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Join Maria Iliakova, a bariatric and general surgeon, as she shares her challenging yet transformative journey through surgical residency, where she faced overwhelming pressures and doubts. Discover how she found solace and fulfillment in the operating room, making surgery her favorite thing to do. Gain valuable insights into the world of surgery and find inspiration to overcome adversities in your own life.

Maria Iliakova is a bariatric and general surgeon.

She discusses the KevinMD article, “The joy of surgery: How one doctor discovered her passion.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Maria Iliakova. She is a bariatric and general surgeon. Her KevinMD article is titled “The joy of surgery: How one doctor discovered her passion.” Maria, welcome to the show.

Maria Iliakova: Thank you so much, Dr. Pho. It’s so nice to be with you.

Kevin Pho: We’ll get into the article in a little bit. First off, briefly share your story and journey to where you are today.

Maria Iliakova: Yes, so I am, as you said, a general and bariatric surgeon. I’m actually just finishing up my first year of practice, which has been a wild ride and a great journey so far. I’m originally from Kansas City, now in Iowa City, so I seem to like places that have the name “City” in them.

But first and foremost, I’m actually an immigrant. My mom and I moved to the United States from Russia when I was six, so this country has definitely afforded us some opportunities that are pretty unique. Coming with just a couple of suitcases to becoming a bariatric surgeon, it takes a village, but it also takes a place like the United States to make that happen.

Kevin Pho: So we’re going to talk a little bit more about your surgical journey and training in a little bit, but you mentioned that you just finished your first year out of fellowship or residency. So how did that transition go, from training to attending?

Maria Iliakova: Oh my goodness. Sometimes it’s almost like I didn’t do residency or fellowship, because of the learning curve. I’ve heard this before; I remember my attendings telling me this in residency and telling me in fellowship: “Your first year out is going to make you feel like you don’t know anything.” And I would say that’s true.

There’s so much more to the practice of medicine and surgery than just what you learn technically. Technical skills are the baseline, right? You have to know what you’re doing, you have to be able to be safe, and you have to be competent in all those things. But actually getting your patient to the OR safely means you have to manage a clinical team, it means you have to manage a surgical team, it means you have to get your administrators on board with the tools and things you want to use, and it means you may have to do some marketing to get patients in the door and certainly develop those kinds of relationships with patients. So it’s a huge learning curve, but one that I have really enjoyed and have really taken a lot of valuable things away from.

Kevin Pho: Those logistical and administrative burdens that you talked about, outside of technical skills: Did you get none of that education during your training?

Maria Iliakova: You know, it does occur, I believe, but there’s such a fire-hydrant effect in residency and fellowship. I will even say that I trained at a really strong residency program, at the University of Missouri-Kansas City, a five-year general surgery program based in the Midwest. So you get a lot of autonomy as you go through. You really develop excellent skills: open, laparoscopic, robotic, trauma, ICU, all kinds of things, and lots of specialties.

But when I went to fellowship, it was again as if I had to break down to the very beginning and start over in many ways, because you learn in such granular detail how to be an excellent technician and how to be a good decision-maker. I will say that while those skills do translate to what you do administratively and managerially in your attending role, they are quite different. And I will say that until you do it yourself, it’s nearly impossible to learn it secondhand.

Kevin Pho: So what kind of setting do you practice in now? Is it a private practice setting? Is it an academic medical center setting?

Maria Iliakova: Yes, it’s a small community hospital. We are down the street from a really big academic center that has served as a really excellent base for collaboration, working together on patients, and having a good community of people to work with. But I am at a small community hospital, which presents its own fairly unique set of challenges, coming from a fairly academic background.

Kevin Pho: All right, so let’s talk more about your passion for surgery. Your KevinMD article is titled “The joy of surgery: How one doctor discovered her passion.” How did your article come together?

Maria Iliakova: Sure. There’s been a lot of talk of burnout overall, I think, in the practice of medicine, and especially with the COVID pandemic and the fallout from that, where I think people felt like they were doing things maybe just because they were told to do things, or doing things just to get through and get by. And I will say that I fell into that somewhat too. Residency can be very long hours and very daunting challenges, where you’re trying to multitask all the time, trying to make everyone happy and making absolutely nobody happy, and it’s a very difficult time. And then on top of that, you do still have all of your regular social and family obligations, which sometimes we treat as extracurricular rather than just as important as what we do clinically.

So it really took me having a little bit of time, and having a little bit more say in the decision-making process, to actually reconnect with why I was doing what I was doing and why I wanted to be there in the first place. Because I do think that if you don’t have that, if you allow the burnout to take hold, if you allow yourself to disconnect from the practice of what you’re doing, it will also affect how well your patients do, and it will also eventually affect everything.

Kevin Pho: So obviously, surgery is a very demanding residency, and a bariatric fellowship is of course very demanding as well, and you throw in the pandemic on top of all that during training. Now tell me about some of the darker days. You said that there were some days when you were questioning what you had to do. So what about it made you question? What were you feeling?

Maria Iliakova: You know, you’re asking me, which is very kind, and I’m very lucky to be asked. I do think a lot of people, probably thousands to tens of thousands of people, have stories very similar to mine.

I remember when the pandemic first started, I was actually at the VA hospital in Kansas City, and it was almost on a daily basis that we were changing protocol, even for entering the building. So it became almost like you’re entering a gated community every day and trying to figure out what’s going on. And then I switched to a private hospital in Kansas City called Saint Luke’s at that time. I remember I was on the transplant service, and you’re walking through the hospital almost like it’s a deserted ghost town, almost like a haunted house sometimes, because there were so few people there. Certainly no families, no other people. You don’t really understand how instrumental that kind of support is for taking care of your patients, figuring out what to do with patients, and getting support until it’s gone. It really felt like I was walking through a warehouse sometimes when I was in the hospital.

It was also very daunting to do trauma at that time, because at that point we didn’t really even know how COVID was transmitted, for instance. So we were wearing N95s and PAPRs and having all kinds of protocols for what we were wearing. And I remember flying into a trauma room, for a second forgetting that we were in the midst of a pandemic, and not putting on my gown and things like that, and an attending literally smashing the PPE into my chest, basically saying, “Get yourself covered. Take care of yourself. Protect yourself. What are you doing?”

And so it was a time of a lot of coming to terms with things, I think. Coming to terms with the fact that you did have a lot of support, that you did have a lot of people there together with you, that we were all in the same boat while we were taking care of people who were sometimes dying right in front of us, and we couldn’t do anything about it other than support them as best we could. So it was a really rough time in a lot of ways. I’m really glad we’re not there anymore.

Kevin Pho: Yes. How did you find the strength to go through that, or what made you see that you had other people around you who were going through the same thing?

Maria Iliakova: Yes, well, luckily I was part of a residency program with five residents a year, so a pretty medium-sized program, with really incredible faculty and staff around us.

I will also say that it was a time when I saw a lot of silos breaking down. We sometimes mention that medicine is kind of separate, you know, it’s surgery versus medicine versus GI versus OB or something like that. But in this circumstance, at least for the first year or so, it really felt like a lot of those barriers broke down, and everyone was laughing together or crying together or trying to figure out how to make each other’s lives just a little bit easier. And I think that mentality has actually stayed. I think it’s a lot less separated than it used to be, at least in my perception of it. We all understand that it’s not us versus them; it’s us and them, for the same goal. So that really helped.

I will say there was also a huge outpouring from the community, certainly in Kansas City, where I lived. The mayor was on top of things really fast, family and friends were on top of things really fast, and even if people didn’t agree politically once that became an issue, there was no question that people supported their health care workers, hospitals, and things like that. So while it was a very, very dark time, it did seem like people really were capable of supporting each other, and they did that really well.

Kevin Pho: One of the things that you said earlier was that it does take a village, sometimes, in order to come out of burnout and reconnect with the passion of medicine. There are a lot of physicians, like you said, who are still siloed, and it’s very difficult to find that community. So how does one go about doing that?

Maria Iliakova: Yes, so there are some ways that have really worked for me. When I came to a small community hospital here in Iowa City, I actually didn’t know a single person here. I was recruited to build a program and start a robotic program, and I really thought that would be a great opportunity, and it has been. But I didn’t really consider what it would be like to be somewhere where I didn’t know anyone, medically or socially.

So it took a minute. I popped up in people’s offices, I went out and shook a lot of hands, and I talked a lot with people in our medical community. Luckily, I landed in a really great neighborhood, where I got to know my neighbors pretty easily, and things like that. I also ended up being pretty involved in our professional organizations. As a bariatric surgeon, we have several, like the ASMBS and SAGES and things like that, national organizations that have also served as a form of community for me. So those are definitely things that I would recommend to other physicians. I think we underestimate the value of things like the AMA and other professional organizations, even in creating both local and broader communities for ourselves.

I will say that, you know, as doctors and surgeons, we really like talking about what we do, even if it’s to complain or to vent or something like that. So really having people who do what you do, whom you can talk with openly about what you’re dealing with, about struggles, and about the realities of practice, to me at least, has been a really critical aspect of coming out of some of that burnout and figuring out how much I actually like doing this.

Kevin Pho: One of the parts of your article was how much you loved operating, and your passion for surgery really shone through. So I was wondering if you could share with our audience: What’s it like for you in the operating room?

Maria Iliakova: Yes, so when you’re in the operating room, it’s almost like you’re with a lot of other people, in your mind at least. When we train through surgical residency and fellowship, you pick up this advice and the ways that other people do things, and they become almost like a quilt of what you are ultimately, or a mesh of what you are. So I constantly have people’s thoughts and sayings and things like that running through my mind, which probably resonates with a lot of people who have gone through training.

And to me, honestly, I know this sounds a little bit crazy, but it’s the calmest part of my life. It is the part in which I as an individual can have the most immediate impact on someone. It’s also the one in which I feel like there is the most control of an environment, as much as possible. And it also is the point at which I feel the closest to the patient. I know that seems funny, because I am actually primarily a robotic surgeon, so physically I’m about 10-20 feet away from my patient throughout most of the case. But the connection is so focused, such a one-on-one interaction, with what is going on with that person in their body, with you and your mind and your hands. I hate to use the word, but there’s almost a magical connection. That is kind of what it feels like when things are going well, which usually is the case.

I will say it can also quickly turn into a pretty chaotic and difficult situation when things are not going well. But even in the situations where there is difficulty or something unexpected happens, I remember one of my attendings in residency, a trauma and critical care surgeon. No matter what the situation, the patient could be coding, we could be doing a thoracotomy, there could be 20 people in the room, but he was always the calmest, the most collected, a cool-as-a-cucumber kind of person. And though I’m not always that way, that’s kind of what I strive to be, because no matter what, people understood that this is the person who’s in control of the situation, who’s going to help out, who’s going to be proud, and who is going to be solely focused on what’s happening and not let anything get to them. And that’s your role as a surgeon in the OR: to be that person no matter what.

Kevin Pho: So you mentioned that you do a lot of robotics as a bariatric surgeon. Tell us a little bit about that intersection. What’s the current state of the art when it comes to that?

Maria Iliakova: Yes, that’s a super interesting question, actually, because there’s a lot of movement right now in robotics. The dominant player on the market is called Intuitive Surgical. They make the da Vinci robot and have about 80 percent of the market. But there are many others that are coming out with robots, and there are some other robots already on the market. Medtronic has one that’s being used globally and isn’t quite FDA-approved yet, but it’s getting there. Same thing with Johnson & Johnson, and some others as well. And then there are other robots, like the orthopedic Stryker robots, and Zimmer, Hansen, and others.

Bariatrics is actually a hugely growing field, excuse the pun, in many ways, including robotics. And the robotic platforms themselves do offer some benefits when it comes to this patient population. We’re working with the abdominal walls of people who have BMIs typically over 40, typically with many comorbidities, so anything that you can do to make the perioperative planning in the OR safer for that patient ultimately can impact outcomes pretty drastically. And that’s to say nothing of the fact that you can actually standardize your procedures a little bit more easily as a surgeon. You can have control of your camera and instruments in a different way than you can laparoscopically or open. And ultimately, I will say that when you’re doing something like that, between five and 10 cases a day, ergonomics matters too. So everything about the procedure really is impacted, and ultimately it has a pretty big impact on how patients recover from surgery too.

Kevin Pho: So in the primary care setting, I do internal medicine primary care, and I’m seeing a patient who may be a candidate for bariatric surgery. What kinds of questions should I be asking them, or what kinds of questions should they be asking me, if they’re considering whether robotic bariatric surgery, or bariatric surgery in general, is right for them?

Maria Iliakova: Yes, that’s also a really interesting question, because we have a lot of those questions ourselves, in the office, in our professional societies, and globally. Bariatric surgery is something that historically, I think, has been seen as pretty extreme, or sort of the last resort for people who have excess weight and want to manage their weight. But there’s a lot of good data coming out now that maybe we should be considering it a lot earlier and for a lot more patients. In fact, fewer than 1 percent of eligible patients ever actually see a bariatric professional, whether that’s a surgeon or a bariatrician. So I think that’s a pretty stunning number. Even in running the numbers in our own hospital, we have thousands of patients who would qualify for evaluations, and certainly we’re not seeing thousands of patients in our clinic. So there is a mismatch there.

Really, anybody who’s interested in weight management, especially those who have a BMI over 30, would be a candidate for a discussion of bariatric surgery or other interventions to help, such as medical management with medication, and certainly physical activity, exercise, and mental health. And so would anyone who has comorbidities that are related to obesity as well. Those include things like high blood pressure and diabetes, but even things that we may not necessarily think of, like NASH and PCOS, are related, and even osteoarthritis. So we have a partnership with our orthopedic surgeons in town, and that’s been, I think, very beneficial for patients with joint problems as well, either in getting to surgery or, in some cases, in not even needing their joint surgeries when they go through the process with us.

Kevin Pho: She’s a bariatric and general surgeon. Her KevinMD article is titled “The joy of surgery: How one doctor discovered her passion.” Maria, tell us why you love what you’re doing, and maybe you can end with some take-home messages for the KevinMD audience.

Maria Iliakova: Yes, so I love that. I came into medicine not necessarily knowing what I was going to do. In fact, maybe I would do internal medicine and do infectious diseases or neurology or something like that, maybe with more of a research focus, and I kind of fell into surgery after a transplant rotation that I did. And I am so lucky that I got to find something that ultimately I couldn’t love more and couldn’t enjoy more, and that’s surgery, but specifically working in bariatric surgery with patients who have weight management needs and lots of other comorbidities and everything else.

I’ll tell you, the coordinator for our program just put up a board in our office that asks people for their non-weight victories, their non-scale victories, basically. And we had a patient who put on there: “I’m able to be off of my insulin, off of my diabetic medications.” And the last line there was: “I get a second chance at life.” That’s why we do this. That’s the best compliment a patient could ever possibly give you, that you’ve given them a second chance and you’ve given them a life, right? So everything that we do is ultimately for the benefit of giving people a better quality of life and better opportunities.

Kevin Pho: Maria, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Maria Iliakova: Thank you so much, Kevin. It’s really great to be with you.