Episode 19

General Surgery in the Last Frontier with Dr. Shannon Gulley

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 healthcare for rural America, I'm glad you're here. Now let's get into the show.

Welcome back, listener to the Rural American Surgeon podcast. My guest today is Dr. Shannon Gulley. She's got a very interesting history, and she is now practicing in Alaska. So it doesn't get much more rural than that, although in somewhat of a referral center. So welcome to the show, Dr. Gulley.

Dr. Shannon Gulley: [00:01:03] Yeah, thanks for having me. Happy to be here.

Dr. Randy Lehman: [00:01:06] Thank you. Hey, you were referred to me by Dr. Stephanie Heller. She said, "You got to interview Shannon. She is the real deal." And so Shannon trained at Mayo Clinic, which is the same as me, and she trained with my program director and they're good, close friends. So maybe just start with that and give us a little background to your training and what sort of practice models you found yourself in and what you're doing now.

Dr. Shannon Gulley: [00:01:30] So yeah, I trained. Stephanie and I finished together at Mayo. It was great. We were co-chief residents on trauma, had a great time doing that. She also helped me through. I had my son my chief year, and she was a great partner during that. It was, as you can imagine, 20 years ago, female residents having babies wasn't the usual. So we played a lot of games to keep that hidden until we needed to.

But yeah, she's great. And so, yeah, I finished at Mayo in '04 and then I went back to my hometown in Montana actually originally to practice, and I was there for eight years. There was basically most of the time it was me and one other general surgeon. So pretty small. We were a level three trauma center. It was a lot of work.

Went through some personal life changes, got divorced, single parent. So I actually moved for two years near where my parents live outside of Louisville, Kentucky down to Bardstown, Kentucky and was employed. When I was in Montana's private practice and was employed, and have to say I'm not an employed surgeon kind of person. I like owning my practice.

So had an opportunity to come to Alaska in a private practice model. And, you know, growing up in Montana, being in Alaska is just an extension of that. It's like Montana on steroids. So had gotten remarried and ended up moving up to Alaska. And I've been here. I hit my 10th year here. So 20 years of practice this year and 10th year in Alaska.

And I'm currently a solo practitioner here, but there's six general surgeons total. So, like you said, we're a referral center, but definitely true general surgery rural. We don't have any specialists really of significance where I'm at as far as surgery goes, with the exception of some occasional people that come through. And so, yeah, private practice on my own. I've had a couple partners in the past, but or a couple other surgeons who've worked for me in the past. But we all share coverage, which is nice. But, yeah, it's a great place to practice. And, yeah, I'm excited to talk to you about, you know, kind of our version of rural surgery here.

Dr. Randy Lehman: [00:03:47] Yeah, sure. So 20 years ago, when... When did you finish residency?

Dr. Shannon Gulley: [00:03:51] 2004.

Dr. Randy Lehman: [00:03:53] So it is 20 years ago. So, yeah, 20 years, for sure.

Dr. Shannon Gulley: [00:03:55] Yeah.

Dr. Randy Lehman: [00:03:56] So 20 years ago, if we were talking... If we were doing this podcast 20 years ago, would it be unusual for a surgeon to be employed at that point, or was it like a 50-50?

Dr. Shannon Gulley: [00:04:12] It was... It was more unusual to be employed. I feel like that at that point, it was still more common, unless you were academics. You know, if you weren't academics, you're going private practice. Pretty much everybody was, you know, on their own, not employed. And then during my career, that has shifted, obviously significantly to now it's more the unusual to be in private practice as opposed to being employed.

Dr. Randy Lehman: [00:04:35] Yeah. Okay. And so when you came out and did that, you get your state license, you get your malpractice set up, and then you... You went and used their equipment, but then you started, you know, you bought the building, and basically you had to have somebody that was managing all of this. How did you do payroll and all the expenses and that sort of thing?

Dr. Shannon Gulley: [00:04:58] Yeah, like I said, that was definitely trial by fire for us. You know, they don't teach you that stuff in residency. So we actually, our spouses both worked at the practice to start with and helped us out. And we did it all in house. All our billing, all our payroll, everything in house at the time.

And eventually we hired a nurse that had worked at the hospital, had gone through, kind of moved up in the ladder and had some business experience. So we eventually hired her as our practice manager and so she did it. But we did everything in house, which is not unlike what I do now in general.

But it definitely was payroll we did ourselves. We did it through QuickBooks and paid it ourselves and paid our payroll taxes. We had an accountant who we worked with but, you know, but day-in, day-out stuff we did ourselves. You know, QuickBooks makes it pretty easy. You set it up, you set up your payroll taxes. My accountant, we do send it to them and they take it, they send it off to the IRS as far as the taxes go. But as far as cutting the checks, doing all that, we do that ourselves. For me it's kind of nice because I have somebody I trust in that role. In the past, my office manager had done it and then I'm the one who signed the checks, you know, so.

Dr. Randy Lehman: [00:06:15] So with my setup, I've got my dad operating, you know, working with me, a COO basically. And he's a non-medical person but you know, obviously trust him. And then my, my wife comes and helps some. Then I've got like a bookkeeper, you know, she, she is like a family friend and we're yeah, obviously really close to you, so. But that being said, my, my experience with private practice was that I was not getting paid as much from insurance company as I was from the hospital per unit, worked per operation, per RVU. However you want to slice it up, which I think in terms of RVUs and I, I'm such an idiot that I did not look that up or if I did see it, I couldn't believe it. I'm like, that can't be true. There's gotta be something else. I'm sure there's enough kind of like meat on the bone that I can actually pay my staff and everything. But it was not true. So what I was getting paid was from insurance on average is about $57 per RVU.

But I've got contracts with hospitals well above that and, and more importantly like daily or annual guarantees that are, that are there regardless of if any patient walks through the door. Now I'm very busy everywhere that I'm at anyway, you know, and I could basically be pure production, no problem. But.

Dr. Shannon Gulley: [00:07:30] Yeah.

Dr. Randy Lehman: [00:07:31] Is that what you're finding now in 2024 in your practice, or how are you getting better set up than what I had?

Dr. Shannon Gulley: [00:07:39] Sure. So, you know, it definitely varies. You know, we, our government payer contracts aren't great obviously, you know, so like Medicare, VA, they don't pay wonderful by any stretch, they are our lowest payers. Our Medicaid in Alaska actually pays better than our Medicare. It just is the way it is.

But my commercial payers pay really pretty well. So Blue Cross, Aetna, those type, and I have separate contracts to see each of those. And like Blue Cross, for instance, I carved out with my contract my most common procedures and those are an even higher dollar per RVU. So if I was only government payers, there's no way I can make ends meet. Luckily, my government payer mix, including all of them, is less than 40% of my practice.

Dr. Randy Lehman: [00:08:32] And if you're out of network, then basically the insurance will chip in for the payment, but not that much. But then you're still getting paid whatever you just billed, right?

Dr. Shannon Gulley: [00:08:46] Yeah. So if you're out of network, typically you get paid a lot more. But insurance companies have really cracked down on that. And in a lot of cases, they tell their patients they can't go out of network if there's an in-network option within so many miles, and then they'll just refuse to pay it. Or you know, for patients, they end up having to pay the balance difference. And that's not always easy to collect from a patient. They just might not have that kind of money. And you're talking about surgeries that cost tens of thousands of dollars. Most people don't have that ability to pay that.

Dr. Randy Lehman: [00:09:18] But if the hospital is in network and the surgeon is not, then it's just the surgeon portion that they would have to pay the out of network, right?

Dr. Shannon Gulley: [00:09:25] Correct. I have a couple that I don't. Just because the reimbursement is so terrible and my numbers on those people are so few that we cross that bridge. Just like you said, when we come to it, we tell them nope, we're not network. It's your choice. You can go to somebody who is, or here's what my cost is. And then we do a cash pay option with those patients where if they pay up front, we give them a decent discount and that helps.

We have a lot of, we have some patients who just don't have insurance either or have super high deductible plans, or the other thing we run into a lot of nowadays are the Medi-Share plans where they don't really pay us well. So we treat those as a self-pay.

Dr. Randy Lehman: [00:10:03] Here's what happened with me. I ended up basically turning into a 1099 contractor with the hospitals, and that model is working really well for me. And then I've actually expanded to two other hospitals since then. And then basically I get a daily rate just for showing up. And I know that I'm going to get paid just for showing up. But then I have RVU kicker. And so if I have a big day and it's calculated daily.

But what I was doing before, I mean, literally I was still having these big monster days, but I was losing like 20, $30,000 a month, and I was literally paying that just to keep my door. Now, I built too big of overhead. I did not have any of my systems down for billing. I just did a terrible job with everything. But if I had to keep that open, if that was like my only option, I was starting to look at it like you're looking at it from a each individual insurance.

Dr. Shannon Gulley: [00:10:53] Right.

Dr. Randy Lehman: [00:10:54] How much do they, you know, dive into each individual operation? And then I'd have to limit basically my services and things where I thought, just come out, do a broad spectrum general surgery practice, it'll work out. No. And then the other thing that I really hated, man, was these. The patients, you, like, bend over backwards for them, and then they got like 150 bucks on their part of the bill or whatever, and you can't, you cannot get them to pay it.

Dr. Shannon Gulley: [00:11:21] Right, right.

Dr. Randy Lehman: [00:11:22] The main thing, it's not the money at that point. Like, they don't understand that basically every time I stood for a year and a half at the bedside and did an operation at the Jasper County Hospital that I was born at, where I wanted to be, and it was my mission to go there for like a decade. And I spent all this time and money and energy at Mayo Clinic, you know, struggling through all the struggles that, you know, so that I can be there and do that operation for them.

For a year and a half, I paid out of my pocket about a thousand bucks every operation to do it. And then at the end of the day, they had like 150 that they, that they owed me and they. And you couldn't get them to pay it. And I just felt so devalued by them. And what I would have had to do is take payment up front. That's what I was going to be moving towards doing. Now do you do that?

Dr. Shannon Gulley: [00:12:09] We do. So we have. So I do have somebody who basically her whole job is insurance and, you know, insurance verifications and looking at deductibles and pre-authorizations. I do have a billing company. I code all my own stuff and whatever. But then they do the process, right, of running it through and sending it and helps. And they do help a little bit with like our insurance contracts and credentialing people.

But so her job is, when we have somebody coming in, we know before they walk through the door, hey, this person has a $5,000 deductible. We're going to set them up for a hernia surgery. We tell them this is how much you're going to owe, this is how much you need to pay up front before we will schedule your surgery. In urgent cases, obviously we don't do that, but we will talk to them about it. We schedule them, we figure it out, and we do payment plans and all kinds of other things, but we try to keep on top of. We don't just do it and then hope to collect it on the back end.

I think whether you're private or whether you're employed, understanding how the system works, understanding where the money comes from, understanding what your overhead is, is important for all physicians. And I really wish we were trained more on that as residents, because it doesn't matter if you're, if you're employed, you want to know how much money you're bringing in and what your contribution is and what they're spending on overhead, even when you go to negotiate your contract. So I think it's something that we all want to be the best physicians we can. But the reality is, whether you're employed or in private, you need to know some of that business stuff to make you most successful you can be.

Dr. Randy Lehman: [00:13:45] Yeah. The other issue is that as a surgeon, my problem was I was limited by the hospital or availability and things that they would and wouldn't let me do. And so I couldn't get these operations done.

And, and I was having same day cancellations because prior auth from the hospital or people within the hospital, such as nursing staff, anesthesia canceling cases for, you know, poor reasons. And the actions that the hospital took really affected my whole thing. Or they're just shutting me off and saying, you can't operate anymore. So now it's the hospital's problem to make me busy.

And I still. So I'm in a place where I'm extremely needed in all the places. And so then my schedule is still quite flexible. And I can still tell them, you know, I still, I gotta be out of here early this day or I gotta start a little bit later, or this is how I'm gonna do my time, or, you know, I have to be able to, I'm not coming to your place unless I can land my helicopter there because it takes too long to drive and stuff like that. And so that's how I'm getting around it and still feeling.

And the other piece for autonomy for me is I really did not let the pandemic go to waste. From a perspective of investing, that was a great time to get money and don't spend it and make it work for you because there's this inflation coming after, and I did that. Now my net worth's in a position where I can do this podcast with you. Other things. I. I actually don't really need the job anymore, so. And on top of that, everything's now better than ever, right?

So I had one more question. Another exposure of my own stupidity. So I didn't realize till I was a fourth year resident that when I was punching in my operations to log them with ACGME that I was using CPT codes to do that. Yeah, I didn't know what a CPT code was like. Every one of these seems to have a five digit code associated with it. But I didn't know. Now obviously I know I spent a lot of time really learning, getting a book. I have the app, it's really good to search and I think I'm pretty good at coding. What I'm not really good at yet is modifiers. So I was wondering if you could tell me your top. Do you know much about modifiers? Could you tell me your top five? Do you know some modifiers and what we need to do with them?

Dr. Shannon Gulley: [00:16:08] Sure. So. So a couple different modifiers. For me, one of my top ones because I do spine exposures is a 62. That's co-surgeons. That's different than an assist. So you know, knowing the difference between co-surgeons assist modifiers and then your assist modifiers are different too, whether it's a surgeon, an RNFA, a surgical first assist. So knowing those is really helpful. You know, there's an AS code, there's a, you know, all those matter.

My other biggest code I use is when I do screening colonoscopies and you take a polyp, there's a code so you got to use. And it's different. For Medicare it's PT. For commercial it's 33. And that modifier says preventative services. Basically. Yeah, I know I did it for screening, but I had to take polyp, so you need to pay me for that.

And then I think the other ones I use a lot are like 59 and 51. So you're doing distinct different procedures at the same time. Like if you like for colonoscopy again, for example, if you do a snare in the cecum but then you do a biopsy in the sigmoid. You can actually bill for both of those, but you need a modifier in there, like a 59 or 51.

Dr. Randy Lehman: [00:17:26] And then what's the difference between 59, 51?

Dr. Shannon Gulley: [00:17:30] 59 is distinct procedural services, 51 is multiple services. So like when I do breast cases and I do a lumpectomy and a sentinel lymph node, I usually use a 51 modifier because they go together, obviously, but they're separate procedures during that same procedure.

Dr. Randy Lehman: [00:17:49] Sure.

Dr. Shannon Gulley: [00:17:49] So, and that's how I kind of think of them. If they go together, don't go together.

Dr. Randy Lehman: [00:17:53] Yeah.

Dr. Shannon Gulley: [00:17:54] And then occasionally you need like a 78 modifier that's doing a procedure during your post-operative period, which is again something specific to surgery. Right. We have times where once you do a surgery, you're on the hook for 90 days to do anything that comes for that patient. But sometimes you got to bring them back for something else, or something else crops up. You know, you do the, you know, one procedure and then, oh, hey, I popped up biliary [corrected from "Bill Garnier"]. You know, I gotta fix that. So knowing those modifiers, I think those really help.

Dr. Randy Lehman: [00:18:26] How does 78 different from 24? Let me see, 24 goes on an E&M.

Dr. Shannon Gulley: [00:18:31] Yeah, 24 is E&M and 78 is procedures.

Dr. Randy Lehman: [00:18:35] Yeah.

Dr. Shannon Gulley: [00:18:35] So those are those differences. Yeah.

Dr. Randy Lehman: [00:18:37] Okay. And then like 25 and 57, you use those probably a lot too. Like. Yeah, those are like on your E&M codes.

Dr. Shannon Gulley: [00:18:45] Same day, same day surgery. Or like I use those a lot too. When I'm on call, I see a patient, I do their appy [corrected from "happy"] the same day. You need a 57 modifier. So you get that E&M code.

Dr. Randy Lehman: [00:18:55] Yeah, but if you see a patient in the office and do like a punch biopsy same day or something like that, then I usually use a 25. Am I doing that correctly?

Dr. Shannon Gulley: [00:19:03] Yep. Yep, 25 for that. And I will say I don't do. Occasionally I do same day procedures. I don't always. So like we see somebody with a lipoma, we usually see them in the office. Or I do have a nurse practitioner who works with me. We usually see them, evaluate them, and bring them back a different day to do their procedure. Not just to get that second code, but mostly because we want to know, can we do it in the office? Do they need sedation?

Dr. Randy Lehman: [00:19:28] Mine would be the same, but except for the ones that I would do would be like biopsy or I&D [corrected from "ind"]. Those are probably the most common.

Dr. Shannon Gulley: [00:19:34] Yeah. Those you do the same day. Yeah.

Dr. Randy Lehman: [00:19:36] And then I usually use the 57 if it's a 90 day global procedure and a 25 if it's a 10 day global.

Dr. Shannon Gulley: [00:19:43] I don't know. Yep, that's. I think that's pretty reasonable.

Dr. Randy Lehman: [00:19:46] I'm not a coder. Okay.

Dr. Shannon Gulley: [00:19:47] Yeah, obviously I do. I will say so I do. Like I said, I have a billing company. They'll go through our stuff and double check things, but, you know, they have data entry people, so they don't always catch stuff either. So that's why I think it's important to know what you're doing.

Dr. Randy Lehman: [00:20:01] Why rural surgery is specialty. I mean, do you consider yourself a rural surgeon?

Dr. Shannon Gulley: [00:20:06] I look at me being a true general surgeon. Like, when I first came out, when I went to Montana, I did vascular. I mean, I was doing aorta bypasses and fem pops and I did all the general surgery stuff. You know, colons, Nissens, breast hernias. When I first got here, though, we had no GI and no vascular surgery. We now have GI, which is one guy rotating at a time, though, so it's not that much. And then we have vascular, who mostly works in Anchorage. They cover some out here, but, like, it depends. Like, my last week in a call, I had a gunshot wound to the groin with femoral injury. We had to transfer him to Anchorage because they weren't on call for us. So I think from that perspective, I still consider myself a rural surgeon, even though I'm more of a regional medical center.

And Alaska is just rural, you know, because we do a little bit of everything, though I feel like that's so much gone away that to do that here still lets me have that big variety. I don't know what's going to walk through the door and I have to take care of it, whether it be a gunshot wound or be, you know, somebody's appendix, you know, so it's kind of nice to have that big, wide range, and I love it that way.

Dr. Randy Lehman: [00:21:21] So it's the variety. I mean, that's the answer.

Dr. Shannon Gulley: [00:21:24] It is. It's the variety. I couldn't do the same thing every day. I think I'd go crazy.

Dr. Randy Lehman: [00:21:29] Yeah. We were going to talk about thyroid today.

Dr. Shannon Gulley: [00:21:32] Yeah.

Dr. Randy Lehman: [00:21:33] And interesting thing is thyroid's something in my practice that, you know, I did the endocrine rotation. 50 thyroids in six weeks. But let's first talk about, in your practice, the most common indications and most common patients to need a thyroidectomy or hemithyroidectomy.

Dr. Shannon Gulley: [00:21:52] Yeah. So usually in my practice, it's mostly nodules. Right. So it's going to be, you know, that enlarged nodule that needs an FNA. And the majority of mine that come back, I, I, for whatever reason, they're mostly follicular. So, you know, large follicular neoplasms that you want to take out, make sure it's not cancer, which my last couple have been, which is crazy. But. Yeah. So I get referred. Typically, I'll get referred. Somebody either palpated something from the primary care or, you know, they got an ultrasound for some reason, have a nodule, and then they'll come. Then they'll send them to me, and then.

Dr. Randy Lehman: [00:22:26] What kind of ultrasound machine do you have?

Dr. Shannon Gulley: [00:22:28] I have a GE. It's one of the notebook ones. It's pretty handy. I use it for my thyroids. I use it for breast stuff. I'll look at abscesses sometimes and then I. Like I said, I do varicose veins, so I use it for that.

Dr. Randy Lehman: [00:22:41] Yeah, I bought one of those Terason units. Kind of nice when you're doing your FNA. Just talk me through that in great detail. Sure, Farley style.

Dr. Shannon Gulley: [00:22:54] Yeah. So typically, you know, we'll get the patient and I have a nice procedure room, so we get them all comfy and situated, and then I ultrasound first just to see. Give my idea of where I'm going to go.

Dr. Randy Lehman: [00:23:06] What kind of music are you listening to?

Dr. Shannon Gulley: [00:23:09] My staff gets to pick their music, so it varies. The other day, we had the Beatles station on. My patient was thrilled, so. But so. And then, you know, I do numb the skin just a little bit just because I think it's more comfortable. Especially after you. A couple passes. You know, this morning it wasn't bad. I think it was like 20. So we're not too terrible. Yeah.

Dr. Randy Lehman: [00:23:30] So some people will do an FNA without a syringe on. Do you do it with a syringe on with suction or.

Dr. Shannon Gulley: [00:23:38] I do it with a syringe on my suction.

Dr. Randy Lehman: [00:23:41] You're aspirating a little bit as I go.

Dr. Shannon Gulley: [00:23:42] I aspirate just a little bit as.

Dr. Randy Lehman: [00:23:44] I go several passes, kind of under ultrasound. Then you pull it out, and then you squirt that on a slide.

Dr. Shannon Gulley: [00:23:49] Then I squirt that on the slide. And then we dump our extra. Because, you know, you drop a few droplets on each slide, and then whatever's left, I stick in a little cup with formalin. And they send that off, too. They like that.

Dr. Randy Lehman: [00:24:00] How many slides are you doing? I usually do about four and about four passes, too. One slide per pass or.

Dr. Shannon Gulley: [00:24:08] No, I usually get it in a couple. Usually I could do it about two passes? Yeah, maybe three at the most. Yeah, not too bad. I want to make sure I don't just get blood, you know, if it's a cystic solid, I want to make sure I'm in that solid spot. So.

Dr. Randy Lehman: [00:24:19] Yeah, yeah. Okay. And then that goes off to your pathologist, but it's not, they're, they're assessing it and telling you the specimen's adequate right then and there or no, no.

Dr. Shannon Gulley: [00:24:30] Okay. No, no, not till usually. So I would say anywhere from four to seven days. I get my path back pretty fast.

Dr. Randy Lehman: [00:24:39] So for Bandaid home allocation, Bandaid home.

Dr. Shannon Gulley: [00:24:43] Good.

Dr. Randy Lehman: [00:24:43] Back with the path report.

Dr. Shannon Gulley: [00:24:44] And we usually. Man, yeah, usually have them come back at a week and go over it with them and then make our decision. So.

Dr. Randy Lehman: [00:24:50] Yeah.

Dr. Shannon Gulley: [00:24:51] Yeah.

Dr. Randy Lehman: [00:24:51] Okay. And do you do neck dissections?

Dr. Shannon Gulley: [00:24:55] I, I, if necessary, I can do them. I feel like it hasn't come up a lot recently. So I would say, honestly, it's been a few years since I've done a true neck dissection, so if I had to, I probably get one of my ENT colleagues to pop in and do it with me. Yeah, I mean, I feel like I could do it. It'd be fine.

Dr. Randy Lehman: [00:25:13] My car 62.

Dr. Shannon Gulley: [00:25:14] Yeah, yeah, exactly. Exactly.

Dr. Randy Lehman: [00:25:17] Okay, gotcha. So you're going to take the patient then to the operating room because it showed follicular needs. Needs a hemi-thyroidectomy.

Dr. Shannon Gulley: [00:25:28] I'll do a hemi. Yeah.

Dr. Randy Lehman: [00:25:30] Okay. And so say we're going to do that and you got the patient position. So are you tucking the arms?

Dr. Shannon Gulley: [00:25:36] I do tuck the arms.

Dr. Randy Lehman: [00:25:37] Where do you, where do your limits of prep go?

Dr. Shannon Gulley: [00:25:40] I go all the way. Chin all the way down to nipples and out wide.

Dr. Randy Lehman: [00:25:44] All the way to the bed? Basically.

Dr. Shannon Gulley: [00:25:46] Yeah, all the way to the bed.

Dr. Randy Lehman: [00:25:47] Crushed up blue towel on each side of the neck.

Dr. Shannon Gulley: [00:25:49] Yeah, crushed our blue towel on each side.

Dr. Randy Lehman: [00:25:51] All right. It sounds familiar to me. All right, so now, now you're ready. And then do you use a nerve monitor?

Dr. Shannon Gulley: [00:25:56] I do not, I do not train with them. So I trained with, you know, Farley, little paddle, little buzz and identification. ID the nerve. Every time. I can feel it, I can see it. I do wear loops. I don't know, maybe I'm just old now, but I do wear my loops for it just because it does help you. I think you can see the nerve just a little bit better as my eyes have gotten a little older. But yeah, no, I just say do the nerve.

Dr. Randy Lehman: [00:26:22] All right, so where are you going? Two centimeters above this sternal notch?

Dr. Shannon Gulley: [00:26:25] Yeah. Pretty much. I do two centimeters, and then I do a finger on each side, and I mark out my incision. I stick. I stick with pretty much depending on the ne. Give yourself the space so you can get up, because you got to get up to that superior pole. Okay, so then go me the hardest part. Yeah. So, you know, make incision subcutaneous. I use a wheat liner because, you know, I don't typically. I do have an assist who helps me in the OR sometimes, but she's not always there. So it's me in attack. So not a lot of extra people. So use a wheat liner, hold things open, split the strap muscles.

I do not touch the side that I'm not going to. I leave it pristine. Work on the other side, move those strap muscles over. And then, you know, my first thing I tend to do is take that middle vein, middle thyroid vein, just because it allows me to start to rotate that thyroid up carefully without creating bleeding. I don't think you worked with Dr. Van Heerden because he retired with me, but he said, you know how you're a fast surgeon. Don't make crap bleed. So. Which is true. Although you might not say crap, but don't make this bleed.

Dr. Randy Lehman: [00:27:25] How do you take the vein?

Dr. Shannon Gulley: [00:27:27] I usually clip and divide it. If I. If it's really tiny, I'll bipolar it and. And divide it. Then my next go is to superior pole because I feel like if I get my superior pole down, it just helps to just elevate everything nicely.

So I typically go up, dissect up, and try to take in. I try to take my vessels separate. It doesn't always work that way. Try to make sure you're not getting the nerve, obviously, but. And with that, because I. It was beaten to my head. You know, once you cut that, it's gone. I tie and clip on it. I just. I feel more comfortable with it rather than just clipping. So I clip, tie, and divide.

Once I get that, I feel like you can start to really rotate that thyroid up and medial. And I. Depending on where the nodule's at, will still use Kocher [Uncertain] on it to have my assist help lift it up. And then I use a ray tech to put my thumb on the end of it and pull it up a little bit more. Then I usually attack the inferior pole. Next. I didn't talk about. But on superior, obviously, I want to look for the parathyroid. Same on the inferior. Try to identify that parathyroid. Drop it down.

Once you take those two poles, then you're at the meat of it. Then my next goal is, where's the nerve? Then I start looking for the nerve I found. If you take the. The tip of a very fine forceps and you kind of run out, you should know that, you know, you need to know your anatomy, obviously.

Dr. Randy Lehman: [00:28:54] Right.

Dr. Shannon Gulley: [00:28:54] You know the direction it should be going. If you run that over, you almost can, like, bump, bump. Like, you'll just feel yourself pop over it before you can ever see it. Then you kind of know where you're working.

Dr. Randy Lehman: [00:29:04] So you're roughly in the tracheoesophageal groove at this point.

Dr. Shannon Gulley: [00:29:07] Exactly. Yep. And so then I very carefully, you know, I kind of work back and forth, back and forth, back and forth, taking down the little bits of tissue as I can get that nerve. And just keep slow, really elevating that thyroid more and more and more medial.

And then once I get down where I can see the nerve, then I'll skeletonize. You know, you'll have that middle thyroid artery there. Just very carefully dissect that out. And I typically. If I can clip it, I'll clip it or I'll bipolar it. I don't use cautery anywhere near the nerve. I just tend to. Not at that point.

Dr. Randy Lehman: [00:29:36] Once this is the thyroid ema artery, or you're. Yeah, okay.

Dr. Shannon Gulley: [00:29:40] Yeah, right on that. Right. It usually lays, right. Sits and goes. Pops right over that nerve. I try to take that, and then what I found is a lot of times after that, that nerve will just kind of slide down low, and then you have a little bit more room. And then I can bring it up with cautery or bipolar, whatever you're more comfortable with. Up to where I can get to where I'm up across the trachea. Then I'll divide this at that point. But I think the working. I usually. Cautery.

Dr. Randy Lehman: [00:30:10] Okay.

Dr. Shannon Gulley: [00:30:11] Yeah, Yeah. I just got her eyes there.

Dr. Randy Lehman: [00:30:13] And you were saying something under it.

Dr. Shannon Gulley: [00:30:14] Oh, just. I find if you feel like the nerve is tight there, if you work. Like I said, if you work a little bit inferior, a little bit superior, a little bit inferior is very slowly work your way toward the middle. It just helps you slowly keep in retraction. So key. And then I just keep testing. I keep looking and kind of feeling that thing, so I know where it's at. And, you know, knock on some wood. Never had a nerve injury, so I. I think it works pretty well.

I will say when I trained at Mayo, I have no idea how many thyroids I did. It was a lot, because at the time, you know, Grant Denim [Uncertain] Van Heerden Farley. Like every rotation he did, I felt like. And then as a chief, he did a ton of them. It was just so many times being in that area. It's one of my most favorite cases. I just love the anatomy. They're just nice cases. Even to people who are obese, they're kind of nice cases. They're just nice cases.

Dr. Randy Lehman: [00:31:10] And still not too much fat right around that thyroid.

Dr. Shannon Gulley: [00:31:13] Exactly. And patients. Patients do well in general. I mean, I don't know, it's just, it's. To me, it's a really enjoyable case. Like I said, for whatever reason, recently I've had a run of thyroid cancer. So I've had to go back and do completions. But since you don't touch that other side once you get through that first little bit, I don't think it's that bad. You know, that first little bit of scar tissue is not too terrible.

Dr. Randy Lehman: [00:31:36] Yeah. Then what kind of lymph node clean out are you doing on those cases? You're going backwards on those?

Dr. Shannon Gulley: [00:31:40] I do none because it's follicular. Probably isn't going to need anything. We don't even know for sure it's a cancer. So unless I feel a palpable lymph node or I knew of something before with my imaging, I don't do any significant lymph nodes.

Dr. Randy Lehman: [00:31:52] Sure. But what about when you come back?

Dr. Shannon Gulley: [00:31:55] Oh, when I go back again. It depends on what it is. So if it's, you know, follicular and there's not any significant lymph nodes, we're not going after all those. We're just on ultrasound.

Dr. Randy Lehman: [00:32:05] You mean or palpation ultrasound?

Dr. Shannon Gulley: [00:32:07] Yeah, on ultrasound. Yeah.

Dr. Randy Lehman: [00:32:09] But if it's an interesting.

Dr. Shannon Gulley: [00:32:11] Papillary is different. You know, papillary. If it's larger than I would take at least the central nerve.

Dr. Randy Lehman: [00:32:16] Central neck dissection.

Dr. Shannon Gulley: [00:32:17] Yeah. And take those. And then if there's something on imaging, you know, I go after that.

Dr. Randy Lehman: [00:32:22] Any special instruments that you use, like a goiter retractor, peanut, Anything that you just love and you're like, I would never do a thyroid without this.

Dr. Shannon Gulley: [00:32:31] I like a goiter especially for the superior pole and holding. I think goiter retracts really nicely for you to see. I do use Kittner occasionally just. Or peanut just to kind of on the nerve area. If I'm trying to get that little fibrous flimsy tissue down real gently, I use that sometimes. So those are probably two things. I. And bipolar. I think bipolar is essential for it. Yeah.

Dr. Randy Lehman: [00:32:53] As you're closing Up. So you. You close up just platysma and skin, or do you do?

Dr. Shannon Gulley: [00:32:59] I do. So I close my strap. I reapprox my strap muscles. I use Vicryl for those same. Platysma. Yeah. Three of acrylic platysma, three of a girl. I do a monocle subcuticular and then dermabond.

Dr. Randy Lehman: [00:33:11] Mm.

Dr. Shannon Gulley: [00:33:12] And that's, yeah. Pretty simple.

Dr. Randy Lehman: [00:33:14] Very good. Any other pitfalls you would tell, like your junior partner that's joining you or anything?

Dr. Shannon Gulley: [00:33:20] So sometimes when you have a really big nodule, it's tough to get that to come up. Or if you have. It's a little substernal. If it's an inferior pole nodule, the. I don't know if you ever use this, but the sterile spoon I have used to pop down and pop around that to pop it up, but something along those lines, you know, to help you get that to pop out of that substernal space and lift it up.

Dr. Randy Lehman: [00:33:45] Did you have to request that at the hospitals you were at?

Dr. Shannon Gulley: [00:33:48] I did request it when I had one big one and they thought I was crazy. And I was like, no, no, legit. We do this at Mayo. It's a spoon. You need a spoon.

Dr. Randy Lehman: [00:33:56] Is that something you buy from a medical device company or it's just a spoon?

Dr. Shannon Gulley: [00:34:00] I think they just got a spoon and sterilizer. I'm not really sure. It's been a little bit. I had to need that for a while, so. But I do remember using the spoon as a resident.

Dr. Randy Lehman: [00:34:09] Yep.

Dr. Shannon Gulley: [00:34:10] I do. I will say 20 years later, now 25, since I was on Farley's service. I can hear him in my head still this many years later, you know, little pot.

Dr. Randy Lehman: [00:34:22] I told him that, too, when he came on the podcast. Little cat, a little buzz. I hear all these things. And we. Did you do TAPP with him?

Dr. Shannon Gulley: [00:34:29] I did. Yeah.

Dr. Randy Lehman: [00:34:31] So it was always. For me, it was always Iliac. Iliac. I'm like, am I a little too low here? What's going on?

Dr. Shannon Gulley: [00:34:38] Yeah, you're like, I'm pretty sure I'm okay, but.

Dr. Randy Lehman: [00:34:40] Okay.

Dr. Shannon Gulley: [00:34:40] Yeah, no, no, totally. And, you know, it's funny. So I went full circle with those TAPP procedures, right? So I did TAPP with him. Then I went to doing another approach. You know, then I did the balloons and everything. And then I went to TAPP, and now I do robotics. So they're all TAPP. Yeah, it's. Yeah, it's kind of funny how that. How you make that big circle. But, yeah, I know that to this day, Dr. Farley in my head.

Dr. Randy Lehman: [00:35:02] So, yeah, quick question.

Dr. Shannon Gulley: [00:35:04] Yeah.

Dr. Randy Lehman: [00:35:05] Since you're on to that, just very briefly, if you have a patient that has a, it's a male unilateral first time inguinal hernia and they have no other hernias that you can identify, do you do that open or robotic?

Dr. Shannon Gulley: [00:35:21] I'll give them both options. So I. Sometimes they come in and they've read and they want it robotic, fine. But I do talk to them about doing it open and because I can do it at my surgery center then so. So it's a little less cost to them, especially if they don't have great insurance. In my hands, the recovery is pretty similar when I'm doing it unilateral, especially if they're a reasonably thin patient. You know, you're not going through a lot of fatty tissue to get down there. My incision's tiny to do it. And so I definitely talked to him about that as an option. And in some people I got, you know, I don't have high recurrence rates at all with my robotics, but you know, I do a PHS repair. So the dual layer mesh when I do it open and there's something about these guys that work on the slope and lift a bunch of weight and stuff that that dual layer just gives me a little bit more confidence. So. But yeah, I do for a unilateral, non recurrent, no chance. They're probably going to have a bilateral. I think it's a great option.

Dr. Randy Lehman: [00:36:29] Yeah. And then what normally happens to me is they say, what do you recommend?

Dr. Shannon Gulley: [00:36:35] Oh yeah.

Dr. Randy Lehman: [00:36:36] So then what do you recommend?

Dr. Shannon Gulley: [00:36:37] I usually tell them I do it open.

Dr. Randy Lehman: [00:36:39] That's what I say. Yeah. Let's move on to the next segment of the show called the Financial Corner. So I was wondering, do you have a money tip for our listener?

Dr. Shannon Gulley: [00:36:48] Well, I kind of talked about it a little bit. I think like I said, no matter private practice or employed, know your worth, right. Know what you should be getting paid, know what things cost, know what your hospital is getting paid if you're employed. Um, I think those are key. I think the other thing I would say as a surgeon, I think it's key. And you talked about a little bit invest in other things. Right. Because something can happen. You can't be a surgeon anymore. You need to have other avenues of revenue stream. Especially like for me, like if I don't work, I don't technically make money. So finding other ways to have revenue stream, like I'm an owner surgery center, I own a spa, I, you know, I think having other ways that you can generate some income when it's not you physically working can make a lot of difference for you. And it doesn't have to be medical.

Dr. Randy Lehman: [00:37:40] You've ever made outside of yourself.

Dr. Shannon Gulley: [00:37:43] Probably real estate. Investing in buildings. Yeah, that's always.

Dr. Randy Lehman: [00:37:47] Now is there something out non medical real estate that you've purchased?

Dr. Shannon Gulley: [00:37:52] Yeah, I mean just honestly my house, because things have gone up so incredibly high here. That's been a huge investment for us. And then I did invest in some commercial property that I'm now gonna probably sell. But yeah, no, I think it's good to just keep your eyes open, look at different things. And I think looking at things outside of medicine is not a bad thing. I think it's good to have some other avenues of income.

Dr. Randy Lehman: [00:38:17] Great, thank you for that advice. And do you have another. You've told some stories about people not getting across during the breakup and they have fly in and all these crazy things up in Alaska. But you have any other classic rural surgery, personal surgery story that you would like to tell us?

Dr. Shannon Gulley: [00:38:33] You know, I think, I think the. My biggest stuff is really these. Well, I think what I found interesting is these patients who live. So a lot of people here live in dry cabins, right. So no water. They might have power, but they don't have water. They have an outhouse, you know, they have, they heat by fire, you know, have to chop wood. And I have these like 80 some year old people coming in and, and, and not to be sexist, but women too who come in and they're like, well, I have to like chop my wood for the winter before I can fix my hernia.

Dr. Randy Lehman: [00:39:05] So it seems to me like people that are living in dry cabin are doing so by choice.

Dr. Shannon Gulley: [00:39:09] Yes, for the most part in general it's by choice.

Dr. Randy Lehman: [00:39:12] Can you have livestock up there?

Dr. Shannon Gulley: [00:39:14] Yeah, oh yeah, yeah. There's. There's a couple farms and dairy farms and cattle ranches. There's bison farms. My. One of my good friends, he's an orthopedic surgeon and his wife, they have a whole little farm. They have sheep and a couple dairy cows.

Dr. Randy Lehman: [00:39:29] Now need some highland cows, I think.

Dr. Shannon Gulley: [00:39:32] Yeah, some highland. I keep telling her that she needs the highland cow.

Dr. Randy Lehman: [00:39:35] But yeah, you need to come visit me in Indiana for sure. And I need to come up there and visit you because it sounds awesome.

Dr. Shannon Gulley: [00:39:40] Yes, you do. You need to come up. That would be great.

Dr. Randy Lehman: [00:39:43] Yes. The last segment of our show is actually resources for the busy rural surgeon. You've told several. Did you have anything else prepared for that?

Dr. Shannon Gulley: [00:39:51] Segment I think really, you know, you need the people around you to surround you, to help you with the stuff you don't know. And then like I said, use things like the College of Surgeons has some great programs. The American Society of Breast Surgeons. I'm on that website a lot. If I have a weird case, I go and look and see what they've got. You know, there's a lot of good stuff out there to use clinically.

And then as far as, you know, business side, I think, you know, learn as much as you can. You don't have to be crazy and go get your MBA, but just, you know, know what you can know about. Know how to read a spreadsheet, know how to read a financial paper. You know, I think it's important.

Dr. Randy Lehman: [00:40:28] Last thing, most people working in my type of environment, critical access hospital, not gonna have a spine surgeon around. You obviously do. I was hoping for a three minute bonus. How I do it, segment on the anterior spine exposure.

Dr. Shannon Gulley: [00:40:42] Yeah. So also one of my other favorite cases. So. Yeah. So quickly we do this in conjunction, right? So we use fluoro, mark the disc space right over the abdominal abdomen. I do a low transverse incision and then go down to the rectus, rotate it medially, go behind the posterior sheath and then down onto the psoas. See the ureter. It's always my first thing I look for.

And then I actually do mostly blunt dissection because it's, if you're in the right plane, it's beautiful and avascular. And I use Wiley retractors and just slowly work that all over so I'm on top of the disc space. Then we have a retractor, holds everything. And then I open that peritoneum and if you lift it and pop it, you know, you get that nice air in there. So you don't annoy the nerve or don't annoy the iliac vein.

And then take down that middle sacral vein and then slowly work your way to pull that vein out of the way over there. I joke that it's the one case I tend to hold my breath occasionally, you know, and I'm moving that big vein with all that blood in it. But. And I think the biggest thing I would tell people is if you're rotating that vein and mobilizing it, there's all those little, tiny, tiny little branches posteriorly. Get all of those branches because your orthopedic surgeon's gonna bang on that and wrench on it. And that's what's going to bleed, and then you can't get to it. It's a pain to get to. So.

Dr. Randy Lehman: [00:42:05] Yeah, when you're going past the rectus, where are you going? I thought you said rotating the rectus.

Dr. Shannon Gulley: [00:42:14] Yeah, no, I rotate it. So I go to the lateral edge of the rectus muscle on the left side, because I do mostly five ones. And so I go to that. To the patient's left. And so I take the muscle and I rotate it so I can see that posterior sheath and right where the posterior sheath and, you know, the transversalis and that linear. I score that, and then you can get down into that retroperitoneal space that way. And I take it all that way. Rather than trying to go medial that way and split the muscle apart. I don't split the muscle in the middle that way. It allows it to rotate very nicely that way.

Dr. Randy Lehman: [00:42:50] You're scoring medial to the semilunar line.

Dr. Shannon Gulley: [00:42:54] Just medial to it. Yeah.

Dr. Randy Lehman: [00:42:56] And then the three lateral muscles go up and the rectus goes down. And then you find yourself down in that.

Dr. Shannon Gulley: [00:43:04] Down in that preperitoneal space. And it. It really. Even in men that are big and muscular, I find that I can get to that, because the key for my surgeon is I need to have that entire spine exposed. And so when you make your incision in the middle and you come to the side and rotate over, it allows you to release a long ways to where I can get everything rotated over. So, yes, I basically can put my retractor on the opposite side of that spine. So the entire spine's exposed, and then.

Dr. Randy Lehman: [00:43:37] You just close up the anterior fascia on your way out.

Dr. Shannon Gulley: [00:43:41] Yeah.

Dr. Randy Lehman: [00:43:42] PDS or what do you use?

Dr. Shannon Gulley: [00:43:43] Yep, I use a double strand of PDS.

Dr. Randy Lehman: [00:43:45] Have you ever had hernia at that location?

Dr. Shannon Gulley: [00:43:48] Only once, and it was in somebody who had prior hernias and prior surgery. And how did you fix it? Robotically.

Dr. Randy Lehman: [00:43:55] Okay.

Dr. Shannon Gulley: [00:43:55] I went in robotically and fixed it.

Dr. Randy Lehman: [00:43:57] Yeah. And how'd you learn how to do this?

Dr. Shannon Gulley: [00:44:00] So I did some of them on vascular when I trained. And then when I moved to Montana, the spine surgeon there was like, hey, you should be able to do this. And so I actually did my first ones, transparent, which is a lot more work because you got to move all the bowel out of the way. And then the second spine surgeon was like, hey, people are starting to do these retroperitoneal. So I went to a course and started doing them, and then I refined my technique.

Whoever his spine rep was at the time, I can't remember his Synthes or one of those. And then as time went on, we refined because I went from, like, an oblique incision to now I do the low transverse. And so I've refined the technique over time. And I'll do four fives. Those are a little more terrifying because you got to move the vein all the way down. Take that lumbar. Lumbar branch, and. But we do mostly five ones because they go down to doing those lateral. But, yeah, it's a fun case. It's a good case. I like my spine guys I work with, they tend to be good, good guys to work with.

Dr. Randy Lehman: [00:44:58] And you have an awesome practice. I just proud of you for taking your training and not, you know, becoming a three operation surgeon.

Dr. Shannon Gulley: [00:45:09] Yeah.

Dr. Randy Lehman: [00:45:09] And I think you're doing a lot of good work up there. Thank you so much for taking the time. Yeah, thanks. Really appreciate it.

Dr. Shannon Gulley: [00:45:15] This is awesome. Yeah. Thanks for having me.

Dr. Randy Lehman: [00:45:17] For the listener, please remember to, like, subscribe. Share this with the rural surgeons that are in your network and interact with us on the Facebook, too. We're trying to build a community here. Thank you very much for joining us. And we'll see you next time on the Rural American Surgeon.