168. When Is It Malpractice?

This week, the topic of discussion was:
-Malpractice
-Lawsuit
-Standard of Care
-Class Action Lawsuit
-Mesh
-Complications
-Bad Outcome
-Unhappy Patients

Welcome to HerniaTalk LIVE, a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh: +1-310-358-5020, info@beverlyhillsherniacenter.com.

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Transcript

Speaker 1 (00:00:12):

All right. Hello everyone. It’s Dr. Towfigh. Thanks for your patience. How are y’all doing? Thanks for joining me on Honey Talk Live. I am your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist at the Beverly Hills Hernia Center. We are joining here every week as our live webinar, zoom and soon to be on YouTube. And then podcast. You can join with me right now on Facebook at Dr. Towfigh and also on Zoom. So thanks for all of you that are already logged in and as always, this will be on my YouTube channel. So do subscribe to at hernia doc on YouTube and every week you’ll be notified when these episodes get loaded up. Thanks also to people who enjoy X or Instagram, and I posted some cute little stories lately on that, so I hope that’s all helpful to you as well and you enjoy it.

Speaker 1 (00:01:13):

So today’s episode is going to be kind of a unique one. Obviously I’m not a lawyer, so don’t take any of what I say as the law or anything specifically highly specialized. But I’ve had recently, and I tell you, I usually am inspired by my patients when I pick topics, but I basically have had a couple of patients recently that have had complications and they’ve come to me to get it fixed. Now what you understand is that I’m always the fixer surgeon. Most of my patients, over 80% are revisional situations and by default, the majority, 80% of my patients are from the revisional aspects. So they’ve had a prior surgery and it’s been complicated now, they could have been 20 years ago, it could have been two weeks ago where they had this surgery. So anyway, long story short, many patients ask me, what do you think? Do you think this was malpractice?

Speaker 1 (00:02:28):

They ask me about lawsuits and so on, and I assume if they’re asking me this question that many of you all are also considering this as a question, and it’s one of those things where we know malpractice is out there. The US has a pretty strong history of medical malpractice. Most European and countries are not very heavily into malpractice. a lot of socialized medicine countries, I don’t think they even allow medical malpractice. You don’t really have rights from what I understand. You just kind of suck it up or you take into your own hands. I know there are some countries where there’s no medical malpractice, they’ll just come after you. I’ve heard stories of doctors where in second and third world countries where let’s say the patient’s family felt there was some malpractice, so they’ll just come after you. It’s like a personal thing. They don’t take it to the courts.

Speaker 1 (00:03:34):

The courts don’t consider that something of interest. You basically, they may accost you to the hospital. I’ve literally heard stories about this. I had one doctor who they told him the patient’s coming after you. So he kind of dressed up really quickly as the janitors started washing the floors, kind of hiding from patients that came after him. So that’s kind of second third world situation. Usually in the United States, we often fight our battles into the court system and there are different types of medical malpractice reforms per each of the different United States. California has one of the more favorable situations for physicians allowing them to not practice as much defensive medicine as other states, which I think is a good thing overall for patients. And I’ll explain to you why, because lately there’s been a lot of malpractice issues in the news. As a hernia surgeon, I’m very well aware of medical malpractice lawsuits. There are individual lawsuits where the patient suits the surgeon, and of course there are all these class action lawsuits and MDR where they are suing.

Speaker 1 (00:05:16):

A group of plaintiffs are getting together with a ligation firm and suing either the doctors or actually even the industry. So that’s kind of the United States way of doing it. But they come to me and they’re like, well, what do you think? Do you think this is malpractice or should we sue? Do you think we should sue? And I personally having been through lawsuits on both ends, and I personally am not a fan of promoting patients to file lawsuits because it’s a very difficult kind of time and I would much more preferred the patient focus on themselves getting better. So I have seen patients that really need medical help that are just so focused on the potential malpractice or the poor care or the poor outcome or the chronic pain or the recurrence that they had that instead of focusing that attention to getting better, they’re just wound up in filing a lawsuit and fighting the court.

Speaker 1 (00:06:39):

And it’s not straightforward. It takes years. It could take four or five or more years of your life and it’s emotionally, I don’t think it’s the right thing for most patients to go through. Lawsuits are not meant for the average patient. It’s a horrible experience. I think for a patient to go through a lawsuit, it’s a horrible thing for a physician to go through a lawsuit. It’s just stressful on all ends. I think only lawyers appreciate lawsuits because that’s their world, and it was joking with a friend of mine who is a lawyer and to lawyers, they don’t think it’s that big a deal as much as it is to us non-lawyers to deal with the court system. And I think it’s the same as maybe it would be, let’s say for a surgeon versus non-surgeons. I don’t consider surgery. I consider surgery a big deal, but not that big a deal compared to let’s say a non aeon, let’s say a lawyer, maybe a lawyer would be like, oh, I need surgery.

Speaker 1 (00:07:49):

It’s a big deal. I don’t know. Let me think about it. Whereas to me, I’d be like, yeah, it’s very clearly you need surgery for this problem, just go have surgery. So I think perspective is important and I personally feel the stress on any part, but we’re here specifically talking about patients, stress on patients. To find a lawyer, figure out the claims, follow up with a lawyer, make sure you’re heard, get into the whole nitty gritty of back and forth paperwork and court systems and then each side fights each other and then how do you pay for it and things like that. Depositions and expert witnesses and discovery and interrogatories. It’s complicated, at least in the United States system. It’s not like, I don’t know if you guys remember people’s court. You file your forms and you show up in people’s court and as long as you have evidence, it’s like within the first 15 minutes to half an hour they figure out what’s wrong and there’s a verdict.

Speaker 1 (00:08:58):

It’s not like that. It’s not like that. And in most situations the patient loses, then they get even more pissed off and angry or best case scenario, they win, but whatever they win it is just not worth the four or five years. The amount is usually not worth the four or five years of anguish. So here’s a question that says, is it malpractice when you’re not completely informed of mesh problems? I simply signed a consent form regarding two to 3% of chronic pain here in France. I was not told it could hardly be removed in case of a problem. The complications I have including sexual digestive and overall sickness and the complications I have do not cover this. Are these statistics realistic plus recent studies about mesh implant illness, rejection syndrome we owe you. So that’s not malpractice. The surgeon is not liable to tell you every single complication in the world, including death. I don’t talk about death. Is it possible for someone to die of an inguinal hernia repair? Yes, it’s not 1%. It’s probably a 0.0001%. But then if a patient dies, can they say, oh, you didn’t tell me I had a risk of death. If I knew my parent, let’s say may die, I would never have consented to surgery.

Speaker 1 (00:10:37):

You can’t consent. For every single detail complication we usually present, we usually present the most likely complications, review, the recovery, et cetera, and then we review maybe some egregious complications, but the majority of people are not going to get a lot of complications even with hernias, even with meshes, no matter what. People that are trolling me on YouTube want to comment on, so I had someone that said the majority of patients have complications or hernias, absolutely not true. It’s just not true. There’s absolutely no data to support that. The majority of patients that have surgery have complications from hernia surgery. If that were true, we would not be doing elective hernia surgery. There is absolutely no elective surgery ever done ever, whether it’s brain, heart, lung, whatever, where the majority of patients have complications, we just don’t do that. We just have to find a better way of operating.

Speaker 1 (00:11:46):

So surgeons don’t really nilly operate if the outcome is going to be poor. So that kind of misinformation is not healthy. And it was a post on YouTube, one of my YouTube videos a couple nights ago, and I’m like, that’s just so wrong. Do you feel like there’s a majority of patients? You may feel like it, but that’s not the fact anyway. So no, just because you had a complication and it wasn’t part of the informed consent does not mean that there was malpractice. And we can go into the definition of malpractice, which is a little bit different probably with each country.

Speaker 1 (00:12:33):

Here’s some more questions. Oh, great. a lot of questions from you guys would a conservative, okay, these are not related to malpractice. Let’s get to questions that are related to malpractice. So the definition of malpractice, I believe is something in the realm of with a typical surgeon out in the community have made the same choice or done the same operation, understanding that this is all in retrospect, right? So let’s say you had a Hernia repair and then the Hernia recurred two weeks later, right? That’s considered a bad outcome. It’s okay to have hernias recur. It’s greater than 0%. So a hernia recurrence in and of itself cannot be a malpractice, right? However, the patient’s going to be pissed off, unhappy, why? I literally just had surgery two weeks ago. Now it’s back again within two weeks. That must be malpractice. Not necessarily did the surgeon do everything in their possible talent to fix the hernia and it recurred despite the hernia recurrence.

Speaker 1 (00:13:55):

That’s the argument. You have to argue that the surgeon did completely wrong operation, like put the Mesh backwards or chose a mesh Mesh that is inappropriate for that kind of Hernia or chose a technique that is clearly inappropriate in that situation and outside what we call standard of care. So things have to fall within what we call standard of care, and the standard is usually set by the community or the local kind of average surgeon. We don’t set the standard very high. So what I say on this show for example, is not necessarily standard of care. I would love it to be standard of care. I follow certain dictum based on my experience and then just having had research on things and so on that I feel for example, that a super thin female with rheumatoid arthritis should not get a mesh repair of their Anglo hernia if they are otherwise a good candidate for tissue repair.

Speaker 1 (00:15:05):

Is that considered standard of care? No. Do I feel that’s the best option for the patient? Yes. Can I be sued for providing a non Mesh repair to a patient that I feel is a better candidate with tissue repair? No, because it’s within the standard to offer a mesh repair, non mesh repair, et cetera. It’s within the standard. I’m not making up some technique that no one’s knew about, but it’s also not wrong to do the opposite. So this is where you get to the nitty gritty, and I feel that a lot of people that are interested in suing or considered there’s been malpractice. a lot of those people are just angry, and if they weren’t so angry and they could kind of disconnect themselves from the complication, they would see objectively that mistakes happen. Car accidents happen. Does it mean you’re a bad driver if you’re in a car accident?

Speaker 1 (00:16:16):

Not necessarily. It happens. You can fall and trip. Does that mean you’re a bad walker? No problems happen. Can bust a button on your shirt? Does that mean that was poorly manufactured short? Not necessarily. When you’re running with a pencil, for those of you that still remember what a pencil is like and the tip breaks, is that a poorly manufactured pencil? Unlikely. There’s millions of these pencils that are made and a fraction of them, the tip will break when it’s medical and operational is performed on you. Sometimes the patient takes a bad outcome very poorly and then immediately takes that anger onto the surgeon and take it from me. It’s not healthy and it doesn’t make you better. No lawsuit will make that hernia recurrence or that chronic pain better, and therefore I always recommend that you just focus on finding the right doctor and getting better and do not focus at all on suing or getting lawyers and so on and wasting your time because it is just not worth it. I think having seen patients go through it, it just overwhelms your whole day and your whole body and so on, and I just think it’s too much. Here’s a question. Let’s see.

Speaker 1 (00:18:07):

The surgeon I had has not been willing to address my problems since surgery and referred me to other doctors who don’t seem to want to say that there may have been a mistake or deal with the problems that were possibly caused by my surgery. Is there not any policy that requires doctors to be honest and accountable if they made a mistake? Also, is a missed hernia concern concerned a mistake? So that’s actually a very good question. So sometimes I feel that if there’s been a complication, the surgeon also reacts to it. So if I have a complication, I don’t feel good about it. In fact, I get stressed out and I think about it and the whole situation goes on my mind. Then I worry about the patient. How am I going to handle it with a patient? You’re right. The best is to be honest with the patient, and there is I think a lot, at least in California that says saying I’m sorry, is not allowed as a excuse for medical malpractice claims.

Speaker 1 (00:19:13):

In other words, showing empathy to the patient for their poor outcome is encouraged and patients doctors should be encouraged to say they’re sorry and be empathic with their patient. And that alone, I think it’s called the Say sorry or say, I’m sorry, act, just saying I’m sorry, is not like a guilty. It’s not a demonstration of guilty conscience or being guilty of performing a mistake. In fact, it shows that you care and showing caring with the patient and helping them through the process. I think it’s a good thing. Now, my personality is very different from other friends of mine who are surgeons and other surgeons in the nation. So some surgeons are very uncomfortable in general, very uncomfortable in general with patients. They’re just awkward. A very large proportion of surgeons are just awkward people, number one. Number two, if you now take this generalization that we’re kind of socially awkward people, otherwise we would’ve done something that involves more kind of patient involvement, patient interaction, then you add on to that, let’s say complication, then at the end of the day, surgeons are not perfect and our personalities are also not perfect, and the way we handle things are also not perfect.

Speaker 1 (00:20:55):

So when we then get this added stress and surgery is a very stressful job because added stress of a complication in a patient, then our reaction to it also may not be perfect. So one doctor’s reaction may be, I don’t know. I don’t know what’s going on. Go see a pain management doctor. The fact that they referred you to another doctor implies one of two things. Either they don’t know what’s going on or they’re unwilling to or uncomfortable taking care of the situation. Either way, you don’t want care by that doctor if you think that they’re not able to take it on. So don’t force your original doctor to take ownership of a problem if they don’t know how to deal with it and they don’t know how to fix it.

Speaker 1 (00:21:45):

But it’s good that they refer to other doctors and maybe use that as a means to find the right doctor and the right specialist to take care of your problem. Going back to the first question about mesh removal and not being informed that nearly impossible to remove the mesh, it’s not true that it’s nearly impossible to remove meshes. I have yet to have a mesh that I have not been able to remove, knock on wood. So the fact that you’ve been given that kind of advice may also not be true, and it’s kind of leading you to believe that why he put mesh in me, if he couldn’t remove it, why was I told to agree to mesh? If there’s a problem with it, it’s nearly impossible to remove it. It’s completely possible to remove it. So don’t let that specific discussion point taint you.

Speaker 1 (00:22:46):

Also, the question was, is a missed hernia considered a mistake? It’s not. We can miss hernias. That’s not considered malpractice. So just because you had a poor outcome or a missed outcome does not mean that there has been malpractice. So for example, in a car accident, if a car hits me and it just happened, right? They thought they saw me, they didn’t see me, I made a fast turn in front of them, they didn’t expect whatever that can happen. If the cars intentionally decides to ram into me because they thought I was driving too slow or they were drunk doing it, or they’re just horrible people and they decided to jam into my car, that would be a malpractice type situation. But most malpractice claims come with the understanding that complications happen and a complication from a Hernia repair is you can miss it. You can be looking in one area and missing it. There could be tissue over it, it can be missed on imaging, et cetera. So no, just a missed Hernia itself is not considered a mistake.

Speaker 1 (00:24:07):

Let’s see. Okay, here it is. In the case of a very rare type of hernia is a general lack of knowledge by many doctors or lack of access to the right care malpractice? No, that’s a very good question. So there will be situations where you go from doctor to doctor to doctor and they miss your diagnosis. And then you come to me, let’s say, and I’m very inquisitive and I love solving puzzles. I’ll spend the hour reviewing your imaging and examining you and figuring out what you’re saying and where is the pain, and then looking back, taking that information, looking back to your imaging form and all that and figuring that out. So that may be something that I enjoy doing, but sorry. And as a result, I have learned things. I have learned little signs on the imaging and learned that this specific symptom, let’s say, is more indicative of occult hernia or perineal hernia or whatever.

Speaker 1 (00:25:16):

In the case of very rare types, that is not, there’s no community standard or standard of care for rare types. If it’s rare, it’s rare and missing a rare problem is not malpractice. So if you have a situation that’s rare and the reason why it was missed, let’s say it’s because of lack of knowledge of that surgeon, that is not considered malpractice. Now if it’s common and the surgeon didn’t know about it, that’s a different situation. But for rare things, again, remember we surgeons are humans just like you patients, so we are just as fallible and we don’t have infinite knowledge. Now, maybe in the world of AI and artificial intelligence where decision-making and diagnosing may be automated, maybe we will have less mistakes. We don’t know.

Speaker 1 (00:26:20):

However, do know that as humans we will make mistakes, and as humans, we cannot know everything. I mean, I will tell you as a surgeon, I’m 20. I’m 22 years out almost from training, right? Most of what I do today, I learned after training. So coming out of residency, I thought I was a great surgeon. I believe I was. I think most people who train under me, even in my first year out of training did agree that I was a really good surgeon. I knew nothing then compared to what I know now. The amount of knowledge I have now is so much higher, but it was all after training. So you gain knowledge over time, you gain knowledge based on your experience. Now, do I know anything about breast cancer, pancreatic cancer, thyroid disease? Not as much as the expert for sure, but I know a lot about my specialty. And do I know more about the hip than a hip doctor? No, but within my own realm of groin pain, I do know a lot about orthopedic diseases that can present as groin pain and be mistaken for an in schizophrenia.

Speaker 1 (00:27:42):

So yes, compassion is very, very important. Let’s see. Is there a consensus in the United States? This is from our French member here. Is there a consensus in the United States from what I understand, that mesh should be removed the same way it came in? Yes, that is a general consensus. It’s actually a European consensus, not just a US consensus. I was proposed an open removal followed by Shouldice repair after tap complications. That would be not what I would recommend. Would this be considered malpractice given that France is very late concerning mesh explanation and not up to the standards? No, that is not considered malpractice. In fact, again, the standard of care is what the average community surgeon would do, and unfortunately, most community surgeons, actually most community surgeons don’t even do laparoscopic Hernia repairs and therefore they’re even less likely to remove mesh laparoscopically than a laparoscopic surgeon number one.

Speaker 1 (00:28:51):

And even if they did laparoscopic Hernia repairs, they’re less comfortable doing the mesh removal laparoscopically. So if you’re a specialist, you’re a specialist and you can do laparoscopic and robotic surgery, then if a laparoscopic Mesh needs to be removed, it should be removed laparoscopically or robotically. If an open mesh needs to be removed, it should be done open, and those two don’t usually overlap. However, there are some excellent Hernia specialists that don’t do laparoscopic surgery and when they see patients, they offer open Mesh removal, even though I personally would hope that they would just refer it to a surgeon like me that does it laparoscopically or robotically.

Speaker 1 (00:29:44):

Also, there are surgeons that put in the mesh laparoscopically that don’t feel comfortable taking out the mesh laparoscopically, so it’s not considered malpractice, it just shows a weakness in their surgical expertise in that situation. It’s a fine line is what I’m trying to say. I underwent al hernia repair five months ago and I’ve had chronic burning and stabbing pain since I asked to have a follow-up with the surgeon and they refused to see me and didn’t refer me out to any other specialist. Is that a reason to sue? Okay, so I don’t understand why a surgeon would refuse follow up if you or their patient they’re obliged to take care of you for. Okay, let’s take it. I’m going to be very dogmatic about this. You paid for the surgery or your insurance paid for the surgery or you were uninsured and the county decided to cover for your surgery.

Speaker 1 (00:30:58):

Regardless of any of those situations, your surgeon is obliged to click. Your surgeons obliged to take care of you for 90 days from your hernia surgery. All hernia surgery, with the exception of ventral hernias nowadays providing the service and the payment that the surgeon gets involves 90 days of care. There are certain situations where you’re uninsured. We’re talking United States here. There are certain situations where you’re uninsured, you had an emergency surgery, the patient was there to save, the surgeon was there to save your life, and then after surgery it would be great if they would take care of you, but there are surgeons that would say, I’m just here for your emergency care unless you’re willing to pay for your care, I cannot see you because that wasn’t my original role. I don’t like that very much. I think it’s your patients, your patient, but I understand that you can’t just give free care all the time.

Speaker 1 (00:32:11):

You have to get paid for your services. So whether that sounds crass or not, you don’t go to your muffler person and say, I really need oil change local place and say, I really need an oil change. They’ll say, well, it’s going to cost you 1995, but I really need it. Yes, it’s still going to cost you 1995. So that’s kind of the situation. In all other situations, your doctor should not refuse to see you. Now if you refuse to pay for the services, they can refuse to see you. There are regulations as to what kind of care that they’re obliged, don’t have to provide you with care. What you should do if you’re uninsured or don’t have the funds to pay for a follow-up after 90 days. So five months will be out after 90 days. Then you’re have to go to a local doctor that is, let’s say, offers care to the indigent. So basically a county type situation.

Speaker 1 (00:33:35):

So there is something called abandonment. In response to that question, it’s usually abandonment of care by a non-specialist. So for example, you have a family practice doctor and the doctor refuses to see you go see you, doesn’t answer on your phone calls, and let’s say you have high blood pressure, you keep going to the doctor and they’re not available and they don’t make you an appointment and they refuse to see you. By law, if you choose not to see a patient, you have to provide them with alternative areas for care. It’s not considered malpractice. I think it’s called abandonment. It’s actually worse than malpractice and it’s not a lawsuit. I think you can take it to the medical board or something like that if you abandon care of your patient. It’s less common for surgeons to abandon care because usually we operate and our job is done.

Speaker 1 (00:34:40):

So any follow up would be nice, but you’ve done the surgery. The follow up is we don’t have to follow you up two years later, for example. So if you’re not getting the care that you need five months after your surgery, then you need to go see someone else who can take care of it. Do not linger or force a doctor that is uncomfortable taking care of you to try and take care of you. I feel like I have to keep saying this because there are plenty of doctors in the United States especially, so don’t act like this is the only doctor you have access to.

Speaker 1 (00:35:19):

My doctor is making me go to an immunologist. Great, that’s great. So if you’re having questions of let’s say some type of weird allergic reaction or something and they’re referring you to a specialist in that field, then great, I’m glad that they’re thinking of that. I had angle Hernia surgery in Minnesota with mesh and a plug. I had pain from day one. We went to Arizona for the winter and I saw a surgeon there. He said he would do exploratory surgery, but he removed the mesh and plug and replaced both the mesh and the plug.

Speaker 1 (00:35:54):

Who does that? They took out the plug and they put another plug back in. That’s ridiculous. I’m still in horrible pain. Should the Arizona doctor have asked me for permission to remove and replace? Well, I assume you consented to surgery, so the surgery, you have to look at your consent to see what you actually consented to. I’ve had horrible pain since 2015 and I have three more hernias, but I’m afraid to have more surgery. I wish you could come to Minnesota. Well, thank you very much. I wouldn’t mind coming to Minnesota. I heard it’s beautiful there, but not during the winter. I can’t do cold. I’m so sorry. I wish I could find a doctor here in Houston, Texas and I wish I could afford to see you. Well, I would say that if you’re having problems finding the right doctor, you should save money and see a specialist. It’s really not worth your time and effort to be moving around from doctor to doctor that are not specialists and spending your time and energy and money on people that really can’t help you when you could have shortened that period of time and seen the right specialists.

Speaker 1 (00:37:10):

How can patients help to change the fact that most surgeons, even specialists, do not know enough about occult hernias? What are your ideas about how that can be improved nationwide? Well, first of all, that’s why I do research. That’s why I give talks. That’s why I publish. So when I give talks, at least the people that are there will listen to me and when I do hernia talk, it’s available for anyone to watch. And if they google groin pain or whatever, it may show up when I write papers that goes in forever so people can read the papers and use that knowledge base. I write book chapters. The more book chapters I write, the more likely it is eventually that that information will seep into the medical school criteria. Now, that’s one of my goals is to make sure the medical school criteria is part of the, that what I do eventually makes into medical schools because that would be great.

Speaker 1 (00:38:11):

It’s not just surgeons that need to know it’s medical doctors, family medicine, emergency surgery, emergency room doctors, orthopedic doctors, gynecologists, et cetera. So that’s kind of my goal is to talk enough about a occult hernias that’s no longer some niche that only Towfigh in Beverly Hills talks about a, it used to be that they would make fun of me. Oh, oh, Towfigh. You are in Beverly Hills. You got these shihi little Beverly Hills housewives that are ultra thin and these are not normal patients. The reality is I actually do not have Beverly Hills Housewives as my typical patients. I have actually operate on Beverly Hills Housewives, even real, what’s it called? Real Housewives of Beverly Hills people from the show. But regardless, that’s not my typical patient. My typical patient comes from Ohio or Tennessee today for example.

Speaker 1 (00:39:15):

So that’s incorrect to kind of brand me as this surgeon that only sees a very particular type of patient and therefore, initially that’s what they were saying. And you know what? They would come to my talks and they would go back to their offices and see patients and be like, oh, I think this is what Towfigh was talking about. And then they would basically start seeing patients and treating patients with occult inguinal hernias and the patients would do better, and then they would start believing me. And guess what? Now I’m invited to give a talk specifically on occult inguinal hernias because it’s no longer considered before I would get myself into the meetings to talk about because I would present them as a research project, but now I’m actual part of the medical surgical society invited lecturers on let’s say occult in hernias. So that’s kind of how I do it here. I understand today’s subject is malpractice. What I’d like to raise is a question whether the term organizational abuse in fits the description of surgical meshes being introduced with health departments enforcing surgeons to be trained to implant these implants with no contingency plan in training surgeons to remove mesh implants successfully or even to identify mesh related complications.

Speaker 1 (00:40:48):

That’s a very good point, very good point. We spent a lot of time and effort on how to implant them, but almost no effort in teaching A how to diagnose a problem with it and B, how to remove it. This failure has led to surgeons not knowing how to treat these patients true, and therefore sent us to pain clinics where we are just drugged up and side benched because nobody seems to know what to do with this. A hundred percent agree with you a hundred percent. It goes back to the other person who basically said that the surgeon didn’t want to see me and sent me to pain management, and yet most pain managements, they’re even worse than surgeons. They know nothing about how we put the mesh in what Mesh means, suture, et cetera. And so like you said, they drug you up and side bent you.

Speaker 1 (00:41:39):

I have copied the definition of organizational abuse for reference. We seem to be considered as unfortunate patients rather than victims of systemic failures leaving us unable to seek compensation via today’s legal processes. I’d be very interested on your views on this angle. I think that’s a very, very good point. It’s a different way of looking at it, and I really like that. I really like that. What’s the definition of organizational abuse? Organizational abuse is the inability to provide a good level of care to an individual or group of people in a care setting such as a hospital or care home or in a person’s own home if they receive care assistance there, it may be a one-off incident, repeated incidents or ongoing ill treatment. This whole issue of systemic mistakes, systemic problems, I think it’s a good one. It’s a good one. Of course, the problem is most people that are not in hernias don’t believe hernias are worth even talking about, let alone own having debates like we’re having right now. So that’s the main problem. That’s question. Can you see migrating mesh on imaging and is it a must that ripped Mesh be removed? Last, do you know any qualified surgeons in Philadelphia? So I recommend you either search my Facebook page or hernia talk.com or YouTube channel for Pennsylvania. We have had a couple of people from Pennsylvania and also Philadelphia that are surgeons that in general when I interview a surgeon, I usually know them and have considered them an important part of the hernia care world.

Speaker 1 (00:43:38):

Let’s see. Let’s go into some more questions. I went to the website. I can’t find a doctor here in Houston. I believe I answered your question on my website and I gave you names of two hernias surgeons in Houston, Texas. So go back to hernia talk.com and I responded to you on that site. Yes, I was also dismissed at eight weeks with lots of complications. Sent me a letter and said they didn’t want me as a patient anymore and didn’t help me with another doctor. I see. So if a doctor sent you a letter and said they don’t want you as a patient anymore, they are not ghosting you. They have fired you as a patient. It’s very uncommon for a doctor to disown a patient. If they do disown you, it’s usually because you’ve harassed ’em enough that they feel either unsafe or your presence is disruptive to their office.

Speaker 1 (00:45:01):

That’s not a good way to get care. You do not want to harass your doctor no matter how much you are uncomfortable with your outcome, you cannot burn bridges like that. So if a doctor has formally written you a letter saying you’re no longer offered care with them, they are not obliged to provide you with alternatives as a surgeon, as a medical doctor, they may have to at least give you some names, but as a surgeon, I don’t believe you’re obliged to go out of your way to find a suitable person for you, and almost always it’s because you have been disruptive to their office. Either you’ve been rude, disruptive, profane, harassing.

Speaker 1 (00:45:54):

I had one patient that kept getting drunk and called the office with death threats against me. I know friends of mine that have had patients that were stalking them outside by their car and also claiming death threats against some. Those were legit patients to quote “fire”. And I’ve also had patients that are just trolling on social media or writing nasty letters or really abusive emails. Those are not patients that usually a doctor would tolerate that kind of disrespect, but no matter what you think of that doctor, yes. Could you just travel around America for everyone? Honestly, I literally said that today I was with a patient from Tennessee today, so she had to fly back in for some examination by me and reviewing things. So I felt guilty that she had to come back and fly back, but she was okay with it, it seemed, and I made the comment, I feel guilty because I treat a lot of patients that are from out of state, but if they have a complication or they have pain or they have questions, I try and deal with it with virtually and then I try and find a patient, a doctor local that I can work with.

Speaker 1 (00:47:29):

Let’s say a pain doctor or whatever. But sometimes the patient just said, you know what, I’m just going to fly back. So that was her decision. She came to fly back, but I feel guilty because if I were there I could just treat it. So I was telling her as I was doing her nerve block said not a nerve block, a trigger point block. I said, I feel guilty. I wish I could just travel around and go see my patients wherever they are.

Speaker 1 (00:47:57):

Logistically, I can’t. You have to be licensed to provide medical care in all of the 50 states, but I literally said that today. Interesting. I met a surgeon who told me only by touching my abdomen that I had three hernias, one umbilical and two inguinal. Okay, that sounds like legitimate. After CT scan and doppler while pushing, I only had one Hernia. This surgeon wanted to implant three meds just by touch exam. Okay. Just because they diagnose you with three hernia doesn’t mean when they’re in there and they don’t find a hernia that they would put Mesh in. So that’s a little bit of a misrepresentation.

Speaker 1 (00:48:37):

I fled. Some surgeries are overzealous in implanting mesh. I fled and looked elsewhere. I consider this malpractice before surgery more than you need. I don’t consider that malpractice. His physical exam was concerning for three hernias. He followed it up with imaging and found there was only one hernia. Totally legit. It doesn’t imply that despite that evidence, he’s going to take you to surgery and just willy-nilly implant mesh in you even if you don’t have a hernia. I had a surgeon say it was fine and they were not going to remove it. I think we’re we’re talking about the mesh. I had a small hernia and the surgeon didn’t describe the type of mesh he would use, which is typical. We don’t go into the details of exactly which Mesh we’ll use. I later received the surgical report and realized they use a large 3D max polypropylene mesh, which is a perfectly good mesh.

Speaker 1 (00:49:35):

I’m a 29-year-old female, five foot five and height, and I weigh 115 pounds. I feel like the Mesh is too big for me. I would say no. The large sounds like it would be appropriate for your size. I feel like the Mesh is too big for me. Is it possible this is causing my pain? Could this be malpractice on the surgeon’s behalf? Again, that would not be malpractice. That’s a standard mesh size for almost everyone, including a 29-year-old, five foot five weighing a one 15 pounds. It’s the 3D max polypropylene mesh and size large. So if you’re having pain, then you should get imaging and examination to see if the mesh is folded, if you’re hernia recurred, if the Mesh was placed too low, too wide, too left, too right, too high up, whatever the situation is to determine the reason for your pain, not malpractice.

Speaker 1 (00:50:30):

I also saw on the report that the surgeon used endo clips to close the peritoneum. Do these clips stay inside permanently? Yes, they do and it is a known technique to close the peritoneum. What would you do if a colleague said they took off a polypropylene Mesh and had a path report that they took off a polypropylene mesh and had a path report? I mean that sounds like what you would do. You would take out the mesh and send it to pathology. I barely saw my surgeon twice. Yes. So usually you would see the surgery before surgery once he or she would do the surgery and then you would see the surgeon at least once after surgery. So seeing the surgeon twice sounds within standard, not malpractice. These so-called hernia specialists are fingers counted. Exactly. So easy to do procedures, but absolutely no expertise on a successful removal or revision. Yes. It’s hard to find a hernia specialist in Texas. Yes. Very hard to find a hernia specialist in Texas for such a big state. It’s unfortunate. I get a lot of patients from Texas, a lot of patients from Texas because it’s very unreliable to find a hernia spread. There are some hernia surgeons for your primary repair, but once you get to the complicated revision situation, there aren’t that many.

Speaker 1 (00:52:03):

It was a medical doctor. I see. So your medical doctor is the one that wrote you the letter that they’ll no longer take care of you. If it’s a medical doctor and by the medical, I mean not MD, but internal medicine or family medicine as opposed to a surgeon or other specialist, then usually they need to at least give you some referral. Like go back to your insurance and see who else can see you. Or here are five other doctors in the 10 mile radius that can see you. Every state may be different as to what kind of letter needs to go out. Okay, I’ll quickly answer these questions.

Speaker 1 (00:52:47):

Would conservative management of a fat containing asymptomatic two centimeter umbilical hernia in a 60-year-old be reasonable? Yes. How likely would it be to enlarge or become symptomatic in the future? Unpredictable. But if you are low risk patients, so you’re not constipated obese, you don’t have a chronic cough, you don’t have a large prostate where you’re straining any straining problems, then the watchful waiting is considered safe. If the expected rate of recurrence was excessively high for an umbilical hernia repair, would it be ethical to do the operation or should a surgeon refuse? Depends on the situation. How likely would it be to have a recurrence of a suture repair of three centimeter epigastric hernia in a man with BMI 31 high? I would say the over 30% risk of recurrence and that to us is high for you, maybe 70% would be a good outcome. But for surgeons, the 30% recurrence or higher is considered high, but it’s not unethical.

Speaker 1 (00:53:57):

So let’s say I talk to a patient and I say, listen, you’re not the perfect BMI of 31. You’re telling me you can’t work because you have too much pain from this hernia. I would like to fix it for you now I need you to lose some weight. I can’t lose low weight because I’m on steroids. I’ve tried losing weight. I need to get back to work. My work won’t approve me unless I have the surgery. Okay, I’m going to put mesh in you. I don’t want mesh. So that patient is not going to consent to mesh repair. Like, well, I can’t do this repair without mesh because you’re going to have a high recurrence rate. That’s fine. I accept the recurrence rate. That’s a good odds for me. 70 30 is a good odd for me, let’s say, and I agreed to have mesh. If a recurs at some point, a surgeon may be like, that’s fine. I’ll do the repair. I’ll do the best job I can do for given your circumstances. And then if a recurs we’ll put mesh, there needs to be a discussion. Let’s not considered malpractice.

Speaker 1 (00:55:05):

Let’s see more questions. Is it possible to release attention or attachment to bone of a mesh without removing it for an enteral or Rectopexy? I mean it’s possible, but why would you do that? Cancel? Sorry. They said they removed the polypropylene mesh and had a pathology report only to find out they didn’t. What would you do? So the question is why didn’t they? Did they request pathology report and the nurse in the room accidentally didn’t send it for pathology, which happens by the way, it’s happened even for cancer patients. They took out the tumor, gave it to the nurse, and then the specimen somehow between the operating surgeon and pathology, somewhere it got lost or didn’t get there. It was misplaced. These things have happened before, so you just understand why it wasn’t set up for pathology. Now the only reason to send Mesh for pathology is to confirm in paper, in your medical record that the mesh was removed that absolutely no other benefit to sent to pathology. So when I sent to pathology, I just say gross only, no microscopic evaluation needed because it doesn’t change anything. It doesn’t change your outcome, it doesn’t change your treatment, it doesn’t change your diagnosis. It just increases the chances that you’ll get charged for pathology report.

Speaker 1 (00:56:47):

That’s completely unnecessary. So I use pathology purely as a way for meshes as a way of just confirming that mesh was removed because literally I’ve had people sue saying mesh was not removed. I literally, I personally was sued by a patient because they’re quack surgeon and I’m happy to call him a quack because he is a quack. His quack surgeon told the patient that I never removed their mesh, and guess what? I actually had pathology proof that I did, and I’m glad I did that because the patient sued me for not removing his mesh. Obviously that was a dismissed lawsuit.

Speaker 1 (00:57:37):

I did have MRI done and there is, and by the way, that surgeon lied to the patient saying that I didn’t remove the Mesh. Complete lie. Okay, where was I? Let’s see. I did have MRI done and there is no indication of Hernia recurrence or Mesh damage. Unfortunately, I’m still under extreme pain every day, so I hope that you had the MRI done and it was reviewed by a hernia specialist that knows how to read MRIs. Otherwise, if it just goes to a radiologist that doesn’t know how to read these images, what they do is they just say, yeah, a hernia repair done. Like everything looks good. But if you have a specialist read it, they will see, they’ll correlate the findings of the imaging with your symptoms and that may include, let’s say, folding of the mesh hernia recurrence and things like that. Let’s see.

Speaker 1 (00:58:40):

Running out of time people. Lots of questions. Yes, that’s what you need a specialist to take out the mesh. Your friend Dr. Eunice, he’s in Florida, was able to remove the program mesh I’ve had for the last five years. Great. He was able to completely remove all the mesh, which was found to be folded in numerous areas. Great. I’m hoping this will eventually stop the pain once I heal up. Thank you for having him on your YouTube channel because I live here in Florida where he resides. Perfect. Thank you so much for answering our questions. My surgeon now knows about your work and is working on learning Mesh removal methods. Admitting surgeons in France should train more for this. They also consider Asia syndrome related to as much as a real possibility. Thanks to your work, your work does trial free. Thank you.

Speaker 1 (00:59:32):

That makes me so happy because it’s a slow process. This whole talks and research and publishing, but I’ve been doing it for 20 years, so over time people are now understanding these and when it’s published in a peer reviewed journal, then it gives legitimacy to it and it is no longer just Towfigh crazy patients that population from the Beverly Hills Hernia Center. Anyway, lots of questions. I love that you are answering all these for me. Let’s see. Thank you very much guys. This is going to be the last of it. I’ve got a great, great, great guest next week. Hernia Talk Live on Tuesday of next week. Please do tune in. Don’t forget, subscribe and like me on YouTube as well as wherever you listen to podcasts. Go on Hernia Talk Live as the podcast and write a review or something and that will hopefully make the podcast more readily available for everyone. Thanks everyone. See you next week. Bye.