Episode 134: Being a Hernia Specialist in Private Practice | Hernia Talk Live Q&A

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Speaker 1 (00:00:10):


Speaker 2 (00:00:12):


Speaker 1 (00:00:13):

How are you?

Speaker 2 (00:00:14):

I’m doing great, thanks. Thanks for having me.

Speaker 1 (00:00:17):

Thanks. And hi everyone, this is Dr. Towfigh. Welcome to Hernia Talk Live. I hope you can see my screen. As many of you know, I am your hernia and laparoscopic surgery specialist. We’re here every week on Hernia Talk Tuesdays. Thanks for everyone who’s logged in live on Facebook. And those of you who are with us on Zoom, as you know, all of this will be shared or and archived on my YouTube channel at Hernia Doc. And so let’s get started. We have an amazing guest today, Dr. Sabrina Drexel, and you realize some of the stories we’re going to share because we’ve already shared some of it before we started and we’re going to try and discuss it with you all. But Dr. Drexel is in private practice. She’s a general surgeon trained in minimally invasive surgery. She loves hernias. She’s a hernia specialist and works in Portland, Oregon. You can follow her on Twitter and other social media out outlets at Sabrina Drexel MD on Twitter. And I think, and Facebook may be Dr. Sabrina Drexel, but I just want you all to say hi to her. Hi there.

Speaker 2 (00:01:31):

Thanks for having me on.

Speaker 1 (00:01:33):

Oh, for sure. So as many of you can tell, Dr. Drexel is much younger than me, and I didn’t know this, but this morning she texted me and she said, this is a very interesting topic we’re going to talk about today because I’m in private practice, you’re in private practice. And I thought we should talk about the fact that there actually are hernia specialists in private practice and the whole concept of that and what that means and how it may be similar or different for the patient experience. And then she shared with me this video, which I will definitely post on my social media once we’re done with this and I get home, I’m going to post it because I loved it. So at many years ago, Sabrina was a resident and she was assigned, oh, maybe you should tell this story because I don’t know the backstory

Speaker 2 (00:02:31):

Either way. It wasn’t that long ago I was a resident, but I think it was 2019. Yeah, 2019

Speaker 2 (00:02:38):

Was, yeah, I was a chief resident here in Oregon at Oregon Health and Science on the acute care surgery and my attending. And I had this really interesting hernia case come in. At this point, I had already matched to minimally invasive surgery fellowships, so I kind of knew I was going down this path. But the patient that came in and had a week of groin pain and on her right side and a lump and came in, got a CT and she had her appendix stuck in her in a femoral hernia, which is a rare hernia, as I’m sure you talked about on the show.

Speaker 1 (00:03:10):

And I don’t think, yeah, so appendix and an Inguinal hernia is considered amnion hernia, but I don’t think we have a name for one that goes into the femoral hernia. No one’s named it. It could be the Drexel hernia. Could

Speaker 2 (00:03:21):

Have been. It could be. Although I’ll probably never see one again in my life, but Right. So we did the case and she had this large ovarian cyst and Nexus assist. We had the consult guide. And so it was a really challenging problem of how do we address the hernia and the appendix and this GYN issue. And so we submitted the video and the problem to the Journal of Trauma and Acute Care Surgery. And it’s these fun talks that they do where it’s like consultant expert where E G S and trauma cases. And so of course the journal had me consult you.

Speaker 1 (00:03:55):

Yeah, it was so cool.

Speaker 2 (00:03:58):

And so I got to interview you. And at that point in my career, I honestly didn’t know there were private practice hernia specialists, you know, would really, and just last week you talked about kind of the hotspots of hernia care and we mostly think about academic centers. And this was my first encounter with someone in private practice. I was a hernia specialist, so of course I did all my research I could about you. I was so nervous about saying your last name correctly. That was more than anything was like, how do I pronounce her name so I don’t make a fool of myself?

Speaker 1 (00:04:27):


Speaker 2 (00:04:27):

Funny. But anyway, it’s just, it’s come full circle. The fact that you’re interviewing me when I interviewed you four years ago and Right.

Speaker 1 (00:04:34):

Oh, I loved it when you sent that to me. I totally remembered it. It was before I had this whole microphones or anything. I was literally in my dining room recording the video. A colleague of mine, very close friend, actually Matt Martin, who’s a fantastic trauma surgeon and emergency general surgery kind of expert and such a talented surgeon. He said, Hey, do you mind doing this expert video consultation thing for hernias? I said, sure. I always say yes to him. And I totally remember doing the video, but you know, were a resident. I didn’t know who you were at the time, and I, up until today did not know that was you. Yeah,

Speaker 2 (00:05:19):

No, why

Speaker 1 (00:05:19):

Would you? That’s Sabrina Drexel that I know. And now here you are in prior practice, so maybe you can, that’s a great story. So thank you for sharing it. Can you tell us a little bit after you did your fellowship, so you were at Cleveland Clinic?

Speaker 2 (00:05:37):

I was actually at Case Western. Yeah.

Speaker 1 (00:05:38):

Oh, sorry. Case Western. That’s correct. You’re at Case Western, which is down the street from Cleveland Clinic. Yeah, rivals. It’s like USC, UCLA. So where are you from originally?

Speaker 2 (00:05:54):

I’m from outside Seattle originally. And all my family’s still in Seattle, so I’m from the northwest west

Speaker 1 (00:05:58):

Coast. Yeah, yeah, yeah. Okay. And then you did your fellowship and then your first job was straight back in Portland or how was your trip there?

Speaker 2 (00:06:06):

Yeah, this is my first job and hopefully my last job because so far I love it.

Speaker 1 (00:06:11):

Yeah, that’s awesome.

Speaker 2 (00:06:12):

Which I think is honestly just really special to find a great practice. So I did my residency out here in Portland, so I’d matched out here. I did undergrad in med school on the East coast and was really ready to come back west, be a little closer to family. And they had a great program here with a lot of women in leadership roles, which is still not very well showcased across the US in surgery. So I really responded to that. So I loved my training out here. And the nice part about our training is you do a lot of community work at the academic center. So you go to nine different hospitals here in Oregon. Cause it’s the only surgery, general surgery residency program other than one BO program in central Oregon in the state. So there’s not a lot of in the whole

Speaker 1 (00:06:54):

State. Yeah, it’s, it’s a go-to place for the whole

Speaker 2 (00:06:57):

State. Yeah. So yeah, another funny story is that now my current senior partner was my very first attending my very first day as an intern. So I knew my current partners as a trainee and they really advanced my skillset as a laparoscopic surgeon for sure. And they do more forget. And so when I went to fellowship, they were starting to look for another partner and they wanted someone that specialized in hernia care because they had a lot of patients coming in that had a little bit more complex hernias and than they were trained to deal with. And so interesting, it was a good fit for me. We knew we wanted to come back to the northwest. At that point I had had a daughter as a chief resident, so we kind of wanted to be closer to family and it was just a really nice fit because they knew me and I knew them and I knew their practice and things like that. I knew nothing about private practice and what that entailed, but it’s been great. So yeah, I’ve been here for two and a half years now.

Speaker 1 (00:07:51):

So for those of you that don’t know, almost every major residency program that trains you for surgery is what we call an academic program, which means it’s usually in affiliated with a medical school or U and a university and the people are almost all just salaried on staff. Their goal there is to teach you to do research to advance their specialty and to operate. And that’s what we call the triple threat. So the great educator, great clinical person, and great researcher. And that’s kind of promoted. And more and more programs are exposing residents to alternative ways of being a surgeon, being going to the VA, going to a Kaiser, other kind of closed kind of group setting, going out into the community and working at community hospitals and community clinics and working with surgeons that are in private practice or employed in a large group practice.

Speaker 1 (00:09:00):

So hopefully the goal of that is to see a variety of patients and also learn from the different types of practices there are. But most people who graduate think that their next job will be similar to what they were trained in residency. Private practice is not usually top on the list for most people. It’s just not exposed to it. I certainly was not exposed to it. I was exposed to it very, very minimal. Maybe less than 5% or 3% of my time was spent with any private doctor. And so in some ways I kind of poo poo them like, we’re better. We do our research and we need to give talks. And here I am,

Speaker 2 (00:09:52):


Speaker 1 (00:09:53):

Practice, your first job.

Speaker 2 (00:09:56):

I think a lot of people think the learning stops once you finish residency and the involvement stops unless you’re at an academic institution. And I think you’re a great phenomenal example of that. Doesn’t have to be the case. So you’re publishing, you’re teaching, and you’re a great clinician in private practice. And I am striving to emulate that. I definitely, so that I get to work with the general surgery residents from OSU at my hospital. So I get to do all the testing that I want and we have medical students and PA students. I’m hoping to start doing some clinical research at some point, but life is busy starting up a practice and having two young kids. But that’s definitely the next hopeful part of my career that I get to be a little bit more involved in.

Speaker 1 (00:10:40):

Usually what they say, oh, there’s the academic docs and the private practice docs. I personally don’t like those who designations because I feel like I am more academic now in private practice than I was in a quote academic institution wasn’t, I’m not bogged down by a lot of just the committee meetings and the staff meetings and all these other kind of useless waste of time, rewriting, handbooks and so on. I spend more of that time either advancing my patient care or doing research or traveling. We were just talking because Sabrina just came back from a major hernia meeting in India, right? Yeah. How many thousands of surgeons were there? I heard it over a thousand.

Speaker 2 (00:11:27):

Yeah. Yeah. About 1500 surgeons from 40 different countries.

Speaker 1 (00:11:31):


Speaker 2 (00:11:32):

All about hernias. Yeah.

Speaker 1 (00:11:34):

Crazy. I mean in a good way. And you were among the faculty that were invited to represent experts in hernias. You’re joining me in three weeks, I think two and a half weeks in Brazil at the International Hernia Collaboration. Dr. Drexel is one of our esteemed faculty for the international hernia collaboration meeting in Brazil where we’ll be, I mean you’re traveling and you’re giving talks and you are representing advances in hernia care everywhere you go alongside other surgeons that may be employed or in a practice where it’s university based or the more kind of to what we call traditional academic institutions. But you’re the perfect example that clinical prowess doesn’t have to occur in a university-based or medical school-based situation. And you have residents that you’re training. I do. The residents love operating with me. First of all, I let them operate and I teach them a lot.

Speaker 2 (00:12:45):

Yeah, I think I get similar feedback. I hope I do. Yeah. I think they enjoy, because we’re in the community, I feel like there’s a lot more throughput of cases. Our volume is just very different because I am first and foremost a community surgeon and I don’t have designated time for research and maybe some of these non-clinical tasks that sometimes academic surgeons and faculty do have. So yeah, we’re in the, OR typically three days a week and doing really advanced stuff with the residents. So I really enjoy teaching them and getting them more skilled in their laparoscopic and robotic especially cases. Yeah,

Speaker 1 (00:13:26):

And I think some of the stuff that bogs us down in these institutions we don’t necessarily have to work with. There’s a question here. It says Dr. Towfigh, are you not still professor of medicine at your medical school clinical track? That’s actually a good question. Do you have a professorial title of any

Speaker 2 (00:13:46):

Sort? I’m like a clinical associated staff I guess, but no, nothing formal. How about that?

Speaker 1 (00:13:53):

Yeah, I mean, when I first started my first job, it was in a traditional tenure track full. So it goes assistant associate professor, that’s kind of like so assistant professor, a social professor, full professor, and then emeritus whatever when you retire. But when you’re employed and part of the medical school officially, then those are the tracks you can follow. And that’s what I initiated. And I thought one day I’d be chair of a department. That was my goal. But then when you go into private practice, those things change. First of all, you’re not employed by them, so whatever you’re doing is voluntary. So your title changes. It becomes either clinical pro professor or it becomes voluntary clinical professor. They kind of want to make sure there’s a distinction in titles because it also implies a different pay pay thing.

Speaker 1 (00:14:51):

But also, I’ll tell you, I’m having a really hard time getting my professorship. I applied to be the it’s, it’s even stupid. It’s a voluntary professor, voluntary clinical professor of surgery. It’s not even tenure track or anything important. It’s just a title. I feel like I might as well have the title. You’re putting the time in your residents. I’m putting the time in for my residents and the medical students and the undergraduate students and the women in surgery group and teaching classes and so on. So it’s nice to have the title. I don’t really use the title because it means literally nothing. Three years, it’s been three freaking years. They claimed they lost my application twice and then everyone kept, I don’t know if they got fired or they kept changing jobs. And then again, my application was lost. And now they’re saying, oh, you know what? We’re actually going to revamp our, the dean of the medical school is revamping everything, so we’re going to put your application on hold for that. But I’m totally over it. I don’t understand. But

Speaker 2 (00:16:06):

You have no official title, right?

Speaker 1 (00:16:09):

I still have my associate professor title, but for the past seven, eight years I could have been professor and I applied for it a little over three years ago. I’m still waiting. It’s so ridiculous. It should be a three month process.

Speaker 2 (00:16:26):

Anything to do. Yeah, it should

Speaker 1 (00:16:27):

Be a three six month

Speaker 2 (00:16:28):

Process. But like you said, the titles means nothing, don’t mean a whole lot. Yeah.

Speaker 1 (00:16:34):

Whereas to me, it was very important early on in my career. Very important, the titles and this, yeah, this and that, but it means nothing right now. Yeah. So is there any reason why you can’t, can’t still wind up chair of a department division? No. In fact, when I was switching from one job to the other to become, I finally chose private practice, I had a couple different chair chair opportunities locally to be chairs of departments and I turn them all down. I can still do it if I wanted to. It’s just having felt the freedom of being your own boss and taking your career and the direction you want to take it without someone above you saying, Sabrina, why were you in India? That’s a very long trip. Or Why are you doing two international trips in one year? We need you more. I don’t have anyone saying that to me. You probably don’t either. And that is priceless. Someone not being on your shoulder, constantly nagging at you because they have an idea of what you should be doing and that’s different within what you’re doing. Understanding that like you and me both probably would’ve been really great employees because we would do everything well. We’d spend time educate. We’d be long hours helping and teaching and promoting and doing everything. But at the end of the day, it’s so nice to not have that extra burden. I think people who are not in private practice don’t get it yet.

Speaker 2 (00:18:23):

Yeah, they haven’t. And granted, I haven’t seen their side. So not to say there’s not. I’ve

Speaker 1 (00:18:27):

Been there.

Speaker 2 (00:18:28):

And the biggest thing with private practice is I’m not affiliated with any one hospital system. So you truly have to get your own referrals for patients and things like that and answer that question too. Yes. So in addition to the academic hospitals, any other non-academic hospital system typically has chairs of departments and things like that? So I’m currently chair of our robotic steering committee at my hospital because I care about the robotics program and advancing it, and

Speaker 1 (00:18:53):

It can influence

Speaker 2 (00:18:55):

A voluntary position. I don’t get paid. I don’t, and it’s extra time and emails and meetings. But I care that our program continues to advance and we do more surgery minimally invasive rather than open. Cause it’s better for the patients, number one. So that’s why I, I’m like you. I pick and choose what I’m involved in and it comes down to what am I passionate about. So yes, you can certainly have plenty of leadership roles even in private practice, even though I’m not employed by the hospital, they have their own general surgeons. True. But they ask me to be their robotics chair because I’m the one that’s doing it and promoting it probably more than their employed surgeons are. So it doesn’t mean be involved.

Speaker 1 (00:19:36):

Yeah. Now how many hospitals do you and or surgery centers do you work out of?

Speaker 2 (00:19:42):

Two main hospitals, two main surgery centers. But I have privileges at four different hospitals because Wow. I, we’re a group of five surgeons and we span Vancouver, which is Southwest Washington and across Portland. So yeah, we can cover each other in things like that. So I have a lot of access to a lot of different places.

Speaker 1 (00:20:00):

Wow. And is there a reason why you choose to operate at one versus another?

Speaker 2 (00:20:06):

Partly insurance. So we have one group of insurance here, Providence, I don’t know if you guys have it in California, but so you have to operate at their hospitals or their affiliated surgery centers, that kind of thing. So it’s partly insurance and then location. What I love about our private practice is we try to go to our patients rather than making our patients come to us. So we have a clinic based in Vancouver. We have a main clinic based in Portland, and then we have a satellite clinic on the west side of Portland about 20 minutes away. And so we host office hours at different places to try to be convenient for patients and then having privileges at all these different places. Then patients can get a choice of where their surgery is, what’s convenient, what’s going to be convenient for them based on the constraints of their insurance.

Speaker 1 (00:20:51):

And then maybe you could explain also access of patients to you, how different that is than people that are working at an institution usually.

Speaker 2 (00:20:58):

Yeah, very easy access. Yeah. Again, another thing I love is that we get to shape our practice how we want, we get to tell our medical assistants and that just ask us questions about patients. So if patients phone in and have a question or medical assistant can’t answer, we’ll answer it very quickly. Usually within the day, patients that need urgent problems fixed. So for example, a lot of primary care docs might see a patient in clinic that has an abscess, a skin issue, not hernia related, but, and they don’t feel comfortable draining it rather than sending them to the emergency room, they just call our office. One of us is here same day, we just see ’em same day appointments and rather than sitting in the ED for hours in between surgeries, they might have to wait 30 minutes for me to finish surgery, but I’ll just run up and deal with it. And an employed system will, that would never cross their mind to alter a schedule or do last minute appointments. Or I had a patient show up yesterday that thought their appointment was the next week. And I’m like, of course we’ll just see them. They’re here. I’m not going to send them away back next week. But I have full control over those decisions versus in a different model, you may not even be aware that that patient showed up and they’ll just say, sorry, doctor can’t see you today. So I love,

Speaker 1 (00:22:12):

In fact, they may not even hear that that patient is asking. They may just call the front desk and the front desk doesn’t really have a relationship with the individual surgeons because they’re employed by the hospital separate from the department of surgery, for example. And then you may not even know that your patient wants to see you because they just call the front desk. That coordination isn’t there necessarily.

Speaker 2 (00:22:37):

Yeah. So that’s,

Speaker 1 (00:22:39):

And the wait time to see you for a new patient,

Speaker 2 (00:22:43):

Less than two weeks.

Speaker 1 (00:22:45):


Speaker 2 (00:22:45):

Our model is if we ever have a wait time more than a couple weeks, that means we need to hire more providers. So I joined in 20 August, 2020, and we’ve had two more surgeons join us since then because we’ve been so busy. So it’s just a very different model than, and urgent appointments for whatever, you have a really painful hernia, you have a gallbladder issue, whatever it is, we’ll get you in if you feel like it’s urgent, typically within a week. And we have the flexibility and our staff understands that we’re happy to see patients on off hours, even if it’s not a clinic day, that kind of thing. So

Speaker 1 (00:23:22):

That’s a sign of a very functional practice.

Speaker 2 (00:23:25):

That’s how I feel like that’s how medicine should be. Should be.

Speaker 1 (00:23:28):

Yeah, I really

Speaker 2 (00:23:29):

Should. Unfortunately it, it’s not because I’ve been on the patients side and you’re stuck on a full tree and you don’t get an answer for three days. And it’s equally frustrating as a physician.

Speaker 1 (00:23:37):


Speaker 2 (00:23:39):

As I’m sure every patient has experienced that. So we don’t have a phone tree, we just call us, we’ll talk to you and luckily, you know, you hopefully counsel your patients well enough that they’re really only calling in if they have an issue and then you want to know about it.

Speaker 1 (00:23:52):

Yeah, I totally agree. I think that’s one of the beauties of private practice. Do you think the charges or the scale is different accessing a private doctor?

Speaker 2 (00:24:07):

I don’t think it is for the patient. I mean, it should be the same in terms of billing and co-pays and the surgeries you get signed up for all of that that goes through your insurance, I don’t believe is different from the patient side. From the physician reimbursement side, you see it differently because most employed surgeons work in this RVU or relative value unit. So each surgery has a number of RVUs attached to it versus in private practice, it’s kind of just what insurance do they have and what do you collect from that. Now most of us, we take all insurance and we really just treat patients as they should be treated no matter what insurance they have. But you may get reimbursed differently based on their coverage.

Speaker 1 (00:24:46):

But the pay scale is a little bit different, like you said, because a hospital also makes money on radiology and laboratory services and ER visits and nursing care, certain nursing cares or procedures, whereas you don’t have access to income from a MRI that you order. And so really, whatever, however hard you work is reflected in your income. Whereas on the institution side, there’s so many other players that pump in income for the hospital, that kind of volume or activities not necessarily mandatory to maintain the same salary or income.

Speaker 2 (00:25:35):

And I think one more point that’s probably important to educate people on is this topic of surprise. Billing has been brought up a lot in legislature settings and things like that. And I think it’s partly because most of the public doesn’t understand how the medical system works. So if I operate on a patient at a hospital, my billing is going to be separate than what the hospital bills because I’m not paid by the hospital. And typically the anesthesia team or your anesthesiologist is also going to bill separately because they’re typically not employed by the hospital. Although there’s different models where sometimes they are. So for one surgery it’s very common to get three different bills, one from your surgeon, one from the anesthesiologist, and one from the hospital. And so it’s not necessarily surprise billing, although people get frustrated when they got one bill and then now they’re getting more. And I can totally see why that’s a point of confusion, but it’s because they are separate systems and how I get paid is different. Reimbursed is different than how the hospital does.

Speaker 1 (00:26:32):

Yeah. So there’s a question that was submitted, which I think is interesting question because it kind of points to how people think hospitals are run. So it says, as a surgeon who runs a private practice, how do you use the time you gain by not having to perform a minimum number of surgeries for a hospital? But hospitals don’t give us a minimum number of surgeries and they don’t pay us and we don’t pay them for using their facilities. It’s completely independent, but it’s mutually beneficial for us to take our patients to the hospital and the hospital to want to take care of our patients. Does that make sense?

Speaker 2 (00:27:16):

Totally. Yeah. And I think, yeah, there’s no minimum, what most hospitals have set up is what’s called operative block time where you’re signed up. I have, for example, every Friday I get to operate. And so if you’re not filling up those that day, over the course of a quarter, maybe if you only used 50% of that time, they might cut, might cut your time down because there might be other surgeons that want to utilize that time. So they do track how much you’re filling the allotted time they have for you. But there isn’t a minimum. So some of these hospitals that my partners are busier at, I don’t have dedicated operative time there, but I can add on cases as needed since I still have privileging there.

Speaker 1 (00:27:56):

Yeah, yeah, exactly. This disconnect between hospitals and we’re very independent and by design we’re independent. They can’t mandate us to operate there for any of our cases. That’s really our choice. And like you said, sometimes affected by the type of insurance. So there’s another question that says, does going to private practice surgeon necessarily raise a cost for the person? And why are we getting three different billings instead of one total for the surgery?

Speaker 2 (00:28:38):

Yeah. I’m not sure what time that question came in, but yeah, I’m happy to reiterate that No, the billing should not be different going to a private practice surgeon versus an employed surgeon, what’s more important is whether they’re in network or out of network with your insurance, but otherwise the billing should be very similar if not the exact same. And so my office is very good at checking to make sure patients are in our network before we schedule them for an appointment so that they’re not getting out of network billing based on their insurance. And then again, for most surgeries, it’s typical I would say, to get at least two bills. So at least the hospital bill. And then around in our area, at least most of the anesthesiologists are in private practice group. So they are not employed by the hospital, so they bill separately. And then if your surgeon is in a private practice group, then they are also going to bill separately. If the surgeon’s employed by the hospital, then that the surgeon’s fees will be included in the hospital bill. So it’s not necessarily more billing, it’s who’s, where the money is going is different depending on whether or not they’re employed by.

Speaker 1 (00:29:48):

But even if you go to, let’s say a hospital, everyone’s employed, you still will get separate bills. It all goes to the hospital. But there are different buckets of money. So for example, the surgical department will bill for the surge and the anesthesia department will bill for the anesthesiologist. The hospital will bill for the use of the hospital, probably lab may be included in that and medications and nursing and all that is already bundled into that hospital cost. But regardless of where you have your surgery and who has it, you will get multiple, at least in the United States, you will have multiple bills. The only time you’ll get one bill is if you’re at a Kaiser Permanente or some other kind of closed system where it’s one employer that does everything and it’s all into one bucket. But even in hospitals and so on, it’s multiple buckets. So you will get multiple

Speaker 2 (00:30:44):

Bills. Yeah, bills. I think sometimes it’s confusing when it doesn’t have the hospital name on it versus when they’re all employed. Yeah, it’s all coming from the hospital. But yes, I totally agree. It can often come in different envelopes from different departments and be like, didn’t I already pay this

Speaker 1 (00:30:58):

Bill? It’s very complicated. Sometimes our patients call us and they’re like, I thought you said I won’t be billed. And I’m like, because we do everything up front, we tell you upfront everything. There’s no surprise anything. It’s like, oh no, this was up from the, this actually the hospital is billing you. And then my office helps figure out from the hospital what is actually going on for the patient. Yeah. Cause it’s very complicated and confusing. Yeah.

Speaker 2 (00:31:26):

I have learned a lot about business in the two and a half years in private practice. I mean that’s good. It’s very, it’s confusing even for us.

Speaker 1 (00:31:34):

Okay. So here’s some follow up comments. One is I’ve had that I was most curious from a total cost perspective, was a total surgery the same cost for services? It depends on how contracts are negotiated and so on. So I actually, I only work at one hospital. I tried to make it clean. I don’t like running around or doing any of that. However, our hospital, which is a great hospital, has increased its cash rates and access to robotics has become a little bit difficult in the outpatient setting. So I am now credentialed elsewhere where for my patients who are cash only, I can get a better rate for them still at a good places. But the main hospital is just super expensive. It’s so ridiculously expensive. I’ll give you an example. Something that used to cost $10,000 outpatient is now close to $80,000, which for cash, that’s just a ridiculous amount for an outpatient operation. So we are looking at other opportunities for our patients. So that’s why I am increasing the different places that I’m privileged in, but that it’s purely to be able to help our patients with more affordable care.

Speaker 2 (00:33:01):

Can I ask, do you go to a surgery center at all or is it like an outpatient ambulatory center within a hospital system? Or what’s your setup?

Speaker 1 (00:33:09):

Both. So our hospital has an outpatient hospital or outpatient center attached to it. In addition, it has two other outpatient surgery centers actually in the building where my office is. So right here where I am upstairs and then down the hall, there’s two separate surgery centers. I usually operate at those, which is great cause it’s still the hospital affiliated surgery center in network. But I don’t have to drive anywhere. It’s right here. It’s literally down the hall. It’s so awesome. I’m very lucky like that. And as a result, also my nurse is my circulator. So it it’s just a perfect. That’s amazing.

Speaker 1 (00:33:54):

It’s such a perfect scenario. I never want this to ever change. Yeah. But we don’t have a robot in the outpatient surgery center in our building. It’s just not a financially doable situation. So I’m dependent on the hospital for all my robotics cases. And that can become difficult because you’re competing with, we have nine robots, but we’re still competing for our, with other surgeons, our space. Yeah. Here’s another question. In Australia we have Medicare, which is free treatment and surgery in the public system, if you go to a private surgeon and you have private health insurance, you can pay a gap. If you’re a military veteran and have a Department of Veterans Affairs gold or white care, your treatment is also free. This is great, but how many hernia specialists do you have? This one, that’s the question unfortunately.

Speaker 2 (00:34:49):

And I’d love to know what makes people decide to go see a private surgeon versus not. I think that sounds more similar to UK and Canada systems, but you’re in the US what private practice means is still very different because we’re still part of the health system and take Medicare and Medicaid and yes, insurance plans except for the closed systems like Kaiser mentioned.

Speaker 1 (00:35:12):

So yes. Should we do some clinical questions?

Speaker 2 (00:35:15):

Sure, yeah.

Speaker 1 (00:35:16):

All right. Cause they’re piling up. Okay. Okay. I am a male with BMI of 29.4, so that puts him technically in the overweight category. Okay. Muscular build. I am having a Shouldice inguinal hernia repair. My surgeon said he can make it last with my B m. I appreciate your thoughts. So the question is, if you are outside the normal weight scale, muscular with overweight category, a tissue repair like a Shouldice, is that still feasible or is it have a higher recurrence rate? I

Speaker 2 (00:35:56):

Think it is very dependent on the surgeon and ensuring that they do high volume tissue-based repairs. In my hands, I was not trained to do many tissue-based repairs. It’s still part of my practice that I want to evolve and learn more, but I don’t necessarily offer a tissue-based repair and I certainly wouldn’t in an overweight patient, but that’s my practice. But certainly if you go to a high volume surgeon, I think you could have a safe tissue-based repair. Certainly.

Speaker 1 (00:36:30):

So the Shouldice clinic that does socialize all day every day? Yeah. I think their cutoff is 25 or 26 BMI. Okay. They would not offer a Shouldice and they just want you to lose weight? I think it depends. I do plenty of tissue based repairs. I do more now than I used to. And it depends. If you’re 29, you say you’re a muscular build and you’re not carrying all of it in your belly, then likely you’ll do just fine. But if it’s all belly and you have thin legs for example, then that’s a lot of extra abdominal pressure that you’re pr, you’re putting your should ice repair against. So here’s another question.

Speaker 1 (00:37:15):

Same patient male with 29.4 BMI. Muscular has small and painful nine millimeter inguinal hernia. And I don’t want mesh, I’m afraid of what could happen if it goes wrong. My surgeon said he can do the should eyes technique, but my B M I may be a little bit high. It is, I would say it is a little high for the classic Shouldice and the Shouldice clinic would probably reject you purely based on your MRI or your B M I. What are your thoughts in general about weight and other risk factors and determining the best surgical technique for patients?

Speaker 2 (00:37:54):

Yeah, I think that’s a great question. Yeah, I definitely, and I think that’s part of the fun of surgery or of hernia care specifically, is that every patient’s different in every hernia is a little bit different. And so you kind of do tailor the technique to the individual patient and that’s what makes hernia care maybe a little bit different than other general surgery subspecialties like colorectal or breast or things where it’s kind of the same surgery regardless of patient factors. So yes, obesity we know is a risk factor for hernia recurrence. And so in a

Speaker 1 (00:38:27):

For all bad outcomes from hernia repair. Yeah.

Speaker 2 (00:38:30):

Yeah. So counsel patients, the three main risk factors for recurrence is going to be obesity, active tobacco use, and poorly controlled diabetes. So for an elective repair, I am ensuring that all of those are at least as optimized as possible. Now certainly patients we typically with a B M I less than 40 or so can offer some type of repair, relatively electively, although I’ll often ask patients to try to lose some weight if they can. But I tend to do a more broader based repair. For example, a primary umbilical hernia that’s one or two centimeters in a thin patient, I may just do an open suture repair. But in an obese patient, I’ll tend to more do a robotic transabdominal peritoneal approach to get a wider piece of Mesh in to help counteract some of the increased pressure on their abdominal wall. So it is an important consideration in addition to age. I also look at a 40 year old. I want the one repair I’m going to do to last the rest of their life, so I might make a different decision than in a 70 year old or things like that. So yeah, I think that’s part of the art of hernia care in all honesty, is really, we have so many tools in our tool belt now on how to fix a hernia and really picking out the right one for each patient. I is what keeps it interesting from my perspective,

Speaker 1 (00:39:47):

And I would say I understand the arguments for and against tissue repair versus Mesh repair, and the comment is, I’m so concerned about things that couldn’t go wrong with the Mesh repair that I want the tissue repair. Well, things can go wrong with a tissue repair. And if you are overweight or have other risk factors like you mentioned, tobacco use, diabetes, chronic cough, constipation, these are all things that can promote bad outcomes after your hernia repair, then you know what? You’re going to tear that tissue repair. And that is a very painful situation. So this is the reason why chronic pain is very similar for tissue repair as well as Mesh based repair. And part of the chronic pain seen with tissue repair is you’re tearing and you’re tearing, and that’s very painful or there’s a nerve involved as part of the scar tissue or the hurting repair, but let’s take the nerve, nerve issue out perfectly good repair. If you’re doing it in a patient that has increased abdominal pressure, it’s going to start tearing. And that’s very painful and that’s where the chronic pain comes from. So that’s where the whole tailoring comes into place, deter, determine what’s the best repair per patient. People always ask me, well, what would you do? I’m like, well, I’m not, I’m different than you.

Speaker 2 (00:41:13):


Speaker 1 (00:41:15):

So whatever I think may be good for me may not be good for you. And this is a great example of it. Here’s another question. I have a recurrent indirect inguinal hernia, but I’m not sure whether it is symptomatic. Sometimes I have one-sided testicle heaviness associated with tenderness to light squeezing and downward traction. Could this be related to the hernia at the internal ring? So as testicular pain or a discomfort I should say, could that be related to a recurrent indirect angle hernia?

Speaker 2 (00:41:52):

Yeah, it’s a great question. Assuming that the pain is on the same side as the hernia, I do have patients that come in with this testicular pain. They almost describe it as a vice. Sometimes this squeezing pulsing sensation on the testicle, and that can certainly be related to a hernia. So I think doing a thorough investigation of that patient to ensure it’s not correct. Any other factors causing the pain or any complications from the prior repair. They didn’t offer what type of repair they’ve had in the past, but certainly there could be other reasons for testicular pain, but it can be a sign of inguinal hernia.

Speaker 1 (00:42:29):

Yeah, that’s exactly right. What’s what you said is very key, which is after really working it up, what I see sometimes is patients clearly have another problem, but the hernia is an obvious one. So the surgeon says oh, I will fix your hernia, but it was their hip or it was their testicle or vericocele, hydrocele, epidermal cyst, all these spermatocele, there are all these other reasons why you could have testicular pain and it wasn’t their hernia. So now they fixed their hernia and their original pain is still there because that wasn’t because the hernia. And they sometimes have a complication from the hernia

Speaker 2 (00:43:10):

Repair from surgery.

Speaker 1 (00:43:12):

So now they have two problems. And so that’s why what you said is very important, which is let’s figure out exactly why you have the pain. And if we rule out urologic problems and maybe a musculoskeletal problem, then yeah, let’s fix the hernia and see.

Speaker 2 (00:43:29):

Yeah. But yeah, the counseling is key. And I think definitely with those patients, I always say I cannot a hundred percent guarantee that your pain is from the hernia, but surgery is typically very safe and that I’m hopeful that it will take away your pain. But yeah, it’s all about that pre-op workup and then counseling about expectations. Yes.

Speaker 1 (00:43:48):

We had other questions submitted. I think we already reviewed this one. Oh yeah, here it is. What are the pros and cons of getting hernia surgery from a specialist in private practice? I think I personally think it’s the closeness of the care and the timeliness of the care. Although I’m sure there are people in institutions where it’s a very functionally well run office, but it tends to be better in private practice.

Speaker 2 (00:44:18):

I would echo those sentiments. I think there’s simply not enough hernia specialists, especially yes, in the US and kind of your talk last week about hotspots. There’s only a few places in the country even have a designated hernia specialist in our community in Portland, we have a fabulous hernia center at the academic institution at O H S U, but they have a six month waiting list to see a surgeon and then often a six to eight month waiting list to get in the operating room. And so the benefits of finding other specialists is a, they’re needed in the community because plenty of these patients don’t necessarily want to wait or need to wait. They oftentimes, it’s inguinal and small medium that can certainly be addressed safely by a hernia specialist in the community. So yeah, I think that’s one of the big benefits is just access to care.

Speaker 1 (00:45:09):

Yeah, I think access, I agree. Can any surgeon start a private practice? Are there any direct or indirect checks in place to ensure that the services offered by a surgeon in private practice are up to some quality standards? So yes, anyone can start a private practice. I mean, it’s risky. It’s like start your business. Yeah. But yeah, that’s a good question about checks in place. I’ll tell you, I know a lot of surgeons in private practice that offer hernia repair, right? Because we’re all general surgeons board certified and hernia repair is part of the training and also the practice of most general surgeons, not necessarily specialists only, but what do you think about these direct or indirect checks on their practice?

Speaker 2 (00:46:01):

I would say that society actually has some indirect checks that are probably higher standards than community employed or even academic surgeons because like you said, you’re starting a business, you have to pay staff, employees rent, et cetera. And if your referral pattern is very different than someone that’s employed, because for the most part they haven’t worried about who is sending them patients because it’s naturally their hospital system. And so if they don’t have good outcomes, that may not change their referral base. True. But if you don’t have good outcomes in private practice, the people sending you patients are likely going to turn to an alternative that may be within their hospital system. Many of the primary care docs that refer to me have surgeons in their own network in the same hospital system, but they know that I offer exceptional care to my patients an exceptional quality in my surgery, and that’s why they keep referring. So I feel like you said it’s risky and it’s hard to start out in private practice where you have to build your brand kind of thing, unlike an employed surgeon. So I feel like the standard is actually higher just based on that.

Speaker 1 (00:47:13):

True. a lot of the employed kind of institutional surgeons, they’re just sitting in the office and patients come to the office because the hospital has already invested in a network or a referral base, whereas in prior practice, it’s really up to you and your ability to make your own referral base and maintain that by offering good service. If you’re a bad private practice surgeon, you’re not going to survive. Basically. It kind of checks on. So that said, hospitals do have a peer review system. So if you’re performing egregiously bad surgery or have bad outcomes, you will get checked by a peer review system by the hospital. And that’s a good way to either be put on some type of probation or even lose your privileges at the hospital. So there are some screening

Speaker 2 (00:48:08):

And I think all surgeons are certainly, he held to the same accountability and minimum standards at any hospital. And even at surgery centers, I have to do peer random peer reviews of other surgeons at that surgery center quarterly. So there’s definitely standards in place. They’re, they’re not specific to private practice.

Speaker 1 (00:48:27):

So here’s a question. What are the options to close a medium to large ventral hernia after intestinal surgery? I have a five to seven centimeter with some call it rectus diastasis, but that’s clearly an incisional hernia. Probably the radiologist call it rectus diastasis. It’s not in the center abdomen, they’re not connected. It’s been suggested to have a component separation without closing both layers and tar surgery, which is a posterior component separation. I don’t want a tar and I don’t think it’s necessary. So five to seven centimeter incision basically.

Speaker 2 (00:49:10):

And again, this is where I say it’s all dependent on those that patient’s individual characteristics. So is that a 4’10” 100 pound lady or is that a 6’1″ 250 pound male? Because those are two very different patients with a 5-7 centimeter hernia. So it’s a little, and 5

Speaker 1 (00:49:28):

Is different than 7. Those 2 centimeters make a difference.

Speaker 2 (00:49:31):

They do. And then the size of their muscles, so those rectus muscles that run up and down the width of them is important. How much weight is in their belly? Have they had any prior repairs? Is the hernia from an incision versus a primary hernia changes what I offer. So

Speaker 1 (00:49:49):

Let’s say 5 centimeter incisional hernia in the average patient.

Speaker 2 (00:49:54):

I think that would be a great case for potentially an robotic or a minimally invasive approach to a retrorectus, I think would often be needed at that size. Exactly. Most five centimeter hernias would not need a TAR or a posterior component separation. In my patient population at least. Correct. Unless there’s extenuating circumstances as to why that tissue can’t get closed with just a retrorectus. But that would probably be my go-to in the average patient.

Speaker 1 (00:50:21):

So it’s an open Rives Stoppa or robotic eTEP, right? Yeah. Would be another term or a robotic Rives Stoppa some people call it. Yeah. With Mesh seven centimeter, how does that change what you offer?

Speaker 2 (00:50:39):

Yeah, like you said, those two centimeters do make a difference. And that’s a little bit where I get to closely measuring that retroactive space. So we actually measure the width and we have this kind of general, what we call the carbon L rule, but we measure the width of each rectus muscle. And if it’s more than double the width of the hernia, then we probably can get that closed without that posterior component separation or that tar. But at seven centimeters, you’re getting a little bit closer to maybe needing that component separation to, again, the whole goal is to offload the tension immediately to be able to close that hernia defect without tension on it so that hopefully it holds.

Speaker 1 (00:51:16):

And I have an issue with this last comment says, I don’t think a TAR is necessary. So if you go to the right doctor and they’re a specialist, then they determine what’s necessary. When you’re in the operating room, usually your specialist will have a plan, we have a plan, can this be done robotically laparoscopically? Should it be done open? And what are the pros and cons in that specific patient? So for a seven centimeter, that’s a good one because that’s tricky. Sometimes you can do a retrorectus for seven centimeters. Most of the time you need a little bit extra help for a seven centimeter. And that usually involves taking a retrorectus and expanding it to a TAR. And so sometimes you don’t know in the or sometimes you’re in the OR you’re like, oh, wow, this actually came together very well. Or you say, oh, wow, I expected this to close and I can’t, so I need to switch my Rives or my retrorectus to a TAR.

Speaker 1 (00:52:14):

So to claim ahead of time, I don’t think it’s necessary. And then to bind your surgeon’s hands or try and find a surgeon who will say, I will absolutely not do a TAR, I think is not the right way to approach the problem. I don’t know how I feel strongly about that because I have a lot of patients that come to me and they only want a certain thing because they’ve done their research, but I feel like I, they kind of lose the forest looking for trees and I can give them a 30,000 viewpoint. I can give them the microscopic viewpoint. My vision is different than them. What do you think about that?

Speaker 2 (00:52:57):

Yeah, I think it’s all at the end of the day of trust in the hands of your surgeon. And I think that’s what makes our job really special when even though our relationships with our patients might be short-lived compared to a primary care doc, that it takes a lot of trust to have a surgeon take you to the operating room and let them cut you open and fix what’s right, but trusting that we’ll do the right thing in those moments, because certainly there’s times I’ve been in the OR where I’m having to use plan B or C because plan A didn’t work. And that’s part of surgery and it’s stressful for us when we’re doing not what we thought we were going to be doing. But yeah, it’s hard to have a patient come and tell you exactly what they want because sometimes they may not be like the patient they read online or things they read online and that they’re different for X, Y, or Z. So

Speaker 1 (00:53:45):

Yeah, I agree. Here’s a comment. It says, I have a small angle hernia. I have no pain coming from the actual hernia. However, I have a palpable, hard, long, painful lump, higher up on my inguinal ligament region. I’ve had multiple scans and only the hernia shows. The surgeon is perplexed as to what the hard pain, palpable lump could be. I have no pain in the morning and the pain comes in the afternoon. The pain will remain for several days if a lump is pushed or pressed, I mean, sounds like a hernia to me. The doctor wants to do a lap laparoscopy to look around and an open repair, the same date to also fix the hernia. What are your thoughts?

Speaker 2 (00:54:26):

It changes if this is a male or a female. Male becomes male. Male looks like

Speaker 1 (00:54:30):

Male, yeah.

Speaker 2 (00:54:33):

Yeah. I mean, it sounds like that’s a reasonable thing as to proceed since we know that there’s a hernia and the palpable lump certainly sounds like the hernia is reduced in the morning, and then as you stand up and move around, there’s more pressure on the belly. And so the hernia, exactly. Retruding is certainly what it sounds like described. Sounds like maybe it’s in a little bit of an odd position or just a little higher than they expect, but everyone’s anatomy,

Speaker 1 (00:54:55):

Interstitial hernia.

Speaker 2 (00:54:56):

Yeah, everyone’s anatomy is a little bit different. And yeah, could be going between the layers there, but I think that’s reasonable in my hands. If I was going to go in laparoscopically to look around, I’d probably just end up doing a laparoscopic or posterior repair. I personally wouldn’t see the need to do an anterior approach if I’m wanting to see posterior as well. But there could be a reason the surgeon was deciding that if the palpable lump is in a hernia or something else and they wanted to visualize it in the or so,

Speaker 1 (00:55:24):

But if you have imaging, you should be able to see all of it and not need a laparoscope to see more. I feel like for some reason, they’re not believing the imaging, which I don’t know why. And then the other thing too is this could be what’s called an interstitial inguinal hernia. So it doesn’t necessarily protrude out. It protrudes up and through up and laterally through the tissue planes. And so it’s not like it’s kind of an interesting Inguinal hernia, but either way, the repair can be done open. It can be a Shouldice repair, but I would trust the imaging and the physical exam and the symptoms and sounds to me it’s just a hernia. I mean it not just a hernia, but then it’s just,

Speaker 2 (00:56:08):

Yeah, without saying the pictures and things. That’s what it sounds like based on the Yeah.

Speaker 1 (00:56:12):

Yeah. That’s what I

Speaker 2 (00:56:13):

Agree. Yeah. Yeah.

Speaker 1 (00:56:16):

Okay. Couple more questions to through. So let’s see. Would you recommend for a hernia specialist to start a private practice only after many years of working as a hospital employee? If yes, can you consequently say that surgeons offering their services in private practice are generally the most experienced surgeons?

Speaker 2 (00:56:39):

What an interesting question. Yeah, I guess I would say no to the first one since I came straight into private practice from completing my training. So I didn’t work as a hospital employee. Again, I’m always very curious what it would feel like to be an employee because there’s just different stressors on the job of being a surgeon, but I don’t think you have to have been employed to go out into private practice. I’m sure you have knowledge that probably would’ve been helpful. But again, I went into practice with two senior surgeons that have helped me through this. And I would say the most important thing is having good partners when you’re first starting out. So true. No, you can’t really say the most experienced or in private practice because we’re all at different stages in our careers. So

Speaker 1 (00:57:21):

Yeah, there’s some really amazing private practice surgeons and some really amazing surgeons and institutions and vice versa, I would say. Yeah. I have a question for you because, so I went backwards, right? I started at a county base in the university base four year, like tenure track situation. I went to a community hospital and I’m in private practice, but I think that was really good for me because my first five or six years, even though I gradually became more hernia specialist, I was doing everything. I was just show up every day and save lives. That was my job. And now I’m very, very specialized. I rarely see a sick patient and I rarely have to do gastric surgery. Or I do maybe a couple, one gallbladder or two a year maybe, and people that want me to do it, but it’s like not my thing. What was your experience when your first year or two did you do other general surgeries? And what do you think about people that go straight from fellowship to a hundred percent like pure hernia? Do you think that’s okay? Do you need to know more general surgery on your belt?

Speaker 2 (00:58:37):

It’s a great question. I think it’s certainly okay, especially if they’re at an institution that supports their practice to be a hundred percent hernia, if that makes sense. And that typically is going to be more an academic center with a hernia specific center or an AB wall center? Actually, no. I take general surgery emergency room call, so okay. I still think I’m a general surgeon at heart. I still have to come in the middle of the night for emergencies and do colon surgery and gallbladder surgery and take out appendixes and things. I love my passion for elective hernia care, and I think my residents always joke that I happen to be the one on call when incarcerated, A hernias come in, and the benefit of me being on call is my patients are going to get a robotic repair when they would’ve gotten an open repair, probably by anyone else.

Speaker 2 (00:59:22):

So that part is fun to blend my passion for hernia surgery with acute care surgery, and I have multiple colorectal partners, so the stuff that I really don’t feel comfortable doing or that can wait till the morning, I will usually ask them to help out with or do because they’re the specialist in that field. Sure. So yeah, I definitely have some general surgery, but my elective practice is, yeah, 90% hernias. A small portion of my fellowship was also advanced endoscopy. So I still do that and that’s kind of my, oh wow. My other passion is doing kind of interventional endoscopy. So yeah, that’s what the beauty of private practice is. I get to kind of craft my practice the way I want it to be. So I love my elective practice and then I sprinkle in kind of the general surgery from the acute care surgery stuff that I do.

Speaker 1 (01:00:11):

Yeah, that’s really great. Okay, one more question. Can you explain the concept of an interstitial hernia? It was tough for me to understand what you described. So yeah, interstitial means it doesn’t go through all the layers and towards the testicle, for example, it kind of burrows its way through different layers. So before the last layer that it pierces, it actually hits that fascia and then goes laterally. So works instead of advancing as it grows anteriorly down the testicle in the groin, it goes through the abdominal wall layers. Actually that’s interstitial inguinal hernia. You could have any type of interstitial hernia, but the implication is that it pierces through different tissue layers as opposed to going full thickness through all the layers. I hope that makes, I don’t know if that makes sense. Do you have a better way of explaining?

Speaker 2 (01:01:11):

Yeah, I sometimes call them in intraparietal hernias too, so that I can explain they’re not going through all the layers. So sometimes you don’t see a bulge or it’s bulging in a place where you didn’t expect because it’s just taking a winding course through the abdominal wall and sometimes it’s not going through all layers of the abdominal wall.

Speaker 1 (01:01:29):

Yeah, that’s a better way of putting it.

Speaker 2 (01:01:31):


Speaker 1 (01:01:35):

Okay. One final comment before we go, cause I know your time is valuable, so thank you very much. Great thoughts from both of you. I’m not trying to suggest that I’m choosing the procedure, but I really feel like I’m getting a one size fits all or easiest response from my surgeon and they’re not considering my specific case, which is why I enjoy listening to Hernia Talk Live for most all of your guests and you me consider more things about an individual circumstance. So that’s why I think they should see a specialist because they can get that kind of feedback and consultation.

Speaker 2 (01:02:15):

And I would say, I know you do virtual consults if that’s something she can do, or I don’t think there’s any harm in ever seeking a second opinion. I always want my patients to be comfortable with my plan for the operating room because if they’re not comfortable with the plan, it’s not going to go well. So I’d say I don’t think there’s any harm in asking for a second opinion from another surgeon to see if they have a different approach for your individual case.

Speaker 1 (01:02:39):

Exactly. And I love that you get that out of what we talk about because I’m a big advocate of tailoring care and I think that’s how you can get the best results, which is not a one size fits all. But I do understand, especially if you go to a non-specialist, you may get one size fits all because they know one size we, they know one really good way of doing things and they apply that to everyone and that may not be the best for you. And so do seek a consultation from a specialist. And if you have to travel, travel, I just got a patient from Louisiana today and they traveled and it was great to meet them and give them the care that perhaps they couldn’t have gotten locally.

Speaker 2 (01:03:25):


Speaker 1 (01:03:27):

Well thank you so much. That was it. I appreciate

Speaker 2 (01:03:31):

It. I can’t believe it’s already been an hour, so. Right. That was really fun. Yeah,

Speaker 1 (01:03:35):

I know. I say that all the time runs quickly. I have so much fun. I had a lot of great time with you. I will definitely share our video on social media. I think people will watch. I was, let’s see, I was 2019, so I was like four years younger and you were still in residency

Speaker 2 (01:03:53):

And I’m embarrassed by the quality of my video. You said yours was bad at the dining room table and I’m like, this is how my attending set it up for me to talk. And I’m like, now that I give talks internationally, I would’ve been done so differently. But I guess it’s good to see how far I’ve come with my IT capability.

Speaker 1 (01:04:08):

Exactly. We’ve all come, the pandemic has helped all of us.

Speaker 1 (01:04:13):

I love it. Well, thanks everyone for joining us. I appreciate all the comments and the questions and the interactions. If we didn’t get to you, I apologize. Thanks to everyone who’s on Facebook right now, live at Dr. Towfigh or those on who found me on Twitter or Instagram at hernia doc. And don’t forget, subscribe to my YouTube channel. This and all prior, I think we’re up to like a hundred and almost a hundred forty, a hundred thirty nine or something episode. They’re all there. Watch ’em, learn from them, watch ’em again. Subscribe on my YouTube channel at Hernia doc and I will see you again next week. Super excited because I’ve got tons of really great guests just like Dr. Drexel. So thanks for your time, Sabrina. Appreciate it so much.

Speaker 2 (01:05:01):

Yeah, pleasure. Thanks.

Speaker 1 (01:05:03):

Thanks. Bye.

Speaker 2 (01:05:05):