The Hernia Gods Podcast E24 - Igor Belyansky, MD

Episode 24 of The Hernia Gods Podcast with guest Igor Belyansky, MD features a conversation about his experience of immigrating to the US, mentorship in fellowship, balancing family and career, and the future of hernia surgery.

Disclaimer: The views, thoughts, and opinions expressed on this podcast belong solely to the hosts and guests, and do not serve as a representation of or necessarily reflect the official policy, position, or opinions of Orlando Health or any of our employers.

Transcript

SPEAKER_02 0:06

Welcome to the Hernia Gods Podcast. This is your mere mortal host, Luke Elms. The views, thoughts, and opinions expressed on this podcast belong solely to the hosts and guests and do not necessarily reflect the official policy, position, or opinions of Orlando Health or any of our employers. And now, without further ado, let's talk Hernia. Hello and welcome to another episode of the Hernia Gods Podcast. This is your mere mortal host, Luke Elms, and today I am joined by Igor Balyanski. Thank you so much for joining us, sir. Good morning. Thank you, Luke, for having me. Absolutely. Well, I've really been looking forward to our conversation, and I'd love to just start like we always start with a little telling us a little bit about who you are, where you come from, and how you got where you are. Okay.

SPEAKER_01 0:50

Again, thank you for being here. My name is Igor. I work in Annapolis, Maryland. Uh, the hospital called Anna Rondo Medical Center. I've been there for 14 years now. I'm uh chief of general surgery there and director of uh Hernia Center and Abdamour Construction Program. Um I guess uh you know we've chatted before, uh kind of right beforehand uh you know we we can make this whatever, you know, go whichever direction we want to, but uh uh how I got here, I guess it's like how I identify. And uh, you know, this my story. I I always think of myself as uh uh first of all an immigrant to this country who was lucky enough to uh end up here and uh a country that gave me a lot of opportunities. So I was uh originally born in a country, uh Azerbaijan, a city called Baku. Um and uh my family left in 1989. Uh this is right before the fall of Soviet Union. So Azerbaijan was uh uh part of the Soviet Union. We immigrated, and uh you know the reason I'm even mentioning that this is really kind of truly the foundation of my personality, kind of those experiences, kind of uh uh they contribute to the drive that I have. And uh so my family immigrated uh from the Soviet Union in 1989. Uh it took about a six-month process. We spent about two and a half months in Austria and about four and a half months in Italy. And then we arrived uh in Maryland, United States, and uh March 13, 1990. And uh so um, you know, I went to high school here, went to college here, went to college, kind of local college, uh uh College Park, University of Maryland, went to medical school in Virginia Company West University. We used to call it MCV, Medical College in Virginia. And then um when I was uh at medical school, um I was um uh kind of I wasn't sure what I want to do. I thought that maybe I want to do surgery. Um and uh uh you know I was uh dating my wife at the time, so we weren't married yet. Uh her father is actually a local community surgeon here, and I was uh trying to figure out I want I loved surgery. I really loved surgery, kind of loved working with my hands. Um, you know, kind of like sometimes I feel like you know, medical students rotate through and kind of ask about like how to choose a specialty. I feel like sometimes, at least back then, uh you choose a specialty by trying to figure out where your personality fit best, so to speak. Kind of uh you you find your group of people, so you click, so to speak, you know, the bunch of crazy people that love to operate, you know, just like are we really normal? I don't know. Uh, you know, I was so excited to be, like I just remember first time I scrubbed in, just uh the excitement I had, uh the intimacy of the experience uh during the operating room of actually having the uh you know being part of this kind of ritual where you're there to fix someone. Just like it's such a cool concept, anyways. Uh so uh so loved surgery and uh really kind of what just wanted to be a really good surgeon. I'm talking to my father-in-law, uh well, or my future father-in-law at the time. He was um by training, he was actually a surgical oncologist. Um he actually did a funny story as a side story. He was uh a uh fellow was uh Paul Sugar Baker. So he was also from Moscow, Russia, and he lived in Paul Sugar Baker's basement for five years, uh, getting paid like something like I don't know exactly, but like $300 a month, just like, and so free uh lodgings. And uh and then he was otherwise uh kind of like uh worked with him in the early uh 1990s, and like all the uh high-pech surgeries that now are kind of popular, that those were kind of described by Sugar Breaker. And my father-in-law was actually his fellow helping me, wrote a lot of books, and there were multiple fellows that were foreign medical grads at the time. Anyways, but my father-in-law did the residency in a community uh residency program, and uh so he suggested that instead of you know they give an academic track, you can go apply for academic residency, you can apply to community residency, and I end up applying uh to community residency with his advice because he's like, What do you want to do? I'm like, I want to be like a really busy community surgeon, like just want to know how to operate really well right away. And he's like, Well, maybe that's his bias, you know, maybe that's my bias, but like back then, you know, if you really wanted to know how to operate, like you go to the community program uh because you get to operate right away. And so I end up in a small community program in Baltimore, Maryland, uh called Union Memorial Hospital. The uh Union Memorial Hospital was uh at the time the oldest uh community residency program in the country. Uh only two residencies a year, and the hospital itself is known for being a hand center. So it's uh actually now they don't have a general surgery residency there anymore, but it's a well-known orthopedic hospital basically now. But back then, this is like back in 2005, you know, so I did my residency program there. Um and uh, you know, sure enough, uh, you know, we got a lot of cases. Uh uh loved what I was doing, uh 1700 cases, uh graduating as a resident. Uh some of them at the end, we you know we didn't lock all of them because uh this is uh I think uh so but but that that's uh you know that was a unique experience for me uh because uh because uh not everyone was like in you know academic residency programs. And not not to say you know academic residency programs, definitely not a lot of strength, strong academic residency programs, but uh but uh you know they still have to compete with fellows, and uh we didn't. We didn't. And uh uh the good thing, you know, we worked with a lot of bread and butter general surgeons, and you know, when I was uh applying, this is my story, maybe I told you this when we talked off the record, uh I was uh uh applying to uh decide to do a fellowship program. I felt like I was strong enough to go into practice. But back then we didn't do much laparoscopy. In fact, the hospital where I was at, so this is from 2005 to 2010, we did some uh lap calls, I love lapcolis. Uh early on in my residency program, after nine o'clock, we would not do laparoscopic appendectomies, we would do open appendectomies probably because like the that would be, and by the end we were doing it. I done three so-called laparoscopic inglohernias, at least part of like looking back on it. I'm like, I'm like, what were we doing? I'm not sure. You know, so like the people were still the surgeons were still going through the learning curve. Yeah, and I probably done like maybe 10 laparoscopic, like when I say done, like I'm I'm I mean assisted, uh and 10 like laparoscopic colons, and they were just horrific experiences because there were four to five plus hours uh of surgeries. Again, the surgeons were going through a learning curve. And so uh I was one of those guys like, why do we need laparoscopy? We can do it so much faster thrown up on approach. And uh I decided to do a laparoscopic fellowship or minimum research fellowship because I wanted to be more marketable, right? Yes, I had uh yeah, zero zero desire to uh to do any academics. Uh didn't really want to teach at the point, like at least didn't have that desire to teach. And um so ended up applying to um uh applying to fellowship. And uh uh my mentor at the time, uh his name is Chris Hugh. He was uh a younger surgeon who is like you know four years ahead of me. He did MIS Fellowship locally in Baltimore. And again, I I have ties to Baltimore, Maryland. You know, I actually live around Baltimore right now, even though I work in Annapolis. And uh so I wanted to stay in Baltimore. At that point, I was already married at the end of the residency. I had a child, uh, my first uh Masha, uh sorry, uh Sasha Alexander, my first one, uh, who was uh, and we were she was two years old. And as I was um, you know, as I was applying, like uh my my mentor was studying for his um for his uh written boards, and he was doing CSAP, CSAP 13. Like, I'm not sure if like they I was asking younger surgeons now if they do CSAP questions. Sounds like it's not a thing anymore, but back then CSAP CSAP questions were kind of a thing he gets ready for boards, and then at the end of each question, you would have a reference uh to different uh uh to different surgeons, different things. And he's like, Oh yeah, um like you know, like we applied to Canalis Medical Center. He's like, Yeah, he named Haderford. I see it all the time in CSAP questions as a reference. He's like, why don't you apply there? Like, and I'm like, okay, well, whatever, you know, apply. So I had no idea what I was applying for, just like literally, like completely blindly, like you just imagine a sheltered, like a surgeon who, like a surgical resident out of smaller community residence program, two residents a year, just applied to uh applied to you know, Todd Head of her program, and applied a bunch of other programs. And so this was a second interview I had. And I would say what on paper, I was below average. You know, as somebody now who is a program director who is like looking at like, I mean, I was way below average uh on paper, like no publications, you know, nothing to show except you know my experience. I think experience-wise, I was out there, but uh but that's you know, that's who knows like what you're hiring until you start working on. Exactly. And right, and so I go get to the fellowship. On my right side is uh a resident from Duke, on my left side is a resident from Cleveland Clinic, and I'm like, what the hell am I doing here? Like I'm like the resident from Mini Memorial Program, and then I look at the list, I'm like, and then I realize it's a two-year fellowship. I'm like, what the hell? You know, like first year research, I'm like, I'm not doing that. Like, and but but I don't want to be a rude, so like I look around and I'm like, okay, well, I'm just gonna stick around. It's like I flew down to North Carolina, I'm like, this is like how unprepared I was. I flew down to North Carolina, and I'm like, okay, well, listen, I just gotta be professional, not burn bridges, and just kind of and then like uh Todd Handeford walks in, and I swear, like he electrified the room. Now, you know, Todd is a polarizing personality. I love the guy, uh, but he's a kind of person that at that time who just completely like I felt like I was right away instantaneously the same wavelengths with him. Like just this energy that was palpable in the room. I just, if he told me to jump off the building, I would have gone and jumped out of the building. That's how I felt like meeting the guy. And so we just hit it off. And uh I'm just actually doing the interview, I'm like, God damn the port, uh, why would you want to hire me?

unknown 11:47

Right.

SPEAKER_01 11:48

Like I actually asked him that, you know, like which is like like like why would you because like I was so excited, I just he made me feel at the same time so comfortable. And I was like, it's like during this interview, you were like almost like so manic, like talking, like you're not even thinking about. And I asked him that, and he just went on to talk about like how the people who came uh before me, and so he trained just like Todd Hen, for those of you who may not know, he trained um Christy Harrell, uh Brent Matthews, uh Michael Rosen, Alfie Carbonell, Yuri Navitsky, um, I mean uh Vedro Augustine, uh Will Hope, Will Cobb. This is just some of the people, if you're an American Hernia Society, and I hope I didn't miss anyone just kind of uh calling the top of my head. Uh, this is the people who truly have made a difference in the world of hernia surgery, in the world of minimal evasive surgery. And uh, I mean, people that I know in many ways look up to. Uh so uh so yeah, so he tried, he he in himself, he's like the godfather of hernia surgery. Uh I would say American hernia surgery, I would say. I didn't know any of that, basically. I just like how his energy. And so I came back and uh, you know, I go, Nadia, uh, I think I'm gonna, and this is the number two interview. I I really like this place, and and but it's a two-year thing, and it's in and it's and it's the farthest place applied to in Charlotte, North Carolina. And I think I'm gonna go there. And I remember having a conversation, it was a lot of like because we always planned for me to stay in Baltimore, at least close by, because she, my my wife is an anesthesiologist, she was already working as an attendant, my chief year, and uh we have a little one, and we needed help with a little one. We we have my in-laws living close by, my mom was living close by, so we didn't want to move away. Right, and so it was a big deal and this decision. And so she is Landy was like, Well, listen, why don't you go ahead and uh you know see what other interviews? And it's so funny, like I would interview, and people would ask what else have you looked at? And uh and they're like, I'm like, Well, I really like this uh Carolina's uh place. Like I went, and like, oh, Dot Hannafort, and everyone would be like this, and so every time I would bring force, and uh and so I I have no idea till this day why he ranked me out, you know, he but he did, and I I matched into Todd's fellowship, and that was for me kind of a changing experience and kind of my direction. I feel like I always had the drive, I always had the drive to kind of want to succeed, but he just uh helped me like you know, we are you know what our mentors uh kind of our mentors really can change the direction we travel our life. And I feel like he has shown me a new pathway in life, which I otherwise would not have seen, would not have fun. I think I would be okay success-wise. Like success, what is success? We can talk about this. Uh but but he has helped me find a pathway which I didn't see there at all. Uh, the research year was the best year for my professional development for many reasons. Uh, first of all, I needed to really kind of grow my horizons, and that was the year that I slowed down from being a surgeon because my five years in residency I concentrated on being this technical surgeon, being proud, rah-rah-rah, surgery, surgery, surgery, which I still was as a fellow as well, but uh but but there was more to build on. And uh and and and one of the things we've talked about, you know, the fears, uh the uh perhaps uh perhaps uh anxieties that we have. My my number one anxiety, uh fear was getting in front of people and speaking. Yeah, it was so difficult for me to get up, you know, like heart rate. We've talked about heart rate of 140, uh, shortness of breath, uh, you know, uh needing sometimes taking beta blockers, you know, uh just to control it because it's just so hard to control the physiological response. And uh Todd really helped me through it uh quite a bit, and uh just the experience of those of you, if anyone listening who has the same fears, I think you just have to keep pushing yourself and uh uh kind of keep doing it. At the end of the day, Todd always told me that uh, you know, Igor, at the end of the day, uh nobody out there in the room knows as much as you do about the stuff that you're presenting. If you have research, nobody knows more about your research than you do. You have to remember that.

SPEAKER_03 16:28

Yeah.

SPEAKER_01 16:28

And that's kind of the approach I took whether whatever I present uh nowadays. I just, if as long as I feel like I'm an expert and uh or I know really a lot of stuff, I feel very comfortable getting up there and just talking about you know the stuff I do my daily basis. And it's really helped me. So I I can stop there, but uh, you know, uh and uh you can direct me or direct me uh go back somewhere, yeah.

SPEAKER_02 16:53

Well, you know, with with your uh telling of your story, my brain just like is firing off like uh like I just took a hit of something. But just because there's so many points that you talked about that I relate so heavily to, uh, one I want to jump back to, and then I have a whole bunch of other questions because you're an incredibly interesting person. Um the uh you talked about you said something about like you thought you you'd have been successful, whether you did the fellowship or not. And I have had that feeling um a lot over the course of my life, and it and I don't think it comes from a place of ego. Um, I'm not trying to say that I am like better than other people, but what I have found in myself, and I wonder if you have that feeling about yourself, is you know, there are times when I've said, like, listen, I, you know, I got into medicine full disclosure for kind of the wrong reasons. I was chasing a girl. I mean, like, I was scared of losing my girlfriend at the time, who's now my wife. And I I suffered from imposter syndrome in my own relationship to the point that I was scared that if I wasn't around, that it was just a matter of time before she looked around and realized that there's way better people than me around that she could, she could, you know, tie her life to. And um, and so I, you know, have at many points through my career had like one foot in, one foot out, kind of always kind of going, I don't know, maybe I didn't make the right decision, you know, all this kind of stuff. And it really goes back to like a fear of failure um and just being scared um that I'm flying too close to the sun or or something like that, which you know, interviewing folks like you, that you know, that is like my peak. Exactly. Because that's my fear, my fear of falling. But but you talked about being successful. And there are times that I've said to people, hey, you know, I think I would, I would want to, I don't think I should have been this or I shouldn't have done that. And and they always say, Yeah, but and this is not people within the within the field, but it's you like just people from back home and things, yeah, but you're so successful as a surgeon. And the point that I always try to make, and it always comes across like I'm being arrogant, but I promise I'm not, is that I would have been successful at whatever I chose to do for a really a couple of reasons. One, I am so scared of failure that I am not gonna do something that I'm certain I'm gonna fail at. And it it probably limits me. It's probably a limiting factor in my life. Uh, but two, I also know that um it's it's it's an incredible thing how our lives when we when we're living our life, our perception of our life many times is way more powerful than the reality. I grew up in the panhandle of Oklahoma. I wasn't trying to immigrate to the United States. I wasn't displacing my whole family my whole life. I didn't have to pass through multiple countries and live months at a time, without which I'm sure was a lot of uncertainty at your in your age, I mean, in your home country, your home that you identified with going through the massive changes and upheaval of the fall of the Soviet Union and things. I didn't have any of that. You know, I had the uncertainty of weather patterns because we were farmers in the Pan Hill of Oklahoma, and the uncertainty of if our bank loan was going to get called. But whenever I went into what I was going into, I didn't feel like I had any fallback plan. None. And that's probably not true, but that was my perception. And so that instilled in me this drive that no matter what it takes, I will be successful because there was no other choice. You know, in my in my psyche, it was success or death. And it there was no in-between. And um, and so I guess my question for you, after that very long-winded lead-in, is did you do you feel like your background did you feel like you had an option besides to succeed?

SPEAKER_01 20:46

Yeah, I mean, look, I can I can really relate to what you just said. Uh even though we we had completely different experiences uh and and hardships growing up. Um I it's uh it's it's interesting because you know, and again, there are many people who have immigrated to this country and have very similar experiences to what I had. So I'm by no means unique in that sense. How you interpret that experience is very different than what you do with it, but and how it impacts you, you know. Like I was I was a I was a you know, I was a teenager, right? And I just remember uh you know, by the way, I was never hungry. I I wouldn't call ourselves poor, but we were lower middle class. And my parents truly have in the 1990s lived from paycheck to paycheck. Yeah, and I just remember the stress that my parents went through. And and I that always stayed with me. And so when you talk about uh, you know, what you want to do is I I I you know, did I want to be a surgeon back? You know, no, like there's some there's some kids who are extremely like I meet some of some of my uh my my kids' friends or my my kids, like they're so driven, they're so they they're so smart, and they know exactly what we're doing early on. I didn't Have any of that. Listen, I I love playing video games. I loved playing basketball. I was I played waterfall growing up. I was an athlete, but not like D1 or even like any collegial athletes. I was just playing in high school. Becoming competitive when it comes to that. I just wanted to play basketball when I was a teenager. I, you know, I just I was, you know, uh in high school or in school, I was an average student. Uh I had C's, uh, especially in sciences where you had to memorize things. I didn't do well. Math and physics were easier for me because like you can spend time figuring out how things work and you can prepare it, and like I would get A's on those, but the rest of the stuff I was the point I'm trying to say is I was not like driven in that sense, but I knew I I was I knew I did not want to be what like you know, uh I didn't know what to be a loser. Loser, like what does that mean? What does that I mean like I hope I don't regret saying that, but what does that mean? It's a matter of like like I didn't want to be a failure, uh, and perhaps that's an immigrant mentality, you know, because because at part of it, I would feel guilty that my parents did so much because I saw my parents struggle. That's the thing. And I would say this uh, you know, my parents struggled, you know, they kind of buffered me and they cushioned me, and and I didn't have the same struggle. You know, my parents, like, you know, I look at the pictures from the 1990s. My dad was 49, so my age when he came here, and my mom was uh 43. You know, they had an age gap between them. And uh, but they came in their 40s, so I'm 49 right now, I'll be 15 January of 27. And, you know, like this is essentially you can just imagine me coming to a new country and starting for fresh. It's it's it is it is you know, my dad never truly learned English uh very well. It's very hard for, especially uh coming in the middle when you didn't know. My mom did quite well, actually. It's interesting. I think women uh in general usually transitions better to looking at immigrant families, um, you know, uh and succeeded better here. But but you know, they sacrificed so much to come here. And a lot of it's for me, and you know, I I I I I would feel like there's a lot of guilt I would feel if I didn't make something of myself.

SPEAKER_00 24:28

Yeah.

SPEAKER_01 24:28

And so, and so I had again like uh a lot of help always. You know, so I remember like I was again an average student, I was a good kid, uh, you know, whatever that means, uh, and likable. And the dean of school picked up the phone and uh she called the admissions office uh in uh College Park. Um and they helped me get in, I think. Whatever, you know, you know, otherwise I would have gone to community college based on my grades, which would have been fine too. Uh but that's uh that's where I got in. And when I got in to College Park, it's the first time, first time I really had to figure out how to even study. I didn't have any kind of I didn't know how to study. So like that was a hard thing in college for me, was like just figuring out how to study. And it just sounds so silly now, but uh because uh it's a basic skill. But uh but the dr I guess we're talking about wanting to succeed, that wanting like not like not being afraid of failure. And and you know, why did I go the direction I went to? I mean, I had nothing else. Why did I become a physician? Well, my remont was a physician. I had uh, you know, um, you know, in Russia. It's interesting. Her story was uh, you know, she was she specialized in C B tuberculosis, and she saw she practiced before antibiotics and after antibiotics. So it just was always crazy to listen to her. So I had deep respect for the woman, I had deep respect for the professional being physician. Uh, you know, like 1990s growing up, if you ever watch ER, like the whole specialty of medicine was like a romanticized, like saving life. It sounds really cool, you know. Like, yeah, so there's like the new reality shows, trauma reality shows we watched, you know, it's very cool stuff. Like, you know, uh Hopkins 24-7, I think, came out later. Like, you know, you saw some of the stuff. And so, you know, when you have nothing else and you see some of the role models, and kind of like my family always encouraged me, like, think about medicine. So I was pre-med. Yeah, but I, you know, I didn't mention initially, but I actually I was gonna finish college in three years. Then I was like, uh, you know, I took AMPCATS, I didn't do well on AMCATs, and I'm like, yeah, let me retake it. My like, let me retake it the following year, and let me like, I was gonna double major uh in computer science. So and I started taking computer science courses, and I realized I would have to stay five years to finish the major because it's actually computer science, it's a very complex major. I'm like, well, listen, I don't need to major computer science. So after four years, I got biochemistry degree, and actually I had a gap year. I work as a uh as a computer programmer, C and C programmer for a year. Uh, and because this is back in 2000, and that was uh those of you like who like remember stock market, that was the um dot-com boom. Yeah, and I worked for a company called Share Media. So a lot of like a code I wrote was C code uh for backend code for uh you know um uh taking uh taking files that you would send through email like that uh like said um uh word files and you would convert them to dot TIF files behind the scenes and they would come out in the fax machine basically. Yes, dot TIFF files. And that's all I did. I loved computer programming. I loved it. And I almost like actually didn't go to medical school. Like I so the same year I got into medical school, I got into Eustace, so military school in Bethesda, I got into uh MCV, and I got into Chicago school. Um and uh, you know, first of all, like it's it's a big accomplishment, competitive. Uh, but I was like, I'm not sure if I want to go until Christmas time, when uh and it's interesting how like sometimes things go because I could totally see myself staying as a computer programmer and maybe becoming very successful because I loved it. As long as you love something, I'm like I was like making like something like $60,000 a year, which is like a lot for a castrenium at college in 2000. And so they they called half of us to a meeting, and the other half uh you know didn't get called. And so I was living in a meeting, and I don't remember what the meeting was like. I just remember that when we came back afterwards, the other half of people were done, and that was so shocking. So that's that happens in real life, and it was such a shock. You know, I was like, I was a kid, like 22 years old, and uh I was like, oh my god, like this, the people I worked with and they lost their jobs. How do they and they have families, kids? You know, I was like, I was living at home, like uh and uh having a good time, like uh you know on the weekends. Uh meanwhile, like these people needed the money to you know to survive, you know. How do they do this? And I'm like, is this the rest of my life? Is you know, and I'm like, well, medicine sounds like a good job security. Let me try this out. Yeah, and that's why I went, yeah, I'm like, that's fine. Like it's it sounds really silly because like it's almost not it's almost not fair because like some people work really hard to get into medical school, and they like there's some people in medical school uh in my class who were like apply two, three years in a row, and then finally got in. And here's this kid who gets in and we wasn't sure what's wants to go. And when I got to medical school, it was like, you know, it was the coolest thing because for me, like you made a lot of good friends. It was like very interesting. This uh, you know, this group of very smart people who are funny and like you know, just became we became close friends uh with a lot of people. I met my wife the first day in medical school, uh, my future wife, I mean, but uh yeah, it's it's just this the story, the story is I kind of went on the tangent there, but the story is uh, you know, do you have the drive to succeed? I think I just needed direction. I was missing direction as a teenager. And uh, you know, a matter of experience, like a combination of experiences got me to where I am right now. I think the drive was there no matter what, whether it was gonna be computer science and becoming a techie IT guy who maybe down the road would have owned his own company, like because he just wanted to succeed, I probably would have gone there. But I didn't go that direction. I wonder sometimes what would happen if I stayed that direction. Sure. But I went down the direction of uh medicine because of that experience of people getting fired. Uh went through two years of medical school, and again, the you know, I was never strong when it came to just purely books and studying. So I was an average, uh, average student in medical school, like tough my wife was like uh top, you know, five percent, she's AOA, you know. Yeah uh and uh I was just an average student. Uh, you know, when until I got to third year, and when you got it, and and the third year, that's when I shared initially kind of just the whole world opened up to me, and I was like, yes, this is it. This is what I want to be, this is what I want to identify as. And I truly identify as a surgeon uh because that became kind of uh uh like the next like the foundation of who I am today, a kind of part of foundation who I am today. And I'm so happy and lucky to be to have gotten there through many experiences. But you know, like I just don't understand how how like we expect you know teenagers to decide where they want to be, like having gone through experiences I've gone through myself, but you know, yeah, you know, um we put a lot of pressure on people to just determine who they are.

SPEAKER_02 31:59

Um, I'm 41, I uh don't know who I am still, you know. I'm waiting to figure that out. Um, I think that it's funny because I've been with my wife since we were 17. And so we went through all these processes together, and what I can say about a relationship with that kind of longevity um is that one, it is extremely hard, and it's definitely not a fairy tale. Um, but the one thing that we figured out through some marriage counseling is essentially you become a different version of yourself every five or six years, at least in my experience. And uh for us in those types of relationships, we had to fall in love again every five or six years. And sometimes that was easier and sometimes it was harder. Sometimes you grew further apart during those years, sometimes you grew together because it's two different people changing, it's not just one. Um but all that to say is as you are going through those changes of life, you know, the person when you're making a decision on your career at the age of 20, age of 17, you know, some of these folks, like uh by the time you're 23, it's a very different world. And you know, I it you talk about how you kind of went through your your medical school application journey. I went like the other way, um, lived kind of a charmed life. I just kind of bumbled my way into medical school. We um I'd come out of a boarding school where I was gonna get it, it was a state-funded boarding school uh for math and science. Um and so I'd transferred a bunch of credits directly into college and and I could graduate after three years, but I wasn't planning on it. And so one there was like an evening where my wife and I, she was on pre-med as well. Uh, we were like, you know, we haven't studied at all for the MCAT, but what if we to figure out kind of where we stand and and what we need to do, what if we just took an MCAT like this year, and then we'll just take we'll then we'll figure out what we need to do, study for it and take it. Great. Yeah. So we signed up for it, and um when we get to and we get to almost to where we're about to take it, we we had not uh partied at all through through um any kind of college. We were young. Well, we had uh recently found like you know, like the girliest drinks alive, you know, like smearing off ice or something. And uh we like bust out uh bust out a few of those the night before because right before, but we're both a type A people here, so we're about to take the MCAT cold. Um, but it's still kind of like you're a little bit of pride going like I don't want to like screw so we're a little nervous, and so uh we we had a few and a few too many. And uh so the next morning we wake up completely hungover and we end up at the at the MCAT. We take it, and at that lunch, we skipped lunch, we actually went back to the car and like slept because we were not feeling well, and we come back and take the rest of it and we go home. And eventually uh time comes for us to uh um uh time it was just going and we're waiting on our scores to come back. And so the the scores come back, and uh and I get we get the scores. I'm like, wow, this is like these are like not as bad as I was expecting. They're kind of like borderline. And and so then we were sitting there one night and the next day we were like, what if, well, I mean, this is just a practice run. What if we just practice applied? We'll only apply to one school and just see what we can do. And so we applied to to University of Oklahoma. The application turned out the application was due in two days, and so we like literally had to get all the application, like the letters of rec. We had to go be like, hey, can you write this today? And um and they did it because you know we were too naive to realize that that was just an absurd request. Um, and so we like hand deliver it five minutes before it's due, and three days later we had first-round interviews, and we were like, holy cow, this is like getting a little bit kind of real. And so then we so we were like, well, we've come this far, might as well just do the interview. So we do the interview and I get in. And um, so I went from getting these MCAT scores back that were just supposed to be a practice run to me being in medical school in like a month and a half.

SPEAKER_01 35:51

What about your wife that she got as well?

SPEAKER_02 35:53

So she got waitlisted.

SPEAKER_01 35:54

Oh, okay.

SPEAKER_02 35:55

And the reason she got waitlisted is um she uh doesn't have a college degree. Okay, but she got in off the wait list right before school started, so we ended up in the same class.

SPEAKER_00 36:08

Interesting.

SPEAKER_02 36:09

So we went together. So yeah, so she just has a high school degree and an MD. And um and so, but yeah, it's uh it was a kind of a serendipitous kind of pathway. But it's funny because as I go through training and as I'm going through these processes, I had you talk about seeing how the people got laid off. And and I I from what I gather from what you said, it was kind of like that the insecurity of life that that showed you you were like, I need something that is a little bit more of a sure thing. Um I had the same feeling when it came to the fact that we were racking up so much debt, uh, because we couldn't we couldn't afford anything, and so we were racking up debt after debt after debt to get through our schooling uh in medical school. And so when it came time to start choosing specialties, I was looking at stuff that I probably would have enjoyed and going, doesn't pay enough. I'm not driven by money, I'm not trying to say I want to be a multi-billionaire here, but I also had never seen anybody in my life get out of debt. Like once you were in debt in where I came from, you were just in debt, and like that was just the hamster wheel you were on the rest of your life. Whenever you were going through and you made that decision to jump away from something, um, the C programming, which is the only pro computer programming class I took, and it's a good thing because if I had ever um actually went into C programming, we had to like program like a vending machine, and my like mind malfunctioned so badly, I just imagine that they like exploding in some like hallway somewhere. But um, so good for you, wasn't for me. But um, you know, whenever you were going through that, it sounds like you really liked it. And um but but that was kind of like the thing that moment was made you kind of go and recoil. Do you think you would have made the decision to jump out of that if you had had a different um childhood? And the fact that it's you know, when you're going through something like you went through, there is a there is a value to certainty, and there is a fear of uncertainty. And do you think that that contributed to that decision, or is that just how you're wired baseline?

SPEAKER_01 38:15

You mean like uh uh jumping uh uh switching from uh C to medical school.

SPEAKER_02 38:23

That that's a more certain, you know. You don't see doctors getting pink slipped near at the rate that you see like computer programmers, for instance.

SPEAKER_01 38:30

I I just I just I just uh felt like here was my thought process. You know, I was young, 22, I wasn't married, you know, I I was in a relationship at that point. But it's it was one of those things where like, listen, now I felt like now is the time to try this. If I didn't try mental school, like I thought, let me just try mental school, let's see what happens. That was really it. Let me see what it's about. It makes sense. Obviously, I had encouragement from my uh parents, you know, but what immigrant parents wouldn't want their uh son or daughter to become physician, you know. So that was that. Uh but uh but but uh it just seemed like a smart decision at the time because I thought I could always come back to become uh an IT guy if that didn't work out. You know, I didn't think about the debt and all that stuff, like really kind of like it was like I didn't understand finances very well until my probably late 30s, 40s.

SPEAKER_03 39:27

Yeah.

SPEAKER_01 39:27

So like the amount of debt I accrued uh, you know, like over medical school, if I understood it, maybe that decision would not be made with such an ease. Uh but uh but yeah, I thought let me try this out because uh the the IT world seemed to me quite unstable. And uh and I and I create and looking back, this was the time, the boom, because literally two years later, you know, many companies, including the one I worked for, went under. You know, and and uh uh but uh yeah, so I I think it was it was one of those things. It's smart, it felt like it's a smart thing if uh to do I I'm not married to anything. Let's just uh let's just uh let's see what happens. So let's let's kind of uh you know, as a young person, you make decisions kind of on the go, and uh, you don't particularly, you know, like for now, I think decision making is very different, right? I mean, I'm a father, I'm a husband, um, I have uh a career. Uh decisions are, you know, we spend time contemplating them, really weighing the pros, the cons. That was not it. It was just like, hey, let's go, let's try this out. It's a very different time in your life, you know.

SPEAKER_02 40:38

Yeah, you know, you you talk about being a father and a husband. Um as that has become, in my experience, uh it it becomes more and more of a part of you and a part of your life, especially as your children start to get older. Um because it at least in in my in my the way that I view the world, that is something that matters a lot to me. Not saying that's right or wrong, just is for me. Um the uh has that changed your career path specifically around the fact that you're very um I'm I'm sure that you have speaking invitations all over the world that pour in on a daily basis. And um and has has that changed how you've approached your career as you've gotten further into you know fatherhood and and into your life with your family?

SPEAKER_00 41:27

Yes, yes. Um yeah, it has.

SPEAKER_01 41:31

I'm just I I want to be fair answering that, not to kind of uh you know, because uh the answer is now uh I always and this is kind of internal, but I always wanted to make sure that my kids have like look up to me in some way and I'm proud of who their dad is. And I wanted to make sure my kids are proud of for their mom is uh and I wanted to make sure they also felt like they have a stable family because that's kind of uh as as they move forward in their life. And that that really developed you know, you know, it's it's it wasn't, you know, when you have a child, right? It's kind of like it's not like even though there are many books of how to be a parent, you just like kind of uh it's an experience you learn to go, so to speak. At least that's been my experience.

SPEAKER_02 42:21

Oh, 100%. Yeah.

SPEAKER_01 42:22

And and and yes, in a way, you they say, like, like, like, do you love the child right away as a of course, but but that relationship forms this child as as my daughter's gotten older. That really we continue to build that relationship and develop that relationship, then we become closer and closer as they get older, if that makes sense. Or before, or before, you know, you're just there uh like as young parents, you're just there to go through the motions, right? Like, you know, whether it's uh nap times, feeding the child, you know, who goes first, you know, and and here both most parents uh you know, like your family as physicians, you know, trying to figure out how, and there are many people that are involved in taking care of the child. So the point is the relationship evolves where at some point the children start giving back emotionally, you know, uh, and and and that's where we're at right now. So the perception, your perception about your career and you as a family person changes as well. And uh perhaps also, you know, you know, I feel like early on in my career, I've accomplished much more in my career than I ever anticipated I would or ever imagined I would. So that part of the ego that we all have, and we all have egos, has been really satisfied. And uh you talk about invitations. I I get some invitations, not as much. I used to say no to, I started saying no to a lot of things after COVID. To me, that was a transition zone. Between 2016 and 2020, I was traveling a lot. And some of my uh friends, close friends, still do the same. They travel once or twice a month, and I think it's absolutely insane. I I just I just don't know how they do it because I got to the point where I was doing that. And uh, you know, at some point I started asking myself a question why am I doing this? So part of it is, you know, there's a couple of things. Part of it is, you know, you're doing it because it's a duty, because I felt like uh there was a duty that I had to teach. Like the you know, we talked about ETEP, TARS, whatever, you know, like all those different procedures. I had to kind of spread the gospel service because that's one thing. Another thing is to be honest, it was also kind of if you are in practice, you know, the way you build practice, because like I'm essentially in a private practice setting. What I mean by that, I'm a hospital employee, but I'm not part of a huge system. In order for me to build my practice, I have to be a known entity.

SPEAKER_03 45:05

Correct.

SPEAKER_01 45:06

As a name. I have to spread, you know, and that's how I build my practice by forming relationships with other surgeons. How do you form a relationship with other surgeons? You teach, you open your door to operating room, they come visit you, uh, you exchange information, you make yourself available to those surgeons to help out whenever they need help, they have information, and the harder cases sometimes they'll send to you. That's been my model. How do you get to that point? You have to be uh at least continue to be present on the national and international stage to teach. There's also been an incredible opportunity to travel, to see countries and everything else, but at some point I got so much to where I was getting burned out. And I wasn't being able to be there for my family. I wasn't being able to be there, I wasn't able to be there for my practice, I was getting stressed about not being in the operating room enough. So the whole thing was just uh it was gonna come crashing down until like luckily we had like you know, like for luckily for me, we had COVID where everything came to a screeching halt. And uh and then I had to kind of reassess some of my personal kind of beliefs, understanding. And so what I said is I'm not gonna completely stop, but I'm gonna go from doing this one trip a month to doing four trips uh a year. Yeah, you know, so I I pick like four trips a year where I go to, and usually kind of like if I promise somebody a year and a half in advance, I'll go like I just came from Greece uh last week. That was a great trip. You know, it's a friend of mine who asked me to be part of it. That's uh, you know, um not going to EHS, but I'll be part of AHS, but then I'm going to Romania in uh in uh in October of 2026. But like, you know, just just just smaller things. ACS is gonna be in Washington, D.C., like I said, okay, you know, but it's that's local, I don't have to travel anywhere. But also what I'm afraid of becoming, and this is talking about ego as well. I didn't, I feel like not all, but I feel like some people uh are on the circuit because they really need it as part of their identity. Yeah, and I was afraid, I was afraid I was gonna fall into that rabbit hole where I needed to be asked. And at some point we all become irrelevant. So in my own way, I said, okay, I'm gonna pull back a little bit, and I'm that's not what I'm gonna make my life about. You know, I'm gonna make my life about local career here and be present there for my kids, my family. And and it's a funny thing, is the kids themselves will probably not, you know, like uh, you know, they may not uh you know, they don't uh need me there all the time, but when they need me, I'm here. Yep, because like I'll stop by my kids' room and hey, you know, Sasha, hey, how's it going? How's your day? They'll find that, you know, like you know, how teenagers are finding that, you know. Sure. Anything you want to talk about? Uh no, it's everything's fine. Okay, that's that's kind of it. Uh, but then sometimes, you know, Sasha or other little one, Marsha, they want to talk. And I'm there actually to talk. And and so, like that once a month type of deal when they want to talk, that makes it all worth it because I was there when they wanted to talk. Same thing for my wife. My wife is always there for my kids. And it's that's just you know, like it just you can't time it around your schedule. Like their schedule is very different. When they want to talk, it's not necessarily in your schedule, and you have to, and I have time, I have the ability. My practice allows me to do this now. And so, and and then as they got older, you know, we tried to travel together now, try to do more things. And so, but but to get to this point, to be completely honest, to get to this point, I had to do some sacrifice initially, and I wasn't there for them, like probably 2015 to 2018-19. I wasn't there for them as much as my wife who was there for the kids. And that was where the family unit came together, um, you know, because it didn't necessarily financially pay for me to drop, because nobody pays you uh to go up there and speak in front of other people. And it's time away from home, they'll pay for the flights and the hotel lodgings, but you know, you get to see some nice places, meet some incredible people along the way, uh, but that's time away from your work, time away from being paid. Yeah, that's the reality of it. Uh and uh but but that helped the way I the way I pivoted is that helped me build my practice and become busier and become kind of the person that like you know, the the professional I am right now, where I have a practice because I've invested the time uh into that. And so it was an I think of it as an investment of practice now, and the reason I continue to speak and talk right now is um uh is probably I think there's also a duty that you have that all of us who are busy surgeons, because where our field is right now, it's in transition. And so I think we have to be available, we have to speak, we have to teach. It's my duty to teach. That's why I have a fellowship and I trained fellows because there's so few programs in the country right now that are specializing like what we call now abdominal construction and hernia surgery, where before we just had MIS, minimal invasive surgery, right? And it was kind of like kind of it's essentially, and what is MIS? It's general surgery, right? Yeah, yeah, yeah. And uh and so and so uh yeah, it's it's uh I hope they answered your question. Absolutely.

SPEAKER_02 50:38

No, no, that it did. It very very much so. There's a couple of points I'd love to get to there. One, sure, you talked about being a father and um and the fact that kind of like early in in the in the lifespan of your children, it's just like they have less need for us, and it doesn't mean that we're not important, we shouldn't be involved. I'm not saying that please don't send hate mail. But um but the uh but what I'm saying is it's like there's a a you know a very, very tight connection with mom during that period of time if they have that luxury. And so uh, you know, my wife uh was breastfeeding and things like that, and so that was very important. She was she was still working, she was doing call, and and I would come home and and um you talk about that period of time in life whenever you're out there trying to to grow um your practice or grow your uh your career to and and and then some of that you're right, we do it for our ego, there's no doubt about that. But then on the other side, there is like the aspect of like, hey, this is how we provide for the family. Um, you and I both have a very different world than majority of people, and that our wives uh also produce, which is uh you know something that I have relied heavily on um that allows me to make decisions that other people who are the sole provider for a household don't get those opportunities. But um, as my children got older, the times uh I couldn't relate more with what you're saying. You know, you were talking about those conversations. You can go for weeks and have like, they won't even tell me, Hey, hey, what'd you do at school today? Nothing. You're like, okay. You know, as like you're like rushing home from I'm like rushing home from work. I'm like, I want to be there when they're eating dinner so I can talk to them. Like, hey, how'd the school go? Fine. What'd you learn?

SPEAKER_01 52:12

Fine, dad. Fine, everything's fine, dad. Nothing.

SPEAKER_02 52:14

You're like, oh, okay. But then there'll be the that day that something will happen and somebody will have something to say. And they don't call your executive assistant and ask for it, ask for a meeting, you know. Um, and and it's not that, and it's not one that you can be like, hey, hold on. Um, dad's getting a call and come back, and the conversation continue. That doesn't happen either. And it's taking me a while to learn that. And so being present is is such an important thing. And as my kids, my my old my son's eight, um, he has a lot of the predilections that I have, it's it would seem. I'm trying not to like you know, project onto him, but anxious kid um at times. And so trying to kind of help him navigate that in ways that um that uh it wasn't navigated for me just because I don't think that people knew like what that wasn't like a thing you thought about back in the 80s and 90s, you know. Um and so we, you know, kind of working through that. I went, I recently took a trip to Belize. It was the first time that we'd really taken a family trip to Belize, and and um I uh had my my office and and partner did some things to where I couldn't get on to work because I'm the world's worst about going on vacation and then being on my phone nonstop working. Yeah, yeah. All I'm doing is managing it from away as opposed to there. And so I went away uh for about uh six days, and um and I came back and the world didn't end. Like the hospital was still seeing patients, like you know, like my office didn't like burn to the ground, and I and it's one of those moments where you come back and I had this moment of clarity where I was just like, you know what? The fact that I thought that all this depended on me and me alone was probably just my ego talking. And I went home that night, was having a little bit of an ego uh uh existential crisis. I have those about once a week, so it's nothing new for me. I talked to my friend the other day and I said, I had this epiphany, and he goes, Another one, huh? And I said, Yeah, I was furious at times. But um, so I came home and that night uh my son asked me to lay down with him to put him to sleep. And that's usually mom's job. But now my daughter and my son sleep in separate rooms. They used to share a bedroom, now they sleep in separate rooms. And so um, my wife was laying with our daughter, and so he asked if I could live with him. What usually happens is I lay there, my daughter falls asleep, my wife gets up, comes in to check on him, and he's like, Okay, okay, dad, see you later. And then mom lays down and he goes to sleep. Well, this time she came in there and he and she's like, Hey, you ready? And he's just like, No, dad's here, I'm good. And she left. And like that moment, you know, it means like I, you know, it's just like an incredible, it means more than anything you've ever done in your career. Like, there's like a 30 seconds of just like, oh my gosh, like the world actually makes sense for a minute. And so it put me into this really weird thing. And so you were talking about asking questions about like why you were doing some of the travel and stuff. What I ended up doing is I ended up having this moment at work where I kind of had these three questions pop into my head that's been kind of a culmination of of uh of a lot of um uh advice I've received from a lot of my mentors, many of who I wet I've met through this podcast, honestly. Um, and so the three questions that I started asking myself when it applies to work, but outside of work as well, was one um, does this add value to me or my family? And the further that was my first question. And the the question is not a value in monetary. Sure, that means something at some level, but more, I mean, I'm okay doing work for free, or that's not compensated well if it makes me fulfilled and I can be a better person for them. That's not the point. The money is not necessarily the only value that matters. Two was is it an apt actual obligation? Because I was talking to uh another friend of mine, and he said, you know, uh the world sometimes in this profession and in our lives, we look at ourselves like in this like jail cell, and then you turn around and realize there's like not a lock on the gate, and the only person keeping you in the cell is you. And so I thought that was kind of uh profound for me. And I said, you know, is this really an actual obligation? And then three is am I just doing this for my ego? And um when I and so I was having this moment, I started flipping through my calendar at work.

SPEAKER_01 56:24

And that's that's a that's a big one. That's the one I asked myself a lot about, you know, because I want to make sure I don't do it just for yeah.

SPEAKER_02 56:32

Yeah, and so I started looking through and I started going to every thing on my calendar and I'd go down the checklist, and um at my peak, I was on 17 committees in addition to a full uh you know, full-time clinic practi clinical practice. And uh, and so I started stepping stepping away from stuff and just clearing space. Um and um I'd like the update is is that guess what? The world didn't end, whatever, despite what my ego would tell me, the world didn't end when I did that. Uh people are doing just fine, and and it did raise questions. People definitely want to know what the hell's happening whenever he starts sending out like resignations from a committee one route after the other. Everybody's like this guy leaving. But but I think that um you know it's a really interesting place that we find ourselves in. Um, and you obviously to an extraordinarily different level than me, but there are definitely opportunities and that have come up in my career over the last year that I've really had to start to kind of navigate the travel um to different different conferences and things like that. What that means uh for me and my family, you're you know, you're correct in that most of the time, contrary to what popular what the opinion might be, most of those are like unpaid. And so you literally probably are if you're looking at money as the only value, then you're actually losing value because um you know you could wait make a lot more by seeing patients and taking care of patients than it is going and participating in these things. But it's just a reassessment. I think that my reassessment has come uh hopefully early enough that my kids aren't going to feel the effects of of my ego running completely unchecked for years on end. Um, but uh, but yeah, I do I do take like your your experience is something that I you know I draw from when I'm making those types of decisions. Um you know, I think that one of the things you talked about was kind of uh our career, or not our career, but our field being in a transitional time. And I was wondering if you wouldn't mind just expanding more on that.

SPEAKER_01 58:27

Yeah, I mean like it's it's uh been a constant evolution, right? Uh this is uh to go back to when I was a resident in 2005 to 2010, you know, hernia surgery was done by general surgeons. What we offered back then was, I would say quite simplistic. You know, we can talk about evolution. Uh one of my favorite uh talks to give like uh Grand Rod's is uh evolution of surgery, kind of where we are at right now and where we came from, and like uh how we stand on the shoulders uh of giants uh that came before us. And uh, you know, I I just think in general it's safe to say that now to be a hernia surgeon or to do what's we would refer to, when I say I've done work construction, what I mean by that is uh something complex where a lot of times you'll uh need to do more than just uh primary closure of the defect, but uh uh you know, but and I think that requires somebody who does things in high volume, uh and perhaps uh that ends up impacting uh general surgeons. And you know, you have to ask yourself a question where is a place, perhaps before answering where uh uh you know where abdominal construction is, perhaps the best question is where is where is general surgery now? And what is it to become a general surgery nowadays? Is it the same as it was 40 years ago, 50 years ago? I don't think so, obviously not. You know, uh general surgeons in the past, used the orthopedic surgery, vascular surgery, uh, you know, everything in the abdomen, uh thorax, you know, over the years, you know, we have specialists. We have thoracic surgeons, we have vascular surgeons, we have colorectal surgeons, we have hypedabiliary surgeons, you know, we have spancare surgeons, uh, you know, we have foregut surgeons, uh, you know, and now we have uh AWR hernia surgeons. I mean, where is general surgery? If you if you do, if you graduate from residency as a general surgeon, what is your practice going to be like, you know, in the future? You know, and it's different for different people. Like, you know, I think from your experience, you said yourself you you didn't end up doing fellowship, you went straight in the practice. And you can certainly uh do, I think, herniest up downward construction, not saying you shouldn't. It's uh I think you're gonna do it. Uh you should do it in high volume. But how how do you get how do you, you know, like what is up downward construction? And so so for for me, uh it's um it is, I think uh people should start considering doing fellowships if you want to do this stuff in the field. And updownward construction itself, it's I think it's a fusion of you have it's a strong foundation and general surgery, and it is some plastic surgery. Uh it's definitely now a big part of this robotic being a robotic surgeon, kind of, or knowing how to use robotic technology. And uh, you know, again, you have to be able to uh do some complex opum cases. Uh it's decision making, which is uh not straightforward uh before the surgery. It's uh uh having the experience to manage the very complex uh complications in some complex patients. Um so what I see is kind of how it evolved to initially. I was, you know, I've been training fellows for 14 years, and uh initially I was uh working with Agent Park, who was kind of my senior partner. Agent Park has left now a few years back, and now the fellowship is truly abdominal construction fellowship where essentially the fellow spends all the time, spends more time with me than I spend with my family, actually. You know, and uh and watching the fellows uh kind of progress over the year, I'm becoming, and I I've taken care of some, I've had the privilege to trade some really smart and technically very savvy uh surgeons um and uh who are quite successful now in their practices, but watching them develop over a year, period, I I'm becoming convinced that I think this needs to, like this is not an overnight type of thing where you'll you go to industry-sponsored course, how to do a tar, and then you can start doing TARS the next day. This is uh really uh or eat up, you know, reef stopper cases uh if you want to. Like this really uh takes a year to at least uh develop a foundation uh to become uh, you know, and uh to set yourself on a pathway to mastery, so to speak, down the road. And mastery takes years after the fellowship, I think, to develop. Uh so I I think it's fair to our patients in the future, not saying that general surgeons shouldn't be doing those who are doing this, but moving forward, I think we need to start talking about more developing more fellowships that will uh will teach this skill set. And uh and and so and there is a need for AWR hurting surgeons, like a strong need. And I don't think it's particularly a procedure anymore that we need to feel like, you know, I think people are still trying to come up with which procedures, but I don't think it's one particular procedure that's better than another. You have to be a true expert and understand when you make the decision whether it's IPOM, whether it's I mean, I can start listing things, you know, uh IPOM, uh retorectus repair, prepritineal repair, you know, uh TARS, uh open TARS robotic TARS, scolar procedures, uh, scolar procedures with mini pneuclectomies, abdominal plasties, um, you know, uh, you know, peneclectomies with open tar procedures, loss of domain cases, uh, you know, progressive new peritoneum botox. I mean, I'm just throwing all the things, uh loss of you know, optimization of the patients beforehand, uh, dealing with complications of a complex uh uh loss of domain cases and knowing how to handle an intensive care unit. You know, uh this is some of the things that just kind of like we experience uh each year, and fellows experience each year in my own practice, uh, that I feel like you know is not enough to do in one course. And uh, you know, but and and these skill sets are needed, are really desperately needed in the community because I do see, I think reason for law recurrences is not like bad uh you know, bad technique, but sometimes uh I think lack of experience, yeah, of really understanding that the difference between success and failure sometimes in this procedure are millimeters of where you make an incision and a release, you know. Um and sometimes, and this is like uh, you know, uh the biggest issue is not knowing what you don't know. Oh, yeah, and it's it's it's it's like you know, and uh oversimplifying it. So, so, anyways, uh that's kind of I think what that field is. The field has been uh the field itself, you know, what is what about component suppression? Component suppression was described first in the early 1990s, even though some people can argue it was like 1920s, like that's some Argentina, but like really it became popular in the 1990s on plastic surgery. Um, you know, minimum each of surgery became early in the 1990s. Uh, really, not until the 2000s we started kind of embracing laparoscopic eye. Repairs, you know, at the same time, uh, with like it for the bigger cases, uh, we start uh we decided like like like guys like who came before me, like Todd Henneford started doing what like uh large pre-perit meal henophort dissections with combination of Ramirez technique where he would release posterior rectus sheath and uh bilateral external bleak releases to kind of do this, you know, fast forward a little bit like in 2012. Only only 14 years ago, tar was described. You know, in my own fellowship, we didn't do like in I trained the start, we didn't do formal TARs in 2010 to 2012. Uh Yuri had a good talk about like we've cut some of these muscles, but it was not formal until Yuri and Mike described it formally, and we started kind of also developing. Even Yuri in 2012, uh, you know, I don't think I understood fully yet the anatomy that we understand the way we understand it now, it has evolved. You know, then on top of that we layer like eat up access surgery, you know, kind of like robotics and so on. And even that, you know, like you know, myself, like now, like I'm getting typecasted talking about closure of posterior rectus sheath, because that's still like, for example, uh a controversial topic, you know, bridging posterior rectus sheath with uh uh phosphoryl ligament umbilic ligaments versus uh versus closing it together, you know, uh not not to get into the the the weeds of it, but talking about there's still so much we don't understand. It continues to evolve, or understanding it continues to evolve. I would say most people, like you're doing well if you at least understand anatomy. Now, like does everyone out there understand true morphological changes and kind of what happens to Abdamo wall after we do like a retrore rectus repair or a tar external bleak? Like, like there's still lack of that full understanding. We don't even know how to measure functionality yet. Like, you know, like Yuri and Mike back in the day, uh they've uh done this like biodex machine where like the machine like develops the force and they like they're looking to see like how much function, like you know, we're talking about uh closing the muscles. The point is there's so much still that needs to be kind of crystallized, needs to be uh kind of the details need to be figured out. I think like guys like me, I think I understand some of the things that are just personal opinions, yeah, and not like uh you know, kind of studies. I'm not the strongest academician, like I don't publish necessarily a lot, like Yuri, like Mike Rosen, like Todd Henneford. You know, I just publish things like if my fellows want to publish things. I'm still thinking of myself as a busy community surgeon that just loves surgery. And like my identity is I'm a surgeon first. Um, you know, uh publishing papers for me is kind of one of those things that it's a necessary evil, I think sometimes when you have something important to share, I will publish. But I don't get anything out of publishing 10, 20 papers uh a year. Like I just like that's not my passion at all. Yeah, zero passion over there, you know. Like you know, it's a you know, but uh you know, so so uh anyway, so I again I went on tangent. I tend to do, I tend to go tangents when you ask me a question, but uh like you can bring me back and uh where do I see our career, like where do I see our field? I see this becoming over naturally, uh organically. I see it heading to towards where it's gonna be another thing like colorectal surgery where they're gonna be specialists doing this. I see I see component separation becoming privileges in a hospital. If you're gonna do component separation, I think for quality control, each hospital has to make an extra step, not to limit people from doing it, but making sure the quality is there, that they're somehow followed the outcomes and follow the quality of it's okay to have complications, but we have to have a way of you know just seeing how good of a quality of outcomes we're having. And that's important. And so I think it's on the hospitals, not even societies, on the hospitals to make special privileges for TARS, for reef stopas, for for uh for all those complex procedures that we're doing now, because otherwise it's a wild west. It's a wild west, and uh, you know, so so it's okay to do it for general surgeon, but make sure you're doing well.

SPEAKER_02 1:10:26

I think that one thing that that people at least my I I'll I'll speak for myself. One thing that is easy to underestimate in the field when you get into more complex cases is you can do a really good job of planning before the surgery. You can be able to handle after the surgery, and you can be able to do the surgery that you're planning to do. The number of times that you get into a surgery, and it may not necessarily be represented by the preoperative imaging, or factors within the surgery are much different than you might have expected, and you have to pivot, and you have to pivot to a different procedure, maybe, or all of a sudden something that looked like it was going to be a much more, you know, a prepared neural repair, all of a sudden is like, okay, well, this probably actually does need, you know, at least a Reeves Topa or something. And then there's also, and so it's the intra-operative decision making that can be very difficult at times, and it's probably one of the things I think is the hardest learning curve. Getting going in, you know, you talk about being a computer programmer. What's that crap in, crap out, right? So if you have bad data going into the into the program, bad data is going to come out. I mean, I think that that that's hernia surgery in a nutshell in a lot of ways, is that the preoperative planning that you do, you know, really determines. I mean, I I use imaging pre-operatively, probably more liberally than most, but I very much want to make sure that I at least have had the opportunity to plan appropriately as best as I can. You know, the number of times that I used to do early in my career, just do this little peri-embilical incisions for the small hernias and go in there and do a sweep and you know get a preprintal pocket and put a piece of mesh in. So it closed, not a bad procedure in and of itself. Um but then a few years later they come back and they have a little epigastric, a little superior uh super umbilical hernia. And then it wasn't until I really started doing uh minimas approaches that you start to see how many people have like uh something, maybe there's something a little bit higher that you may not feel or see through that little now. Does that does that warrant a bigger surgery the first time? You know, I mean I think there's a lot of debate that you can have about around those topics, but but it is uh the field of abdominal wall reconstruction, especially, and even down to the simplest of what we consider simple hernias, yeah, it's a little bit more complex than just plugging a hole. And and I think that um you're right in that many general surgeons identify with that procedure, it seems to be pretty aggressively. It would be like if we decided it's it's similar to if you decided that like all gallbladders had to be do done by a hepatobiliary surgeon. You know, you'd have like a big and and I'm not saying that a gallbladder and a reef stopa or a gallbladder and a uh and a um uh and a tar are the same. I'm not suggesting that. Absolutely. But gallbladder cancer might be, you know, and that maybe.

SPEAKER_01 1:13:22

I want to be clear. Yeah, I think I think preparenal repairs and and and and eye pumps, I mean, if you do them well, they're great procedures, uh, like robotically or even open. Uh it's just at which point uh do we draw a line when it comes to something a little bit more complex when you start doing retromuscular and you start considering the plastic component points of it. And uh, you know, and and and you're right, uh you know, it kind of like you have to be dynamic in a way, uh, and you experience kind of dictate uh how you know something that kind of just flows interoperably. Uh, you know, you you meet a problem that you were just saying, and you just have to uh change uh the pathway a little bit uh to get you to the end of the surgery. Um but but yeah, so I just want to be clear. I it's it's it's more of a complex thing. I personally became come to believe now that it needs specialized training, and I think it needs specialized privileges. But I am still a minority. I am not trying to necessarily promote this uh one way or another, but it is my personal belief that uh patients will fare better for those complex procedures in high volume uh by by surgeons who do this in high volume, so to speak.

SPEAKER_02 1:14:41

Yeah. It's not and we're not the we're not the first specialty to find that. Um the data on thyroids, data on pancreas. I mean, there's data out there about this. And you you brought up colorectal as an op as a uh kind of a a similar field. Well, I mean, within colorectal surgery, there are people that have are more anorectal specified. There are people that that specify you know more in motility disorders. Like there's all kinds of of different subspecialties within colorectal. And um and you know, similarly, I for instance, I don't do very many peristomals. I well, let me rephrase. I don't do hardly any peristomals anymore, that I don't at least have a partner with me that does them frequently because I just don't get those referrals. I think if I if all of a sudden I had, you know, if I was getting 20 peristomals a year or something like that, and there were 30 or something, whatever number that needs to be, that would be different. But that's not realistically how my practice has lined itself up. My practice has lined itself up for better or worse to be inguinals, and those seem to be getting more and more complex as time goes. Um I do, um, I do uh, you know, abdominal wall reconstructions as well. Um, I, you know, it depends on where you put the number. I think that I'm I'm definitely higher volume than most, but definitely, but I'm not, you know, I'm not Igor. Um that there are very few people are, but I think that it's an it's an interesting thing. But going back to the idea of where of needing to be uh you know a CPD code for our credentialing purposes as far or a CPD for the credentialing aspect of the hospital systems for the more complex procedures, I think there's really two challenges that I see. One is when we have the conversation um about that, you have to be able to do the interoperative decision making. And sometimes you can get into a situation where all of a sudden it's much more. And we have to be, if we do go in that direction, we have to be prepared that there may be cases where people get in and have to bail out or stop. And maybe that's actually the right thing for that patient. I'm not suggesting, you know, I used to have a partner and sit would um uh he and his he was very conservative around some things, and he would always say, save them in two surgeries, don't kill them in one. And um, and that was that was kind of his his mantra of that. But the second thing that I think that warrants um clarification, because I don't think anybody's actually saying it, especially you, um uh with what you've said, is that there seems to be that sometimes a misnomer about the fact that every that talk when we start talking about the complexity of some hernia repairs, that probably the majority of hernia is don't require complex repairs, and that we don't need to over make this overly complex. I think that that's where the pendulum has swung, where you know, it's a it doesn't just because we have a Ferrari doesn't mean we need to make it our daily driver.

SPEAKER_01 1:17:27

100%.

SPEAKER_02 1:17:28

And I think that that's where people kind of get lost in the weeds, and and there's also the argument to be made that especially there's critical access issues where right now you're right, we do not have the number of abdominal wall fellowships to take care of the patient population that probably needs their care. Um that's definitely something to work on. Um the but then on the flip side, um, you know, it it is an interesting um situation where you have these patients that may not travel and they may not go to to a center of excellence and stuff, and you have to have surgeons that have those have somewhat of a capability. And those surgeons that you're gonna train up, we don't really have a good system in place to have surgeons who may be like me, maybe 11 years into my career. In an ideal world, would I be able to stop and go to a fellowship? I mean, yeah, I ideally, but realistically, just for the the in a reality, that's probably not that's not really a reality for me. Um and so you you end up in these kind of very, very real situations. But whenever you start doing those complex surgeries, there's a you definitely don't want to start on a loss of domain to make a loss of domain case your first tar. You know? And so it's but I think also transitioning out of the stuff that you may be getting your feet under you because at the end of the day we still practice um and we still go through our learning curve most of the time on patients, whether it's right or wrong, that is a reality of a lot of what we do in medicine in general. It's there's it's such a complex topic. And um I think that at times you make it.

SPEAKER_01 1:19:06

It's an inflammatory topic. It's an inflammatory topic because uh it's it's natural to get defensive about this. Sure. Uh, because uh, you know, uh it's natural. That's that's the bottom line. But but I think if we talk about long term, uh I the big picture, uh we're talking about the long term, not now. That's why I'm saying we're in transition. You you you're outlined this. You you've made the points that are perfect to say that to explain why we're in transition, because there's first of all, there are not enough uh AWR surgeons to do this. Absolutely right. Uh, you know, patient access also still a problem. Uh, but I I think also we have to start honestly talking about that uh the complexity of these procedures where I feel like 10 years ago we weren't. And we're saying, oh, you can, you know, so now at least we have to have an honest discussion, and sometimes it's gonna hurt some people's feelings. Sure. Uh you know, and uh but but we have to, but you know, uh those people who specialist in LWR, they they see some bad component separations done. And uh part of my practice uh is uh repairing uh poor poorly performed, very poorly performed uh component separations um at the time, previous time. And and some of the injuries that happened are irreversible, right? Uh nerve injuries because uh atropy of the muscles. And and so I feel like at this point in 2026, there's less excuse now to do a poor component separation because they're as opposed to 14 years ago.

SPEAKER_02 1:20:44

100% yeah, right. Absolutely.

SPEAKER_01 1:20:46

So so that's that's all I'm saying. So uh so that's it. I just think we have to have a discussion, and I think the younger surgeons uh should consider this more of a sub-specialty now, and consider it, and yes, we definitely need more fellowships around the country. And hopefully 10 years from now, we have plenty of fellowships that specialize in this, uh, that uh will deliver the critical mass of uh uh AWS surgeons to uh everywhere. But right now, there's very few of us out there.

SPEAKER_02 1:21:14

Then the part that that I didn't bring up that I think is probably maybe the biggest key is that we don't have the respect for the pathology that other specialties do for equally complex pathologies within their lines. Right? You're not seeing a community surgeon saying, well, you know, this person may not travel to, you know, a community surgeon that does very low volume or none. You'll see them saying, Well, this is I I don't have a cancer center in my hometown, so and I haven't done one really ever in practice, but I'll just go ahead and do this whipple, right? That's not really part of that's not really part of that vernacular. And it's because we don't treat uh we don't, we everybody uh you know it drives me crazy. Well, it's just a hernia.

SPEAKER_01 1:21:53

Yeah.

SPEAKER_02 1:21:53

I mean, man.

SPEAKER_01 1:21:54

And part part part reason uh, you know, look, uh, what happens is if you make a mistake as a like doing a hepatitis procedure, you have a higher risk of killing the patient on the table, you know, like injuring the poral vein, uh, you know, uh getting in the liver and not knowing how to kind of bail yourself out. In hernee surgery, it's a structural functional problem, which which is a huge impact on the quality of life to the patient long term, but short term you get them out of operating room, you get them to heal. They may have some bulging, new bulging, you know, but it's not the same as like actually it's not gonna be necessarily a mortality uh because of the mistake right there. That makes sense, right?

SPEAKER_02 1:22:44

It's the common bile duct injury, yeah. A common bile duct injury equivalent in a in a component separation is very different in that it's very rare that a component separation that has an equivalently negative out a negative complication shows up in the shows up back in the hospital three days later on death's door.

SPEAKER_00 1:23:05

Exactly.

SPEAKER_02 1:23:06

Exactly. But it might be ten years later.

SPEAKER_01 1:23:10

Maybe you know it's gonna be quality of life, you know, that's what happens. Like they come back, it was like new bulges, and they're like, oh, it's okay, you know, it's just some bulge, and then they end up getting a second opinion, and you're like, oh, you know, yeah, I think there's there's an issue, let's let's fix it.

SPEAKER_02 1:23:26

Sure, yeah, and I think that and and also um it it's hard if you're not doing high volume based on radiographic imaging, especially with the disconnect between what we see as surgeons and what radiologists see in their standard practice. It's sometimes difficult to identify the complications for what they are on radiography. You say, well, the muscles are still together. I mean, I don't have like a I don't see uh I'm not seeing a linea alba hernia defect anymore. But it's a very different thing than maybe what you've dealt with. And and uh, you know, in our in our practice, we routinely share the imaging of our complex patients amongst all of the complex surgeons that you know, and it's and it's interesting uh what happens when I may there may be times when I come in with an idea about what I was gonna do, I present it to the group, and the consensus comes out someplace different. And you say, actually, you know, you're scrolling through a scan, you go, actually, no, I didn't catch that. Because it's such a complex and there's so much nuance and and everything. And so it's very, it's very beneficial. I think that when we really get to hernia surgery and we start treating it more like a uh cancer surgery, I think that that's probably when you get into the complex stuff, that's probably more more, you know, uh realistic. You know, you look at like things like gallbladder cancer, for instance, right? Well, that could just be you could go all the way from a tiny little polyp that you just do a colosystectomy, and there's nothing, no big deal. Maybe that's your primary, you know, one centimeter umbilical. Um, and then you go all the way to needing lymphadenectomy and and liver resection, and maybe needing adjunctive therapy afterwards, and all of a sudden you're dealing with all of a sudden you have a port site met and and you're dealing with all these other issues that can come about it. And that, and you know, we have established very clearly in other specialties that multidisciplinary approach across multiple specialties and the the other services such as the physical therapy and even nutritional therapy, all those they contribute to the positive outcomes in that patient population. Yeah, we have us, yet we kind of at times it feels like we have blinders on, except in some of these major specialty centers or very progressive thinking surgeons in the field at their own practice, where we don't necessarily treat it with the same level of um of respect that maybe it deserves. Yet again, then there's the other side of that argument that not every hernia requires a tar. And I think that that's where that's where we end up in this kind of weird zone of the pendulum swinging of like, hey, we really need to be not oversimplifying the complex stuff, and hey, we don't need to be making more complex the simple stuff. And and it's that judgment required by the surgeon at the time and the individual training and all that stuff that just makes it so difficult. That's just my humble opinion. I may be completely wrong.

SPEAKER_01 1:26:20

I mean uh you actually very eloquently put this together. I agree.

SPEAKER_02 1:26:25

But uh, but I and I do think that it it does strike at the level of it it does strike to the to the core of what it means to be a general surgeon. I mean, I didn't come out trying to be a hernia surgeon. The reason I'm doing hernia surgery is because that's what the market dictated to me. Yeah, that's what I was getting. And I'm a perfectionist to a fault at times, and so I felt really, really bad not being able to do what I thought was what I could see was out there in the universe, going like, this is not how most of these people would take some of these people that I really respect would take care of this. Maybe I need to up my game. And as you said before, it is a very difficult thing to do that in practice. It's getting much easier, and there's much more ability out there, but it's really hard. I mean, because when you're in a high volume practice and you're cranking through patients, taking time to go away and do an extended course. I mean, like you said, you can go you can go on a weekend and do 30 minutes in a lab with somebody, but to say that that translates over into being able to do it effectively in a patient the next week is not necessarily accurate.

SPEAKER_01 1:27:21

It's not fair to the patient, yeah.

SPEAKER_02 1:27:23

No. One more thing I wanted to touch on with you, and I know you and I have had it, we've had this conversation um a little bit, but it's around it's around anxiety. And I think that that um it's something that I'm a huge proponent that we do not talk about this aspect of our practice enough. I think that surgery in general lends itself to a certain type of personality, and then where there's scopes, but people that legitimately are pretty type A or pretty driven and pretty hard on ourselves and things like that, and um, that can sometimes lead to can sometimes Be a positive to have those types of hyper awareness and hypervigilance, but at times it can kind of boil over into a little bit of a less of a of a beneficial thing for us personally. And um, and so whenever you're dealing with the complexity of the cases you're dealing with, even in the hands of someone like you, that is as you know easily defended as one of the world's experts in what you do, you you obviously take care of complex patients, you have complications, and I'm sure that that does strike you um at a personal level, just having had our conversations. How do you handle that and how does that affect you with like you talked about having your social anxieties and those types of things? How does that how does that resonate with you? And do you have any advice for people that may be be struggling with that?

SPEAKER_01 1:28:48

Yeah, it's uh that's a good question. And it's uh we all have like different social anxieties, it's uh it's interesting. I truly like when when I'm an OR, the that I don't have you know, I really don't have anxieties in the operating room. I truly, you know, I believe that deliver I'm able, like if I'm an OR as a patient, it's because I feel like I can deliver what I need to deliver. That that that like that that belief in myself is there. The anxieties start with understanding that the human body is very complex and how they recover from very complex traumatic surgery is very different. And uh then you you get uh it's very easy to get in this emotional roller coaster, uh depending on how the patient is doing afterwards. And how do you deal with this? Uh uh, I mean, it's no easy. I have been doing this for 14 years. It's not, there's no easier way of kind of saying I am able to turn off my brain and not think about, because here I am spending 45 minutes to an hour, sometimes more, talking to the patient, talking to the family about the complexity of the outcomes, the morbidity, the mortality sometimes of the cases. Sometimes uh even if I prepare them for everything, if they're not doing well, it's uh it's it's very it's very, very, very tough to uh kind of deal with this, sleep with this. Not not that my wife knows when whenever a patient is not doing well, you know, afterwards. Uh for me personally, what has helped me over the years is have is having fellows, having a little bit of that buffer between me and the patient sometimes. And they the fellows have really truly uh made a difference in my life and helping me manage the patients. Uh my partners, uh my who used uh two of them used to be my fellows, kind of just talking, having somebody to talk to. My my friends around the country who I can call and just chat about the patients, just just chatting and just having an outlet, somebody to talk to, not just holding it inside and knowing that sometimes, you know, I know what the right thing to do is, but sometimes talking it out with other people who go through this, it really is helpful. Um so so I I wish I can uh give you, you know, one one of the things uh here here's the thing. When I was, and I'm a very emotional person, and I'm very sometimes I can be high. Like when I was young, I was much more kind of hyper, like yeah, and then I like a low, kind of like when things are bad. So uh early on, like this is kind of again digressing a little bit, but early on when I started as an attending, I would do some really cool cases or something that I thought was really cool, and I would get so excited, so up. And then I would have like a case which the outcomes are not what I expected, or like somebody's having, like, say, you know, an inloher who is having pain longer than I expected them, and I start stressing out about it, like early on, and I would have a bigger load.

SPEAKER_00 1:32:03

Yeah.

SPEAKER_01 1:32:04

So one thing I learned early on, and this took me about I would say a good six years to get to that point mentally, is I honestly just don't get excited about those crazy cases. Like you do some really cool cases, I just don't get excited about it anymore. So that has helped me keep it. And the really kind of the bad outcomes, they just they get they cause it, they still cause a dip. The the really cool cases, flat. The the the uh the the bad cases still cause a dip, not as uh not as deep of a dip, but just a little dip. And so so I don't have this kind of roller coaster anymore. It's it's just dip, dip, dip, you know, like sometimes. And that's that's what helped me kind of maintain. And uh what also helps me, I don't think I would have been mentally successful in a practice where I would have to take ER call, where like you have to, I'm very structural, my life is extremely structured. Operate Monday, Wednesday, Friday, a clinic Tuesday, Thursday, weekends, uh usually unless there is uh something bad, I don't operate, and then so on. It's it's very structured. Wake up the same day, go to sleep the same day, you know. It's kind of like uh, you know, so it becomes it becomes kind of it's a routine. And uh and you know, the relationship is fellows, it's kind of routine, how okay, the job of a fellow, my job, the fellows again, and the fellows over the years. So what has helped me though is the fellows and the partners and the friends or uh experts in the field uh to talk to people and and knowing how not to hold inside, but have some an outlet to talk about and just uh sometimes get advice. Um, even though you could argue like after 14 years, I don't need much advice, but it's still nice to talk things out with someone uh and making sure you're in the right step. Because when a person, the hardest thing is sometimes every day going in there, seeing a patient nice to you, intubated, maybe not doing well, meeting their uh their sometimes uh sons, daughters, husbands, wives, you know, and talking to them and having that hard conversation and uh putting the best things forward, and uh, you know, that everyone wants to see a confident surgeon and telling them all of this. And deep inside, we all know all the little things that can go wrong. Yeah, you have to and you have to paint an honest picture, and you have to paint at the same time an optimistic picture when it's appropriate, and and know when start talking about other things, but deep inside you you've seen after 14 years I've been humbled so many times that uh you know you've you've seen it all, and yet sometimes it still tends to surprise you. And and that's like uh you know, like maybe I have another 14 years left in me, but uh it is a humbling, humbling profession. And I think uh uh I think the biggest uh biggest uh thing that can hurt us is our egos thinking that we know everything, that we've done everything.

SPEAKER_02 1:35:09

But yeah, yeah. That was beautifully said. I yeah, it's a it is a tough, it's a tough thing. I think there's many more people like you and I out there than than we probably admit as a as a field. Um and I think that these discussions are critical for us to to be able to increase the longevity because dealing with that in isolation or thinking it it's abnormal or uh somehow a liability um when it's handled appropriately, I think is something that really kills the longevity of a career and it kills the fulfillment of a career and and that the the dominoes that can fall because of because of that isolation can be really detrimental. So appreciate you talking about it. I um you know towards the end of every episode, we always give uh people their opportunity to give their hernia hot take. So this is the chance for you to give uh give us your hernia hot take.

SPEAKER_01 1:36:06

Uh it's an excited field, uh, and make sure uh you know it's it's hard sometimes to figure out what you want to do in life as a as a resident, but uh uh or as a technical. But I think it's a very exciting field, very fulfilling field, and it also I feel like this field, at least me personally, helped me uh tap into my creativity. And uh uh it is uh uh people talk about uh you know, see one, do one, teach one. Uh I I really feel like uh, especially hernias surgery abdominal construction, it's truly is an art form. Uh and it's it is impossible to publish in a paper and to really kind of uh explain what this is until you truly live it. And it's an exciting field because it's now a fusion, in my opinion, of uh really three specialties uh uh general surgery, uh kind of uh the newer stuff, robotics uh and uh uh and plastic surgery, kind of all fused together. Uh and it's uh it's a lot of fun. It's it's a very cool field, and it's still evolving, and I think uh we'll be very curious to see where it's gonna be 10 years from now.

SPEAKER_02 1:37:24

Well, we very much appreciate you taking the time. Uh, I know that uh that you're a really busy guy and and have and obviously value time with your family. So taking the time to talk to us is something that we we very much appreciate and respect. So uh with that, uh thank you again for coming on, and we'll go ahead and wrap up uh another episode of the Hernia Gods Podcast. This is your mere mortal host, Luke Elm, signing off. Thank you. Thank you very much.