Episode 22

Technology Disruptors in Rural Medicine with Dan Leman - Part 2

Episode Transcript

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

Dr. Randy Lehman: [00:00:47] Welcome to the second part of our series where we're talking with Dan Leman, PA. We talked last week about a lot of technology disruptions that exist in rural America. And what are we talking about today? Dan, take it away.

Dan Leman: [00:01:00] Yeah, sorry, Randy. I got excited and in our conversation wanted to ask Randy about the success of rural surgery in America over the next 10 years, what that looks like, and what it means for the individual rural American surgeon to do well in their community. And so I didn't mean to hijack it, but it was a fun conversation. So thanks, Randy. Look forward to it.

Dr. Randy Lehman: [00:01:20] We can talk about tech sometimes, but sometimes we have to pull at the heartstrings too. We'll see you inside on the show. Moving on to the next episode of the show, the resources for the busy rural surgeon. So we talked a lot about technology today. I think technology has changed the game in so many ways, and it impacts rural because that distance shrinks. So do you have any additional resources for the busy rural surgeon or pieces of that technology that you think we should be sharing or connected with?

Dan Leman: [00:01:51] I mean, I think so because I'm out of the care side as much. I see it much more from the patient side. And so whether it's our Haitian patients that are walking in, I think it's similar to rural America where a lot of these patients, they come in and they're wide-eyed, just like, "I got an issue, help me fix my issue." And so I guess I would turn it back to you thinking about that patient care and how when they—you may be the first touch when they come in and potentially the last if it's not handled right. What resources do you use to advocate for that patient all the way through? Whether you take out their gallbladder or whatever, what do you do to enable to think about it from the patient care and then take care of them so that they're not just left in the dust? Because I've seen that so many different times.

Dr. Randy Lehman: [00:02:40] Selected readings in general surgery up to Date.

Dan Leman: [00:02:43] Yeah.

Dr. Randy Lehman: [00:02:44] I've had a few specialists that have provided us some niche resources.

Dan Leman: [00:02:49] No AI yet.

Dr. Randy Lehman: [00:02:50] Nobody said AI, but by far the most common answer is your friend on the phone.

Dan Leman: [00:02:58] Sure.

Dr. Randy Lehman: [00:02:58] A real person, a human being, whether it's a general surgeon or another subspecialist. And I would tend to agree with that. And I have a story to illustrate this point, which is a vulnerable story for myself, somewhat like the other story that I just told. So please don't raise a crucifix here. I'm a human being and I'm doing the best I can, and I'm sincerely trying to help these patients in the small towns.

The situation is I had a patient recently who is a wonderful lady, and she was trying to get her health in order. Her father had colon cancer and passed away. And she went and got her screening colonoscopy from GI Doctor. And the GI Doctor found an adenocarcinoma, which was measured at 30 centimeters from the anal verge and was recorded as a sigmoid cancer and was tattooed. And the patient was then referred to me.

I finished completing the staging workups, CT chest, abdomen, pelvis is negative for metastasis. And so I talked to the patient about our options, and I recommended sigmoid colectomy. And I performed those hand assist. And it's super slick and straightforward. I feel very comfortable doing it. There's a lot of ways to do colectomy safe, but that's the way I have been doing it for four and a half years.

And she was very comfortable with it. She really was on board with having her care local. So I took her for a hand assist sigmoid colectomy, placed my hand port. There were some adhesions. She didn't have prior surgery, but I'm not sure what they were from. I had to lyse several adhesions. And the first thing I see is I don't see a tattoo anywhere in the sigmoid colon. And most of the colon cancer that I'm doing, I've done the scope myself. And then I know a little bit more detail, but in this particular patient is one of them that was referred to me by GI.

Well, okay, so I'm lysing these adhesions, I'm like, sure, it's got to be up above these adhesions. I'm chasing up the descending colon all the way up to the splenic flexure. Still can't find it. Go down to the pelvis, and there well below the peritoneal reflection is the hint of tattoo. And so I'm looking at a rectal cancer.

And so, what do I do? You know, what's, who goes to colorectal in my practice versus who do I actually do? I do a fair amount of colon cancer and I want to continue that. And I think it's great. I mean the last—I'm losing count, but it seems like all of my right colons have been going home on post-op day one. They're doing excellent. There's—I don't see really a lot of benefit to leaving and I see a lot of benefits to staying. I think it's a good resource for a rural general surgeon to have but to offer.

But I don't do any rectal cancer surgery. Really don't do any rectal cancer in general. Obviously the anal things like fistula and hemorrhoids and fissure, I do manage in an abscess. But the rectal cancers, that's where I have a resource in my personal network, which is a friend of mine that trained at Mayo Clinic with me and he stayed and did the one year colorectal fellowship at Mayo. Then he came back and now he's practicing in Indianapolis.

So I've got this, you know, a guy and that's where the question we're trying to answer is what are the best resources for the busy rural surgeon? And now for the last four and a half years I've been sending my rectal stuff there. And he understands I'm not sending every single colon cancer there. That's not the idea. But for him to be there for that nursing home patient with the rectal prolapse, that's one. I've sent several rectal cancers. I've sent rectal cancer or advanced rectal polyp, that's not cancer, but high grade dysplasia that would benefit from TAMIS.

And I can talk to the patient and be the surgical gatekeeper and explain what TAMIS is and explain what I'm sending the patient for. But you know, it doesn't make sense. What am I going to have one of those every five to 10 years? So I'm not going to like buy the equipment or do it. That's what they're there for. You want to do the high volume things that are going to keep the majority of patients local.

So anyway, I called my buddy in the case and he didn't answer and I immediately called him again and he picked up the second time. So he must have recognized the bat signal. And I'm like, I'm in a pickle here. What do I do?

I was able to talk it over with him, and we talked back and forth about how high rectal cancer is really colon cancer and could proceed with an LAR. He was very supportive of me deciding to do that if I wanted to, which I didn't. I really didn't feel like it was right. And it was also, this is the most recent hospital that I started going to. I've done just four colon cancers there, but actually no sigmoids and no low anteriors.

There's a lot of things that play into whether it's right or wrong to proceed. And the other thing is I felt the uterus had some abnormalities, and it ended up just being a fibroid uterus, but it was clearly abnormal on palpation, was not related, you know, like cancer extension or anything of that nature. But there were some questions about it. And I was able to actually FaceTime him during the case, show him what I was looking at, say what I wanted to do, which was send the patient to him.

And, you know, he's gracious enough and the patient's gracious enough to just make that happen. And of course I regret, like putting a hand port, you know, I wish I would have seen this with just a single laparoscope, but, you know, it's that discretion to say no and back out. And I can't think of any right this second, but I've had several of those times where you just have to set your ego to the side, back out of the moment, take stock, do no harm.

And I honestly think that that experience as a fourth-year medical student still is a helpful guiding principle because you can see how you can just charge in and be the big hero surgeon and then you did not do the right thing later on. And so that's what I ended up doing, actually. I ended up doing a D&C on the patient. So we put some histopathologic answers to what was the fibroid uterus, got the pelvic and vaginal ultrasound, got her all worked up, sent her down to Indianapolis, you know, she can have her operation there.

And the patient, of course, was... It takes time to explain all of the nuance, but very gracious. And that is how a detailed example of how somebody on the phone is the most important, in my opinion, resource for the busy rural surgeon. And the majority of my guests have agreed. So developing that network... And I would love to hear from you guys more. From you as the listener more. I'm not really sure the best way to do that. So I'll be working on developing that for the next several episodes. But one way we can connect is through the Rural American Surgeon Facebook page. If you have a Facebook, you could comment on any of the links in there. Tell me, have you had situations like this? Let's be a rural general surgeons lounge for each other and talk about the stories that need to be talked about. Because there is an element of professional isolation, which is part of what I'm trying to fight with this podcast. So thanks for listening to that long story, but can I make a comment on that? Yes, please.

Dan Leman: [00:11:18] I think it's interesting. So it's maybe not a resource, but I think one theme... We talked about technology sort of as a theme, but one thing that has come up consistently throughout this, I think is humility. When you think about, like, you could have just gone forward with that case, like, I already made the hand port, like, it's high enough up. You said I could probably get, you know, I'll make myself comfortable and I'll do it. But having the humility to say, you know what, yes, I maybe shouldn't have done this, but it's going to be best for the patient and now it may change your practice into the future. Whereas the hubris to just move forward would have... Would have done nothing.

But when you think of that as a resource and not just how that's going to benefit that patient, but how is it going to benefit other patients? I'm curious if you've had other cases or think of times where having the humility in case one has affected your practice into the future and that, I mean, I think when you talk about resources, to me, that kind of a sharing on your lounge or whatever, that kind of a learning is hugely valuable. Because if people are thinking about that, like, oh, how am I going to make sure that that doesn't happen to me in the future? Not only did you bless that one patient, you blessed many patients.

Dr. Randy Lehman: [00:12:35] When I get vulnerable with other surgeons, they tell me stories like that. When I don't, we're all perfect, right? That's why I share the story here. There's a great story about my grandpa that we don't have time for, but there will be a teaser here. I'll share it sometime on this podcast. And it is a dramatic story, but all laced with that.

But it factors in that experience. A lot of several of these experiences that I had, of course, experiences in residency, because some people are going to succumb to their surgical disease even if they find themselves in the Mayo Clinic ivory tower. You know, it's not the... The die were cast before, you know, and, you know, like the lady that came to the surgical ICU at Mayo, traveled around the world hoping for a Mayo miracle with metastatic rectal cancer throughout her whole body, and flew from China all the way to Rochester, Minnesota, stood up from her plane flight and threw a saddle embolus.

And then I have to talk to her as a second-year resident in the surgical ICU and explain that she's now going to die there in Rochester with her son back in China, and her husband's with her, but the rest of her family's not. And having an understanding of what's actually going on, all those little stories, they stick with you. But what I was going to say is my informed consent discussion with the patient. One of the buzzwords that I say is the patient takes the risk, not the surgeon.

And it's such a hard discussion to have because I feel like you could frame any operation you wanted to in a way where you made the risk sound so bad that nobody would ever choose to do any operation. And at the same time, you could frame every other operation in a way where everybody would come into it not really understanding the risks. So it's a hard balance to reassure the patient.

Dan Leman: [00:14:50] You want to project confidence.

Dr. Randy Lehman: [00:14:52] Yeah. And the nice thing you can say is, you know, this is a single digit risk. That means that 90 plus percent of the time, most of the time, this doesn't happen. But it is a risk that could happen. You know, see, everybody kind of probably perfects their own way of discussing it. But one thing that I do say, this one trying to paint the picture towards, is I tell people that if you drove 100 miles an hour to work and you got there safely, should you be high fiving or did you take an unnecessary risk and just because you didn't get a ticket or you didn't get into an accident, you survived. Did you do the right thing? And so that's where I was at with that lady is even if I did the operation, like probably she actually would have done fine and she probably wouldn't have leaked, and I probably would have got a good enough distal margin and she probably would have been fine. She probably wouldn't have had a delayed bleeding, you know, but even if she did, should I be high fiving afterwards or did I take an unnecessary risk with the patient asleep in front of me? And so that's where really understanding and looking back and you're not going to make all the decisions right.

You want to put the pressure on yourself, but at the same time, not so much that it becomes overwhelming. You know, doing your best is always all that you can do. But part of doing your best is looking back and saying, where did I take unnecessary risk? And then just making... That's part of experience. And residency is five years for a reason. That's a lot of good experience.

But you know, even longer, like through your career, it just keeps building. Having somebody with gray hair that you talk to regularly about how would you handle this case? And trying to talk about it before you make the incision, those are the ways that you can build on somebody else's experience, even if you're on your first year out, you know. Yeah.

Dan Leman: [00:17:02] What is the culture like? And I don't know this for especially, you know, rural surgeons. You don't... It's not like you have tons of colleagues day to day that you're seeing like you would necessarily in a bigger hospital. What is the culture as far as the balance of humility with each? Like, how well does, how well is humility received with your colleagues? If you're showing humility, is it, do people, do your colleagues tend to see you? And maybe it's not fair just to say you. But in general, what's the culture? Is it sort of a sign of weakness, or is it a sign of like, hey, this guy's real and he's actually gonna do better? How do people see it? Do you have any sense?

Dr. Randy Lehman: [00:17:40] I don't know if it ever was a sign of weakness. Like there's this perception of a surgeon being like a jerk or whatever.

Dan Leman: [00:17:49] Right.

Dr. Randy Lehman: [00:17:49] But that's different because I think that comes from not a surgeon-to-surgeon interaction. I think that comes from a surgeon with all the weight of the decision and caring a lot and all the responsibility, then by necessity relying and trusting on other people who do not have the same level of understanding, for sure of the surgical anatomy, what's going on. And... But some, it seems and sometimes feels like not the same level of care and definitely not the same level of responsibility.

Dan Leman: [00:18:41] Right.

Dr. Randy Lehman: [00:18:43] So then your nurse who gives the general diet when the patient shouldn't be getting, or the ICU that gives the post-op day zero, 120mg Lasix challenge in the patient that's anuric, who really needs 10 liters of fluid and then their kidneys are boxed and then they live in the ICU for six to eight months and then die, right?

Dan Leman: [00:19:15] Yeah.

Dr. Randy Lehman: [00:19:16] So that person then catches the wrath of the person who carries the responsibility and actually, sure... More of understanding. And that's where the, the...

Dan Leman: [00:19:30] That's where the persona is. People get it from.

Dr. Randy Lehman: [00:19:33] But I have never, never felt any pressure from any other surgeon to be anything other than humble. That I think it really looks good on the surgeon to be humble, especially in the surgical decision-making, which a lot of those other ancillary staff, anesthesia nurses, techs, they don't see that decision. Now in that day in that operating room, I don't know if I earned more respect from the team that was around me or not. You know, I think there was definitely some like, shifty, you know, what are we doing here?

Dan Leman: [00:20:11] Sure.

Dr. Randy Lehman: [00:20:11] But once I pivoted and had a plan and it was very clear that all the decisions were about that person, that individual that's asleep on the table that I knew I could say all of this stuff during the case. Like, I know this person because I actually talk to them, you know, then it becomes very personal. And then they... I think it actually can be a trust-building experiment. Should be to, to show humility, to be a trust-building experience, you know, because you're not that you're not in a total island, although you are isolated.

Dan Leman: [00:20:51] Yeah, yeah, well, and it's back to that. Maintaining connection, not, not just with, I mean both with specialties and with various colleagues through different platforms to the rural.

Dr. Randy Lehman: [00:21:02] Surgeon doesn't have to do esophagectomies and whipples with three anastomoses, liver resections or rectal cancer. You don't have to do it. You can do the 90% of operations that have the low morbidity mortality. You might have a higher call burden. It depends on your situation in terms of days.

But like for me, a week on call many times... My average is two operations on a call week, seven days. Every year I have a couple weeks where I have no calls the entire week even though I'm on call. And I gotta check my phone, make sure that, you know, it's still working. I call the hospital every once in a while. Hey, you guys still have my number? Yeah, we just got nothing going on. Cause the townie, the county's 12,000 people and we only see 4,000 ER visits a year.

So my pitch is from my small way to encourage the rural surgeon that's practicing to keep practicing to encourage the trainee to consider rural surgery and in that small way, help rural America by keeping our hospitals open, delivering care local, giving our community something to be proud of because we have a hospital in our town. All that said, it all comes down to policy. Because if the critical access dollars goes away, tomorrow, it's all over.

Dan Leman: [00:22:27] Because the only sustainability currently in the reimbursement model is through the critical access mechanism.

Dr. Randy Lehman: [00:22:33] Right. And so the big issue, of course, is that healthcare has now been 80% of my patients is some sort of government pay. And everything that the government delivers is not as high quality or efficient, especially not efficient. And so you look at the USPS versus FedEx.

Dan Leman: [00:22:58] Sure.

Dr. Randy Lehman: [00:22:59] You know, you look at, we're outsourcing the military operations because you can't do it as well. You look at the school systems.

Dan Leman: [00:23:08] Okay, so is there an outsourced model for healthcare, for rural healthcare?

Dr. Randy Lehman: [00:23:14] No, that doesn't exist because you... It's... The free market doesn't exist in healthcare. I mean, I came out and I tried to do private practice in my hometown and I came up against the hard reality of how much it costs to deliver the care and how the reimbursement model is currently set. So if I don't accept insurance, patients, patients can't... I mean, they just, they wouldn't choose to pay out of pocket when they have insurance and they could go somewhere else. And you can't blame them.

But the whole system has been set up. The reason it's been set up like this is primarily government interference. And private insurance is definitely more of an enemy at this moment than public insurance. But that doesn't mean that private insurance is the problem. The problem is most likely government interference. And the issue is that the question of is healthcare right? And I don't believe that healthcare is a right. It's not an unalienable right, because neither is education. Your education is not a right. A right is something that is not a good or a service that has to be taken from somebody else.

Dan Leman: [00:24:33] Sure.

Dr. Randy Lehman: [00:24:34] So what are the rights? You have the right to assemble in a group. You have the right to bear arms. You don't have the right to a gun.

Government isn't obligated to give you a gun. You have the right to own it. If you own it, you have the right to free speech. You have the right to be free from quartering soldiers in your home. You don't have the right to an appendectomy if you have appendicitis.

Now the question is, should we, are we wealthy enough as a society that we should provide some sort of base education to everybody and some sort of base healthcare to everyone? And that's an argument that I guess I don't have as much of an opinion on. But I do have a strong opinion that healthcare is not a right. A right is not a good or a service that can be taken from somewhere else. You don't have a right to a basic level of avoiding poverty, right?

And that is a controversial topic, but it's not in my mind. And so how do I think it's going to go versus how would I love it to go? You know, I'd love to get the existing system scrapped and go back to some sort of a model where, you know, we're basically performing operations for reasonable and customary services, and the charity care isn't like built into it. You know, it's like the FFA creed says, "Less need for charity and more of it when needed."

But what do I really think is going to happen? I have no idea. I know that right now the contracted model with the critical access hospital financially works and allows me to do meaningful work for the community. And I know the private practice model is dead, and you can be employed if you want to be, but I feel like I have a bit more freedom as a contractor.

And I think if you at the end of the day are choosing to do the surgery with the best interest of that one patient in front of you in mind, and you're kind of like getting the best training that you can when you're a trainee, getting the best experience that you can, bringing the best you to the operating room and trying to do the right thing... I think it'll be fine for you individually as a surgeon, but nationally we're not headed the right direction. And I mean, you're asking me who am I? You know, I don't have the answer.

Dan Leman: [00:27:14] No, but you did hit a couple things I think that are interesting. One is OB care makes a difference. And so even somebody who's debating about like, you know, how much do I do in OB? But, but I think more importantly what you hit on is if it's gonna, if rural healthcare, which seems to be important, it's gonna make a difference for people. It does make a difference. Not just for patients in rural America.

I think you could make the case that it makes having functioning, quality hospitals in rural America is actually good for the culture of America and brings a stabilizing presence. Not that urban is bad, but I think the mixture of it is what we are as a country. And so to maintain or even grow rural healthcare includes better rural hospitals.

And so for the rural surgeon like yourself, the contract piece is great because you can make money. How many of your colleagues are bouncing, know the towns that they're working in? Like you're working in your hometown. You know the hospital, you were born there, the staff and the people. Like many of them, you're connected into it.

You're... There's people, hopefully, as they see you see, man, this... Somebody is investing into us. It's not like somebody's coming in from the big city and just doing some rural healthcare. Like they're like, no, Randy's here for us and it's going to make a difference. And as people see that, I think they're going to drive improvements in rural healthcare. They're going to demand it more than... Yeah, I don't know the policy is going to shift, but is it going to create a demand for it? Because the rural surgeon is better at taking care of the patient and the patient feels that than in the inner city where you're just a number. And so there's a demand piece that you can and your colleagues can create by not just being some rando surgeon in a small town, but investing into the community on more parts than just providing good surgery.

Dr. Randy Lehman: [00:29:12] Yeah. So you can have success with somebody who did not grow up there or didn't even grow up in this country.

Dan Leman: [00:29:20] Sure.

Dr. Randy Lehman: [00:29:22] Or grew up in the city. In this country.

Dan Leman: [00:29:24] Right.

Dr. Randy Lehman: [00:29:24] They can move to a town and...

Dan Leman: [00:29:26] Own, but they have to invest into the town.

Dr. Randy Lehman: [00:29:29] Yes. So I don't want to say it's the only way because there are rural surgeons that I know that are doing it without having been grown up in that particular place.

Dan Leman: [00:29:41] Yeah.

Dr. Randy Lehman: [00:29:42] But recruitment, finding a way to get into the small town. The problem is you go to high school and how many pre-med students every year versus how many rural surgeons are we going to crank out? It's a big time funnel numbers game.

Dan Leman: [00:30:02] Just looking from the outside at the rural surgeon profession, it is distinct. I think that's one of the points that you're trying to make. It is a distinct profession. I think there's some work that you're doing on some of these different pieces. But when you think about that 10, 20 year success of more hospitals opening back up or better more rural surgeons engaged into that, there's a lot of questions I could ask about just what that does to the landscape of surgery as a whole, if that's happening. But what does the leadership look like moving into it? I mean, is it just a pocketed like as long as people are getting out there kind of doing their own thing and semi-connected... What is, what is the advancement of the profession look like?

Dr. Randy Lehman: [00:30:51] Well, I think it starts with training. And so if you can have a person that has in mind, that's where they're going to go. And I've heard there's two types of people that practice in rural America, sadly is those that want to be there and those that have to be there. And so it's fighting that side of...

Dan Leman: [00:31:11] Things and those that have to be there. It's sort of a second best.

Dr. Randy Lehman: [00:31:14] Right.

Dan Leman: [00:31:14] Which doesn't do anything good for the profession. Yeah.

Dr. Randy Lehman: [00:31:17] So if you can find that person that sincerely wants to be out there and then you can have the quality surgeon, the quality training and you can sincerely tell the patient that you're not getting anything different when you go to see, because it can't...

Dan Leman: [00:31:33] So somehow there's a marketing of eliteness that needs to be there.

Dr. Randy Lehman: [00:31:36] Right.

Dan Leman: [00:31:37] You have to somehow set an elite standard.

Dr. Randy Lehman: [00:31:38] Right.

Dan Leman: [00:31:39] Like you're the SEALs of surgeons.

Dr. Randy Lehman: [00:31:41] It helps you train at Mayo Clinic and you just say there's like inherent trust, you know, but how do people know? You know, so you have to bring in the quality and you just have to... It starts with one person. And the thing is, you know, most rural communities, they really need like half of a surgeon.

Dan Leman: [00:31:59] So they're not going to be helicopter pilots. You can go between cities.

Dr. Randy Lehman: [00:32:04] Yeah, just take your helicopter. What place, like what apartment in the city is going to let me, you know, land my helicopter on top and then go see?

Dan Leman: [00:32:15] It's just, I mean we had gangs here in Aurora that were taking care of things.

So you could probably land a helicopter.

Dr. Randy Lehman: [00:32:21] I think it's slow – What I'm doing here is basically talking to the abyss and probably nothing more than that. But if anything, I'm not trying to change the big macro rules. I'm just recognizing the rules that currently exist and what are the things that we can do, like one town at a time, one person at a time in our small towns, kind of meet the needs of the community, talk about in a group fashion the challenges that we face, you know, and commiserating a little bit, trying to pep talk each other and you know, trying to make a difference, one person's life at a time.

End of the day, if you're a Christian, this is the other angle to the whole thing. I can get really focused on goals, smart goals, and I can really care about the things that I'm doing. You know, I'm a conscientious individual. I learned the meaning of the word conscientious when I was in first grade because I saw it on my report card, and so I had to look it up because I was concerned that it might be something bad. Right?

Dan Leman: [00:33:32] You know how to look up words in first grade.

Dr. Randy Lehman: [00:33:34] Right. So, you're... but at the end of the day, does any of that matter in a long-term perspective? And I'm not trying to necessarily use this podcast to preach, but I don't think that it matters actually, long term. And I think that there's an eternity waiting for you and that's probably all that matters. And then doing some work, you know, for God's kingdom.

Dan Leman: [00:34:08] But you hit on the, you did hit on a piece that does matter, which is the people. And I think you can make the argument that even if you're just comparing rural to city surgeon, you have the opportunity to engage with people better in rural America. Your community engagement is better. Your ability to relate is better. Your ability to be in a, to witness and be an example is better as a rural surgeon.

Dr. Randy Lehman: [00:34:35] It's beautiful. Well, you took this podcast on a different bent from how it normally did, and then I like how you ended up interviewing me. I really appreciate you coming on.

Dan Leman: [00:34:43] Thank you.

Dr. Randy Lehman: [00:34:43] Being vulnerable, sharing all kinds of crazy stories from all over the world.

Dan Leman: [00:34:46] Your world exploits not that much, but maybe more.

Dr. Randy Lehman: [00:34:51] And it was, it was just an extreme pleasure. So thank you very much.

Dan Leman: [00:34:53] Likewise. Appreciate it.

Dr. Randy Lehman: [00:34:55] Thank you for joining us for this episode of the Rural American Surgeon. See you on the next episode. Please don't hesitate to smash the like and subscribe button. Please share with any rural surgeons or anyone that's passionate about rural surgery that's in your circles. I really appreciate the time and the opportunity just to share these conversations with you. So we'll see you on the next episode of the Rural American Surgeon.