EPISODE 58
Building a High Quality Rural Breast Surgery Program with Dr. Jill Ties
Episode Transcript
Dr. Randy Lehman (00:00:00):
Welcome back listener to the Rural American Surgeon Podcast. I'm your host, Dr. Randy Lehman, and I'm so honored to have with me today Dr. Jill Ties from Wisconsin. Thank you, Dr. Ties for joining me.
Dr. Jill Ties (00:00:17):
Absolutely. Thank you for the invitation.
Dr. Randy Lehman (00:00:19):
So let's start with an introduction of you and I would say we have yet another ACS governor on the show. I'm so proud and honored to have you. I'd like to hear about how that all happened and also [00:00:30] just your practice background training and how you became the rural surgeon that you are.
Dr. Jill Ties (00:00:34):
Yeah, absolutely. Thanks. So I think it's a little bit of a long story. I grew up in a little bit bigger town. The only thing I knew going into medical school is that I didn't want to be a surgeon. So that didn't work out super well for me. I didn't get into med school the first time I tried and I ended up doing some research for a while and I worked with some surgeons on research and I think they kind of saw in me, what I [00:01:00] didn't see in myself was that I really liked process and quality and I liked being done with something at the end of it. And I tried my very best to not like surgery throughout my medical school career, which again started one year late, which felt like a hundred years. And now I'm just like, man, that's the greatest to have a year off.
(00:01:21):
So I just kind of built some relationships with surgeons and learned about what they did and really enjoyed them. And it was interesting because they're trauma surgeons and I really don't do much trauma [00:01:30] at all now and I really don't like it, but I sure liked it at that phase in life, which I think is one of the things about rural surgery is that it works for all phases of life. I then through the mentorship of some folks who really invested in me during my medical school years, they thought we looked at all the different types of programs and what we might want and what would fit best. And they directed me to apply for a little residency in lacrosse Wisconsin called [00:02:00] Gundersen Residency or the Gundersen Fellowship, I believe what they call the Gundersen Foundation now. But it was Gundersen Lutheran at the time. There was just two residents per year and interestingly for the last maybe decade prior to me joining, a female resident had not graduated from that program. Oh wow. So I really didn't think that I had a super high shot at getting in there, but I did go and do a rotation there. Really liked the program, liked [00:02:30] the people, and then again found that when I matched there that really investing in the people that were there and valuing their mentorship is really valuable still to me to this day. So I trained there and I
Dr. Randy Lehman (00:02:48):
Interrupt you real quick, just a great program. That was my number one. Of course, I ended up matching at my number two, which was Mayo Clinic. Now we had Mel Johnson on the show. Obviously the Gunnerson program has just [00:03:00] made a huge impact in rural surgery nationally and helps shape a lot of other training. Was Dr. Cobi or Dr. Jarin there as the PD when you
Dr. Jill Ties (00:03:08):
Were there? Dr. I was Dr. Cogbill's last intern class. He was kind of handing over the reins to Dr. Jarman the year that I started. So I was kind of his last in Jarman's first, and they both are absolutely the giants whose shoulders we stand on to this day. [00:03:30] Fantastic human beings. And I feel very fortunate to have met them both and could tell a lot of stories that may or may not be podcast appropriate
Dr. Randy Lehman (00:03:42):
If you have any that are, we can talk about 'em, but sure. But anyway, let's go back to you. So after residency then, where did you land?
Dr. Jill Ties (00:03:50):
So during residency, had thoughts. I really loved breast surgery. I like that a lot, but I also really love general surgery and I love taking care of lots [00:04:00] of different issues. There was a time in my residency where I thought I was going to do only breast surgery. I was going to do a breast fellowship. I even thought about doing some reconstructive work considered plastics, and I was kind of in that line of thought when I fell in love with my husband, which wasn't part of the plan at all. And he grew up in a really small town. I also had at that point set up a rural rotation just because [00:04:30] I wanted to know what it was like. And it was right about that same time that I had gone and done an international rotation in the Dominican Republic and through that international rotation as well as the rural rotation that I did in Prairie du Chien, Wisconsin, which I know you're familiar with, I just really fell in love with the idea of being able to take care of so many things, being able to really be an important part of a rural hospital. Thriving.
(00:04:58):
Obviously as we all know, there [00:05:00] are decisions that we make that by saying yes to one thing, you say no to another thing. And there were things that I really loved about a busier tertiary care practice that I just aren't part of what I do anymore, but there are things about my current practice that I really love and I don't think that I could imagine a better fit for myself or for my family. So anyhow, I came while I was in residency, then decided that I would like to at least look at rural practices. [00:05:30] I came up here to St. Croix Falls, Wisconsin to interview and actually I'll tell them, and I have told them multiple times that I actually came to practice interviewing here. I didn't think this was going to be my fit. I really wanted to be closer to my family and maybe closer to or closer to my husband's family.
(00:05:45):
We're about two and a half hours from his and about six from mine. But it was a great fit. And the reasons I really liked this practice, it's an independent hospital. I think that I have a little bit more [00:06:00] autonomy to help shape my practice to what the community needs. There was great support for breast surgery, which even though I didn't want to do that only, I wanted to do a lot of that. I'm one of the little bit weird surgeons who really like C-sections as well. So I had an opportunity to do that here. I had very supportive partners. It's a multi-specialty group. It's kind of a gem of a hospital because it is definitely rural. We are critical access. We're 25 beds, [00:06:30] but we have had a large range of surgical specialists that I've been able to work with while I've been here from EMT to orthopedics to urology, gynecology.
(00:06:43):
We help each other and I think we all get better when we learn each other's work. So I think mentorship has always been important for me and that was I think probably the number one reason that I chose to come here. Great partners and a great multidisciplinary practice, multidisciplinary medical practice too. [00:07:00] So the cardiology and the pulmonology and the things that I just don't really have the expertise in, it's good to have those experts. I think that what I've learned about rural surgery is that patients shouldn't have to have worse care because they're in a rural hospital, but we have to figure out how to do what we do as well or better than the people that are down the road in the bigger hospitals. Our patients need to be cared for. Well. So it's been great to be able to do that with a multidisciplinary [00:07:30] group.
Dr. Randy Lehman (00:07:30):
Preach. That's exactly what we're talking about. Absolutely. You've kind of covered the why rural surgery, why you're there and why it matters. I mean that's exactly what we talk about all day every day. I'd like to go straight into how I do it, which we wanted to talk about how you were able to develop a breast practice in a rural place and do it at a high level and then we may have some bonus how I do it as well. So if we could keep moving, tell me first [00:08:00] how you started, what did it look like when you started? Were they doing that surgery there and then what needed to change over the, how many years have you been there?
Dr. Jill Ties (00:08:09):
I've been here for 13 years now.
Dr. Randy Lehman (00:08:11):
Yeah, over the 13 years you've been.
Dr. Jill Ties (00:08:13):
Yeah. Alright. So I had one partner when I joined and my partner when I joined was very busy and didn't love breast surgery. Would do it occasionally if there was an elderly patient who needed a mastectomy and didn't want to go somewhere else. [00:08:30] That was really the cases that he was doing and he was doing a beautiful job with them. The patients did well, but he understood and as all of us who do breast surgery, that it's such a multidisciplinary field, it moves so fast, you really have to be engaged with the other members of the team and also the literature on a really regular basis and with all the other stuff that was going on, there just really wasn't the capacity for that. When you bring in a new partner, as I'm sure [00:09:00] suddenly there's a lot of capacity in the practice. And so in those first couple of years when it wasn't as busy, I'm kind of stubborn.
(00:09:12):
So I would say first of all, just having a certain degree of stubbornness and bullheadedness to actually bring the process through is important. That's why they brought me there. And I think that that's the first piece of building a breast center is that your goals and the goals of the administration that you work for have to [00:09:30] align because if I didn't have the support of my administration, none of this would've happened. They're fantastic and very supportive and we talk about common things being common and things that we can do well in a rural hospital. And I think there's absolutely no reason that with appropriate support, you can't do breast surgery well in a rural hospital, but if you're not going to have the support for things like a navigator or a multidisciplinary tumor board or [00:10:00] processes that help support patients through their diagnosis, it's really hard to do this well and in a way that patients find to be appropriate and our colleagues and our societies find to be adequate.
(00:10:11):
So I think that aligning with administration was really the first and major thing and that continues to be a piece. Certainly I know what I want to do, but we also have to be realistic about what we can do. So I think then you get into the process of compromise on that. [00:10:30] So I came the process, the general process for a patient who was getting a biopsy from abnormal lesion was that they would get their screening mammogram and then that screening mammogram would get read and they'd get a letter in the mail and that letter would say that we need to bring you back. And then per MQSAs a regulations that can be anywhere up to 30 days that it takes for those patients to get that letter. And then they would call and they'd have to make a schedule for their diagnostic and then, oh, just kidding, we need an ultrasound too.
(00:10:59):
And then after [00:11:00] that, then they would need to be biopsied and then who's looking to see if they're on an anticoagulant. And so sometimes this process, even though it was absolutely following the absolute minimum of standard of care was and probably is absolutely medically appropriate, really wasn't what you would want for yourself or for your family member. And so I think the first thing we did was really look at the data and look at the experience that the patients were having. And I think being data driven and quality driven is critical. So we found that I think the average, [00:11:30] this is a little fuzzy in my head right now, but the average from an abnormal mammogram to getting a biopsy was somewhere around 32 days. And personally I just didn't think that was good enough. And so we started working on processes around that and we developed what we call breast batch hours, which when a patient had an abnormal mammogram, it went to a specific person in the radiology department who then owned that process.
(00:11:55):
And until that person was through the process, they owned that process. And then [00:12:00] we also scheduled that the mammogram and the ultrasound and the radiologist would all be available on the same day. And that just absolutely revolutionized things to the point where now it's from an abnormal mammogram to having a biopsy and a diagnosis is generally less than a week, often less than a couple of days. So I think that matters. It matters for patients, it matters for reputation and it matters in the community. That's the kind of things that patients talk about is how you cared for them and how they felt. And obviously doing [00:12:30] it in a scientifically and care focused way is really important too. How did you market that? So that's been a process.
(00:12:42):
So we started with, so actually it was the navigator originally when we started. And so I was really keeping track of that stuff very carefully and that was when obviously at a time in my practice where I had a little bit more bandwidth from a time perspective. I'm pretty busy with some additional things now, but I remember [00:13:00] when I was first starting, I always say that my referral docs are my customers, my patients are my patients. So my first and most important marketing has always been to the people who refer patients to me. My goal in interacting with those people and with interacting with their patients, I mean they're our patients, but there's a really special relationship that patients have with their primary care doctors. And I think that the first hurdle I came up against [00:13:30] is that the primary care doctors wanted to own the process or at least know that they could trust the process because this is so personal for patients.
(00:13:37):
Their relationship is so sacred, right? They've been friends and partners and doctors and patient for so long that they wanted to feel like they could trust the person whose hands this is in. On my side of things, I wanted to have ownership of the process because I think we all know what happens when five or six different people call and the nurse calls and the doctor calls and the radiology department calls and everyone gives [00:14:00] a slightly different story that frustrates patients and it makes them scared and rightfully so. What we did was we first worked with the docs in our group and said, this is what we're planning to do. We started with a small group, small focus group that was really on board with the idea of breast surgery. We said, this is what we think we can do. Do you think this will fly in the practice?
(00:14:21):
And it was things like when the biopsy comes back, the breast center will call with that biopsy and give them their next steps. We promise you we'll do that within 24 [00:14:30] hours. We'll send you a message to let you know that we did it and we are 100% happy. If you want to call your patient and offer that support, do it. But we want to have the plan in place even before you make that phone call. And they were 100% on board with that. They loved that because those calls in their busy days are also, they're hard calls talking to patient that way. I think that way as the EMR has evolved even within my practice, I think if people talk about how nice it would be to have that conversation [00:15:00] in person, rarely are we able to do that anymore because those results are released to patients immediately.
(00:15:06):
You can't beat the results. Even if you had a 100% open door, you can walk in and have a consult whenever you want policy. You can't ever beat those results. So having a process was really important. So once we had the buy-in of a core group of the primary care docs, we then worked with all of them and told them, look, I want to be your easy button. I want this to be the easiest consult [00:15:30] you do. Just call me. I'll help you. I'll take care of it. So if you have a patient clinic who has an abnormal exam, we want to see and we want to help. So I think sometimes you get to do things that maybe aren't your favorite when you make yourself that big of an easy button. Things like a lot of breast pain consults and things that make us less thrilled, but you build trust that way. And oftentimes those breast pain patients end up having something that you need to talk about, whether there's a lesion, whether there's a high risk [00:16:00] lesion, whether there's dense breasts. I think that none of those experiences are wasted. So as we built the program internally, we then talked about numbers, we built the processes, and I think having the program built to some extent before you really majorly market as important because you don't want to go to the patients and then not have the processes to support that. So I then went to our administration.
Dr. Randy Lehman (00:16:30):
[00:16:30] You started with the doctors before administration or was it simultaneous?
Dr. Jill Ties (00:16:35):
Administration was in support of the process of building breast surgery. But if I just talked with administration and said, well, we're going to do this and we're going to do that and we're going to do the next thing, and you don't engage with the partners in the practice, the primary care partners in the practice, I always find that asking people as opposed to telling them works better. And to some extent, once you have a critical mass of people that support, [00:17:00] then you tell the rest. And I had people who let me know that they don't think that mammograms are standard of care. And I had patients, I had physicians, I had people who would say things like, well, why aren't you guys doing thermograms and things like that. And so there was great opportunity for education and for camaraderie and for building the practice that way and for engaging honestly. I feel like even questions that make you frustrated at least are engaging. You want people to be on the same page with you [00:17:30] and it gives you opportunity to interact with them. Right,
Dr. Randy Lehman (00:17:34):
Yeah. Before you go to the next, so how big of a catchment area do you think that a surgeon would need to have to be able to success or how small of a place would be like, don't even bother. It's not worth it. I see here that St. Croix Falls is a town of just over 2000 people according to wikipedia.com. But it does say Polk County has a population of around 45,000. Correct. So what do you consider the [00:18:00] catchment area for your hospital? Are people coming from Minnesota as well and then at what point is it too small?
Dr. Jill Ties (00:18:07):
Yeah, so our location there, our geography is really interesting. As you pointed out, we're right across the St. Croix River from Minnesota. We're about an hour outside of the Twin Cities. We're north and west of the Twin Cities, excuse me. We're north and east, they're west of us. And so we don't get as much from the Minnesota side. [00:18:30] We do have, our hospital is kind of the center of our hub. And then we have, I believe five community clinics. One of those community clinics is right across the river in Lindstrom, Minnesota. So we do get some patients from that side. I would say we get a lot more patients from north of us, so we get into Burnett County as well. Danbury Webster area, we consider our catchment area to be around 70,000, but there are so many systems [00:19:00] around us that we aren't unopposed in this area. There's the Mayo system and the health partners system. There are a couple other independent ish hospitals. Not all of them are. There's always so-and-so has a seat on so-and-so's board and things like that. Ours truly is independent, which I think has been really helpful for me and for our practice.
Dr. Randy Lehman (00:19:24):
It's county hospital board run county hospital.
Dr. Jill Ties (00:19:26):
It is a 5 0 1 C3 nonprofit hospital. [00:19:30] The board of trusTiess is the ultimate authority of the hospital. It's owned I guess by the community. We obviously run our finances in the hospital and the community. The mayor doesn't show up for anything, but it's not owned by a hospital system.
Dr. Randy Lehman (00:19:48):
Do you have a percent market capture that you think of those 70,000, like Mayo has 10% and whoever else?
Dr. Jill Ties (00:19:57):
I don't have that data in front of me right now. [00:20:00] I have seen it and it depends on the service line, what the it not percent? Oh no, absolutely not.
Dr. Randy Lehman (00:20:07):
Okay. And then I did some seer looking and basically it's 130 per hundred thousand new diagnosis of breast cancer. So that's like every thousand people. You've got one new breast cancer. So presumably say you have 70,000 catchment, but maybe you get 60% of that. I
Dr. Jill Ties (00:20:28):
Think 60 would probably be generous.
Dr. Randy Lehman (00:20:30):
[00:20:30] Okay, maybe half. So maybe 30,000 say so say of those 30, so then you get 30 new breast cancers a year. Do you think that that's true? Or how many are you actually, how many new breast, obviously there's abnormal mammogram and you've got to bring those people through and get 'em an answer quickly, which is a higher number than your actual new diagnosis of breast cancer. But with where you've ended up, how many breast cancer cases are you able to do per year
Dr. Jill Ties (00:20:55):
Now? So it depends on the year. We're somewhere in the 50 to 80 new [00:21:00] cases a year, which we currently have two breast surgeons working. So you kind of work that out. It's a new breast cancer every week or two for each of us, which works out really pretty well. I think it's kind of a sweet spot where you have enough cases that you're seeing a lot and doing a lot, not so many that you don't know the names or who's who in your practice. I do think that volume matters to some extent just because [00:21:30] you're forced to keep up on the things that you see all the time. Maybe there are docs who are super duper self motivated to read about stuff. They never see. I'm not that doc. I read a lot about the things that I do see, but I think that volume matters and it matters for patients too because I think as you build the volume, you also have the systems and so they feel confidence in the system that the system knows how to help them and how to care for them.
(00:21:53):
And we really are very careful about speaking well of [00:22:00] our teammates, our navigators, our mammogram techs, et cetera, and everyone, we've built a team where there's respect among the members. And so it's not a lie when we speak that way, but it's important that our patients see that this is a team. I think that having it be a team is really important. As surgeons, we want to be, we've been trained to be the captain of the ship and a lot of responsibility falls on us, but I think the best thing that I ever did was I hired a to be, I got to participate in the process of hiring a gal [00:22:30] who is our navigator. And in the interview process I said to her, what I really need from a navigator is that the navigator needs to care more about these patients than I do. I said, and I don't think you can do it. Sure. And I think she has. She's absolutely fantastic. So building a team of people that you trust because is
Dr. Randy Lehman (00:22:50):
That person an rn?
Dr. Jill Ties (00:22:51):
She is an rn, correct. Yeah, and she has a background in public health. She's local to the area. She knows [00:23:00] a lot of the systems in the area and is able to interact really well with them and then also has that system basis. So she's able to help with building, she loves data, she loves collecting data and trying to figure out things that matter. So she does a fantastic job, but I think as surgeons, we can't be all things to all people and nobody can be right. You can do it all, but you can't do it all at once. So I can't call patients while I'm operating. I can't call patients to try [00:23:30] to discuss their new cancer diagnosis and when I'm operating as business hours. And so when I was navigating by myself, I was the one who was calling people at eight o'clock at night with these diagnoses and just having a process that you trust. I think the other piece is what happens if I get run over by a bus or have a baby, which I did three times during the process of building the center. It's just really important that the processes move forward and it doesn't matter who's in each seat that [00:24:00] the roles are defined.
Dr. Randy Lehman (00:24:02):
I'm maturing also as a surgeon. I'm almost six years out and I just hired Now you're hospital employed and always have been, right?
Dr. Jill Ties (00:24:12):
That's tricky too. Yes. Currently I'm I'm hospital employed. When I started with the practice, there was a multidisciplinary, technically private practice group that was employed or was hired by the hospital. There was a medical services agreement and that stopped [00:24:30] maybe seven ish, eight ish years ago. And then that whole group,
Dr. Randy Lehman (00:24:35):
When you're that close, just say six, seven, you're so close, seven,
Dr. Jill Ties (00:24:39):
Eight. My kids would love that. That's good. So that was, yeah,
Dr. Randy Lehman (00:24:47):
There's different ways that you can
Dr. Jill Ties (00:24:48):
Do it. It's always felt like an employed position.
Dr. Randy Lehman (00:24:51):
Sure. Well, I've kind of turned it into this contracted single specialty, which is general surgery, I guess wound care in that too, endoscopy in that too [00:25:00] sort of thing. And we're growing and I've hired a surgeon and now I just hired a person that's more in terms of strategy and it's realizing that things aren't moving forward in my practice because there's a key email that I haven't sent, and once I'm done with my clinical work and I've got a 7-year-old and a 9-year-old, I feel like the highest and best use of my time. There will be many doctors for your patients [00:25:30] and there can be many husbands for your wife, but there will only be one father for your children. I don't agree with that middle one, but that's how it was told to me when I was a resident and there's just certain times certain things got to happen. So then there's delay. If you can have somebody that can take time during business hours and do those things for you, I'm sure many different ways that can apply, but that's the leverage of somebody else actually can care. And [00:26:00] that's very interesting that you said that can care as much or more about the thing that you care about than you do. It's just finding that right person. So very inspirational.
Dr. Jill Ties (00:26:10):
She's been fantastic, but it's also a process to build that person so you can't just hire somebody and throw 'em out there to do it. That was also in those times when I had more time on my hands and now she does so much of the work that I used to do that it's just absolutely fantastic and I think she [00:26:30] does it at least as well. The other day I had, it's a while ago now, but for many reasons I didn't have a navigator around to help pull together the PowerPoint presentation to do for tumor board. It took me a full day and I'm like, I do not know how she does this, but we all have our different things. She doesn't do surgery real well.
(00:26:52):
So I think that getting first buy-in from administration, second, engaging your primary customers [00:27:00] who are the physicians who are going to be referring to you and assuring them of the care level that you'll plan to give. Third and probably most important is a strong navigator, which is part of the processes in the system and getting people on board. I remember a really interesting conversation that we were having when we were trying to get these batch hours up and ultrasound tech who I love dearly and I respect just absolutely love her, respect her. I said, no, well this is what we have to [00:27:30] do. We have to call patients within so and so hours. We have to get their biopsy done within so and so hours and this is why. And we looked at data and so forth and she's like, well, I can't do that because I can't do the same thing for the liver patients.
(00:27:43):
I said, well, how about we worry about improving everybody instead of holding people back artificially because we can't. I said, and I promise you, if you have breast cancer, these are the processes and I'm the surgeon that you want building these processes. [00:28:00] We have to happen. This has to happen for patients, for their outcomes, for our reputation, for the relationship that we build with people. And she actually became one of our very, very best supporters and advocates for our practice. So I think that just being forceful but not too forceful. I think at the beginning I probably came out a little strong and have really focused on building relationships and building a team, which has been really important. And then obviously working [00:28:30] with the marketing systems within the hospital about how we market. We do market directly to patients in the region. There are billboards, there are newspapers.
(00:28:38):
They market through social media, so digital marketing as well. And we have in the past done some events where we've brought women into the hospital for additional education around breast care and just to get to know the team and kind of demystify some of that, which I think has been really, the patients in a small community tend to be very proud of their [00:29:00] hospitals. And so they love to come and interact and say they know the surgeon and the surgeon's a friend or that they live in the same town or whatever. So I think that being personal and being approachable and being part of the community is really important too.
Dr. Randy Lehman (00:29:13):
Yeah, that's perfect. The reason I say that is there's a lot of things that I do and I just feel like nobody knows. Nobody really. There's all this background and I dedicate my twenties to it, come and be there. It could be anywhere in the world, but choosing to be there and what that actually means, a lot of people, [00:29:30] it's hard. And so I find myself trying to do it one-on-one with patients when they're in my office and they come back, they're done and they're all happy and they're discharging and they give me a compliment. And so then I just take that opportunity to say, Hey, if you were going to do something for me, spread the news. Tell your primary care doc. We took good care of you. Could you do an online review for me? I take the compliment and ask them for something back. No, that's smart. But that's one thing at a time. And if you can get the hospital marketing this [00:30:00] whole thing behind you, it's another thing is I'm not the best marketer. Somebody else could definitely do a better job. So very good. I like to talk about technical stuff too. And so is there anything else system that you really wanted to cover there? I got a good handle on how you made that a success, but yeah,
Dr. Jill Ties (00:30:19):
I mean I think just the one thing I think I've mentioned briefly, but data matters. So keep track of your numbers, keep track of your outcomes. We keep track of our re-excision [00:30:30] rates. We keep track of the hours from our diagnosis to biopsy and from biopsy to surgery. We make sure that we're getting within those appropriate windows and we work on quality projects as a group. I think those things are really important too. It helps with team building and it also obviously helps with outcomes and being able to say that we have quality because we started the show with a patient should not have worse care because they live in a rural area. In fact, I would argue to have better care. I think one other thing that I didn't specifically mention is actually having the [00:31:00] resources to do the quality care. And so things like I have a plastic surgeon who comes and works with me once a month.
Dr. Randy Lehman (00:31:07):
That's exactly what I was going to ask. So perfect.
Dr. Jill Ties (00:31:09):
We have an MRI machine, so we don't have to send all of that out. So having enough infrastructure to actually keep care close to home is important.
Dr. Randy Lehman (00:31:18):
Okay, good. So a lot of my listeners are, first off, I like to call it a listener because it's only one person listening. They have their podcast or their earbuds in and is just me and you and one [00:31:30] person listening right now, which is kind of cool and very intimate and awesome. And so thank you listener for being here. The average listener is somebody early in their training. So from a high level you have breast cancer, we'll say there's other things that are non-cancer that may need surgery, but what are the operations? Forget the indications. It's too much for one thing. So the operations are lumpectomy with or without a sentinel lymph node biopsy. The other operation is mastectomy. [00:32:00] I mean you can talk contralateral mastectomy,
Dr. Jill Ties (00:32:03):
Mastectomy with or without reconstruction, with or without nipple sparing with or without skin sparing. And then complete axillary dissection. And excisional biopsy I would say is the other one.
Dr. Randy Lehman (00:32:14):
And if you wanted to, you could throw in oncoplastic, but we don't want to.
Dr. Jill Ties (00:32:19):
We do. I love it. So I think that's all part of continuing to grow your practice.
Dr. Randy Lehman (00:32:25):
I mean, it's not that we don't want do it, it's that we don't want to talk about it on this show because [00:32:30] we're going to exhaust ourselves. I want to ask some very quick hit questions on how exactly you're doing lumpectomy, and then really what I want to talk about is how did you get that plastic surgeon and how do you guys do all of the recon and stuff, because that's something I haven't talked about on the show. And personally I'm interested in when you do a lumpectomy, how do you localize it and how do you do sentinel? No. Which pieces and tools do you use?
Dr. Jill Ties (00:32:57):
You use? Yeah. So every lumpectomy I use a [00:33:00] Localizer device, the Hologic Localizer. Currently prior to that we are using wires. I've looked through all or many of the different products on the market. I really like the Hologic Localizer, but I think that any sort of RFID that works with you and your system well is fine. I like having the separation of the radiology and the surgery experience, so it makes scheduling easier. Wires are really good too. I think there are a lot of breast surgeons who have done a lot of ultrasound training on their own [00:33:30] and do their own wires in the operating room, which is a nice way too. But I personally use the localizer good.
Dr. Randy Lehman (00:33:34):
So the Localizer RFID, and it's placed by radiology, but on a different day
Dr. Jill Ties (00:33:41):
In our hospital placed by radiology on a different day, there are surgeons who place them themselves and that's the way it works in our hospital.
Dr. Randy Lehman (00:33:49):
Okay, great. And then if you have to do a sentinel lymph node biopsy at the same time, do you do your own injection?
Dr. Jill Ties (00:33:57):
I do the blue dye injection. The radiologist does [00:34:00] the Tian injection. Although we do have a workaround process where essentially if I inject the Tian, the radiologist writes a note saying they supervised me to do it. We've kind of built that supervisory relationship is kind of like being a resident, but at least I don't have to go through all the nuclear medicine training. So yeah, usually the radiologist injects the nuclear medicine trace release same
Dr. Randy Lehman (00:34:21):
Morning.
Dr. Jill Ties (00:34:22):
Yes, we use Lymphoseek done 30 to 60 minutes prior to the procedure. And then I do the blue dye use, [00:34:30] oh my goodness, Isosulfan blue in the operating room. And I do that as soon as the patient is under anesthesia myself.
Dr. Randy Lehman (00:34:37):
And you just go retro?
Dr. Jill Ties (00:34:40):
Yeah, I go just into the venous plexus and Sappey’s plexus. Yeah, I usually 10 and two o'clock.
Dr. Randy Lehman (00:34:50):
Okay. And so what device do you use for the localization on the lip biopsy?
Dr. Jill Ties (00:35:00):
[00:35:00] Oh,
Dr. Randy Lehman (00:35:00):
Is it the neo?
Dr. Jill Ties (00:35:01):
Like I use the localizer. Yeah. So you use neoprobe for that part.
Dr. Randy Lehman (00:35:08):
Do you start with your sentinel biopsy, sentinel node biopsy or start with your lumpectomy? I
Dr. Jill Ties (00:35:13):
Usually start with the lumpectomy. I think it gives me a little bit more time for the dye to go to the axilla. Obviously if you're going to go right through, if it's an upper outer quadrant, it probably doesn't matter, but I usually
Dr. Randy Lehman (00:35:22):
Start with the
Dr. Jill Ties (00:35:22):
Lumpectomy. Yeah, so that's the other reason I start with the lumpectomy I that it gives time for that specimen mammogram to be off in the radiology department. [00:35:30] I don't currently have the intra in the OR specimen mammogram machine. We've trialed it, but our radiologists are so good with getting them to us quickly in the operating room that it hasn't been worth the investment for us. Yeah, we always do as specimen mammogram. Sometimes they'll have intraoperative pathology as well available. So a pathologist in-house who can look at gross margins or also can do frozens on lymph nodes. And I think the indications for that are getting less and less as time is marching on, but occasionally they'll [00:36:00] still use those for various cases.
Dr. Randy Lehman (00:36:01):
Do you know details about the specimen mammogram? Do they shoot it and then rotate it 90 degrees and shoot it again? Yep.
Dr. Jill Ties (00:36:08):
So we have a little box that we put the specimen in. I paint every specimen in the operating room. We put it in the box, we label the sides for the radiologist. They take the picture and then rotate it 90 degrees, take another one.
Dr. Randy Lehman (00:36:22):
Do use the six colored painting system or I
Dr. Jill Ties (00:36:24):
Do.
Dr. Randy Lehman (00:36:25):
Okay. What's that called? I can't remember. If you don't know,
Dr. Jill Ties (00:36:28):
That's okay. Well, you can [00:36:30] just get cheap paints from the pathology lab and then there's also a system out there and it's escaping margin marker I think it's called, where there's little sponges that they are actually sterile and on the field. And we changed to using those during COVID back when we didn't have enough PPE and PPE was more expensive than paint and now I don't think I'll ever go back because I really like being able to market right there on the field, not having to leave unscr market. I think that it leaves too much margin for error when you're moving and twisting the [00:37:00] specimen so many times.
Dr. Randy Lehman (00:37:01):
And then there's a little clip that goes on it too.
Dr. Jill Ties (00:37:04):
I don't use their clips. I put it in a box and right with a marker on the box
Dr. Randy Lehman (00:37:09):
What size? So then you're putting a short superior long lateral stitch or something?
Dr. Jill Ties (00:37:14):
No, I just write on the box with a marker color and the color is on the edges? Yes.
Dr. Randy Lehman (00:37:20):
So yellow is superior, whatever, however
Dr. Jill Ties (00:37:22):
You do it. So the nurse will just say it's, it's a cube box like this, and on the top she'll write anterior on the bottom, she'll write posterior [00:37:30] and then
Dr. Randy Lehman (00:37:31):
Got it. Okay. Well thanks for humoring me on all that because not everybody does that. I mean, not everybody uses margin market. Not everybody uses the localizer
Dr. Jill Ties (00:37:40):
Think you got to figure it out what works for you. There's this really great toolkit that Dr. Lander Casper, who's one of my other mentors came up with in association with some of the quality groups about how to decrease your positive margin rate. And there's a lot of really good ideas in that toolkit that he developed many years ago now. But I still think it's [00:38:00] relevant. There's some people that do a shave on every case. There's some people that do a specimen mammogram on every case. I think that measuring your outcomes and doing what works for you is really important and there's just a lot of options, a lot of ways. Some people are doing touch prints, intraoperatively, we just don't have the infrastructure to do that. But having a really good radiologist. And I think another piece I would emphasize, I go and look at my images with my radiologist [00:38:30] for every case and make sure that I know exactly where the lesion is, exactly where the clip is, exactly where the marker is, and I figure out my lumpectomy with them. They say, I want you to get this and could I look at it myself? Yep, absolutely. But I'm not a radiologist, so understanding that they may see things differently than I do is really important. And just having that moment to kind of center us both on this is what we're doing today. I think it's really important for the patients too.
Dr. Randy Lehman (00:38:56):
Yeah. One more question about sentinel node. I've heard of some [00:39:00] people doing ICG as their second marker and I've actually had, I had a patient back that went somewhere and got blue dye and ICG, but no tech 99 negative sentinel lymph node biopsy did not achieve a sentinel lymph node biopsy. Which
Dr. Jill Ties (00:39:17):
One did they use first?
Dr. Randy Lehman (00:39:18):
Well, I mean they used both at the same time like ICG and blue dye and then they didn't find a sentinel node. I mean to me, I've never not found it with using tech 99. I found nodes that are [00:39:30] not blue, but I've always found a sentinel node with Tech 99. I don't know why you would go away from that.
Dr. Jill Ties (00:39:38):
So I've used ICG one time for a very specific case. It was a really challenging case for a lot of reasons. I don't love it as much as I like blue dye. I think having a process that works for you is really important. That's not the process that works for me. I think that it has its place. [00:40:00] I think another important one that's coming up on the scene or has been up on the scene is the meg trace, which gives you the option of, especially in somebody like DCIS that you wouldn't necessarily need to do a sentinel node unless there was a invasive component, gives you the option of going back and getting that sentinel node when you might not be able to. Otherwise I think that's helpful. But I didn't like the magnetic stuff because I like to use metal instruments. So I think that marker to me is more exciting than the [00:40:30] I cg. Although the case that I did with ICG was technically difficult for a lot of reasons. So I don't think I probably gave it the most fair shake.
Dr. Randy Lehman (00:40:38):
Was that your third tracer then on that specific case or
Dr. Jill Ties (00:40:42):
Why
Dr. Randy Lehman (00:40:42):
Did you use the icg?
Dr. Jill Ties (00:40:43):
I used the ICG in this case because I'm trying to, the patient had previously had a breast cancer. It was upper outer quadrant. She had previously had a sentinel lymph node and she had reconstruction. She had a high risk lesion with [00:41:00] clinically negative nodes and a complete pathologic response after neoadjuvant chemotherapy. And she was somebody who used her arms a lot for her career. If I couldn't find a sentinel node, I thought that we really needed to do a complete dissection just due to the pathology. And I kind of reviewed that with a couple different tumor boards. And so I did the ICG just to kind of improve my chances of finding a note and seeing if there was lymphatics [00:41:30] that went out there
Dr. Randy Lehman (00:41:32):
As a third tracer.
Dr. Jill Ties (00:41:34):
I only did two. I did ICG and I did ICG and technetium. Okay. Lymphoseek, the rep who worked with me on the ICG actually said that if you do the blue dye first, or if you don't give enough time between the green and the blue, the green is a smaller molecule, so the blue will clog things up. So I think that they say if you're going to use both blue and green, you have to give green some time to get going [00:42:00] before you put the blue in. So yeah, I think that's important. I think another tool that I'll use on a technically difficult sentinel lymph node is a lympho, which isn't perfect either, but I think helps with the conversations around it. So if I have a patient where I'm really concerned about whether or not I'll be able to find that node, I occasionally leave and do lymphoscintogram a week prior so we can talk about what the implications of that are. But sometimes we'll just [00:42:30] do it on the same day and talk with them in the pre-op area. Look, we don't see it on here. I'll tell you one time I did a lympho gram, it was negative, but I still found the node with my neo probe. So I think that not finding a node is really highly unusual in my practice. Maybe once in 13 years, I think we're up to eight or 900 press cases since I've been there.
Dr. Randy Lehman (00:42:59):
Nice. [00:43:00] Yeah, I do lympho actually, I just do all my breast cases in the afternoon and I do info on everybody and then map it out. I can think of one that at two, three hours there was still nothing, but I just waited. I massaged a little bit more and waited and had 'em keep shooting and then at four hours it showed up and it was right there where it showed up. I feel like it increases my yield, definitely decreases my stress level, makes me feel a lot more comfortable. So
Dr. Jill Ties (00:43:29):
You do Aly Igram [00:43:30] on every sentinel node you do? Yeah. Oh wow.
Dr. Randy Lehman (00:43:33):
And then just do 'em all in the afternoon.
Dr. Jill Ties (00:43:36):
Okay. Yeah, I do I about two or three a year. Yeah,
Dr. Randy Lehman (00:43:43):
Very good. And the blue dye, I mean I have great success with the blue dye too, so I wouldn't say that I'd feel more comfortable with ICG than blue dye. That's the other thing. Yeah,
Dr. Jill Ties (00:43:54):
I'm not sure. I think there are reasons to do it and the other reps will give you a lot to, [00:44:00] I think it's good to know what's out there though. The problem is if you only ever use a certain technology when the case is hard, it's going to be hard because the case is hard. So I think that whatever you do you have to use regularly and know the ins and outs of it and be the expert on that particular thing.
Dr. Randy Lehman (00:44:16):
Yes, very good. So say you have a patient that once reconstructed, how did you get that plastic surgeon to come join you and what's the role of everybody?
Dr. Jill Ties (00:44:28):
So if I have a patient that I [00:44:30] actually offer reconstruction, I say that we have that option to every patient that I see. I don't think that that's necessarily a decision that I always get to make for the patient. I have a lot of patients who have really strong feelings right away. They know they want it or they know they don't. If I have a patient who wants reconstruction, my plastic surgeon who comes and works with me as an independent private practice plastic surgeon, he comes and he does consults for one day or for one day, and if we need to add more in a month, he's very flexible with that too. We've kind of built a relationship where we [00:45:00] kind of both know what the other one needs and expects. So if I have a patient who wants to see plastics, I write specifically in my note my thoughts about how close the lesion is to the nipple, whether or not I think oncologically the patient would be a candidate for nipple sparing. Some of my favorite cases I do with my plastic surgeon or oncoplastic lumpectomies with reconstruction afterwards. So they'll do a large lumpectomy and then they'll do the reconstruction and then they'll do a contralateral reduction for symmetry. [00:45:30] And those patients are so happy. And that was
Dr. Randy Lehman (00:45:32):
One of my questions is do they get involved in any cases that are not mastectomy? So there's that. And is there any other scenario where the plastic surgeon gets involved?
Dr. Jill Ties (00:45:42):
Plastic surgeon gets involved with that. And I think the other thing that we always try to work together is whether this is something that we do on the same day, which obviously if we can we do, but some of the really high risk patients, some of the patients who are getting chemo and radiation and [00:46:00] have planned radiation afterwards and so forth will do. He'll decide we want to do it as an interval. So we kind of have things that we've talked about together as a group, the two of us that he wants to know from me where the lesion is and can we keep the nipple and what I think is a good idea. And then he ultimately obviously is going to tell the patient what he thinks works best from a reconstruction standpoint. Think in a small hospital, you can't always be as aggressive with reconstruction as you can be in a hospital where [00:46:30] there's things like an ICU to monitor your flap, we don't have that.
(00:46:33):
So some of those patients will say, yeah, we can do that, but I need to take you to tertiary care hospital X to do that procedure. And so not being super territorial about patients I think is important and being able to rise above and know that we need to do what's best for the patient. I don't think ever taken a patient and not let me do the cancer operation on them, then we just do them as an interval operation. If a patient chooses that they want to go to a bigger hospital for all of it, we certainly support them [00:47:00] in that and help them. I never ever want to operate on a patient who doesn't want to be in my hospital.
Dr. Randy Lehman (00:47:05):
So you go direct to implant with him sometimes? Yeah,
Dr. Jill Ties (00:47:08):
Absolutely. Sometimes direct to implant, sometimes to expanders and then sometimes interval depending on patient and
Dr. Randy Lehman (00:47:14):
With the interval then patient factors, you save as much skin as you can. I do. How does that look and how do you close it and how do you keep seroma from happening?
Dr. Jill Ties (00:47:24):
I don't love how it looks. Every time I see the patient, I'm like, you're going to go see him. Right? Right. You're go see them. [00:47:30] It's kind of like those old pictures that you look up online when if you look up the flat aesthetic closure pages and things like that and you see what patients used to look like before, we really worried about how flat they were. So I don't love the way they look. I do save skin for him though. And he usually again mentions that in the know and we talk about these patients, so I know what he wants and the patients. And I think the really big part of that is educating the patients about what to expect. Even when we educate patients that we go [00:48:00] flat with, you have tissue out here that's not your breast. We do our best to lay it flat, but I can't pull you up a sock, that sort of conversation.
Dr. Randy Lehman (00:48:09):
So
Dr. Jill Ties (00:48:09):
I think educat
Dr. Randy Lehman (00:48:11):
Patients, I have not done that. So just tell me a little bit more. So when you leave a drain, I would assume, and then do you do some quilting to the skin flaps that are there? No,
Dr. Jill Ties (00:48:22):
Not on a patient that who's going to have reconstruction.
Dr. Randy Lehman (00:48:25):
So it's just a drain and then it kind of has wrinkly skin and then eventually you pull the drain. Yeah,
Dr. Jill Ties (00:48:30):
[00:48:30] It's actually not as wrinkly as you might think. It just isn't tight.
Dr. Randy Lehman (00:48:35):
And that's something he can then mobilize and then do whatever.
Dr. Jill Ties (00:48:38):
And ultimately if they decide to do this as an interval, or a lot of times those patients will be patients he's going to do autologous flaps on later. So he uses whatever skin is there and then supplements with flaps.
Dr. Randy Lehman (00:48:52):
Yep. Very good. Hey, that was an awesome how I do it. Do you want to take the time to discuss [00:49:00] any of these other bonus how I do, because you mentioned something unique that you do with pilonidal disease.
Dr. Jill Ties (00:49:07):
Well, I don't know how unique it is anymore. I hear a lot of people who are doing it, but this is just very, very brief. It's called the Gipps procedure, GIPS, and it's minimally invasive pilonidal disease. So you know that when a patient has pilonidal disease, they have the pits in the midline and then if you put a probe in the pit, it'll go up to wherever the cyst is, which is usually laterally on the superior buttock. [00:49:30] And so when I take these patients to the operating room to do their procedure, traditionally prior to gips, what I do is if it was small, I would just kind of put a lacrimal duct probe inside there and open up the tissue and scrape out the cyst and the epithelial tract, and then the patient would have a three or four centimeter incision that would just kind heal in secondary intention over time, which I think is a great and fine way to do this.
(00:49:58):
GS saves [00:50:00] the skin, so essentially it's doing the same procedure but keeping the overlying skin intact. You can read about the technical pieces from the actual description of the procedure, but what works for me in my hospitals, I still use the lacrimal duct probes and then I use a punch biopsy. I open up the cyst, which is kind of my bigger hole, and then the pit and the midline. I like to keep relatively small again to save the skin. And then I run my lacrimal duct probe through that whole thing [00:50:30] and I will then put a punch biopsy essentially onto the lacrimal duct probe and pull the whole thing through the tract. And then you get that whole epithelial tract that comes out in a nice little core with your probe. It's kind of a template that goes along so you don't get too much or get just the fous tissue. You get the actual track.
Dr. Randy Lehman (00:50:55):
What size of a punch do you usually use?
Dr. Jill Ties (00:50:57):
It depends on the size of the tracks. So some [00:51:00] of those midline holes are really small in those cases, maybe two millimeter, but I've gone up as big as three or four, depends on the patient, depends on the size of the tract. And then I use a curette to clean out the rest of the tract, make sure it's not bleeding. The procedure description describes using hydrogen peroxide to clean out that tract as well. And then I see these patients back every week and just make sure that there's no hair accumulating [00:51:30] in there and make sure that it's healing well. Occasionally I'll use silver nitrate as well to try to help stimulate the growth of that tissue to itself. It's a pretty slick procedure actually, and I've had very few recurrences with it. I think occasionally there's the patient that this has a very, very large cyst or abscess where maybe it's not amenable to that and you have to talk about things like wound vacs or flaps. I found that even large ones, I'll call and talk to my plastic or [00:52:00] my colorectal surgery colleagues. I'm like, would you just skip this? And they're like, yeah, just do it. It's going to take a while to heal. It's a bigger wound with bigger time to heal, but when I talk to the colorectal surgeons, that's the same thing they're doing too. Yeah,
Dr. Randy Lehman (00:52:14):
Kind of like it's a modified bas picking type of a thing. Yeah,
Dr. Jill Ties (00:52:18):
It's kind of a pit picking with a slick little punch biopsy that you pull along and you're like, how does that make sense? How does it even pull through? Once you see it, you're like, oh yeah. And sometimes [00:52:30] usually I'll come down from the larger cyst to the smaller pit and you don't want to pull the entire punch through there because obviously you're then losing your skin. So when you do it, it makes a lot of sense. It works really well.
Dr. Randy Lehman (00:52:43):
There's no elevation of the cleft with this procedure, right? No. Yeah, no. So just leaving the skin,
Dr. Jill Ties (00:52:49):
I mean just in what releases when you take the tract out, but it's not a formal elevation of the cleft.
Dr. Randy Lehman (00:52:55):
Right. Love it. Any high level quick hits for C-section for the rural [00:53:00] surgeon? What you wish somebody told you before you went up? What I
Dr. Jill Ties (00:53:09):
Learned on my rural surgery rotation was that you just cut till something cries, make sure it's not your assistant and close. Oh geez. That's what I learned in Prairie. I think that you could do a whole episode on,
Dr. Randy Lehman (00:53:25):
And I have, and there's plenty of episodes that you can go back and listen to for the listener that [00:53:30] I'm saying really
Dr. Jill Ties (00:53:30):
Important
Dr. Randy Lehman (00:53:31):
A trick that you have that maybe not everybody has.
Dr. Jill Ties (00:53:36):
I think that the trick is to get there in time and to trust your team.
Dr. Randy Lehman (00:53:40):
Okay.
Dr. Jill Ties (00:53:41):
I think it's a pretty straightforward operation for the most part. I'll say, here's one that one of my gynecologist friends taught me. So when you have a patient that you're doing a C-section on and that baby is wedged so low in the pelvis, we all know that when that baby is wedged low in the pelvis and you go to pull 'em out, then that uterine incision [00:54:00] can sometimes extend laterally or maybe even inferiorly to minimize that lateral or inferior spread. Usually if you're there standing on the patient's right side doing the operation, traditionally I always put my right hand in under the head to deliver the head. If you can in your head think I need to use my other hand, it actually is, it's a different movement and it injures the uterus less. So if you then go in over the top with that head and pull that baby [00:54:30] up as opposed to kind of pulling your hand underneath, I've found that that causes less lateral and inferior extension of the hy. So I think that's good. And I think
Dr. Randy Lehman (00:54:43):
Locking
Dr. Jill Ties (00:54:43):
Your wrist have to use the,
Dr. Randy Lehman (00:54:46):
Don't allow your wrist to flex.
Dr. Jill Ties (00:54:49):
I think it depends on how you're going to get the baby out.
Dr. Randy Lehman (00:54:52):
Yeah, I would say generally that's the thing to do. Lock your wrist, get down there with your left hand, lock your wrist and bring the head out all as [00:55:00] one motion because if you do this motion with your wrist where you're flexing your wrist, then that really can push against the thinned out uterus.
Dr. Jill Ties (00:55:10):
Ultimately these babies are sick and they need to come out and it's baby over uterus, but I think that, I'm not sure if I necessarily lock my wrist, but it's more of a lifting motion as opposed to a turning motion. So I guess that's locking my wrist. I just think more about lifting straight as opposed to locking or not locking. And then we also have, you've been using a fetal pillow, which I [00:55:30] think is really nice, which is a huge Foley essentially they put in the vagina that pushes the baby's head up in those cases where patients have been laboring. And another little trick, another device that is nice is a drape, which is a big sticky drape that holds up a pan on a really large patient.
Dr. Randy Lehman (00:55:50):
Yep. Love it. Those are great tips. Thank you so much. Let's move on to the financial corner. So one practical money or practice management tip that you [00:56:00] have insight that you'd like to share with the listener.
Dr. Jill Ties (00:56:02):
So I'm an employed physician, so I generally let the hospital manage the majority of the practice management, if you will. I think that personal finance, it's really important that you have either you are a person who watches that closely yourself or you have a person that watches that closely for you. For you. There's no amount of money that you can't spend, no matter how much money you make, you can spend it. And I think having your goals and knowing your goals is really [00:56:30] important. My husband is really good at finance and that's what he does. We run our finance and our family like a business, which is kind of, I think it is nice because it allows you to kind of take some of the personal blame out of it and you just run your family like a business. You look at your goals, you look at what you're spending, what you're not spending.
(00:56:54):
But I think the biggest thing I think about rural surgery and finance that's important is leveraging [00:57:00] the things that rural surgery gives you financially. So we have a lower cost of living. Appreciate that and actually make something of it. If you don't watch what you're doing with your money, you can literally, it just goes away. So I think my best advice is keeping an eye on it. I mean then there's always the one house, one spouse thing too. So do what you need to do, keep your marriage happy and don't get in over your tips on large investments like houses and cars and so forth.
Dr. Randy Lehman (00:57:29):
Perfect. Thank [00:57:30] you so much. Any classic rural surgery for us, a case or moment that could only happen in rural practice?
Dr. Jill Ties (00:57:36):
It's interesting that when I was thinking about that, I'm like, I think we probably all have the gifts or the stories from patients that are pretty funny, but I have one that just kind of has grounded me. It happened really early in my career as patient who had a mastectomy and some patients are cleaner and some patients are less clean. This patient wasn't always the most kept up and she's very sweet and kind. And [00:58:00] so she had a mastectomy and never came back to get her drain removed, which made me crazy because I was calling and where are you? Why aren't you coming? And finally she came back maybe three or four weeks later to get her drain removed, but she really didn't need to because everything had completely fallen apart at that point. So I dunno why she left the drain, but it was really clear that she hadn't been able to take care of her wound and maybe hadn't done much of anything.
(00:58:25):
The dressings were still there, but everything was crusty and dirty and there was a smell. [00:58:30] So I got a wound vac authorized for this patient and she would sometimes come and sometimes not. So then we kind of were like, well, maybe we need to stop the wound vac. And finally I just sat down with her. I was like, how come this wound vac is working sometimes and it isn't working other times is something happening at home or is it not sticking? Does it hurt you? What's going on? And she said, well, it really just kind of depends upon who's working at the gas station because one of 'em lets me charge it in the [00:59:00] gas station. And the other one, I don't have any power in my home.
(00:59:06):
This is not what I was expecting. Ma'am, here we are in the two thousands, not 2026, I was probably 18 or something. And the things that you take for granted, granted. And I think that that's not unique to rural practice. I think that all underserved populations, I think that understanding [00:59:30] that we have to meet our patients where they're at, whether they're super sophisticated and they want to talk about trials or whether they're patients who can't plug in their wound vac if someone they like isn't working at the gas station. Just understanding that. I think that's one of the beauties of rural surgery is that our patients are so unique that some of their needs are really stuff that you don't think that you're really going to come across. So being open to that and not judgmental and having some compassion I think is important.
Dr. Randy Lehman (01:00:00):
[01:00:00] Yeah, man. Makes you thankful. So thank you for sharing that. Okay, so last segment of the show resources for the busy rural surgeon, do you have a habit or a book or a system or something that you genuinely use and recommend?
Dr. Jill Ties (01:00:14):
Well, this is, I'm going to be a little off the beaten path on this one. I think the best resource for a busy rural general surgeon is to get engaged and involved with their local state surgical society or a [01:00:30] surgical society that is meaningful and relevant to them because I think that books really matter, but so do relationships and people you mentioned at the beginning of the show that I'm one of the governors for the state of Wisconsin and that I certain happened because of my engagement with the Wisconsin Surgical Society. I think that having engagement both with rural surgeons and non-rural surgeons really helps us to understand that they're all our patients and how do we [01:01:00] as a state or how do we as a region or an area take care of patients? And in the process you also get to meet all sorts of specialty surgeons.
(01:01:07):
And so when you have a patient that really needs an ICU and you can't transfer them and you call somebody that person knows you and you know them, I think that's different. I think that that matters for patient care. I know in my career it has. I also think that engaging with people that both are rural and aren't rural helps us all to be better. When we [01:01:30] know people as people and we engage, you kind of understand the pressures that each system has. I think it humanizes things and it makes things better for patients. I don't consider myself an eloquent speaker. I don't consider myself somebody who ever aspired to state or national leadership titles. That's not ever been my goal, but it has been an absolute privilege and opportunity to be a mouthpiece for our patients and for our profession. And so I think that I love up to date for the stuff that is [01:02:00] medical that I don't see every day. I love the hernia calculator that talks about complications. I can look up the name of it, Cedars. I think that's really good. Is it Cedars app? Yes, that one. Okay. But I think that the resource that's been the most meaningful for my career and for my patients, and then also an ability to give back to the profession has been my engagement with societies.
Dr. Randy Lehman (01:02:25):
Perfect. You need to come to the North American Rural Surgical Society.
Dr. Jill Ties (01:02:29):
I've heard that [01:02:30] and I've got to figure out a way to get it done. I've heard it's a really good one.
Dr. Randy Lehman (01:02:34):
We just met, it's two weeks ago as of this time of the report and where was it? It was in San Diego. So normally it's in Denver and they have made some changes. First off, they changed the name to North American and then decided to go to a warmer place after several bitter winters. And they changed the date a little bit. Used to be always on MLK weekend. But now they went with November or I mean not February 6th, [01:03:00] seventh. And I'm like, wait, did you text my buddy that's in charge? I was like, did you mean to do this? He's like, no, it just happened that way. I was like, okay. So anyway, we're sitting there talking about colorectal surgery, one of the sessions and kind of like an interactive thing. And I'm sitting next to a buddy of mine who is practicing up at International Falls and we've kind of met each other through this society.
(01:03:25):
And he looked turned to me and he said, it's like having a partner for a day. [01:03:30] But really it's more than that. There are people that I message from the society with questions just to chit chat. And some people like it more than others. And so if you have questions about cases, I mean, how else are you going to keep up? You got your buddies from residency, many of whom go into other specialties and they don't have a practice anything like yours. For me, I have people that were from my residency that went and have practices kind of like mine, but they don't really want to talk about things. So I agree with you. I've developed good friends through a CS through North American Rural [01:04:00] Surgical Society where I can message, obviously this podcast is a way for me to personally fight the professional isolation that we're all talking about, but you have to have people that are at your own referring institutions as well. That's where your state society comes
Dr. Jill Ties (01:04:15):
In place. Absolutely. And I mean actually interestingly for me, my referring people are in Minnesota, not part of Wisconsin Surgical Society, but I do have the person, you have had a biliary surgeon that you and you trust. You have a colorectal surgeon that you know and [01:04:30] you trust, and those are relationships that you build over time. And I don't know how that always happens, but I do think that's really important because again, you don't want to be a nameless, faceless, and I think that the professional isolation is sometimes maybe what draws some people to rural surgery. That wasn't what drew me. I really thrive in community and I think that our patients do better when even if it's like you call 'em, you're like, Hey, would you do anything different? Nope. Nope. Okay. Well then I'll do what I was going to do here.
Dr. Randy Lehman (01:04:59):
Really helps to load [01:05:00] the boat. So thank you so much for all the inspirational work that you're doing up there and just for sharing your story with me and my listener. I really appreciate it and thanks again for coming on the show. Very
Dr. Jill Ties (01:05:10):
Good. I appreciate the work that you're doing and appreciate all of those rural surgeons who are listening, so have a good day.
Dr. Randy Lehman (01:05:16):
That's right. Thanks for joining us on this episode of the Rural American Surgeon. I wanted to remind you that I'm actually looking for a partner in the next two years or so to join me in rural Northwest Indiana. If this [01:05:30] is something that you are interested in or of somebody that might be great for this, please visit theruralamericansurgeon.com and just submit a request for information or whatever the form on the website is, and I will get back to you and we'll be interviewing for that shortly. So please reach out if you know of someone or if you yourself and maybe somebody that's interested in that type of practice. There's a couple different models and opportunities that could possibly exist. So thank you for being a listener. I hope you enjoyed this episode as much [01:06:00] as I did, and I'll see you on the next episode of The Rural American Surgeon.
