The Hernia Gods Podcast E23 - Michael J. Rosen, MD

Episode 23 of The Hernia Gods Podcast with Michael J. Rosen, MD features a candid conversation about mentorship, complications, the ACHQC, and his thoughts on the surgery community's relationship with industry.

Transcript

SPEAKER_00 0:06

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

SPEAKER_02 0:35

Thank you so much for having me. It's a pleasure to be here.

SPEAKER_00 0:38

Well, um, you know, sometimes sometimes we have uh episodes where we try to put a spotlight on surgeons that nobody knows. And so hopefully this is your chance to get your name out there to where to where the public knows who you are.

SPEAKER_02 0:51

If I can go back to nobody knows me, I'd happily go there. I I want to like I want to kick us off by saying, Luke, I'm a mere mortal too. And you should never forget, we're all mortals.

SPEAKER_00 1:03

Exactly. That well, that's that's the point, despite what some people say in the comments. I'm not just a raging narcissist, quite the quite the opposite.

SPEAKER_01 1:11

I've got to get some of those comments too. So you gotta be able to brush that stuff off.

SPEAKER_00 1:15

Yeah. Well, as we start every episode, uh, I wanted to just uh give you a chance to tell us you know who you are, uh how you got where you are, and and where you come from.

SPEAKER_02 1:26

Sure, sure. So well, listen, I I think probably who I am, you have to start from the beginning to understand Mike Rosen. And so um I would say who I am at my core is a middle child. Uh so so I'm a middle child. Um, and I kind of I I grew up in Atlanta. My dad was a general surgeon. Uh he's a private practice general surgeon, solo private practice general surgeon. I I kind of always thought he worked too hard, and I would never want to be a general surgeon. So I went off to college uh in Vanderbilt to be a lawyer, and then uh I found out that I hated to write, which is interesting because that's a fair amount of what I do right now, but but I hated it, I didn't like it, and I kind of drifted over a little bit more to the sciences, and um I thought I wanted to be uh, which was kind of my dream job, uh, was to be a biologist and be a high school biology teacher and a high school basketball coach, uh, which was kind of my plan. And I throughout college to kind of do that, I traveled most of the time to uh Baja and South, kind of the southwest of the U.S. And I was in a place called Bahia de Los Angeles, if you guys have ever heard of that. If you look at the Baja Coast, it's halfway down the Baja Coast on the Sea of Cortez side. I mean, it's in the absolute middle of nowhere. And we used to go out on the islands and we studied the migration patterns of black widows, spiders, and scorpions. Whoa. And it sounds pretty cool. Um, and it actually kind of helped formulate my idea of science. But but what we basically did was uh in Baja, uh there's these cactus on the mainland and then cactus on these islands that could be like 50 feet offshore to 15 miles offshore. And a cactus on the mainland would have one black widow spider and one scorpion, and then a cactus on the on one of the islands would have 50 black widow spiders and a hundred scorpions. And so our job was to study. We would go out and collect them, we would we would kind of bring them back to the lab, we would understand the genetics and where they came from and why they migrated that way. And so it was beautiful. I spent all my summers out there, we would go out on boats, we would fish, we would camp on the islands, it was absolutely incredible. And so I always tell the story when I give grand rounds, is that um so I asked my professor, you know, kind of towards the end of my time, I'm like, hey, Dr. Paulis, like when do we get the answer? Like, like when do we know that we figured out the migration patterns? And and he was like, Mike, you idiot. We'll never find that out. Because if we figure that out, we can't come back here. So so so that that taught me about uh good science, ask more questions than it answers, and and um and and so anyway, so I finished all that, and then kind of towards the end of my time I decided I wanted to go to medical school. I I kind of volunteered in the burns room, and and I really thought it was exciting, and I'm like, funniest thing ever, because if you made me work in the burns room right now, I probably quit. Um so so, anyways, then I decided to go to medical school, but I had this uh offer to go with my professor to um Africa to study uh in the Gabi Desert, the same thing, the migration patterns of this uh black widow spiders and scorpions. And so I I had that, so I actually got to defer medical school for a year. So I actually got in and they let me defer it. I I I encourage all young people um take a year off for medical school. My daughter's a fourth-year medical student right now, she's about to graduate. She took a year off. I I think take a year off if you can do it and and don't work in somebody's stupid lab or do ridiculous medical things, go off and see the world and become a kind of an interesting person and learn what's out there. So I traveled. I went with a buddy of mine because it was like a three-month block where I was gonna be able to do that. And I went with a buddy of mine, and we went uh through South Pacific, New Zealand, Australia, traveled all over the place, and he left. I went to Africa, and I spent three months, and it's like it's a place called Namibia. It was called it was called Southwest Africa at the time because it was part of South Africa. And I was there, this was like um maybe like November, maybe like November, December-ish in 1992. Um, and I after I finished that, I took three months, and I I had uh a truck that I drove all throughout Southern Africa by myself, which is like kind of hard to imagine nowadays. We didn't have cell phones, we didn't have anything. And I I drove and I was actually um just randomly in Cape Town, uh, South Africa, in a shantytown by myself the day the departheid ended, uh, which was like this like magical thing that like just completely randomly, like it's the only place I've ever been in my life where nobody knew my accent because Americans just did not go there. So that was pretty spectacular. I was in Cape Town, I went to Zimbabwe, I did all that stuff, and then I came back um and uh I had six months off. So I moved to Vale, Colorado with a fraternity brother of mine, and I actually slept under his kitchen in uh East Vale uh in his condo. And I like maybe my second week out there, I met who was my wife now for 30 years. Um she was a ski instructor in Vale. I did not know how to ski. Um, and kind of she taught me how to ski, which was hard for me. Uh but but but uh but that's kind of that's my skiing story. Then I went off to medical school uh at the University of Southern California, and and you know, I went there initially wanted to be an orthopedic surgeon, um, but at the time there at least, and I probably would have loved being an orthopedic surgeon too, but at the time I I went into the the trauma group was just incredible. Uh when you look at some of the people who came out of there at that time, it was really unreal. It was just an awesome group of people. We would like to be up all night operating, then we would go play basketball the next day together, kill each other. It was just like such a great kind of vibe and a group to be with. So I thought, all right, I want to be a general surgeon. So then I did my um training at Mass General, which was a great experience, and I think probably has a reputation that it's not really accurate. It was really great people, great teachers, uh just an incredible group cohort that I went through with. And when I think about how successful they are right now, but really it was just an awesome experience. I would say my wife did not love it. Uh this was like pre-80-hour work week, which is like we work like 120 hours. I mean, it was busy. And and and then I went, and so this was kind of transformative for me. I went um and spent, I was gonna go in the lab, I was gonna actually work in David Ratner's lab, and he happened to be the visiting professor at Cleveland Clinic, like the the weekend before I was gonna do it on Monday, signed the deal with him. And he came back, and I mean truthfully, like a lot of my success in my life is the people I've worked with and my mentors, and like at times being stupid and not listening to them, but at lucky moments being smart enough to like listen to the advice and and take that advice, which is sometimes hard. Um, but anyways, he came back, he's like, Mike, you gotta go to Cleveland. Like, they got so much great stuff going on, it's incredible. So I was like, uh so actually, my dad, who's a general surgeon, trained at Case Western. And you know, this was like back in the 70s, and like absolutely hated it there. It was like Cleveland's the worst place, the lake caught on fire, like it was terrible. And so I was like, I'm not going to Cleveland, forget it. And he's like, Well, you gotta think about it. And my wife um was she went to Ohio State and she's from Chicago, actually, where I'm at now. And so she was like, I wish you go check it out. Um, and yeah, we were, I think she was pregnant with my first child at that time, so we knew we kind of wanted to be closer to home. So I was like, all right, I'll go, I'll go out there. And um, so I met Jeff Posky, who's probably like one of the most influential people. And if we tell stories today, as I'm sure we will, uh, he's probably the most responsible for like my career and just really incredible mentorship on family, academics, surgery life, like everything. I mean, to me, that's what really makes people is your mentor. So I worked with him for two years and just kind of was like blown away by all the minimally evasive stuff. It was like a magical moment in Cleveland. They had all these resources, all this money, and I just like really got excited by it and then came back, finished my residency, and then I did my fellowship with Todd Henneford, which was another like transformative moment for me. And again, I would say for every young surgeon out there, you know, there's probably like three people you hear in your ear while you're operating as a as a attendant. Young, old, doesn't matter. And you know, like I hear Todd's voice in my ear. Sometimes I wake up in the middle of the night sweating, hysterical, and having an anxiety attack because of Todd. It took me like 10 years to get over that. But but he, I mean, truly to his credit, like I think he, number one, I mean, on a personal level, he taught me how to be a better surgeon, as well as Ken Kircher, his partner. Like, they I kind of graduated my residency definitely thinking I was the man. I mean, there's no question about it. Uh, and then I went out there and I realized, like, wow, there's a there's another level to this stuff. And those guys were just unbelievable surgeons, unbelievable doctors, clinicians, like took care of patients, cared, like wanted to be great. So, so he was transformative. And I I would say, I mean, on this podcast, really think about like I when I think about like leaders and leadership and things like that, I think the only real way to measure that is like look at their wake and like what comes behind them. And I think Todd is, I mean, it's unbelievable. He's he has created this field. Um, and and so funny enough, I finished my fellowship there. And I the last thing I said was, this is the last damn hernia I will ever fix. And that's actually, I like to tell that story because like I think it's so key. People don't know what they're really gonna do. So when I I went there because I wanted to learn minimum invasive surgery because 20 whatever years ago or so, my goal for myself was to be a um laparoscopic liver surgeon. And and I had that goal because I had done a lot of uh hepatobiliary surgery in my residency, and I was really comfortable with that. And there was no minimally invasive liver surgeons at the time. I mean, really, it was a field that didn't exist. So I knew how to do all the open stuff from residency, and I wanted to go learn all the laparoscopic kind of skills from Todd. And we did everything, I mean, the laparoscopic stuff there was unbelievable. Um but when I came back, and I came back, so so what happened was Jeff Ponsky started as the chair at University Hospitals in Case. And I was his first recruit, and I kind of went there because I wanted to watch somebody build a department and learn how to lead and do all that stuff. So I mean that that kind of moment in time for me was absolutely transformative, just watching him kind of going through your own like young surgeon struggles of being an idiot, like you know, uh being insecure and not being an adult and not understanding the bigger picture, like all that stupid stuff that many people kind of falter with. I went through a factor of 10. And um, and I I I'll just tell you a funny story real quick. Um so I remember I went to Jeff and I was really pissed that I wasn't one of my partners was sending the adrenals to somebody else. And I was like, I mean, what the heck? Like, they're sending to another division. Like, I've done more adrenals than anybody. Like, I just finished this fellowship. Like, come on. Like, why am I not getting adrenals? I'm like, okay, I hear you. He's like, so I just want to know what number of adrenals does it take to make Mike Rosen happy and get out of my office. Like, if this is your only goal in life, you tell me, is it three, is it five, is it nine? I'll make sure you get those. Then I want to hear back from you because if that's your goal, we're gonna achieve that one goal and you be quiet. And I was like, all right, whatever. I'm an idiot, I understand, yeah, move on with my life. So it's like that's kind of that's the kind of mentoring I need. It's like when it's fourth and one in your own five-yard line, you you must punt. Um, so so, anyways, I went, uh I spent like nine or ten years there, and then we all moved to Cleveland Clinic, and that's how these kind of places work is they go every 10 years, everybody switches and gets pissed off at the administration. And then I spent 10 years at Cleveland Clinic, kind of built up a great team, great people, kind of accomplished all my goals. Um, really kind of transition. That was kind of my transition away from kind of focusing on like me and really thinking more about the team and the people and everything, which has been probably the most rewarding part. And then I kind of accomplished everything there, and now I'm at Northwestern, and I've been here a little, well, about like 15 months, and uh it's been wonderful. Chicago's unbelievable. All my kids are out of the house. It's my wife and I, my daughter lives right down the street. Uh, my wife, I said, is from Chicago. Um and so so here I am.

unknown 15:26

Yeah.

SPEAKER_02 15:27

Still fixing hernias. I do a little more bread and butter stuff, but but still got the kind of disaster stuff, and uh building up a division and GI surgery, which has been kind of really rewarding and exciting, and just work with an awesome team. So that's a long answer.

SPEAKER_00 15:42

Oh no, that's well, that's exactly the answer we want on this podcast. So uh feel free to keep it up. Um it's so funny. You've there are you you know, I don't I don't I I'll be a little behind the scenes. I actually don't prepare very much at all for these because I don't want to come in with like a preconceived bias about where to drive the conversation or anything. So a lot of stuff that you were talking about, I I knew a little bit about it. But for instance, um one of the things I did know is that you did scorpion research. You can thank uh Charlotte for that. But um, but uh you talk about wanting to grow up uh when you were young and wanting to be a high school basketball coach and a biology teacher. That's exactly what I wanted, what I thought I was gonna be. Um that's awesome.

SPEAKER_02 16:21

Well, you know, it's funny. I I tell you, I think um I think this is one of the biggest mistakes that a lot of young people make is they think that the title affects your ability to kind of be happy and be successful. And I often tell people, I'm sure I've read this, or maybe one of my mentors told me this, but there are many, many times that if you can kind of pull back and look at it with, okay, I said I want to be a high school basketball coach, and I said I want to teach biology. And you kind of dig a little bit into it about like what exactly is it that made you want to coach high school basketball? What exactly is it that made you want to teach biology? And are you actually achieving those goals and what you're doing right now? Because I uh on a kind of professional level, I had written out my one, five, and ten year goals when I was like in the v. And it was basically centered around setting up a minimum invasive surgery center. Because I mean, at that time, I mean, like somewhat similar, and like this is the one thing like the world, this stuff just happens over and over again. We all think it's the new moment, but as you get older, you realize. So, like, like what's happening with robotics right now, it was mirror image of what's happen, what was happening with minimum invasive surgery right when I came out was that we need minimum invasive surgery centers, we've got to have all this stuff. It's all this input and all this excitement, and it was awesome. So I focused on that and kind of the referral base and all those things, and I wanted I it was really important to me because these were who my mentors were, and these were who I really like looked up to. I wanted a surgeon referral practice. Um I had written that down in one of my things, funny enough. Like I wanted people to send me pancreas and liver cases that surgeons felt like they couldn't do that I would take on minimally invasively. And so while I didn't achieve any of that and have had abiliary surgery, it's funny if you if you look at every single box, you know, I wanted to create a fellowship in minimally invasive liver surgery. Okay, but I didn't do that, but I did it with ad wall reconstruction. I wanted a national referral practice in livers and pancreas. Again, so I think a lot of times, and this is where you know it's funny, like people talk about mentoring, and I think in today's world, not universally, but just at a high level, and I mean I was guilty of this when I was younger too. People get confused with mentoring and hearing what you want to hear from an older person, right? Like, like I think like mentoring should be hard, it shouldn't be easy. Like it sometimes a mentor is telling you something that you disagree with, that you think that mentor is wrong, and they don't understand you, and they don't know your unique skill set, and they're missing the point. And I think it's very easy. I mean, I often look back at myself and think like I had this kind of instrumental conversation that changed my life with Jeff Ponsky, right? Like when he told me you should fix herans. Oh, I didn't tell that story, I'll tell it real quick. So, so actually, this is my story of like why I fixed hernians. Um, I told you that I want to do livers and whatnot. So when I got to uh UH, um within like a couple weeks, I I had a clinic with Jeff Ponsky. Um, and that, by the way, my advice to all young surgeons. Um, when you're young, when you're a chief resident, you want to be by yourself, right? They're gonna get on my OR, give me autonomy, like this stupid autonomy word that doesn't like what I think autonomy is, is not what residents think autonomy is. It's just a like terrible word in the dictionary that is just like jolting surgical education because like none of us really define it well, and it doesn't make a great surgeon. It it exposes bad surgeons and it exposes good surgeons. It's not the answer. But, anyways, um uh that's what you want. Like, get out of my OR, get out of my clinic, I'm a master. But when you're a young attending, you want some gray hair around you and you want some help, and you everything changes in one day, which which that right there should be defined for everybody. Yeah, like autonomy is not the answer because the minute you actually get it, you're like, I'll take some help, please. Um if you're safe and you should take that. So um, so and but but I would recommend having clinic with your chair. Not a lot of great things come out of that because they're not gonna give you the greatest cases, they're gonna you're gonna get the cases that they don't want to do. So, anyways, I was there, it's maybe like by the second or third week. I was literally sitting there, kind of wondering, like, why am I even getting paid to do this? I think I had like one medical. Like, I come from Henneford's Fellowship, where we were literally operating like mad, saying 50 patients a day. And um, and I was like, Stay there, Jeff Ponsky walks out of the room, and he is like smiling from ear to ear. And the medical student behind him, just he has his head down, his face looks ashy, and he's like, oh my God, the chief resident, she just looks like unhappy and like she's just seen something terrible. And he kind of came out and he goes right to me. He's like, Hey, Mike, I'm gonna teach you how to make an academic career. I'm like, all right, this guy's done everything in academics, I'm gonna listen. He's like, You gotta pick something that nobody wants to do, that we don't do very well, and you gotta try and make it better. And I'm like, all right, what is that? He's like, Your thing is hernius. I'm like, okay, I can do some lap angles and lap ventures on the side. Like, that's fine, but I'm not really gonna be doing livers. And then he gave me my first patient, and it was like this absolutely insane case where some woman had Had a J2 fallout. She had neck fast, she had tooth fistulas, reconstructed with polypropylene mass and skin graph. I mean, it was like horrific. It still ranks up. It's probably like one of the top five worst cases I've ever done. And I go and look in the literature and I'm like, all right, what do I do? Like, I just finished all this training. I'm the man, like, I love the literature. Like, there's not one thing written about this. Oh my gosh. And I'm thinking like, why has nobody written about this? And I learned my lesson. Nobody writes about this stuff because if you write about this stuff, people send you this stuff. And so I was like, I was like, I'm in. I'm in, I'm gonna go fix this lady. So it's it, and this is the other thing I'd like to talk about for young people. I mean, I was really well trained at that time. And what I did to that person is nothing like what I would do today. Um, I finished on my training, finished on my fellowship. I was a great surgeon. I mean, I might not have, you know, I thought I was the person. And I completely did the wrong stuff, but I learned along the way. And I think what what that taught me, and what I hope everybody gets, is that your residency is not about getting a playbook, right? It's not about this is what you need to do. It's about learning basic skill sets so that you can then go apply them and you can hopefully make things better and improve things. Because like everybody thinks we're like at the end, right? Like we thought laparoscopy is the end of the story. Clearly it's not. Robotics is the next story. Yeah, but there'll be something after robotics. There'll be AI. There'll be AI and robotics, there'll be micro robotics. Like the story will always, always go on. And so I I think it's easy to focus on the moment. It's more important to focus on like how are we doing this, what is the process, like like what can we do to make it better, and that type of stuff, which is sometimes hard to do in the moment. So, anyways, yeah.

SPEAKER_00 23:55

You know, you had you had two things that you talked about there. Um, one the one of which uh, well, three things really I want to touch on, and I can give you my opinions, and feel free to tell me if I'm completely off base. Um, one, I think that we choose our mentors incorrectly. Uh, I well, and this is from my experience. I chose my mentors incorrectly, not in the fact I chose the wrong people. I chose people that were absolutely worthy of being mentors, but the problem was I didn't have the awareness, the self-awareness to realize where they were in their career. Because you can have a mentor that you look up to, like a lot of people that would probably look at you, right? They want to if they want to become Mike Rosen, they've got to go through the process that made you Mike Rosen, right? And and they don't if so, if you think that you're gonna come out of training and you don't have the self-awareness to realize your kind of place in the world, you have this weird, why am I not, you know, this? So, like I came out of training wanting to do elective general surgery. That's what I wanted to do. That was what spoke to me. I actually don't mind the clinic, I actually enjoy it. I under I think the clinic that interaction is rewarding to me, as I know I'm a kind of an enigma, but um, and so I wanted to do that side. I came out wanting to do that and didn't realize the aspect of like paying your dues, going through the the just brutal call beatdown and and all that stuff that many people still have to go through to get to that point. And so whenever I was talking to my mentors, you talk about mentors not just telling you what you want to hear. Whenever I was I was talking to my mentors, they were telling me the things that I needed to hear that were not what I wanted to hear, but I didn't have the self-awareness to realize that it was applying to me. Right. You know what I mean? You know, I there's an episode I I watch It's Always Sunny in Philadelphia. There's an episode where two of the characters are talking to Charlie and they're like, listen, we don't need a wild card, and Charlie's like, yeah, yeah, that guy's crazy. And they're like, We're talking about you. Like, that's that I was Charlie in that situation. The second thing you talk about is like the difference in autonomy as you get out of get to the end of training. And one of the things that kind of always it is something I experienced significantly, and I've talked about it before, but the first time you go to cut a cystic duct in your first gallbladder, that's the most lonely feeling in the world. You're right, you're like, nobody's gonna stop me if I'm about to do something horrific right here. Like, there's nobody gonna be like, Are you sure? You know? And um, and so there are those those moments that you get out and go, Oh, this is a different game. Things I felt confident about a week ago, now it's a completely different scenario. And we talk about autonomy letting people operate, but one of the things is there's a difference between being able to get through a case and being able to get through a case well. And so getting through, you know, a standard outpatient gallbladder and having 150 cc's of blood loss and going, that's not very elegant, and probably need some refining of techniques and things. And sometimes people get a little bit annoyed about being what they would consider, you know, micromanaging the case when they're a chief. And I so I try to tell people, like, listen, I'm not saying you can't get to the case. I think you're gonna be fine. If you if the you were here by yourself, you'd get through it, the patient would recover. So, but let me just tell you like a couple of things that I've learned uh like over the years that have made these look a lot better, a lot good the cases progress a lot more smoothly for me. And so that's that was the that was really kind of the other thing that that you brought up that I was just like, yeah, that that applies to me.

SPEAKER_02 27:18

I would echo what you so what I call I call that survival surgery, right? Like, like the reality is most people, if you give them a knife, some sutures, and and a scissors, you can get through just about everything in a bogey, maybe, right? Like, like you can take out the pancreas, you can do a liver, you could do a boba, you can certainly do a hernia, you can do all that stuff. And I there is this battle, and again, I mean, look, uh, you want residents that want it. You want people that want to be great, right? Like this gets back to kind of being the basketball coach, right? Yeah. Like the, you know, like what is the joy that you get out of that? And and I kind of say that, you know, this is kind of where I think there's a bit of a fundamental breakdown in some of these types of things. And it's a little bit of, you know, what take the residents' perspective. Why do they want autonomy, right? Because they that that's what they feel like they're learning to be who they're gonna be. Now, you know, as an expert at this, that that's like telling somebody to go to the gym and practice bad technique. Right, the ball is still gonna go in sometimes. Like if you shoot with poor technique, the ball will go in. You will score if you work hard. Right, but you're not gonna be the best basketball player that you can be. And again, likewise, you know, the story of incredible basketball athletes that don't turn into great basketball players has been told many, many times because just like in surgery and medicine and life, right? Like people have a hard time taking coaching. There's a lot of people that like, uh it's not a good coach, right? That's not a good fit for me. Um, and and that's because they're hearing what they really need to hear, and they don't they don't want to hear that. So I think that and I mean I think there's a little bit in today's culture, and I don't blame the residents for this, it's just it's kind of how the world is. It's like if you don't like what you're hearing, you go hear something else. And it's become much, much easier to do that. So so I think you have to be hyper-aware of that. You gotta still be able to find a way to communicate with people where they can be at. But but again, I always tell people, I'm like, I mean, you know, if you're my fellow, I've got one year with you. Like, that's it, to impart everything I've learned. Like, I I know you can get through this on your own. I've got I want to make you do this to the best of your ability. Like, I I have to watch your movie, I have to comment. But I will say, this is one thing I've learned, actually, it's something that's really, I mean, I'm gonna do it monthly much easier just because of some technologic advances here that we didn't have in Cleveland, is um, and I'll liken this to coaching, and I would, and I'll give this to both any you know learner, like a resident or fellow, but also to uh to uh an attendee, is that um, you know, and this is a good parallel to coaching, you cannot really do a lot of coaching during the game, right? Yes, like during a basketball game, you're kind of somewhat, you're not you're not coaching technique, right? You're coaching the flow, you're coaching the approach, you're not coaching the minutia of the game. If you start to do that, you get into people's minds and they're not going to perform well. So I think that's the same thing is true for surgery, in that people are the learner is stressed, they're anxious. As you get older as an attending, and you more people want to impress you, maybe you have an impact on their job, their their how they feel, all this stuff, it gets harder and harder and harder for people to perform in that moment. Or not even not to perform, to learn in that moment. And so I here it's been awesome. All the laparoscopic and robotic cases, they're all recorded with I can't remember the name of the site. So I spend one hour. The way my my process here is I have one chief for every two months. And it's awesome. It's like an apprentice thing. They do everything with me. And uh, and I'm there's always like a bell-shaped curve or whatever, but still it's it's great to work with one person. And so we spend one hour a week reviewing the film of their choice, and that's where our like teaching part goes. That's where we can slow it down and say, look, when I tell you to pull this way, you see how you're not doing it. And it's a calm moment. And it's to me, it's always I always said, like, if you don't watch film on Monday in basketball, you will never get good. If you don't watch what you did in the game, sometimes it's embarrassing, sometimes it's uncomfortable, it's hard to do in front of the whole team. But like if you haven't, and like if you think about any sport that involves technical skill as they all do, if you aren't watching film, you are not getting better. And so I think taking the time, especially now with the robot, it's easy. Take the time to watch that film with the person who's teaching you and be open to that and do it in a kind of where the time doesn't matter, you're not trying to get to the next case, and and everybody's calm. Um, I I think that's something that I've done here. It was really hard to do in clinic because we couldn't really record stuff because of IP things and everything. So here it's been a huge advance. I don't know how many people like really take advantage of it, but you know, for me, again, going back, like I'd like to be a coach. Like, I want what what joy do I get out of the OR? Like you said too, by the way, like my favorite place nowadays, I love the clinic. Like the clinic as a surgeon is different than when you're a resident because it's people who you're establishing a relationship with, it's people who you made better, hopefully, or it's people who you didn't make better. Yeah, and you gotta kind of you know stay engaged and and and still be with them and kind of work through that with your patient. And so I I totally enjoyed clinic and that thing. In fact, there's kind of this thing now where we want, so I can see more new people. We want our APPs to see all the post-ops and the follow-ups. And I I I do that a little bit now, to be honest, because it's really hard to get into my clinic. But I do think that like you need to see your post-ops, or else this job kind of becomes hard because you don't really, I mean, you can forget why you are a surgeon. Like you, I I'm a big fan, big fan of, and I'm sure we'll dig into this more, but like I think if there's one thing I would tell you that everybody, every young person, every old person, every surgeon, if you want to have a long career that you can retire and feel happy about, make sure that the spotlight is on the patient at all times. Everything that you do when you take on something new, when you say you won't do something, when you won't refer someone, when you take on an operation, ask yourself, am I doing what's best for this patient? And if you are, you'll live a long, healthy, prosperous life. You won't always do what's best for patients. Sometimes what we do is hard and people get hurt. But but if you start from the start with, this is about the patients. It's not about me, it's not about what I can do, it's not about what I can build, it's not about my national priorities, all that type of stuff. Um, I think that's the key. Um and I'll I'll take one last thing. I don't want to forget to answer your the first part of your question, yeah, which is like, okay, mentoring and like people say they want to be like Mike Rosen. So let me just say this. Let me say this. Like, first of all, more than anything, um, you should always like if your goal is to be famous and kind of have that notoriety, just like step back for a minute and and like I would just self-reflect on that. And I to be honest, unfortunately, like I think there's a lot of that right now in her name surgery. I don't have a lot of perspective on everything else. I'm sure it's true everywhere. I I think there's a little bit of like the the the world that we live in right now is a much harder world than when I grew up. There's social media, there's the ability to be seen nationally while you're on your maturation phase. Yes. There's an ability to say things that won't go away that you say and you like I've always said, like I have adult kids now. So right, so when my kid texts or calls my wife and kind of like dumps their stuff on my wife, my kids are over in five minutes. They're done. My wife carries it with her for the next week and like and like absorbs that so so I I think that you know I didn't have to deal with that. I mean, for God's sakes, if there was social media when I was younger, I probably would be in jail. Like, I mean, I I'm I'm like I would not have been mature enough to handle social media. So this is not from a place of criticism. I couldn't do it, it's more of a place for sympathy. So, so so I think that kind of understanding that is key. And then again, for me, I I I did. I mean, my goal right, I wanted to have this practice where I could take on these basis to do this type of stuff. But there's another piece, there's kind of two pieces to this I think that are important. Is the other thing is there's just an incredible amount of luck, right? Like sometimes it's just the timing, and and I kind of credit anything that I have achieved to a certain extent, is I got lucky. There was like a magical moment in time where kind of complex that wall started taking off, biologic mesh became a big thing, and it kind of swept up this whole hernia thing, and I was just like at the right moment at the right time. And the only credit I'll give myself is I didn't just say, hey, I don't want to do this, I'm I'm doing liver surgery. Like I just like at least opened my mind to it. And after that, it was working hard, which which again, I feel like to me, it actually that's another like good little thing, is it's like um, you know, people find it hard. They're like, well, how do you do this? How do you find the time? And like I this always gets in this conversation of like work-life balance, and and I I if I could impart any other wisdom on people, I heard this great lecture, I can't remember the guy's name, but I took this like leadership development course when I got to Northwestern at Northwestern Kellogg, which was like incredible. This guy was the CEO of I can't remember what company right now, but he gave an incredible talk, and it really kind of resonated with me. He said what I would say in a much more elegant way, which was that the whole concept of work-life balance is bad. That's not a good concept because what that basically means is both things are pulling against each other, right? And it's like a it's like a fight, right? So it's and so often when you're at work, you're trying to balance your life. And when you're in your life, you're you're dealing with your work. So what he said is it should just be life balancing, right? And in life balancing, you have your five priorities. Like, what are they? Like they're they're basically come down to your job, your health exercise, family, um, you know, religious things, and and potentially some other hobby or whatever that is. I can't remember exactly the five things are. And then you just figure out what percentage you want, what what are your priorities, right? Like if family is your fifth priority, then so be it. But then don't complain if your family doesn't like you when you're 16 years old, right? If it's job is all you care about. If your family is what you care about and they're one or two, then make sure you carve out the time for them and be there. And that's that's the other part of this, is I think being present, being present at work and being present at home. And don't blur those lines. Doesn't matter what the mix-up is, it can be it's different for everybody. But but anyway, so so I I think that you know there are no shortcuts to long-term notoriety in something, right? Like there are no shortcuts. I think be honest, be true, um, be willing to withstand criticism, uh, keep your focus where it should be. And then my only other thing I would just say like my luck is I've had great partners who have done great things throughout my time, who are incredible people, who, if I have guided in any way or collaborated with any way, like I mean, a lot of it is their hard work and just kind of be able to get out of the way and let those people be great. I think that's that's how I got where I am. Um, it's not some magical thing. It's not some magical thing that like one day I just woke up with this thing. I was like, oh my God, this is it. So so I think that's if I could tell all young people, like just take a breath, like let it happen. It doesn't have to happen overnight. And and by the way, sometimes once it happened, you don't even like it. You're like, I don't, I don't, I don't enjoy this as much as I thought I would. Like, I I I mean I there's no question, I get much more joy out of spending time with my kids in the background, right? Like that's my joy. I love that.

SPEAKER_00 40:11

Sure.

SPEAKER_02 40:12

Um so so, anyways.

SPEAKER_00 40:14

Yeah, you it's funny because I've I'm, you know, I just turned uh 41 this week, and so I'm kind of in that you know phase of the career where you're kind of the I've I've heard that the 40, that your 40s are kind of a really impactful period of time for a surgeon's career normally. Um just because kind of we all get out and usually are getting into practice at some point in our 30s, and then like that 40s, you kind of have your feet under you, you know, you're not freaking out every time you cut a cystic duct, so to speak, and then you have that developmental phase where things are starting to kind of take off, hopefully, if that's what you want. Um I, you know, I did something, I took like the opposite approach of you, and I would absolutely support your approach. I did college in three years and went straight to medical school in four, and I was uh an attending surgeon uh like a month and a half after I turned 30. And um what if I would do it, it's it's hard to it's hard to argue with where I am now. Like I'm happy with what I've accomplished so far. Um and and the you know, like you said about my kid, I have two kids and they're they're the accomplishment I'm I'm happy about, you know, and it can everything kind of led to that. So I wouldn't, you know, it's like the butterfly effect. You don't want to change one thing that could could just disrupt other things that are just beyond amazing. Um But uh, you know, I got through, got all the way through my training and came out of training and then have been kind of in a crisis, even up until now, like, who am I? You know, because I you know, when you have your head down in a book, and you know, my friends were out exploring the world, partying, doing whatever they wanted to do through college, and I was always like, well, studying, or I was working too, I was working two part-time jobs while I was taking 18 hours of college. This was after I had played a year of college basketball, which absolutely you know, talk about getting into something being like, wow, I hate this.

SPEAKER_03 42:00

That was that was not like basketball for me.

SPEAKER_00 42:02

I was just like, nope. But the other thing about that is one thing is I one of the reasons I didn't like it is I don't think I took coaching very well. Um it I had a very aggressive coach who's actually an extremely good friend of mine now. Um he was very aggressive, told me what I needed to hear. Um, I was so terrified of failure that it really shaped my whole experience. I mean, I was a guard, um, I was a three-point shooter and everything like that. Um, and and that was kind of, and I was a defender. I was really a three and D guy before that was the thing. Um, you know, and it was not a flashy player, um, was a guy that was always where I was supposed to be, you know, set the picks, took the charges, you know, always got my defensive rotations right, was tipping the ball, uh, rebound came off. I wasn't getting the rebound most of the time, but my guy definitely wasn't, you know, and that's that's kind of how I played. Um, and and so the stuff that I needed to hear probably to become that next version of a player, but really kind of the next version of a of maturing into a manhood for me at the time or adulthood, um, it was said to me in a way that uh I was not used to taking, and um, and it kind of shocked me a little bit, made me really uncomfortable even all the way through my training. So the surgeons that were more aggressively um direct with me, um, I, you know, looking back, I it was not anything I had any self-awareness of at the time, but looking back, I think I shied away from opportunities that would really have been good learning points for me in residency because I didn't like that kind of like being brought on me, um, you know, sometimes brutal truths about like that wasn't a very good move or that wasn't a very good operation. It was definitely not like an ego thing. I wasn't like indignant and being like, oh well, this guy doesn't know what he's talking about. It was just it hit me at such a point in my core because I don't think I ever had that maturity process of going to South Africa to, you know, to study.

SPEAKER_02 43:56

I'll tell you what I think about that. So I I think a lot about this stuff, and I've read a lot of I mean, I love to read all these type of books in this type of stuff. I I I I try and read every night before I go to bed for at least like 30 minutes. And I'm an avid reader and love it. And I I I tend to read like a leadership book and then a mystery. And I just because if you read too many leadership books at once, it gets like you start to hate them. Because they somebody once said, I think it's so true. Like most leadership books are 300 pages, but they could be 50. Yes. But but I think like so my interpretation of what you describe, and I mean I may or may not be right about this, is and I have a very good example with my oldest daughter who's a medical student. It's a fixed mindset versus a growth mindset. Um right, and so I would tell you so my oldest daughter, I she was a really competitive tennis player, and she made varsity when she was a fresher. And I watched her at the trials, and she was absolutely incredible. I was like, I cannot believe this is my daughter. Like it was amazing trying out. But then when she made the team, she would not play at the level that she tried out at. And her coach, who my daughter hated, was beating her to death about it. And I actually talked to the coach after I like just I was like, hey, like, what can I do to help my daughter? Like, you know, it's weird. And she's like, she's like, well, I'm gonna tell you the thing about your daughter. And by the way, I think this is such a good learning point for most surgeons, because in order to get what you did, what we all did, you all have the same trait. When you are a straight A student, you are not used to failing, and you can control your environment by studying and you're what you're good at. So so then when you are put in a situation where you must fail, you you do not know how to handle that because you have never failed, right? And I think that this is one of the things about I always say, like, we're picking the wrong people for medical school, we're picking the wrong people for once you get the wrong people, medical school gets the wrong people in residency. In order to get to medical school, you must be perfect. If you have a failure, if you have a C when you were younger, you're you're done, right? Like God, it's not the person we want. If you didn't do well on your board, but then you overcame some other great things. Well, that's the one struct. We don't want you. And I I I've always felt that things must be very, very different. Like I'm looking for the person who failed at one moment in their life and then woke up, rebounded, and overcame that. Because, first of all, that is a hundred percent what surgical residency is is failing every day, getting better, and coming back too. And it and and it's very difficult to do that at that age in your life when you really have not been able to fail, where you wouldn't be there. And so I think that that that is number one. Number two is you know, for me, when you do a fellowship, you operate with me. My philosophy is I continue to elevate. So if you start off here, yeah, you are gonna feel like a failure until you get to the top. If you start off here, it doesn't matter where you start, I will elevate it. Because I and that sometimes, like when you're young, you've got to think about what is my perspective as your teacher. I must make you better. If you're already good, okay, the pressure's on me to make you great. If you're already great, the pressure on me. So that is the difference. And I don't really know, let's get to like the whole grit thing. There's a great, there's a if you haven't read anybody out there if you've ever read the book Grit, I love that book. And it talks about similar, it's a very similar story which you just told, Luke, which is that like to get into West Point, you have to be like valedictorian state championship. Like, I mean, these people are unbelievable.

SPEAKER_00 47:46

Yeah.

SPEAKER_02 47:46

And something like, I don't know, 15-20% quit within the first year. Because at West Point, you will fail your first year. So that's the they're there to make sure that you can overcome that. And so I think that you know, this is the process. And I think maybe like seeing the world helps with that a little bit, but I but I also I think there's just so many other things that um that people forget that you know I've experienced failure, we've all experienced failure. I I I carry that failure with me as a chip on my shoulder every day. I mean, I I can tell like one, I mean it's a crazy story so long ago, but like I don't remember it today. Like, so I went to Vanderbilt for college, but not like now. Like Vanderbilt's, I would never have gotten into Vanderbilt now. Like my oldest daughter went to Vanderbilt, and she reminds me of that daily. Um but but I had gotten two C's when I was a freshman in high school because I played basketball like literally all the time. And then I had then I moved schools and I got straight A's the rest of my time. And I did good on the SAT or whatever it was, and and but I only got to that one college. I got into one college. I applied to a ton of different places, and I applied to a bunch of high places, I got rejected from everywhere else. And I was like devastated by that. And I took to this day, I take that to realize that when you start somewhere, that first day matters. And everything you do that day matters, and you must work hard that first day. And I took that failure to me every day of my life, and I still carry it with me. And that is why like everybody has their own failure stories, right? Like with when you take care of patients, when you do complex things, you have your morbidities, I mean, unfortunately, your mortalities. And that is the question: can you take that stuff? Can you internalize that stuff, make you better, not let it destroy you, which is hard, make you better, and go. And that to me, right, that's the growth mentality. That is the I'm here to get better. And that and and I will say, I think the growth, if if you haven't ever read about growth and fixed mentality, it's such a great concept to me. But I also think that that's not what you are born with. That is not a that is not a this is your capacity. I think those are all things that can be worked on, that can be developed. They first must be acknowledged. And I think in surgery, this is one of the things that makes surgery so hard, and quite frankly, I think a lot of people have trouble being successful, is that as you push it in surgery, there are going to be failures, there are going to be setbacks, there are going to be criticisms, there are going to be public things now because of all this stuff. And kind of being able to withstand that and keep your north, or change because you realize that, hey, maybe I'm not right here, and kind of grow from that. And I think like everything in life, you know, the older you get, the more perspective you have, the more of an adult you become. And so part of this is just growing up. I think in in medicine, we're somewhat like institutionalized, that you're a little bit like, I mean, I think most of our like emotional and intellectual growth is stunted when you go into surgery because you like you're stuck in college studying all the time, you're in medical school trying to get to residency, and then you get to your residency, and you're by the time you're mid-30s, like I mean, a lot of life has passed you by. Um, and so I think that you grow up the first 10 years as a young attending to learn how to be an adult, basically. And and I think, and you know, sometimes that's hard because you're like, now that I, you know, leader of younger people, you're like, I mean, come on. You're like 37 years old, like wake up. But but I think that that is the the kind of the nature of the being of medicine, especially surgery. I mean, it's just so long. So I think that's why to the point of like taking some time off seeing things, um, it it gives you a moment to mature, realize that life is more than just about you, and and hopefully develop some gross stuff. I've always felt like the more you see around, right, the more perspectives you have, the more you realize that, like, wow, look, I don't know it all. Wow, my life is different than these people's lives. Like, when I say things that are relevant to me, that I believe passionately, yeah, that might not be what this other person who is equally right believes in. And I think, you know, it takes time to develop that. And and that's okay. It's okay. But but in today's world, like I said before, it's a little harder because a lot of this growth and maturation is happening online in front of thousands of people that don't know what your flippant comment was that you didn't even think about right now is like, you know, sure really upsetting people.

SPEAKER_00 52:58

So yeah. Well, we lose uh sound bites, don't have context. And so, you know, if you know, even things that have been snipped, uh, even things that I've said that have been snipped uh for like news publications or something, I go like, woof, that makes me sound horrific. That was not the point at all. Um anyway, you know, that's a yeah, I could have a whole hour-long discussion on that. You talk about coming through and learning how to fail. We I think that we in and let me let me say we, I'll say I. Um, I think that I never learned how to fail um successfully. Meaning, um, take a failure and not have it reflect so heavily on who I was as a human being that it was so white hot I couldn't look at it. You know what I mean? Like it takes it takes self-reflection and self-awareness to examine your failures, to learn from them. But if you are so tied to your success being your self-worth, which many of us I think are in our perfectionism and what it takes to get, like you said, what it takes to get to where we are, sometimes it's so uh the bar is so high that really failure has never been an option. And so to but so we it's stunted, it stunted my growth as a surgeon heavily. Still does. Like I still struggle with it on failures and being able to step back and look at a failure and go, like, you know, okay, what does it look like to um what does it look like to fail and not just think I'm just like a horrific surgeon and shouldn't be doing this, you know, and and learn from that. One thing that I struggle with, and I would love your you you said something earlier about it, but one thing I struggle with is looking at failures from the past. So say I had a patient I operated on like four years ago, and I did a surgery that at the time I was convinced was the right surgery. And realistically, with our knowledge of everything and kind of what the general consensus was, and it probably was the right surgery at that moment. I look back now and I look at the CT scan and I go, I would never do that surgery for that problem now. Ever. Like I did it would be completely different. And the patient had a complication from it, and I'm struggling with a couple of cases that I look back and go, and it's hard to forgive myself because I take it so personal. It's hard to give myself the grace of going, like, hey, I made the best decision with the information I had at the time, and I probably wasn't necessarily wrong then, but the the field and knowledge and techniques have advanced, and now we now that's not really what I would do for that. Um, how do you handle it whenever, especially in your situation, you're pushing the forefront, right? So it's hard, it's not like you're sitting there reacting to other people. Many times you're the people you're the person or you're the research people are reacting to. Not everything is successful, and looking back and going, like, man, that person got hurt, or maybe they had a less than ideal outcome from something that I did. How do you how do you reconcile that? Because that's something I need to grow on.

SPEAKER_02 55:50

I'll do that, but I'll end it with something that I promoted. So I have a lot of experience with that. So so let me just say, first of all, when I was like maybe my second year out, but I'll give you another Jeff Ponsky story. I kind of went up to Ponsky and I'm like, hey, like, at what point in my life am I going to be able to sleep the night before a big case and not be anxious about it? And he gave me the best answer. I still tell this to every young person. I'm like, the day you can do that is probably the day you should stop operating. Uh and so I think that there is a little bit of just giving yourself the grace that being anxious and nervous before you're about to do big things to patients is actually normal. It's actually the hard part about this great job is that it is you. You are the ones making decisions, you are the ones these people are putting their lives in your hands, you are the ones who carry that burden. And the minute that you lose sight of that is when it's no longer about them and it starts to become about you. And that's where things get off the rails, in my view, uh, of things. And so I think that that responsibility is challenging. And um, I don't really have like a magical thing other than having really good partners, people that you can talk to, your spouse who either does or does not do this stuff, and and and try not to carry it with you the best of your ability, but also carry it with you as a way to learn and do better. So I think there's a balance in that. Um, the the the idea that you know you never fail and you can't do that, I share that too. I mean, I think, listen, surgeons are judgmental people, surgeons are competitive people. Um, we have a lot of demons that make it hard on ourselves that we will not acknowledge. Like, there's no question that surgeons feel much more comfortable attacking other people than self-reflection. And I mean, I'm not even saying that as a negative. Like, I understand why it takes those things to be a good surgeon. So that's not a negative, that's more of just a be aware of that and think about it to yourself and think about it. Um, and and so the kind of like the second victim thing, I believe in. I believe in that wholeheartedly when you're young. But even when you're older, like I mean, when I get complications, I can't sleep at night. Like when I have people who are sick in the hospital, I'm up worried about it. When I have somebody who I maybe should take back or I don't, like, I mean, I've been doing this for a long time. I still like it hurts. So I don't think that ever goes away. I I don't it I don't think it probably, I mean, I it's terrible to say this, but I kind of think it probably shouldn't ever go away. You must be able to manage it though. You must be able to manage it. Um, but it is the part that makes this job hard, but it's also the part I think to to give my next answer to your question that is if you take it and you and you take it internally and you deal with that, and and then you can find a way to open-mindedly, not defensively, and I mean I think this part of that is just growing up to be able to the ability to say, hmm, I might be wrong, is really hard for people. And I think it's particularly hard when you're younger nowadays for all the reasons we've already talked about. It's really hard because you got on this bandwagon, you're out there, you're promoting. I mean, especially if you happen to be promoting something that aligns with industry, and now you're a speaker, which I have been. This is not this is not me being critical. I get, oh, actually, I'll just tell you my story, right? Like, this is me. I mean, I was the number one pro, I don't know if I was number one, but like I was up there for biological maths, right? Like I was driving the ship, I was teaching people how to operate, teaching people about maths. I thought it was great, I loved it, I thought I was helping people, and then all of a sudden I looked at the data five years later, I was like, oh my God, like it's not that good. Like, we were wrong. And and I always tell people, like, when I published that paper, there's no question in my mind, I was like, uh oh, like I'm making a lot of money from these companies. Like, I'm on every single podium, I'm flying all over the world. Like, are they gonna be okay with me doing this? Like, like that conflict is so real.

SPEAKER_00 1:00:20

Yes.

SPEAKER_02 1:00:20

And and I I think that's where we get kind of um people get crazy that like I don't have a conflict. Yeah, of course you have a conflict. It's conflict management, it's not conflict avoidance. It's fine to have those conflicts, right? But like managing them. So I wouldn't do all of that. And then and then I was like, he hates us. He doesn't, he wants to see us fail. He'd rather be with this other company. And I was just like, I mean, my guys, like this stuff just didn't work, like I thought it was, then we did a randomized controlled trial. And so, so listen, I I I think all of that stuff is learning things. We all went through it 20 years ago, so it's not new, okay? It's the same old thing, but it's much more public now, it's it's much more difficult. I also think being a surgeon now, it's harder because you there's all these measurements, there's these quality rankings, your mortality, your readmission. Like, I didn't have any of that stuff when I was younger. I did not have those stressors that people have now, where there's all these people measuring you. So so then I think the other thing is just to like I I would just say, and this is why I look at it as a positive thing when I talk to people, it's have the confidence to self-reflect and then be like, huh. And I would just say, I mean, this is where mentors really come into play. And anybody who's watching this podcast, if you get to a moment where you're like, uh-oh, should I be doing this anymore? Feel free to call me. I'd be happy to chat with you. I've had many, many, many of those moments. I think kind of the whole field of complex southwall reconstruction for me has been somewhat of an eye-opening experience where I've certainly been through some of that stuff. I I think for me, what was transformative that I did not appreciate is when we started the Abdominal Core Health Quality Collaborative. And we have private practice surgeons, like Solo Private Practice, we have uh community surgeons, we have big academic, we have academic affiliated, and I I review the data that we put out for these foundation partner reports, and I just see at a very high level. And not no nobody's individual data, but I see like the conglomerate data like every quarter, and it kind of opened my eyes up where I'll never forget this moment where I was like, wow, like the average incisional hernia in our collaborative of 500 surgeons is like four or five percent, or four or five centimeters, right? So when I'm running around talking about my 15 to 20 centimeter hernias, like I'm not sure that it's relevant for people in the audience. Like, I and that was a moment, probably like I don't know, like maybe 12, 13 years into my career, where I just thought if you fix incisional hernias, you saw what I saw. I don't know why I thought it sounds so stupid when I say it now, but like I thought that that's what complex alcohol reconstruction was, and I and it kind of opened my mind up to like, wait a second, like I might be saying my perspective that is not everybody else's perspective. And then we started seeing complications come in, and I would go back and look at images, and I'd be like, whoa, like I would not have done that. And so there was kind of a self-reflection of like, what's happening here? Uh and and I think that that, listen, when you've promoted something and you've like engaged in it and stuff, uh, I it's hard to do that. I I will say we kind of went back to like how do you become Mike Rosen or whatever. That please don't have that as your goal. But if you did, then then I would just say, like, what I've learned probably the most is if you want longevity, don't be afraid to be honest about this stuff. Like it's kind of one of those things, like you resist it, obviously, but after you do it, then you realize like like everything in life, right? Like there's the extremes on both ends who are very loud, and then there's all these people in the middle who actually just want the truth, right? Like it's very much like our political world right now. Yes, there's extremes that are blasting it out, and you're like, oh God, if I say this, this extreme's gonna hate me, or this extreme is gonna hate me.

SPEAKER_00 1:04:34

Right.

SPEAKER_02 1:04:34

But 80% of the world is just sitting in the middle. It's like, oh, that makes sense. Thank you for saying that. And so I think to me, that's been a big, like, that's a positive thing. Uh that should make you feel comfortable. Just kind of people kind of migrate to people who uh the people in the middle, which are the majority, migrate to just honest people who are just trying to do a good job. And then there's certainly people that migrate to the extremes, and again, I think that's totally okay. I mean, that's fine. The world is a bell curve. Like, there's extremes at either end, and most people live in the middle. But I think you just have to figure out like kind of where do you want to be, and I think for short-term kind of growth notoriety, be at the extremes, it'll happen quick, but then it goes quick. You want to kind of live your life in the middle, and it's okay to be impassionate that you think that you're right. My my message to people though is when you see the data and when you look at it, it's rarely an easy answer. And by the way, every single randomized control trial that I have done almost invariably proves that I was wrong. And like it's it's not what I thought it was. And and then you have to like come to grips with that and find a way to like interpret that data and still be honest about it.

SPEAKER_00 1:05:53

Yeah. I have the three three things about what you just said that I'd love to get your opinion on. First of all, in the spirit of in the spirit spirit of uh truth and and humbleness and honesty so I had this I had this complication and uh and it was a it was a reef stopa and it was a posterior sheet failure and I was really struggling with it at that moment I was very much struggling with it and was questioning like man should I have just should I have left the diastasis alone that this person like all these like thoughts that every time I have a case that goes well I struggle with it like I you know I just I struggle with my I I'm always like terrified of hurting someone and so I'm always in this moment of really doubling down to make sure that I don't well this is this is funny and but I I was in the middle I was sitting in the doctor's lounge and I'm sitting there thinking about this case I'm trying to decide like what I'm gonna do and um and my buddy sends me an article on uh on uh the text he goes hey check this out and it was a New York Times article that you're quoted heavily in which you thought about that and I was like and I and I read it and I was like literally put me like into a panic attack was like oh my god did I do this did I like over operate all my so anyway it was it I could I could say you know the what what I will say is that the people the people that have the the voice and things that you have it has a dramatic impact even on that 80% because we do look to people who are pushing the boundaries to kind of help set our compass I think that people who don't want who are trying to stay up to date with the literature trying to stay up to date and offer our patients the most current beneficial the most current beneficial um repairs or or things like that in hernia I think that we have the best of intentions but at times you know you can kind of hear whichever voice piece is the loudest at the time and it may it may shift the whole middle right because many of us um it don't have the the time to go out and do the primary research ourselves um sometimes sometimes it is um we know our data but we're not but you know we're being forced contractually or what have you the pressures of of the realities of our practice to get out there and we don't we're not putting it into the the database as frequently or as of as we should and things like that. And it's not that we don't care and it's not that we don't think that it's very very important. It's just that when at the end of the day I'm going I'd either sit here and put in this database stuff because I don't have they won't give us the person to help put it in or I'm gonna go home and spend an hour with my kids before they go to bed. You know and that's really kind of like like honestly the the check marks that I'm like struggling with and so let me say let me down for you.

SPEAKER_02 1:08:31

So so I would just say a couple things I think first of all the one thing that I have learned is that literally almost exclusively very very few exceptions there are obviously exceptions vast majority of people just want to do the right thing and they want to go home to their kids and they don't want to hurt people like I 100% I I I believe that to my core and I think there are probably a few people that are swaying things maybe because of industry and stuff but even those people I bet you in their heart of hearts they believe that they're doing the right thing. So I don't think any I think very very very rarely on the surgeon side of this is there nefarious activity going on. But but what the message what I would give to all surgeons and this is what's hard for people is to accept the uncertainty of why we are doing what we are doing. And so the reality is like why do things change but I mean I can only speak to her surgery I I don't know how much this is true in other things I have no idea but but I do know for a fact in her surgery like why do we go over here then we go over here then we go over here then we go over here why do we do that well we do that because invariably there is a person who might happen to be an incredible public speaker a very dynamic person who often is doing one of two things like me they're trying to take care of a very unique patient population that they have and they're innovative people and they're trying to innovate within their world for that or they are a person that got very advanced training perhaps in a fellowship or even in their residency and they are great laparoscopic people great open people great robotic people and so they have this skill set that they are trying to apply to their specific patient population because they have the skill set equally if any one of those people aligns with industry and let me just address industry for a moment here and the reality is when we talk about robotics it's intuitive like I and I'm gonna start out by saying I have the most respect for intuitive as a company I think that they are probably one of the most well-run companies I've ever seen in this space but they are and this is like any company mass companies robotic company whatever they're about to be more robotic companies these are for-profit companies that many of us are invested in our mutual funds and you probably don't even know that. Okay so you want them to run like a great company but those two things a person who is innovative and excited and a company that aligns with that creates the potential for exponential growth without safety and that I want to be clear that doesn't mean that any one of those people are coming from a bad place but for the rank and file surgeon that is just out there being like how do I digest this information and know what to do with my patients know without even knowing your own well and actually and and then like you said for all the reasons you said which are all fair and accurate like our system is set up for volume right yes and and and churnal cases and long-term stuff even if you want to know it's hard to know it even if you want to know your data and like the reality is accept the uncertainty also of most of us I mean 95-99% of us don't know our own data right we don't know long term what we're doing until you see that complication you're devastated like oh my God but you don't know what's your true denominator you don't know how many of these things aren't diagnosed it's hard to know that information so there's that level of uncertainty. So I think that if I could give that message like how do we function this world right like there's not going to be a randomized controlled trial for every single person and even randomized controlled trials. Look when I do a randomized controlled trial with an open tar, trust me, that data is not relevant for very very very many people out in the world because they're not going to do a tar like how I do a tar. So there's this like expertise bias. Same thing if Alfred Carbonal does a robotic tar thing right like his data is not relevant to me doing robotic surgery. He's different he's much much more elite than I am so even randomized controlled trials that's not the answer. So to me the answer is all of us as surgeons accept the uncertainty of the environment and be skeptical and take a moment to be like huh am I just doing this because pressure from my rep this person's a great public speaker I just saw a really cool video that like maybe I don't have that skill set for but they just showed me the post op follow-ups and in in the you know two week follow-up I didn't say long-term data like that's my message is to be skeptical number one number two just for taking the time let's talk about this New York Times article I that's another way to be uh relevant is um uh is is to be memorable is to be memorable so the other part of this I think and I think this is true for leaders it if you know if you get lucky enough or unlucky enough to become a leader is to be comfortable speaking out when you think things have gotten too far acknowledging that there will be prices to pay for that stuff. And I think that in today's world way outside of hernia surgery this this is true now right like there's a price to pay for like it and maybe there needs to be a correction maybe there doesn't in my view there happened to be so that New York Times article funny enough I actually didn't call the New York Times they had called me because I'd written the paper with the largest amount of component separations and so they kind of wanted my take and at that time I have to say like I was seeing a lot of people in clinic I still do who were being armed by this operation for relatively like when I went back and looked if I was being honest it's like relatively small hernia people are getting very aggressive operations and I just I I kind of fundamentally did not think that was the right thing to do. So the the way the New York Times stuff works is I got interviewed twice. You don't get to see the article you don't have any say in the words when you see when it comes out and I I would say this about that article um interestingly enough I asked the reporter I'm like listen I'll be honest with you I I'm happy to participate in this but I don't like I don't like the concept that this most of what you guys write is just exposing the negative without offering a solution I I just don't find this to be like helpful. And she said something that like resonated with me and I think that there's a good story to it and there's a story that didn't happen is that she's like well listen our job is to put a spotlight on the problem your job as surgeons and surgical societies is to either address it or ignore it. Right? And so I think that there were kind of like four parts of it that um that that were in that article and like some of them quite frankly like I disagree with and some of them I agree with and for me I think that there was kind of that perfect storm as we've alluded to already is that you know I think you had a robot company that was taking off you had some speakers who were pushing very advanced robotic techniques and again I I think in their hands they were getting great results. And I don't I I don't think these folks were doing it with to hurt people but but I think that they often did not think about the consequences of when the rank and file people are out there doing some of these things to hug people like what could be the harm and that's we often have trouble as surgeons considering like what I do might do this well for patients, which is great.

SPEAKER_00 1:16:30

Right.

SPEAKER_02 1:16:30

But we often struggle with the with the counterargument which is what is the harm that I might be causing people and should I do this and these are the lessons we learned the hard way and so so I think that that article um I think it was successful in starting the conversation. I think it was successful in like I mean you know quite frankly like the people that lashed out at it the most I think you know that's that's equally like these are the like you know the 5% the 5% of us who think all hernias surgeons are you know industry people who are paid to say these things like I don't agree with those people. And the 5% of people who are like if you say anything against us, you're the worst human being in the world, that's not the position to be in. I I think it kind of got people in the middle and my final take I actually saw a patient um from Connecticut uh who came down to see me and I got the notes and everything. And this is why I I'll never regret that article no matter what it cost me is that um it was uh it was a guy with a 1.8 centimeter umbilical crania no diastasis no prior surgeries and I I got the note from the surgeon he was looked for a robotic tar. Right and and I did a 20 minute lap IP he went home the same day right and I think to myself like you know listen tar is a great operation robot tar has its place of course it does but like we have to acknowledge I mean it shouldn't be that hard if we're patient first to say like something's like gone off the rails here and like and we can correct it without going nuts about it and and and and you know kind of falling into like what our political parties have done. So so but but again like I I'm also old enough to like be okay with the fact that that's hard. Yeah it's hard to do that. It's hard for people to change it's hard for people to look back it it's it's there there's this whole thing of I if if if if if the NIH is listening, which I'm sure they if they are please do.

SPEAKER_00 1:18:44

If the NIH is listening to this podcast then they probably should be doing better things.

SPEAKER_02 1:18:49

So this this is like there's every grant that you submit now there's this whole thing about implementation science where like when you do a randomized control child you need a plan that once those results come out how are you going to change everybody right I'm a big believer in we need equal amount of work in what I would call de-implementation science. Like how do we get people to stop doing what we now know is probably not the right thing to do without you feeling like you're not good enough. You you did it wrong it's you know this person's better than me like like how do we get it back to that and there's so many things in surgery where we we we like we thought it was great we've learned that we were wrong but there's so many people that like can't get off that bang right because it's like well it's good in my hands. Well but do you really know if it's good in your hands like it's hard to know my life is about collecting data. Yeah and even me if I get 60% follow-up hounding patients I I'm happy and that's missing almost half the people I have no idea what's happening. So so so I think that that again that's that's like kind of the the be okay with the uncertainty and then you know be a little skeptical be a little resistant and I think if that article makes you step back and be like hmm then I'm like thrilled and I'm happy I did it um it definitely like you know I mean it's crazy what how some of the people's response like I I'm a big can we just have a conversation yeah so um some surgeon uh called my chair at the time and said that I need to be brought up to the uh conduct board because I'm trying to do insider trading on intuitive stock. Oh wow so so I I'm a I'm a big believer in this uh said okay give me the name of the guy I'm gonna call him myself and like let me just have a conversation with him.

SPEAKER_03 1:20:51

Sure.

SPEAKER_02 1:20:52

So I called the guy I call every single person who had a negative thing to say about it and said hey can we just have a conversation like I just want you to know where I'm coming from. I didn't write that article I'm quoted I don't agree with everything but I just would like you to hear my perspective and I want to hear your perspective and funny enough as it turns out I did go back and look because I'm like I wonder if like I am invested in intuitive and my investment guy in his mutual funds I have some intuitive stock as I think everybody does. Oh yeah so like so not only was I not shorting it I hurt myself doing it. Yeah so but anyways we had a good conversation with that guy and I think that is my like you know I mean we can talk about this stuff for hours the the concept that we cannot debate anything anymore without anybody getting like butthurt and emotional is is is sad to me because a lot of these things just deserve to be debated and and discussed.

SPEAKER_00 1:21:52

Yeah no I I agree I I agree 100% with the discussion that's why we're having it I mean I wanted to talk I really I truthfully I wanted to talk to you about the article because I had a suspicion that it's in the middle I I was out um talking about ERAS multimodal pain control. That was one of the things early in my career I realized it it was something that I was focused on and I did a bunch of interviews about multimodal pain control with opioid minimization and it was right during the middle of the rise of the of the overdose crisis um and and let me rephrase it was not in the rise of the overdose crisis it was when it became in vogue to publish articles about it. Like which is a very different thing because it was a going on for a long time then all of a sudden everybody latched on and it was a big thing. Well it all like like you said everything came together all at once and I was a person that was interviewed and and did a bunch of of interviews about it. Was also early in the Dunning Kruger curve where I live I think most of my life that first little like hey I think I know something then nope nope don't at all um so I I got I had a couple of articles where I was quoted in the larger context of a of a uh conversation and it came out and I was just like terrified. I I was mortified I was just oh my gosh I even published a like an op-ed in our local newspaper being like this I'm not saying that people don't need opioids. I'm just saying that we have a whole bunch of tools and we only seem to want to use one of them in many cases and that may be absolutely necessary but if we use all of them we may even be able to get better pain control. Like this is I'm not saying we need to like sacrifice pain control. I'm saying we could even do better than we are if we just like look at prescribing more than one medication for a patient. And um and it it went sideways. And I got like death threats on my Twitter account and I like deleted my Twitter account and all this other stuff and and what it brought up brought to my after I got over like the an immediate just like more I was I was so personally hurt by this. Like I it it was for people that have no idea who I am or anything like that. I took it so intensely personal because that's just how I've been wired since I was a couple so young you're young like this stuff is that's like the so it's hard when you're young on social media to be attacked.

SPEAKER_02 1:23:59

I felt bad for people.

SPEAKER_00 1:24:01

Yeah and it it so once I got through it it kind of did that and it's on when I saw your article um it it made me take pause and and you'll you'd be happy to know that even though it it made me change some of the things I was doing not necessarily and again I was not going out just going like ooh I get like you know more RVUs if I if I do this or this you know I'm saying that wasn't I I was just sitting there going like well you know I think tension is probably one of the reasons why these herniers are failing and and maybe if we do things to relieve that tension and maybe I was putting too much tension on my previous closures and you know like you said it's like my practice at the time was not set up to track these patients and it the EMR was even worse and harder to find these people after the fact and I was in the standard kind of I'll see you at two weeks and then maybe again at six weeks and then let me know if there's a problem and I meant that but nobody comes back very rarely if there's a problem they go to someone else or they are at a different place in their life geographically and and so all that kind of can hit me in a way that I was like oh my gosh and then I'm reading the example surgeon who's you know just from up the road from me and I was just sitting there going oh that could have been me I'm sure there's a I'm sure there's a patient that you know could have been that so you know it's just kind of funny how things will hit you but many times the way people perceive things is through the lens of their own biases and through the lens of their own experience. And I live in a constant state of imposter syndrome and I wish I could say that it's not like just in my professional life. It's just part of my like thread of my being and I have a lot of work to do on that. Like I have imposter syndrome in my own marriage. I've been married for for almost 20 years I've been with my wife since we were 17 and um and I'm still just like waiting on the day that she like wakes up and like recovers from her head injury and goes like oh wait I could do way better than this Joker over here. So but I I think that that's just it's an interesting way. So I I did wanted to kind of talk to you and I'm glad you were willing to talk about it just about the fact that I had suspicion that the article was not necessarily representative of everything that you believe in its totality um but but is definitely through the lens of and then and an article that pres also articles that present a like a kind of a very fair um picture of the situation they don't get a whole lot of read.

SPEAKER_02 1:26:21

Well so a lot of people complain about that and and that's a fair critique is it's not balanced, right? Like we didn't talk about all the good um and and I I think that that is something that um is a surgical surgical community especially as surgical leaders and leaders in surgical societies because of how common hernial surgery is should think about that argument carefully. Because number one as you said the New York Times which I'm not a big fan of that newspaper for the record but but but they're not there to provide balance that that that is obvious. This is an investigative thing from the New York Times they don't they don't fake it like they're trying to provide balance but but I think that what we should do as surgeons right and it's a lot of the conversation that we had earlier which is the harm that we can create and and and the lasting effect on patients and us is I think we should be very careful to argue the balance argument because regardless of the balance how much balance must there be to justify doing aggressive inappropriate procedures on patients potentially causing harm I don't think there is enough balance for that. So I think that the the the the balance argument I don't really agree with per se. And and like oh this is what I was gonna say but I remember now I I really to be honest I I the one thing I did not like about the article was the the CPT code billing stuff. I recognized that there was a lot of promotion Of inappropriate billing and whatnot. But I, in my heart of hearts, I truly believe that most surgeons are not sitting next to the patient or the console wherever thinking that if I actually cut this muscle, I'm gonna get paid more money. I really don't believe. I'm sure that there are a few people that do, but I think that is the vast, vast, vast minority. Um, now there might be people that are kind of like describing what they didn't do to get that. That's a different story, but but I'm just I'm talking about the actual what is driving people to cut muscles that might cause people harm. And I don't think it's financial. I really do not. To me, that's what that article is in. It's like, what is driving people? It is the combination of some surgical people who are out there promoting this stuff, combined with an industry leader that is extremely powerful in this world right now. And to me, that was the spotlight. Um, and I think that's in the background of the ability on social media to put up videos and kind of see things very, very quickly. That was the kind of milieu I the the the billing and like stuff, I that was less relevant to me. I think it's it's an issue. I get it. There's like this four codes and all this craziness, but but but to me, I think it was more about like just trying to get into what is influencing us as surgeons. And you know, what can we do if we step back and say, you know, can we provide balance, right? Like, like you know, if you're a leader of American College surgeries, American Hernian Society, SAGES, whatever, right? When you have a uh lecture about minimum invasive hernium surgery, having balance of, and I'm not talking about balance of conflict, I can care less about the conflict. Um, I'm talking about balance of approaches because you know, if you stop talking about robotic IPOMs or a lap, whatever, an IPOM right, if you just that becomes like we're not talking about that anymore. Yeah, that drives behavior. Yes, and we can control it. Like if you just look at right now, like you know, even on like CNN now, they provide conservative balance on some of the things with liberal thought, just trying to get the conversation. So I think there's a lot that we could do as leaders to give people the whole picture, right? So there were people should in the audience, people there. Because as soon as you take away that stuff and you silently remove it and you stop hearing about it, if you are a practicing surgeon trying to do the right thing, you are naturally going to drift to where they're leading you. And I think that that we could do a better job providing the whole spectrum of folks what to do instead of kind of naturally flowing with the tides of what's hot today without knowing the consequences of these things. And like everything in life, right? Like, like we have learned the consequences the hard way. Like we should acknowledge that. Yeah, push your sheet breakdowns. We've learned that the hard way. Uh, you know, um uh linear seminaris injuries, we've learned that the hard way, denervating the abdominal wall, we've learned that the hard way. Like, we gotta have a way to be safer in how we do it. And I put that to the young people. Like, I I certainly was not successful in coming up with a way to have the safe introduction of knowledge and ideas and techniques. I think that's what the next generation should do. Stop focusing on the technique, it'll change. Focus on the process of how do we tell the surgeon who's just out there trying to operate, do a good job, and get home to their family for dinner. Like, how do we tell them what to do in a way that hurts the least amount of patients possible? And I I don't think we've figured that out.

SPEAKER_00 1:31:59

No, I don't. I it's a it's an interesting thing because there's also a little bit of an access issue when it comes to patient care. And so people will show up. I mean, I grew up in the very tip of the Oklahoma panhandle. So sometimes the difference between a person getting a hernia repair or just never getting it repaired is whether that surgeon offers a repair that can fix it. And you know, you're talking about surgeons that may be, you know, in their 50s, they're not that's not a surgeon that's going to go back to a fellowship. I mean, they're they're gonna go to a a training set, a training course or a cadaver course, but that's like two days off. You know, teleproctoring has made it a bigger, it made it much easier, but the the idea that that person, especially if they don't have like the newest teleproctoring equipment, maybe they're still working with a you know an XI or something that doesn't have the ability, like getting them or their hospital or somebody gonna get them a person to come in and like proctor them for a series of a series of those types of cases. The reality is it's just not uh feasible. Even in a person that wants it, it's it's hard. And so there's a there's an access issue, and I think the the other thing that we don't really have a good grip on is how do you implement these techniques to people such as myself. I didn't do a fellowship. I went out, I did not plan on being a hernia surgeon. That was just what showed up in my clinic. And so over the course of time, my interest in hernia surgery rose because I was just going, I've got a whole bunch of patients coming to see me for this. I really don't want to hurt somebody. Let me see what I can do. And patients were coming in, and then all of a sudden more and more, and so then I started expanding my techniques. I went to the courses and all that kind of stuff, but as you said, most of them are by industry, right? Um, and so in many cases. Um and so you go through the process of of trying to learn. I think the the biggest question is like, what do you do to the for those people that have act that there are some patients that just aren't gonna have access? Like in a perfect world, everybody would be conglomerated up to you know Northwestern or wherever it is.

SPEAKER_02 1:33:58

That's huge. So so this is um, I think that's a really important thing. And I think that um, you know, first of all, uh the fact that industry controls the majority of our education, I don't think it's a terrible thing. Um, I don't think that's like a deal breaker. Again, I think it's just like always one of those things. Just be a thoughtful consumer of that knowledge, so that, you know, when you go to a course that's just put on by a mesh company teaching about how to do hernial surgery, I can assure you you will see their mesh going in. And that is going to have an effect on you. That's why they're paying for you to be there. And that's okay. That's the that's the kind of win-win that that you know, I always say, okay, if I want to put a course on and teach you how to operate the way Mike Rosen operates, it's gonna cost you 10, 15 grand. If you do it with industry, it's free. They'll fly you out here, they'll do so, so it's just a simple financial decision for people, and I get it. And so so we shouldn't like say that industry cannot be involved in education. They absolutely should be and they can be. But but we, as the consumers and the people who are ultimately operating our patients, just just acknowledge the conflict and then manage it and say, huh. You know, and so this is actually to me, this is one of my fundamentals. And I think I'm gonna speak for intuitive, but uh watching them over the last 10 years, I believe that they would agree with what I said. What I'm about to say is that I think that maybe their biggest regret, and I truly understand where it came from, is that when they introduced robotic hernia surgery, there was a huge push. We don't need a $2 million thing to do hernias. This is stupid. We don't need a robot, it's a waste of money. So the natural response to that, which this is why I think the regrettable move, and this is what unfortunately is gonna be hard to undo, is let's make hernia surgery more complicated and minimally invasively than perhaps it needs to be, so that we're gonna promote things that you could not do laparoscopically that would have required being done open. And so we're gonna drive the field to doing more advanced surgeries robotically that cannot be done laparoscopically. And I think that that kind of business model made sense for intuitive at the time. It also uh created a very interesting platform, and again, this is like being a thoughtful consumer is like let me just give you like a perfect example. It's hard for surgeons, most people, to get up and like just openly promote a device, a robot, or whatnot. Like it's awkward as a surgeon, you kind of lose your credibility if you get up and say you've got to use the robot, this is the robot, blah, blah, blah, blah, blah. Like, I get that. Most people don't like to do that. Some people can, but whatever. Most people do not like that. So if you can change the conversation to you're no longer promoting the robot, you're promoting a technique, an approach. Now we love to talk about techniques.

SPEAKER_00 1:37:14

Correct.

SPEAKER_02 1:37:14

And we love to talk about approaches, and we love to show videos, especially videos that I can cut up and make myself look spectacular.

SPEAKER_00 1:37:22

Yes.

SPEAKER_02 1:37:23

So if all we have to do is talk about ETEP or RTEP, these are things that cannot be reproduced laparoscopically or robotic TARS, right? Like they, I mean, there are people who have done them laparoscopically, but it's not, that's never gonna happen. So if you can go out and promote a technique that requires the robot, then no longer we don't have to talk about the robot anymore. We can just talk about the technique and things will naturally drift to the robot. And so I get where all that came from. I don't think that's from a bad place. I get why people thought that, but but like I think that if we could rewrite the ship, what I would say is just because you can do these advanced things on the console, just ask yourself, back up like one step in the algorithm, and say, is it the right operation for this patient?

SPEAKER_00 1:38:10

Yeah.

SPEAKER_02 1:38:11

Or maybe something smaller. And this gets this is where I'm getting to with your point of like the person in Oklahoma who who isn't robotic advanced this, they're a general surgeon, they're doing everything, and hurting is part of their practice. We should be promoting to that person the least complex, most reproducible case to just take good care of their community. Because when I used to put on this course in Colorado for um when I was in the clinic, with we would get about 250 critical access general surgeons. And I mean, like, I absolutely love those people because these were surgeons that had no angle, no, they just they would often say, and I love this, like I wish I had this in my life, they are taking care of their community and they just want to know what to do, what's right. And if it was hard, they would do whatever it took. But if there was a way to do it like without hurting people as much, they were into it. And they were just like, they were such, they were like, to me, they're those people in the middle, right? In our world. They're the good people. They're the people who just just they don't have an angle. They don't care about the RVUs, they don't care about the billing, they don't care about this. If it has to be done robotically this way, they'll do it. If it doesn't, they'll do it. And so they were just truth seekers. And I like, I always like, it's my favorite meeting because it's just like no angles, no BS, just good, good general surgeons trying to do it. So to your point, I always say, like, look, the average person out there, like sometimes the right answer for them is primary closure. Sometimes the right answer for them is an IPOM. It could be done robotically, it's beautiful. You can sew the defect closed, you sew the mess up, or you tack the mess, whatever you want to do. Like, so when we get up and we make it all, mess has to be outside the perineal cavity, leave no trace. Like, I think we often forget the consequences of those people, and we and we leave them behind and we make them feel like they're doing an inferior job, and we make them feel like they're not taking good care of their patients, and we start to push them to do things that are just unproven yet. If you prove to me that getting the mess outside the perineal cavity is better, then okay, we need to teach people to do it, but except like right now we don't have that answer. Right. And when we talk about ballots, everybody wants balance, but sometimes they don't. Like, if I even give you that there's some theoretical meaning of getting messed outside the perineal cavity, I will even throw you that bone, although I don't believe it to be true, but I'll throw you that bone. What about all the risks of trying to create the extraperitoneal place? Yeah. Interstysor hernias, bleeding, nerve damage, like like so that's the balance, right? And we don't know what that is yet. We just don't know, and we certainly don't know it for the rank and file general surgeon who is not a hernia expert and is just has to be able to do hernias and you can't take hernians away from these people. And you just tell these folks what to do. And I think that's where our messaging we should all just take a moment and rethink what we're doing. And I think most people, as they get older, I have certainly, will have that moment where they're like, ooh, what am I really promoting here? Like, is this really right for everybody? Um, and and so I think if we could just get there quicker, hurt less people along the way, or just acknowledge the uncertainty, that would be the perfect future state.

SPEAKER_00 1:41:35

It, you know, mine my rates of ETEPs have been dramatically declining over the past two years. My rates of eye palms have gone up. Um Right.

SPEAKER_02 1:41:45

Well, you know what's funny, like when you said when you're like my age, I looked at ETEP in the first five minutes, and I was like, wow, that is beautiful and cool and incredibly elegant. And when I watch some of these advanced robotic guys do it, I think they make it look fantastic. But I have done thousands of retromuscular surgery cases, and I know what can go wrong.

SPEAKER_03 1:42:09

Yep.

SPEAKER_02 1:42:09

And I immediately was like, this is a lot of surgery for small defects. And once you mess around in that retromuscular space, you're kind of stuck. You now you have a posterior sheath. Now you have to end it somewhere. All these things that I struggle with for 20 years doing open retromuscular surgery, when you apply that to like a two-semine or defect, it kind of like sounds cool. But but like people had to get there. And if you got there, you got and like that. You saw it, you introspect it, and you're like, okay, what am I doing here? And and I bet you it wasn't easy because the world is pushing against that right there. It is, yeah. But the world in five years from now will be like, I can't believe we ever even did these things. You know, like it's it's and that is like when you're in the middle of your first pendulum swing, you feel like the world is so unsteady and everything. But when you've seen it swing back and forth five times, you're just like, okay, like let it swing. Let it actually there's a there's a saying that um I think he I think he might even be dead now. Bob Beer, he was my one of my first mentors. I was a medical student, he was a he was chief of colorector surgery at USC. This was in 1994, maybe or something like that, right when laparoscopic colectomies were taking off. And and he told me something. I'll never forget this. He said, Um, when new things come out, Mike, you don't have to be the first person that runs around saying, do it, do it, do it. You also don't want to be the last person saying, don't do it, don't do it, don't do it. So the way to really make a career, and this is what I try to do, is sit back and watch these things. And when you see something that might be sticking, be the one who studies it. Be the one who brings the knowledge and the data and then figure it out. And not that every study is perfect, every study is definitive, but I think that, you know, that's why it's okay to wait and watch and be like, let me give this ETEP thing a couple years and let's see what these guys talk about. And most people, I think like robotic TARS, it's the same thing, right? Like, like, God, it's elegant. Like when I watch it, like, I don't even think Alfie does it anymore, right? Like it's beautiful. But I mean, like, it takes like five, six hours for an operation that would take one or two. Like, is it really one day difference on length of stay? Is it really worth it? Like when you're actually getting paid for what you do every day and you gotta get home and see your family. Like, it it these things swing back. And it's like, okay, of course it has its indications. Yeah, it's great that you know how to do it, but like at the end of the day, for small things, you probably don't need it.

SPEAKER_00 1:44:57

Yeah, I think the biggest, so the biggest problem that you get into in my experience with ETAPs, right? So then you talk about the pendulum and the it's like, well, everybody close the posterior sheath. Nope, just reestablish the visceral sac. And then so then you're in this kind of like the average surgeon's going, like, what am I supposed to do here? Like, and then you sit there and go, Okay, well, I've got to get this closed. Well, the posterior sheath won't come together now. So now I'm doing a myofascial advancement flap to get a posterior sheath together. And so, and then you go, well, that seems like a lot for what I was just trying to fix in something much smaller, you know. And you get into those moments, and then I think that that's when they take a step back and go, was that like, where did that end up? You know, and you sit there.

SPEAKER_02 1:45:34

So that you said it so well, and I want to like just kind of reinforce what you just said, which is that that is the problem with the retromuscular space. And and and when the next new thing comes out, which I know that it will. Always remember if it if it starts to change and violate basic surgical principles so that you can accomplish doing it that way. That is when you should, as a surgeon, take a positive. We've always closed the posterior sheath. It's hard to close the posterior sheath for small defects, so now you don't need to do it. When I heard that discussion, I didn't even, to be honest with you, I didn't even anticipate the bulging thing because truthfully, like I've never not closed the posterior sheath, so I never really realized that that would be a future thing. But but hats off to I think it was Jorge Diaz who was kind of the first one that kind of sounded along for this. I think that you know, those are the hard lessons that we learn, but but I think that that is the like when you mess around in the retromuscular space, and and that's what I want always people to realize is we're doing tars, not for the anterior sheath, it's for the posterior sheath. And so it's to take the tension off the posterior sheath, right? That's what the transverse subgonomic, and that is the whole problem when you do an ETEP for a three-centimeter hernia, is all of a sudden you're stuck. You're like, uh-oh, I'm in this space, I can't close it, so you're not, you're, you're doing, you need to do the tar. It's the right thing to do the tar because you gotta get the posterior sheath back together without tension, you're gonna get these hernias. Same thing for diastes. But that's when you, as you get older and you think about it, like, well, wait a second. Like, if you're already five steps down the wrong path, does it really matter whether you take it right or left? You really ought to back up and be like, should I ever been on this retromuscular path? And like, I think that is kind of the story of like retromuscular surgery. I mean, God, it has its place. Like, it's what I do every day. I'm I'm not against it. I'm I'm as pro, I mean, honestly, I think I might do more tars than anybody on the planet. So, like, this is not me being against the operation, it's just knowing kind of appropriate usage of it.

SPEAKER_00 1:47:50

It's indication, and which is yeah, you know, nothing uh, you know, as we go down this path, and and listen, one of the things about this podcast that has makes me very uncomfortable, and I think this goes to your idea about social media and the stuff, is that um people somehow there is some folks have this mistake that I'm like, listen, I'm just talking to people. That doesn't mean I'm an expert at an ETAP. Or I'm you know, I've I've given lectures on how to do like the basics of it, but every time I talk about stuff, I'm just like, listen, this is you know you keep in mind who I am, right? So you got to keep in mind, like, there's a there's a weird conflation of people, the loudest speaker or the people that have the most exposure being assuming that they're like the best surgeons. And I and I'm a big proponent of the majority of the best surgeons in this country, not one person knows their name outside of 50 miles from where they live. You know, those people that showed up.

SPEAKER_02 1:48:46

First of all, depending on how you define the best surgeon, to me, the best surgeon usually is the surgeon that takes the best care of their patients. Yeah, and those people are rarely on the podium, they're rarely writing papers. It's a different skill set. And a lot of the people on the podium, a lot of the people writing the papers, a lot of the people in leadership positions, these are just facts. I'm not, it's not critical. They're assumed to be great at some of these things, and they're not all, and that's not bad. They might be have great other skill sets of leadership, programmatic development, all that type of stuff. But to me, and this is one of the things that the quality collaborative has taught me, some of the best people are the people just out in the battlefield fighting, yeah, trying to do a good job. And they have the most technical knowledge, and they are the people that do everything every day, like you were just saying, right? And they look at it and they're like, huh, I'm sitting by myself at home after this complication. I'm like, why did I even do this? And to me, to me, that is the path to becoming, and I'll always say it, right? Like the reality is life is a bell curve. Your job is to be the best surgeon that you can be, provide the best care that you can. And shift yourself as far to the right on the curve as you possibly can. And that is what the best surgeon is. And you'll be influenced along the way by different things, and that's okay. But keep your focus on that and then just look at yourself and be like, hey, look, maybe these guys get these great results with e-tests, but like I just don't. It's not my thing. Like, you know, it's funny. Like, I don't like doing reef stopas for small hernias. Because the truth is, I've learned in my life, I end up like doing a tar because I can't get the posterior sheath closed, and I feel like, oh my God, I just did a tar for like a four-center hernia. That seems ridiculous.

SPEAKER_00 1:50:33

Yep.

SPEAKER_02 1:50:33

Like it's embarrassing. But I will only close posterior sheath without tension because I'm afraid of interstitial hernia. I'd rather deal with the morbidity of a tar than deal with the interstitial hernia disaster. So that to me, that's why I am as advanced in retromuscular as you can get, but I just stay away from it for small things because I I know my mindset will be you're getting a tar because I will not accept tension.

SPEAKER_00 1:50:59

And you can you can make the argument about like the approach and the intuitive thought process and how that how the retromuscular stuff kind of grew in popularity. Um, one thing that I think that um if influences folks like me was uh the fear because we because I spend so much of my time talking to patients about the plaintiff's attorney commercials around mesh. Right? And so there's a fear of intra-abdominal mesh placement. Whether it is justified in the literature or not, there's a fear of it. And so I think the the a lot of the allure of what turns out to be much more complex surgery than maybe needed was uh alleviating that fear. And it's not, you know, having a new toy to play with, getting your reps in, people don't talk about it enough. There's a little bit of a level of people, you can't go if you're gonna start doing a tar, and you have gone through the training and so stuff, your first one shouldn't be a 15-centimeter tar. Right? You know, you have to get a few that are not that are a little, you know, a little less, and I'm not saying that it it's just knowing when to stop, you know.

SPEAKER_02 1:52:11

Well, I think it's being able to set back. So so let me tell you. So again, I I see this happening again, it's just the next phase, right? So, so the concept of mash causing harm is like it's a really important concept to discuss because I get that question a lot too. Um, and I would just say that a few things I would say is number one, the way I typically address this question is to say, look, there's three things involved in almost every honey operation. There's a patient, there's a surgeon, and there's a mesh. Okay? And when things go wrong, there's only one thing that can't speak up for themselves. It's the mesh. Uh, and so the mesh almost always gets the blame. Yeah, but the reality is it's almost never the mesh. It's patient factors, obesity smoking, diabetes, whatever. It's surgeon factors, technical issues. Um, you know, what it's very rarely the mesh itself. Like there's a couple meshes that we probably should have not used, right? There's the Kugel mesh with the ring in it. That was a bad idea. There's the Composics mesh with the heavyweight polypropylene cortex, and we've learned that's the bad idea. But like a lot of these other meshes, like when things go wrong, it's almost never the mesh. It's almost always technical. And so it is interesting though. So, and again, I I would just encourage everybody, just this is not, I just want to be because now we're being critical. Industry is meant to follow the trends and make money. But the but the story that you just brought up about get the mesh outside the peritoneal cavity, intraperentineal mesh might cause problems. That's actually the same story that is being told right now with absorbable synthetic mesh. It's the exact same story. How long do we need this mesh? You don't need it in you forever. Uh, avoid permanent things. So now things are shifting to we don't need a permanent piece of mesh. Now, when you look at the long-term data, it's not very encouraging. Well, I take it back. There's a price to pay for not having mesh, right? So if you look at, to my knowledge, kind of the best paper out there right now, the five-year data, is Scott Ross. And if you look at his data, and depending on how you kind of do the numerators and nominatives, it's always controversial, if you take the most optimistic view, it's probably about 20%-ish five-year radiographic recurrence. If you compare that to, say, my experience with radiographic recurrence rate in TARS, okay, with synthetic mesh, that's about maybe a four or five percent recurrence rate radiographically. Now, they'll often compare it to balls, which is to me not really accurate. So if you don't use mesh, I'm sorry, if you don't use permanent mesh, the way it should be described to patients is you will have a five times higher chance of recurrence. So, so so to me, when we talk about like shared decision making, right? Some patients might be like, well, well, I'll accept that risk because I don't want to have a permanent synthetic mesh. And you say, Okay, fair enough, then you're the one. But it can't be described as equivalent or non-inferior. It actually is worse. Same thing, I think. If we talked, you had a you had a discussion with patients, you could say, if I put this synthetic mesh with my technique inside the perineal cavity, when you look at like the real long-term data, not uncoded polypropylene mesh and not composite mesh, long-term direct mesh-related complications, it's probably less than 2%, right? Like it's about what it is. So that's what your risk is, versus what is the risk of uh interstitial hernia, uh, hematoma, nerve injuries, uh, uh huge bulbs from not closing your posterior sheath. Like people might be like, you know what? I'll take the 2%. Sure. Uh so I think, you know, you just have to be careful how you present it. Because I think that the the hardest part of surgery is to realize that neither of the ways are harmless. They all have their limitations, but we like to simplify things in our mind. And the story of leave no mesh behind is a great story. But uh, you know, I I always said like um I wrote some article, I can't remember what it is, but it was about like the Yeti effect, uh, which is that like just because you can't see the uh abominable snowman does not mean he cannot cause you harm. So so you know, it's just kind of understanding the all the risks of what we do, and just again, just be okay with the uncertainty. We don't know the answer.

SPEAKER_00 1:56:59

I have um, I don't want to take take all your time. I could have this conversation for the whole day. Uh one quick question, and and then I want to hear your hernia hot take. The quick question I have, which may not be that fast, was um, you know, with the database, the all the information you're getting, the 80% in the middle, many of those folks that are doing, if you take the volume of the 80% are doing out of the overall versus the people that are publishing things like that, that 80% volume far outnumbers the the rates of of the patients, right? In the grand scope of how many hernias are being fixed. The majority of those folks aren't necessarily in a position um to submit, right? Maybe it's it just from from all for all the reasons. Not again, not suggesting that they don't care. That's I don't think that's the case. Do you think that that skews the data and the in and the information we're able to glean from the data for the average surgeon with that patient population and that surgical population population missing?

SPEAKER_02 1:58:00

Yeah, so so essentially saying, is the QC generalizable, right? Um and so so the answer to that question is I mean, we don't really know the answer to that because we don't know the data of those 80% of people, right? So so I can only speculate and kind of measure it against like what else is available there. And I think that that is you know, it's a limitation of every database. It might be a limitation of this database. Um I I don't know if it is or isn't. I I would just say that if you look at like NISQIP, uh, which would be kind of a uh a good database to consider in that. I mean, that for sure doesn't represent the real world because you have to pay whatever, you know, 125 grand for an abstract, or that's mostly just academic centers. It's very expensive, and I think not enough people. Um if you compare it to the other thing, which is like individual centers having their Excel and whatnot, definitely those folks are not generalizable because they're just the experts. And again, they provide value, and there's value in that data and understanding what the data would be and what the results would be in an expert's hands. I would say for us, I think we I feel confident that we probably approach it just because the numbers are it's about 56% self-reflect as academic, and 46% reflect as community or or academic affiliated. So we're we're about half and half. Um I don't, you know, the question is do the community surgeons reflect reality or not? You know, we have some people. I'll mention my, you know, we have Todd Harris, who is a surgeon in Orange County, California, who literally does lap inguinals in an outpatient surgery center every day by himself. He's a solo practice guy. We have another one, Mickey Reinhorn, who works out of Boston, who does both shouldice and preparate neo-inguinal hernias open and some laparoscopy with his partner, Nora Fullington. It's just the two of them. They're solo, they work out of an ambulatory surgery center. They're just really committed to this process. So I think we have that. So I think we get closer. Now they're probably experts and they're hernia-focused people. Um in the ideal world, if we could get everybody, that would be it. Um, it is funny though, you know, I gotta tell you with like clinical trials and research and everything, and the QC is like a perfect example, right? Uh I get this all the time with myself. Like when I write a paper, like let's say my biologic first synthetic that showed that um that synthetic worked better than biologic. So there was the the argument that it's this expertise argument that, well, you know, if you're a biologic mess company, how do you sell against that article? You say, well, you're not Mike Rosen. Mike Rosen's done 3,000 of these. Are you sure you can get his results? Because if you can't get his results, you might not want to use synthetic mess. So that's I'm too good of a surgeon to believe my results. And sometimes that's an argument to QC. It's a bunch of experts, it doesn't result. But then when I publish a paper about robotic surgery, and the outcomes are not better than laparoscopy, and they're not better than open, then the argument is microsin sucks. And microsin's a terrible surgeon, and microsin can't operate. So that's the other expertise argument, is that you're not good enough. So that argument often happens with the QC2, which is that like we get we get kind of branded as like, uh, it's a bunch of open people who suck, uh, can't do robotics, or it's a bunch of, you know, so so I think that the I I think those are great arguments to have. And and I don't like shy away from that. I'll lean into that and say that, yeah, there might be some uncertainty. I would definitely say personally, I think a paper from the QC would be more valuable to the rank and file surgeon than a paper written by just my own experience. Um because it's just I do different things and I'm like hyper-focused. Um, you know, but but I guess that's the thing. Like when I do a robotic thing and I'm not the world's greatest robotic surgeon, that might be more generalizable for the rank and file person with the results that I get. So it's a funny argument that you can have a million different ways, and it gets back to, you know, and this is again, this is like our whole political world that we live in right now, that there is just some magical right and wrong answer. Right. And the the truth of the matter is it's gray. Absolutely. And it's it's sometimes the QC probably does represent the real world, and sometimes we might not represent the real world. And both of those things can exist, and you as the surgeon can digest that individually and think about it. And and it's a and I think always to say, like, use it as a part of your decision-making process. And just like how it shouldn't sway you into doing yes or no, neither should somebody who's getting up in the podium giving you the most elegant talk, who's an incredible public speaker, they shouldn't make you do something either. It should just be all the bits and pieces of information that you take in, and then you go home and you say you try it, and you're like, hmm. Like, you know, I did some robotic tars after Alfie taught me, and I did like maybe five or ten of them or something. And I kind of was like, just personally, I was like, you know what? These are people that don't need tars. Uh this is too much surgery, it's taking too long. I do the spine open. I don't really think I'm getting any better. So I got off of it. I'm not anti-robotic tar. Just me personally, I was like, this doesn't provide value for me and my patients. I don't criticize people who do it. I think young people should learn how to do it. But I think that's kind of the taking all the bits and pieces, try stuff, and then it's okay if it doesn't work out.

SPEAKER_00 2:03:56

Yeah. Well, you know, this has been an incredible conversation. Um, very, very, very much appreciate you coming on. I would love to hear if you have any uh uh hernia hot take for us.

SPEAKER_02 2:04:10

My hernia hot take is for all young people out there fixing hernias right now. Take a deep breath. At the end of the day, we are not doing life and death surgery, we are quality of life surgeons. And that actually is why I chose this field, and it's what I love most about this. To be able to give people's quality of life back is one of the greatest skills to have. And I always tell people like, like, there's no chemotherapy, there's no radiation for what I do. I gotta do the right thing for patients. It's up to me as a surgeon. But just remember, it's just her name surgery. And we don't have to make it more complicated than it needs to be. And so when you're young, you're trying to get out there, you're trying to come up with innovative things, you're trying to come up with the next acronym, which I do hate, uh, you're trying to do whatever. Just don't lose sight of your long-term career will be based on helping patients and keeping them first. And so it's easy in today's world to get caught up in some of this stuff, but for the longevity of your career, and quite frankly, for your family, your patients, your mental health, just keep patients first. If you can do that, then I uh to me that's the first step amongst many steps to having a long, healthy, happy career. And that's all I got. And keep innovating, keep pushing it. Uh, and it's an awesome field.

SPEAKER_00 2:05:38

Well, I yeah, again, I uh very, very honored to have you on. Uh, appreciate you taking your time. Uh, I know it's uh it's a valuable, it's a valuable commodity. Um, but this will wrap up our uh episode of the Hernia Gods podcast. And I again want to thank uh Mike Rosen for coming on and and sharing his uh his experience with us.

SPEAKER_02 2:05:59

I appreciate it. Thanks everybody. Hope you got something out of it.

SPEAKER_00 2:06:01

Absolutely appreciate it. All right, see you next time.