E103 Teodor Grantcharov on the OR Blackbox
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Chad Ball 00:02
Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only masterclasses on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment of the surgeon and perhaps more importantly, as a human.
Ameer Farooq 00:28
Dr. Teodor Grantcharov is a bariatric surgeon at St. Michael's Hospital in Toronto. Dr. Grantcharov is world renowned for his work on the OR black box, a platform that allows for immense capture and analytics of operative data. We asked Dr. Grantcharov about what it took to develop the OR black box, not just technologically, but culturally, and institutionally. You can find out more about the OR black box at surgicalsafety.com and check out all the links in our show notes.
Teodor Grantcharov 00:58
I was born in Bulgaria, and moved to Denmark and did my training, surgical training. And at the University of Copenhagen, I did my PhD there, then spent a year and a half, a couple years in Pittsburgh, and I've been in Toronto since end of 2006. So, it will be close to 15 years later this year. So, thank you, I've seen a lot of different educational systems, I've seen various healthcare systems. And I always tell residents and fellows, my advice to you is, look for some diversity and experience. Look for different ways of doing things. And that's how you build your own style.
Ameer Farooq 01:47
Yeah, you know, we've talked a lot about on the podcast about how having that diversity of experience really does make a difference in broaden your horizon. If there are a few things that you could kind of pinpoint as being different, let's say between your training in Copenhagen and the North American system, could you highlight some of those differences?
Teodor Grantcharov 02:06
So, it's, I think probably things have changed a lot in Copenhagen since I left. But there was a lot of independence, there was a lot of opportunities to make decisions independently and execute them independently. I think that was important. I think that's how you grow as an individual and as a surgeon, rather than close supervision that I saw a lot once I came here. But you know, at the same time, the amount of volume, the amount of massive experience, our residents here in Toronto and throughout North America get throughout their education, I think it's phenomenal. So, there are good and bad things with every system. I think, overall, we're lucky in North America. I think a lot of the residents in Europe or in Denmark are also lucky. But the perfect place doesn't exist. So that's why I say go different places, see a lot of things that are good. And you'll see a lot of things that are not so good. But when you finally settle, and you want to build your own environment and contribute to a certain system, that's how we become better contributors and that's how we can make a place better by adopting the good things and trying to avoid the bad things.
Ameer Farooq 03:36
Yeah, absolutely. And I think it's all about bursting your bubble and challenge your dogma, which is, you know, that's sort of a theme of all the work that you've done is challenging dogma. And not deciding that whatever we do is the only way and the right way of doing things.
Teodor Grantcharov 03:53
No, absolutely. Yeah, absolutely. I completely agree with you.
Ameer Farooq 03:58
We're very lucky, obviously, in Canada to have you in Toronto. How did you actually end up coming from Pittsburgh to Toronto?
Teodor Grantcharov 04:08
You know, one of the basic principles for me, in life, in everything I do, both personal and professional has been if there is an opportunity that presents itself, never say no to an opportunity. So, I clearly remember when I came to Toronto for the first time in 2001. And I visited Dr. Resnick, I've been a follower of his work, and he's inspired me a lot throughout my career. So, I visited him in 2001. And it was one November day. Toronto was great, it was raining, it was cold. And I thought, wow, I can't wait to leave. It wasn't a great experience. And then in 2006, I had another conversation with Dr. Resnick, and there was an opportunity to join the faculty here at U of T and he said why don't you come and visit us in Toronto. And it was amazing. It was, I think, June or July, it was during World Cup of soccer. The city was amazing, you can see all the flags, so diverse people with different backgrounds, celebrating their soccer teams, and I thought this is the best place in the world. So that was the summer. By November, my entire family was in Toronto. And it wasn't the plan, but that's how sometimes life offers you an opportunity, and as long as you keep an open mind and ready to take challenges, a lot of good things are gonna happen. So being in Toronto has been a tremendous experience for both me and my family. And I think I learned a lot, I grew a lot as a surgeon, as a teacher, as an academic. So, I feel home here.
Chad Ball 06:08
You know, I think that's such a great story. And it's an important message too that we hear a lot in the podcast with a lot of different really successful people. And sometimes you know, the opportunities that come your way maybe are sometimes right in front of you. And you should take each one of them and give it real thought. Absolutely. And you know, it's what I always tell the residents, the fellows, the research group around me, is that life will offer you opportunities. When you see a good opportunity, don't wait for a better one, grab it and make the best out of it. Last week I was in California and I had a coffee at a place called Joe & the Juice, maybe some of you have seen it or not. Joe & the Juice started his first place in Copenhagen. I used to go there after I was called to grab a juice or coffee then in the past couple of years, they kind of exploded, primarily in the New York City area and Silicon Valley. So, I had a coffee last week. And remembering the days when I was a resident after 24 hours on call. And there was a big slogan on Joe & the Juice. And it said, "when life offers you strawberries, take them and make a power shake". I love it!
Teodor Grantcharov 07:39
Life will always offer us great opportunities as professionals and individuals on our end, we just need to keep an open mind and take advantage of those. Because then good things are going to happen. People always wait for a secure choice, a better option, you know, then there's nothing worse than looking back and saying, you know, I had this opportunity, I didn't take advantage and it never came back. So that's very hard to live with. Well, if you take an opportunity, and even though it turns out to be the wrong one, and you failed, you still learn a lot. And I still think that you become a better person and a better professional.
Chad Ball 08:22
That's great advice, particularly for you know, prototypically conservative surgeons, right, that's a hard thing to do. But you're right, we have to keep that in mind for sure. You know, your background, as Ameer talked about, is so broad and so varied. And I remember that you first came onto our radar here in Calgary with regard to surgical education and virtual simulation. I'm curious if you could sort of start us there and walk us into your OR black box and define for our audience what that is how it works and what was the inspiration or the genesis of it?
Teodor Grantcharov 08:59
Yeah, so happy to do that. You know, I was chatting just before we started the podcast with Ameer, he was telling me that he joined the fellowship has started recording his cases and I hope we'll have the opportunity to talk a little bit more about your experience. But I clearly remember when I recorded my first case, and I think it was PGY-2. Very early in my career. And I did a Lap Chole. And at that point I recorded on a VHS tape. I don't know whether I still keep this tape, I got to look in my basement. But you know, when I was at the OR, I was so excited. I did this cholecystectomy alone with a little bit of supervision. I felt that nobody in the world could do better quality cholecystectomy than I did that day. It was one of the best days of my life. I recorded on the VHS tape, and I watched it later on the TV, and it looked terrible. It was terrible, it was very humbling to see how slow I was, how uncoordinated my movements were, I could see things when I was watching the video that I couldn't believe I didn't see while I was doing the case. And since that day, I've recorded every single case in my career. And there were some cases, maybe some in malfunction, but I've had hundreds and hundreds of procedures recorded. And especially in the early phase of my development, this made a huge impact, the ability to review your performance and see things that you miss while you're in the middle of the action, which is inevitable. So later on, when I started my research on performance measurement in surgery, and I started in 99, 2000, I completed my PhD in 2003. So many years ago. I was really fascinated by the huge variability in performance in a simulated environment, in a virtual reality environment. And later on, we started measuring outcomes through an S group and other measures. So, we found significant variability in outcomes. And I always wanted to understand what were the factors that contribute to that variability. So obviously, ability is one thing, performance is something else. And then understanding what, and again, performance can be measured using many different frameworks. It can be technical performance, non-technical, and other aspects. So, when we started studying technical performance, we saw variability between surgeons, but also within the same surgeon, then, we looked at non-technical performance on the team level. And we found that that's very important, who is with you in the operating room matters. Who your assistant is, who the scrub tech is, who the circulating nurse is, who is the physiologist, so the performance on a team level matters. The technology we use in the operating room matters, distractions matter. So, we understood the more and more we dig into that, we found that this is a fascinating but also very, very complex area. So, in order to study these dependencies installed, in order to study the relationship between various factors that influence our performance, we understood that we need to capture a significant amount of data. And we couldn't do that with procedural video alone. So that's why the idea of the first generation of the black box came and initially, we found a lot of technological challenges that we kind of overcame throughout the experience. But we found also massive cultural challenges, which is one of these things that are difficult to solve, but also very, a really fascinating task. And I think this cultural transformation in our profession is critical if we want to improve. So, we learn a lot through this process. And then obviously, being here in Toronto with access to great engineers, computer scientists, human factors, experts, designers helped us learn a lot. And I think we will always look back and wish we had done things faster. But I think we're in good position now to one day soon change the way we practice surgery.
Ameer Farooq 13:58
Yeah, one of the things that I love about your body of research is that you've really taken each of those kinds of elements and problems that you just described and broken it down and really tried to dig deep into all those. Like, for example, even the whole idea of, you know, I love this image of you watching your video as a PGY-2, all excited, like "ah, I did the best lap-coolly possible", and then afterwards, looking back and thinking, oh, shucks, that wasn't actually that good. And you've done some, like actual quantitative data about this exact topic. You know, two of the studies that I can think of are, you know, this one where you went back and looked at various needle injuries, and how those were under reported. Another where you actually asked surgeons and fellows and residents to recall if there are any misadventures or adverse events during a case and they really could not recall anything significant or in an accurate sort of way. Can you talk a little bit about that line of research?
Teodor Grantcharov 15:04
Yeah, it is surprising, but at the same time not that surprising. I'm sure that you, I mean, the morbidity and mortality meeting is one of the foundational QI interventions in our practice. So, you know, the thought is amazing. We need to learn from our mistakes, we need to understand that if a patient suffers through complication, we need to see, is there something that we did wrong? Is there something that we could do better next time, but the reality is that modern morbidity and mortality, or they've always been like that, turn very quickly into discussions about anecdotal experience of the surgeon in the room or literature review. But I think all of us will agree that it's very difficult to remember what happened in the operating room a week or two weeks prior to that event. So, we kind of knew that, but we wanted to verify that. So, that's why we started a number of cases, we asked the surgical team to tell us at the end of the case, was this case perfect? Or did you notice any adverse events? And actually, the majority of the cases, they felt that they had went perfect, regardless of whether they were adverse events or not. And actually, when I look back in my career, I don't think I have ever dictated a non-perfect or not. Which, I am sure we'll get some perfect procedures once in a while. But usually there is always something to do better. So, we wanted to verify. So, in a study design, we asked systematically, individuals, did they notice anything unusual. They weren't able to classify very well at the end of the procedure. And a week later, when we asked them again, the same procedure and this was some procedures with high severity. There was absolutely nothing that they could remember about this event. So, it got to show that it's very, very difficult to have a meaningful conversation at a morbidity and mortality meeting about what could be improved inter-operatively. So, that's we've kind of verified again, that we can do better than that. The second example you gave was, again, the reporting near misses, and using existing data sources, which is the electronic patient records to do research or to extract some data. Because a lot of the current initiatives, quality improvement initiatives are based on data that's been reported electronic patient. And we found that data is not great. What we report is often not what really happened. And again, there is a lot of work around this concept of work done versus work imagined. And there is always some discrepancy between these two. And again, once again, showed that in order to get an accurate image of the OR environment, and, most importantly, understand and study what we did right and wrong. We can't rely on existing data sources. We need to create high quality data streams. And this is what we do with the OR box. We want to eliminate this bias recall, bias and other biases in our perception of our performance. We want to replace those with objective image or objective evaluation of everything that happened in the operating room. And only then we can design meaningful actionable interventions, individualized interventions, that could help us help us improve. So, when we do that, then we can shift this traditional approach in surgical education and surgical quality improvement, which is based on reactive measures. Let's wait for something bad to happen and let's study it, let's do root cause analysis. Let's wait through the NSQIP data sources to tell us that we are statistically significant outlier, six to nine months after things have happened. And replace that with something proactive. Something that will show a strength, that will show us safety threats before some patient has been harmed. And then develop effective mitigation strategies. So, I think this shift from reactive to proactive, we've seen it in other high-risk industries, we've seen it in aviation, we've seen it in nuclear, we've seen it in oil industry. We've seen it in professional sports, hasn't happened in surgery yet. But I firmly believe that as we continue to grow this awareness and we continue to get more comfortable with air and get more comfortable with performance assessment and get more comfortable with transparency in the operating room, I think I still believe that one day, this will become reality in surgery and hopefully, within my professional life.
Chad Ball 20:57
You know, I really like how you frame that. It is, I think important in terms of, you know, opening folks mind and moving forward to use examples in other industries. And I think of a Formula One team and how they break down a simple pitstop to save, you know, point 01 seconds. It's remarkable, right? The quality improvement cycles that go into that. It's not only audio and video, of course, but it's a lot more than that. I am curious, from a purely mechanical point of view, what equipment are you using for the black box? And specifically, the audio side and the video side? And then that's clearly an enormous amount of data? How do you go about storing that? And what's that process like?
Teodor Grantcharov 21:40
Yeah, so the audio video is obviously one of the key components of the OR black box data, but not the only one. So, we do our black box, we capture procedural video, we capture Rovio, we capture audio, we capture physiological data, we capture device data, and a bunch of other sensors. For example, wearable technology that can help us quantify stress, quantify fatigue, and so on. So, you're absolutely right, this is a massive amount of structured and unstructured data. And the video is a very powerful data source, and so is the audio. But the challenge is, how can we extract meaningful information out of that, hours and hours of video. And this is where we've focused for a very, very long time. And we've done a lot of errors, and we've learned from those errors, but we're at the point now that we can extract an accurate digital footprint from this massive amount of data. So, after we've done that, we actually don't need the raw video anymore. We've extracted the story; we've extracted the learning points. At that point, we actually get rid of the video, we destroy the video after 30 days, for many reasons, but one of the reasons is it's too much to store. And second is, it's too difficult to use it for anything meaningful later on. Well, maybe we could use it for some more research. But at this point, we extract things that we can learn, we don't need to store things where everything is going on autopilot. But if there are some segments of the video with high educational value, we store those and then we use it to enhance education and to improve education. But the large amounts of raw audio-visual data, I don't think that it's humanly possible to review, and definitely adds a lot of cost if we want to store. So, we don't do that.
Chad Ball 24:13
Yeah, that makes that makes total sense when you describe it, thank you. I'm curious, you sort of touched on it just a little bit earlier. You didn't use the word resistance, but maybe I would, you know, I think that there's certainly... my sense is resistance not only in our local operating rooms, but really across the board for some of the conceptual concepts that are inherent, and you and I believe, of course Ameer does, important in your black box and what that really represents and how it's delivered. I'm curious, you know, as you roll it out into a new hospital or a new OR, or with new surgeons. How do you frame it? How do you engage them and involve them and convince them and that's the surgeon side. I'm also curious on the patient side. Like, will this be typically something that would require consent from a patient to record? Or do we treat it just like we do when we record a Lap Chole per se, may not actually explicitly talk about that?
Teodor Grantcharov 25:14
Yeah, so that's a great question. And I think there is actually, I clearly remember, first time I was presenting this concept at a conference. And I remember, it was a full room, and there was a surgeon who got up and said, hey, you know, I've been practicing for 20 years, there is nothing I can learn anymore. I don't need video; I don't need data. I've seen it all. And this is the worst idea that someone could ever come up with. So, that was the first comment after my presentation. And he said, I hope you fail with that initiative. I thought it's good and bad. I mean, obviously, that's not the response I was hoping for. But at the same time, it is a natural response. You know, in surgery, we've been practicing in the OR, and we've turned the OR into a secretive environment. We as surgeons have started believing over the years that this is our own personal space, and nobody has right to enter that space other than ourselves. We, as surgeons have views, have created these false expectations, and patients. Our goal is perfection. We hear it once in a while. Once in a while, we hear this. I see these slogans. Our goal of zero errors, our goal of 100% success. And that's all an illusion. It's all false expectations. And as long as we maintain these expectations, we will never be able to improve. If we maintain these expectations to ourselves, and let our patients believe that these expectations are realistic, we failed in this journey to improve. This journey starts with the recognition that we as humans will fail. It's inevitable. We will make errors, and we need to learn to tolerate these errors. We learn because only then we'll be able to study them, we'll be able to learn from them. And we'll be able to create an environment that brings this psychological safety and supportive environment. So, I think there are many reasons why there is resistance, there are many reasons why there is anxiety. And with anything new, that's a healthy debate. That's a good discussion. To bring down these barriers, which are purely cultural. They're not technological, they're not scientific, they are cultural, they're emotional, and they are natural. So, I think when we talk about it, and especially in the room with doctors, nurses, and other people who participate, we are part of the surgical team in the operating room, I think it's important to remember why we are all there. And we're there because of the patients. And we will be patients one day as well. So, I think everything we do there should be directed towards patients, and we have an obligation not for perfection, but we have an obligation to make sure that when errors happen, when something bad and adverse events happen, which is a natural event in anything we do as humans. Our obligation is to learn from it. Our obligation is to make the system better, whether through education or quality improvement or other modern measures like automation, computerization and forcing functions. It's our obligation to make this less likely in the future. It's our obligation to build a system that makes it easy to do the right thing and difficult the wrong thing. And if something goes wrong, it's never the individual. That individual error is never the root cause of something going wrong. It's usually systemic factors. It's usually educational system or design of the OR, or institutional culture. So, we need to recognize that, and I think if we look at it that way, I think we've suddenly created a better environment. Supportive environments, psychologically safe environment, and a learning environment. So, I think that's how we usually approach it. We need to do the right thing for the patients, we need to do the right thing for our profession. But at the same time, we also need to respect the privacy and confidentiality of every single practitioner in the room. We need to understand that for this initiative or any initiative like that, to be successful, the foundational principle has to be confidential and non-punitive process. So, hospitals or organizations that adopt that approach will be a high-performance organization, will continue to improve and organizations that adopt the opposite, which is blame, shame, and individual seeking for individual errors will be poor performers. And I can tell you that now, when we've been implementing Blackbox, throughout multiple organizations in US, Canada and Western Europe, we can clearly see the massive variability in culture. The massive variability in openness, transparency, and an attitude towards safety. And I can quickly tell you where I'll be excited to work, in what environment I'll be excited to work on. And I think all of us know that. I think all of us have been in places where we've observed this backward sculpture of authority, of hierarchal structure, as opposed to flat supportive and well-led organizations. So, I think we'll see a lot of growth from a cultural point of view in our ORs. And I think I can clearly see that the new generation adopts this principle much easier. And it makes me hopeful that we will see changes in the way we practice surgery, and we will make the ORs much more fun, much more supportive, but also much safer than they are today.
Ameer Farooq 32:55
I want to come back to all the points that you made. Because I think, fundamentally, one of the cool things about any new technology or technique that really has the potential to change things is that it's not just, it's not about like some piece of technology or some tool or some, you know, like even when we talk about the OR checklist, I think if we really take a step back, it's not the checklist per se, that was what has changed or what led to that 4% mortality difference that they showed in that initial paper or 1% mortality rather. But I think it's like what it does under the hood, so to speak, that it changes the culture dynamics in the operating room such that, the checklist allowed people to actually speak up. It allowed the nurse to speak up. And so, when you've introduced this idea of recording all the operative data, it changes the culture from being that of like, oh, it must have been the surgeon's fault to taking a much more nuanced picture. So, I want to come back to that in a second. But before we move on from the technical side, I wanted to put a pin in the open recording. So, you know, we had a little bit of discussion a few months back, I think now about the challenges of recording open surgeries, and particularly the video around that. You know, I was asking people, what's the best modality for recording open cases? You know, I'm doing my colorectal fellowship. And there's still a number of cases that happen in an open fashion. And I was looking around and you know, trying to figure out what camera would work best and none of them work well. You know, when you're looking down in a pelvis, even with the head mounted camera that I have currently, that kind of sits over your ear, you don't see the details of what's happening in the pelvis because I mean, just the way we're standing is our eyes are looking another way but our head is pointed a different way. And so, you kind of miss all those nuances. Can you talk a little bit about kind of overcoming that challenge?
Chad Ball 34:53
Yeah, so that's a massive challenge in open surgery - capturing the procedural video. Have you watched some of the video footage on a head mounted camera?
Ameer Farooq 35:04
I've watched my own data, it's good for like the parts where you're looking right at the field. But anytime your eyes are slightly off in a slightly different trajectory than your head, than the axis of your head, then it's very difficult. Like, you know, the classic that I pointed out was the pelvic dissection, when you're doing the TME, and you can't see any of the nuances there.
Teodor Grantcharov 35:27
Yeah, so I've watched it, and it makes me seasick, to watch the camera moving all the time. And it's obviously very, very difficult to do that at scale. So, we've done a bunch of work in that area. And we've experimented with everything out there - with GoPro and head mounted and camera in the light. Camera in the light is not bad in general, but in certain cases, like in the pelvis, or deep, narrow spaces it's usually very difficult to capture. So, one of the residents, the surgeon scientists in our lab, [insert name], he actually did his master's thesis on developing a modern video capture system for open surgery. So, he designed, he built it himself. And it utilizes some of the gimbal technology used in drones, it stabilizes, it always keeps me focused, and he worked closely with our AI group to develop an algorithm that directs the camera always to focus on surgeon's hands and surgeon instruments. And so, the initial work and the initial experiments with that prototype were fascinating. And now, we have another student, a PhD student in our lab, taking that further, and making it more scalable. And one of the feeds in the OR black box platform technology. So, we've reviewed everything on the market, none of it was good enough. So, there is still some time before we move it from prototype to production. But I know that will be a problem that will be solved fairly soon.
Ameer Farooq 37:36
You know, I think this highlights again, what a multidisciplinary kind of approach you have to take to this. It's not just about, you know, putting a camera on someone's head, it's making a design that works ergonomically with the surgeon. It's the video capture, the gimbal, the AI component of it. So clearly, you had to put together a team that's very unlike a lot of other typical research teams that are found in healthcare systems, or that typically surgeons work with. How did you kind of assemble this multidisciplinary team? And what has that experience been like?
Teodor Grantcharov 38:10
It's been fascinating. And it's really the key for, you know, to a certain extent, some of the success stories we've built throughout the years, but also the experience of having people around the table who think different, who use different methodologies, who express themselves differently is fascinating. You know, in surgery we've been trying for very, very long time to solve complex problems just by ourselves. But with a bunch of surgeons sitting around the table and trying to find solutions using the same methods, using the same thinking that we've been using for decades. And that's not where the growth and the real solutions are going to come from. The growth is real solutions are going to come if we bring a diverse group of people with diverse backgrounds with diverse experiences to solve a complex problem using modern methodologies that they are familiar with. So, for us, it was fascinating when we started bringing people with design backgrounds. They brainstorm in a different way than we brainstorm. It was fascinating when we got people with biomedical engineering or computer science or data science background. But bringing all these people in the same room at the same time has really been fascinating. It's one of my favorite things that I kind of missed during COVID. There was a time where we couldn't bring together and I think we found that we could collaborate remotely, but I think it impacted a little bit our ability to innovate. I still don't believe that we can innovate effectively through zoom. I don't think we can schedule, "let's innovate tomorrow between one and two". It comes spontaneously. It comes by bringing a bunch of people in the same room around an empty whiteboard. So, I think it is critical if we want to advance our field that we bring individuals with various backgrounds, because these are complex questions. They can't be solved by a single professional group.
Chad Ball 40:44
I'm curious, in particular, have you had any medical legal issues that surround the use of the black box? And that's part one. And part two is, it's the chicken or the egg question. Do you think that being recorded, knowing you're being recorded, changes the way that you interact in an environment, like the operating room, and maybe even how you operate?
Teodor Grantcharov 41:12
So, these are both great questions. So, I knew that the medical legal question has to come up, it always does. And it's there. So, we've designed, even before we launched it. And we launched in 2014, we spent a very long time designing a process that will help us get to take advantage of the benefits of video and data and using that for constructive purposes to get better and to improve and eliminate the risks of feeding the malpractice litigation industry. So, the process is very robust. The process uses various AI algorithms that identify the data that, you know, there is a time bop in the raw audio video file that expires at 30 days. And the reality is that we really don't care. The principle is we don't care who the surgeon was, who the nurse was, who the patient was, we want to know what happened, and how we can make sure that it doesn't happen again. So, we've created a process, we've introduced technologies that securitize, that identify the data. And we've launched in 2014, we've never had any challenges. And, you know, we see now tremendous growth throughout the US. And as you know, the malpractice litigation industry is at a different level compared with anywhere else in the world. But everywhere we work, it is a challenge. It is a challenge that we've identified, we've addressed. And that doesn't allow or makes it extremely impossible to use something like this for destructive purposes against our profession. The second question about how data capture in the operating room impacts our behavior, or which is also known as the Hawthorne effect. It's well studied in healthcare. It's well studied in medicine and surgery that we actually published a meta-analysis a year or two ago, and we were hoping in the beginning that if people know that is captured, they will behave much better, that they will perform much better. The reality is, and this demonstrated a number of studies. And it is the conclusion of the meta-analysis that the Hawthorne effect in healthcare is very short-lived. In an environment like the OR with the black box, which is not in tune if you don't see it. People forget about it after 10 to 15 minutes. And they're back to normal behavior. And we haven't found it to impact our behavior, decisions, or communication in the OR. So, it's just pretty consistent with what other researchers have found.
Ameer Farooq 44:39
That's so funny. I mean, you'd think that everyone would just, you know, totally change their behavior, and completely change the way that they, you know, like, when we were thinking of these questions, you know, Dr. Ball, and I were thinking maybe, if you felt like you were being recorded all the time, maybe you know, you wouldn't joke the same way or you wouldn't have that kind of natural interaction. And maybe that would make the operating room a very kind of stifled environment. Because I think many of us enjoy that aspect of being in the OR. Like you got your tunes on, you're with your friends, with the nurses, the anesthetists, who are hopefully your friends. And, you know, maybe feeling like you're being recorded wouldn't allow that natural environment. But I guess it's kind of good and bad that people don't change their behavior, whether they're being recorded or not.
Teodor Grantcharov 45:26
I joke exactly the same way. I listen to the same music. I actually don't think about it when I practice surgery, and I have been capturing all my procedures since 2014. Using the OR black box.
Ameer Farooq 45:42
I mean, one of the interesting things that you've obviously published on and that I noticed when I started recording when my head mounted cameras - and I didn't even realize this - but the head mounted camera picks up the noise, right? Like, just of people talking. And one of the things you realize is just how much noise there is in the operating room. And it's kind of shocking, that we were able to do anything or concentrate on anything. And you've done a number of studies that kind of show how much distractions there are in the operating room.
Teodor Grantcharov 46:11
There are a ton of distractions. And you know, I've seen cases where we've had 50 and 60 people in the room. And it's in a low risk, routine procedure, probably the impact is not going to be that significant. But in a critical situation that requires the maximum of your cognitive capacity and requires communication and team execution on a very high level, this becomes the difference between success and failure. We've also found that distractions impact people with different experience differently. So, a highly experienced surgeon doing a routine task may not be subject to, may not be that influenced by distractions, versus somebody, a trainee who is doing a task for the first time or is still within the learning curve and has mobilized the maximum of their cognitive capacity to execute that task. Distraction could be very, very disruptive on performance.
Ameer Farooq 47:29
The distraction piece was certainly very surprising to me, in my limited kind of experience now, recording some my own cases in fellowship. Are there any other unexpected things that you've noticed from doing this project, things that you did not expect to find from recording, from doing the black box that have come out from just the sheer amount of data that has come through?
Teodor Grantcharov 47:52
We've seen a bunch of findings that often confirm our intuitive feeling. You know, so one thing is that not too long ago, we published some work on the impact of stress. So, we know that stress generally, we assume that stress is not good. And well, being in a good supportive environment is a good thing. But now we showed that has a direct impact on our performance and some of the intermediate safety outcomes like adverse events, we found that the risk of an adverse event that could potentially compromise patient safety increases with 60 to 70%, if the patient experiences stress and has objective physiological evidence of stress. So, a lot of these things, the distractions, the impact of stress has confirmed some of these things that we intuitively knew but once you see the evidence, you can't unsee it. And it changed the way I lead in the OR, the way I interact with people in the OR because I know that if they don't feel comfortable, if they don't feel supported, they will underperform and at the end of the day, that will impact all of us. If one of us underperforms, that doesn't benefit the care of the patient, who is the reason why we are all there.
Ameer Farooq 49:35
You know, Dr. Grantcharov, we had recently on the podcast JC Alverdy, whose name you may have heard of. He's a surgeon out of Chicago. And he recently gave the Norman Niagra lectureship at ASCRS. And one of the things he talked about, just like you talked about. is that you know, M&M rounds are where we go to learn from the ignorance of experts, you know, in other words, we have all these people talking about things - really senior people who have seen it all, and sort of infer where complications may have happened, where they may not have happened. But we really don't know. And as we talked about at the top of the show, our recall of these events is not very good. So, I think at St. Mike's you had started to incorporate video review as part of the M&M rounds, I'm curious if you actually have found things that you wouldn't have otherwise picked up, is sort of the first part of the question. And the second part of the question is, you know, one of the things JC already did is where he showed two groups of surgeons two videos. In the first video, he showed, you know, that this anastomosis leaked, and asked them to critique the creation of the anastomosis. And they said, well, there was this problem, and that problem, and this problem. And the second video, he said this anastomosis didn't leak, tell me what went right. And they said, well, this was much better. And this was much better. And you know, the bytes of the suture were much more evenly placed, what have you. And then at the end of that session, he said to that group of surgeons, well actually, the videos were reversed. And so, I'm wondering, you know, we're still kind of at the early phases of being able to analyze our technical performance. How do you kind of reconcile the fact that maybe we don't even know what makes things leak, or what doesn't make things leak, or what makes things go wrong, or doesn't go wrong, even if we have the video data to watch?
Teodor Grantcharov 51:28
Yeah, so that again shows the complexity of the factors and interaction between factors that could contribute to an adverse outcome. And, again, there are a lot of factors here. There are the patient factors, disease factors. There is post operative management, enhanced recovery or other things where there is a significant variability in how we manage the patient post operatively. There are also the intraoperative factors, which in addition to the pure technical execution, there are a bunch of other things. Was the patient hypertensive during the procedure? Was the patient hypothermic? How much blood loss there was? So, there are tons of parameters there. So, these are small pieces of the whole puzzle that will show us why a patient experienced a complication or an adverse outcome. So, only when we have all the pieces of the puzzle, we will be able to build predictive algorithms about outcomes. I feel that we are getting much closer to them. A lot of the previous work has looked at risk calculators based on only patient factors or disease factors and use that to predict outcomes, but they don't take into account the intraoperative factors or the post operative management. There is some work, especially after we introduce the enhanced recovery, that looked at the post operative management, or other aspects of care, and their predictive value on outcomes. But they didn't take into account the intraoperative factors. Now we have all of the pieces of the puzzle. And it's very important to highlight the interpretive factors, only the technical execution of the anastomosis. You know, you can have a perfect anastomosis and the same anastomosis get two different outcomes. If the procedure took you seven hours, and the patient had two liters of blood loss, and was hypotensive for 25% of the time versus the patient where the procedure took 45 minutes. And the patient followed all the principles of hypothermia and wasn't hypoxic or hypertensive. So again, we will only be able to build reliable predictive algorithms if we have all these pieces of the puzzle. We will only be able to achieve... and I really believe in the future of surgery to be data driven, predictive, transparent and ultra-safe. And I think we'll get to that point only if we study the operating room holistically. And it hasn't been possible so far. And this is what we're trying to do with introducing modern better capture and volume data science to surgery.
Ameer Farooq 54:41
And can you talk a little bit about potentially how this might be incorporated into an M&M rounds? Because I think you had been doing this at St. Mike's to a certain extent.
Teodor Grantcharov 54:50
Yeah. So, we call it enhanced M&Ms. And this is one of the things that black box is used for today and groups or hospitals or departments that have access to the Blackbox data can log in to their portal and run M&M sessions using the OR black box, which breaks down the procedures into steps and sub steps. It quantifies performance in each of these steps and identifies adverse events. So, it identifies all these things that are outside the norm, that could potentially have contributed to the adverse outcome. Also, it's important to highlight that the OR black box or the M&M, not only identifies failures or things that could have done better, but it also identifies good things. The near miss that was recognized by the team, and was rectified, so the patient still had a good outcome. I think which kind of fuels the safety too approach that was introduced by a professor in Denmark, Eriko Nagel, who said, you know, we've been doing quality improvement or safety improvement using this tradition. The Swiss cheese image there, which kind of focuses on the failure, the variability, then the malfunction, the root cause, and so on. And he said, let's forget that, really, it's so much more powerful to focus around the good things. The near miss that was followed by mobilization of the team resilience, that was followed by recognizing the near miss, by rectifying it. And all these things that we do as surgeons and as surgical teams to, despite their ability and malfunction and failure, to still achieve good clinical outcomes for our patients. So, I think this is a much more powerful educational tool, much more powerful quality improvement tool. And this is one of the other principles that we have adopted in the OR black box and the M&M too: to identify these behaviors, to celebrate good behaviors and find a good balance between reducing safety threats, and enhancing resilience supports.
Ameer Farooq 57:22
It has been an absolute pleasure to chat with you today. I've learned so much. And I'm so excited, honestly, for the future of surgery. It seems very, very bright. And I just can't wait to see where you go next with the OR black box. If you could go back in time, now having had the experience with the OR black box through your whole career, if you could go back in time to when you were a resident, or maybe even as an early attending, what advice would you have for a younger Dr. Grantcharov?
Teodor Grantcharov 57:55
That's a great question. I probably would have used a little bit more this type of philosophy where I use more time to look in the mirror and focus on things to improve. Rather than you know, it's a natural feeling with surgeons to be confident and sometimes overly confident. And it's important in order to deliver great care. But I think it's important to maintain this humble feeling and again, recognize the power of the team. The power that every single team member brings to the team, and I think only then, we can achieve the potential, or our maximum impact when we care for patients. So, I think my work throughout the years, it has made me humbler. It has showed me very clear how important every single team member is and how important it is to make every single person in the room comfortable with each other. So, I think this is something that probably I learned throughout the years but didn't fully recognize in my early days where I felt that it's all about me. It's all about us as surgeons and everything is our responsibility. So, I think that's kind of universally accepted today. But probably wasn't like that 15 or 20 years ago when I started my career.
Ameer Farooq 59:56
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. This podcast was edited and produced by Tyler Daniels. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your comments and feedback. So, feel free to email us at [email protected] or connect with us on Twitter @CanJSurg. Thanks again.