The Hernia Gods Podcast E16 - Mazen Al-Mansour, MD

Episode 16 of The Hernia Gods Podcast features a great discussion with Mazen Al-Mansour, MD regarding the stresses of being an international medical graduate and preliminary resident, the realities of being married to someone in the medical field, and his thoughts on teaching residents and the way parenthood has changed his approach.

Disclaimer: The views, thoughts, and opinions expressed on this podcast belong solely to the hosts and guests, and do not serve as a representation of or necessarily reflect the official policy, position, or opinions of Orlando Health or any of our employers.

Transcript

SPEAKER_00 0:06

Welcome to the Hernia Gods Podcast. This is your mere mortal host, Luke Elms. The views, thoughts, and opinions expressed on this podcast belong solely to the hosts and guests and do not necessarily reflect the official policy, position, or opinions of Orlando Health or any of our employers. And now, without further ado, let's talk hernias. All right, welcome to another episode of the Hernia Gods Podcast. This is your mere mortal host, Luke Elms, and today I am joined by Mazan Al-Mansur out of Gainesville, Florida. Thank you so much for joining us, sir.

SPEAKER_01 0:38

Thanks for having me, Luke.

SPEAKER_00 0:40

All right, so as we start every podcast, I'd love to hear just a little bit about who you are, where you came from, and how you got where you are today.

SPEAKER_01 0:48

My name is Mazen Al-Mansur. I'm uh hernia and adult surgeon of the University of Florida in Gainesville. Um I'm originally from the Middle East. I grew up in Jordan and did my medical school there, and then moved over to the United States in 2007 to pursue surgical residency. I started off at the University of New Mexico in Albuquerque. I did two years of uh preeliminary surgical residency there and then moved to uh Springfield, Massachusetts uh as a PGY3 categorical resident. I uh finished my residency there. Um I then joined um a uh community practice in uh same area where I did about three and a half years of general surgery um before I moved on to uh pursue a fellowship in minimally invasive surgery at uh Ohio State University. Uh I then went back to uh Springfield and enjoyed base eight as a faculty for two years and then moved to the University of Florida where I serve as a minimally invasive surgeon there.

SPEAKER_00 1:55

So uh when you came over from Jordan, you had already uh completed medical school there. And what is the medical school pathway like in Jordan?

SPEAKER_01 2:05

So it's kind of resembles more the uh European, particularly the British uh system where you go from high school to med school. Um it's a six-year uh program where you do sort of underground uh undergrad courses, but then you just immediately go into the medical school uh curriculum. Um after that, you have to do a one year of internship, or it's sort of like an extension of the medical school, but with a little bit more responsibilities.

SPEAKER_00 2:35

And so you're having to make the decision on whether to go into medicine at a pretty young age. Was there ever a time where uh you thought you were going to do something else, or was this medicine something you wanted to do from a real young age?

SPEAKER_01 2:48

Um frankly, uh not really. I wasn't sure what I wanted to do. Uh, but generally speaking, medicine is a pretty safe bet. Um, so that's sort of how it went. You know, I I knew I would be able to get into med school, and that's what I did, but I didn't really know uh that I wanted to do medicine, and uh I definitely did not know that I wanted to do surgery. I thought I was gonna be an internist um until uh until I actually did my surgical rotation, which I enjoyed, but it was my first rotation, and I thought I just enjoyed it because it's clinical, and then I did medicine and uh that did it for me. It's like no way, that's not for me.

SPEAKER_00 3:32

Yeah. Yeah, I um was there was there a particular type of this of surgery in your rotation that caught your eye, or was it just the whole experience in general?

SPEAKER_01 3:41

You know, I really I really like to think in algorithms, and I felt like during my surgical rotation, like you know, I remember like rotating on surgeon and and you know, uh, you know, breast cancer and the whole algorithm. You know, if it's this dot in breast cancer, you do this, and that's when you do a lopectomy, and that's when you do a central lift no vibes. And in this case, you do mastectomy. And I just really like to think in algorithms. Uh I've always been more of an I've always enjoyed anatomy, um, much more than physiology, so to speak. So I remember as a kid, um, you know, English is the second language, so I have a huge dictionary, and right in the middle of it, it has some interesting pages where it has the human body anatomy. So on one page, it has the skeleton, and then you flip the next page, which is like a transparent page, it has like the retroperitoneal muscles, and then you can superimpose the nerve, and then you know the kidneys, then the GI and so on and so forth. And I remember looking at this repeatedly as just a child, I'm just mesmerized by it, uh, not realizing that at some point I'll be doing this for a career.

SPEAKER_00 4:55

Yeah. And then when you came over, you did uh uh two prelim years at uh in Albuquerque. Did you start back as a as a PGY one uh when you went to your residency, uh second residency there, or was that something you were able to get a PGY two or three spot?

SPEAKER_01 5:12

No, I actually didn't have repeat any years. I was I was lucky to go on from a prelim PGY two to a categorical PGY three without having to do any redo any part of my training.

SPEAKER_00 5:22

Is that a pretty stressful process when you're in your kind of second prelim year going, you know, nothing's guaranteed, or did you ever lose the faith, or was it something you had confidence that eventually the right opportunity would come around?

SPEAKER_01 5:34

Uh you have no idea how stressful it is. You know, if if if you're in a training program and you have preliminary residents, you may not realize what they're going through because you just don't know. And uh especially as an international medical graduate, um I I heard really nothing until April of my PJ two year. And at the end of June, you're done. And I was on a visa, which means you're done, you go back home. I mean, there's just no, you know, whatever you did the two years, maybe they'll count for something, but uh yeah, it was very stressful. And so I actually got my offer um in June, early June. Otherwise, I don't know what I would have done.

SPEAKER_00 6:19

Yeah, that's uh I I think that that is something that uh you know I never experienced that. I was you know lucky enough to be a categorical, you know, my wife and I we we couples matched, and so there was still there was a little bit of that concern of rolling the dice, trying to get two people at the same location. We didn't rank anything to match separately. Uh we were we were committed to our relationship and and thought that one of us would just take some time if needed. But yeah, I can't imagine going through the the grinder that is the first two years of of surgery residency and still just having no stability or idea about what comes next. I think that that's a level of stress that I don't think I ever experienced. So whenever and then you ended up going uh out into practice and then decide to go back and do a a fellowship. What kind of of a uh mental strain is it to go from kind of being you know the attending and kind of have a little bit more control of your schedule and then going back into a fellowship where you kind of sacrifice some of those? Was that a hard transition for you?

SPEAKER_01 7:26

Uh frankly it wasn't because it was planned that way. So when um when I finished my residency, I actually applied for fellowship and then I withdrew from the match. Um, I I just had a change of heart and I talked to my wife. My wife is a doctor too. So she was actually um just matched in a fellowship in in Massachusetts. So I knew she's gonna be there for three years. She was pregnant with our first child at the time, so I didn't want to leave her at that critical time while she's doing uh fellowship. So the plan was that uh I'll just um go into practice, uh try to get a waiver for my visa situation, um, which is a major barrier uh for any employment. Um and after that kind of goes through after she completes her fellowship, then I'll do mine. So uh just I think having the mindset of being prepared to do that, it wasn't so much of a transition. I think people when I did when I um a lot of people did expect it too. So when you when you interview after you've been out, people kind of anticipate that you're gonna be difficult. Like you're gonna be difficult to work with, you're not gonna think like a trainee, you're gonna think like you know, you're independent, you're not gonna take orders from anybody, and and that kind of stuff. So I think that uh can impact the prospects of matching. But I was very lucky to match at Ohio State and um it went fine, you know. I just came in, did my duties. Um, it kind of also worked out well financially because you know, my salary went down, obviously, going from an attending to a trainee. Uh, but my wife's salary went up going from fellowship to it kind of worked out for us.

SPEAKER_00 9:11

Did um, and then now you are after a brief stop, you're now at uh UF Gainesville. What's your practice uh mostly consist of now?

SPEAKER_01 9:22

So my practice um consists of ABOL, um I would say completely, really. Um so the only thing that I don't uh do that some people would consider it outside of the of the realm of hernias surgery is idle hermes, which to me is still abdominal core uh surgery. So um I do inguinal and ventrils for about 80% of what I do, and then about 20-25% is uh foregut surgery. Um I do endoscopy as well. Um, so I'm in an endoscopy suite currently every other week, uh, just to a full day.

SPEAKER_00 9:59

And do you uh in your uh fellowship, was it mostly abwall, or did you have some like bariatrics and other MIS mixed in?

SPEAKER_01 10:08

So my fellowship was actually focused on flexible endoscopy. So I was doing ERCPs, bones, um, you know, uh visual stents and dilations and whatnot, uh, with some other you know, claw, some forga, not really having a focus in the fellowship. I have no bariatrics, so I don't do any bariatric surgery, but you know, by virtue of being an MIS surgeon and a gastrointestinal surgeon, I share colon with my bariatric coli. So I deal with bariatric complications. Um bariatric operations.

SPEAKER_00 10:42

And having your advanced endoscopy training that probably does provide some some level of uh of comfort with some of the bariatric situations that you may encounter, I'm sure.

SPEAKER_01 10:53

Oh, yeah, absolutely. And I don't think just uh general understanding of the GI anatomy and um you know, but I do advanced operoscopy and robotics as well. So I've got the skill skill and I have a lot of the knowledge, uh, but I just simply don't do any primary bariatric operations.

SPEAKER_00 11:11

Right. Do you do any uh do you still do ERCPs in your practice currently?

SPEAKER_01 11:16

No, I do not.

SPEAKER_00 11:18

Yeah, that's a really my uh my partner and I here, we had talked before, we were taking high-volume call, and and sometimes our um emergency department feels like a mini hepatobiliary fellowship. We we end up with such complex uh uh gallbladders and and colidocalithiasis and things like that. So there's there were times where we were like maybe we should just stop and go out and learn how to do some more of this advanced endoscopy, just so we can bring that back to our practice. But it's uh it's an interesting, you know, obviously that that's kind of the gastroenterologist turf in our in our area, and we have some really good ones, but but that was something we had discussed. So hearing that you had that experience was interesting.

SPEAKER_01 11:57

In a lot of places it is that way, and I think I think for a general surgeon, just really that good knowledge of the biliary intervention and what's possible is extremely helpful. Um, but um I've made a choice and I do some interventional uh endoscopy, but um I don't do ERCP or anything like that, or stents for that matter. Um it's a choice, and you know, I really enjoy Apple, so it's kind of working out for me the way that I have enough endoscopy to keep me engaged, but uh I probably wouldn't want to do any more endoscopy.

SPEAKER_00 12:33

And you're you're at a tertiary center, and and so what is your kind of makeup of more primary hernias versus like the redoes and the more complex uh you know complications that show up at your practice?

SPEAKER_01 12:47

You know, I would say by far, you know, primary hernias are the most common. So I I do a lot of primary inguinals and you know umbilicals and ventral, but uh uh you know, being a tertiary care center in the area, we do a higher proportion of the revisional surgeries. So I would say, you know, my my rate of recurrent hernias is about 25%.

SPEAKER_00 13:15

Do you uh what is what's kind of your your favorite uh what's your favorite surgery to pursue since you do kind of cover a broad spectrum of the of the hernia surgery.

SPEAKER_01 13:27

My my favorite uh surgery to perform personally.

SPEAKER_00 13:30

Yeah.

SPEAKER_01 13:31

I I really like hydrolyner surgery. Um they're they're you know, they can be challenging, uh they are um advanced. Um you get to teach the residents some of the case, but you still get to operate.

SPEAKER_00 13:46

Yeah.

SPEAKER_01 13:46

I like in Anguinal Hernia, where you pretty much have to give up the case.

SPEAKER_00 13:50

Right. Yeah. We um well, I gave up hydles in my practice uh, you know, recently. Um it I didn't ever do a high volume of them, so I never really pursued like the redo's or or any of the more complex stuff, just because I didn't feel like I ever got the numbers of of reps on a more this more straightforward hydols that that I thought that I was the right person to do those. And it just kind of seems like after a while, you know, it's been so long since you've done them in training that you're kind of like, I probably am just not the right person to do that anymore. Um and then and as you get busier with other things, it makes it a lot easier to give up some of those uh some of those pathologies. So I can't. Yeah, we you know, we always it's it's such a when you're doing complex ABWALL, obviously, a lot of those a lot of those cases can be fairly complex. And uh with that complexity does come a level of um you know complications that are just you know, try do everything you can to avoid them, but they will happen if you do do the work enough. Uh how does that affect you uh now and how has that progressed as you have uh progressed through your career and got you know more reps under your belt? Have you felt a change in the way that that complications affect you personally, or is that something that's maintained itself?

SPEAKER_01 15:08

Well, that's that's actually a timely question. I had a rough January um when it comes to complications. And you know, the reality is is you can you can be as experienced as you can, but a hostile abdomen is still a hostile abdomen. There's nothing you can do to change about that, and with that hostility complications just getting happened. Um so it it you know it can be quite humbling and quite frustrating, to be honest with you. And um, you know, the key thing really in my mind, you know, as much as I hate to have a complication and for my patients to have complications, it uh recognizing complications early and managing them appropriately makes a huge difference. And I think that really kind of gives me the satisfaction. You know, I may have a really tough week. I'd be frustrated that I, you know, had a patient about, you know, a couple of weeks ago where it was redo, redo, redo, um, evil, um, recurrent incisional early. I did a bilateral tar, came to it was a tough case, and then it came together nicely at the end. Then I have to take her back two days later for a medicine to rob me, just to like a pinpoint hole. I have to remove my it just kind of eats at you. But you know, we'll we'll we'll left to fight, you know. Number one, we recognize that we took care of it, the patient is alive, she wants she was discharged, and if she gets a recurrent honey, I'll have to deal with her ticket.

SPEAKER_00 16:32

Yeah, those are it definitely does. It definitely does. I have found that you know, early, early in my career, a complication kind of hits you different, but when you've done a smaller number of cases, because you I don't personally feel like I, you know, I don't have that that bank, that Rolodex of old cases where you go, well, all I know I can do this. This is something that that's you know is known to happen, and it may be that it even does isn't happening outside of a a normal rate, but you don't have you know hundreds and hundreds of examples of of things going well. And so they they definitely affected me differently early in my career, but even now, you know, uh it it I had you know two in a week, two of which it really there was like nothing I could do. It was just bad luck. Um looking back at it, and I even you know, you run it, I've ran them past all my partners and everything, and you kind of go like, what would you have done different? They're like, no, nothing, you know, it's kind of it's kind of just comes with the territory. Um, you know, and I think that that's really one of the things that I've had to kind of come to terms with over time is that if you do have a complication and you go back and review, you know, review what happened and you review it, you know, objectively and ask for input. And if everybody kind of says the same thing, that it's just kind of a bad situation, then you kind of have to just continue to go back and do kind of the same, do it again and hope, you know. And if you start having, you know, multiple of the same kind of thing, then it kind of raises the question of what you're doing wrong. But it's my you know, my initial tendency early in my career was you know, have one problem and be like, I need to change everything I'm doing. And I always had a had one of my senior partners be like, you know, you you kind of have to know what your rates are to know if this is just part of the game and obviously you try to learn from it, or if it's something that's like kind of a recurring problem. But that the rough January, I definitely understand that.

SPEAKER_01 18:25

Yeah, I mean, I think I think it's healthy to question uh yourself and you know, ask yourself was this preventable? Could I have done something different? Uh, but I agree with you. I I think one complication should not change your practice. Um, you know, there's there's a well-known complication rate for everything that we do. And if you have a bad outcome, well, it doesn't mean we have to change, but like you said, if there's a pattern, if you have a surgery complication, you're seeing it more often than you would expect it to be, then yeah, maybe there's something to change, something to pursue.

SPEAKER_00 19:01

I think hernia surgery is a little bit difficult in that um a lot of times, you know, the fact that a hernia can recur, you know, years and years down the line, it's it's very different from like a leak from an anastomosis, where you know, if you get a month out, the chances are you're kind of through it and you kind of know that that didn't happen, doesn't mean you can't develop a stricture or something else down the line. But you know, it's it's sometimes I I think that it's really difficult to know uh the how how your complication rates are doing just because of the nature of the fact that many people don't follow back up with you consistently. And we try to trend try to track our patients uh longitudinally um over the past few years. That's something we implemented and it it really has. It's shown some it's shown some patterns that we've been able to address and and um and it's really been been eye-opening, but I don't know that that uh if we hadn't done that, I probably would not have changed some of the practices that I've changed in them in the recent past. So whenever you're coming, um whenever you're coming through uh a uh I'm assuming you're working with trainees uh at up there at your current job, is this something that you find uh to be uh rewarding? Do you find it to be difficult at times? Like how does that affect you? I know there are times in my practice that that you know it working with trainees in a in like a really tough case, I struggle with giving up the sticks, so to speak, in in some cases. Is that something that you feel uh is something you've experienced as well, or is it something you feel comfortable with?

SPEAKER_01 20:38

Yeah, I mean, it it's always a it's always a challenge to know exactly how much of a case. And you know, I and I think as uh surgical educators, you know, we absolutely have a duty to things like generation. Um, but we also have duty to the patient on the table. Um but it does come with time. I think I think the nice thing about my practice is that I have um uh sort of a narrow uh range of cases. So and I tend to work with the same level of residence. I usually have a chief resident committee. So I can tell, like, okay, well, you know, at the beginning, maybe of the glotation, I expect them to do this percentage of an abundant hernia, depending on their skill level. But as the patient continues, they should be able to do that the entire case by the end of the glotation. Um heidal hernia is a different story. So maybe I'll start off with you know, hydal closure. You know, they are involved in the dissection and the reduction of the hernia, uh, but maybe not the biggest kind of portion. And then as they progress, they start doing the wrap, um, and you know, and so on and so forth. So I think you know, everybody comes up with their own system, but you know, um certainly with resonance, uh the biggest challenge is every couple of months you start to over versus if you have an LL. There's more of a consistency over a long period of time. And you really feel like, you know, you just spend maybe a couple of months to get the fellow up to speed. And then um they just you know take it in one moment. So I I don't have that luxury of working with fellows, but you know, residents are uh different groups of trainees, and you know, a lot of them are a pleasure to work with, and you know, they show most of them show enthusiasm and you know, they feel a lot of the calls. I mean, they improved my quality of life tremendously. So that part is extremely rewarding too.

SPEAKER_00 22:34

Absolutely. Yeah, I think there's definitely kind of that, there's definitely that trade-off where right there they're obviously providing value uh to us and and that obligation that we we have to teach them is definitely something that that you know we is is a nice it's a nice mutually beneficial uh relationship in most cases. So um you you mentioned uh earlier that uh your wife uh you she had gone through her training and then had kind of bounced around. Have you did you find it uh helpful or kind of difficult to both be in the medical field? My wife is also a physician, and I think there are definitely positives and negatives that we've that we've taken from our experience together, where at times we are able to commiserate, but then also that at times it's it's when you're both down in the trenches, it can be kind of a kind of a difficult thing to to uh separate yourself from from the job when you're both in it.

SPEAKER_01 23:28

Yeah, I mean, I think there's uh for working couples, I think it's very difficult. I mean, there's a lot of especially if you're parents that we have we have two kids. Um and for working professionals full-time, it's gonna be hard no matter what your specialty is. Uh, but we're both specialists. When you know, I'm an adult surgeon, she's a bone heart transplanter. And uh one of the biggest challenges we encounter is is finding jobs in the same area. Sure. Um, so that's that's something that I feel like a lot of people, you know, we had we had to spend uh some years when we were part. You know, when I got my categorical position in Springfield, she stayed behind in New Mexico for uh a year or two, because she was in residency as well as me. And also when um I did my fellowship, uh she was faculty in Chicago. So we got separated again. And uh one of the the reasons we moved from Massachusetts is you know, we were in the same state, but we worked in two different cities and neutral stuff, and we were far from both you know, daughter when she was in school. So there's a lot of challenging that comes with that. And part of the reason we moved to Florida is because we both found a job in the same institution, which we haven't done in a long time.

SPEAKER_00 24:52

Yeah.

SPEAKER_01 24:53

So that's that's a big challenge, I think, for physician couples. But I think there are a lot of challenges that happen for any couples who are full-time, you know, uh you know, professions.

SPEAKER_00 25:04

Yeah, we um, you know, it we when we came through, we've never had to live separately. I think that that's probably something that would have been very, very difficult for us. Um she, whenever we couples matched, uh we couples matched off uh to Orlando. Um and when we went through our residency, of course, there were times that it felt like we were living in separate cities just because we there was a period of, I remember when we were, I think it was maybe second year, where we were on nights and we had alternated who was on nights like three months in a row. And the way that the the shifts starting and end time worked, we would just like wave at each other as we like passed on this road going to our house to and from. And you know, we we went through, it was funny because we went through um residency, and you know, it's such a formative time of life just in general, because when we I started residency when I was 25 and she was also 25. I'd love to give her a hard time because she's like six months older than me. So, you know, she's she was she's an older woman, but um, but so we had uh but we started um our residency uh when we were 25, and then we you know I got done when I was 30. And so during that period of time, it's it's like you're such a completely different person, just independent of any of anything else. And then you go through the the changes of a of a medical training. And I think that there was a really difficult time for us to kind of reconnect um as we came out of training. And you know, for instance, she had she had literally developed like all new hobbies and was like had a whole new uh group of friends that I didn't really know. And we had historically had like all of our friends had been kind of the same group. And so it was a really weird, it was a really weird thing. I'm not sure how we would have handled um going through all the the dedication that you that you and your wife had to have just to pursue your careers and still still maintain that family. So I'm sure it was a I'm sure it was a a a pleasant and and yet still probably some unexpected challenges whenever you guys did get to Florida and finally got to be together.

SPEAKER_01 27:09

Oh, absolutely. You know, but at the end of the day, you know, we uh she knows about surgery more than any uh, you know, most, I would say more than most of the internists and definitely most of the hematologists out there. And I know more about hematology than uh most of the search that you can think of. Uh so it's it's nice to have somebody that you can kind of discuss things with in in depth and details, and they get it. You know, like when you have a complication, she knows exactly what that means. Um you know, we have difficulties with work. We're you know, we were just exhausted from being on goal and having to work a lot. Um, she gets it. So that it's extremely rewarding at the same time.

SPEAKER_00 27:50

Yeah, we um we the only thing we run into is sometimes we like come home and and you're like focused on medicine non-stop, and you come home and then you're we're out to dinner, we're talking about like medicine again for the whole dinner. We're just like, man, we we don't have a life anymore. What's going on here? But uh yeah, my wife's in what's your wife's uh specialty? She's in the so she's in the OBGYN. Um she she came through and did uh general OB with a very busy practice um for a couple of years, and then after that, she went back and joined the teaching faculty um at Winnie Palmer Hospital, where um that's a very high-risk, um, high-volume hospital. Um, you know, uh at least back then it was the second highest number of deliveries in the country and has the one of the largest NICUs in the world. And so very high volume, high acuity. Um, they were taking care of all the high-risk patients through the teaching service. And so she did that for about six years. And and as we had children, um, you know, that's when things started to change. So, really, her first job was not really conducive to us even pursuing having kids. Um, I was in my job and it seemed like more of a longitudinal kind of build. And so, whenever it came came time for one of us to have to change kind of what we were doing, she was the one that that changed. And so she went to when she went to the teaching faculty, that was shift work. And so that really allowed us to to kind of schedule our lives um a little bit more around that. And then it got to a point where you know the kids were getting older and starting school and things, and then the shift work kind of became more difficult. So when the shift work, uh, you know, her not being home in the evenings and being gone in the mornings when the kids were getting up and going to school and and all those things. So she went back into a kind of a clinic and and there was just two partners. And so we thought that that would be a significant improvement um in the quality of life. But what that ended up being was you know on call for OB 50% of the time. And so here, so she was gone uh even more uh and in unexpected ways. And so she came back and she's she's worked as a laborist for a couple of years, and now she is uh going in and doing a um a specialty. She kind of she got certified and she's gonna be starting a menopause specialty program for like perimenopause, sexual health, and um and longevity. So she's kind of now getting into more of her kind of long-term vision. Um, and so whereas I've been able to kind of stay um in the same job since I graduated, and and that has kind of morphed from a more of a general surgery where I did a lot of the acute care surgery that came through our practice. And then as my elective practice grew, um, it just turned itself more and more into hernia surgery uh just by the referral patterns. It wasn't actually something I was pursuing, it's just if that's what's in your clinic, then eventually you start doing it and and more and more patients start showing up with more and more complex cases. And so I gradually kind of kind of progressed from you know sending those up to see you to keeping them more of my practice and and kind of working on that. So that's just kind of how our our careers progressed. But but yeah, I'm sure being a uh bone marrow transplant specialist, that's you know, that's another one of those um that uh that you know outcomes, I'm sure, are not always great. So she probably understands whenever whenever you're going through kind of a tough time. I think definit definitely different specialties have different definitions of uh of a bad day, and hers is probably closer to to to a uh a surgeon's than than just regular doc.

SPEAKER_01 31:18

That's true.

SPEAKER_00 31:19

Yeah, we um it's been a it's been a very interesting progression uh going through having kids. Um how old are your children, if you don't mind me asking?

SPEAKER_01 31:28

I have two kids. Uh my oldest uh is uh 13, uh she's a daughter. Um, and then my bobby is an eight-year-old.

SPEAKER_00 31:38

Yeah, well, I you know, being a parent, whenever I have an eight-year-old and a five-year-old, and being a parent, you know, it it changed it pretty much everything about how I approached my life and how I approached my practice. And one of the things that that changed was actually how I taught. Um, it for some reason, I I don't know. I just it just made me a lot, I think, a lot more patient. I think I was not a great, not a great educator earlier in my career and was just uh wasn't like a yeller or anything. I just didn't have as much of that, like, okay, just let them kind of work through it was much more uh this you know, micromanage everything. Um, probably still do to a large extent, but but uh but it definitely kind of changed how I approached my practice in life. Did you feel that do you feel that as you've been able to kind of progress through the different ages of of your family, that that has some been something that's affected your career?

SPEAKER_01 32:35

Um can you rephrase that question? I'm not too sure I've just said it.

SPEAKER_00 32:40

Sure, yeah. So if you would as you've kind of gone through uh become, you know, being a father and all those and the experiencing of being a father, do you think that that's impacted uh your patient care or your teaching as you've kind of uh grown through those phases with your family?

SPEAKER_01 32:57

I I do think so. I think I think there's some sort of uh I feel like sometimes I look at residents um as my children to some degree. The age the age difference is maybe not not as uh dramatic, but I still feel that paternal uh instinct. And you know sometimes, you know, like they do something and I'm so proud of it. And then sometimes they do stuff, and it's like I take it personally. It's like I'm not happy with it. Why am I why am I taking it personally? You know, but like I think there is this paternal instinct, you know, like I really care about these people. And if they do something I don't like, uh then I just don't like it. I I I do see some of that, not so much with patients. Um, you know, most of my patients are, you know, I mean, I I create a lot of age group, so I don't feel that that translate necessarily to teaching care, but definitely for teaching, absolutely.

SPEAKER_00 33:51

Yeah, and how it's a it's funny you mentioned the the feeling paternal. I think that's that's a very good way to describe it. It's it's um it's just it's almost like you know, it's I'm sure the residents would probably be like, what are you talking about? But it it definitely there definitely is like a level of um of kind of like uh almost just feeling very responsible. And whenever you do see those residents that come back through, we have multiple years, and so you can we've been able to watch them progress through their training, and they come back a year later and they're just like so much better, it's almost just like, wow, that's amazing. You kind of like kind of like watch them progress through, uh progress through it. It's not something I felt before, but it definitely has a lot of parallels to like being a parent, and and uh and so that's been something that I've found I've found rewarding as it's kind of as it's kind of progressed through. We um, you know, we've had uh in in many cases, the um our practice has been uh very driven and our practice has changed, uh, my partner and I, as we've gone through and the balance of the amount of like clinic versus elective work versus uh versus emergent work. What's your what's your kind of balance currently in your practice for you know the clinic and and versus like the operating room and how do you have that arranged?

SPEAKER_01 35:07

So I have um I have a full day of clinic uh every Tuesday. Um and I do have uh three Omar days. Um on the third day of the week, I alternate between uh doing endoscopy or having admin day. So that's how it kind of works out. Uh it's it's all you know, it's almost changing. Um, you know, there there should be so basically if I'm have a full-day clinic and I operate three days a week, that means that the clinic should generate cases for three days a week. Right. And uh yes, I and I was doing two days a week, but I was just kind of looking farther and farther back. So I felt like I need um an extra day. Um, but now I'm kind of caught up, so I feel like, well, I need to start seeing more patients. So we'll see how that comes.

SPEAKER_00 36:02

It's weird. It kind of comes in C it kind of comes in waves where every now and then I'll have a clinic, and every like every patient I see that has a has a major hernia is gonna need months of optimization. You know, it's like, okay, we're gonna get to be long-term friends, and then the next month it seems like everybody that walks in is more straightforward. And so I'll, you know, I'll see a full day of clinic and and book you know three cases, and then I'll the a month later I'll see a full day of clinic and book like 12 cases. I'm going, uh oh. Now I've got now I've got this like weird, weird backlog. And I think my surgery schedulers are just like pulling out their hair, going, what's going on here? Where's it need some consistency? But I think that's really kind of indicative of the type of work that we do that um you know that that optimization pathway that you have to take some of these people through uh to get them, you know, ready for those types of surgeries is is something that has has really become more and more important as the complexity of our of our practice has has increased. One thing that's really changed for us is the when with the GLP medications and the people uh utilizing those, we've seen a lot of people have these um situations where they've may come in with these hernias or these significant diastases that are functionally a hernia with all the core instability that comes with that. But they have a lot of um a lot of the extra tissue and a lot of the the aesthetic concerns that are on top of that. Is that something you've experienced and and how how have you handled that?

SPEAKER_01 37:37

Uh so yeah, you know, one of one of my pit phases is you cannot fix the abdominal wall defect and still leave the patient disfigured. You know, uh hernias, uh especially large uh hernias, is they can be disfigured, you know, they're very abnormal. You know, we oftentimes focus on pain and functional limitation, but you know, we're we're not I'm not a plastic surgeon, and my aim is not to make the patients necessarily more aesthetically appealing, as much as try to bring the patient to more of a normal anatomy. So if you have in your abdomen, you know, sometimes it's shown through your clothes. That's not, even if it's not painful, that's in my mind, it's not a way to live. Um, so you know, I I do a fair amount of sort of you know, you know, skin and soft tissue management, which I think is absolutely uh essential for complex apple risk, because you cannot fix the hole in the muscle or the fascia and just leave a bunch of redundant skin with hypertrophic scars. And um, so that that's absolutely important. You need to, you know, you know, I think it's an obligation to make the patient look as close to normal as possible.

SPEAKER_00 38:50

Do you do you find yourself when you're dealing with those types of situations, uh you do robotics as kind of one of your primary means of earnier repair in your regular patient population?

SPEAKER_01 39:01

Yeah, I mean I do uh probably about maybe 60% robotic, 40% open. Um I I rarely do any laparoscopy uh nowadays, but um yeah, I mean, if if the patient needs, like one of the things I assess is the patient needs any major skin and soft tissue work. Um and if they do, then you know it's gonna be either an open case or maybe a hybrid case where I would do part of it robotically and then you know, some of it to some skin and soft tissue work as well.

SPEAKER_00 39:34

Yeah, that that was actually where I was going with that with that question was the amount of hybrid procedures you do, because I think that that's something that I've I've started to increase in my practice, where you know, I like the ability to do some of the work more minimally invasive and then just address what's kind of left after you pull after you've kind of like pulled everything back together. But we also have really started working a lot with our plastic surgery colleagues. Um is that something that you that you guys do up there in your practice being at a tertiary center?

SPEAKER_01 40:06

Not commonly, uh frankly. You know, I've I've needed, I rarely need plastic surgery, mostly to do um, you know, flaps if I have concerns about socket recovery, which is not very common. For the most part, in paniculectomy or scolar vision medicine or something that I do independently.

SPEAKER_00 40:28

Is that ever something uh when you're doing a paniculectomy, does that ever change your approach or the maybe the mesh choice or the the type of repair when you're dealing with a wound that that that's that large that has a higher risk of wound complication?

SPEAKER_01 40:44

Yeah, so when I do paniclectomies, it's you know, um, and and by by when I say paneculectomy, I'm talking about removing a large amount of skin and soft tissue. Um, oftentimes raising lipogutaneous laps. And if I'm doing that, uh, I am creating the on-lay plant. And uh usually uh my go-to would be an online mesh. And I know a lot of people um prefer not to do that, and I think um rightly so. I think the data generally uh shows that retromuscular mesh placement is associated with complication in all of the country, considering it's getting complicated. But I think penicillin patients are a little bit different. You are already making the morbidity and accepting the morbidity that comes from raising the life of cutaneous blood. So like mesh, I don't think it really makes a huge difference in terms of complication risk. Um and I I generally believe that we should preserve that retrobus kind of plane. It's such a good plane. I'd like to preserve as a last resource option. And I sort of change, you know. I think as learning surgeons, when when you get a recurrence, I used to beat myself up, I would I would really feel embarrassed. Um be embarrassed to talk to the patient about it. But the reality is early has come back. You can do it, and they can still recur. So for me, it's not the end of the world. You know, the patient recovery, I still have an option or maybe a couple of options. So that's a usual idea. And we're actually one of my residents' leading uh a study uh looking at on lay versus retromuscular mesh placement, uh, specifically in patients who undergo penicolectomy. That's all that's what we find.

SPEAKER_00 42:37

Yeah. Is it do you use just a macroporous like polypropylene type mesh in that in that plane?

SPEAKER_01 42:43

Yes, that's what's good too.

SPEAKER_00 42:45

And you, I'm assuming you drain that widely with with multiple drains in those situations?

SPEAKER_01 42:51

I usually depend depending on the patient, usually um I use quilting stitches. So I reattach this, you know, subcutaneous fat down to the fascia to try to moderate the dead space as much as possible. And usually I add one or two drains depending on the extent of the section.

SPEAKER_00 43:09

Yeah, we've had, you know, we've we've been moving further and further away from drains, mostly just because the risk of complication and the fact that we've gone more to a robotic approach. Um, so in those in those patients where they have a large defect, are you do you uh gravitate towards like an anterior release as opposed to the posterior release?

SPEAKER_01 43:27

Yeah, I mean, uh these patients oftentimes the hernia is so large that it's already dissected uh the plane for you. And you know, you just get it there and you incise the hernia second, you're looking at the extra link. So it's right there. You just incise it to an anterior release and an all image, and you know, you still have that entire retorect display reserved in case the patient.

SPEAKER_00 43:53

Yeah, it's not it, it is kind of nice to have like a fresh plane to approach and kind of get it's almost like you know, approaching. a a recurrent opening all with in the posterior layer, uh posterior repair and things like that. It is it's definitely nice to have that to go back to if you ever do have an issue. But yeah, we've been we have been starting to move more and more towards that soft tissue management. What I do find in our practice is many of our uh many of our uh plastic surgeons that we work with for those paniculectomies and things, many of them uh prefer like a staged approach. And so they'll ask us to go in and kind of take care of the the hernia usually robotically and then they follow back up for the soft tissue management uh you know a few months later that's kind of how how it's been in our in our practice and and so that's but it's it's something that we probably have you know obviously would love to we'll love to see your data and just see what see if there's ways that we can definitely improve our practice we're always open to that. But yeah it's a it's a really interesting thing whenever you have the hernias and every patient's so so unique uh with their with their own specific disease process and and things like that that it it's nice to have multiple tool tools in your toolbox that you could kind of approach and and use all of them. Do you um you said you had kind of gotten away from laparoscopy did you ever do higher volume laparoscopy or was that something that you kind of just went straight into the robotics or went from open to robotics?

SPEAKER_01 45:16

Oh no I mean I I I when I graduated residency I didn't do any robotics um so I graduated in 2012 um it wasn't really the robotics wasn't very popular in general surgery and a couple years later I started doing some robotic gallbladders and then moved on to inkward and hernias and then ventrals and uh but I think the main reason I kind of went um exclusive robotic is it feels like if you just pick and choose it's very hard to get access to the robot. And uh I think a lot of hospitals look at it and say well you've done you know 20 robotic cases last year you really don't need the robot versus if you ask for every single case they look back and say oh we've done it a hundred times you know we definitely need it right which you could have done a lot of these cases lap or scalping sleep but um everybody that I talk to seems like the people who have a lot of access to the robot are the people who just decided to go over. Yeah definitely and they that was really the patient is his access really was the was a challenging point for me.

SPEAKER_00 46:22

Yeah we've definitely they they definitely look at a a use to investment ratio kind of they definitely want it you know after making that investment definitely don't want it just sitting in the hallway or something but uh but yeah no we've I actually did I did some laparoscopy not a ton uh but most of my I I jumped a little bit from basically from open into the robotics and I I really liked the the ability to replicate a lot of the techniques that I was utilizing open with the robot which was one of the one of the things that I really enjoyed. I in my patients at least whenever I was doing like laparoscopic eye palms and things it was um man the transfascial sutures that I was using when I first started the the pain complaints from those was was always something that I that I kind of struggled with and kind of felt bad about because it didn't happen all the time by any means but those people that came back with that oh it hurts like right here and it's like they're pointing at your stab and saying you're going oh hopefully that that suture will go away it's just going to take a bit but uh but yeah so then I whenever I made that jump into robotics I was able to to kind of leave some of that in the past which really helped me. But yeah you know we really appreciate you appreciate you coming on as we as we get to the end of a podcast episode I always offer people the opportunity to uh to kind of get uh their their opinion on uh their own hernia hot take and give them an opportunity to give an opinion on something related to hernia surgery whether it be popular or unpopular uh as give you your opportunity do you have a hernia hot take for us?

SPEAKER_01 47:52

Yeah so one of my uh passions is is the subject of pre-optive optimization and and my opinions of that may not be um I would say mainstream uh I absolutely think that we need to optimize our patients you know if it's an elective operation uh we you need to give the patient the best reasonable outcome uh of their operation but there's a few caveats to that you know number one um if the patient is having obstructive symptoms uh in my mind the best optimization is to operate on the patient you know you're not trying to hernia that's not gonna come back you're just trying to avoid an emergency which I think you'll do the patient a huge favor. But the other thing is you know we need to be uh realistic and responsible you know pre-optive optimization is not pre-operative optimization unless it results in an operation um and what I have seen is a lot of people create these impossible targets for the patient that they're never gonna get you have a patient whose body am I BMI 70 they're never gonna get down to 35. They're just not you can offer them any bariatric operations you're basically telling the patient they're just not gonna get an operation ever. I think that's unfair um and and it needs to be something realistic achievable that should happen within a reasonable timeframe. So um same thing I think for smoking I'd love uh not to operate on any smoker just like any other surgeon but the reality is some people just cannot quit and you know if if you know I I I negotiate with my patients I try to pressure them but then I meet them halfway if if they've done their best. So in my mind your patient is optimized if they're in the best possible shape that individual patient can get to do you have any uh yeah that's that's a really good that's a really good one.

SPEAKER_00 49:45

Do you have any um any like targets that you say like hey I'm gonna give you we're gonna put you through this program or smoking cessation or something and we'll give you you know X number of weeks or months to try or do you just say hey we need you to stop and and this rely on their on their you know kind of motivation and then kind of move through the scheduling process with them.

SPEAKER_01 50:08

So so what I tell the patient is you know smoking increases your risk of complications decreases your risk of hernia recurrence very possibly and I'd like you to stop if you're able to um but but at least cut down as much as you can and let's meet again and I schedule and a follow-up appointment. I think that's the key other things we should tell the patients you know call me back when you quit smoking. Right schedule that appointments you back you know it's gonna take you some time to do this let's wait back in three to six months back to you know how are things working with you um any help any resources you need you need to prescribe your patches in the inventory for you to a program um things for weight loss but at the end of the day if they really tried like you know they went down from smoking a pack a day to smoking two cigarettes a day and they can't quit completely then I'm gonna operate on them. So that's the best that they're ever going to get.

SPEAKER_00 51:07

Sure.

SPEAKER_01 51:08

Have they tried?

SPEAKER_00 51:10

Yeah when I counsel my patients on like their optimization some of them have pretty big targets and you know we I tell them what we'd ideally get to and and and you kind of work with them through it. But the one thing I say is like hey this is something we're in together. And so at minimum I see them or the longest time frame I go is every three months. So we check in every three months and and sometimes you know they're they come in and their weight has gone up and it's an opportunity to be like hey like this is really going to get you you know this is going to be a a major issue for you for numerous reasons um you know not just from a hernia recurrence standpoint but just from every all your other health as well and so it gives this not me an opportunity to to intervene and and I have quite a few patients that are able to stop uh smoking of course I think we all probably do if we counsel on that um and you know one of the things I I tell them is like hey you know I cheer them on you know you're like you have to be their biggest cheerleader as they're going through that process and I tell them hey you know this is hard and the average average person you know fails multiple times before they ever are able to quit completely so a failure or starting again does not necessarily mean it's the end and it's impossible. But the the those that are able to stop you know I sometimes I tell them like hey you know stopping smoking was probably the best thing you could do for your health even more so than than me fixing your hernia. But yeah it's it's a really interesting balance because you do have some people um you know that their life is significantly limited by pain. And and so then you know you kind of have to feel feel it out. And I have a lot of patients you know that I I mean I try to give them a a reasonable uh you know alternative to surgery which is discussing the what happens if we do nothing and uh and you know many people uh especially with all the uh concerns with the you know the the mesh and things like that that we I spend a lot of time talking about um with the patients um they many people will you know want to opt for that kind of well if I just if I just don't ever move it doesn't hurt you know and if I'm not moving it's fine and and what I or or you know if what if I just don't want to get it fixed what limitations you know do you want me to never lift more than 10 pounds again or and I always tell them the same thing I'm like listen like if you're if you're having to significantly modify your life for the hernia you know my recommendation is we get the hernia fixed because ultimately you know the goal is not for you to be long long term disabled from this the goal is for you to get back to a normal life and and me telling like a like I've operated on a few significantly older people. One gentleman in particular came in and said you know I I have this inguinal hernia I really don't want an operation and I said okay well like what's what's your activity level and he's like I'm walking two miles a day and he's like an 80 year old guy and he's like I don't want an operation I was like okay that's fine here's the risks and everything and so I said let's see you again in three months. So I see him again in three months and he's like I you know I really don't want an operation um but you know I've I can't walk anymore it hurts too much and you know so then we had the discussion like the fact that you were walking two miles a day as an 80 year old is probably the reason you were so healthy as an 80 year old. And so we really have to consider what what the risk is of you becoming completely sedentary trying to avoid an operation for your hernia. And so that was kind of the the discussion and I think for me it kind of changed the the discussion between the risk and benefit because then the risk of doing nothing is significantly different if if you think that their overall health is going to plummet because of their lack of of that. So yeah I definitely think that you know having hard and fast rules definitely that that you have to apply those optimization protocols and those optimization numbers to the individual patient because it's kind of hard to to give everybody a straightforward number whenever every patient's a little bit different. And there may be times that that yeah they're just you know some of these people it's just their candidacy for surgery is just poor you know and it's going to remain poor um and and some of those but other people um I have found that that with the right you know enthusiasm and with the right support they can really make a significant change in their life and it's been and if the herny getting your hernia fixed is what thing that motivates them to do that then you know that's a that's also kind of a plus in some cases. Yeah.

SPEAKER_01 55:13

And I think also it depends where the patient is is you know where they're starting you know what's the starting point matters right because if your BMI's 38 and you want to get it down to 35, that's a completely different story than starting at a BMI seventh. Like also what type of hernia you're treating you know it's one thing to treat the small epigastric hernia versus doing a big abdominal reconstruction. Yeah so I think has to be factored in I think we need to be more individualized in our optimization goals and then kind of team up for the patient and work with that.

SPEAKER_00 55:48

Yeah I don't think any I don't think there's ever a it very rarely could go poorly if you're trying to treat the patient in front of you as an individual and apply and apply your knowledge to the individual as opposed to just following a protocol blindly without taking that into account. I think that's always probably going to turn out for the best in the vast majority of cases. But you know we really do appreciate you taking the time I know that uh uh it's it's hard to take time away to do things like this so we really do uh we're honored that you took the time to talk with us and um and hope to see you again soon well thank you very much Luke this this was a lot of fun I really enjoyed it and um I'm I'm so uh happy that you're actually doing this work I think it's um it's we'll need it it's definitely fun and droid uh I certainly enjoyed what I think I'm learning more by my colleague or yeah keep the good work going well I I very much appreciate that I you know it's it's it's as much for me as it is for anybody else I I just very I get a lot of fulfillment from having conversations with people such as yourself so that's why I'm always so grateful to to be here and to have these conversations.

SPEAKER_01 56:54

So again thank you very much for volunteering uh your time and your family time on a weekend as well I really appreciate it.

SPEAKER_00 57:02

Yeah my I you know really my wife is probably just excited I'm not bothering her so it's probably just she probably views it as a positive well this wraps up another episode of the Hernia Gods podcast I'm your Mere Mortal host signing off thank you so much for listening and we'll catch you next time