The Hernia Gods Podcast E21 - Peter Santoro, MD, FACS

Episode 21 of The Hernia Gods Podcast features a great chat with Peter Santoro, MD, FACS about the difference between speed and efficiency, the beauty and struggle of being a parent and surgeon, the difficulty of accepting praise for our work, and the realities of mental health in the medical 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_02 0:06

Welcome to the Hernia Gods Podcast. This is your Mere Mortal host, Luke Elms. The views, thoughts, and opinions expressed on this podcast belong solely to the hosts and guests and do not necessarily reflect the official policy, position, or opinions of Orlando Health or any of our employers. And now, without further ado, let's talk hernias. Hello, and welcome to another episode of the Hernia Gods Podcast. This is your mere mortal host, Luke Elms, and I'm joined today by Pete Santoro. Thank you so much for joining us, Sor.

SPEAKER_00 0:36

Thank you very much for having me.

SPEAKER_02 0:38

Yeah, so we uh as we start every episode, uh, we appreciate you uh coming on and we'd love to hear a little bit about who you are, where you come from, and how you got where you are.

SPEAKER_00 0:48

Uh absolutely. So my name is Pete Santoro. I am a general surgeon, um, abdominal surgeon, um, and I work in the state of Delaware. Um, I'm from Delaware. Um, if nobody knows where that is, it is a little state on the east coast, uh, just south of like the Philadelphia area. Um, so grew up here, uh, born here, raised here, um and uh went away from med school and then came back and did my residency at Christiana Hospital, which is the biggest healthcare system in the state of Delaware. And then I stayed in the area uh in practice. I uh went into private practice initially after training um for four years and then uh was recruited to um basically sort of head up the robotics um department at Christiana and start a hernia center. So um I started working there in uh in 2018 and that's where I've been since. And my focus um as far as work is abdominal wall um surgery, uh hernia surgery. About probably 90 plus percent of what I practice now is hernia surgery. I do a little bit of other general surgery stuff, lumps, lumps and bumps, gallbladders, that kind of stuff. But um it's and you know, call, acute care. Um, but the majority of what I do is is uh is hernia, and uh sort of have a that little niche in my practice uh that not a lot of other people in this area do, which is like sort of the complex abball reconstruction and and uh uh dealing with that kind of stuff, and started doing those robotically in 2017 um and have been doing ever since. And sort of more and more of my practice every year is is that. Uh so it's it's uh it's what I really enjoy doing and and what I've sort of focused on.

SPEAKER_02 2:41

And you are in private practice, correct?

SPEAKER_00 2:45

Nope. I'm I am hospital employed. Okay. So um I was in private practice for the first four years and then uh joined the the staff at Christiana, which is uh it's a it's a big academic affiliated healthcare system in the state of Delaware, um uh affiliated with Jeff, Jefferson University in Philadelphia.

SPEAKER_02 3:07

When you've uh uh as you've kind of made those that transition, has there been any um major changes to the way that your practices has you know run? Any changes in the stressors of the job, things like that as you've made went from a private model to an employed model?

SPEAKER_00 3:25

Um I there's definitely differences. Um it was you know, it was a while ago now, 2018, so like feel like it's a whole lifetime ago, the world's totally different now than it was back then. Um there's there's definitely pluses and minuses to being in private practice. There's definitely pluses and minuses to being in an employed um model. But either way, it's um uh it's been really good to sort of, you know, when I was in private practice, um having senior partners, I was the by far the youngest uh guy in my group, and uh I replaced you know a very senior surgeon who had he basically retired you know June 30th and I started July 1st um in the job. So um right out of training and and uh so having senior partners that that um you know were able to to mentor me a little bit initially was was very helpful. When I started in private practice, I joined a a general surgery group that basically had a focus on abball um and had her had a hernia center associated with it. And so right out of training, I was doing a lot of um you know hernial surgery and dominant wall reconstruction, which was only being done open back then. Um and uh so had good mentors um you know for the first four years, which was I think really, really helpful um as I sort of got into you know practice and you know adapted my techniques from open to more minimally invasive as as I sort of as those things sort of evolved.

SPEAKER_02 4:59

That's one thing that you and I have in common. Whenever I first came out, I was doing almost all open. And you know, for me, that was a there was a little bit of a a feeling, uh I was always a big believer, still am, that if you're doing something minimally invasive, um, with rare, well, I would say with rare exception, I can't think of any currently, but being able to at least do the open version of that procedure in case you had to bail out or something is an extremely important skill to have. Um and so I felt I had initially trained like in in residency and had all the uh plans to come out and do like lap teps, um, you know, balloon dissector whole nine yards, and did a few of those. Uh, was not super supported by my senior partner who was very much still in an open kind of mindset. Um, and so I it I naturally started to gravitate towards open. Um and during that time, it was really actually helpful to kind of get that senior mentorship on how to do the hern repairs. Ironically, the way he did them is still something that uh I take a lot of my lessons from. And and even after going through a bunch of different education and listening to all these, you know, super experts on inwinal hernias and things talk, there's still a lot, but a lot about what I learned from him and through that kind of mentorship time. So I definitely know that um that what what you're saying, like it you go through that and coming out, it's like so difficult, and you have this I expectation of what practice is going to be and what you're gonna do. And then sometimes the situation you end up in is so different that you kind of have to have to reset. But it seems like you've really kind of progressed in your career into the minimally invasive pretty heavily.

SPEAKER_00 6:39

Yeah, it it was actually it's a really interesting time. Uh it was really fortunate for me that that you know I started when I did because um it's sort of everything sort of in the in the world of like the more advanced and like modern hernia world these days was like just sort of becoming big right around that time. So like I started practice in 2014. So um, you know, in the next two years, you know, the you know, well, you know, tar had just been described two years before that, right? I mean, Uri's paper just came, you know, was was published in 2012. I mean, we they were doing that a little bit before, but um it was just becoming, you know, mainstream. Um, and you know, at the same time, um, you know, the IHC, the RSC, robotics and general surgery um were just being, you know, created um uh and people like sort of developing, like, how is this going to be adapted to the world of general surgery? Um, and then just the field of robotics in general um was sort of you know just happening. Um and uh and people, you know, when I was in training, like we were doing like occasional gallbladders, occasional ingonals, um, but there was no one doing you know general surgical cases, particularly complex cases, um, you know, in my area. And so um uh it was just fortunate that um uh you know at the time that I was coming out, and and for everybody, you know, for people similar in my similar situation, um, that we had all of that sort of whirlwind whirlwind of stuff happening at the same time. So, you know, um as I started, I was just doing, you know, inguinals, gallbladders occasionally, um, robotic, um, and you know, was doing all uh all the ventral work I was doing was all done open because I didn't really have a lot of belief in labroscopic ventral hernia repair, you know, without defect closure. You saw so many recurrences after those operations. And so, you know, I wasn't gonna do it that way because I didn't really believe in it. And so as as time sort of went on, people started, you know, reporting, you know, how they were doing robotic ventral. I sort of thought that that was pretty interesting, like 2016, like 2015, 2016. I went up and watched um Yusuf Goodsey do uh a day of ventral hernias on the robot. I think it was pretty sure it was on the SI. Yeah, it definitely was, um, back then in 2016. And then I started doing robotic ventrals, preperitoneal, you know, started out just sort of wanting to get into that because it just seemed like a good way to use the robot, a good use of the robot, and uh definitely like good for patients, beneficial for patients. And so that's what I started doing. Um, and then after that, it was sort of all in, you know, I'm gonna do everything on the robot, and then 2017. And at the same time, I was doing a lot of open abwall reconstruction. Um, that was a big part of our practice in our in the private practice that I was in initially. So had a lot of experience doing, you know, open ab wall and and so um sort of adapted, you know, the the pre-peritoneal techniques and the the tissue planes and everything that we knew from open ab wall, which was you know, posterior, you know, tar, transverse subdominus release operations in uh 2017 was able to do um a robotic tar for my first uh time. I had um I had Igor come and proc to me for my first case and he mentored me for that. And then after that, it was off and running, you know, with uh with robotic abwall. And I still do a lot of open, you know, when when when it needs to be done, but um a significant part of my practice is robotic abdominal wall reconstruction, which I feel very, very fortunate to be able to do. I was feel just feel like I was sort of in the right place at the right time to be able to do that.

SPEAKER_02 10:35

Yeah, you definitely, I mean, definitely on the early port part of the adoption of that technique for sure. I mean, I came much later. Uh it's it's you know, it's funny you mentioned doing you still do some open. We what we're finding is the more that you do the robotic abdominal wall recon, the more people view you as like the abdominal wall recon person, or at least one of the people. And so then they then you start seeing more and more complexity. And so, like the more abdominal wall recon we do, the more open we do, because then you sh have people show up that you're like, well, this you know is just not a good, not a candidate for a robotic approach.

SPEAKER_00 11:12

There's definitely cases where you see and you say this is there's no chance this is going to be done robotically.

SPEAKER_02 11:16

Yeah, the more comfortable you get with a robotic uh abdominal recon, the more open you do.

SPEAKER_00 11:22

Because the case is the thing that the a huge thing that I that I noticed over you know the f the first few years and even now doing a robotic evol is that I understand the anatomy so much better now than I did when I was, you know, before I did it robotic. Like I was doing them first open, but particularly like the sub xiphoid and the subdiaphragmatic dissection, the um the the the dissection in the pelvis, um the uh the way that I do it now is totally different than the way I used to do it. Um and it's all been adapted because of the way that sort of I've uh been able to, you know, do it on the robot and see the different tissue planes, and just you just I just wasn't aware of what I was probably what I was even doing back then. Um not that I was doing anything not safe. I think I was doing it safely. I just don't think I understood the anatomy back then nearly as well as I do now.

SPEAKER_02 12:21

100%. Like in the in some of those cases, there are there are the techniques that you know are safe intuitively because that's how it's taught. And as long as you're like maintaining those techniques, you know that you're not gonna like do provide gonna harm somebody. Um, but there's a difference between knowing a technique and understanding the reason behind the technique, and that's what really you know the robotics really did for me, you know. Yeah, in the OR, sometimes even doing like the uh robotic inguinal, so straightforward robotic inguinal. For me to see that anatomy like in real time, doing it because I mean I did a few open prepared meals before I was doing robotics just because that's what the patient needed. But like you're like standing on your head, like trying to look down into the pelvis, like it's a really hard area to get to and see. And then then you get comfortable with it robotically, and the next time you're in there in an open setting, you're like, oh, that's that, that's that. It's just it really does feed to both both sides feed different levels of understanding and knowledge because there is some benefit to having your hand in there and being like, oh, that's actually a lot thicker plane than I thought, or or that's you know, it the relation's a lot different than you can see robotically, but then but there's nothing like being able to visualize, you know, on just on a straightforward tar, like those neurovascular bundles coming down, and and you know exactly where you're cutting on the posterior sheath, and there's you know, it's a very interesting, uh, interesting thing, and that the visualization is so much better. And that's been one of the real hard parts for me because we we still have a surgery center, so occasionally I'll do uh laparoscopic colosystectomy, and the visualization for me is so much worse as far as like this the cameras, you know, still safe.

SPEAKER_00 13:58

It's been like somebody holding the camera and great, and you're you know, it's not steady, it's like it's just a totally different experience. And it's doable, obviously, but it's feels like going back in time, right?

SPEAKER_02 14:07

Yeah, because you you sit there and you'll have the nurse the or the scrub that's holding like the drifter. Like so, pretty soon you're just like trying to operate out of the corner of the visual field, you're like, Can we please center the camera? And they like look back, and then like three seconds later the camera's staring off the abdominal wall again. You're like, uh, can we center the camera? Yeah. It's it's a very funny. And the other thing about it though is that as we go more and more robotic, people do lose those skills. And so then your assistants who aren't doing it on a daily basis anymore, all of a sudden, when you try to do it, it's harder. And and uh, you know, it's a very it's a it's an interesting conundrum because we do have something that's so much better um uh in a lot of ways, but then like some of the older techniques, as you lose those, you lose them. And and so it's a very, I understand people's concerns about you know, we still need to be learning the laparoscopic, but it's still one of the things about like an open colocystectomy where you come into a point where you're going, well, what are we gonna do to train people for open colocystectomies that are hard? Um, you know, doing an open cole during like a whipple procedure, sure, but that doesn't necessarily replicate in a lot of times what you're getting into if you get into a conversion to an open coley. Those in nowadays, those aren't like easy cases. Um, you know, those are the ones that are the hard ones, yeah. And and doing something that you do infrequently in your hardest cases doesn't lend itself to safety just in general. So it's like you get to the point like, what are we gonna do? Just start randomly selecting people, like, well, sorry, you're getting an open colocystectomy because we need the educational value. It's such a it's such a um a weird a weird thing. Um, and so it's you know, I I understand some of the concerns that are raised by people 100%, but uh, it does raise concerns.

SPEAKER_00 15:53

Yeah, and even like like the like you mentioned, the losing the skills, but that um with the with the junior residents coming up, you know, some of them won't haven't even you know, like you they get to like their PGY two or three year, and they don't even know how to hold a camera because like they never have, because they've everything that has been done has been robotic, which is not their fault. Um, but they just don't know how to assist an operation, you know, and because they just don't have experience, and that that that happens sometimes. Um, so it's it is an interesting conundrum of how to train you know the younger generation of residents, you know. When they have now, you know, we you know, we we had two modalities, we had open and laparoscopic, now they have three because it's open, robotic, and laparoscopic, and they are very different, even though they're very similar, they're still very different. So it is something that that everybody I think struggles through a little bit.

SPEAKER_02 16:46

Yeah, it's uh it's it's interesting, and I think that um I I definitely don't have the answer, and I'm not sure there's a good answer. I think that this is there are definitely some trans transitions, but one thing I you know, one thing about it is that some of these residents are gonna go out and graduate and go places where robotic access is not consistent, especially for stuff like acute care surgery. So being able to get through a hard laparoscopic coley um you know in a in an acute setting for colitis is is a skill that's probably still gonna be necessary, but I just don't know how, you know, I don't know how you standardize that. I I know that our modeling and our and our you know um simulation is so much better than it used to be. But you know, whenever I was coming up, it was pretty crude as far as like you know just basic steps of the operation um as opposed to what you can actually get into in the actual OL.

SPEAKER_00 17:40

I mean the simulators now are are much, much better than back in the day with the SI and you know with the just you know um uh task-based simulation as opposed to now like the SimNow 2.0 is is you know very c all case-based or you know, uh procedure-based um simulation. And that and the simulation tasks that they do now are are it they're I mean the technology is amazing. Um so it's definitely better from a simulation standpoint, but um yeah, I mean from a from a uh an education standpoint, the residents um I think they they get an excellent experience. I mean, I mean certainly depends on where they are, but at least in my place they they get a really good experience doing robotics. And um, but as that happens, you sort of you you you you sacrifice one modality for the other, and they definitely get less laparoscopic, you know. Um I I would suspect that the the average uh chief nowadays does you know a fraction of the lap colleagues that used to be done by you know as as a chief, just because it's it's just not done anymore as much. Um so um, but I think that's probably I guess there are good and bad that go with it, but I mean if you look at the good side, I mean it's it's the I think the the operations are safer, um, the techniques are better and the patients are gonna do better.

SPEAKER_02 18:59

So it's nice to see it's nice to see data coming out now that supports my anecdotal experience. Because, you know, I think that sometimes the data would come out and you're going, man, that really doesn't represent what I feel like I'm experiencing. And maybe I just have like an inherent observational bias of my own practice. I mean, that's always possible, especially when you know everybody talks about like tracking your outcomes, and it is so incredibly important. But the one thing that tracking your outcomes requires is time and resources, um, realistically. And so if you're in like in kind of like a run and gun type practice, if that's what the expectation is is of you in your role, or you're in a um a model where you know that you're the sole provider and you've got to produce, or your family's gonna feel it, those types of things. There are definitely pressures that make that harder. And um, and it's kind of an interesting issue, you know. I think that it would be it'll be so much nicer when everything integrates so much easier, and hopefully we have the ability to integrate all the across all these EMRs and be able to track that data much more seamlessly. Because it right now there's a lot of data out there that's that's not captured and that would probably provide some pretty good insight for some of the uh general surgeons that are not necessarily academically inclined but are high volume doing the things we're talking about.

SPEAKER_00 20:15

I mean, it would it would be great if we could have you know huge pools of data. And I th I guess there in some ways there are, you know, with the HCQC and um somehow intuitive data has to be somehow accepted. Maybe I don't know, maybe it's not, but it would be great if you could have you know access to significant amounts of uh data from them de-identified or whatever. But but yeah, I think um generally speaking, like you're talking about keeping track of your own data is is uh is really important. Um uh uh you know, follow-up, you know, for the you know, hu a hue surgery in the field of abdominal wall surgery is and I tell patients this all the time, because you know, one of the biggest questions you get asked when they come into the office is like, what about that mesh? You know, or uh I heard that you know uh this is gonna be you know terribly painful or something like they they always hear terrible, you know, these horror stories. Sure. Um and like my one of my lines that I always tell patients is like the field of abdominal wall surgery today is nothing like it was 15 years ago. It's it's totally changed. Um and not only you know the the you know, they a lot of patients are it's less nowadays, but patients are still coming, you know, with issues about mesh. Like I heard I saw that commercial on TV about that mesh. Um, but not only the products that we use are different, some some are similar but very different. Um, but the techniques that we use are totally different. And then just the fact that we have people that are, you know, this is their this is a specialty now, right? This is like something that people are dedicated to doing, and this is all they do. So we have very much highly Specialized people that are doing this on a daily basis. So it's, you know, it's it's a different field than it was 10, 15 years ago.

SPEAKER_02 22:06

Yeah. It's interesting. We were I was listening to a um lecture by Igor recently, and he was talking about the techniques he uses in the ETEP, right? He was talking about all the different steps that he has added to his technique over the course of time and how it actually takes him longer now to do it than it did earlier in his learning curve. You know, and and I think that that's one of the dangers that we run into when we only track time as the metric for quality. Um obviously there's there are diminishing returns when time is excessive. There's diminishing returns when time is a marker for incompetence, obviously. But um, but whenever you start adding steps to a procedure because of lessons learned from experience that may add time to the procedure, that's actually a net positive. And and you know, I think that it it's just a it's an interesting thing that I 100% related when he was talking about that, just in straightforward general hernias. You know, I've had a couple of recurrences where I tried I reduced these big cord lipomas back and I tucked them on top of the mesh like I was taught and like I'd done a bunch before. But then when I've I had a couple of them where these big cord lipomas, for whatever reason, got back under the mesh. Obviously a technical issue. And so, you know, I changed a technique for that. So now I resect those. I don't just reduce them. I like take those, I get those out of there so that they don't do that again. But that adds time to the case.

SPEAKER_00 23:28

You know what I do with them? I think resecting them was is totally fine. Um but I I don't know if I think I can't think of any one major case that I know that like the cord lipoma like scooted back under the mesh and recurred. But I was thinking at one point, this is years ago, probably, that like that there's a good chance that that could happen. So I started with the bigger ones. I just take like I find like the apex of the of the lipoma and I put a figure of eight vicral and I sew it to the abdominal wall up high. Um, not to the point of being able to um disrupt the mesh laterally and inferiorly, but um just a tagging stitch to just get it to scar there so that it doesn't fall down. I don't know. Hopefully it works.

SPEAKER_02 24:14

I yeah, it's you know something really funny the other day because I I send them all for path because I take where I take stuff out, I take I send it the vast majority of the time. So I take I took it out and I sent this one for path. And it was not an excessively large lipoma, and you know, you have to make sure you're not getting back into your lymph node tissue and know what plane you're in and all those things appropriately. But you know, I took it out and I sent it and it came back. And of course, usually when you're going through like I see that patient's path come back, I'm like, you know, lipoma click, yeah, click click. You know, just like click through. And it goes, and this one goes, I read it down, I go to click and I'm like, what did that just say? And I go back and it was uh it had ectopic adrenal tissue in the tip of the left. Oh wow. Like in the very tip. Like they were they were talking about like the everything, and they were like, Yeah, at the at the in, and I was just like, that is really crazy.

SPEAKER_00 24:59

So has that ever been described before? I've never heard of that.

SPEAKER_02 25:02

So yeah, actually, I did. There's a few cases.

SPEAKER_00 25:04

Well, I guess because I mean theoretically, the you know, cord lipoma is an extension of Jerotis fascia fat, right? So it's somehow, you know, in that area of the adrenal. I don't know.

SPEAKER_02 25:13

Like an ectopic arrest of some developmental issue. But yeah, those are the those are the things the guy came back and I was like, Did you have like blood pressure issues before or something?

SPEAKER_00 25:21

Like that would be a surprise to put somebody into an adrenal crisis during an inguinal hernia, and you're like, or cure them, or cure them of some kind of hyperadrenalism by taking out their cord lipomer. That would be really cool. Yeah, but the thing you mentioned about um about Igor just talking about ETAP. Uh were you was it at the uh was it at the summit? Yes, it was. Yeah, yeah, yeah. I wasn't there, but it isn't it it I find it amazing with these guys listening to them speak about operations that they basically invented, uh or you know, basically describe, you know, they were the first person to describe it like Yuri and Gore and these guys. It is just amazing to listen to them and their experience. But um uh so that's one thing, um, just as a um an aside, but also the thing that you mentioned about um time um being a marker for a prof, you know, um in my practice generally I I do value efficiency. I wouldn't call it time, like I'm not like sprinting towards the goal the end to, but I don't like to waste time in in an operation. Like I'm not like a big, you know, uh I I like efficiency, but at the same time, um using time as the measuring stick for good versus not good is is not a good idea. So um, you know, like and um a lot of a lot of posts, you know, they talk about how long it takes to do this or that or how fast I could do this or that, and that's probably not you know, that's not a great way to describe who's good and who's not.

SPEAKER_02 26:55

Yeah, well, I listen, I understand that if you're an incredibly skilled, incredibly efficient surgeon and your times reflect that, that is absolutely it's something that can be commended. You know, I'm not suggesting that somebody that does a full critical view, very safe dissection, and could do a gallbladder in you know 10 minutes, good for you. Like that is fantastic. I mean, there's people are going to benefit from your efficiency and your safety. But we've all seen people where they they brag about how fast they are, and you go in the operating room or you see their complications, or you see like I mean, when we were residents, I mean I I you can see people that do stuff very quickly. And I always tell the residents, you don't gain speed in the operating room by cutting corners or moving faster, you gain it by being more efficient. Because I always tell them, I'm like, if you're if your goal is to just tear stuff to get the dissection done, but you create a bunch of bleeding, in my experience, many times that adds time to my case. If I'm like chasing a whole bunch of bleeding. And so, you know, like I try to, and then uh, and then also for me personally, there's a I again I've said it so many times on the here, but I take my complications as such a reflection of me as a person. But whenever I have a complication where I say, you know, if did I go too fast? If I'd have slowed down, would I have been able to avoid that? Did I, you know, you always those are questions that you that at least I always ask myself. First and foremost, when I see somebody come back, I you know, the tent you can have like, I think people kind of fall into multiple categories, but some people are like going, you know, what did they do? Because it can be very, very it can be painful to be like, well, this is obviously my fault, or you know, there are obviously patient factors involved too, no doubt. But it in in a lot of cases, I'm looking at it and I'm going, like, okay, what could I have done different to prevent this? And if I ever feel like I was in a situation where I was being rushed, or I was not, you know, if you ever feel like there's pressure to go faster, maybe it's like, well, anesthesia, they've got to go home, or the the cRNA needs to be out of here by three, you know, and you're like, and so you feel these, and so I've always told the residents, I'm like, hurry, hurry, hurry until the timeout. And the moment that timeout starts, the kit the case slows down. And you and if you ever feel rushed, intentionally slow down because you're you're gonna get yourself into trouble and you're gonna feel really bad if you realize that you were uh in retrospect that maybe you were rushing through something and there was a complication. And and so I tell them, I'm like, listen, you you get it by being more efficient. I think the frustration is when the efficient the lack of efficiency is not something you can control when you're like, I need this piece of equipment, and they're like, Oh, well, they're they're being processed downstairs. It's like, what are you talking about? Like, we didn't have an extra, like, you know, and and so those are those are the things that get that can really just destroy your well-being throughout the course of your day when the efficiency lost is not even your under your control.

SPEAKER_00 30:01

Yeah, I always I always say it with regards to that, that like as far as like burnout and you know, things that make it difficult to do this job, I think that we're we are as surgeons extremely blessed and fortunate to do the job that we do. Um the thing maybe people get burnt out by just doing this. Uh for me, I I could do this all day, every day, as long as I had good outcomes and good, you know, access to an operate, you know, an operating room and patients that would allow me to operate on them. I think the thing that burns us out the most is that we rely on so many other people to do our job and rely on so many other things like going well to be able to get to the point of getting through our day. Um, it it is just a huge um, I'm not sure what the right word is. Uh it's just a difficult thing to have to, you know, you can do all of your stuff right. Um, but there's so many other, you know, factors throughout the day that need to line up so that things go smoothly and sometimes they don't. And it's just it can be like you said, it can be very frustrating um when it's not efficient like that.

SPEAKER_02 31:15

Um yeah. It's so tough because it and it at times it can be a little bit disheartening too, because whether it's true or not, when you're in the heat of the moment, sometimes it can feel like the people around you aren't as invested as you are, and maybe that's not true, maybe they are, but at the time you just sit there and you know, I maybe it's because I hold people to such a high standard, and because I hold myself to such an incredibly high standard, um, and that may not be a fair, that just may not be fair. Um, but but it's sometimes it can be disheartening. You just look around and going, like, does nobody does nobody care as much? You know, and and maybe they don't, maybe they do, I don't know. But it can be just you're sitting there going, and it can be really lonely when things are not going smoothly or not going well, and you look around, you're like, do I have anybody else that's in this, in this with me, or am I just sitting here like the only person that really sees what's going on and is really trying? It can be tough.

SPEAKER_00 32:07

Yeah, and I think that's sort of what one like sort of goes along with exactly what I was just talking about, is like, you know, we we as surgeons, you know, take everything, I think everything we do very personally, our outcomes, how our patients do, how we're seen as, you know, our how we're viewed as a surgeon, like our, you know, how people see us, or are we, you know, are we considered, you know, a good surgeon, not a good surgeon, slow, fast, um uh, you know, skilled, no, whatever. Um, but we take everything very, very personally. Um, and and you know, there's there's lots of things throughout the day where, you know, some you know, some people don't take it like that. It's just a it's just a job, you know, and it's just something to get through the day. And and it's hard when, you know, you know, your your idea of what's good is is different. It doesn't go along with everybody else's. It can be difficult. Um, but yeah, I mean, same. I'm very similar to you in that way. Um, I take things very, very personally as far as like my how my patients do, their outcomes. Um I do really poorly with complications. Um I take them very personally. Um and uh, you know, it's just something it's something we all have to deal with, but it is it is really difficult.

SPEAKER_02 33:29

Yeah, it it can really um having a run of complications, it it affects you so much more than at work, too. And I think that that's like one of the things that um that's kind of hard to that's kind of hard to reconcile for me is when I come to the realization that that my work is bleeding over into the rest of my life. Um and not necessarily because it's affecting me. Like I I don't know, maybe I'm just like uh maybe I'm a nihilist or something, but I'm just like I guess that's just the way it is. But I think it's when it affects my family, you know, because I'll be like, because I come home after a really stressful week and and everybody's like they're super excited for it to be Friday night. And one thing that my kids love, they have they absolutely love having like family movie night. And so they'll all pile pile up on the couch and make popcorn and and do all that stuff. My my son's eight, my daughter's five, so we're usually watching, you know, some kids' movie, which is fine, with with one one side note caveat that annoys me about children, my children specifically. And here is I watched the same movie 40 times, and by the time we watch it the 40th time, I'm like, you know what? This is actually a really good movie. And then my kids never want to watch it again, and so then I'm like, can we please go watch like well it's Bailey movie night six months later? I'm like, you know what we should do? We should watch Coco again or Encanto or something, and then they're like, no, no, and I'm like, come on, man, I watched it. I watched it like 40 times with you, and now I I like I'm feeling a little nostalgic and you won't even watch it with me now. So like, I don't know.

SPEAKER_00 35:00

Man, you you gotta you gotta enjoy those the these moments because I'll tell you, I I eight, eight, nine, ten, I think, set maybe seven, eight, nine, ten, something like that. Those ages, those were my favorite that was my favorite time with the boys. Um, I have 15-year-old twin boys, and uh and so they're freshmen in high school now. And uh I when they were like that age, it was the best. When I come home, when I would come home, like they'd be so excited, they'd come running to the door, they'd come see me, you know, they want to show me from stuff from school, they want to go play outside, you know, do whatever. And now, you know, they're high school, they're playing varsity baseball, they're you know, doing schoolwork, they're on their iPads doing whatever, and and they, you know, they're less interested in hanging out with dad. So this is this that is the best time when they're when they're like sub-ten years old.

SPEAKER_02 35:52

Yeah, I'm coming, I'm finally coming into this period of time where like being dad's cool because usually usually I'll come walking in. My wife and I both wait we may both be working during the day. And so we're rolling in at you know seven, sometimes later at night, and the kids are usually either getting ready for bed or they're like sitting there having having um dinner with the the nannies, made them dinner or something after school. So we'll I like walking the doors. So it's whenever my wife is working, it's always the same thing, and it's it's funny because you kind of have to put your you have to put a little bit of a case around your own feelings. But I walk in and they hear the door close and I hear mama, and I like walking the door, and they're like, Oh, it's just dad.

SPEAKER_01 36:31

Oh okay, great.

SPEAKER_02 36:35

It's just dad. It's pretty funny, but I don't I don't take it personal, but it is it there is something really hilarious about it. And then what the real the true testament of that is that my wife is like fantastic with our kids, and she's always game to like play their games, and she's always down to do the do the stuff they are, and um, and sometimes I'm not. Sometimes my brain is just so locked up with fear of, you know, it's that person's I hope that repair holds, or you know, or you know, like you get done and you're just like something just didn't feel good about that case. I hope they do okay, you know, and and so I'm in, I'm just in this like cycle in my own head, and then and it's not something that I'm like intentionally not, I'm intentionally ignoring them. It's that I may be sitting there watching the movie, and then my kids will be like, Dad, you're not even watching the movie, and I'll realize I'm just you know completely zoned out. And so my wife is much better at that compartmentalization than than I am, and so she she has uh historically been much more um much more with them. Also, and she works shift work, and so she gets the chance when she's not working, um to turn off and to drive them to school and to pick them up from school, and and I'm always you know on the job. So it's different.

SPEAKER_00 37:50

Yeah, I think that I mean, I think that I think I would assume most of us are like that. I mean, um uh there's definitely times when I'm here and you know, my wife will be like, what are you like what are you doing right now? Like, what are you thinking about? Because you're like I'm totally not even like in you know, mentally in the same room as as the rest of the family because I'm thinking about some, like you said, uh you know, is that patient gonna come back in with some kind of problem? Or did I was that you know, was that fascia closure, you know, good enough? Is it gonna break, you know, it's gonna break the whatever. Um but yeah, it's all I mean I think we all we all have that. Um yeah, and it's and it can be really difficult if I if something happens like you were saying a little bit earlier, if you have some, you know, some complication or some issue that happens at work uh it's hard to not bring it home. And um, and a lot of times uh I I unfortunately do, and I can be uh I can be very difficult to deal with because I'm uh you know I'm like carrying that weight uh with me and and they can they can absolutely tell right away. You know, wife is like, what the you know, what's the matter with you? And I'll have you know, I'll tell her, you know, something generally something happened and whether or not I explain it to her is you know it depends on what what the thing is, but it's uh it's difficult. I mean it's really hard to leave things at work and not you know and not bring those emotions into your house.

SPEAKER_02 39:23

There's some there's so many of us that are married or or dating or or there are significant others within at least some level of the medical field. And I think that that has like it's like a double-edged sword because we do have the ability to relate, probably in a way that when I go tell my wife, you know, uh, a wound infection, my wife's no big guy, she gets a wound infection, right? And she understands conceptually, she's had patients that have had that, those types of things. And so there's a an understanding there. But on the flip side, um, it also can be kind of like a an echo chamber. And sometimes you have to it's it's nice sometimes to be around people that are not within the medical field to realize there's like life outside of this bubble, which at times can feel so toxic. Um and it's not that and it's yeah, I think it's part of it's just my the way I'm made in that I don't feel the successes like at all. Like I don't ever feel whenever something goes well, uh my reaction is well, of course it went well, it's supposed to go well, right? I don't sit there and go, like, hey, you know, that one really tough case, they did really well, and that pat me on the back. And um, and my my office staff actually knows that. I had a patient, um, she had uh this very uh difficult vasculitis. Um they used to call it Wegner's, now it's like a different name. And I only know I only know anything really about it because um I've been diagnosed with the precursor uh biomarkers for that. So that's kind of always just kind of like on the back of my mind, like hanging there like this is gonna go poorly at some point. Um, but uh so she had this this hard problem. She was diagnosed with spit with it when her colon died from microvasculitis, like she just woke up one day with pain and her colon was dead. Um she ended up with an ostomy that ended up getting reversed and her reversal, she was in the hospital for like a month and it was like a really rough recovery. And then she comes to me for this enormous uh colostomy site hernia, which was completely pr predictable because she had to be on high dose steroids to get her through the recovery the first time. And and so all these other things. And so we ended up taking her and get the case done, and I lost legitimately like eight weeks of well-being, truthfully, just like every day, just being like, oh, when is that when is that other shoe gonna drop, you know? And luckily she did very, very well, like surprisingly well for what I was expecting. And she got through it, and the the her and her family are like so, so kind and so so thankful. And um, I'm in the room with them, and they're like telling me how much that like our work and my team's work and my work has really like impacted their lives in a positive way. And um, and you know, I don't understand why. I think it's it's it's me. I understand it's me, but like that just that I'm almost like uncomfortable in those moments.

SPEAKER_00 42:09

Like I literally am just sitting there, like I'm being very gracious and stuff, but it's just like like every time it's so funny to hear you, it's so funny to hear you talk about this because it's just so familiar. It's just it's just me also. So it it's I I maybe it's I don't know, maybe it's a personality uh thing, maybe it's uh the way that you were brought up, maybe it's uh I don't know what it is. I have to say, I mean, I'm very much the same way. I I I have very I I have a very difficult time accepting um praise. Like I I I almost it makes me uncomfortable um in those situations. Um I don't know why. It I've always been that way. I was al I was a very successful athlete, um, high level, you know, I I never like to talk about it, never like to, you know, bring that stuff up. Um and then in in this situation, you know, as far as like the line of work that we're in, you know, you have patients coming in telling you like, you know, that you're you're the best. You've I you know came highly recommended by this and that, and they said you're the best, and I mean, you know, the you know, all this stuff. And it's very difficult to listen to that and and uh accept that and and be comfortable with it because I think one of the big reasons is like I like I in the back of my mind, I'm I'm thinking you're saying that, but something really bad could happen, and then you're gonna be like very disappointed. Um, you know, that kind of thing. But also like the one thing, the one thing I wanted to just mention that that you mentioned earlier is the the thing about how you know it's hard to be happy with not happy with, but uh let positives affect you in a positive way. But negatives affect you in such a negative way. You know, everything's just supposed to be that. Everything's just supposed to be right. Right. Or you know, end up, you know, the way that it is perfectly. But when it doesn't happen, you know, that's a big problem. I don't know how you can combat that. It's it's something whenever like whenever something a significant complication or some kind of like you know big problem happens or a bad outcome and they they have these you know meetings, you know, these uh, you know, what do they call them? Like uh peer reviews. Yeah, like peer review or quality improvement reviews, these kinds of things. Uh I I I've kind of joked with, not really a joke, but you know, said to the to our one of our you know, some of our staff that that run those, um, you know, it's amazing that we put such emphasis on the negatives, but like if I do something awesome, it just it's just it just happens and it just goes out one in one door, out the you know, way in the door, out the door, just happens as you know, that's the way it's supposed to end up. Right. You know, nobody says anything, you know, it's just the way that it is. But if something really bad happens, that's a big problem.

SPEAKER_02 45:15

So I don't know.

SPEAKER_00 45:16

Well, I don't know what to do about that.

SPEAKER_02 45:18

You know, that's been one of my you you you talk about is going back to something you said, you talk about being like a uh successful athlete. Um I it's funny because I play, I mean, I signed a national letter of intent and I played a year of college basketball. And I tore both meniscus in my my right knee in the offseason and was and was super, super anxious um around performance, like performance anxiety surrounding my my basketball career. And so whenever I tore my meniscus, it it was gonna set me back. I probably truthfully um I didn't get surgery on it, it would just kind of let it scar down. I didn't, it would have probably taken me out of the majority of the next season anyway. Uh, but I just took that as an opportunity to exit because I was just not in a good mental place about the whole process. And I was talking to one of my good friends who I've known since uh since high school, and it was funny because he he loves to call me out on like these uh on these weird like mental ticks that I have about my uh myself. And so I was um talking to him and I said, you know, he said something about me playing college ball, and I was like, Yeah, but I mean like that was kind of a failure. And he was just like, What do you mean? And I was just like, Yeah, I mean, I only played for like a year, and and you know, I didn't really feel like I ever performed at the level I was capable of during that season. And and he was just like, and he was he goes, Do you understand though that the number of people that get signed to a national letter of intent and play college ball, percentage of people that play even high school basketball is incredibly small. And I was just like, well, yeah, I mean, I I guess I understand that, but it doesn't really but stuff the when you're in that kind of mindset, statistics don't apply to you. Like that's the that's the biggest thing. You know, like the statistics don't apply. And whenever I hear somebody give me like a compliment about an outcome, I heard one of my in our physician book club that we host, one of the one of my mentors was there and he was talking, and he said, um, when people say that to him, the second they start complimenting him, the only thing in his head is a replay of all the cases that went poorly. And you know, and I think that that's and it almost when you take your complications so personal, it almost feels like insincere or wrong or like unethical to feel good about a case that goes well when you it's almost like you're dishonoring the person whose case didn't go well. And I know that sounds so it's so weird to like articulate, but it but it's real. And I don't really and I'm working on it, but it I'm definitely not, I haven't conquered that.

SPEAKER_00 47:53

No, I mean I I I feel that I I hear that. I I've definitely experienced that. Also, like, yeah, no, it's just yeah, it's it's hard. I mean, you know, the the thing that you just know that you know looming over everything is the potential for something really, really negative to happen. So, you know, if if you get really excited about something good happening, you know, all of a sudden, you know, is is the complete opposite gonna happen the next case or something like that. You know, so everything's a law of averages, everything's gonna come back to the middle. So it's not like you can have great forever. It's gonna something bad, you know, something bad's gonna happen.

SPEAKER_02 48:32

So you just have to be ready for it. My wife and I are the exact same way. Sometimes we'll be like things will be really, really good. And sometimes when things are super good at my own in my own family, like we'll have like this afternoon, like it's a beautiful Sunday afternoon, the kids are playing in the pool, we're just like hanging out, listening to music. Like it's so like it is by all intents and purposes, like the definition of happiness, right? And I will be out there and it is for some reason there's like it's like I have this continuum where it's like I'm so happy that all of a sudden I'm sad. And like I'll roll over into this like weird melancholy. And and I was talking to my wife about it one time, and she goes, Yeah, but doesn't it feel like things are like too good? Like you're getting like karma's gonna correct at some point and like this could all go away. And I'm like, Yeah, it does. And I know, and that is totally like that's like trauma speak, that's like PTSD. But the funny thing is, is people talk about PTSD, and we have like you can have some things in your life that you can be like, hey, if someone tells if you know that someone has this like thing in their past, you go and they say they have PTSD, you're like, Yeah, I get it, right? So they have like a um incredibly traumatic childhood with like abuse or so or neglect or something, or they have like um our war veterans that have seen just horrific things, but we don't actually treat a lot of healthcare workers the same way. And you know, and I was talking to to one of my friends who's a urologist, and we went and um it's funny because I I'm an all or nothing person. I recently started journaling, and all of a sudden I'm 50,000 words into an autobiography. But I um I was talking to him, and this is one of the stories I was writing about recently, but I was talking to him as we left Halloween Horror Nights a few years ago here at Universal. And so we exit this deal, and I was and he was just like, What'd you think? And I was just like, wasn't that scary? And he's like, Yeah, yeah, the stuff like movies and stuff, they don't scare me that much. And I said, I said, honestly, you know, the thing about it is I don't think anything can ever be as scary as that moment you're in the operating room and you realize the only thing between you and this person being dead, or between like this person being dead and alive is you, and and there's like that momentary like oh gosh, where I don't know how everybody else experiences it, but like my ears will ring, like I will, you know, there's like this weird like temperature dysregulation that suddenly happens, and like, and you know, and it's it's all that adrenaline rush and everything that's happening, but there's nothing like that fear, and when you experience something like that, it can go and it can be it can even turn out really well, but it sticks with you. And I mean, I am the I'm like the have these nightmares, it'll happen over and over again, and they happen about things that happened years ago, and they'll just continue to happen. And we don't really give ourselves enough.

SPEAKER_00 51:25

Yeah, and from years ago, yeah.

SPEAKER_02 51:27

Oh, yeah, all the time. And in that, and I don't think that we give a lot of like the we see horrible stuff, but it we just kind of write it off as part of the job, and then but it it devalues the human experience of what we're undergoing, and sometimes I think we need to really focus more on that.

SPEAKER_00 51:46

Uh yeah, I mean as you as you go through as a surgeon, it it's it's hard to not depersonalize some things. I mean, you just like you said, you see such bad, such bad stuff sometimes, and um as far as like you know, pathology or like trauma, um, but also just like you know, the way people treat each other. Yeah, um, there's lots of things that that you know people with normal jobs just don't see. Um and it's hard, yeah, it's hard to I think after after a while you just sort of you become hardened to it and and it's it's um it affects you, it definitely affects you. Um I I've not had the experience of like like uh uh recurring dreams or anything like that. Um I mean the the I I've I definitely have PTSD from when my boys were born. Yeah, but but uh because they were very sick and and had a lot of trouble. Um but um but from a work standpoint I don't think I've had that. But otherwise, like my experience is very similar to yours in a lot of ways.

SPEAKER_02 52:55

Yeah, it's it's tough. Um and it's it's one of those things that you talk about going through care reviews. As I've moved into leadership roles, I really kind of view my leadership role as really like three main components. And at different times, the components are weighted differently depending on the circumstance, but it's kind of like you know, you have the component of your role as a leader is really patient safety to prevent patients from being harmed, get them the best outcome for the for the system that you're kind of overseeing or responsible for. There's like a culture that you need to maintain of of safe of like the people that are functioning under your realm are all kind of in a safe space, so to speak. I mean, you know, not having like an abusive department kind of situation. Um, and then but then thirdly, there's this aspect of like when you're like the chairman of the department of surgery, like I'm serving as currently, um, you know, that's an elected position by surgeons. And so you're kind of representing them. And one thing that that you can hear sometimes, and I'm not pointing out anything, and I'm not saying that this is my own institution or anything like that, but I think when you listen around, there is an there is this idea sometimes that surgeons don't care, and or sometimes that like some people don't react the way other people think they should to a situation, like in in their in their interpersonal interactions. Um, and so then there's this like major extrapolation by maybe the way the surgeon reacted in in one conversation or something, an extrapolation to saying that this is how they approach it or this is how it's affected them. But just like you said, you know, sometimes we have to harden ourselves a little bit just to get through the day to continue to deal with like telling 30-year-old mothers of three that they have like stage four right-sided colon cancer. I mean, yeah, those types of situations are becoming much more frequent, and at least in our experience. And so, you know, you get in these situations where if you let, if you're like letting yourself fall apart every single time something that really could justify you falling apart, if you let yourself do that, you're really going to be kind of a poorly like it doesn't make sure you're functioning as a physician compromised for the next patients you're going to see. And so we have like a responsibility at some level uh to be able to compartmentalize that enough to maintain the quality across the spectrum with people we're expected to take care of. Um, but other people don't see the nights that we're at home and are and we're like zoned out because we're focused on something, you know, and other people don't see how it affects us behind closed doors. And so I think I got some feedback actually recently from someone who was listening to this podcast. Um, and um they they're not a surgeon, but they're in the medical field, and their feedback was I never understood what surgeons go through, and I have a newfound respect for surgeons, and it's going to change the way that I interact with them. And I honestly, that was like one of the biggest compliments I've ever gotten for for this. Um, because otherwise, I you talk about imposter syndrome. This podcast has been like the biggest level of imposter syndrome for me. Like people come and talk to me, and I'm just like, you guys get that I'm just like making this up, right? I don't know. There's no this is not some like master plan. This is just this is completely just made up on the spot. But um, but I think that, you know, I do think that us having these conversations more openly, uh, while yeah, it's sometimes it is uncomfortable and it's not something we're used to doing, it does have the benefit, hopefully, of being able to kind of bring shed some light on the fact that, man, this stuff is hard sometimes. Um, not saying that everybody feels the same way. I'm not saying that there aren't bad actors in in every single profession. And there's definitely some surgeons that we probably all know a surgeon or two that you that we their actions would suggest that they just, you know, it they take it a little bit less personal than others. Um we'll say it that way. But but um, but it's it is it can be very, very tough, and and it can and it's something that can really affect a person. And so I do think that we need to do a better job of talking about it.

SPEAKER_00 57:08

Absolutely. I think the I mean, generally speaking, like you said, there could be, you know, outliers, but generally speaking, surgeons are extremely dedicated to what what we do, and we take what we do very, very personally and want nothing but the best outcomes for the people that we take care of. And I think, generally speaking, again, feel extremely honored and blessed to be able to do the up there, do the the job uh that we do.

SPEAKER_02 57:38

Yeah, it's um and it also can show up in weird ways, like it can show up in the OR with frustration when you feel like other people aren't taking it as serious.

SPEAKER_00 57:48

And it has yeah, 100%.

SPEAKER_02 57:50

And it has a potential, and you you look at it and you're in a situation where you're going like, guys, we need to take like we need to tighten up because this is somebody relying on us to do a good job, and we can only do as good a job as the team's doing. And so if not everybody is rowing in the same direction, it can sometimes come out as frustration. And you know, in leadership roles, sometimes you get those complaints and things, and you kind of look into it, and you can go and kind of provide it as an opportunity to have a discussion about, hey, this is how you're being perceived. Um, it's probably I understand the frustration. I'm not saying that there's not, but there's a there is a level of bridging that gap between people that aren't surgeons and are um on trying to develop that understanding. Because I think many, many times people are all speaking the same people are all wanting the same thing, but they're speaking slightly different language on how to get there. And it's just such a it's that gap can be very detrimental.

SPEAKER_00 58:43

Yeah, and and the position that you're in, uh surgeon versus not, um your your words are perceived differently. Um, and I I didn't realize that um uh probably for a while uh well stepping into this kind of job. Um, but you really have to be careful with what you say and how you say it, because um what we say is perceived differently by different sort of levels of you know people that we work with. And it can things that you say that may just be, you know, you feel is very uh benign can be taken, you know, very, very differently by you know, say a nurse or you know, an anesthesiologist or someone, you know, it it we definitely have to be cognizant of of how we say things as a in addition to you know what we say and and and just be you know sensitive to that kind of stuff.

SPEAKER_02 59:46

And and the other thing that really kind of is is honestly it's one of my pet peeves is sometimes there I'm not saying that we shouldn't hold ourselves to an incredibly high standard as surgeons. I'm not suggesting that. But um one of my things is whenever I feel like there is a a lack of continuity or fairness amongst how everybody in the situation is being held. Like one of my biggest things that drives me crazy is watching interactions between two physicians, and one physician is deemed as like a problem physician, and the other one's deemed as like really passionate about patient care. That drives me insane because I'm I'm you know, you sit there and you go, that that insinuation, the problem is that the insinuation is that the other person, that the surgeon is the other person or whoever it might be, is not, and that's not necessarily true because people have different ways of expressing themselves, and um, there's definitely levels of professionalism that need to be maintained. But if we're gonna ask for professionalism from one side of this coin, we need to be sure that we're asking for similar professionalism from the other side. And I understand that heavy is the head that wears the crown, and that being the leader in the operating room uh comes with it certain expectations that are probably above and beyond the expectations of everybody else. But when you're trying to really function as a culture of a team, because I think that the the old days of the paternalistic or even maternalistic view of the operating room where you know this is what I'm saying is happening, and nobody gets to nobody gets to raise any concerns and stuff, that that age has for the most part passed in a lot of ways. Um, sometimes the pendulum swings too far the other direction where we can see there's like if nobody's leading the ship, then the ship's just kind of going rudderless. Um, but you know, I think that we need there's a there's definitely a balance that needs to be struck. But I do think that everybody along the line um hopefully is maintaining and being held to the same standard along that because that's one of the other things that really frustrates me because uh you know surgeons and many times are very direct communicators. And we're direct communicators because that's what that's what we need, right? So we don't, you know, whenever we ask for an instrument in the operating room during, if someone's bleeding, we don't go, hey, when you have a chance, could you would you mind handing me that you know that hemostat, please? You know, we're like somebody's bleeding, you're like hemostatic, you put your hand out, right? Well, and like if that was how we behave when we were picking up you know silverware at a restaurant, that would be a very different scenario. And and I think everybody can understand that that would be like a silly thing to expect in that setting. But in the operating room, under very intense settings, I just hope that the opposite is true, that everybody kind of goes like, well, yeah, there were people were very direct, and there was not a whole lot of niceties being said, or we weren't saying please and thank you, we were just trying to get to the point. Because in those situations, it was a very critical point in the case, and we needed some direct communication to make sure that there was no ambiguity that could that could potentially delay or or lead to harm. And so it is a it's definitely a balance between being malignant and being direct, but sometimes even being direct if the person is not used to that culture in that situation can be perceived differently. And that's really goes to the culture of an operating room and how it is a really it's a really weird microcosm, right? A lot of dark humor, uh, a lot of those things that we all kind of, it's a culture in and of itself that uh right or wrong develops, and I think a lot of it develops around the fact that it is an incredibly stressful situation, and at some points you have to have those little vents to diffuse off some of that to reach maximum function.

SPEAKER_00 1:03:26

So, what are what are some things that that you what are some strategies that you use to keep to keep your stress to a minimum in the operating room?

SPEAKER_02 1:03:35

Um at appropriate times during at appropriate times, um, I joke and I keep things very light. Um at a again, appropriate times. Um I also um you know try to I try to know I have the luxury of having a fairly consistent team, um, not a hundred percent, but like some some people that that I work with frequently, knowing them on a personal level as far as like having a conversation, you know, during turnover or having something like that, just getting to know them, that kind of personal relationship, um, so that they understand who I am as a person, so that if we are in a very intense situation and I'm having to be very direct um or things are getting tense in the operating room, that they understand that I'm not I'm not trying to be malignant. Like we're all it's just this requires a very we're this is very, very serious. Um I think that that that those things are how I do it. Um I live I do little things. Like I let the staff choose the music in the room. You know, just things like that, because you know, I if everybody's sitting there listening to the only time I don't is I have this really fun joke that I do around the holidays and I ask for Christmas death metal playlist, and they exist, and they are the most like intense Christmas carols you'll ever hear. And I make people listen to it for significant times, or I'll go in while Bobby, my partner's operating, and I'll put like everybody's busy, and I'll put uh Aqua Barbie girl on repeat in the operating room and I'll just leave. Um I'll do that occasionally, but um, but I do think that the you know keeping it, knowing who you're working with, trying to keep it light when it's appropriate, so that you're so that it also helps so that when you are serious, everybody understands that it's a that it's a serious time.

SPEAKER_00 1:05:19

Yeah, I think the the the thing that that you said, I mean the the um I I'm not a um I don't know, I don't think I'm a big joker, but the for me the the biggest thing as far as stress relief is having a a solid and uh consistent team. Yeah. Um and to be comfortable in the OR with the people that are are helping. Um I think that's the the biggest thing for me. Like when I have a team that is, you know, what when we're doing robotics um at my place, we we always have a PA uh at the bedside. So that's like one of the standard things in our in our system that we always have a position. assistant um to do the bedside assisting. And when it's a PA that that I'm very comfortable with or I know very well, it's way more like when I know going into that day that I'm going to have, you know, Tracy or Malcolm or one of the one of the PAs that I'm really, really comfortable with. I'm going into that day way more relaxed than if I'm going in not knowing or if I know that it's going to be like some brand new person who I'm going to have to walk through every single little thing. It just makes me feel more comfortable knowing that like everybody in the room is on the same page, knows all the steps of the case, you know, knows what's going to happen. I'm not, I don't have to like, you know, because a lot of the stress is like remembering every little possible thing. Like you know, not remembering to like say what kind of sutures you want and then it comes the time to start doing stuff and there's nothing on the field. Right. You know, whereas if the team knows you and knows what's going to happen, everything's just there. You know, like those are the kind of things that make me feel better that I don't have to like like be on top of every little thing. I think that's a huge deal. I think most surgeons are probably that way.

SPEAKER_02 1:07:13

Massive, massive because there's what people don't understand is the level of there's so much that the the the human element there's so many steps that can go wrong during a surgery. It is it is it is an incredibly human experience because you have so many people contributing um that Swiss cheese model of safety uh you start removing a few of those sheets with people that just aren't experienced or don't or have an issue and then all of a sudden it's a lot thinner and there's a lot higher chance of that. And I think we all can sense that whenever you're in the operating room and and you know that and people just didn't like just don't get it. You know they don't know what the steps of the surgery they don't have the suture. You're in a bleeding situation you're like call for a clip and then you know you have somebody who's like advancing the the port you know a millimeter at a time because they don't understand that like the flashing green light gives you some ability to put that back to that location. Little stuff like that that makes a big difference.

SPEAKER_00 1:08:13

And um or even like even like just like the scrub and the circulator like being people that you know very well and you know you can trust and like are you know you know people that are uh you know very uh responsible and all that because like even things like the count you know what I mean like you know you can I'm like a I'm like very very very uh cognizant of the count and the uh the the potential for retained foreign objects and lost things and all that stuff so I I'm like you know I I I can't I the the surgeon who doesn't uh stop or slow down or have take you know a second to pause when there's a there's a discrepancy in the count I can't understand that because like there is such it's it's a it's something that we you can fix. It's something that we do purposefully to make sure that a negative outcome doesn't happen. And it's something that can cause such a big problem if it's not taken care of. So um I'm like a bad like I like there's a scrub that uh the the the scrub tech that works in in the one of the robotic rooms that works with me a lot like she knows like at the end of the case I'm gonna ask did I did I take the ruler out did I did I get all the needles that I get every single thing like I always ask her even though I'm pretty sure I did like a lot of times I will I will finish a case like if like is it like even if it's a bigger or smaller you know ventral or something like that. But if it's a longer case where I did you know I was measuring stuff and so I won't remember like no recollection of taking the ruler out like I or of taking like a the big you know stratifix that I used to close the fascia. Like I don't remember taking it out whatsoever. I don't remember handing it to the PA to take it out. I don't remember it coming out. So I it's just because I'm so focused on whatever that I just I can't remember it. And I'll go back and I'll watch the video and I'm like oh yeah I just took it out right there. But I can't remember it.

SPEAKER_02 1:10:21

So like I'm like very much uh uh aware of the potential for that so but back to the whole point like having someone that you trust um and yet you know um makes it so much less stressful um than have you know working with people that you don't that you don't know and and that not all cases are created equal like a big if you're doing a tar and you're putting in needle after needle after needle and and stuff like that there's it is such a disruption some people have spoken about it. I don't know that I've ever actually gotten into it. They talk about the flow state um I think uh Flavio was talking about flow state and I was just you know he might as well have been speaking a completely different language I was like wait so there's a point in time when you're in the operating room and things seem like they're going correctly like that exists. I don't even know what you're talking about. But um no it's this yeah I think that there's there are those moments where nothing could be more disruptive to kind of like your progression and you're paying attention to stuff than going like okay I'll take um I'll take the 2O lock and two seconds later someone's tapping you on the shoulder and they're like they hold up like four different sutures. Which one do you want? You're like um okay uh that one you know and then you're like okay what was I doing? And you're like back to it and and we have you know not all hospitals have the ability to have like dedicated teams and we're kind of in a hybrid situation where we kind of do but everybody needs to do needs to kind of be able to know everything because they have a craft that they're doing too you know they uh our call teams cover a wide spectrum of cases and specialties and they can you know the the people that work in our robot room they need to be able to function for a broken femur in the middle of the night you know what I'm saying like these these types of things too so I understand it um but there are different cases that have different potential for complexity and those cases by far it is undeniable benefit from standardized teams with more experience and um and it's a tough thing because I understand the staffing concerns and and some and and some people are more demanding about it than others but um but it it is that it definitely does affect your day and at the end of the day it affects your well being because again if you're with if I were with the team that I trust um I'm not you know like you said I'm not reviewing the video at two in the morning on my on my app going okay did like as you said did the ruler come out did the it all did this I did this needle I don't you know I verbally confirm it but I don't remember seeing it go out of the trow car did it did it go out you know in all these things that you're like going back watching these these steps of these videos and and again I'm I will look at all the counts myself and all that stuff but I was you know I've also served in some reviews and read and read things and one of the most common things about um retained foreign bodies is a correct count and that's like probably the most terrifying thing is you mean like the count is correct in the case where there's retained yeah because if it's incorrect you stop well I mean with rare exception right but for the most part like if it's a if it's the count was all the count was always correct in those cases or most you know because if it wasn't correct then the case wouldn't have ended.

SPEAKER_00 1:13:27

Right. So it had to have been correct even though it wasn't but yeah the other thing with that those kind of cases is it typically something about the case was not the typical correct if that makes sense. It's like you know something that was done was not how I typically did it or do it or there was some variable that was like out of the ordinary and it just sets you up for those kinds of things.

SPEAKER_02 1:13:50

So yeah you know it might be boring but like uh you know standardization of things is like it's like really really important to just make sure that you do it the same way every single time you know yeah it is and it it's harder and again these cases there are definitely standard is standardized points and then there are parts of the cases when you're doing like complex ABWAL that some of that stuff is you know it's on the fly you have you get in there and you go wow they don't have a posterior sheath that's a completely different that's a that was unexpected. You know like I I put a camera in the other day and like there was just the rectus muscles were staring at me from the arcuate line down and I was like oh let me guess it was the GYN case the C section. Yeah they didn't get the back they didn't get the back close um you know it's like and you're like oh well this is a much more complex problem than I thought it was going to be and um and those situations you know you have to be prepared for those and I think also that's one of the things that when you talk about people doing these more advanced techniques it's kind of hard in some cases to predict um what you're getting into because even I mean I do a lot of pretty I do a lot of bigger inguinal hernias and I do very thorough exams and I'm I would like to think I'm pretty good at it. And the number of times that I get surprised by man that did not match on exam what I was ex what I see when I insulate the belly versus what I felt on exam and or even sometimes if they have imaging you know sometimes it could be like whoa that was that extended way deeper than I expected it to this is a big inguinal scroll and and so sometimes these prediction a prediction pre-op you can get into trouble if you're not prepared um for that and I think that that's where a lot of we're really well meaning surgeons can get into situations that aren't great uh just by getting caught off guard in the operating room.

SPEAKER_00 1:15:37

No doubt. I mean one of the so that is one of the things about doing ab wall as as you know a big part of your practice or the main part of your practice is like it it it's a stressful thing walking into a case not knowing what you're gonna find in there. So like um you know you could take somebody I always this is the way I'd explain it to patients a lot of the times like you know you could take somebody who's had one laparotomy for whatever and go in there and it could be like a bomb went off. Or you could take somebody who's had 10 laparotomies and go in there and they have no adhesions. So like you really can't you know absolutely predict it can like after a period of time of like doing this for a long time, you sort of get your own sort of gestalt of looking at this person and looking at their op reports and looking at all the information and say I think you're gonna be all right I'm gonna be able to get into your belly and do it minimally basically or not and then you do it open. But you definitely you know there's cases where you're where you're wrong particularly like like I I when I take patients for open operations like more often than not I'm saying to the resident that's doing this me I could have done this robotic. You know what I mean? Like it's but but but you know I I never I never I'm never like unhappy with myself about doing it open number one because doing open surgery is a lot of fun. The cases are great the residents love them they get a they get a lot out of it. They and you know um that anatomy um but ultimately it's it's for patient it's the it's for the safety of the patient. If I don't think it's gonna be safe to try to get into their belly to try to get you know gain you know intraperitoneal access and and develop pneumo without potential for bowel injury I'm not gonna I'm not gonna try um unless I think that it's very the the the ability of me getting in minimally invasively is the stopping point of whether I'm gonna do it open or robotic or you know laparoscopic minimally invasive. And um and if I if I can't justify to myself that I think it's gonna be safe to do it that way then I'm gonna do it open and I think that that's completely fine. It's very very it doesn't happen that often I do like I probably it's like 10 to 1 robotic to open or maybe eight to one or something like that. But um you know that is what it is.

SPEAKER_02 1:18:00

Yeah it's um yeah you're you're 100% right it you know you get when you make the best decision with the information that you have at the time um there's nothing wrong with that. I mean like expectation like is there a situation where you maybe uh a year years down the line you've seen enough like rip you've seen this presentation enough that then all of a sudden you have a little bit better gestalt and you can predict a little bit more accurately just through the the tincture of experience. And for me I have a really hard time looking back on cases that I may have done like five years ago or even longer maybe 10 years ago now and going feeling bad about myself and then going like I didn't even like like that patient would have done so much better with robotics. I'm like feeling bad about the decision I made and I'm like I wasn't even doing robotics like it wasn't even that wasn't even like a thing back then like wasn't an option back then. Right and and it's so funny because again perfectionism and this like it it serves us well in so many ways but it can also be so toxic internally for yourself whenever like if the I've said it before but if the expectation is perfection you're never you never succeed you either meet expectation or fail. And so it's just like you are you're always you're always on this hamster wheel of this like self-reflection leading to this fulfillment of a prophecy that you are in that you're not doing well enough because the only you never feel there's never above zero is always just zero or below and so you're always like kind of fighting it and and many times patients they they benefit from that level of like hypervigilance and that awareness and and uh the double and triple checking things like sometimes that can be actually beneficial there are things that people catch that you may not have if you didn't have that level of of like urgency to make sure things go well. But it but at other times it's like is it shortening your career is it making your learning curve for these cases longer I mean we talk about like efficiency in the operating room um I would love to see a study where they go over like okay well this patient this person's learning curve and their operative times and their efficiency you know at early in their career it was this number and then then it may dip a little bit as they get more comfortable then they may start doing more complex cases so it worsens again and then it as they develop that that better you know understanding going kind of like down the Dunning Kruger curve it goes it gets better. I would love to see that paired with uh a surgeon's mental health right so you have somebody who has baseline anxiety or baseline um perfectionism that is you know maybe higher than the average what does it look like how does that curve change you know um how do their outcomes match right because that many times on those like curves of stuff that there's no like going like quality and complication curve running along with this like you know that's an assumption there's an assumption made that all these cases turned out well you know and um and so there's so much more complexity and we don't take into account the the human aspect of performance in surgeons currently near to the level that other high performing fields do uh you know professional sports sports it's a big deal like it human performance that's the whole thing right and and they have to have a competency they have to have a skill set they have to have a a dedication and a drive and there's all these other factors that they have to have but at the end of the day if someone gets the yips you know it doesn't matter those other things don't matter at all and surgeons are like not immune to that and we don't do a good enough job of of providing we we have a really good job of working through these peer reviews and these care reviews and stuff to make sure patient safety is maintained. Again incredibly important you could I mean you could the most important but what about like the psychological safety of the surgeon the getting them through that to get them back on their feet because you have someone here that has gone through years and years and years of training there's been a lot of resources invested in getting this person to the level of proficiency that they can positively impact their community in the field and their patient population and if we don't support them we're losing like we could lose significant investment if nothing else just from the pure not even the human side but just the pure economic side you can lose significant investment because we're not focusing on it enough and so yeah we uh at our place at my place we have we have something for that I don't know if you have have experienced that at anything at your place but um we have uh at Christiana we have something called care for the caregiver um I don't know if you if you guys have something like that at your hospital but it's actually a really nice resource which is um you know if there's a negative event if there's a some kind of traumatic experience um patient dies something bad happens uh negative outcomes uh traumatic something or other um they have like people come in like in person but they also have resources that you can actually you know get you know some counseling and and uh talk to somebody and sort of like go through it so you don't you know you you you work through it without sort of being alone I I actually you I just share with you one I had one experience where I had a patient uh pass away on the table in the operating room um an elective case um on table mi died right there and it really really messed me up like that um and it was really difficult um to get through that uh and I I used that I I used the uh the counseling and and I went through the sessions and it helped a lot um uh I don't think you ever get over anything you know something like that I think about it all the time um but um I think I hope most places have that kind of resource for you know the the people that that work at these at the institutions because it is important to support us um because you know just like we've been talking about for the last hour or whatever you know we we are incredibly affected by our jobs um and our patients and how they do or how they you know how the outcomes are and and uh you know it can be really really devastating when it's not good. Yeah we do we do have that that resource available we have an employee assistance resource we have resource for like the care that for like support for all the team members from you know from all the way from the people that were transporting them to the people that were in the to the administrators that some that feels you know feel responsibility for the patients in their facility. So I mean it it does br and they do an absolutely tremendous job um and and I have utilized those resources before I know colleagues that have and I've never heard anybody have a bad I've never heard of anybody having a bad experience or negative thing. I mean I'm sure that exists but um but at least in our situation the people you know they're you know shout out to Mary and Laura they do just an incredible work here. But uh what what I can say is I think there's two things that are that are also true. One is that I think there's like this micro um there's like these micro um complications. I think it's really easy for us to look at those situations like the one you're talking about which is you know like you said that that realistically is going to stick with you forever. And um and so those things are really easily identifiable when we're looking from the outside and it's not necessarily our case to go like hey that person probably needs some help. It's the micro stuff where you have like those three or four like the other day I saw a patient that had a recurrent inguinal hernia and then like the next patient I saw was having some chronic groin pain and both of them were my cases from like a year ago and I went home just like frankly just devastated. I was just like like what the heck like I looked at the imaging and I'm going like well there's probably the most there's probably what I did that made this fail and and then I'm sitting there going to it's hard it's so hard to like not tell yourself that you suck yeah in those situations.

SPEAKER_00 1:26:15

You know what I mean like I'm I must be the most terrible surgery what how why am I allowed to do this? How am I allowed to do this? I shouldn't be doing this anymore because I'm I'm not doing a good job. It's so hard to deal with those situations.

SPEAKER_02 1:26:27

Yeah and you know so those like little micro things just from a day of clinic like nobody from the outside is going to go like hey man he probably needs somebody to talk to you know and and and that's and different people react differently listen like I'm on probably one far end of the spectrum um and there are people that are very very well adjusted and they have great perspective and and all that you know there's the whole scope and so I'm not saying a one size fits all approach is the right thing but I think there's probably room for expansion and and more and more understanding but realistically you're not going to know unless the surgeon feels comfortable talking about it and and reaching out for that help. And there's still so much stigma. I mean I think we're so much kinder you know I've always said that like we're way kinder to our pets at the end of their life than we are other humans in a lot of cases. And we're and similarly we're way kinder to our patients and give our patients a lot more grace for their own struggles and mental health and stuff like that than we ever give to ourselves or our colleagues. And it's again it's not like we're trying to be malicious but you know it's it's a it's something where we really could could improve upon. I've been in counseling for years um my own personal counseling I've utilized the physician resources too for my like physician specific stuff. It's hard to separate the two many times like you know we're when you're working 80 hours a week it that is kind of your life being a physician in many cases is your life. One of the things that I've said uh to many people and I'll say it here is some of the best sessions I've ever had were when I wasn't in a crisis. Because that's sometimes when you can have that work if you're not trying to put out the fire You can talk about the things that you can do to prevent the fire from happening. And so, you know, like the cases when I'm not sitting there reeling from a bad uh from something that was very triggering like a bad patient outcome or something. That's one type of intervention. And then there's like the intervention to build that resilience to, hey, you know, get that to try to gain that perspective when you're not in a crisis to go, you know, actually, you know, maybe maybe a good idea would be to look at my data. Maybe, you know, not saying that any complicated any recurrence is good, but if I'm like way under the national average, then you know, having a recurrence is kind of expected. Like you said, it's a law of averages. Even the best people have recurrences. And um, and if you are if I am over the law of averages and I am above the average, well, does it and you know my initial thought is I shouldn't be doing this. And that's probably not the right thing to think. The probably the right thing to think is I've got a really good skill set, I just need to figure out what I need to modify to make it better so that people can have a better outcome. But that requires forgiving yourself, and that's where it gets really hard for me. And because that's that's the part that that can be really tough. But yeah, I, you know, power to you for speaking out about utilizing resources. I think that's what it's going to take, is people that are respected in the community just saying, like, hey, yeah, this is tough because otherwise people just feel alone when we are so not alone. Like it's so many, I can tell you, I have tremendous conversations with people that never appear on this podcast. And the the amount of people that are just like you and I is enormous. And um, and not everybody feels comfortable talking about it publicly, and I a hundred percent respect that. Um, many people think that I'm clinically insane for doing it, and I can I half the time it's me thinking that, but um, but uh, but you know, yeah, I appreciate you coming on and talking about this stuff. I think it's just incredibly important.

SPEAKER_00 1:29:54

I appreciate you having me. Um it's um like I told you, what I listened to that, you know, your first your first go-around with the podcast, and just everything you said, not everything, but whatever. The the vast majority of of the stuff that you talked about just sounded like me. You know what I mean? It's just it's very, very close. We're I think we're very similar in a lot of ways, and and uh I think that's a good thing because we we take what we do very personally and and uh you know, and take a lot of pride in what we do.

SPEAKER_02 1:30:24

Yeah. I will uh I'll actually take this opportunity. I'll let I'll let the the people that listen at home kind of behind the curtain for a second. So there's uh I do have like my own podcast um that has not been released, and in that podcast, there's an episode where I talk about my intense struggles with my own practice growth, the transitions between like residency and my attending time, and and my own like how mental health affected that and how how um I, you know, the lessons that I learned and the ways in retrospect after a lot of work that I feel like I could have done things better or different. Um, and so I've actually shared that. I usually share that with most of the guests before they come on just to kind of give them for some perspective about why this podcast exists, because this is kind of a natural progression of that. Um, but that's that's uh it's it's funny because there's been a few people have mentioned that and I and I've had a a couple people be like, you know, what's what's what are you they what are we talking about? But yeah, that that's what it is. I think that there's a um and at some point I'll try to figure out the best way to to release that wider. I just haven't necessarily figured it out yet. But um, but yeah, no, I I do appreciate you coming on. Um as we come to the end of an episode, I always give every guest the opportunity to give their hernia hot take, uh just kind of an opinion about hernia surgery or or life in general. Um and so this is uh this is uh Pete Santoro's hernia hot take.

SPEAKER_00 1:31:45

Uh I I think again, I appreciate you having me on. Um I think what I would end with is is how I describe this sub-specialty to people that come and observe me, and even to some patients, is and that it it is a labor of love. So this is a this is a field that is the way I just the way I a lot of times the way I describe it to to to other surgeons or residents is that this is a field of surgery that's very personal to patients because the problem that they have, they can see. Um it's almost like plastic surgery. It's very similar to plastic surgery in a lot of ways because their problem is visible. It's not like I have colon cancer, it's in there, I gotta have it out, but I don't see it, or I have a bad gallbladder or appendix or anything. Um, it's just the problem that's inside. And when I have surgery, I have a couple of little incisions and it's gone. Um, this is like a big a big bulge in my belly or a big bulge in my groin or you know, something like that. And it's visible and it's uh it's something that can cause me like significant problems, but also I don't like the way it looks and I want it gone. Um, and so the the field of hernia surgery is a very personal thing for patients, um, and uh it can be very complex. Um, there's a lot of techniques and a lot of newer things that you know is every every day things are being you know described and and invented, you know, different techniques and things. And it's like, you know, it's a it's all a lifetime of learning as a surgeon and as a physician, obviously. Um, but you know, we have to adapt. Um, but on the other end of it is is a patient who um uh you know genuinely appreciates what we do and um and and usually you know uh you know can't be more you know grateful for the operation that that you do for them and and and your skill and and and all that. And so it's it's a very rewarding field. Um and I think it it is because of how personal it is to the patients, um, because like I said, because of you know, it is a physical thing that they see like abnormal with their body. Um and and I do when I when I you know I have surgeons come and watch um for robotic surgery, and I always that's what I a lot of times I tell them it's a labor of love. This is something that you know you can't be getting into, you know, doing robotic tar because of the you know RVUs or because of the whatever. This is something that you have to do because you love it, um, and you enjoy it and you enjoy taking care of these patients because ultimately you can really cause major problems with these operations, and and if you're not careful and you you don't understand the tissue planes and everything. Um, but it's something that if you enjoy and you're passionate about it, um it's really rewarding. The patients are really, really grateful, and and it's a really it's a really great field to be in.

SPEAKER_02 1:35:02

Yeah, uh good and that's uh incredible insight. Um it's definitely much more complex than preventing strangulation or obstruction, you know, which I think is is a way that um a lot of people think about hernias is uh the potential for the emergency. But we talk about it being all the time about quality of life surgery is one of the things that you know some of the leaders of our field love to refer to it as. And and um, and I don't think that until you just had that hernia hot take, I don't honestly think that I had really considered the visible aspect to the patient and how much that is different than so many of our other of our other uh you know pathologies that we take care of. So uh kudos for a for a very thought-provoking and uh insightful uh hernia hot take there. You got it. Well, I appreciate you coming on again. Um, thank you so much, sir, for your time. And uh this will wrap up another episode of the Hernia Gods podcast. This is your immortal host, Luke, signing off. Thank you so much.

SPEAKER_00 1:36:04

Thank you.