Episode 10
Purpose, Practicing, and Publishing with Dr. Michael Sarap
Episode Transcript
Dr. Randy Lehman: [00:00:07] Welcome to the Rural American Surgeon. I'm your host, Dr. Randy Lehman. On this show, you'll receive powerful insights and resources for rural surgeons. I'm a general surgeon in northwest Indiana, and this show is tailored around the nuts and bolts of rural general surgery practice. But you'll find topics ranging from practical surgical tips to a host of others, including rural lifestyle, finance, training, practice models, and more. We'll have a segment called Classic Rural Surgery Stories where you'll get a feel for how practice in the country differs from the city. Whether you're a surgeon, other specialist, or primary care, or simply someone interested in health care for rural America, I'm glad you're here. Now let's get into the show.
Dr. Randy Lehman: [00:00:46] Why don't we move on to the next section of the show, which I also like, called the Financial Corner. Do you have any particular big money win or big money loser, a tip that you would really want your junior partner or somebody like that to know?
Dr. Michael D. Sarap: [00:01:03] Yeah, I think that you need to get yourself a financial consultant and not look at the market every day or read the Wall Street Journal. And I think it's really important. I've been very, very fortunate to find one that's a fiduciary—you're not getting charged every time they trade a stock. The people you need to be talking to are the ones who, as the commercials say, do better when you do better.
It is tough to find a company that will take you on unless you've built a pretty good sum. Some companies won't take you until you have about a million dollars saved up. It's very difficult to get to that point, but I think the important part is to avoid someone who churns constantly or sells their own company's assets, stocks, and bonds.
The people I use go through Schwab, and they do such massive amounts with Schwab that there are no trading fees. They can buy and sell with no fees to me whatsoever. It's all third-party with Schwab. At the end of the year, they charge me a certain percentage of what I have in my account, and it's been incredible.
We've had our personal pension fund from the company with the same people managing it, along with my personal accounts. The other great thing is that I have both a financial guy and a life planner for the same fee. At every stage of my life, whether I have a new kid, a new grandkid, or I want to set up a tuition fund, the financial planner's whole job is to make me successful.
They ask the right questions and provide answers because life changes a lot. Society changes, things happen, and you go through different stages. I've been so fortunate to have these people for about 30 years. I never check the stock market, never worry when it crashes, because I know I'm leveled out. They know my level of risk, and we understand each other. The bottom line is, if I do well, they do well.
Dr. Randy Lehman: [00:03:48] So how did you find them, and how would you recommend a junior partner, for example, find someone if, say, they don't live in your town?
Dr. Michael D. Sarap: [00:03:58] Yeah, I think you can talk to people—talk to surgeons who've been around. You know the ones who are comfortable versus the ones scraping for cases because they've had two divorces and are in bad financial shape. Ask people in the community, especially those who have been successful, what they do.
Dr. Michael D. Sarap: [00:04:30] You know, I think that part of the mentoring from a senior partner is to help you with your life as well as your practice. I've connected every one of my junior partners with my group. Even if they don’t have a large amount in their savings, these folks know that they’re surgeons. They know their salaries, and they understand their employment stability. So, they take them on early, even without that $1 million minimum.
We also group a pension from the corporation with their personal assets, and that makes them more willing to take them on. Sometimes smaller companies do better in this regard. These companies are nationally rated, so you can start by reading about them and learning who they are.
Dr. Randy Lehman: [00:05:14] What percent do they charge you?
Dr. Michael D. Sarap: [00:05:16] You know, I’d have to look at that. I haven’t checked in a while because, over the last 30 years, it’s averaged about an 8% to 10% gain through thick and thin. But I’d have to look at the specific charges.
Dr. Randy Lehman: [00:05:31] I have a senior partner story about that. My senior partner told me, "I have every dollar I’ve ever made." That resonated with me. I realized I’ve saved every dollar I’ve ever made, too—not from passive income, obviously, but from my active earnings.
If you blow it all and don’t have anything to invest, there’s no point in us giving you advice. An investment advisor might help coach you on increasing your savings rate, but they can’t solve the problem if you’re not saving anything. It’s not a scarcity mindset—it’s about discipline. If you can’t hang on to it, no one can help you.
Dr. Michael D. Sarap: [00:06:34] Got it.
Dr. Randy Lehman: [00:06:35] My mentor said he had every dollar he’d ever made, and he shared that advice with someone who looked at him funny. I understood immediately. It’s a mindset of thinking long-term. There are so many ways to approach this—some people invest traditionally, some explore alternative methods, and others embrace the "fire your financial advisor" movement to save on fees. But when the market’s down and you panic sell, you really hurt yourself. Thank you for sharing all of that. Did you have anything else?
Dr. Michael D. Sarap: [00:07:28] The advice about living like a resident after becoming an attending is crucial. If you maintain that mindset—avoiding brand-new cars and extravagant spending—you can save significantly in the first few years of your practice. Compounding works amazingly well.
That said, you can still enjoy yourself. Transitioning from a resident’s salary to an attending’s salary is a big jump. There’s no reason you can’t have fun, travel, and enjoy life. But you need to track your monthly expenses and know what you’re putting away. A good financial planner or life planner will warn you about potential issues—like running up credit card debt—and help you stay on track.
Dr. Michael D. Sarap: [00:08:10] You can’t carry an interest. Maybe your expenses are a little high for what you’re bringing in right now. And you have all these other things, and you’ve got three kids, and you know what college costs in 10 years. So, I think it’s good to have that little whisper in your ear from somebody that knows—knows better than you.
Dr. Randy Lehman: [00:08:36] What was the happiest year of your life?
Dr. Michael D. Sarap: [00:08:38] Oh, man, that’s a difficult question. It really is.
Dr. Randy Lehman: [00:08:44] Thing to do with your bank account?
Dr. Michael D. Sarap: [00:08:50] No, absolutely not. Some of the happiest years of my life were during residency. I had a bunch of great colleagues—guys and girls. Even though we were working like dogs, we had great camaraderie. I’ve had the greatest partners in the world—both the older partners I started with and the younger ones I have now.
We have fun every day. I have a great family, and we’ve spent time traveling and watching my kids grow. Now, I’m chasing my grandkids. My childhood was really fun too. I don’t think I can put my finger on one happiest year, but it has nothing to do with my bank account. I think you make a wonderful point there.
Dr. Randy Lehman: [00:09:35] To me, I mean, freedom is great. I love freedom. That’s one of my highest values, and that’s what the money in my bank account represents to me. That’s why I think the personal financial journey is important for people. For example, this podcast costs me about $37,000 a year to produce. That’s no problem.
Even if I quit working as a surgeon right now, I could still do this from my passive income. I’m okay. Now, this allows me to pursue a dream I’ve always had: doing this podcast. Basically, I’m just talking to myself—nobody else is listening, Mike, you know? But that’s okay. This is something I’ve wanted to do, and now I can.
It comes down to limiting myself in other areas, being halfway smart, and investing in the right things. That’s where money helps. But happiness doesn’t come from that. It comes from your experiences, relationships, purpose, and the good you do for others. Those are the things that give you deep satisfaction. Have you ever heard of the Japanese concept ikigai?
Dr. Michael D. Sarap: [00:10:57] It’s on my list to talk to you about! It sounds like you’re already there, but go for it.
Dr. Randy Lehman: [00:11:05] No, no, I mean, it’s a perfect word. The Japanese have so many one-word meanings that could fill an entire book. They strive their whole lives to find the sweet spot in life. That sweet spot means doing something you love, that you’re passionate about, and that you feel you’re the best at—even if it’s the best in a small rural county.
It’s about doing something you’re compensated for—financially, socially, or emotionally. That could be as simple as your grandkid hugging you after school. Lastly, it’s doing something the world really needs. Those 60 million people in rural America need you. They need me. I may not be the best surgeon in the world, but when they come in with a bad gallbladder, an obstructed colon, or after a horrible accident, they need me there.
That allows me to live my ikigai. The other meaning of ikigai is the reason you get out of bed every morning. It’s your meaning, the reason for your life. Being a rural surgeon has allowed me to find my ikigai well before most people reach it in their lives.
Dr. Randy Lehman: [00:12:55] And then the other thing is, Viktor Frankl wrote this book called Man's Search for Meaning. He says that people travel forever and spend lots of money trying to find the meaning of life. But it’s different. It’s actually about being able to live a life of meaning. It’s a play on words, but it means that one of the ways you do that is by caring for others and involving yourself in important endeavors, deeds, and experiences—like your podcast.
It makes your life meaningful. So, to me, when I think about what I’m going to get involved in or what causes I say yes to, I ask myself: Does it make my life more meaningful? And your podcast certainly does. The experiences I’ve had and the things I’ve gotten into—that’s kind of my mantra, my reason.
Dr. Randy Lehman: [00:13:14] Yeah. And having fun. Don’t forget to have fun.
Dr. Michael D. Sarap: [00:13:17] Well, that’s all part of it. Absolutely. Yeah.
Dr. Randy Lehman: [00:13:20] For me, I found four things: coffee, my family, doing surgery, and flying. Those are my things. A lot of days, I do all four of those things. One time, I was flying in my scrubs with my son sitting next to me, a cup of coffee in my hand. I took a picture because it embodied all four. I was flying to do surgery, you know—it was perfect.
So, you have to have those things that just make your day. And then try to enjoy them in the moment, right? I’m not preaching to you—I’m preaching to myself. Okay, this is something I try to remind myself to do. Someone said recently there’s no such thing except for the present. The past is gone, and the future is going to be different than you expect. Once you get there, it’s the present.
I spend so much time not being in the present moment. I need to remind myself: Wow, I’m not in pain, I’ve got a comfortable chair, great company—Mike Sarap—and we’re talking about rural surgery. Really, what’s better than that?
Dr. Michael D. Sarap: [00:14:50] You know, it doesn’t get any better than that. Yeah. That’s so true.
Dr. Randy Lehman: [00:14:54] Thank you for being here again. So, let’s move on to the next section of the show called Classic Rural Surgery. This segment highlights classic rural surgery scenarios—things that urban surgeons might not experience.
Dr. Michael D. Sarap: [00:15:11] Well, I mean, that’s kind of a daily thing. Just off the top of my head, somebody comes in the middle of the night with a stuck piece of chicken that’s been there for six hours. It can be very difficult to remove. Urban surgeons have no clue—they’ve never seen it. Many of my new partners, that’s their first case, and they’re asking why.
They’ve done colonoscopies with colorectal surgeons, but not a lot of therapeutic upper endoscopies. Another classic rural surgery scenario is when a patient can’t be transferred for various reasons—they’re unstable, and you’re forced to do something outside your comfort zone. In the urban setting, you’d just call someone. But if you’re alone and someone is bleeding to death on the table, you draw on every experience from your five years of general surgery training and your years in practice.
I remember a nine-year-old girl who came in with a gunshot wound from a local campground. She was hypotensive, and there was no way we could put her on a helicopter. We managed to get her from the emergency room to the operating room in 15 minutes. Thankfully, we had a little advance warning.
Dr. Michael D. Sarap: [00:16:20] She had one gunshot wound, but it went through her stomach, liver, spleen, pancreas, and kidney. She was nine years old. We don’t do pediatric trauma—we shouldn’t be doing it. We have nurse anesthetists, so my partner and I performed a laparotomy. Thankfully, our partners who live in town are willing to come in and help.
During the laparotomy, we found her kidney was completely shattered. There was retroperitoneal bleeding. With a nine-year-old girl, I was faced with the choice to remove the kidney or let her die. We patched her stomach—she had a through-and-through wound—packed the liver, and used a little argon on the spleen. But ultimately, we had to remove her kidney. The entire laparotomy took about 60 minutes. She stabilized and did well.
Once stable, we transferred her to the children’s hospital, leaving some drains in place. They didn’t have to operate on her again. Would I ever do a nephrectomy on a nine-year-old again? I hope not. But that’s classic rural surgery. We all have stories like that—cases we’ll never forget. She later came back, sat with us, and laughed. Those moments make it worthwhile.
When I talk to residents, I tell them: no matter what rotation you’re on or how boring it seems, don’t leave the operating room. Look over the surgeon’s shoulder. Get your hands in there. Whether it’s vascular or pediatric surgery, even if they’re not letting you do anything, watch and learn. It will come back to you later.
I wrote an article called "Ripples." In it, I mentioned a young girl who, during the worst blizzard in 20 years, got T-boned by a semi. She came in with multiple injuries, including a diaphragm rupture with her liver pushed into her right chest and a thoracic aortic tear at the ligamentum arteriosum. I personally called every helicopter service in three states, but the snow was so bad they couldn’t fly.
Her legs started tingling, and I knew she was at risk of paralysis if we didn’t act. My partner and I, who had experience with abdominal aortas, decided to take a chance. We performed a left thoracotomy, placed an interposition graft, and clamped the aorta—without bypass. Afterward, we opened her abdomen, tried to reposition her liver, and close her diaphragm. When that failed, we extended the incision into the right thoracic area. Finally, we repositioned the liver and closed the diaphragm. She also had a pelvic fracture.
Incredibly, she walked out of the hospital 10 days later with a walker due to her pelvic fracture. Would we ever do a thoracic aortic case again? No. But when faced with the choice of letting a patient die or taking a shot, we decided to try—and we were transparent with her family about the risks.
Eight months later, she came back to tell me she was pregnant. I couldn’t believe it. I told her, "Are you crazy? You had a pelvic fracture and a new diaphragm!" We sent her to the university, but they said, "You’ve got OBs here. You’ve already saved her life; there’s no reason you can’t deliver her baby." She gave birth to a beautiful baby girl.
A few years ago, my patient came back with her grown daughter, who was now pregnant herself. My patient became a grandmother. That’s why I titled my article "Ripples." In the big city, you might never see those patients again, but in rural surgery, you witness the ripples of your work over time.
Dr. Michael D. Sarap: [00:21:00] In a small town, you see your patients all the time. You know what your work has done for them and now for two more generations in your community. This isn’t a boast—I’m not boasting—but when you’re in training, watch everything. Sooner or later, you’ll need those skills, maybe even to save a life. That’s as rural as it gets—those kinds of stories.
Dr. Randy Lehman: [00:21:23] Yeah, that doesn’t feel like a boast. It feels inspirational. So thank you for sharing that. It makes me think about the next section of the show: Rural Resources for the Busy Rural Surgeon. Sorry. I want to mention one first, and then we’ll get into your list, because I know you have some points to cover too.
What I would do if I got called from the ER with a patient like that—maybe not the trauma or the gunshot wound, but definitely the aortic case—is call a vascular surgeon. I have a vascular surgeon in my state who I send cases to. We have an established relationship, and I know he’ll take my call. In fact, the only time I’ve called him in the middle of the night was for a fasciotomy question.
Dr. Michael D. Sarap: [00:22:22] Yeah.
Dr. Randy Lehman: [00:22:23] The last time I performed a fasciotomy was during residency. I explained what I was thinking, and talking it through with someone else helped a lot. Having someone with a sane, clear mind to bounce ideas off of doesn’t take long, but it’s incredibly helpful. That’s a resource in itself—having those connections in your state.
I don’t want anyone listening to this podcast to feel overwhelmed. I don’t want them to think, “I hope I’m never in that situation Dr. Sarap described.” It’s tough, and even listening to your story is stressful. I don’t know how you do it—the level of bravado it takes. But if it were me, I would call someone. That’s what I would do.
Dr. Michael D. Sarap: [00:23:16] Yeah, we tried calling for transfers. Literally, there was no way to transfer during the blizzard. Trust me, I wasn’t saying I wanted to do that case.
Dr. Randy Lehman: [00:23:25] I get that. But when I call, it’s to talk through the case with someone and plan what I’m going to do. I had a similar situation with a patient who came back with a fistula. It developed after a ventral hernia repair with mesh. I called a referral center to discuss it and ultimately decided to manage the case myself.
I explained what I was thinking and laid out the resources I had. I don’t have an ICU, and there were several limitations with my hospital. The referral center gave me gentle encouragement. They told me, “We’re here if you need to send the patient, but it sounds like you’ve got a good handle on it.” And I did. I managed my own complication. Afterward, I touched base with them, and everything worked out.
In that case, I had to remove the infected piece of mesh and fix the situation. These situations emphasize the importance of having a network of people you can call. It’s even better when you have a second-line connection—someone higher up the chain—who’s willing to take your call. That makes a big difference as a rural surgeon.
Dr. Randy Lehman: [00:25:00] But what other resources did you have that you wanted to talk about?
Dr. Michael D. Sarap: [00:25:08] Yeah. Similar to what you said, I just want to make one more point about that. During my training, we had a young patient with a traumatic thoracic injury, and my attending waited too long. That young person became paralyzed because the spinal artery was thrombosed. That memory kept coming back to me as I was calling transfer centers, and then her legs started tingling. That forced me to act, drawing from that past experience.
But I think the best resource you can have is being involved in your state’s chapter of the College of Surgeons. By doing so, you build personal connections with specialists across the state. I have their cell phone numbers, and we text each other. Just like you called someone at a higher level, I do the same almost weekly. We’re rural, so we encounter unusual cases and problems. I regularly consult colorectal, thoracic, and vascular specialists. Many times, they say, “You’re on the right track; just keep them.”
Patients appreciate that communication. When I tell them, “Hey, I spoke to someone at Ohio State—a good friend of mine—and they agree we can handle this here,” it builds trust. If they do need to go elsewhere, I know exactly who to send them to. That personal connection often means the families feel reassured, knowing there’s collegiality between their small-town surgeon and someone like a department chair.
This also benefits residents. If you have these relationships and a resident in the city is interested in rural surgery, you can arrange for them to spend time with you. I did just that. I was good friends with Randy Wood at the University of Dayton, and some of his residents, some of whom wanted to explore community surgery, came to work with us for a month.
They gained all their endoscopy experience in that one month, which would have taken years otherwise. They also got to do open surgeries and learn what it means to be a rural surgeon. We even wrote a paper about it, highlighting how it’s not just about the cases—they saw how deeply a rural surgeon is integrated into the community. It gave them more enthusiasm when they returned to the big city.
Another resource to consider is the state chapter as a stepping stone to the national College of Surgeons. I got involved locally, joined a committee, and was eventually elected as president of our state chapter, even though we have five or six major medical schools in the state. If you stay involved long enough, you can even become a governor, which is a national office. That opens doors to joining committees on a national level.
You had a previous guest, Tyler Hughes. One time, I volunteered at the Clinical Congress for what we called the medical student dating round robin. Students rotated among tables for specialties like chest, thoracic, vascular, and rural surgery. Tyler and I manned the Rural Surgery table, and we struck up a friendship. That led to my involvement in the first Rural Surgery Council, where I succeeded Tyler as chair.
Being part of the council got me invited to conferences in Australia and Canada. The Ohio chapter has been instrumental in elevating me to the national level, and I’ve had the privilege of contributing to many Clinical Congresses.
Dr. Michael D. Sarap: [00:29:10] So it makes things exciting. It prevents burnout because it’s a whole different vibe to be involved in the College on a national level, to attend the Clinical Congress, and maybe even be on a panel session. Those kinds of experiences are invaluable.
Dr. Randy Lehman: [00:29:10] I would agree. I’m getting that same sense of purpose through the podcast, as well as through national meetups. It really feels like being part of a great team. And as a small-town surgeon, you can inspire your team to have that same sense of purpose.
A couple of weeks ago, I had a big day at one of the hospitals where I’m relatively new. I called a team meeting in a circle at the start of the day. They hadn’t done much general surgery there, and we were just starting to ramp it back up. I said, “We have six cases today. That means five turnovers. If each turnover takes an hour, that’s five hours spent on turnovers alone. But if we can do them in 20 or 30 minutes, we can all get home earlier.”
Before that, I explained why we’re here—not just for the individual patients but for the viability of the hospital and the vibrancy of our community. That’s our mission. The team really responded to that, and it was fun to see. But at the end of the day, even the coaches need to inspire themselves. That’s where national meetups and chapter involvement are so helpful. Otherwise, burnout can creep in quickly.
Dr. Michael D. Sarap: [00:30:57] Yeah, it can.
Dr. Randy Lehman: [00:31:00] This has been really great. One thing you’ve done that’s not typical for a rural surgeon is publish. How were you able to publish academic papers while managing a busy rural and independent practice?
Dr. Michael D. Sarap: [00:31:23] A busy rural practice lends itself to unique experiences that others want to hear about. Most rural surgeons do plenty of endoscopy, for instance. When I started, our area had a high rate of late-stage colon cancer. We began offering education and free colonoscopies to appropriate patients. We went online to spread awareness, and over several years, we drastically reduced the late-stage colon cancer rates in the surrounding counties.
I partnered with the American Cancer Society during their “80% by 2018” campaign to increase screening rates. At the time, we were already doing everything they recommended. I presented our work in several states and had five to eight years of data showing how our efforts improved outcomes. That led to publishing on the subject because people were interested in what we’d achieved.
Endoscopy is a focus, but we’ve also written about laparoscopic common duct exploration and other cancer screening initiatives. If you concentrate on what you do often and do well, you can study it and write about it. For instance, we implemented a program where, if we diagnose colon cancer during a colonoscopy, we offer to perform the surgery the next day. The patient doesn’t have to re-prep, and we can complete any necessary workups beforehand.
Across the country, the delay between diagnosis and treatment for colon and breast cancer is often far too long—sometimes four to six weeks. Our approach eliminates that delay, and that’s something worth sharing with others.
Dr. Randy Lehman: [00:33:20] Do you use frozen sections or something to get pathologic confirmation?
Dr. Michael D. Sarap: [00:33:23] We don’t. But obviously, if it’s colon cancer, you know it. We’ve done the CT of the chest, abdomen, and pelvis, the CEA, and our staging workup. If it’s an obvious, large cancer right in front of you, we offer the patient the option to stay for surgery. For example, if they’re 80 years old and live on a farm, they don’t want to go home, re-prep, and come back. But if they prefer to wait for the pathology, we offer to schedule them for surgery within a few days.
Our diagnosis-to-treatment times are significantly shorter than most. As a Commission on Cancer-accredited program, we submit our data, which is compiled and sent back to us. We can see on graphs how much quicker we are at getting patients into surgery. Compressed colon cancer rates and melanoma cases are much lower in our area. People are curious about how we achieve this, which opens opportunities to present or publish on the topic.
A lot of it comes down to the same team you mentioned earlier. They take pride in their work. In a rural community, most team members know the patient, are related to them, or their kids go to school together. That personal connection motivates them to go the extra mile to make things happen.
Dr. Randy Lehman: [00:34:46] At Mayo Clinic, everyone had to publish a paper to graduate, so we at least learned how. We had a team to help with publishing. You’d work with a mentor, write your article, and then send it to the publishing team. They’d handle the editing, fix errors, and ensure accuracy. For instance, they’d catch if I said “significant” when it wasn’t statistically significant and correct that. They polished it, submitted it, and it came back for a final review.
Let’s say someone had that experience but hasn’t published independently. What’s the next step if they’ve got data, an abstract, and a draft? Where should they submit it, and who can proofread it? Should they collaborate with a university, or are there other options?
Dr. Michael D. Sarap: [00:36:25] There’s something called the Northern Plains Rural Surgical Society. Have you heard of it? It’s the only rural surgical society, now known as the North American Rural Surgical Society. If you present a paper at their conference, a certain percentage are accepted into The American Surgeon, where you can develop it into a full article.
The Southern Surgical Association has a similar arrangement with The American Surgeon. One approach is to submit your work as an abstract, poster presentation, or full presentation at these conferences. Some of those presentations are later accepted for publication. Alternatively, you can send your paper directly to journals and hope it gets accepted.
Start small. Celebrate small victories. We’ve published six articles—many written with PA students who worked with us. These articles were published in national journals, which is a big achievement for a rural practice.
Dr. Michael D. Sarap: [00:39:00] Maybe that’s not a big deal—it’s not very academic—but it’s exciting for those students. The PA school absolutely loves it. They have all our publications plastered on their walls because it gives them some prestige. You can start small with case presentations or small series. Submit them, and the journal reviewers will provide feedback. They might say, “Change this, this, and this.” It’s a learning process, but you can’t hurt anything by trying.
Alternatively, present your work at a specialty conference. The Bulletin of the American College of Surgeons accepts submissions about unique community practices, whether essays or reports, and it provides national exposure. Your state chapter might also have a newsletter where you could publish. These smaller steps are helpful, especially since we don’t have personal secretaries or publishing teams. It’s all hands-on—we hammer them out ourselves.
We involve students and junior partners in the work. Right now, we’re working on Cologuard testing. I believe many false positives aren’t truly false but result from significant upper GI pathology. For these patients, I do double scopes, and in cases where the colonoscopy is negative, a majority show upper GI issues like esophageal or gastric cancer. It’s similar to treating positive FIT test referrals—ignoring the upper GI tract could mean missing something critical.
I’ve completed 87 or 90 cases, and once I reach 100, we’ll compile the data for publication. My partners and I share the workload—two of them are contributing to the laparoscopic common duct exploration paper. It’s about teamwork and spreading the effort to develop meaningful manuscripts.
Dr. Randy Lehman: [00:39:48] Have you received any pushback from insurance companies on this?
Dr. Michael D. Sarap: [00:39:51] No. We pre-certify everything, but there are a couple of cases where we couldn’t get approval.
Dr. Randy Lehman: [00:39:56] Do you need IRB approval for this?
Dr. Michael D. Sarap: [00:40:00] No, because it’s part of the endoscopic workup. They have blood in their GI tract, so this is clinically justified. It’s not experimental. I think this approach could be a game changer. These aren’t truly false positives—there’s pathology present. Do you want to risk missing a small gastric cancer by skipping the upper endoscopy after a negative colonoscopy? I’d rather solve the patient’s problem than just complete a procedure.
Dr. Randy Lehman: [00:40:41] I’ve seen a lot of those cases.
Dr. Michael D. Sarap: [00:40:44] Exactly. It’s about thinking outside the box.
Dr. Randy Lehman: [00:40:50] This is a great example of how rural surgeons can approach problems differently. It’s not just about completing cases—it’s about contributing to the broader conversation and finding inspiration in solving unique challenges.
Dr. Michael D. Sarap: [00:41:15] Your whole career, and then, you know, turning it into keys or whatever when you're done, you want to give back in small ways and big ways.
Dr. Randy Lehman: [00:41:15] That’s beautiful.
Dr. Michael D. Sarap: [00:41:17] Agreed.
Dr. Randy Lehman: [00:41:18] Thank you so much for your time. This has been an inspirational interview for me. I look forward to seeing you at the North American Rural Surgical Society in the future. Please keep in touch. If you ever want to come back on the podcast, I’d love to hear how your new partner and everything works out. Maybe she can share her story once she gets more experience.
Dr. Michael D. Sarap: [00:41:39] Fantastic. Thanks for doing the podcast. I think this is a fantastic initiative, and I believe it’s going to catch on more and more. There’s certainly a niche and a need for it. I think even the layman would be interested in hearing about what we do out in the boonies.
Dr. Randy Lehman: [00:41:52] You know, the layman—they’ve got it.
Dr. Michael D. Sarap: [00:41:55] Very good. Well said.
Dr. Randy Lehman: [00:41:58] All right. Thank you so much, Mike. We’ll see you.
Dr. Michael D. Sarap: [00:42:00] Thanks for having me. Have a great night.
