The Hernia Gods Podcast E18 - Charlotte Horne, MD

Episode 18 of The Hernia Gods Podcast features a great discussion with Charlotte Horne, MD regarding her journey from Canada through her training, the realities of starting a practice and being an attending, and her thoughts on being a female surgeon in the field.

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 Herme of Gods Podcast. This is your mere mortal host, Luke El. 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 Hernia. Hello and welcome to another episode of the Hernia Gods Podcast. This is your Mirmortal host, Luke Holmes. Today we are joined by Charlotte Horn, a hernia surgeon out of the Mayo Clinic. Thank you so much for joining us.

SPEAKER_01 0:38

Thank you so much for having me.

SPEAKER_00 0:41

It's a real honor to have you on, and we really appreciate you taking the time to talk to us. As we start every episode, I'd love to just hear you tell us who you are, how you got where you are, and where you come from.

SPEAKER_01 0:54

Awesome. Well, I am a Canadian, uh currently living in probably the most Canadian part of the US. I did all of my non-medical education in Canada and then actually went to medical school in the Cayman Islands in Grand Cayman, which was absolutely lovely. We do two years there, and then I did two years kind of all throughout all my clinicals throughout the eastern coast or eastern side of the US. And then did my residency in Cleveland at the Cleveland Clinic. I stayed on for an extra year to do the Abwall Recon Fellowship with Rosen. I was gonna do an MIS fellowship after that because I just wanted to be trained forever. And I said, I'm gonna fix parasophageals and peristomal hernias, and that's gonna be my life. Um but uh actually the fellowship director of the MIS fellowship sat me down and said, Hey, are you allergic to money? And I was like, Well, clearly, clearly I am. Um and so he thoughtfully um told me that you know you'd probably be more marketable as a hernia surgeon than an MIS surgeon. So, you know, get a job. Um, and so I did. Um my first job was in Hershey, Pennsylvania with Eric Pawley. I was there for three years and now have moved to Rochester, Minnesota at the Mayo Clinic. I've been here for two and a half years already.

SPEAKER_00 2:24

So nice. And so uh what part of Canada did you grow up in?

SPEAKER_01 2:29

I'm from super northern Alberta. So I grew up in the small town called Fort McMurray, Alberta. There was like 30,000 people there when we first moved there. Um now there's like 150,000, so the same size as Rochester, um, and then went and did uh my uh university at the University of Alberta, so in Edmonton. So I say I'm from Alberta because I've literally lived in every major city in Alberta for at least a few years of my life.

SPEAKER_00 2:59

Nice. Yeah, we um so is that like a is is that like area farming area or what what kind of uh industries are in there?

SPEAKER_01 3:06

So in uh Port McMurray, it's all oil and mining, so that's actually where a lot of the oil comes from in Canada. As you move further south, uh you have a lot of farming and agriculture. And then I think what makes uh Alberta the most famous is we have the beautiful Rocky Mountains and Mount.

SPEAKER_00 3:23

So yeah. So did you uh did you grow up doing any winter sports up there?

SPEAKER_01 3:28

Absolutely. Uh was a big snowboarder for the overwhelming majority of my life. Um, and I then I met my husband who is from Florida, introduced him to the sports activities, but shockingly enough, um uh I became a certified scuba diver when I was in university because my parents were like, you know, let's just do this, it'll be fun. Um, and so me and all of my siblings got scuba certified um when I was in university, and I introduced my husband to scuba diving, and we are now like addicted. So when we are not in freezing in Rochester, we're under the water somewhere looking at fishes and sharks for the most part.

SPEAKER_00 4:11

Yeah, I um I I'm not a scuba diver. I, you know, that's uh for some reason, I think it's like philosophia or whatever it is, the the uh a sphere of like the super depths of the ocean, like the the part of like Titanic when the ship goes like under the water all the way, and then the then there's like nothing on the surface. That's like the most terrifying thing in the world to me. And I I don't know why I would it's uh so scuba diving's not for me.

SPEAKER_01 4:37

Oh my gosh, we we love it. Well, you would hate it because uh the reason we go back to the Cayman Islands, because that's where we met. So we met in medical school. We go back there every single year to scuba dive because the um underwater uh topology of the Cayman Islands is quite interesting. There's a huge trench right off um the Cayman Islands that's like 5,000 feet deep. So you get to dive all of these beautiful pinnacles, and like one side it's just coral, and then you look to the other side, it's just blue forever. It's quite eerie, but it's very, very cool.

SPEAKER_00 5:10

Yeah, yeah, that sounds like a quick way for me to get like the bends. I would like freak out and try to swim to the surface. I'd be like, I'd be the guy you did be like holding down. I did snoob, I did like snooba diving once when I was in Hawaii as a kid, and um I got to like 25 feet, my ears wouldn't equal equalize because my face is all misshapen, and I think my station tubes are all jacked up. But anyway, I got to like 25 feet and I just like sat there at 25 feet while everybody else went down further and I was like, okay. But um, but yeah, no, you'll never catch me doing that. But you get you have a very interesting uh like leisure activity range. It's like you have like a what is it, I don't know, a 15,000 foot range between like bamp snowboarding all the way to the the depth of a trench.

SPEAKER_01 5:50

Yeah, yeah. It's a it's a real big problem though, because you can't do both activities at the same time. Um, because you can't go to super high altitudes after you scoop at. And it's also really important uh or unfortunate because Mayo does all of their, they've very thoughtfully scheduled all of their educational meetings or CME meetings in Hawaii every year um in January and February because nobody wants to be in Rochester at that time. It's like brutally cold, but all the hurrian meetings are ski meetings in February, so it's like hard to justify being gone for a week to Hawaii and then gone being gone for a week to ski all because of education. So I'm forced every single year to choose either scuba diving or snowboarding, and my husband heavily leans to scuba diving, and so we've been absent from the the winter ski meetings for the past couple of years because we've been scuba diving in Hawaii.

SPEAKER_00 6:48

So I you know, I can think of worse reasons. I can think of worse reasons to be uh to be uh to miss the uh the meeting. Yeah, no, we um we uh that's it. It's a very interesting thing. Do you get how often do you get to go do those things? Is that what you kind of do to decompress?

SPEAKER_01 7:05

Absolutely. I think you know, the the best part about scuba diving is nobody can talk to you, nobody can email you, nobody can page you for just like an hour. It's like the most peace, peaceful thing in the world. Um, and so we try to avoid Rochester winters as much as possible. So the rule is you can't take any vacation from June until August, because that's when it's actually nice here. And then starting November, we uh pick places to go. We have actually uh scuba dive with two of my girlfriends residency. So we do a group trip once a year, we go back to Cayman every year, and then we try to find a new interesting place every year to go.

SPEAKER_00 7:48

So that's you know, you did the uh so you would have been considered an international medical grad, right?

SPEAKER_01 7:54

I was.

SPEAKER_00 7:55

Yeah, that's pretty and and did you feel like that put you at a disadvantage, or did you feel like you were on a level playing field when you came back? Because we always heard, you know, if you when we were going through and talking about applying, like the only place we knew about whenever my wife and I were applying for medical school was like Ross. And so we were talking about applying all those different places, and they're like, Well, you may have a hard time matching. Did was that your experience? Or you obviously matched extraordinarily well, so I'm assuming you just like kick buttons school.

SPEAKER_01 8:24

Yeah, well, I think the other thing is is like right when um I was going into matching things are a little bit different now or then than they are now. Like, I think to be an IMG and not have like I didn't do any research years and I actually didn't do a prelim spot. I matched directly into a categorical position. And I will say, like, I was convinced that they had made a mistake on their paperwork. So I signed that contract and returned it like within hours of like I'm in, I have the paperwork. Um, and but I think like now to be an IMG and try and get into a categorical spot is like really unfortunate and probably something that just like almost never happens. And to be honest, I think that's kind of a sad thing because oftentimes there are some unique qualities that people that are either uh are international for whatever reason kind of have to overcome in order to get into uh a position where they are a competitive candidate. Like oftentimes you have to have like back then insane step scores. You see these people um doing all of this research. And honestly, as a medical student at a Caribbean school, it was kind of up to me to plan all of my electives. So here I am, like, you know, living in some pretty suboptimal places in the middle of nowhere, Baltimore, um driving up after like a day of a surgery rotation um in Baltimore to New York to look at an apartment because that's where my next place was. Um, and so I think there are a lot of things that you learn about life. Um, and you kind of learn how to overcome obstacles and not deal with no. Um and I think those are things that it's really hard to um actively portray in an application. I think a lot of times when you're reviewing applications, you're kind of like, well, you know, how do we even compare these people to these people? Because for some reason they weren't a good candidate and couldn't get into a US medical school. And I honestly think that's actually pretty short-sighted because oftentimes the route that these um international medical grads have to take or we have to take in order to get into a competitive spot is so it's so much work. Um, and a lot of times it's so much work with not a lot of guidance. Like I remember I was in um Brooklyn, New York for my PEED sortation. We only saw like sickle cell kids. It was actually a very eye-opening experience, but I needed to take step two CS in order at a certain time in order to like get my score in for my application, so my application package would be complete. And I literally like there was no dates available, and they email you to say one is available. Um, and I called my parents, I'm like, you're gonna get a call from me. I'm gonna ask for your credit card number and I'm gonna be booking flights to do this test because I absolutely have to, and that's what happened. You know, you booked the test in. I called my mom and I was like, I gotta go to LA, I'm in New York City to take this test and come back. Um, and it was just like it's just kind of it is what it is. And I look back now and I'm like, oh my gosh, I would just absolutely never do any of the things that I did back then, and you're kind of just oblivious. Um, and you're on your mission to like, you know, get your spot, um and you do what it takes.

SPEAKER_00 11:58

So yeah, I think looking from the outside in with the perspective of time, um, it's been a while since I graduated medical school, probably longer than I'd like to admit. But the um, you know, I with the way that my medical education went, I look at some of the people's pathways like you took, and I'm just like, dude, there were so many times that I was living a charmed life by comparison, and I was just like, I can't do this. This is ridiculous. You know, and you're like, you're I was, you know, the thing I think I would find the hardest was jumping around all over the like the eastern seaboard to get your clinicals in and the the kind of like a nomadic lifestyle while under the incredible pressure to perform, you know, because I think that it was it's hard enough when you have like a stable home life and you're kind of like at your home, you get to go home and do your decompression, you're relaxing, but much less trying to find like your next place to live and trying to find your um trying to figure out like where I can go buy groceries. That's a good grocery store around here. Like even just little basic things that I think would make just the experience of medical school even harder. Um, and I, you know, uh I have a ton of respect for people such as yourself that that go through that. I it obviously you have to be, it probably self, it probably selects out pretty heavily for like self-starters and people. I mean, just I I would imagine that when you got into uh when you got in at when you got into surgery residency, did you feel like that level of uncertainty, the kind of make it, you know, get graduate or bust kind of attitude? Do you think that that helped you through your surgery residency?

SPEAKER_01 13:40

I mean, totally. Well, and actually my parents had kind of told me um at the end of four years, they're like, you know, uh med school is four years, so you have four years to get this sorted, and like you have to get a job. Like, you know, what are you gonna do for this? Like, if you don't match, what are you gonna do? So I actually had um three general surgery interviews, that was all, and programs four through like 15 that I think rank were all medicine. Um, and so I was like, listen, I'll I will go into the things, I'll be very happy if I get into surgery, and obviously it like found its way. Um, but uh you kind of learn how to to get things done, and I think you you're very used to not, you know, having things straightforward from the beginning. And I think the other thing that made it like super complex is obviously I am Canadian living in the US. And so things like having to register a vehicle, like my boyfriend at the time, his dad had like legal power of attorney in order to for me to register the vehicle so I could actually have a car to drive to all of these things. So, like all of these things you kind of really start to learn how to be like, okay, like here's the problem. And when you hear no or I don't know the first time, you start to be like, all right, so but I need to get this done. How am I gonna figure out the solution to the problem? And so you're kind of kind of just used to life being hiccup after hiccup. And I feel like sometimes that's what residency is like hiccup after hiccup. I also like am super grateful from like of where I trained, you know. Uh, we trained some fantastic residents here, but I think one thing uh for better or worse about my training program is I kind of equate it to being like a Bambi where you're just a baby deer. And if you don't learn how to run immediately, you will 100% get Eton. Um, they were such a high-volume institution doing very, very complex procedures. And now as an attending, I go back and like just thank God for all of these very, very patient people that were willing to just like watch me be an absolute terrible laparoscopist and just struggle. But they're doing that in doing so many cases a day. So I think you know, one thing that I picked up pretty early on is I'm in a residency with a lot of people, and I could either be somebody that you know just fades into the background and go unnoticed 100%, or I can kind of like really take the initiative to get good, and you had to get good quick. Because if you wanted to do things, which obviously you want to do as a surgery resident, you'd have to be able to like know what needs to happen, you need to know what the attendee wants you to do, and then to be able to do it like with relatively few tries. And so I think recognizing that fairly early on, to be like, listen, I'm this baby deer, and I'm gonna have to learn how to run real quick, otherwise, I'm never gonna get to do the stuff that I want to do in the OR. Um, was really helpful. And I think one of the things that translates from being an international medical guide is you understand there's got a lot of work you got to do on your own time. And so I will say, until like almost my last day of fellowship, I was in the FLS trainer suturing something, doing something. It was just kind of, you know, it became my decompression to just go there and just tie laparoscopic knots at the end of the day.

SPEAKER_00 17:16

So yeah. You talked about how you have to kind of learn how to just work through uncertainty, you have to kind of blaze your own path, you have to be pretty um adaptive, it sounds like, through your education to get to where you are today. Do you think that um it is that living in those types of uncertainties and that kind of um kind of prove it, having to prove yourself through uh the different adaptions you have to overcome and the different uh obstacles you have to overcome? Do you feel like that that's something that provides you like professional fulfillment?

SPEAKER_01 17:51

Um I wouldn't say it provides professional fulfillment. I do think it helps you kind of uh navigate challenges throughout your professional career. So um, you know, when I started my job at all, there hadn't really been somebody that has done an ABWAL fellowship almost ever here. And there wasn't a truly um trained abwall surgeon here for at least two years before I started. So here I am at like the number one institution in the world, and I'm like, all right, we're gonna do an ETEP. And nobody has seen one, nobody even knows what you need to do. Um, none of the residents have seen one. Like it's you kind of realize that you're gonna have to grow this in a way that is, I would say, like 100% taken for granted for. Like, I had been at two institutions where I had fantastic mentors that kind of had set the pathway. Um, and so you kind of could just like plug and go, if you will. But now I'm here at an institution where I'm like, okay, doing robotic surgeries, which most people have not been doing, or if they have, it was that pretty low volume. And then on top of that, also doing some of these crazy massive, very large hernias and trying to curate a narrative that was very different um than most people had even heard for honestly, like a decade, like still doing plugs, and I'm like, all right, guys, like here I am. I know I'm not like maybe who you would expect to be here telling you how we're gonna fix her nias, but like, okay, it'll be it'll be okay. And so I think it's you know, same sort of grind mentality of like you hear, I'm not sure, or we've never done that before, to be like, okay, I get that. Here's how we're gonna navigate this relationship in order to get everybody on board. I think that's one of the things that's been the most challenging here is to be like, yes, I understand that this is how you've done things for a very, very long time. But how do we kind of grow this moving forward? And it's really hard to grow when you're a voice of one and an NFL one, and people are like, what you're doing is absolutely crazy. Um, and it does take a lot of work to do that, but I have truly found that here, like once you get people to buy in and get everybody on board, we are like cruising, which has been really fantastic.

SPEAKER_00 20:26

Yeah, I mean because you come in with a pretty uh incredible pedigree um of education, and then you um, but you're entering a place that has uh the reputation that has, and um usually with that reputation, there's a an expectation of quality. Um and the expectation of quality prior to getting there and even after you're there, I'm sure it was high both times, but maybe even higher now. But there's a lot of inertia even in smaller institutions around this is the way we've all we've always done it. And I can only imagine in a place that is uh is um you know accepted as one of the top institutions in the world, that inertia may even be harder to shift. Was that your experience?

SPEAKER_01 21:12

Yeah, and I think one of the things that makes her new surgery such a fun field to go into is not only is there there's a lot of inertia in our own subspecialties, like we're constantly trying to evolve techniques, we're constantly trying to improve care for patients. There are so many things that we're learning every single day. And so I sort of, you know, unless you're somebody that's kind of in that educational space, you know, if you thought, hey, I'm gonna miss, you know, let's say you didn't attend her meetings for like the last five or six years, certainly the last decade, you're just like it's it's it's completely different. Like the world of hernia surgery is so different than it was like ten, fifteen years ago. And I think that is great for so many reasons. Um, but it's also something that if you're kind of walking into an environment where people have been trained a while ago, um they're just gonna do things differently. And it's not that it's wrong, um, but it's sort of also trying to get people on board to be like, all right, let's keep learning, let's keep innovating, um, that we can function in parallel. Um, but like there is a benefit to kind of, you know, continuing on um with your education in order to provide the best care for patients. And so I think that's a a challenging thing because you have a lot of people that are entering the field at a very different educational platform. Obviously, you have people such as myself that have done these super complex ABWAL reconstruction um fellowships, but you also have people that do MIS fellowships. And what I have found here is like, you know, they'll send you a hernia and you'll be like, okay, this is a complex hernia, and sometimes it's somebody that has just a large hernia, and sometimes it's a guy that like has no pubis and is like a three-time recurrence, and you're like, oh my gosh, like the spectrum of hernia disease is huge.

SPEAKER_00 23:13

Enormous, yeah.

SPEAKER_01 23:14

And so trying to get everybody kind of on board and understanding, I think like the hardest thing is getting people to understand that hernia surgery can be extraordinarily complex. And no, we're not doing all the GI reconstruction and these crazy whipples and vascular recons. But like we have an opportunity to really impact somebody's quality of life for better or for worse. And this is not something that you just kind of come in and you know, do one here or one there. It's like it actually takes a lot of thought in order to get the right team around you, do the right operation, provide the right postoperative care. And, you know, even myself, like I think one of the things that's important for me is I have to keep innovating because I have seen pernious surgery mature in my very short career lifespan. There's no doubt that it's going to be like that for the next 10 or 15 years as we start to kind of understand long-term outcomes, etc. So yeah.

SPEAKER_00 24:10

Yeah, the whole field is kind of just in this like full court press of of growth and of um innovation, and it can be just bewildering. And and especially for those of us that still, I mean, I do a you know, a good a good good number of hernias, but I still do other stuff as well. And so, you know, every once in a while, you know, you you get on uh whether it might be like the International Hernia Collaborative or something like that, and you look and you go, wait, what's that abbreviation stand for? Like I just learned the last one. You're like looking it up, going, wait, what is going on here? But it's it's interesting, like you said, uh there's a we're in this kind of flux where we have so many new techniques, um, many of which are so young that we don't know, you know, we don't really know like 15, 20 year data on some of these, and and so some of them are probably obviously going to turn out to not be as beneficial long term as we had hoped. Um but it but do you feel like um you know there's the adaptability of the specialty as a whole, but then there's also like that adaptability that you have to have as a surgeon in the actual surgery, like during the surgery? And hopefully that you're you hope that your pre-operative workup was good and that you're not having to adapt too much beyond your expectation. But um, do you feel like the adaptability that you kind of had to display early in your career, moving to your education and things, is that something that drew you to hernia surgery and abd abdominal wall uh surgery as a field of specialty?

SPEAKER_01 25:41

Yeah, so actually I didn't want to be a hernia surgeon. Um as a PGY3, I actually applied for an integrated vascular spot. That was, you know, there was a uh just a fantastic uh vascular surgeon that I worked with as an intern that was just the nicest human being, technically competent, um, that let me do an A B fistula in the wrist when I was at PGY1 on a Saturday. And it was like he took his time, he let me do it, and I was like, these operations are technically demanding, they are very, very cool, the disease process is cool, and I was like, that is what I want to do. So I applied for this, you know, integrated vascular surgery spot, and I didn't get it. And I was like, you know, obviously bummed about it at the time. Um, and then kind of the reason I could, you know, wasn't even really thinking the world of hernia until actually Ajina Prabhu approached me and was like, hey, listen, what do you think about Abwall? We think he would be a good candidate for it. And I was like, well, you know, let me think about it. Um and ultimately the reason why I went into the fellowship that I did is that I had a lot of respect for Rose. And he is somebody that, you know, I kind of aligned with from an educational standpoint, in the point that, like, you know, I grew up playing competitive sports. Um, I knew that if I did training with him, I would actually be able to do whatever I wanted and be okay at it. Because it was like, if you're in the wrong plane, you are in the right plane immediately. It was like, I will be very direct about what I expect. We will teach you good operative principles um and uh literally just teach you how to operate well. Um, and so I sort of thought, you know, this is gonna be great. Like I'll, you know, whatever, whatever life brings at me, I'll feel as though that I'm like technically competent. Um, and it wasn't really until kind of almost like honestly, PGY four, PGY five year, as I, you know, had already was gonna be their fellow, um kind of really started to dig into the niche of ABWAL. You see these really big operations. Because, you know, I think one of the things that a lot of people don't, maybe even I don't realize is that like you're in this institution with all these fantastic pernious surgeons, but as like a a junior resident, you're kind of just like, all right, like just don't die or have a problem. And you really don't understand kind of like the nuances and understanding and all of that stuff kind of associated with that field. And so it wasn't really until um, you know, you I was at PGI4 and PGI five that I was like, okay, like, you know, you see these people, they do these, and honestly, like all of them there, great operations, they were into research, really good technical principles in the OR, and they just seemed like a really cool group to hang out with. They prioritized their family, um, you know, their the hospital and and good surgery was important to them, but it wasn't their life. Um, and so I would say from that standpoint, I was like, oh, like these people seem to have it together. They are doing something right. And I think it was it was a lot of that, but also a lot of like once I kind of matched into the fellowship, it was like, all right, this actually has a real opportunity for uh a growth and something that I like really aligned with in terms of just like how neat the operations look, how how stepwise they are. They kind of are very like congruent with how I think. And so that's very helpful. And then we did this operation where we had to cut through some stratus mesh with a sternal saw. So that also was pretty interesting. So I was like, oh, so this is hernia surgery that everybody speaks about. So yeah.

SPEAKER_00 29:38

Yeah, we um, you know, you said so many, so many good points during your during some of this conversation already. But one of the things you were talking about is like the complexity um and how even complex hernia surgery is such a broad scope of complex. And and so, you know, and so I think that some people that may identify as complex hernias surgeons, like there are still things that, you know, that whenever I see it, I'm like, this needs to go someplace different, you know, like you oh, and and you talk about like the adaptability, you know, you talk about the uh the whipples or the big the vascular reconstructions and things like that. It's interesting because in many cases these complex hernias can can have some very some similarities and some, but I don't think that the expectation of the broader medical community of surgeons that don't do that type of work, and then especially from patients, um, they don't have the same level of tolerance of complications or the same level of tolerance or expectation of outcomes. And so it's a very unforgiving field in some in some regards. And beyond that, I think the problem that I I see uh just from afar, from a lot of people getting into, and when I what I try to really impress upon the residents that I work with is the success of the hernia surgery really being determined long long before you get into the operating room, that the importance of the clinic and the pre-operative workup and optimize optimization and everything and what that, because I think there's a you know, there's like kind of an old school mentality in many cases where you get in, you're like, well, if I find this or this and in a bad gallbladder, I'll just convert or I'll do a calangiogram or I'll do this or that. And it's it's kind of like that on-the-spot decision making. But whenever you get into a complex hernia, um, you know, it's whenever things you have to be adaptable and you have to have all these tools in your tool belt. But if you get into a situation which you're not prepared for, it can get out of hand quickly. And and it doesn't get out of hand in a way that, you know, usually the patients aren't like coating on the table or you know, or things. But pretty soon, you know, they're in post-op or years later and you're going, uh-oh, that didn't turn out the way I wanted it. And so it's a very interesting, it's a very interesting and humbling field in both that it is um uh very complex, but a lot, but it's kind of underestimated in its complexity, and then also um uh requires a lot more focus on the outpatient pre-op planning than a lot of surgeries do.

SPEAKER_01 32:07

Oh my god. Well, I always say like I I have the uh I guess opportunity to care for a lot of these really lost loss of domain hernias. Um, and I always say to patients, like, when you have a hernia of this size, um people are like it's it's still just a hernia, right? And a lot of people defer their care because they're like, well, it's just a hernia. So we have these people that have been walking around huge hernias for like a decade. And I think the thing is, is when you have like a cancer surgery and you're undergoing a whiffle, you kind of expect there to be some amount of post-operative morbidity associated with that. Because you know it's a big operation, like a cabbage. You're expecting a problem to happen. And I think when a patient walks in, they're very much like, I understand that I'm sick, this is a really big operation. If something bad happens, then that's sort of an expected or like not unexpected outcome, I will say. And here I am sitting with these patients to say, listen, we're gonna fix your hernia. You've had multiple repairs that have failed. This time's gonna be different. We may take you from the OR to the ICU in debated, but everything went totally fine. Um, and it's expected. And that's like such a huge mental jump for the patients to get to when they're like, none of these things sound like it's a smooth operation. Right.

SPEAKER_02 33:34

Yeah.

SPEAKER_01 33:35

And I completely agree with you, like the margin of error is so narrow because the impression that people come in with it is it is just a hernia. And I think a lot of times as hernias grow in size, they are um, you know, become symptomatic in such a slow way that it's like, well, yeah, it's bothering me, but I've been living with it for so long. Like, and a lot of people have told me no. So it's like you're kind of trying to get somebody from like, do I even need this fixed to like, yeah, we're gonna fix it, but you know, you might be intubated after, and trust me, everything's gonna be okay. Like the leaps are massive. And I also tell like all of the residents on my service, like, the thing about being a hernia surgeon is you are the only one that cares about the abdominal wall. Um, your colorectal surgeons don't care about it. Your urologists will take portions of it in order to do a good cancer operation. So not only do you have to know everything about hernia surgery, you have to know everything about all of these other subspecialties because they're gonna take your tissue, they're gonna be in your planes, and when you are planning on these operations, you kind of have to know where people have been before, what tissue is gonna be missing, where parts of the dissection will be challenging. So it's kind of like it really is not just a for me. Like you have to kind of be this like, you know, a little bit of everything to kind of figure out exactly how am I even going to do this operation, what tissue is gonna be there, what plane should I be in? Um, and so it's not as straightforward as close the hole, put the mesh in right away.

SPEAKER_00 35:12

Yeah, you're like oh, stick a port in and you're looking at the rectus muscle like from the inside, you're like, oh devastating. Perfect.

SPEAKER_01 35:19

Right.

SPEAKER_00 35:20

Excellent. Didn't uh didn't catch that on the CT. Um yeah, I know it's um it is a uh a humbling field, and uh in my own practice, you know, I've I've shied away. I got I've gotten to where, though it's not exactly 100% accurate, I'm like, this isn't a hernia surgery, this is an abdominal wall reconstruction. And that's like for some reason, it like that kind of shifts it in a few people. And then then other people show up and um you know, they're in pre-op and we're about to do this like huge case, and they're just like all happy go lucky, like, so when can I get back to playing golf? And I'm they're going like, well, we need to uh let's let's re let's re-establish the uh the level of of of um you know seriousness that we need to have going into the to what we're about to undertake. But it is um it's definitely something that uh because hernias are so massively wide and how far they can go from like just a stitch to to the the biggest of the big. And and like you said, those loss of domain cases, you know, a hernia surgeon better be really up to speed on like pulmonary and cardiovascular function dynamics and things because you're having to take that into consideration at like every step of the operation. And am I putting them into compartment syndrome or all these other things that that you know, definitely not just a straightforward, you know, uh definitely not a plug-in patch from the old days, that's for sure.

SPEAKER_01 36:47

Oh my gosh, no. Well, and I think that's like something that's also really unique about the world of hernia is you have things that are true, like you know, they're hernias, these small umbilical ones, the growing first, like first-time growing hernias, you have to deal with that, and then you have these like absolutely massive cases, and we're kind of using the same nomenclature to discuss all of it.

SPEAKER_02 37:10

Yeah.

SPEAKER_01 37:10

Um, and so I think that's also something that's really challenging, and I'm sure that will kind of move forward is this yes, you have your hernia disease, but then you also have this like ABWAL recon niche of hernia surgery, which is like completely different, and what we need to do um is is completely different. And maybe what we're doing, you know, for both of these things can be innovated significantly, but it does, it really requires you to kind of think out of the box and say, okay, and like, you know, I fully prepared myself, like, you know, now I guess six years into my career that like in five years from now, all I'm gonna be doing is reutars. Like people will have their mesh cut through for a vigorous number of reasons. Um, and so like my practice is gonna be way, way different. Um, and you know, the challenging thing about hernia surgery is you're right, our failures don't happen immediately. I think if we were surgeons and had some more immediate feedback, like you know, GI leaks or like your hernia immediately falls apart, like that would be very, very, very good for us and informative. Unfortunately, or fortunately, we're all much better surgeons than that. And a lot of times our problems happen one, two, five, ten years down the road. And if you're not at the same institution, and even if you are, like understanding why things have failed is very, very challenging. And so oftentimes you get no feedback about what you're doing. And so, you know, as you said, like our our issue is is these things fall apart over time, and we just have very little way to capture that data well.

SPEAKER_00 38:52

Keeps me up at night. I'll admit that's that's like one of the things that I like wake up in the middle of the night and I'm just going, man, I hope that I hope that the decisions I'm making now aren't, you know, 20 years down the line, cautionary tales, you know, because it it's and I will say just from a personal standpoint, I have a really hard time just personally outside of outside of surgery in general, like giving myself grace for decisions that I made in the past that I made with the best information I had at the time and that now I know more or or different. And I'm like, I wouldn't have made I wouldn't make that same decision now. I have a hard enough time giving myself that grace in my personal life. And then I add in the the immense like pressure I feel for patient care, and it can become uh, like I said, it keeps me up at night. I uh something that I take lightly.

SPEAKER_01 39:41

Yeah, I think you know, if you are not at least nervous a little bit and not sleeping well, you're probably not caring for patients as much as maybe you could be. Um, I certainly, you know, I I see, you know, those people that they have like or the memes with uh the phone on at night, I would say like having access to the EMR on your phone is probably the most terrible thing that you could have as a surgeon. You're like, why are they updating their vitals? And it's like they just put them in five minutes ago, and you're like, ha ha ha. So that's me also.

SPEAKER_00 40:16

Oh, it's me. Well, I'm the one that's like, I like wake up at two in the morning and uh the nurses on the floor like know me. And and most of my stuff, a lot of my stuff's outpatient now. So like the the days of me taking high volume ER call where everybody was on the floor um are gone. But now this I get the the two in the morning call, it's like, hello, Dr. Elms. And I'm like, was uh they're like they were walking around the floor and we took their vitals. I'm like, okay, well, what are their vibe vials? What's their hurt rate now? They're like, it's 86. I'm like, okay, good.

unknown 40:45

Yeah.

SPEAKER_00 40:46

How about to go back to sleep for another 30 minutes?

SPEAKER_01 40:48

Yeah, yeah. Well, the thing is, is once you're awake, you can't go to sleep. It's like this rabbit hole of like, all right, well, yeah, oh most of the time, especially when I'm doing some of these like really big cases, I am as I am falling asleep, replaying the moves in the OR, having like worst case scenario played through my head, and I'm like, oh my gosh, like, and then with the the anesthesia monitor beeping in the background, that's like my now my like nocturnal lullaby at this point.

SPEAKER_00 41:15

Oh, I I found the uh I found the one you I thought that the EMR on my phone was like the worst, and then I found like the boss of mental health disasters for me, and that is the DV5 robot that records all my cases on an easily watchable platform. Like my wife will wake up, it's like three in the morning, I've got like a surgery on like four times speed, and I'm like watching it over and over again. She's like, What are you doing? I'm like, I don't know, maybe this stitch could have been better. I'm hoping that wasn't too much tension. Did I do this enough? And she's just like, You gotta go to sleep. And I'm like, I've already tried that. This is so this is so far past me going to sleep. I'm just gonna be uh taking a uh it's gonna be a two-energy drink kind of day this day.

SPEAKER_01 41:57

So my husband also makes fun of me because he was like, You you watch the robot all day and then you come home and you watch the videos all night. You watch golf all day and then watch golf all night. It's the same thing, it's just different.

SPEAKER_00 42:11

Now, you said you played uh you played uh sports growing up.

SPEAKER_01 42:16

Yeah, yeah, I played um college soccer actually.

SPEAKER_00 42:19

Nice. So did my wife. Yeah, she was uh I went to my first soccer game. She was playing, uh, she played at Oklahoma City University. I actually played uh I played a year of college basketball and and uh was like, no, not for me. I injured my knee and it was just like, well, that's a good, that's a natural ending point for this career. Um, but she uh I went to the first college soccer game that she had, and um it was 105 degrees on like a July day in Oklahoma City. And so I'm sitting there in the stands. There's it's it's like NAI Division I women's soccer. So it's like me and like five people in the stands. And I'm sitting there, first time watching a soccer game ever, because I came from a small town. We didn't have enough barely, we didn't have enough to field a full foot, uh, to field a full football team, much less a full like football team. But um, so we're sitting there and it's it gets done, 90 minutes is over, they play, they're tied, they play an overtime, they're tied, play another overtime. So we're sitting there at 110 minutes in 105 degree heat, and it's it's two overtime. So I'm like, okay, well, now we get the shootout. Nope.

unknown 43:28

Nope.

SPEAKER_00 43:28

They just like shook hands and walked off the field in a zero-zero draw. And I was like, I was like, what just happened? And she's like, she's like, it was a draw. I was like, you guys just played for 110 minutes and didn't even determine a winner. And she's like, no, I was like, I don't understand this sport at all.

SPEAKER_01 43:46

Were you there to impress a future girlfriend or were you actually dating at this time?

SPEAKER_00 43:51

So uh, you know, we were so a little bit of uh a little bit of both. No, uh, we were dating, we had been dating for like six months. Um Even more than that, eight months, we started dating at boarding school and high school. And so we ended up, um, she'd actually got into the Naval Academy and decided not to go. So she needed a place for college. And I was going on a basketball scholarship, and she ended up getting a college and uh college soccer and academic scholarship. So she joined me. But um it was one of those deals where the level of commitment to our relationship was a little bit out of whack. Like I was like deeply in love with her, and she was like, I'm not feeling it. And so it was one of those things where I was always just like, I better like, I was like a little puppy and just like ran around after. So I was like, I'll sit in 105 degree heat every day. No, but it was uh yeah, yeah. So yes, yes and no. And so both kind of both all at once.

SPEAKER_01 44:49

I uh I met my husband after his uh after I played soccer. He actually played uh uh college baseball in South Carolina, um, and obviously had not attended any of the sporting events whatsoever. And I was kind of like, you know, as a Canadian, I don't understand baseball or, you know, the technique required to play baseball. Um, and we he he did all this training in New York and I was in Cleveland, so we were apart for a quite a long time. Um, but whenever we would go to New York, I was again trying to teach him like winter activities as a Canadian. So we would go to Chelsea Pierce quite a bit, and so um I uh taught him how to skate, which was absolutely hilarious, because he like got uh the hang of it quite quickly as a as a natural athlete, and then like five minutes later he gets like taken down by a small kid, and I was just like dying laughing. But um, we went to like the batting cages, and here he is, like just hammering like 70 or 80 mile-an-hour fastballs. I was like, oh, you actually really played baseball. Okay, okay, okay, okay, okay. You were quite good at your sport, very good, fantastic.

SPEAKER_00 46:01

Yeah, I played when we were in um, I think it was actually medical school. We were in medical school and we we um got into an indoor soccer league. And so she's like, it'll be fun, you should play. I'm like, okay. So I get out there, and like the first game, somebody like comes down and I'm guarding them like a basketball player. And she's like, You're not, you're moving like a basketball player. I was like, I don't know how to move. Like, I'm I'm between him and the goal. I don't know. And so it eventually like she comes down, and the time, the time that sealed my fate that I was never getting invited back to that team was uh they kicked the ball and it was coming like right at my face, and so I caught it because it was coming at my face, and she she was just like, What are you doing? And I was like, they kicked it in my face, and she's like, Okay, so that was last that was the last indoor soccer game I played, and I don't think I don't think I'll ever be invited back.

SPEAKER_01 46:50

Yeah, me and my husband and I have not done any coke team sports, that's probably not the best. But if we try to golf together now, not good, no, no, yeah. I go I go for like five bowls and then I'm like, I'm I'm out.

SPEAKER_00 47:04

There's one thing that is certain is that um there, you know, my wife is always ready to play a game with me, like as far as we board games or what have you, and she usually just beats the snot out of me until she doesn't. And then that's the last time we play that game.

SPEAKER_01 47:20

I mean, that that is absolutely fair. I can be on board with that.

SPEAKER_00 47:23

We're playing Rummy, and I lost like 150 times in a row, and then I beat her the first time, and I don't think we've played Rummy since. And she's she is uh she is not a very uh she there are a lot of people that have their like you know Achilles heel of who they can't lose to, and she just it annoys her. Of course, I can I can talk a pretty good smack game, so it's not I don't I don't you know blame her that much, but it is it's one of those deals. So what do you do? Uh so you I mean it so you're in Rochester. Do you still what do you do for your fun besides flying all the all over the world to scuba dive?

SPEAKER_01 47:57

Well, that's pretty much it. Um in the summer, I actually have a small garden plot that um the city that I live in um has a community garden. So I uh start my little my little seedlings actually like next weekend. They get all planted in the garage. And then uh mid-May we get them planted in the ground. Um and so I'll tend to my little garden plot. Uh I do the thing that I honestly miss about Hershey the most is you could put anything in the ground there and it would grow. Like the soil was just so fertile. So I had this beautiful peach tree that made fresh peaches, and my garden was fantastic. Um, Rochester winters are not great for like literally any plant. So I'm constantly kind of curating things in my yard. Um, I I run like I don't play soccer anymore, but I run like all of the time. Um, I have two doggos that take up a lot of my time, and then we live on a golf course, so I'm extraordinarily stubborn, and I'm like, if I'm living looking at the course, then I might as well learn how to play this game because I literally look at it every day. However, a golf is the most frustrating thing in the world, and I'm like, sometimes I'm like, I'm frustrated at work, so why would I come home and then take a hobby where I am also frustrated? Yeah, this seems like a bad idea. So, you know, we'll see how things go this year. Last summer they did not go well, so we're slowly heading in that direction, but yeah.

SPEAKER_00 49:36

A beer a hole helps. I'll just tell you that right now. It uh it helps a lot, and and the thing I've found about golf is there's usually one shot every round that makes you think you can play golf.

SPEAKER_01 49:47

It's it's like the most insane thing in the world. You're like, okay, you know, like 12 strokes on one hole, par the next hole. I'm like, this is the hugest roller coaster of a game. And because you have that one shot, you are just like seeing that one shot over and over and over again, and you're like, I just can't do this.

SPEAKER_00 50:08

It's like the dumb and dumber of sports, too, because you get to the end of it and you're and they have like a one shot, and it's like, what's that? What's the chance of that happening again? It's like one in a million. So you're like, ooh, so you're saying there's a chance, and you're like back for that next uh back for that next round. Yeah, I I loved playing golf. And then, you know, I um I'm 6'3, so I worked with all the surgeons in residency and never requested the bed be higher, and I couldn't dig a hole to stand in. So my neck got all messed up. And so now I'm good for about nine holes, and then my hands start hurting because of the old uh cervical spine. And so I I don't really play that much anymore. My son, he he's getting into it, and so hopefully I can get myself uh physically fit enough and and all that. Everybody tells me I need to do yoga, but I don't know what's more painful trying to stretch or be alone with my thoughts. But both of those things are pretty intolerable for me right now, so yoga just might not be my thing.

SPEAKER_01 51:03

Well, I was uh there's a new Plotting studio that's open next to my house, and I was like, I'll go check it out. Um, and like my husband is like an avid golfer. We have a sim in our garage, he gets up at 5 a.m. to practice the swing. Like it's quite good, which makes it even worse for me because here I'm like, can't even hit the ball, and he's like, Oh, that was such a terrible shot, and it's like in the middle of the fairway. And I'm like, We cannot golf together. But I'm here doing this Pilates, which is all of this like twisting and stretching, and I'm like, you know what this is probably very good for? Your golf game.

SPEAKER_00 51:41

Yeah, exactly.

SPEAKER_01 51:42

Yeah, yeah.

SPEAKER_00 51:43

No, that's a uh I'm yeah, I'm I'm fairly inflexible in pretty much all areas of my life, not just uh not just actual flexibility, but it fits with like the surgeon thing, yeah, it does. It does, but I do think that um, you know, being an athlete, um, did you feel like being a uh a college athlete kind of prepared you for residency?

SPEAKER_01 52:04

A hundred percent. I think one of the things about being an athlete is you're kind of used to getting feedback that is probably not pleasant. Like not everybody's next to you as an athlete. And I think that's fine. Like I honestly, you know, um I think some of like the hardest things to do when you're training people is like I I have to give you feedback, it's not gonna be comfortable for you to hear. It's also not comfortable for me to give it to you. So I think that's the thing, is is like when you are uh an athlete, you do realize that there is some amount of work that you have to do outside of regular hours to get better. Like, if you truly want to get better, you're gonna have to invest a significant amount of time to do it. Um, that people um are not always gonna tell you that you are great, you're gonna hear a lot of negative feedback. And I would challenge people that like honestly, the negative feedback is a lot more informative than positive feedback.

SPEAKER_02 53:03

Yeah.

SPEAKER_01 53:03

Because everybody says, Oh, you're doing great, you're doing fine. Like, how do you improve upon that? You you you can't actually. Um, and so there's that. And then the other thing is you're for the most part used to working with the team, even some you know, single sports, you have a coach that maybe helps you if you're at a um a very high level um or you're on a team sport, like you are forced to interact with people that maybe you don't see eye to eye to um or eye to eye with. And so kind of again, um as much as surgeon surgery isn't an individual kind of event per se, or people think it is, it is so much more of a team than people realize in the OR, out of the OR, all of that stuff. So you kind of learn actually how to work with other people um that you know you certainly don't see eye to eye with which is just kind of life in general.

SPEAKER_00 53:59

Yeah, it it also makes you it trains you to have a short memory or at least be able to perform through failure um because of the number of times that you know you have that, you know. For me, it would be go down and like miss the point blank layup on a fast break, and then the next time down, you know, got to do the same thing. And and that's always in this in the OR, that's always the hardest one when you have a case that um doesn't go as well as you want it to, and then having to walk up to like the next patient after speaking to the last patient's family, you like walk up and do it all over again. You're sitting like, geez, wish I had only had one case today, you know, wish I could go home. But nope, that's not the that's just not the name of the game.

SPEAKER_01 54:40

Well, you know, it's like the hardest part about surgery is when you think about some of the things that we have to do. Um you're kind of like nobody else would expect you to do this. Like I was doing this case, um, like got into the iliac vein of a transplanted kidney, and like obviously, like, you know, blood everywhere, everything was fine, the patient ended up doing okay. But like the next case I was doing was like almost the exact same access. And I was like, I don't think that I, and it's now like 3 p.m. because this thing case is taking forever. And I'm like, I can't, I don't think that I can actually mentally go there again because I'm not done mentally processing what just happened. And I would say this is the first time in my career I said to the patient, I was like, you know what? We are running significantly behind today. We should reschedule a surgery. I will find a day for you, like in the near future. We ended up doing it like honestly the next day. But being like, oh my gosh, like as you said earlier, like giving yourself grace, like nowhere else um do you like have to do these things and then immediately go to some the exact same thing over again. Like, you know, as much as we are surgeons, we also like are you know athletes in a way where we have these we're like very, very strenuous challenges that we have to go through. Um, and I would say like realizing that you don't have to be on job all of the time, that you are allowed to kind of prioritize yourself, which ultimately means you're probably prioritizing your patients when you have some of these like horrendous things happen. Um, you know, when I first started, thank God someone told me, they were like, when you start at mail, you know, you're gonna have all these complications that you've absolutely never had before in your life. Um, and you're gonna think you're a terrible surgeon, and it's okay. There are so many things that people were doing in the background that you have taken advantage of that you don't even realize. So, like within my first like three to six months here, I had a loss of domain horea that had like a terrible complication. We had uh a bowel obstruction from like the suture when you do the TAPP, just the suture caused a problem and a posterior sheath breakdown. And I was like, oh my god, I am a terrible surgeon. Um, and all of these things that are like relative relatively never events just kind of kept happening. And you're like, I am at a new institution doing brand new surgeries, and people are like, Who is this person that is bringing these people back to the OR? Um, and it's it sucks, it's brutal. I always say, like, surgery is a contact story, like things will happen despite your best effort, and that is the hardest part, is like you are doing everything that you thought was right and everything that you thought was safe, and it still didn't work out. And thank God somebody told me that like things would take a while to adjust, because I got through that. Uh, things are are much, much better now. But I mean, like it's it at some point you have to realize like this this isn't about me, I'm trying to do the right thing. Um, I'm taking great care of patients and really kind of put yourself first. Because if you allow yourself to be okay, your patients will be okay too. And you know, it's not that I'm complication free, like you know, things happen, and I think the thing that I've learned the most is patients in general are pretty grateful when you say, Hey, we've got to do something about this. This is not going according to a plan. Um, and as long as you stay with them through their, you know, complication, every person that I've had has been actually quite grateful. We've been able to kind of manage those things, solve the problem, and we both get to the end in the in the end. And you know, it's just surgery's tough. Surgery is tough.

SPEAKER_00 58:33

Well, you don't become you don't get to the level that you are without being at least a little bit of a perfectionist and and a little bit um type A to the fact that you I mean, like you don't you don't go through the IMG route, bouncing city to city on the East Coast, match you interview three places and match into Cleveland Clinic. I mean, bam, you know, and then end up at Hershey, which smells amazing, by the way. I interviewed those.

SPEAKER_01 59:02

Oh delicious. Yes. Oh my gosh. Yes.

SPEAKER_00 59:04

I would be even heavier if I lived there. And then uh and then end up at the Mayo Clinic, you know. I mean, those are that pathway alone, um, whether you know you want to admit it or not, is like it'd a pretty incredible pathway. So you get up to a point where you are in that new setting, like people know where you came from, they understand that pathway, there are expectations, and those expectations are probably no higher than the expectations you put on yourself. And and you get out there and you have like a hiccup, and it really, it really stinks because if those same two complications happen now, people would probably be like, oh man, that was a bad case. Must just been a bad case, right? Early in your career, we have, and there's nobody harder on others on surgeons than other surgeons, but we have this have this ability to be like, you know, we don't ever give new surgeons the benefit of the doubt. They're always just like, oh, that guy must suck, you know, or this person just must not be the look at that case. You know what I'm saying? That it's the that early phase of career, and I always try to warn people because I struggled so hard with that in my career early on. It is, it is so devastating. And then there's that level, and and I I work way better. You talk about teaching residents, I work way better with residents when I'm trying to like prevent them from being from being overly hard on themselves than the ones that don't have the self-awareness that they're not doing a good job. That's by far the hardest people for me to like try to coach up. Like the people that I'm like, chill, like this is your first or second time. Like you're gonna get better at this. Like you're seeing the planes, you just had a, you know, you're or you know, you're gonna be just fine. You're a two, you know, you got four more or three more years to figure this out. Um, and so, you know, those types of people, because my biggest problem is my um the way that I approach life, and it boils over into surgery, and it can affect the way it definitely affects my job satisfaction, is um when I expect perfection from myself and my surgeries, even the parts of my surgery that I have no control over, I still hold myself accountable for. And you know, you expect perfection from yourself. You go out, and for me, it's either I meet my expectation or I fail. And so I never feel success. But there's plenty of opportunity in the in the game that we're playing to feel failure. And on top of that, that the definition of failure for me doesn't just mean a complication or a bad outcome. It also means a case that I did that actually the outcome was fine, but it could have been faster, it could have been smoother. Um, I meant, you know, I shouldn't have had to rethrow that stitch, or I got done sewing in that mesh and it was crinkling up all messy. And like, you know, the definitions of success are so narrow that I almost like exclude myself from even being able to hit it, even if I am perfect. And so in those situations, I think that early in my practice it was even harder. And so when you're talking about having those early, early, you know, issues at a new facility, man, that's so hard. It's just difficult, difficult.

SPEAKER_01 1:02:17

Oh my god. Well, and I think, you know, as a resident and even as a fellow, you see all these people that seem to have like things together and the surgeries go well. If they have a complication, it's like, yeah, you know, and they manage it like fantastically, and you're like, oh, like life as an attending is gonna be, you know, super straightforward. It's great. Like, I'm finally out of my own, I'm not being supervised or told what I to do. This is great. You know, whenever I talk to residents and you know, med students, I'm like, listen, attending life is actually not much different than life as a residency and fellowship. We have a little bit more control of your time per se. Um, you're certainly making more money, but it's almost a little bit more challenging because when you're a resident, if you have any problems with people on your service or an attending, you're on that service for a short amount of time and then you leave. All right. If you don't want to do vascular, you don't have to pay attention to vascular. You can kind of, you know, get by. Um your patients, if they have a problem, you know, sometimes you don't even know about it. They rotate off service, you're not answering all these phone calls. You're kind of very limited into kind of what you're experiencing. And yes, you have notes and documentation and preparing. I mean, when you're attending, you still have all those notes, documentation and preparing, but now people are asking you like, how do you want to build your career? You're constantly interacting with people that you may or may not agree on, and they have full control over your time. Like, as a surgeon, yes, I can choose to book eight hours or 20 hours of surgery, but how long that takes really depends on everybody else but me. Um, and yes, I can kind of get through an operation relatively quickly, but it is my job to train people and to teach them. And you know, sometimes you have your fellow and sometimes you have a PGY too, and you know, they're not really offering you help based on the complexity of the case. It's like this is the schedule, here I am. And so there are so many things that you have to kind of mentally deal with when you are starting your career, and even now, like um getting through your day is sometimes just like, well, I'm here, I will fix the surgeries uh or fix the hernia, and and things things will happen. And as a very type A in control type of person, you're like, why can't we? Um, and you kind of sometimes have to like let go a little bit to be like, all right, I can control the things I can. These are all the things that I cannot control, um, and just just make it through the day. I will say, like, having my husband's an anesthesiologist. So he obviously is in the OR as much as I am, well, not as much as I am, but in the OR as well. And you know, having a little bit of perspective of like, you know, these are the things that you can actually have control over. Here are the things that you just you just gotta let go. And the thing that he says the most is he's like, nobody will care about what you're doing as much as you do. Yes, you are by far the most invested person, and so you just have to sit with that and realize that's where you're coming from. Everybody else is just trying to get their job done, and there will always be that difference. So just live with it. And I'm like, you know what? It's very sage advice.

SPEAKER_00 1:05:44

Yeah, I um, you know, that may have been the first time that anesthesia wasn't the re wasn't wrong, you know, that that with that one bit of advice. See, I would hold that over if if my wife was anesthesia, I'd just be like, you know, I've won every argument forever because it's always anesthesia's fault. But um but no, I think that it's a very interesting thing um whenever you go through your day and it it it's like this accumulation of like microaggressions. And I'm just like, okay, gonna swallow that one down. And then like, okay, gonna swallow that one down. And then I come home in their days. I'm just like, I don't mind if other people don't care. I just want people to not actively work against what I'm trying to accomplish. Like if we just I don't mind, just don't do anything. Just stop, stop completely. I'll like just please, just please. And it it stinks because sometimes I come home and um, you know, you just bring it home with you. And and that that um, you know, that just the frustrations boil over and come home, and like my kids will be, you know, just being kids, and I'm just like, God, just like please stop, you know, and and then you get done. And like, oh man. And then most of the time my kids are more mature than I am, so they're like, Dad, that wasn't a very good way to parent. And I'm just like, oh no, no, not right now. Don't say that right now. Oh my god. But so I gotta, I gotta ask. The um I uh the Instagram handle, I love it.

SPEAKER_01 1:07:10

Oh yeah, yeah. Oh my gosh. Well, actually, oh in my first job, uh, I saw this person that clearly was having obstructive symptoms from their inguinal hernia, like really old person. For some reason, they decided to do a capsule endoscopy to figure out what's going on. And I'm like, that's a terrible now. They're obstructive. It's gonna get stuck, yeah, yeah, yeah. Um, and uh they were being like like I met with the patient who was quite nice, the wife and the son. Um, and they were being kind of super wishy-washy about surgery. And I'm like, listen, like this is an open inguinal hernia, like pretty straightforward. Um, I mean, I definitely think you need to have this done. You can work up whatever sort of motility or ever after, but like until we like deal with this hernia with Val, like, I mean, this is certainly gonna be a question of everybody's. Um, and after like a couple of months, they ended up actually in Poly's clinic. Um, and uh the surgeon or the patient was like, Oh, I was fine with Dr. Horn. And his wife was like, you know, we like Dr. Horn, she's very pleasant, but I we kind of felt like she was looked too much like a Barbie in order to fix the hernia. And I was like, Okay. And he was like, of course, Paul I was like very, very polite and nice and was like, you know, Dr. Horn is like fantastically trained, she's a very good surgeon, etc. Um, uh, but is is more than like, you know, capable. But I'll fix your hernia, and I'll be like you know, it's it's an opening or hernia. I'll see very many more in my lifetime. I'm not at all. Um, but sort of, you know, put it out there to be like, listen, you know, I'm aware of of what I look like. I often get asked about how young I am, how many of these I do. And it's just sort of um kind of the nature of honestly, like at this point, everybody's um job. Like, you know, yes, I get maybe a little bit more than most because I'm a female and I look young. Um, and and I'm doing like quite a complex practice for someone that's fairly junior in their career. Um, and so those those questions come up quite a bit. And I think it was it was done to kind of say, hey, listen, like, yes, we can get over that hump and then just start talking directly about you know how we can care for you. And actually, it's been uh a way to connect with patients on a level that has been absolutely fantastic, actually. So um, I have a patient whenever they uh see me, oftentimes, if I get to see them at their one-year post-op visit, they'll give me little Barbie things. So um, I have a patient that is huge, huge subxiphoid hernia um that actually used a tennis ball to keep it reduced. So she would like wear like two bras and then like double abdominal, like those white abdominal binders over top of it with a tennis ball to keep it in. Um, and after like a year after we fixed her hernia, she gave me a brand new tennis ball. It's named Tilly. You know, a bright pink box with a pink bow and it sits in my office. So now I get all these like adorable, cute pink things from patients um uh because of it. And I think it like hopefully helps other people that are junior in the field that have some amount of thing that they're like, oh, it's like super annoying that people ask me about this. And you know, I mean it happens, it absolutely happens. Yeah from my perspective, you can either kind of let that irk you or you can say, Listen, I'm just it is what it is, it's part of my personality. I mean, I'm not gonna like get shorter anytime soon, so I might as well like you know use it to my advantage and move on.

SPEAKER_00 1:11:00

Yeah, you've kind of harnessed the like the jokes on them. And patients love being patients love their physicians and their doc and their surgeons being human. And it's just like, and they also, you know, I had a patient one time early in my career. Uh there's only two of us in the practice, and so they called her, I need to make an appointment, a follow-up appointment with your surgeon. And they said, Well, which surgeon did you see? He said, I don't know. And they go, Well, like, were they young, were they old? And this the uh my partner was like a 75-year-old Chilean guy, and there's me. And they go, It's the one that looks like the Canadian lumberjack. And that's there you go. Okay. I had long hair at the time, so it worked, it worked more than it does now. But the um, but yeah, no, I think it's um it's interesting, you know, that's definitely something that my you know, my wife talks about being an Obi-Guy and going in and like delivering the baby and then coming back in and the and the husband being like, Are we ever gonna see the doctor? And she's just like, well, I've been here the whole day. I wearing a tag that says MD. Um just did the delivery. But yeah, it's uh it's interesting. I I um uh it's it's one of those things that I never have to deal with that. You know, people I early in my career they used to say that I looked young. They don't say that anymore. I kind of wish they would, but that's not a that's neither here nor there. But do you feel that that's something that early on did it make you irritated, or is that just something that's always just been kind of like a whatever?

SPEAKER_01 1:12:31

You know, I think earlier on it didn't. Um now, you know, honestly, I I I just like it doesn't even it doesn't even create any sort of emotion at this point. Like I think there is an opportunity to kind of choose to um to let that bother you. Uh there's certainly some situations where uh the the fact that I'm young um it and I I feel as though I'm not kind of getting the maybe respect is the best word for like the training that I have or knowledge that I have, it certainly does irk me. Like don't get me wrong.

SPEAKER_02 1:13:12

Yeah.

SPEAKER_01 1:13:12

Um, but I think you kind of when it comes from patients, again, like they're just patients, all right. Nobody intentionally does things for the most part, I find, to be offensive. Yeah, um, and everybody just wants the best care for their family members. And so, you know, especially now, like I there are hernias coming out of my eyeballs. And so if I don't fix one because you don't like how I look or or whatever, I mean it's not a big deal. It's probably not a good way to start this surgical relationship, anyways. Um, you know, I will say sometimes I use it to my advantage, like it's very easy for me to call from Dr. Horn's office and sound like a nurse. Like, great, awesome. I I get to kind of navigate this. So I, you know, it is what it is. You know, yes, yes, people assume a female voice from uh an office is a nurse, and sometimes I might not correct them if I don't want to go down the whole spiel of et cetera, et cetera. Um, but you know, I think it is there are certainly, you know, the world for women and men in in surgery and in the world of medicine is not the same. But I I do think there are opportunities for um you to kind of grow and and learn how you can leverage the things that women do very well and men do very well to benefit your patients and your partners. And so I never think that I'm gonna be treated like a male or want to be treated like a male or identical. Like there are things that I'm actually gonna do different because of my gender, and I think that's fantastic. Um, and so I'm just gonna, you know, be me and leverage the things that I do well at. And if those things kind of align with, you know, the fact that I'm a female and might spend a little bit more time or a little bit more caring, I'm not gonna care if you call me honey. Okay. Most people don't call their person that they do not like honey. So at least we know that you are happy with me, and so I can be okay with that. Does not bother me at all.

SPEAKER_00 1:15:15

Yeah, that's a um I uh would probably not be so graceful, frankly. But um, but then again, my wife says I'm 100% driven by spite, so maybe that's uh more of a character flaw than anything. But um, you know, we do many of us are in in education of residents. Um and so it always is something that I have I try to be cognizant of the way that my female trainees are treated differently than my male trainees. Um it I would be lying if I didn't say that nurses write up our female residents way more frequently than our male residents for literally the same statements or the same behavior. Um, and neither of them are being inappropriate. It's just the perception changes. For a guy like me who realistically has never really personally experienced that type of bias, um you know, I'm a six foot three white dude from Oklahoma. That's not, I'm not exactly, you know, a uh in the minority, most places I'm at. The uh how do I how should I handle that? Do you have any tips for folks like me that want to be cognizant of it, but also don't want to don't want to be demeaning or assume that they're not empowered to take care of themselves or need to be, quote, taken care of in any way. How do I approach that in a in the most uh you know thoughtful and meaningful way?

SPEAKER_01 1:16:36

Uh yeah, I think you know, I think um having uh I like to use the term male champion is something that is oftentimes kind of gets, especially female trainees or females, kind of like out of this, you know, um role is seen as less, I will say. You know, a lot of times I agree, like the thing that is most horrible about what happens to a woman trainee is oftentimes it's not men that are a problem to the women, it's other women. Um and we have to figure that out, number one. But I think, you know, when especially when you see it happening, if you say, hey, listen, I understand that you have a problem with this trainee, like what she's doing is not wrong, and kind of just nipping that in the bud before it even kind of escalates to a complaint, or even, you know, bringing that nurse aside, whoever complained to be like, hey, listen, you know, this surgeon, she is a very important member for the team. I think she acted, you know, with accordance as to how I would act. Um, I think sometimes it can be uncomfortable for males to stand up for women because they don't want to be like, well, I don't want to feel like I'm like, you know, uh putting you down or anything like that. But I think a lot of times we do, you know, would love to have someone interject to be like, listen, you know, she knows exactly what's going on, and I respect her. You know, my chief resident makes the same decisions I would make. So if she said that this is what's going on, then I have full faith in her and you know, we'll proceed with how, you know, she has decided to care for this patient. And I think that is an uncomfortable situation because most of the time, you know, it's uncomfortable to begin with. Um, and I think a lot of times uh men prefer to not interject themselves into the discomfort, which is totally reasonable. But if especially when you see somebody saying, like, you know, calling your resident, you know, a nurse or not addressing them as doctor right in front of you, that's an opportunity to say, hey, no, this is Dr. So-and-so. Um, and while it is uncomfortable for just a few seconds for everybody, the lasting impression that that trainee has because you stood up for them in an uncomfortable moment. And for that, you know, you're not doing anything that's patronizing to the patient or the nurse or whoever it is, it corrects the problem immediately. And now it's kind of like, okay. Because I think a lot of times, you know, especially in my life, I would have loved to have the more senior male stand in and be like, no, like you can't speak to her like that, or this is actually the doctor. Um, but a lot of times that doesn't happen, and so we're kind of forced to navigate this world. And I think one of the things that is unfortunate is I think a lot of times people are like, well, women have to, you know, storm the castle by themselves. And this is a very gender-separate experience, but like that's not how we function, all right? We work with other genders, and so this is something that we can work together to make both of us better. So I think there's a lot of misperception that if we elevate women in the field, that we will be seen as less, and that's very, very untrue. Like we function great together, and when we elevate women, we have an opportunity to learn uh from more women. We also have an opportunity to interact with men more, and that's just kind of the nature of how life is. Um, and so I, you know, very much see that, you know, when we put women in fields of of power or leadership, the same thing that we should do for men. Like it just both of us are here. Let's make it comfortable for everybody. But yeah, if I could give you one piece of advice, I would say if you see it happening in front of your eyes, just you know, interject really quickly. And oftentimes that that problem will no longer be a problem. And I will say the person that's gonna remember it the most is that female trainee that was like, finally, somebody said something. And I I will I will venture to guess that they probably won't forget it for a long time.

SPEAKER_00 1:20:52

Yeah, so it's really kind of more of a empower and support, they don't not necessarily like quote save. So it's more of a yeah, yeah. And I mean, and just to to your point, you know, being a fantastic surgeon, being a fantastic leader, fantastic uh human being is not gender specific or or gender influenced. Um, you know, and I think we have we have uh the opportunity, you know, to make a field that has that has all kinds of people to treat all kinds of patients because different patients are gonna connect with different people. And that's irrespective of gender, nationality, whatever. But it's if you if you only have one type of person or one, you know, if if we have a mold that we're creating somebody out of that we think is like the perfect idea of a hernia surgeon, we're gonna have a portion of our patient population that doesn't connect with them and is not receiving, they may receive good care, but they may not be receiving the full experience of comfort and um and connection with their surgeon that can really bring them into a feeling of of uh making a really difficult situation for them as easy as it can be. And so I think it's it's incredibly um incredibly important. And and you know, I I don't think I cared about it near as much. Definitely not any, I'm definitely not some like um, you know, I I've had many times in my career I probably could have done way, way better than I did in in regards to that. But becoming a girl dad, that really that'll that'll change your perspective real quick. And I'm just so then it so then I'm just like, okay, somebody's gonna pay for this, you know. But it it's it uh unfortunately, you know, as with most things, it it doesn't matter near as much until it affects you. And um, and that's and I'm probably no different, but but definitely appreciate your willingness to to talk to that because I do think it is something that's extremely important, but it's also something that we want to navigate in a thoughtful way, because again, I think it that even uh efforts to do the right thing can come across extraordinarily like can the effect can be the wrong effect for even when it's like the best of intention, just like poorly executed. So I think it's important to know how to do it right.

SPEAKER_01 1:23:06

I think also like you know, in any irrespective of gender, you or race or or whatever, you have an opportunity to be offended or just sort of move on. Um, and if every little thing somebody says or does to you, you get offended by, you're gonna live your life pretty offended. Um, but if you can say, you know, at least, you know, develop some amount of like I'm an I'm an okay person. Um so that like when people say things, you know, it's so it's so much easier, you know, to just just move on versus kind of let that sit and brew with you. And you think of like all of all of the time that you can spend with your kids, you want to spend that interacting with the kids versus sitting and brewing over some random off comment somebody made, probably when they're having a really bad day in the hospital, like whatever. Like, you know, and you know, we were talking to this about the uh beginning in terms of like, you know, hernia data and women, and there are so many nuances to humanity and how everybody's presenting, what life they're in. And I think, you know, as we start to thoughtfully study different races, different genders, we're gonna get a lot more data. And I think, you know, there's there's perception that maybe we'll find out that we're doing things wrong. Well, you know, what is if we find out something wonderful and we're like, oh my God, we should have been treating everybody like this, and we found that out because we're looking at a completely different population or a different socioeconomic science. So, like more data is never bad. But as we start to kind of again grow this world of hernia with, you know, providers in different locations, different training, different genders, we really just open the opportunities to care for all of our patients better. And we learn more because we have more perspective.

SPEAKER_00 1:25:03

There's also something could be poetic if we find out that some of these different groups are not nearly as different as we thought.

SPEAKER_01 1:25:09

Exactly.

SPEAKER_00 1:25:10

So, well, you know, it's been a I again, thank you so much for coming on. As we get towards the end of the episode, I always ask everybody their opportunity to uh to give their hernia hot take. So this is your chance to give your hernia hot take.

SPEAKER_01 1:25:25

Well, uh yeah, what is my hernia hot take? Um, you know, I think it kind of uh branches on to the world of gender and hernia. And I would say like what I what I I say, what I would hope for the world uh or world of hernia moving forward is that we actually kind of start to solve some of these gender differences in hernia outcomes, figure out why our women are not doing as well, figure out how to care half of our uh for half of the population that we operate on. Um, and you know, I think honestly, sometimes people think mesh gets a really bad rap. I love mesh so much mesh. And so the answer is if it needs mesh, put mesh in, irrespective of gender. So um those are my two hernia hot takes.

SPEAKER_00 1:26:11

Those are fantastic ones. I um again, thank you so much for taking your time. I know this is in another in a very busy world, um, taking time to stop and have a conversation uh like this is something that could be kind of burdensome, but we really do appreciate your perspective and very much respect your opinion and appreciate it.

SPEAKER_01 1:26:29

Oh, it's been an absolute pleasure. So thanks for having me on.

SPEAKER_00 1:26:32

Absolutely. Well, this will wrap up another episode of the Hernanie You Gods podcast. This is your mere mortal host, Luke, signing off. Thank you so much.