EPISODE 46
Money Miniseries 5: Efficiency
Episode Transcript
Dr. Randy Lehman [00:00:00]: Welcome back to The Rural American Surgeon. I'm your host, Dr. Randy Lehman. And yes, I recognize the irony of producing an episode on the concept of efficiency when I have just missed two weeks in a row— not just one, but two weeks of producing an episode for you. That being said, let's stop and celebrate one year of The Rural American Surgeon.
Dr. Randy Lehman [00:00:35]: The first episode came out 9/11/23 and this episode, if I can get it out on time, should come out on 9/18/24. I think I've missed maybe four total weeks in a year. And a weekly podcast, I will tell you, is not for the faint of heart. It does require a fair amount of focus and efficiency to get it done, if you will. So I would like to first thank my podcast producers.
Dr. Randy Lehman [00:01:06]: That would be On Air Brands, and Eric Cabral and his assistant, Kaylee Green. There's no way I could have done this without you. You guys don't see what goes on behind the scenes for The Rural American Surgeon. Basically, I use software to record, and then the editing and the producing, the Facebook, the shorts, the reels, posting to YouTube, and maintaining the website, which includes full-length transcriptions of all the episodes and is searchable. I would not have the time to do that.
Dr. Randy Lehman [00:01:36]: So step one with efficiency is really talking about something like that. Thank you so much to On Air Brands for what you do. If anybody's considering a podcast, I couldn't recommend them more. They are wonderful people to work with, very good at what they do, and very reasonable. So, let's use that as an illustration for the first concept of efficiency.
Dr. Randy Lehman [00:02:07]: I would say efficiency is something that I am very good at. I'm so good at efficiency that I now waste a lot of time because I've gotten my hours of my day so efficient. But I've always wondered if there's mental clarity that comes from wasting time. There are a lot of ways to waste time. Let's not talk about how I waste time; let's talk about how I'm efficient. You can maybe apply some of those things to your life.
Dr. Randy Lehman [00:02:37]: One of the other highly efficient people of our time, I would say, would be Elon Musk. It's a little different than what he does versus what a general surgeon does in rural America because the rural surgeon still has to actually crank out the work. But I just want to use one quote, basically. The quote is: I think it's the most common or maybe the biggest mistake of a smart engineer is optimizing something which should not exist.
Dr. Randy Lehman [00:03:08]: That is the best way to be efficient—don't do something unnecessary. A lot of people are very busy, running around trying to quickly and efficiently do things they shouldn't be doing at all. The best way to be efficient is just don't do it. You can think about that concept and apply it to your life in many different ways. I would leave it up to you how you want to apply it.
Dr. Randy Lehman [00:03:39]: I have some examples of how to apply things in my life, both personally, professionally, and in surgery. If something's important, you must do it. But to be really efficient, you must identify important things. In surgery, there are certain important steps that must not be left out and must be done well. Another way to be efficient as a surgeon is to do those things well so you don't have complications and don't have to come back.
Dr. Randy Lehman [00:04:10]: Because the least efficient way to manage your practice is to be cleaning up messes and putting out fires all the time. There's no such thing as complication-free surgery. The only way to not have any complications is to not do any surgery. But basically, if you can focus, if, when you're a resident, you can do more cases, be a generally busier surgeon, and focus on the right things, you can minimize your complication rate as much as possible.
Dr. Randy Lehman [00:04:41]: Let me give you one example. Let's talk about laparoscopic cholecystectomy. When you're making incisions for laparoscopic sites: the idea of making one incision, placing one port site; making the second incision, placing the second port site; making the third incision, placing the third port. You can look and know where your ports are going to go: 1, 2, 3, make the incisions with the scalpel, 1, 2, 3, put the ports in, and you're off to the races.
Dr. Randy Lehman [00:05:12]: Another example with laparoscopic cholecystectomy is my favorite instrument, the suction irrigator that contains the hook cautery inside of it. Pulling an instrument out and putting a new instrument in takes time and is very inefficient. Using that instrument, pulling the sleeve back, the hook cautery is exposed, and then you push the sleeve back out, returning to suction. Ensure you're not pushing it into the port, which could inadvertently expose the hook cautery.
Dr. Randy Lehman [00:06:13]: I do my entire lap cholecystectomy with that instrument. It's in and out with the hook cautery and the suction. I do more dissection with the suction irrigator than with the cautery. It's really like, we had a concept: little paddle, little buzz that would be like an open Bovie technique. I do it that way, but the little paddle is with the suction. The nice thing about the suction is you can hit the suction while cauterizing, sucking up smoke at the same time.
Dr. Randy Lehman [00:06:43]: Not being able to see is another inefficient thing. If you're having issues seeing, make sure your laparoscopic equipment doesn’t need polishing. Another quote on efficiency is from Abraham Lincoln, "If I had 10 hours to cut down a tree, I'd spend the first eight sharpening my axe." You cannot spend all your time sharpening the saw without actually chopping, but work on the system and flow of what you do. More than just chopping with a dull axe, you'll get more done when your axe is sharp.
Dr. Randy Lehman [00:07:44]: When you're a resident, focus on little tips and tricks, write them down, and tell me what they are if you can, because I'm always looking for such things. No wasted steps. Don't repeat unnecessary actions, like with clipping the cyst back to the gallbladder, or clipping the cystic duct and cystic artery when it's time. After your cholangiogram, when everything looks good, I've got my Maryland ready, I bring it in, and I take my clip off that held my cholangiocatheter in place, and then I just take it out.
I usually take my Maryland, set it on the skin right where the angiocath is, where my cholangiocatheter went through in the right upper quadrant. I squeeze it with my Maryland, pick the whole thing up, pull the whole catheter out all at once with the angiocath, and hand the Maryland back. I don't need that for the rest of the case. Then, I usually have my clip applier sitting right there. I reach back over and pick up my clip applier, and I'm coming in. My duct and my artery are already dissected, my critical view is already there. I bring it right in, and I clip right below where the cholangiocatheter was in.
Clip, clip to my artery. Clip, clip, clip. There does not need to be coming out with the clip applier on the artery, flipping it over to push up into the gallbladder if there's enough space. That said, if there's not, you have to do that move, but you can just do it in a row, like coming out, flipping over. It's wasted time. I think people do that move because they saw others do it and think that's how it should be done. It doesn't—you know—and then I'm out, and I go with my scissors. Sometimes I go with my cautery to save a step, but it depends if I have enough space or not. If it's tight, I bring my scissors in. Bam, bam.
Then back to my suction hook, cautery, and I'm off to the races. The other thing is, take that gallbladder down, put it in a bag, take it out. Don't struggle with your extraction. Make a bigger incision if you need to, open the gallbladder in the bag to suck it if it's just fluid. If it's just a stone, you have to make a bigger incision. Don't hesitate; try to get it out. But if the gallbladder doesn't come out because the incision for your Hasan trocar or whatever trocar you're using, just make it bigger right away. Quickly make that decision and carry on. Figure out what works for you efficiency-wise for closing, closing fascia, but closing skin.
Does it need to be done by you? Is there someone on the team that is willing and interested, and you can invest in them, making them feel better about themselves afterward? They can end up closing skin as well as you can. I think you can teach them. I think everybody knows it doesn't have to be you that closes the skin. Working with your hospital to develop that—it's all just in one case. But if you have each case kind of mentally prepared like that, step by step by step, and between steps, there doesn't need to be any time, and there doesn't need to be anything else going on besides those steps.
Most of my open inguinal hernias, they end up taking over 40 minutes. But I have done an appendectomy in 18 minutes, done a laparoscopic cholecystectomy in 18 minutes, and an open inguinal hernia repair with mesh using the Lichtenstein technique. It was a small one. I didn't hardly say a word during the case, but I did do that in 18 minutes. So 18 minutes is apparently my, like, asymptote or whatever where on all these cases I end up capping out. A Lichtenstein opening without hernia repair in 18 minutes, no complications, no problems. On a thin, indirect male, fine, but it was male. I had to do the keyhole and everything.
The staff knew step by step what the next things were, and you have to reinforce that. So that's efficiency in surgery. But this is a money miniseries as well as a surgery podcast. I think I've hammered the point of why we want to be efficient, right? Because you want to reclaim your time for things that are important to you. I've talked about personally what's important to me and what I think my purpose is in life. So I'm not going to talk about that again right now. If you want to talk about that, go back to episode one of the Money miniseries. Financially, I think about things in terms of a dollar per hour on everything I do.
You have to be careful with this because it has gotten so ridiculous, like my life has gotten ridiculous in a good way. If I'm taking time away from work, I know what that costs on a per day basis, or per hour basis. But it's quite good because when I take a full day away from a weekday, and we have friends come to town and stay with us, we do a slow day with our families together, and we talk about things and sharpen the saw with each other, right? I know the dollar amount that day costs me, and it's a large number. It's like I'm paying that amount of money to spend time with my family and friends.
The obvious reason it's bad is you can then not spend time with your family and friends because you feel like it's too expensive. So I don't do that. However, it does cross your mind if you go as far as I have with thinking about efficiency. You just have to be aware of that. The good thing is it makes you think about who you're spending your time with and if it's worth it. Is this the true cost, the opportunity cost, if you will, of spending this day with this person? Is it worth it? Not to be cruel, but there are millions of people you could choose to spend your time with. There are actually billions of people you could be spending your time with.
It forces you to focus on who's actually sharpening your saw. I'd say it makes your friendships deeper and more meaningful. I tend to invest more in close friends because it's a give-and-take relationship. I know they are that important to me; I'm going to spend these hours or this day with the person. Especially when it's business hours. I'd say nights, evenings, and weekends, it is what it is. But if I'm going to take a day off and spend time with somebody, a couple of weeks ago, I went with just my wife and kids to the zoo during business hours, not during the nights and weekends. It felt like a worthwhile investment.
I'm very happy I spent that day; it was wonderful. When you think about it in terms of efficiency, it feels like you're choosing that over this other money thing. It makes your values— for me, makes my values feel aligned and intentional, which is a goal. I want my life to be intentional. Next is to think about your dollar per hour. I have a net worth spreadsheet that I track on Excel monthly. I've done this since 2017, so I'm about eight years into it. It's amazing to see the up and to the right and the hockey stick nature of it. I understand there's been a lot of printed money, and maybe I can't buy as many cheeseburgers with that dollar as eight years ago, but nonetheless, it keeps you very accountable.
What gets measured gets managed. Another point about efficiency: the main thing is—don't do it. Don't do the thing. Just be efficient with your time. In surgery, right, are there surgeries you don't want to do, like those that are not worth it? You could take your practice to the point, like maybe when you start out, but you can say, "Look, like I now am looking at my."
However, you know, if I'm paid RVUs or if I'm fee-for-service or whatever, I know that at my max producing peak, I'm generating this amount of dollars per hour. And so now I can compare everything to that. For me, another consideration is the clinic. Being in the operating room generates more.
For me personally, and it depends on how fast you are at the clinic and how fast you are in the operating room, but I am not very good at the clinic and hyper-focused on efficiency in the operating room. The OR is worth about two and a half times per hour personally for me as the operating room is. That being said, the clinic is worth nothing for the hospital system with which I am contracted because they're essentially paying me everything that I'm generating from the clinic, and sometimes more.
But in the operating room, it's the opposite. I'm running their machine, which may generate 10 to 15 thousand dollars an hour in charges. Net revenues have got to be five to ten thousand dollars, I would think, but it depends on what you're doing. You're operating a machine that only you can turn the keys on and start it and run it. The machine has a lot of expensive parts, which would be the nurses, the techs, anesthesia, the equipment in the room, and keeping the lights on, including billing, coding, and EMR, everything. But only you can turn the key. The administrator can't come and put that case in the operating room.
When you're choosing to do that case in a rural hospital rather than in an urban hospital, you are now creating jobs in your community because you turn that key and you're running this engine, choosing to do it in your rural county rather than sending the patient elsewhere. That is one of the big purposes of why I love rural surgery.
Knowing a little more about me and how efficiency is a focus of mine, you might see why I feel that way. Of course, I care about the one patient that doesn't have to travel, as it's more efficient and convenient for them. Sometimes they won't get the care; sometimes the cost of gas to get to the city is too much; sometimes they're 85 years old, and the burden of travel is just too much on them and their family.
You want to be there for the poor, the old, and the medically indigent, to be able to provide care locally. But the reality is you're also just increasing the quality of life for everybody in the whole county when you choose to do the operation there. That's different from an urban surgeon who comes out for outreach clinics only and takes the cases back to an urban center. That does not do the same thing for the county as what I'm describing.
Being able to do the surgery close to home for people is my whole goal. I understand not all surgery can or should, by any means, be done there. You have to know your resources. If you don't have an ICU, inpatient cardiology, dialysis, inpatient nephrology, or IR, there are things you don't have. But you can learn your limitations, go up to the edge of what you can do, and choose to do it all there. And then what can't and shouldn't, well, that's your judgment. You take that in a different direction, wherever it needs to go.
Let me bounce back to what I was trying to say. Being in the OR for my hospital system is infinitely better than me being in the clinic because they're not making anything from me being in the clinic. It's not sustaining anything when I'm there. To grow and provide for the hospital so that it continues to exist and everything I'm talking about can actually happen, I have to find myself in the operating room. The more I do that, the better it is.
For me personally, I do get paid for doing clinic, but I make probably two to two and a half times more in the operating room. Plus, I love being in the operating room and generally dislike being in the clinic. I mean, I love people; I'm an extrovert. I'm wiped out at the end of a clinic day, and at the end of a surgery day, I'm like, "Isn't there one more case to do?" You have to know yourself and know what gives you energy.
I have essentially replaced almost all of my clinic with Taylor, my nurse practitioner. She's been working with me for four years. It required a lot more effort upfront to sharpen the saw, so to speak, and train Taylor to think the way I do. But now she does. Her notes read like my notes. I think she's at the level of a third, maybe fourth-year resident in terms of her thought process. She knows what she doesn't know and she knows how.
Maybe she sees 16 patients on a clinic day, and maybe in two cases, I need to be involved in the decision-making. We talk every day. She texts or calls me; a lot of times we travel together, and she's with me in the same building. I'm doing surgery in the surgery department, and then if I have to come between cases for a patient I need to see or an add-on, I do.
We've just focused on what's the highest value and how we can do this. The hospital systems are seeing it and it's saving them money on the cost of the clinic because we're having a nurse practitioner do it rather than a general surgeon. The cost to produce a general surgeon is much higher, obviously, taking 13 years of training, whereas a nurse practitioner requires nursing school and an NP program. It's mostly what she's doing with me, and I've trained her.
For me, it's also just rewarding because I can track my productivity metrics in many different ways. Another thing I tracked almost from day one, or maybe from three months in, is every single case I've done, ever, at any facility, is recorded. Most of it is on one master spreadsheet. A few locum things are somewhere else, but every case is there. Then I dump it into the SSR for my case logs.
Do I dump it into the SSR myself? Thank you for asking. No, I do not. I have my assistant do it. I've realized that charting is a total waste of time, and if I can hire somebody, even if they take two or three times as long as I do to do the chart, note, wrestle with the computer, and dump things into SSR, even if I could do it more efficiently, if I know what my dollar per hour is, there's a tipping point for them to do it instead of me.
That's where it starts with knowing your dollar per hour. What's your highest and best dollar per hour? Now everything you do needs to compare to that. If it's not your highest dollar per hour, it needs to be hitting some other buckets for you besides just making money. Like, it needs to strengthen your family relationships or be something you love and wouldn't want to give to someone else, which is fine.
And if that's the case and you can't do that thing more efficiently and you can't make that thing profitable, then you have 168 hours per week, and you choose how many hours you want to spend doing that thing. But if you're
Dr. Randy Lehman [00:24:03]: like me, and being paid for your work still matters, which I think for me, for a few more years, it still will. Although I could argue that it doesn't, then focusing on your highest dollar per hour is a great way to make sure that you can keep your work confined and you don't turn your practice from being 40 to 50 to 60 to 70 hours to make more money by just doing more work, you can actually be more efficient, and you can actually make more money over time by adding more value to the hospital system you work for and the community that you work for.
Dr. Randy Lehman [00:24:33]: If you don't add value, then you shouldn't be making more money. I strongly believe that. But right now, in 2025, being a rural surgeon adds more value than being an urban surgeon because there's a demand there, and it's a supply and demand thing. And I think people are professionally intimidated by the concept of being out there on your own. It is intimidating. I feel it. I 100% feel it.
Dr. Randy Lehman [00:25:04]: If you have a complication and you have to send a patient, first off, managing it on your own is hard. Secondly, having the humility to be talking to your surgical colleagues at university, and sharing with them, you know, the situation, and sharing the patient with them and transferring patients is very hard. It's humbling. Knowing your resources and managing your resources is hard, but that's the value that you're adding. And it is worth it. It's very worth it. For me, I, I love it. It's worth the challenge. And so I support you in your efforts to, you know, to provide care close
Dr. Randy Lehman [00:26:05]: to home for people in rural surgery in 2021. So I finished residency in 2020, and then I started investing in real estate really hard when I got out. And it was a great time to be investing in real estate. It's like, don't let a good pandemic go to waste, so to speak. And obviously, that's a hundred percent joke, but you gotta recognize the economic times that you're in. And what was happening is money was being printed and it's a good time to own assets, and it's even
Dr. Randy Lehman [00:26:36]: better time to own leveraged assets with low interest rates. So I bought millions of dollars of real estate, and I tracked my net worth. And usually on the net worth statement, what I use for the value of the real estate, it's not like I change it every month. I don't go in there and say, oh, you know, I'm estimating this is going to be worth, you know, and, and, or lying to myself and saying that it's worth more than it is. What I do is I write the last appraised value of the property. So usually that
Dr. Randy Lehman [00:27:06]: happens at a sale. And then maybe every five years or so if you're owning it, if there's some other reason that I've done something to it, then I might change the value. But usually it's the last appraised value. And I was able to watch over the year of 2021 what happened to my net worth by going in and out of several real estate transactions. And I feel like in that year I was
Dr. Randy Lehman [00:27:37]: only in one location. I did about like 4,500 RVUs, I think, in that year total. So it wasn't that busy of a year. Now I'm doing basically 9,500 or so a year. Like last year, I think I did over 10,000, but I'm doing it highly efficiently. But still, at that time, I was, I think, I put in about 20 hours a week into real estate investing in the year of 2021. And at the end of the year, I was able to look at the dollar amounts
Dr. Randy Lehman [00:28:08]: and I made about as much money investing in real estate averaged out over those hours. Now that's hard because you don't actually make money when you're spending time doing real estate at the moment that you spent that hour. But I made, in terms of increase in my net worth, almost exactly the same amount per hour if I assume it was 20 hours a week, which is very close, as I did at my top hour doing surgery.
Dr. Randy Lehman [00:28:39]: Now I can't, I don't think I can always do that. I think that was a moment in time. But the other kicker about that is all those hours that I spent doing surgery, that was it. But then going forward in '22, '23, '24, the hours that I spent investing in real estate, not only did it kick my net... Now it didn't give me the cash. Actually, most of the time, I made equity in the building by doing the deals because I negotiated them to
Dr. Randy Lehman [00:29:09]: a good price and maybe I did a value add, right? But the equity was there and I could have exited. Okay, but you can't eat equity, so you have to have both. Nonetheless, each additional year going forward, there is a loan paydown, there is cash flow from rent, right? There's appreciation in the building, and there are some ongoing tax advantages.
Dr. Randy Lehman [00:29:39]: And there's a huge tax advantage for me the way that I'm doing it in year one. So it's an efficient investment for me that keeps getting better. And most real estate deals, 30 years later, they look like a genius. It doesn't matter what you paid for it in 30 years; it just looks like you were a genius. In five years it might not. And in five to ten year time horizon, you might bankrupt yourself by investing
Dr. Randy Lehman [00:30:10]: in real estate and doing the wrong thing. Right? So it's not without risk. Right. And you have to go into it appropriately capitalized, minimizing your personal expenses, having a good, strong dollar amount to invest with to begin with, and coming at it from a strong position. But all those little pieces for the first couple of years, when you look on a longer time horizon, they just all generally wash out from
Dr. Randy Lehman [00:30:40]: the ongoing. And so then I'm not spending 20 hours a week managing those investments. Now, it's not truly passive. You have to spend a little bit of time. You know, you got to make sure you got big enough, thick enough, rubber bands that they don't snap on the side of all your stacks of money. But aside from that, you're going to have your most efficient hours, I think, from your passive income. And so if you don't have passive income, you need to get some. That would be my take
Dr. Randy Lehman [00:31:11]: on it. And then start now and learn and grow and don't over-leverage yourself. Don't stick your neck out so far that you're going to get hurt. But it starts by focusing on your job, your dollar per hour, your highest dollar per hour. How much time do you want to spend working? Maximize it. Minimize your personal expenses and minimize the things that you just shouldn't be doing. And then take that money, invest it, and get yourself financially free.
Dr. Randy Lehman [00:31:42]: That's what efficiency, that's the point of efficiency. And then my grandpa said that there's, he talked to an old farmer and the farmer said, you know, it's like you're pushing a rock over the hill. And once you get that rock over the hill, then it's all pretty easy. And it's like that. I mean, once you get to level one financial independence, which is like your daily needs are met, that changes your mindset. And now you're
Dr. Randy Lehman [00:32:13]: able to do things like make a podcast and put your ideas out there for the world and try to help other people where you, you couldn't do that when you're like hand to mouth. And if you're.
And then once you get beyond that level, you know, then things start to snowball, and you can give generously. You can think more in terms of impact and spend a little bit more time really focusing on just what is important to you and then focusing on it.
For me, like I said, it's basically my family and spirituality. In the light of everything that's happened with Charlie Kirk in the last week, there's a battle out there. My participation in that battle, I would say, is one of the most important ways that I can spend and invest my time.
Some people might take the efficiency so far and then struggle with what is the point. But that's a question that everybody needs to answer. I think it's very obvious that the point is Jesus, and so you decide for yourself.
There's a book with more details about this that's written by dozens of authors over thousands of years and is congruent with itself. I would check that out. At the end of Ecclesiastes, it says, fear God and keep his commandments. This is basically the whole duty of man. Jesus said, love the Lord your God with all your heart, soul, and mind, and love your neighbor as yourself.
I'm preaching to the choir. How am I doing right on a daily basis with the people that I'm interacting with? How am I doing with my kindness? How am I doing with my gentleness? That's my own problem, and I'm working on it. For you, focus on your efficiency. Get yourself free from the hand-to-mouth thing. Stop doing all the things that don't matter.
There are things in my house that are left undone. There's a song called "This Old House." The concept is, do you have to do all the things to create your utopia with your perfect McMansion American house? Okay, yeah, there's a white picket fence in a yard that you want. But there are a lot of things undone at my house that I want to have done, but I am actively choosing not to do them for the sake of efficiency because there are other things that are more important.
So, find your priorities. Work on those things. You're going to spend some time working, so make it as efficient as possible. Then you will actually reclaim time, money, and energy, and it will be clear what else is important that needs to be done.
There are thoughts about efficiency that I think will come out in the rest of the podcast, in all of my episodes, because it's just something I think about all the time. This is like a summary, I would say, of how I think about it. What gets measured, gets managed. Track your time, know your worth, know your dollar per hour worth.
Understand that in investing, it's not going to be that dollar per hour right out the gate, but investing because of the long time horizon, the long payoff, and spending some investor hours is a great way to be very efficient, actually, in the long run with your time.
I support you as being a rural surgeon. I support you for what you're doing for rural America. I appreciate it. Rural America deserves it. There are values and just qualities that are just so beautiful. Being out on a farm, in nature, in a community where you know the people that are around you. That's what I am loving.
We're in a time in 2025 where we can connect even virtually when we're miles apart. I just support you guys in everything that you're doing. Thank you for listening to the show. I will do my best to not be skipping too many episodes, but overall, one year in, I think we've only missed four or five episodes. Something like that. All of them are there on the RuralAmericanSurgeon.com, you can like us on Facebook, you can follow us.
Make sure to share the show if you've enjoyed this. If you've found any value and you have a friend that you think would benefit from it, please feel free to share. Don't hesitate to reach out to us. There's a get in touch on the RuralAmericanSurgeon.com, and you can share the reels and whatever.
It's been a great year. I plan to continue to do it. I am loving it, and I hope you have found some value. Thank you very much for listening. I will see you on the next episode of The Rural American Surgeon podcast. Have a great day.
