The OR Black Box and Improving Surgery with Dr. Teodor Grantcharov

In this episode, host Rachel Baker sits down with Dr. Teodor Grantcharov, a professor in the Division of General Surgery at Stanford University. They explore Dr. Grantcharov's journey across the globe from his early days doing surgical residency in Copenhagen to Toronto and now Silicon Valley and how each country’s unique healthcare system impacts patient care and research.

The inventor of the OR Black Box, Dr. Grantcharov shares insights on the importance of continuous learning, the role of entrepreneurship in medicine, and his passion for improving surgical practices through innovative technologies. He also emphasizes the need for surgeons to find balance outside of their demanding careers, highlighting the importance of hobbies and personal growth.

Rachel Baker: [00:00:00] Welcome to ScrubCast, where we take a closer look at the research happening at Stanford University's Department of Surgery. I'm your host, Rachel Baker. Today, we're speaking with Dr. Teodor Grantcharov. Welcome to the show.

Teodor Grantcharov: Thank you, Rachel.

Rachel Baker: Thank you for joining us, Dr. Grantcharov. You are a professor in our Division of General Surgery's Bariatric and MIS section.

Why did you choose Bariatric/MIS?

Teodor Grantcharov: I chose it many years ago. I was a resident in Copenhagen, and I was doing my PhD in the department of surgery at the university there and the focus of my work was To develop a virtual reality simulator that could, uh, measure the skill of the operating surgeon. And I started that in 1999.

Uh, I remember we developed the simulator and we started practicing on it and measuring skills. So I was fascinated by [00:01:00] the skill development in minimally invasive surgery. It was still kind of fairly new, uh, discipline at that point. Uh, and, and I love innovation. I love developing, uh, new skills. I love measuring skills.

I am a competitive person. So I felt that my skills were pretty good. I felt that this was an area that I should pursue. And obviously, as many residents, we find a person who we want to be like. So I was fortunate enough to work with some great mentors who were minimally invasive surgery pioneers. So they inspired me.

It was many years ago, but I've been excited about this field, and I still am.

Rachel Baker: Wonderful. Well, I was stalking your CV, and I read that you did your medical education in Bulgaria, your residency in Denmark, as you were just saying, in Copenhagen, your fellowship at Temple in Philly, and then before Stanford, where we are now in [00:02:00] California, uh, you were most recently in Toronto.

So, I was thinking about this. I was homicidal trying to move across the country once, and that didn't require learning a new language or a visa. So I figure you must've had a pretty good reason each time you moved. Can you tell us about the catalysts?

Teodore Grantcharov: That's a great point. I, I remember when my kids were smaller, they were born in Denmark and then we kept on moving.

They were asking me, Dad, what nationality are we? It was a funny question, and there is something sad in it.

Rachel Baker: Citizens of the world.

Teodor Grantcharov: Yeah, you don't belong to a certain nation or a certain place, which is a little sad, but also at the same time is very liberating. You feel home wherever you go. You feel open to, uh, new people, new culture, new ways of doing things.

And, uh, it's kind of, it has been our family philosophy to always be open for new opportunities. And, uh, I can't say that there were always, uh, [00:03:00] amazing reasons. I remember when I finished my. Training in Denmark. I was presenting at a conference in, uh, in New York and the chair of the surgical department in Pittsburgh at that point said, Hey, uh, why don't you come and work with us and continue your research in our center?

And, um, I went home, we chatted about it. And a few months later, me, my wife and two small kids and nine suitcases were in Pittsburgh, Pennsylvania.

Rachel Baker: Oh my gosh.

Teodor Grantcharov: It's not easy to, uh, to pack everything and move to a different continent. So we said, this is the last time we're going to move. Uh, and then, uh, a year later, the chair of surgery in Toronto, who had also heard about some of my research, said, Hey, uh, we will, um, give you the opportunity to realize your academic dream here.

And, uh, four months later, uh, the whole family was in Toronto. And then I, at that point, we also said, this is the last time we're gonna, we're gonna move. And here you go, 16 [00:04:00] years went by, uh, when I met Mary Hawn and Mary said, uh, what do you think about joining us at Stanford? And I clearly remember in the recruitment process, I had a conversation with Tom Krummel, the previous chair of surgery here.

I was chatting the pros and cons about moving to Stanford and he said that ultimately there is only one question here. Are you a guy who likes comfort? Are you a comfortable guy? Are you a risk taker? And, uh, and that kind of reminded me who I really was. And, uh, 15 minutes later I signed the contract and here I am in Stanford.

Rachel Baker: Amazing. Well, so our next question is coming from Maria Rakutko, who's on our finance team. She asks, how much do you feel based on your experience in multiple countries? Does healthcare infrastructure affect research, patient safety and training?

Teodor Grantcharov: So by healthcare infrastructure, I assume, uh, She means the health care system.

Rachel Baker: I think so.

Teodor Grantcharov: And the business model around the health care system. And that impacts it [00:05:00] dramatically. It obviously, the system in the United States is unique. Health care system is a business model. It is the rules of the market. Everything is supply and demand. And, uh, there is a demand for surgery. And, uh, the job of the doctor is to provide service.

Um, so, uh, often, uh, Here, the doctors are measured by number of RVUs, and this was one of my main fears before coming. Stanford is different, but generally, there is a reason why Stanford is a leader in so many areas of academic research. But generally, the healthcare system in the United States promotes production of surgical services, and not necessarily production of academic output.

It was very different in Europe, and Canada is a unique system. I mean, it's kind of a hybrid between US and Europe. I really think that, uh, while I was in Toronto, that was a quite successful model of building academic [00:06:00] practice where, uh, it is, uh, it is a hybrid between your productivity and skill and performance as a clinical surgeon and ability to capture grant and build an academic enterprise.

So, uh, I keep saying to whoever asked me, well, so what do you think? Where is the best place? I usually answer. The perfect place doesn't exist. Uh, there are positives and negatives everywhere. But generally I've been pretty lucky. Both Denmark, Toronto, and Stanford have been exceptional places. Very different practice, very different healthcare system.

But everywhere great people and great commitment to excellence, both clinical and academic. So, um, it is an important question to always, uh, understand. The business model behind every system and the business models here are very different.

Rachel Baker: Well, speaking of business models, let's talk about your invention, the OR Black Box.

So based on the name, I was thinking airplanes, but ORs don't usually fall out of the sky. So that got [00:07:00] me thinking about a more figurative type of crash. And I thought of the crash cart. Is that what this thing does? Do they provide like an unbiased recording when something goes wrong in an operation?

Teodor Grantcharov: The association usually brings the image of the orange box that we see usually when a plane crashes.

But in the early days, when I was developing that platform, I spent some time with the flight data analysis team with Air Canada. And I realized that there is a secondary black box. It's not just the orange black box that's used only. Extremely rare, luckily, uh, when there is an accident, but they have a secondary black box installed on every single aircraft.

And overnight, the data is transferred to their flight data analysis center in Toronto and it's analyzed by an unbiased team. And really the focus is to understand risk safety threats before they've resulted in catastrophic outcomes. And they've been building this for decades, maybe a couple of decades now, where they have a very sophisticated [00:08:00] database that can predict what are the most common risks on a flight from San Francisco to New York depending on the type of aircraft, depending on the experience of the crew, time of the year, time of the day, and so on and so on. So they've replaced the reactive model with a proactive model where they identify risks and mitigate them before they've resulted in catastrophic outcomes. And this is really the philosophy behind The operating room black box, we don't have to wait to see statistically significant differences in morbidity and mortality before we act.

We want to know what we do, right? We want to measure our process. We want to celebrate our success cause that's as important as studying our failures. Um, in fact, I would argue that studying success is much more meaningful and. valuable than studying failure. But this is the philosophy that we follow and this ability to make this transition from reactive, which is the morbidity and mortality [00:09:00] to proactive, which is the predictive model, the quality review and ability to adjust practices, to improve process and to strengthen the collaborative culture in the operating, we want our ORs to be the most efficient, the safest, but also most collaborative and fun.

Uh, and, uh, this unique combination of data and culture, uh, is the key to, uh, this transition from safe to ultra safe and to the world of high reliability that nuclear, aviation, oil, and other industries have figured out, but we're still on our journey.

Rachel Baker: I had no idea about the second black box. That's fascinating. And I love that we're moving towards a proactive model. One question. I was under the impression that most surgeons don't like being recorded. Did you meet any resistance?

Teodor Grantcharov: Yes. So it is a natural reaction. I can tell you that on our way to the hospital today, [00:10:00] we probably were captured by a hundred cameras.

Right. It is the reality of the world we live in, but, uh, but it is true. It is natural. It is a natural reaction that anything disruptive, anything that changes the way we do business, we should resist that. And there is a lot of, uh, misperceptions here around, uh, the OR Black box. It's not recording. In fact, it is capturing data.

It's processing data, but the actual recording is destroyed for privacy reasons. I remember first time I presented it in a conference, it was a room of 500 surgeons there. And I remember this guy. Stood up and said, Hey, uh, what, what do you think you're doing? I've been practicing surgery for 30 years.

There's nothing I can learn. And, uh, you know, this is the, always the clash between the conservative views and, uh, progressive futuristic views, the attitude of, if it's not broken, don't fix it, and there is always better. But I firmly believe that this is something that we [00:11:00] owe to our profession. We owe to our trainees.

We owe to our colleagues and most importantly, we owe to our patients. I remember when I first launched this in Toronto and it got a lot of public attention, I think my wait times quadrupled, patients were moving from other hospitals and they were saying the same thing. They were saying, I can't believe this hasn't been done before.

We can't believe that there is no system in place that makes sure that you continuously improve. We don't expect you to be perfect. We don't expect you to never commit errors, but we do expect you when you commit errors, when you are not perfect to study it, to learn from it. And the next time you get into the operating room to make sure this doesn't happen again.

So this is the driver for us. We want today to be better than. Yesterday and tomorrow to be better than today. So we can get there without more transparency we can get there without this cultural transformation where we learn [00:12:00] how to tolerate error, and we'll learn to look in the mirror. The surgeons are not very good at this, or they see something very different than reality when they look in the mirror.

But I think it is a good exercise, and it is a fantastic feeling once you embrace the philosophy of continuous improvement, I learned a lot from it. I've been doing this since I was PGY2 and I certainly have met a lot of surgeons around the world who feel that this is the right way to do business.

Rachel Baker: Well, I am a huge believer in the growth mindset. I believe a day is wasted if I haven't learned anything, so I am right there with you.

I was speaking, uh, with one of our general surgery residents last week, and this is Dr. Josh Villareal. He told me that I should ask you about entrepreneurship in medicine. Is that something you feel strongly about?

Teodor Grantcharov: I feel very strongly about, about that.

Uh, I remember how this happened with me. I was driving home [00:13:00] after our last publication, we celebrated in the hospital, I was driving home and I thought, okay, that's great. It's another line on my CV. It's a great investment in my career. Uh, I will get promoted from assistant associate to full professor.

But what have I really changed? And that feeling of coming up with an idea, finding funding to execute the study. presenting the study, publishing the paper and stopping there was extremely unsatisfactory. I felt that there was something missing there. I felt that if we don't bring this paper, these research findings to the bedside, to the patient, actually nothing else matters.

And I was thinking, well, what are the options here? The options were Knock on the doors of administrators and make them adopt my findings, knock on the doors of industry and ask them to, to use our findings. And I've [00:14:00] done that for, for decades. It wasn't. Taking me anywhere. So I thought the only way to bring it to the world is to take responsibility for the last, most important step of innovation and research, which is bringing it to the world.

And I felt that the commercialization entrepreneurship was such a powerful. vehicle for that. So I've heard a lot about the doctors shouldn't be doing this. We're not trained. We don't know how to do it. We're not good enough. And I firmly disagree with that. I feel that there is no one better in the world to bring innovation to the world than the people who have experienced it in practice, who believe in it, who do it for the right reasons and the right way.

So, uh, Probably that's going to be one of my, uh, goals in, at some point in my career is to travel around and encourage physicians to pursue. Entrepreneurship and see it as part of the circle of academic enterprise to come with the idea, [00:15:00] prove or reject the hypothesis, and then publish it in a scientifically sound way and then take it to the world.

Rachel Baker: Amazing. Well, we are at that point in each episode of Scrubcast where we ask each of our guests these same two questions. And the first one is. Who is a surgeon you admire and why?

Teodor Grantcharov: There are so many people I admire throughout my career. It's hard to point one person. At different stages of my career, different people have inspired me.

Usually, the surgeon that inspires me is not those who are technically perfect or extremely bright or brilliant, but those who've been able to develop holistically and see, see the good things in the hospital, but also see the great thing outside the hospital. Uh, and I think these are the people that future generations should use as, as role models, where [00:16:00] we need to remember that the number of RVUs don't define us, the number of research papers don't define us, but our attitude to patients, our, you know, attitude and support to each other, our ability to.

To be happy for the success of people around us, our ability to enjoy our family and the fun world outside the hospital. So these are usually the people in my career who have been. Great role models and great surgeons.

Rachel Baker: I agree. I, uh, wrote a story about Dr. Spain and his decision to step down from being the director of the trauma section. It's inspiring how he's like, there are books I haven't read, walks I haven't taken. I'm just like, I can totally get behind that.

Teodor Grantcharov: I love that. The ability to recognize that, uh, you know, it's time to advance your own career and to leave your own legacy. And, uh, and then it's time to [00:17:00] support those who, uh, come behind us with more energy, uh, with more ambition and be happy for their success and be supportive to them is, is a phenomenal, uh, quality.

Rachel Baker: Absolutely. Well, the second question is—really hard hitting this one: What is the best advice you have received in 10 words or less?

Teodor Grantcharov: So I, I clearly remember that I clearly remember that moment I was a resident and I, uh, received an important award in Denmark. And one of the senior surgeons came to me and said that, yeah, I know this is one of the greatest days in your career so far, uh, but just, I've got only one advice to you.

And that's, uh, that is. Remember to find a hobby or something outside the hospital. Today, you're on the top of your game, but if that's all you've got, there will be time not too far in the future, where there'll be people who are better than you, and that will be a catastrophic moment for you. So find something outside the [00:18:00] hospital, find a hobby, find a.

Something that excites you and you'll be happy for a very long time. So I don't know, maybe it was a little more than 10 words, uh, but, uh, it was remarkable advice and I've never forgotten it.

Rachel Baker: Love it. Well, it has been a pleasure chatting with you. Before we go, I have one last question and that is what is next for Dr. Grantcharov? Hmm.

Teodor Grantcharov: My next thing is I want to improve my tennis game.

Rachel Baker: Okay.

Teodor Grantcharov: Actually, I'm on my way here to, uh, play a tennis game. I have approached tennis the way I approached surgical training. , I, uh, uh, oh, I wanna, I wanna see the video of my game. I wanna see areas that I can do better. Uh, so maybe, um, my next thing is gonna be join the senior tour in tennis.

Rachel Baker: Oooo, yes! Sounds good. Well, I'm looking forward to it. Thank you again for joining us on the show.

Teodor Grantcharov: Thank you, Rachel.

Rachel Baker: And that brings us to the end of another episode. If [00:19:00] you like Scrubcast, we hope you'll tell your friends and subscribe wherever you get your podcasts. Scrubcast is a production of Stanford University's Department of Surgery.

Today's episode was produced by Rachel Baker. The music is by Midnight Round. And our chair is Dr. Mary Hawn.