Yeah.

David G. Armstrong (27:02.51)

Sure. Yeah.

David G. Armstrong (27:11.444)

sure. It's well, again, it's it's there's just so much happening right now. And of course, everyone adds a dot AI to whatever they're doing now. And, you know, and they're, they, they instantly up their valuation. And, you know, you wouldn't be wrong to do that, because most of the stuff now, it's, it's a fait accompli that you're going to be, I had to add a little French in there, even though I'm a francophobe, not a francophile.

But maybe I'll get some German in as well. I'll talk about the Gestalt but the but the point is that we have to All of this is inexorable now, you know the that These tools are are entering our our lives. I I'm recording this you guys just noticed I have my

Meta AI glasses. I use these in the OR. I use it daily and I just ask it to take a picture now. I can take phone calls on the darn thing, but I also can ask it questions now. And it's amazing. I asked it just now, what am I looking at? And it said, you're looking at two people on a computer screen in what looks like a sunny kitchen. And it was right. And I didn't know we were recording a podcast, but that's only getting better and better. I also use the, right over there I have,

of my Apple Vision Pro, the AVP. We were the first to use that in the OR. We were the first to use Google Glass 10 years ago in the OR. But the Apple Vision Pro right over there, it's astonishing because I've been using that. And actually also, I had a chat GPT window open and I was asking some questions of chat GPT.

during the procedure. Some of it was right, some of it was wrong when I was doing it, but it was astonishing. And then I was sending some of that by FaceTime when we did our first cases. I did the first cases in Italy with, actually with my daughter, we were both at a meeting in Italy. This was in February when it first came out, February, March. And we, but I was having a FaceTime with one of my medical students here who's now going to be a vascular surgeon.

David G. Armstrong (29:30.862)

And he also was writing a paper on this same thing, and he used Chad GPT to help to format the paper while he was doing that. He was sending it over to me while I was on the airplane flying home from Italy. I was wearing, I'm not kidding, the darn geeky glasses, those Apple Vision Pro things. I would call it geek-tastic. And I also...

was using this to help format and correct it. But of course, loaded with hallucinations, but you have to modify it. But this is our current, you know, this is now, this is not vaporware. figuring out how to incorporate this kind of thing is really the order of the day. I think right now, the use cases are exactly what I talked about before. I talked about some scribe, scribes, think also, I think vision.

computer vision now is very real and giving us some really good information. But I also think that assisting us now in some of the some of the chores in terms of formatting and such is only getting better and better and better and more and more accurate when you are training it with your own stuff. You know, like like the notebook LM I mentioned not like on the whole Internet that I think makes the

some of the hallucinations a little less egregious. And so that's only getting better and better and better when we have our whole ecosystem to overuse the term ecosystem that is hyper-personalized. I think that's what we're starting to see right now. Super exciting. Sorry for going all over the place. This is like a keep it.

Akifa Khattak (31:21.748)

That's... I am here for it. I love it.

David G. Armstrong (31:27.372)

This is like adult daycare for me, I'm just kinda hanging out and bumping into things, this is great.

Akifa Khattak (31:32.592)

The best thing ever. I think more people need to have that attitude. think I'm right there. You're preaching to the choir. I actually am familiar with, I mean, actually I have had a lot of conversations with certain surgeons using the Apple vision and incorporating it and how exactly it assists with the surgery and it better patient outcomes because of it. So, I mean, I think all of these things are really

for layman's terms, super rad, and I love it. And so actually I wrote a paper on brain computer interface technology, and it was a Google paper. So you were talking about BCIs. I mean, maybe we could briefly explain a bit of what that is and how it will be used in the future for foot care. So that would be really cool. My particular article, I explained the legal considerations

David G. Armstrong (32:20.824)

Yeah

Akifa Khattak (32:31.492)

and behind it too because mine went a little bit more towards if you have paralysis, so what would informed consent be, would you be able to use this kind of stuff in, you know, end of care when you're in court, those kind of things, but I want to know all about the treatment side of it.

David G. Armstrong (32:47.406)

I'm happy to do that. this is so fascinating now, BCIs. This has been a dream of mine forever. But you start to wonder now when you add a brain computer interface and then you hook that up now to a large language model. You have to ask the question now, what is it that makes us us? I mean, if we are

if we are what we how we interact with the world and And you know like Spinoza would talk about you know touching the world to be able to interact with it and to really be in the world What if we didn't do that if we're just the sum of our memories? Like right what if we what if we weren't what if our memories were never summarized right and what if we were? Asking it a question or just thinking about a question now. There are some I mean, it's all

Some of it's a little bit hyped, but there are some concepts creating a thought now and transferring that thought from one BCI to another. Again, this is where I'm extremely over-hyping and oversimplifying some of this stuff, but they're doing it from lab to lab right now. But all of these things are fascinating. In terms of use cases for us, literally today, I was just on

with a company that have an implantable distal nerve stimulator that can give some sensory substitution to the bottom of the foot. Remember, I was saying that folks with diabetes have loss of protective sensation and they wear a hole in their foot. That's how they get these wounds every second now around the world. Imagine if you could, I was calling it re-gifting the gift of pain. One of my mentors used to say that pain is a gift. It's a gift that no one wants.

but it tells you when there's problems. What if you could re-gift that to people who have lost it and you could tell them when there's a problem that's about to happen? Well, that was my discussion with this group just literally 45 minutes ago. But that now has the potential to be linked up with a BCI, a brain computer interface. Now, there are, as you know, there are different sort of form factors for BCIs. There's the kind...

David G. Armstrong (35:14.926)

that are essentially just networks that you could put on like a Michael Phelps sort of squid swim cap and just do the really important signal just the signal modulation and all the signal processing the Masters of the universe here are not the hardware people the Masters of the universe here are the people that are doing the signal processing the translation of what is that little signal coming from that swim cap or through another form factor through an actual

wire, if you will, very, very small ones that go into a certain locus in the brain or somewhere else that may be a little easier to get a transduction. But imagine now if you could be you could take a person that has no sensation and then allow them to actually feel something more proximally. This is something that is extremely real and is happening.

Now my one of my friends, you guys got to get him on here. I just talked to him early this morning as well is Charles Lu Li you and Charles is like my brother from another mother and he is a neurosurgeon here at USC. As you know, I am a podiatric surgeon, a foot doctor, a toe doctor, and we like to make a joke. He does the brain stuff. I did the foot stuff and we kind of meet in the middle at the the belly button at the umbilicus.

But he is doing quite a lot of work with another friend of ours at Caltech, Fisner Anderson, and there's just a lot of work going on between our units in brain-computer interfaces. He has wanted forever to help make women and men with spinal cord injury be able to walk again. These exos, the exoskeletons now are getting better and better. There's an entire

Society run by friends of ours called the wearable robot Association wearable robot society. They have a they have a symposium called no kidding where I can and we were at the first one. It's like a decade ago now, but there's a whole lot happening in this area. But from my little humble area at the end of the body. It's always fascinated me and I believe it's very real.

David G. Armstrong (37:39.128)

that we could create almost a closed loop system to where we could allow people to feel what they couldn't feel and then allow them to change the way they're walking to allow them to move a little bit better. When we hook that up now to some better quality, quieter, better battery life, having kind of wearable robots, there's just the sky's the limit. There's other, there's.

Again, I mentioned Caltech as well. There's some really great robotics we're going on in another friend of ours lab at Caltech that have knee based kind of wearable robots and also full on exos. So buckle up because there's a lot of really cool stuff happening that are basically just acting like appliances for our life and extending our capacity. But again,

It really does change. You we have to ask ourselves, what is it that makes us us? Because we may start modding our bodies with a doctor's and a nurse's and a technician's help and figuring out the regulatory, just like you were talking about, Akifah, the regulatory path, the dangers there, the ethics surrounding that, and as well as the technical and the medical is.

It's really exciting.

Akifa Khattak (39:07.686)

And another point also to make is we have all these technologies and then what about access, right? So that was my next question was everything sounds so amazing and so how would we be able to get this to the community and people that are underserved? What would that look like for insurances to be able to say, hey, this is covered for you to get it into, I'm assuming some of this also goes.

to physical therapists as well. So those centers, what are your thoughts on all of that?

David G. Armstrong (39:45.506)

Wow, so that's a great question. And by the way, Akif, even if it wasn't a great question, I would say that's a great question, but that's a great question. the answer is that it's, so we have a saying in our unit that hard things are hard, but just because they're hard doesn't mean they're not fun. And it doesn't mean that it's not worth a life's work.

Just in our area, just I'll give you just in Los Angeles County, 10.1 million give or take people across enormously broad geographic area, enormously diverse, not just in terms of in terms of ethnicity, but socioeconomically. There is a tenfold zip code lottery, as I said earlier, like depending on what's going to happen or what.

emergency department you roll into whether you're going to get an amputation or not. And that's no one's fault. It's not some evil cabal that's trying to suck it to humanity. It is structural, but we have to improve that and instead of just talking about it. And so I'll give you an example. We have and we work on it on a daily basis. In fact, I have a text coming in right now. I see little bubbles.

from one group that is called Clemente Clinical Research with whom we work that are working. This is a private research company with whom we formed kind of this university kind of private collaboration where they are working with another not-for-profit called Altamed who are a wonderful federally qualified health center who are treating people that are either underinsured or completely uninsured.

with the goal of keeping people out of the emergency department. They are now seeing, again, without exaggeration, 80,000 people a year, about 80 % of them. These are all foot cases now. These trying to prevent amputations. About 80 % have diabetes. And give or take something like 20 % of those people have wounds. That's astonishing number. And it's across the entire geographic area. And these patients now are being offered the ability to come into

David G. Armstrong (42:10.162)

federally sponsored and industry sponsored studies that would only usually be offered to rich people and and and it's It well, it's life-affirming. I mean it just is and and it's the but these kinds of innovations now are Really taking off and what's happening now because you're seeing some of these federally qualified health centers Coming in you're also seeing some

insurance companies, some of the more progressive ones, but even some of the really hyper conservative, almost obstructionist, traditionally, you'd think, these people are just getting in the way. All these folks are starting to say, hold on a second. She's really benefiting from this, and she is a beneficiary of mine. And they use all these terms like per member, per month, PM, PM, and all these weird terms that I, again, when I hear it, I often feel like I have to take a shower because

It almost objectify, it's not, but yet what's amazing is they're starting to say, I could potentially treat this person with this technology and reduce my per member per month amount across, and then I could scale that up. And so you're starting to see the bottom up work that's happening from patient to patient, like we talked about, and then also top down efforts.

And that's never happened in my little career. Like I'm starting to see it happening now. People used to just blow a lot of this stuff off and they say, Ms. Garcia, why don't you just cut her leg off right now and be done with her. It'd be easier for her and easier for us in the system. And you know, maybe for some people that is the best therapy, but that is a vanishingly small number now.

And with all of this, think we're starting to see everyone agree that that's the case.

Shayan Mashatian (44:14.241)

David, this is great and we know you travel a lot. You go around the world. You've been in Singapore, India, Australia. I lose track of your travels. So I don't know how you do it. But the question is, how do you see this is happening globally? Do you think all this innovation happens at Caltech and the advanced ecosystem in the United States or you see this is a global trend?

David G. Armstrong (44:38.444)

Yeah, well, I see it inextricably as a global trend. Again, this is something that we're talking about, you know, by Zoom here, but and it's easy just to say it's a global trend. But we are seeing now, I'll just say in South Asia right now, in India, across the country, you know, from

Lucknow and Mumbai all the way down south into Chennai, even into even into Colombo and to Sri Lanka. I mean, you're starting to see now innovation units popping up and we're working with many of them. You have astonishing amounts of like an innovation ecosystem. There's a there's a technology university in every single one of those places. We work really closely with PGI and

Chandigarh up in the north and and also with all India in in in In Delhi, but but you see this kind of thing and that's country, you know the largest country in the world now and But yet there's a massive inequality across that country But there there is now effort with some of this innovation to be able to get some of this to people who would have never been offered this

in the past. So it is really exciting throughout the Middle East and North Africa. There's a lot of work going on with our unit and with others in Australasia, with Singapore as kind of an innovation hub. I was just visiting there as part of the Singapore Ministry of Health. You have this little kind of group

oligarchy but a spectacular center of innovation at the end of the peninsula, but innovating all the way into Malaysia, into Indonesia, and throughout Australasia. And some of these things now are built in and embedded into this. So every single country now, even those that

David G. Armstrong (47:03.746)

But with the exception of maybe failed states are have kind of these innovation engines that you're starting to see where you're starting to see some real change happening, even if it's just on the one to one kind of basis. And this kind of thing where we can just chat with people is, you know, it's just it's happening. Let me give you another example. Talking about one to one and talking about a tough place to be right now. I.

just got this morning. usually get maybe eight or 10, you know, WhatsApps or, you know, like a Facebook message a day from, from doctors or patients. They're just sending stuff from around the world. This one was from a colleague of ours in Yemen. And I get probably three pings a week from him. This guy who's running a unit in Yemen. And you would say, what the heck Yemen? I this is a country that is a hot zone.

And yet he is asking me questions about wound healing and frustrations that he's having. But what would he do here? What would he do there? And I'm hooking him up with friends of mine on the Arabian Peninsula as well. And he's and there's a little group chat that's happening now. Believe it or not, we also have one in Damascus of all places. I we can be kind of Switzerland here. You we could be sort of neutral and just wanting to help people. Yeah, no matter what their political leanings in this sort of thing.

So you're starting to see these sorts of innovations in my little area, just the most humble one, in trying to help people heal and move through the world a little, starting to happen and happening on the day to day. And all I have to do for me, again, I'm just one toe doctor, is look on my WhatsApp feed. I mean, it's crazy. it is amazing how, especially in places where it's tough.

how individual women and men can make a difference, right? And they can make a difference for good and they can make a difference for bad, but it could definitely make a difference, I think, predominantly for good. And you see how that happens. so whenever anyone says, well, I'm here or I'm there and I can't do it, first of all, I empathize with them. But then I say, you know what? That's not true. Do you know this guy or do know her? And putting weird ideas together with weird people is where it's at.

Shayan Mashatian (49:27.989)

I love that.

Akifa Khattak (49:30.324)

No, that's awesome. I I love all of the momentum towards this and towards innovation. obviously, you are the right person because of your experience, your credentials, everything you're doing. it's really reassuring. And I hope that it reassures others that say, hey, look, if you're doing it, then hopefully that they will also be more willing to adopt those things.

I do have a little bit of a funny story because you did mention how, you know, previously people would say, you know, let's just cut this off and just write off that patient and then let's get on our way. Well, I was a student at the time before I went to law school, trying to figure out what I was going to do. And my mother is an infectious disease specialist. So, and she was one of the only specialists during the AIDS epidemic I grew up in Zimbabwe. So she would.

David G. Armstrong (50:19.138)

Awesome.

David G. Armstrong (50:26.803)

my gosh, we're in Zimbabwe! you sure told me! my gosh, I have friends! Okay, wait, we gotta do this later. This is great! Wow!

Akifa Khattak (50:28.318)

Yeah.

Akifa Khattak (50:33.746)

Yeah, we'll do a Zoom afterwards and maybe do another intro. So she dealt with quite a lot of different things. And at one point she said, hey, why don't you go and shadow a podiatrist? Go and see a surgery. Go see what they do. I'm over there. I'm young. I'm a student. And I'm learning. And then the surgeon says, hey, look at their foot. How much do you think we need to cut off? And the whole thing was pretty much it.

David G. Armstrong (50:37.813)

gosh.

Akifa Khattak (51:03.41)

gangrene like the whole thing was with the limited knowledge I said you know what it looks real bad I think you need to cut off the whole thing I mean I would go up to the knee if you could and so then he goes Akita in the surgery we tried to preserve body parts and that was the biggest yeah okay then he said actually we only need to cut off maybe two toes

David G. Armstrong (51:04.706)

Yeah.

Akifa Khattak (51:30.492)

And I said, but the whole thing looks like it's gone. said, put it in the hyperbaric chamber. The whole foot could regenerate antibiotics, et cetera, try to preserve that. And then the person, if you have to think about it, they go home, I mean, are they going to have to deal with not having a foot or not having to deal with a couple of toes, right? So that was a huge learning experience. mean, I've obviously grew a lot since then, right? But to understand.

where people come from and what they're going to have to deal with. so actually with endometriosis, I would say there's still kind of is this stigma that, you have this pain, we don't know what to do, get a hysterectomy. And that's almost like the Stone Age that hopefully people are not, you know, actively saying that that's the solution. So preserving limbs, I think, is really awesome. Technology, I think, is really cool.

And also, you know, when you mentioned the different systems, Singapore is phenomenal with innovation. I think that my follow-up question is I'm interested because I did do a little bit of a deep dive on the different healthcare systems, Brazil, UK, Middle East, et cetera. When you're dealing with people in these different healthcare systems, what do you think we could learn from them?

David G. Armstrong (52:33.23)

yeah.

Akifa Khattak (52:51.412)

in the US. So what do you think that we do good and what do think that we could learn from other systems?

David G. Armstrong (52:57.158)

Yeah, wow. So first of all, I mean, it's astonishing when you start talking about what now is called, you know, femtech, but colloquially, but I mean, literally and figuratively, when you talk about you talk about a hysterectomy, you talk about people, we even our language about women, you know, we say she is hysterical coming from the, you know, coming from the uterus, like it is something that is that is a stigma.

Attached to her in this case never to him and that the really great thing now is that's changed dramatically because of people like you so I mean you're just you're taking it on and you're so anyway that is friggin great, but if you're looking at different health systems, okay, so I think that Every country I think probably has some you positives and negatives

And you sort of have to do with every system, with every health ministry, with every, or in our area, in our most Byzantine world here in the United States, where quite literally every patient is their own kind of medical system. And you have to do almost a biopsy on the person to find out what can get covered and what can't and work with them. There's good and bad. In the United States, the good is that

It's phenomenally expensive. takes a phenomenal amount of our GDP, what is it, like 16, 17, crazy percent and growing. That's bad that it does, but it's good in that there's a massive budget in R &D for this area because people charge so much for this that a lot of companies say, well, I could recoup my investment on something like this. Therefore, I'm going to continue innovating.

Of course, the bad part here in the United States is that there are so many different complicated systems. And when you start drilling down, you see that each person is their own unique kind of ecosystem, health care-wise. And it's really hard to figure out how to get past that. That is a massive negative, because I think that stifles innovation.

David G. Armstrong (55:22.586)

Stifling who's going to get what and where if we could just have something that was more streamlined where we said, okay, look, we're going to invest this in this area. This is probably going to fail, but we want to take like the guys and gals at ARPA and DARPA say we want to take this glorious attempt and we're going to try this and go for it. If we fail, at least we're going to fail forward, right? but and if we don't, then we're going to have a fast track designation for this.

And this and so this is getting better and better in the US. It's not getting worse and worse. So I'm I'm optimistic about this in the US, not not pessimistic. In other countries you have top down systems that are much more kind of centralized. It's easier. I mean, it's hard, but still, but it's easier to do it in a country like Singapore, where you have about 6 million people, you know, rather than 350 million. And you have just a few health districts and you also have a really awesome.

kind of innovation ecosystem with great universities and whatnot, great public transit, et cetera, et cetera. And you can do top down and bottom up, but even there, it is so hard to adopt stuff culturally and across different systems. And you also have private and public insurance in the UK. You have the NHS and within NHS, NHS my whole life, I used to have a license to practice in the UK.

but and I have so many friends there, so many patients across. Well, but the point is in NHS, everyone loves the NHS and they love to hate it. And there's always a massive crisis. Now, of course, many people think it's the massive crisis, but still it's great. It's still cradle to grave health care, but.

Akifa Khattak (56:54.568)

The question is what don't you do? That's amazing.

David G. Armstrong (57:18.19)

There's a long line if you want to get, there's a queue if you will, if you want to get something elected, if you want to get your hip or your knee, you have to wait a long time and so you have to supplement that with private insurance to get to the front of the line with your Bupa or whatever your insurances that you have. Now don't even know what these insurance companies are anymore. But the goal for you as an innovator, I guess, it's the same goal for me as a clinician or as a clinician researcher.

And I have to find where the buckets of resources are. And then each one of those buckets of resources is both really complicated, right? But it's also an opportunity because I could say, okay, she is the CEO here. I know that she is overseeing all of these folks and she is taking risk on all of this. But maybe if we did this and this and this, we could help her look after these people a little bit better. He, he

is the head of this department. And his department is getting paid based on how many things that they're doing. Now, I don't necessarily like that philosophically. I don't think it's the right way to treat him, but you know what? I really like this guy and I like what he's doing. I know his heart's in the right place, but maybe we can attract and get resources here by identifying how he can do more of these widgets and procedures in a procedure-driven kind of...

environment, even whilst making I say whilst that's kind of affecting something British there. Don't tell my wife. Don't tell her. She'll she'll roll her eyes. My long suffering much better half Tanya. But she's like on my shoulder here. But but you can do this, you know, whilst still trying to identify the the problem, the big problem at hand that you're trying to accomplish. So you can work in all these different environments.

or you're in the clinic and it's a nurse and she is saying or he is saying, you know, this is my problem. And you understand that they can do a lot with that in that individual clinic, but maybe their resources, they're going to have to go through 10 different people on the wiring diagram to effect change. So your goal is to figure out where these folks are and how to optimize that. And if you get good at it, I think different people

David G. Armstrong (59:43.448)

can do that fast. And then they can find out how to triage it, just like you're assessing a patient. It's like physiology, but for resources.

Shayan Mashatian (59:54.369)

Wow, we came up with a few metaphors today, David. The part you said, find weird people to work on weird problems. was, if I recall, that's what I love it. I guess we can continue this conversation forever. I hope we will have you again in future, get an update. Before we wrap this up, I just wanted to ask you about the upcoming conference, DFCon next week, right? Would you like to share a bit about that?

David G. Armstrong (01:00:21.102)

yeah. for sure. listen, you're all very welcome. if you want to kind of hang out virtually or actually, we have a meeting called the International Dive Bigfoot Conference or DEFCON. So it's a joke because it's a kind of a double entendre. There's another French thing, but it's both a, you know, it's like the war on amputation is kind of the joke. And you know how DEFCON as the number gets bigger,

Hopefully the theory or the risk would get smaller for thermonuclear war. The double entendre is the risk gets lower for amputation. So DEFCON 24, as in it's literally the 24th year. It started 20 something years ago. We have all kinds of people, 50 countries, all 50 states. It's gonna be here in Los Angeles area in Anaheim at the JW Marriott near Disneyland. So you're very, very welcome. Or you can just go to DEFCON.com. You're welcome.

Anytime you could join ALPS, join ALPS for free if you want. There's always some kind of offer. And the goal for that for ALPS is to try to bring people together to try to eliminate preventable amputation over the next generation. And that's the same mission for DEFCON and for all of us that are looking after these patients, trying to help them move through the world. Total pleasure, man.

Akifa Khattak (01:01:41.22)

Awesome. Thank you. Thanks. We have to let everybody know about that to get the more the merrier. So I guess my closing, you know, comment or question is, do you have any recommendations for young people? Because, you know, one thing I'm a huge advocate is bridging the gap between different generations and different the public and the professional sector. you know, medical students, entrepreneurs, but also the general public. mean, people that all of this lingo, they might not speak it. So

you know, their place is, so any kind of notes for any of them.

David G. Armstrong (01:02:15.822)

Yeah, 100 % yes. So none of this stuff, I mean, I think at the end of the day, the way that, I don't think even though we all want people to remember our name, no one's gonna remember our name in the arc of time. But what they'll remember hopefully is some of the things that we've done and hopefully maybe push things forward and paid it forward a little bit. And that only comes by hooking up with folks

that have had a little more experience than you. And what I would say is to young women, young men coming up is I wish that you could be so fortunate as I have been to find mentors. And these are mentors that are, again, women and men that are excellent in what you maybe want to do, and you seek them out, and you ask them, and you, and don't be afraid.

to seek someone's advice and to ask them for this because when you do that, you are honoring them. And if they blow you off, don't worry about that. That's not worth your time. And they're probably not even a mentor anyway, but the women and the men that will take you in, that's a sacred duty for the mentor and for the mentee because the real immortality for her or for him that's mentoring you is to see that you, the mentee.

are doing well, making a difference and paying it forward. And that's the immortality, that's the arc of time. And if I can give you any kind of advice, it would be just to collect as many of those key mentors as you can and ping them every now and then. Now it's so easy to do. You could just message them and call them, but really ask them. And then you start hearing their voice in your head. And it's not schizophrenia. It's actually, it might be.

But it's actually your, it's right. It's the right thing because you're asking, well, what would she say? What would he say? What kind of advice? Whether it's about a job, whether it's about an idea or innovation. And that is the way that you move the arc and you move the needle and you really affect change. And here's to that, you guys, for real. And here's to paying it forward.

Shayan Mashatian (01:04:39.275)

Thank you so much, David. And we know you are so busy between surgeries, travels, lectures. We really appreciate you assigned generously this time to us. Thank you very much.

Akifa Khattak (01:04:40.904)

Thank you.

David G. Armstrong (01:04:49.678)

The pleasure is absolutely, positively mine.

Shayan Mashatian (01:04:54.542)

Thank you very much. Have good day.

Akifa Khattak (01:04:56.382)

Thank you for your time. Thank you so much for all the information.

Shayan Mashatian (01:05:03.073)

Okay, awesome. Just it needs to be finished uploading.

David G. Armstrong (01:05:07.866)

yeah, don't you have to do that thing where you wait? Yeah. there it is. It's 99 % uploading.

Shayan Mashatian (01:05:12.265)

yes yes okay

David G. Armstrong (01:05:13.976)

Yeah, I'll make sure to wait because I know people say you gotta wait otherwise you can screw the whole thing up.

Shayan Mashatian (01:05:21.749)

yes yes i'm looking to stop the recording it keeps recording and uploading i shouldn't

David G. Armstrong (01:05:31.091)

Have you tried shaking your machine, your computer? No? Not shaking it. Try taking your head and hitting the camera with it, like the headbutting. No? That doesn't work either?

Shayan Mashatian (01:05:35.175)

I haven't yet...

Akifa Khattak (01:05:41.396)

is my go-to. This is my go-to.

Shayan Mashatian (01:05:41.547)

Connecting maybe? Let me see. Usually you click on record. Okay, let me open another.

David G. Armstrong (01:05:49.106)

yeah, well I could do a thing where I say leave if I do it here, but I don't want to do that. Am I allowed to do that or no? Do I wait?

Shayan Mashatian (01:05:55.713)

Yeah, it allows you to leave just you shouldn't Shut down your Chrome. I would say because then it it caches and

David G. Armstrong (01:06:03.542)

All right. When your recording is done, you may need to stick around a little to upload your high quality recording. Yeah, it says when the recording is done. It still says recording. You're having a hard time identifying where to record.

Shayan Mashatian (01:06:10.153)

Thanks.

Shayan Mashatian (01:06:16.237)

Yeah, when I want to... Let me sign in again. When I try to stop recording, it doesn't give me an option to stop it. Let me join session with another one.

Shayan Mashatian (01:06:36.277)

I mean it has uploaded it wouldn't lose it.

Shayan Mashatian (01:06:45.019)

see it says leave a studio or end session for all I guess if I end session it will keep uploading right it naturally stops recording David it was a pleasure really thank you very much and this is great

David G. Armstrong (01:06:52.536)

Yeah. Yeah, I think so.

Akifa Khattak (01:06:56.372)

the things that we need to

David G. Armstrong (01:07:00.898)

The pleasure's mine, totally. It's super fun, you guys. I look for the next one. Akif, I look forward to the next one, whether it's in O-Town, Orlando, or wherever, for sure.

Akifa Khattak (01:07:04.816)

Thank you.

Akifa Khattak (01:07:15.1)

Absolutely. What's the best way to connect LinkedIn?

David G. Armstrong (01:07:18.542)

I guess so. Yeah, I people use that a lot. Yeah, go for it. I get a lot of Yeah, please do that. And you can but definitely you just email me