Episode 23

Understanding Nvidia's Market Impact with Isaac Schafer

Episode Transcript

Dr. Randy Lehman [0:11 - 1:15]: Welcome to The Rural American Surgeon. I'm your host, Dr. Randy Lehman, a general surgeon from Indiana. This show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics such as practical surgical tips, rural lifestyle, finance, training, practice models, and more.

We have a segment called Classic Rural Surgery Stories, where you'll get a feel for how practice in the country differs from the city. If rural surgery is your passion, this show is for you. So now that the ChloraPrep has dried, let's make our incision. Welcome back, listener, to The Rural American Surgeon podcast. I'm your host, Dr. Randy Lehman, and I have with me today a special guest, Dr. Mel Johnson.

She is the newly elected president of the North American Rural Surgical Society. She's also a program director at Gundersen Lutheran, which is in La Crosse, Wisconsin, and has a history of training rural surgeons. She has a special passion and interest, and I'm so honored to have you on. Thank you so much for joining us, Dr. Johnson.

Dr. Mel Johnson [1:15 - 1:32]: Thank you so much, Dr. Lehman, for the invitation to be on your podcast. I am absolutely passionate about training individuals to become rural surgeons. This is an absolute privilege for me to be on your podcast today.

Dr. Randy Lehman [1:32 - 1:43]: Yes, thank you for being here. So you trained at South Dakota and then went to medical school at South Dakota, then went to Rush, and then you ended up back in the role that you're in. Could you tell us a little bit about that journey?

Dr. Mel Johnson [1:43 - 3:01]: Absolutely. I am a South Dakota native, born and raised in Sioux Falls, South Dakota. So when I decided to go to medical school, I went to the University of South Dakota. I was mentored very much by a gentleman who was a rural surgeon for years, and I ended up going to Rush and Cook County Hospital in Chicago for my residency training, which may not sound very rural.

However, 50% of our training was at Cook County Hospital, working with an underserved population, oftentimes with advanced disease due to lack of healthcare access. I really felt that this trained me perfectly for treating the underserved of America, and it absolutely did. I returned to South Dakota upon my graduation from residency and practiced in Sioux Falls, both at Sanford and the VA Hospital, and helped start the surgical residency program there.

Then, just five years ago, Gundersen reached out to me and said, "Hey, will you come take a look at our program?" I made the move to Gundersen and then took over two years ago as the program director of the residency program. So that's how I ended up from South Dakota over to La Crosse, Wisconsin.

Dr. Randy Lehman [3:01 - 3:16]: Yeah, and of course, we just elected you in January as our president. We're so glad to have you as our representative. The other thing I, you know, wanted to touch on was that. Was that Dr. Timmerman who was mentoring you, or somebody else?

Dr. Mel Johnson [3:16 - 3:19]: That is correct. Yep. He is my surgical mentor.

Dr. Randy Lehman [3:19 - 4:32]: We're working on getting him on the show as well, just a giant in rural surgery. The other thing I wanted to mention is I totally agree with you that training for a rural surgeon doesn't mean that you spend five years in a critical access hospital. That would be terrible training. As a matter of fact, I was on, what is it, like a focus group or something like that?

I was working in Indiana on potentially making a one-year fellowship after residency for rural surgery. At the moment it is paused for financial reasons. But that was one of my big pushbacks. They can come rotate with me in the critical access setting, but if you want them to do hysterectomies, they shouldn't maybe do one in a month with me. They should go to an OB/GYN rotate, that sort of thing.

You need to be in a high-volume center and high-acuity center. Also, because you're the surgical gatekeeper for your community later, you need to know what they can handle and when to send them to places like Mayo to see new procedures and clinical trials. Thank you for commenting on that.

Dr. Mel Johnson [4:33 - 5:47]: Yeah, absolutely. When I reflect on my training, being in a high-acuity, high-volume setting, especially at Cook County, taught me to think outside the box due to limited resources. It set me up for rural settings where availability may vary, and you need to adapt.

I love that you mentioned that IU is considering a sixth year. You should ask Dr. Timmerman about this when he's on your podcast, as he's a huge believer in fixing the five-year program, which influenced starting the surgical residency program in South Dakota focused on producing broad-spectrum general surgeons.

He's a firm believer in getting people ready in five years.

Dr. Randy Lehman [5:48 - 6:22]: I'm a believer in that too. But if it's not practical, you know, having multiple tracks is not necessarily wrong. I could talk about this all day, but one more thought I had is, if trainees get a chance to do international surgery, it puts them in resource-limited situations, letting them distinguish what's essential. But perhaps we'll move on to the next segment of the show. Why is rural surgery special to you, being born and raised in South Dakota?

Dr. Mel Johnson [6:22 - 8:27]: Yep, that was a major influence—seeing throughout med school how much rural areas lacked access to care. Practicing trauma after Cook County, I realized disparities in trauma care access.

In Chicago, everyone's within minutes of a center, but in South Dakota, I took patients from Pine Ridge Reservation, with an average transport time of 12 hours. The resulting death and disability from geographic isolation starkly highlighted these issues.

Our residency program at USD focused on broad-spectrum training deepened my insights, and Gundersen’s focus on rural general surgeons for over 60 years has only reinforced my commitment. Just to plug our program, 2/3 of our grads go into practice, 1/3 into fellowship.

And if you look at national statistics, 80 to 90% of people in general surgery residency programs go on to fellowship. One-third of ours go on to fellowship. Of our two-thirds that practice general surgery, half of those go into what would be an urban practice, which means greater than 50,000. The other half are practicing in a place that's less than 50,000.

And so, again, that really led me in going there because, again, that's what they've been doing for years. That's what we continue to try to do. Because when you look at the shortages in the nation, that's where we need surgeons. We don't need more urban, academic, subspecialized surgeons. We need them out there caring for people as broad-spectrum general surgeons.

Dr. Randy Lehman [8:28 - 8:37]: Could not agree more. I have a couple of specific questions to answer to your comfort level about Gundersen. So they just had a big Bellin merger.

Dr. Mel Johnson [8:37 - 8:37]: Correct.

Dr. Randy Lehman [8:37 - 8:42]: Is that going to affect your residency program? Is there a different name now to your residency program?

Dr. Mel Johnson [8:43 - 9:35]: Great question. Because if you look us up online, you'll see this word Amplyfi. So, Amplyfi is the name that they have given to the two of us together. Gundersen's been around forever, Bellin out in Green Bay has been around forever. Bellin does not have a surgical residency program, nor do they have plans to have one.

Gundersen has had one for decades, and we will continue to have that. So the merger was really more of an expansion of our footprint across the state of Wisconsin as healthcare systems bring more patients into the system, expanding the insurance network. And it really wasn't based on the residency at all. Our residency is actually the Gundersen Foundation General Surgery Residency Program. Even though the healthcare system will now be Amplyfi, the residency will still retain the Gundersen name because we are funded by the Gundersen Foundation.

Dr. Randy Lehman [9:35 - 9:57]: Okay, sounds great. And the second thing that I would say is, I think I told you this, but I ranked Gundersen number one for my training program on the match, you know, but ended up matching at my number two, which was Mayo Clinic rural surgery track. Mayo Clinic has, you know, a specific, what is it in our NRMP or.

Dr. Mel Johnson [9:57 - 10:00]: What's the acronym or ERAS, whatever.

Dr. Randy Lehman [10:00 - 11:09]: Yeah, it's a specific thing that you're applying for general surgery at Mayo versus the other. Whereas Gundersen would be just kind of all applying to the same program. I only applied to that rural surgery track at Mayo, did not apply to the regular program at all. I find out later there's 300 applicants, and I got the one spot. 

This is why, so if you're a medical student, trust the match. Don't worry about it. Because if you match somewhere, then you know that that place wanted you too. But the thing about Gundersen is they often go really high on their match list. And what I was told sort of later, I mean, I came late to the game. As a third into fourth-year medical student, it really helps to do an elective at the place where you're trying to go.

I did not do an elective at Gundersen. I kind of wish I would have. I did come for a second look and did a few cases with your vascular surgeon and some people up there. What do you think? Should I be encouraging right now, if there's a medical student listening and they want to go to Gundersen to do a fourth-year, are you guys already overwhelmed with applications for away rotations or what do you think about that idea?

Dr. Mel Johnson [11:09 - 12:07]: Luckily, I get to screen everyone that applies for the sub-internships. So I really do screen out people that at least they're telling me they want to be number one, a general surgeon, broad-spectrum general surgeon. They're not looking to become some small subspecialist. So I look for that and then I also look for if they have some sort of connection to rural America. It doesn't have to be people just from the Midwest.

But because we have limited sub-internship spots, I do select those who will be, in my mind, a great fit for our mission. Yet, it is a highly competitive world out there. The last three years, this is my third season interviewing as the program director. We vet over 600 applicants, I interview only 40 out of those 600 plus, and then we match only four people. It's a numbers game, and in the last two years, we matched our four people out of our top 10 candidates.

Dr. Randy Lehman [12:07 - 12:08]: That's crazy.

Dr. Mel Johnson [12:08 - 12:52]: I think it does help. But when I'm thinking about last year's class, only one of them did a sub-internship there. So it certainly is possible to match with us. It again just depends on how much do I see them as the right fit. But regardless, I just did my rank list this week, and I would say that, well, I'd say everyone that we interviewed really fits what we're training. 

So I think we're getting better and better about it and I feel terrible that we won't match people probably above the 10 spot because they're all good. I wish I could train all of them. As you know, it's a financial game too, as far as how many people we can train at each site.

Dr. Randy Lehman [12:53 - 13:19]: Well, they'll all find spots. I mean, residency is one of those things where you get out of it what you put into it, for sure. And you can become a great surgeon at a lot of different places. I mean, you can go to Caribbean medical school and become an excellent doctor, for example. Some of the best doctors I know took some sort of track like that, and then they owned it. 

Then there's other people that went to the beach, partied, and dropped out. Once you get in that door, it's what you make of it.

Dr. Mel Johnson [13:19 - 14:14]: And, Randy, one other comment on rural tracks, because Mayo's got the rural track. I believe they're still just matching one, but I've heard rumors that maybe they would increase that. UW Madison also has a rural track, and they just increased from one to two spots. What really encourages me, especially from my role with North American Rural Surgical Society, is seeing that many, many programs are beginning to realize.

Because, again, oftentimes, programs are run by academics, researchers, subspecialists who have been focused on the training of the general surgeon. But I really think we're the cool kids on the block right now. I believe this is a great time to be focused on general and rural surgery. And I think we're seeing that even with our society, in that more and more residency programs that would have been considered more urban training programs are now realizing the benefit of training people for general surgery.

Dr. Randy Lehman [14:14 - 14:52]: Yeah, great. Madison was my number three, of course. So I interviewed at three places that had a rural track, and those were Gundersen, Mayo, and Madison. I had no connection to that i90 corridor. Before that, I was, you know, down in Indiana. But then it's just ironic how I ranked 1, 2, 3 like that, but it's a beautiful section of the world.

And now I have Gundersen privileges, actually, still. I'm sort of like in your group in this Locums role a little bit. So it gives me a little bit of... People like to be connected still to their residency program. I like to be connected to the Coulee region of the world with those beautiful bluffs and go up there a few times in the summer.

Dr. Mel Johnson [14:52 - 14:52]: It's.

Dr. Randy Lehman [14:52 - 15:15]: It's awesome. So why don't we move on to the "How I Do It" section of the show? We're going to be talking about sentinel lymph node biopsy as it pertains mostly to breast cancer, the associated nuance, and rolling out a program in a rural place.

So let's talk about first just who the candidates are for sentinel lymph node biopsy and getting a patient to the operating room, and then we'll talk about the technical details.

Dr. Mel Johnson [15:15 - 17:01]: Perfect. Yes. So a big part of my practice is doing sentinel lymph node biopsies and mostly doing cancer surgeries. I do it primarily for both breast and melanoma. But we'll focus on breast for today because there are extensive nuances to all of that. 

I have gone through the process of rolling it out with one of my partners who provides care on an outreach basis in Hillsborough, Wisconsin, which is very rural. So I helped him get a program up and running to add more breast cancer care out there. I also brought breast cancer care to the Sioux Falls VA when I was there. And so I'm happy to talk, too, about how to bring in a sort of new technology or new surgical procedures to an environment that maybe isn't used to having those. Who needs sentinel lymph node biopsy for breast cancer? Well, currently, we still do recommend those for all patients with invasive breast cancer. 

We'll talk a little bit later in the segment about newer trials, which may be leaning away from doing them in many T1 patients. But for the sake of this beginning conversation, we'll just say if a patient has invasive breast cancer, at least for the last few decades, a sentinel lymph node biopsy was indicated. It is not indicated for patients with DCIS unless you're doing a mastectomy. We can even talk about nuances of that. But for now, again, if you have a patient wanting a mastectomy with DCIS, we typically will do the sentinel node biopsy because if you find any invasive cancer during that mastectomy, for the most part, it's very difficult to go back and do a sentinel nod.

Dr. Randy Lehman [17:01 - 17:33]: Right. So if somebody has, I'm going to sidebar for just a quick second. Somebody has DCIS, they're going for mastectomy. What level of risk would you consider and discuss and potentially offer a contralateral prophylactic mastectomy for a patient versus, like, encourage them to do it? Like, in terms of a percent risk, like, is it 20, you know, 40? You encourage, you know, just throwing out some numbers.

Dr. Mel Johnson [17:33 - 17:45]: When I'm counseling someone, and again, let's say they've already said, hey, I want a mastectomy for my... And you want me to specifically discuss DCIS for mastectomy or invasive?

Dr. Randy Lehman [17:45 - 18:02]: Sure. You're doing a mastectomy on one side for either DCIS or invasive cancer. Okay. The reason that... First off, back to the sentinel node thing. The reason you're doing a sentinel node if you're doing a mastectomy for DCIS is because there's a significant upstage risk, correct?

Dr. Mel Johnson [18:02 - 18:02]: Correct.

Dr. Randy Lehman [18:03 - 18:27]: Okay, so it's either reason you're doing a mastectomy on the one side. Now, the conversation about prophylactic contralateral mastectomy, I just kind of want to know how that goes and if there's numbers that you can share with our audience, like where. Like, if their contralateral risk is 9% lifetime, do you steer them away from it? You know, just tell me a few thoughts about that.

Dr. Mel Johnson [18:27 - 19:54]: Absolutely. If I'm offering them a unilateral mastectomy, as long as they're an appropriate surgical candidate for a longer procedure, I would offer the possibility of a contralateral mastectomy to all of them. Let's say it's a patient with BRCA or PALB2 or some genetic variant that increases their risk significantly on the other side, then I would counsel them to have the contralateral mastectomy. That would be my recommendation.

Included in that group would be, let's say, they have LCIS, because we can see up to 40 to 50% risk for both sides. Again, it depends. There are so many factors, including family history. But for things like LCIS, BRCA, PALB2, I really would recommend that they consider doing both sides at the same time because all of those groups, we can also offer bilateral prophylactic mastectomy to those patients. So even if they don't have a cancer, it's appropriate to offer bilateral to those patients.

But if they just have cancer on the one side and their screening on the other side is completely negative, I still will offer the possibility of both sides if they want. I offer that to every single patient, again, as long as they can tolerate that degree of surgery. I also offer up the possibility of breast reconstruction for anybody that's having either unilateral or bilateral.

Dr. Randy Lehman [19:54 - 20:02]: Yeah. And so tell me, why do you offer the other side? Is it for symmetry or is it for risk reduction? Or what's the reason?

Dr. Mel Johnson [20:02 - 20:51]: Mostly, if they desire it, I give it as a choice. All right, here's what... And I go through, here’s what it would be like if we do a unilateral. This is how many hours you'll be under anesthesia. This is what it will look like when we get done. I also offer them the possibility of reconstruction or just wearing a prosthesis if they do one side. So I really try to lay out absolutely everything.

If they’re not in that high-risk population, I say it is completely patient choice. It is not necessary to take the other side. If we don't take it, you're going to get a mammogram every year. But if they're not in that high-risk group, I really just say it's their lifetime risk. I can put in numbers for them, too. I mean, you can even use something as simple as the Gail model and say, all right, here's your risk on the other side.

Dr. Randy Lehman [20:51 - 20:54]: Do you like the Gail or the Tyrer-Cuzick model?

Dr. Mel Johnson [20:54 - 21:11]: We have just started switching over. We were using the Gail model, and now our high-risk clinic is using the Tyrer-Cuzick. In fact, they're now doing that on all of our patients coming for screening mammography. So patients actually have that. So every single patient that gets a screening mammo now has that number on their sheet.

Dr. Randy Lehman [21:12 - 21:43]: Yeah, I love it because it comes on the report, and then I don't have to actually plug a lot of stuff in. I just use it. I was talking to one of my colleagues that trained with me at Mayo, and she went to breast fellowship. Now she practices in Arizona. And my question to her, because I had somebody coming to me just asking for prophylactic mastectomy... She didn't have cancer. She was asking for prophylactic bilateral mastectomy. Busy mother. She was recommended six every six months, MRI and mammogram indefinitely.

Dr. Mel Johnson [21:44 - 21:47]: And what was her calculated lifetime risk?

Dr. Randy Lehman [21:47 - 21:49]: I think her risk was around 20%.

Dr. Mel Johnson [21:49 - 21:52]: That's usually the cutoff for insurance companies.

Dr. Randy Lehman [21:52 - 22:17]: Okay, so you're gonna encourage them over 20%. That was my question to her, like, if there's a... She said she would encourage somebody over 40% risk to have a prophylactic mastectomy. Even for a patient that doesn't have any cancer, both sides do a mastectomy. But if it's like 20 to 40, reasonable to do. Under 20, counsel them away from it. Do you agree with those numbers?

Dr. Mel Johnson [22:17 - 23:35]: I do. You know, when we refer someone to our high-risk breast surveillance clinic, which could come out of their, you know, when they calculate their Tyrer-Cuzick, or let's say they had ADH or some other high-risk lesion at some point, we outline everything that can be offered for them. From increased surveillance, maybe with adding in a breast MRI, to the possibility of doing endocrine therapy, all the way to the possibility of doing bilateral.

Have I had patients opt for bilateral prophylactic above 20%? I have. I certainly don't push for that.

That, to me, seems, you know, if you look at baseline risk of being one in eight women will get breast cancer, that's 12%. 20% is not a whole lot higher. I would say for most of my patients, 50% seems for them mentally to be a major cutoff. If you give somebody a greater than 50, that's a flip of a coin. Once they get above 50, almost everybody will opt for the prophylactic surgery. But have I seen people opt for it right at, like, 20.2%? I have. I don't encourage that. But it is approved. It's approved by insurance.

Dr. Randy Lehman [23:36 - 23:40]: It's helpful for me to tell the patient, well, you've got an 80% chance you're not going to get breast cancer your whole life.

Dr. Mel Johnson [23:40 - 23:58]: Correct. Yeah, I do that rarely. But I do have patients. In fact, I had one of my partners who is a breast fellowship-trained surgeon. She just had someone who is 21 years old who's just hovering around that 20% saying, I want both of them off at age 20.

Dr. Randy Lehman [23:58 - 24:21]: Yeah, that's kind of how this situation was. The main thing for this lady wasn't like honestly being too scared of getting breast cancer. It was like, I don't want to do every six months. I don't have the time, energy, and resources to do all this. And I would rather just do surgery now if the choice is between those two things. It's not actually like an I'm worried about getting breast cancer thing. So that was a weird conversation to have as well.

Dr. Mel Johnson [24:22 - 24:51]: They have to drive. You know, if you think about somebody that needs a mammogram and MRI every six months, and let's say they live two hours away from the nearest place, especially for a breast MRI, those patients, or let's say they're a farmer, right, they don't want to take the time off, they'd rather just be done with it. So it is definitely acceptable to offer all those options. But at 20%, I don't. Again, I agree with you where you just say you have an 80% chance that you never get it.

Dr. Randy Lehman [24:52 - 25:03]: Okay, I have one more question before we get into the technical part of the sentinel lymph node biopsy. That pertains to what we were just talking about. So your colleague that's in Hillsborough, they are doing full spectrum breast practice there.

Dr. Mel Johnson [25:04 - 27:18]: He does not have the ability to offer breast reconstruction. We do not have any plastic surgeons. So for patients that want reconstruction, he would refer them to Gundersen for that. But he is able to offer sentinel lymph node biopsy. There's a lot of logistics with that because we use, at Gundersen La Crosse, we use the neoprobe. So those patients that go out to Hillsborough, they're getting their radioactive seed placed at Gundersen La Crosse, which can be placed up to two weeks before surgery. So that can be done well ahead of time. At Gundersen, we do something relatively unique. I was not doing it back in South Dakota. In South Dakota, all our patients went to nukemed for formal lymphoscintigraphy before we did sentinel nodes. Gundersen doesn't want to do that. We inject our own lymphoseek in the pre-op holding area. So we go through a short training with nukemed. So he can bring lymphoseek out to Hillsborough and do his own injection because he's already verified to do that. Frankly, our lymphoseek actually comes from UW Madison. So on any given day when we're doing sentinel node biopsies at Gundersen, it's arriving at 6:40 a.m. So we already are shipping in our lymphoseek. So that can be done really at any facility. So the lymphoseek arrives. All you have to do is be certified to inject it. That doesn’t really hold much up. It's easy to get that certification. He's got the neoprobe out there. So your hospital, no matter what you're using, let's say you're using Magtrace or lymphoseek, or you want to use ICG, you've got to have the equipment then to find those nodes. What does your hospital want to invest in? We have the neoprobe already at Gundersen. So he was able to arrange to just have a neoprobe be out there when he's scheduled. Cases are always elective. But that brings up another point for many rural surgeons. A lot of rural surgeons now are getting a robot. So many more are having ICG capability. If you have ICG capability, you really probably don't need the lymphoseek. You could do blue dye and ICG.

Dr. Randy Lehman [27:18 - 27:25]: I don't know. I've seen some patients back that had that somewhere else and they didn't catch the nodes. Right.

Dr. Mel Johnson [27:25 - 28:00]: And I'm not saying it's better. We're still doing lymphoseek. I certainly think that two tracers are better than one. I would not rely on just blue dye. I just did a case yesterday. The blue dye injected looked like it was moving nicely. I had zero blue channels, and I had zero blue lymph nodes. It was my lymphoseek that picked it up. So, you know, in the days now where we really are trying to minimize lymph node surgery, I really think you have to have two methods to do it so that you're not doing full node dissections.

Dr. Randy Lehman [28:00 - 28:15]: Yeah. So at the big house, we'll say in La Crosse, Wisconsin, Main Gundersen Hospital, where you're practicing, if the patient wants reconstruction, then they'll meet with the plastic surgeon and you have the plastic surgeons on staff, and you do a combined case.

Dr. Mel Johnson [28:15 - 28:32]: Typically, yes, unless there's something about the patient that they want to do delayed. But that would be a decision made by plastics. But I would say most people getting immediate reconstruction, most of them are getting it in the primary setting. I'd say maybe 10% are getting delayed.

Dr. Randy Lehman [28:32 - 29:48]: Yeah. Because I have a desire and I think it's a great thing for breast surgery to be able to be done in rural hospitals. I'm now in four critical access hospitals. All have totally different arrangements. Some of them have different types of probes and different. And then some of them have nukemed and some don't. That can come and go based on even tech availability. So there's lots of crazy things. I don't have any plastic surgeons with me at any place. But what I was wanting to do at some point, hopefully sooner than later, is find somebody that would be willing to come in and help me, but that's really hard to do. And then do, like, the combined cases. I don't know if there would be a way to line up some other skin stuff and whatever for a plastic surgeon to come in and maybe have a full day, have other things to do while I was doing my part of the case. These are the things I haven't got there yet with my own practice. And so then I end up having these conversations. And I've also heard of some people, especially in the Dakotas. I've heard of this. First off, you could place a tissue expander if you had a relationship with a plastic surgeon that was willing to do that. I have not found anybody in Indiana that wants to do that with me. The other one is to leave the skin and just kind of stitch it up like a little volcano and then send them for plastics afterwards.

Dr. Mel Johnson [29:49 - 30:15]: You can absolutely do that. I have done that even at the big house. Again, that's in a patient whereby they had already decided, but you could make that decision anyway, again, based on availability. Where the patient's a good candidate for skin nipple areola sparing surgery, you can do the entire case there, you put a drain in and three months later, they go down the road and they get their reconstruction.

Dr. Randy Lehman [30:15 - 30:22]: So you close the skin completely up at your incision. You don't do a purse string stitch and leave it a little bit open, do you?

Dr. Mel Johnson [30:22 - 30:22]: No.

Dr. Randy Lehman [30:22 - 30:25]: No. Okay. That's some ways, like a colostomy site, you know.

Dr. Mel Johnson [30:25 - 31:05]: Yeah, it works fine because they're, you know, our plastic surgeons primarily are doing sub-pec implants, you know, sub-tissue expanders and implants. So there have been times that they've decided to do that anyway. For instance, I've had some patients who are extraordinarily thin, so they don't have much of a fatty layer behind the skin. And so they don't want to stress it at all initially.

I'll do the skin, nipple areola-sparing mastectomy, put the drain in, Plastics follows up with them, and then they wait. They let that flap basically sort of breathe, and then they put the expander in down the road. So the results look beautiful. So there's no reason why you can't.

Dr. Randy Lehman [31:06 - 31:28]: Do a multi-stage procedure including mastectomy. Right. And that's why I'm saying how can we do the mastectomy in the rural environment? That's why I was asking about Hillsboro, but great answers.

The Lymphoseek trade name. So that is tech 99. Correct. Okay, so is that the same stuff that's being injected in nucmed when they're doing the scintigraphy? It's the exact same stuff. Right?

Dr. Mel Johnson [31:28 - 32:07]: Same stuff. We just don't do the imaging. Yeah, we do for melanoma. So don't take this to mean because melanoma, especially melanoma of the trunk, can cross over. It can go up to the neck, it can go multiple places. So for our melanoma patients, they still get formal nucmed lymphoscintigraphy with imaging.

For breast, we do zero imaging. We do the injection literally in the pre-op holding area, and that patient rolls back to the OR. We inject the blue dye in the operating room, and we go ahead and do it. And I listen, and I already have uptake in the axilla by the time they've rolled from pre-op to intra-op. I already have Lymphoseek uptake out there.

Dr. Randy Lehman [32:08 - 32:30]: I think that would make me comfortable if I heard counts in the armpit. But it really gives me a lot of peace of mind to see the picture, too. Even in a breast case. I did see a case in residency that was a re-op, and that one tracked to the internal mammary nodes, but that would be a specific thing. Maybe you would still get imaging on something like that to track it down.

Dr. Mel Johnson [32:30 - 33:19]: But yep, re-ops, I send to nucmed and I have to get imaging. And I have to admit, and again, I don't know that you'll find a protocol for this, but I have even done. Let's say your patient has a bilateral mastectomy with reconstruction, and five to ten years down the road, they get a local recurrence, like along the skin incision. I do send those patients to nucmed because by then, especially if a lot of time has passed, they have already established new lymphatic channels and networks.

So those patients, I get them injected, but I do it in nucmed, because you're right, they could go to internal mammary. I've even seen them go across the chest. But then I do a repeat sentinel lymph node biopsy, and we're talking about people that have really no breast tissue left, but they have a skin level recurrence. So I treat it almost more like a melanoma as far as that protocol.

Dr. Randy Lehman [33:19 - 33:30]: Yeah, great. And our listener may find themselves in a rural place where they don't have those nucmed capabilities. So that would be a patient that you then have to send out.

Dr. Mel Johnson [33:30 - 33:31]: Yep. But I.

Dr. Randy Lehman [33:31 - 33:33]: And that. That's the problem is your.

Dr. Mel Johnson [33:33 - 33:37]: I can do with lymphocyte injection myself with no imaging.

Dr. Randy Lehman [33:37 - 34:34]: But the problem is there becomes so many patients that then you're sending out because of the plastics thing or because of the nucmed thing or one reason or another. And then. And then, you know, there's only so many cases to begin with. Now you're cutting the volume in whatever half or, you know, down by a third or something. And so then it's even further sort of out of your hands.

And I think that it for a rural surgeon, it can become one of those things where you just say, like, I don't do. The problem is blessed is the best case to do. From an anesthesia risk perspective, it's not cavitary surgery. You're never gonna need an ICU for the most part. For these patients, it's skin and subcutaneous tissue. A lot of it's going home the same day. It's like the exact type of surgery, a short, simple case with low morbidity mortality that we want to be doing. But then because of this, if we lose it, you know, that's why we're having the conversation. What can we do to keep it, you know, close to home?

Dr. Mel Johnson [34:34 - 36:45]: But I think the surgeon has to want to do it. And then you've got to be willing to get by some of those obstacles, like you've got to have multidisciplinary discussions about these patients. And you think, well, how can I do that? When I was at the VA, even though I was located in Sioux Falls, we didn't have all the players to have a multidisciplinary conference.

So I reached out to our two private hospitals and said, hey, I want to present my patients, albeit virtually at your multidisciplinary conferences. So I could still, not just to check the box, but that really is the best way to care for them. But immediately it just happened to be Sanford that said, hey, we'd love it if you did that. And again, you can scrub patients names so there's not HIPAA issues, but you can do that in the world of virtual care. You can check that box.

You can figure out two ways to do sentinel lymph nodes. You can try to recruit a plastic surgeon to come out maybe twice a month. That's possible. I did recruit a plastic surgeon to come over to the VA just to do breast reconstructions. He was an older, nearly retired guy, but he said, hey, I'd love to do that, you know, so it's. It's possible. You've got to know the people and go after them, but you can also do delayed reconstruction. So that's possible. There's many, many ways to sort of get around, but there will be roadblocks thrown in your way, so you have to want to do it.

And you can run your own high-risk surveillance clinic too. You really can. And patients absolutely love it. They want to stay rural. So it's possible to do, but you've got to, I think, let's say you trained wherever you trained. I think you have to go with that mindset to whatever hospital you set up shop and say, I realize you haven't been doing breast care. Here's the pieces we need to build. And it is possible to build almost all of those pieces.

Again, you're right. You're gonna have to send out certain patients that just can't stay there. But I would say over 75% of the people that I operate on regularly for breast. I could easily do at a critical access hospital if I built in these. These pieces. So it takes. It just takes the passion to do it.

Dr. Randy Lehman [36:45 - 38:03]: I feel like everything you say triggers me for, like, three, four questions. Right. We could go all day, but there is one that I want to touch on, because a buddy of mine this week asked me about, do you have a tumor board that you can present your cases at? And the answer is kind of yes, but I haven't done it.

But the other thing that I ran into this was, like, a couple years ago. So my memory is a little fuzzy on how this went. But the way I remember it happening is I approached a system nearby, and now I'm more, like, tied in with a few other systems. So I think I have more options. But at that time, what I remember them saying was, we would be happy for you to present your own cases, but we would not welcome you to attend our tumor board. You could come in, present your case, then go. Go away.

And I don't feel comfortable with that, because what I want to do, actually, is just, like, attend their tumor board for, like, four to six months, you know, and get comfortable with how they talk about things so that when I come in, I don't look like an idiot, you know, because I'm presenting it.

However, whatever the way I would normally present it, I want to kind of, like, fit into their system, and that wasn't cool. So I just, like, said no. Did you experience that with Stanford?

Dr. Mel Johnson [38:04 - 38:36]: I would look for a different system, yeah, because Stanford was very willing. Again, I also had privileges at Stanford, but again, this was me bringing in outside cases. At the time, I was clinically 100% at my elective practice, was 100% at the VA, and they said, absolutely. 

I was allowed to attend their tumor board, and I could pipe up about their cases. They gave me input on mine. But I have to tell you, the other system that I approached with it wanted nothing to do with it. So you've got to find an organization that is open and willing, and it should be.

Dr. Randy Lehman [38:40 - 39:01]: I just want to sit in on, like, you know, at least a half a dozen tumor boards before I, like, open my big mouth and say something. You know, it's just a little intimidating. I mean, if it's intimidating for me, I'm sure it's intimidating because I got, like, too much extroversion to begin with. So for most people, I can imagine it would be intimidating.

Anyway, tell me about CMEs though, too, right, because it makes it easy for you to get CMEs at your rural hospital. We offer CMEs for our breast tumor conference, which we have every single week at Gundersen. It's a great way, again, for you, as the rural surgeon, to stay up to date on everything related to breast care and to earn CMEs at the same time.

Dr. Randy Lehman [39:22 - 39:40]: Well, you know, I have Gundersen privileges. Maybe I should look into the Gundersen breast thing. That's not even in my state. This conversation was so good and packed with information that I had to split it into two parts. Trust me, you're not going to want to miss the second part. So join me next week for more with Mel Johnson [Uncertain] on The Rural American Surgeon.