USA vs. UK: ASGBI Ep. 11 - Surgeons Are Human Too- Breaking the Silence on Mental Health

Behind the Knife: Hi, everyone, and welcome back to Behind the Knife. We're back with our friends from across the pond in our BTK/ASGBI collaborative series. Agnes Pramkumar. I'm one of the Behind the Knife fellows. I'm a general surgery resident who'll be representing the US side, along with our UK-based co-hosts, Geeta Lingham and Elizabeth McLennan.

Gita (2)GitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGita: Hi, I'm Geeta. I'm the president of the Moynihan

Academy, which is a trainee group in the UK

Elizabeth: Hi, I'm Elizabeth. I'm the vice president of the Moynihan Academy. Today, we're gonna be delivering quite an important topic, mental health for

surgeons and cultivating a

culture of support

Gita (2)GitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGita: So we hope to see how surgeons navigate the psychological demands of training and practice, but also look at how the US and the UK health

systems differ in supporting surgeon wellbeing, along with tips on how to make it better for the future

Behind the Knife: And we're honored to have such great guests to discuss this important topic. It's my pleasure to introduce Dr. Luke Elms from Orlando. He's a board certified general surgeon, and he specializes in abdominal wall reconstruction and hernia repairs. He also leads the Hernia Gods podcast, along

with numerous other renowned hernia surgeons from around the world to discuss the humanity within surgery. Thank you so much for joining

Luke Elms: Appreciate it

Elizabeth: And I'm very honored to introduce Dr. Liz Miller from the UK side today. Dr. Miller was a trained neurosurgeon and now works as an occupational health physician, and is a passionate advocate for mental health in the UK, and has

championed reforms in the NHS healthcare system throughout her career. also published Mood Mapping, which is a practical guide that teaches readers how to improve their

emotional health and wellbeing, and

we're very grateful to have you

Dr Liz Miller: Oh, thank you. I'm pleased to be here.

Thank you

Behind the Knife: So just to get us started, how would you describe the current culture surrounding mental health, both in

training in the US and the UK, and then has it changed since you were a trainee?

Dr Liz Miller: I think

although when I was training and, and what happened to me was that I was training as a neurosurgeon, almost reached the role of consultant, then got bipolar disorder and was admitted to hospital, several

admissions over the subsequent years. Now recovered, written a book, "Mood Mapping," which is about the strategies I used, been working in occupational health and general practice since then. thinking about that really, think that it hasn't changed. Although when I was in

training, doctors were terrified of anybody finding out about their mental health because you could be referred to the General Medical Council and put through fitness to practice procedures, and you had to have a barrister to defend yourself.

It was a bit like dunking witches in the Middle Ages. That improved, but I don't think that

attitudes have changed because certainly when I talk about bipolar, if I talk to, non-doctors, they say, "Oh dear, that's interesting. That's fine, move on." But you talk to a doctor and it's a bit like, "Oh my goodness," you know, "Step away.

Keep clear," you know? And when we went to, as part of the Doctor's Support Network, we went to see the head of the Royal College of

Psychiatrists, they simply said, "Doctors don't have mental health problems." Now, I think we've moved on, but not as far as one would perhaps hope

Luke Elms: I think we're more aware now than we were before. you know, I can speak from the surgeon side, from general surgery. Surgeons are a cross-section of society, and so to

expect, like Dr. Miller just said, to expect a surgeon to not experience mental health disorders, to not have, stresses in their lives or personal aspects that affect their ability to perform their career ever, is just unrealistic. I think that in the past, it was probably less talked about than it is now. I think that we have a long, long way to go. But

from my own personal experience, I've dealt with depression and anxiety through the majority of my life. This was not something that came on late in life.

When I came through training, there was a, the attitude that you needed to be a self-sacrificial being to be a surgeon, and there is absolutely some truth to that, that we do have to have a level of

compartmentalization in our lives that allow us to go through and to care for our patients in the most, in the best way possible. But what that led to was an isolation of people that we kind of tamped down our humanity and didn't discuss that openly. And so I think that y- there is still a lot of stigma involved, but I think

that the more open discussions we have about it in forums like this one, that is my hope for progress.

We sometimes have much more grace and give much more grace to our patient population than we do ourselves or our colleagues. many of us are hopeless perfectionists, and view, mental

health disorders as weakness, not as part of us as a human being. And I have found is that people that embrace who they are, that are, that are comfortable talking about who they are and, um, are self-aware enough to seek help and to work on themselves as the product that allows us to care for patients as...

which

is part of our mission, acknowledgment of that doesn't make you weaker, it makes you a better surgeon, and it makes you a better person. So

I think we've come a long way, but from when I was in training where it just wasn't talked about, but to say that we're where we need to be to maximize the capabilities of the profession and maximize the

capabilities of us to take care of our patients, I think that would be a mistake.

I think we have a long way to go.

Elizabeth: I think it's So

interesting to, to hear both of your takes on that we've made over the years. And almost both Dr. Miller and, Dr. Elms have said that things have gotten better, but we're still not quite there. And why I'm so

grateful that, Behind the Knife have given us the chance to have a discussion like this. So hopefully, you know, our generation coming through, having support and, insight from previous generations like yourselves is so helpful, and positive, I think

Gita (2)GitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGita: Yeah, definitely. Couldn't agree more. Do you think there's a difference between, having mental health difficulties

as a trainee and then as a consultant or attending?

Dr Liz Miller: I, yes, because certainly in my time, and I'm not sure that things have really changed as much as we'd like. there were at least two consultants who I came across, surgeons, consultant surgeons, in my career,

and they had both got histories of mental health problems. One of them I know had got bipolar, and there was another one, who had quite severe depression and taken time out. But I think once you'd got to the consultant post, of course, you had security of tenure. And the problem with the trainee is that you don't have

security of tenure. You're dependent on your references. because after I was ill with, bipolar disorder, the consultant simply said, "Dr.

Miller should never work in medicine again." And I actually only got another job because my father was a consultant at the local hospital, he arranged it with one of the consultants,

and that's how I got back in on the ladder. But I do know that people of my generation simply didn't get back in training.

I don't think it's so bad now, I think that there's still quite a lot of stigma out there

Luke Elms: Yeah, I think there's absolutely a difference between the, the trainee and the attending. And, let's

take the humanity out of this completely and just view this purely as a cog. I don't adhere to that thought, but let's just from an argument standpoint, you're a trainee, you're pretty much a product in development. You're a product going through the manufacturing process to reach a level where you can be a product in the world, in the workforce

that produces. And that, and in that case, the production, you can take a very bleak approach to that thought process and think about producing for the, corporation or whatever that you're working for.

But in general, what we would you like to think is that our production in our careers is to help people and to help our patients. you're, whenever you're a trainee When you start to

express the weaknesses of a mental health disorder or, even other aspects of health disorders,, there's a question I think raised in our minds as the trainee is of, am I a defective product? do I get the opportunity to ever become the actual product? Because I'm still in the manufacturing mode. Is this a,

is this a flaw in me that doesn't allow me to become the surgeon I want to be? I mean, I thought those questions when I was dealing with, like, incredible anxiety that I experienced going through my own career, and you wonder, it's like, have I just worked for twenty-five plus years now and I'm never gonna make it to my goal? And when you're in

attending, it's a different scenario where now you're out in the market and the question becomes from, is this a product that is somehow risky? this a product that does what it needs to do? What's the longevity of this product You know, and so from a very sterile aspect, yes, there's a definite difference in when they look at you as an

investment, from society and from, the training institutions and things that we come through. But I think it's important for us to keep in mind that we're not products, we're humans. And at the end of the day, there is a wide range of mental health disorders. There's a wide range of their effect on us to perform our jobs. I think we lump

everybody into one bucket where we talk about somebody that has a mental health disorder. But if we just approach this as a human and not as a, generalization of a group, I think we make it a lot further in making sure that we get people through this, and the people that are able to be very great contributors to society get to do that

Gita (2)GitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGita: Yeah, I think the, the

product analogy is a really good analogy. And I think what often happens is that trainees feel like if I just get through this product testing, it will be fine once I'm on the shelf. Once I'm at that end point,

Elizabeth: Yeah.

Gita (2)GitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGita: I'm good. And what would you say to trainees who are struggling with various disorders who think, "If I just power through..."

Like Dr. Miller, you were saying you were very close to the end. "If I just power through and hide what's happening, it will be okay in the end." What advice would you give to them?

Dr Liz Miller: I mean, I think that's where I went wrong. You know, I was in this sort of school of if you can't stand the heat, then get out the kitchen. And I think one of the things, 'cause as a result of all the mental health

problems I had, and met other people with similar problems, we set up the Doctor Support Network. And the motto of the Doctor Support Network was we must learn to be kinder to ourselves and to other people. And I think it is about, showing yourself the same compassion that you'd show a patient or another person or your best friend. And the whole sort of

shifting of people and treating you as you'd treat your best friend, because, you're stuck with you really. And then if you give yourself the same leeway that you'd give somebody else in your situation, then I think it gets easier to move forward

Luke Elms: Yeah. Showing compassion to yourself, that looks very, very different than the

motivational techniques that many of us have used to get where we are. it also flies in the face of some of this attitude that we have to martyr ourselves to be an effective surgeon. so whenever you get to a situation where you're in a position where maybe you have had a complication and that's like deeply affecting you, on a human level, not just on a professional level, maybe I'll have

to present this at an M&M conference, maybe I'll get peer reviewed, maybe there's implications from a medical legal standpoint.

But from a personal standpoint, so sometimes I felt, and still do to this day, guilty feeling personally, bad about a complication because in some level there's this twisted thought

process in my own head that by me feeling bad about it, I'm somehow devaluing how much it's affected my patient, and how dare I feel bad about something when I'm not the one suffering the consequence. so the, the about showing yourself the same compassion you would the patient, I think is incredibly key and I think that's an

incredibly good point because it, it-- I don't think we're very good at that just in general. But what I would tell my trainees is of what I came through and what I went through Was greatly impacted by development of self-awareness. It's important to understand that many of us being high achievers, we're

successful or you don't get to be a medical trainee through medical school. That just doesn't happen.

So what I would tell my trainees and what I do tell my trainees is, "You gotta figure out who you are, and don't be afraid of who you are. There's not everybody's cut out to be everything, right?" I had a trainee one time that was struggling. She hated

surgery. I said, "That's not a failure. Determining that this is not right for you and pivoting to something that is correct for you, that is a massive success.

You've just saved yourself of doing something that fundamentally is not you." I would argue that Dr. Miller has had an incredibly successful career. I would guarantee that's not what she thought

her career would look like when she was going through training.

Dr Liz Miller: Yeah. I, absolutely. I agree with that absolutely. And it wasn't until I'd had sort of, oh, I don't know, eight or so years of quite significant bipolar depression, being sectioned, et cetera, that I actually began to accept that maybe I had something that I needed to sort out. And

the various sort of techniques and strategies and i've put them in the book actually, but with those sort of managed to get to the point that I'm completely drug-free. I'm living a different life, have the intensity that surgery did. And so it's, it's successful in a different way, and that's fine. You know, I'm very happy where I am

Behind the Knife: Yeah. What do you think are aspects of support?

Like, how can others show up for you,

Dr Liz Miller: I, didn't get a lot of support, I have to say, so it's kind of a bit difficult. My family were more ashamed than I was, which was, because it's just the kind of, you know, father was a doctor, grandfather was a doctor, et cetera. And

I've suddenly blown my, what looked like quite promising career. You do find out who your friends are because, it's the people who still ring up when, when you've lost your job, when you haven't got any, anywhere to go or whatever. And so it is, it is like being, anything from a concerned friend, and I think that's wh- those were the sort of people who were the most helpful.

get a lot of support in the medical establishment. As I said, the consultant said I should never work in medicine again under any guise. But I think that's the whole thing. You need friends. You've got to network with people, other people who are in the same position. Find out what they're doing, how they're feeling because as you said

before, basically we all have similar sets of feelings. It's Just that it's difficult to talk about them, I think, in the context of surgery and s- being a surgeon

Luke Elms: I have found that some of my biggest critics and some of the people that were the least supportive were people outside of medicine actually. The people saying things like, "Don't ever tell anybody that.

Nobody will ever go to a

surgeon that's been depressed." There's two things about that, one is that you have to be self-aware enough to realize you need the help. So having people show up, I had many people in my life show up for me in very meaningful ways that I didn't understand that they were showing up for me. People were trying to tell me, like, "Hey, man, you're kind of screwing this up," I

didn't have the self-awareness to realize that I was. And so when they gave me very good sage advice, it fell on deaf ears. I think it also goes back to the idea of mentorship. Mentorship, I think I came through thinking that this was a one, one-to-one deal.

But you gotta keep in mind about mentorship, and this is how people show up for you, is you gotta

choose your mentors based on the qualities that you need from them. And also surround yourself with people that are at your level of your career, because there is a misunderstanding that you look at people that you may respect in the profession, and you are at a completely different, point in your career than they are. And things have changed. Residents coming through now, I

graduated eleven years ago, residents coming through now experience a very different scenario than I did. And there's different pressures and I think that I'm a good mentor for what I do from that time, but there's probably people closer to the training that would be able to provide some better understanding than I could

Elizabeth: That's so helpful to hear you say that about trying to

find people at the same level of the career as you to sort of look towards for a bit of support. I suppose this question's more to Agnes and Geeta, like current trainee perspective. 'Cause I know I've certainly surrounded myself with friends and colleagues who not only are at the same level as me, but are similar-minded in terms of being open about stresses

and talking about our complications if someone comes back in and we were part of the case. I appreciate we're trainees, but, have you found that helpful?

Gita (2)GitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGitaGita: yeah, I would say, yeah, definitely really helpful, and it's great. And it's great when you can do it. I think this is where a difference between the UK and the US system might come in.

But in the UK, we move around

every year- and some places every six months, and it's hard. Yeah. It's like changing school every year- Yeah... basically. But it's like you have to make new friends, you have to meet new people, you have to figure them out.

And I think it's great if you can surround yourself, and I definitely have a core group of friends that I've like maybe met at a placement a few years ago, and we

still have the WhatsApp chat, and we still talk. But sometimes it can be hard to find, people in-house, especially when you're new and constantly moving.

Yeah. And I think the US, Agnes, correct me if I'm wrong, is different. You guys stay in a hospital.

Behind the Knife: Yeah, so we stay in the same place for all five to seven years, right? And it does help with that feeling of like, "Hey, I've

watched you as an intern, and now you're senior residents together," so you can progress alongside them. But I think what you mentioned, Elizabeth,, similar minded is very important because there have been times that I've tried to open up or discuss about a difficult case with some of my other co-residents.

And, I don't know if it's a different perception, but they're like, "Oh, yeah, that's never been a problem for me." And I was like, "Okay,

well, I clearly am a terrible resident then." I'm sure we're all struggling in different ways.

And I think you gain more from opening up, but it doesn't necessarily mean that everyone is on the same page about talking about their struggles.

Luke Elms: Like the first time I opened up as a resident to one of my attendings, we were at the scrub sink. I was talking to her. She's an incredible surgeon.

I respected her greatly. I was looking to potentially join the, her in practice. Like I said, I went and I said, am just incredibly depressed." Like, my marriage is not going well. My wife was an OBGYN resident, had just graduated. I was the chief resident. By all intents and purposes, everything from the outside looked like I should be

incredibly happy, and that was what she said. She said, "What do you have to be depressed about? Your career's going great. You got a great marriage. Your wife's really successful. You know, just, think of that and be happy." And, I walked away from that conversation ashamed of being depressed. And let me tell you what shame does to depression. doesn't help it.

I think that there's a level of

when you decide to open up to somebody, it is a vulnerability that you need to be prepared, it may not go like you ideally need it to. there's a perspective that you have to have as the person who's going through that, is incredibly hard to have at the time, but maybe in retrospect, you can kinda gain some perspective, that,

um, it may be the other person's lack of self-awareness or lack of their own self-experience, and it doesn't necessarily reflect on you. but that is so hard to have, that's so hard to have that perspective in the moment. and depression and anxiety and mental health disorders, they're not logical. That's the part that you have to really keep in mind, because it can be

really devastating to reach out to people that you think might be supportive and not necessarily find that or not be able to perceive it in the way that it was intended.

Dr Liz Miller: Yeah. I think that's very true. Also, I think there's this business of shame I know how ashamed I was of all the mental health history, and I simply... I went from hospital to hospital.

I'd have a breakdown, leave, get a new set of qualifications. And go and try a different specialty, And then settled in occupational health practice, part-time in both, and the part-time was very helpful for me. But it is that terrible sense of shame, and that does make it difficult to open up, to tell anybody, because you think

they're going to react to it in the same way they do, you do. And I think one of the things, though, is, I learned, was that basically if you go to someone and say, "I've got bipolar," as though it was the worst thing in the world and totally, something to be really ashamed of and was just awful, they're gonna feel the same about you because most people

don't know about mental health problems unless they've also been down that road. But if you go along saying, "Well, I've got bipolar," or, "I've been depressed," like it was interesting and artistic, then they will pick up on that attitude, and they'll say, "Ooh, I wish I'd had some of that." So to a certain extent, if you're ashamed of it, you can spread the shame. But if

you're actually, "Well, to be quite honest, it was one of the best things that happened.

It gave me a new perspective on patients, on medicine," et cetera. So if you can be positive, I think, about how... I know you're feeling negative, but if one could be positive about how one is feeling about feeling negative, Because there's a book that, I think it's called, The Wounded Healer, and

written by

chapters by various doctors. And it really said the benefits they'd got from their mental health problems. And certainly I'd say from my point of view, having seen it from the other side, it does make you more empathic with patients. You do have more cha- time for their sort of foibles and, you may say, "Well, you've got to do this.

You need to take your tablets," or

whatever, and they say, "Oh, but it makes me anxious." You can sympathize more with that anxiety. So I think there is, there are, to rather than being ashamed of it, to put across the positive side of it

Luke Elms: absolutely. I think that having, working through your own issues and becoming aware of your own humanity, so to speak, because I would

say that some of these aren't disorders, some of these are just the price of being human, that,, it allows you to be more connected.

There are patients now that I would've thought were difficult patients or patients I would've considered pain seekers or things like that. These are not, that's not the case. After going through my own rise of self-awareness, I realized this is a person that's

scared. is a person that's anxious.

They're not broken, they're not difficult, they're just navigating life on their terms. And if you understand that, it allows you to meet them where they are. And if you're able to meet your patient where they are, that trust and that bond that you develop, that, that pays dividends well down the line.

I had issues whenever I was in

training, going back to the training question, I had concerns about getting my anxiety treated. I thought that me feeling an incredible level of anxiety around failure, thought that's why I was successful. In my head I'm going, "What if I calm down and this all goes away?" Like what if I, what if the incredible double, triple checking all

my answers on a test or studying that extra two hours at night to, in spite of the need for sleep, what if that's the reason I'm successful? What if that is the ingredient, not a, a bad byproduct of me being driven? And so that, those types of thought processes, that's the things that prevent you from seeking help,

that if you weren't able to seek help, get yourself to a better place and develop empathy from your own experiences, it can actually help translate to patient care in a very positive way

Dr Liz Miller: Ja

Elizabeth: Well, it's interesting though, isn't it? 'Cause I think if we were to compare, a- as often we do compare, try and compare mental health to, to physical illnesses. If

you as a hernia surgeon had a hernia repaired, you would then feel that you had the insight of that for your patients, you know?

You'd understand the recovery of that better than someone who'd never had it. And that would be seen as a strength for sure, when you were consenting people. And it's just funny that that, doesn't translate often into

mental

health,

really.

Dr Liz Miller:

Yeah. A- and I think the other thing is that mental health, it isn't permanent, and this was one of the things with the Doctor Support Network, was that the attitudes at those times was that, ill doctors shouldn't work. That was it. They were completely written off. And on the other hand, we had doctors who had wanted to soldier on regardless.

And what course we tried to steer with the Doctor Support Network

was saying, " when you're ill, you're ill, and you must take time off. But when you're well, that's fine. Get back to work." I think it is that acceptance that you can have periods when you aren't well, and yet you can be completely well at other times.

And also, that treatments do work You know, so it isn't a permanent state

Luke Elms: I

would say that, from the US side, there are really kind of two different types of medical student, for instance, or resident. There are those that go straight through, like I went through undergrad, in three years. So I started medical school a couple of months after I turned 21 and was an attending surgeon a couple of months after I turned 30.

And so I went through very, very quickly. That is very like socially, it, it stunts you socially, right? I had a different childhood than a lot, and so I'd had some jobs and things like that. But many times, like you're getting all the way through becoming a physician your first actual like real-life job, right?

And every time up until then, it's been more of an

educational kind of pathway. That adjustment period that happens for some people at the age of, you know, 20, 21, even 18, that's being delayed. And so sometimes you're coming out into the workforce later in life.

And that pressure that you can feel without perspective of the rest of the world and life outside of your

career, that pressure can really contribute to mental health, issues. It can amplify every high. It amplifies every low. You lose perspective. And so, yeah, I think that the training system, that we have in some respects is helpful, other respects it's not, but it definitely leads you to a different life experience than your

peers.

Dr Liz Miller: Mm-hmm. Yeah. I think that's right. I think also you mentioned briefly, I think doctors get very caught up with their identity as a doctor, and unless you have that outside experience of life, you don't experience yourself as anything other than being a doctor. So if along comes illness or mental health problems, and you lose that identity,

your whole world comes to a halt. And one of the most valuable things I think I learned was that, because we're all driven into medicine because we want to help people, but actually that you don't have to be a doctor to help people. is actually, it means that even when you're not in a or a situation that you're practicing medicine, you can still be

helpful. don't have to lose all of yourself.

Behind the Knife: And I think we've both touched on it, but I think one of the most difficult aspects of surgery is definitely dealing with complications, and I can, tell you about different cases that's impacted me and has changed how I move forward. So taking that, compounded with mental health,

that's an incredibly huge stressor.

So what would you say to a junior surgeon who's experienced their first patient death and they're just questioning their worth in continuing in surgery or as a doctor?

Dr Liz Miller: It's a long time since I did surgery, I think the most important thing when you deal with any kind of complications, for me coming through the thing is,

what have I learned? Because that way then you can, as well, get some kind of positive learning out of it. And accepting that we all make mistakes. I don't think anybody's heard of Wendy Savage anymore, but she was a obstetrician gynecologist who up for women's right to choose in the '80s, and got hauled

before the General Medical Council because somebody went through a casebook, colleagues who felt differently. And they picked on all the cases where they, where there could've been any mistake. She was, one of the first women in obstetrics and gynecology at a London teaching hospital, et cetera. But you can go through everybody's casebook, I think, and find

mistakes, and so you're not alone. And I don't think mistakes necessarily indicate incompetence, there's circumstances, environments, and it's really very rare if something goes wrong that you can simply put it down to one thing you did. There may be things that you could have done better, but it won't

be just that.

It's likely even if you did make it, or if you did make a mistake, that it was one of several things that went wrong. Because it really is never one thing. I sort of think it's a bit grandiose to think that, "Well, I did it all," because it won't.

It'll be in a set of circumstances. The patient may have been sicker than you thought. Operation may have been

harder. Untoward events that you couldn't predict. So for me, the thing is always, it's like taking out the what have I learnt from it, saying, "Well, from now onwards that makes me a better surgeon."

Luke Elms: Yeah, I think that's a very healthy way to approach complications, right. To approach it from a, "Hey, this is a obviously

a, a difficult thing." Nobody enjoys having-- feeling like they've failed their patient. Nobody enjoys going through the scrutiny that you go through as a physician whenever you have to go through the review of the case, peer review, medical legal aspects.

Sometimes M&Ms can be very malignant in the way that they're held. And I'm a big believer that a

poorly held M&M conference does more to hurt the culture of safety and patient care than a positively held one. If you use it as a time to dunk on your colleagues or make yourself look smart or play the politics of your institution what the trainees, impression is that do not discuss your

complications or you may get publicly humiliated. And that is the exact opposite because you lose the benefit of learning from watching other people. But complications and the d- discussion of complications, of a better term, is extraordinarily complicated, and that is that it's experienced by the

person going through it. And again, the human experiencing that from a physician side, it's informed by things like shame. when you identify only as a surgeon and that is your core identity or the people around you's opinion dictates how you feel about yourself at a core identity level. A failure for your patient,

even if it is multifactorial, it can be devastating so whenever you got to a point that you did have that complication and you're going through it yourself- There was a level of reaching out and sharing with other people. It's, I felt ashamed about what happened, know? And many times there, it was

not anything that I did wrong myself, but it still hit me the same way. I think that we devalue the secondary trauma of complications on the healthcare system, on the participants, but I would also argue that there's a tertiary trauma that exists. When I'm going through a complication, even in my current practice, I am not the type of father and husband that I strive to be.

It takes enough of my emotional and mental load that I'm not able to be there for those around me in a way that, that represents, an ideal situation. So even my family suffers when, my patients have a complication and that's the reality of it. And I think that again, it goes back to self-awareness, it goes back to transparency, and it goes back to the culture that we wanna

create, in the field of surgery and in, in the field of medicine in general.

Dr Liz Miller: I think that's right. And I think the tone of the meetings is really important because one time when I was in Guy's Casualty as a registrar there, the consultant ran really the best audit meetings that I've ever been involved in. we basically took

cases that had been seen at random. Some had done well, some had done badly. And it was, it done anonymously, but everybody chipped in as to how this would've been done better or whatever. But because it was such a supportive atmosphere, nobody felt threatened by it. And so people

would come forward and say, "Well, actually, I did that. These were my reasons for doing that, but I realize now it was probably not the best thing." And those made really good learning experiences, I think, for everybody

Behind the Knife: Yeah, and I think we're hitting on there is that, without a safe culture, feeling like we can show up at our most vulnerable selves,

then all the aspects that we just talked about, just opening up to someone about your mental health struggles or, times where you felt you could have done better, I think become significantly harder than they need to be.

Dr Liz Miller: Yeah. Think that's exactly sums up what, what these meetings, the ones that really worked well, they were

Behind the Knife: Yeah, exactly. So as we start to

wind down, looking back on your career, what do you wish someone had told you, about the emotional demands of being a physician or a surgeon, and what advice would you give?

Dr Liz Miller: I think, I think probably this, this business about actually being kinder to myself and self-awareness really. I think I was

far too on myself with it. Um, and therefore you know, every tiny, anything I missed was sort of, you know, I'd overthink hopelessly

Because I was the first woman in neurosurgery in the UK training. There had been previous UK neur- women

neurosurgeons-

but I felt that I really had the whole burden of, female liberation. And I think, yes, just to have been a bit more relaxed about it, I think would have been very

Dr Liz Miller: helpful.

Luke Elms: i, think that I would tell myself a few things. One, everybody goes through it, like you're not alone. And I think that

despite people not talking about it, the people that I looked up to that I thought were superhuman, that never experienced the struggles I was experiencing, I finally opened up, they would say, "Well, yeah. I had a headache the first two years of my career, I had a headache nonstop. I was so stressed out." And at that moment, I remember

experiencing a sense of relief, but also like a sense of just like indignation of going like, "Well, why didn't you say something?" I could have not just been, drowning in internal turmoil over the last few years if I'd have understood that this is not an abnormality, it's not a flaw in the product, it's about being a human in an

incredibly stressful and incredibly, high-stakes environment. the other thing I would say, to myself back then is the world doesn't need me to be perfect, it needs me to be me. I think that we live in an expectation of perfection ourselves that is, is noble in the fact that we strive for that,

there is a difference between striving for perfection and needing perfection to feel okay. So self-sacrifice, while necessary, I'm not saying you, you say, I know my patient's got a, a leak from their anastomosis, but, I had scheduled Pilates.

I'm gonna, I'm gonna bounce, and so my..." You know,

that's not what I'm talking about. But self-sacrifice to a fault where you're saying like, "I am struggling so badly that I'm not sure I can function at the level that I hold myself to, I'm just gonna keep pushing through because this is what it is to be a surgeon." I think that is probably a fairly common feeling that we all

experience. I'm just not sure that's the best way that we create a culture and create a, an area practice and create the future of what surgery looks like, where we can expect the best outcomes for our patients. Because the last thing I would tell myself is it doesn't get better. It gets

different. The stresses change. They don't go away. I don't mean that to sound bleak, but I mean that to be realistic in your expectations, that if you're struggling as a resident, those struggles don't just disappear when you become an attending. So there's no time like the present to

develop that self-awareness and work on yourself, because ultimately, the more work you do on yourself, the better work you'll do on others

Elizabeth: What a lovely summary to, to finish on, Dr. Elms. That just summarizes all of what we've talked about so well. We have a couple of questions for both of you just briefly before we close, but just to say thank you so much for sharing so openly, both of you of your

experiences, and it's been really refreshing. Dr. Miller, do you want to share a little bit about your book before we leave the

Dr Liz Miller: Oh, yes, it's about how to self-manage, moods effectively, and the idea is that you do mood mapping and you see how much energy, how good or bad you feel. And then if you're not feeling good, it contains

strategies, in how to improve your mood. Music I've always found incredibly helpful.

Exercise, going out in nature, talking to friends. It was really the things that I did to get to where I am now. Yeah, so it was one of the benefits that came out of being ill actually. I got to write a book. So

That's

awesome. Thank you so much for sharing, Dr. Miller. I'm looking forward to reading the book

Behind the Knife: Dr. Elms, do you wanna tell us a little bit about, your podcast, The Hernia Gods, and how we can listen to it?

Luke Elms: Yeah sure. The Hernia Gods started as a mental health exercise for me. I don't like journaling necessarily, but verbal journaling was something I felt comfortable doing. I started my own private podcast, which has never been

released, and then I ended up at the American Hernia Society meeting back in twenty twenty-five. And I was sitting in the audience, and I felt an incredible amount of imposter syndrome, knowing that I was doing the same surgeries as the people talking, but I never felt like I would be capable to be them. And was talking to someone, at the hotel bar after that had all, wrapped up, and that person, turned to me and said,

"They're just like us.

They just get up there and talk about it." And it got me thinking about, that maybe we're all the same and maybe we're all mere mortals practicing under the same, in my case, hernia gods. Those, those ethereal beings that we all pray to when we're in some disaster case and we're going, " Oh my gosh, this is a no-win situation.

I need all the help I can get," so you pray to the hernia gods in that case. came home, and I started a podcast where I planned to just talk to my partners about the realities of being a surgeon, about what it is to go to work and not feel like maybe you're doing what you were meant to do, or having those days where you wake up and say, "Is this sacrifice of everything

that makes me happy, is it worth it? am I really being the best parent I want to be? Am I failing my patients because I had that one complication?" All those thoughts that roll around in my head that I realized other people have too. And so I started this podcast, and all of a sudden I was interviewing, very prominent names in the field, and have found that we're all the same

And even the top names experience the same level of self-criticism, the same doubts, the same fears.

Complications hurt them just as much as it hurts us. People that invented the surgery will lay in bed awake at night worrying about doing that surgery the next day. And those types of

facts, I think, are incredibly important for us to understand so we don't feel so alone, because we're not alone. We are all mere mortals.

We're not superhuman. We're just human. And so the Hernia Gods podcast is a podcast about the surgeon. It's not about the hernia surgery. We talk a little bit about it, but it's about the surgeon. We're available on all the different

platforms. You can listen on Apple Podcasts, Spotify, YouTube and, the SurgOn platform. We're gonna have the Prometheus podcast, where we have discussions with people that aren't the surgeon that impact our lives and impact our ability to do what we do. We're gonna be rolling out the Surgical Goddess podcast, and that is gonna be a podcast amongst women. It's a discussion about what it is, the realities of

being a female in surgery, and the realities of the disparity in, gender in the research and the way we treat our patients, 'cause much of research around medicine has historically been male-biased, and it does have an effect on our patients and the treatment algorithms we use for those.

And so that's the other one, so stay tuned for that. So I really appreciate the opportunity to talk with you guys

today.

Gita (3): Thank you, Dr. Elms. That, sounds incredible. We're not alone, I think is the summary. We'll close it there. So thank you, Dr. Elms, Dr. Miller, thank you for joining us. We've really enjoyed it. It's been great. Amazing pearls of wisdom. And I think, like we've all said, the more we talk about it, the better this becomes.

And we are getting there, but there is still room for improvement. But thank you so

much. Thank you to all of our listeners. And be sure to look out for future episodes.

Behind the Knife: Dominate the day.

Elizabeth: the day