The Hernia Gods Podcast E22 - Diego Lima, MD MSc

Episode 22 of The Hernia Gods Podcast with Diego Lima, MD MSc features a great discussion on his life and career including going through training again in the US, his contributions to the hernia research world, and AI in surgery.

Transcript

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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 mirror immortal host, Luke Elms, and today I am joined by Diego Lima. Thank you so much for joining us, sir. Well, thank you for thank you for having me. It's an honor to be to be here. Well, we're really looking forward to our discussion. And so as we usually do, I'd love to just hear a little bit about uh you know who you are, where you come from, and how you got where you are. Uh okay, I'm Diego Lima. Uh I'm from Brazil. Uh I did my uh my med school in Brazil, and I was born in Rio, um, but I grew up in the Northeast and a city called Recife. Um, the first doctor in my family, actually. My dad works uh worked for the government, and my mom had a catering service with her sisters. Um so I went, I was the first doctor in my family. And since early my med school, I I was fascinated by research and obviously medicine and surgery. Uh so I started like really uh early on uh med school like to do um to do research. Uh and this opened me um a lot of doors. Um I ended up in Japan in 2011 uh for my last year of med school. And I was there doing the Fukushima uh earthquake uh and uh the nuclear power plant accident. Whoa. Um I was I was in the OR um during the earthquake. And um I don't know, you you're gonna remember like 10 years ago, like sales was very like uh it was like kind of a hot topic, the single effusion laparoscopic surgery. Yes. And so we were doing like a single incision lap uh cholesteractomy uh when the building just started like shaking like crazy. I thought, okay, I'm gonna die here. Uh and um yeah, so uh after that like I I came to the to to the US like to doing like observationships and stuff, and um did ended up doing my residency in Brazil. And I I my mentor, Dr. Flavio Mausher, who participated here on the podcast already, who loves pizza, by the way. Uh he he had a great opportunity like to come to the US to do research with him initially, but obviously with the goal of applying for residency here. So I came in 2020, uh, in the middle of the pandemic, I had finished my residency in Brazil, had finished my master's. I came in August 2020 with my wife. Um, again, very challenging. Uh New York, in the middle of the pandemic, we were like in um Airbnb room, my wife and I, for three months. I I joke with her, I tell her like that we, you know, if we never, if we didn't get a divorce, if it didn't kill me like at that during that time, like three months in a room, like we're good, you know, we passed the test. Yeah. Uh so then I was here for two years um with uh Dr. Maushat uh Montefiore uh and Dr. Camacho, sorry, Dr. Seramuju. And then I matched, and then uh now I'm here, almost finishing Rivency applying for fellowships. And that's a little bit yeah. Well, I you know, I've I've often thought about uh because of many of the uh many of the very interesting people I've got the chance to talk to come from you know other countries or they've had to like do medical school over or or parts of their uh of their um you know training pathway again. And it's always it blows my mind, uh frankly. I I don't know that I have it in me that if I was at this point in my career and someone said, Hey, we need you to go to another country and like start over and and do residency again, I I don't know that I would be down for the task. I I I look back and even the residents now I look at them and I'm just like, man, I feel sorry for you guys having to having to deal with this. Because I think it, you know, it is uh it's something I look back on, and there's definitely aspects of residency that you go, you know, those are the camaraderie, the friendships, and and there's some excitement about like some of the first times you're experiencing certain things. But I'm assuming that that excitement kind of wears off a little bit when it's your second time through. Uh would that be uh accurate? I mean, if it's like, oh, doing a lap coli, you know, like okay, it swears off. But like I didn't have robotic surgery in my training in Brazil. Uh even like most of our epis were open. Like, I've done my first laparoscopic appendectomy was like when I after I finished back in Brazil working like in a private hospital. Um, but like robotic surgery for sure, 100%. Like uh and obviously like all things hernia related because like I I did like Liechtensteins, right? Like we had most of our uh Inguinover Liechtensteins back in Brazil, and like to be able to do robotic TAPP and uh everything, it's like it's it's pretty cool. Like that's how I got interested in hernia. Like, I was doing research with Dr. Maush, I was like looking at all these videos, and this is so cool. You know, this robot anatomy is amazing, and then that's because people I keep saying this, like uh nobody's gonna tell you, like, hey, I wanna do surgery because I want to operate on hernias, right? Uh people say, like, oh, I wanna do transplants, I want to do operate on the heart, you know, be a cardiovascular surgeon. But when you start doing hernias, and you you you it grows, it just grows on you, you know. It's like it's it's very interesting, it's the anatomy is great. Uh, and you see someone that you know, this person was like miserable, and so you know the next day they're they're they're doing better, they can go almost back to their baseline, um, depending obviously depending on on the on the on on the surgery. Uh and it's pretty cool. And like when you see these robotic hernias that uh in the past it used to be open, patient would stay three, five days in the hospital, and now they go home like the same day on next day, it just blew my mind. Like this is this is the way to go, you know. Yeah, it's um you know, it's so interesting. Um, you know, coming back from a few of the conferences was just out at the summit recently. Um, you know, people talking about that, you know, hernia surgery is quality of life surgery. And people, you know, something else that and I understood that intuitively, but then there's also the fact, I think that historically um I have not necessarily taken into account as much about the aesthetics aspect of it. Not that I didn't care about how my wounds looked or anything like that. I was always very hyper aware of that, but it um, but you just the the possibility, and and um I was talking with uh Pete Santoro recently and he was talking about the fact that hernia patients are kind of unique in the fact that you can see their many times you can actually see their disease. You know, you look at somebody and they have um, you know, they have high blood pressure or they have diabetes, or even if they have certain types of cancers, like you can look at them and you don't know that. Um, but if you have somebody with a very large abdominal wall hernia, you know, people can see it bulging through their shirt. And they when they go to the pool, people notice and things like that, you know. And so I think it's one of those, one of those things that that it is really, it's a very rewarding field. But talking about the anatomy, I think that's one of the things that's made me really fall in love with hernias was the robot allows such great visualization of the anatomy for me. And then it's also I'm a little bit OCD in the fact that it's kind of cool to take something that is like not anatomically correct and try to make it like either anatomically correct or as close as we can get it. You know, there's just some some little bit of a of a little bit of a you know, kind of, you know, arranging your your crayons and the the color wheel, you know. It kind of allows you to get that kind of uh that kind of satisfaction in order. No, absolutely. It's it's it's pretty cool when you, you know, and then um I recently um we had a cave that you know, a big hernia with love of domain, like you see the patient the next day. We did we did it open uh in this case, um, but like uh when you see the patient the next day and the guy's like smiling, you know, and it's it's just like it's it's it you see that you make a difference um in their lives. Yeah, and it I had a patient recently and it was it was very interesting. I it was a patient that had a um uh vasculitis, and um and they their first presenting symptom was um their colon died. And and so ended up having an ostomy, uh had the ostomy reversed, and then presented to me with a very, very large previous colostomy cyhernia, but every operation up until that time, you know, was on death's door, you know, even the colostomy reversal was very, very difficult, you know, days and days and weeks, and it was actually weeks in the hospital recovering and and everything was going poorly. And so now I'm there there in my clinic and I'm sitting there looking at this patient going, uh-oh, like this is a very high-risk procedure, you know. I can do it, but it's high risk. And um, and so, you know, the in that case, you talk, you know, over and over and over again about those types of uh risks. And so the the thing that I think was so the case we did it, it took a really long time. Like it was just a very, very long, incredibly difficult case robotically. My partner and I worked on it together, uh, just because it was one of those that, you know, the mental fatigue of doing a humongous case like that, you just sometimes you need you need that other set of hands and eyes just to help you get through. And so we did it together and we knocked it out, and it was a long, long case, but we stayed robotic. Um, if it had been somebody that wasn't requiring the medications that she was requiring and things like that, we probably would have converted. But um, but this one we just like slugged through and um got done and recovered. And the whole time, of course, I'm like losing nights and nights of sleep, just going, oh, waiting for the other shoe to fall, you know, here it comes, you know. And um everything went white, it went fine. And so now we're we're quite a ways out, and um uh a little over a year, in fact. And so uh, but I saw I I got the chance to see him again recently, and the the them and their spouse, they came in and they were just talking about how like the whole their whole life has changed. And we're talking about the fact that when she had the hernia, she did not feel you know, pretty to say to say it bluntly. Like just it was something that bothered her so much, it just like destroyed her confidence and that how it had affected their relationship. And and that was really one of those moments that I it actually made me pause for a second and go, like, wow, that's pretty cool what we're able to do. And you know, you talk about these people waking up and feeling good, like those are pretty, pretty incredible moments if you stop to recognize them. Many times they get washed, they get lost in the day, but if you stop, it's really it's really impressive. So are you are you trying to go through um you're trying you're getting ready to match for try to match in fellowship? Are you going what what's your route? Are you going abdominal wall reconstruction? You go minimally evasive? How's your what are you planning for? I apply for just abdominal wall reconstruction. Um I don't uh I I I I I had a few projects like the on bariatrics uh with um Diego Camacho here at Montefiore. I I joke, I tell him like, hey, don't don't be offended, but that's not what I wanted to do. Um he understands, he's he's such a great guy. And um uh but like I apply only for abdominal uh head construction programs. Like I that's that's what what I want to do. Um I feel like I tailored my career in this direction. Um and uh it's something that I really enjoy. You know, if I if I'm in the OR like doing these cases, like I really enjoy doing these cases and all. And um, so let's see. Let's see where I'm gonna end up. I don't think you have to worry about any research requirements. I think you've met you've met those with with the prolific with the your prolific uh uh research experience. So are you when you're looking at like what you talk about the the cases that you've come come up here and and been doing? What's like your what if you had a a day in the operating room currently, like what would be your ideal day? I mean three, four cases, you know, ventral hernias. You can start with an ingino, like uh just to warm up. Uh um, but like I would like a full day, like robotic cases. Um I do I do enjoy open as well. Like um, you know, I think every case is is interesting. Um and uh I spent some time uh in Charlotte with um Dr. who also came to you also had uh an episode here. So I spent like a month with her and with Kersher um doing cases, and it was like I was in Disneyland, you know, like I was so happy uh this that month. And it was like my I told her like this is my the best month of my residency, you know, because it was it was like pretty cool. Uh yeah. Yeah, we uh it with uh there are a few people I've had the chance to to talk to on the podcast and uh have not had the chance, you know, obviously haven't had the chance to to watch them operate, but man, I tell you, there's a there's quite a few of them. I'm like, man, if I could ever get a chance just to go up and observe for a while, that'd be pretty sweet. And she's definitely one of them with all the all that pre-pregnal work that they do with the Carolinas. It's you know, you try to they make it they make it sound and and look so easy, and it it is at least in my hands, it's not nearly as easy as it looks. No, and I mean it it's it's pretty cool. Like we did a bunch of preparatory repairs, uh, and um she's like try obviously like trying to convince me you don't you don't need to cut into all these muscles, just a preparation ear repair. And like also Dr. Kershaw is he's awesome. And um, I remember like um if you like Dr. Haneyford, uh, he would say, like, oh Dr. Kershaw is the the you know the best surgeon I ever operated with, and blah blah blah. And then I I got to operate with him, and I was like, holy cow, he is he's really awesome. Yeah. Uh so I I really enjoyed my time with them. Um, and it was it was the best month of residency so far. That's fantastic. And you've got you've had some experience in residency, so that's saying something. You know, you're having your second go of it. Now, yeah, whenever you um, you know, through this whole time, you've maintained uh your your work with all the research and everything that you do. Have you been able to maintain the the research component of your career despite going through another set of rigorous training with a second uh residency at this point? Yeah, it's it's difficult. As a resident, it's very difficult to do research. You need to be very uh resilient and disciplined, um, which is something that I I've always been. Um, you know, I've I've I I I tell I I joke that I I lived in Japan and now I'm very disciplined and stuff. And my family, my dad was very uh he was not in the military, but he could be because there was a lot of discipline. Uh and um so I've always been like very disciplined and everything. But once you start residency, you just don't have the time. Um it's like you're working 80 hours a week, you know, when you're off, you're tired. Uh, you want to spend time with like I want to spend time with my wife. Um, and then it's tough. So when I was a research fellow, it's easy. You're just like in the off in your office the whole day uh writing papers. But once you're a resident, no. What happened is that back a few years ago, um, my wife and I, we we we started a company, like we started a research course, online research course, clinical research course, where we would teach like the methodology, statistics, and everything. And we ended up creating a research group uh people who would go to the course, take the course, and then be interested in coming to the US, being research fellows, applying for residency, wanted to publish papers. We started this group basically with like four or five people um back like in two or three years ago. Um, and then uh now I think we have around 35 to 40 working with us uh on several projects. But so I start to delegate, so I keep telling them like I'm I'm I'm in the business of developing people. I want you guys to grow uh personally and professionally. I want you guys to meet your deadlines, I want you guys to communicate, I want you guys to be better. Uh so what I do is basically like for each project, I have a leader, and this leader is responsible for getting the job done. They have like four or five people in the project. We discuss, we talk, you know, I answer questions, anything that they need, they send papers, anything that they need, and they start the project. And they I basically, you know, I just tailor and then they sent me what they have, like a draft, I review it and I send it back. It's funny because they're always afraid of my feedback. They're always afraid. Oh my god, you're just gonna think it's terrible. Okay, you you you so you don't have expectations, you're good. Um yeah, so um so I started to delegate and they started publishing with me, publishing with me, publishing with Dr. Mausher, publishing with Dr. Camacho, Dr. Seramuju. Uh I have a few papers uh with other people that we invited as well, uh like Dr. Hanford, Dr. Pale, and other other people, uh Dosimu. Um, and um and then we started just you know, it becomes like um snowball because you have always these projects going, always these projects going, always thinking about new ideas, and always curious, always thinking about something. Uh like uh, you know, and um uh and and that's how and it's very it it's very nice to see um them getting published as first authors in journals like hernia, you know, right? Um and um and they matching like we had we had the match this week, and like six or seven people that worked with me match in general surgery uh in in our research group. And I I feel like I'm very happy for them um because I can see they they they I don't think they notice, but you know, people we that we are looking from the outside and we see their personal growth. We see like that two years ago, one year ago, they were working on this project, and it was terrible. And now they are doing it beautifully, you know, and it's so I it I'm very happy um to see um their growth and that they are achieving their um their goals um and that I was able to help them. And sometimes, you know, we try like, oh, someone is applying for a green card for like if I can write a letter, or like they're applying for a research fellow position with someone. Uh, we try to talk to people, we try to find positions for them uh because we know that they want to um to match uh in a in a surgery uh residency uh in the States. Uh my wife always she also just met on Monday. Uh great. So she's gonna start uh general surgery residency as well. Wow. Um and now we work together. I joke that she's my boss because look, there's something that I learned like you have two options in your life. You can be right or you can be happy. I chose to be happy, you know. And the second thing is that you need to buy a really nice couch for the moment where you forgot that you chose to be happy. Yeah. Because it's gonna leave that. Yeah, we uh it spoke never never truer words have been spoken, no. We uh yeah, no, it's it's funny. That's the uh my wife and I are always joking. It's like there's the the price of winning the argument. You're just at some point we say, okay, let's just call this a truce. You know, we're both being physicians as as you as you guys are as well. It's like we're such limited time together. You're like, are we really gonna waste our the the short time we have now like fighting about something stupid? And I will tell you, usually the answer is yes. We still end up, but but uh that's what you have. That's why you know you don't get to where we are by not being pretty hyper-competitive at some level, I would suspect. So that's true. But you know, I think it's a very interesting thing. You're talking about the people that you've been able to mentor and work up through the research route really brought two things to mind. One, um, you know, as someone who doesn't do research, I don't, I mean, I I think I have like one paper that was that was published back when I had to do a research article, and it was with uh Dr. Tashera and Dr. Um and uh Dr. Jawad about their about their bowel obstructions after after bariatric surgery. So now people show up and ask me about my like experience with bariatric surgery, and I'm like, I have none. Like that's that let's be clear. I might be cited, but that's that's not really me. But I think that um you know there's there's a level of uh needing to learn that um because it's not something that if you're a clinician, um the majority of us are I mean, it's it's not like a major part of most people's practice. And I, you know, I think that the obviously the hernia world in the fact of like the innovations and the participants in this, I think a lot of us, um, you know, a lot of the people that are doing a lot of the hernia work as a whole are not necessarily involved in like the academic side of it. It's just part of a practice that they are, you know, taking care of patients and doing the and doing the daily work, which is fantastic. But there's Also, the whole other side that advances the field, um, like the things that you guys are doing. And and so um going through like a regular kind of residency experience is not necessarily something I think that lends itself well to to learning the ins and outs of the research um aspect. So to hear how you've kind of like brought these folks along and and been able to kind of like uh teach them how to do that, I think that's that's obviously probably very, very beneficial for their career, not just from the mentorship aspect, just from the knowledge that they gain on how that all works. Yeah, and I mean I tell them like, look, uh life's gonna hit harder than uh bad feedback from me, you know, like you just get you need to get used to it. Um I tell them like you guys need to communicate it. Communication is very important. If you for some reason uh you can't finish that in the deadline that we establish, you guys need to talk to each other, need to help each other. So it's not just about getting the research and the publication and everything, but also like learning to work in a group, uh, to be a leader, to develop their skills, like uh leadership skills of being a leader and like being a finisher. Um because I feel like every project, even if they reject our paper and we give up, but you finished, you submit it to the journal. Unfortunately, it gets rejected. It's not because we publish a bunch of paper that we don't get rejections, we also get the rejections. Um it's like it's like the joke that people say, Oh, um, people who don't have complications is because they don't operate, right? Um so it's the same, it's it's the same thing. So I tell them, like, you're learning research, but you're also learning other very important uh skills. Yeah, you know, it's funny because I think that many times people assume as we go through our careers and we become, you know, physicians and then we become residents. And I know for me personally, I went through my career and ended up in my chief year, and I became the administrative chief resident. And at no point during that, and I'm I've played sports, I understood the team aspect, um, I understood the communication aspect, but learning to be a leader is something that's purposeful. It's there's very few people that that is just like some innate ability. There are people that demonstrate leadership qualities all the time. And most people that end up where we are at least have some level of that. But it's a very different thing to have the qualities of a leader versus the executing on leading, which is a completely different thing, especially when things aren't going well or you're gonna miss a deadline. And so I think that again, that what you're what you're working with, you know, that's gonna pay dividends out well outside of their research career as well. Yeah, true. And um people um, you know, uh I uh they need to take ownership. I think the words uh ownership of of what they're doing. Like if something's not going well, like it's not about blaming, it's about like that was my fault, you know. Uh I'm sorry, um, this happened, and you know, we're gonna fix this. Uh, but uh I I really enjoy I I I love reading. You can you can see in the background I have a bunch of stuff. Uh but like I read this book from Joe Co Willink. Um, and he's a former uh Navy SEO, uh, and he has several several books. Um it's um he his first book was called Extreme Ownership. Ah yes. And you know, that book is amazing. You know, it's not because it's in the military, it's there's nothing to do with the militaries, it has to do with leadership, you know, and taking ownership of your things. So um I I'm very um it's like a joke that I I could I could be in the military because of my my my my family. My my dad he he had some uh O C D with like cleaning. Um he still he still has it. And my my my wife tells me that my their house in Brazil is cleaner than uh than a hospital. Uh but like I grew up in um we didn't have a lot of money. Um and um I had to you know study because I wanted to be a doctor and in Brazil. It's uh the public uh schools, the public universities, they were very competitive to to get into. So you have to just study really hard, wake up really early in the morning. Um and um so since when I was uh a kid, I had I have to be very disciplined and take ownership of everything. Um so this was just like common for me. It's just like it is part of me. And then like when I we I went to Japan and they're extremely um disciplined, and they're extremely like they they take loyalty to another level in Japan. And then I I recently took my wife there, and uh, this was 2024, October 2024. I took her for the her first time. They invited me to go to the university. Uh uh, I did part of my med school there in KU University in Tokyo uh in 2011. Uh, and I kept coming back like to observe cases like if I came back in 2012, 2013. My mom was crazy, she was like, you should never go back because she was traumatized by the my experience with the the earthquake. For sure. And then but I I grew up, I I love the culture, and I uh I grew up watching animes and everything. And um I still watch actually. Uh so so uh and then after 2013, I never came back, and then 2024 I spoke with my my my friends there and came back. They invited me to give like a lecture, like what have you done after you left Japan? Some sure. So I took my wife there, and then one of my mentors he was like, Diego, uh, let's have dinner. Uh it's eight, he he's he's he scheduled the dinner three months before. Uh three months. So it's gonna be this place, it's like uh eight, uh 8 p.m. Um, that's it. I said, okay. So I told my wife, he said eight, we are there 7:30. So uh we got there 7:30. He got that 7:45. Yeah, and then he was like, huh. And then we had dinner, blah, blah, blah. And then, oh, Diego, tomorrow for your lecture, I'm gonna meet you at the hostel in front of the train station. And then he's like, Diego, we're gonna meet you. Uh let's meet at 7 a.m. in front of the train station. Okay. I look at my wife, 6:30. So we got there 6:30. He got there 6 45. And then he was like, huh, I didn't remember Brazilian versus. You're like, yeah, I'm here to talk about what I learned while I was in Japan. Exactly. Exactly, exactly. So uh I'm I'm very like uh I'm very like uh punctual and discipline with everything that I do in my life. For sure, yeah. You know, it's funny because you talk about like uh like extreme ownership, you talk about being able to receive feedback. Um I think that there's an art to receiving feedback as well. I think that uh I probably have not always been very good at it. Um I see other people, I see residents that aren't very good at it. And I've it's it's got me thinking as to why that is for me personally. And I suspect that the other people may have you know similar stories or or at least relate on some level. But I think that at times when you when you're trying to receive feedback, and you know, many times, like for instance, if you're doing something that requires like some pretty brutally honest feedback, and you've been a high achiever and you're somebody who has uh you know kind of succeeded your way through life, um, then when you receive that negative feedback, it may be some of the first time in your life you're ever really receiving feedback that you like didn't do well enough or it wasn't good. And um, and that can be super traumatic to the to you just you as a person because it was I was operating with a resident one time and um there was this I can't remember what it was. I I do actually remember. We were doing a we were doing a um an umbilical hernia and we were getting ready, and it was like it was like borderline, it was like right at the two centimeter mark. So I was just doing an open umbilical with some preperitineal mesh. And at some point, the uh something happened and and sterility was broke. And so and it was at that point that was the resident's fault, um, not trying to put blame, but that they were the ones that broke the sterility. And so I said, it's okay, we're gonna like change the mesh out, we're like we're gonna redo this and we we finish the patient did great. But um, like this person was being incredibly hard on themselves. And I'm and I was like during the case, like just almost distraught, and I was just like, it's okay, like I you know, it was a mistake, it's okay. And the what they said was this is the only thing I'm good at. If I'm not good at this, what does that mean? And you know, I think that that, you know, to me, that just gives like some context to the fact that that receiving feedback is an art, giving feedback is also an art, and that there is a level of personal biases or personal experiences that kind of shade how you receive that. And it can be really difficult to learn how to do that well if there is a lot of other internal things going on that it's kind of shading your view of that. Because I think that many times it, whenever I've been given feedback that's negative, it kind of hits me on a deeply personal level where I don't think the people that are giving that feedback mean it that way. But I guess all that to say, as you've you've kind of experienced the mentorship aspect through your work with the research and your company, and you've also been through residency training once before. You have the perspective of a career that has progressed beyond residency and now you're back in it. When you come back through residency this time, what kind of observation have you made about the way that we as attendings and educators are doing our are performing our role in the residency education? Have have you had a different perspective on it, specifically like the leadership, the mentorship, how we how we're teaching residents in this system? Yes. So the first thing is like I think the the word is like you need to be humble. Um and you need to, there's a book that I uh I really like. This author is called uh Ryan Holiday. Uh he writes a lot about stoicism. And there's this book that's called Ego is the enemy. And that's what we need to uh pay attention when we are um you know in engraved the scene in life. And um feedback has everything to do with that. Like um the difference from training in Brazil and here uh they are gigantic. Um the feedback here is you have more you you get more feedback here. Also, the training is longer. Um it's like in Brazil, day one, you have an umbilical hernia. Oh, this is the intern's case, you're doing it. Day one residency. Here it's like takes a while for you to start actually doing these cases. Okay. Um because like if in in Brazil, six months into residency, you are doing lap colis. You know, you are the the one doing the the case. Um and at least that was that was my training there. And um, and here it's gonna take a little longer for you to be you know operating on this uh these cases. And um but here I get more feedback from from from the attendees. They're they uh they they not gonna say that they're paying more attention, like they are, but like there is something that kind of a standard, like, oh I'm training, it's a residency program, uh a resident, and I'm gonna um give feedback to to the resident on how he's uh performing. Um and so that's the difference that I see. Um going through residency again, people think, oh what it, you know, you always get these questions, right? Like, oh, uh, how is this guy gonna be because he wasn't attending and now he's going through residency again? And I mean, you need to be humble. Um, people have different experiences in life, um, in work, um, from you. And like um, it's a team, it's a team. It's not, you know, it's residency, you're in that service, it's a team. Like you have the intern, you have the counsel, you have the chief, you have the attending. Like uh, you need to get the job done. Uh, you need to get, you know, at the end of the day, everybody needs to help everybody. It's it we're thinking about everybody thinks about the same thing, the best for the patient. And um that that that's every time that's my goal. Uh everybody thinking about uh what is the best uh for the patient, but you have on hierarchy. You have your chief, you have your attending, um, and then um I I was always pretty cool with uh with RevC the second time. Like now I'm older and um you know I just have more muscle pain and bone pain and stuff. My back hurts, you know. Or like I fall asleep in the couch when I get home. Yeah, it never happened to me before. Uh, but other than that, I'm I I'm I'm pretty chill with my colleagues. Obviously, like I'm 10 years older than them, most most of them. Um like I'm I'm not the one that is gonna be going like to bars and pubs and stuff anymore. I just want to go come home, stay with my wife. Obviously, have good friends, like we have our group, we go out once a month, um, usually to uh some Asian restaurant in Flushing and Queens. And uh but no, like I wanna come back home. Like we my my wife, we have three cats. I I tell her that it's the her cats, her cats. Uh and then it really helps. I never had a pet growing up because of my dad. Um, and now we have three cats, and it's it makes a big difference in life, um, like during residency, because it's it really helps with emotional support. Because we're talking about research and performance and excellence and all that, uh, but you need to be very careful with burnout. Um, it's very easy to go into this spiral and get burned out. Um, so now like I pull this myself, like I'm always like paying attention to uh the amount of work that I'm doing. Um and someone that is focused is not because of you have this many things to do, it's when you start saying no. Yes. In mean of, you know, like you have you you need to learn how to say no to people, like obviously. The same thing with feedback is an art. You need to be, you know, there's a way, right? You know, of of talking uh to people, like um, but I uh you need to be very careful with burnout, it's very easy to to to be burned out. Uh I've been um a few years ago, and after that, like I started to that's when let's delegate more, let's have this, you know, more people working, let's help people, let's delegate more. This cannot be on my shoulders. Uh all of this, you know, it's resonance, residency stuff, and having like a company and a research group and all that stuff, uh, it makes things like even more um difficult. Um so it's an art. It's an art to give do give feedback. You need to be humble, um, to listen to the feedback that you are uh receiving uh and work on your deficiencies, right? Like if someone's telling you that you need to be better on the robot or or lab, like I I live approach from the hostel. We have a simulator. I can just like let's say on the weekend I'm free. Can you just go there and practice? Or you know, I I even have a like a lab simulator at home that I just can't I can just practice. But like you need there's there's a book. I'm sorry, I sometimes I talk too much, but like there's a book that and I I love books, like I read all the time. Uh I I'll I'll tell you a little uh something interesting. Like we I have a deal with my wife. Like I when I'm off, let's say I'm off on a Saturday, I have a deal with her. Like, look, I I always wake up earlier. I I tell her that it's because I'm old, I'm 65 or something, you know. Like I'm older, I wake up early. So I wake up at like five. And even when I'm off, and then I tell her, Raquel, look, you're gonna give me two hours. During these two hours, I'm gonna be in the couch, I'm gonna have a coffee, I'm gonna read my book. At seven, whenever you want to wake up, I'll make breakfast. But give me two hours. She's like, of course, I'm not gonna wake up at five. Uh but there's a book, it's uh Malcolm Gladwell, uh Outliers. It's a very famous book. Yeah um and he talks about the 10,000 hours to be like right to achieve uh excellence. And I read it, it's like okay, that's very interesting. But like I I don't I don't agree with him. I think like you can do something wrong even if you do for 10,000 hours. Sure, you can keep doing things wrong, right? So there's another book called Peak that talks about the deliberate practice, yeah, which is basically someone, a coach, uh an attending, guiding you, showing you how you should do things. And that's uh how how you learn, that that's how you get better. Um, I I grew up in the I was a kid in the 90s, and um, I don't know if you follow Formula One, uh, but I I grew up in Brazil watching Ayrton Senna uh racing. He was three three times world champion, and he died when I was 10 years old, and I watched him die dying live in a race, uh in Imola. Um and um, but Ayrton Senna, he was what we could say like he he was pursuing excellence, right? You know, he was he he for me, obviously I'm biased in Brazilian, but he's the best Formula One driver from all time. He's the GOAT, he's awesome, not just because of his titles, but because of his mentality, you know. Um, so I I've and I grew up with that, and now that's what I'm doing, I'm trying to do it's the pursuit of excellence. I I saw a video, someone saying, like, uh, oh, you need to be careful with the noises and with the signals, which is basically like, let's say in 24 hours, how many hours you spend like on social media or in something that is really not productive, and how many hours these are this is the noise, yeah, and how many hours you spend on the signals, which is like the things that you know will make will help you to get where you want to go be. Um, so the every day you you you look at when the the day is over, you just think, what did I do today that makes me to get closer to what I really want in life? And then every day you just try to avoid the noise, avoid the scrolling down, avoid all that stuff, and focus on what you really want to do that's gonna help you to achieve your goals. So I try to do this exercise. Sometimes I forget, but that's fine. Uh but I try to do this exercise almost uh like um daily, and because like I can I I I publish papers and stuff, and you know, but it at the end of the day, look, we we I mean I'm a surgeon in Brazil, I'm gonna be a surgeon here. Like, but we're dealing with patients. These patients they come to us, they they are suffering, um, they need our help, and we need to offer them the best that we can. Um and we have to improve our surgical techniques, we have also to be with innovation and robotic surgeon, and then the next thing, and you know, always practicing to offer them the best our of our our skills. Like I don't need to publish 10, 15, 20 papers more. Like it doesn't make that much of a difference. But what we we need to be uh looking at, it's like how can I do better um for these patients? How can I offer, you know, how can I improve my skills? How can I and and and because at the end of the day, that that's our that's our goal. You know, it it's interesting. You talk about um having to be at pursuing excellence. And it's I don't remember where I saw it recently, but um so I'm I'm you know, I'm gonna paraphrase whatever whatever the source was, but it was basically that there is there's basically a price of excellence. And the price of excellence is that there are certain things that that we do sacrifice in that pursuit. It's unavoidable. Like you either you either achieve excellence at something, or you it maybe that not saying it's a bad thing, or you pursue other things that prohibits you from really achieving excellence. And so I you know, I think there I think back on on opportunities in college, for instance, where I would have probably made some really great memories uh going out and hanging out with my friends on like these certain nights. But I didn't, you know, I was in my dorm room studying. You know, in I had a great time in medical school, but when it's time to work, it's time to work. And so leading a test block, you know, life, everything stopped. You know, whenever I was in residency, I missed um weddings, I missed funerals, I missed, you know, birthdays, I missed all kinds of things for friends and family that I still hold dear, but the relationships are kind of they're kind of gone, you know, because what we do does it it is all consuming at some level. And, you know, the the price of the the the we we many times take a lot of the positives of what we do, right? We receive a lot of praise, get feedback from patients that, you know, you saved my life, you you changed my life. You know, when you really stop and think about that, there's not a whole lot of professions out there that get that kind of feedback on their work. You know, a tax accountant very rarely, I'm assuming, gets people being like, you saved my life, or you know, you're the reason that that I'm here, or uh, you know, those types of things. And so there's there's the obvious upside. There's also a downside. Most things are not, you know, there's obviously what goes up must come down. And the downside is that pursuit of excellence aspect does uh does harm certain relationships or certain pursuits. And I mean, like for instance, I love music. I've played music my whole life. I um I've been in bands, I've you know, produced, I've released, you know, four different albums and things like that. I barely play anymore. And why? Because realistically, the time that I was playing was time is time that now I am either dedicating to my patient care, I'm dedicating to leadership activities that I'm doing through through my work, or I'm dedicating it to my kids. But the truth is, is those are the things that I really want to be excellent at. That's the you know the phase of life that I'm in currently. So I think that it's a really interesting, it's really that that pursuit of excellence does take a lot. But the interesting part for me has been the mindset that I've had to really try to change, which is self-care, taking that 5 a.m. to 7 a.m. to sit on the couch, read a book, drink a cup of coffee. You know, that two-hour period for you is probably equally important for the care of your patients than the two hours you spend on your lab trainer. Because at the end of the day, if you're not a good version of yourself, there's no amount of skill, there's no amount of technical prowess, there's no amount of knowledge that can overcome poor personal performance. And that's that's been really the the mind shift I've had to make, which is hey, I could stay up and get this note done or this or or review, you know, this non-emergent imaging study or something, or I could make sure that I get enough sleep that that my surgery's tomorrow that I'm you know fully focused and fully there. And so I think that that's been a big change for me in that pursuit of excellence is realizing that self-care is part of that pursuit, and it's not something that gets in the way of that pursuit. That's absolutely true. And um, I used to sleep six hours every night until I saw this on somewhere on the internet, someone saying, like, uh, if you if you sleep seven hours instead of six, you added one night's sleep in a week. Right. One night sleep in a week of like damn. Let's start sleeping seven. Right. Do it makes a difference. Now it makes a huge difference. Now I can feel it. You're arrested, you know, you you're in a good mood, you're arrested, you know, you function better. Um, and I I completely agree with the sacrifices. Like, um, it's me and my wife in the States, like no, no water family. So I'm not part of I can't I'm not seeing my cousins growing up because I have I have I I grew up with my cousins in Brazil. We're very close, they're like brothers and sisters to me. Uh and I'm not seeing their kids growing up. Yeah. Um, like I count the days in the in the year that I see my parents uh when they come visit. I go to Brazil probably like once a year or even less than that. So there's a lot of sacrifice, you know, and um that people they don't I'm not sure if they don't uh see or they don't want to believe in. People they want the the outcome, but uh a lot of people they don't want to go through uh the sacrifices that uh people went through to get to that position. It's like they they they they want the bonuses, but they don't want to go through all the the fight all and and everything, and they think that uh it was overnight and it was not. It's been years, you know, it's been years. Um and um it it's it's very interesting, um, especially like um when I deal uh with these um students that I have to show them um that it doesn't happen overnight. It's a lot of work. If you are willing to go through the pain, um then you you know you may find uh you may achieve your goals um at the end. And then you're gonna see that all all you've been through was worth it. You know, um, but you need to there's a really nice book from also from Ryan Holiday. It's called The Obstacle is the way. Um and obviously like meditations from Marcus Aurelius is also a really good uh good book, and helping me through residency, the obstacle is the way, helped me through uh residency, especially in difficult uh months because we have difficult rotations, and people think that matching is the end, and matching into residency is just the beginning. Just the beginning. It's just the beginning. And you still have five years my friend to go when you start, you know. And remember, you're gonna work weekends, you're gonna work 24-hour shifts, you're gonna you're gonna be tired, you know, you're gonna be frustrated. And all of this is gonna is is gonna happen. It's not just like looking people on social media, say, oh, they have uh tell them, like it's not people, oh this this person is in this program, blah, blah. Don't don't don't don't think that uh he's not being true, like, you know, uh challenges and everything. Everybody has been true through that. Sure. Yeah. Yeah, it's there the um, and I think you know, knowing uh the looking back and um and and knowing what it took to get to where where I am today, I think that's the reason that I find it so uh so incredible with people like yourself that are willing to do it again. Because you talk about people being willing to make the sacrifice. I don't know that I have it in me to make the sacrifice again right now. And um, you know, I think that it was uh surgery was something that um I was drawn to, but I was actually kind of scared of. Like in medical school, I did not particularly enjoy my surgery rotations. They may they were like very intimidating to me. But the reason I wanted to do surgery was mostly driven by my ego, I'll be honest. Like it was the ego of whenever I'm my um you know emergency department rotation. Whenever the really cool stuff came in, the trauma team came down and took care of it, right? Whenever I was on another surgical or procedural specialty and things got really hairy, they called the general surgeon. And and my ego, I wanted to be that guy, right? I wanted to be the superhero that comes rolling in and saves the day. And and so that the ego drove me to choose surgery, even though there are certain aspects about it that I just particularly didn't enjoy or like. So I've had to come around to what it is about surgery that I enjoy and what it is about surgery that I like. It's not something that I went in and every single day I woke up and I was just like, this is the best thing ever. Like I, you know, I woke up day after day going, did I make the right choice? Holy smolly, like I'm not sure this is exactly what I thought it was gonna be. And and am I am I too am I too deep to change? And and so it that's those kind of the way that I pursued it. Now, I've you know, it I would have never, ever, ever in my wildest dream predicted that hernia surgery would be something that I would be so drawn to and be so fond of. Um and uh uh you know, I I think that that's something that's just kind of shocking. And it's one of those deals that you kind of just learn that you gotta keep your up, you gotta keep your eyes open or you may miss something that you may enjoy just because you just don't think that's something that you'd be into. But but yeah, no, I think it's a very, it's very interesting. I will I will tell you, you I love the the number of books that you've read. I have a lot of books that I want to read that I haven't, and I have and I have about 50 books that are part read. Like you talk about executing and finishing the job. Well, I would not be one of your favorite students if it came to the if it required me to read a book, because I am two-thirds of the way through about 40 books right now. No, but I also have a bunch of books like that I haven't read yet. And my wife was like, You need to stop buying these books, man. And then I just you know, I can just start buying like on key on Kindle, so she she won't see it. Oh, it's dangerous. Kindle's dangerous, it's way too easy. You know, it's different, it's different when they're like piled up on your bedstand like two feet high, and you're going like, uh I should probably, I should probably not buy the next one. The Kindle, they just kind of they just sit there. You know, it's funny. My my wife is um, she's doing um, she's getting ready to take over as uh a director of a minute uh she's starting a menopause and perimenopause program, a sexual wellness program. And so she is uh you know reading and and uh aggressively on the topic, just you know, in preparation for her new role. And and um, so I come home and like every day there's like two new books on the table. And eventually I was like, when are you gonna have the time to read all these? She's just like it, she's the type of person that's like, but isn't it awesome? Look how much stuff there is to like learn about this. And I was like, you and I are very, very different people. Yeah. So I tell my wife that like I want to retire in Japan. Yeah. And um then I'm gonna have time the time to read all my books. Yeah. You know what? That's actually here's something something else I was gonna admit mean, I was gonna ask you. So you actually saw the Brazilian system, you saw the US system. How's the the Japanese system compared to that? So Japanese system, um, nine 95% of the population, they have access to the free um health system. Um, you can also have like private health system, um, which probably is gonna give you access to more to different and uh stuff. But let's say uh just an example, like we want to have like robotic surgery in Japan, right? Like um you want to have like the a robotic inguinal hernia. The public health the health system in Japan does not cover for robotic hernias. So they're so good lab that they say, why? Uh but like um so they're they've been trying to change this because the things like Japanese people they're they're not they're not big, they're thin, they're healthy, so they don't have big hernias. So um that's the thing. They're not used to all the the things that we are used to, like these uh big defects and uh constructions and everything. Um so like if there is a Japanese robotic system, the Hinotori, that I I played with uh a few times there, and um they they can't use for uh for herness because the public health system doesn't cover. So if someone wants, they have to pay from their pockets or have like a private um system, health help uh insurance um to um to cover for them. Um Brazil it's public and private, and uh public it's not really good. Um sometimes you're gonna still have like open colleagues in public hospitals because they don't have laparoscopic uh instruments available. Uh I remember when I was a resident back, this was 2017. Uh we would go to a distant hospital for a month uh to do open colies because they didn't have the instruments. So we would go there because of that and to do in in we did, like I said before, like open appies. Um and then you you and here this the difference that I see is like it's the axe the access to technology, you know, like everybody people have access to all these uh new technologies and robots and everything, um which is which is pretty cool. And like you come to a university uh hospital and you have access to this world famous surgeon that's gonna operate on you uh in the Bronx, like you have like famous people like thoracic surgery, bariatric surgery, you know, and and everything. Um general surgery. So the access that you have to these um people um is is something that uh I was uh impressed um when I when I came here. Yeah, you know, you talk about that kind of access. One thing that I am proud of that at our facility is you know we do have um robotic access for our acute care surgeons for the most part. I mean, obviously we don't have unlimited robots, so occasionally there's times when we don't have access. But but for the most part, if your surgeon wants to do, for instance, a gallbladder or a or a hernia or something robotic um and they need to add that on as an uh for the acute care surgery team, they can do that. And I think it's pretty neat that you know it's not like we go and do like the a wallet biopsy and say, like, oh, well, this person's uninsured, so they're only getting this or that. Like if you come in and you, it doesn't matter your insurance, you're gonna get offered the surgery that the surgeon thinks is best for you in the system we have. Now, that obviously has there's positives and negatives to everything, right? So, so you know, the cost of healthcare and and all that is is extremely complex. And I understand that there's certain practice patterns and things that contribute to that. But I do think that it's nice to be able to, at least in my practice, not everybody has this luxury, in my practice, I'm able to make decisions on my patients that I think are the best medical decisions that don't, that are not limited by you know access. And that's not true even in the United States, so many areas of the United States, much less um, you know, worldwide. And so that's that's a luxury that that I don't take for granted. Yeah, in Brazil, if you want to have uh robotic surgery, the patient has to pay uh from their pocket like extra because it's not covered by uh by insurance. So we do have uh I don't know how many robots we have in Brazil right now, obviously not as many as in the US, obviously. Um, but like if you want to if you want to do robotic surgery, like you have to um they have to pay for it. So like surgeons they will have like a lower number of cases compared to surgeons in the US uh using um using the robot. Yeah, I mean we have we have 10 ORs at the hospital where I'm a chairman currently, and we have 10 ORs. Uh we have three robots and we're getting rid and we're looking to a fourth. That's cool. So I mean, I mean, and and the truth is is you know, the reason we are doing it is because they're getting used and they're being used by all the different specialties. Um, and it's all you know in the name of in the name of getting you know the best outcomes. Because I think it it's it's hard once you see the outcomes of some of the things we're able to do robotically, at least in my practice, when I made some of the jumps from uh open to robotic, I jumped over lap. So that was like my experience. Like some people can do things incredibly laparoscopically, and you're going, you know, listen, if you can do a lap tep for an inguinal hernia and you're proficient at it and you accomplish all the same, you know, the the 10 steps of the mouth, you know, the 10 commandments of the mouthpectal orifice, if you do all that, then the robot and you're proficient at it, you do it all the time. The robot doesn't make a ton of sense for you in a lot of those cases, you know. Um, but if you're somebody that's doing that's doing only Liechtenstein and you go do lab taps and there's not, you don't feel like you're getting quite as good of a dissection or something as you'd really like to, and then you go do the robot, you go use the robot and you go, oh well, I get a way better dissection, or I feel more, I feel much better about my hemostasis, and which I think plays an enormous role in in a patient's recovery. Uh that's just my personal opinion. But you know, those types of things, uh, that's where that's where the uh the robotic access has been really dramatic to see the differences in my patients, just from jumping from doing even things like you know, open reef stopas to a robotic reef stopa. That's just it it's a completely different, it's just completely different for the patient. It's not even close. No, yeah, I I I I completely agree. Like, um, and this this is something like that happened in Japan, like like they're they're a good lap, you know, uh doing inguinal hernia. So the government is like, okay, what's the benefit of bringing the robot if you guys are good doing lap and it's just gonna add uh cost. Uh obviously, like with in the near future with new robotic systems and being becoming cheaper and and everything is a different reality. And I think we're going in this direction with all these different uh new these different robotic systems coming into play. Um I think there's a recent paper that was called the death of laparoscopies, very dramatic, the death of laparoscopy. Right. Um and if you look at the numbers, like in in the US, like the robot like growing, you know, increasing in numbers and lap going down, or open like stable, uh, which means like what is being done done open keeps being done, you know, they're still doing open, but like people are changing like the lab for the uh laparoscopy, laparoscopy for the um the robotic um system. Um and uh but I I I I think like in the next like five years with different uh robotic systems, um in a in also like I think the learning curve like for different news rob robots are not gonna be you know um too too long, like I think because they're very similar. Like I let let's say I play with the Hinotori, like I wasn't the console, it's the same thing. There's no difference. So you know, it's like the docking is different, but the rest is the same thing, right? Um, so I think it's gonna make easier for uh for us, for the for the system, and um it's gonna be better. Yeah, you know, you look at those numbers, you look at the numbers, and I think it's gonna be really interesting to see what happens with some of the robotic, laparoscopic, and open numbers for some of these cases as you progress through the next like 10 years. Because then you're gonna have residents that come out that were essentially taught on robot. You know, and so you're you're you're right. You're definitely gonna have a drop-off in laparoscopy when a lot of residents coming out are doing you know high-volume robotic choli cystectomies, for instance. Um, you know, the lap coli rate is probably gonna drop. Um, there are also people out there that are towards the end of their career um or just you know, never bought into minimally invasive surgery, which is not really not really something you can do. You can't be like a denier of minimally invasive surgery earlier in your career now, or your career's gonna be kind of short, you know. So I mean, it's you don't have people lining up around the block to go get an open cole these days. But I think that it's like the flat earth society. Yeah, yeah. I mean, but there are some people that still do it, and you know, I'm not not crit not being critical of them, but as those people, uh I would I would venture a guess, and you know, you'll have to do a study on it, but I would venture a guess that um that those are mostly people that are you know a little later in their career, and as they do exit the workforce, which we do know that there's a uh tremendous, there's gonna be a tremendous need for new surgeons coming in the next you know decade or two here, um you'll you may see those open numbers drop off even more dramatically, just because you have some people that were they were not choosing, they didn't want to ever go to the minimum invasive, right? That wasn't like a consideration. And so it's it's gonna be a really interesting thing to see what those numbers continue to do. Um, obviously market pressures put are kind of interesting too. Um, you know, in the United States, uh a lot of people want the the newest and best. Um you know, and and a lot of people are are uh even even to the point of wanting things that necessarily haven't been tried you know extensively or studied extensively, they still want like the newest technology. Um and and so that there are definitely pressures as far as as your own practice growth and things when it comes to to those types of decisions. Nobody, I don't think anybody can realistically deny that that um that medicine in the United States is a service industry, whether it's right or wrong, there's a uh definitely a massive component of it that is uh is definitively service industry type, uh, you know, ideal driven. Um so it's gonna be really it's gonna be really interesting. Going back to your to your research, what's the uh if you had to choose one or two of your papers that you've that you have been a part of or published that you feel like were the one the two that you were the most hang your hat on, which one which ones would those be? It's difficult. It's like it's like choosing you between your kids, you know. That's why I only have two. That way I can just say like That these are my two favorites. Um, I'm I'm proud of one uh we published in so in surgery journal. Um we use the ACHQC database, uh, which also is like very uh interesting because we have like uh uh large number of patients and we compare like open lab and robotic uh ingern repairs, um doing the propensity score matching. And we got to publish in surgery journal a couple years ago. And this paper I also got an award like in residency, like in the hospital. Like in January, you'll submit your your papers, uh, and then the hospital picks like a few, like and give an award and stuff. So I'll say this, I was I was proud of this um of these um of this paper. Yeah. Yeah. Do you think that using the registries, like the large, large patient cohorts, do you think there's an an inherent bias with the number, with the types of surgeons that are submitting their data to those to those registries that may not represent the average, uh may not be necessarily representative of many of the average surgeons that are performing the same procedures? Absolutely. Um first, um surgeons that are sending submitting their data, they are uh interested in in the kernel in this case. Um also the surgeon is submitting his data. So this is another bias, right? Because he's the one submitting his own data to the correct to the uh to the platform to the registry. So I think it you can't uh assume that this is like, oh, you have all these numbers and this is the practice in the United States. And no, it's because it reflects the practice of these people who are interested in hernias, who are submitting their data to the um to the to the registry. That being said, also you have a large number of patients. Um so as long as you recognize the limitations of your uh study, and I feel like the Achilles heel for hernial research is uh also like it's difficult to get follow-up, like long follow-up for these patients. Uh the patient he comes back once to your clinic, he's doing well, he never comes back. Uh he comes back if there's a problem. Um so it's difficult to have like, unless they are part of a clinical trial, you know, that they have to come back in a year, two years, five years, but then do you have what we call the attrition bias, uh, which is basically when you you lose this patient's like to follow up. Yes. There's a joke uh that I tell people like there's like you you are in the in an MM, and then the surgeon say, you know, all my umbolical hernia, uh they do fine. I have no recurrences. And then the other surgeon is like, yeah, your recurrences come to me. Yeah, because you you don't know. Like, let's say you have uh, oh, the follow-up was like um a one-year follow-up is like 70%, and the recurrence rate is like five percent. Okay, what happened to the 30% that didn't come come back? Yeah, you don't know. So you don't truly know the recurrence rate because you don't know what happened to these patients. Yeah, um, so you have this um, but you need to recognize this bias. You need to take with a grain of salt the doubt the data that you that you are uh reading and interpreting. Um the same thing, like I do a bunch of like systematic reviews and meta-analysis, because since we have this large group, um they can't have access to the hospital data. It's uh it's HIPAA protection. We you can't they can't have access. There are most of them in Brazil. So what we can do is like we do projects with AI, we do we do projects with um uh systematic reviews and meta-analysis. Um and you know, um it's it's for for systematic reviews of meta-analysis. They say, oh, it's the top of the pyramid for the uh evidence, right? Like you know, remember the triangle that they have in all the epidemiology books, they have this several different colors and at the very, very bottom is Dr. Elms' opinion. That's like the that's the basement. That's the basement of the pyramid. But like it depends on the data that you put in together. Um it's if you put it garbage in, garbage out, you know, it's not because you have 10 different papers that you're gonna make a huge, uh beautiful systematic review of meta-analysis. Depends on the data that you are putting there. Um, if you have one paper, it's like you want to make an apple pie. If one of the apples is not good, the pie is not gonna be good. It's the same thing with the with this with um these papers, these papers. And I see like the literature, uh, you know, with internet and everything, all journals going um digital and everything, the number of papers published uh every year is like just growing and growing and growing. Um and like it's difficult to find um we try our best to answer our questions, right? We have a question, we try to answer. Sometimes you don't like the answer. Um, but like uh when you talk to people, there's a um there's a saying, a saying, a quote that is like, oh, uh in God we trust, all the others uh should bring data. Um right, and then like uh so you you need to be so that's why I try talking to the students, like you need to learn to to interpret the data, is to interpret these studies to so you are not full because statistics can give you the answer that you want. Yes, you know, like they can play with statistics until you get the answer that you want. Um, so like in the um, so we try to we have a clear question. Like I usually I'm in a conference, like we have we have uh stages coming up. So I sit in my computer. If if if if you're there, I'm gonna be like in my computer, watching the hernia uh session and looking for you know questions and stuff based on what I'm listening from uh um from the talks. And um so we try to answer our questions. Sometimes the answer we may or may not answer, uh, get an answer for our questions. Yeah, and we may get an answer that we're not expecting. And I like the those are the answers that I like. The one that's like the unexpected one, you know. Um to give you one example, uh doing a study looking, you know, these uh oh, the mesh overlap. It's five centimeters. People say, like, not everybody obviously, but a lot of people, this comes from the even from a paper from uh LeBlanc did a meta-analysis like years and years ago. Uh oh, it's five centimeters in every direction. And then, like, okay, let's study this. And we we got the data, we look at the data, and we found that the bigger the the the overlap does not necessarily decrease the odds of recurrence, but increase the odds of uh wound morbidity. You know, so like when you look at this, that that's interesting, right? Um so uh we try our best um to you know, we have a clear question, we have our uh we try to look to do uh to get studies that we can't pile together for um systematic review. Sometimes you you can't do a meta-analysis, and that's fine. You can do a really good review of that topic without doing because people are like, oh, it has to be a meta-analysis. It has to no no, because if the intervention is different in these studies, even they are the same topic, but the intervention is different, you can't put them all together because it's different interventions. Uh so the heterogeneity of these studies is gonna be really high, and then you're not gonna have a good study at the end. Um, so so we do these studies, but uh we try our best, uh, and I try my best like to talk to the students and tell them like the the right thing to do, you know. Like uh they all come with this mentality that oh meta-analysis is the is a no, let's do a meta-analysis. And I was like, first, you know that meta-analysis is a statistical two, it's not a it's not a type of study, it's a two. The study is a systematic review. If you're gonna do a meta-analysis of that systematic review, you can or you you will, you will, or you won't. Depends on uh if the studies can be combined uh and and make sense to do um to do a meta-analysis. Um but the last few years, like going to conferences and presenting, I feel like there's an interest more about like what you've been doing, how you're treating your patients, your patients, your hospital, you know, your your management, not whatever is out there, just what what you've been doing. Um like the pre-operative optimization of patients, you know. So even like when I'm we're seeing questions and everything, like in conferences, like people are very curious curious about what people how people are managing their patients. Yes. Uh, not just about uh and their outcomes, not just about the the you know, this the the big data or the systematic reviews uh and meta-analysis. Um I I I do a bunch of them, I like them. Um it's a way of of also like helping uh people like to get uh to get publications and all. Um and um well like like like I like I said before, like I we can publish like and keep publishing and keep publishing. And uh, but at the end of the day, it's like we have to be humble and see that we need to develop our surgical skills and clinical skills to deal with patients because we're surgeons. Um and um research is something that is like in my blood. Um never gonna stop doing it. I think like um when I finish uh training, I'll go to like an academic center, you know, and um that's that's my plan before retiring in Japan, which is like my final plan. Um but um but that's how I how I see uh research. Also, like every ever every type of study has their limitations. Like Dod Hanford likes he likes to say that clinical tribes uh randomize, control, clinical trifft it's too controlled, like it doesn't uh translate real life. That that you know, so like every every study is gonna have uh limitations. You just need to acknowledge, you need to read, know how to interpret these studies, and take whatever you you you you can uh from these studies. From a very scientific method standpoint, you know, the scientific method would suggest that even uh a null hypothesis or you know, not find finding something doesn't matter is equally as important as finding something that does, just from a pure scientific method. Do you think that there's an inherent bias within with what with publications and what journals will be willing to put out there against what you would consider as like these null hypotheses where the findings are not necessarily as sexy as as like something that does show significance in a in an unexpected way? Do you feel like that that that there's kind of a that we we lose some of the pure scientific aspect of what we do with the inability of those journal of the of like kind of like I guess just not necessarily focusing as much on the the negative outcomes or the negative findings as opposed to just positives? Yeah, there's a publication bias, like uh journals want to publish like papers that have a difference um that show like statistical difference and stuff and all. Uh I when when I'm when I'm working with my team and they find no difference and they are like sad, it's like look, to not have a difference is also an outcome, also a result, you know, it's as important as finding one. And sometimes you will find one that is statistically significant, but it's clinically not significant. That's irrelevant, yeah. You know, so like if you have uh let's say uh inguinal hernial robotic versus laparoscopic study, and you find you have like thousands of patients, and you find like a P less than 0.05, but like recurrence rate at one year is like one is 4.8, the other one is like 5%. Right. There's no difference. You know, clinically, there's no difference. You only found a statistically significant difference because your power, because the sample is too large. Right. But you need to be careful when you interpret this uh this data. I I I I think I have a couple papers on like uh that we are talking about the p-values, and um um like if you if statisticians they they they hate it, they hate the p-values uh because of because of that. And um, because the the history of the p-values is kind of uh interesting. I read a book on the history of that statistics, it's called a lady drinking tea or something. I don't remember the title in Portuguese, but the book was in Portuguese. But they they they talk about it. There's a lot of gossip on the on the and and rivalry in the early like uh 20th century uh statisticians, you know, and um very interesting stories. You know, the you know this test the student tea test? Yeah, so nobody ever asked themselves why someone is called a student, right? So the guy used to work in a beer company in the in in the UK, and the company was afraid that people would leak the the the formula for the for the beer, you know, so the can the chemistries and stuff. So he started publishing his studies under the name student. That's why we have the student the t test. But he has you know it's very interesting, but people they don't ask why why this person has this name, right? You know, and uh why why is the P lower than 0.05? What's the story behind what is the you have to ask these questions. Uh don't don't just accept, like ask these questions, uh, and the answer may be very uh interesting, actually. Well, it's it's there's also a level of of you talk about the the fun the study showing one thing, but it not necessarily being as clinically significant as the study would suggest. When we talk about like risk ratios or odds ratios, and you say, you know, it's twice as likely to recur. And then you talk to a patient and you say, well, it's a 2% chance versus a 4% chance. You know, and then in the pay to the patient, that 2%, they don't care, right? And so you and it's really interesting because we with the way that we counsel patients, we I think that we need to be very cautious with the way we talk about studies. One, because you can get kind of deep into this jargon and and that they don't you gotta make sure that you're not you know getting so deep in the woods of of what you what you know and you're an expert in that you may be like not explaining it well. But also the way we present things, it leads our patients to conclusions that we want there. Like I tell residents all the time, you can consent somebody in or out of any procedure you want, right? If I go in there and I say, you know, yeah, there's really low chance of you having any kind of complication that these things can happen, you know, and you talk about them individually, but you know, most people do very, very well. Or if you go in there and be like, you could die, right? People can die under anesthesia, you know, we could hurt we could harm you irreparably. Like that if you don't give context to the discussion, then you're you can kind of manipulate the situation into whatever you really want the outcome to be as far as their decision. I think that the same thing kind of goes with the way we present some of the data. And I think that one of the things that I have found is there were there were studies or there were studies or there were uh you know kind of like surgical dogma that was presented to me even when I was a resident, and I knew, you know, it's twice as likely to come back or twice or three times as likely as this. And then I remember sometimes like I actually got back to the original like literature and I'm going, that's that's like infant, that's like minuscule difference when it comes to the actual thing. And so we were talking about like, you know, you drop the ratio if you put in a piece of mesh in somebody with a 1.5 centimeter hernia, that 1.5 to 2 range, right? Uh and you know, you know, it lowers the it lowers the risk of recurrence. Well, yeah. But it also has other risks associate with that. And in most patients, if you really talk to them about the you know, the definitive actual numeric values, uh, in my experience, when you actually present that, the patients actually many times will choose, you know, a primary repair over a mesh-based repair, understanding that it may be slightly higher risk. But it's all in how you present it, you know, and I think that that that goes back to some of the art of medicine and um and being able to kind of, you know, physicians in many cases are are really kind of advocates for science in the fact that we're we're bridging a gap between the basic sciences of what we all know, because at the bay at our most basic, we are scientists and educating the public that are not experts in what we are experts in, but how you but trying to you know give them a level of expertise that they're able to make a good decision for themselves. And it's kind of our job is kind of very interesting in the fact that we we're kind of a bridge for that gap. And it's something that I don't know that we focus as um specifically on as we should. Yeah, no, no, I I I I completely agree. And there's another thing that we call the MCID, which is like the minimal clinical like difference to make a make a difference in the patient's life. Yeah. Uh and we we see that with the pain scores. Um if uh pain scores one to ten, like the difference, if there is a difference of one point, this is the MCID, like to for the patient to clinically see a difference, like to feel better. Um, so you need to when you read these studies, like you need to be aware of of that. I I think I reviewed a paper recently that they included this, and I was like, kudos to the authors for including this information because not everybody will do it, you know. Right. Well, uh yeah, I mean it's just it that's the the level of detail that you can get into to do research well is well beyond the scope of you know normal physicians in many cases, you know, and and you as being one of the experts, I would say, you know, one of the experts in this, or you know, is there any resources that you have or that you would that you would recommend for people who are trying to get you know bring themselves up to speed on how to do this effectively? Um yeah, like um if people if they know nothing, right? Like um and they want to I obviously like I I I I have a course I would say like do my course sure enroll in my course. Like we do have a clinical research course. Um I have a systematic reviews of meta-analysis uh course like in English, and I have a whole research, uh clinical research course in Portuguese. Um but let's say someone, even like oh Diego, I don't wanna, you know, I just want another uh course, whatever. There are there are courses that you can find like uh even for free, like in the Coursera, uh, you know, like on systematic reviews and other uh types of uh study. Like if you if you want to um like uh Cochrane uh has also like good uh material, like either they have like books, they have courses, they have all that stuff. But like depends on your interest. Like even YouTube, you know, go into YouTube and like uh sometimes I don't know something, like uh, oh, I don't know how to do like uh network meta-analysis, and then okay, let's let me look on YouTube and see what I can find. Uh and then you have like a one-hour lecture from someone in some university, right? Uh you know, uh, and then like sometimes I I don't have time for that, all that. Right. Uh but like you you can find like when I was a medical student, like there was nothing. There's no YouTube, there's no nothing, you know, and like we have access to information that we never had before right now. Um and um so it's it's pretty cool. Like you can find a lot of stuff like online. You know, I love the lectures from Johan Renaud from uh Franz. Like he he he he draws like with shock and everything, and it's on YouTube. You can you can look so sometimes I I I'm overnight, I have a medical student with me, and I show like a video from him drawing or a video from Nicole or Mausher or someone, and they are like, Oh my god, this is so cool, this is awesome, you know. Uh in it's all on the internet now, yeah. You know, and so uh this is uh this is pretty pretty cool, and I also recommended the podcast to them. I appreciate that. I also recommending the podcast for everybody. Uh but like it it's pretty cool the access that we have to to information uh nowadays. Well, if they want it, if someone wants to take your course, where they find that. Um they can find me like on Instagram. Uh we have the Clinical Research Academy like page on Instagram, um, or like my Instagram, like D uh D Laurentino. It it's funny because Laurentino is my middle name. Um but in Brazil everybody knew me by Laurentino. Um but like it's difficult to to say like Laurentino like here or in Japan, so it's just Lima, it's easier to ex Lima. Which is like actually my last name is Lima from my my my dad's um uh my my my dad's family and the the the funny thing is that my wife she's so close to my mother's family and when we got married and she had she she wanted she wanted to take my name um and then she was like I don't know which one should I take and I said I don't know Raquel and then she got she got both she got both um and um yeah so that that's where we have our courses um and uh people can find me like on LinkedIn I'm very very active as well and I see social media as a way to spread uh science um I I don't want to for people to think that oh this guy is always like showing this on on um on social media and stuff this is like to spread science um to spread like our papers um to also uh recognize the work from our uh people like the the students working uh with us uh because they are working really hard they they I'm very proud of them like the other day I was in the hospital and this attendant came to me oh Diego congratulations for these papers blah blah blah I said look I have a team it's not just me like these kids they work like really hard you know and like they like I'm talking to you and they are like uh sending me emails and texting and like you know getting getting getting the job done yeah um and like um there's uh uh something very uh famous from Joe Coaling he says like discipline is freedom and that's true if you're disciplined today and get everything done today in the future you have the freedom to choose whatever you want to do. That's true. So like and I try to to translate this um to them um and I'm I'm I'm very happy um for everything that they've been uh achieving uh we we have um we we we we've been working really hard and um and and I'm I'm very proud of of these students you know I can see their personal um growth uh over over the years and this makes me um very happy. Yeah well it's you know obviously it's uh it's impressive the work that you and your team do and and um you know again we I very much appreciate your support of the podcast and and of what we're doing here and I've been very much looking forward to to having a conversation with you and you know now as as we wrap up you know a podcast I always give everybody their opportunity to give their their hernia hot take so this is uh Diego Lima's hernia hot take what I think is like um for the few next few years uh it's kind of it's it's gonna sound like a cliche I think like it's AI right it's everything about AI and um people keep saying oh AI is gonna take your job no someone using AI better than you is gonna you know uh so we we all have to incorporate AI in in in our lives um I'm not saying for us to like use AI like to substitute our uh thinking our critical thinking but like to help us some somehow you know like AI can can help us like uh with like oh I'm I'm I'm not a native uh English native speaker so oh can I get AI to just look at the grammar for something for me you know like for an abstract or for you know um so these minor things can help can help you uh a lot um like surgery what what I think is like that AI will be able to help us in the near future like to with imaging right like uh you're doing your your robotic immunogernia and AI can identify the structure for you help you you know oh this is the vast deaf this is this is the nerve this is you know can help identify this uh there are already papers on this um with AI trying to oh uh let's say has the collectystectomy uh project going on if they finish um but like they were getting like videos from um uh the whole world like on uh lap callies um like you you can do like the critical view of safety using AI or like for hernias you can do the critical view of the Meopactino orifice and and everything in the near future uh so I think like AI is the is the next uh it's I would say it's my hot it's kind of cliche all right like AI everybody's talking about AI you know like there's a meme that I love like what you see yourself in five years and then there's this uh picture of like um the the the guy from Terminator like corner of like you know like with a gun like shooting like robots but but I think I think it's uh AI is gonna be something that um the next like few years we're gonna be using way more than we are already uh doing it. Yeah I mean it's it it may be cliche but it's probably also true. And so you know I mean everything everything is moving in that in that direction and and obviously we've already in our practice we've already incorporated ai into our uh you know visits with our patients and helping us with documentation and things and that that has actually been um a very uh refreshing use of AI that it's allowed us to to really get back to having just a human discussion with somebody instead of frantically like taking notes and so that has been something that's been very helpful and it's also allowed us a lot less time documenting that allows you to get that recharge and really kind of prevents the burnout that we were talking about before. But yeah no I think that's a that's a very timely and um and uh probably very true um hot take so I sure appreciate you giving that but again so so happy to have you on um really you know appreciate you taking the time I know that uh with everything that you're doing and then also uh wrapping up another residency here that you time is is of the essence and so we really appreciate you taking the time to come talk to us. No thank you so much it's it's an honor for me like I see all the people that you have here and I'm not even close to them. Like I'm I'm I'm I'm a resident and um it it's an honor to be here talking to you and like uh I I'm always listening to the to to the podcast. I used to have one years ago and then I it's pretty cool like I I I listen to podcasts all the time you know like uh in Brazil I just stopped the ones talking about politics because it was giving me like some population you know yeah so just like but it's it's it's pretty cool like I I I I I don't really watch like normal regular TV anymore. If I put in YouTube and watch like the podcast with the people that you know so it's something that I I really like and um it's such an honor to be here um talking to you I just see the people that you had here and I was like oh my god this they're they're so awesome and it's it's it's incredible. Yeah you know it's it's funny I've I have had obviously a very it's been an extreme honor for me as well to get the opportunity to talk to people that I that I admire so much uh professionally and even and personally um but the the beautiful thing that I think the the one of the biggest purposes of the podcast and and what I have come to realize even more having spoken to them is that we're all just mere mortals and that we're it's a it's a very you know the you know it's just a very um humbling profession we're in. It's an honor to do it. Um it doesn't mean that it's not difficult and um and the the experiences of of uh the person that you know has never been heard of before but it's doing good work out in the community uh is very similar to the people that have their names on everything. And and that is the the unifying factor is the fact that we're all just you know mere mortals uh practicing uh praying to the herning of gods hoping that they give us give us the best outcome for our patients so again we uh you know uh Diego we really do appreciate you coming on it's been a it's been a great uh conversation and and hope to have it have you on again soon no thank thank you so much uh it's an honor to be here and just just let me know all right well hopefully next time we're we we talk you're you're in the middle of a nice abdominal wall fellowship so for all those for all those listening he's he's on the market so come get him so thank you thank you so much this will wrap up another episode of the Hernia Gods podcast it's your Mirmortal host Luke signing off thank you so much thank you