Episode 38

The Colonoscopy Chronicles with Dr. Dan Margo

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. Welcome back, listener, to The Rural American Surgeon Podcast. I'm your host, Dr. Randy Lehman, and I have with me today Dr. Dan Margo. He's practicing all the way up just at the tip of America in International Falls and other places in Wisconsin. It is my pleasure and honor to have you on the show today, Dr. Margo.

Dr. Dan Margo [00:01:05]: Hey, thanks, Randy. It's great to be here, and it's good to see you again.

Dr. Randy Lehman [00:01:09]: Yep. And we've gotten to know each other through our interactions at the Northern Plains Rural Surgical Society, now the North American Rural Surgical Society. My understanding is that in 2015, it was the Northern Plains Vascular Surgery Society. You were heavily involved in the decision to not disband it, but change it to a rural surgery program, basically. Does that sound right?

Dr. Dan Margo [00:01:35]: That's exactly right. I was actually the president of the Vascular Surgical Society but lived in a rural community. There were a bunch of us in rural communities that loved to get together to talk about vascular surgery. But as we did less and less vascular surgery in the rural community, we knew it was time for a change. So we just redefined the society. We focused on rural surgery in the general sense, and we've been growing ever since.

Dr. Randy Lehman [00:02:01]: Yep. So, membership-wise, where was it at in 2015 and how has it grown now?

Dr. Dan Margo [00:02:07]: Membership-wise, the Vascular Society probably fluctuated between 20 to 30, maybe up to 40 members speckled across the United States. But the attendance at the meeting might be 20 to 30 surgeons. But all of a sudden, the meetings were down to eight or ten surgeons, and we could sense that time for a change.

Dr. Randy Lehman [00:02:26]: How many members do we have now?

Dr. Dan Margo [00:02:27]: You know, I'm not sure of the member number, but I know that at our meeting last January, I think there were 70 of us in the room at least. So, I mean, definitely on the growth curve, and people seem excited.

Dr. Randy Lehman [00:02:38]: Yeah, I'm happy to be part of it. It's always, like, very relevant; every conversation, every session. It's all super relevant to my daily practice. So maybe give us a little more introduction of you, your training, your background, where you've practiced, what kind of practice you've had, and then what are you doing now? What do you plan to do in the future?

Dr. Dan Margo [00:02:58]: Got it. Well, thanks, Randy. Yeah. Dan Margo went to medical school in Minnesota. I grew up in Minnesota, went to medical school at the University of Minnesota, and then moved on to a residency in North Dakota. That's probably where I started to pick up an interest or at least an understanding of what rural surgery meant. You know, having the privilege of doing a residency in a more rural state.

But after that, it just wasn't enough. So I went off and did a vascular surgical fellowship. Even though I was a vascular surgeon, I wanted to live in a small town. My goal was to bring these vascular surgical services into my small community. For 10, 15 years, we did that. We were doing some significant vascular procedures in our community, but we didn't have the official vascular lab, for example. We weren't able to do an endoluminal aneurysm repair. As our world changed, it was time to just let that go.

I have to tell you, I still, to this day, miss the vascular procedures. But it was just something I had to do if I wanted to maintain my marriage, my life, and my home in the small community. So we knew we wanted to live here. We live in Grand Rapids, Minnesota. We're happy to be here, and we weren't going to move chasing a career in vascular surgery. So we did a pivot, and so far, no regrets.

Dr. Randy Lehman [00:04:20]: It's funny because there's an element of me wanting to be a surgeon but also wanting to live in a small town. When I came here, there were a couple of surgeons coming up and down the interstate doing very minimal procedures in my hometown, doing clinic, taking a lot of things out of the county. I just looked at it and said it doesn't have to be this way, and I'm only going to operate here.

So, by default, it's going to push it into more services offered locally, close to home. That's what you did with vascular surgery, but then times sort of change. I'm not sure; I hope it doesn't change for general surgery. I don't think it necessarily has to because it's not quite as resource-intensive necessarily as vascular. The general surgeon is still the person that basically every hospital needs. Would you agree with that or have any thoughts?

Dr. Dan Margo [00:05:22]: Absolutely. I think the general surgeon can be the lifeblood of the very small hospitals, and that's really where my practice has gone. I think you're probably working to really expand the services available at your home hospital. You're committed to that place, and you're going to do everything you can very safely and very well for your community members, your friends, and neighbors.

My model's a little bit different. I'm traveling. I'm the guy on the highway now, heading to even smaller communities than the one I live in, trying to help them stay alive and doing the most basic procedures. Well, some would say they're maybe not so basic, but things that can be done safely and well in these very small hospitals. That's my goal. We bring that service to the small community so the people from that town don't have to travel for certain things.

Dr. Randy Lehman [00:06:13]: Yep. So tell me more about the procedures that you're mostly doing, finding yourself doing these days.

Dr. Dan Margo [00:06:20]: Yeah, well, you know, in the rural surgical business, at least one of the models is to have a short trapline. There are probably three communities away from my hometown where I do travel every month: Big Fork, Minnesota; International Falls, Minnesota; and up to Baudette, Minnesota. All in northern Minnesota. All small communities that don't have a surgeon living in the town.

And really, as much as I love replacing someone's aorta and doing vascular surgery, I'm not doing that anymore, and especially not in these small communities. So to your question, Randy, it's really a lot of endoscopy. I mean, almost to a fault. The service that we can really bring to these small towns is endoscopy. I do a whole bunch of colonoscopy and upper endoscopy.

And then on the surgical side, laparoscopic cholecystectomy, hernia repairs of every flavor, skin cancers, skin lesions, soft tissue lesions, carpal tunnel release. Those kinds of things I feel that we can bring to these very small hospitals and do them very well and very safely for the community members.

Dr. Randy Lehman [00:07:34]: Let me say a few things. You say yes or no. Vasectomy?

Dr. Dan Margo [00:07:37]: Yes. Yeah.

Dr. Randy Lehman [00:07:39]: Ganglion cyst.

Dr. Dan Margo [00:07:41]: Yes. We do have some orthopedic surgeons that also travel to these same towns, but if the right ganglion cyst comes up, we'd certainly take care of that.

Dr. Randy Lehman [00:07:50]: Ovarian torsion.

Dr. Dan Margo [00:07:54]: If it came up, we would have the equipment to solve that. I haven't seen that for a while.

And as a more of a traveling surgeon, it would have to come in on just the right day.

Dr. Randy Lehman [00:08:03]: How about bilateral laparoscopic salpingectomy for sterilization?

Dr. Dan Margo [00:08:08]: Yeah, not doing that. We do have a GYN that also travels, and he is doing that now. Back through the years, I have done that in some of these small communities, but not currently. It's not as big a part of my practice right now.

Dr. Randy Lehman [00:08:22]: Any vascular going on, like any AV fistulas, varicose veins, ports, lines, anything like that? Hickman's okay.

Dr. Dan Margo [00:08:31]: I would say the varicose veins, something I did much, much more of in the past. Being more of a traveling surgeon now, less. But I would take care of varicose veins in the proper setting. AV fistulas, dialysis, access. Not really. You know, again, because it seems like those things don't come in when I'm traveling. But then fast forward to your other access procedures, like the Hickman placement, Portacatheter placement. We're certainly doing those, and that's a great thing.

For example, with colonoscopy, we might find the colon cancer. We take care of that, the patient meets their oncologist, they've got a future with some chemotherapy, and they'll want and love when they can have that port placed right at home. So we do do those kinds of things.

Dr. Randy Lehman [00:09:18]: Okay, so that brings me to the last two that I was gonna say. I was gonna say hiatal hernia and colectomy.

Dr. Dan Margo [00:09:24]: Yeah. And so really, it depends on which town we're talking about, but no on the hiatal hernia. I have a long history of fundoplications in my past as well, but these smaller communities that I travel to, let that go. We're not doing the hiatal hernia surgeries. If I had a surgeon partner in those communities that would be around to help take care of them, we could certainly think about that. And colectomy, not currently.

And part of the reason for that is when I go to these communities, the schedule's full. And if I'm coming once or twice a month, the schedule is elective procedures, and it's full for the next two, three months, let's say. So a lot of times the best service for that patient is to travel. And I'll set them up with one of my colleagues at my home community or one of the surrounding communities that they're comfortable traveling to, and they'll have their elective colon surgery there.

Dr. Randy Lehman [00:10:22]: Yeah. Great. So how does it go when you're not in town and how often are you in these places?

Dr. Dan Margo [00:10:28]: Well, let's pick International Falls.

Dr. Randy Lehman [00:10:29]: What period of time, too.

Dr. Dan Margo [00:10:31]: Yeah, great. International Falls, for example, is probably my home hospital now. It's where I spend most of my time, and I'll travel to International Falls twice a month, but when I go, I go for three days each time. So my commitment to International Falls right now is six days. When I'm there, I'm there for three days at a time. If it's midnight and appendicitis comes in, we're going to take care of it. When I'm there, if that appendicitis comes in the next week and there's no one there, that same patient has to get in an ambulance and travel all the way to Duluth, Minnesota, to be cared for.

So that's, I think, part of the reason that we have full schedules when I'm there, but also why there's just no room to add something elective. If we do a procedure that requires a short hospitalization and it just happens to be on my last day, we have a very good relationship with the hospitalist team, and typically they're very comfortable taking care of those things overnight until we get the patient discharged.

Dr. Randy Lehman [00:11:36]: Do you ever shut your cell phone off?

Dr. Dan Margo [00:11:39]: I don't, but it hasn't been abused. It seems like we have a pretty good balance. People don't tend to overuse that or over call. And I tend to leave it on all the time. That's an interesting question, Randy.

Dr. Randy Lehman [00:11:54]: So basically, if somebody came in 10 days later with a potential surgical complication, would you be contacted about it?

Dr. Dan Margo [00:12:01]: Oh, I would hope to be contacted. I may not be able to address that patient directly because I live two hours away. For example, I can certainly work with the emergency room doctor or the physicians on staff that are managing this in the outlying community and help them manage that problem, get the patient proper care, or at least to transfer to a higher level of a service.

Dr. Randy Lehman [00:12:27]: Right. I don't know how pointed I want to be. Not for myself, necessarily. I know you very well. I, to a degree, I'm doing the same model in Indiana, but I happen to be geographically closer. Like, the farthest place is about an hour from my house, and it's 18 minutes by helicopter.

But the thing is, some of these places that I'm operating at don't have 24/7 anesthesia. So even if a person came in and they had a surgical problem, I don't operate, like, for example, in Lafayette, which would be a town, bigger town around here, who would have 24/7 anesthesia and then have the ability to pull those patients, transfer them to myself, and manage them myself. So that is something that I think really influences the choice of the operation and the types of patients that you give the operations to in the first place.

Dr. Dan Margo [00:13:26]: Yes.

Dr. Randy Lehman [00:13:26]: But you know, how, what is the difference between doing that and not having a call team to be able to go back with a patient, even if you have your cell phone on, even if you physically could travel in, and being an itinerant surgeon.

Dr. Dan Margo [00:13:45]: Yeah. Well, I don't know that I'm going to answer your question directly, but I'm going to answer it this way. If I'm in International Falls and I do a procedure and that patient has an unfortunate complication five days later and I'm not there, that's identical to that same patient driving to Duluth to have that same procedure done, and they drive home, and five days later they have that same complication, and they end up in the emergency room in International Falls.

It's identical. And so what we're trying to do is not be itinerant surgeons in the negative sense, but visiting surgeons in the very positive sense, where we can provide services to these community members and doing the right surgeries, minimizing your complication profile. Of course, you never get rid of it, but you strive to minimize that and realizing that if these same people had to drive 2, 3 hours for their surgery, they're in the same boat on day five if a complication were to arise.

Dr. Randy Lehman [00:14:50]: Have you had a patient that has come in and needed then a transfer to a center for something else?

Dr. Dan Margo [00:14:57]: I'm sure I can't think of one right now, but yes, the physicians in these outlying communities have my cell phone number, and I never turn it off. And so when things come up, they tend to call. We solve the problem and we get them down to the city.

Dr. Randy Lehman [00:15:13]: Yeah. I have one example. I have many examples. Okay, but one comes to mind. I had a lady I did a gallbladder on, and she came back mildly jaundiced and some residual pain. I thought she might have choledocolithiasis and then needed an ERCP, which we wouldn't do anyway.

So I guess even if I did have a call team, that wouldn't, but the thing is, this lady didn't come to the facility where I operated on her anyway. She came to another ER, right, who then got a hold of me on my cell and did call me. And I'm glad they did. But that's the funny part, is she didn't even come back to that same hospital. Not that I could have done anything different if she was there, but it's just funny. So then I send her to be managed at a place where they had ERCP capabilities.

Speaker A: They trained their bilirubin, so they didn't even need to do an ERCP anyway. But that's a good example of anybody that you do a gallbladder on could come back a little jaundice. They could have a retained combo stone. There's just every single thing. There are possible complications. I agree with minimizing, but you can't ever completely eliminate your risk profile. So I guess I support what you're doing, but I think that if a person wants to do it, first off, it's nice to have a seasoned surgeon coming in and doing that who sort of understands those things.

The second thing is there are training tracks for rural surgery programs, if you can think about it, if you know where you're going. I was trying to think all the way through residency about being in the town I knew I was going to go to because I signed my contract halfway through my second year. And I knew that I wanted to go back home anyway.

I remember being on vascular surgery as an intern and talking to the vascular surgeon, asking her while we're doing an AAA. And I said, if this is an emergency and it comes into my critical access hospital, how would I, you know, do my super celiac clamp and everything? And we talked through exactly how I would make the incision bigger than her tiny hands need to be, and you know where I would go with my clamp and everything. Of course, now, the thing is, my point of telling you that story is when I was a resident, I didn't know what I didn't know because now I know what the resources actually are.

Speaker B: True.

Speaker A: And I've got five nurses and four techs, and I've got a PCU, not an ICU. I can't really run a vent, I can't really run a drip. And I really don't think at this point that even if that AAA came in right then and there, I—first of all, I don't even have any Dacron or anything like that, so, I mean, I wouldn't do that case now. But, you know, at least I was thinking about it. You know, how do you know what you don't know?

Speaker B: Yeah, exactly. And honestly, when you do cover multiple hospitals, the resource set is different in each one. And so your list and your case list might be different in each one as well. I think the resource base and the access to the higher level of care, the proximity to the next hospital probably comes into our decisions as well, Randy.

You know, when we do something like this, if something were to go awry, how would we manage that at midnight on a Sunday when we're away? You know, when you ask about is the cell phone ever off? And then the other way to ask that question is, do you ever take a vacation? Do you ever, you know, run off with your family and do something different where you're out of the state? And I think the obligations are the same, you know, to know those patients have a system in place where they can get to the care.

Speaker A: Yeah, I mean, I had a surgeon that I talked to at the North American Rural Surgical Society, and his perspective is very different than yours. And I'm hearing him out, and he said, you know, if you're doing an operation, like, you have to be in town afterwards. Again, it depends on the operation.

But I asked, how long do you have to be in town afterwards? You know, and he said it's whatever the global period is. So if you're going to do a gallbladder, you need to be in town for the next 90 days. But that doesn't make, I mean, that just does not compute for me.

Except if you say, well, then I'm not going to take a job unless if I have a practice, a partner or somebody who's there when I'm not and who always can take the call. I get around it by, you know, if I'm going to be leaving the next week and I'm going to be going to Hawaii or go to Honduras or something like that, then obviously I do lower level things that have minimal complications. I do have a nurse practitioner that has the ability to write a prescription or open a wound or something like that, you know, if she were needed to do that. She can't take somebody back for surgery, though.

And so I'm just kind of telling you where I'm at and explaining my perspective with other people, which is quite a variety of spectrum, which everybody seems to be motivated really internally by generally the right thing, the right care. But it's funny how you can come to different conclusions.

Speaker B: It's all an interpretation. I think I hear you saying you lean a little more my direction in the way you practice currently. I wasn't a part of that nice conversation you had out in Denver this year. But the counter-argument there would be, if the patient travels three hours for their laparoscopic cholecystectomy, does that mean they need to stay in that town for 90 days before they go home?

It's exactly the same. I think that's the kind of logic that we're here to defy. You know, the reason this, for you very young surgeons, this whole topic of itinerant surgery. When I went through my training, it was a horrible sin for a surgeon to do something called itinerant surgery. And that's what makes this discussion with Randy so pertinent right now, is that we're not looking to swoop in.

It'd be a lot easier for me to stay in Grand Rapids every day and take care of patients right here. But I found that these communities have a need and a desire to have me travel. I can't live there, and I'm not staying for 90 days, but I'm willing to come and then put in place the postoperative care that we feel is appropriate. And I think it works, Randy.

Speaker A: Yep. Yeah, I could go on this topic forever. It's not even really part of the show, but I think it's relevant, and I'm glad that we talked about it. I did have, let's see, one other thought. If it doesn't escape me.

Speaker B: It'll come back.

Speaker A: All right, whatever. Let's move on.

Speaker B: Well, I was going to tell you, and I don't have a chopper.

Speaker A: Right. That helicopter, I mean, that shortens the commute, but then it's limited by weather and certain things, but pretty cool that some surgeons do.

Speaker B: So that's pretty neat. Pretty neat about you.

Speaker A: When you can land direct, it makes a big difference.

Speaker B: Yes, sir.

Speaker A: All right, so you've. Why don't we move on to the next segment of the show, which is just to tell us what's so special about rural surgery that you've chosen to do this with the second half of your career.

Speaker B: You know, my wife is from a very small town, small farming community, and I think that was probably part of the inspiration. My dad was from a small town, and that was part of the inspiration. My mom's from Madrid, Spain, so that's a big city. I wasn't going to live and work in Madrid either. But when I was going through my training, I think I just felt this draw to be a part of a small community, a place where I had an identity, a place where I might know the staff and the patients at another level than just going to work and having a different group of friends the rest of the time. So I just think it's something in me about this appreciation for smaller towns and having an identity in your community.

Speaker A: Today we're going to do the How I Do It on the most common operation that you perform, which is colonoscopy.

Speaker B: Correct.

Speaker A: This is one of my least favorite things to do, but it is also one of the most common things that I do. I have. I don't want to discourage anybody else by saying that too much, that I don't like it because it is so needed.

Speaker A: It's just not necessarily why I went to surgery residency, and I really don't like it. So I have found ways to support people around me to do colonoscopy, and still, it's like the most common thing I do. But I've hired at one location a family practice doctor who does colonoscopy, and she comes in two days a month and takes that much off my plate. In another hospital where I recently started going, they've actually hired a new family practice doctor just out of residency, who has an interest in doing colonoscopy. He had more of an experience in colonoscopy when he was in training, did about 50, but it was more of pulling it out rather than inserting. So it's not starting from total scratch, but it's basically training him how to do it.

I have sort of taken on that challenge because it's good for him and the hospital and then also good for me because I can train him how to work up my hiatal hernias, you know, how to tattoo the colon the way I want him to do it and communicate things back to me. And then I can do the surgical things that I really want to do out of that practice as well.

But if you're going to choose to be in one place, you almost have to do the colonoscopies because it builds your practice so much. So there's just a lot of different ways you can take it. But when you were a vascular, my guess is there were, like, decades where you didn't do any colonoscopies. Would I be correct in that or no?

Dr. Dan Margo [00:25:52]: No. But I would say that in my residency, we didn't do enough colonoscopies because that was still back when we all hated colonoscopy. The gastroenterologists did the colonoscopy, and my goal in life was to never do a colonoscopy. But when you end up in a small community, you realize pretty fast that that's something you need to have a skill set for.

Really, I did a lot of my colonoscopy training with my first surgeon partners. I joined a small group in the Upper Peninsula of Michigan for a short while, and they were general surgeons doing colonoscopies, and they mentored me through that, and I picked up the skill that way.

Dr. Randy Lehman [00:26:34]: Okay, and so then how many colonoscopies are you doing in a day and in maybe a year at this point?

Dr. Dan Margo [00:26:43]: Yeah, I would say five to ten in a day, depending on the location and the way they schedule. So in a typical week, I might do 15 to 20. So it's very possible that I'm doing 800 to 1,000 a year.

Dr. Randy Lehman [00:26:59]: Okay. And when I talk on this show, there is one listener, and they have possibly earbuds in or maybe they're listening in their car, but they're not listening in a big group. It's not like people are coming together as a family and watching this show. It's one listener that's listening to us right now.

Dr. Dan Margo [00:27:21]: Yeah.

Dr. Randy Lehman [00:27:22]: And some of them, so I like to talk to one person at a time. And I really appreciate you, by the way, listener, for listening to us because it's a very cool and intimate thing to just have sort of a, almost a relationship. And you're really getting on this long-form podcast, a stream of consciousness that is more authentic than anything else. It's very limited editing. But that being said, let's focus on one specific listener now, which is a medical student or a resident who potentially wants to go into rural surgery. Maybe they haven't already self-differentiated, and they're just now learning that colonoscopy is important in a small town, right?

So the first thing I would like you to tell, let's, now we're going to walk through a patient, okay? The first thing I'd like you to tell them is, what are the most common indications that a person gets a colonoscopy? Then we're going to talk about prep, then we're going to talk about the procedure itself and the post-care.

Dr. Dan Margo [00:28:33]: Okay.

Dr. Randy Lehman [00:28:33]: So start with the indications if you don't mind.

Dr. Dan Margo [00:28:36]: All right. Well, typically one of the most common indications we'll have is just screening for colorectal cancer. And of course, nowadays we have some alternatives. As a surgeon that does too many colonoscopies, I'm a strong advocate for the Cologuard test. I think in the proper patient population, it's an acceptable alternative to what we do. So that helps to unload the colonoscopy backlog a little bit.

Dr. Randy Lehman [00:29:02]: Who is an acceptable candidate for Cologuard?

Dr. Dan Margo [00:29:05]: You know, just simply speaking, to me, it's if you're truly an average-risk patient, and they even say that on the Cologuard ads. They'll say it's a great alternative for average-risk patients, which I've condensed down to mean if you're asymptomatic, you don't have colon cancer in your family, you don't have a family history, and you're not bleeding, and there are no symptoms. Yeah, you may be a good candidate for Cologuard. Of course, review it with your family doctor. But I don't speak down on the Cologuard test.

Dr. Randy Lehman [00:29:36]: So what if a patient had a prior Cologuard and it was positive, but it was a false positive?

Dr. Dan Margo [00:29:41]: Yeah, definitely. I like to follow them up with a colonoscopy, especially if it's my colonoscopy, meaning I did it. If someone comes in with a positive Cologuard test, and they're truly asymptomatic and I come up with nothing, I like to follow up with them with another colonoscopy in five years. I'm kind of telling myself, what if there's a small adenoma that I missed? I'm not going to let that go ten years and another positive Cologuard in five years doesn't do us any good. So we just look again in five years.

Dr. Randy Lehman [00:30:16]: Dr. Sareup says he does EGDs on all those patients.

Dr. Dan Margo [00:30:19]: Yeah.

Dr. Randy Lehman [00:30:20]: Finds a lot of upper pathology. Do you do that?

Dr. Dan Margo [00:30:23]: I've started to ask my patients some questions about that. So what I got from Dr. Sareup on that was if they have epigastric symptoms, his yield on the upper scope was very high. So the scenario here is a patient comes in with a positive Cologuard, the colonoscopy is negative. But if you really talk to them, they'll tell you, you know, I've been having some epigastric discomfort. And he said so many times he'll do an upper scope on those people and he'll find legitimate pathology. Anything from peptic disease, maybe a positive H. pylori infection. That's what you're getting at, right, Randy?

Dr. Randy Lehman [00:31:01]: Correct. Yeah, that was an interesting talk. I usually go out of my way to dig for the epigastric symptoms ahead of time, and I'M usually doing the double scope ahead of time, even if they're there for positive Cologuard, but not always. So it's something to consider if they come back and it's negative. But you do have a follow-up scope in five years that it makes sense to me. There's a textbook in a couple rooms over from where I'm currently sitting. I bought this clinic that is the clinic I grew up going to as a kid. And I'm in the basement right now. That's where I put in my recording studio. There's a textbook from the 1980s, and it's from one of the doctors that used to work here. It's about colonoscopy. The whole textbook's about colonoscopy. So I cracked it open just out of curiosity after I had bought the building. It says now, because colonoscopy is so expensive and so limited and so few people know how to do it. This is in the 80s. We do not recommend screening for the general population, you know, only a very high-risk candidate or someone that has symptoms or whatever.

And then there's all these pictures in there of live fluoro watching the reduction of an alpha loop, you know, and it's just so incredible how far we've come to where now it's not 50, but it's 45 for an average risk person for screening colonoscopy and then every 10 years thereafter, as long as they don't have polyps. Now, if you do have polyps, do you have any guidelines you follow or how do you determine when they get their next one?

Dr. Dan Margo [00:32:38]: Yeah, through the years this has been a moving target and I've worked to try and come up with an algorithm, some consistency on how to advise my patients. You had everything from the gastroenterologists who had one school of thought and the American College of Surgeons who had their school of thought, and then there was the American Cancer Society that had recommendations. So I do have an algorithm. It's been challenged recently, even at our meeting. Randy, I know they're starting to talk about six and seven year intervals and three and four year intervals for certain things. But to me, I'm really still sticking with this five-year follow-up on adenomas.

My basic first thing that I teach medical students or rural residents that I have the luxury of encountering is every 10 years we do colonoscopy. If you have a first-degree relative, we shift it to every five years. If you have an adenoma, we put you in the five-year group. If you have a family history and an adenoma, I'll sometimes go three years. That's a three-year interval. It's almost like the risk factors kind of compound a little bit. Tubulovillous adenoma, we shorten the interval as well. Again, when I try to find this even on up-to-date or any of these resources that we have, it's really hard to get just clear answers.

So I've typed it out, and I have that at all of my facilities. Every time I go, we go over all the pathology reports from the previous day's work and give the patients a call on our recommendation for their follow-up. But like I said, the pathology report alone is not enough to give a recommendation on follow-up. I want the pathology report, their family history, and my operative report together. Then I can give recommendations on when they should come back.

Dr. Randy Lehman [00:34:36]: Yeah, what you're describing there is something that I don't think a lot of people come out of training appreciating, and that is that first off, whatever. So we're doing the app-side every year in training, right? It's a multiple-choice test, and there is a right answer. In the real world, what are we really trying to do here with screening colonoscopies?

We know that the average risk person in the United States has a 4% chance of getting colon cancer in their lifetime. So 96% of people, we're going to scope them four times at 45, 55, 65, and 75, maybe a lot more. Because if we might find adenomas that actually wouldn't have gone to cancer, we're going to do that to 96% of the population so that we can detect earlier colon cancer in the 4%. You start to realize, like I have now realized in five years, that if somebody has had an advanced adenoma in the past or colon cancer in the past, or they had a family history of colon cancer, there are always places where the guidelines will stop, and you're going to have to use your professional best judgment.

I would like to share the guidelines that I've used since I got out, which is the ASGE guidelines. You can just do a web search and find them for free. But it's funny because if three or four different places are all releasing guidelines and they disagree, then you start to realize, oh, I'm the doctor, and I'm the one that's going to make this recommendation to this patient. It's kind of like any other professional relationship. If you're an attorney, if you're an accountant, you know the facts. But different people might come to a different conclusion. That's where three or more adenomas or an adenoma greater than 1cm comes into play. I do that very often, but it still depends. If both mom and dad had colon cancer and you got one adenoma, I don’t know, what's the right answer? So then there are people that have scopes for symptoms too. I'd like you to just briefly talk about that as well. Anything else you had to add?

Dr. Dan Margo [00:37:08]: Yeah, no, I really appreciate your summary there. Honestly, I think ASGE, is that what you refer to?

Dr. Randy Lehman [00:37:17]: Yeah, the American Society of Gastroenterology.

Dr. Dan Margo [00:37:19]: Gastroenterology. So, yeah, the gastroenterology guidelines overlap pretty well with what I'm doing. When you summarized it, for example, the adenoma over 1cm or more than three adenomas, is why I like to have the pathology report and my operative report when I give recommendations. In my operative report, I'll always estimate the size of the lesion that I've removed, and that is an important part of this.

In addition to colon cancer and colon cancer screening, rectal bleeding is another common indication for colonoscopy. Sometimes it'll be a recent bout of diverticulitis. That one's a little confusing. They'll have a bout of diverticulitis, manage through it, and see their family doctor, who will say, you should have a colonoscopy because you just had diverticulitis. So that's another indication. Chronic diarrhea is a common indication that we deal with. I guess that's a pretty good short list right there, so rectal bleeding, anemia, diarrhea, and recent diverticulitis.

Dr. Randy Lehman [00:38:30]: Some guidelines that I found, I can't remember which guidelines this is, state that everybody with chronic anemia needs a colonoscopy, except maybe a woman in menstrual age, where you could consider going a little bit longer, but yeah, definitely. If you're going to go in and try to build a practice, you want to talk about that. You know, find a hematologist that knows that as well. Share that information with the primary care base, you'll find a lot of colon cancers that way too. For the chronic diarrhea patient, you're specifically looking for microscopic colitis or collagenous colitis. What I do is random biopsies, usually in the ascending transverse descending colon, two bites each, send them together collectively, six pieces in a single cup. I call them random colon biopsies. Is that what you do with the chronic diarrhea patient, or how do you do it differently?

Dr. Dan Margo [00:39:33]: Exactly, and I was into my practice when this light bulb went on. This is a great example of how you can make it through an entire surgical residency that isn't focused on colonoscopy, then work in a community and pick up the skill of colonoscopy, and then do a bunch of them. Finally, over a cup of coffee with the gastroenterologist, you realize that when you have a middle-aged 50-year-old woman, especially with chronic diarrhea, you do random biopsies. It was like this light bulb went on that, okay, there's this diagnosis, microscopic colitis, collagenous colitis. I do a lot like what you just suggested. I'm a little more aggressive with the biopsies. I don't know, there's probably some good ASGE guidelines for that as well. I'm more, I take, I get about five bites with each pass. I like the biting forceps with the spike, and I know that with that spike, I can stack three, four, five good bites. I'll just slowly withdraw the colonoscope, trying to get my complete colon cancer surveillance in at the same time.

And just pluck random biopsies along the way. Early in my practice, I was separating them into different jars and telling the pathologist what was coming. But now I've come to putting them all in one jar and just let them look. You know, a couple of times a year, they give me the diagnosis of microscopic collagenous colitis. It seems to really be helpful to the patient and the family docs when we do that.

Dr. Randy Lehman [00:41:07]: So who manages that condition when you find it?

Dr. Dan Margo [00:41:10]: I hand that back to the family physician and let them kind of work with that.

Dr. Randy Lehman [00:41:15]: Yeah. Have you ever heard any long-term follow-up from those patients? Because it can be very dramatically improved.

Dr. Dan Margo [00:41:21]: Yeah, I have, and I agree with you on that. But again, with the family docs kind of working on them and seeing them more on the week-by-week basis, they can really change some people's lives.

Dr. Randy Lehman [00:41:33]: Yeah, it's one of those. It's just when you take a pill and you're all better. People feel pretty good about medicine when we have the opportunity to do that. Last thing on the indications is I agree, diverticulitis. So how long do you wait until you scope them?

Dr. Dan Margo [00:41:51]: Yeah, it's sure nice when they're asymptomatic and for some reason, six weeks jumps out at me. What are you doing?

Dr. Randy Lehman [00:41:56]: That's what I do, too. What if they had a scope nine months ago?

Dr. Dan Margo [00:42:02]: That's the confusing thing. I think as an endoscopist, we always have to realize that it's not a perfect test. I remembered a mentor surgeon talking about that. That colonoscopy, it's probably better than a guaiac card, but it's not a perfect test. You might miss something. So to be willing to admit that, I think is healthy as a physician and as an endoscopist. You know, that's always tricky. Or the other way to look at that one, Randy, is they had a colonoscopy nine months ago, their dad had colon cancer, and now they're bleeding again. You know, and it's not on the toilet paper. It's like blood coming down into the toilet water. Do you look again if it was another surgeon in a small town? You look again because you're not going to let that patient miss anything. So do you re-scope on your own patient? I don't know. Back to your question.

Dr. Randy Lehman [00:42:59]: That is a very funny way of thinking about that. Because if it was somebody else's patient and they showed back up with rectal bleeding, there's no question I would scope them.

Dr. Dan Margo [00:43:09]: Well, the other way to look at that is they go down to the Mayo Clinic in Rochester. I did their scope five months ago and I cleared them. Now they're in Rochester. The first thing they're going to do is scope them again.

Dr. Randy Lehman [00:43:19]: Of course, they're not going to take...

Dr. Dan Margo [00:43:20]: Any chance on that. So... Right. Should we have that same threshold when our same patient loops back to us?

Dr. Randy Lehman [00:43:27]: You know, there's this thing called doing to others what you would want done to you. That's a good rule, right? I would want myself re-scoped. You know, don't... But at the same time, I guess what I would really want is I would want to be educated about the situation, and I would want to make the decision for myself. It's probably what I would really want. So if you tell the patient, and the other thing is I do this with... You're talking about like surgical. This is what I was going to talk to you about earlier. I have a very frank discussion with patients about what my resources are in the small town very frequently. So I say, like, for example, especially if I'm saying no to a patient because they have a bad heart or something like that, I say, look, it's me and one CRNA. You know, her name is Jing. She's very good. I like her, I trust her. I would go to sleep under her care as well. But you don't want me to be coding you with just me and Jing and the resources that we have here. Like it... We would be calling literally the ER doctor to come over and help us. And if there was a hospitalist in the building, we would be calling them to come help us too. But if you go to XYZ other hospital, where there's whatever 15 ORs, you push a blue button on the wall, and five anesthesiologists come in. Everybody's there, and one person can put an A line, one person can put a central line. You've got plenty of people to code you. And I like, I talk to them just like that. Usually when you explain it, they understand what the difference is. That doesn't mean that we shouldn't do... Just because anybody could theoretically code, you know, doesn't mean that we shouldn't do the things that are extremely unlikely to have those things happen. But if you tell the patient the risks, then you document that you said it. That's what I would really want if I was a patient.

Dr. Dan Margo [00:45:30]: True, true. I think that's valuable, and I think to have a careful threshold. And I think the threshold is different in every community, and it's based on the resource base in that hospital. But we do the same. I do all my colonoscopies with CRNA. That would be another great topic for a podcast. Early in my practice, it was all self-directed IV conscious sedation. But now I do all of them with the CRNA in all of my hospitals and facilities. And the CRNA is a very good final filter. I've looked at the chart the family doctor sent them for the scope. They've considered the situation, but the CRNA needs to buy in completely. As a matter of fact, I always tell the RNs and the surgical team that they get a vote too. If anyone ever feels that we have a patient that's beyond the risk profile that we should manage at the facility, I want to hear from them about that. So we just kind of... Everyone has the ability to stop the chain.

Dr. Randy Lehman [00:46:32]: Yep. Do you ever do moderate sedation for any other procedures or any reason at this point?

Dr. Dan Margo [00:46:40]: I do, you know, in certain situations. Even to place a chest tube. It's something I would definitely... I'm happy to have that skill and something I would definitely keep keen to me when you go that way. I was just taught, make sure you're properly monitored and have some backup. So if we're going to give anyone any sedation, we get them hooked up to the monitor, and you know, we still, still would do that.

Dr. Randy Lehman [00:47:03]: Yeah, I need to have that as a topic at some point. Moderate sedation for the... How I do it, because I think it's a great skill to have. You can kind of offload your CRNA, like if you're in a place where there's only one CRNA, you know, and you can get some things done, and it's really nice to just have an option for the patient. A lot of things can be done under local, you know, or you can use your CRNA. But there's a sort of middle ground, which is moderate sedation now I guess is the correct term. Okay, so we got the patient. You're taking them now. You already touched on anesthesia, which was one of my questions. How do you position the patient? And actually, how do you prep the patient first and then position them?

Dr. Dan Margo [00:47:46]: Okay, so really quick on the prep. A lot of the gastroenterologists in the big city are insisting on this full gallon GoLYTELY prep. I still use that here and there, but our go-to prep has become this Miralax prep. Miralax with the Dulcolax tablets and Gatorade. And you know, I don't know how this got accepted and started and considered an acceptable alternative. But when people follow the instructions, we get really good preps. The problem is if they don't get good, clear instructions, sometimes we don't get great preps. But that day before is so important.

Dr. Randy Lehman [00:48:34]: So we've come to use the Miralax prep, as it seems to be more patient-friendly and predictable, and we get good results. Let me describe exactly. I do a lot of different things, but let me describe exactly what that Miralax prep is and tell me if this is what it sounds like for you. So, the day before, clear liquids only. Then they drink all 238 grams from a jug of Miralax in the afternoon. Basically, we'll say maybe it's one, two o'clock, whenever you want to do it, or some people do it a certain number of hours before their scope. So if the scope's at 7 versus a scope at 2 o'clock in the afternoon, the time would be a little different. And then they usually have... Is it 64 ounces of Gatorade, something like that?

Dr. Dan Margo [00:49:17]: Yeah, and more if desired. So at least 64 ounces of a clear liquid.

Dr. Randy Lehman [00:49:23]: And you tell them no reds.

Dr. Dan Margo [00:49:25]: We tell them no reds. But I had one surgeon up here that said if I can't tell the difference between red Gatorade and blood, I have a problem.

Dr. Randy Lehman [00:49:33]: And they take two Dulcolax tablets just once.

Dr. Dan Margo [00:49:37]: Is that, I think once at the beginning? Yes. Yeah.

Dr. Randy Lehman [00:49:41]: So I agree. Basically, it's two 32-ounce bottles of Gatorade and a bottle of Miralax, or two tablets Dulcolax, and that's it.

Dr. Dan Margo [00:49:48]: Clear liquids the day before. And the other thing we do is we talk about no grains for like, I'd love to say for a month before, but I think it's three or four days on our prep sheet. The one up here that gets us is wild rice. Wild rice is exactly the size of the suction portal on the kaleidoscope. So you can fill a kaleidoscope with wild rice fragments and so avoiding grains, I think a couple days before. Clear liquids only the day before. And then the prep as you outlined it. And we do pretty well.

Dr. Randy Lehman [00:50:20]: Yeah. So I have Golytely at one place and at that location. This is kind of a hangover from previous practice that was absorbed by the hospital. But I get a great prep out of it, and I don't complain. But the other issue is people not going to the store and buying it and knowing the right things to get, you know. And that place we do the gallon jug of prep with a sheet stapled onto it. It is the dual ax. Here you go. And give it to them, and they don't sell it to them or anything. They just give it to them for free. Because the other issue is that 10 bucks to do that is a barrier for some people in our community. I mean, they, at the same time, the eight-dollar cigarettes are being consumed. Yeah, but that's neither here nor there. The money would feel like a barrier. So I just go with it because that's what they're doing there. But if somebody asks me for something different, I have the Miralax prep printed out there. I give them that option, and then sometimes people are like, I don't want to drink that nasty prep. Give me the pills. What do you tell them?

Dr. Dan Margo [00:51:26]: We do have a one-page description of what we call the pill prep. That I have no idea what that protocol is, but it is available maybe once a year. We get asked for that. I'm not opposed to. It requires drinking a bunch of water with the pills. I don't know, what's your experience with that one? Do you allow your patients to do that if they request it?

Dr. Randy Lehman [00:51:47]: Yeah, they ask me for it all the time.

Dr. Dan Margo [00:51:50]: Yeah.

Dr. Randy Lehman [00:51:50]: And it is, it's the one that I usually use is called Sutab and I think it's 32 tablets. I always have to look it up every time. No, it looks like I'm looking it up as we're talking here. It's 24 tablets, split 12 and 12, and you have to drink, yeah, a bunch of water. The problem is, I have called it into the pharmacy and I've warned patients about it and I'm like, it's often not covered by your insurance and it's expensive. And they'll say, oh no, I've still wanted, I ain't not drinking that prep. So then I do the Sutab and then I get a call later, hey, it's 250 at the pharmacy. Can you actually just, you know, teach me about the other prep instead? Like, that has happened many times to me. So I hate it whenever I hear that because I know it's just going to be more work later. But whatever.

Dr. Dan Margo [00:52:42]: I think what I would do in that situation. They ask for the pill prep. My typical speaking might be, oh, you had the Golytely last time. We have a new one that's a little easier. Tell them about the Miralax, see if I can't get them to bite. And then every now and then, if they just insist, we do allow that pill prep.

Dr. Randy Lehman [00:52:58]: Yeah. Okay, wonderful.

Dr. Dan Margo [00:53:01]: I was just going to move on to your good question. I have a couple little things about the beginning. I love to interview my patients in the colonoscopy room. There's a couple of my facilities that don't allow that. They say that the patient needs to be consented and ready before they enter the room. And I've always argued, well, that should happen before they're sedated. But I like to interview my patients in the procedure room because I like the team to hear the interaction. I'm worried about the bleeding, or they'll say, I have chronic diarrhea. And then everyone knows, oh, we're gonna do random biopsies. Or my mom and dad both had colon cancer, and all of a sudden, just the antenna goes up a little bit. So I like to interview the patients in the room. We do a timeout. You know, I'm sure everybody does the timeout, even for endoscopy. And then I do put my patients in left lateral decubitus. I like to get their knees tucked up a little bit towards their chest, kind of into a sitting in a chair kind of position. I like their knees up because it just makes the perianal exam a little easier. And what the anesthetists have been doing lately is actually raising the head of the bed, a couple clips, getting the shoulders up a little bit, kind of an anti-reflux maneuver. And it doesn't affect me. It doesn't bother me when they move the shoulders up a little bit to elevate the head of the bed. And then, you know, timeout. We get started, and I get going. I always have a scribe in the room, and if I don't have my scribe and typist there, I ask the RNs to make notes for me. Because sometimes you can get pretty carried away. You know, you get into your fifth or sixth polyp and you're starting to forget exactly what you just did. So I start out by checking, and I'll tell them, write roids down. If I see soft external circumferential hemorrhoids, I'll write that down. Because when I get to sit down and do the dictated report, I want to know that so I get a good look. And then everybody gets the finger check. Every single patient gets the digital exam. At the beginning, I always. I put my gloves on, and then I put a second glove on that hand, get my digital exam done, throw the outer glove away, and I'm ready.

Dr. Randy Lehman [00:55:15]: To go, you know. Digital exam. When I was in medical school, we had to have these kind of fake patients come in and they pay them to do this thing. And one of the fake patients was like, this prostate test. And I, I kid you not, I thought that the digital exam was like, I was going to have some sort of, like, digital thermometer or like, digital instrument that I was going to do. And then when it hit me, like, oh, digital exam. Whoa. You know?

Dr. Dan Margo [00:55:50]: Yeah, exactly. You know, the other thing, it really should just be called the finger check, which is much more descriptive. I don't know where this term digital exam came from, but no, the good old fast and finger check. And I think, honestly, that's your chance to find the anal cancers. And when people ask me why that, I think it's the hardest part to visualize.

Dr. Randy Lehman [00:56:22]: Just.

Dr. Dan Margo [00:56:23]: It's not right, and you know it right off the bat. You know that patient needs a little extra, so my mentors got me doing that right away. It's just every time. Good finger check.

Dr. Randy Lehman [00:56:33]: Do you ever break out a Hill Ferguson anal retractor? Like, in that situation, you did a retroflexion, you still can't really see, but you feel something or any other thing. Do you do it like that day, or do you set them up for an exam under anesthesia another day? Or how do you do it?

Dr. Dan Margo [00:56:47]: You know, fortunately, I haven't seen a lot of these. I think my bias would be that that we're in there to do a colonoscopy, and the next patient's late now, so I just keep going. But I set that patient up for a biopsy and a speculum exam, and, yeah, we'll get some tissue form.

Dr. Randy Lehman [00:57:04]: Yep. Okay. So anyway, carry on.

Dr. Dan Margo [00:57:07]: Yeah. And so once they're in position, I have my finger checked. We grab the flexible colonoscope and get underway. I think that the insertion of the scope is really the learning curve part of this. It's amazing how different your first colonoscopy is from your 1,000th colonoscopy, and the tricks and the ability to manipulate that scope that you acquire with time. There's no way to read a book on it. I don't know if you agree with that, Randy, but you just hold that scope and pass it. Your left, right, up, down dials are good, but everything in between with twisting that scope is really how you move that scope up and through the colon.

Goal number one is to get that scope up and into the cecum. You talked about the alpha loop earlier, and really the challenges going through the sigmoid. I think that's really a lot of the learning curve. Again, I have a technique. I think what I try to do is get up and into the descending colon. And then a lot of times I'll find myself gathering the scope back towards me, trying to straighten that piece out and then go forward again. That works quite often. I don't know comments there, Randy. Otherwise, I'd...

Dr. Randy Lehman [00:58:32]: Well, I have one question before you start the colonoscopy still, which is you mentioned and kind of in brief that you're meeting these patients the same day, which I think is what most GI doctors are doing. But it's not what I'm doing. Is most of the time someone doing a pre-anesthesia evaluation on these...

Dr. Dan Margo [00:58:52]: Patients really just their family doc, me, and the anesthetist. But when me and the anesthetist do our pre-exam, it's based on the chart only. We haven't laid eyes on these patients until they show up for their colonoscopy. So when I work with the staff at various hospitals, I've drawn a hard line, and I tell them this is a unique situation. I would never do a surgical procedure like this. If I'm doing a gallbladder or a hernia, even in these remote locations, I'm not going to do it the day that I met the patient. We're going to set up a clinic visit, we're going to go over the risks and benefits, we're going to spend some time together building a relationship, and I'm going to schedule you for a month from now. Then we'll come in and take care of things. But the endoscopy, to me, is an exception. We let the family doctors schedule these, and I show up and I do the procedure. Now I interview them before we sedate them, but I haven't met them before that. Is that kind of what you're getting at?

Dr. Randy Lehman [00:59:54]: Yeah, it is what I'm getting at. What I was saying is, does, for example, anesthesia chart-check some of these people and then end up canceling them? And do they cancel them the same day or do they do it ahead of time? Because by the time they come to you, they're prepped or even like your nursing open suggestion for canceling. Like we normally really hate to cancel colonoscopy. It's like they're more willing to cancel other things than they are colonoscopy because that poor patient's already prepped.

Dr. Dan Margo [01:00:24]: Agree completely. So yes, first of all, when the family doctor puts them on the schedule, they've given their initial consent that they feel they're clear and ready to go. The anesthetists, though, do a formal chart check. We strive to do that three to seven days ahead of time for the reasons you just said. If there's a red flag in that chart, we don't want to find it on the morning of the procedure. But that said, every now and then there's still a patient where on the morning of, the right thing is to cancel them. They'll say, but geez, I took my prep. And then we have to just have that heart-to-heart with the patient and explain to them that we're sorry, but the right thing to do here is to wait. The prep is a nuisance. We admit that, Mrs. Johnson, but we need to cancel it. We need to get your cardiac workup completed and then we'll get you right back on the schedule.

Dr. Randy Lehman [01:01:17]: What percentage of your cases do you think cancels of colonoscopies on the day of?

Dr. Dan Margo [01:01:19]: I'd say 1 to 3%.

Dr. Randy Lehman [01:01:28]: Yep.

Dr. Dan Margo [01:01:28]: Very low.

Dr. Randy Lehman [01:01:29]: Seems acceptable. Yeah, sure. So, and the other thing I would say, my personal bias on, which is also the bias of every single cardiologist everywhere, is there's no such thing as a quote unquote cardiac clearance for surgery, even though that's what we say. But I never write that in my own notes, ever. I write preoperative cardiac risk stratification and optimization. That's what I write in my note, because that's what it is. The question is, does this patient need an echo? Do they need an angio? Do they need a stress test? And I'm not going to be the person that orders that test. So I'm going to send them to the cardiologist for their preoperative cardiac risk stratification and optimization. Then they're going to come back to me, and they're going to say the patient is optimized for the procedure. I think they're low, medium, high risk. Then they're going to have some cardiac risk no matter what, but we've done everything we can to optimize them.

Dr. Dan Margo [01:02:21]: Yeah, I agree with you. I think when we use the term cleared, it almost means the chance of a complication is zero.

Dr. Randy Lehman [01:02:27]: Right.

Dr. Dan Margo [01:02:28]: They're clear. So yeah, their risk is stratified and minimized and they are now optimized. But yeah, of course, they're not risk-free. The other one that we talk about a couple of times a year at the medical staff meetings at these, at any hospital, big hospitals and small hospitals, is when the family doctor orders the echocardiogram and the colonoscopy at the same time. No one discriminates over what happened first. They know they need their colonoscopy and they need an echo because of their chest pain. Sometimes, because we can get them on sooner, they get on for their colonoscopy first. Well, that's one of those things where the anesthetists are savvy enough to know, hey, wait, this doesn't add up. We need to cancel this before their prep.

Dr. Randy Lehman [01:03:14]: Yeah. And I'll say one more thing that I have moved towards very much a nurse practitioner, strong support in clinic, and I have an awesome one, so that helps, I would say. But, you know, like last year both my kids got their tonsils out, and they went down to Carmel and the IU system with the Riley Hospital and all this stuff, and they all saw, they both saw, a nurse practitioner.

Nurse practitioner said, yep, the degree needs to toss us out. It's going to be at some later date at one of two hospitals by one of six surgeons who will call you and tell you who it's going to be. And I actually was perfectly fine with that because the thing is, if it becomes so routine that it can work well in that kind of a model, I guess I was just comfortable with it. Some people don't like that, some surgeons don't like that, some patients don't like that. But that's what I have moved towards with Taylor.

At first, I had wound care, and I needed it taken off my plate, so Taylor did wound care for me. Then I was getting eaten up by, you know, basically. I do think there is a benefit, and you definitely don't have to do this. I would do open scheduling if I could, but there's sort of an expectation because a lot of primary care docs have done colonoscopies in the towns I'm in. The patients want to see you before; they're expecting a clinic visit a lot of times. Also, then we do our own kind of like, not cardiac clearance, but, you know, like a pre-anesthesia eval. We also have very low cancellations because, you know, Taylor's basically, she's a family nurse practitioner, and so she approaches it thinking of the patient's heart and risk for surgery, you know, ordering some tests and getting them to cardiology when appropriate, so then I don't have to.

And, because it's her time, you know, I'm more patient about it. I don't even know about it. Where was I going with all this? What happened is I was getting eaten alive with the colonoscopy clinic time. So then I said, hey, listen, this is how I think about colonoscopy. Could you be this buffer for me? She said yes. Then that went awesome. A little bit later, I said, hey, you know, this is actually how I think about inguinal hernia. Do you think you could handle this? And then she said yes. So she started doing inguinal hernia. I was like, well, I'll still keep the ventral hernia because that's tough and it's complicated. Then after a while, I was like, let me tell you how I think about ventral hernia. So now she's like, I would say, at the level of maybe a second or third-year resident in terms of her decision-making, and we talk basically every day.

Oh, gallbladder too—that was an early handoff, but even now, she's incredible because she had a patient that came with some abdominal pain or something, like some weird complaint. Wasn't really, I don't think it was for colonoscopy, the complaint. On physical exam, she felt a cecal cancer, got a CT scan, lined him up.

Speaker B: I'll be done.

Speaker A: So she's doing a great job. I usually have her see the patients pre-op, and we bring them back post-op and explain it. I think it increases understanding and compliance with the prep and compliance with the follow-up recommendation. We sit them down and show them physically the pathology and say, this is what it is and this is why, what guidelines we're following, and this is what we recommend next. So people leave the office with a really good understanding, and then we have an opportunity for them to give us some positive feedback, say everything went great. Then we say, okay, you're dismissed, back to your primary doctor. We get our little pitch in there where we say, don't forget to tell them we took good care of you, and all that stuff. There are so many ways that you can take your practice. Nobody is talking about this in residency, or they didn't to me. That's like the art of medicine. I feel like it's worth exposing that there are a lot of different ways to do it, talking to different people like yourself, who, you know, just a lot of different things can be done in zillion ways. Anything to add to that, or shall we move on?

Speaker B: Just that.

Speaker A: I agree.

Speaker B: And so in these smaller communities, I don't have the luxury of the nurse practitioner, physician assistant, but what a great way to duplicate yourself. So when your practice is mature enough that you can bring a person like that on, you can duplicate yourself to the point where you can become so much more efficient. In the absence of that, in these small communities, I find myself doing the preoperative visit. I have insisted on meeting all my surgical patients in advance, but the colonoscopies are the exception. That's why that preoperative visit with my patient is so important. Even the colonoscopy patient, I want some face time with them to establish, at least in a short time, a relationship with them before we put them off to sleep and take care of them.

Speaker A: One last question. Do you charge an E and M visit for that conversation that you have in the room?

Speaker B: I do not. But going back to something you said, in that group of patients who say, well, geez, I'd really like to meet him first, or I have some questions before the day of my colonoscopy, we always make room in the clinic for those folks that want and desire that. Then, of course, there's a charge for that visit.

Speaker A: And then your call, when you describe the path, are you making the call or is a nurse?

Speaker B: I'm having the nurses do it after I've written a note to summarize my recommendation.

Speaker A: Okay, and if you had to make the call, would you charge an E and M for that?

Speaker B: I don't because I'm not smart enough. Is that something that we can and should do?

Speaker A: I don't know. I think you could charge it as a telehealth. I think that if you talk to the patient about it ahead of time, I think the patient many times would be dissatisfied. But when you physically come into the office and you sit down, and they end up getting a charge afterwards, it's a little bit easier to sell. But there's some people who have been practicing around me who bring them physically back into the office, sit them down afterwards, talk about the pathology, and then don't charge. I think you could argue that that's fraudulent when you bring some people in during the service and you don't charge there. But I don't want to go there necessarily and say.

Speaker B: Right now, if we get a cancer diagnosis, we're going to bring them back in and talk with them about it. If it's a tubular adenoma, the nurse is going to call and say we recommend a five-year follow-up. We haven't been charging.

Speaker A: Everybody is. Not charging for something that you did on a Medicare patient is just as much fraud as charging for something that you didn't do. But the thing is, nobody has gone to Medicare jail for not charging for something.

Speaker B: I think the other point, something you brought up earlier, is the whole global follow-up period. I think on the colonoscopy there's zero days, right? So if you bring someone back a week later to talk about their results, to me that's an obvious charge.

Speaker A: Right. What if you consult on a patient in the ER or on the floor and then scope them the same day? Then you would drop a.

Speaker B: Sometimes I will.

And there's that special modifier where it includes a decision to operate.

Dr. Randy Lehman [01:10:52]: Right.

Dr. Dan Margo [01:10:52]: Usually, you know, document that the consultation in the ER included a discussion and a decision to go to the procedure. And then, and then I think typically that's paid and very justifiable.

Dr. Randy Lehman [01:11:04]: Yeah, 100%. Okay, great. So the people that trained me at Mayo, we went to Owatonna, Minnesota. There are three people out there doing scopes. They did 1500 a year. We did a six-week block rotation. They clicked the timer and started it. And you go as far as you can go for 10 minutes, and then we're taking over because we gotta do 1500 a year.

And so, you know, some people on their first day, they're getting all the way through. There are colonoscopy trainers. I actually learned from the colonoscopy trainer several little tricks and tips. One thing is just jiggling the scope is a great trick, but skiing through the moguls is something that was told for like the rectal valves. Skiing through the moguls and then it's a series of right, basically right turns, clockwise turns, you know, to get up and around the, up, you know, the question mark of the colon.

Basically, people get hung up in the sigmoid colon. The other place to get hung up would be splenic flexure, and you can get hung up in the transverse colon, and then also the hepatic flexure, all of which require different tips. So you, I believe, were talking about being in the sigmoid colon, and then you kind of brought up the alpha loop. So that's where the scope's going up and your, your scope's coming back around in front of it. And to reduce that loop, if you can't go forward, do you do anything in particular?

Dr. Dan Margo [01:12:27]: Well, I think that we advance the scope up and through the sigmoid point. If we can't reduce it, a lot of times just stop and come back. And as you're pulling back on the scope to turn the scope, it will help to alleviate that loop. There's also the stiffener on the scope that I think is perhaps oversold, but there's a purpose for it.

So I like to advance my scope in the loose setting, and if I run into trouble, I like to draw back and then consider stiffening it as I advance again, hoping to keep that loop as a non-loop, you know, as far as right turns and left turns. Randy, I'm not as mechanical as that. I know that if I would watch myself next time, I'd do a better job of talking about if I'm going right or left. But it's. It becomes so instinctive after doing many that it's more of a generalized push. More push is definitely not the answer. Right. That's one of the ways we can injure a colon. So we need to have a level of delicateness, awareness of the tissues and what they'll tolerate to do this job that we do.

Dr. Randy Lehman [01:13:37]: Why don't we pause there? Have you had perforations and do you mind sharing about that?

Dr. Dan Margo [01:13:43]: Yeah, perforations. I think every time we do have one as surgeons, it's a bummer, but it reminds me of some of my first surgeons I worked with that said if you don't like complications, you can't do these procedures. And what we work to do is minimize our complications and admit that we never make that zero.

Early on, I remembered navigating a sigmoid in a patient with diverticular disease. And I pushed the scope right through the wall of the sigmoid. I was looking at small intestines, and I knew in a split second what had happened. Fortunately, I haven't seen that one happen for a while. But that was from just too much forward pressure and not an appreciation of the anatomy and the tissue and where I was.

Dr. Randy Lehman [01:14:31]: Do you remember any details about that patient? Like, were there any. Aside from the diverticulitis that would cause inflammation, woodiness, probably in that area. Were there any other comorbidities or anything that.

Dr. Dan Margo [01:14:41]: That's 20 years ago. I don't remember. But it was an older gentleman that I'm sure exactly, you know. And when we get these complications, you don't want to brush them off. But typically there's an underlying disease process or something that led to it. The next collection of perforations, often in the setting of a biopsy, you know, there's. There's a lesion, and you're trying to remove it, and you're maybe a little too aggressive, you know, and it brings you back to the fact that we didn't put the lesion there.

And in the old days, that lesion would have required surgery anyway. But, you know, just walking that fine line and reminding yourself, what's the goal for the day? Is it to get some tissue and biopsy, diagnose this thing, or is it to remove it? And if you really know you're not going to remove it, then just get some tissue and try to have some judgment.

One final comment there would be the old hot forceps. I had bad luck with the hot forceps. I would be removing a small sessile lesion, the ones that I removed now just with a cold forceps, and just pluck them. I, early in my practice, was using the hot forceps to do the same thing. And I recall a perforation doing that. And I think that's one of the key reasons I would say I almost never use that hot forceps anymore.

Dr. Randy Lehman [01:16:04]: What do you set your cautery on when you do colonoscopy?

Dr. Dan Margo [01:16:07]: You know, and that's. It's a little bit different at different facilities. And 30 rings a bell, I think. Valley Lab 30. But it depends on the equipment, I think. And that's why at every facility, when they say, what do you want the cautery on? I say, I have it written on the top of the machine, you know, so I want it to be standardized. And I want. If that gets bumped or changed or one of the other doctors is in here, it should be on 30. What do you use, Randy?

Dr. Randy Lehman [01:16:36]: I use 18, but if you have 30, it's just you. You have to know what you're setting it on because the amount of time. And I, I still do quite short bursts, but if I was on 30, I would do even shorter bursts of cautery. And I do use cautery most of the time when I snare, I would say. But it's 18, and it's just a little tap, tap as I'm cutting through. I feel like it has reduced my bleed, oozing, and everything afterwards.

And hot biopsy. So do you remember, like on that hot biopsy perforation, how big the lesion was? Because I do use hot biopsy as well, and so I can tell you exactly how I think about it, but I don't know that it's necessarily right either.

Dr. Dan Margo [01:17:20]: Yeah, yeah. No, I'm just. What I'm saying is those little sessile diminutive lesions.

Dr. Randy Lehman [01:17:27]: Yeah.

Dr. Dan Margo [01:17:27]: That are sometimes even hyperplastic. A lot of times we'll take those. The nurses see them. You're obligated to biopsy that thing. And I'll just pluck them with the cold forceps. I've had very. Been very fortunate to not see bleeding with that technique. But in the past, I used hot on those and I had a perforation. And so in that series, it's by. It's biased me for the rest of my career that I am chicken to use hot forceps.

Now fast forward to the snare. I almost always use cautery with the snare, even though nowadays there's a trend to more cold snaring. There's this crazy argument that the bleeding rate goes down when you use the cold snare. You've heard.

Dr. Randy Lehman [01:18:12]: I've heard the argument. It's not my. Been my experience, but.

Dr. Dan Margo [01:18:16]: Right same. So I still use cautery. I think that the. I wish I had the machine. It might be 20 that we're setting it at. Randy. I don't know. I just, you know, when they ask, I look at that sheet because it can be variable, depending on your equipment. But going through a larger lesion, I do like to have that heat kind of following it as I bring the snare through the tissue.

Dr. Randy Lehman [01:18:40]: So, since we're on this topic, why don't we keep talking? We will come back to getting the scope all the way over. I've got a few more things I'd like to ask about that. But you have a larger, so easy decision—if you've got a pedunculated polyp, you're snaring it off. For me, 3 millimeters or less will fit in my jumbo forceps, and I usually actually use a hot jaw. I'm much more aggressive in the rectum with the hot forceps, much less aggressive in the cecum with the hot forceps. You're thinking about the thickness, right?

But one thing about the hot forceps I do like is it just makes just a little rim. Because, rather than using the snare where you're taking normal mucosa around it, your margin may not be there with a cold snare, or I mean a cold biopsy forceps, rather than the snare. And so I'm thinking that it's like, it's not the penumbra, you know, but it's almost like the penumbra around it that you're maybe destroying the rest of that polyp.

Dr. Dan Margo [01:19:38]: I don't.

Dr. Randy Lehman [01:19:39]: That's just kind of how I think about it. So, usually, 3 millimeters or less use hot biopsy, and 4 millimeters or bigger, I use the snare. Basically, know the rules, follow the rules, and then break the rules, right? That's for every single thing in life. For the cold biopsy, then I'm usually taking a cold biopsy if it's something that obviously I'm not going to be removing because I think it's cancer or something, or I'm doing my random colon biopsies, or I've got inflammation. That's when I usually find myself using the cold biopsy.

We talked about the pedunculated polyp, but what about that polyp that's like 2 cm or bigger and it's flat? Do you do any special techniques like mucosal saline lift, or what do you do in that scenario?

Dr. Dan Margo [01:20:28]: I do not. If there's a lesion, I typically use the hot snare only and lift it. If there's a scenario where I'm able to get 80%, or let's say I get 80% of one of those big, complex, flat sessile lesions, and it comes back as a tubulovillous adenoma, I get my tissue, we didn't have a complication, and it comes back as benign. This is one where I will send them away to the gastroenterologist partly for a second opinion, partly to do a saline-injected technique, and just to get them plugged into another system and to give myself some backup on that.

So I haven't done the saline injection. I haven't used the needle for much anything at all until I started tattooing. You know, that was really the first time I started injecting into the colon.

Dr. Randy Lehman [01:21:21]: Yep. So the EMR, endoscopic mucosal resection, I also send that out. But I know several rural surgeons that do that themselves. There's a mucosal resection, and then there's an endoscopic submucosal dissection, basically going a layer deeper and actually doing more of a dissection that I obviously definitely do not do. And I don't know that any rural surgeons personally are doing that as well, although they could. But basically, I will send those out. Those would be polyps where I would consider them, in my hands, unresectable, but somebody else might be able to.

Now, I had one lady in five years who said, "I don't want to go anywhere for that. Do I have any other options?" I told her that I do recommend that it's completely removed. The only other option is partial colectomy. I talked to her about it and essentially advised her against it, but she still said that's what she wanted, and that's what I did. And then she was very happy afterwards. Was it all right?

Dr. Dan Margo [01:22:32]: I mean, do you remember?

Dr. Randy Lehman [01:22:33]: Yeah, it was all right. So, you know, it's not as bad as doing a sigmoid with a colorectal anastomosis.

Dr. Dan Margo [01:22:41]: But, you know, back before we did all these colonoscopies, it was a flex sig and a barium enema. They'd see a filling defect in the cecum, and they'd take it out in surgery. And it was sometimes a tubular adenoma.

Dr. Randy Lehman [01:22:54]: Right.

Dr. Dan Margo [01:22:54]: You know, and it was benign tissue, and they put themselves through that. I think with your well-informed patient, that's exactly what you should do. You know, the patient got to be a part of the decision. She wanted you to do it, and right there in that hospital. So I respect that.

Dr. Randy Lehman [01:23:12]: Good. So we talked about the sigmoid colon, and you're talking about pulling back and then stiffening the scope. I think about the colon; it has to stack up on the scope, like sliding a sleeve off of your shirt or sliding your cuff up, right? So going in and out, in and out for me, like kind of quickly with the lumen in view, not up against the wall, obviously, just a jiggle, really gives me a lot of scope advancement. I don't know. That's a layman jiggle, I guess.

Dr. Dan Margo [01:23:48]: No, I think the jiggle technique—let's call it the layman jiggle—I think there's value to that. I'll often use the word accordion when describing it to nursing students or something. We're just kind of gathering it up on here now. You know, I had the scope into 70-80 centimeters, and we were maybe only this far in. Then we describe how we're pulling that back. Your sleeve analogy is really a good one, but that's exactly how I picture it. You're trying to gather that up, and then as you advance again, I think there's room for this abdominal pressure thing.

So I call it the abdominal pressure maneuvers. I've had speakers in the past pooh-pooh it and talk about if your surgeons are making you push on the abdomen, they're not doing it right. And I tell you what, I still think there's value in it. I think it needs to be gentle. I have one anesthetist that doesn't like it because he thinks it increases the aspiration risk, but in general, we still will do it. I'll have whoever's in the room assist. It's usually the nurse with a gentle fist or a palm. Just almost once I gather back, I like to push the umbilicus, the belly button area, straight back. To me, that just allows. It's a focal point for that question mark you talked about to kind of work around that pressure. That's another trick. You know when you have a big, deep splenic flexure, that can be a headache in a different way, because all the pressure in the middle of the belly in the world doesn't change that. That scope just wants to go up into that splenic flexure. But again, the first goal is to just find a way to get that scope in. I'd say one in every 50 to 75 scopes will actually roll the patient onto their back. That's a trick late. I don't do that one very often, but every now and then I'm like, okay, let's try them on their back, and we'll roll them on their back and try a little more to find our way to the cecum.

Dr. Randy Lehman [01:25:45]: Yep. Any other places to push pressure, or is it always if you're doing pressure at the belly button going straight back?

Dr. Dan Margo [01:25:53]: No, I think that's my go-to at the beginning. So we'll advance the scope, come back, and I'll say, okay, let's put the pressure on. I'll say a soft hand straight back at the umbilicus, and we'll see if we can go. After that, I think it is a little more, honestly, a little more trial and error. We might compress the left lower quadrant, trying to hold the sigmoid down into the pelvic fossa. We might come high in the left upper quadrant, trying to splint that splenic flexure. But have you found a way to summarize better?

Dr. Randy Lehman [01:26:21]: No, it's just, I think, what's the point of the pressure?

Speaker A: So the point is you start with a straight scope. You've got to pull back before you apply pressure because what's happening is most of the time, 90 plus percent of the time, your scope is looping in the sigmoid colon. You're trying to prevent it from re-looping as you push forward so that you can push through that. I think the belly button makes sense. You push straight back, and it kinds of tampons it down. I usually say left lower quadrant, push towards the belly button. That's how I describe it to the person applying the pressure. I also use positioning the back all the time, but I always make sure I pull back first. I've got a straight scope, and it usually helps me around the splenic flexure. If I'm still in the rectum, abdominal pressure is obviously not going to help.

Speaker B: Right.

Speaker A: The sigmoid colon, it's hit or miss. Usually doesn't help. Usually, I've got to get my way through the sigmoid colon into the ascending colon before that becomes any benefit. But the other thing is sometimes you can loop in the transverse as well. That pressure might be one where you're pushing epigastric and pushing up to try and bring the transverse into a more straight position.

Speaker B: Yeah, yeah, agreed.

Speaker A: Did I say sigmoid? Yeah, transverse, make it straight.

Speaker B: I'm following you. You know, almost identical, except in my mind's eye, I would take—if I was working on the sigmoid, I would take the umbilicus and head down towards the left lower quadrant. You're pressing the left lower quadrant up towards the umbilicus. It's kind of a matter of how we're picturing the spatial anatomy, which is why I think I like that umbilical pressure, just like you said. I think it just pushes everything down towards the left lower quadrant. The other one that's great is when the patient's relaxed, and you haven't over-insufflated. So that's another key pearl. Right. Don't use too much air too early, and if you have too much air, then ride your suction button a little bit instead of your air insufflation button and try and decompress things. The sleeve analogy works better when things are empty. Trying to keep the colon from being overinflated can be very helpful. But the point I wanted to make, with the patient well relaxed and sedated, they're not over-insufflated, and you're pushing the scope. Sometimes the nurse will say, oh, I feel it. Now you have a clue.

Speaker A: Push right on that spot.

Speaker B: Right. That's the spot. Push that back down into the pelvis where it belongs. Then we can advance the scope.

Speaker A: Yeah, very good. Have you ever heard of the scope guide?

Speaker B: I've seen it. I've used it once. The big hospital in our hometown here in Grand Rapids has the scope guide, and I have to admit I found it helpful.

Speaker A: I love the scope guide. I think that if it's worth the investment to somebody that's going out on their own in a small town early on, there's magnets in the scope. I don't exactly know how it works, but I don't know how really my microwave works either. But I trust it. And what you see is a real-time picture in the corner of your screen that looks like what it would look like if you did fluoro. There's a little paddle that goes in front of the abdomen. I think it's an Olympus-only product. There may be others for different manufacturers. But you basically get a live view, and so you can see your loop. First off, it helped me to advance early on, and now it makes me so much faster because I pull back exactly how much I need so that I have a straight scope, and I can do that so much faster and then quickly advance again.

Speaker B: That was wonderful. The other thing I loved about the scope guide, Randy, was it validated what I thought I was seeing in my mind for years before. When I could finally see that scope and the loops and things, I was like, oh, that's kind of how I pictured it. And you see it in real-time, and it's a wonderful thing. Sounds like it's very time-saving for you. So that's a good addition.

Speaker A: Yep. Then going around the splenic flexure, did you have anything else to add about that? I would just say one thing, that what I normally do is I go in with zero on my stiffener, and as soon as I get around the splenic flexure, I go boom to three, like almost every time. I will sometimes change it based on what's going on, but once I've made it past the splenic flexure with a straight scope, that is 90 over 90% of my looping. So I just want it to stay like that, and then I just kind of advance on through. I feel like that's made me faster.

Speaker B: As well, but probably a good tip. No, I leave the scope soft until I need it. So it's almost the same. If I'm around the splenic flexure and struggling, then I'll stiffen it up. But if it continues to advance for me and I know where I'm at, and I'm looking at the appendix and the cecum, a lot of times I'm like, ooh, I'm still on soft, I'm still at zero, and I'm okay. I always take a picture of the appendiceal opening. It's just part of my routine. I get a picture there. I've tried to intubate the ileum more and more lately. I had someone say they would start requiring that to validate position. I've never heard that truthified or validated.

Speaker A: I doubt that. But I have heard a description of how do you know someone's proficient at colonoscopy? The answer was when they can intubate the terminal ileum at will.

Speaker B: It is a great skill. And so I've been working towards that more often. Every now and then, they want biopsies at the terminal ileum, and it's nice to have the skill to get in there. But I would be humbled to say that I've intubated everyone or to say that I could because I've tried a few times in some that fortunately didn't need it. It can be a trick.

Speaker A: Luckily, I'm persistent, and I almost always can get it, but it can be a lot of work. Sometimes a little pressure there can actually reposition the colon sometimes, too, sucking the air out. The last thing is going around the hepatic flexure. Do you have a tip on that one? Because I have a phrase.

Speaker B: Yeah, I want to hear it. Because, no, I don't have a tip other than gentle persistence.

Speaker A: But okay, it's suck and pull, basically. Once you see the cecum, you need to suck all the air out that you can and usually pull back on the scope. You will paradoxically fall down into the cecum very, very frequently. Sometimes there's a Lehman jiggle associated with your sucking and pulling, and then you find yourself down in the cecum.

Speaker B: Yep, yep, that's good. I've fascinated many a student by telling them, watch this. I'm going to pull the scope out, and you're going to watch it travel forward. That paradoxical motion you talk about, that's a great skill also to have.

Speaker A: Also, a half, half, or a quarter clockwise turn. I'm doing that simultaneously.

Speaker B: Yeah. I think the twisting of the scope is the thing that. That's just time in the procedure room, where you learn how valuable those quarter turns can be at certain positions.

Speaker A: Yeah. So some people, if you want to be fast, I would.

Speaker A: I would make sure that you're running the scope, both ends of the scope. I guess some people have nurses advance the scope for them. Again, like, if you want to be fast at some point in your career, you don't have to be fast on day one, but it's worth it to learn how to do both.

Dr. Dan Margo [01:34:03]: No, I agree. That's what I do. And I think that's, you know, sometimes the nurses are uncomfortable when you tell them to advance or push. And so I think it's good that you do it on your own. I do that.

Dr. Randy Lehman [01:34:13]: What else do we need to talk? This was, I would say, a very technical deep dive. And you're making me feel like I put so much effort into learning this skill. Maybe I shouldn't hate it quite so much.

Dr. Dan Margo [01:34:24]: But, yeah, I've come to love it. I mean, the first five years in practice, my goal was to grow my practice enough that the junior guys would do all the scopes. And then I realized that, you know, it's a pretty nice way to get home on time, and, you know, it's a scheduled procedure, and it's somewhat predictable. I just turned it into my lifeblood and learned to not hate it so bad.

So, yeah, the only thing I was going to.... I had a little asterisk, is at our facilities, I've implemented—and it might be required now—but the timeout at the end of the procedure.

Dr. Randy Lehman [01:34:57]: Okay.

Dr. Dan Margo [01:34:58]: Colonoscopies. It's just super important. It's like, okay, what did we do? Okay, we did A through G, and then we go through what we called each of them. I take that note sheet with me to dictate the report. And so I think the timeout at the end is very important to make sure they have tissue in each jar and that we're all saying the same thing. But no, other than that, I think we can wrap it up. And I appreciate the deep dive. I haven't been able to talk with anybody about that for 20 years.

Dr. Randy Lehman [01:35:24]: My pleasure. All right. And do you have any resources for somebody else that, if they were going to do a colonoscopy, you know, on their own, yeah, maybe a mentor or maybe I would love to have any textbook or website references.

Dr. Dan Margo [01:35:40]: Yeah, yeah, I don't. Other than the value of time in the procedure room: patient, instructor. I loved your 10-minute rule. What a great way to teach somebody without going crazy because when you're bringing a new partner in or teaching a family doc this skill, you need some guidelines or you can go crazy.

There's no way it's worth it for you to take the time out of your procedure list to do that. So I love that. I was going to, as far as resource recommendation, just emphasize the importance of collegiality and how rare a resource that is when you're a small-town surgeon. And that's what brings us together as rural surgeons is our isolation.

We should all crave collegiality. So I was just going to plug our society and other chances to rub elbows next door to each other with real-life rural surgeons doing the same thing we do. Because that's when you can learn about the Lehman jiggle and things like that. But you need to sit together to do that.

So any rural surgeon that's looking for a way to get that just once a year out in Denver—the location might shift, but once a year—we get this group together in January. And it's been very valuable because I don't have partners. Right. I'm all by my sewing, all by myself out here. I need partners and collegiality.

Dr. Randy Lehman [01:37:06]: Yes. Thank you very much. North American Rural Surgical Society in January. Martin Luther King Jr. Weekend. Be there, be square.

Dr. Dan Margo [01:37:14]: Typically now. And my financial tip, yeah, let's do it really quick, is if you are a rural surgeon paid on an RVU basis, make sure you work into your contract some kind of a daily minimum, especially if you let other people schedule your day. So the classic for me is I take a day off to drive all the way to Big Fork, Minnesota, for seven colonoscopies, and I get there and we're only doing four because three canceled. Okay.

So I would just say that as a rural surgeon doing these kinds of things, and maybe it works even if you're a one-hospital rural neural surgeon, you know you've got your whole day blocked out. If they're paying you RVU, think about making sure there's some way to have a daily minimum in your compensation.

Dr. Randy Lehman [01:38:06]: Yep. That is something I'm doing everywhere now. So great tip. I love it. Thank you so much, Dr. Margo, for joining me. This has been nothing but gold about colonoscopy, and I just appreciate you taking the time to talk to us.

Dr. Dan Margo [01:38:20]: Okay. I hope you find several good minutes out of this time that you can put together to make a valuable podcast for your listeners.

Dr. Randy Lehman [01:38:30]: Yep. I appreciate it, and I thank you too, listener, for joining us on this episode of the Rural American Surgeon. Don't forget to like, subscribe, share with your friends. Thank you for being here. I appreciate you. Keep up the good work, and we'll see you on the next episode.