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Speaker 1 (00:00:11):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I’m joining you on a Tuesday evening. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic and robotic surgery specialist. Thanks for everyone who’s joining me live as a Facebook Live or Zoom. And many of you know that at the end of this show you can watch this and all previous ones on my YouTube channel, and you can catch up on all the previous episodes as well as a podcast. So please do subscribe to my podcast channel, which is Hernia Talk Live, and also if you prefer video, you can do YouTube. So welcome everyone. Okay, so a couple of things. First of all, I’m in my office, which I usually do at the end of the day after my full office day. On Tuesdays, I stay in the office and I do my hernia talk sessions.
Speaker 1 (00:01:08):
So that’s usually the background that you see. I have a very kind of simple clean luck to my office and today I’m wearing a very beautiful pashmina shawl that was given to me as a gift from one of my great patients. Thank you very much for it. It came in really handy because my office for some reason is super, super cold and I hate the cold. That’s why I live in Southern California and it’s actually very warm outside. It’s like I think high eighties and it’s beautiful. The sun is shining, but it’s not hot. It’s just great. And yet in the office it’s freezing cold. So I’m really, really grateful for you all who give me gifts that are, and especially to my one patient who this week gave me this beautiful, soft and gorgeous pashmina scarf and it’s also goes nicely with my blue motif.
Speaker 1 (00:02:14):
So I do like that. Thank you very much. Okay, so today’s discussion is going to be focused on the team approach. We’ve had one prior episode which talked about multidisciplinary teams and how important it is to approach hernias in a multidisciplinary matter. This will be in the same line of discussion specifically talking about teams and the team approach. And the reason why I say that is because this past week or so, I’ve seen patients from a very wide range of places from local hospitals, academic centers, big university centers and so on. And the one thing that was missing in most of these places is their team approach.
Speaker 1 (00:03:09):
I’m sorry. And in addition, last week and also two weeks ago, I had some operations with colleagues of mine, plastic surgery, gynecology, urology, together in the same operating room, which was a very great opportunity for my residents to also learn from other specialties because for example, in general surgery, the first year of general surgery, it’s a five-year program minimum. The first year is spent dabbling in different specialties. They’re often general surgical specialties like colorectal surgery, bariatric surgery, surgical oncology. Some institutions also have you rotate on more subspecialty groups, so cardiac surgery, neurosurgery, head and neck surgery and urology. And they almost never rotate through gynecology rotation.
Speaker 1 (00:04:11):
So it’s really great for the residents to get that opportunity one-on-one with another attending in a different specialty when they operate with me so that they can learn all the little tips and tricks that you can get from another specialist. Because when I operate, I have a certain set of instruments, but you know what? Urologists maybe operating in the same area, but they have other instruments and it’s kind of unique to be able to learn instruments and techniques and stuff from another specialist that maybe I can include in my own operating room. I’ll give you a great example.
Speaker 1 (00:04:53):
There’s something called, there’s something which is an anti-adhesive barrier. So every operation involves adhesions and adhesions is basically scar tissue, but the scar tissue may be involving skin and fat, but the important ones are the ones that may be involving nerves or intestines. Those are called adhesions. You can put anti adhesives there. What does anti-adhesive do? It basically prevents scar formation. Now scars good too much scars not so good. So you want a little bit of scar, not a big scar. So even if you think of your wound, you want a well-healed wound, but you don’t want it overheating, so you get a keloid, that would be a keloid. So in terms of scar tissue related to adhesions, my world, I don’t want the Mesh to adhere to certain things. Nerves would be one of them. Spermatic cord contents which go down the test will be another one. And going down to the vessels or the third one, so the major vessels, even the bladder. So I would like to use an anti adhesive barrier in general surgery, my specialty, there’s really only one type of anti adhesive barrier, which is called seprafilm. It works really well for open surgery. It kind of worked for laparoscopic surgery. It’s kind of difficult to do. You have to make up things. And now I think they have a new laparoscopic surgery like slurry that they sell that you can use laparoscopically.
Speaker 1 (00:06:40):
I didn’t know, but I soon learned because I operate with them, I didn’t know that gynecologists have an anti-adhesive barrier, which is actually really easy to use. I don’t know why they don’t try and sell it to the general surgeons and get F D a approval to sell it to the general surgeons. But the indication is for pelvic surgery, I do pelvic surgery, so I can use it without a problem. You can pretty much use it anywhere. It doesn’t really matter. The point is I think there varies much better because easier to handle it works just as well, but it’s easier to handle. So I use this and when I have my general surgery colleagues in the operating room like, oh, what is that? And I say, oh, try this Enterocele. It’s really good. It’s made by Ethibond and they are sold by Ethibond and they just, they’re like, wow, that is so cool.
Speaker 1 (00:07:30):
We didn’t know that there is such a thing. So there are instruments and products that are marketed toward one specialty and not another. And when you have a multidisciplinary approach, you can learn some of the tips and tricks from other specialties. But I digress. The point is let’s talk about the team approach. So multidisciplinary is great. That means multiple disciplines are involved in your care to make sure you don’t get a delay in care. So do you have a gynecologic problem or urologic problem? Is this an orthopedic surgeon comes into play or is there a need for pain management and so on? So those are kind of collaborations you can do and you can, for example, today I saw a patient who may have a colorectal problem, they were sent to me for possible hernia. She’s already seeing the gynecologist and the urologists, so that’s kind of like the group that I’m with.
Speaker 1 (00:08:35):
However, the team doesn’t necessarily have to be interdisciplinary. It needs to just be a team. And the ideal team is both a team and also involves multiple disciplines. And that’s what I really like about what I do is because I do have my different specialists who understand my world and I understand their world. And so that’s why we’re a good team. And I also have a fantastic team for the hernia team. You all know about Nurse Bell. I should bring her on. Do you guys want to talk about Nurse Bell? She may be watching Nurse Bell. Do you want to come on as a guest? I kind of think you should share your story. So Nurse Bell, everyone knows she’s probably the world’s best, most qualified, most gifted, most knowledgeable nurse in hernias. She’s a hernia specialist in nursing and just amazing those of you who’ve ever called the office or been to the office, you all know Sheila.
Speaker 1 (00:09:44):
Sheila is my manager. She runs my life. She is the one who’s the patient advocate and liaison talks to all the patients and make sure you get timely care and that all your questions are answered and people deal with insurance crap and Sheila helps you through the insurance stuff and so on. So the team in the office is great. And then of course I also have Myron, many of you have spoken to Myron. He’s kind of the glue, the one that gets the scheduling through, gets you appointments, gets you to see your doctor for preoperative appointments for surgery and then gets the scheduling. And then we also have a research team. Right now Sharon is our research fellow. We had Nagin last year and the years before and Sharon started last year as well. So we have got a great research team.
Speaker 1 (00:10:45):
The reason why I say that is, for example, today I had a patient that drove up about 300 miles to see me and the doctor that he saw just wasn’t giving him the vibe that he was going to do anything special or do any special thinking in his hernia case and was treating his hernia as just a hernia. My motto hashtag, it’s not just a hernia. And so I do sit down and discuss everything you need to know about your hernia, watchful waiting, surgical options, pros and cons of each one and help answer your questions. He was told, oh, we do this. We do a thousand of these a year. It’s like the back of our hand, no problem in and out, you’ll do great. And that was just not adequate for the patient. He had no team. This surgeon, he basically sees the patient, the person in the front office doesn’t know who the patient really is, doesn’t have that kind of team mentality.
Speaker 1 (00:11:58):
Oftentimes if you’re at an institution, the people that work at the front desk are disconnected from the doctors and nurses. They have a different boss. It’s a different, different hierarchy, different leadership for the front office staff and that disconnects you. So they don’t have that feeling that they’re part of the team. Anyway, the patient felt that left the office was like, I don’t know. And then started watching a bunch of her talk episodes and understood that what we do is we promote your education and we promote your knowledge. And a hernia should not just be, oh, it’s just a hernia. You just fine. When you get disillusioned when or if something goes wrong or you have an outcome you need to reach a doctor, you can’t really reach ’em and there’s nobody part of their team that would kick in. So my point is people often travel to see a specialist because many of us true specialists do have that team. And the reason why we’re successful is because there’s a team approach. So let’s just take surgery for example. If you decide to have surgery, my team will start initially with the planning for the surgery and come up with good dates and blah, blah, blah. And that’s after I’ve already communicated my needs for the patient. To them they help as a team figure out your billing and your out-of-pocket and the surgical facility and the anesthesia and blah, blah, blah.
Speaker 1 (00:13:43):
During surgery we have a special team. So we don’t just operate on patients. And one of the reasons why I love operating in my surgery center is because I have a very dedicated team. It’s not a random person. Every time I work with the same anesthesiologist, the same nurse, I always get the same nurse in the operating room and the recovery nurse is always the same. So they understand my protocol, they understand how my patients shouldn’t get a lot of narcotics that need to urinate before they go home, shouldn’t be sent home too early, need to need to walk around.
Speaker 1 (00:14:26):
If I do a lot of local anesthetics, sometimes the leg gets weakened. So don’t just have the patient stand up, be careful about checking for the leg. It happens about 5% of the time when the leg gets weakened because of the local anesthetic. And then once that wears off it gets better. But it’s something to be wary of. The anesthesiologist as part of my team, no without me having to tell them that the patient should get anti-inflammatories for pain controls, should have minimized use of opioids and I don’t want them bucking or vomiting or coughing after surgery. So they do everything they can to prevent the patient from coughing and bucking and vomiting. Now when I go to the hospital, that team approach is not really there compared to the opportunity that I have at the surgery center. Of course they have great anesthesiologists and if you need to be in the hospital, that’s all really great and we all talk and I have residents and we collaborate, but the team is different. And I have to have a makeshift team where, okay, here’s my anesthesiologist. Everything that my anesthesiologist at the surgery center already knows because they’re part of a routine team, I will review with the new anesthesiologist. I maybe haven’t worked with them before. They’re new to the hospital, whatever the situation is.
Speaker 1 (00:15:54):
And then my residents are always part of my team. So my point is it’s always to the patient’s benefit to be cared for with this kind of team. So for example, if you call and you have a question, we know the protocol of how to handle it. If it’s a billing question goes to Sheila. If it’s a scheduling question, it goes to Myron. If it’s patient care related question, it goes to Nurse Bell, she may talk to me, I may need to be the person that handles the phone calls, et cetera. We don’t have that many what we call drop balls.
Speaker 1 (00:16:39):
And when you’re a team, everyone is focused forward and in parallel with the same mentality. So there’s no strife. I have the most amazing team, I don’t want to jinx it. We’ve been together since 2008, the best team ever, and they know exactly what I’m used to, what I need and what my patients need. So one of you just asked, why can’t your team from the surgery center follow you to the hospital? I wish they could. Multiple reasons. One is that they’re essentially employees. So an employee of the surgery center and an employee at the hospital, they’re two different sets of employees and you don’t move that way. So I move, the residents move, but the employees are part of are with their employer. So the employees at the surgery center are employed by the surgery center and the employees at the hospital are employed by the hospital. Now in my situation, the hospital owns a surgery center. So technically if they really wanted to, they can move. It just doesn’t work that way.
Speaker 1 (00:18:04):
What’s a good example? It’s like saying if you’re at this Costco, why can’t you work at the other Costco? I mean you’re just not employed by the other Costco, you’re kind of employed by Costco, but there’s a whole training and availability and so on. So I wish it were possible where people just, I could just have my own team and they could just go with me wherever I want to go, but it’s just not possible. And the more hospitals you work at, the more surgery centers you work at, the more likely it is that you’ll have broken teams, which is why I love working in our surgery center because I can do most operations here and have a very smooth team and it’s less work for me because I’m not running around trying to make sure all my protocols and algorithms are followed because they already know.
Speaker 1 (00:19:02):
So going back to the example of their patient from earlier today, they’re going to see another patient, another surgeon as well do their due diligence. I had another patient come in from a major institution, a different state, and they were a little bit disillusioned with the care there even though it’s one of the top universities in the world for patient care because there was no team, there’s no hernia team. Now they’re really amazing institution and they have research and they have cancer and other things, very well organized team approach for pancreas cancer, for colorectal surgery, but they don’t have that for hernia. And that’s one of the problems and why I’m bringing this topic up for hernia talk as alive is because if it is, because it’s very easy and common actually to have teamed approach for cancer. There are so many regulations about how to follow up with cancer patients and protocols for cancer patients and you really can’t be a cancer doctor without having the oncologist and the radiation oncologist and the surgical oncology surgeon and the specialists and all that.
Speaker 1 (00:20:37):
So they have a team, it’s part of the cancer center. You have to have a team. Most places don’t have a hernia center that is team-based. It’s like one doctor who does bariatric surgery and hernia surgery or let’s say trauma surgery and hernia surgeries. It’s not really a team approach. It’s kind of like thrown out there. We also do hernias and there are multiple different major institutions that have doctors that offer hernia surgery as most general surgeons can, but it’s not a team approach. It’s like one of those, yeah, we do hernia surgery. And so the patient was a bit disillusioned and traveled out of state to see me in order to get her questions answered and understood that I have this kind of team approach to these things.
Speaker 1 (00:21:36):
I’ll give you another example actually, before we do that, I want to be fair to the people who sent in questions. So let me go through some of the questions and see if any of them are answerable by what I’m saying. So okay, this is kind of very good. How would you compare long-term patients’ outcomes from hernia specialists who handpicked their hernia care team versus large institutions where a surgeon is not able to choose the team to work with but a multidisciplinary approach is adopted? Okay, really good question. It’s all about leadership, I would say. So you and you as a patient have no role in making sure there’s adequate leadership or appropriate leadership in any department or institution. So you do have the opportunity, however, to pick and choose which doctor and specialist and hernia care team that you want take care of you.
Speaker 1 (00:22:42):
So for example, the best example of a fantastic team is the Cleveland Clinic. So the Cleveland Clinic I believe, and I spoke with Dr. Krpata a couple of weeks ago when I was in Cleveland and learn a lot about their system and I did do Hernia Talk Live with Dr. Krpata. If you want to go back about a year, a little bit over a year, you can listen to that. I thought it was very good. So here’s the situation. Cleveland Clinic, you dedicate three hours and you are taken care of by their entire team. And that team approach may include a surgeon, a pain psychologist, a pain management specialist, a radiologist, and I believe that’s pretty much it. Don’t quote me on that, but I believe that’s it. And during that three hours you’re seen by multiple doctors and I believe the beauty of it is then those doctors collaborate together and say, okay, here is a coordinated team approach plan.
Speaker 1 (00:23:56):
It’s great. It’s a great, great system. The doctors are very caring, they love what they do, they have great outcomes. So that’s Cleveland Clinic. How did that happen? Because their leader, Dr. Rosen, Mike Rosen, who is also a prior guest on Hernia Talk Live, go listen to him. He had a great session with me, is a great leader and he understood hernia surgery and even more important, his boss, his boss had the interest to develop a hernia center. So it’s all about leadership. So start from the top. The chairman says, we would like to put resources to empower you, Dr. Rosen, to develop a hernia center. Dr. Rosen says, thank you. I want to not only develop a center and name only, but I want to make it a team-based approach for chronic pain, let’s say, because that’s something that’s hard to handle on its own. And then he did it and he hired the appropriate team and put Dr. Krpata in charge to make sure that team is functional.
Speaker 1 (00:25:19):
That’s how it works. What doesn’t work is when you go to the next state over and you think you’re being seen by specialists, you’re not. You’re being seen at a hernia center and name only where patients go for their hernias and it’s a trauma surgeon or a general surgeon that does gallbladder surgery and breast surgery and takes emergency surgery, call and takes trauma and also does hernias and has no idea about urologic problems, gynecologic problems or orthopedic problems and so on. So when you go to see them, all they can say is, yes, you have a hernia. No, you don’t have a hernia. In fact, the one patient I told you about was basically, I don’t want to say she was told she was stupid, but she was basically told whatever she’s feeling, she’s not feeling the bold she’s seeing just doesn’t exist and the problem that she has is not important.
Speaker 1 (00:26:28):
Why? Because that surgeon did not understand what the patient was having or or experienced could not come up with a diagnosis and so blame the patient instead of blaming their own lack of multidisciplinary approach. And that surgeon, that institution I should say, did not have a team approach. It was just a virtual center that if you call for hernia, they’ll go do the hernia center and whoever’s there will take care of you. And those people Don don’t necessarily have a true love and interest in hernias and therefore did not take the time and effort to develop the team to provide your needs.
Speaker 1 (00:27:15):
Okay, so the question was how would you compare long-term patient outcomes from hernia specialists who handpicked their hernia care team versus large institutions where a surgeon is not able to choose the team to work with, but they do offer a multidisciplinary approach. So the outcome is if you have a simple straightforward operation and a simple straightforward patient, most likely you’ll do fine. But if you have a complication or you’re there because you have a complication, if you don’t have the team or you’re part of some of these large institutions that don’t really have an interest in hernia, it’s just there. They have a hernia center and maybe will not have a hernia center, just have a general surgery clinic If you have a problem or complication, all they say is, I don’t know what’s going on or everything is fine, you don’t have a hernia.
Speaker 1 (00:28:21):
And that’s what I see. I see patients that are just pushed away from the office because that surgeon is unable to with a team approach, provide some insight into why the patient has this new pain or old pain or whatever. And so instead they blame the patient. It’s kind of the gaslighting, which is we had a gaslighting episode in the past. I highly encourage you to watch that, but blame the patient for imagining symptoms or downplay the severity of your symptoms or because they don’t know the answer to why you have these symptoms just kind of send you to pain management at the best.
Speaker 1 (00:29:14):
So let’s go to the next question and I think it’s maybe related. Okay, so what are the essential specialists that should be included in every hernia care team? Excellent question. Okay, so definitely a general surgeon who has a special interest in hernias and that special interest needs to be academic. You can’t be like, oh, I love hernias, I love to do hernias. And then you just do the same operation on everyone. You need to have an academic interest in hernias. Now it doesn’t mean you have to be at what we call an academic center because I consider myself academic, but I’m in a private practice, but you have to have an academic interest. That means you read, you go to meetings. At the very least you should be going to meetings. Ideally your hernias surgeon should also be studying their own outcomes and reporting their own outcomes. And then even better would be if they actually publish or give talks and or publish about their own outcomes and experiences.
Speaker 1 (00:30:27):
That way they’re learning from themselves and then they’re teaching others as well. So that’s number one. In addition, you need nurses and office staff that are dedicated to that center, not random people that come and go. So for example, there are certain institutions like a university hospital where on Mondays it’s bariatric clinic on Tuesdays, colorectal clinic, Wednesday it’s breast surgery clinic. On Friday it’s hernia clinic or general surgery clinic. And Thursday and Friday is trauma clinic. Same space, same nursing team in front office, different doctors every week, every day of the week. That’s the most common scenario. That is not a healthy scenario because the front desk person has no interest in you as a hernia patient necessarily. And the nurses are not specialized. They’re just there to take your vitals and do their administrative work without really caring about you as a hernia patient because tomorrow it’ll be like breast patients, the next day will be colorectal patients.
Speaker 1 (00:31:51):
So it’s more of a generic support team. You don’t want a generic support team. Ideally for a good hernia care team, you want to have dedicated staff. So everyone knows just call Sheila or Text Nurse Bell. In my office, it’s been the same thing since 2008. The no, I had a patient that came today who was here a long time ago, can’t eat with his wife. Now it’s for him and we’re the same people, it’s the same interests and we’re just working on improving stuff. So that implies that when you call the office for example, and you speak with Myron or Sheila, when you call my office, they don’t just book your appointment. They ask you, have you had imaging? Have you had prior surgeries? Who’s the referring doctor?
Speaker 1 (00:32:54):
Where were these operations and imaging done? Let’s get those reports. They understand there’s a lot of work to be done on the backend before you see me. Otherwise you may show up and say you’ve had five operations and six MRIs and have none of them with you because you didn’t know that you had to bring it. Or worst case scenario, you don’t even have a hernia. You have let’s say a hiatal hernia and the front desk person, my front desk person would know, oh, hiatal hernia, let us refer you to a surgeon who’s a thoracic surgeon or a foregut surgeon who does hiatal hernias. I don’t do hiatal hernias, I do abdominal wall surgery, but the word hernia is there so people think it’s a hernia. It’s more of an internal organ process.
Speaker 1 (00:33:44):
When I used to work elsewhere, these poor patients, they would take time off from work. They made the appointment for the hernia, they didn’t told all the purpose that this was a prior offices prior employment and then they show up and I’m like, I don’t do hiatal hernias or spine hernias or whatever and you should have brought all these things and they would say, if I had known I would not have taken time off from work, I would not have driven all this time this. So at the very least that’s the important part of the front office. Even the phone calls, right?
Speaker 1 (00:34:28):
So where am I going with this? That’s part of their hernia care team. So then the next question is, so that was about nurses and front office. Then the next question is other specialists. So in general you want to have your hernia surgeon specialist. Let’s assume they’re specialists. You want them to have pain doctors, urologists and gynecologists. Those are the top three. In addition, it would be nice if they had a orthopedic surgeon, pain psychologist would be great, physical therapist would be great. Pelvic floor physical therapist would be great. Sometimes a neurologist would be great. So I have all of those in my black book and because we share these different patients together, I understand a lot of those specialties and they understand me. They don’t all have to be in the office waiting for you to show up, but for me, they’re just a phone call away. I texted them today, I texted with a gynecologist and a gastroenterologist and cardiologist because the patient was on blood thinners and I need to make sure that it was okay to stop it before surgery. So super important, just pick up the phone and pick up your referring doctors or your specialist. I’ll give you example actually, I think the next question is, is a good one.
Speaker 1 (00:36:00):
One, can you make some examples where deficiencies in the hernia care team determined a less than optimal outcome for the patient despite a flawlessly performed operation by a talented hernia specialty? Yes. I’ll give you an example. It’s kind a sad example, but it’s real. So this patient had – this is the story of the patient. I’ll give you multiple stories actually, they’re all coming to my mind. So this patient had a perfectly fine hernia but continued to have bulging in the groin area and it seemed that despite the fact that the hernia repair was fine, the spermmatic cord lipoma was left behind, which is one of the brisk of this operation. As you can leave a spermatic cord lipoma, usually you take extra effort to look for those hernias and lipomas and remove them. Some people, their anatomy is such that even if you look, you miss it. So he needed this spermatic cord lipoma removed. He went to another surgeon.
Speaker 1 (00:37:15):
That surgeon is a great surgeon. I know him personally. Really great surgeon. I would consider him operating on my family members. So that surgeon screwed up, okay, it just happens. He screwed up and the patient had a complication. Now did he screw up because he is a bad surgeon? No, he’s a great surgeon, but he is screwed up because he’s a surgeon. We all have complications, I have complications, and the beauty of having a team approach is you can ask for help and you can, everyone learns from that for the next patient. Well, this surgeon doesn’t have a team, so he had no idea why the patient had chronic pain. He thought his surgery was perfect and did not offer him any imaging, did not offer him any injections and did not refer him to any specialist. Said you just have a lot of pain, everything looks fine.
Speaker 1 (00:38:29):
Go to pain management. That pain management also very good pain doctor, not part of a team, not part of the hernia team, has no idea what is done during hernia surgery and has no idea why this patient has pain as it relates to the hernia surgery, right? So if you are part of a team, you would know if this is a meshoma or a nerve damage or retained lipoma, et cetera. But if you don’t typically see these patients and you’re not part of a team that handles this, then you don’t know. So this poor guy basically got given narcotics, narcotics, narcotics, they start with injections, but of course it wasn’t a nerve issue. They kept giving him more injections and since the injections weren’t helping because of course it wasn’t a nerve issue, they just gave him more narcotics. Now he’s completely doped up on narcotics.
Speaker 1 (00:39:42):
Whereas if he were evaluated by a team, a hernia care team, which would include the surgeon who’s a specialist and talks with other surgeons and goes to meetings and conferences and shares, patients, et cetera, and a pain doctor who’s part of the team who talks with the surgeon on a regular basis and sees these patients, they would’ve known by the very small fact that the patient did not want to bend. He says, too painful to bend. He always stood. They would’ve known that he had a meshoma, which is a balled up Mesh, classic telltale. Anyone who does chronic pain, groin pain, ankle hernia, revisional cases, noses. If the Mesh is balled up, it prevents you from sitting, bending and if a patient comes into your office and they’re standing, it’s a meshoma. I don’t have to do any imaging to prove that. I mean I will, I would.
Speaker 1 (00:40:48):
But so he was never given imaging, he was never diagnosed with a meshoma, which by the way is a surgical problem, has nothing to do with nerves, and they kept focusing on the nerves and became opioid dependent, completely preventable outcome if you were seen by a team of surgeons and doctors. So yes, the question was can you make some examples where deficiencies in the hernia care team determine a less an optimal outcome for the patient despite a flawlessly performed procedure by a talented hernia special? That’s the best example I can give you because that was an unfortunate and actually very sad, very, very sad. I think about this patient a lot. I knew the situation and it should not have happened that way.
Speaker 1 (00:41:55):
I see patients that have completely treatable problems and they see me 7, 8, 12 years after the initial event and I’m just thinking like, dude, this is very treatable. But no, they kind of see people who aren’t really private team, they work in isolation. They come in the office, they see their patients, they leave. They don’t go to conferences, they don’t give talks. They don’t read as much as they should and they don’t pick up the phone and call and then one thing leads to another and then they have bad outcomes and there’s no help for them. So that’s kind of where we are with the team approach. And I would like to say that in general, hold on. Do we go through all these questions?
Speaker 1 (00:42:58):
Yeah, so in general it’s not so much. I’ll tell you I’ve worked at various different types of situations. I’m currently in private practice as a solo surgeon. However, I have worked in group practices, I’ve worked in community-based hospitals that are very academic with lots of residents and trainees. I’ve worked in county hospital, university-based settings. What I’ve learned is that if you’re your own boss like I am, I can do whatever I want with my office practice and I choose to have a team and that team follows my patients not only throughout their consultation, but we’re available twenty four seven by phone when you have surgery, nurse Bell will be there. So that’s part of my team and I have a roster of doctors and specialists both locally and throughout the United States that I can tap into to provide help for my patients. Right at that picture, did you guys see the picture that I posted along with the post about today’s session that is my chronic pelvic pain team with urologists and gynecologists. All three of us were operating on the same patient that day and it was just amazing. I love it.
Speaker 1 (00:44:31):
So I as a solo practitioner have a hundred percent of control over what I’m doing. However, having worked at these other different institutions, I understand the natural tendency is for the hospital to be run the way it’s always run, which is the front desk are some people that are unrelated to the practice itself and show up and check in patients and often it’s not a very loving and caring check-in. I’ve been to doctors myself at these institutions and people don’t even look up to look at you when they greet you. They’re just like, name, appointment time, date of birth, phone number, have a seat here, fill this form out. Very impersonal.
Speaker 1 (00:45:23):
It doesn’t have to be that way by the way. It’s just that’s the default because it’s a big institution that’s often impersonal. But every so often, like Cleveland Clinic, you’ll find an institution where from the leader on down, they have chosen a specific disease process, let’s say hernia, and they’ve chosen to make that a priority with a team-based approach and the people that are within that team are a hundred percent dedicated to hernia and a hundred percent of their time is spent treating and seeing and interacting with hernia patients. So the nurse who may be checking you in and checking your vitals and asking your medications in a hernia care team situation may be more interested to know why you’re there, how you’re feeling, what your scars look like, what’s your recovery been, how much medications you’ve been taking, and get a little bit more information than at a major institution where you’re just like the Thursday clinic person and there’s very little interaction interest in that patient care population.
Speaker 1 (00:46:49):
It’s very nice that oncology has moved away from that. So oncology and to some degree transplant those two specialties possibly because there’s a national effort to incentivize that anytime there’s a cancer center or a transplant center that there’s a team approach. So it comes from above again, but it’s extra institutional. So it’s outside the institution, but possibly because there’s already that demand externally to have a team approach. So you see nurses that are cancer specialists, right, and they understand some of your symptoms with the dry mouth or the problem swallowing or whatever it’s from the chemotherapy or for the radiation and can help commiserate with the patient and guide them a little bit instead of all they’re doing is walking you to your room and having, giving you a gown to change into. That’s not, I mean you don’t have to be an RN to do that.
Speaker 1 (00:47:52):
So that’s kind of the situation. Let’s see. Next question. Did we go over this already? What are the essential, I went backwards. Oh, can complex hernia, patients who have had multiple revision surgeries need lifelong follow-up by a competent team who is trained in the prevention and early diagnosis of all kinds of hernia related issues, including, for example, core instability problems or occult hernia occurrence. Yes, very good point. So for example, let’s say 10 years ago you had this complete abdominal wall reconstruction or you had Mesh removed or you had a revisional operation where you fall into this complex hernia patient category and you did just fine, but then you were in a car crash, you had COVID and you were coughing for a long time. You gained weight, lost weight, had a hysterectomy or colon surgery. In the meantime, if you forget about your past and just move forward with just a regular generalist, they may not know what’s going, oh, I have the perfect patient for you for that.
Speaker 1 (00:49:14):
Oh, let me share you this story. This is going to be great. So this is a recent situation. I had a patient who had a tummy tuck. This is classic. She had tummy tuck. I’m going to say I don’t remember the exact dates, but I’m going to say let’s say 15 years ago. Okay, 15 years ago she had a tummy tuck, no issues, happy as clam, just great. She’d had multiple operations prior to that. Just in her internal organs. We know we talked about scars and adhesions. So from that she had a bowel obstruction and it happens. You can get intestinal obstruction if you had prior abdominal surgery. Unfortunately, her bowel obstruction happened a year after her tummy tuck and they cut through the tummy tuck to operate on her and they sewed her back up. Ever since then, let’s say 15, 16 years, ever since then she’s had chronic abdominal pain, pain. No one can figure it out. She’s had endoscopy, colonoscopy, diet changes, allergy testing, CAT scan, MRI, ultrasound gastroenterologists saw her. They did a food allergy testing. They did upper GI studies, lower GI studies. They took out her appendix, they took out her gallbladder. Their uterus was already out. What else can they take out? They did another operation for adhesions thinking maybe that’s what it was. She didn’t have adhesions that much. They did some ligament release. They, what else? They do?
Speaker 1 (00:51:11):
Nerve blocks, lots of nerve blocks, Botox injections, just a lot. It was a lot. Just think over 50. Then she was given opioids, she was given nerve pain medications. She was told it’s all in her head. She put a psychiatrist that she was told there’s nothing wrong with her. Anyway, so ladies and gentlemen, you got to go back to the story. She had a tummy tuck. She said just fine. Then she had this open operation through her tummy tuck and then she was in pain ever since then. I mean you couldn’t touch her belly. She’s in so much pain and they finally said, we don’t know what’s wrong with you. What she should have done, let’s go back to her tummy tuck surgeon or understand this was an abdominal wall thing. Let’s say it wasn’t a tummy tuck. Let’s say it was an abdominal wall reconstruction and they had to go through that and then she’s got the chronic pain.
Speaker 1 (00:52:18):
If you go back to your hernia surgeon who did the original operation and they have a team approach, they may be able to find out that, you know what, this is not a GI problem. It’s not your pancreas or your intestines or your liver or any ligaments or stuff. This is all related to your abdominal wall and how it was sewn back up. And each time people go through the abdominal wall where her pain is to figure out what’s, if there’s anything going on inside, not understanding that the actual problem is her abdominal wall. Basically if you’ve had a tummy tuck, you have to be very careful about future operations because those surges may disrupt your tummy tuck and that can induce not only a cosmetic outcome that looks ugly, but also it’ll disrupt your abdominal wall and cause chronic pain. And that’s what happened.
Speaker 1 (00:53:25):
Her and I fixed the patient. My point is, oh, the doctor that who sent her to me, oh, one of the GI doctors, I believe that’s who sent it to me. One of the GI doctors is part of my team is like about this. This is something that tophi should be able to figure out. And I did because I listened to her story. It’s all about the story. But my point is, yes, if you are part of a team and he was part of my team, we can say, oh, I’ve seen this before. I know who you can go to and you can refer.
Speaker 1 (00:54:06):
Whereas if you just work in isolation and so on, it wouldn’t have been, she would’ve just resigned to the fact that she has to live with this abdominal pain for the rest of her life. Okay, here’s another question. What are your views on the American Hernia Society suggesting introducing an extra area specialty for complex hernia repairs? Well, I think it’s great for multiple reasons. One is it justifies the fact that there are specialists among us who are real. And we’re not just using hernia as a marketing ploy. There are literally centers around me that call themselves or the hernia center and in the same office, if you Google them, there are also a gallbladder center. They’re also a plastic surgery center. It’s crazy. Well, what are you, are you just a specialist in all of these or are you just a general surgeon that provides all these services and you’re using those as marketing tools to grab the attention of Google Searchers?
Speaker 2 (00:55:16):
Also,
Speaker 1 (00:55:16):
Usually when you have a designation of a specialty, it comes with minimum requirements. Right now, there’s no minimum requirement for anyone to call themselves a hernia specialist or a hernia doctor or anything because it’s considered all part of general surgery. And therefore what can happen is anyone can call themselves. In fact, one of my patients is going to go see a doctor and he said on their website, he claims to have done 20,000, 2000 or 20,000 hernia repairs. I think 2000, which is a lot, but fine. And in his website he says he has the best outcome of any surgeon in the entire United States. Okay, how did they come up with that? I don’t know who this person is.
Speaker 1 (00:56:17):
I mean, I know everyone that is in the hernia world how I know the best hernia surgeon in the world. You’d think I would know them being in the hernia world. So there’s no accountability based on what, whereas if you do develop a specialty for complex hernia repairs, there’s a minimum requirement. You have to see this many patients, you have to have a team and they’ll define the team. You have to have a pain doctor, you have to have whatever. They’re going to come up with a team and then they’re going to say, you need to see this many patients of this variety. You have to be able to offer a laparoscopic robotic open tissue, non tissue. They’ll come up with some type of requirement.
Speaker 1 (00:57:12):
You have to follow your outcomes and your outcomes have to follow a certain category. You can’t just say you’re the best doctor in the world without backing it up with data. You have to do research, you have to present it at meetings, et cetera. So this is actually a great question because I talked about earlier about cancer and transplant. They are both specialties and they both are heavily team-based approaches and you can’t have a cancer center or a transplant center without meeting certain requirements. And we don’t have that right now for hernias. And I’m hopeful that the same way a cancer center has to have a research team, a nursing team, various specialists in oncology, whether it’s medical, radiation, surgical, and they have to follow their outcomes and they have to follow their patients for life. Life. A similar thing will hopefully happen with hernias where doctors are then held accountable for this designation of a complex hernia repair.
Speaker 1 (00:58:34):
I think I’m a hernia specialist. Most people consider me a hernia specialist. I don’t know if I don’t really have haters or be like, ah, she’s not a specialist. I do offer all those options, but even within our hierarchy, some people think they’re better than others and that’s just the surgical ego. But if you actually develop a hernia specialty designation that you can apply for or fall into, there’s some minimum. So for example, the European Board of Surgery has abdominal wall reconstruction specialty that you can, it’s like you have to be able to provide your caseload to show you do so many cases, and then you have to answer, do a formal exam and pass it at a certain level and then you have to have an oral questionnaire section every year. When I go to the European Hernia Society, I participate on the oral boards part of it, and that’s because I have that designation. I am boarded by the European Board of Surgery. I’m a fellow of the European Board of Surgery in the abdominal wall reconstruction level. It’s kind of what they do in Europe. We don’t have that in the United States. We just have American Board of Surgery. So I am board certified in general surgery, but there’s no separate hernia designation. So I’m really excited because there is discussion about that. It doesn’t mean you can’t do hernias as a general surgeon. You just don’t have the additional designation for complex hernia repairs and therefore, therefore, hopefully.
Speaker 1 (01:00:34):
Therefore, what that implies is that when you as a patient go to see a doctor and you have a complex hernia, and that will be defined, usually it’s like loss of domain, multiply, recurrent Mesh complications, nerve complications, maybe morbidly obese, then maybe don’t go to a general surgeon, go to one of these doctors that are taking the time, effort, and care to get that complex hernia specialty designation. On that note, let’s finish up today’s Hernia Talk Live. Thanks everyone. Go watch this in the future, sorry. And past episodes on YouTube or listen on my podcast, Hernia Talk Live. Thanks everyone for joining me on Facebook, Instagram, Twitter, X at hernia doc and Facebook at Dr. Towfigh. And next week I will be in Boston. We have the Annual Clinical Congress of the American College of Surgeons. I’m going to be teaching a course and giving a talk. So I’ll be in Boston. I’ll be live tweeting from that meeting. So if you don’t already follow me on Twitter. Every time I go to a meeting, I live tweet from it so that I can express to you everything that I learned. So go to at hernia doc on Twitter, follow me and you’ll see what I’m doing next week. So there’ll be no Hernia Talk Live next week because I’ll be in Boston and I’ll see you that following week. And until then, peace. I hope to see you soon.
