The Hernia Gods Podcast E19 - Paul Colavita, MD

Episode 19 of The Hernia Gods Podcast features Paul Colavita, MD discussing the evolution of a foregut practice, the benefits of getting back in the gym, and the struggle of dealing with a complication.

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_01 0:06

Welcome to the Hernia Gods Podcast. This is your mere mortal host, Luke Helms. 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 Paul Colovita out of the Carolinas. Thank you so much for coming on with us.

SPEAKER_00 0:39

Oh, thanks for having me. I'm excited to be here.

SPEAKER_01 0:43

Yeah, I was just, you know, this is a full circle moment for the podcast because I've told the story a bunch of times about uh the fact that I was at the American Hernanian Society sitting down, um just kind of hanging out. I think I was like having a beer or something at the bar down in the hotel there and was having struck up a conversation and during the conversation realized that we're all the same and that we had the uh opportunity to kind of talk about it. And that conversation was with you. And so I it's a full circle moment for me to actually have you on the podcast. And and also I think it's uh it's a it's about time because we have not gotten any of our Heidel Hernia uh members, you know, their their fair share of respect for the hernia game that they bring. So uh again, I'm just so thankful you came on. Like we uh like we saw all of our episodes, I'd love to just hear a little bit about you know who you are, where you come from, and how you got where you are.

SPEAKER_00 1:37

Absolutely. No, I remember our conversation well. It was uh you're right, we were shared a lot of the same interests, uh, whether it was lifting, music, and hernias. And uh here we are. Um so I'm Paul Colavita. I uh lived in North Carolina most of my life, grew up in Charlotte. Uh, went to Duke, uh undergraduate, uh then UNC from medical school, and did my residency here in Charlotte, Carolinas. I was trained by Vedgir Augenstein, who was on last week. Todd Henneford, uh, Ken Kircher were kind of my my hernia mentors, and Brett Matthews became the chairman halfway through my my time here. And so I kind of had a uh ventral hernia pedigree, uh I feel, and I was well trained and then went to Oregon, did a fellowship with Lee Swanstrom, Steve DeMeester, Christy Dunst, and Kevin Revis. Kind of became a foregut guy, uh, was hired back at Carolinas and I got back here in 2016 and lived in a hernia and foregut world for a little while in the last, oh, probably five years, it shifted to to mostly foregut, and I I don't really do uh very many uh abwall surgeries anymore.

SPEAKER_01 2:43

Yeah, is that something that um that is the foregut shift and the and I'm assuming you still do uh quite a few high idles in the in the foregut world?

SPEAKER_00 2:52

Absolutely. I I do probably a hundred parasophageal hernias a year. Um I have uh surgical endoscopy practice as well. I do poem, G poem, Zanker's, but uh my number one customer is a as a parasophageal hernia for sure.

SPEAKER_01 3:08

And was that something that um that when you went to Oregon, they they trained you up in kind of the foregut side? And that was so when you came back, that was an expectation that you were going to be doing that, or is that just something that you kind of filled a void or a need for those patients?

SPEAKER_00 3:22

Uh so uh I went to Oregon really to focus on that, and I saw myself probably having a career where I did both. Um I was the frequent um presenter of the American Hearning Society, European Hearning Society. Uh when I was in Todd Hanniford's lab, uh incredible mentorship, and we we traveled uh the globe, we went to Asia, Europe, all over the United States presenting our research. And I I thought that I was gonna live in both worlds. And uh there was there was a little bit of a void to fill. Todd uh was the primary foregut person here uh when I came back, and uh he was obviously very busy with ventral hernia as well, so there was um space for me to fit in and uh build a foregut practice, and then as uh times changed, um we uh kind of had ventral harnius covered, so to speak, and my need wasn't really there, and I was doing I don't know, a handful of really complex abwall surgeries a year, and there were um uh it kind of got to the point where it was kind of silly to do 12 big cases and uh just stick with the devil I the point that I knew well, which was foregut surgery.

SPEAKER_01 4:33

Yeah, I think that's always a very interesting, it's an interesting point for uh for for the people out in the community as well, you know, because we know that there are certain uh surgeries that it's really well documented that high volume centers do uh do them well and and have lower complications than if you just kind of dabble. And you're at a place that has a lot of volume of that type of of that type of work. And so, you know, in a set in the setting, your your definition of doing 12, it probably would be would seem like quite a few for some of the people that are out in the community that may not be may not be seeing it as frequently. Do you feel like um you know, from your from your standpoint, what do you think is like the magic number for doing like those types of the big complex abdominal walls that would have made you feel comfortable continuing that?

SPEAKER_00 5:24

I don't know. Um, I mean, I think that you know, 12 a year, uh like I I think that I wasn't getting the efficiency my partners had. Uh you watch Federal Augenstein do a preparing heart repair, Todd Henneford, Kent Kircher, they are it's like magic. They can just separate that peritoneum from the uh posterior sheath, make a huge pocket and put a piece of mesh. And if I was doing the same case in the next room, they're probably closing the fashion. I'm you know, maybe finishing my flaps. I mean, just uh doing 12 a year, I wasn't I didn't have the speed they had. And that you know, it starts to get frustrating. You know, you do uh a big case, uh takes you know hours, and my partners uh who are you better than I am at it are faster. It didn't make sense for me to do it. Um if I had to guess, I think you gotta do it, you know, uh super complex revisional ab wall surgery. You have to do a couple of month minimum to be the top of your game, I think.

SPEAKER_01 6:24

Yeah, it's uh it's so it's so interesting just because you we have um I come from the panhandle of Oklahoma, and so out there you have surgeons that are doing a lot of stuff that other places are specialized out, and they may not do high volume, but there are significant times and in places like where I grew up where they're just not gonna travel. You know, like the idea of someone traveling to one of the major centers for a lot of those folks, it just doesn't happen. And so it becomes an interesting like dynamic and an interesting question between access for some of these patients and competence and you know, efficiency of the surgeon. It's it's a really interesting, delicate balance between the two. Do you feel like I mean you've you practice in a very large in a large center, and so you have uh the ability to to maintain volume in in your other things. And so when you jumped into the Parisophageals, is that it sounds like that's kind of what you really wanted to do anyway.

SPEAKER_00 7:21

Uh yes, I would say that that was became my primary interest after fellowship. Uh, I think I I I began to enjoy Forgun more than Abwall, but I mean when I was a resident, um, I spent probably a total of 12 months uh with Henneford uh over the five years. And I spent a year in his lab outside of that, uh in the middle. And so I felt well trained. I mean, you know, by the end of my residency, I mean, I felt like I could tackle a whole uh a whole lot of abdominal wall cases. Um and uh I enjoyed them. Uh and I I guess I still do, but uh when all you see is the really tough ones just because of the practice we have, um it just didn't make sense for me to keep doing them. Um forgo is definitely my became my love, and um it's it uh it's rewarding. It it's like a ventral hernia, they're often different. Uh you have to be technically sound, uh it's a you know, follow attention uh principles, and uh it's you know part science, part art. And um, obviously the patients get you know that uh gratification from symptom resolution almost immediately after both of them.

SPEAKER_01 8:28

Yeah, it's funny you talk about you went into foregut uh and kind of gave up the abwall stuff. I went the opposite direction. I don't do foregut and I don't do like parasophageals anymore. And it's for the very same reason is that I was doing such a low volume of them and other people were doing more that I just I have always kind of been of the opinion for myself. I can only speak for myself, but I I always feel kind of doesn't feel right if I'm doing a surgery that I don't do very often, and like the guy right next door does it like every day, and you're and I'm and I always try to like practice by the same principles of you know, who would I, who would I send my family to kind of aspect. And and so there's it is an interesting thing because I, you know, in our in our system, the with the way things are set up, you're giving up volume. Uh, and and that volume, you know, can sometimes really be something that you're being scrutinized for, especially, you know, as you're kind of growing a practice. But at the end of the day, it it never just it just never felt right to me. And so that's one of the reasons I actually gave the uh that game up is just because I wasn't doing very many of them, and I thought, you know, this is this is not something that that after 10 years out of residency, I'm just all of a sudden gonna start getting a deluge of those types of referrals. So I probably should just consider not saying that I don't do those anymore.

SPEAKER_00 9:48

Yeah, no, it's it's mirror images, just foregun hernia. Yeah, it's you know, exact same, just opposite here. No, you're absolutely right. It's uh uh they're both uh high-stakes environments, right? We have uh you have potential for major abdominal wall complications, you know, infections, hernia recurrence, mesh infections. Um, and there's processes and protocols you're gonna follow to minimize those, and it's a high volume person who's gonna have those and and know how to avoid the avoid the pitfalls.

SPEAKER_01 10:17

Yeah, it's it's interesting too, because you do go through that kind of learning curve early in your practice where you are kind of having to practice on people. I mean, you we go through all the training, you go through the the simulators, you go through all the all the different educational tools, but eventually, you know, you have to have your first patient, you know, and it and that is a that for me, you know, it's it's one of those stressful things taken at prime time. That's why, you know, I've always I've asked the people that I've had the the opportunity to talk to that have invented big things, like what's your what's your thought process when you go into a case and you're like, well, this is the first time I'm taking this to an actual you know human being that's that we're gonna see how this works. It's it's really interesting because most of their answers are based around the fact that they're really just building on, like you just said, core surgical principles and usually are building on knowledge from previous types of procedures. Do you what's your when you get to a uh a when you walk into the operating room for a day of surgery and you see the board, like what's your what's your ideal mix for you to be like, this is gonna be a good day?

SPEAKER_00 11:19

Well, I I'd say my favorite case, um, I do love an esophageal poem. So um I do zanchers, I do G poems for the uh gastroparesis, but an esophageal poem, uh, they're just fun. That's an elegant endoscopic procedure. Um, but I think my favorite laparoscopic would be a small sliding hiatal hernia. Um there's you just have uh you have enough of a hernia to have planes, and you can do a nice media sound dissection, close the hiatus, uh do a fun application, or you know, any anti reflux surgery you're choosing. Um and like the recurrence rates aren't terrible for the small sliders. That's that's uh those are my favorite. Um for the I don't know technical satisfaction of doing the case and speed and efficiency and uh patient outcomes. Um so Dream Day, it's probably a mix of sliding heidel hernias and and esophageal poems. Um the problem is we don't get a lot of sliding heidel hernias and surgical referrals, it's all lots of gigantic paresophageals, and that's okay. They're they're fun too.

SPEAKER_01 12:20

Yeah, we uh that isn't that always the way. You're like, man, I love that. I that's the way I do. I the majority of my practice now seems to be inguinal hernias, and I have talked, I mean, I enjoy doing them. I'm definitely not complaining about the people that that I get the opportunity to to work with and help. But you get there and you go, I I used to have small hernias in my practice. Like, did they just start referring those to someone else? Like, where did all where did the straightforward stuff go? Like, I used to actually have those, and I didn't the same people are referring to me. I don't know where they where they all went, but you know, you never want to bite the hand that feeds you, you know, because you're just happy to have it. But definitely as you do something more and more and kind of become known for it, all of a sudden all the the the game that made you fall in love with it usually kind of disappears and you're left with the uh little higher stakes environment.

SPEAKER_00 13:09

Oh yeah, no, it's uh the foregut, it's it's you start getting all the redoes and the revisional uh parasophageals. Uh I try to give the residents like a lesson every case, like today's lesson is this, and the redo's the lessons usually don't go into foregut surgery. Um, just because it's a slug fest every every redo.

SPEAKER_01 13:28

Yeah. Yeah, those I you know, as a resident watching those redoos, and they'd be like taking down a wrap or something, and I'm sitting there going like they're gonna they're gonna use the harmonic there. And then and then the patient does well, and I'm just like, okay, wow, that's crazy. I would have never, you know, I I definitely didn't see that plane. And then you get older and you're like, oh yeah, they didn't either. They were having to like, they were just using experience to make the plane.

SPEAKER_00 13:56

But same thing with the operative abdominal wall, right? Uh they've got mesh in a couple different planes. You gotta find them or create them. Uh it's yeah, uh, it's all hernia surgery. It's uh it's what makes it fun.

SPEAKER_01 14:08

Yeah, well, it's it's some of it is also what you're comfortable dealing with the complication of because at some point in these cases you have to make the move that is you know, uh you're playing statistics, or you're you have to make that move that you're like, well, this could go well or this could go poorly. I've done everything in my power to raise the level of success to a level that's acceptable, but at some point you have to make the move, and you're like you make that move and you go, you know, most of the time you're like, all right, good. And then then occasionally you're like, well, okay, now I've got to fix that. And that was kind of always the the stress. I don't know why, like the the distal esophagus, like that injury or something, that always is like it that always freaked me out. So that was uh so I you know, power to you when you're doing when you're doing all those.

SPEAKER_00 14:55

Yeah, it's uh it's funny. I I think training with people I trained with were all uh perfectionists, right? I mean, we uh everything you can do to minimize the complication. And when I first started, like I remember my first redo, we're taking the wrap apart, and um I'm it's my first year back in Charlotte, probably my first three months. And I probably scoped that patient eight times during the fun application takedown, just like uh like you know, insufflate this side, okay. That is the fundus, and then you know, over here, and then leave the scope in as a bougie to feel the esophagus. And then again, with time and experience, you you could you start to see it, and um, but it's uh they're just uh so afraid of the complications. Um and you're right, it's you know, once you start to figure it out and you can see through the mess, um there's there's times there's uh you know, I'm not really a hundred percent sure uh is this the exact right plane? And yet you know sometimes you have to go for it because you don't have any other options. Um, I'd I would scope so much. And now uh, you know, with age and experience, I'd uh I'd scope a lot less. I still do it, but a lot less during the case.

SPEAKER_01 16:05

Yeah, like uh for me the equivalent was like the big Ingrid of Scrottles having like the resident reach out of the drape and pull the testicle down to make sure I'm looking at like what I think I'm looking at. You know, you shouldn't go like, is that the cord? And you're you're like, pull it, pull on the testicle, you're like, okay, I can see it moving there. Yeah, it's um it's interesting because you know, early, like you talk about those early cases, it can really shake your confidence pretty hard. At least me, if you have a complication early in your in your learning curve of something, especially in that technical aspect, I think as you get more and more volume, the complications still hurt the same. It's not like that goes away. But at least at the end of the day, so you know, I fall back on, well, at least I've done at least I at least this is my first one, and now I just don't know whether I can do it or not. I've done X numbers successfully, and this is obviously not one that didn't go as well as I wanted, but but at least I have that track record. You know, when you're doing you know, the esophagus is pretty high stakes in a lot of cases. Um, and we've all sat through a you know residency MM and heard the the esophageal leaks and things like that. How does that do you are you the type of person that's able to kind of compartmentalize your life? Or is is though are those types of cases that stuff that you lose sleep over?

SPEAKER_00 17:21

Um that's that's a great question. I I so um I would say I I have trouble compartmentalizing it, um, especially early on. Like I uh inherited some complex leak bariatric cases when I first came because I I gave a grand rounds on endoscopic leak management uh when I first got back, and that was a terrible idea. I was on 24-7 leak call for a year. I mean, if there's a leak, I got the call. Um but uh it was a patient who had a sleeve leak, and uh we uh she had a stricture of her sleeve, so we we ended up trying to convert her to like a subtotal gastrectomy. Uh complicated story, but she she leaked at her GJ. Um she had a rich reperineal fish shell we didn't know about that we found and repaired, but she was sick. And I would just sit at home and like every commercial break and watch a TV with my wife, I pick up my phone and check her vitals and uh put it down, um, you know, check again the next commercial break. Um just uh I come obsessive over this my first really complex um case. And um I think now uh I I worry about them um but I I don't check every 15 minutes on their vitals. Um rely a little bit more on the residents to call me if there's issues. And um uh but it's it's tough. It's you know, you put a lot into these patients, it's a long operation, it's a long recovery when they they come in with a complication and you're trying to fix it. Um it's it's stressful for the patient, stressful for the surgeon. Um, but it's uh as as I think as I've gotten older, I'm getting better at that kind of work-life balance and trying to leave work at home when I can.

SPEAKER_01 19:02

Yeah, I um yeah, I you know, I've I've made a lot of progress. I think I was at 15 minutes. I think I'm at like 17 now. Maybe I've I've bumped at least that extra two minutes on that vital sign. You know, I had a patient that had a big abdominal wall recon. Uh tough, tough case. Was uh was one of those cases that's like unexpectedly tough that early in my career would have been just an absolute disaster because I didn't have the tools that I have to deal with something where you get in there and go, uh-oh, this is like way worse than it than the CT scan suggested initially. Um, and so you go back and and and now I was able to convert and do the more the more complex deal. And she's doing fine right now. But even last week, you know, I'm I'm sitting there, you know, I'm I'm the type of dude that you know, she goes home from the hospital after a few days, and you know, they they get a call from me every day. And so like on Sunday, she's just like, okay, you again? I'm doing fine. I'm like, okay, well, just checking, just checking, you know. But it's it's one of those like call you like call the nurse, it's like, I saw the heart rate was 105. It's like, yeah, she was walking. I'm like, okay, well, you should make a note next time. My heart rate's 150. But yeah, I know it's uh it's like it's so tough. I I am a I am a um a perfectionist to a fault, and it uh it drives me crazy because that perfectionism sometimes it makes me just like not trust anybody else. Because I, you know, I don't know if you if you ever have those issues, but I you know, I I never it it's you know, I also know that you know nurses are busy and they got multiple patients and stuff, and nobody's gonna watch as close as I would, you know.

SPEAKER_00 20:37

Yeah, no, I I I think I got to look at my uh resident like you know reviews of me uh when I went for a promotion to associate professor uh four years ago. And the biggest complaint was micromanager. Um just you know, uh you know, no autonomy, um, like with floor care. And uh it's but when you're a perfectionist, uh you you want to squeeze the margins, you know. Every chance you have to optimize your outcome, you want to exploit. And um that's uh it's a challenge when you're trying to teach and um and you know, let the residents have some uh some say in the care. Um but uh I agree. Perfection is too a fault of guilty of the same. It's it's uh minutia is what makes a difference.

SPEAKER_01 21:24

Yeah, exactly. Like I I don't know. There's there's a fine line between you know the that have to be perfect versus doing a good job. But then there's also like this line between good enough and good. And for me, like the people are like, eh, it'll probably be good enough. I'm like, whoa! Like if it, you know, if if you ever like if I ever hear someone say that, I'm like, okay, what did we just do? But you know, it's funny because there's a there's a toll that is taken on you. It um, especially especially earlier in my career, it was even more, it's still. today, but there's a major toll that's taken on me trying to teach when you're a perfectionist. Because the you they throw a stitch, they do something, you're like, ugh, that's not exactly okay. You know, you kind of got to let them, you got to let them make mistakes because they need to learn. But then on the flip side of it, you know, I'm so terribly tough on myself when I do have a complication that I you know you hate the idea that, well, if I would have just done X, Y, or Z, or if I'd have just, you know, if I'd have just gone back and reinforced that area or something, I never want to have one of those moments where I look back and go, I could have done that better. You know, and that's that's the part that's so hard for me.

SPEAKER_00 22:42

100%. No, you're absolutely right. I mean uh it's it's a it's a tough balance. And I mean I think that's that's the micromanager complaints I get it's like yep no we're gonna cut that stitch out where that that fundos a little asymmetric. We're gonna redo the toupee there. Uh it's where it's worth the time if they're gonna have a better outcome but it's um it's it's it's a challenge.

SPEAKER_01 23:06

And it's also funny because a lot of the stuff that we do you know we let the stuff that we let the resident do you know routinely routinely like the closures and stuff that's what the patients care about. And so occasionally you're sitting there like they're like are they micromanaging my port closure? I'm like well yeah because it doesn't look very good and that's the only thing they're gonna care about in the office you know and and there's also a difference whenever you're uh pure elective surgeon and there's an expectation of outcomes from not just the patient but the referring physician and and you know and that's like how you feed your family you know and so there's a level of there's a level of uh of pressure and I was just talking to some of the residents today about the fact that you know I'm a firm believer that and this it this comes across very pessimistic and probably is because I'm a pretty pessimistic person. But the uh you know I'm like nothing ever really gets better from through residency and into practice. It just gets different. And so like you know you get out and you're like oh I could I don't have to be in a round at 5 a.m I can do X I can this determine my schedule a little bit more. And then you get out and realize that like all the pressures that you know didn't realize existed when you become an attending that as a resident those weren't those were just different pressures. They weren't the same and and it's not like the pressure disappears it just morphs into something different.

SPEAKER_00 24:26

Absolutely right it's uh new you know administrative uh headaches right like epic messages patient calls um you know committee meetings uh it's it's it's it's it's different noise um but it's it's still noise I will say this though I would not go back and do residency again I I like this noise better.

SPEAKER_01 24:47

Yeah yeah yeah no you have it you definitely have a lot more control over the noise and um you know this this noise believe me I I having control over your schedule somewhat is way better than anything in residency but I think that they that I at least underestimated the X the different pressures that arose you know and and it's like you said it's it's a um it's a double edged sword you're sitting there and like meeting after meeting and then you're going well if I put that meeting there I can't do this case and these this patients really want their case done that day and it's just like you're you're always kind of in this balancing act of it feels like sometimes I go to work and I'm just like okay I got to choose who I'm gonna disappoint today. Somebody's getting disappointed I just got to figure out which one it is so but uh I don't know it's it's an interesting it's a it's a really interesting thing because I had some of the same complaints on my evaluations and I still do. Now I'm just I uh am just brutally honest with the residents about like my perfectionism. I'm like we're taking that stitch out and redoing that because otherwise I'm not gonna sleep for the next three nights and I really need my sleep.

SPEAKER_00 25:56

So yeah if I if I explain my um I don't know what the eccentricities to them it they they accept it more. Yeah that's how I feel like uh like I I drape this way and yeah it's part superstition and um you know or whatever you know my minutia I like to do is I just tell them it's just me. This is this is what what I need to do to to to sleep at night like you're saying I mean it's uh it's kind of funny how we we we get a path we want to do it and um we don't accept variation from the path.

SPEAKER_01 26:31

Yeah. The um uh whenever you have like a you know the for me I think there are people everybody takes complications seriously that's not the that's not the insinuation but some people take them very seriously from a professional side and they they do the right thing and everything then there are other people I've seen that it's not just a professional hit it's really kind of like a really personal hit to them um and are where do you fall kind of in that in that gradient?

SPEAKER_00 26:58

Oh no it hurts personally um and you know I'm lucky to have a benign forgo practice I'm not doing esophageomies um and our complication rates are are low. Um you know if I was a I talked about this last week I was on call and recovering colorectal and surgical oncology and they're doing surgeries that have known leak rates that are you know are significant. I was like I I couldn't do this like I couldn't you know do this L A R and they have a leak I would this would this would emotionally hurt me. But I I also think that when you're in that field you you get used to it. You know the percentages and it gets back to you saying earlier like you know the you have a denominator you know uh the ones you know have your success rates and you're on par with national benchmarks and maybe that gives them comfort and they'd accept this is going to happen.

SPEAKER_01 27:47

And when you have a field where you know a le an injury to the esophagus should be at 1% or less you know that would just be a devastating injury uh for you know to for me emotionally to deal with um uh so definitely personal side I I that hurts yeah I it's uh and it for me I I take it home and and it I think here more recently there's uh kind of a compounding of the fact that I'm kind of going through it and then it also I also see it like affecting my kids you know they're obviously not like upset about the complication but they are kind of like upset that you know dad is kind of just kind of distant you know they'll come up and be talking to me and it'll be you know 10 seconds before I'm like even in the same room with them mentally and so it's a it's a it's a very interesting thing something I've really been thinking about a lot lately is we talk about you know the primary trauma of a situation like that where this the patient and they're there and they're people that that are affected by that directly um and then there's the secondary trauma of the caregivers and the and the providers and things like that that are dealing with it. But really I I think that there's like that whole you know it's hard to be married to a doctor I'm sure um I'm married to one but you know she's you know I I know that that she's blessed because I I'm just like a fantastic husband I'm sure she would I'm sure she would uh suggest that she didn't listen to the podcast so I can say pretty much anything and people will think it's true. But uh but you know I think that there's that that tertiary kind of trauma and uh whenever I whenever I'm going through something like that it's really hard. It's funny because I was uh you know that was actually kind of what I was thinking about when we started our conversation up in Nashville uh because I was just thinking about you know I was sitting there in those meetings and and listening to the lectures and you're listening to all these people talk about you know this is how I do this and this is how I do this and then all of a sudden I'm sitting there having like flashbacks of oh man I bet if you know five years ago maybe if I would have done that technique this patient wouldn't have had that problem or if I would have known that you know and then you know my partner he always has a much better perspective he's like you know that let's be clear like that didn't exist five years ago I'm like well yeah you know but but it's just uh it's tough for me sometimes yeah no I I totally agree I mean uh the when you take it home and you're thinking about the patient you're checking your phone every 15 minutes um I uh I I I don't I think I don't know how to stop doing it.

SPEAKER_00 30:19

Um you know what I mean I don't know I think it's it's either it's again if it's uh you have a surgery that has a 10% complication rate I think you get numb to it right you have a denominator you know what your statistics are but the the one off disaster um that that that's tough and I mean I we the pay the first reason I talked about my wife would refer to her as VIP um I guess I I pull up my phone she's like checking on VIP yeah checking on VIP and then a couple years later I had a younger patient and uh another complex situation that was VIP two and we now have three VIPs uh that uh that pop in and out of the hospital sometimes and I'm like oh VIP two's back and uh she's like okay uh I understand I was like I've got to go take this call that kind of thing um so yeah my wife let's be you know she understands but the the kids don't and um I I try to turn it off dinner time bedtime and then if I got work stuff to do I'll take care of work stuff then.

SPEAKER_01 31:20

Yeah I um my kids are getting a little bit older of course early really early in their life they don't have any idea um you know and it's funny because my my wife's nobi guyne and so she'd understand she's you know being procedural I think helps because you know it wasn't until she got back to do it she was doing like uh hysterectomies after a period of time where she was out doing mostly just obstetrics as part of like a laborist program. And when she got back doing hysterectomies she was just like I can't sleep I'm worried about this patient I can't I'm waiting like counting down the days until their follow-up appointment and and all this stuff she's like this is brutal and I'm like that that's exactly what I've been feeling like all those times you're upset that's me you know uh so there's there is but but it's really it's really interesting how you know even people within the medical field uh may not fully grasp it it can be and it can be like really really isolating when you're going you know man I'm really going through it and and nobody else around me really gets like they're like I'm sure the the one that kills me is I'm sure they'll be fine. It's like okay oh now I feel great.

SPEAKER_00 32:28

Yeah man I'll just see a tincture of time it'll look better um you're like let's go really slow right now I don't know but what do you do uh what do you do for uh for decompression obviously you you work a lot I'm sure and everything like that but what what's your uh what's your kind of let it all let it all loose and let it all go routine yeah so I started to hit the gym uh well a little under a year and a half ago uh I when I was younger worked out a lot and halfway through residency I just stopped and took 13 14 years off and uh got back at it and that has been the biggest quality life improvement uh for me in the last year and a half just going to the gym before clinic day you know we start at eight I can get there at 5 30 and get a workout in shower and head to work uh my attitude the way I feel is just so much better if I work out in the morning so I I can usually make that happen um maybe one or two work days and then on the weekend and get three in a week and um that's that's how I decompress and it's uh it's it's really helped a lot.

SPEAKER_01 33:34

I mean just in all aspects I'm healthier uh leaner stronger and you know the dopamine the endorphins whatever it's uh it's uh it's good for mental health oh yeah I have these like I do these workouts on the weekends I for some reason can't have I've been trying really hard I have an alarm that's set at 5 a.m to get up and work out before work and every single day I change it to 6 30 so I don't know like I should probably just change it to 6 30 at this point but um I uh I will have these like workouts on the weekends and and my trainer I have a trainer that just like texts me's like hey how's the week look I'm like horrible he's like okay I'll check in with you on Saturday so but anyway we uh he's always like you need to get in and out man and I'm like no you don't understand I'll do these like two two and a half hour workouts each day on the weekend and I call like my mental health workouts it's like half listening half listening or half lifting and half listening to like music from my teens just like it depends on the mood like sometimes I'm almost like chill I'm like oh this is nice and other times it's like straight up like limp biscuit and corn just like blaring and I'm getting all the anger out but you you're right you get done and you're like okay I can I can handle this now it's like there's a level of uh of release that comes with that yeah go to full clinic day 15 16 patients you know however many are consults and that's just easier to get through if you've start off in the gym that morning at least you know for me yeah we had a we were just dying before they got us an APP here recently and um my clinic days were like I finally had to be like I can't see like please don't schedule more than 45 and it was it was crazy and so finally we've got some support now so now I'm like okay if I if I have like a 15 patient clinic day I'm like oh this is nice I actually get to get to connect with them on a deeper level than just like trying to put out the fires because it is a it's it's interesting when you're you know we were trying to cover a really busy busy emergency department and all the follow-up from that and and our own practice and you know everybody identifies a need but it's it's unfortunate with the way that it goes it's like once you identify the need it still takes months to get the full like to get it fully in place and get the help and during that time you're just like grinding it out and like burning down and and so it I was doing really well in lifting for a long time there and was just I was feeling fantastic like my back stopped hurting like my neck didn't hurt anymore. I'd even got to where I could do a day of like laparoscopic surgery and my hands wouldn't be numb by the end. You know it's like it just like the the ergonomics of everything was was improving and then and then it just you know you have like a period of time where for for me this time it was December where everybody's just trying to hit their get all their surgeries in and so I was just cranking through them in December and and it comes up you come home you're just dead tired and I just can't I can't do it. But for some reason I can't get up early maybe you've inspired me maybe I'll maybe I'll leave the alarm on for 5 a.m and just snooze for an hour and a half tomorrow. It'll be a step in the right direction there you go.

SPEAKER_00 36:41

I uh did you say 45 patients in the clinic?

SPEAKER_01 36:44

Yeah it was brutal and we didn't have that was with no no residents no PAs no scribe nothing and so the problem was is we'd get I would see you know up to you know sometimes I'd have over 120 patients and then like the you don't document so I'd be like frantically like scribbling notes on a sh on a paper and then on the weekend I'd come home with like a hundred charts. So I'd end up working like the whole weekend and so it'd just be this like never ending cycle and I don't want it to I don't want it to seem like my employers were like forcing this. They were not my employers were like are you insane and I was just like no we're trying to get to this like next goal because we need the problem is you have to justify you have to justify help and the and the way everybody looks at the justification is volume. And so if you're going like hey I I'm you know I'm kind of at max capacity I could really use somebody else they're like well what are they going to do? Like you're you're doing it. And so then you're kind of you it's like that whole it's a weird thing where you have to be at like 150% capacity for them for people to be like well now it makes sense to do that. And um I call it like the opposite of the field of dreams. It's like no there's no like if you build it they will come. It's just like wait until the corn feels like burning down and then they'll call the fire department. You know it's like that's that's kind of how that always that always seems to work. And it's not I don't think it's like place specific it's just the the name of the game of of medicine as it is currently yeah I mean I I've hit the 20s uh but 45 i i couldn't do that i um i've I I took a foreigner consult I spent 30 minutes with him uh probably and um uh fellowship swanstrom would triple book every clinic uh yeah they would do it half day uh a week but every spot was triple booked and we'd finish at 10 o'clock at night like the last patient leaving the building at 10 o'clock um it was wild um but yeah the guy was he had had a lot of uh responsibilities he was like he was uh editor for surgical innovations he's like editing journal articles uh in the middle of the clinic uh and uh I come see him to present the patient we go see them and he would see a patient while I was in one room it was uh insane um but I uh 45 solo I I can't believe you were doing that yeah that went on for about six months and um and it really you know it uh that was real during that period of time that's actually when my like working out stopped because it was just kind of like I'd get home and and uh for me there's by the time I get home at night sometimes I'm so just mentally exhausted and that's even now it's not like it's I mean now we're much better we've got a lot of a lot more support and and everybody identified it and I have zero complaints about how that was handled. It was just that's just getting people and the right people in the positions and getting people to accept the job and stuff just takes time. But um but you know I get home and the problem is I have all these wellness things right so if I could just you know I always have these like grand ideas. I'm gonna just I'm gonna read you know I'm gonna read books and I come home and pick up a book and I'm asleep before I get past the first page you know or I'm gonna you know I need to lose some weight because I constantly am battling that and the uh come home and I have like such decision fatigue that I walk in like open the fridge and before I even sit down with my meal I've already eaten like 2,000 calories and I'm like oh well that's gone. It's a it's an interesting thing and at the end of the day but we're the product and how we take care of ourselves really impacts how we take care of our patients. And so it's a really it's a it's a really delicate balance because I feel I feel an obligation and again people weren't forcing me to do that. We were trying to get our surgicalist program off the ground to really take care of our patients effectively to get the inpatients taken care of and that required us following up. So those 44 um you know a lot of them were post ops a lot of them were we would follow our hernia patients you know pretty serially for that first year and then again serially for the first five years. And so a lot of those are like check-in type visits where you're kind of just going in hey are you having any chronic pain are you back to your normal activities? Do you have any you know any other things and doing an exam and so some of those visits are pretty pretty slow and really realistically are pretty fast. And realistically those are are things that are best served for you know an APP to begin with. But um but once once we got that that set up then it really allowed me to focus back in and so I really have so much more enjoyment in clinic now being able to actually sit down and take the time and get to know the person. And the funny part was is that um we during that middle of that period of time we were working so hard and seeing so many patients um as they were building our support around us uh we got uh AI dictation and so then it was like listening and so it was really incredible when that happened like it was like getting to take back the human interaction of medicine again the same thing there not taking notes just like having a conversation and um and getting done with the clinic and having at least the framework of your note done made a huge difference. Uh so that was another another big step for us. But I'm sure that you're you're probably seeing so much of the I mean like a redo the redo stuff that you're doing I mean just the counseling on the risks and benefits alone is a significant chunk of time I'm sure yeah well honestly the biggest chunk is reviewing the records right it's getting their old op notes and some of that's before you see them.

SPEAKER_00 42:24

Um but you know it's it's you get this pile of stuff and it's all we get it all it's all scanned into their chart. You gotta go through it and you either do it the night before uh which you know you got probably want to do other things or maybe you're doing stuff from that day. Uh right that what if you did a Monday you gotta do Monday night and then Tuesday clinic pile of stuff you didn't review yet. So you're going through their old pH tests, their old monometry you know imaging studies, op notes um that takes time and then uh it's just like a redo patient probably needs like an extended visit. But we just run it long and my nurses are just they they know that we're we're gonna we're gonna you know kind of work through I'm gonna work through lunch um and then well you know we'll we'll catch up by the end of the day kind of thing. But um yeah the post op is it's uh like hernia it's it's pretty straightforward right it's uh any reflux you're off your PPI dysphagia and stuff like that but um I think without a doubt I I having the patient interaction getting to know them I spend a lot of time up front in the consult and that actually makes the post op stuff uh seem to go a lot smoother because they know me we've talked about all the stuff that recovery was going to be like and you know they're either on that path or we've had some speed bumps or they're cruising and uh it just seems like it's a uh makes if you spend a lot of time up front it makes the post op care a little smoother.

SPEAKER_01 43:49

Absolutely especially if things aren't going well like if you're trying to develop a relationship with the patient during a complication oh my gosh like it you're so far behind the age Like if if you get to the end and they're, you know, the best, the let me put this in air quotes, like the best complication, um, which is none of them are great, but the best ones when the patient gets done and we sit there and you're like, well, this is what's happening. They're like, Yeah, you said this could happen. And you're like, Oh, good. You were listed. The ones where they're like, You didn't say tell me this. You're like, I promise you I did. But um, but you know, I think that's that's a big big deal. Jumping back to your um to your lifting. Were you an athlete in high school and and earlier in your life?

SPEAKER_00 44:33

Uh my big sport was uh wrestling. I was a high school wrestler, uh, pretty good. Uh one stage my senior year of high school. Um that's not pretty good. That's really good. Thank you. Um and then I played football. I wasn't very good at football, but uh played two years of high school. Um and then I just I stayed in the gym after that college, med school, early residency, and um then I let it all go for 15 years.

SPEAKER_01 45:01

Yeah, yeah. I same. Yeah, I was uh I played um I was a track and cross-country and basketball player, and um uh now everybody just assumes I either played football or was like a sumo wrestler. But the um but we get to uh when I got uh into college, I played college ball for a year, uh kind of tore up my knee um uh and used that as my excuse to get out of it because college basketball for me was like all the parts of high school basketball I didn't like. Like all the all the stuff that I was like, I love basketball, like that all went away. It was everybody was you know, a lot of people are just looking to like get their stats to make sure that they're kind of moving on to the next level because I wasn't playing like D1 or anything, I was in AI D1. So that a lot of those folks are trying to jump into the NCAA D2 or D1 level. And so it was uh it was a very interesting, uh, interesting experience. And so then I kind of just like burned out on it. And I'm one of these guys that unfortunately I'm like an all or nothing person, like to a fault, like always to a fault. I'm the guy that's like, I'm gonna start working out, and I go to the gym, I'm like, I'm gonna work out three three hours a day, seven days a week. And the first day I miss, I'm like, well, I guess I'm not working out anymore, you know? It's not like and so I got into residency, and of course I like wasn't working out at all. And one time I went home. This is this is kind of funny. My wife, she's a she's I love her to death. She's sweet, but she is also super blunt at times. And um, she uh um I came home and I was like, man, some of the nurses on the floor were calling me fat. I was actually feeling kind of bad about myself. They're gonna call me fat. And she looks at me and she goes, Well, do you think it's like your medications or do you just have no self-control? I was just like, Oh, oh, okay, I'm just gonna go over here and and eat this whole sleeve of Oreos now.

SPEAKER_00 46:51

It's like, thanks, honey, appreciate the support. Yeah, why it's funny. I mean, like I I got fat and I you it happened slowly. You don't notice it, and you're like, oh that's a bad picture of me, you know. You see some picture and and uh I don't know then I I didn't even know that it one day it clicked. Uh I just I wanted to start working out again and I just started doing it, and then you slim down. I was like, holy crap, I was fat. Oh yeah. And um and uh I Same it's you just you don't notice it as it happens.

SPEAKER_01 47:23

Um it's insidious, it just like sneaks up on you, and then pretty soon, pretty soon you lose the weight, and you're like, hey, my knees don't hurt anymore. That's weird.

unknown 47:32

Right.

SPEAKER_00 47:34

And like you said, you said your back didn't hurt. Same. I mean, like I used to always like I'm stretching, popping my back, and I don't make core stronger, yeah, better posture. Uh it's uh it's a game changer. I I wish I'd gotten back at it sooner.

SPEAKER_01 47:47

Yeah, me too. It's and it's so funny because there'll be periods of time um like my wife, she's worked out like non-stop. She's worked out her whole life and she played college soccer and stuff, and so she doesn't know what it is to be like out of shape. And so she's she recently had some orthopedic surgeries, and so she hadn't been able to work out for like six weeks, and she's you know, she's dying. And I was just like, honey, believe me, you're gonna be just fine. Like you're gonna bounce back in a couple of weeks. But my problem always was when I even when I had the best of intentions and wasn't just doing something ridiculous, like trying to work out three hours a day every day, but even when I had the best of intentions, I'd go back and like forget that I'm 40 now and I'm not 18 anymore. And so, like, put up put some weight on, and I'm like, oh yeah, I'm doing this. Like, I'm like dad strong, and then boom, shoulder goes out. I'm like, oh God. And so it's funny to be in the gym and be working out with like these little, like much lighter weights than than I ever would have wanted to be seen working out with before. And I'm just like, you guys, wait until you pull something, then you're just like it's like not a walk it off kind of moment. It's I pull my shoulder and I'm down for like three weeks.

SPEAKER_00 48:53

Yeah, no, I did my first day back. I remember I put 95 pounds on the bench press, uh, like like 25 on each side, uh in the 45 pound bar. And you know, I forgot 10 reps, and I and I was like, Oh, I think I actually have a pump. I mean, like how weak was I? What happened? Um after a couple months, I mean it's like there's muscle memory, and uh I started like reading about it, like you know, it seems like it's coming back really fast, and there's you know literature and scientific hypertrophy stuff, but um it came back quick. And I mean I'm and now I'm I don't know, I've got to keep grinding. Uh I'm I'm definitely addicted now. Like it's uh there's no going back.

SPEAKER_01 49:38

For sure. It gets it gets to a point where then you and then you start to like I'll have a really busy time and I'll start to slide a little bit, and I'm like, God, it's like painful. You just like watch it, you're like, oh man, I was getting so close. And and uh and uh you I just have to keep in mind that you know all this stuff comes in phases, but I also lose lose track of where I came from because it got it got pretty rough there. I got really into uh craft beers, and I was just like, this is amazing. There's this like really cool craft beer bar down the street, and I was like, I gotta try all of these, and and then you stop and start, and so then eventually it's also like I am a little bit uh overweight. Maybe I should start to see. So the first thing they're like reading, like you should track your calories, like track one day's calories, and I was like, six thousand calories. I was like, How am I not dead? People, people are like, What is I'm like, I'm like, I'm eating six thousand calories a day, and they're like, No, you're not. I'm like, no, I really am. And they're like, Well, what are you eating at night? And then somebody will come over. I had this one friend who came over one time, and he was just like, he goes, uh, uh, did you uh did you eat? He's like, he's like, You can't be eating that much. I was like, no, really. I think I have been. And the other day he was hanging out and he's just like, and we ate something, and I ate like a few pieces of pizza, and he's like, Dang, you're still eating. I was like, Hey man, this is a lot better. I was like, I used to order when my wife would go off, and this is before we had kids, and I would order two large pizzas and slam them by myself in an evening. It was not there was no, it was all you know, no holds barred, and then all of a sudden that stopped being a functional thing because you know I was not burning all those calories back in the day.

SPEAKER_00 51:20

So that's yeah, no, I yeah, I mean you could you could put it away when you're 20 and you burn it off, and then uh we get older and it uh we can't anymore. Um I got I remember doing like you know wing eating contests, and I was like in college at the competitive eating was so big, and we like it would have campus-wide hot dog eating contests, and I'm trying to crush 20 hot dogs in 10 minutes. And I I'm getting two hot dogs now, and I think I'm stuffed. Um it's just uh it's it's crazy what you can do when you're younger.

SPEAKER_01 51:52

Yeah, and I I work with a lot of bariatrics guys, and I and they they look at me as a little bit weird now, and I'm just like, hey, like ease up, buddy. I'm not like not yet. Not yet. So like you know, you're sitting there going, like, I'm not I'm not sending your kids on that vacation this time. So I think they're just like waiting around. They're like, well, these days this guy's gonna fail his diet, and it's we're gonna get him. But we had a um, we've uh you also uh do music, right?

SPEAKER_00 52:21

Uh yeah, so I uh uh we were I played guitar in a in a past life. I have hardly played uh in 20 years, but uh I still enjoy music. I listen to uh a lot of uh music gym carr uh at home. I've recently got a record player, so I just throw a throw a record on and sit at my office and do some stuff. Um so I'd say I'm a music lover, uh, but I'm not a musician anymore.

SPEAKER_01 52:46

Yeah. What's your what's your go-to in the OR?

SPEAKER_00 52:51

So I I gotta kind of cater to the crowd in the room. Um so safe safe music is like 90s on nine on Sirius XM, uh maybe um 90s alternative, uh lithium channel 34. But if with the right crew, um like a circulator, crna, scrub, who I know like heavier music, uh we'll we'll listen to some octane, uh maybe some 90s hip hop. Um but uh a whole lot of 90s alternative.

SPEAKER_01 53:18

Yeah, one of my one of my favorite things to do would be go in the room with my partner and he would have his phone set up um playing music. I would log on to his phone and uh while he was scrubbed in and uh put on and it was playing over his phone, I'd put on Aqua's Barbie Girl, and then I'll just like lock his phone and leave. That's a that's a good one. That you know, it's it's I think he would get so angry, it might have become a patient safety issue after a while. So maybe I probably shouldn't do that again. But that was a that was a good one to pull on people there for a while. But yeah, no, I think I I have to watch when I listen to music in the operating room. I almost have to listen to music I don't like because otherwise I'll get like to thinking about it or singing along with it and it'll like distract me. So I have to I have to find something. I've I've got to where I let um I let the um uh the scrub, well our scrub tech has a few playlists that she knows that that the whole room kind of likes, so we just kind of roll with that. But yeah, well, you know, as we um as we come again again, I'm just super excited that we were able to get on and talk because again, I it's funny because this was again that sitting in Nashville at the having a drink, whatever. I think what you said to me, the the phrase you said to me, to give a little behind the scenes here, the conversation was about how I was I was sitting there listening to all the people lecture, and I was saying that I did not feel that um that I would ever be on their level. And I'll and you basically said, I know most of these people, and they're just normal human beings. They they get up and present and everything, but they're just people at the end of the day. And I think that that was the moment that I was just like, I think I I know that, but I don't think I like I intuitively knew that, but I don't think I'd really considered the fact that some of these massive names um are just normal, just normal human beings. And so that was when I was just like, you know what, I think we're all more alike than we think, and we can get it, and hopefully we can just have a chance to talk about it. So again, thanks for the inspiration. You're the you're the it's kind of taken off in a really cool way. So I appreciate the the conversation that we had. You never know when I guess we never know when our actions might impact somebody else, but yours definitely uh set this in motion.

SPEAKER_00 55:28

Well, thanks, man. I'm glad to be part of it. Uh I've well I've tuned into a bunch of your episodes. I think it's great. And um I I enjoyed that. I got to play a small part in uh the snowball that became this this awesome podcast. So kudos to you for taking FD and running with it and and building this. It's awesome.

SPEAKER_01 55:45

Yeah, I sure appreciate it. And you'll have to uh you'll have to to you know compare with veterans, see which one of you think you guys did the best, uh had the best podcast. A little partner partner competition there.

SPEAKER_00 55:57

Yeah, no, her walls directly like the other side of this wall is her office. So I'll that's funny.

SPEAKER_01 56:02

Well, I've I've looked at that wall before then, I'm assuming maybe. It's the other side, yeah. So at the end of uh like we do at the end of every episode, I do give people their chance for their for their hernia hot take. This might be our first hydal hernia hot take. And so, you know, no pressure, but you are setting the bar for the parasophageal hydal community currently.

SPEAKER_00 56:23

Yeah, well, I think on the topic of hot take, it needs to be a little controversial. And um, you're gonna find uh all sides to this argument, but I uh my hot take is reinforcement of the of uh the diaphragm diaphragmatic closure for parasophageal hernia with a prosthetic mesh uh absorbable synthetic or a collagen-based biologic mesh is the correct thing to do to minimize your short-term recurrence and uh perhaps if you even if you're just delaying a hernia recurrence, it's worth it and mesh should be considered a diatus.

SPEAKER_01 56:58

There it is. There it is. Yeah, I know I I uh I know a few people that would uh that would argue both sides of that point just in my hospital system. So yes, I think that will uh that will serve as the as the benchmark for the parasophageal. And so the next uh four gut guy we have on, I'll have they'll have to to you know up the bar.

SPEAKER_00 57:17

Yeah, we'll see what DuCoin thinks.

SPEAKER_01 57:19

Yeah, I've known I've known Chris a long time. He I can promise you one thing about Chris, and he he probably won't listen to this, but it will be it will be very well spoken. He will have a very it will be eloquently delivered the hot take.

SPEAKER_00 57:33

Oh you know, he's uh he's a good guy. We're we're on a sages committee together. Um I just interacted at the meetings, but uh great surgeon. Uh seems like he's a budding, budding leader in uh USF.

SPEAKER_01 57:45

Yeah, he's uh he's been a um uh a very good friend of mine. He was uh one year ahead of me at um in residency, and we've we've stayed in touch uh in touch since then. And he was even the resident that gave us, gave me my tour at um uh when I came down here for my interview uh at Orlando Health. And I'll never forget because I walked out of it and I said, man, it's crazy. I was like, this guy's saying that he's going surfing like two or three times a week over on the coast during residency. And uh I got into residency and about halfway through my intern year, I'm like, man, I have not had any time at all to go to the beach at all. Like, how is this working? And I talked to him, and he's just like, Oh yeah, no, that wasn't a thing. I was like, oh, I came here for that. The old bait and switch. Exactly, exactly. But no, I love Chris. And we we're we're trying to work out a date. So he'll, like I said, we'll have to have him try to up your up the bar on your on your hot take. But again, this man, I really appreciate you coming on, appreciate the conversation, and um, and look forward to seeing you at the at the meetings.

SPEAKER_00 58:45

Likewise, thanks for having me. Uh, it's been fun, and uh hope to see you in person soon.

SPEAKER_01 58:50

Yeah, absolutely, man. Well, this wraps up another episode of the Hernia Gods podcast. It's your Mirmortal host, Luke Elms, signing off. Thanks.