Episode 8
Rural Robotic Revolution with Dr. John Robertson
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 provider, or simply someone interested in healthcare for rural America, I'm glad you're here. Now let's get into the show.
Welcome back to another episode of the Rural American Surgeon Podcast. I'm honored to be joined by Dr. John Robertson of Tomah, Wisconsin, today. Thanks for joining us, Dr. Robertson.
Dr. John Robertson: [00:00:56] Glad to be here. Thank you for inviting me.
Dr. Randy Lehman: [00:00:58] We're recording outside at your home. It's a beautiful [mustache (misty) morning] [Uncertain] here. So we're going to be talking about all things rural surgery, and Dr. Robertson has a very interesting story to tell.
He is a rural surgeon who transitioned from the urban area in Philly to a small town in central Wisconsin. So why don’t we start with that introduction? Tell me just a brief bit about your training and the first part of your practice, and then we'll see how that differs from what you're doing now.
Dr. John Robertson: [00:01:26] Yeah. So I did medical school at Howard University in D.C., and from there, I completed my residency at Harlem Hospital. Then, I had the fortunate circumstance of practicing at the same institutions where my dad worked. We practiced together for approximately three to four years before his retirement.
That was one of the highlights of my career—being able to share an operating suite with him. Following that, I worked in large metropolitan hospitals in Philadelphia. However, Philadelphia experienced a situation with malpractice insurance rates skyrocketing to untenable levels. That forced many surgeons, including orthopedics, general surgeons, and OB-GYNs, to look elsewhere.
Many of my peers never returned, citing the challenges outside of the city. I decided to take a leap of faith and explore rural practice myself. I ended up here in Tomah, Wisconsin, and I’ve been pleasantly surprised by the complexities and rewards of rural surgery.
It’s been different both culturally and in terms of work-life balance. I trained in both general and vascular surgery, but I’m performing less of the advanced vascular surgeries I trained for and more cosmetic vascular procedures here. On the general side, I’ve had to broaden my skill set significantly.
For instance, I’ve started performing C-sections—something no surgeon in Philadelphia would handle, as it’s the domain of OB. I also do both lower and upper endoscopies, which are typically handled by GI specialists in urban areas. Adapting to these changes has been challenging but rewarding.
Dr. Randy Lehman: [00:04:31] So how many years did you spend in Philly versus here so far?
Dr. John Robertson: [00:04:36] I spent 22 years in Philly, and I’ve been here for about 17 years.
Dr. Randy Lehman: [00:04:45] Yeah. So that’s a pretty good comparison.
Dr. John Robertson: [00:04:48] Yeah.
Dr. Randy Lehman: [00:04:49] One question an urban surgeon might wonder is, you didn’t necessarily have C-section training in residency. So how did you acquire the skills required to come out to a small town and perform C-sections safely?
Dr. John Robertson: [00:05:06] So what’s interesting is that, at that point in time, the administrative staff of surgeons working in the city had little understanding of what we did and didn’t do. They assumed I was performing all types of surgery, including C-sections.
I clarified that I wasn’t, and they asked if I was interested. I looked at it as surgery and found it fascinating because it reminded me of what my dad used to do. He belonged to a generation of surgeons who performed all types of surgery, including OBGYN and orthopedic procedures.
They arranged for me to receive training at Gundersen Lutheran in La Crosse, Wisconsin. After completing the training, I was proctored at the hospital and eventually started performing C-sections independently.
Dr. Randy Lehman: [00:06:19] That’s interesting. So, Gundersen trained you through a spoke-and-hub model that actually works.
Dr. John Robertson: [00:06:26] Right.
Dr. Randy Lehman: [00:06:26] But what’s remarkable is that you’re not directly working for Gundersen, yet they were willing to provide that support.
Dr. John Robertson: [00:06:32] Right. It was nice because their mission focuses on supporting the community. In their effort to help surrounding areas, they made it happen, which was generous.
Dr. Randy Lehman: [00:06:51] Yeah, it’s something you...
Dr. John Robertson: [00:06:53] Don’t necessarily see elsewhere.
Dr. Randy Lehman: [00:06:56] No, many of these large systems aren’t the enemy, unlike some insurance companies.
Dr. John Robertson: [00:07:03] Right, right.
Dr. Randy Lehman: [00:07:04] But sometimes, they’re not helpful either. Decisions made by non-clinicians often complicate things. I think some people see the world as a pizza—if I take my slice, you can’t have it.
Dr. John Robertson: [00:07:17] Right.
Dr. Randy Lehman: [00:07:18] But the world isn’t like that. The world is more like an oven where we can bake as much pie as we collectively want. If we collaborate, we can achieve more—improving quality, availability, and quantity. There’s so much unmet need, and working together can really raise the bar. It’s refreshing to hear that Gundersen did that for you, though it was 17 years ago.
Dr. John Robertson: [00:07:45] It’s nice that you brought that up because you’re right. In larger cities, it’s essentially a dog-eat-dog environment. The idea of collaboration is almost nonexistent.
What I found here, specifically, was unique. While I officially work for Tomah, there are clinics from both Mayo and Gundersen systems nearby, each with their own surgeons. We’ve all worked together—sharing call responsibilities and collaborating on difficult cases.
Dr. Randy Lehman: [00:08:34] Yeah, I feel like there’s less competition, though it probably depends on the number of surgeons in the area. I once talked to a surgeon about this, saying that rural surgeons should see themselves as a team working to meet the needs of rural America.
That surgeon responded, “I definitely don’t view it that way.” I was surprised but realized not everyone shares my perspective. Some see themselves as heroes, while others feel the need to protect rural areas from other surgeons. There’s also the factor of competition.
Dr. Randy Lehman: [00:10:00] So, there are different ways of thinking about it, but I challenge the listener to try to have an open mind. Maybe I’m fortunate enough that there’s so much demand I don’t feel competition.
The other thing is surgeons are very competitive people in general. For example, the Enneagram personality profile type three is very common among surgeons—the achiever, the doer, or the competitor—which I identify with. We recently did an Enneagram personality test with an organization I work with.
I said, “I am competitive, and I do want to win, but I don’t like to beat people.” So there’s a distinction. Like the pizza pie analogy, I feel we can all win together. You’re going to go further as a team. That’s me at my best—on a Saturday morning in a beautiful environment, talking with a mentor. But that’s what I strive for.
Dr. John Robertson: [00:10:27] Right. I kind of follow the same philosophy my dad lived by: we’re all working toward the same end, and that is, ultimately, our death.
Dr. Randy Lehman: [00:10:42] No! Sorry. Laughing so you don’t cry.
Dr. John Robertson: [00:10:45] Exactly. And that means taking care of patients, providing access, offering the best opportunities, and delivering good care. That’s how we act as a team.
I see this collaboration more here than I did in Philadelphia. But like you said, we’re all individuals with different perspectives. I’ve always shared your view that working together enables us to provide the best care.
Dr. Randy Lehman: [00:11:29] That’s beautiful. I had one more question about your dad. Was he still alive when you came to Tomah?
Dr. John Robertson: [00:11:34] No.
Dr. Randy Lehman: [00:11:35] Okay.
Dr. John Robertson: [00:11:35] No, he had passed by the time I left Philadelphia. That’s when I decided to look elsewhere. Otherwise, I would have stayed in Philadelphia.
Dr. Randy Lehman: [00:11:48] I understand. I was just wondering if he had an opinion about it. But, of course, we don’t have that luxury.
Dr. John Robertson: [00:11:54] Well, he told me never to go into surgery. He said it had changed so much from his time. I remember going on house calls with him and seeing patients he cared for in the community.
Dr. Randy Lehman: [00:12:13] What kind of patients would he do house calls for?
Dr. John Robertson: [00:12:17] Well, he practiced medicine as well, so it was a different era.
Dr. Randy Lehman: [00:12:23] Yeah. You know, I’ve done house calls too.
Dr. John Robertson: [00:12:26] Yeah?
Dr. Randy Lehman: [00:12:27] In Indiana, I’ve done a couple. One was for a wound, and the other was a post-op question. Both were after hours on weekends. One I set up myself because I’d done a debridement on a Friday, and I wanted to check on them.
The patient didn’t need admission, and they didn’t want to be admitted. So I went to her house, did a wound change, and, wow, she was so grateful. That’s in my hometown.
Another time, a patient called with a post-op question after hours. I thought, “Do I send them to the ER?” But I happened to be in the same town where she was. So I went over, checked her situation—it didn’t require admission—and provided reassurance.
Dr. John Robertson: [00:13:23] Well, I mean, there…
Dr. John Robertson: [00:14:00] And there are opportunities for that. That’s what I’ve always found interesting about medicine. It might not be within the community you’re in, but there are certainly pockets within the nation where you can find your niche. It’s still a big country out there, even though it appears to be getting smaller as a result of insurance constraints.
Dr. Randy Lehman: [00:14:04] Yeah. Well, that’s beautiful. I think that pretty well covers what you love about rural surgery. I guess there’s one more thing I’d like to talk about.
When I was in training, I did the rural surgery track at Mayo. The idea was to work in a small town, like a critical access hospital, where they may not have specialists like OB-GYN, urology, ENT, plastics, or others. There are small, low-morbidity and low-mortality cases, such as carpal tunnel surgeries or vasectomies, that don’t require a specialist.
These procedures have high volumes and can be performed safely, allowing people to stay in town. My track included dedicated rotations in these areas. By that time, I was already a surgeon capable of performing cases independently. The rotations allowed me to also participate in general surgery, which was great.
Dr. John Robertson: [00:15:21] Right.
Dr. Randy Lehman: [00:15:22] Out of all the things I trained for, two stood out as the most in demand: C-sections and scopes. These account for 80% of the work—the Pareto principle, where 80% of the value comes from 20% of the procedures.
For instance, I trained in ENT and thought I’d perform parotid surgeries. But in reality, there’s maybe one every 10 years. Even in thoracic surgery, I was trained to perform VATS. Early in my career, I performed a few, but now I transfer patients because hospitals are not equipped for it.
For example, I recently transferred a patient with a spontaneous pneumothorax who likely needed a bullectomy and pleurodesis. Cases like that occur maybe once every two to four years, whereas I perform hundreds of scopes annually.
Dr. John Robertson: [00:16:28] Yeah.
Dr. Randy Lehman: [00:16:29] So where’s the greatest value to the community?
Dr. John Robertson: [00:16:31] Right. And as you said, those two—C-sections and scopes—are the most important. But, as you mentioned, there are other minor procedures like vasectomies and tubal ligations. I’ve even found myself performing tubal ligations, which is very different from my work in Philadelphia.
Dr. Randy Lehman: [00:16:56] Yep. It’s beautiful. All right, let’s move on to the “How I Do It” section, which is my favorite part of the show.
If you’re a hospital administrator or a family practice doctor listening, feel free to skip ahead. If you’re a resident, turn the volume up. We’re going to talk about a case I haven’t discussed yet but that I love—starting with a hernia.
Dr. John Robertson: [00:17:17] Yeah.
Dr. John Robertson: [00:20:00] My approach to open inguinal hernias typically involves what I call a modified plug-and-patch technique. This was taught to me by Dr. Keith Milligan at Rush University in Chicago. It’s derived from the Lichtenstein method for tension-free repair.
The procedure starts with a roughly 3.5 x 4 cm incision along the inguinal ligament, between the ASIS (anterior superior iliac spine) and the pectineal pubis, depending on the side being worked on. Dissection proceeds through the subcutaneous tissue, down to the level of Scarpa's fascia, and then to the external oblique aponeurosis.
The external oblique is opened with a scalpel, both proximally and distally, through the external ring. The cord structures are identified, and a Penrose drain is placed around them. The next step is determining whether the hernia is direct or indirect, locating the sac medially, and identifying it.
One major change from my residency days is that we no longer divide the sac and tie it with silk sutures, as it’s believed this is a source of postoperative pain. Instead, the sac is stripped from the spermatic cord and placed into the preperitoneal space for an indirect hernia. A large plug is inserted into the preperitoneal space, with the plug’s leaves secured using 3-0 Vicryl to the iliopubic tract and surrounding structures, such as the internal oblique aponeurosis.
An onlay patch is then placed and secured only at the wings, recreating the internal ring. Closure is done anatomically. For a direct hernia, I use an extra-large plug, create an entrance into the preperitoneal space through the transversalis fascia, and secure the plug with 2-0 Prolene sutures. Following this, the onlay patch is applied, and the incision is closed with 3-0 Vicryl and 4-0 Monocryl PDS for the skin, finished with Durabond.
Dr. Randy Lehman: [00:20:48] What I love about this is that there are so many ways to approach open inguinal hernia repair. Studies often compare lap versus open techniques, but even within open repairs, there’s a lot of variety.
Dr. John Robertson: [00:20:59] Right.
Dr. Randy Lehman: [00:21:00] When you’re opening the external oblique, you mentioned using a scalpel. Do you extend it with Metzenbaum scissors, or do you continue with the scalpel?
Dr. John Robertson: [00:21:17] I start with the scalpel—specifically a #15 blade. Then, I use Metzenbaum scissors to sweep underneath and free the nerve from the aponeurosis before guiding the incision proximally and distally through the external ring.
Dr. Randy Lehman: [00:21:41] How do you handle the nerve during this step?
Dr. John Robertson: [00:21:44] I sometimes loop a vessel loop around the nerve or place straight clamps on either side of the external oblique aponeurosis, positioning the nerve behind one of the clamps to keep it out of the field.
Dr. Randy Lehman: [00:22:04] What do you do if the nerve is in poor condition or obstructing the field? Under what circumstances would you decide to resect the nerve?
Dr. John Robertson: [00:22:14] If the ilioinguinal nerve is particularly ratty or causing significant obstruction, I would simply divide it.
Dr. John Robertson: [00:23:00] I know some people advocate tying the nerve, but I’ve seen patients develop neuromas at the site. So, I simply cut it and haven’t encountered issues as a result.
When discussing complications with patients, chronic pain is one potential outcome. If chronic pain arises, some refer patients to a pain clinic for RFA (radiofrequency ablation) to deaden the nerve. What I used to do was apply Kenalog to the area, which chemically achieved the same effect.
Dr. Randy Lehman: [00:23:09] So you try to find the specific point of tenderness?
Dr. John Robertson: [00:23:11] Yes, the patient identifies the point of tenderness where they feel the pain.
Dr. Randy Lehman: [00:23:15] Did you ever conduct a test using local anesthesia?
Dr. John Robertson: [00:23:18] Yes, I did.
Dr. Randy Lehman: [00:23:19] Was that performed on a separate day?
Dr. John Robertson: [00:23:21] Yes, it was done on a separate day.
Dr. Randy Lehman: [00:23:22] After administering local anesthesia, did some patients experience lasting relief, or did the pain usually return?
Dr. John Robertson: [00:23:28] For some patients, the pain resolved completely and didn’t return.
Dr. Randy Lehman: [00:23:33] Interesting.
Dr. John Robertson: [00:23:33] Right.
Dr. Randy Lehman: [00:23:34] If the pain returned, you’d document the specific point and apply Kenalog, correct? I’ve also heard of alcohol ablation, but I’ve not personally used it. In residency, we referred such cases to anesthesia or pain management.
Dr. John Robertson: [00:23:48] Gotcha.
Dr. Randy Lehman: [00:23:48] And you’d avoid re-operating on patients with chronic pain, right?
Dr. John Robertson: [00:23:54] Correct. Don’t fall into that trap.
Dr. Randy Lehman: [00:23:57] Both the plug and patch are made of polypropylene, right?
Dr. John Robertson: [00:24:03] Correct.
Dr. Randy Lehman: [00:24:04] For an indirect hernia, you place the plug first and then the patch, but you don’t secure the patch. Is that correct?
Dr. John Robertson: [00:24:12] That’s correct.
Dr. Randy Lehman: [00:24:12] So, you don’t stitch the patch to the shelving edge of Poupart’s ligament?
Dr. John Robertson: [00:24:17] No, I just let it lie in place.
Dr. Randy Lehman: [00:24:17] What if you encounter a large direct defect that obstructs your view? Would you perform a Bassini repair underneath the patch?
Dr. John Robertson: [00:24:31] There are many approaches, but yes, if needed, I’d revert to the Bassini technique, as I was trained in that method.
Dr. Randy Lehman: [00:24:40] Would you use Ethibond sutures for a Bassini repair, or do you prefer Prolene?
Dr. John Robertson: [00:24:46] For a Bassini repair, I typically use Prolene sutures.
Dr. Randy Lehman: [00:24:52] I’ve had similar cases with large direct defects. Sometimes, the defect is discrete, but this might be a good moment to differentiate between direct and indirect hernias.
The abdominal wall is supplied by four vessels: the paired deep inferior epigastric vessels and the superior epigastric vessels. The superior epigastric vessels are extensions of the internal mammary vessels superiorly, while the deep inferior epigastric vessels arise from the iliac-femoral region.
If there’s a “deep,” there must also be a “superficial,” and if there’s a “superior,” there must be an “inferior.” That’s how the naming convention works.
Dr. Randy Lehman: [00:28:00] The superficial epigastric vessels run through the subcutaneous tissue in this area. Sometimes they’re in the way, so we ligate them or push them aside as needed. But we’re primarily discussing the deep inferior epigastric vessels, which branch off the groin and feed the inferior abdominal wall.
These vessels typically distribute one branch to each quadrant, which explains why the belly button is considered the true watershed area. This central region often converges vascular supply, which can create issues for hernias and recurrent hernias. Additionally, the umbilical cord passes through this area, making it the terminal point for vascular supply.
Laterally, the spermatic cord or the round ligament always travels just lateral to the deep inferior epigastric vessels, serving as a reliable anatomical landmark. The most common type of hernia in all demographics is the indirect inguinal hernia, which travels along this natural area of weakness and exits just lateral to the deep inferior epigastrics.
It doesn’t matter whether the patient is an 85-year-old woman, a 4-day-old preemie, or anything in between. The most common hernia is an indirect hernia. However, there are relative differences: older women have a higher risk of femoral hernias, while older men are more likely to develop direct hernias.
My mnemonic for remembering direct hernias is “MD”—medial direct. If the hernia sac is medial to the deep inferior epigastric vessels, it’s a direct hernia. This type of hernia often results from a blowout of the inguinal floor due to chronic lifting or muscle loss over time.
Sometimes, these hernias are small and discrete, but other times, the entire area is weakened. When both direct and indirect components are present, it’s called a pantaloon hernia. In such cases, I often use a Bassini repair—a suture repair beneath the patch—to reinforce the area before completing the open repair on top.
Now, say a 60-year-old man presents with a small-to-moderate unilateral primary inguinal hernia that hasn’t descended into the scrotum. Would you use the approach you just described, or would you consider a laparoscopic or robotic technique?
Dr. John Robertson: [00:28:48] Today, I primarily perform robotic surgery.
Dr. Randy Lehman: [00:28:51] Boom! Mic drop. Very cool. Okay, so for me, if it’s a unilateral hernia in a man...
Dr. John Robertson: [00:29:02] Right.
Dr. Randy Lehman: [00:29:03] ...I typically repair it with an open approach. For bilateral hernias, recurrent hernias after open repair, or hernias in women, I lean toward laparoscopic surgery unless contraindications exist.
That said, I don’t hold rigidly to this. If a patient specifically requests a laparoscopic repair, I’ll discuss the options and potential outcomes. Ultimately, if they’re insistent, I’ll proceed laparoscopically, as it’s not wrong to start with a minimally invasive approach. However, when left to my own decision, my preferences guide me.
We don’t need to dive deep into robotic surgery, but I’m curious—why do you favor the robotic approach over open techniques these days?
Dr. John Robertson: [00:29:50] Right. I’ve gone through all the stages over my career because I’ve been doing this for a long time. Initially, I did mostly open repairs. Then laparoscopic surgery became popular, but back in Philadelphia, no one really cared if I stuck with open techniques.
When I moved here, more people were interested in laparoscopic surgery, so I transitioned to doing more laparoscopic inguinal hernia repairs. Eventually, we got the robot, which is now the latest and greatest, and I believe it will become the standard of care.
What I enjoy about surgery is that there are so many different ways to perform a procedure. Depending on the patient’s prior surgeries, you might have to return to an open approach. Having experience with both methods is valuable. However, I now love robotic surgery and use it whenever possible.
Dr. Randy Lehman: [00:31:14] Why do you prefer the robot? What do you like most about it?
Dr. John Robertson: [00:31:16] The robot makes dissection very clean. No two inguinal hernias are the same, but with robotic surgery, performed transabdominally, the structures are consistent. The same anatomical areas are accessible every time, and I find that aspect reassuring.
There are no hidden surprises. You can clearly identify the cord structures and easily determine whether the hernia is indirect, direct, or femoral.
Dr. Randy Lehman: [00:32:10] What about large inguinoscrotal hernias? Do you repair those robotically?
Dr. John Robertson: [00:32:17] I’ve done them both ways. Ideally, I try to reduce the hernia before attempting a robotic repair. However, since the robot is relatively new, my go-to approach for complex cases remains open surgery. That said, I have successfully repaired large inguinoscrotal hernias robotically.
Dr. Randy Lehman: [00:32:48] I remember a case during my chief residency. It was 3 a.m., an incarcerated left inguinal hernia containing the sigmoid colon under a rigid FEM bypass graft. The patient had sigmoid colon cancer within the incarcerated segment, and the sigmoid was threatened.
That case involved both groin and midline incisions, bowel resection, and everything in between. It was probably my craziest inguinal hernia story. The patient had a fantastic outcome, with no positive lymph nodes. He was cured in every sense, and his family even sent cards thanking us.
Dr. John Robertson: [00:34:12] That’s amazing.
Dr. Randy Lehman: [00:34:13] The lesson I took away from that is the importance of being versatile. By 2024, you need multiple techniques in your toolbox. If you’re a resident, don’t stick to what you’re comfortable with—challenge yourself.
Dr. John Robertson: [00:34:23] Exactly.
Dr. Randy Lehman: [00:34:25] Especially if you plan to go into rural surgery. In rural settings, you’re the one they call.
Dr. John Robertson: [00:34:25] Right. You won’t always have assistance or extra help.
Dr. Randy Lehman: [00:34:28] So you have to be ready. All right, I have one more question. Have you ever heard of anyone doing an open inguinal hernia repair, closing it, and then performing a laparoscopic repair in the same case under the same anesthetic?
Dr. John Robertson: [00:34:47] No.
Dr. Randy Lehman: [00:34:48] Me neither. Okay, but carry on. Speak louder into the mic—no, I’m just kidding. All right, that’s a beautiful one. Let’s move on to the next section of our show, called the Financial Corner.
So, is there any money tip, big win, or loss that you’ve had in the past that you’d love to share?
Dr. John Robertson: [00:35:08] Well, I’d say, look, I knew very little about the business side of medicine, except for what my dad taught me. But I’ll say this: with the money you’re generating, get yourself a good advisor so you can put your money away thoughtfully.
You’ll be tempted to take on other projects, but each project should be self-sustaining. Never throw good money after bad.
Dr. Randy Lehman: [00:35:58] That’s beautiful. How does someone find a trusted advisor? How do you know they’re good?
Dr. John Robertson: [00:36:04] From other individuals.
Dr. Randy Lehman: [00:36:07] Get a referral?
Dr. John Robertson: [00:36:08] Yeah, get a referral.
Dr. Randy Lehman: [00:36:09] Okay, very good. That’s beautiful. Let’s move on to the Classic Rural Surgery segment, where we tell a story that is just so “classic rural surgery.” Do you have anything like that?
Dr. John Robertson: [00:36:21] Yeah. I’ll tell you this: COVID was hard on everyone. Patients who wouldn’t typically be seen in a rural setting were arriving in our emergency room.
We had a middle-aged man who had fallen off his bike about a week earlier. He came in complaining of pain, but no one realized how serious it was. After a CT scan, we saw he was bleeding from his spleen.
At that point, there was a mad rush to transfer the patient, but all nearby hospitals were dealing with staffing shortages and were on diversion. Splenectomies weren’t performed at our institution, and we tried every hospital in the state—and even outside the state—to take him.
Unfortunately, we were his last hope. Luckily, I had trauma training during residency, and there are things you don’t forget. We took him to the OR and performed a splenectomy. He did well, thankfully.
These are the kinds of situations you face in rural settings, especially with the challenges COVID brought to many hospitals across the country.
Dr. Randy Lehman: [00:38:42] How would you handle that in a non-COVID, non-diversion setting?
Dr. John Robertson: [00:38:46] Transport availability can still be an issue. Air transport, for example, might be grounded due to low ceilings. It also depends on how hemodynamically stable the patient is.
Dr. Randy Lehman: [00:39:00] Right, it’s tricky. It’s like a GI bleeder—the gastroenterologist might say, “They’re stable enough to prep and scope tomorrow.” But if they’re unstable, then they’re too unstable for a scope, so you resuscitate them and scope them the next day. It’s always a balancing act.
Dr. Randy Lehman: [00:39:28] So what if there’s no air transport available, it has nothing to do with COVID, and you’re looking at a two-hour ambulance ride for a patient with a shattered spleen who is hemodynamically unstable in your ER? Wouldn’t that case still need to be done at your institution?
Dr. John Robertson: [00:39:45] I would say the team would do their best to transfer the patient. At our institution, anesthesia plays a critical role, but they are not accustomed to handling these types of procedures.
This is part of the challenge—you’re dealing with cases that aren’t common, so there’s a general reluctance to take them on. Even though we have the experience, like with your VATS cases, there is often hesitation. If there’s an option to transfer the patient, they will try to make it happen.
Dr. Randy Lehman: [00:40:41] Rural surgery is so variable. Whether you’re in Wisconsin or Indiana, it’s similar in some ways. For example, I have ICU beds an hour away and full-spectrum care about two hours away in places like Chicago or Indianapolis.
But it’s entirely different in Alaska or remote parts of Canada. I had Lauren Smithson on the podcast—she’s in Newfoundland. She mentioned being 11 hours away by vehicle, two hours by fixed-wing aircraft, or three hours by helicopter. She has no choice but to do those cases herself because the risk of transport is too high.
Dr. John Robertson: [00:41:25] Another issue is the availability of blood products.
Dr. Randy Lehman: [00:41:34] What do you typically have? Two units?
Dr. John Robertson: [00:41:35] Two units.
Dr. Randy Lehman: [00:41:36] Two units of O-negative?
Dr. John Robertson: [00:41:37] Right.
Dr. Randy Lehman: [00:41:38] These are the resource limitations we discuss often on this podcast. We’re not solving all the issues today, but at least we’re highlighting them.
Dr. John Robertson: [00:41:51] Right.
Dr. Randy Lehman: [00:41:52] Let’s move on to the next segment: Resources for the Busy Rural Surgeon. What tools or resources have you found most helpful since transitioning to a small-town setting?
Dr. John Robertson: [00:42:12] For me, mentorship and UpToDate have been invaluable. Our institution has a collaborative environment among surgeons, including locums, which we take pride in. Everyone is eager to help, and that has been a significant asset to our community.
Dr. Randy Lehman: [00:42:49] That’s fantastic. You’ve been a great resource for me, and I’ve appreciated the chance to scrub cases with you.
Dr. John Robertson: [00:42:57] Thank you.
Dr. Randy Lehman: [00:42:57] It’s been a pleasure. I’ve heard what you said about mentorship and fighting professional isolation—it’s something many people I’ve interviewed emphasize. You’re also in the middle of recertifying, right?
Dr. John Robertson: [00:43:12] Yes.
Dr. Randy Lehman: [00:43:13] So, that’s both a resource and a bit of a burden, wouldn’t you say?
Dr. John Robertson: [00:43:17] Yeah, but it’s a double-edged sword.
Dr. Randy Lehman: [00:43:19] Tell me—so, you’ve taken the recertification exam twice. This is your third?
Dr. John Robertson: [00:43:23] This is my third.
Dr. Randy Lehman: [00:43:23] Since they moved to the new every-other-year model?
Dr. John Robertson: [00:43:27] Right.
Dr. Randy Lehman: [00:43:28] And they’re sending you a hundred articles to review?
Dr. John Robertson: [00:43:32] They’ve reduced it to 40 this year.
Dr. Randy Lehman: [00:43:35] Okay.
Dr. John Robertson: [00:43:36] Thank God. We review those 40 articles, and then we’re given 40 questions based on them. The questions are divided into sections: a core section that everyone must complete, and then additional sections on topics like breast oncology, alimentary tract, and comprehensive abdomen.
Dr. Randy Lehman: [00:44:11] But there are no questions about carpal tunnel or C-sections.
Dr. John Robertson: [00:44:14] Right.
Dr. Randy Lehman: [00:44:15] That’s the ironic part.
Dr. John Robertson: [00:44:16] No, there aren’t any. That’s correct.
Dr. Randy Lehman: [00:44:18] In your practice in Philly, were you doing esophagectomies, Whipple procedures, or liver resections?
Dr. John Robertson: [00:44:26] Yes, esophagectomies and liver resections.
Dr. Randy Lehman: [00:44:29] Yeah, sure. I would never do those in a rural setting—I don’t have the resources. But now I’m doing things like ganglions, carpal tunnels, trigger fingers, and basal and squamous cell carcinomas.
They don’t include much about those topics in the recertification, other than melanoma, even though they’re very relevant. I’m dealing with basal cells and squamous cells regularly.
Dr. John Robertson: [00:44:54] Right.
Dr. Randy Lehman: [00:44:54] So, this is the world we live in. It’s very different from the city. I appreciate you detailing those differences for us.
If you had any advice for an urban surgeon who’s burned out or frustrated with competition and considering rural surgery, what would you say? Would you do it again?
Dr. John Robertson: [00:45:28] Speaking personally, my decision to move was influenced by the circumstances in Philadelphia at the time. However, knowing what I know now, I wouldn’t hesitate to do it again.
Where I am now, there’s camaraderie among colleagues, and the work-life balance is far better. It’s not the chaos I experienced in the urban setting—it’s more controllable.
If you work in a system like mine, which brought in a robot, you’re still practicing cutting-edge surgery, for which I’m very thankful. In Philadelphia, I knew I was making a difference, but here, I can actually see the impact.
Some of the patients I treat are my neighbors, which is a different kind of fulfillment. You see them at the grocery store or pharmacy. That sense of community, combined with the ability to still practice high-quality surgery, makes this experience fulfilling.
Dr. John Robertson: [00:48:00] This improves their access to medicine because they no longer have to travel 40 miles for care—it’s available within the community. The economic impact of that is significant.
Additionally, our interaction with the community helps them better understand their disease processes, making them more aware of issues like hypertension, diabetes, and the importance of screening colonoscopies.
Because we live here, we’re more integrated into the community. In a smaller community of 10,000 people, as opposed to a city of 2.5 million, the impact feels much more personal.
Dr. Randy Lehman: [00:49:18] In Philadelphia, you feel more replaceable. I mean, you are more replaceable in the city.
Dr. John Robertson: [00:49:22] Oh, yeah, absolutely.
Dr. Randy Lehman: [00:49:24] That’s how I see your answer.
Dr. John Robertson: [00:49:25] Exactly. Here, you’re a vital member of the community. You provide education to people who need it, and hopefully, this inspires others in the community to pursue careers in medicine or surgery.
One of the biggest challenges in rural areas is keeping practitioners here to sustain rural practices. By staying, you’re contributing to community growth and helping solve that problem.
Dr. Randy Lehman: [00:50:09] I’m inspired. Don’t be part of the rural brain drain. Be a rural surgeon! You heard it here first from Dr. Robertson. Thank you so much for joining me on the show. I really appreciate it.
Dr. John Robertson: [00:50:19] Thank you very much. Thanks for having me.
Dr. Randy Lehman: [00:50:20] This has been The Rural American Surgeon. Don’t forget to share this podcast with the surgeons in your life or anyone interested in rural healthcare and practice. We’re so glad you’re here. I’ll see you in the next episode of The Rural American Surgeon. Thanks.
Dr. John Robertson: [00:50:34] Thank you.
