EPISODE 57

Keeping Up Without Wasting Resources in Rural Surgery with Dr. Steven Bodney

Dr. Randy Lehman (00:00:00):

Welcome back to the Rural American Surgeon. I'm your host, Dr. Randy Lehman, and today I have with me Dr. Stephen Bodney. Thank you so much, Dr. Bodney for joining me.

Dr. Stephen Bodney (00:00:15):

Thank you for inviting.

Dr. Randy Lehman (00:00:17):

Dr. Bodney is from Indiana as well, and he's practiced for a long time in Corydon, Indiana, and he's actually a former or current ACS governor

Dr. Stephen Bodney (00:00:27):

Former, just ended my term at the last clinical Congress. So

Dr. Randy Lehman (00:00:33):

He's been active in the Indiana chapter of American College of Surgeons. He's been a leader just in the fact that he is doing it and showing us all how to do it. And we were chatting just a little bit about, my specific question to him was not just, I think the governorship might be the most prestigious thing that's on necessarily your cv, but sometimes the most prestigious thing is not the thing that you're most proud of. And he was starting to tell me one of the professional things that he's most proud of is he actually helped to get a new rural county hospital built. And that involved a lot of politicking, I would say, no doubt. And working with medical staff. And so I just appreciate your perspective and I'm so glad that you're here on the show. So thanks again. Thank

Dr. Stephen Bodney (00:01:24):

You.

Dr. Randy Lehman (00:01:24):

And then perhaps you can just start by giving us a pathway from college and medical school through your career, what sort of practice model you've had so far.

Dr. Stephen Bodney (00:01:35):

Okay. Well, basically I started my practice in the Army. I was ROTC scholarship and then the Health Professions scholarship. And so I ended up active duty for 13 years, five of that being residency in El Paso, Texas at William Beaumont Army Med Center. And I got to say I did some, the Army's not for everybody or military, that environment's not for everybody. I did very well in it and did some very interesting things. I did become a flight surgeon, spent a year out in Egypt as a flight surgeon, so got some Huey stick time and also got a real honest to goodness shuttle mission patch out of the deal because I had to man White Sand's missile range once when the shuttle was landing. So I've done some things that aren't in the usual.

Dr. Randy Lehman (00:02:42):

That is very cool. Tell me about being a flight surgeon. I've heard that word used several times and sometimes it's like a medical doctor that says they're a flight surgeon.

Dr. Stephen Bodney (00:02:50):

Well, the flight surgeon is really the primary care surgeon for flight crew. So when we, obviously surgeons, we are surgeons, we think of somebody with scalpels or robots and things like that in operating rooms, but that's actually a flight surgeon is primary care. So when you say you hear medicine physicians, family practice, that's true. That's their title though, is a flight surgeon. And what you learn is a lot of it's actually environmental medicine and occupational medicine. You learn about the different occupational hazards of flight. Hearing protection is a big deal. That's a very noisy environment. You learn about fatigue, things like that. You learn a lot of visual and spatial disorientation effects. You learn what medicines can affect these things. So something that you might think, oh man, I've got a stuffy nose. I'll take whatever antihistamine and clear that up. Then you get it in an aircraft, especially in something like a military environment where things aren't always super pristine and your head's a little foggy and some rounds start coming the wrong way. You can make critical errors. And so you learn about, okay, what's safe for a person to take in that environment? What's potentially not

Dr. Randy Lehman (00:04:15):

No doubt hypoxia is a

Dr. Stephen Bodney (00:04:17):

Right, right. And it was interesting going the course. We learned how to egress from a helicopter underwater, so water ditching, things like that.

Dr. Randy Lehman (00:04:30):

So I know if you have to emergency land a helicopter, I mean, I'm not sure if you're aware, did you know that I fly a helicopter? Oh

Dr. Stephen Bodney (00:04:36):

No, that's cool. Yeah.

Dr. Randy Lehman (00:04:38):

So I know if you have to emergency land a helicopter in water that you land and then you tilt your blades into the water so that it stops the momentum. You don't get sliced up and you're supposed to do it the gentleman's way where you tilt it towards yourself, let the passengers out the other side and you climb out after them. But that's not underwater. Is there something different about underwater? Well,

Dr. Stephen Bodney (00:05:00):

What happens is, I don't know if you've been through any courses on that, but of course part of the reason the helicopters tilt is they're top heavy, the engine's up top, and that's where the weight is. And so they're going to tilt over anyway. Obviously, as you said, you try to control that, but they're going over anyway. And so you'll be underwater real quick. And when they're underwater, they've rolled, they're upside down. And so it's very disorienting. But with, again, even a proper briefing before flight or proper training, you can quickly unbuckle and egress hopefully without too much difficulty. You're not trying to kick out windows and stuff. But yeah, that's what happens. And they actually have, in Pensacola, as part of their course, they have a helo dunker. It is this big cylinder. Oh, wow. Yeah. Goes into the water flips goes underwater, and then they have divers in the water to help anybody might be struggling, but yeah, you got to shove your way out of there for the surface. Wow. And you do it, you some with your eyes open and then some blinded, so you're practicing night egress. So that's all just part of the training and learning again, what might happen to aircrew and stuff.

Dr. Randy Lehman (00:06:25):

You said you got some stick time. Do you mean were you actually

Dr. Stephen Bodney (00:06:29):

To fly? Yeah.

Dr. Randy Lehman (00:06:30):

And so did you have your license then too? No,

Dr. Stephen Bodney (00:06:34):

No, we did not. At the time I was going through the course, we were allowed to fly, but not solo. Several years before they were actually letting surgeon solo or physician solo. Now, I'm not sure they even let them fly, but we were able to fly. And so what happened was did you hover? Oh yeah. Okay. And yeah, had 15 hours in LOBs, little orange bastards, the Schweitzer 300 C and then some Huey stick time. I wouldn't be allowed to fly like Blackhawks because those need for the emergency procedures, they need two pilots, whereas the Huey only needs one pilot. And so what happened was I was in the right seat and always had an IP in the left seat. So yeah,

Dr. Randy Lehman (00:07:22):

Same experience. Very cool.

Dr. Stephen Bodney (00:07:24):

Yeah.

Dr. Randy Lehman (00:07:25):

All right. And did you grow up in Indiana or

Dr. Stephen Bodney (00:07:29):

Yes, I grew up in the region, which might soon have a football team,

Dr. Randy Lehman (00:07:37):

The Hammond Bears.

Dr. Stephen Bodney (00:07:38):

Yeah, I know that's where I grew up was in Hammond. That'll be interesting. But then again and did undergraduate and IU Bloomington, another place where I'd never thought, I'd say I'm from a football school and then medical school in Bloomington, in Indianapolis, and then off to the Army for 13 years residency, like I said in El Paso. But then my practice was at an Army community hospital of Fort Leonard Wood, Missouri, which not a large place, not a small place either. I wouldn't call it critical access, but it certainly was isolated. We call it Fort Lost in the woods halfway between Springfield, Missouri and St. Louis and not too much nearby or if we had real disasters, our referral plan was to University of Missouri and Columbia for the most part, occasionally to Springfield, Missouri. And that's who we would collaborate with if we had questions or we did remote tumor boards with University of Missouri and that kind of thing.

Dr. Randy Lehman (00:08:50):

And then you ended up going from there to Corden, correct?

Dr. Stephen Bodney (00:08:53):

Yeah, I liked, again, it was not a big place, not a particularly small place. It was a good place to learn things. There were four surgeons at Fort Leonard Wood for general surgeons, but there was orthopedics, there was a couple of ENT docs. There were several of the subspecialties were there, ob, GYN. And it was a good place to learn and to train. And that's one thing for a lot of rural surgeons, I was directed at younger ones. I'd say if you can get some time under your belt before you go on your own if you can, because you will learn sort of what you can do and some of your limitations. So either just stay the hell away from it or overcome that train learn, okay, here's where I'm a little short. I need to work on that to get good at it if I'm going to be out in a more isolated spot, coming out of there.

(00:09:56):

I really liked being a general surgeon. And when I was looking at places, it was pretty clear that if you went to some of the more metro areas and stuff, well, you're the gallbladder guy or you're the hernia guy or vascular access is your thing, or something like that. You did a bunch of stuff, but you were really focused. And I liked doing a little broader practice. Actually, when I first came to Corydon, I did thyroid surgery, I did some general thoracic surgery, things like that. And so it was as the place grew and some specialists had come into our special referral clinic, that sort of business went away. But again, where I was in Corydon was a half hour from Louisville and Major Metro. And so some things were close by, but not everything. And quite honestly, a lot of patients, they preferred to stay at their local hospital.

(00:11:04):

You may have experienced that. I know you practiced it a couple of smaller places. And for us at Louisville, that's across that Ohio River, which might as well be an ocean for some folks. And so they want to stay where their family is and where they know the streets and know the people and stuff. And then I think you have a story about the first interview you had with your CEO. Yeah. One thing, when you're looking, interviewing at jobs, they're trying to get a feel for you, but you should get a feel for them also. And there's, I think a big difference between places that are major corporate where their goal might be just to feed the corporate, feed the mothership or something. Versus where I worked was truly a county hospital and still is one of the rare ones not owned by anybody and that kind of thing.

(00:11:54):

And so their goal is to survive and they want you to do stuff. They want to keep stuff that's safe and that kind of thing, but they want you to do things locally if you can and you can get a feel for that. A lot of times by just talking and my first show up for the interview with the CFO and CEO and the CEO and I ended up talking, and then when I came, a lot of places when you go interview, they put you up in a nice bed and breakfast or whatever and try to treat you nice and well, I came with my wife and my dogs in our camper and we stayed in our little RV campground and that raised a couple eyebrows, but there you go. That's me. I get used to it. And after talking with one of my little hobbies is I like to make home brew and make my beer at home. And I had some with me. And so after talking with the CEO and stuff, I said, well, let's go get a home brew. And he came over to my camper and we chipped on a beer for a little bit while we were still talking over things. And he said, let's get something to eat. And we went to this little hole in the wall spot, which I love these little tiny places. One of those where the cook is he is flipping burgers and got a cigarette hanging out of his mouth.

(00:13:22):

It's like real people. And instead of the fancy place and that kind of thing, and it's like, so we went duct tape on the vinyl seats and that kind of thing, and we went there and had a couple of burgers and whatever, and my wife said, you guys went there? And I said, yeah, that's where we ended up. He said, I think you're going to do okay here. I said, yeah, it just feels like this could work out. And it did. So for the next 27 years I was there in Harrison County Hospital in Corydon Indiana.

Dr. Randy Lehman (00:13:59):

What a great intro. And if after that interview it's either going to work out great or it's not going to work out,

Dr. Stephen Bodney (00:14:06):

And usually you can pick up, there was one place I went to that was a large multispecialty group that you could tell they were very interested in having me. And this is something I would say, if you're looking, make sure that your spouse or significant other partner that they're good with it because if they're not, you'll be leaving. One thing my wife and I noticed when we look at places, why do you need somebody? Well, the last person left because their spouse didn't like it, and that kind of thing. So whether they're another professional, a physician or a non-physician professional job or if they're running a household, there has to be something there for 'em or something that they're, that's going to make them want to stick around too. Otherwise you might be looking at a shorter term there. But that's one other place I looked at. You could just tell they just wanted a body in the call schedule. It's like, I mean, you can pick up this stuff when you're talking to 'em. It's like, if you do well here, good for you. If you don't do so well, we'll find somebody else and you can pick up those kind of things. And I could tell that where a place I interviewed they were interested in not only just having a surgeon, but having me as a surgeon. It looked like we were getting along well.

Dr. Randy Lehman (00:15:39):

Yeah, and that worked out. I mean, it turned out that you're a leader in the community and everything. So I think we've pretty well covered basically the why rural surgery. I mean, you've given me some good examples. I'd like to go ahead and move on to how I do it now. And we have a few things that we were thinking of talking about, but specifically you were saying how you built a breast practice in a rural environment. And so maybe start with that and then let's talk about some technical tips and tricks.

Dr. Stephen Bodney (00:16:08):

Okay. Yeah. Keep in mind now that I'm just retired at the beginning of the year, and I've been a little slow before, so some of this stuff I haven't done for a few years,

Dr. Randy Lehman (00:16:24):

But you're still saying that you have decades more experience of surgery than I do. Okay,

Dr. Stephen Bodney (00:16:28):

There you go. Some of the things that you'll find in rural surgery is sometimes they don't have stuff and you'd say, well, I don't want to go. They don't have this. I don't want to go there. They don't have that. And sometimes that's an opportunity because what that means is that you can, as long as they're willing to support you, and that's what you got to tease out, okay, are you going to support me in building this? It's a way to build it the way you want to build it. Okay, you're not, okay, I got to do this because that's the way Dr. So-and-so set it up or whatever. This is your opportunity to say, this is my show and here's how I want to do this. And one of the things that I learned in, again, now there's breast specialists, surgeons and stuff like that. Well, gee, if somebody has an abnormal mammogram and a geo biopsy shows cancer, do they have to go there? No, they don't. I mean, you can do as well a job as they are, and a lot of times they're so darn busy that unless it's some strange thing or the patient has some factors that would indicate otherwise, they'll be happy for you. They're

Dr. Randy Lehman (00:17:45):

Happy for you to do

Dr. Stephen Bodney (00:17:45):

It. Yeah, absolutely. And I think a couple of things you need to do is sort of expand your horizons a little bit. I know of some surgeons that if they don't want to see a person with an abnormal mammogram, they want to wait until after let somebody, they want to see the biopsy. They don't care about anything before that. If the biopsy shows cancer, yeah, we'll make an appointment, otherwise I don't care. I don't want to see 'em. But especially in a smaller place, this is how you can build trust not just with your administrators and community, but with the patients individually is tell the primary care folks, Hey, if somebody has an abnormal mammogram, send 'em to me and I'll take it from there. So you can start directing the workup and stuff so that they don't end up with the mammogram, the ultrasound, the two MRIs, and then eventually a biopsy. It's like, well, if you take it from the beginning, especially if it's an ultrasound visible lesion, you can do an ultrasound and do your own biopsy and get that right up front without all this other diddling around.

(00:19:18):

And that's what you need to do though, is develop the skills to do that. And there's courses for that. A big thing, one of the hard things with for surgery is keeping up and learning new stuff. When I came out of the Army, sentinel lymph node biopsy did not exist for breast surgery. And it came, and what you have to watch for is there's a lot of trends that are flash in the pants type things and you don't want to get caught in that. But it was pretty clear pretty quickly that sentinel no biopsy was going to be the thing for breast surgery. So I had to learn that. You say, well, how do you do that? Well, again, fortunately, Louisville wasn't too far away and they had a course on it, go to the course, and I just talked to the guys that gave the course afterwards and said, Hey, I'm out here, this place half hour, 45 minutes away, but I need to learn how to do this, and is it okay if I come over when you got some cases and scrub in or at least watch? And they say, I said, yeah, sure. Just call my office on Tuesdays and they'll let you know what I got for Wednesday or Thursday. And we didn't bother telling lawyers and stuff. We'd probably get in trouble now.

(00:20:44):

But I ended up scrubbing several cases with the guys who put on the course and learning how to do it and getting comfortable with the technique and actually showed one of them a technique, which they said, oh, I like that. What I'd do is when we'd locate the sentinel node, I would put a figure eight three oh silk on a pop off on it and use that for traction rather than trying to grab it with the different forceps or whatever and letting it slip away all the time. So that was,

Dr. Randy Lehman (00:21:24):

I love that trick. I do the same thing for lumpectomy, so that's perfect.

Dr. Stephen Bodney (00:21:29):

Yeah, right. And I'll tell you what, sometimes when these lymph nodes are really small, it can be hard to tease 'em out. That's one of the more difficult things that, and things like, okay, you want to learn again, in my day was we did open colectomies. Okay, if I need to learn laparoscopic ones, which I eventually did, it's like, okay, how are you going to do that? How are you going to get proctors in to help with that? What courses are you going to go to? But that's something that is one of the more difficult things in rural surgery is keeping up as techniques change. And I think it's important there to avoid the flash in the pan ones wait until a little bit until something's proven, because otherwise what happens is not only are you wasting a lot of time doing something that doesn't really matter, but your hospital admin then is spending money on a bunch of equipment that is then just going to sit there gathering dust in the back room, and then next time you come to them with something that you really do need, they're going to be, well, what about this other stuff in the storage room over here that we still got?

(00:22:43):

And it's just going to sit there. So you need to learn, as a rural surgeon, you need to learn some of the business planning that goes not just in your own little private practice, but as a hospital from the system point of view, from what's the business model? How are we going to get patients? They

Dr. Randy Lehman (00:23:07):

Don't trust the reps

Dr. Stephen Bodney (00:23:08):

Either. No, gosh, no. The reps, I mean, let's face it, they're doing their job. They're selling stuff. I mean, that's their job, but you got to realize that's their job. And yeah, don't trust me.

Dr. Randy Lehman (00:23:19):

I have a story for that. So I was coming into town and nobody was doing varicose veins before I was in a rural place, and so I kind of told 'em the equipment that I needed that pretty much I had trained with laser and with RFA, you got to pick one or the other because you're only going to buy one set of equipment. I like the RFA better. So we bought the RFA equipment, we got the pump, we got the tumescent ordered from pharmacy, all the essential things that I need, catheters ordered and whatnot, phlebectomy hooks, and just doing it exactly the way that I did with all the vascular surgeons that I trained with at Mayo Clinic, right? First day, first case, we go and we do a vein ablation and phlebectomy, I'm talking to the rep. The rep has been very helpful to get the equipment, but I'm out scrubbing and I walk in to hearing the rep telling the staff that this is what we're doing now, but the future is VenaSeal and we will be injecting this foam crap to seal the veins in the future. So you'll see that. Okay, so first off, at that time, this is 2020, I had never heard of VenaSeal, and I just finished literally doing vascular surgery with the surgeons at Mayo Clinic. Nobody had ever mentioned VenaSeal ever to me. And I'm not saying it may not be part of a practice for somebody and there's a place for it, but when the rep comes into Mayo or I mean, I told him, don't ever come back. Right?

Dr. Stephen Bodney (00:24:57):

Yeah,

Dr. Randy Lehman (00:24:57):

That's extremely inappropriate. And then of course, I called my buddy who's a vascular surgeon at Mayo Clinic right after I said, are you guys using VenaSeal? He said, never. I'm like, okay, well only once you say you've been using it for four to five years and then it's like working. Well, we have some data behind it, we've studied it. That's when we'll order these things. Right?

Dr. Stephen Bodney (00:25:16):

Yeah. Actually you bring up a really good important point there. As a rural surgeon, you can be kind of isolated. Call your buddy. When I got out of the army, when I was in the Army, okay, there were two or three other surgeons with me, general surgeons, when I was out and I was solo for five years. And one of the things that I've learned real quick is that you get tested, what's he going to do with this? And sometimes you'll get cases referred to you that if you took 'em to the operating room, you'd probably never see another patient from that family practice doc again or whatever, because they're almost like sending you a test case. Is he going to operate on this? Is he going to do something crazy or what? And when I first got out, one of the interns sent me somebody with an esophageal cancer. I knew how to do an Ivor Lewis. I had a case series of one and that kind of thing. And I just told the patient, look, here's what you need. Explain his disease process to him and that kind of thing and say, here's what you need, but I'm not the guy that needs to be doing it, and let's get you where you need to go. Happy

Dr. Randy Lehman (00:26:41):

To place your report,

Dr. Stephen Bodney (00:26:42):

Right? Yeah. And it was a couple of years later that internist told me, he said, I know you're a great surgeon and here's why, because you didn't operate. In other cases you get where somebody really does want you to do something and you're pretty sure it's not the right thing to do. One internist wanted me to open a pelvic hematoma to stop it from bleeding, and I'm like, I was getting a lot of pressure. So I just called up one of my old chiefs from my residency and said, here's what I got doc. Here's my plan. And he said, stick to your guns there buddy. And it helps to have that reassurance when you're solo or just like you said, have you guys seen this before? Nope. Yeah, thanks. It just helps you. So it's real important. You're not alone. You're alone, but you're not really alone. You've got call somebody. Just call and talk it out. Perfect.

Dr. Randy Lehman (00:27:46):

I have one more question on the how I do it. Before we move on. One thing that I haven't talked about on the show is breast biopsy. So since you specifically brought up abnormal mammogram and then what you're doing in your office, maybe you could explain who you do what on and where people need to get to do whatever and then what you personally can do yourself in the office.

Dr. Stephen Bodney (00:28:07):

Okay, sure. One of the things that, again, sort of going through that abnormal mammogram workup and stuff is obviously there's the abnormal mammogram and then an ultrasound should be the next move typically. And if it can be seen on ultrasound, which, and it's a BI-RADS 3 or 4 BI-RADS 3 we used to watch, nobody watches those anymore appropriately. So because it's much easier to biopsy if it can be seen on ultrasound, you have to ask you, how good am I at doing that? And you get good by doing more of 'em. And I know when I first started, I had to, if it was depending on where it was, I might send that to the radiologist depending on the size. Eventually got though to, I could get something that was a half centimeter. If it was smaller net and they wanted a biopsy, I said, well, you guys do it then.

(00:29:14):

But I could get down to a five, six millimeter in most locations of breast pretty reliably and get a piece of it. Always leave a tag, leave a little clip by that just every time. And it could be done in the office under really a local anesthetic. I would do it that it does take a little time. So again, this sort of depends on this, if this is an interest of yours or not, but I think an important thing once, if it was microcalcifications, obviously I would send, okay, you guys need, that needs to be mammographically biopsied because I can't see it on ultrasound. But you also learn to place wires yourself for localization in case you do need to do an open biopsy or even do a lumpectomy, which can be helpful. Again, in small places, you may or may not have radiology every day.

(00:30:23):

We used to have a radiologist five days a week, but now at Harris County, I think it's only two or three days a week, there's actual radiologist in house. So if you say, well, I need a localization or something like that, I need a wire place or something, well, now you got to schedule it. When's the guy here? When do I have a hard time with? Or if you put your own wires in, you say, well, I don't care about any of that stuff. I can see it. I can throw a wire in, that's all billable, and then I can take it out. And you don't have to worry about what's the radiologist's going to schedule even here. So

Dr. Randy Lehman (00:30:54):

You place the wire by ultrasound? Yeah,

Dr. Stephen Bodney (00:30:56):

Yeah. If it's an ultrasound, if it's an lesion, I can see on ultrasound again, if it's microcalcifications or something like that, well then I got to coordinate with the radiologist. But if I can see it on

Dr. Randy Lehman (00:31:06):

Ultrasound. When you starting, what size of a lesion would you do these things with? I know you said you ended up at five millimeters.

Dr. Stephen Bodney (00:31:12):

Yeah, they had to be at least a centimeter. Centimeter to a centimeter and a half.

Dr. Randy Lehman (00:31:22):

So if somebody's a resident right now and they want to do this in their practice, but they don't see any surgeons that they're training with doing it, would you recommend that they go down to radiology and kind of explain their situation, go to their program director and explain their situation, get some time set up where they can get into radiology and do it or what?

Dr. Stephen Bodney (00:31:40):

Yeah, that would be useful if the radiologists are going to let 'em do it. Sometimes you get into that medical turf politics, but especially if they plan on doing a real thing where explain that they might be able to get through that. And the other is, again, just start doing it on real people. Just make sure they're lesions big enough that you can see and get the biopsy device into it. I mean, let's face it, you're a surgeon. You have pretty good eye hand coordination and spatial abilities. So I mean, it can't be that hard. Radiologist does it, right?

Dr. Randy Lehman (00:32:31):

I think your sterile technique will be better too,

Dr. Stephen Bodney (00:32:34):

Probably. But even if you're not getting it so much in training, just do every one that you can and the other, if you happen to go to a spot where you're not alone, where you're one of a couple, eventually I ended up having a partner where I was, and mostly to split up the call of duty. And another one of the downsides of being rural is like, gee, are you always on call? You can be if you don't put up walls for yourself. But he wasn't quite that interested in doing that. So if he had a patient referred to him with something that was seen on sonogram, he'd send it to me to do the biopsy. We shared the office, he'd say, Hey, Steve, can you do this? I said, I can do that in a few days. And so yeah, check with the patient. And so that way that's where really just practicing and doing it, you get better. And then as you get better, you can get at the smaller lesions or the ones that are in a little more unusual spots and stuff.

Dr. Randy Lehman (00:33:41):

Can you tell me, did you use the spring loaded core biopsy?

Dr. Stephen Bodney (00:33:46):

I'd used a few different ones. Some were the, I had used those. Some were the mammotome. There was a handheld one that was vacuum into a little basket at the base of it and that kind of thing. Yeah, you don't,

Dr. Randy Lehman (00:34:11):

Was that your favorite one by the end? Yeah.

Dr. Stephen Bodney (00:34:14):

Yeah, because weren't still at any kind of near the volume where we would've afford one of those, the big main units that the radiologist liked to use and stuff like that. In fact, the radiologist didn't, they would actually borrow my handheld unit if they ended up doing one. If somebody referred them one instead of me. And

Dr. Randy Lehman (00:34:38):

Then the marker goes through the device.

Dr. Stephen Bodney (00:34:42):

Well, no, it's separate. So you still got the, now the device does have, or at least the one I used, had a guide sheet, basically a big ass core needle that would put down to the lesion so that then you could go back and forth through. I found that not to be too useful for the most part, but in some cases it was. But usually it was just easy enough to go back into the tissue and you'd find the spot and let it do the biopsy. And then you put again under ultrasound guidance, put the clip by it.

Dr. Randy Lehman (00:35:23):

Yeah. Did you do this with an ultrasound tech or were you running the ultrasound?

Dr. Stephen Bodney (00:35:28):

No, I'm running the ultrasound. I'm running the ultrasound. It was me and the nurse in the room. I was the only one sterile, really

Dr. Randy Lehman (00:35:37):

Sterile.

Dr. Stephen Bodney (00:35:40):

It would've been easier to have maybe one more person in handing me stuff, but it wasn't necessary. So that device

Dr. Randy Lehman (00:35:52):

Is not spring loaded,

Dr. Stephen Bodney (00:35:54):

Correct. Yeah, it was not spring loaded, so you had to put it through the lesion. And for some lesions, especially if it turns out it's a fibroadenoma, they can be pretty tough. And so that was started pushing hard. And then patient's like they're pushing their hard air docking. It's like, okay, we'll get this through. But you were able with that to biopsy several quarters because you'd let it take its biopsy and then you'd just give it a turn. You wouldn't have to come in and out each time, or if the spring loaded one, you'd have to go in and out each time because it was like one shot and done.

Dr. Randy Lehman (00:36:37):

And then the other ones that you can't handle. So if you can't see it, if you can't feel it, if you can feel it, you can biopsy it, right? If you can see it with ultrasound, but you can't feel it, then you can biopsy it as long as it's big enough. If it is not visible by ultrasound or quite small, non palpable, then you send those for stereotactic biopsy and then you've already kind of gotten involved with them. So you can explain that. And then they naturally find their way back to you afterwards.

Dr. Stephen Bodney (00:37:12):

Right, because I'm the one sending them. So I'm the one that'll get the path report and the radiology report. And again, for some primary cares, they really like to stay involved, but especially in the older days now, less so. Yeah, it's less for 'em to worry about. They're paid to see more patients and not spend a lot of time talking about your breast disease. And that's one thing I think that helps build up the trust, not only with the patient, but the primary care physician too, because they get these weird path reports. They say, I don't know what the hell this is. And you say, well, I'm a surgeon. I know what that is and I know if we need to worry about it or not. And you can talk with the patient and help them through it. And that's one thing I think it's important too, and we would get somebody through, and their pathology does show a cancer, is to tap the brakes a little bit.

(00:38:08):

Some people rush through, here's your cancer, and a few days later you're seeing an oncologist and then you're getting this and that and the other. And the patient really hasn't had a chance to sort it out. And I would always tell the patients, look, it's your breast. It's your breast cancer. You need to figure out what's best for you. Okay. Because there's so many more options nowadays. And I would sit 'em down and say, okay, here's how cancer works. Here's how we treat it. We can get you to an oncologist before you decide anything. We can get you to a plastic surgeon before you decide anything. So you can get you to the radiation oncologist if it's appropriate before you decide anything and get your data and come back with a friend. Because most patients, as you've probably seen, they hear the word cancer and the rest is blah, blah, blah, blah, blah. Yeah, exactly. And so it's come back with a friend, come back with some Now stump patients, they, they're half expecting it or whatever, and they know what they want and that's okay. But some of 'em, they're just smacked and it's like, okay, just put the brakes on it. We don't been there a little while waiting a few weeks or a month to get all your data and make up your mind. It's not going to hurt you.

(00:39:35):

What will hurt you is if you're not happy in six months or a year because you think you did the wrong thing. And I've had a couple of patients that have wanted bilateral mastectomies that have cancer in one side and they want bilaterals. And I think one operation that I sometimes try to talk 'em out of some, I usually don't okay, what the patient wants, because to me, that's twice the surgery, twice the complications for really no improvement. We haven't shown that save lives other, unless you have genetic predispose or anything. So it's not too many people that want that. But the couple that have had it since we kind of went through that process years later, they're still very happy with their outcomes, happy. They don't have to worry about it. They're happy that whatever, they're still, I've seen them eight, 10 years later and they're still like, oh, I did the right thing.

(00:40:31):

I'm like, that's good. What you want is the patient to feel one, you want to know that you've done an appropriate procedure, but you want them to be happy with their choices too and how they are. How about recon? Did you have No, that was one thing that was, there were a couple of things that I didn't have. We did have oncology present on our campus and very good oncology, but we did not have radiation therapy and we did not have reconstructive surgery. And so that was something, again, by putting the brakes on a little bit and saying, this is one way to treat it, okay, if you want reconstruction, if you think you might want reconstruction, let's get you to a plastic surgeon first so that you know what the options are and see if it's right for you. And the plastic surgeons of course, want to do one procedure and stuff. And I think there's data that shows if people delay, if they have their mastectomy or lumpectomy or whatever and then delay any reconstruction things, they're less likely to do it. So there's some lost business now it turns out they're not any less happy. Okay. They're just less likely to do that. They come to terms with how they look and that kind of thing.

Dr. Randy Lehman (00:41:53):

I had a guy like that recently with an ear skin cancer, basically. I was kind of worried about the margin, so we just took it off and packed it. And then I was planning on doing the reconstruction of the ear with the Uck heel gram advancement flap later. And I mean, I can't imagine somebody not doing that. He comes back, he's like, I'm okay. My wife says, my ear looks fine like this. Yeah, there you go. You look like somebody, a dog bit part of your ear out. I mean, you're cancer free. You don't have to do it, but Right.

Dr. Stephen Bodney (00:42:25):

Yeah, I see that too. There some people, one doc in particular would send me stuff with people on their nose or their ear or something like that. And it was like, well, I'll tell you what, I can take that off. You might look like you went around with Mike Tyson and we can get you to somebody. You can do a better job. And they'd say, nah, I'm fine with it. I don't care. And it's like, okay, what does this patient want? What they're happy with?

Dr. Randy Lehman (00:42:53):

Well, I love doing those ear flaps and I rotated with plastics and that was a whole thing. I want to be able to offer that. It's just odd that the patient,

Dr. Stephen Bodney (00:43:02):

They don't always see the necessity, didn't want them. They don't always feel it. And the same thing with the breast stuff. They might not want reconstruction now if they wanted it. That's when I said, well, if you want that at the same setting, that's when I call up the breast surgeon in Louisville and say that sometimes they might've gone forward, except that's across that Ohio River and I'm not going that far. And plus you've developed a relationship with 'em and they say, I trust what you're doing. Let's take care of it. And if I want reconstruction later, I can always have it later. And I said, that's true, because they can always get it later. That's covered. They don't have to have it right away. So again, that patient relationship comes into play, which is something that if you're running the mill so to speak, you don't develop that.

(00:44:03):

Whereas if you've had 'em right from the beginning, you've walked 'em through all this stuff and they develop a real trust in you, they know you know what you're doing. You haven't let 'em wrong, and they know you care about what they think and you're working that way. And if they say, well, no, I still want reconstruction, I say, that's fine. We'll set you up with it. And that's one thing too. You can't have that big ego, I got to do this. It's me or nobody, a patient or even a patient's family. If they're saying, we got to, even if it's something that you know how to fix, I can fix this hernia or whatever. It's a little complex, but I can take care of it. No, we got to have this done by the specialist in name the major metro area. I says, well, okay, I'll get you set up with him. Don't worry about. So here showing up, that's the one that you'll have the complication.

Dr. Randy Lehman (00:45:01):

Real situation, my patient. Alright, tell me what you would do here. I'm dragging on here, but I got to ask you this question. So, alright. I have a patient comes to my office, primary care nurse practitioner, biopsies a spot on the outside of her upper arm.

(00:45:20):

The punch biopsy has removed the entire lesion. It comes back as melanoma situ two. She's sitting in my office. My question isn't even, it's nothing about anything. My question is, are we going to do it today in the office or are we going to go to the operating room and do it or schedule it another day? That's it. All you need is you could just do a centimeter margin and you don't need a sentinel node. And that's probably already completely out. So I kind of explain melanoma to the patient, talk to em about, and then go through my whole spiel, get to the end, and she's like, well, my daughter says that I should go to the Melanoma Institute of Indianapolis. Of course. Which I've never heard of. Right?

Dr. Stephen Bodney (00:46:10):

Right. Yeah.

Dr. Randy Lehman (00:46:11):

Me having done

Dr. Stephen Bodney (00:46:12):

Somebody who hung out a shingle,

Dr. Randy Lehman (00:46:14):

Right? Me having trained at Mayo Clinic, having done Hyperthermic, isolated limb perfusion therapy with Jim Jacob, take the leg, put it on bypass, run hot chemo through it, do the groin dissection. I know what the ivory tower is. I know when it's not something I'm going to do. And this is literally melanoma situ you on the outside of an arm of a saggy baggy arm and a 65-year-old lady. So I sent, I mean, what would you do? I mean,

Dr. Stephen Bodney (00:46:43):

I think so I'd say I'd let 'em know, look, this is something that I can do. I can do. Well, they're probably not going to do anything different. If you want to stay home and have it taken care of, we can do that. Like you said today, if you want to see the specialist though, had it good marketing on the melanoma institute's part, good for them. But yeah, totally as you say, pretty unnecessary. But if they're the fence, that's maybe one that you could say, look, this is well within my wheelhouse. They're not going to do anything different. But still, if they're telling you, no, I think I need to see the pro from Dover, well, we'll get you out of Dover then. And you can see the pro and because that is the one that God forbid, you inject some local anesthetic and she passes out conc, her head, you'll be talking to lawyers, whatever, because you didn't send her to the pro from Dover. All

Dr. Randy Lehman (00:48:03):

Right. I agree. I think we got to be very careful now if you can upfront try and help people understand what you're bringing to the community. And I try to tell as many people as I can. What I do here is something that I can easily look you in the eye and tell you that you're not getting anything better anywhere else. The other thing is, when I was in residency, I loved the people that flew in on their private 747 from Abu Dhabi land at Rochester International Airport, and they come and get their second year resident fixing their umbilical hernia, flying over thousands of capable surgeons on the way there because

Dr. Stephen Bodney (00:48:42):

It's the Mayo Clinic or whatever. Yeah.

Dr. Randy Lehman (00:48:45):

How do you explain this to people? You just can't. Okay, very good. Let's move on to the financial corner. We've probably beaten that one to death, but I was just wondering if you had one practical money or practice management insight that you've learned you'd like to share with the listener? Oh,

Dr. Stephen Bodney (00:49:00):

Let's see. A couple of things. One is save early and save often for your max out your retirement plans. I mean, really maximum out whatever, 457s, 403(b)s, 401(a)s, whatever it is you have max it out. Believe in the, it was funny, one a time somebody was asking around in the, OR doing some minor case and somebody said, what do you believe in? What do you believe in? You see that on TV or something sometimes. And the anesthesiologist says, I believe in the power of compound interest. And it's true, unless you're really into the markets and understand 'em and stuff, get a financial advisor, but understand who they are. I ended up on a third one eventually, and it doesn't necessarily mean that somebody's bad, they just might not be the right fit for you. The first one, he was first gave some sound advice, but he was an insurance guy, insurance

Dr. Randy Lehman (00:50:03):

Insurance.

Dr. Stephen Bodney (00:50:04):

So his answer to everything was an insurance product. Now, some of 'em were good and some of 'em are not so good, but that was the answer to everything. One was the guy who's very good, but since I didn't have multimillions of dollars of assets, I was on the low end of his list and then finally found one, it was a crook. We learned that pretty quick and stayed away from him, but then found one that I seemed to understand and pay for the advice, a reasonable fee, but get good advice and that kind of thing. And this was somebody who was an independent, so he wasn't trying to sell me his product or anything like that. He said, here's what I'd recommend you do, whether you do it from me or get it from somewhere else or whatever. That's up to you. He says, I can sell it to you if you want me to, but if you have some other broker or some other insurance agent or whatever you want to, that's fine too.

(00:51:08):

You're just paying me for my advice. Here's my advice. So the independent financial advisor. So those are, that's really great tips. As far as a practice financials, I was employed, I was employed by the army and then I was employed by hospital. So not too much from that point of view other than, as I mentioned earlier, especially if you're after a new program or a piece of equipment, make the business case, learn the business case, learn how your CFO talks so you can make the business case, because that'll go a long way towards, again, if you just go and say, well, I need this expensive piece of equipment, and then it sits there next time you come by and say, well, I need this other expensive piece of equipment. They're not going to be that interested. They're going to say, so you got to learn that talk and learn that. But yeah, save relief, save often.

Dr. Randy Lehman (00:52:08):

Yeah. Thank you very much. If your financial advisor is trying to sell you insurance and turn around and run. Yeah.

Dr. Stephen Bodney (00:52:14):

Sounds good.

Dr. Randy Lehman (00:52:16):

Next segment of the show is classic rural surgery stories. Do you have a classic moment or a case that could only happen in rural practice?

Dr. Stephen Bodney (00:52:23):

Yeah, there's a couple. One of 'em I guess could happen in any, it was a guy drives himself to the yard with a thorac abdominal stab wound, and I just happened to be there, but that was in with a hole in diaphragm and a stab to the spleen, which I did not have to take out. He was lucky a drug deal gone bad, but that could happen everywhere. But with his dad, one that I think happened more likely and in not downtown indie or whatever, was a patient that with a pretty much a nearly complete obstructed distal colon from diverticular disease, just sat in the ER for three days and say, well, how the hell did that happen?

(00:53:16):

And how did I get involved in that? Well, this was when I was slowing down my practice some, so I wasn't taking full-time call and I was off for whatever, a week or whatever and come back on a Monday morning. And at the time, we didn't necessarily have full-time surgery coverage. We had it mostly covered, but there were some days we didn't have a surgeon. And the weekend, it happened to be one of those where we didn't have a surgeon. Well, there was somebody came in on a Friday, and this was post pandemic, it was winding down, but the tertiary care centers, you may recall were full still. They didn't have beds. Well, somebody came to our ER that looked like they had a chronic obstruction near complete, not complete, but almost bloated, the usual stuff they did. And she just had a colonoscopy. It was less than a year before.

(00:54:16):

So we're pretty not malignant, very highly unlikely to be malignant. And they got ahold of the surgeon that was on call on the Friday, and he said, wow, she's morbidly obese. They said, that needs to be out of here. I'm not going to be here Saturday or Sunday anyway, and she needs to be out. And they said, sure. They call up one of the Louisville hospitals, get colorectal surgeon accepts them, everything sounds cool. We'll just wait for a bed. We'll transfer when we get a bed available. Well come Monday morning, they still don't have a bed available. I come into work and the ERI calls me and says, we've got this lady that's down here and she's just waiting for a bed, so she's already been accepted, blah, blah, blah, but I just need to know if there's anything I can do for her until she gets a bed. And I said, well, when are they going to get a bed? Well, we don't know. And I go down to look at her. I says, what does she need? And I said, well, she needs surgery.

(00:55:19):

That was pretty easy. And they said, but this is going to be a disaster. And so I actually ended up calling the colorectal surgeon and it's very helpful, but it's like, we just don't have a bed. I said, well, that's insane. Here's okay, I'm going to dive in on this and you'll get the complication. And that's what I did. Went in very difficult. She'd had prior surgery. It was all stuck in there, and it was diverticular mass due to blow-out and try to drain what I could and stay out of trouble and close her up. And so when you go get put back together, you're going across the river there. And the patient survived it all. She was very happy. But that was something, that kind of thing. I don't think you'd see too much at the tertiary center because well, you're already there.

(00:56:17):

Another, that was a weird time. I am glad that that has mostly resolved. Yeah, usually you can get 'em in. And that's one thing you need to, I think do, is make sure that you have a relationship with your tertiary center so that you can actually talk to somebody there and not just have it go through their care coordinators and yeah, we're okay. We're waiting about, but you can talk to somebody and give 'em 'em the scoop on what's going on so they can get a sense of how urgent or not urgent this needs to be. And the other thing, I think as a real surgeon, you need to get comfortable with stuff. Sometimes you hear the folks at the tertiary center say, well, they send us this garbage because well, they're just not comfortable and they think we're lazy and stuff. Well, that might be the case occasionally, but usually it's because we have very limited resources.

(00:57:11):

Your anesthesia provider might not become, somebody weighs 450 or 500 pounds and they're there alone. It's not like we have other people around to help us out. Sometimes we're just busy. I sent something up to Indianapolis one time that clearly needed some surgery. She had a G-tube that was in the wrong place and had a belly full of, was actually doing clinically fairly well though. And she didn't want to go to Louisville, which is closer because she just came from there and the family was convinced they're the ones that screwed this up. Anyway, so I'm trying to get her to Indy, and the surgeon up there says, are you sure she's stable and you can't do that? I said, well, I can do it, but I also got somebody with, I have a bad gallbladder that that's going to wait, but I have an at, and then I have somebody else with a perfect intestine.

(00:58:02):

So it's like, I'm plenty busy here. And this one, she's going to need a little more than what I could do on a good day, but she's stable enough to head up your way. And we got a helicopter here that can take her there pretty quickly and that kind of thing. But you do have to be comfortable with some stuff. You can't just send it all up to 'em. That's not really helping your hospital out very much. And again, that adds to the backlog up there. So then when you really do need something, gee, we don't have a bed because we're full of all this stuff that somebody wasn't comfortable with. So you got to learn your limits, but you got to sometimes push 'em a little bit and get comfortable with other stuff.

Dr. Randy Lehman (00:58:46):

And I think in your words, it takes five to six years to learn how to operate, but a lifetime to learn

Dr. Stephen Bodney (00:58:50):

Not to when not to. Yeah, yeah, yeah. Another rural surgery story, and this was more of a community story that's kind of funny. This was 2016 was Indiana's bicentennial, and there's a parade in Corydon was its first state capital. And so there's a parade that's kind of significant there. And one of my little hobbies too is I'm kind of a World War II history buff and my midlife crisis, instead of getting the convertible and the new blonde and that kind of junk, I got an Army Jeep. So I have a World War ii Army Jeep that I fool with, and I had it in the parade. And with me, I had three World War II Army vets, and I'd done surgery on all of them, and that doesn't happen. That's cool. In the major metros. And so they're writing through me in this parade. Three guys that I've done surgery on World War II vets.

(00:59:47):

In fact, one of 'em is, there's a picture of 'em in one of the, Steve Ambrose, I don't know if you're familiar with him, historian, what's the book? Citizen Soldiers, the name of the book. And I'd read that. And there was a picture Battle of Bulls where one of the guys and somebody else, they're digging out their frozen sleeping bags and it says, Sergeant so-and-so. And I said, Hey, that's this guy. I did something. So I have his signature in my book by his picture. And so there's a rural surgery story that, not really true, a medical disaster kind of thing, but that's the kind of community thing that just doesn't, I don't think I would've gotten that if I was a cog in the wheel at some major church race center or something.

Dr. Randy Lehman (01:00:40):

It becomes very personal, and you go to the county fair and you go to get your groceries and just everything that you do, you go to church and all of a sudden you have this, you're really integrated. And so I think that's one of the most attractive things of rural practice as well as a broad based, I mean, there's lots of things that we could go on and on about. Oh yeah, I agree. So we better take it to a close. We've got the last segment of the show resources for the busy rural surgeon. What do you recommend that you generally use and recommend for a rural surgery?

Dr. Stephen Bodney (01:01:12):

Right. Okay. A couple of things. For one is I'll put in a plug for the American College. Okay. I went through the ranks, was the governor, all that kind of stuff. Excellent educational opportunities. Their website is also great for practice management and they have some that are geared for rural surgeons also contract review. And I highly recommend that whatever contract you're going to sign, whether it's with the local place or the major, whoever the major employer is of physicians, have an attorney review it. And why is that? Well, they're not going to change anything. Why should I pay money to do that? Because the attorney can tell you what you're signing, you're smart, you're a physician, a lot of things. But attorneys, they work in words the way an artist might work in oils or something, that's their medium. And little words mean certain things and they can tell you even if you're not going to be able to change it, they can tell you what you're signing so you're not surprised. Later. I knew one surgeon that when he was quitting somewhere, he didn't even know that he had a non-compete clause.

(01:02:37):

Pretty important stuff. And when I was hiring on, there was somebody I'd interviewed with that I was working through a contract and the attorney I had reviewing it, he was like, I don't know, there's just something I don't know, it's not quite right. And to me it looked okay, but to him something was a little off and that guy ended up not hiring me, hiring somebody else. And then I ended up at Corydon and when I showed the contract that the Corydon hospital he's looked at and he said, these guys want to hire you. And to me they looked fairly similar but to an attorney it was like there's a world of difference here.

Dr. Randy Lehman (01:03:18):

What did chat GPT say about your contracts?

Dr. Stephen Bodney (01:03:21):

I never ran through chat. GT didn't have that at the time, but that's, I think pay somebody to do that. And again, with the American College, they can actually give you a reduced rate on it. So I think it's a really excellent resource for all that. And then another, here's my use UpToDate. And the reason that I use that is for the weird thing that patient will show up with that they went on Dr. Google and said, doc, what about this? So you can go up to date, at least get some reliable information for something if it's something that you're not that familiar with or something. So those, well, nice

Dr. Randy Lehman (01:04:05):

Thing about UpToDate too is it gives you CME for just browsing.

Dr. Stephen Bodney (01:04:09):

Yeah. So those are a couple of top things that I like.

Dr. Randy Lehman (01:04:15):

Alright, well Dr. Bodney, thank you so much. This has just been a wealth of information and I'm so glad fellow Hoosier coming on the show and giving me your perspective. So thanks again for coming on. Thank

Dr. Stephen Bodney (01:04:25):

You so much for the invitation. And I hope I didn't bo people with my boring stories of glory days.

Dr. Randy Lehman (01:04:33):

If they're still with us, I'm sure they're pleased. If they're not, then who cares? It was just me and you talking. Yeah, right.

Dr. Stephen Bodney (01:04:41):

I appreciate it, Randy. It's excellent.

Dr. Randy Lehman (01:04:42):

What a great episode with Dr. Poney. I hope you enjoyed it as much as I did. Thank you for listening to the Rural American surgeon and I wanted to remind you that I am looking for a partner, possibly two in the next two years or so to join me in rural northwest Indiana. And that would include a practice, much like you've heard described here on the podcast, also with a sort of spoken hub model with another opportunity. So if you are interested in that or of somebody that would be a great fit, please submit on the rural american surgeon.com, a submission in the form there. And I will get back to you. And I really appreciate you considering. I also appreciate you as a listener and keep up the good work out there in rural America. And I will see you on the next episode of the show.