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Speaker 1 (00:00:10):
Good evening everyone. It’s Dr. Tophi. Welcome to Hernia Talk Live. My name is Dr. Shirin Tofi. I am your hernia and laparoscopic surgery specialist joining you every Tuesday. We call it hernia talk Tuesdays. Thanks for joining me on Facebook Live and those of you are who are on Zoom. As you know, this episode as well as all prior episodes are all archived on my YouTube channel, so you can share it at hernia doc. And I’m also on Twitter and Instagram on hernia doc. So today’s excellent and probably the youngest guest we’ve had so far is Dr. Kathryn Schlosser. She is in fellowship training. We’re going to discuss all the, what that means, but in minimally, minimally invasive surgery and hernia surgery in particular with an emphasis in hernia surgery. She is currently in Greenville, South Carolina. You can follow her on Twitter at KT_Schlosser. So please welcome Kathryn. Hi Katie.
Speaker 2 (00:01:08):
Thanks so much. Hi there. Thank you so much for having me. And I definitely go by Katie by anyone who has met me in person, so thank you.
Speaker 1 (00:01:16):
Yes, I know. So, okay, so what’s unique about Katie for the audience is we go to a lot of meetings and we belong to societies and usually we interact with our peers and my peers. I mean people that are already finished all their training and they’re just like what we call attendings. So attendings or faculty are people that are done with their training, typically board certified and are in practice like independent practice, whether it’s private institution or private practice or part of a group. Katie has been in our groups and honestly Katie, I didn’t know you were a resident until well after I first met you and I was like, wait, she’s a resident, she’s so active. She’s in SAGES, she’s in American Hernia Society. You’re in a lot of our committees. And are you in a book chapter that I was involved with? Maybe thank, so I’m very impressed because usually at your level you’re not, you’re like under your superiors, you’re not like on par on committees and stuff than others, but you are, you’ve been an amazing leader without having let anything get, I dunno, how about better to say that?
Speaker 2 (00:02:35):
Well, I really appreciate that. I’m definitely have been lucky to find things that I’m passionate about and had opportunities to really explore them pretty early and I’ve definitely pounced on a lot of those opportunities and continue to do so.
Speaker 1 (00:02:49):
I think it’s great. And congratulations to doing that. You are what, six months almost away from being an attending. You’re not planning on doing any more training than what you’ve already done
Speaker 2 (00:03:03):
So far. And right now they say they’ll graduate me, so yes.
Speaker 1 (00:03:08):
Okay. So maybe you can explain to them a little bit about your story and everyone who listens pretty much is potential patient. So maybe it’ll be good to have them understand the amount of education training you have to go to get to this stage and then what you foresee doing afterwards.
Speaker 2 (00:03:29):
Gotcha. Okay. So I’m first going to preface, I have a cat in the room with me who’s a little vocal, so you may hear her contribute. Oh. But I’ll kind of start back and sketch out how you get to surgery and then I’ll be a little bit more detailed in how I get into a subspecialization in surgery. So I initially was interested in medicine when I had a knee injury in high school and I thought that I wanted to go into massage therapy and then I moved towards physical therapy and then I realized that I really wanted to know more and do more. And I started pursuing medicine. I went to an undergraduate that allowed me to get both my pre-medical prerequisites, which included broad chemistry, physics and biology, as well as obtain a degree in English literature and a minor in cultural anthropology. So when I was setting up my undergraduate, I basically said I want to do everything I possibly can. And I wedged it in there knowing that if I pursued medicine, I was still going to be set up to take the first round of serious tests, which is the MCATs for anyone who wants to apply for medical school.
Speaker 1 (00:04:41):
And which college was this at?
Speaker 2 (00:04:43):
So I went to Kenyon College in Ohio. I’m originally from California and I got offered a great scholarship to go out there. Alright, she’s going to join the conversation. Little
Speaker 1 (00:04:53):
Covid cat.
Speaker 2 (00:04:54):
Yeah. So I got a great scholarship out to this small liberal arts school in rural Ohio, which was a great adventure. Oh,
Speaker 1 (00:05:04):
Interesting.
Speaker 2 (00:05:05):
Yeah. And finished out there, graduated and then actually spent two years in coastal California working in a state park. And I retook my MCATs and applied to medical school. And again, I applied extremely broadly to medical school. And I wound up getting in and going to the University of Vermont College of Medicine. And now when I started in Vermont, I thought I wanted to do primary care. I thought I wanted to treat the whole person from cradle to grave and they have a great primary care program and
Speaker 1 (00:05:37):
That’s their influence or their specialty.
Speaker 2 (00:05:40):
And so I brought in with me this expectation and medical school is four years and most schools do two years of lecture based in some way learning. And then two years of what’s called clinical rotations where you spend one to three months working with people in various fields of medicine. And there are standards that you have to go include. And that includes things like surgery, obstetrics and gynecology, psychiatry, primary care, pediatrics, everyone who becomes a doctor in the United States has to do these things. And then as you come out of your third year and you go into your fourth year, you still have some criteria you need to meet, but you get to pick what they call electives. And as I came into my fourth year, I was actually deciding between physical medicine and rehab, which is sort of a whole, yeah, it’s a different lifestyle for sure. And surgery. And you can kind of see trace completely
Speaker 1 (00:06:36):
Different. Completely. It’s like I would like the chocolate moose cake or this vegan,
Speaker 2 (00:06:46):
But you can trace it. If you remember I was interested in massage therapy, I was interested in physical therapy and I also did a bunch of away rotations. I worked with a ton of different practitioners around the country for a month at a time I lived out of my suitcase. And I found that while I loved physical medicine, every time one of my patients had to have surgery, I was like, Ooh, can I go see it? And that kind of tipped it off for me. And I decided fairly late that I wanted to apply for surgery having pretty poor, let’s say my resume was not stacked for surgery. I had decent recommendations
Speaker 1 (00:07:23):
Competition. Competition. They know from the beginning and from the beginning. It’s all surgical research, surgical meetings, surgical this and that.
Speaker 2 (00:07:33):
So as a student coming out of medical school and applying for residency, I applied very broadly and I wound up matching in a program I was very excited about. It was a community program in western Massachusetts at Bay State Medical Center, my program and they have a very strong minimally invasive program.
Speaker 1 (00:07:55):
Was David Earl part of your group back then?
Speaker 2 (00:07:57):
So he actually left the year before I got there. And the names that people know, John Romanelli was there Yes. When I was there. And he, he’s still a presence at Sages. And so I matched there and to take a step back while I was doing my away rotations, I did a rotation in Denver and I did this really cool surgery with a very cool surgeon and it was this complex abdominal wall reconstruction. And I thought, this is a really cool surgery. I’m seeing a lot of cool surgeries. And so it kind of went back on the shelf of things that I have seen. And then as I began to work in Bay State, I decided- they had a general surgeon join the practice who also did complex abdominal wall reconstruction. Dr oh gosh, what’s her first name? It’s a j Wang. And she was lovely and she was putting people packed together and I thought it was the coolest thing. And so I kind of at that time, so I’ve done four years of undergraduate. Okay.
Speaker 1 (00:08:59):
humpty dumpty
Speaker 2 (00:09:00):
Yeah, I’ve done four years of undergraduate. I’ve done four years of medical school where I had to make these decisions to go into surgery. And then I was at this community program that trained excellent surgeons, just really good manual skills, but did not have heavy clinical, every academic focus, some people did some research and residents, often one or two residents would step out to do research. But the day-to-day life of the hospital was not very research oriented. And I kind of looked around and said, I think I want to do more. I want to learn more about hernias and I don’t know where I’m going to get there
Speaker 1 (00:09:38):
For the audience. During my level, no one said I want to learn more about hernias. That was never, I don’t think anyone ever said that when I was at your stage
Speaker 2 (00:09:48):
And everyone thought, I was like, what are you doing? Why are you this excited? And so I actually posted, there is a Facebook group specifically for people interested in hernias. And I made a post on that that said, Hey, I have possibly two years of research time. Does anyone need a research person? And Dr. Towfigh, you responded, I remember that. You responded, remember that. Yeah. But also someone else who responded was a team member of Dr. Todd Heniford, who is one of the big names in hernia surgery out of Charlotte, North Carolina. And they created a position for me that was just a pure clinical research position. And I went there for two years and worked my tail off and really focused on figuring out, I say it’s how the sausage got made, how does one ask a question that of why did my patient do well? Why did they do poorly? Frame that question in a way that we can either create a study to investigate it going forward or we can date data that we already have and try to answer that question. And so I did a ton of different studies in that time period and that’s when I’m met Dr. Towfigh, who saw me hitting the conferences, hitting the conference circuit for two, three years in a row, talking about the research and meeting people who were on that stage.
Speaker 2 (00:11:23):
And so if you go back to this timeline, surgical residency in entirety is five years. You have to do five years of clinical work. And they’re usually at least 80 patient care, direct patient care at least 80 hours a week. Well not at least, but maximum 80 hours a week. And there’s a little flux around there in order to qualify to take your boards to be a surgeon in the United States. At that time, I had done two years of surgical training. I had stepped out and done two years of research and I looked to step in and for very step back in at Bay State. And for various reason I was not able to step in that year. And so I turned my attention sort of to the rest of the country and started shaking hands at conferences saying, do you know of a job for me? And I really,
Speaker 1 (00:12:14):
Yeah,
Speaker 2 (00:12:15):
Yeah. And so cause your
Speaker 1 (00:12:16):
Class was filled already. Well were most people didn’t do two years. And so you were off the
Speaker 2 (00:12:24):
Yeah, well what wound up happening, as I understand it, is the person who was going to step out wound up not stepping out. And so there was not a position for me to step back into. And for the people who are not aware of this, the federal government pays a hospital to train a resident. And so they give a hospital a chunk of money and out of that money goes the resident’s salary, their benefits, their educational materials, their healthcare, all of those things. And so they couldn’t just create a position for me out of thin air. There wasn’t money for that position. And they offered to bring me back and do research and I would do some clinical work and hopefully step into next year, but it wasn’t a guarantee. That was my backup. And so they wrote me a lovely letter of recommendation and I wound up landing a position with Ohio State University fantastic.
Speaker 2 (00:13:19):
Who had obtained funding for a additional resident. So they were expanding the number of residents that they could train every year. And so they went from six residents per year to seven residents per year. And I was that seven seventh resident. So I picked up everything again, I disassembled all my furniture and I moved from Charlotte to Ohio State and I was there for three years. And so that completed my surgical training. And at the end of that I had to make a decision on whether or not I wanted to go into general practice and sort of start a career out of that or if I wanted to do additional training. And there are specialties in the United States that re absolutely require additional training. If you’re going to be a cardiothoracic surgeon, if you’re going to be a pediatric surgeon, you have to take one or more years of additional training. The specialty that I chose does not require additional training per se.
Speaker 1 (00:14:22):
As a general surgeon, you should be able to offer hernia surgery, maybe not advanced hernia surgery, but every general surgeon should be qualified to perform hernia surgery.
Speaker 2 (00:14:31):
Correct. And that is part of the qualifications of graduating residency is that you tick this box, you know how to do a safe hernia surgery. And so I decided that I wanted additional specialization training in both minimally invasive and what we’re now calling complex abdominal wall reconstruction. And I applied to programs around the country and the one that I wound up coming to is Prisma Health in Greenville, South Carolina that has formal fantastic program. Yes. And it has former men trainees of Dr. Todd Heniford, who’s been training fellows for a long, long time recall. We call
Speaker 1 (00:15:10):
Him the Godfather.
Speaker 2 (00:15:12):
Yes. I call it the multi-level marketing. Yeah,
Speaker 1 (00:15:16):
There
Speaker 2 (00:15:16):
You go. You can trace your lineage. Yes. And so now I’m here, and actually my training here is half bariatrics, half complex abdominal wall. And I didn’t set out looking for bariatrics, but I’m glad that I’m doing it because it’s a really good minimally invasive surgery side. So even if I don’t wind up being a bariatric surgeon, I can do stuff laparoscopically or minimally invasively that I would not have been able to do had I not done this fellowship. I would have to look at that problem and say, I need to make a bigger incision and now I can look at the same problem and say, I think we can do this. I think I can do this.
Speaker 1 (00:15:57):
Yeah, these are great. You’ve done your rounds throughout. So almost every surgeon you’ve mentioned so far has been a guest. So obviously Todd Heniford has been a guest. Brian Jacob who started the hernia Facebook group that you told about was one of our original guests. David Earl, who was the Bay State was a guest. Dr. Carbonell, who’s who you’re under has not been a guest yet, but I’ll make sure he’s a guest
Speaker 2 (00:16:28):
From you. Good luck. He’s retreating into the mountains, I think.
Speaker 1 (00:16:32):
I know there’s a reason why certain people don’t show up on this show. It’s harder to book some people,
Speaker 1 (00:16:42):
But kudos to him. And the key with Dr. Heniford, which we discussed is that he is been literally the Todd father, the godfather of current trainees, not of the original ones, but of current trainees. He was one of the few in his generation that took hernias to minimally invasive surgery options going from open to laparoscopic. And then he trained a very large proportion of the greats out there, including your own boss. So yeah, it’s pretty fantastic. Great training you’re getting at South Carolina. And you’re right with bariatric surgery, you have extra skills that the average early surgeon will not have laparoscopically. And that’s a very positive thing, even if, like you said, you don’t plan on doing bariatric surgery. Cool. So now you have six more months. So did you take your boards?
Speaker 2 (00:17:49):
Yes, I took my boards in November. I’m officially a board certified surgeon. Woohoo.
Speaker 1 (00:17:54):
Congratulations. That’s a big deal. Very big deal. And for those of you out there, it’s not easy taking the boards. You have oral, you have a written boards would you have to pass, which has a good failure rate. And then you have the oral boards you have to pass as a present for having passed the written boards. And that’s even more difficult to pass. So yeah, yeah, you’re grilled through the whole process, congratulations on that. And in six months you’ll have finished your minimally invasive surgery and bariatric surgery, what we call fellowship, which is the training out after hernia surgery or after general surgery. And then what do you plan to do?
Speaker 2 (00:18:36):
So my next step is figuring out the best job for me, and that’s obviously a combination of what’s on the market, what’s available to me, location, what they’re looking for, as well as figuring out what I want the madam wants back on the lap. My apologies.
Speaker 1 (00:18:54):
COVID cat.
Speaker 2 (00:18:55):
Yeah. So I’m currently on the job market applying to various places and I’m hearing what they are looking for and what sort of niche my skillset can fill. And then stepping back and deciding what do I really want to do? And this, you’ve kind of heard how I’ve lived in, I did the math, I have moved every two to three years for the past 15. That’s a lot. And I’ve really prioritized getting the best possible education for myself over many other things. And so now I’m sort of stepping back and saying, I know I love to do hernias. Where does that take me? Where do I want to go? Do I want to keep researching? Do I want to teach? Do I want to spend some time in general practice and be the best hernia surgeon that I want to be? And I’m sort of at that beginning knowing that that may change both if I join a practice or I join an institution and their needs change, or I joined something and say, I thought I wanted this and I didn’t want this, I’m going to pursue something else. So that’s both exciting and scary.
Speaker 1 (00:20:07):
And are there hernia specific jobs out there currently? Well, first of all, lemme preface by saying ever since COVID, the job market has dropped dramatically because hospitals lost a lot of a lot of money during COVID and they don’t have the funding for jobs like they did before. So a lot of the jobs out there for surgeons are hospital based and you’re dependent on the hospital to hire you. And they’re either on a hiring freeze, they’re on a budget crunch, and therefore either there’s no job or it’s a very low paying job, relatively speaking. So that put aside, are you seeing job openings for pure hernia surgeons or primarily abdominal wall?
Speaker 2 (00:20:53):
I have seen a handful that are advertising as we want someone with this specific skillset, we want want to expand in this niche. Now some of them are in areas of the country where there’s definitely a need and some of them are in areas of the country where that market may already be saturated. And so I can definitely see that there’s recognition at a national level that having a hernia center or having a Hurley hernia specialist is beneficial for that institution. And what that means on the ground, if I make a match with an institution, I sign a contract, I show up on day one. What that means on the ground seems to be highly variable. And that can be anything from, we need someone to do a broad range of surgeries and we’re really excited that you have this skillset and maybe you can build it out at some point to nobody here wants to do these cases. You can have them all and your clinic will be full the first day. And so I’m seeing that whole range. There’s definitely what I think is an increased awareness of this specialization. So if I walk into an interview and say, I can bring this skillset, I often get a response of that would be a great self skillset to have on our team. What that means for what I would be doing on a day-to-day, month-to-month basis varies a lot based on what you mentioned, what the hospital is willing to support and fund.
Speaker 1 (00:22:31):
Yeah, yeah. It’s a problem because it’s often not so much patient need because there’s hernias everywhere. So every state needs a needs hernia specialists. And even the states that have quite a number on the East coast need more hernia specialists. It’s more like the leader of the group and where they would like you to operate. Unfortunately, hernia surgery doesn’t really pay very well and they would prefer that you do bariatrics or intestinal surgery or Foregut surgery, which is all part of your training rather than focus on the least paying kind of portion. And I was just reviewing the new 2023 Medicare codes that have changed. Hernia got a big hit and the reimbursement dropped by as much as 70%. And
Speaker 2 (00:23:34):
That’s a, a lot of that’s going to mean a huge deal for people who need even very small hernia pairs who need care. It’s going to decrease the willingness of the hospital and the practices to invest in that space to invest in dedicated roots for workup management and post-operative care. Because the more I use breast surgery as a success story in this breast surgery of the past 40 years has gained nationwide attention, has gained specialty billions, has gained billions of dollars of investment in research, research. And from that has gained very structured support for patients who are going through these problems. And they’ve been able to, from the moment of a possible diagnosis to the final ringing the bell that this patient has cured of their cancer, there are systems in place to support them. And this comes from both an awareness as well as the funding and the reimbursement that the hospital was able to give back into that.
Speaker 2 (00:24:45):
And I am by no way in saying that a hernia is as serious or not as serious as breast cancer. But I see this as a model of what happens when we have investment and when we have buy-in from multiple layers and that worry, the reimbursement model worry worries me because yeah, when I am a practitioner who has hernia, patients who have a lot of needs, I need to be able to go to my administration and say, I need this additional staff, I need these people to take my phone calls. I need these people to help me see patients preoperatively or postoperatively. I need schedulers who know my needs, who so I can take care of people from the first time they called a clinic to when I tell them, have a nice life. I hope you never need a surgeon again. But I need to be able to advocate for that to my administration. And the way that I do that, it’s saying this is how you bring in money.
Speaker 1 (00:25:43):
Well, the issue is this breast is a very good way, good comparator. Breast surgery itself is actually even less reimbursed than hernia surgery. Many of the breast operations, I think in terms of the least paid, least paid operations, number one is breast. Number two is hernias, something like that. However, as a breast surgeon, you are also using radiologists, oncologists, radiation therapists, and all of those are money makers for the hospital system. And you cannot make money from those without having the breast surgeon. So they’re a very main, they’re like the yeast for the bread and you can’t make the bread without the yeast. You can make it without maybe some of the other ingredients. Whereas with hernia surgery, we use imaging. We may use physical therapy a little bit, but we’re not huge resource users. We’re often outpatient and so on. So it’s a little bit harder to negotiate having multiple hernia surgeons on a hospital’s payroll when reimbursement is so low and they can spend money and sit on liver transplants or the reimbursement is humongous. So it’s a problem. And most hernia jobs out there, unless you have a leader that is really into you. So Hanford and others, most hernia jobs are a general surgery slash hernia. We have this general surgery need. Oh, you like to do hernias? Okay, great. I mean that’s fine. Don’t forget about this big chunk of general surgery.
Speaker 2 (00:27:37):
And this
Speaker 2 (00:27:39):
Comes back to some excellent advice I got from a plastic surgeon, and this is also a road not taken. I love plastic surgery. I think it’s fascinating. But he told me I do three types of operations. I do operations that keep me in business. Those are post mastectomy, breast reconstructions, those are the where the hospital needs me. That is how I tick the box to keep my clinic running. And then I do the operations that will never make the hospital any money, but they need to be done. Those are the massive facial reconstructions after motor vehicle accidents. So those are days out of his life in the operating room, actual days that he spends in the operating room built, rebuilding somebody’s face. He’s not never going to be reimbursed adequately by that, but it’s the right thing to do and it needs to be done. And then there is whatever extra he wants in his life and those are the elective procedures that he does that are cash only, that sort of thing. And so he kind of divides his time out of that. And I think that that is sort of what the hospital has to look at with hernia surgery because some of these big reconstructions may not be financially appropriate, but there is a need. And so that’s an
Speaker 1 (00:28:55):
Issue that I currently have. Besides me, we have no one else at our hospital, which is a major hospital and world renowned, no one else does hernias the way I do. They’re general surgeons a do hernias, but abdominal wall reconstructed, there’s no one. And in California actually, there’s literally just two of us that have an interest in it for a huge state, which is a problem. And yet, unless I can convince the leadership of the hospital that because we are such a force in the society that we must excel in, especially I do, if it were me, I would have every single hernia in the hospital just referred to a group that I run because we can give the best care in the best hospital, which I think is a good match. But financially, but
Speaker 2 (00:29:52):
That also comes, but that also comes to who am I to tell a very solid surgeon that they can’t do a straightforward hernia. And one of the best pieces of literature that I’ve ever read on this, I’ve done a lot of reading and publications on how to build a hernia center, which long term is my goal. One of my favorite publications came out of an institution that realized that they were having below average outcomes for all of their hernias, both the ones done by the hernia specialists and the ones but being done by their non hernia specialists. And so they got together and implemented protocols in terms of what should be referred to the specialist, what should be managed in-house by the general surgeons, and really basic things like smoking cessation, weight loss, some of the preoperative optimization to be plugged in very early in the care.
Speaker 2 (00:30:46):
And you could tell from the tone of the article, they very tactfully said, we had to fight this out. Nobody wanted to give up a piece of this pie and we had to fight it out. But once we did, everybody’s outcomes got better. And the general practitioners were turned out to be pretty glad to give up the complex hernias and also pretty excited that their overall outcomes were getting better once the standard had been raised for everybody. And I think that’s an ideal world. Perfect. Which keeps the general practitioners of this country safe and able to take care of a good number of hernias, but also aware of what should be referred like recurrent hernias or chronic pain or loss of domain and setting them up to feel supported in doing what they’re doing at their clinic and at their outpatient or as well as when they do have problems to send it off to somebody who can manage it. Yeah,
Speaker 1 (00:31:47):
I get it. We have a couple questions that have been submitted. Let’s go through some of them. You’ve answered many of them and maybe it’ll spark some more discussion. So do all her new surgery specialists start as general surgeons? Yes. We already discussed that. No,
Speaker 2 (00:32:02):
No, no plastic’s
Speaker 1 (00:32:04):
True. No plastic surgeons and urologists.
Speaker 2 (00:32:08):
Yes. So there are plastic surgeons and urologists who develop an interest in abdominal wall and can be excellent hernia surgeons. Often they will use their general surgery colleagues for some of the management of intestines if there’s scar tissue between intestines and that sort of thing. But there are other specialists, Jeffrey Janice is very prominent in both the hernia world and the plastics world, or
Speaker 1 (00:32:34):
A guest on our show
Speaker 2 (00:32:37):
Who don’t start as general surgeons. But I would say the majority do.
Speaker 1 (00:32:41):
Majority do. Let’s not forget for colorectal surgeons they do parastomal hernias. Many urologists or colorectal surgeons do perineal hernias. Yeah, this is very true. Yeah. And is there a formal path that surgeons have to follow before they can call themselves hernia surgery specialists? I answer that as also no.
Speaker 2 (00:33:01):
Yeah, no. Right. Anyone. And that’s highly people. A
Speaker 1 (00:33:05):
Hernia specialist in my town, lemme tell you, around my office alone, there’s like seven hernia centers
Speaker 2 (00:33:13):
And that’s come to
Speaker 1 (00:33:14):
Me and say, oh, I went to a hernia special. I’m like, and who would that be?
Speaker 2 (00:33:18):
And of course, and that’s really hard because again, who am I to look at someone? I know some excellent surgeons who never went to fellowship who can do an excellent hernia repair. But currently in the United States there’s no formal accreditation of hernia specialization. And my suspicion is that it will move the way of bariatric surgery. So you could do a fellowship in bariatric surgery if you don’t do, and you can get accredited as a bariatric surgery through the bar National Bariatric Association, you can become a general surgeon, meet a set of criteria of training and access at your hospital and then become accredited after becoming a general surgeon. So there’s different paths to becoming an accredited general surgeon, or sorry, an accredited bariatric surgeon. And there are nationwide standards for an institution to maintain bariatric excellence. So when I graduated general surgery residency, I was accredited to do bariatric surgery. I legally in the United States had the skillset to do bariatric surgery. However, I don’t have the seal of approval from the National Bariatric Institution and I don’t have, currently I’m not, well I am at because I’m at a training program. But wherever I wind up, if I can start a bariatric clinic, but I have to meet certain criteria to get national accreditation, that’s where I imagine hernia surgery to go in the future for specialized abdominal reconstruction. We’re not there yet.
Speaker 1 (00:34:55):
Yeah, we’re not, but we’re getting there. I think we will be getting there. It’s going to be tricky. Like you said, the general surgeon should be able to do hernia surgery and especially in a practice setting where if you get that patient, that means another surgeon’s not getting that patient, then it’s going to be kind of difficult to do. Here’s a question live. What would the process be for making a complex type of hernia surgery requires something other than just a general surgeon?
Speaker 2 (00:35:25):
So we
Speaker 1 (00:35:27):
Actually on that, but is a complex hernia. Yeah.
Speaker 2 (00:35:32):
Off the top of my head, what I would define as a complex hernia, there’s a couple things. One would be if it’s been recurrent, if it’s come back several times, yes. Two would be sort of the size of the hernia. And this is a little bit of a wishy-washy thing, but a big hernia that’s not going to pull together easily in that patient. And the final one for me is how complex is the patient? Does the patient have an active or a history of cancer? Are they on steroids or do they have other factors within this patient that is going to make it much harder for them to heal from a hernia surgery?
Speaker 1 (00:36:14):
What else do you I would add, I would add Mesh infection or a fistula involved in the hernia. Yeah. And then chronic pain associated with a prior hernia repair.
Speaker 2 (00:36:23):
Yeah, absolutely. Absolutely. I think all of those things should push for extra eyes, extra people on deck with that
Speaker 1 (00:36:34):
As a patient in addition to trusting what surgeons say. How can you be sure that your surgeon is really specialized in hernia surgery? That’s the problem I have so many people come and tell me, I just saw hernia specialist and they said this, that and the other. I’m like, well, I mean I’m not really a hernia specialist. They do hernia surgery.
Speaker 2 (00:36:55):
Yeah. Yeah. That’s really
Speaker 1 (00:36:56):
Best for them to ask.
Speaker 2 (00:36:59):
I don’t,
Speaker 1 (00:37:00):
But you may not agree with what I say.
Speaker 2 (00:37:02):
Oh, I’m super curious. I think that there are several markers. My personal gestalt for going to a specialist whose specialization I don’t understand is that they should be able to explain their thought process and decision making to me in entirety in words that I can understand. And I use this at the mechanic, I use this at the dentist, they should be able to tell me what’s happening, why this will or won’t work in a way that I can understand and in a way where I can say, well, what if I don’t do this? What if I do do this? What will happen and what are the options? I think that’s the first thing for just a good practitioner because that shows that they’ve thought about the patient entirety. And then I think that there are some markers that show that someone has been invested in ongoing hernia improvement, and some of those markers include publications in hernia.
Speaker 2 (00:37:57):
Some of them can include membership in what we call the ACHQC, which is a self-monitoring nationwide database in which surgeons put in their own data, their own patient results and use it to track their outcomes and use it to say, out of all these patients, how am I doing? And it’s a way for them to measure themselves against the rest of the country as well as potentially do research out of the summative data. So that’s kind of what I think are good markers of a specialist. What else have you seen or what else do you think a patient
Speaker 1 (00:38:33):
Can do? Yeah, we had Dr. Ben Poulose as a guest too. He kind of really went over the whole ACHQC and how it’s helped. In last week we had Dr. Hans Fr Anderson, who’s the head of the Denmark, the Danish hernia registry, which is really cool. So yes, I would say for your type of hernia, the question I would ask is it is threefold. One is, can the surgeon do it open, lap or robotic? If they can only do open, they’re not going to necessarily say, oh, this is best done laparoscopically or robotically and vice versa. So that’s funny. The second is, do they deal with Mesh versus no Mesh issues? Can they offer you a non Mesh repair, for example, femoral hernias and therefore not always give you one choice? I think as a hernia specialist, that’s someone who has a full encyclopedia of options available to you because they can provide that and then they’ll say, okay, now that I know these are all the options for you, I recommend A and B and not C and d, for example.
Speaker 1 (00:39:41):
And then lastly, I’m always curious if they deal, I would say they should have at least 50% of their practice should be hernias. Most people are not a hundred percent. There’s only a handful of us that do that, but at least 50% because that implies that they have an interest in hernias. And then I would also say ask them how much of their operations are either revisional or deal with chronic pain, because that’s definitely a sign that you have an interest in doing. And if all you’re doing are outpatient umbilical hernias, that’s not really a hernia specialist, a hernia surgeon, but to be a specialist, I think it should be you offer the full menu of options and therefore when they provide you with the recommendations, because they know the nitty gritty of pros and cons of every option, and that’s why they offer you the laparoscopic or the open or the Mesh or the non Mesh options. But I’m biased because I’m literally surrounded with hundreds of specialists.
Speaker 2 (00:40:50):
Yeah, and I think kind of what you’re saying about knowing the options and knowing what those outcomes would be is really important because I think we both know surgeons who are really good at one mo modality, and that kind of goes back to the saying of when you have a hammer, everything looks like a nail. And I think that’s something that it, it’s definitely, there are many people who will do a surgery that would not be my first choice, but is also not a bad surgery. And I think the best example of that, not every surgeon has regular access to a robot and that I think that can be a really hard thing for, there are some surgeons who will fix everything with a robot. There are some surgeons who will fix nothing with a robot, and the correct answer is probably somewhere in between. But that’s a gray zone in there. And so I think that if the difference is getting a solid hernia surgery within 20 minutes of your home versus traveling a ton to get a robotic surgery from someone who does a lot of robots, that’s a really hard decision for a patient to make. And I don’t undo that.
Speaker 1 (00:42:07):
Yeah. Here’s a lot of question. If a surgeon limits his practice, the inguinal hernias, but not ventral hernias, is that surgeon considered a hernia specialist?
Speaker 2 (00:42:18):
I think they can be. I think inguinal hernias can be quite complex, and I think there are very few people who have either the case volume, the interest or the technical expertise to really approach those. But it really falls into, and you can probably add more to this, what you were saying, you can do an inguinal hernia laparoscopically, robotically or open, and there’s a reason to do all of those and with or without Mesh,
Speaker 1 (00:42:42):
Right? Yeah. I think it’s really rare for anyone who’s a true hernia specialist only doing orals. It’s really, really rare. I mean, even the Shouldice people, they’re great at the Shouldice repair, but I wouldn’t call them hernia specialists. They don’t do revisional surgery. Some of them do laparoscopic surgery, they don’t do much ventral surgery. So they do some, not a lot. But I would say if you have a hernia at the, and you’re like in some local town outskirts of Ohio, let’s say Go see your a hernia specialist, pay that extra money, whatever, it’s invest in that opinion, then that person may say, oh yeah, you need a laparoscopic surgery or you need a open surgery, or Don’t do this surgery for sure. That’ll be a horrible decision. Make sure this is a plan of care. Get at least your plan of care and then locally go to your LO surgeon who maybe does exactly that operation very well and do that. That’s one way of doing it because we don’t have as hernia spread, we don’t have to operate on every single patient who has a hernia. But I feel like our plan of care is often more thoughtful and nuanced because we see such a wide variety of problems in addition to patients I learned from complications in other people’s operations. I think that the forensics part of it is really cool.
Speaker 2 (00:44:14):
And I think that sometimes you may have seen this, but I’ve started to do this. Sometimes what I wind up doing is giving people permission to either stay local, to stay with someone or to fire them to make these choices about their healthcare that they haven’t felt and able to do yet, and saying that this what they are offering you may not be what I would do, but this is very reasonable. This is a very safe thing. And if it keeps you near your family, it’s very reasonable.
Speaker 1 (00:44:46):
From a patient perspective, what does an educational level and the other trait surgeon should have before you can trust them to operate on a revisional or complex case? We’ve already discussed what it takes to become a surgeon, but do you think where they trained at the undergraduate medical school or even general surgery residency level predicts how good of a assertion they would be?
Speaker 2 (00:45:12):
I wish it did. I really wish it did. I find that that often is very predictive of academic excellence of people who do good research. And I think that there are excellent surgeons who graduate out of, I have colleagues who I went to Bay State with, and that is an excellent community, serve a community program, little bit of academics, but a really good community program. And I have people that I’ve graduated out of Ohio State with that are also excellent. I also have people that I’ve graduated with or worked with that I, who make choices that I would not make. I don’t think there’s anyone that I’ve worked with who is truly unsafe, but unfortunately I don’t think where they graduate from. I think what’s more important is asking about specialization training, saying where did you learn how to do this? Yes. How, who did you work with? Who do you call? This is a good one. Who do you call when you get into trouble? And that, I think even just having a surgeon admit that they call someone when they get into trouble. Yeah, the sneaky question.
Speaker 1 (00:46:28):
Yeah. Stay away from the surgeon’s like, oh, I never get into trouble. Oh, I never have complications.
Speaker 2 (00:46:34):
And they may say, yeah, they may say, I call my partners, they’re really helpful. They’ll come in with me. They may say, I call my former boss, I call this person that I worked with that, whatever that is. And having that deep bench is really helpful.
Speaker 1 (00:46:49):
I would say I’ve interacted with a handful of surgeons that are so gifted, like amazingly gifted, and then I got to learn about their train, their education. One guy was lucky to have finished high school. He was a complete reject in high school. And then later on in life really kind of became more interested in the fact that he’s a shape up and is now one of the most skilled surgeons I know. And the other surgeon, I’m thinking about head of a division, like super talented surgeon. And I was surprised he did not go to medical school in the United States. He ended up in one of the Caribbean schools, which usually is considered like a lower tier schools. Most people don’t choose to go to Caribbean schools. They got accepted to a US school at the least, and yet he’s like a department head.
Speaker 2 (00:47:49):
And I’ve seen many people who had to redo their residency in the United States because whatever country they did their medical training in the US does not recognize. And there’s a good reason for many of that because there’s huge differences in the medical structure. But I have seen many extraordinarily skilled surgeons who by the time they finish medical ed education in a different country residency and in a different country, and then have to go back and start from the beginning, either from medical school or residency, by the time they’re done, they don’t want to do any academics. They want to go operate, they want to spend time with their family. And so you wind up with these extraordinarily skilled surgeons. So true. No interest in coming to our meetings. They just want to be a good surgeon.
Speaker 1 (00:48:33):
So true. Can a skill in diagnosing hernias or hard to diagnose complications such as Mesh reactions be taken for granted in all specialized hernia surgeons? I don’t know what that question’s about.
Speaker 2 (00:48:48):
For me,
Speaker 1 (00:48:48):
They’re basically saying, is diagnostic skill something that people sometimes overlook and they focus on surgical skill
Speaker 2 (00:48:57):
That, or can I trust this hernia specialist to figure out what’s going on with me? Yeah. I mean, I think that it is with possible for all of us, I’m sure you’ve experienced this to miss a diagnosis, and I think that the more skilled and experience that you have, the more likely you are to catch a diagnosis. But I think that if you are not progressing under someone’s care, that may be useful. There is a saying in medicine that sometimes the best thing that can happen to a patient is for them to be discharged and readmitted because they get a whole new team to look at them
Speaker 1 (00:49:47):
Whole new eyes.
Speaker 2 (00:49:49):
And so I think it’s within me definitely to miss a diagnosis, to miss part of the story, to not ask the right question. And hopefully as I move forward, I will get better and better at this, and I will also know who to call when it something’s not making sense. But definitely I think that that’s a hard thing to recognize.
Speaker 1 (00:50:12):
I have some patients that it’s mostly because of the geography of where they live. They’ve had three or four operations by the same surgeon before they see me. And then I always ask, I can understand complications. I’ve had my own. So you do one operation, you had a complication, then you have a second operation. But then the third and fourth, if you think of maybe looking outside, and it’s hard to get yourself to go to different city or a state to get medical care.
Speaker 2 (00:50:46):
And it’s even harder if the surgeon’s a nice person.
Speaker 1 (00:50:50):
Exactly.
Speaker 2 (00:50:51):
It’s really easy to fire an asshole.
Speaker 1 (00:50:54):
Yeah. Sorry. I dunno
Speaker 2 (00:50:55):
If I dunno. Very
Speaker 1 (00:50:58):
Good point. No, you have very good point. Yeah, there are plenty of not so good, but very nice surgeons out there. Okay. What are the most common mistakes and misdiagnose is made by non-specialized hernia surgeons that lead to further revisional or complicated surgery? That’s a good question.
Speaker 2 (00:51:16):
Ooh, I want to hear your answer on this one. This is me learning.
Speaker 1 (00:51:20):
Well, I’ll tell you, the most common mistake is not planning. So they go in there and they’re like, oh, this is a bigger hernia than I thought, or something like that. So it’s not planning. So I’m a big planner. I don’t want to be surprised when I go in there imaging, I’m getting good history, examining the patient and all that. The other common mistake I would say for inguinal is they don’t do a wide enough dissection and they just try and futz it and stick a Mesh there. The Mesh ends up folding or they don’t dissect enough tissue out. So you’re trapping fat with a Mesh. Now the other major issue for ventrals is also too small of a Mesh usually. So it’s not uncommon for me to have someone with a five centimeter centimeter hernia at a six centimeter Mesh. That makes no sense to me, but it happens a lot. And lastly is anatomy. I feel like they don’t know their anatomy very well. Anatomy, and physics. I don’t know if you’re a physics fan, are you a fan of physics?
Speaker 2 (00:52:29):
I am! Come on, right? Yes. Yes. So
Speaker 1 (00:52:33):
Thank you. Is the logic of surgeons, if it makes sense by the laws of phyics, it should make sense surgically. And I feel that a lot of decisions are made. I’m like, that makes no sense. Why would you do what you just did? Because from a physics standpoint, it makes no sense. Like a five centimeter hernia with a six centimeter Mesh makes no sense physically.
Speaker 2 (00:53:01):
And I’ve had these discussions in person several times. I’m not as empowered to have them depending on how junior I am, six, four months. Oh yes. But politics. But I think that, and those mistakes can come from several, some of my own mistakes can come from that. I made a mistake recently when in retrospect, the physics didn’t make sense in retrospect. And we wound up having to do a different surgery on the patient in fairly short order. And the decisions we made at the time, we were weighing a bunch of different variables and we weighed them incorrectly. And so the kindest response I have for that is whatever they were seeing in that moment, yeah, they were trying to get this patient over the next hump. They were trying to get the patient to the next stage. That’s
Speaker 1 (00:53:56):
Okay if the logic is there, I’m okay with that. Yeah. We’re not going to do a definitive hernia repair today because you’re having whatever other operation, but know that you are highly likely to have a hernia recurrence, but at the next stage we’ll do the perfect repair. I’m totally okay with that.
Speaker 2 (00:54:15):
Yeah. Yeah, I think so. The mistakes from sort of weighing the risk factors are one part and hindsight is 2020. It’s 2020 for me, and I have my regrets. And on the other side, the mistakes based on knowledge and understanding of our tools. And that can be understanding of the characteristics of the Mesh that we’re putting in understanding of the characteristics of the sutures that we use to put people back together. We still have surgeons all over the country who, for example, will, if someone has to get a surgery and they’ve already had a Mesh, they’ll cut, make a cut through that Mesh to get in to do whatever they need to do. And they’ll so up the Mesh with an absorbable suture, more suture, which will become a new hernia. And that for us, a specialist. Yeah, a hernia specialist. That’s bonkers. But that is a knowledge deficit that is just a basic knowledge deficit that is I think, part of you and my job to help bring the next information that we have to the rest of the country.
Speaker 1 (00:55:21):
Or they use absorbable Mesh with non-absorbable suture. They suture them. Why that makes, these are like, I call it logic, but some of it’s also knowledge. Many surgeons do not know the intricacies of lightweight Mesh, heavyweight Mesh, dual Mesh barrier, Mesh, all these different meshes, absorbable commonly using whatever the nurse has in the room. And my very first case at one of my hospitals, my very first case, the surgeon called me, he’s like, oh, the resident called me because surgeon didn’t even know I was hired yet. Right. The residents already knew me. And they said, would you mind coming and seeing this patient? I said, sure, there’s stool coming out of his wound. I was like, he needs to go back to the operating room. The surgery was I think two days before right ventral hernia. And they’re like, oh, okay. So I said, would you like me to in there with you? Yes, please. We don’t know what to do. Why? It was perfectly well done case. So I go in there, you may not remember. Maybe, do you remember there’s something called composites, Google patches.
Speaker 2 (00:56:35):
I’ve taken them out.
Speaker 1 (00:56:37):
Yes.
Speaker 2 (00:56:38):
I’ve never put them in. That was before my time. I’ve taken them out.
Speaker 1 (00:56:41):
Yeah. They were made in a way that the lower, there’s like three layers of Mesh, two like heavyweight polypropylene meshes, and then E P T F E Mesh on the bottom with a ring. But the way it was, it’s put together is the barrier Mesh. The lower Mesh is wider than the polypropylene Mesh by a small rim. You’re not supposed to cut this Mesh because by cutting it, you now have a very razor sharp edge, number one, and number two, you’re exposing the thicker polypropylene Mesh to bowel, which specifically the design of Mesh was made not to expose that part. So senior surgeon, I go in OR with him, just me, the resident, the other senior surgeon, are looking to see how I can help this situation. And I look at the Mesh and I’m like, it’s clearly kind. Did you cut this Mesh? And he said, yeah, as if, of course I cut the Mesh and I said, you can’t cut this Mesh. I was like, what do you mean it was too big? Then you order a smaller Mesh, specifically this Mesh, you can’t cut. That’s why the patient had fistula, which was basically a stool coming out because you now basically put a razor blade into the abdominal wall. So he just didn’t know. No one told him he’s probably cut Mesh before. I don’t even know. Because he didn’t act like that wasn’t like a detail he wanted to share with me necessarily. That was important.
Speaker 2 (00:58:18):
And the challenge in that moment, you are a new hire helping out a senior surgeon, is to educate in a way that he can hold onto that information and that everybody else in the room knows that they can come to you when they have these questions.
Speaker 1 (00:58:37):
Yes. I was like, okay, well, lemme explain.
Speaker 2 (00:58:43):
Right?
Speaker 1 (00:58:44):
Not meant to be cut
Speaker 2 (00:58:46):
And let’s go over Mesh. Let’s, when we’re done with this case, let’s take a tour of the cabinet. Yes. Let’s see what we have. You can show me what we, all of that politics. Yeah. So we
Speaker 1 (00:58:57):
Have a question now because of this, is it wrong to cut all types of Mesh, only the one that I just specifically discussed?
Speaker 2 (00:59:02):
No, no. And this is part of the nuance, and this is sort of where the arc between a general surgeon and a specialist goes, because a general surgeon will probably have anywhere from three to five meshes in their arsenal. They will say, I use this Mesh for this and that Mesh for this, and those are my options. And then a specialist will often say, these are my preferences and this is what I would recommend. This is what else I know about. So that that’s sort of the deeper level of knowledge, and I think goal for the generalist is to really know the limitations that the meshes that they’re handling and sort of when they’re appropriate and when they need to reach outside of that.
Speaker 1 (00:59:45):
Yeah, the majority of currently available meshes can be cut. There’s a handful that are these multiple layer meshes that are in multiple layers for a reason because one layer is supposed to shield the other layers that you’re not supposed to cut. Usually they’re called composite meshes, but yeah, so little things
Speaker 2 (01:00:09):
Like that. Yeah. Yeah. I mean, it’ll always keep, I think we’re in a field that’s going to keep us busy and it keeps changing because it’s so imperfect right now. Yeah, both. Even if everybody in the country was using the perfect hernia techniques to the best research that we have available, we would still have a ton of complications because it’s so imperfect, and so that’s a ton of work that we can do.
Speaker 1 (01:00:35):
We had more questions, but time is up, my friend.
Speaker 2 (01:00:40):
This went really fast. Thank you so much for having me.
Speaker 1 (01:00:42):
I took hold you a go fast. It was super fun. I love hearing people’s stories. Your story’s an excellent one, and I’m so happy that you forward us some of your time and effort, and I know it’s late and you’re probably deprived compared to me, although I’m dealing with lots of ring that you’re not dealing with, but that’s
Speaker 2 (01:01:03):
True.
Speaker 1 (01:01:04):
Yeah.
Speaker 2 (01:01:05):
I hope to hear your story. Excuse me.
Speaker 1 (01:01:09):
I’ll tell it to you briefly here. I’ll tell it to you briefly. My story is I hated hernias with a passion. It was horrible. I didn’t like the groin exam. I didn’t understand inguinal hernia surgery, and I would specifically not do hernia surgeries if I could help it, give me a gallbladder any day. Then my last year of training, I was like, oh, shoot. Once I graduate, the number one surgery I’ll be doing will be hernia surgery. I’d better really learn how to do this really well. I can do a Whipple, which is a very complicated pancreatic surgery, like the back of my hand, but I won’t be doing any Whipples when I graduate. I’m going to be doing lots of hernias. So I started learning how to do hernias and my first job, I got bomb. It was a county job. I got bombarded with hernias and I saw a flyer for the American Hernia Society pinned to the one of those,
Speaker 2 (01:02:12):
What do you call, a poster board? Something like that. Yeah, there’s Okay, you’re not that old. That’s not, yeah.
Speaker 1 (01:02:22):
And I was like, hernia society, there’s a whole society just for hernias, because I was part of that camp of, it’s just a hernia, and I went to the Hernia Society and I met people that I had read about. I met Dr. Conden, Dr. Parvez Amid. I met Dr. Shouldice, like all these people were there that I had read about this is amazing. And they looked at me and they’re like, who are you? You’re too young and of the wrong sex to be in this meeting. And so I kind of stood out in some ways that way and I’ve never looked back. I love what I do in hernia surgery and I’m so happy that you are part of our group of hernia specialists to be because
Speaker 2 (01:03:09):
Well, I see that. I see we have that in common, that we run towards the things that we don’t like and challenge us so we can do them better. And I think that is extremely valuable to recognize that and to go towards it and say, I don’t like this because I’m not good at it and I’m going to do it better. Yeah.
Speaker 1 (01:03:31):
Yeah. That was the impetus. And here I am. All I do is
Speaker 2 (01:03:35):
That’s awesome. That’s awesome.
Speaker 1 (01:03:38):
On that note, everyone, thank you for joining us. We’ve put over time. Thanks for your time, Dr. Schlosser. Katie, you can follow her at Katie Schlosser on Twitter. You can follow me also on Twitter at Hernia doc and on Instagram at Hernia doc. Thanks for everyone for joining me. On Facebook and Zoom, go to my YouTube channel. Please subscribe every week we post another new episode at Hernia doc. See you next week. Thanks everyone.
Speaker 2 (01:04:06):
Take care. Have a good evening.
Speaker 1 (01:04:08):
You too. Bye.
