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Speaker 1 (00:00:10):
Hello. Welcome everyone. It’s Dr. Towfigh. Welcome to Hernia Talk Live. We are so happy to have you. My name is Dr. Shirin Towfigh hernia and laparoscopic surgery specialist and your host every week. Many of you are with me as a Facebook Live on the Beverly Hills Hernia Center site. And as you know, this will be broadcast as an archive on my YouTube channel at Hernia Doc. And then thanks for everyone else who also supports me on the social media groups on X and Instagram at hernia doc. And this week we have a great, great guest, very nice friend of mine. We always love to catch up Dr. Dana Telem. She’s joining us all the way from University of Michigan Ann Arbor. It’s later in the evening for her, so I do appreciate your time, Dana, but we were just catching up right before the show and I’m so happy that you agreed to be our guest.
Speaker 2 (00:01:09):
Well, thank you so much for having me. I couldn’t be more excited. I think I told you when you invited me that I secretly been waiting and hoping that you would invite me on one day and was so excited when the invitation came, but then try to play cool but then couldn’t do it anyway because I told you how excited I was. So thank you.
Speaker 1 (00:01:26):
Really appreciate it. I mean, you’re always on the list. I just need to coordinate with your calendar. So we’ve known each other for a while, mostly through the hernia world and a little bit through the minimally invasive surgery world, but you have a lot of different hats that you wear. The more I get to know you, the more hats I see. But maybe you can explain exactly what your practice is like and also a lot of the leadership positions you have in your department and elsewhere.
Speaker 2 (00:01:57):
Sure. I consider myself super fortunate in terms of the opportunities that have come and the things that I get to do. And I always say life is about finding meaning, passion, and purpose. And it’s really nice when all those things align. At the end of the day, I think of myself as a clinical surgeon, independent of all those leadership paths or whatever I’m doing and went into the business. I love taking care of patients and I fell in love with minimally invasive surgery. It was one of those areas where you think about how can I do more for people? How can I make people better? How can I push the envelope and do hard things through smaller cuts and get people recovered sooner? And then slowly also got drawn to what I call quality of life operations, meaning that they’re not operations just as improved quantity of life, but they’re really things meant to improve quality of life as well, which is where I fell in love with hernia.
Speaker 2 (00:02:52):
And hernia is the most fascinating area for me with my research cap on. Also because it’s a little bit like wild west. Everybody has an opinion on what they want to do. There’s not a ton of evidence guiding it. And so I find that to be a lot of fuel and really invigorating in terms of spawning my research career. So at work for my day job, I’m the section head of general surgery. As section head I oversee of our entire division of general surgery, which is 44 surgeons and about 109 admin staff and oversee surgical oncology, hepatobiliary, endocrine, everybody in that department. I’m also the second vice chair for Sages, which is our national organization dedicated to the care of minimally invasive patients. Very
Speaker 1 (00:03:40):
Busy job.
Speaker 2 (00:03:41):
Yeah, it’s busy and it’s fine. That stage
Speaker 1 (00:03:43):
Is always so busy.
Speaker 2 (00:03:46):
And my favorite day dog is as N I H funded researcher where I get to study and understand how to leverage data to translate into better care and have that synergistic of my surgical practice, which is amazing because things that frustrate me in the clinic, I get to study to make clinic better and to have better answers for my patients and others patients too.
Speaker 1 (00:04:10):
So I was telling you that I gave a talk, I think it was the European Hernia Society, me, I’m not sure. It was a recent talk. And as part of the talk I thought, oh, I should do some research as to funding who’s funding hernia research. And I always knew that N I H funding the National Institutes of Health funding for hernia has been poor or minimal, maybe even not. And I actually went into the N I H archives to search for hernia, see who has been funded for hernias because it’s the number one most common general surgery operation, right? It’s like 7 million hernias annually in the world, a million of it through the US approximately. Assuming those numbers are right, and yet we’re constantly doing research and showing stuff that we learned before is not necessarily true like me, you like how much I like promoting women’s hernia care because we’re not studying about women and so on. So I did the research and there’s only three. There’s one from I think the 1980s or nineties, which was the watchful waiting trial,
Speaker 2 (00:05:39):
The inguinal hernia, watchful waiting with
Speaker 1 (00:05:41):
Dr. Fitzgibbons who we interviewed by the way, for hernia attack. He was great. And they’re like nothing for 30 years. And then there’s you, you’re really the only one talking about Anglo hernias and care related to hernias. And that O H S D with Ben Paul has hernia adjacent research about ergonomics and that’s pretty much it. And you are the one that’s the hernia research. Now. What do you want to say about that?
Speaker 2 (00:06:15):
I think that’s right. I think what’s frustrating is there’s a lot of money spent studying conditions which are really important but don’t impact as many people. And so when I actually wanted to make this my career arc, everybody kind of was like, you’re never going to get funded. I said, no, we’re we’re going to make this work.
Speaker 2 (00:06:34):
I think it’s about selling the story. It’s the exact story you told. We do a million hernia repairs. People think it’s a throwaway operation, meaning that you just do it, you fix a hole, and life is good and it’s better and it’s not for many people. There’s a lot of people who suffer after this condition. There’s a lot of variation in how we treat patients, particularly females, and we have to study it if we’re going to improve the health of our country in general. And so thankfully I was able to make a convincing argument, but fingers crossed because Annie Eller is my junior partner and mentee got a super fundable score on her K O A, which is essentially stunning sex as a biological variable for hernia disease, specifically looking at females because we’ve seen no matter how we cut the data, women just do worse and we don’t know why. And just trying to figure it out. Exactly. And we’re like, and every domain they do it just as if
Speaker 1 (00:07:29):
We were okay with it. When you go to talks and yeah, women do worse and then they just move on. They’re like, wait,
Speaker 2 (00:07:37):
It’s not a big deal. And it’s a huge deal. And so if you think about that, it’s kind of crazy. Do you know, speaking of the watch full waiting trial, do you know in the three or four randomized control trials in which we base all of our decision making for inguinal hernia, do you know how many females were enrolled in those trials?
Speaker 1 (00:07:59):
Less than
Speaker 2 (00:08:01):
Zero, maybe three. And so if we accept that there’s some probably different morphology to female bodies, they get different types of groin hernias, and yet we’re using the same recommendations that were frankly designed for white men to use those. How can we expect to have any different outcomes? And every time I have a female patient in my office and I get a lot of females in one of the few female surgeons in Michigan who comes to me, I’m always like, I’m going to give you this recommendation, but understand, I don’t actually know if this applies to you because all of these data were just studied and sort of literally healthy white men. And so how do I translate that
Speaker 1 (00:08:41):
To you? That’s my day, that’s my day all
Speaker 2 (00:08:43):
Day.
Speaker 1 (00:08:44):
I say, okay, for watchful waiting for example, zero, what is it? 0.18% risk annually of something going wrong in needing surgery for men? I said, I don’t know what it’s for women. I’m going to assume it’s more. I actually don’t know, but let’s say it’s 10 times more. So that’s going to be a 1.8% per year risk. Are you okay with that? I don’t even know. It’s still a relatively small number, but we just don’t know. Yeah, I have that talk all the
Speaker 2 (00:09:15):
Time, every day, all day. And it’s interesting because, and we also talk about different ways people manage women especially. Sorry, I know this is one of your favorite topics too, and I don’t get to talk about this that much, so I’m super excited to do it. Yes, we did this qualitative study where we went and asked all these surgeons in the state of Michigan about how they approach women of childbearing age. So giving them a case scenario of a 24 year old who’s interested in having kids to look at some of the variation in decision making about whether they fix the hernia, whether or not they use Mesh, whether and all these different decisions that likely matter a great deal to the long-term outcomes. No
Speaker 1 (00:09:55):
One’s studied, no one’s ever studied it.
Speaker 2 (00:09:58):
And I think we’re the only qualitative paper JAMA surgery ever took, ever. It was like a research letter, but they’re like, this is just too crazy because you had some people being super thoughtful and then other people, I mean, one surgeon was like, well, you can get pregnant or you can get that. You can’t really control it, so just fix it. And I’m like, okay. Because the key is if you send young college students, not me, they won’t say those things to me. But you send some young college kids in there that look like nice and naive people, it’s crazy when people say them. But you’d imagine that those differences in how we treat people make a big difference downstream.
Speaker 1 (00:10:39):
Yeah, it’s so crazy. So my efforts are kind of like I can just do my own patients. I have access to the ACHQC database, but that database is so difficult to get any good research out of because it’s highly empty. And then I try and promote gender, gender-based studies. So at the A h s give out that award every year to kind of promote gender-based research. So fund an award at a h s for that. And I was like, thank you Dana for doing this. But I think women keeping on the women thing, I think because the female pelvis is different in many ways, neurologically different, the shape is different, that doing the same exact operational, the same exact algorithm we use for men and translating that for women is why we have the problem. I don’t think it’s necessarily that women just have more pain, which is what they been saying, or they’ve always had chronic pelvic pain and so they’re just going to have chronic pelvic pain. I think it’s fundamentally we’re doing the same thing for men as women, and it’s not the same organ in many ways.
Speaker 2 (00:12:11):
I couldn’t agree with you more. I think everything is probably many different factors that lead in some of it’s decision making, some of it’s lack of data, but some of it is a physical difference in morphology of our bodies, which probably matter a great deal to decision making around what kind of operation to offer. And you see hints of that coming around. You see there’s for minimally invasive chlorine hernias, women do a little bit better than men. So there are some things that you start seeing piecemeal coming out, which shouldn’t make sense, but totally do.
Speaker 1 (00:12:50):
Yeah, my algorithm is very different treating women just based on my own experience, but I’d like to have some data behind it. Talking about data, we put out a round ligament survey. It’s one of those other things that no one talks about pregnancy is one and how to handle the round ligament because some people are like, oh, don’t touch the round ligament. And then you talk to a urogynecologist that deals with female pelvis all the time, they’re like, oh, just cut it. Cut it. No. So we have a round ligament survey going around. If you can share with your Michigan,
Speaker 2 (00:13:21):
I would love to, we always get in this debate too, should I cut it? Should I not cut it? What should we do?
Speaker 1 (00:13:27):
Who knows? No one knows no one’s looked at it. So at least we’re going to see what people’s attitude is about it and then hopefully have some research.
Speaker 2 (00:13:36):
I love it. No, I’ll a hundred percent send that around to everybody here.
Speaker 1 (00:13:40):
Love it. Love it. Maybe you can explain what your funded research is today.
Speaker 2 (00:13:46):
Yeah, sure. So one of the area that I most often study is sort of an implementation science and essentially what implementation science is a domain that kind of tries to figure out who needs to do what differently and why to get sustained practice change. So basically either we have evidence or we generate evidence and then it sits here and then people practice here and never the two should meet. So if you think if you published a guideline on average, it takes 17 years for that to actually get into practice. Now they don’t have that problem in Europe, but we definitely have that problem in this country because everybody believes their patients are snowflakes. And we all practice on our own dogmas, but not necessarily sort of align. So where I like to focus is kind of like, well, how do we get people over the hump to do evidence-based practice?
Speaker 2 (00:14:42):
And then how do we generate new data in a way where people are going to accept it and adopt it instead of just letting it hang in the ether? So the big study we have now is kind of looking at preoperative optimization before hernia repair and trying to identify ways to help surgeons make better preoperative decisions or change their preoperative decision making practices and make it okay to delay or defer surgeries until we can sometimes mitigate factors because sometimes there’s more harm you can do by operating than by not operating. And there’s a lot of variation in how people approach persons who may be better by not having an operation right away. For sure. And so that’s what we study. So we look at the different policies and different interventions and trying to understand can we get surgeons to make better decisions all while we’re generating more evidence? Well, if we make a better decision, then what is the decision once we make it? And so that’s probably the crux right now, which is around pre-op optimization for hernia repair. And the next gen is figuring out well matching the right surgery to the right patient. So you mentioned the AHSQC, which is a great dataset, but I always think of that as the best possible outcome of highly invested surgeons entering highly invested data. And so you’re ING best of the best. So in 2020, excellent year to do this, by the way, in 2020, right as the pandemic started. Yeah,
Speaker 1 (00:16:21):
Perfect.
Speaker 2 (00:16:23):
We started MSGC Core, nothing’s
Speaker 1 (00:16:24):
Going on in 2020,
Speaker 2 (00:16:25):
Not at all. It was the best time to start this. So we started M S G C core, which is our core optimization registry for hernia. And we started collecting population level data similar to the QC elements and variables, but that’s abstracted, which essentially means that agnostic nurses are abstracting the sample from the entire state of Michigan from all surgeons. And while it’s one state, it’s really representative of what are people actually doing in practice. And we have about 20,000 entries now so we can really start drilling down. But what was really cool is about a year ago we started entering one year on proms or patient reported outcome metrics. So at a year we collect data on pain using some of the pain intensity scores. We collect data on the ventral hernia recurrence inventory, and we collect data on abdominal wall function. And we just hit over 2001 year, which is really exciting. That was
Speaker 1 (00:17:29):
Be my question is how do you get the patients to respond?
Speaker 2 (00:17:34):
We email, we call, we text, which means that we have an adequate sample of the population. So with waiting and stuff, we can really try to understand what’s happening to people at one year. And we’re just trying to climb through this data and try to figure out what’s going on because we don’t measure the success of a hernia repair 30 days. This isn’t a depth and destruction obligation. It’s a quality of life operation and we have to start measuring operations. But did we improve quality of life? And spoiler alert, we didn’t for many people. And if you look at one year, I think it was like 30% of persons, and again, this is unadjusted, so it might be a little hyperbolic, but this is just what we’re seeing in the raw data. There’s still 30% of people who had a hernia repair that are experiencing pain and discomfort in abdominal wall changes a year after surgery. And you’d say, well, maybe it’s just the big hernia. It’s the median hernia size in our state is two to three centimeters, so we’re not doing something right if we are not fixing kind of quality of life. So I think there’ll be a ton to unpack as we kind of move forward, but I’m really excited about that.
Speaker 1 (00:18:55):
That’s exciting. Took the
Speaker 2 (00:18:57):
Whole lab out.
Speaker 1 (00:18:59):
The
Speaker 2 (00:18:59):
Issue
Speaker 1 (00:19:02):
AHSQC is the patients are not filling it out. So if you go to the Facebook groups, the patients would like this kind of data. They want to see what happens to, why can’t you tell me what my expectations should be at five years or even one year? And then now there is a database that they can respond to. No one responds. So we need help from the patient’s student. It’s very expensive to get people hired to do the work to follow
Speaker 2 (00:19:32):
Up. I pay a lot of money to get patient follow up. We have a lot of interns doing phone calls, giving surveys, a lot of emails and all that stuff. But funding, I have to do it. I use whatever discretionary research money I have to fund it because we’re not going to get to answers if we don’t have a critical mass of data to know what happens. And all we really have now is sort of what you can pull from claims data, which is sort of reoperative recurrence rates, and that’s great, but it’s only one part of the story. How likely am I to have a reoperation in 10 years is important. But again, it’s only one small aspect of why we do the surgery because maybe they had a recurrence, but maybe they’re really happy they got eight years of good quality of life out of it. We make a lot of assumptions that that’s a failure, but maybe it’s not a failure. And so I think we just need the holistic picture to understand what’s going on.
Speaker 1 (00:20:38):
And so one of the questions asked is what’s the incidence of disabling pain after hernia surgery in your sample?
Speaker 2 (00:20:45):
We’re literally, this is hot off the presses. We were just pulling this off and it’s not adjusted and it’s not anything. So I hate to even put it out there. And it’s going to be like Dana tell said that extra portion of patients have disabling pain after surgery. And I’m sure it’s going to matter by signing a size and everything, but it’s certainly not close to zero is what I’m going to say there because I don’t want to overestimate or underestimate because the numbers
Speaker 1 (00:21:14):
Are everywhere. The numbers are everywhere depending on what talk and what person.
Speaker 2 (00:21:20):
But I suspect they’re going to be much higher than we and want to see. But I think anecdotally that passes the sniff test. I think we all know that. I know Shirin, I know your practice and I knew you specialize in a lot of revisions.
Speaker 1 (00:21:34):
Most of my patients. Yeah,
Speaker 2 (00:21:35):
I am the final common pathway for all things in Michigan that don’t go as planned. And so you see patients like this, you see patients who have been hurt, not intentionally, but who’ve been hurt by this surgery, who I always tell my residents that the road to problem is paved with a two centimeter hernia and grade intentions. It’s true though, right? It’s
Speaker 1 (00:22:03):
Two centimeter, one, two
Speaker 2 (00:22:04):
Centimeter hernia and good intentions and then six operations later. Here we are.
Speaker 1 (00:22:11):
Yeah, so true. And I have a question about this whole follow-up thing because maybe correct me if I’m wrong, I did a little session a couple of weeks ago because I was watching Stand Up to Cancer and it’s on TV about cancer and there are patients and doctors and advocates and everything fundraising on TV for cancer, which is great. And then I’m like, we don’t have any of this type of fundraising for hernias. Not that I know of. There’s funding for research that you are seeking and very few people actually are seeking. There’s maybe some privately funded stuff for internally funded work. Mine’s basically I pay for it. So why is that? Is it because let’s say taking cancer an example, there are cancer centers, there’s database mandates, there’s therefore as a cancer, like a center, even for bariatrics, they have bariatrics center of excellence. So with a center of excellence comes funding for research for example. Is that why we don’t even have an idea of what a center of excellence should be or is it just no one cares about hernias?
Speaker 2 (00:23:39):
People care about what you make them care about. People want to put their money into that. They find meaning and purpose. People want to find purpose with their dollars. How do you not find purpose if you think that you’re saving somebody’s life from breast cancer, from ovarian cancer or from colon cancer or helping to prevent that from somebody else? I think language matters. I think that the way we refer to common general surgical conditions like hernias and gallbladders is essentially like they’re just right. They’re just this. They’re just that. And that’s all. And that’s all. So when you downplay or diminish or somehow lessen the work that you do, then who’s going to want to put funding into that? And I think the onus is on us to help people understand that for some people, a hernia repair is akin to a cancer operation and gives somebody their life back or gives somebody, or sometimes it’s palliative.
Speaker 2 (00:24:49):
And even if you can give somebody a couple good years, we just did this qualitative study like talking to patients whom we said no to for preoperative optimization and things like that. And when you listen and you hear the patient perspective, it’s like I can’t leave the house. I’m embarrassed to be seen in public. I don’t want to go to the beach and I don’t want to show anybody. I get made fun of all the time. Sometimes we forget as physicians sort of the psychosocial impact of these things. And like I said, if we diminish ourselves and we diminish our profession and make it less than who’s going to want to invest in hernia when you could fund a cancer center, when you go to a cocktail party, I gave $10,000 to hernia research or to cure pancreatic cancer doesn’t right now. It doesn’t. But I went into
Speaker 1 (00:25:44):
A bone marrow fundraiser they raised in one night, like $200,000.
Speaker 2 (00:25:49):
Exactly. Bone marrow, right? So I think it’s on us to make it interesting and help people understand why this is so important. It harms many people, it helps many people, but it’s the wild west. And if we don’t have data, then we are essentially impacting a million people a year versus, I mean, I don’t want to pick on thyroid cancer. All the cancers are terrible, but where there’s a 99% sort of survival rate, but it’s just kind of where people find purpose because that’s what they were told has purpose. Yeah,
Speaker 1 (00:26:30):
Yeah. No, I totally agree with that. So can you just briefly talk about your diversity, equity, and inclusion research too? I love that part about you as well.
Speaker 2 (00:26:42):
Oh my God, yes.
Speaker 1 (00:26:44):
It links patients and clinical care, but also nonclinical care work that you do too.
Speaker 2 (00:26:53):
What I found in my life is everybody’s like, how do you do all these things? But what I found in life is that if there’s synergy with what you love clinically and synergy with what you love to do and what you love to study, everything just kind of works itself out and it doesn’t feel sort of work. And so I think of the d I work. Work, yeah. I think of the D e I work and two buckets. One is what’s called sex as a biological variable or underrepresented minorities or different things that impact the clinical care that we deliver, the outcomes of patients we do, which is I think reflected in a lot of the hernia work that we’ve done. But then the second is really in the space of achievement attrition for females in academic surgery or persons who identify as women. And while there’s a lot of marginalized groups, it was just kind of the space that I entered in first and kind of learning about patients and their lived experience.
Speaker 2 (00:27:54):
I really like learning about other females and other women in our space and L G B T Q and understanding about their experience and how can we create a workforce or an equitable workforce where we are represented and not just represented but have equal opportunity. And I think there’s plenty of data now to show that it’s not about being better or not better, but there is some benefits like concordance between gender and race and patients. And not even just in terms of outcomes, but in trust. I think everybody accepts diverse teams function better. And I think we also accept that there’s higher rates of burnout and fatigue and dropout for females and underrepresented minorities because it’s just every day is just so much harder. And when things are hard to begin with, I think it was Carla for SFAs who started that backpack challenge when they filled backpacks and had people to represent kind of the extra weight that race and everything kind of brings to your day and had them walk around with backpacks every day.
Speaker 2 (00:28:58):
So if you’re walking around with a backpack every day with 20 pounds extra weight, how much harder is your day just as a physical manifestation? And I loved that. I thought it was such a great idea. But it’s so funny, every time I give a talk to mixed audience, I’m like, who this morning thought about what they were going to wear to work every female. I was like, who this morning was worried that somebody was going to say something about what they wore to work every female. I’m like, did you notice a single male hand going up? That’s
Speaker 1 (00:29:22):
A good point.
Speaker 2 (00:29:24):
It’s because when you have to worry and think about all these extra things, it just makes everything harder, which then leads to all the dropouts. So we
Speaker 1 (00:29:36):
As a resident, I would wake up earlier just to make sure that I looked appropriated. You don’t have that much extra time as a resident to work on yourself. But I try to look fine, even post-call like you’re on call 24 hours and then your starts again, but you need to look fresh and not look like you did 24 hours after a bad call. And I would try and do that, and people were like, Towfigh, you can’t look put together post college. Then they think you didn’t work hard enough or you’re not tired enough. You have to look to
Speaker 2 (00:30:07):
Shovel. Yeah, you’re not good enough no matter what you do. I had the opposite approach. I hated getting any type of attention for my physical appearance. I’m like, what can I do to today to be even more haggard than I was yesterday? And I didn’t get to this point, but I remember I still have some identities to do this now when females were always wearing their scrub tops backwards because there was always the looky-loo or maybe you didn’t have that. Maybe that was, oh,
Speaker 1 (00:30:32):
Because I don’t have that problem was
Speaker 2 (00:30:37):
There was always this action kind of going on. So do that. That’s true. So anyway, it’s still with my implementation science hat, we have a gap. There’s evidence that we have to fix it, that we don’t do it. So how do we create system level strategies? Because it can’t be on me, it can’t be on you. It can’t be on persons of color to fix their own problems. We need system level solutions. You know what I mean? To do things, otherwise it’s not going to get done. I
Speaker 1 (00:31:04):
Should have one of my patients contact you. She’s a professor in sociology, but she does healthcare behavioral sociology.
Speaker 2 (00:31:14):
Oh, that’s awesome. It’s
Speaker 1 (00:31:16):
So interesting. I spend half the consultation learning about the stuff that she does because we deal with so much of that stuff
Speaker 2 (00:31:25):
Isn’t the best
Speaker 1 (00:31:27):
Different,
Speaker 2 (00:31:28):
Isn’t it the best? Having interesting patients. And I’m always like, okay, we’ve done your consult. Let’s talk about you and try to learn everything about it.
Speaker 1 (00:31:35):
Absolutely.
Speaker 2 (00:31:37):
Getting surgery, you’re like, we’ll get to that. We’ll get to that. Let tell me more
Speaker 1 (00:31:41):
About, I even apologize. I said, we’ll get to your hernia in a second, but tell me more.
Speaker 2 (00:31:45):
I’m like, don’t worry about it. They’re like, aren’t you late? I’m like very late, very, very late. But I still want to hear all of these things.
Speaker 1 (00:31:51):
Yeah, it’s one of the stuff, I love people’s stories. That’s why I like doing hernia talk too. I get to just talk and sage’s stories coming up. You’re going to be one of our guests. So I love just the stories of people. Shoot, I forgot what I was going to say. It was about the whole, oh, it’s good to mention. It’s timely to mention since you bring this up, that in the past year, including most recently, there’s been at least what three articles that showed patients prefer female surgeons. Female surgeons have better short-term outcome for surgeries. They have better long-term outcome from surgeries, gallbladder surgeries do better, and the life the you’re more likely to survive if your surgeon is female. Did I get all that right?
Speaker 2 (00:32:45):
You did. You got all that right. But what’s most interesting is Nancy Baxter’s work, which showed that you are also more likely to be penalized as a female in terms of referral and referral patterns if you have complications.
Speaker 1 (00:33:02):
Oh, yes, that’s right. Yeah.
Speaker 2 (00:33:05):
I mean it kind of aligns, right? You have to be better to be considered just as good. You have to do better. And the one second, you don’t do better. There’s heavily penalized. And it’s the same thing as your makeup story, getting yourself together and trying to be presentable and trying to show your best face and then told that you don’t work hard enough. Right. I’ll tell
Speaker 1 (00:33:26):
You though, it’s hard to generalize because yeah, I can see how during a morbidity and mortality conference, which is what surgeons do, they go over the complications to learn from it. It’s very unique to surgery to have that. There’s this study that shows that women are more likely to be condoned for you must be a bad surgeon, and therefore you may need to be penalized. Peer review, have oversight, have people in the room watching you make sure you do better whereas better, oh, must’ve been a hard case. Sorry, you had a bad outcome. But when I was a resident, and I think it was my demeanor, so at my hospital, at my training center, the chief resident presents all the complications. Doesn’t matter if you were doing the operation or not, things have changed. But back then you were the chief of your service. And so you were responsible regardless of what the outcome was, even if you weren’t scrubbed in.
Speaker 1 (00:34:27):
So the chief resident would go a very formal presentation. I would present my Rives were like Towfigh, how do you do it? Because they could present a small wound infection from some horrible, horrible operation, and it’d be a very small wound infection with minimal consequences. And they’d say, that’s unacceptable. You should have done this. You should have done that. And then you go up there and present this horrible situation, the patient dies or some bad outcome is there. They’d be like, I’m sure you did the best job. You must have done really a good job to be able to get it to where it was. And it must’ve been a difficult situation how I presented myself.
Speaker 2 (00:35:18):
But I think when we look at studies like that, you know what I mean, it’s always on average. And it’s funny because I probably have a lot of women that I need to apologize to because I’ve always had the ability to put blinders on. And what I mean by that is I focus on what I need to focus. I look ahead. I compete with myself. I’m not somebody who I have many bad traits. One of my good traits is I don’t look to the side, but sometimes that kind of makes me a little bit blind to others experience. And I remember being a resident and I was a female resident, but I never felt a lot of that gender pressure or anything like that because I was always laser focused on what is, I’m a really good intern. I could check. I’m like, what is the next box that I need to check? And it was only as I started moving on a little later in life and starting to be more open and with my eyes and seeing various injustices or things that happened to me or to others when you’re like, wait, that’s not right, and that’s not fair. And then I went from this fixed mindset of gender is not a problem. It’s your problem that you’re just not doing this to this space of I was wrong. And I can’t believe that that was my mental model. And I buy from that because it was my survival. I
Speaker 1 (00:36:40):
Think we were just naive. Speaking of myself, I was very naive as a resident.
Speaker 2 (00:36:46):
I think I was naive. And I think a survival skill, you just need to do the next thing, right? Yeah. I just
Speaker 1 (00:36:51):
Did whatever they told me to do. I didn’t question anything. They told me what to do. I just did it. Yeah.
Speaker 2 (00:36:58):
Everybody’s like, you’re amazing. And you’re like, I can check a box. I’m really good at it.
Speaker 1 (00:37:03):
Really good at doing really good college orders and then eventually get to point where you’re giving orders. You’re like, oh
Speaker 2 (00:37:11):
Yeah. And you get there, but then you also, I don’t know. I think there’s some maturity in your first job. I think all of us learn a lot the first couple years out in our career. And I think some people grow from that and open their mind and figure out, whoa, well this was good or this wasn’t good, and how can I help others and maybe make other people’s lived experience a little bit better? And some keep on. But it’s funny how it’s evolved over time. And like I said, I have no complaints. I’ve been God willingly, totally blessed in life, and I couldn’t be happier in a place that’s more supportive. But I also recognize that that’s not everybody’s truth and that’s not what everybody has. And we have to do everything we can to make sure that everybody has the same opportunities that I was lucky enough to get in many ways.
Speaker 1 (00:38:04):
You’re part of an amazing system with great leadership. Your chair is very supportive. I’m lucky that our chair is now so amazing and supportive.
Speaker 2 (00:38:17):
She’s amazing. We were talking about her offline too. You guys are very lucky.
Speaker 1 (00:38:23):
So happy to have her. And you built an amazing, amazing department because I’m going to say 15 years ago, hernia was kind of not a thing at University of Michigan, maybe pancreatic surgery but not hernias. And now MIS and hernias has become, you have hired some amazing people and I’m slowly interviewing many of them for hernia talk, just so you know. Love it. We had Jenny Shao and then Annie Ehlors will be coming on.
Speaker 2 (00:38:56):
Amazing in the future.
Speaker 1 (00:38:58):
Looking forward
Speaker 2 (00:38:59):
To that. You can’t be what you can’t see. And I know this sounds kind of crazy, but I think we were just talking about this. We started a minimally invasive surgery fellowship, and it’s Des, who was your previous resident, is our first fellow this year who’s amazing. And the number one reason I started that fellowship was to help train our next generation of academic, minimally invasive surgeon. And the reason for that is I think a lot of times people feel pressured to choose certain specialties because they don’t think that they’ll be able to ascend in leadership if they’re not. And if you look at leadership in American surgery, it’s very heavily dominated by cancer and cancer subspecialties. And if we don’t have leaders in very prominent places where, oh, I can choose M I s, I am a real surgeon, people are going to make fun of me for doing this and I can have a career.
Speaker 2 (00:40:01):
And us creating a fellowship was one our way to put a stamp on American surgery and be like, we are people out to be leaders in their domain as many of our fellowships do. But also my goal, Justin’s goal, everybody’s goal is to show people you can choose this specialty. You can be an academic N I H funded surgeon. You can be a department chair, you can be a section chief. There is no limits. Because my feeling is a lot of times burnout happens when you feel like you have to choose something because you didn’t have a choice. Certain goals you want to get that may not actually align with your interest. And for one of the first times, we have many residents at Michigan interested in m i s surgery, which 15 years ago we were, I mean, don’t get it twisted. Still everybody wants to do transplant because our transplant department is off the chart. Amazing. But we’re catching up. We’re catching up. But that’s
Speaker 1 (00:40:56):
Very unique. Yeah. Let me go through some questions that have been shared with us. Oh, sure. Regarding your research. Have you ever reconsidered some aspects of your practice based on new studies or patient reported evidence?
Speaker 2 (00:41:11):
Good question. Absolutely. Absolutely. First of all, surgeons, we practiced our last complication, I’m just kidding. There we were. I was in clinic and I see a lot of parastomal hernias. So these are hernias that are at the site of people’s stoma sites, and they’re notoriously difficult to fix and hard. And I think traditional dogma kind of represents reciting them and starting fresh and new. And I was just frustrated in clinic one day and I was like, well, what can I do? Because no matter what I do, these tend to come back. They always come back last. But I had this anecdotal bias that maybe just a site specific repair would have similar types of, but nobody really knew. So I called one of my research residents who’s brilliant, Ryan Howard. He actually matched with us, and I’ll be our fellow after death. And I’m like, Ryan, we got a look at this.
Speaker 2 (00:42:10):
We pulled out some Medicare data and we looked at long-term reoperative recurrence at 10 years from site-specific versus reciting or moving the hernia. And it turned out that there was really no difference in reoperative recurrence, but the complication rate of reciting was so, so much higher. And so in my practice now, I tend more to always try to salvage the site before I recite it. And I felt that way before, but didn’t really feel as secure in that and sort of went back in terms of patient reported outcomes. That’s one example of how I used claims data to do that. In terms of patient reported outcomes, I haven’t seen the data well enough to really understand what we need to do. But I will tell you, after hearing lived experiences, I was, and still sometimes very stringent on preoperative and perioperative optimization, meaning weight loss before surgery and smoking cessation. But sometimes I hate
Speaker 1 (00:43:15):
When surgeons say, and they say it publicly and online, oh, well, you should offer this patient. They need to lose weight, stop smoking, get their diabetes better, whatever the situation is. And they’re like, well, if I don’t operate on them then,
Speaker 2 (00:43:29):
Or somebody else is going
Speaker 1 (00:43:30):
To do it, constitution down the street’s going to operate like, well, they shouldn’t either. That’s not a reason for you to do it. That’s my take. I hate,
Speaker 2 (00:43:39):
And that’s my take, and I’m super staunch on that. But hearing some lived experiences from people who we’ve said no to, they have a million different repairs. I’ve put the patient a little bit more in the center of the conversation also. So if it’s someone who’s like, listen, I get it. I might only have a year out of this, but I need to get to this wedding. But there’s real compelling reason about why to do it, and they understand the risk. It’s not someone on either end of this extreme, but I always tend to be a little bit, I always lean more conservative, but kind of bringing in the psychosocial element of the disease is probably something new because honestly, I anchored on recurrence. I anchored on pain, but I didn’t really, I think, take much of the psychosocial impact into account. And now I think that that’s something that I consider also when I talk to people. I mean, it’s not going to sway me in a really poor candidate, but it is something that I factor in. Now
Speaker 1 (00:44:47):
Here’s another question that was submitted, and it really addresses industry funded research. What do you think about it?
Speaker 2 (00:44:58):
Industry funded research?
Speaker 1 (00:45:00):
Yeah. What are your thoughts on that? There’s a lot of research that’s either industry funded or the researchers are heavily funded by research. Does that make sense?
Speaker 2 (00:45:12):
Yeah. I think it’s hard. I think research dollars are not common. It’s actually super hard to get N I H funding, I think that
Speaker 1 (00:45:24):
Well-designed except from one other institutions
Speaker 2 (00:45:26):
I know and we have to study things. I think well-designed studies are okay. I don’t think you can throw the baby out with the bath water and be like, oh, it was industry sponsored, so we can’t trust the data. But I think you need to keep your eyes a little bit more open, really read the methodology, really understand how the data we’re accrued. And we see this all the time in vascular surgery. A quintessential example of one of these areas where adoption far outstrips data. And then by the time the data comes out that shows something doesn’t work, people don’t sort of adopt it. So I don’t have a problem with research money if the methods are rigorous and they’re open to a negative result. And here’s a study. Here’s an example. Do you remember [inaudible] study about hiatal hernia?
Speaker 1 (00:46:17):
Mesh? hiatal hernia is a Mesh. Yeah.
Speaker 2 (00:46:19):
And that was a trial funded by industry that had a negative result that fundamentally changed how many of us did laparoscopic hiatal hernias and that people don’t use NASH almost at all anymore. It showed that long term outcomes were no different. And I think that’s an example of when things work well, they had a positive result early on that didn’t last, and they were honest and they published their data. So like I said, I think research is good, but when it’s industry sponsored, you just need to look at it a little bit more critically and not just accept everything that you see at face value.
Speaker 1 (00:46:53):
I’ll tell you on the patient forums, they read all of this research. It’s pretty fascinating how involved and informed so many patients are in the hernia world, and one of the things they look at is who are these doctors that are writing up these papers? Some of the stuff that they’ve said is, well, it seems very interesting that all these surgeons are funded by Mesh companies and all of their studies show that Mesh is superior and they have a point. I’m going to assume that these people are truthfully expressing their findings. However, there’s different ways of interpreting the same data. You know what I mean? So from a patient standpoint, I’ll take that one centimeter umbilical hernia, all about this umbilical hernia research. It’s actually better with Mesh and without Mesh in terms of recurrence. But how much better for a one centimeter compared to a four centimeter? So for someone to come out and say it’s superior, and there’s a recent publication on Twitter, we kind of slam the authors for promoting overuse of Mesh when though statistically speaking, you had a lower recurrence rate using Mesh for one centimeter umbilical hernia. But practically speaking, the difference was so minimal that other aspects should be discussed in the conclusions. You know what I mean? Because
Speaker 2 (00:48:32):
There’s statistical significant
Speaker 1 (00:48:33):
Data, patient patient’s,
Speaker 2 (00:48:39):
You bring up the one centimeter hernia whenever somebody cuts to my office with a one centimeter hernia, you have the most controversial hernia of all time and nobody knows what to do for you. I’m like, if this were 10 centimeters, I would know what to do. I go, we have to have a really long conversation now because I always have have that. I’m like four centimeters. There’s the RCTs. I know that Mesh is okay. I’m like,
Speaker 1 (00:49:04):
Yeah, there are trials on
Speaker 2 (00:49:06):
Me. It’s a problem. It’s
Speaker 1 (00:49:09):
Very controversial.
Speaker 2 (00:49:10):
Well, it’s true. It’s true. I think the whole issue with Mesh in general is a problem. So I mean, as you know, but maybe listeners and met and patients don’t know, every Mesh that gets put out with whatever claims it comes out with goes through that five 10 K approval process, which means that the F D A essentially clears it because it’s predicated on an original phenotype. However, we know that even though it’s similar, it’s not similar. There’s different materials or different by absorptions. What I tell people about Mesh in my office is that oftentimes Mesh itself isn’t the demon, but kind of the bystander of something that’s gone wrong and something that’s gone amiss from surgery. And anytime you put anything artificial in your body, whether it’s a valve or a joint for a replacement, something can happen. It can get infected. It’s difficult to clear.
Speaker 2 (00:50:04):
It can encapsulate or not go and do that. But most of the time when these things happen, there’s a missed injury or there’s fistula or something or other that’s kind of going down there. But when we do research on Mesh, it’s kind of ridiculous. It goes through that whole process anyway, so it doesn’t, you know what I mean? It doesn’t even matter. I think what’s really useful if we really want to be serious research with Mesh is to use registries like the QC and our Michigan core registries to see Mesh, to track Mesh out. As you recall, or you probably remember that whole Mesh recall happened because of the European registries that were looking and seeing higher rates of recurrence because they were actually able to
Speaker 2 (00:50:46):
Do that. And I feel very strongly, and I gave a presentation once to this and spoke to the F D A, that we need to track devices that we put into humans, and whether that’s through a claim code that you could put so that you can look for signal amongst the noise because it’s always possible for somebody to react to something. But if there’s true signal, we should be able to pick that up. There was a great paper on the gastric band, for instance, at some point there was more removals you could see in Medicare than placements and things like that should be a tip off or something. That’s something. And we should be able to identify these issues earlier. Anyway, I’m going off on my bandwagon about these monitoring.
Speaker 1 (00:51:32):
I so wish that we had a database. Does who’s your current fellow? So much research with me and our database, because it’s my own patients, we have a lot of granular data. We can go through it and come up with the randomest questions. It’s in the chart. That’s not possible with databases, right? Databases only log whatever question has been asked, and you can’t go back to patient’s charts to double check because it’s an anonymous large population database. And so we’re able to come up with some unique questions to ask, but I so wish there was an opportunity to do that in a grander scale. I don’t know. What are your thoughts about hernia research and how it’s going to improve hopefully?
Speaker 2 (00:52:31):
Yeah. I think between large national efforts and in some of the efforts that we’re doing, I think we will be able to start making specific recommendations around where is robotics most beneficial, in whom is this beneficial? When should we be using component separation techniques and how does that change and how do patient factors modify? And then as not to circle back to where we started, the key isn’t so much in identifying the practices, but making sure that we adopt ’em and we embrace them as a society and as hernia surgeons so that it’s not enough just to say, okay, I may not do robotic surgery, but if my patient’s going to benefit, I need to send my patient to somebody who’s going to do this, right? It’s not about me, it’s not about that. It’s about what’s the right thing to do for this person. And I think that’s where we need to evolve. I think we need to have better predictive analytics of who’s going to do well, not at 30 days, but at a year, at five years. I think we need to know what operation’s going to make that better and we need to communicate it well, and then we have to make sure that it’s adopted.
Speaker 1 (00:53:54):
Yeah, that’s so true. The whole and it’s adopted is such a slow process.
Speaker 2 (00:54:01):
It shouldn’t be.
Speaker 1 (00:54:05):
I love teaching because that’s a fast adoption process. You teach the resident and then they come back to the chief resident and you see them kind of teaching the same thing that you taught them to their junior residents. You’re like, okay, cool. I made a difference, right?
Speaker 2 (00:54:20):
I did it.
Speaker 1 (00:54:22):
But you and I have similar practices in that we see the complications, the problems, and so much of it is if only they knew not to do this. This has been established data that you shouldn’t do X, Y, and Z. And yet people still do it.
Speaker 2 (00:54:43):
No. Yeah. I’m always like, wait, what happened? I’m always like, every day I’m surprised. Wait, what happened? What did they do? I’m like, okay, let’s figure it out.
Speaker 1 (00:54:53):
Yeah, yeah, it’s true. It’s true. So what are the kind of common funding opportunities right now for hernia surgery?
Speaker 2 (00:55:06):
Yeah, not everybody is going to, nor should they or want to be NH funded. I think it would be great if everybody was, and that was an aspiration, but it can be challenging I think before you even think about the funding mechanism. I think the big thing we need to know, and maybe this is something we come together with as a Delphi, what are the big unanswered questions and where are there areas where we can million,
Speaker 1 (00:55:33):
I can give you thousand
Speaker 2 (00:55:34):
And areas where we can get alignment and say, what is our first, is our third tier priority? And then come together and find funding opportunities and create. So there’s obviously N I H level funding. I haven’t done this, but I think this would be funding, right? For PCORI, which is the Patient Centered Outcomes and Research Institute, they really kind of center on patients as partners in decision making. Every contract or grant you put in has to have the patient voice. I don’t think hernia has cracked in there. They’ve typically been into other mental models, but I think that’s sort of rip. I think there’s industry sponsored grants. A h s grant has Grants, sages has grants. American Colleges Surgeon has Grants Association for Academic Surgery has grants, and he is won. A couple of them. Brian Fry, who’s one of our research residents, has gotten a couple of grants through them.
Speaker 2 (00:56:29):
Insurers have grants. a lot of insurance companies are really interested in this. So I know that there’s mechanisms, I know we just talked about it, but agnostic, industry sponsored grants where they fund your idea and not their idea coming to you. So I think the money is there and I think the opportunities are there, and I tell everybody, I’m like, don’t worry about the money. If you do good work, the funding is going to come think about what is your question? Do you have the data to answer your question? Because a lot of times people have super interesting questions, but they can’t actually study the question that they want. And so they try to piecemeal, you’ve seen those papers and you’re like, wait, you can’t answer the hypothesis that you have with this data. I want to know lots of things, but it’s not going to be in Medicare data. And then sell it. Learn how to write for impact, learn how to sell your story, learn how to make your work important so that other people care about it. If you can’t do that, then you’re never going to get people to care about it. And it can’t just be important to other hernia surgeons. You have to make people care. You have to make, and that’s what I love about this show, and that’s what I love about you. I love that your audience is patients. I love that it’s people outside of our small circle of friends and colleagues. We’ve all drank the Kool-Aid. You have to make it important.
Speaker 1 (00:58:00):
People don’t believe, surgeons don’t believe that. Patients sit down and they watch hernia talk on YouTube. My patient today, she’s like, oh yeah, I’ve been watching her. I have these questions, blah, blah, blah. And I’m thinking like, really? Watch. But we get 8,000 views a month and growing on hernias, and then the patients are like, no, it’s because we have questions. Everyone goes online to find questions. And there’s very little like hernia focused, legitimate data that’s not just very, very general
Speaker 2 (00:58:40):
Online. No online’s all polarizing. Mesh is the worst thing that ever happened to me and destroyed my life. Or Mesh is the best thing. And I always tell patients happy people don’t post. You’re always going to see the extremes online. And that’s why I think Shirin, I always say, what you do is so important. This is such a great public service that you’re doing, giving people content that they can trust with people who can do that. And so it’s awesome. Kudos to you for this.
Speaker 1 (00:59:07):
It’s fun. And I have friends like you who agree to spend their evening with me just to make it work.
Speaker 2 (00:59:13):
I came here with you all night. My kids are going to kill me at some. I’m like, I would stay here all
Speaker 1 (00:59:17):
Night for sure. We’re going to have to catch up in Boston.
Speaker 2 (00:59:23):
I’d love that. I’ll be there. Yeah, just text me and we will definitely catch up. But thank you for having me. This has been totally awesome. It was worth the wait. Like I said, I waited for this invite and it was totally worth the wait. I love talking to you for an hour. I
Speaker 1 (00:59:37):
Love you are the best. I can’t wait to see you again. So thanks for your timely and everyone that joined us. Thank you for joining us, spending an hour with us learning and getting to know Dr. Telem. She’s just amazing gem in our hernia world and one of the great leaders and definitely a force for making change, which is what I love. I’m all about improving her new care and she’s doing it actively. So thanks everyone.
Speaker 2 (01:00:07):
Take care. Have a great night.
