Episode 117: Why Your Surgical Consultation Gets Lost in Translation | Hernia Talk Live Q&A

You can listen to this episode by clicking here.

Speaker 1 (00:00:10):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. This is our I believe, 116th episode of Hernia Talk Live. We are here with you every Tuesday and we talk about everything related to hernias and hernia related topics, including complications and major questions and concerns that I see from my patients that are all hernia related. As you know, my name is Dr. Shirin Towfigh. I’m your hernia and laparoscopic surgery specialist. Thank you for joining me live as a Zoom as well as on Facebook Live. Many of you are also following me on hernia, Twitter, basically Twitter and Instagram at hernia doc. So I’ve been working really hard lately and the reason why I picked this topic is because I kind of need to vent and I also need your support. So as you know, I do hernia surgery as a surgeon. My life involves seeing patients in the office and also operating on patients.

Speaker 1 (00:01:16):

So that’s all good. That’s a typical surgical kind of lifestyle. I also have of course, Hernia Talk and I’m on social media. I give talks and go to presentations and go to meetings. So that adds some more kind of work for me, although I do enjoy it. I also publish and do research, so that’s another aspect of what I do. So all that is good. Here’s the issue. I feel that I am seeing a lot of patients that come to see me that I wish did not have the complications that they did, and I’d like to get some feedback from you all because what I’m seeing is that what patients are being told and what surgeons are saying may not be the same thing. And then there’s what I call getting lost in translation, and that’s one issue. And the other issue is that what patients expect to happen and what the actually happens to the patient are also conflicting.

Speaker 1 (00:02:24):

And so this all becomes very, very frustrating. So basically I want to share with you some of my own stories and maybe hopefully prevent any potential miscommunication or complications that you may experience as a patient. I’ll give you a good example. So the topic today, the title is why there’s this miscommunication. I almost said like patients are from Venus and surgeons are from Mars. Or you can do it the other way around, but it just seems like we may say something to a patient and then the patient may completely take it the wrong way. Many of you may have been on Twitter, and lately there was this discussion among surgeons about this patient. So there was a picture that was posted and on the picture was from a surgeon’s standpoint, it looked like a disaster. I personally thought that what was done to the patient cannot be good.

Speaker 1 (00:03:32):

So it’s a belly picture of a belly, can’t see who the patient is, but it’s a scar with a bunch of sutures. And it looked like the sutures were really tight and the repair was really tight and they had really tight what we call retention sutures. Now, there may be a situation where you have to use these kind of techniques with different sutures and what we call retention sutures. It’s part of the armamentarium of an emergency surgeon, and I definitely use that when I used to do a lot of emergency surgeries. However, there’s a way to do it correctly and it’s a way to do it where you can cause harm. And the way that this picture looked, it looked like the patient was in harm. So it was meant to be a discussion among surgeons, even though Twitter is a public scenario, we call it hashtag Med Twitter or surge Twitter.

Speaker 1 (00:04:25):

And the surgeon’s comments were pretty much all the same. And it was, oh my God, this is horrible. We would never do this. And it was an educational discussion. Then we had non-surgeons come on board and I’m followed by non-surgeons. A lot of the surgeons that were making comments are followed by non-surgeons on public Twitter. And unfortunately, and rightfully so, from a patient standpoint, our discussion was very crass and not respectful. And the reason for that is their feedback was how could you put a picture of a patient? You don’t know who this person is, we may know who that person is. This is very disrespectful. Did the patient even consent to have you put their picture on et cetera? And how could you disparagingly talk about a patient when you don’t even know what’s going on? So it was a bit heated because from a surgeon standpoint, we were like, oh my God, this is a horrible complication.

Speaker 1 (00:05:36):

Let’s all discuss this and make sure that that it’s known amongst surgeons. This is not the right technique to use. From the patient’s standpoint, that part didn’t matter to them. They were saying, oh my God, how could you talk about a patient the way you are? How could you make comments about a patient in a public forum even though we don’t know who the patient is? But you never know, maybe someone could see that picture and think it’s their belly, and that’s very disrespectful. So it was two different pillars of people, two different verticals talking two different topics, about two different situations, about the same picture. And it became heated because as surgeons, the people that were on the surgery part of it were like, what are you talking about? We’re trying to educate ourselves and tell everyone this is not good. And the patients are like, this is disrespectful.

Speaker 1 (00:06:39):

Why would you do that? So the problem is this miscommunication. And I feel that sometimes as doctors, we have our own language and we already know certain information that’s not being verbally expressed, and the patient does not know that. And so when they fall into a discussion between patients, then I mean between amongst surgeons, then the patient’s interpretation becomes very cross. And the other issue is I believe there’s so much mistrust. There’s so much mistrust among patients against their doctors, especially surgeons, especially in hernia surgery, that there’s automatically this feeling that the surgeon must be evil, doing bad disrespectful, and not saying that this schedule was purely an educational forum and ability for us to reach out to millions of potential doctors out there and teach them not to do what we were seeing. So I’d like you to know your feedback on it.

Speaker 1 (00:07:55):

Maybe it’s a little long-winded story about a Twitter feed, but I see this over and over again where surgeons are having one discussion and patients are seeing that discussion and interpreting it in a different way. I’ll give you another example. Currently, if you go on hernia talk.com, there’s a discussion about different surgeons and who they should choose based on different criteria to fix their hernias. And there’s a comment about a surgeon who has recently left their job and moved on to another job. Now it’s up to that surgeon to share with his patients where that surgeon will be whenever they start their job. But now it’s turned out that the patients are questioning, why did he leave that job? He must have been fired. No people, I’ve left two jobs, never fired any of those operation, those jobs. It was my choice to leave. And being employed has its pros and cons.

Speaker 1 (00:09:04):

And as you may change jobs because you want to make more money, have an easier lifestyle, geography’s important to you, your family situation has changed. Whatever the reason is, you may change jobs. Surgeons do the same things. So for a surgeon to change jobs has nothing to do with anything nefarious. But there’s all this discussion about potentially the surgeon must have done something bad to have left the job, which is completely not true by the way. And secondly, the fact that there’s no obvious kind of landing point yet for that surgeon doesn’t mean that that surgeon is somehow hiding something. I mean, the conspiratorial tone of this thread is pretty horrible. I don’t like it. I may even consider taking it off or I may just say something on hernia talk.com about it, but it’s just horrible and it’s inappropriate. And whenever the surgeon actually signs the contract for the next job, then it will be public as to where he or she may be going. So I don’t understand why there’s so much animosity about simple information, and I think part of it is mistrust in the whole medical system.

Speaker 1 (00:10:33):

So that’s one issue, which is what we say and we, how we talk amongst our peers is different than how we talk with our patients because there can always be this miscommunication. I’ll give you something funny. So when I was an undergraduate, I really wanted to be a doctor and I thought if I volunteer at the emergency room, I will see the glorious most kind of disgusting things. And if I like it, then that means I should definitely go to medical school and if I’m turned off by it, maybe I should find another career. So it’s kind of a test. So I volunteered at the emergency room and a trauma came in and that was like, oh my god, trauma as opposed to someone who came in with a stubbed toe. So there was this back room where you can just look at what’s going on and not be in the midst of the trauma team.

Speaker 1 (00:11:38):

So I was watching and it was was like a mom and some kids in a minivan that rolled over. So they brought the mom in and they paralyzed. So they said she’s paralyzed. And okay, now I know what that means is the anesthesia given to the mom was a paralytic agent, which means it, they gave her medication to allow them to take over everything that needs to be taken over. They put a tube down her throat. And in order to do that, you give what’s called paralysis. It’s an IV type medication that paralyzes chemically paralyzes your muscles, so everything relaxes, including your lung, and then you kind of take over with machines and so on, because the lady was very critically ill. I didn’t know that wasn’t like a junior or sophomore in college. So all I had heard was she’s paralyzed and I thought she was literally paralyzed from the car accident.

Speaker 1 (00:12:51):

And I went home and I said, you don’t know like this mom. And she had these three kids and it was a minivan and it rolled over and now she’s paralyzed. And I completely misinterpreted everything that was going on because I didn’t have the insight that those specialists did. And their language was not the language that I knew that I was speaking at the time because it was medical language and it was lingo. And they didn’t say, I injected a paralytic agent. They said she’s paralyzed. And in the right context, that means she got anesthesia in the wrong context. It means she’s literally got spinal injury and is paralyzed. So the same happens between groups of patients and groups of doctors, including surgeons. So I wanted to express my 2 cents about this because the amount of discussion between the patients and the surgeons was so heated on Twitter for no reason, purely because of miscommunication.

Speaker 1 (00:14:04):

The other thing I wanted to discuss is along the lines of surgical consultations because I feel that when surgeons go see, when patients go see a surgeon, many times they end up not understanding what they have, what they need and so on. So in my consultations, I spend a lot of time, it’s a little bit too much. I think sometimes we dedicate an hour for every consult, new consultation, and sometimes it takes longer than the hour. And I’ve always had that educational bent where I talk to patients and it’s kind of something that I enjoy doing and teaching. But what happens is I feel like I need to talk at a level where they’re completely understanding of what I’m telling them. So I come up with analogies and pictures and going over anatomy and scars and reviewing possibilities and as much of lay terms as possible.

Speaker 1 (00:15:14):

But I have the luxury of doing that because my patients have up to an hour or more sometimes to discuss everything, get all the questions answered. Most of my colleagues do not have that luxury. They have 10, 15, maybe half an hour dedicated to those patients. They’re already running behind because it’s really hard to do 10 or 15 minutes for a surgical patient, especially if they’re complicated. And so the patients come out not knowing what’s going on. In fact, it’s kind of a joke, but there are some doctors in our neighborhood where patients literally come out, they’re like, I have no idea what the plan is. And they come to me and I said, okay, you saw Dr so-and-so. So what did he say or what was the plan? They’re like, I have no idea. I know I saw him. I have no idea what the plan is because they’re just overwhelmed with what I was being told.

Speaker 1 (00:16:10):

And the surgeon is not a good communicator. So I would like to also spend some time talking about how you can get the best information from your surgeon and use that to your advantage. Because if you don’t, then you end up having an operation that maybe you shouldn’t need. For example, I’ll give you an example. Today I had a patient who had a tummy tuck. Now she legit had a tummy tuck. She needed the tummy tuck that was the right operation in her mind. She did not need the tummy tuck and she did not need that as an operation. She just needed her diastasis closed. So she had, let’s say a couple of kids and then the muscles spread apart. They need the muscle to put back together. Now there are multiple techniques. 30 years ago, the only technique was a tummy tuck or abdominalplasty, and she went to a plastic surgeon.

Speaker 1 (00:17:05):

The plastic, I assume, I don’t know, I think it was a plastic surgeon. The plastic surgeon did an abdominalplasty. That’s a big operation. If you don’t know you’re going into a big operation like a tummy tuck. That’s some serious miscommunication with a patient because it implies a new belly button, a huge scar in the lower abdomen, the positioning of the scar compared to where your other scars may be as important, how tight you’re going to be, what the recovery is, whether you’re going to have children or not afterwards. These are all important topics to discussed when having a major operation like that. It sounds to me she never had any of those discussions. So now she wakes up, she’s got this huge scar that was difficult to heal. It affected her ability to be active for quite a while. She didn’t like the cosmetics of it anyway, and it was painful.

Speaker 1 (00:17:58):

And then she didn’t even know if she could have chilling afterwards and if that would screw up the operation. And these are all questions that should have been addressed before the surgery, and I highly recommend that you do that. Now I do Li would like to say, I would to say that I do know that many of you do listen to me and many of you who tune in have heard me say multiple times that you should go into a consultation with pre-prepared questions, do your research and get a second consultation with another doctor because it’s good to know what is being told to you and then double check it or even triple check it with another doctor and make sure that it’s correct. So for example, and I love that you guys listened to me on that because I had a patient who’s not around here and I gave them my recommendations and the plan is great, but then they said, but you told me to get a second opinion, so now you are telling me this.

Speaker 1 (00:19:14):

Who do I go for a second opinion and I refer them to someone else? And they said, well, we want a second opinion by the radiologist too. So I had it reviewed by three radiologists, not just two, and that calmed their them and gave them a little peace of mind that the diagnosis is correct and therefore the plan of care is correct and that it’s a good, you’re basically going into it much more knowledgeable and with much more ease than if you didn’t have any of those priorities. You just kind of trusted everyone and went in place.

Speaker 1 (00:19:52):

So just want to give my 2 cents about that. I love that you listened to me. It’s so good that people listened to me. So here’s some questions that were proposed and I’d like to answer them. What are the main misunderstandings that you encounter when communicating with patients? So there’s multiple, and the older I get, the longer my consultations get because I try to address all the misunderstandings that I’ve heard from other patients in the next patient. So I don’t like to say, oh, this is just a minor surgery. It’s not any surgery that requires you to go to a hospital or a surgery center to have surgery is not minor. Minor would be in the office if you need your belly button ring scar fixed, that’s a minor operation. If you need a scar revision, that’s a minor, but if you’re having a hernia repair that is not minor in any sort of hernia repair.

Speaker 1 (00:20:52):

Now there are levels of complexity for hernias, so I do explain that. So one is like, oh, well this is just a minor surgery, right? I say, no, not minor. Not minor because minor implies little to no risk and none of the operations I do has little to no risk. It has little risk, but no operation has no risk that I do. The other main misunderstanding when I communicate with patients is that about anesthesia. They either think they’re going to be completely knocked out, which maybe they won’t be or they think they won’t get any anesthesia in which they will be. And that’s important to understand because the anesthesia part of surgery has a little bit to do with the control that you may lose during the operation. If you have an anesthesiologist taking over control of your breathing and you’re kind of allow, you have to kind of go to sleep and allow anyone to do whatever they need to do while you have zero control over them, that can be scary for patients.

Speaker 1 (00:22:00):

And so one of the issues that we have is a misunderstanding about type of anesthesia they can have. You can’t do laparoscopic surgery, for example, under local anesthesia. That just can’t, can’t happen. I mean, theoretically it can happen, but like 99.999999% of the time, age cannot happen. So that’s where we are with that. The other misunderstandings I feel, is when there’s a complication, the natural tendency for many doctor, sorry, the natural tendency for many patients is to blame the doctor or blame themselves. And usually it’s neither. So I don’t like to blame the patient, oh, well, you should never have gone on that skiing trip or How dare you go hiking after hernia repair? No repairs are done with the intention for you to have a normal lifestyle afterwards. And if it recurs, there’s a lot of reasons why it recurs, but it won’t necessarily be because you enjoyed your life.

Speaker 1 (00:23:12):

The other one is blaming the surgeon so that the surgeon must have done something wrong with the surgeon. Must have, and I see this more online than among my own patients where they claim, oh, the surgeon was lazy, or the surgeon had to go somewhere earlier or the surgeon didn’t want to do. I had some one patient say, the surgeon did this to me because they wanted me to learn a lesson because I first asked, like I didn’t, I asked, I didn’t want to Mesh, so they gave me a botched tissue repair because they wanted to teach me a lesson. That just doesn’t occur. We don’t operate based on spite. So anger is sometimes associated with recurrences or complications. What I love though are patients that understand that as with anything in life, whether it’s walking around the street or driving in a car or having surgery, things can happen that are not planned. You can twist your ankle, you can get hit by a car, your car can break down or your surgery may have a complication. Just understand that these things happen. Your surgeon most likely has done everything they can to prevent something bad from happening and unfortunately did happen. So let’s move forward and not look back.

Speaker 1 (00:24:42):

In saying that I’d like to share some things. I’m drinking water for those of you that are watching, I’m drinking water from this beautiful cup. I don’t know if you can see it, but it’s this very ornate, beautiful, almost like a princess cup that was gifted to me with, by the way, matching spoon. I’m a big tea drinker, so this is perfect for all the tea that I drink. So this was gifted to me by a patient’s family that did have a complication. And again, they understood that there are complications that can happen, and they’re very grateful that I kicked in and was able to help them address the complication. And I was very upfront with them like, this is what you got to do, this is what’s going to happen. And then we got to do another operation potentially. So they were very open to understanding, getting all their questions answered.

Speaker 1 (00:25:39):

There are multiple complications that need to be addressed, and now the patient’s doing really great, but it’s a process. And oftentimes when there’s a complication, the next step is not a quick fix. You need to have multiple procedures after one complication. I’ll give you an example. If a patient has a hernia pair and it’s infected, that’s like two or three operations that need to be done now. One is to remove the infected Mesh. Second is to clean out the space and allow it to heal with wound care, dressings, antibiotics, whatever. And then you’re going to have a hernia again at some point, maybe, maybe not, and at that time you get another hernia repair and so on. So I always like to set patient’s expectations that there will be a multiple stage operation potentially, and get their mind prepared for that so that you don’t do one.

Speaker 1 (00:26:39):

I’m like, okay, now, oh shoot, now I have do another. Oh, okay, another operation. What is this process going to end? But that’s something that I think communication really helps. And it’s not that I’m a bad surgeon for recommending a three stage process now that your measures infected. It’s just that I’ve done it one stage before as a single stage and we found higher recurrence rate, higher risk of infections, less cosmesis, and we decide if we take into two or three steps, the patients do much better. And of course, that’s what happens. So again, I’m going to take a sip of this beautiful cup with water in it.

Speaker 1 (00:27:24):

I’m going to cherish this. I love gifts. I have my office, if any of you come to it. I’m now currently in my office. It’s filled with little trinkets. It’s filled with little trinkets and gifts from all over the world from my patients, and I love it. I even have some that are framed. It’s really cute. So this cup will go amongst those. All right, next question. What are the patient’s behaviors that you find more of an obstacle to productive communication? That is a great question. I’ll tell you patients that are not willing to be open-minded is the biggest obstacle for me. So because of the internet, it is so easy to do research before you come to see me. Now it’s possible that you did all the right research and you’re now coming to see me and you’re very well informed and you’re able to get just everything you learn validated by me.

Speaker 1 (00:28:38):

However, sometimes you can go down this rabbit hole, and I have several patients currently that are falling into this trap of this rabbit hole. They think based on what they read, that they know what their diagnosis is, and they’re completely wrong with that diagnosis. And that could be they think their Mesh is infected. They think they have pudendal neuralgia, they think that they need a neurectomy or triple neurectomy. They think they need Mesh removal. They think they’re reacting to the Mesh. And yet after a thorough evaluation by me, I feel that’s not what’s going on. But it is so hard to right that ship. They came in by boat, let’s say with their ship aiming one way, and I’m saying, no, you got to turn this ship all the way around. It’s a totally different issue for you, different problem, different complications, et cetera. And in doing that, I can’t just say you’re absolutely wrong because an immediate rejection of what they came in with is too hard for them to handle. And the responses to reject what I’m saying, what can happen, which I prefer, is for me to then logically walk them through the step. If you have a Mesh infection, you have to have X, Y, and Z. If you need Mesh removal, it’s because of X, Y, and Z. You don’t have those symptoms and therefore you should not have that problem or you should not have that operation or whatever the situation is. And I feel that.

Speaker 1 (00:30:27):

I feel that you can’t just spring on the spring it on. So I see patients that go to doctors and say, oh, that doesn’t happen. Well, if you just say that to the patient, they’re not going to believe you. You can’t be like, just trust me. I know what I’m talking about you. I feel at least that you have to talk the patient through it and provide evidence. I’m very evidence based person, so if you want to teach me something, you can’t just tell me this is the answer. You have to explain to me how you got to that answer and give me the evidence to support it. The same is true I feel for patients. You can’t just say, here’s your diagnosis. You’re completely wrong. It’s not pudendal neuralgia. You just have a pelvic floor spasm. No, you just have a hernia without explaining that hernias cause pelvic floor spasm, the pudendal nerve runs through the pelvic floor.

Speaker 1 (00:31:19):

You can’t really injure the pudendal nerve. It’s a very difficult nerve to injure. And so your nerve is actually normal. It’s just causing hyperactivity of the nerve because the nerve runs through the pelvic floor and you get pelvic floor spasm with hernias and the hernia repair will get rid of the pelvic floor and therefore get rid of the pudendal neuralgia. So that takes a while to explain, even I get dizzy, just trying to explain that. So I think the patients that come in with an agenda, because they feel like they’ve been hurt by so many doctors in the past and now they, they’re taking over and they know what’s going on and they come in and they don’t want to hear anything else. I had a patient that said, wait, I just paid for a consultation. You’re telling me I don’t need surgery? And I said, yeah, you’re hurting.

Speaker 1 (00:32:08):

Your hair is fine. And they’re like, but I just came to you. I said, you didn’t pay your consultation so that I can give you the answer you want. I’m giving you my expert opinion. My expert opinion is, you do not have a hernia, you do not need surgery, or you not need Mesh removal, whatever the situation is because the symptoms you’re suffering from is not related to a hernia. And that’s the way it goes. So if a patient comes in with a certain mindset, they’re very difficult to change that mindset. Those are the most difficult. Oh, here’s a question. What type of gifts do you appreciate? Trinkets or gift card trinkets? Gift cards, I’ll tell you. So the gifts I prefer the most are the cards because I like to read cards and people don’t write cards that much anymore. We sometimes get Google reviews or Yelp reviews and it’s really nice to read it. But I like the handwriting on the cards. Some of ’em put little hearts. I’ve had patients children write me cards and that really, I don’t know, I feel like it comes from the heart. Even the card they pick and the design on the card always means something. So I do appreciate cards. I also like trinkets, I’ll tell you. So this cup was, today I am obsessed with this. It is so beautiful. It’s like a princess cup. And I’ve had two cups of tea from it already.

Speaker 1 (00:33:41):

And like I said, I’m a tea drinker. I have other things on my desk. This is like a, here, let me show you. I have little things on my desk. So here, this is a beautiful little box I got as a gift. It’s always on my desk. And in it is this blue, blue marble. So I don’t know if you guys know, but some people believe in the forces of different types of marbles. And this is glass. I, I don’t think it’s true marble. And the patient that gave this to me strongly believed in the forces of these blue marbles. So, oh no, who am I to disagree? It’s on my desk. I enjoy it. I have other things on my desk that are trinkets. Oh, I’ll show you this one.

Speaker 1 (00:34:38):

This was from one of my residents, actually one of my students who’s now a doctor, surgeon, and doctor. It says it’s a quote by Lao Tzu, which is a philosopher in China. And it says, I have just three things to teach. Simplicity, patience, compassion. These three are your greatest treasures. So I’ve had this for years, I’m going to say maybe more than 10 years. I have this little trinket. It’s from the 2021 European Hernia Society meeting, which was in Barcelona that was canceled. And then 2022 European Hernia Society meeting will be in Manchester. So if anyone is in Manchester next week, let me know. I’m going to be meeting some patients and patient advocates at the meeting, and you’re all, you’re free to come.

Speaker 1 (00:35:35):

This was a Russian patient that gave me this, which is those dolls where people are added. But this one in particular is very unique because it has, the smallest one is about two less than centimeter. It’s the size of a piece of rice. That’s how small it gets. So that’s really, really cool. So I have lots of, I’m surrounded with trinkets in this office. I wish you guys could see it. All you see are my flowers or you just listen to me. But you know that this is stuff that brings me joy. I’m just surrounded by love in the office, which is really, really great. I even have this, it’s a, I dunno, it’s a sushi, it’s a sushi magnet, like a piece of sushi that’s plastic. Of course that’s a magnet for this board. I have a board. I have a board with all my research projects on it that’s in front of me. So yeah, I like gifts, I like trinkets. We love chocolate and food is always good. I get a lot of champagne towards the Christmas time, which is great because my friends enjoy champagne. Anyway, yeah, I think it’s the thought that counts. Usually I just like cards. My office probably prefers food and if it’s something that I can hold onto and have in my office, of course I like that too. So wide range of things in my office since you asked. Okay, let’s go on to the next question.

Speaker 1 (00:37:26):

As a patient, what are the red flags that you should be able to spot when consulting with a surgeon? Okay, good question about the red flag for a surgeon. As surgeons, we always talk about red flags of the patient. If the patient comes in saying, I’ve sued the last 10 people and all surgeons are evil, and you’re probably doing this because you’re the devil and want to hurt people, that’s a red flag. And maybe don’t do that when you go see a patient, but when you go see a surgeon. But the question here is the red flags for a surgeon. So I used to think that going to the top surgeon because of their amazing standing in the surgical community is the best choice. I don’t believe that anymore. In fact, I feel sometimes a narcissistic surgeon is not the right surgeon because if you fall into trouble, they don’t have the compassion and empathy that you need from a surgeon to deal with your complication or with your special need, whether it’s pain control or wound care or another problem or just like me warm.

Speaker 1 (00:38:41):

So I feel that bed, good bedside manner is very important. And if you have a surgeon where you feel you don’t feel comfortable with ’em, you just don’t trust ’em, there’s just something about them or they’re a little, they touched you weird or they dismissed you. That’s what we call mansplain things to you or just plain narcissist. And unfortunately, many surgeons are narcissist. That’s just the way that the hierarchy kind of plays onto people’s psychiatric tendencies. But I think you need a surgeon that’s compassion. That’s first of all, they happy a good surgeon, but there are a lot of good surgeons. So of the surgeons, I would not necessarily choose the one who’s, oh, dean of the school and chairman of the department and so on. I would really go to the one who is compassionate, empathetic, and listens to you and doesn’t discount you.

Speaker 1 (00:39:44):

Here’s a question. I have a large abdominal composite Mesh due to an incisional hernia after a radical hysterectomy. Since the insertion of the Mesh, I’ve been diagnosed with lichen planus, lichenoid dermatitis, and currently waiting for other biopsy results. Have you seen many Mesh patients with different types of rashes caused by meshes? Absolutely. In fact, the first patient that I treated who had a Mesh reaction and needed Mesh removal had lichen planus. And the lichen planus was their reaction. And it is an autoimmune dermatitis that you get with this kind of lichenoid dermatitis. So yes, I would recommend definitely being evaluated for it. Many of you heard my talk, yes, last week. So we are embarking on even a deeper dive than I was doing before on Mesh implant illness. So we are launching that term Mesh implant illness. We have multiple papers that are in the process of being published in peer reviewed journals.

Speaker 1 (00:40:51):

I’m working very closely with Dr. Schoenfeld of Shoenfeld syndrome fame where he has been shown and is studying auto immunity and reactions to implants, including meshes. And we’re coming up with standardized questionnaires and standardized blood tests and so on. But to answer your question, yes, random rashes after hernia repair in areas where the hernia Mesh is not, can be a manifestation of or reaction to the Mesh and lichen plans is one of those autoimmune type disorders that can be associated with a Mesh reaction. And Mesh removal would be the cure for that. So I’m not saying you have that, it’s more than just rashes. You have to have other things and it could include any of the following. Chronic fatigue syndrome, headaches, rituals, changes, ringing in the ear, joint pain and swelling, numbness or tingling and burning in the fingers, feeling hot, brain fog, memory, memory changes.

Speaker 1 (00:42:00):

One lady had pancreatitis or pancreatic enzyme changes and rashes. So if you have a multiple syndromes of that, especially if it started after the Mesh within days, weeks, or months, usually within the first year, then you should definitely consider Mesh implant illness as a reason for that. Okay, next question. Surgery. Should the information that a surgeon provides to a patient be tailored? Oh, you know what? Let’s go back to that red flags question. So another red flags about consulting with a surgeon is if you feel that the surgeon is selling you the operation, oh yeah, it’s Mesh pain, got to take it out and they haven’t even heard your story yet or examined you. Or if everything is Mesh pain and everyone needs to have their Mesh removed, for example, that’s a red flag. The other red flag I would like to also talk about are surgeons that are not accountable.

Speaker 1 (00:43:10):

So many patients have gone to see surgeons and then the minute things get hairy and they have a little bit too many questions or they run into a problem, then poof, the patient, the surgeon’s gone, not available, can’t answer questions, et cetera. And that’s just a flaw. And I feel that that’s not the best surgeon for your needs. You want a surgeon that’s accountable and reachable. In fact, I’ll give you another story. So there’s a local town around here. It’s about two or three hours drive. I’ve had many patients from that town, they have hospitals there. But the hospitals are kind of hit and miss, especially when it comes to hernias and surgical complications. So they send me patients, which is great because they know that they can only do so much and they send me the complicated ones, which I’m totally happy to take care of. But what happened was one of my patients went to the hospital and they had a problem unrelated to their hernia repair for which they were hospitalized. And a surgeon came and said, oh, we need to take out your gallbladder. And the gallbladder hernia is not really related necessarily, but from my standpoint, if you have had an abdominal wall surgery and you need your gallbladder out, make sure the area where the gallbladder surgery will be performed is not also overlapping with the area of your hernia repair. Does that make sense?

Speaker 1 (00:44:52):

Cause they said, oh yeah, our surgeon is Dr. Towfigh, so you can’t do any surgery until you speak with Dr. Towfigh. And they’re like, oh my god, Dr. Towfigh is your surgeon. Because they know I repair all their complications or comp, I should say complexities. She said yes. And she’s like, oh, okay. She’s like, yeah, can you talk to her? I’m going to call her right now. They’re like, wait, you have time to find cell phone number, which they do because the patient is very complicated and I don’t want anyone to lay hands on my patient unless it is run by me because I do not want all the hard work I put into this patient to be fraught. If a surgeon that didn’t know what I did then goes through my Mesh or infects my Mesh or whatever the situation is, their Mesh, but it’s also my Mesh, so, so she just called and I was like, Hey, what’s going on?

Speaker 1 (00:45:58):

And oh my, Hey Dr. Towfigh, my surgeon’s here. Can you talk with the surgeon? So I talk with the surgeon who’s very nice. I explained to him the things they have to do to prevent going through the dementia I put in, which were very specifically certain areas of the body and they can’t, and the surgeons say, well, I’m going to do this robotically. I’m like, why are you going to do robotic gallbladder surgery if you do it robotically, you’ll definitely go through my Mesh. I don’t want you going through my Mesh. You have to do it laparoscopically where you can kind of not go through my Mesh. He’s like, well, I prefer robotic. I’m like, well then I prefer you don’t do the surgery because there’s no way I’m going to let you potentially infect this patient’s Mesh. He’s been through so much. So long story short, they got discharged from the hospital.

Speaker 1 (00:46:48):

I did the gallbladder surgery for them so that the Mesh is protected. But these are little things where the surgeon could have simply said, oh, I understand, and yes, I can do laparoscopic gallbladder surgery, which of course they can do, but they just weren’t willing to do that. And that’s not a surgeon you would want to have your surgery done unless of course it’s emergency, but it wasn’t because they’re not budging, they’re not tailoring to your needs, they’re not listening to what I’m saying, which is I understand what you do for all your patients. This is not all your patient. This is a very specific patient who cannot have the same operation that other patients have that don’t have a different surgical history. So I don’t like it when people don’t listen and especially if they don’t listen to me.

Speaker 1 (00:47:41):

I don’t want to sound arrogant, but we’re a little controlling and that’s okay. I’m very controlling when it comes to my patients. All right, next question. Surgery. Should the information that a surgeon provides to a patient be tailored to the specific patient as well? No. So I do not believe in tailoring what you tell the surgeon based on the surgery that is needed. So for example, I don’t want you to not tell me everything. I want you to tell me everything. And some patients like, oh yeah, I didn’t want to tell you about the fact that my car accident because, or I didn’t want to tell you about the fact that I’m having these dizzy spells, or I didn’t want to tell you about the fact that I have these twerking movements because I don’t want to, I didn’t think it was relevant or I didn’t want you to think I’m nuts because I’m giving you so much information.

Speaker 1 (00:48:36):

And I said, no, please tell me everything. I had to cancel a patient recently because we weren’t told about these seizure-like activities that are going on. I can’t give you anesthesia and you have seizures. That’s a relevant information. You may not have thought it was relevant to your hernia, but now that you need surgery is relevant to your anesthesia. So I like to get to know everything. And then once I have everything, then I will digest what is important, what is not. But I don’t like information to be kept for me because you don’t want to bombard me or you think like it’s too much, I can handle it. And the surgeon that you find should also want to handle it and not just say, there are surgeons that’ll say, oh, just I don’t care about your rheumatologist, or I don’t care about your this, that, and neither, just tell me.

Speaker 1 (00:49:28):

And does it hurt here? Does it hurt there? Okay, you have a hernia go. I don’t think that’s the best choice for you. Next question, I have trouble understanding how the retrorectus and intraabdominal section of this spermatic cord is handled during a laparoscopic repair without putting a keyhole in the Mesh for the cord to pass through. How does a cord pass through? This is a very complex concept for a neurosurgeon to understand perhaps a picture or model. Okay, well, I’ll try to explain to you. So the spermatic cord follows the vessels and everything from your back. It’s towards your back and it comes up, think of it like a electrical cord, right? So if you have an electrical cord that gets plugged into the wall, that’s going to be your spermatic cord entering the internal ring into your hernia. But then you can tape or move that cord to follow down the wall and then follow the floor instead of it having, instead of it being straight out from the wall wall because then you’re going to trip over it.

Speaker 1 (00:50:44):

So in order for it not to you not to trip over a cord, you have to have the cord hang down against the wall and then along the floor, the same thing happens with a spermatic cord, and therefore you can put Mesh over it without having it to go through the Mesh. If you go through the Mesh, that’s a situation where you put a hole in the Mesh and then the cord comes out through the Mesh called the keyhole, and it’s like putting a cord of electrical cord into a plug in the wall, but having the cord come straight out, you could trip over it, but if you have the cord follow the wall down and then on the floor, then you can put, I don’t know, curtain, let’s say against the wall, and you still don’t need a hole in your curtain to drape. So the curtain can go across the floor to the wall, and that’s how it’s done. I hope that makes sense. I just made up that analogy, by the way. So I’m very proud of myself and I think it’s a good analogy, but I hope you understand it because I should not understand it either. But now I get it.

Speaker 1 (00:52:04):

Mesh complications are rare, but they can also be serious and difficult to diagnose or treat. What reassurances can you give to patients who are scared by them? Well, I have a very honest discussion. I do tell them exactly that Mesh complications are rare and serious. I do treat Mesh complications for a living. So if you do have a Mesh complication, I can handle it. I don’t need to refer you to anyone because I treat Mesh complications myself. I’m very, very wary of how to do my best to prevent Mesh complications. So that gives them some reassurance, but I can also not promise that they won’t have a complication. I hope to say that as a specialist, I have lower complications than a non-specialist. That’s usually true, and I learned a lot from other people’s complications. So I’ll tell you, the past week has been really rough for me because I’m almost, every patient I saw was a complication, and it wasn’t just a complication, it was even worse than that.

Speaker 1 (00:53:16):

It was a preventable complication because I have my own complications. But in their situation, it was a preventable complication, and it’s very stressful to see all these people that could have just had a normal, I’ll give you an example. I had a lady, so she had a perfectly good hernia repair intention by the surgeon, but the surgeon’s like, oh, the Mesh come bake. I’m going to cut it. He cut two inches off the Mesh. The Mesh is only four and a half inches anyway. And listen, if you have a smaller piece of Mesh on a hernia, the risk of recurrence is greater. There’s a reason why there’s a standard size of Mesh for a growing hernia because smaller hernia sizes have been shown to have higher recurrences. So the reason why the surgeon thought the hernia Mesh was too big was because the space that he made was too small.

Speaker 1 (00:54:17):

He just needed to make the space larger. Instead, he cut the Mesh smaller, which means he didn’t understand that there’s a reason why there’s a certain size Mesh. So now she has a hernia recurrence. Okay, I had to fix that. I’m happy to fix that. She’s a housewife. She has two kids. They both go to school. She can’t take time off from taking them to school because her husband works hours that are not amenable. So she can’t have surgery around the time when the kids need to be taken to school and dropped back from school because she can’t drive after the surgery. So we have to figure out, do we do it during Thanksgiving break? Do we do it during Christmas break? Is that enough time for her to recover, like she’s going to need another surgery, which is another out-of-pocket cost. She needs to not be able to take care of her kids as much as she likes and schedule it that way. I mean, that one decision by the surgeon to cut the Mesh a little bit smaller than it should be has completely affected this patient both financially. For her family, she’s going to have extra scar, extra pain, extra recovery time, and every time you do a second, third, fourth, whatever operation, the outcomes are worse and there’s more to recover from. So these preventable complications really, really irk me. And unfortunately this past week has been a lot of it, and it’s just too much.

Speaker 1 (00:55:46):

Do you think that since many surgeons deny Mesh complications such as Mesh implant illness or chronic pain when they occur, contributes to the bad reputation of Mesh among patients and compromise how much they trust surgeons? I mean, I’m sure there, there’s some ability to that. We discussed a lot of this in the gaslighting, the medical gaslighting episode that I had I think earlier this year. I highly recommend that episode. We talked very honestly about surgeons denying co match complications when there is one, then the patient’s like, okay, then if it’s not the match, then why am I feeling so horrible? And they’re just giving given narcotics, and whereas maybe removing the Mesh would’ve helped ’em.

Speaker 1 (00:56:30):

And then after years and years and years, someone says, oh, maybe it’s your Mesh. They take out the Mesh, they feel better, and then they don’t trust their surgeon anymore. From then on, if someone is maybe to go see a specialist, how are they going to trust that that specialist is going to tell ’em the right thing? Because they’ve already had a bad experience. So what you’re saying is I agree with, on the case of a patient with pain from an open repair due attention, does laparoscopic repair relieve this tension or do the sutures from the open repair have to be removed? Very good question. Oftentimes the laparoscopic repair takes attention off of the tissue repair, and therefore you don’t need to undo the tissue repair. So the first line of treatment is just to do laparoscopic repair and take attention off. The tension you’re feeling is not so much the tightness, it’s the tr, it’s so tight, it’s ti it’s trying to tear. So if you offload that pressure with a laparoscopic repair for the inguinal hernia, then you don’t get the tearing sensation, therefore you don’t get the pain.

Speaker 1 (00:57:38):

When is long-term follow-up really important in hernia surgery? Yes, it is. And do you actively pursue it? Is it worth the effort? I do. It’s very labor intensive. We also belong to the ACHQC. You have heard about this. It’s a national database in the United States where patients are followed throughout the life of their hernia Mesh, and that helps us a little bit with the long-term follow-up. Dr. Ben Poulose is one of the brains behind that, and we did interview him a couple years ago in the early stages of hernia talk. So if you want to learn more about that, I recommend you listen to that one. What are the best questions to ask to get the most direct answers? Well, first of all, you should have questions and don’t think that your questions have to be these scientific, highly advanced questions. It could be simple.

Speaker 1 (00:58:28):

What is a hernia? What is Mesh? Can I see it? Where are my scars going to be? Even those things can be simple questions, but in your mind, take yourself through the process. Okay, I need to plan for surgery. Do I see a doctor blood test, blood test you need? How soon do I need the surgery? What do I not do before surgery? Can I walk stairs? Can I take care of my kid? Can I exercise before surgery? Then think about the surgery and how long does it take and what are my, do I go home? Does someone need to pick me up? How groggy will I be? Can I drive? When can I go back to work? And then afterwards, okay, now I’ve recovered from my hernia or the chances it’ll recur with the chances that I’ll have chronic pain or the chances of infection. How soon can I go back to exercise? These are all things that just process, like take process all the way through the whole kind of calendar of dealing with your hernia before, during, and after surgery. That’s how I would think about it.

Speaker 1 (00:59:32):

The next question is about consultations. How much do you charge for a consultation? So when you ask your surgeon how much there is for a consult for you, call them up. Just call the office and say how much you charge for a consultation. Everyone’s different. So for me, I offer in-person or a telehealth consultation. If you’re in California, you can fly in to see me. Or if you can’t, outside of my state, I offer what’s called online consultation, and we have different prices for those. So if you have insurance or you don’t have insurance, that may have different implications for you. So just call your doctor’s office, ask them to run your insurance card if you have one. And then what are the options? Can this be a telehealth? Do I have to come in? What information do you need before the consultation? And so on.

Speaker 1 (01:00:19):

So these are all hopefully helpful. I know that a lot of what I do on hernia talk is discussing questions and answering your questions about hernia related stuff. But I feel that a lot of what I do is also translating for you what maybe you’ve been told by a doctor or translating for you what you’ve read on Google or Facebook group. Let’s say, and I wish I could be everyone’s translator, but hopefully sessions like episodes like today’s will give you some clarity. Everyone needs to calm down, understand most doctors are there. Almost the majority of doctors are there to help you. They want to be able to help you. But we are all humans. So not everything is a conspiracy. I’m going to make some comments on hernia talk.com tonight to answer some of the questions that are out there, all these conspiracy theories about doctors changing offices and so on.

Speaker 1 (01:01:23):

So based on that, I would like to say thank you everyone for joining me. It’s been a great session. I always love my hernia talk sessions with you guys. I actually look forward to it quite a bit. Every week we’ll be off for two weeks. I will be at the European Hernia Society meeting. So please, if you follow me on Twitter, I will be live tweeting the meeting. So if you want to learn, and also I will have a ch, I’ll be in Manchester, United Kingdom. So if any of you are from the UK, Tuesday, the 17th, yeah, I think the 17th of October, Tuesday, I will be meeting with some patient advocates and hopefully I get to know some of you that I’ve seen and heard on social media, but haven’t gotten to meet. You’re like the United Kingdom. So thanks everyone. I do appreciate it. And join me next week, actually not next week in three weeks. So three weeks from today on our next hernia talk. Take care, everyone.