Diving Into General Surgery With A Hernia Repair Specialist

Session 170

Dr. Shirin Towfigh is a female general surgeon and hernia repair specialist. She talks about the importance of female surgeons and what she loves about hernia surgery. Follow Shirin on Twitter and Instagram. And if you want some more information about hernia surgery, go to AmericasHerniaSociety.org.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:14] Interest in Hernia Surgery

Shirin considers herself being late in the act. She was a third-year medical student and surgery being her second to the last rotation. Because all she wanted was internal medicine to be her last rotation. She had planned on getting into the best internal medicine specialty residency program because she wanted to be a nephrologist.

Back in undergrad, she met a nephrologist whom she looked up to. Then she loved her surgery rotation at UC San Diego. She felt like she was a valuable member of the team. Her intern quit so she was the default intern as a third year. Her chief was really difficult so she tried really hard to please him.

She really wanted to be a nephrologist. Unfortunately, she did her internal medicine rotation already. And having had a taste of surgery, and it just didn’t compare for her. So she ended up being a surgeon.

[03:12] As a Female in a Male-Dominated Field

'The more we have female surgeons in the specialties, the more we can serve as mentors and role models for all different types of students.'Click To Tweet

Shirin didn’t really have any female mentors. But her family was very supportive and they were fine with whatever field she wanted to get into. It wasn’t really an issue in her family. But her mom hearing about things she would ask Shirin if she’d consider getting into a more “feminine” field like pediatrics.

Throughout her career, there were issues like leaving her first job because the glass ceiling was super low. And now being on her third job, she felt it was the best ever because now she’s her own boss. There’s no other person preventing her from doing what she wanted to do.

[05:32] Her Journey into Hernia Surgery

'Hernia surgery is not something most surgeons go into, especially female surgeons. It's the urology of general surgery.'Click To Tweet

Shirin initially didn’t consider being a hernia surgeon when she was in training and she didn’t really understand hernia surgery very well at that time. So this made her a little uncomfortable.

Her first job was at the big County Hospital in Los Angeles, one of the biggest in the U.S., if not the world. And her first patient was a mesh infection that kept getting bounced from GYN clinic to General Surgery Clinic and back and not really getting treatment. So she just jumped in and took care of her as her first patient. And she did great.

Then she got involved with the American Hernia Society and showed up at their meeting. And they were so gracious and so grateful to have new members because it was a small society of mostly elderly men. And they were just really supportive.

She loved it because everything she learned about hernia surgery, they debunked and she felt like she was learning something new. Slowly, she then became less of an acute care type of general surgeon and more of a hernia specialist. Now in her own solo practice, she has dedicated 100% of her time to take care of hernia problems, as well as all her research is hernia-based.

[07:45] Biggest Myths or Misconceptions Around Hernia Surgery

'It's not just a hernia.'Click To Tweet

One of the problems is that people think “it’s just a hernia.” And so it’s not given the time and effort and respect that hernia surgery needs. And this is one of the reasons she feels there are a lot of patients hurt by hernia surgery, whether they have nerve injuries or mesh problems. The surgeons may not be aware of the newest treatments and newest technologies as well as the importance of technique. And so, they treat it as “just a hernia.”

It’s not just a hernia. Therefore, it should be treated with the same respect as colon cancer, breast cancer, pancreatic surgery, and heart surgery.

If you go to an expert, as with any other specialty operation, the experts’ outcomes are much better. That’s why people think it’s just a hernia surgery. They don’t do their research, or the surgeon doesn’t necessarily tailor their surgery to the needs of that patient. And so, some people may have bad outcomes.

Secondly, as a female surgeon, there are very few of them in the hernia surgery field. So she ends up seeing many more women than usual. Shirin also learned that women are completely different than men when it comes to hernias. They present differently, they have different symptoms, and they don’t even have a bulge most of the time. So they get the runaround of different diagnoses and not hernia diagnosis. This is one of her main research projects, which is to debunk the treatment of hernias among women.

The New York Times did an article with her about one of her patients back in 2011. And she still has patients coming to see her based on that one article because they read it and they say, they felt they were reading about themselves.

[11:01] How Hernias Present in Women vs. Men

Women present differently. They don’t have a bulge necessarily, but they have groin pain. And they’re most more likely to have pain with menses, but it’s not endometriosis. They are more likely present with pain than the bulge. Whereas men have a bulge, and then they may get pain. And their symptoms are very different.

“Because the symptoms are so different, women get much delayed in their diagnosis by over a year.'Click To Tweet

Because the symptoms are so different, women get much delayed in their diagnosis by over a year. And they’re more likely to be given narcotics and opioids than men before they get the definitive diagnosis. They’re labeled with chronic pelvic pain, which means nothing. It just means you have pain. And so, they fall into this and people think it’s all in their head or they have hysteria.

[13:03] What is a Hernia?

A hernia is a hole. That hole is either man-made either as a result from surgery or you were born with it, like a belly button. And that hole should not be there. Or maybe it was there naturally and just got bigger.

Then that hole in the muscle can then have things go through it. It’s usually fat, but sometimes intestines. And so they worry if there’s an intestine stuck, or there’s a need for emergency surgery because something is stuck in that hole.

Fortunately, the majority of the time, it just causes either no symptoms or pain, and it’s not an emergency. However, you have to fix that hole.

It can be done in different ways and there are consequences for the different choices. Whether it’s mesh, no mesh laparoscopic, open. Each option has its own kind of cadre of complications. And that’s what Shirin does is to cut the complications. 80% of what she does is revisional, meaning she’s not the first surgeon who operates on the patient. And then the other 20% are primary patients. A lot of them are women with undiagnosed hernias as a cause of their pelvic pain.

[14:45] Typical Day and Taking Calls

Shirin has a research student that works full-time with her and a resident that does research with her. So they come in and out of the office, and she gets to hang out with young people. She also has a nurse who is awesome. Shirin then sees patients about two to three days a week and she operates two to three days a week.

She used to take calls when was still part of an institution. But she no longer does that now that she’s in private practice. However, she’s always available for her patients 24/7. That being said, it’s not very onerous at all, but she’s available all the time for her own patients. And if they end up having emergency needs, she’s available.

[16:56] Hitting the Glass Ceiling

Shirin wrote a chapter in the book by Dr. Dana Telem called Diversity, Equality, and Inclusion that is going to be released soon. And it’s a book written to help people manage their careers. And in that chapter, Shirin shared a lot of details of what she went through.

When you graduate from residency, you have this ideal of what your job will be like. It’s probably like what you’ve seen in your own professors so you want to be just like them. And the reality is you will change your job, and on average, three jobs. And that’s normal. Plus, you want to also feel like you’re a valuable person to your place of employment. You want to get appropriately praised for what you do, and also that you get paid appropriately.

For Shirin, payment was important. But she also mostly wanted to just to be acknowledged for the amount of work she put in.

“Most people will not stay on their first job. And as you grow older, your values change.”Click To Tweet

In her first job as an associate professor, she wanted to be Chairman or Dean one day, but she was at a position where she felt her Chairman didn’t support her in her career ambitions. And she couldn’t allow anyone to actively affect her career trajectory so she left her first job.

In her second job, she grew out of it because she was doing everything in her power to do what she was hired for as a surgical educator to run programs and to build her practice. She became the busiest general surgeon but it still wasn’t good enough.

But as a general surgeon, especially as a hernia surgeon, she couldn’t bring in the numbers that, for instance, a transplant surgeon was bringing in. She felt happy with what she was doing, but it was just never good enough for the needs of the department.

'There's only so much an institution can offer you. And when you're your own boss, it's risky. But it's also so gratifying.'Click To Tweet

Now that she’s her own boss, she goes to meetings. No one asks her why she’s out of town. She gets to give talks. And no one says she needs to see 10 patients a day. In other words, she loves the autonomy that she has now, with no one badgering her. And it took her 12 years to gain the prominence to be able to sustain her own practice.

[21:04] Life Outside of Medicine

Originally from doing 9-5, they’re now open from 8-4. So traffic is much better and they’re able to see more patients in the morning before work. So they start earlier and leave earlier. Shirin says she definitely has 100% control over her schedule so everything works out really well.

Shirin had two spine surgeries within a matter of 13 months. And her mom called the office and said Shirin can’t work these hours anymore. Because she used to work Saturdays if she had surgeries backed up. So her mom called the office telling them that Shirin needs to be off on Fridays. It was something she fought so much because it was against her personality. It’s been three years now where she doesn’t operate on Fridays sometimes. So it’s the one day of the week that she gets to have her day off. And she loves it!

'As a surgeon to take time off for yourself, that's not heard of.'Click To Tweet

Shirin is turning 50 in a year so she says she also has to think about what happens one day when she wants to retire. She doesn’t want to be that surgeon who’s 80 years old or 75 years old and still operating. She has a lot more things she wants to do with her life like inventing products and education and so on.

She did try to hire a physician assistant to at least decompress her for some of the post op work. But the patients didn’t want to be seen by the physician assistant as they wanted to be seen by her. So that didn’t work out. She’s been looking to hire someone to join her practice but she needs to find someone she can trust who can also represent her and who gets along with patients and her team.

[25:24] Path to Becoming a Hernia Specialist

Anyone who is trained in general surgery can choose to focus their time and effort to hernia surgery. There’s no other official training pathway.

A lot of the MRIs or minimally invasive surgery fellowships can be hernia-heavy. And so, if you’re interested in hernia surgery, you can do a mass fellowship, where you’re doing a lot of laparoscopic or robotic surgery. But a large proportion of it is abdominal wall-based.

There are a couple of abdominal wall hernia fellowships that are not yet accredited, but they’re very good. They’re with other surgeons mostly on the East Coast and they have a fellowship as part of it, which just comes with a certificate. And there’s no society or council that oversees it yet.

With that said, as a society, they’re looking towards having an official hernia surgery fellowship because it’s becoming more popular. In fact, every fellow that she has graduated within the past couple years have all gotten hernia-based jobs in really top notch institutions because of their experience.

“Our society has grown stronger and hospitals are seeing the need for it. More jobs are looking for people that are interested in hernia surgery.”Click To Tweet

[27:37] Opportunities for Subspecialization

Shirin explains that there’s no official designation. There are surgeons that only do open surgery. But all they do is hernia surgery but only open. There are surgeons that do primarily robotic laparoscopic surgery, and actually don’t even know how to do a tissue repair. As a society, they have not really defined what it means to be a hernia expert.

Around her block alone, there are about 10 hernia centers, and it’s mostly a marketing decision there. They also probably have a gallbladder center and a breast center, but it doesn’t mean necessarily that they are in any way officially recognized by any society.

[29:03] Message to DO Students and Future Primary Care Doctors

They’re actually seeing more and more of DOs in the general surgery. But as of 2020, it’s a single accreditation now. As long as you’re a good candidate, then she doesn’t see much of a difference as to what happens once you’re done with your residency.

Her message to primary care doctors is to definitely recognize hernia as a cause of symptoms. And there are people like Shirin who are there who can treat the complications.

So if a patient is really not getting the care they need to, they can find them either online or on AmericasHerniaSociety.org. Just go to Find a Surgeon tab to find and refer.

What she doesn’t like is when people are sent to pain management when their primary problem can be surgical. She often sees people getting CAT-scan-after-CAT-scan. And that’s really unnecessary for most hernias, and probably not the best for groin hernias anyway. So you don’t have to do a full workup. Just send them to your local general surgeon or hernia surgery specialist and they should be able to take care of that for them.

'A lot of pain doctors are not aware of what happens with hernia problems.'Click To Tweet

[31:16] Other Specialties They Work the Closest With

Her hernia center is multi-specialty. She works closely with gynecology, orthopedic surgery, spine surgery, urology, pain management, physical therapy. They’re all part of her world.

She also does a lot of combination operations with plastic surgery, urology,gynecology, where they may have endometriosis, and a hernia or their bladder stuck to their mesh. And so she works with these specialists together.

[32:35] Most and Least Liked Things

She enjoys the fact that she treats mostly healthy patients, and they’re not terribly ill. And that she can significantly improve their quality of life.

She also loves being able to have the time and interest to sit down with patients and figure out their problem. And they’ll have like a million-dollar workup and all these things, and no one can figure out what their problem is. And then she’s able to figure out what they have. And it could be something totally esoteric. So she loves to be able to do all the mystery puzzle solving part of it.

What she likes the least probably is how some people think being in private practice as less glamorous. She does love her job even though in the eyes of many, it’s like a step-down because you went from the hierarchy of a surgical institution to your beautiful private practice. And for ther, the fact that she’s her own boss is just priceless.

'When you're in private practice, a lot of those labels and titles are gone.'Click To Tweet

[36:53] Major Changes Coming Into the Field of Hernia Surgery

Robotic surgery wasn’t intended to be something for hernia surgeons. It was really for urology and some of the other specialties like colorectal surgery where the robot added a lot of benefit. And then all of a sudden, some really innovative surgeons started using it for hernias.

Now, they’re doing things they thought could only be done open because you can’t do it laparoscopically because it was too complicated. And now you can do it robotically. And that has really improved patient outcomes.

'Robotic surgery has completely changed the world of hernia surgery.'Click To Tweet

They’re also going backwards as they’re really understanding the benefits of some of the original operations done in the 60s, 70s, and late 50s, where it was tissue-based. Mesh is very overused in the United States, and so they’re getting a lot of mesh-related complications that can be avoided in certain patients where maybe a tissue repair would have been just as good.

So they’re moving forward with robotics. And in some ways, they have to go backwards a little bit and learn better tissue repairs.

[38:21] Final Words of Wisdom

If she had to do it all over again, Shirin would still be a hernia specialist. Finally, she wishes to tell students listening to this who might be interested in hernia surgery that things will probably change. There was no such thing as hernia surgery specialty when she was in training. So you really have to keep your options open.

'Keep your options always open. You really cannot predict your future and always be open for change.'Click To Tweet

Shirin didn’t want to be a surgeon before the end of medical school, but she became one. She definitely didn’t like hernia surgery, and then she became one. She thought she’d be a future chairman and she booed people in private practice. And now, she’s in private practice.