Episode 35
Carotid Endarterectomy Mastery with Dr. Michael Roskos
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 practicing in the country differs from the city. If rural surgery is your passion, this show is for you. So now that the chloraprep has dried, let's make our incision. Welcome back to The Rural American Surgeon. I'm your host, Dr. Randy Lehman, and I'm joined by Dr. Michael Roskos, my former program director for the rural surgery track. I really appreciate you joining us, Dr. Roskos. This is my honor.
Dr. Michael Roskos [00:01:02]: It's great to be here, Randy. Thank you for inviting me.
Dr. Randy Lehman [00:01:05]: So, Dr. Roskos has several interesting connections to rural surgery. Number one is I met him as the associate program director for the rural surgery track at Mayo Clinic, and he had a long practice at the Mayo Clinic Hospital in La Crosse, Wisconsin, which is where we. A place where I did a lot of my subspecialty training, and he helped with coordinating all that. But he's also from a small town in Wisconsin and considers his home to be Independence, and he had a rural practice of his own in that. In that area. And so, thank you for joining us. Is there anything else you'd like to share about your background and training? And then what I'd like to hear most is your path sort of back home and what your practice looked like over time.
Dr. Michael Roskos [00:01:54]: So my training was obviously in general surgery, but I was very fortunate in that I had an excellent experience in vascular surgery parlayed with cardiac surgery, and then an exceptional opportunity to work at Children's Hospital in Cincinnati and the Shriners Burn Institute. So I came out of my training feeling very confident and in a wide spectrum of practice. I didn't know it at the time, but that helped me in a smaller town starting in La Crosse. But it helped me even more when I was doing surgery in the town of 2,000, which I did on a weekly basis in Arcadia, which is where both my parents grew up, and then all of my extended family immigrated to that area in the 1800s. So hence the roots, which is fun because so many people knew my parents, my grandparents, my great-grandparents coming into my clinic that I felt like I knew them. I had their trust immediately upon seeing them. So it was truly a highlight of my career of 23 years.
Dr. Randy Lehman [00:03:20]: Yeah. So what kind of operations did you do in that small town?
Dr. Michael Roskos [00:03:24]: So mostly hernias, like umbilical hernias, inguinal hernias, and I did a couple of appendectomies for cases that would come in that morning, that Friday morning. Then I would circle back on Saturday to discharge them, again in conjunction with visiting any relatives that happen to be close by during that return visit. Laparoscopy, open surgery, lipomas, lumps, bumps. Pretty straightforward, easy things. No endoscopy in this situation.
Dr. Randy Lehman [00:04:03]: Yeah. Great. So, you know, it may almost go without saying, but the next question I ask every guest is why is rural surgery special to you?
Dr. Michael Roskos [00:04:15]: So rural surgery is special to me because I was always going to the patients. Arcadia is a 45-minute drive from La Crosse. Easy, simple roads. But what I realized early on is so many people not only found it difficult to find rides and transportation there but found it downright intimidating. If you could do what they needed and see them where they lived, you provided so much comfort to them with their care, especially from somebody they knew and trusted. Probably the most striking interaction I ever had with a patient was as we talked about the need for screening colonoscopy. They would rather die of colon cancer than drive to La Crosse to get their screening colonoscopy. I realized very quickly that people were compromising their own care because of the fear they had for something that seemed so easy, so simple for the average person.
Dr. Randy Lehman [00:05:24]: Yep. Yeah, that's. I think we're all basically living that. So I completely relate. I know you have some great stories for us about some of those patients. Let's get to that a little bit later. But first, I'd like to do the "how I do it." Today we're going to be talking about something that I would say is happening very infrequently in rural America, but it's something that we're all interested in just chit-chatting about. So I think my listener would like to talk about carotids today, which you had a good practice for a long time in La Crosse. La Crosse is what, 200,000 people just north of 52. Oh, really? Okay. Yeah.
Dr. Michael Roskos [00:06:08]: So it is, it's small townish.
Dr. Randy Lehman [00:06:11]: Okay. It feels bigger to me. But the city is just trapped in between the bluffs and the river there. So anyway, but you're doing, you're doing, you have Gundersen, which is sort of a bigger hospital, I would say, in that town. And then the Skemp Clinic, which joined Mayo, which is where you were practicing, and carotids happening, vascular happening at both places. I scrubbed lots of those cases with you and Dr. Kuris, in some cases with Dr. Chapman. And I want to talk about the details of the operation and how you guys did it, but I also want to talk about working the patient up. And lastly, the changes that you saw through the decades in vascular surgery access. So where should we start? Maybe let's start with a patient. And who would be the right patient to get a carotid endarterectomy?
Dr. Michael Roskos [00:07:05]: Well, in our practice, the first level decision was symptomatic versus asymptomatic carotid disease. And as simple as that sounds, sometimes it's very hard to sort out who has symptoms, who doesn't. We took a lot of people who, for example, had vertigo and had to sort out whether or not that was carotid related or not. Some of that was patient-driven. A lot of it was primary care-driven, who part and parcel with those symptoms, often got a carotid ultrasound. It makes a difference, obviously, if you're dealing with symptoms versus no symptoms and the degree of stenosis you have. I think the patients that benefited the most were those that were symptomatic and they would have classic symptoms with a degree of stenosis that correlated with something that indicated carotid endarterectomy.
Dr. Randy Lehman [00:08:15]: So you're thinking that would be like a 50% stenosis with symptoms.
Dr. Michael Roskos [00:08:19]: Yeah, that. Yes, absolutely.
Dr. Randy Lehman [00:08:23]: And then the cutoff for asymptomatic carotid disease, we were using 80 for most of the time.
Dr. Michael Roskos [00:08:28]: Yes. That's where we gravitated to. In training, it was 70%. It gravitated to 80%. Even then, you have to be a little bit careful. What's always part of that discussion is, here are the risks, and you balance it with the benefits. It's not just as simple as 80%, no symptoms, let's go fix you. Let's describe the surgery, some of the complications, and decide if that makes a lot of sense for you. Where do you stand, not only from a medical standpoint but from what you experience in dealing with this as a family or as a patient?
Dr. Randy Lehman [00:09:14]: Yeah. And, yeah, you don't want to, you know, try to do a stroke reduction procedure and then stroke from the procedure. It's hard to know. So you have to have the cutoffs and guidelines and whatnot. So. All right. So, so you have a patient that you're. They meet criteria for carotid endarterectomy. We're going to take. Jump all the way to the operation. Speaker A: So there are different ways to do intraoperative monitoring, but most of these you did under general anesthesia, not with the patient awake.
Dr. Michael Roskos [00:09:44]: Mine was exclusively under general anesthetic. And I was trained in a program where we had non-shunters and selective shunters with stump pressure monitoring.
Dr. Randy Lehman [00:09:59]: And so then you'll take the patient. You're going to position them with arms tucked?
Dr. Michael Roskos [00:10:03]: Correct.
Dr. Randy Lehman [00:10:04]: And are they going to have an A-line?
Dr. Michael Roskos [00:10:07]: All of them have an A-line? Yep.
Dr. Randy Lehman [00:10:09]: And general anesthesia. And then you're going to position their shoulder roll.
Dr. Michael Roskos [00:10:15]: Shoulder roll? Absolutely.
Dr. Randy Lehman [00:10:17]: So slightly turn the head away.
Dr. Michael Roskos [00:10:19]: Yep. Turn the head away from the operative side.
Dr. Randy Lehman [00:10:22]: And you prep from just above the jawline to just below the clavicle?
Dr. Michael Roskos [00:10:27]: Yep.
Dr. Randy Lehman [00:10:28]: And then maybe to the bed. How far do you go to the other side with your prep and your drape?
Dr. Michael Roskos [00:10:35]: So we're well over midline, but it's still a relatively small field of ultimately draped area.
Dr. Randy Lehman [00:10:45]: Yep. And then where do you place your incision?
Dr. Michael Roskos [00:10:48]: So I go along the anterior border of the sternocleidomastoid, so more or less a vertical incision.
Dr. Randy Lehman [00:10:56]: How long?
Dr. Michael Roskos [00:10:57]: As long as it needs to be. I preferred to make longer incisions. I wasn't going to compromise cosmetic outcome for lack of exposure.
Dr. Randy Lehman [00:11:07]: Sure.
Dr. Michael Roskos [00:11:08]: So it's a balance.
Dr. Randy Lehman [00:11:09]: So anterior border of the SCM, go down through the subcutaneous and talk me through dissection down to the carotid.
Dr. Michael Roskos [00:11:17]: After following the anterior border of the sternocleidomastoid, you encounter the carotid sheath. For me, identifying the crossing vein provided the best landmark. Maximizing exposure of the carotid artery was probably the most important part of the surgery.
Dr. Randy Lehman [00:11:50]: Okay. And then with the vein, you tie it off?
Dr. Michael Roskos [00:11:54]: Absolutely.
Dr. Randy Lehman [00:11:56]: Okay. Are you going to place some sort of self-retaining retractor?
Dr. Michael Roskos [00:12:00]: Yep. A self-retaining retractor that was manipulated as little as possible, ideally once.
Dr. Randy Lehman [00:12:15]: And any other special retractors you wouldn't do the case without?
Dr. Michael Roskos [00:12:22]: Oh, boy, that's a great question.
Dr. Randy Lehman [00:12:25]: Like a goiter retractor? Did you mostly use the Army-Navy with the assistant?
Dr. Michael Roskos [00:12:31]: No, it was a self-retainer. We used an Army-Navy but sparingly. I resisted replacing retractors too much because of neurovascular bundles, named and unnamed.
Dr. Randy Lehman [00:12:54]: Okay. And so you've got the anterior carotid exposed. How much of the bifurcation do you need to expose before starting your carotid endarterectomy?
Dr. Michael Roskos [00:13:05]: Anatomically, it’s an anatomic decision. No reason not to dissect as much as you can without compromising. It's not always possible to get the same amount in every person. During surgery, spend extra time getting more vessel out. Ultimately, enough exposure for a retractor above the anticipated site is required.
Dr. Randy Lehman [00:13:45]: You don't want to be too aggressive manipulating. Do you use a no-touch technique or have tips there?
Dr. Michael Roskos [00:13:56]: Minimize manipulation. Benefit from figuring out clamp site first and then cleaning the vessel. Clamp placement is priority for safe endarterectomy. Touching can be done once clamps are in place.
Dr. Randy Lehman [00:14:30]: First clamp is a proximal one to avoid dislodging clot. I haven't done carotids in six years, so I rely on you. What kind of clamp is that, a bulldog or Satinski?
Dr. Michael Roskos [00:15:07]: You’re testing me here. I typically used a Bulldog vascular clamp.
Dr. Randy Lehman [00:15:20]: Did you measure stump pressure always, or did that change?
Dr. Michael Roskos [00:15:31]: Always measured stump pressure. Evolution was what pressure to accept, paired with back bleeding. Stump pressure 20 or above was a hard stop for me. Shunt use correlated with back bleeding.
Dr. Randy Lehman [00:16:09]: After endarterectomy, you release proximal clamp and check back bleeding?
Dr. Michael Roskos [00:16:16]: Yes.
Dr. Randy Lehman [00:16:16]: How do you?
Dr. Michael Roskos [00:16:17]: Once committed to endarterectomy based on stump pressure, you open vessel to check back pressure. Have shunt ready if needed.
Dr. Randy Lehman [00:16:46]: Dumb it down: stump pressure involves a clamp, needle to a pressure monitor measuring flow from the other side?
Dr. Michael Roskos [00:16:57]: Correct.
Dr. Randy Lehman [00:16:59]: Ensures good flow from the vertebrals and contralateral carotid to perfuse the brain and prevent ischemia.
Dr. Michael Roskos [00:17:23]: Absolutely. Yep.
Dr. Randy Lehman [00:17:24]: And then, we jumped to the carotid endarterectomy incision. What knife do you use, how do you navigate around the bifurcation?
Dr. Michael Roskos [00:17:42]: Used an 11 blade to enter the vessel, scissors to extend the incision for patch placement.
Dr. Randy Lehman [00:18:08]: And your patch is your bovine pericardial patch.
Dr. Michael Roskos [00:18:10]: Yes.
Dr. Randy Lehman [00:18:12]: And you put the smooth side in.
Dr. Michael Roskos [00:18:15]: Smooth side in, although the manufacturers will say it doesn't matter.
Dr. Randy Lehman [00:18:20]: Okay, very good. So, one thing that's probably not as common is seeing that shunt. So, tell me, how do you put the shunt in? Say you have a pressure of less than 20, then you need to make your endarterectomy to place your shunt, right.
Dr. Michael Roskos [00:18:36]: Correct.
Dr. Randy Lehman [00:18:38]: And so then how do you secure it? And where exactly do you put it? Just if you were telling, like telling Jack.
Dr. Michael Roskos [00:18:46]: So, the key to that shunt is doing so in a way that minimizes dislodgement of plaque. And there's almost no way to avoid the fact that that shunt's going to go through that. I put the proximal shunt in first. Back bleed, so you're sure that the shunt is then filled, and then the distal point goes in first, the proximal goes in second, and attention is then paid to minimizing all the bubbles, obviously in the shunt, minimizing that risk of emboli. They're held in place with balloons. And, yeah, again, exposure is key.
Dr. Randy Lehman [00:19:42]: Yep. And you're going to have to basically do your endarterectomy around the shunt. It's in your way now, right?
Dr. Michael Roskos [00:19:47]: Yes, absolutely. And it's surprising how little that plays into the distraction. I mean, it actually keeps your visualization. It gives you more visualization than it impairs, strangely.
Dr. Randy Lehman [00:20:04]: Okay, and so then, say we didn't have to shunt, and now we are just open. And you made your incision with your 11 blade, extended it with scissor, and you're ready to start your endarterectomy. Do you start at distal or proximal?
Dr. Michael Roskos [00:20:21]: The endarterectomy started distal. So, on the internal carotid, I think it's probably the most important stitch in there. It's the smallest part of the vessel, the area that's most likely to restenose. And so being able to visualize that is super, super important.
Dr. Randy Lehman [00:20:43]: Okay, and then how do you start it? So, you get behind it based on your cut edge of your endarterectomy.
Dr. Michael Roskos [00:20:52]: So, I will go outside in on the patch, inside out on the vessel.
Dr. Randy Lehman [00:20:58]: Wait, wait, I'm talking about. We're doing not the patch, but the endarterectomy. Getting the plaque out.
Dr. Michael Roskos [00:21:03]: Ah, yes.
Dr. Randy Lehman [00:21:04]: Yeah.
Dr. Michael Roskos [00:21:05]: So, getting the plaque out. I always start on the common carotid artery with getting. And then you extend it very carefully up to the distal endpoint, which also is probably, probably the most important part of the endarterectomy. Any flaps you develop there, obviously, will set yourself up for dissections and troubles.
Dr. Randy Lehman [00:21:31]: So if you have a little flap, then you stitch it down.
Dr. Michael Roskos [00:21:35]: Yep. I'm a big fan of tacking sutures.
Dr. Randy Lehman [00:21:39]: Yeah. And to place that tacking suture, do you come in from the outside of the artery all the way through and then back down? Or how do you. Or the knot can't be in the lumen.
Dr. Michael Roskos [00:21:49]: Right, right. It ends up being an inside-out stitch. Double arm suture that obviously you take two passes, then through the vessel and tie the knot on the outside.
Dr. Randy Lehman [00:22:04]: Gotcha. Double arm suture, bring it out and then tie on the outside. Got it. And then do you. If it gives it to you, you'll take it up the external carotid just to kind of. As far as it's easy to give it to you, the plaque?
Dr. Michael Roskos [00:22:17]: Absolutely. Yep.
Dr. Randy Lehman [00:22:19]: Yeah. All right. And when we just want to start that endarterectomy taking that plaque out, do you start at the cut edge of your incision? Like, because you can see the layers of the vessel there.
Dr. Michael Roskos [00:22:31]: Yes. Yep.
Dr. Randy Lehman [00:22:33]: Okay. And you're using a freer elevator.
Dr. Michael Roskos [00:22:35]: Yep.
Dr. Randy Lehman [00:22:36]: And what other instruments? Debakey.
Dr. Michael Roskos [00:22:39]: Yeah, probably those two instruments. And that plane is super, obviously, super crucial. And what I found over the years is that it shows itself. If you're working hard to find the plane, you're in the wrong plane.
Dr. Randy Lehman [00:22:55]: Okay. How can you mess that part up?
Dr. Michael Roskos [00:23:01]: I think there's two ways. One, too deep, you'll put a rent in the vessel. The other one is, I think if you're too shallow, you get an irregularity in there that becomes thrombogenic.
Dr. Randy Lehman [00:23:20]: Okay, got it. So, you're basically cutting sort of through the plaque. At that point, you don't want to do that. And the intima comes up with it.
Dr. Michael Roskos [00:23:28]: The intima comes up with it. Yep.
Dr. Randy Lehman [00:23:30]: Yeah. Okay. And now you're putting your bovine pericardial patch. You said already that you're using the pointed end of it to start distally on the internal carotid artery.
Dr. Michael Roskos [00:23:41]: Correct.
Dr. Randy Lehman [00:23:42]: Smooth side in. And you're still using. You said that's the most important stitch. So, the patch is on the outside, you're still using your double-armed Prolene.
Dr. Michael Roskos [00:23:54]: Yep. Six, zero.
Dr. Randy Lehman [00:23:54]: What is it? Six, zero. Okay. And you're using a.
Dr. Michael Roskos [00:24:02]: Castro.
Dr. Randy Lehman [00:24:02]: Castro, man. Good. That we're reading my mind, but it's exposing the time, you know, weighing on Dr. Lehman's mind. So good. Use a Castro. And you're going inside to out on the vessel and inside to out on the patch and then tying on top of the patch, correct?
Dr. Michael Roskos [00:24:23]: Yep.
Dr. Randy Lehman [00:24:23]: And then you're going to run that down each side. Which side do you run first?
Dr. Michael Roskos [00:24:33]: I have to think about that one, I think.
Dr. Randy Lehman [00:24:36]: Or is it not always the same? It's just whatever looks right.
Dr. Michael Roskos [00:24:47]: I think I do my forehand first, so it depends on which side you're using, but I would prefer to do my forehand first just because it gets you in, I think, the right frame of mind, gives you a little bit of confidence and flow. And then, yeah, switching to the backhand.
Dr. Randy Lehman [00:25:07]: So then when you're coming down forehand, you're going down through the patch, down through the vessel.
Dr. Michael Roskos [00:25:13]: Yep.
Dr. Randy Lehman [00:25:14]: And then back up through the vessel? Back up through the patch or?
Dr. Michael Roskos [00:25:19]: No, it's a running suture.
Dr. Randy Lehman [00:25:21]: So it's just like a baseball.
Dr. Michael Roskos [00:25:23]: Like a baseball. So outside in on the patch, inside out on the vessel, and then running about halfway down.
Dr. Randy Lehman [00:25:31]: Outside in, inside out, and then run. Yep, got it. Okay, go halfway down and you do that on each side. And then what?
Dr. Michael Roskos [00:25:40]: Then I'll start a second suture proximately and repeat the same thing.
Dr. Randy Lehman [00:25:46]: Okay. And then, if you did shunt, at what point do you take the shunt out?
Dr. Michael Roskos [00:25:56]: I take the shunt out when you have probably two or three sutures left.
Dr. Randy Lehman [00:26:02]: Okay.
Dr. Michael Roskos [00:26:02]: So the shunt ends up being very flexible. You can get it out through a relatively small hole. And obviously, because it's a baseball stitch, you can loosen it enough to kind of get things out.
Dr. Randy Lehman [00:26:13]: So just take it and put a little. Put your clamp back on approximately. Finish it up. And then how. Once you get your. You ran up from the bottom. So you probably. If you had a shunt, you would tie the one side already. And there's only one side that has a few more stitches to go.
Dr. Michael Roskos [00:26:30]: Yes.
Dr. Randy Lehman [00:26:31]: And then the shunt comes out, and then you put some sort of catheter or flush in there so there are no bubbles, right?
Dr. Michael Roskos [00:26:39]: So I'll just back bleed and bleed forward. I don't have to put a needle in, per se.
Dr. Randy Lehman [00:26:47]: Okay. So you let blood sort of fill up behind the patch before you throw your last couple. You've tied down your last stitch, I should say, probably you already have the stitches thrown.
Dr. Michael Roskos [00:26:56]: Yes.
Dr. Randy Lehman [00:26:56]: Just holding it open, and then you back bleed, tie it, and then come off of everything, right?
Dr. Michael Roskos [00:27:02]: Correct.
Dr. Randy Lehman [00:27:03]: All right. Did I miss anything?
Dr. Michael Roskos [00:27:05]: To this point, there's nuances along the way. I think the order of back bleeding is important: internal carotid first, common carotid second, and then external last.
Dr. Randy Lehman [00:27:25]: Okay, fair enough. And then you did some ultrasound after the. After the carotid was then open, right?
Dr. Michael Roskos [00:27:35]: Correct. We ultrasounded everybody after the patch is sewn into place.
Dr. Randy Lehman [00:27:43]: And so you're looking for no stenosis, meaning that the velocities are nice and low.
Dr. Michael Roskos [00:27:48]: Correct.
Dr. Randy Lehman [00:27:49]: And anything else on that ultrasound you're looking for? I would look for flaps maybe.
Dr. Michael Roskos [00:27:57]: Yeah, flaps would be the most common thing. And the evolution we learned is that it was really hard to find those flaps, and because of the ultrasound, they oftentimes looked much worse than they actually were. In trying to figure out how much the ultrasound helped versus hurt, there is a price to be paid for chasing everything you see on ultrasound and opening that vessel up. So the balance is: are you going to prevent a stroke by going back or cause a stroke by going back?
Dr. Randy Lehman [00:28:35]: Yeah. Risk, benefit. Here we are again.
Dr. Michael Roskos [00:28:37]: Yes, here we are again.
Dr. Randy Lehman [00:28:39]: And then for closure, what did you do for closure?
Dr. Michael Roskos [00:28:43]: So I closed in probably two layers. So we closed the carotid sheath and then a subcutaneous layer, and then finished up with 4-0 Monocryl on the skin.
Dr. Randy Lehman [00:29:03]: So it's not really a named platysma layer when you're this far lateral.
Dr. Michael Roskos [00:29:08]: Correct.
Dr. Randy Lehman [00:29:09]: Yeah. All right, very good. Well, I think honestly, I might have seen you do a carotid faster than we can describe it. But it's, it takes a little bit to use, you know, a picture's worth a thousand words, you know, so that was an excellent description. Thank you very much.
Dr. Michael Roskos [00:29:29]: Yes, you're very welcome.
Dr. Randy Lehman [00:29:30]: So let's move on to the next segment of the show. It's called the Financial Corner. Do you have any particular money tip that you could share with our listener?
Dr. Michael Roskos [00:29:40]: Gosh, I think the important part of a surgical practice, whether you're part of a multi-specialty group or an independent practitioner, is just getting the coding right. And there are abuses that can take place of overcoding or making up codes. I think at the end you just have to be knowledgeable and code accurately. And what shocked me in my career is how some of the things you took for granted as simple and easy were significant coding opportunities.
Dr. Randy Lehman [00:30:18]: Do you have any examples of that?
Dr. Michael Roskos [00:30:23]: Probably like mobilization of the splenic flexure would be one. In colon surgery, there were situations, I think, when you had to manipulate, like the ileum to get down to a low anterior anastomosis that was. And I can't remember the details of that, but how you use the omentum in that situation was also a codable elemental flaps.
Dr. Randy Lehman [00:30:57]: Yeah, yeah, sure. Obviously, TAR, you know, can code as a plastics flap. The other thing we've talked about on this show is the codes for laparoscopic common bile duct exploration. There's actually a code for cholangiocolostomy that I did not know for like several years. And I was like, oh, geez, you know, add-on code that I shouldn't. Could have used and then, you know, just good documentation for some of the basic stuff like your lipomas. If it's subfascial, that's obviously a huge bump in your code and you need to make sure that you're documenting in that as well as the size and just not losing out on any of that because they may default it to subcutaneous. If you're using a coder when it's actually subfascial, it's worth like twice as much.
Dr. Michael Roskos [00:31:41]: Right.
Dr. Randy Lehman [00:31:41]: Those would be things that I saw. Um, so great.
Dr. Michael Roskos [00:31:45]: Yeah, I think wide local excisions that come along with melanomas were always good. And then knowing how much skin you graft on, split thickness skin grafts matter. And I think it comes down to two parts. One is your own knowledge, but I think the coder's knowledge too. And there were situations where, for example, in spine exposure cases where the coders just weren't aware of the procedure I was doing. And it took a little work to go from an unspecified code, which is default, to an actual description. And the RVUs is a factor of three, sometimes four in a situation like that.
Dr. Randy Lehman [00:32:32]: Gotcha. Yeah, I guess one last question on this topic is how would you recommend that a person learn about this? They come out of training. I mean, honestly, I did not realize that what I was putting into the residency code logbook was a CPT code until I was a fourth-year resident. Okay. And I'm like somebody that cares about that stuff. So you know how you need to learn about CPT codes if you're a resident. But then when you get out, how to. Is there a course or any other thing that you'd recommend?
Dr. Michael Roskos [00:33:12]: I never took a course. I took an interest in it only because I tend to be curious about things that I'm expected to provide. Time doesn't always allow that to happen, but I think it's more important now than ever that you take a shot at trying to understand it.
Dr. Randy Lehman [00:33:32]: Yep. Okay, great. So the next segment of the show is a classic rural surgery story. I know you've told me some stories before about some of these patients from Arcadia.
Dr. Michael Roskos [00:33:42]: Yeah.
Dr. Randy Lehman [00:33:42]: And so anything come to mind, things that an urban surgeon just wouldn't believe?
Dr. Michael Roskos [00:33:52]: Oh my gosh. I don't know. I feel like general surgery in general is full of those stories, regardless of where you're at. You know, the one that bugged me the most, and I don't know what category this falls in, but it's some of the frustration that we feel in this environment is seeing somebody for inguinal hernia who has intense groin pain a week after the pain started. And when you examine them, it's pretty clear that they torched a testicle. So a misdiagnosis in an environment that doesn't see that, that often gets frustrating because they didn't reach out, they didn't understand the limitations. You weren't there every day to bounce something off. And they're very willing to wait for some of those problems until you show up a week later, four days, five days later. And it's. Under those circumstances, it's a teaching moment to say, I'm available. Call. Here's what I would do. Interestingly enough, they have 24/7 ultrasound access, so could have sorted that out, but I think I was surprised by people's willingness to live with things that would bug most people enough that they would find their way to a clinic much, much sooner.
Dr. Randy Lehman [00:35:23]: Yeah. That's crazy. Speaker A: Did you do an orchiectomy on that patient?
Dr. Michael Roskos [00:35:27]: I did not.
Dr. Randy Lehman [00:35:29]: Okay.
Dr. Michael Roskos [00:35:29]: No, I. That was.
Dr. Randy Lehman [00:35:31]: Somebody.
Dr. Michael Roskos [00:35:31]: Somebody did, yes.
Dr. Randy Lehman [00:35:33]: Okay, got it. And the other one that I wanted to say, I think there were some people that were. They walked to their surgeries.
Dr. Michael Roskos [00:35:43]: Yeah, those are my favorite stories. You know, they would literally, they lived within a block or two of the hospital, so they could walk up, get their surgery. Somebody, theoretically, would walk them home.
Dr. Randy Lehman [00:35:56]: Yeah.
Dr. Michael Roskos [00:35:58]: But it was nice to know that they were that close to be able to come in and have minimal disruption with their lives.
Dr. Randy Lehman [00:36:08]: Yeah.
Dr. Michael Roskos [00:36:08]: And it wasn't unusual to do one or two surgeries every week there. So that not only impacted the people with surgery, but the 10 or 12 people I would see in clinic as well.
Dr. Randy Lehman [00:36:20]: Yeah. I want to share one more thing before we get to the resources for a busy, rural surgeon and then close it out that you told me. That's always stuck in my mind. When I was a resident, a chief resident, I was kind of wondering, like, how busy do I want to be? Like, do I just keep pushing? And, you know, so now I'm operating in four different hospitals, right. And all the places want more days of my time. And now I. When I first went out, I went to just one place that was a county of 12,000, and I was only operating in one place, and there were two other people there. Now, granted, everybody's practice is kind of slow, but I had tons of free time. I actually bought a bunch of real estate and set myself up for life. So that was good with my free time. But, like, I remember at the beginning and saying, man, if I don't pick my practice up, I'm going to, like, lose my skills, you know? Now I'm so far to the other extreme of that, and I've gotten to a point where now I can see, well, if you're at four hospitals, why not be at five, why not be at six? And at some point, there's going to be a limit. If you can operate eight hours a day, why not 10, why not 12? And you told me, well, well, let me take, say this. Dr. Uecker told me I shoot to do one case a day. That's one thing he said to me. You told me 40 cases a month and you'll be bored. 60 cases a month and your home life will suffer. Shoot for 50 cases a month. Do you remember saying that?
Dr. Michael Roskos [00:37:58]: I do. I do.
Dr. Randy Lehman [00:38:01]: But that's variable, because if your practice is colonoscopy, do you count the colonoscopy as a case? Right. So then everybody. That's the other thing is if you're doing carotids, a carotid is going to take a lot more out of you on a given day.
Dr. Michael Roskos [00:38:13]: Right.
Dr. Randy Lehman [00:38:14]: Than a scope.
Dr. Michael Roskos [00:38:16]: Yep. And I didn't do scopes, so I can't comment on that. But it felt like there was, like, internal balancing. If you had a carotid, you might do one or two surgeries less that day and more on other days. You're not doing carotids every day, every week, sometimes not even every month. So I think it balances out. I think what counted was in the OR. So if it was challenging enough to be done in the OR, whether it's a patient preference or just a big case, I didn't put the clinic procedures I do into that category.
Dr. Randy Lehman [00:39:03]: Yeah. Then there's other ways you could potentially measure your amount of time that you're spending working. You could use hours. You could also use RVUs, which is sort of a neutralizing metric, but depends on how you measure a lot of those things. You know, second code, is it half or not? You know, and then somebody like what I'm trying to do is I'm moving away from clinic, and I have a nurse practitioner works with me full time, and she's doing a lot of my clinic. What I found in my practice is I can generate around 3 to 4 RVUs per hour in the clinic, but I can generate about 8 to 10, sometimes RVUs per hour in surgery, more like 8. And then when I'm in scopes, it's somewhere in the middle of that. Like, maybe it's around six to eight or six or so. And so if I. If I really, end of the day, what I'm trying to say is, you know, I don't want to work more than 2,000 hours a year or something, you know, then. Or like, that's the limit between being able to spend time with this guy or, you know, whatever. So that's where RVU doesn't hit you as the right number, and case volume doesn't hit you as the right number. So it's a complicated question. It depends on what your practice is like. And I guess you just. You could shoot for 50 cases a month coming out of training and then see what your practice is actually like and how you feel.
Dr. Michael Roskos [00:40:31]: Right. Well. And isn't the balance you really want to take on what people give you, but do it so in an honest manner? I think the challenges are the extremes. I think there's too much there, which I think is hard as a resident to identify because you're used to doing too much. I think there's a lot of I'm not doing enough, which is frustrating because you want to do more, but the less you do, the less you can do. And so I think it behooves you to be willing, especially in rural practice, to take on almost anything, regardless of how fancy and crazy it is, as long as you're comfortable doing it. And the best way to become uncomfortable with doing it is to stop doing it.
Dr. Randy Lehman [00:41:27]: Yeah, tell me about it. I'm starting to feel some of that stuff. But the things I remember, I think you and some other people said, you know, now's the time you list everything for your privileges, you know, when you come out of residency. And then you're only. Your scope of practice generally is only going to shrink. Now, we do have some studies going on, American College of Surgeons and the Rural Surgery listserv. There's a study that Dan Bacon is putting on. If you haven't done that, please do that study. Okay. You and the listener. But learning. It's a study on learning new skills during the course of a surgical career. So that can happen. But I would say in general, like, you're going to lose from your. What you walked out. Like, say you're ready to walk out and do lobectomies. And then now I haven't done low back, you know, or I'm trying to think what other things are that? Or even simple things that recently I know I had one. Oh, I came out, I was thinking maybe I would do parotids, but there's no way I'd do a parotid now. I mean, it's, you know, it's just you go out and you realize these things. One in a hundred thousand things you're only going to see once every five years. And you're not really adding a lot of value by doing it.
Dr. Michael Roskos [00:42:39]: Right. Yep. And I'll be honest, if you're able to tell a patient you can't do it, um, and it's because you haven't done them often enough, they appreciate that you don't lose a patient. You actually gain a patient in having those conversations.
Dr. Randy Lehman [00:42:59]: Yep. A lot of times patients ask, well, you know, ask me also, what else do you do? And I. And then you tell them. And then all of a sudden, the last thing I say is usually skin cancer. And then it's always, well, I got this spot right here. And so there's plenty of other work to do. So. Great. Any other resources that you have for a busy rural surgeon, that's like a resource you love, that rural surgeons should know about?
Dr. Michael Roskos [00:43:24]: Gosh, that's an evolving question. I mean, I really gravitated to UpToDate. It's a little clumsy at times because you get linked through a bunch of different chapters, so it's hard to do in between patients. But to me, that was an exceptional resource for cancer.
Dr. Randy Lehman [00:43:50]: Did you use NCCN guidelines a lot?
Dr. Michael Roskos [00:43:52]: Absolutely. So, that would be the second data set that I used a lot, and I was just shocked at how few people actually took the time to look at it. This was true from primary care right up through surgeons. I think it's nice to be able to understand that, not only because it impacts your surgery, but it impacts how that care is going to be provided. Having that background knowledge, even though you won't give the radiation or the chemotherapy, helps in describing to patients the context of their options.
Dr. Randy Lehman [00:44:28]: Yeah, very good. Well, thank you so much for taking the time to share all this stuff with us today. I really appreciate it and just catching up with you. You just mean so much to me and to my training. I can't even say how much you impacted, advocated for me specifically, and us as residents. You've been such a great mentor to work with, so I can't say enough praises about you. I hope you're just doing awesome up there in La Crosse. Thanks again for taking the time.
Dr. Michael Roskos [00:45:01]: Oh, you're very welcome. Thank you, Randy.
Dr. Randy Lehman [00:45:03]: And thanks to our listener for being here. This has been The Rural American Surgeon, and we will see you on the next episode. Don't forget to like us, interact with us on Facebook, share this with all your friends, and we appreciate you very much. I'll see you on the next episode of the show.
