Episode 40

Bringing Robotics to Rural Alabama with Dr. Quince Gibson

Episode Transcript

Dr. Randy Lehman [00:00:05]: Welcome back, listener, to the Rural American Surgeon podcast. I'm your host, Dr. Randy Lehman. I have with me today Dr. Quince Gibson, who's practicing in Demopolis, Alabama, and he's going to talk to us about bringing a robot into rural America and what brought him to that region, the Black Belt in Alabama. Welcome to the Rural American Surgeon. Hi, 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. Thank you so much, Dr. Gibson, for joining the show.

Dr. Quince Gibson [00:01:08]: Absolutely. Good to be here.

Dr. Randy Lehman [00:01:09]: Let's start with an introduction of you. Could you tell us a little about your background and your practice over time and what you're doing now?

Dr. Quince Gibson [00:01:16]: Yeah, sure. So, personally, I was born on the island of Jamaica and then immigrated to Canada. I met a girl after I was in college, and she brought me down to the United States. I'm now a proud United States citizen. I went to medical school after spending nine years in business and computing. So this is a second career for me. I went to Loma Linda University, where I had a fantastic time. They taught me how to be a very good doctor, not just academically, but also from a character and integrity standpoint. I really appreciated that curriculum.

I was fortunate enough to sneak into UAB. I don't know how I got in, but they took me and trained me for five years and subsequently hired me. They were expanding their rural surgery program and establishing what they called community partnerships. I was employed in Demopolis, Alabama. I'm currently serving as the general surgeon at Whitfield Regional Hospital, and I've been doing that for the last four years. So, I'm still relatively a new surgeon, despite being old, if that makes sense.

Dr. Randy Lehman [00:02:36]: So you finished your training in 21?

Dr. Quince Gibson [00:02:39]: That's correct. Right. I was the second class. I wrote the second board examination. That was remote.

Dr. Randy Lehman [00:02:48]: Gotcha. Yeah, that was the first class.

Dr. Quince Gibson [00:02:49]: You were the first. Gotcha. Yeah.

Dr. Randy Lehman [00:02:52]: So the same demographic. I've had a few guests on the podcast who have been from India and different places, and they've had to do J1 visa work, going to rural areas. Is that what you have to do? Are you doing that too, or is that something different?

Dr. Quince Gibson [00:03:09]: No, this is different. I became a US citizen before I even contemplated medicine. In fact, there are still a lot of differences. I was an F1 student when I was doing my master's in Business Administration. So, I am familiar with the process of coming to the United States and studying, etc.

Dr. Randy Lehman [00:03:27]: Yeah. It's funny how you can have so many paths. I've had one guest who originally started on a J1 visa, and that's what took him to the town where he ended up practicing for, like, 40 years. Then you've got others, like friends of mine who were on J1 visas from training. I trained at Mayo Clinic. So, talk about a melting pot. There are people from all over, like Alexandria, Egypt, one of my buddies. I've seen them go into different places for that reason. Some of them stay, some leave.

Dr. Quince Gibson [00:04:00]: It's. Yeah.

Dr. Randy Lehman [00:04:01]: And then there's a. Do you know Dorothy Hughes?

Dr. Quince Gibson [00:04:04]: I don't.

Dr. Randy Lehman [00:04:05]: Or Tyler Hughes? Tyler Hughes is a leader in the American College of Surgeons. He's a rural surgeon from Kansas, and his daughter has done a lot of public health work, specifically some related to rural surgery. She gave a presentation to us at the Northern Plains Rural Surgical Society, now the North American Rural Surgical Society, about rural surgeons. There's a categorization where there's the people from rural areas who came back, and then those from urban areas who decided they wanted something different and went to the rural. The motivations are complex. Now I think you're my 36th or 37th podcast guest, and I've seen a great variety.

Dr. Quince Gibson [00:05:01]: Yeah. I would put myself in that second category—definitely urban all the way—and then decided I wanted to be rural.

Dr. Randy Lehman [00:05:10]: Yeah, that's a great segue into the next segment of the show, which is, why is rural surgery special to you? And I know there was a story about Baltimore, and maybe you can tie it all together. How did that come to be where you're in Demopolis?

Dr. Quince Gibson [00:05:25]: Yeah. So, you know, I don't know if you're familiar with a show called The Wire. I've never watched it personally, but many people have told me about it. The story is about wiretaps, and it's just about Baltimore and the seedy underside of Baltimore. Well, I lived in one of those neighborhoods, so inner city. In that inner city, there are people in various living situations.

Dr. Quince Gibson [00:05:56]: I met a wonderful lady who was a widow and the matriarch of her family. She became a close part of our family. She got metastatic breast cancer, didn't tell us until it was too late. She was on a fixed income and wanted to avoid the healthcare system. She was trying to pray it away and had poor health literacy. At this time, I was in business, working at the University of Maryland or Lockheed Martin. We visited her, and she stopped breathing while we were there.

Dr. Quince Gibson [00:06:27]: I had absolutely no clue what to do. I didn't know how to check for a pulse. My work in information systems and programming couldn't help her. I realized there was a need for people who are economically or geographically disadvantaged to access quality medical care. After she passed away, I did some introspection and decided to change careers.

Dr. Quince Gibson [00:06:57]: With two kids and a house, being the only one working, my wife was homeschooling at the time. We decided to move to California, and the rest is history. Lady Athena is still on my mind when patients come to see me. When she died, she left a big gap in her community because she was a stabilizing force in the lives of many people.

Dr. Quince Gibson [00:07:28]: If you imagine inner city Baltimore, there's a lot of unemployment, lack of education, and poverty. Her death left her family at a disadvantage. She was the home that everyone went to when they got kicked out of somewhere else. When she wasn't there, I realized, as a physician, you have the opportunity to help keep communities together.

And, and Athena really helped me to,

Dr. Quince Gibson [00:08:29]: realize that. And so, as I made the trek through medicine, I really did have a motivating factor. I think that it stayed with me all the way through residency. Now, I was actually supposed to go overseas to do mission work with my church as a physician. So they had. I heard in one of your programs, there's a PAX residency, for example, that you're familiar with doing some, you know. So there are hospitals where I had the opportunity to go to one during residency where I would have gone to as a surgeon.

Dr. Quince Gibson [00:08:59]: But then one of my, my son got sick, and we decided to stay in the United States. And I thought, what could I do to have that same impact here? And I realized that there is a big field here in rural surgery, particularly in western rural Alabama, which has some of the poorest counties and some of the poorest living situations and disadvantaged folks that you'll see probably not just nationally but internationally. And so I thought I could make a big impact here, and that's what led me to the current position that I'm in.

Dr. Randy Lehman [00:09:37]: Has it been what you expected it to be?

Dr. Quince Gibson [00:09:41]: Yes and no. So I thought I was going to be doing good, just helping disadvantaged people, but I didn't realize the extent of poverty here. My wife participates in some of the community programs here, and we had to go to some of the trailer parks and just see some of the children. I've gone with her to do these, like, you know, reading programs and teaching some of these kids to read. And wow. You know, we spent a month together as a family in Malawi, at Malamulo Hospital in Malamulo, Malawi. And I saw poverty there. And I've got to tell you that it's actually a little bit more sad here because we live in the richest country in the world, and we're still seeing some of the same things. Right. And so, that has been a little surprising.

Dr. Randy Lehman [00:10:30]: So give me, like, specifically, tell me, like, give me a little more color to that. So, like, places with no running water, power, anything like that, or what else?

Dr. Quince Gibson [00:10:39]: Yeah, I mean, sure. So, you know, there are people who don't have running water because the bill isn't paid. There are people who, you know, we have these single-wide trailers with like 12 people in them, you know, in very filthy conditions. Sometimes I, when I close a wound for surgery, you know, I've got to think long and hard about sending that person home sometimes. And I'm not saying that for everybody, but I have to think long and hard. Like, is this amputation site going to survive the environment I'm sending it to? So, you know, there are places with well water. There are places where people don't have any transportation. Living conditions are just horrendous in some respects. And I know that can be in urban areas as well, but I've just seen it more pronounced here. We have the poverty rate in some of the counties here in excess of 31%, which is some of the highest in the country.

Dr. Randy Lehman [00:11:52]: Yeah. I read an article that said, quote, "The rural America is the new inner city," specifically talking about poverty and drugs as the two things associated with the inner city but very much rampant in rural America. I mean, but like you said, it's very juxtaposed because we've got the McMansion.

Dr. Quince Gibson [00:12:15]: Yep.

Dr. Randy Lehman [00:12:16]: And then down the road, we've got the squalor, the cleanliness is its own thing, you know, because like my grandpa, he's 95 now, and he was born the same month that the Great Depression started, and he's lived through. And he never, I would say, made much. He saved a lot through his years. But he has a phrase that says, "Even the poor can be clean."

Dr. Quince Gibson [00:12:46]: Absolutely.

Dr. Randy Lehman [00:12:47]: Which I've heard him say. So that is its own problem compared to just not having resources. But I hear what you're saying. I've done mission work myself too, and sometimes you go in. And in the United States, I would definitely trade some of the bad situations I've seen in developing countries for some of the worst situations I've seen here, except for the fact that opportunity does still exist in America if you know how to access it, I guess.

Dr. Quince Gibson [00:13:18]: Yes.

Dr. Randy Lehman [00:13:19]: So.

Dr. Quince Gibson [00:13:20]: Yeah.

Dr. Randy Lehman [00:13:21]: Yeah. Well, that's beautiful. So the big thing I wanted to bring you on to the show and talk about is you have some experience using a robot in your hospital. So we're gonna do how I do it about robotic ventral hernia repair. But before we get there, I want to talk about the demographics of Demopolis and, size-wise, how many other surgeons are practicing there, what your hospital is, if it's a critical access or not. And then did they have a robot when you started? If not, what did it take to get it there, and then how it kind of turned out? So start telling me about Demopolis, if you would.

Dr. Quince Gibson [00:14:00]: Yeah, yeah, sure. So, you know, really, Demopolis is just one town that I serve in a conglomerate of towns. It is a critical access hospital, Level 3 trauma. And in terms of demographics, I think they've got several industries there that are pretty steady employers, like paper mills. The hospital is one, obviously, and then other retail shops, etc. In terms of whether or not the robot was there when I started, we didn't actually have a robot. And then the CEO found out that I was trained robotically and thought it would be a good idea to get one for the hospital in terms of the recruitment of patients as well as the recruitment of other surgeons. I am the only general surgeon on staff. There's another general surgeon that works there, currently working in the ED, but has sort of transitioned to working in the ED. And so, I was excited because, as you know, probably in training, a lot of training, especially at UAB, where I trained, was robotic-based. Right. It's such a great training tool. And, given the challenges of rural surgery, I thought that it provided quite a bit of opportunity for me to do more than could typically be done there.

Dr. Randy Lehman [00:15:28]: So when they brought in the robot, first off, is this hospital part of UAB?

Dr. Quince Gibson [00:15:34]: Yeah, so they're affiliated with UAB; they run independently, but they do have some of the staff actually staffed by UAB. So the CEO is staffed by UAB, and we provide, I think, a tele-ICU and general surgery services there.

Dr. Randy Lehman [00:15:50]: So your check, does it come from UAB?

Dr. Quince Gibson [00:15:52]: Yes, sir.

Dr. Randy Lehman [00:15:53]: And you're a W2 employee with them?

Dr. Quince Gibson [00:15:55]: Yes, sir.

Dr. Randy Lehman [00:15:56]: Okay, so when they brought the robot in, was it a contract specifically with this hospital, or was it like one of the university robots, or how involved was the university?

Dr. Quince Gibson [00:16:06]: It was specifically with this hospital.

Dr. Randy Lehman [00:16:08]: Now we did try to sort of leverage the relationship between UAB and Intuitive to get the robot there, but it was specifically with the hospital.

Dr. Randy Lehman [00:16:20]: Okay. Did it come in 21?

Dr. Quince Gibson [00:16:24]: Yes, I would. Late 21.

Dr. Randy Lehman [00:16:26]: Late 21. And which model?

Dr. Quince Gibson [00:16:30]: It was the Xi.

Dr. Randy Lehman [00:16:32]: Okay.

Dr. Quince Gibson [00:16:33]: Yeah.

Dr. Randy Lehman [00:16:34]: So. And there's no. Are there any other surgical specialists like OBGYN, urology, anything like that?

Dr. Quince Gibson [00:16:40]: No. So we do have urology services, so we do contract with someone. And, but they. One of the challenges for us, and I don't know if it's for everyone else and we, we can get into this too. But is anesthesia. Right. So yeah, getting anesthesia is. It's been a little tough. And so we don't have an MBA here.

Dr. Randy Lehman [00:17:02]: Right.

Dr. Quince Gibson [00:17:02]: We have, we. We're a CRNA based practice, and they practice independently here. So some people are not comfortable with that. And so you know, being. I think from a general surgery standpoint, we're a little bit more comfortable because our training involves significant critical care, you know, managing and things like that. But that was sort of an issue. But I was the only one using the robot, and we were hoping it would be a recruiting tool for other people to come in, particularly urology and OBGYN to come in and use it, but that didn't. Didn't pan out.

Dr. Randy Lehman [00:17:37]: Didn't really work out. And I've experienced that same thing. We had that at my hometown hospital. They have MD anesthesia exclusively at this time because ortho said that it was a deal breaker for particularly one of them. But the urologists are fine with it, actually. And so it all just depends. And. But, you know, I think of it because if. If I've got a patient and they're coding, it's me and that CRNA that are the only ones that are. And then you've got one person in the ER, so. And I would. I mean, obviously, if I. If I had an interoperative code, I'd be calling the ER physician to come down and help me out.

Dr. Quince Gibson [00:18:17]: Yep.

Dr. Randy Lehman [00:18:19]: If. I guess if the hospitalist is still in the building, then, you know, I would try to call them. But other than that, I mean, what am I gonna. There is a radiologist in some of the places that I'm at, but there's like, what. Who other physicians do we have in the. In the building?

Dr. Quince Gibson [00:18:34]: Nobody.

Dr. Randy Lehman [00:18:35]: So, you, you know, you have to think about it that way, and that ends up helping me to discern, determine, like, who I want to take to the operating room in the first place and what kind of anesthesia I want to give them, and talking about, like, MAC local for inguinal hernias or. Or something that I could do under local only, but I wouldn't give them any sedation at all, or else I would make them go somewhere else. You know, it's something that maybe day one out of residency is hard to completely comprehend when you're training at a big academic ivory tower.

Dr. Quince Gibson [00:19:05]: Yeah.

Dr. Randy Lehman [00:19:06]: But it's just a part of everyday life. So the robot's not there anymore.

Dr. Quince Gibson [00:19:11]: It isn't. And that. That was a financial. That's because some financial issue, being able to pay for it. So, you know, in retrospect, and I could say this right off the bat, that you can't really sustain a robot in a rural area with one surgeon. The robot has to be used. Now. Surgeons can't operate 24/7, or five days a week because they have to be in clinic sometimes to actually get those patients to operate on. And so you really need someone who is also operating and using the robot in order to sort of make it economically feasible. And so that's one of the things I think I would, in retrospect, kind of be more heavy on. Hey, we need another specialist here who's committed to using this in order to gain sort of the economic advantage of paying for it.

Dr. Randy Lehman [00:20:09]: How many cases do you think would need to be done, whether that's per year, per month, or whatever, to keep it viable?

Dr. Quince Gibson [00:20:18]: Well, that's a great question and I, so thank you. Well, I mean, I got a colleague that used to always say that. Thank you. Thank you for letting me know my question. Yeah. So it depends on the case. Right. So I know that if you're doing a lot of colon resections on patients who have Medicare, you know, you can make it viable. Right. If I'm doing a bunch of hernias, right. Like inguinal hernias and gallbladders, I need a lot of those in order to sort of make it do. Right. There are a variety of indices that go into even reimbursement for these. Right. Because the reimbursement in Alabama, it's actually more the same case. Right. I do a right hemicolectomy, I, on the same patient. And depending on where I do this, this case, I get reimbursed differently. And in rural areas in Alabama, they pay a fraction of what they pay in an urban area. I would say that it depends on the case mix. Right. And so I, I, I would say from an RVU standpoint, you would like to get more of your colons, you know, foregut sleeves, that sort of thing in order to make this work. I would not say that a practice that is you, that is heavily lap coli, inguinal hernia, that is going to be a little bit more difficult to finance a robot.

Dr. Randy Lehman [00:21:53]: So were you under a lease model?

Dr. Quince Gibson [00:21:58]: Yes, and it was a three-year lease, I believe it was. Yeah. I wasn't involved in a lot of the, you know, tried to stay out of that, but.

Dr. Randy Lehman [00:22:04]: Yeah, well, you're the one with the MBA, so I wonder.

Dr. Quince Gibson [00:22:08]: Maybe I am. And I tried to stay in my lane a little bit, but I did, you know, these are questions that I did contemplate quite a bit. I can't put away that MBA side of my brain, so.

Dr. Randy Lehman [00:22:20]: Yeah, sure. So do you know offhand the volumes for your practice like over the past four years?

Dr. Quince Gibson [00:22:29]: Yeah. So it's, it's interesting. We can give, you know, RVU range. Right. For a year, I think we were, we were probably in the 9,000 to 11,000 RVUs. Now a lot of that, you know, that's seeing patients in the hospital, that's consults, that's clinic, that's cases. That also includes some partners that came down to help me with some of my cases. So I did. One of the benefits of my practice is that I have, you know, UAB colorectal surgery that comes down on once a month. And so I can plan some of my difficult cases with them and we can do that case together or at least they're in the building. Right. And so that included their, their, their outputs as well. But that, you know, I would say that that was a, probably around a good target. We went, we went higher than that sometimes and I think we, we were, I think my first year I was lower than that. But that's a, that's a good range. Yeah.

Dr. Randy Lehman [00:23:27]: And how do you feel about those? Those numbers are, are pretty high productivity. National average is 6,500 RVUs per general surgeon. Sure. Last year I did 10,500 and I got to the end of the year and I'm like, man, I don't need to do this. So. But you know, you, you mentioned also having, trying to have the robot busy all the time.

Dr. Quince Gibson [00:23:50]: Yeah.

Dr. Randy Lehman [00:23:52]: I have a nurse practitioner that I've now been working with for three years who does. It's long story how we kind of got started, but she's, she kind of fell into my lap because she's a friend of a friend and she's a fantastic nurse practitioner in terms of how she thinks about things. But what I initially had going was I was covering wound care for a hospital and I needed somebody to take that off my plate. So that's how I started with her. And then I, I was like, listen, I've got all these scope referrals and. Are you doing scopes?

Dr. Quince Gibson [00:24:26]: I am.

Dr. Randy Lehman [00:24:27]: Okay. So I'm getting all these scope referrals and it's really kind of the main thing I'm see first of, I don't really need to see them. Five pre op.

Dr. Quince Gibson [00:24:38]: Yeah. Right.

Dr. Randy Lehman [00:24:39]: But if, but you know, if I'm going to do this, where most people are seeing them pre-op in the places where I'm working. And so if I'm going to see them, it's mostly a medical fitness for anesthesia, you know, and putting a little color to why we're doing the scope.

Dr. Quince Gibson [00:24:56]: Right.

Dr. Randy Lehman [00:24:57]: And I think you could easily take this off my plate. Would you be willing to do this and see them back and follow up on the pathology? So, so then she added that, and then it went really well. And then I said, hey, this is how I think about gallbladders. And then she took that over. And then I was like, I'm gonna hang on to hernia because it's so complicated. But then after a little while, I was like, well, this is how you think about inguinal hernia for sure. And then now she's seeing them too and even cancer patients and things now on those where, you know, we talk every single day.

Dr. Quince Gibson [00:25:26]: Sure.

Dr. Randy Lehman [00:25:27]: But I think we have a good model. So I'm moving towards a mid-level, not, not every day being a surgery day for me, but closer to it.

Dr. Quince Gibson [00:25:36]: Yeah.

Dr. Randy Lehman [00:25:37]: And then ask you that question.

Dr. Quince Gibson [00:25:39]: I mean, because right now I'm in clinic twice a week, you know, and I'm not seeing that many patients. I had the very same experience, I think one year we clocked in around that in terms of RVUs. And you know, I looked at my wife and kids and was like, I'm not in residency anymore. You know, I don't, I don't need to do this. And so we kind of backed up.

But, you know, that is one model that I actually am probably going to look at shortly because getting into, getting into the OR is really big. One of the things that I did consider starting off in a rural area, and I didn't realize this initially, but I really thought it was necessary for me to establish my brand. Right. So in rural, in rural areas, particularly in Alabama, there's a lot of distrust in the, the hospital. Right. And so in order to establish trust, I had to see patients.

And there was a lot of word of mouth, right. That went, that said, hey, this guy is sane and he'll give you good care and he'll have a good conversation with you as well and, and, and smile with you. So I, I did want to see my patients. You know what I mean?

Dr. Randy Lehman [00:26:57]: Yeah.

Dr. Quince Gibson [00:26:57]: I wanted to see them post-op. And then now that the, the, the reputation's established, then you can kind of say, okay, all right, now I can kind of hand this off. This is what I do for my patients. This is how I would like them to be treated. This is the standard, et cetera.

Dr. Randy Lehman [00:27:13]: Yeah. You've heard of the three A's of success in surgery? I don't know if it's just rural surgery. So the three A's are availability, affability, or likableness, and ability. And they're important in that order, which is sad. But basically, if you're just there, that's step one. That's like the most important thing. The next most important thing is, you know, likability, and finally the ability, which is, you know, of course, you wish it was you. You spend all this time. Yeah.

Dr. Quince Gibson [00:27:46]: What?

Dr. Randy Lehman [00:27:46]: I actually just went out to Phoenix this weekend, last weekend, and gave grand rounds on rural surgery at a surgery residency program in Phoenix where the program director helped train me at Mayo, basically. And then he came out there and said, you know, some of our residents are asking about this topic. And I'm like, well, I am the expert on that topic and not on many things, but so we had a great discussion.

And I told them that if you go ignore duty hours basically and don't think of work-life balance during the five-year period of time that is your residency, if you just kind of do what you got to do to get as good as you possibly can for surgery, all that comes back to you when you're out in practice because you're not having that complication, which would have consumed so much of your time. Your practice is so much more efficient.

You save so much time on every single case because you're quicker, you know, and more efficient. And that's your life lifelong. So that's like a little dump in training and then it'll, it'll come back to you in spades. So that's where like the ability thing, the patients don't know or, and, or care. I mean, I tell them I trained at Mayo Clinic that places people like that and they know that that's going to be a good training program. But do they really, really know? You know, all they have to go on is like their incision, you know, and like whether they had a complication and how they interact with you and, you know, unlike you.

But then for me, the ability helps me out with my success because I can do 10,000 instead of 5,000 RVUs because I'm, I'm not, you know, farting around, basically.

Dr. Quince Gibson [00:29:31]: Yes, absolutely.

Dr. Randy Lehman [00:29:32]: Let's go into the actual nuts and bolts of how you did a robotic ventral hernia.

Dr. Quince Gibson [00:29:40]: Yeah.

Dr. Randy Lehman [00:29:41]: So, first off, which hernia? Like when you had the robot, were you doing every single ventral hernia on the robot?

Dr. Quince Gibson [00:29:49]: Absolutely. So if it was a, if I suspected a small umbilical or something like that, I would not do that. I would do it open.

Dr. Randy Lehman [00:29:59]: How small is small?

Dr. Quince Gibson [00:30:00]: 2 centimeters or less.

Dr. Randy Lehman [00:30:02]: Okay, so less than 2 centimeters. You're doing an open repair primary. Are you still putting a piece of mesh there?

Dr. Quince Gibson [00:30:08]: I, I, it depends. If it's greater than 1cm to me, I put in a piece of mesh. If it's less than that, I just do primary interrupted PDS.

Dr. Randy Lehman [00:30:17]: So PDS.

Dr. Quince Gibson [00:30:19]: Yeah, actually I use two O, two O PDS. Yeah.

Dr. Randy Lehman [00:30:24]: And then you, if they're like one to two, then you're putting in a what, a Ventralex or something like that?

Dr. Quince Gibson [00:30:28]: Exactly. Yep. We just, we do that. But that, that was actually really rare. I would probably lean towards doing a lot of those robotically. Okay. You know, once it got in, in that, in that sort of size range. And the reason is that I really didn't know. So our, you know, in terms of BMI, Alabama is up there, as we said before, you know, Mississippi beats us, West Virginia beats us. But we're number three, right? And so, and so appreciating the size without a CT or even with a CT is a little bit difficult. So I, I would lean more to the robot. I've been surprised a little bit, you know, too often for me to, so I'd actually lean towards doing it robotically.

Dr. Randy Lehman [00:31:17]: Okay, what about in, first off, let me, boy, you're on BMI. Do you have a cutoff for who you won't give an operation to for ventral hernia?

Dr. Quince Gibson [00:31:25]: Yes. That question's a little complicated. I'm going to tell you why. A lot of my patients don't have the means to go somewhere to either lose the weight or they, they also, I am worried about people getting incarcerated. You know, so it's a BMI cutoff with size, if that makes sense. Right. Like, if I see something that looks like, do I want to be doing this emergently in this person with the 45 BMI at 2 in the morning by myself. Right. No. Let's see what we can do here. Now, I, I don't think I would do 45 BMI, but, but that's to be, you know, something that I would take sort of clinically hard cutoffs. I would say anything above, you know, 37 BMI. 37. I don't think I would do a 40 with that. I've told people greater than that to come back after losing some weight.

Dr. Randy Lehman [00:32:21]: But do you schedule them for an appointment back after they lose weight or do you just kind of say come back when you lose weight?

Dr. Quince Gibson [00:32:28]: Yeah, so I actually schedule them for an appointment. How far out? I do a year. And they get scheduled before they leave. But I also was doing bariatrics, and so I'd have that discussion with them as well. With doing bariatrics, I actually do a full visit with them on weight loss as well. Like, you know, what are some of the lifestyle modifications that you can make in order to lose weight? Are you on an exercise program? First off, do you want to lose weight? You know, that's, there are people here.

Dr. Randy Lehman [00:32:59]: Great question.

Dr. Quince Gibson [00:33:00]: Yeah. And so once they do, I got you. Once they do, then I talk to them about strategies. Well, are you on an exercise program? No. Well, that's like, hey, I want to get married, but I'm not dating. You know, you need to be on an exercise program. Right. And then what constitutes the type of diet? And so I give a full visit on that. I really believe in lifestyle modifications, lifestyle medicine. And then I have them come back in a year. Did you do what I said? If they need to meet with a nutritionist and we do have a dietitian, I do also try to arrange things like that.

Dr. Randy Lehman [00:33:39]: Okay, so did you do any additional training in bariatrics or you came out of general surgery residency doing that?

Dr. Quince Gibson [00:33:47]: I came out of general surgery residency doing that. Now, when I say bariatrics, I'm talking about sleeve gastrectomies. I don't do Roux-en-Ys.

Dr. Randy Lehman [00:33:54]: So then are you connected still with UAB? So then do you send those people that they say they have reflux or whatever, a good candidate for a sleeve?

Dr. Quince Gibson [00:34:03]: Did it. Just did it just this week. Yeah. So, yeah, I do send people and we do have a bariatrics team at UAB with a weight loss clinic. Now, the major issue was insurance. Right, like we had as a rural access hospital, we were trying to even do Medicaid patients with bariatrics. So we were doing some of those. Very difficult to get them. The hospital kind of took a loss on those. But we thought it was an important mission for, you know, what we were doing. And I thought it was an important mission as well. And so finding someone who would do that, give that surgery with that insurance was difficult. But thankfully, UAB has kind of changed that and they are actually doing some Medicaid patients now. So I do refer all them.

Dr. Randy Lehman [00:34:44]: Wow, that's great. Because I had Kabir Mehta on a couple episodes ago, and he's a bariatric surgeon, trained with me at Mayo, but then did an actual bariatric fellowship. But he's practicing in Hazard, Kentucky.

Dr. Quince Gibson [00:34:56]: Yeah.

Dr. Randy Lehman [00:34:56]: Which is like a small town. And so I asked him that question. I'm like, do you think that it's right for a general surgeon or, yeah, like a non-bariatric surgeon to do sleeve gastrectomy in a small town without also offering Roux-en-Y or other things like, you know, duodenal switch or SADI-S or whatever. Right. And he, he kind of gave me a, I mean, he, I think he gave me a clear no on that, which was, I could see both sides of it, you know, and I'm going to take his answer as validation for me to not to have to do it, but more power to you.

Dr. Quince Gibson [00:35:37]: Yeah, well, I'm not doing it anymore. Right. So for me, what I have is a referral base. So if I do get in trouble, I do have colleagues that I can say, hey, this person needs conversion. Right. And I have three colleagues that do bariatrics at UAB. So I, you know, and I can even get them to come down and help me if I needed to. Right. So those were some of the, you know, nuances. That's why I did it. But now that the robot's gone. Right. There's the other challenge of help. Right. And assistance while I'm doing that procedure. And so that's changed the calculus significantly.

Dr. Randy Lehman [00:36:12]: It's just like so many things like when you're a resident, you're trying, first off, you're trained on multiple choice answers. So there's a right or wrong answer and real life is just not like that. So any question, I mean, I can ask you this question. What's your BMI cutoff, you know, for ventral hernia? And it's not, there's not really an answer because who can, who can get CRNA anesthesia? You know, who can get anesthesia with a single, forget the CRNA piece. With a single provider in a critical access setting. Like, and what's right and wrong? And it becomes something sort of like the old way that we would do appendicitis, where you need to have a negative API rate of 20%. You know, where do you draw that, you know, line for like, how many bad outcomes can you allow? You know, if you were. And you could say zero. But then I'm living it and you're living it. We're out there in. And there's going to be a lot of people that are going to get no care rather than get, you know, what we kind of have to offer.

Dr. Quince Gibson [00:37:14]: Right, right.

Dr. Randy Lehman [00:37:15]: If you say that. So. Right, it's difficult. All right, so. But I digress. So say you got a patient, then that's the most typical one. Say it's a 4 centimeter reducible. So if it's incarcerated, you still go robotic, right?

Dr. Quince Gibson [00:37:30]: Absolutely.

Dr. Randy Lehman [00:37:31]: What if it's incarcerated with bowel in, it still go robotic?

Dr. Quince Gibson [00:37:34]: I still go robotic, yep. I could always. Okay. So you know, in a setting like that, even I've actually done robotic surgery for, you know, emergent, you know, just to kind of see and assess the bowel viability. We used to have ICG availability and use that to kind of help assess bowel viability if needed. I really like the robotic approach. It gives a good dissection, good visual, good visibility, and I've had very good success with it over the last four years. So that's, that's one of the things that I would kind of advocate for, for myself. You know, I just felt very comfortable doing it that way.

Dr. Randy Lehman [00:38:13]: So let's say it is a 4 centimeter reducible. How are you putting your ports? You take that patient, put them in general anesthesia. How do you tuck the arms?

Dr. Quince Gibson [00:38:21]: Yep. So I tuck the arms loosely on the left side, one arm out on the right. I like to give anesthesia an arm and I do it the same way every time. So you know, my staff knows we need to do it the same way. I veres in just always versed and not a cut down person. My colleague at Palmer's Point or where at Palmer's Point. And after veressing in and obtaining, you know, pneumoperitoneum, I actually put a 12 port on the patient's right flank, and I opt to view in with that. It saves me having to switch out ports and doing different cameras because the robotic camera can actually fit down a 12 port. So I would go in that way. And it's also easier to pass mesh and sutures through that port. So I do that and then on the, the patient's left side as low as possible in direct visualization, I'd put three ports, three robotic 8-millimeter ports. And I do upper flank, mid flank, lower flank.

Dr. Randy Lehman [00:39:28]: So your 12 that you put on the right flank, is that like straight out from the umbilicus or?

Dr. Quince Gibson [00:39:35]: Yeah, I put it straight out on the umbilicus. And then, you know, I kind of have a, the, the scary moment for that is like, am I going into the colon? Right. But I try to be as lateral as possible, depending on the size of the hernia. I kind of know, am I going to have enough overlap? Is this port going to be in the way of me putting the mesh? And, and I've, I've never generally had a problem with that.

Dr. Randy Lehman [00:39:56]: And I kind of really dumb this down.

Well, first off, just basically for myself, you know, my listener wants to know, which is basically me, exactly how you do this. So, it's been a while since I've done a varus at Palmer's Point. You make a tiny skin nick there, and then you bring your varus needle in with nothing on it. Or do you have a little bit of water sitting on it?

Dr. Quince Gibson [00:40:20]: Yeah, actually, I do it with nothing on it. So, I use an 11 blade, tiny neck. And then, I go through the skin, look for that second pop. After I've got that, I actually do aspirate to see if I'm in the bowel or not. If I'm not, I inject a little saline, look for my saline drop test, and then I attach my insufflation and watch my pressures. You know, I do have med students there, so we go over the PV = nRT, all that. But I watch that very closely to make sure that I'm in the right space.

After we've achieved new apparent name, I actually Optiview in. I do have colleagues, and sometimes I've done this. If I have a problem with the Palmer's Point, like I'm not getting the right insufflation or something's going on, I actually do Optiview in just with the 12 port. I've done that many times as well.

Dr. Randy Lehman [00:41:15]: That's in the right lateral abdomen. You opt in with. And that's obviously a radially dilating 12.

Dr. Quince Gibson [00:41:22]: Correct.

Dr. Randy Lehman [00:41:22]: Not the Hassan port.

Dr. Quince Gibson [00:41:24]: Correct.

Dr. Randy Lehman [00:41:25]: But it's big enough for you to bring needles in. And so, that's where your assistance bringing that in, your mesh obviously, is coming in through there.

Dr. Quince Gibson [00:41:31]: Right.

Dr. Randy Lehman [00:41:32]: And it's.

Dr. Quince Gibson [00:41:32]: What about a camera? Right. So, I get to see them as they're coming in. I think that's important because I've had some, you know, in residency, there was a patient I had where a blind sort of assistant created an iatrogenic bowel injury. I think that visualization while you're having an assistant, particularly in a rural setting, is really good practice. As you're watching those needles coming in and out, you want to minimize the number of passes, and you also want to be able to watch what's going on so that you can recognize. That's the number one complication—a missed hollow viscous injury. So, if I can watch for that, I think that we're.

Dr. Randy Lehman [00:42:13]: We're.

Dr. Quince Gibson [00:42:13]: We're heading in the right direction.

Dr. Randy Lehman [00:42:16]: So, regarding that port, do you close it at the end? I do the regularly dilating tool.

Dr. Quince Gibson [00:42:22]: Yes. I close it with a WECK device. I push it in, and I use the WECK also to help me with putting the mesh on. The WECK device, I don't know if you know, these little Carter-Thomason.

Dr. Randy Lehman [00:42:35]: Is a WECK similar? Yeah. Is it the same thing as a Carter-Thomason suture passer? You push up something, and it opens up?

Dr. Quince Gibson [00:42:42]: Yep, it opens up, grabs a suture, pulls it right through. And I do that under visualization as well.

Dr. Randy Lehman [00:42:47]: Yeah. Okay, great. And what suture do you use for that? Just curious.

Dr. Quince Gibson [00:42:54]: I use a Vicryl.

Dr. Randy Lehman [00:42:56]: Yeah.

Dr. Quince Gibson [00:42:56]: I usually get.

Dr. Randy Lehman [00:42:58]: But you're far enough lateral that you might. Are you lateral to the semilunar line?

Dr. Quince Gibson [00:43:02]: Yep. I mean, I do close it. I had one patient that was on steroids that came back with another hernia. At that point, he would get sarcoidosis.

Dr. Randy Lehman [00:43:13]: How do you deal with that?

Dr. Quince Gibson [00:43:14]: I actually did it primarily, but his tissue, okay, his tissue was paper thin from chronic steroid use. I mean, I literally flicked the port, and it went in. That was a learning experience for me. But I did get the opportunity to suture that one primarily, and I did that under visualization from a five port.

Dr. Randy Lehman [00:43:39]: Because you have three layers out there.

Dr. Quince Gibson [00:43:40]: Yeah.

Dr. Randy Lehman [00:43:41]: So, you're just closing all three layers en masse when you're doing that technique. And it's like Billy Joel says, you know, you can't dress trashy until you spend a lot of money. I trained at Mayo Clinic and did all this stuff, and now I've got the credibility to ask the stupid questions in a public format. So, that's what I'm doing here.

Dr. Quince Gibson [00:44:09]: Yeah.

Dr. Randy Lehman [00:44:10]: Great. So, you've got your ports in the setup you described. The last question I have is when you put that radially dilating port, after you have pneumoperitoneum, do you take the pneumoperitoneum all the way up to 15 before you put that 12 in?

Dr. Quince Gibson [00:44:28]: Yeah, well, not all the way up to 15. I just need to see air. So, when I'm going in and Optiviewing with that radially dilating port, I'm just looking for a little air. I don't need it to be at 15.

Dr. Randy Lehman [00:44:43]: So, you're always coming in optical?

Dr. Quince Gibson [00:44:47]: I'm always coming in optical as new apparent name is being achieved.

Dr. Randy Lehman [00:44:52]: Got it. Okay. And then, do you have the patient rolled a little bit to the left, or do you have them straight supine when you're putting that port in?

Dr. Quince Gibson [00:45:00]: I do have them supine while I'm putting it in. There's a little bit of a break in the bed, so I have them kind of extended, if you will. I do it about 10 degrees, so we open up that space between the costal margin and the iliac crest.

Dr. Randy Lehman [00:45:17]: Asis.

Dr. Quince Gibson [00:45:17]: Yeah, and that allows me to get my ports in and gets the patient in a position to help me get the best visualization.

Dr. Randy Lehman [00:45:25]: Okay. So, you're sitting like that. Your camera is in your middle port, you've got your assistant port across the way, you've got your two instruments. What instruments do you put in your right and left hand?

Dr. Quince Gibson [00:45:36]: Yeah. So, monopolar scissors in the right. And then, I have a Cartier or tip-up in the left. If there's bowel involved, I like to use a tip-up.

Dr. Randy Lehman [00:45:46]: Let's make it easy because I'm going to blow my time here if I don't. So, let's say there's nothing in the hernia, just a sack going into it, and it's 4 cm. Where do you start?

Dr. Quince Gibson [00:45:56]: So, I start with dissecting the hernia sac circumferentially around the hernia. I don't try to get the whole sac dissected. Sometimes I'll take it down depending on how easy it is. But I just want to free up some edge so that when I start sewing, I make sure that the falciform is out of the way, so it can lay properly. Sometimes there are some high hernias that are closer to the xiphoid. After I do that, I start sewing. I use a MegaCut suture driver, needle driver to do that. I like the zero V-lock sutures, absorbable zero V-lock sutures, and I close a defect primarily before I put a mesh down. I'll use one to two of those.

Speaker A: Those are expensive sutures, I think, you know, 90 bucks each, if I remember correctly. But I close those. And when I have good closure, then I start thinking about putting in the mesh.

Now, before I put the mesh in, I always have a finder needle to get me right in the middle of the defect, right? So, I have the assistant put a finder needle, a 22-gauge or something like that, a spinal needle, it doesn't matter, so I can see, hey, yeah, that's the spot. I want you to insert the with the suture passer. Once they've done that, then we put in a Bard Echo 2 mesh with the Echo 2 positioning. I like that. It's so easy to get that mesh put in place. They grab the suture.

Dr. Randy Lehman [00:47:30]: So, it's got ST barrier on it then.

Dr. Quince Gibson [00:47:33]: Yes, it does.

Dr. Randy Lehman [00:47:34]: And ventral, ventral light ST.

Dr. Quince Gibson [00:47:37]: Yes. Yeah. Correct.

Dr. Randy Lehman [00:47:38]: So, straight polypropylene on one side and separate technology on the other side.

Dr. Quince Gibson [00:47:42]: Correct, correct. And I like that because of the positioning, actually. And so, once they put the positioning and it's up against the abdominal wall, I make sure we've got good coverage. Of course, I've already given my dimen to, you know, to my circulating nurse so that I can dictate that I like to have 5 centimeter overlap as much as possible. Usually, I'm using an 11 or, you know, the 11 round for smaller defects and, or there's bigger ones, like the 15 by 20s. Doesn't really matter.

Then I suture in place. I use a 4.0 V-Loc to do that. It's easy and fast. We've run out of 4-0 V-Locs before, and I've used a 4.0 Vicryl, and that worked fine as well. And I suture that circumferentially, making sure that, you know, we have good overlap. Take one final look, get all the needles out, take the positioning system out. That's important. And once that's out and everything's cut, we desufflate. Well, we don't desufflate. We close that 12 port, and then we desufflate and get the rest of the ports out. Yeah.

Dr. Randy Lehman [00:48:50]: What kind of shoes do you wear while you're doing this, or do you do it barefoot?

Dr. Quince Gibson [00:48:54]: I use Cal Zeros. Cal Zeros.

Dr. Randy Lehman [00:48:56]: Okay.

Dr. Quince Gibson [00:48:56]: Very good.

Dr. Randy Lehman [00:48:57]: What color?

Dr. Quince Gibson [00:48:58]: They're black. Yeah.

Dr. Randy Lehman [00:49:00]: Okay.

Dr. Quince Gibson [00:49:01]: It hides the blood.

Dr. Randy Lehman [00:49:03]: Yeah.

Dr. Quince Gibson [00:49:03]: A little bit better. But I'm using. I've got some Air Jordans that I use in clinic, so.

Dr. Randy Lehman [00:49:09]: Yeah. Nice. Great.

Dr. Quince Gibson [00:49:10]: Sweet kicks. Yeah.

Dr. Randy Lehman [00:49:12]: Okay. That's good. Is there anything else that we're missing about that? I mean, there's you. We could talk, like, for literally three hours, and I can ask you all the questions.

Dr. Quince Gibson [00:49:20]: But, you know, the only other thing is I think a lot of the work's done before the OR. Right. It's patient selection. Right. And that's, to me, more art than science. Just from what I've been going through in my, you know, patient demographics, I just know there's some patients that feel, using the science evidence, I can then make decisions about people who are, you know, on the borderline and so forth. And I think that doing that workup ahead of time is good. I like to get a CT on everybody. You know, I just think it's good. We've caught a lot of other things on a CT, and there is prevalent. There's a tendency for some people not to go to the doctor for a lot of things.

So, you know, we catch, you know, renal masses, we catch adrenal masses. We catch all sorts of different things sometimes. And we catch an inguinal, you know, a very large one. So, and so I like to do that as well. And those are probably the only other things I would mention.

Dr. Randy Lehman [00:50:21]: Do you make sure the patient's up to date on their screening colonoscopy before you do a ventral hernia repair?

Dr. Quince Gibson [00:50:28]: I do not. That is a good idea. But I don't usually. If they're coming for ventral hernia, they're usually up to date on that. And I do have a custom questionnaire that I do give to all my patients, actually review systems that I dictate in so that they check off everything. Thoughts of suicide, you know, family history of colon cancer, and all sorts of other questions that I really do. Because one of the things about rural surgery that I think we need to keep in mind is that sometimes we're actually the primary care physician, you know, and that's just more of a reality in rural settings than it is in urban settings. Right.

Dr. Randy Lehman [00:51:08]: And that's where I just try to do the things for myself. The way I've kind of approached that is if it's something that I'm offering, like a screening colonoscopy, it's just kind of poor form. If I have just fixed a ventral hernia, and then all of a sudden I have to cut straight through that mesh to do a colectomy. You know, it was something simple that we can do. Now, I've had. I might have had one patient or two patients maybe to, like, just say, I just can't get my mind around it. I refuse. And of course, you got Cologuard as an option, so I've gotten people to do that. I don't, like, spend my whole life doing. You know, it's just. You got the patient, and it's part of maybe your bias of I could just see this happening, you know, and so that's one thing that I've kind of specifically tried to ask them about.

Dr. Quince Gibson [00:52:00]: But. Yeah. And.

Dr. Randy Lehman [00:52:01]: All right. Yep, go ahead.

Dr. Quince Gibson [00:52:04]: Yeah, I was just gonna say. And then you have the patients who have, you know, oh, yeah, by the way, I'm also having right upper quadrant pain. Right. So, what do I do in that scenario? So, we try to offer and do things sequentially and also take into consideration what the patient can tolerate and what they want to tolerate.

Dr. Randy Lehman [00:52:20]: You know, so say they said that. And then you got an ultrasound. They have gallstones.

Dr. Quince Gibson [00:52:26]: Yeah.

Dr. Randy Lehman [00:52:26]: Then do you ever fix a hernia and do the gallbladder at the same time?

Dr. Quince Gibson [00:52:30]: I try not to do that. You know, I don't like some of the gallbladders in Alabama, and I hear everybody talking about Irish gallbladders, you know, but sometimes we've gotten into some, you know, pretty dicey situations, and I don't like doing that. So, I've had them either fix one first, wait a few, and then get the other, depending on if they're symptomatic. I think the gallbladder is priority.

Dr. Randy Lehman [00:52:53]: Yeah, I agree. That's exactly what I'm not. There's actually, I don't think necessarily a right or wrong. So just because I agree doesn't mean that we're. Um, but that is exactly what I do, too. Well, I mean, it is what it is, but how long. Just curious. How long do you wait between, if you, if they did want them both fixed, what would be the minimum amount of time between the two cases that you would wait to fix hernia?

Dr. Quince Gibson [00:53:15]: Oh, I don't think we have to wait to do the six weeks or anything like that. I think, you know, four weeks, three weeks. I would. I don't have to wait for an anastomosis to heal. I don't have to wait for any of that. So I usually.

Dr. Randy Lehman [00:53:31]: I know, like, historically with open surgery, you have this period of time where your bowel is just completely gelatinized and very fraught with danger. Yeah, that I have until from two to two to six weeks. Right. But laparoscopic surgery isn't necessarily the same. You could come back in four weeks later and there's nothing there. But I, I've always told them six weeks anyway, because by the time you get it scheduled and everything. But yeah, I was just curious.

Perfect. Let's move on to the next segment of our show that's called the Financial Corner. Do you have a financial tip you'd like to share with our listener?

Dr. Quince Gibson [00:54:02]: Yeah. Get rid of debt like the plague. That's one thing that I would highly recommend. You know, I've listened to Ramsey, I've listened to Pill Method, and I've listened to a bunch of other podcasts. I also have an MBA. Right. So that doesn't, by the way, make you any more financially savvy than other people. But debt, I think, is probably the biggest issue that's stopping us from being financially free. Getting rid of debt, I think, is really important.

Also, interest management. Managing the interest on things is really good. If you do take out any loans, which I don't advise, paying for things in cash is preferable. Then, watching the interest and managing that very well is good. The last thing I would say is to stay within your means. A lot of people have big eyes, you know, as we say in Jamaica. You have big eyes, meaning you want something you can't afford, so don't get it. That's how you know if—

Dr. Randy Lehman [00:55:23]: You can afford something?

Dr. Quince Gibson [00:55:25]: If you can afford something, for me, I look at how many debts I have. If I'm paying for something, and if I have debts, I really can't afford to get something that's a luxury. So I think it really depends on personal spending. The other thing is if you need to get some sort of loan for something, think long and hard about whether you actually need it. Can you save up for it? For me, I don't buy new cars. It's just not worth it because I like to buy them with cash. I try not to get loans for things that aren't essential for me. I have a mortgage, some student loan debt, and that's about it. I plan to put my daughter through college and that's it.

Dr. Randy Lehman [00:56:39]: Yeah, there's a spectrum of what you just described. People will argue and push back, saying they need the car. But I would push back even further on the house. I would say there is a house you could pay cash for right now, 1000%. And why don't you just sell your house, get rid of all that debt, and buy that house that you can pay cash for? Because that's the house you can afford, right? Otherwise, maybe you should be renting and having no debt.

Dr. Quince Gibson [00:57:20]: Right.

Dr. Randy Lehman [00:57:21]: That's devil's advocate, right? Easy for me to say.

Dr. Quince Gibson [00:57:26]: What you actually said, there's a guy, G. Ed Reid, that I did a seminar with once, who talks about the benefit of doing something like that. If you get this house you can afford, and you pay cash, he actually advocated a seven-year mortgage. You stay there, save all those payments you would have made on the other house, and then you upgrade. If you look at how much equity you develop by upgrading versus paying long-term debt, you pay it off faster and end up in a better house much sooner. So I agree 100%.

Dr. Randy Lehman [00:58:15]: If that's your goal, I guess. The other thing is like Dave Ramsey said, I consumed a lot of Dave Ramsey when I was a resident, laying the foundation for my future. The big problem with a bigger house is the expenses that come with it. Okay, you can afford the mortgage. Right. That's why I asked, how do you know if you can afford something? Your answer was you can afford it if you can pay cash for it, except for a house. That's why it's personal. I don't think there's a right or wrong answer.

It's good advice to define those things for yourself. Like, what airplane can I afford? How do I know I can afford an airplane? If it's 4% or less of my net worth and I'm paying cash, I can afford it. That was my guideline until my eyes were too big, and I broke my own rules. There's another phrase: know the rules, follow the rules, break the rules. It's applicable across many disciplines or whatever, including personal finance and parenting—knowing when it's right to break the rule.

Dr. Quince Gibson [00:59:52]: Yeah.

Dr. Randy Lehman [00:59:53]: Those are musings of a rural surgeon on a Sunday afternoon. Anything else to add to that or shall we move on?

Dr. Quince Gibson [01:00:04]: No, I think I like your philosophy. What you stated is more eloquent than I did. You can afford it once you've set your boundaries, and you can meet whatever boundaries you've set. So I like that.

Dr. Randy Lehman [01:00:23]: Right. The next segment of our show is called Classic Rural Surgery Stories. These are stories your urban counterpart wouldn't believe. Do you have anything like that that's happened in the last four years for you?

Dr. Quince Gibson [01:00:32]: Yeah, I do. I did a grand rounds at UAB and started with this vignette. I think I have a presentation.

Dr. Randy Lehman [01:00:41]: Here, but this is a good time to let the listener know that all of these episodes are on YouTube. TheRuralAmericanSurgeon.com actually has transcripts of all our episodes and links to various places so you can find the video if you want on YouTube. If it doesn't come through and you want to see the pictures.

Dr. Quince Gibson [01:01:04]: Okay. A 59-year-old gentleman comes in, unable to pass solid stool for the last seven days. Nothing's working. We got a CT showing a transition point at the proximal transverse colon. Heavy drinker, lactic is two, and we see a little bit of pneumatosis. I take him to the operating room for a large bowel obstruction. We perform an extended right hemicolectomy, and the final pathology shows stage three colon cancer.

Dr. Quince Gibson [01:01:35]: Post-op day two, he gets diaphoretic, agitated, altered. He was a heavy drinker. I'm thinking DTs, but vitals start getting out of whack. We get a CT, and he seems to have some post-op bleeding. On the CT, we see a little free fluid around the liver. I'm really concerned.

We do a hemoglobin on him, and it's like five. So I need to take him back to the OR, but there's no OR call for the next 14 hours. All the surgical hospitals are on diversion, and we're running out of blood in the hospital. We're like on our last for him. So I'm at home, come in, we see the guy.

Dr. Quince Gibson [01:02:36]: I'm calling everybody I can, and everybody's on diversion. Can't get him in. What do I do? Wait 14 hours until we get staff, ask my ED doctor to run an anesthesia machine for me, or what? Right. So I literally had to transfuse this guy with crystalloid and product until we were able to get to the operating room because the earliest bed that was available was not going to be there on time. Also, taking into consideration the travel time. And so that story is how I started grand rounds. Then I said, welcome, welcome to rural Alabama.

So, you know, that story kind of highlights some of the challenges that we face. Right. Like it's resource management, it is how to take care of patients not in a setting where you have a urologist available if you make a bladder injury, you know, an ICU, you know, staffed by anesthesia and critical care doctors, interventional radiology to help you with, you know, abscesses and, and all sorts of other things. It's like, how do I plan to say to help these people when I don't have that safety net that you trained with in residency? Right.

The thinking that I had in residency being trained in an academic center was like, hey, oh, the answer is to get this person. The answer is to get that person. The answer is to get this test and that test. Well, there's none of that now. What. And I got a lot of feedback after that presentation on wow; I now kind of see what's happening with you.

I've had a lot of tough decisions. That patient represents a tough decision. I actually had to go to the operating room. He did fine. We transfused him very, you know, we had to watch him really closely that night, but that I lost some years on my life with that one. Got a couple of extra gray hairs in my beard here because of that. But those are some of the challenges in rural surgery. A lot of people came to me and said, man, I see now, I see what you go through. And that's just the tip of the iceberg.

Dr. Randy Lehman [01:04:54]: So the reason you didn't have call was because you didn't have anesthesia.

Dr. Quince Gibson [01:04:58]: Correct. So we don't have call. And so when we don't have anesthesia, we actually don't have a call team.

Dr. Randy Lehman [01:05:04]: Right, so you only have that during business hours or when do you have anesthesia? Right now that.

Dr. Quince Gibson [01:05:09]: So we are having a challenge with that right now because we're having trouble staffing CRNAs at our hospital. So there actually is no call for the next month.

Dr. Randy Lehman [01:05:23]: So.

Dr. Quince Gibson [01:05:23]: But overnight, every two, every other week.

Dr. Randy Lehman [01:05:26]: Every other week, you have 24 hours. You have 24 hour. And there's a, there's a, every other week you have 24-hour call for what period of time? Or is it a CRNA comes in.

Dr. Quince Gibson [01:05:38]: For one week. So for one week straight, we have 24-hour call for that.

Dr. Randy Lehman [01:05:45]: Got it. And so basically then you're doing your bigger cases on like the earlier part of that call week so that you could take them back if you needed to. So what are you doing for the next month? Are you going to not do anything? Not doing any colons?

Dr. Quince Gibson [01:05:58]: I have one on Tuesday, so. But it's still May, still me. So we're gonna go ahead and do that one. Then I actually have to rearrange my schedule. I just found out on a Friday about that. So I have to rearrange my schedule. I gotta look seriously at the patients that I have scheduled for the next month and see if those are patients I really want to do here. The other thing I need to do is to just give a heads-up to my colleagues at UAB so that they can kind of remember that, hey, I'm here. Just please, if I call you, I need you.

Dr. Randy Lehman [01:06:32]: Because, you know, there's this concept of itinerant surgery, you know, that you. None of us want to be. And you're balancing this resource management. So for me, I'm now in four different hospitals actually, all critical access kind of centered around my house. Three of them don't have call ever. But then in the other, one said, I said, look, you know, some colon cancers and hiatal hernias were coming into the clinic. And I'm like, I'll do them. But we, I'm admitting them. So I'm admitting them for a reason. I've never actually had to go back in the middle of the night with that case you're talking about with like a bleeding from the right colic artery or something like that over five years, but I guarantee you that sometime in my career, it's going to happen.

Dr. Quince Gibson [01:07:24]: Oh yeah.

Dr. Randy Lehman [01:07:24]: And so I don't think it's right if I'm admitting them to the hospital for me not to be able to take them back in the middle of the night, so they set up. But, but, but at the same time, like 100 days later, I don't need to have a call team. There's somewhere between that night and 100 days later, there's a number. I talked to different people. One surgeon at the North American Rural Surgical Society told me he thinks it's based off the global period. You need to be in town and available with a full team for 90 days for a 90-day global thing. I do not agree with that. Strongly do not agree with that. But I told them, right, you would never ever do any surgery, and then they would all have to travel, and a lot of it wouldn't get done in the first place.

Dr. Quince Gibson [01:08:15]: So.

Dr. Randy Lehman [01:08:15]: You're not a bad surgeon for not doing it. But you have to figure out this is kind of like a personal finance thing. You have to figure out for you and your patients what you're okay with. So I ended up telling that hospital we agreed for 24 hours they have a nurse, a tech, and anesthesia that they're paying to be on call for those cases. So far, every single one of them there has gone home on Post OP Day 1. All those colons and the hiatal hernias that I did, I think there's a total of like 10 over maybe 10 months or so. So those, they're going well if I have to keep them another day or two. The other thing is I know some of the CRNAs around, and there's an element of like, you know, you're presenting this patient. I'm like, can I call that person that's supposed to be there in 14 hours, and could they come early for me? Could I call some people from home and kind of get to the OR a little earlier just given the situation? Yeah, that's real life.

Dr. Quince Gibson [01:09:12]: Yeah, absolutely. I have great relationships with the CRNAs. The issue is that some of them are in other hospitals and taking calls at other places, you know, so. But it's not just that. It's also the call team. Right. I need a scrub tech, and I need a circulating nurse. Those things are kind of important as well. Now, just as an aside, how are you doing your hiatal hernias? Are you doing those robotically or laparoscopically?

Dr. Randy Lehman [01:09:38]: Yeah.

Dr. Quince Gibson [01:09:38]: Wow.

Dr. Randy Lehman [01:09:38]: I don't have a robot anywhere. Yeah, I just do them lap with endo stitch, and basically, I drop a. Usually, I use a 50 French bougie. I do two; I don't do. I did one Nissen only, but I don't think I would do any more Nissens just because of gas bloat.

Speaker B: And I think the anti-reflux component of a Toupet is just as good as a Nissen, but without as much gas bloat. So I do a lot of Toupets, and then for the larger hiatal hernias, well, if I'm just doing it for reflux and there's no hiatal hernia, then I do a manometry and a PH test beforehand. But if it's just like a larger, like a type 3 paraesophageal hernia, I just assume that their esophagus doesn't work. And I usually do an anterior Dor, like a three-stitch Dor fundoplication.

Speaker A: Gotcha.

Speaker B: That's gone pretty well for me. And then sometimes if they have a really foreshortened esophagus, I do a Collis, and I just do that down with, you know, with the little stapler, purple load stapler, yeah, onto the 50 French bougie, and gotcha.

Speaker A: The reason I asked you is that, you know, I was doing those robotically. Right. And for me, assistance—I've been a robotic surgeon, I guess, for the last four years. And so now I'm transitioning back to being laparoscopic. Right. Where I was doing everything robotically. And so one of the things that I was contemplating was whether or not I was going to actually have to get an assistant, you know, to kind of help me. And what are you doing in terms of assistance? Is it just you with the tech, or do you have somebody?

Speaker B: Yeah, I started at one place.

Speaker A: Welcome to my podcast, by the way.

Speaker B: Thank you. Hey, great question.

Speaker A: All the questions. Sorry about that.

Speaker B: I started at one critical access hospital where there were actually two other surgeons, and part of the reason I took that job is because there were other surgeons there. Turns out there's an—I don't—I may not have needed them. Well, one of my mentors, I talked to him shortly after I started there about some things, and he, exactly—his exact words were, with your training, you actually don't need them as much as you think that you need them. And that, to a certain degree, it was kind of true. But especially for the hiatal hernias, my senior partner, Dr. Hsu, did scrub probably my first six with me, and it was very helpful. He's so good to operate with because he never tells me what to do, but he just, like, it's an unspoken language between surgeons where it's like, oh, he just points something out, but you know what he's saying? He's saying, do this, and it's like, yes, okay, thank you. Then we keep talking about, like, what our favorite food is and everything. Yeah. Then I started doing a few on my own. It just happened because he was out of town and, you know, timing and everything on little ones. But then I would have him do the bigger ones with me still for a while. And now I haven't had him do them with me maybe for a year or so. And so it's not as easy with the techs. But, you know, the nice part about it is, it's good and bad. You get a tech, and you can't change them, and they're, you know, 65 years old, and the camera's wandering and everything, but you just have to. Most of the techs I work with are very good. And I mean, all of them are very good, actually, but they have different levels of skill and things that they're specifically good at. Like, one tech that's really interested in varicose veins, and she goes above and beyond, and if I need wires and stuff, she's doing fancy next-level. Really, really enjoying that for some reason.

Speaker A: Yeah.

Speaker B: Other people enjoy, like, laparoscopic, you know, but basically, I have the assistant port, and I stand between the patient's legs. And then a camera operator stands off to the patient's right. And then I have my assistant on the patient's left. And then actually, they're usually operating the camera and assisting, but then they'll trade off when they are really involved with assisting. And so that means, like, mainly holding up the momentum and holding it out for me, as I'm taking the short gastrics. That's one big thing. And then I just usually grab the instrument, stick it where I want, like if I'm trying to retract the stomach out, and then I do my dissection or I'm doing my stitching at the hiatus. It's more or less just like I put them where I want them to stay. Stay here. And then I train them because I use the ligasure. Okay. So as I'm taking the shorties, I'll like, grab the stomach, take my bite, and I'll say, now, you know, go. So while I'm sealing, they're grabbing up higher to retract a little bit. And some of them can get in, some of them can't. And if they can't, it takes me basically an extra probably 10 minutes, 150 seconds, you know, to do it for them.

Speaker A: Yeah.

Speaker B: And you just try not to lose your mind because mostly things are so efficient for me, actually, because I don't have to walk so far from the pre-op to the surgery area. And everything's right there in that tiny little hospital. Yeah. Basically, these hospitals are like a surgery center with a hospital attached to them.

Speaker A: Yep.

Speaker B: Absolutely. And so there's other ways that I'm making up for not necessarily always having the same team at every place because each hospital has its own, you know, where I really can still crank it out and get home in a decent time.

Speaker A: Yeah.

Speaker B: So I'm happy.

Speaker A: Well, that's fantastic. I mean, I think you've got a really good setup. The reason I ask is because, you know, that's one of my major concerns is assistance. Right now that the robot's gone, I control that assistant arm, I control the camera. Right. And now I have to relinquish that control.

Speaker B: Right.

Speaker A: And I've got to work on my laparoscopy skills. I'm just being, you know, because I've been a robotic surgeon for some time, so it's the amount of procedures and things that I'm doing. I have to think about that. But I appreciate your take on that.

Speaker B: Yeah. So my point of this podcast is just to essentially create my own echo chamber and talk to myself about the things I want to talk about. Alright. But I have considered like I have a plane, and in your situation, you should just get some good laparoscopic UAB surgeons that were good at laparoscopy before the robot came out and have a good relationship with them and bring them out, and then they proctor you and walk you through a number until you feel comfortable. But, you know, if there was a rural surgeon somewhere that I could get to with my plane and they wanted to line up a few cases and have an assistant come in and set it up through their hospital to somehow reimburse and pay for, like, me to come in for a couple of days and help them out, even doing check-off things, I would be interested and willing to do that. That would be an awesome—I think it would be fun for me and it would be a nice give-back to rural America on the whole, you know. So, yeah, that's not for you necessarily here, maybe for the audience.

Speaker A: No, no, no. I'm thinking for me, so yeah, but there are. That's actually a fantastic idea. And I think that that's one of the things—coming out of training, we didn't really talk about this, but coming out of training, you and I came out around the same time. And having—it's so valuable to have individuals who can proctor you and help you during those first months, you know, to a year. It.

Dr. Quince Gibson [01:17:19]: I just can't speak about just how valuable that was, and that's something I never really appreciated until now.

Dr. Randy Lehman [01:17:19]: Yep. Perfect. The last segment of the show is resources for the busy rural surgeon. Do you have one great resource you love that every rural surgeon should know about?

Dr. Quince Gibson [01:17:28]: Yeah. And it's not—it has nothing to do with surgery. My resource is a book or books. I really like to read. One book, the Holy Bible, that is number one.

But this one is—I think that's useful for everybody, not just surgeons. But I would suggest there's a book that I really like called "Atomic Habits" by James Clear. Yeah, probably a lot of people have read that book.

But I just can't say how much I appreciate just the change in my sort of paradigm about how to utilize my day. I like that book. I also like "The Talent Code." I can't remember who the author is for "The Talent Code," but I like music, and just increasing my skills with music was one reason I got the book.

But surgery is a skill. Taking care of patients is a skill. And so these are talents that we have. And I think that just being able to utilize and perform at a high level is super important.

Dr. Randy Lehman [01:18:31]: Yeah, perfect. I appreciate those book references. I actually did want to say I sent a few questions out to all the guests beforehand, and one of the questions is, who are some of the biggest influences in your life and why? And you said, you know, your preceptors and mentors that you've had. And then you also said the historical Jesus. So what is the difference between the historical Jesus and just Jesus?

Dr. Quince Gibson [01:18:57]: There is no difference. But the reason I say that is that, you know, a lot of people don't think that this guy is a—this didn't exist, right? Like, he did. I believe he did. You know, there's plenty.

Dr. Randy Lehman [01:19:12]: Oh, I mean, time itself reset.

Dr. Quince Gibson [01:19:15]: Absolutely, it did.

Dr. Randy Lehman [01:19:16]: And there's a lot of accounts about...

Dr. Quince Gibson [01:19:19]: Yes, yeah. Very reliable ones. And in terms of the reliability of the, you know, Judeo-Christian Bible and all that, I really think—I put "the historical" there because there may be people who say, well, you believe in this. You know, you're claiming as an influence this person that didn't really exist. But no, no, that's the one.

Dr. Randy Lehman [01:19:46]: Not Bible stories or Bible accounts. And then it's, well, you know, you got 12 people walking around plus lots of other ones that went to the death. Nobody, nobody said that was their firsthand account.

Dr. Quince Gibson [01:20:01]: Yeah.

Dr. Randy Lehman [01:20:02]: Said it didn't actually happen.

Dr. Quince Gibson [01:20:03]: Right, right.

Dr. Randy Lehman [01:20:05]: So that changes everything.

Dr. Quince Gibson [01:20:06]: Absolutely, yeah.

Dr. Randy Lehman [01:20:08]: And very interesting.

Dr. Quince Gibson [01:20:09]: Yeah. And there's also, you know, there are a bunch of other books that I've read in terms of apologetics and things like that, and that's one of the reasons that I read a lot of, you know, Ravi Zacharias, and Subab Pandit, who's an MD. He's pretty good, too. I've read "The Case for Jesus," and the author is escaping my memory right now. But just a lot of that stuff. I really think there's a historical case.

And one of the reasons I did say that is because I think that even the teachings there, you know, I got a shirt that says, "Do justice, love mercy." And I really think that in terms of the compassionate care that we have, I think that he epitomized that. And so I incorporate that into my practice, and I take it very, very seriously in terms of the way that I approach patients and patient care.

Dr. Randy Lehman [01:20:56]: Yeah, I love it and really appreciate your perspective on that. It has been my honor having you on for this episode of The Rural American Surgeon. Thank you for joining us.

Dr. Quince Gibson [01:21:07]: The honor has been all mine. Thank you so much, and I enjoyed this chat.

Dr. Randy Lehman [01:21:10]: And thanks to the listener for being here with us for this episode of The Rural American Surgeon. Don't forget to follow us on Facebook, give us likes on all the platforms, tell all your friends, family, and your dog and cat about us, and we will see you on the next episode of The Rural American Surgeon.