Phone: 512-238-0762

Fax: 512-341-7370

December 15, 2019

Special Guest Dr. Declan Fleming Shares About Treating Cancer with Surgery

Speaker 1: 0:09
Welcome back to the Armor Men’s Health Hour with Dr. Mistry and Donna Lee.

Dr. Mistry: 0:16
Hello and welcome back to the Armor Men’s Health Hour. This is Dr. Mistry, your host here with my cohost as always, Donna Lee.

Donna Lee: 0:22
Hi, welcome back. Happy Sunday, everybody. I’m super excited about our guests.

Dr. Mistry: 0:26
Absolutely, our special guests. Now this special guest has a real close relationship to both of us, right, Donna Lee?

Donna Lee: 0:32
Yeah, he got the C-word out of my mom’s abdomen.

Dr. Mistry: 0:35
That’s right. That’s right.

Donna Lee: 0:36
Along with your help on stuff but I’ll let y’all talk about that. My mom is healthy and cancer free, so thank you. She just had her follow up.

Dr. Mistry: 0:42
So we have Dr. Declan Fleming. He is an Assistant Professor in the Department of Surgery and Perioperative Care at Dell Seton Medical School. Thanks a lot for joining us, Declan.

Dr. Fleming: 0:51
Hey, thanks. I’m really happy to be here, Sunny.

Dr. Mistry: 0:54
For our listeners out there, I sound like a pretty like, calm and collected, capable surgeon, right?

Donna Lee: 1:01
Haha! Sorry, yes.

Dr. Mistry: 1:02
I don’t know. You’re not…

Dr. Fleming: 1:03
That was tough!

Dr. Mistry: 1:04
…you’re not supposed to laugh at that.

Dr. Fleming: 1:06
I didn’t know this room is going to be this hard!

Dr. Mistry: 1:08
But there are times that I will look at somebody’s CAT scan or MRI and totally get the blood drained out of my face. A big pancreatic mass, a big mass in the retroperitoneum like your mother had…something that just, you know, frightens us because we don’t have an easy way of fixing it. But luckily we have a phone number and that phone number, and that phone number is Dr. Declan.

Donna Lee: 1:29
We have Dr. Fleming on speed dial.

Dr. Mistry: 1:34
So, maybe you could tell us a little bit about what you do for a living. What kinds of medicine you practice.

Dr. Fleming: 1:39
All right, awesome. Well they’ve changed the name of my sub specialty recently to complex general surgical oncology. Somebody wanted to throw the word complex in there because apparently our egos were so small we needed to boost ourselves up.

Donna Lee: 1:56
Wow. We’re going to add some more names to Dr. Mistry’s titles.

Dr. Mistry: 1:59
Please. I need to increase my cup size.

Dr. Fleming: 2:02
Some of my specialty is cancer care and I do it by not by giving chemotherapy or by giving radiation therapy. I do surgery on people. Typically as a surgical oncologist, I’m going to be trying to treat people with surgery, either to completely remove all evidence of cancer or to treat symptoms related to their cancer that can’t be fixed otherwise. Sometimes a person might have an obstruction of their intestine or something, and even if their cancer can’t be removed, there are certain circumstances where an operation might be something that can relieve pain or suffering, allow them to live longer and live better. And that’s the goal of my specialty.

Dr. Mistry: 2:38
What’s interesting about what you do is there’s going to be cancers that we know of that you treat routinely. There’s going to be colon type cancers, there’s going to be pancreatic type things. You leave the kidneys to me, please.

Dr. Fleming: 2:48
Oh yeah, absolutely. No. You know, genitalia, kidneys, bladder.

Dr. Mistry: 2:52
Thank you. Thank you. I appreciate that.

Donna Lee: 2:56
Dr. Mistry does love genitalia.

Dr. Mistry: 2:56
But what’s most interesting about what you do is 90% of the time that I operate on somebody, I know what I’m getting into. And there’s a lot of times when we send things to you that we’re not even sure what it is, and you may not be sure what it is, and you just got to go in with guns blazing.

Dr. Fleming: 3:12
Well, with guns blazing….that’s a little strong. You know…

Dr. Mistry: 3:16
Cowboy Declan Fleming.

Dr. Fleming: 3:16
…I’ve got my six shooter right over here. One of the really beautiful things right now about my specialty is that the diagnostic imaging that we have, CT scans, MRI scans, PET scans, all those things, a lot of the questions that we used to have that we couldn’t answer without doing an operation, we can now get a lot closer to figuring out what’s going on with imaging beforehand. So there are fewer and fewer exploratory surgeries the way we used to do them where, “Okay, well there’s something going on. We’re just going to open things up and take a look around.” The, when I was a student early in my residency, I had a professor who said that the best scan in the world was a Bard Parker scan, and Bard Parker is the company that makes the scalpel blades. So he was saying there is nothing like opening things up and looking around. With the scans that we can do and, and the technology is getting better and better, we’re getting higher and higher resolutions of the way we can look at things, we at least know sort of the area that things exist, the relationship of whatever growth we might be going after to nearby blood vessels or other vital structures. The thing that the scans really can’t tell us though is what’s going on on a cellular basis. They can’t give me the answer to things and sometimes things look similar and you have to do an operation because you can’t get a good biopsy and, you go in with your list of the top 4 or 5 things that this might be and you find out during the operation what it is you’re really dealing with and that then colors everything else that you do from that point forward.

Dr. Mistry: 4:56
I think for a lot of people when they’re first diagnosed because of either symptoms or imaging with some type of mass that they need to fix, they kind of naturally assume that they’re going to meet a surgeon like very early in the process because…

Dr. Fleming: 5:07
I sure hope they do.

Dr. Mistry: 5:10
…because in our minds we think, man, there’s something there. We need to cut this thing out right away. And you know, Donna Lee, with your mother when she was diagnosed with a tumor at a small hospital–What was the hospital?

Donna Lee: 5:24
In San Marcos.

Dr. Mistry: 5:25
…a small San Marcos hospital. She was immediately referred to a San Marcos general surgeon. And they may be great at what they do. But for something that I thought was something very weird when I first saw it, I thought that maybe bumping up that level of care to somebody, you know? And now we have a medical school…I sent them to you when you were Texas Oncology.

Dr. Fleming: 5:47
Right? And I still am Texas Oncology.

Dr. Mistry: 5:49
Oh, my mistake.

Dr. Fleming: 5:52
Well, no, no. You know, the really beautiful thing for me professionally right now is I get to be both. I’ve been in Austin for the last 18 years. So I was here long before the medical school was here, I was part of the community. I joined Texas Oncology from my general surgery group because I wanted to practice with other surgical oncologists, and so many people that I take care of need multi disciplinary, multi specialty care, right? We work with medical oncologists and radiation oncologists all the time. And so if you’re all in one place together, it makes care that much easier. So Texas Oncology gave me the opportunity to do that and I’ve been working with them. And then as the medical school started, I had been saying for a long time, if there’s something that I can do to help develop that in the community that I love, and be a positive influence for the students in the residence, that’s something I want to do. And Texas Oncology has given me the opportunity to be able to do that. And fortunately UT has really welcomed me. And so I get the best of both worlds.

Dr. Mistry: 6:57
And you’re not wanting for business, but you know, if you’re out there in the community and you’re diagnosed with something, when should you seek care from a complex general surgery oncologist? And maybe you could give me your insight into what are those characteristics of a surgeon that you should look for when you’re being faced with something that you think is going to eminently kind of take you out. So you’re kind of like less apt to kind of research things when you’re so afraid.

Dr. Fleming: 7:25
Right. Well, I think if you look across the United States, the most common tumors that we’re seeing, solid organ tumors, are lung, prostate, breast, and colon. Right? Those are the big 4. And you wouldn’t go to a urologist to get your lung cancer taken care of and you wouldn’t go to…

Donna Lee: 7:52
…but he’ll take the breast one.

Dr. Mistry: 7:54
No, no, we’re not fixing that.

Donna Lee: 7:59
Just kidding.

Dr. Mistry: 7:59
That was pretty good. Thank you.

Dr. Fleming: 8:01
There are people now, and in this day and age surgery, general surgery as a subspecialty, has become more and more even sub-specialized within that. So, when I was a resident back in the late ’80’s and early ’90’s, about 85 to 90% of people that finished a general surgery residency just went into practice, didn’t do any additional training. So I was kind of an outlier back then in that I wanted to get expert at something else.

Dr. Mistry: 8:29
At MD Anderson.

Dr. Fleming: 8:30
Yeah. And then as time has gone on now about 80% of graduating residents from surgery programs across the United States go on and do subspecialty training. So I think that if a person has a diagnosis, the two things that you want are expertise and understanding. Right? You’ve got to find that person that you can connect with because it is a process. And, it’s a tough process sometimes, certainly emotionally all the time.

Dr. Mistry: 9:09
That’s right. It’s not transactional. You’re not going to someone to just take this thing out of you and then you’re not going to see them again.

Dr. Fleming: 9:16
No, no, this is a relationship.

Dr. Mistry: 9:16
That’s a relationship.

Dr. Fleming: 9:18
You’re exactly right.

Dr. Mistry: 9:19
And if something goes wrong, which it does, then that relationship is often what builds upon the trust, and how are you going to go about it, right?

Dr. Fleming: 9:29
Because no matter what, people are always going to second guess their choices, when they’ve been diagnosed with a cancer and they’re going to wonder, you know, “Am I getting the best care? Am I doing the right thing? What’s going to guarantee that I beat this?” And, there’s no guarantee, right? So you need to make sure that you feel that type of trust connection with the person that’s going to take care of you. And then I, you know, I think beyond that, you’ve got to have someone that has experience, that has done the thing that you’re going to have done a lot of times.

Dr. Mistry: 10:05
That’s right. So we’re out of time for this segment. Donna, you want to tell people how to get ahold of us or ask us questions?

Donna Lee: 10:09
Yep, you can ask questions by email. You can ask us or Dr. Fleming armormenshealth@gmail.com, that’s armormenshealth@gmail.com. Our phone number is (512) 238-0762. We have four locations in the Austin area and check out our website, armormenshealth.com. We will be right back.

: 10:27
The Armor Men’s Health Hour. We’ll be right back. If you have questions for Dr. Mistry, email him at armor men’s health@gmail.com.

: 10:52
Welcome back to the Armor Men’s Health Hour with Dr. Mistry and Donna Lee.

Dr. Mistry: 10:58
Welcome back to the Armor Men’s Health Hour. This is Dr. Mistry, your host here with my co-host, Donna Lee.

Donna Lee: 11:03
Hi, welcome back everybody and welcome back to Dr. Fleming, and his physician liaison Rachel is here. We didn’t mention, she’s in the studio today.

Dr. Mistry: 11:09
Hey Rachel!

Dr. Fleming: 11:09
That’s right, it’s always nice to have another opinion.

Dr. Mistry: 11:12
If you missed the first part of the conversation, I think that you really missed out and I would definitely encourage you to get our podcast, the Armor Men’s Health Hour. It’s available wherever you get a podcast. We have 16 listeners on the page.

Donna Lee: 11:24
Hey, that was five more than last week!

Dr. Mistry: 11:26
We just downloaded our 50th episode, which is pretty good. They sent us a little congratulations.

Dr. Fleming: 11:32
A geometric code.

Dr. Mistry: 11:34
Hopefully it’s just geometric, you know, everybody started out at some number, right. We’ll see. Dr. Fleming works at the Texas Oncology as well as the Dell Seton Medical School. His specialty is complex general surgery oncology, and as I mentioned earlier in the show, he’s who we send things that are very complicated that are going to require big operations and oftentimes very frightening to patients. Right?

Dr. Fleming: 11:58
Oh yeah. Most of the things that I did, if you’re not at least a little bit frightened, then you’re not…you don’t know what’s going on. That’s right, exactly.

Dr. Mistry: 12:06
And you know, I really like to explore that idea of being frightened when you’re being faced with a life threatening diagnosis. I think that fear is probably one of the emotions that clouds our judgment almost more than anything. I don’t think I’m a therapist that can win a Nobel prize for doing this. I think that when you’re scared you are prone to make poor decisions. So maybe you could talk a little bit about how fear and when you’re being diagnosed with a cancer makes you do things that you would try to advise patients to try to avoid.

Dr. Fleming: 12:37
Okay. I think that it is a slap in the face when you get a cancer diagnosis, right? Because most of us go through our lives sort of blissfully willing to disregard our mortality. When you hear the word cancer, it’s brought right into your face and you can’t avoid it. A little bit of panic sets in and I think that that’s a natural thing. It’s hard for people to recognize though that when you get a cancer diagnosis, what was found that day probably has been going on for somewhere between three and seven years to get to the point where it’s even noticeable at all. And so what feels like an emergency is actually the point of discovery of a really long process that’s been going on. You know, it’s strange, but I tell the people that I’m seeing, well, thank goodness we found this, right? Because that allows us now to have the opportunity to change the trajectory of what’s going to happen.

Dr. Mistry: 13:27
It’s a great point you make because we deal with certain cancers all day. Prostate cancer is an example for me. When I find a low grade slow growing prostate cancer, sometimes it’s hard to remember that that person just heard cancer. They didn’t hear the “low grade, slow growing,” they heard “cancer.” And so, you know, sometimes you’re taken aback at how aggressively people want to treat things that you think we should slow down with. And I think that’s another aspect of how fear kind of makes people, you know, maybe not think of their choices.

Dr. Fleming: 13:56
Absolutely. You know, people can kill or damage themselves by wanting to be ultra aggressive. It’s really interesting to think that a person can live a normal lifespan and have a metastatic cancer, that not all cancers are an immediate death sentence. And truthfully, we all kind of live under a death sentence. We’re all gonna pass away from something and what we want…

Dr. Mistry: 14:20
You’re a bummer.

Dr. Fleming: 14:21
Oh no, I know. I do this, you know, thanks…You know, but if you get, if what happens in your mind is that the only conversation you can have is “I’ve got to get all of this out of me no matter what.” Sometimes people in intending to be kind can do something that ends up making things worse for you.

Dr. Mistry: 14:44
Oh yeah. I mean, you trained at MD Anderson. When I was there, I mean, we had patients that would have hemipelvectomies, they would just cut their body in half at the belly button. I would think to myself, if I was in that position, would I, you know, was that person motivated by fear or really what they would expect to be kind of a natural cure for their disease process?

Dr. Fleming: 15:05
Well, and I, and I think that it’s really important to have conversations about, you know, what am I trying to accomplish here? Are we going to you know, are we realistically going to give me a chance to be cured of this if I do something radical? Or are we doing this just because we really hope maybe we get a good outcome out of it, but we can’t create a good percentage chance of getting better from this.

Dr. Mistry: 15:32
And I think that patients also are afraid of asking their surgeon, “What happens if I don’t do anything or what happens if we take a less aggressive course?” And I would encourage listeners to know that we don’t often bring that up necessarily, especially if you’re really afraid of what’s going on. But that should be a natural question, right?

Dr. Fleming: 15:51
Oh yeah. I think that anytime we speak, we ought to be looking at what are the risks and benefits and remembering that one choice that’s a really reasonable choice is “I’m not gonna do anything about this maybe ever or, or maybe just right now,” and let’s talk about the consequences of that. And, sometimes it’s really better to say, “Nah, I’m not ready to, to do something for this ride. That’s not what I want for myself. I’d rather just live in this way and not subject myself to that.” You know, all of us surgeons went into our field because we are convinced that we have the opportunity to do good things for people. And sometimes we get carried away with that. Right? And it’s important to remember that although I’m supposed to look at things objectively for people, I’m also human and I want good things for them. And it feels kinder in some circumstances to be willing to push the envelope a little bit. But I think that taking, number one, people knowing that their hair is not on fire, “I don’t have to make this decision today. I can think about it a bit. I can ask questions, we can have time to reflect on things before final decision is made about treatment.” Number two, you can always have somebody there that’s an advocate. We were talking about this just a little bit earlier. Sometimes that best advocate might not be a family member because they can be too heavily invested in something emotionally. And I can’t tell you the number of times that a family member pushed one of my patients into getting something done that they weren’t really certain about.

Dr. Mistry: 17:30
We’ve seen it all the time.

Dr. Fleming: 17:31
And you’ve got to step back and ask the person, it’s my responsibility to ask them, you know, “Is this what you really want, and are there other things that you want to talk about that we could explore that might be a different treatment to this?” Now I say all this and I’m thoroughly convinced that in a lot of circumstances, me doing a surgery is going to be great. And especially now with some different techniques, some of these minimally invasive surgeries, we are able to do things that become less traumatic so the recovery time is a little bit easier on people. We don’t change our principle of surgery, you know, there are oncologic principles–we’ve got to remove the whole thing when we do a surgery and all the rest of that. With these minimally invasive techniques and now with other tools to help people avoid having to take narcotic pain medicines when they have surgery so that they don’t have all the side effects from that type of medicine stacked up on top of the consequences of having a surgery. We’re really doing better things to help people recover better.

Dr. Mistry: 18:36
You really come upon a very interesting point, which is, you know, and I don’t know, you were trained at UT&B, and you know, Baylor was much better, but at Baylor…

Dr. Fleming: 18:46
I’ve heard that number of times from everybody from Baylor. Yes.

Donna Lee: 18:49
And in the last few minutes.

Dr. Mistry: 18:49
So, at Baylor, you know, when you’re trained to be a surgeon, you learn these mantras like, you know, you know, “You steal to heal,” and.

Dr. Fleming: 19:00
and “It’s a chance to cure.”

Dr. Mistry: 19:00
…and you get this like real machismo about what you’re doing. And what’s interesting is how different when you’re actually practicing and taking care of patients is, you know, this idea of really, in residency you learn how to operate, becoming experienced is learning when not to operate, and how to make people recover better.

Dr. Fleming: 19:22
Right, recovery is the key. We are at our essence now and we were saying this earlier, recoverists. Everybody who goes through a surgical training program can learn to draw a scalpel across skin and cut a straight line, and we learned to put in stitches. But figuring out what you need to do to shepherd a person through their experience of trauma from surgery and the recovery after it, that’s the art of being a surgeon these days.

Dr. Mistry: 19:52
And that’s why you have to trust your surgeon, because you know, for me, if you’re going to get your prostate removed, you’re scared about your cancer and that day really, literally, I only spent two hours of actually operating on you, you know? And you’re going to spend a certain amount of time operating on people, but it’s really the years in the time afterwards that you spend with them that really you’re going to have a big impact on their recovery.

Dr. Fleming: 20:16
Exactly. Exactly. It’s a relationship.

Dr. Mistry: 20:20
Dr. Fleming, thank you so much for joining us here today. For those of you listening on the podcast, we’re going to have a little bonus segment. And Donna Lee, why don’t you tell people how to get ahold of us.

Donna Lee: 20:28
You can call us during the week (512) 238-0762 if you want to reach out to Dr. Fleming, his phone number is (512) 421-4250 and I’ll put that on our Facebook page. The Armor Men’s Health Facebook page. Our website is armormenshealth.com. We have four locations in the Austin area. Round Rock, North Austin, South Austin, and Dripping Springs, and we’re super excited to have Dr. Fleming. So listen in for the next podcast, the bonus podcast where you can hear podcast.

Dr. Mistry: 20:54
Awesome. And Dr. Fleming, how do they get ahold of you? How to make an appointment with you?

Dr. Fleming: 21:01
That number, (512) 421-4250…

Dr. Mistry: 21:01
You gave the number?

Donna Lee: 21:01
Our host doesn’t listen to me. I’ll have all that information on our Facebook page like I said.

Dr. Mistry: 21:06
Oh, Okay. Awesome. Well, we’re going to be right back.

: 21:08
Dr. Mistry wants to hear from you. Email questions to armormenshealth@gmail.com. We’ll be right back with the Armor Men’s Health Hour.

Dr. Mistry: 21:25
BONUS, BONUS, BONUS! Welcome back to the bonus segment of the Armor Men’s Health Hour. This is Dr. Mistry. I’m here with Donna Lee and Dr. Declan Fleming.

Donna Lee: 21:36
Hey guys.

Dr. Mistry: 21:37
Hey. I really appreciate you sticking around for our little bonus segment. The radio show, which I love doing has this limitation on time. I don’t know.

Donna Lee: 21:47
They have commercials, something called commercials.

Dr. Mistry: 21:48
We just can’t keep talking and talking and talking.

Donna Lee: 21:50
…there are paid advertisers.

Dr. Mistry: 21:51
And because I have you here first, I want to tell you how much I respect you, and thanks for all, for what you do. You know, I’ve sent 2 of the family members of people here, if I ever have a problem, God forbid…I mean, it just, your personality and your calmness..even when something’s really kind of dangerous and frightening is just wonderful. So thank you.

Dr. Fleming: 22:18
Thank you very much.

Donna Lee: 22:20
I have to interject. My elderly asian mom cannot pronounce your name.

Dr. Mistry: 22:24
Oh no, wait, wait, wait. How does she say it?

Donna Lee: 22:26
She said, “Tell doctor, the white doctor, he very nice, very nice white doctor.”

Dr. Mistry: 22:33
What’s weird is that he’s not Indian. You know and that’s weird to me…because he’s so highly respected.

Donna Lee: 22:40
And not from Baylor.

Dr. Mistry: 22:43
Oh wait, you’re not from Baylor? Oh crap! Oh, man, we have low standards around here. So, Declan, I thought maybe what we could do in this bonus segment is, you know, in my mind, I think about cases that both encapsulate my philosophy about how I want to practice medicine, and, or maybe had a big impact on me. I thought maybe if you wouldn’t mind sharing something, that’d be great.

Dr. Fleming: 23:07
Sure. Boy. Of course, you know, you always go to the things that are freshest in your mind. So I had an 11 hour operation yesterday, and I think that actually that is a pretty good example of part of my philosophy, is that this operation, the person had a tumor of the appendix, a cancer of the appendix, and the appendix ruptured. That’s how the person ended up going to the hospital and having this found. And when that happened, the tumor cells seeded out of the appendix to the inside lining of the abdominal cavity. And these tumor cells make mucin. And so the mucin is snot essentially. And so tumor cells seed the inside of the abdominal cavity and then it makes snot, and the person’s abdomen gets big from this snot filling up their abdomen. We jokingly call it a jelly belly. Yeah. And so doing a surgery for getting rid of these tumors is almost impossible, to get rid of every single cell that’s there. In fact, you know, you can’t, right. But what we found, and this is where science comes in. What we’ve found is that for this particular type of tumor, if you go in and you do a big surgery and you take the jelly out and you go around and you’re meticulous about finding as many of the places where you see the cells growing and you remove that, or you hit it with a heat instrument to cauterize and destroy the area, and then beyond that, we do a process where we take hot chemotherapy and we put it inside the abdomen and we jiggle it around for an hour and a half. And that bathes the inside of the abdominal cavity…

Dr. Mistry: 25:14
That’s called HIPEC, right?

Dr. Fleming: 25:15
HIPEC. And by doing this, the cells that we know are there that we can’t see at least get exposed to something that will kill them. And by choosing to do something pretty radical like that, it’s a big deal surgery to have done, we can actually give people a lot longer time. Some people will be cured and the people that aren’t cured have a lot longer life before they develop a recurrence and their quality of life is better. So I think that…

Dr. Mistry: 25:46
Comparing this to how we would deal with that 20 years ago, we’d open up and close right back.

Dr. Fleming: 25:50
Right? I mean, the old joke about a “peek and shriek,” and you look inside, “Oh my gosh, no.” And, or just going in and doing as much surgery as possible and saying, “Okay, well that’s it.”

Dr. Mistry: 26:02
That’s all we can do, yeah.

Dr. Fleming: 26:02
When you’re willing to do those things and you’ve taken the time to look critically at what other people have done, look at the data and not just say, “Hey, we can do this,” but “We can do this and it works well in these certain circumstances,” right? So this person had a low grade mucin making tumor of the appendix. You can have a higher grade mucin making tumor of the colon or of the stomach and you lose the value of doing that. You could still do the same operation. But by knowing the circumstance where it’s really the right thing to do, you can choose to go to the mattresses, right, for the people that really need it in that circumstance. And then you can offer other less dramatic or less traumatic things to the people that aren’t really going to benefit from that bigger thing, right? It’s not that it’s off the table, it’s just that man, when we’ve looked at this critically, we know we shouldn’t be doing this as frequently for something like that.

Dr. Mistry: 27:07
You know, how you chose that case is very telling. You chose a case that took a lot of time. I’ve been involved in these cases. You are literally sitting there looking at every square micro meter of the abdomen and picking little things off like little dots. Like, you know, those candy dots on a strip that’s kind of exactly. And each one can bleed. You have to like stop it, it is such a tedious operation and, and you picked a case dimension that you couldn’t necessarily guarantee a full cure, just better. And, you know, I as a surgeon, you know, when I think about cases that really affect me, I usually think about cases that things didn’t go perfectly right. And so, because I think that as surgeons we have like this expectations of perfection. And you brought up this concept earlier of, when you do a big operation on somebody, there are consequences and complications, right? Maybe you could go over that a little.

Dr. Fleming: 28:09
Sure, Absolutely. So a consequence is something that happens, not because something went wrong, but it happens as a, as a natural part of what you choose to do. So for the simplest example, a consequence of, if I’m right handed and I have an amputation of my right hand, I have to become a left-hander, right? That’s a consequence. It’s not that something went wrong and it’s not that it was something good necessarily. It’s just that it cannot be avoided. All right? So I do a type of surgery where a person develops a tumor at the junction between the esophagus and the stomach. And when you do that, under normal circumstances, there’s a muscle that helps to separate the stomach from the esophagus. And if our stomach gets full, fluid doesn’t reflux back up into our esophagus. So we don’t get heartburn and things like that. Well, when you remove a tumor from that area, you have to cut out part of the stomach so the stomach becomes smaller and you cut it into an elongated structure, almost more like a tube so it can reach up to be reconnected to the esophagus so that the person can eat and drink. Now a consequence of that is that muscle is gone and the stomach’s not as big as it used to be. So every single person who has that will feel full after just a few bites. Maybe after a while the stomach will stretch out, but that’s going to be months down the line. And every single person who has that has reflux for the rest of their life and it’s unavoidable, right? That is a consequence of the surgery and we know it’s going to happen.

Dr. Mistry: 29:47
That’s easy, I think when you know that something’s going to happen for sure as a consequence, it’s easy as a physician to explain it and for the person a little easier for them to understand it. So sometimes there are things that aren’t always going to happen, but very predictably could. And I think those are harder.

Dr. Fleming: 30:07
Yes, they are. Well, you know, and it’s funny though, even with, and I’ve been doing this a long time now. I’ve finished my fellowship at Anderson ’97. So I have been a cancer surgery doctor only for 22 years. Well, I mean, I guess 25 if you count the three years that I was in training at Anderson.

Dr. Mistry: 30:27
You can barely count the time at Galveston.

Dr. Fleming: 30:30
Oh yeah, no, that’s like halftime. So…

Dr. Mistry: 30:31
…they’re going to hate me.

Donna Lee: 30:37
Yeah, they are. I’m already getting emails right now.

Dr. Fleming: 30:39
Yeah, exactly. You’re going to lose, you know, two or three of your followers.

Dr. Mistry: 30:45
Dr. Yang, my partner went to UTB, so when he hears this, he’s going to be like…

Donna Lee: 30:49
We won’t tell him about this additional poscast.

Dr. Fleming: 30:49
Can’t you like bleep parts of this out, so every time he says UTB just make it silent.

Dr. Mistry: 30:58
Southwestern.

Dr. Fleming: 31:00
So, when I tell people about this operation, you know, I tell them this is going to happen, no doubt about it. 100%. And everybody forgets.

Dr. Mistry: 31:11
And they still are surprised!

Dr. Fleming: 31:14
Because our mind gets to the place where we really embrace that’s the truth. You know, there’s one thing to understand something intellectually it’s a completely different thing to experience it personally. There’s head knowledge and experiential knowledge and we impart head knowledge on people and then we have to care for them as they gain the experiential knowledge. Right.

Donna Lee: 31:40
Wow. That’s intense.

Dr. Mistry: 31:42
Well, I don’t know. I think that you and I should become philosophers.

Dr. Fleming: 31:45
Absolutely. Aren’t we?

Dr. Mistry: 31:46
I think, if we did sometimes, right? Philosophers, therapists.

Dr. Fleming: 31:49
Well, we all get philosophy degrees when we graduat from UT&D.

Dr. Mistry: 31:52
Oh boy. Man, that’s why Baylor was so quick. We didn’t take the philosophy class. Well, Dr. Fleming, I can’t thank you enough for sharing yourself with us today, and our listeners. You really are somebody that I know I can always count on to do what’s best for patients. And, if you’re out there struggling with a new diagnosis or as you’ve heard on this show, many times I’m a big fan of second opinions. Even if it, and it’s not an insult, you just, you want to find the surgeon that you’re going to trust and, you know, you’re going to put your life in their hands and you want to go to somebody that’s experienced and somebody that you know can handle problems if they have happened afterwards and, and you are definitely somebody that I know I can trust.

Dr. Fleming: 32:39
Thanks man. I really appreciate that, Dr. Mistry.

Donna Lee: 32:40
Aww, a little love-fest right there. And he’s a nice white doctor.

Dr. Fleming: 32:45
A nice white doctor, yeah.

Dr. Mistry: 32:45
Well thank you. You have to say it in the accent or racist.

Donna Lee: 32:49
“Nice white doctor.” It’s the “L” in your name that threw her off. She can’t, the Asians can’t say the “L.”

Dr. Mistry: 32:53
Fleming? You are Asian. Make sure that’s clear.

Donna Lee: 32:57
Oh yeah, I forgot.

Dr. Mistry: 33:00
Let’s make it clear.

Donna Lee: 33:02
I’m not just making fun of the Asians.

Dr. Mistry: 33:04
Well at least we’ll get some listener responses.

Dr. Fleming: 33:06
Yeah, exactly.

Donna Lee: 33:06
Maybe one or two Asians are listening. But yeah. That was awesome guys.

Dr. Mistry: 33:10
Well, thanks a lot, and join us next week.

Donna Lee: 33:12
Alright. Thanks, Dr. Fleming.

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