Dr. Teodor Grantcharov

Professor, Department of Surgery, University of Toronto; Staff Surgeon, Division of General Surgery, St. Michael’s Hospital, Toronto
Researcher of the month: 
Jul 2015

Surgical “black box” may revolutionize surgical care

Imagine how Tiger Woods would play without someone to analyze and give feedback on the mechanics of his golf swing.

“No matter what we do, if we don’t know what we’re doing wrong, we’ll never improve,” says Dr. Teodor Grantcharov, a minimally invasive surgeon at St. Michael’s Hospital, Toronto, and developer of a surgical “black box” that helps doctors to reduce surgical errors in the operating room.

“In surgery, we don’t know what we’re doing wrong. We ignore it, forget it or deny it.”

The main problem, he says, is that, after graduation, surgeons have no coaching on how to improve their skills. To make matters worse, training programs teach a one-size-fits-all approach to surgery. That’s akin to giving the same training on how to swing a bat to José Bautista of the Toronto Blue Jays and a college student with a baseball scholarship. Each player approaches the game from a different psychological and motivational angle and each has a different skill set.

Yet “we continue to deliver educational interventions based on the average but not the individual,” he laments. Like professional athletes, surgeons have different levels of skill. “My educational needs are different than the needs of my colleagues. I operate differently and I need to know what’s important for me.”

That’s why Grantcharov led a research initiative to develop a surgical “black box”. The computer-driven system uses video cameras to track every surgical movement and conversation between surgical teams in the operating theatre.

Actually blue, the box performs analyses that can help surgeons to improve their skills and reduce surgical errors. In short, it helps surgeons to identify what went wrong and why.

“The purpose of the black box is to generate the information we need to coach effectively,” he says.

Like black boxes on airplanes, the invention attempts to ferret out mistakes to avoid the repetition of accidental errors. But not every surgical error results in patient complications, so Grantcharov’s team has been analyzing surgical procedures to determine which errors lead to poor outcomes.

The device could be a game changer in surgical healthcare. Reducing surgeons’ errors could significantly improve surgical safety. Better patient outcomes could save millions of healthcare dollars attributed to the care of surgical complications.

Encountering resistance

Fear of patient perceptions holds surgeons back, says Grantcharov. “We’re afraid that patients will judge us, if this image of the perfect surgeon falls apart. We don’t focus on errors, so we keep doing them. This cultural perception creates a vicious circle that doesn’t allow us to improve.”

Just as it’s impossible for a golfer to score a perfect round, a baseball star to bat 1000, and a sprinter to win every race, it’s impossible to expect surgeons to be perfect, he insists. They need coaching to improve. 

“We have to start somewhere,” he states. “And, unless we do, we won’t see significant improvements in terms of surgical safety and patient outcomes.”

Drawn from experience

“There’s nothing more exciting than leaving an operating room and feeling that you’ve done an amazing job to help somebody,” says Grantcharov.

But often there is a discrepancy between what I see when we review the video of our performance and our perceptions during the procedure. I have experienced this in my own practice. The more I watch my videos, the more I see what I can improve.”

He learned to become a better surgeon by reviewing videotapes of his work. “When you get better at something, the feeling is incredible, no matter what you do.”

His experience sparked a lifelong interest in surgical skill assessment and education, which has blossomed since Copenhagen. But the black box idea didn’t take flight until he combined this professional passion with a personal interest in aviation accident investigations.

“It always impressed me how the aviation industry was able to identify root causes and, most importantly, do something about them to ensure that the same accidents didn’t occur twice.”

After conceptualizing a prototype, Grantcharov and his team actually worked with Air Canada to refine the surgical black box concept.

From Bulgaria to Toronto

Born in Bulgaria, Grantcharov completed his doctorate and residency in General Surgery in Copenhagen, Denmark. There, he met his wife and his two sons were born.

Grantcharov, who specializes in minimally invasive foregut surgery and bariatric surgery, completed a fellowship at the Temple University School of Medicine in Pittsburgh, PA, before he was recruited to Toronto.

Grantcharov has become an internationally recognized leader in the assessment of surgical competence, surgical education and impact of surgical performance on patient outcomes.

He holds a Canada Research Chair in Simulation and Surgical Safety. He is a Professor of Surgical Simulation at Copenhagen University and sits on numerous committees of many prestigious medical associations in Canada, the USA and Europe. He is a member of the editorial board of The British Journal of Surgery and Surgical Endoscopy.