EPISODE 62

Why Some Fit Rural Practice and Others Don’t | Dr. Jesse Van Maanen

Episode Transcript

Dr. Randy Lehman (00:00):

Welcome back to the Rural American Surgeon. I'm your host, Dr. Randy Lehman, and I am so pleased and honored to have as my guest today Dr. Jesse Van Maanen. Thank you, Jesse for joining us. Thank

Dr. Jesse Van Maanen (00:17):

You. It's a pleasure.

Dr. Randy Lehman (00:18):

And so Jesse and I have become friends and colleagues through our association at the North American Rural Surgical Society where Jesse now serves on the exec committee and we just had a great time in San Diego again and so I was just wondering if he would be on the show and he has graciously agreed to join us. So first thing we always do is we talk about just an introduction of you, so that's been my experience, but tell us about the path that took you to the place you're at and what your practice looks like now.

Dr. Jesse Van Maanen (00:50):

Yeah, so again, thanks for having me. It's an honor to be on here with some other huge dames that I've followed your podcast for a while and been able to listen to. So to be a small fish in a big pond, this is a fun thing for me, so appreciate that. Thank

Dr. Randy Lehman (01:06):

You.

Dr. Jesse Van Maanen (01:07):

Yeah, so I've been in practice in a rural community for about four and a half years or so. I went to the University of Iowa for medical school and then did my surgical training up in Sioux Falls, South Dakota at Sanford. Knew forever that I wanted to be a rural surgeon. I actually now practice in a hospital that is about 10 minutes from where I grew up. And so I was 16 and all I wanted to do was get my license and drive a car, but I spent my birthday essentially in the hospital with appendicitis and always had a knack for science, enjoyed human anatomy, that sort of thing. But as a high schooler, especially a sophomore, you're not thinking about your full career. What do I want

Dr. Randy Lehman (01:48):

To do

Dr. Jesse Van Maanen (01:48):

When I grow up? You just want to get done with class and enjoy the weekend. But I did have an interest in science and so there I was laying in the hospital with an almost perforated appendicitis and I felt terrible and then an hour and a half later I didn't. And so I think it clicked for me. I liked science. I the first child of five total kids in my family, so I've always just been like a goer doer, got to get things done and it clicked with me that medicine made sense and surgery made sense because as a little bit of an instant gratification bent that I have, I like to fix problems and move on.

(02:27):

And when you like science in school, you really can do about three things with it. You can teach it, you can research it or you can use it to treat whether that's humans or animals. And I like teaching, but as a surgeon and a physician, I get to teach patients and residents and med students all the time. Wasn't big into research, super important, glad people do it, but it wasn't something that I was passionate about. And then I got my appendix out and decided on my 16th birthday essentially that's what I'm going to do. So that was my initial ongoing to medicine. My mom's a nurse, but we don't have any other doctors, physicians in the family.

(03:05):

So I went off to undergrad and then University of Iowa for med school, like I said, training up in Sioux Falls and then started here at Mahaka Health in Oscaloosa, Iowa, which is about 10 minutes from where I grew up. So I had the idea just from being in a small town that hey, I want to do rural community surgery. I like this kind of a place to raise a family. It's a low cost of living good schools, all that sort of sense of community. Did I know I was going to end up 10 minutes from my home? Not necessarily, but it did work out really well for me. Now I'm at a critical access hospital, so by definition that's 25 inpatient beds. It's a fairly large hospital if you consider the number of staff that they employ, we have a lot of service lines.

(03:50):

We're expanding like crazy. We can talk about that a little bit. This is not a plug for my hospital, but just uniqueness to rural surgery, we have a lot going on where we're at and in part because many service lines, and I think most rural surgeons feel this push or this pain I should say, a lot of service lines in small rural communities are closing. And so we as a hospital have been able to not have to close services but expand them. So even though we're rural critical access 25 beds, we offer a lot of service and general surgery is one of them, which I'm thankful for.

Dr. Randy Lehman (04:28):

I've

Dr. Jesse Van Maanen (04:28):

Got two partners that are full-time and then one who has a split time between some administrative work and clinical work. And so again, for a town of 10,000 with a small hospital, to have really three and a half surgeons is also a robust thing. And I know most rural surgeons may be listening in, we'll say I'm the only one for 70 mile radius. So I realize that's also a difference, but it gives me the opportunity to do some things that maybe others can't and it's fun.

Dr. Randy Lehman (05:01):

Yeah, there's a huge spectrum. That's the thing with rural surgery from one critical access hospital to the next and then others that aren't necessarily critical access too. So I'd like to dig in a little bit deeper into how your hospital has success in this environment, but first I'm going to ask the first question of the show, which is really why rural surgery is important. So you gave us a great intro into you personally, why you ended up found your way into it with your appendicitis, but take it next level. Why then once you can take out a lot of appendixes in la So why did you choose to come back to where you did and why is it important?

Dr. Jesse Van Maanen (05:54):

I think I alluded to some of that. I think the key, and I can go more into more, but the key to capturing rural surgery or surgeons is I think recruiting them from that environment. The idea that you go to a rural community because you're getting tired of being busy in the rat race in the big city with a large institution. And so you want to move to a rural community so that you can slow down is really not at all what the rural community needs. What the rural world needs is folks who are busy and young at heart, maybe not young in age but young at heart. They want to serve the community, they want to bring options to people who maybe don't have the means to travel. And everybody knows that rural patients have a generally lower access to care for a variety of reasons, whether that's socioeconomic travel constraints, just distrust in the larger institutions and medical facilities thinking they're just a number and a cog in the wheel.

(07:01):

When I grew up in a rural community, you have that sense of belonging. People, you run into them at church, at school, your kids go to the same schools, your parents hang out on weekends and go camping and bring the families. And so when you live in a rural community, you feel like you're part of something and in a larger institution, larger hospital, larger city, the employees, but also just patients in general, I think at the sense that they're just a blank check or an insurance company number and they don't feel like they may not matter as much. Now I don't think the care is necessarily worse. That's not at all what I mean. But when you operate on or treat or care for somebody that you personally know or knows somebody, that there's that sense of trust and the idea that farmers, for example, don't come in until they're on death's door is absolutely true. They're busy. They have a sense of pride in their work, they're incredibly hardworking folks and if they're in the hospital it's because either their wife dragged them in or they're really quite ill.

Dr. Randy Lehman (08:17):

I

Dr. Jesse Van Maanen (08:17):

Don't know how many times I've heard somebody say either I'm having it done here or I'm going back home and I know

Dr. Randy Lehman (08:23):

That's

Dr. Jesse Van Maanen (08:23):

Cliche and it's kitchen and you can say, well, if you really it mattered to you, you'd go ahead and go to the big city. But the access to care in a rural community I think is huge for the community because a lot of times you wear multiple hats. In a small town you might be involved in school board and a physician or you might be working at the chamber of commerce and also at your church. And so having that multiple hats mentality but also a hospital that supports that community feel, I think just builds trust. And so I wanted to raise a family in a small town. I wanted to be back in a small community because I like knowing people as a surgeon, I like knowing them well enough that I can fix them and then also graduate them from my care, which is different than family med or primary care, but I also like getting to know my patients instead of seeing them from 45 minutes or two hours away and then not being able to longitudinally follow up.

Dr. Randy Lehman (09:24):

Yeah, great. I mean like I said, this is the rural surgery echo chamber, so welcome to the club and preach on. That's what we all already believe, but it's just good to hear somebody else say it and it's refreshing to hear somebody say it. That's also early in their career, so thanks for what you're doing. So real quick before we go to the how I do it, I just want to know, I have an idea of the hospital that you're working at is a town of 10,000, but what's your catchment area?

Dr. Jesse Van Maanen (09:53):

So catchment area has expanded rapidly I would say since I've been there. We actually started, I was in a meeting, a med staff meeting earlier tonight actually, and they were throwing up some statistics about the growth that our hospital has seen since 2018. Back in 2018 we had 280 something employees amongst all things which include kitchen staff and physicians and nurses and everybody in the building, 280 something. Today we're at 710 and that's from 2018. So that's not something that a lot of rural hospitals can say that in eight years they've essentially tripled their staff or near tripled their staff. We have, I would say a two county radius where the majority, except for a few hospitals have lost OB services. They have lost night, weekend and holiday surgical services. They have surgeons that may come in from a different hospital and do a Tuesday afternoon clinic and a Wednesday morning scopes or only outpatient procedures. They're basically ambulatory surgery centers have a hard time admitting patients don't have things like cardiology in the building. And so even since I've been there since 2021, the referral patterns have just exploded. Would when I'm on call, I would say 80, between 70 and 80% of the phone calls I take about accepting a patient aren't from the town that I'm in. They're from the other ones that essentially have turned into acute care clinics but not, they don't want to be. They've lost service lines. And

Dr. Randy Lehman (11:39):

Those other hospitals, how many of them are there? Three or,

Dr. Jesse Van Maanen (11:44):

Well, I would in Iowa, about every 15 minutes in any direction that you travel, you reach a town of somewhere between 2000 and 8,000 and then you hit that one, you go any direction you're going to hit another one of 2,008,000. So many of them never really had full scale hospitals, but they'll have branch campuses of other facilities or they have walk-in clinics and things with CT scans and ability to do labs. But I would say there's a two county radius that needs a surgeon on a 24 7 basis

Dr. Randy Lehman (12:17):

And we have do that. My question is the other facilities that have sort of been if you're not growing, you're dying. So they're dying, you're growing as a result, are they part of generally part of a chain and are you part of a chain?

Dr. Jesse Van Maanen (12:33):

We are independent. We've remained that way on purpose because we want to be able to move with the tides and do what we need to do as opposed to answer or ask permission to add a service line or change some things. Many of the other hospitals have been independents, not part of chains subsequently purchased by a larger one and then service lines were cut because financially it didn't make sense for them to keep those. So they were doing their best to stay open, struggled financially needed to be bought out, and then whoever it was decided it's not worth pouring money into this start cutting services.

Dr. Randy Lehman (13:12):

So to a certain degree we could lament it and we could say, ah, see big system evil, don't let the big system come to your town and see the independent hospitals winner. But another way to look at it would be even though there's not so much free market in healthcare because it's largely government payer and all these other things, that's kind of the free market fixing the problem because maybe there were too many facilities for the overall catchment area. It just kind of depends. It gets really messy when the government is providing goods and services and so then things get messed up. But to a certain degree, I have seen the same thing with my mentors hospital in central Kentucky. They were used to be called a county hospital, now they're called a regional hospital while all the other counties around sort of did exactly what you said, whether they were independent or not, their hospital kept an ICU, kept certain services open and then became over time more of a regional referral place. So that's a strategy for success seems to be working for you for the time. It is all dependent on a couple key players. You get a bad egg in as administrator or a couple bad years and then you never know. But I'm glad that it hear that it's working for you right now.

(14:48):

Anything else to add to that?

Dr. Jesse Van Maanen (14:50):

Well, no, the regionalization of care I think in a rural community is super important, right? Because even our facility, we can't have everything to start a radiation oncology program is $30 million of equipment alone. And that's just to put the building up. And so one thing we have been able to do from an administrative perspective is look at some of these other satellite facilities, or not satellite facilities, but other hospitals and say, look, you may not have medical oncology, we do. You have radiation oncology, we don't. How about we partner together because we don't want to lose patients to a bigger system, not because we don't want to lose them, but they don't want to go elsewhere either. They'd rather travel 15 minutes southeast of us and have their radiation than go to someplace two hours away every time. And so by combining some of those things and saying, you've got something great, we have something great, we're not taking your patients and you're not taking ours, but how can we do this together? And so we have a tumor board in our facility that meets monthly and radiation oncologists from the neighboring and technically competing hospital jump on and they're part of our team. And so we can set some of those differences aside from a catchment area perspective and say, look, we need you, you need us. How do we make that work? And that does take administrative buy-in and quite a bit of pushing because it can seem from a top down perspective as some sort of competitive play, which it really isn't, but it's benefiting the patients. So that's

Dr. Randy Lehman (16:25):

The most

Dr. Jesse Van Maanen (16:25):

Important thing.

Dr. Randy Lehman (16:26):

I love that. And I strongly believe in the win-win win and that the world is not a pizza to be divided up so that we all, if I eat a piece, you can't have it. The world is an oven and we can bake as much pizza as we all want. I mean within reason and just if you keep kind of thinking about other people what you would want done and then also the fact that you got to be viable, then naturally the right decisions are going to come. So I love that. Let's move on to how I do it if we're going to talk about robots today. So not a topic I always talk about, but lemme give you my quick perspective of what I've done. So graduated from residency 2020 robot certified. It's now 2026. I'm almost done with my six year out and I have never operated at a hospital that has a robot, so I have naturally not done that and I can do nice quick laparoscopic cases and I enjoy it.

(17:24):

I do laparoscopic colon intersections, hiatal hernias, and then usually do most of my laparoscopic colon intersections, hand assists, which you could say is cheating, but I've really enjoyed it and the outcomes have been great. So you're talking about an eight centimeter incision and then of course the hi hernias are straight lap and done some lap bowel sections and things like that too. So now I'm doing a little bit of coverage in a Wisconsin hospital where there is a robot and back home there's some opportunity happening where I may end up in a bigger hospital and there are some cases that I would like to see if I had the robot I would use for. And so I'm taking the time to go ahead and get a check off so that I have full robot privileges at this hospital in Wisconsin and today I did my first robot case since residency and it was a robot gallbladder and so the timing is perfect for this conversation.

(18:34):

So it went fine to my opinion, fussy and a bit of an ordeal, and I really miss my favorite instrument, which is the suction cautery instrument where the sheath slides over the, and it's got a hook cautery on the inside and that's the only instrument that I have pretty much in my right hand, the whole entire case when I do a lap coley, just do the whole entire case with it except for when I'm clipping or whatever, but I'm not using the robot to do gallbladders necessarily. I'm just using that case to get back familiar with the equipment. Obviously I think it really shines for general surgery with ventral hernias, inguinal hernias, and then things that are obviously up in the top of the abdomen, bottom of the abdomen. But I'm interested to hear your perspective on how you use the robot and how you can use it effectively in a critical access setting like you're talking about.

Dr. Jesse Van Maanen (19:42):

Yeah. Well anyway, congrats on case one. That's great.

Dr. Randy Lehman (19:47):

Yay.

Dr. Jesse Van Maanen (19:48):

It's fitting for this discussion. So in residency we had robot consoles, we had a dual console there that allowed the surgeon and the resident to both sit at a console and control different arms. And so there was some ongoing teaching that would happen that's sort of more natural that's getting up and sitting down and getting up and sitting down. So we got a reasonable amount of robot training in residency, but when I left residency, I still was of the opinion that laparoscopic gallbladders hernias, nisson hidal hernia repairs, I mean that's what I knew how to do. And so in all honesty, I had this chip on my shoulder, I don't need this thing. It's a fancy billboard shiny thing. It's meant to attract patients, but outcomes aren't better. You need to know how to do open and laparoscopic surgery first. And what's the point of this?

(20:42):

In a rural community, it costs 2 million bucks. Well, we had one at the hospital I was at when I started and it had been there for maybe five or so years before then, and my partners have been using it for pretty much all laparoscopic cases and interestingly not colons, and we can talk about those too because I often laparoscopic and hand assists my colon resections as you had mentioned, but gallbladders, hernias, those sort of things that you trained to do laparoscopically were all being done robotic. And so admittedly I was doing way more laparoscopic cases, not I guess maybe to just prove that I didn't need it.

(21:23):

And then I learned that as the tail goes, the gallbladders that come in a rural community at two in the morning on a Saturday are really nasty cases. They're gangrenous, you're doing subtotal fenestrated cases that the cystic duct is all messed around with by a large gallstone the size of a quarter that's been distorting the anatomy of the infundibulum and it's hard to find where you're supposed to be and in the evenings or nights or holidays or weekends in a rural access or critical access hospital, you've got one tack, one circulator, one tack. And so when you're trying to run two hands laparoscopically, they're holding the camera, which is a 30 degree, and they need to kind of be working that thing by two angles, but also retracting the gallbladder. Everybody's hands for a nasty gangrenous case are used and then the back table has that other screw on tip for my laparoscopic scissors or whatever that I need, and I'm setting my instruments down or they're setting their instruments down, running back and forth, and it actually takes a lot longer.

(22:35):

And so I started slowly adopting the robot for even cases like gallbladders that didn't seem like they were necessary for the benefit of I need a second set of hands and if I can be my own set, know exactly where my camera needs to be adjusted in a minor way, do all the retraction and dissection myself, all of a sudden these really nasty cases started taking way less time than they would've with one tech at the table. And so I slowly became, after a couple of bad ones, I quickly became a huge fan of the robot in a rural setting. I think personally maybe even more useful than in a large institution that has umpteen number of staff in the room to be assisting. And since then we've hired PAs with our team and so on during the day. I've always got a second set and I'll switch back and forth between robot and laparoscopic, mostly if the robot is open or not.

(23:32):

I mean if it's being used by OB GYN and I've got a lap case to do, I'll just do it that way to keep things moving. But that is where I switched to think that I really feel that robot cases in a small town can afford you the ability to do a higher complexity thing with fewer staff available. That's my overall feeling on the robot. Now, all my inguinal hernias are done that way just because it's fun to sew with the robot. Most of the gallbladders, I would say 70 30, I'm still doing my colon resections, laparoscopic. I'll put a hand in if I need it for lifting a heavy colon with lots of momentum around in a more obese patient, but trying to just do them essentially, mostly laparoscopic and I still need an extraction site, so whether I use my hand and that same one or not, I don't think it's cheating at all. When you can swipe that dissection plane around the flexor fast, you can almost do it with your eyes closed. It's so fast. You feel everything. You know where you need to be. You can feel for the vessels. So I don't think it's cheating to back up you on that one.

Dr. Randy Lehman (24:38):

Yeah, well, I mean we had an applied talk at the thing and I told the speaker that I was like, it feels like you're kind of selling this thing, but I don't need to be sold because what you're describing is exactly the way I do it. He's like, okay, well somebody else needs to hear it. Okay, so no, that's perfect. So tell me, what about the finances of it? How can your hospital afford to do that?

Dr. Jesse Van Maanen (25:08):

So I'll be honest with you there. It was in our building when I got there.

Dr. Randy Lehman (25:14):

Okay.

Dr. Jesse Van Maanen (25:16):

Whoever wrote the check, whether it was on some sort of lease to own sort of thing or not, to be honest with you, I can't tell you we own it now. It is an exci. So the exci is 12 years old, and now of course DaVinci has come out with their five, and so they want everybody to trade up and trade in. We are doing well with our xxi. It's a fantastic machine. We also have OB that does a significant number of pelvic cases, particularly hysterectomies with it. So there is not a day that goes by where that case is not used. The argument about affordability and how it's so much more expensive than a laparoscopic case to some degree I think is true, but if I factor in, for example, a really nasty gallbladder even that I did just the other day in the middle of the night for someone who needed it out because we were talking lots of pain and really sepsis and some atrial fibrillation related to the sepsis, getting that thing out with the robot with no other staff but myself and one tech and one circulator in less time also equates to less anesthesia charge. You're not paying your staff to come in at night for overtime pay, and I've sort of adapted my port placement in such a way that I'm not using much. Once I set my instruments in, we're not exchanging until it's time for clips.

Dr. Randy Lehman (26:43):

So tell me about that. So for a gallbladder, how do you get access?

Dr. Jesse Van Maanen (26:47):

Access is up at Palmer's point where one of the eight millimeter ports go and then sort of I

Dr. Randy Lehman (26:54):

Would say you access optical access or what do you do? I

Dr. Jesse Van Maanen (26:57):

Have varus access at Palmers unless I have reason to believe I need the optical, but can and do both, but usually varus needle up there, then extend that incision a little bit, go ahead and place a five. Then under direct visualization, I'm putting the other three eight millimeter port heading across the abdomen, slightly lower than the other one towards the right side. So they

Dr. Randy Lehman (27:22):

Each one slightly farther inferior, each one

Dr. Jesse Van Maanen (27:24):

Slightly farther down. It does depend when I get that first one in, it depends on where the falciform is at, where the edge of the liver's at, where the gallbladder's at. I may move them down or move them up some just so I get my working space. But generally speaking from polymers across, there's four eight millimeter trocars and they're slightly lower than each one. I think from a grasper setup perspective, my camera then goes in arm two, so we're going to call arm one the right most port arm two, the sort of right mid abdomen three is more of a supra umbilical epigastric style port, more in the midline. And then four is my palmers, so my camera goes in two, my bipolar goes in one, my hook goes in three, and then some sort of non-energy device grasper in four, contrary to a lap case where you're retracting that gallbladder over on the rightmost side, I'm retracting it from the left side of Palmers because when I take that one in and I lift that gallbladder up, the forearm of that instrument also pulls the falciform up.

(28:38):

So you get this beautiful retraction and I lock that thing in place and essentially don't move it the entire case because once it is up, the falciform is tented up. I can come in and out with the suction if I need it, hook or put the clips in through arm three and essentially never snag any tissue because the falciform is pushed up out of the way coming in it from the Palmer's point and you've got your camera directly at the gallbladder at arm two. So when you're reaching to the left side and you're reaching to the right side of the gallbladder with your hook, you're not coming in at such a crazy angle. You're just basically triangulated tight right at the gallbladder. So I find that to be really quick and really don't have to at all ever move that retracting arm until maybe at the very end when I want to triangulate those last few attachments and that's cut my time down.

(29:28):

I don't ever have them open the suction irrigator unless I decide I need it. I kind of feel like with the 3D optical view and the ability to zoom way into stuff, it's rare that I need to open a suction irrigator so it sits in the room, but I just don't have it at the bedside right away. ICG is great, which I know you can use laparoscopically, and when I do, I still use in green for duct identification, but it's easy and quick to toggle back and forth on the robot. That's my setup from a retracting perspective. I think that makes the case go very quickly.

Dr. Randy Lehman (30:05):

What's the fastest you've ever done a robot gallbladder? Skin to skin?

Dr. Jesse Van Maanen (30:10):

Skin to skin I believe was 28 minutes.

Dr. Randy Lehman (30:20):

What's the fastest you've ever done a laparoscopic one?

Dr. Jesse Van Maanen (30:23):

Faster? I don't know.

Dr. Randy Lehman (30:25):

Right, but on average, do you think you're

Dr. Jesse Van Maanen (30:28):

Throwing the stuff off? It's the bringing the machine in. The actual gallbladder time was I think 11 or 12 sitting the robot and working at the gallbladder was maybe 12, and there's another 10 minutes of that extra stuff.

Dr. Randy Lehman (30:42):

So it really saves you on the hard ones though. And the overnights

Dr. Jesse Van Maanen (30:47):

Does not save you on the easy ones. And that's where when I know I got a biliary dyskinesia or hypokinesia case and they haven't had 10 other abdominal surgeries and they're not morbidly obese, and I know that on the ultrasound or the CT scan, their liver doesn't weigh a thousand pounds and I can't get good retraction. I'm going to just do that thing lap.

Dr. Randy Lehman (31:07):

You are the one that said the word biliary.

Dr. Jesse Van Maanen (31:12):

Yeah.

Dr. Randy Lehman (31:12):

Now tell me more.

Dr. Jesse Van Maanen (31:15):

Because nobody believes it's a thing.

Dr. Randy Lehman (31:18):

I have had, I'll tell you my experience. First

(31:24):

Patient I had that had an EF of 97% and extremely reproducible classic biliary colic symptoms, no stones, every other study completed. I was looking this up basically, and it's not in the textbooks. And so I told that patient, I was like, first off we, I am willing to go there with you. Not something that I've heard of a lot, but when they got the CCK injection, it produced their symptoms. So I'm like, I feel like it might work. You're the one that's doing it. I got to try and argue this to the insurance company. I'm willing to try. I did. They went with it and a patient got better. I have since had maybe two other patients that are kind of like that, but then I have some radiologists that are like EF over 90% demonstrating excellent gallbladder function. You have to hear that in the report. So I guess I believe that biliary hypokinesia is a thing and is symptomatic and gets better with laparoscopic cystectomy. I don't know if there's any medical treatment options or what may be out there, but you tell me

Dr. Jesse Van Maanen (32:49):

Your Yeah,

(32:51):

You make a good point about radiology. I would say of the dyskinesia or hypokinesia cases, if we take all the cholecystitis from gallstones out of the picture, I probably do as many minimally invasive cholecystectomies for hypokinesia as I do for hypokinesia or dyskinesia. I don't know if it's an Iowa thing, I don't know if it's in the roundup or in the beef, but so many hyperkinetic gallbladders and I became a believer in it in residency. And so for me, I didn't come out of training thinking like, what is this new fangled diagnosis I've never heard of? Is this a thing? We talked about it pretty extensively in my fourth and fifth year. We had some surgeons really get on the bandwagon for it. Now, I will say I think there is, at least for me, a fairly important algorithm to follow because a lot of my patients are smokers.

(33:50):

A lot of my patients have heartburn, reflux, dyspepsia issues. And so if I'm seeing them for classic epigastric, maybe right up upper quadrant abdominal pain, they eat greasy food that everyone's eating. They're a smoker, they drink too much what have you. I'm fairly quick to, if I get a diagnosis of hypokinesia because their ultrasound is normal and it's followed with the HIDA scan, if I have any concern for a stomach or duodenal pathology, I'm giving them an upper scope first. I'm going to check an EGD because I would say probably about a quarter of the time I'll find some big ulcer or terrible gastritis or something of that nature that describes your symptoms first. But if that looks okay or if their symptoms really are classic and CCK injection reproduces symptoms, I have really not shied away from many of them and I don't know the numbers, but I'd say in the last 20, maybe in the last two months even, I've probably done six hypokinesia gallbladders. I mean they're at least every other week, hypo and hypokinesia about every other week.

Dr. Randy Lehman (35:07):

And

Dr. Jesse Van Maanen (35:08):

I have yet, and I'm knocking on wood, so we'll see. But I have yet to have somebody come back and say, okay, maybe I have a little loose stool. Maybe I have a little whatever. I can take some fiber. But I don't know of anyone who's not said, I don't feel significantly better, but I do make sure I rule out some upper GI source in most of those cases. First the radiologists don't know it's a thing because they either say excellent function like you said, or normal function, and by the time they get to my office or maybe yours, they've had biliary colic symptoms for two and a half years because the HIA scan back in 2023 showed it was normal according to the read. So we're finding it all the time in Iowa, but I don't know if that's unique to us.

Dr. Randy Lehman (35:50):

What number do you use as a cutoff for high?

Dr. Jesse Van Maanen (35:53):

Well, 85% for high.

Dr. Randy Lehman (35:57):

So for you, 35 to 85.

Dr. Jesse Van Maanen (35:59):

35 to 85. But I tell 'em too, sometimes they'll just show up and somehow by some way, they got a IIDA scan and their symptoms clearly are not biliary related. And so I think it's important to remember for patients, you can have an ejection fraction of 92% and have zero symptoms and live your whole life and die with your gallbladder at 92% and you're fine. Don't take it out because of the number, right? Don't take it out because your gallbladder rejects 10% and you have no salt.

Dr. Randy Lehman (36:28):

What if it's 84%? And they had to just totally reproducible crampy pain with the C, CK,

Dr. Jesse Van Maanen (36:36):

Right? So we have a real honest discussion. Those are the ones that I'm definitely giving an EGD to. First I got to rule out some sort of upper GI pathology. And then honestly, we sit and talk about generally speaking, and these are ballpark numbers, but I think they're easy to remember. I tell folks, a third of the time, you're going to get your gallbladder out if we end up there because everything else looks fine. A third of the time you're going to feel amazing and you're going to love it and you're going to be happy with life. A third of the time you're going to have some improvement in symptoms, but maybe not everything you thought or hoped it would be, but maybe you're net even to net happy and a third of the time, you're not going to feel good at all, and maybe you're going to get post cholecystectomy syndrome, a bunch of diarrhea and really be upset with me.

(37:26):

And it's not as conversation I have with 'em because generally speaking, roughly, I think those are the data driven numbers and I could be off, so maybe I'm lying to the community, but that's what I've seen and I'll just look 'em in the face. And I think patients, especially anywhere, but in rural communities for sure, they just want straight honesty. And so I say, look, we've scoped, if you want to go on this journey, I'll go with you, but you've got to know these likelihoods. And I wouldn't say that it's quite panning out to that amount because what I find some upper GI issue, we're treating that first I think without doing appropriate preoperative workup. That third, third, third probably applies because a third of the time they did have an ulcer. They did have gastritis or they did have h pylori. If I'm ruling stuff out and taking those people off the table, like I said, I'm seeing good results with hyperkinetic, gallbladder. Cholecystectomies.

Dr. Randy Lehman (38:22):

Yeah, great. I had one patient

Dr. Jesse Van Maanen (38:26):

Because they're not inflamed.

Dr. Randy Lehman (38:27):

Oh, of course. Yeah. I had one patient who had an EF of 1% and he was like, oh, probably 75 old guy and had classic symptoms. I said, don't ever say this. Okay, we figured it out. I can solve your problem. So what I was told to tell patients, I should probably have a site for this or whatever. But basically what I tell 'em is that if it's gallstones and you have classic symptoms, there's a 97% chance that we fix your problem. If you have biliary dyskinesia, then it's more of around an 85% chance is what I've been telling people and probably as close to what I've clinically now seen in six years. And it's possible that it is something else in those other situations. So the question is, do you want to take that? I would say most people generally do, but definitely don't twist somebody's arm and you got to disclose that there's that percentage.

(39:44):

Well, this guy, I was stronger than that in my recommendation because his number was so low and he came back two week follow-up is very happy, thought he was totally fixed, comes back like three months later, you didn't do anything for me. I don't even know if he took my gallbladder out. It's like, just so you know, the number itself is just one piece of the equation. Okay, well thanks for all of that. I think from a robot perspective, from a how I do a perspective, this has been great. Is there anything else if you just had one more or nugget for somebody on robot surgery that you really want to share with the listener?

Dr. Jesse Van Maanen (40:35):

I think doing those easy cases, although it feels a little wasteful and slow at first, and I mean this is, I'm speaking to you now, having

Dr. Randy Lehman (40:43):

Sort

Dr. Jesse Van Maanen (40:43):

Of mucked with a robot gallbladder when you could have done it in a quarter of the time or less. Those are the ones I think for someone who's interested in robotics who's maybe starting out or hasn't done it in a while, those easy ones are the ones you want to do it on at first, the biliary dyskinesia, the one, the anatomy is fine, where you're like, I could be doing three or four, what am I doing? That's the one you want to do it on, right? I mean that's why I use an ultrasound when I place a central line, not because I need it, but because I have it and when I don't have it, then I'm going to be better. Or when I got to use an ultrasound for some other reason that's unrelated to this, I'm really facile with it. Right? I use not an easy case. So robotics, same thing. You got to

Dr. Randy Lehman (41:27):

Practice on those. Same reason I do a cholangiogram on every gallbladder.

Dr. Jesse Van Maanen (41:31):

Oh wow. Are you in every cholangiogram guy?

Dr. Randy Lehman (41:34):

Yes.

Dr. Jesse Van Maanen (41:35):

Oh, okay. Well, we ain't going to talk about that.

Dr. Randy Lehman (41:39):

Well, I mean basically I'm in three small hospitals in northwest Indiana, so my overall volumes are high for me, but each volume at each place is pretty still low. And I'm the only guy in any of those places besides one. There's another guy, but really all he does is scopes. So all the gallbladders that are being done with each one of these techs at each one of these places come straight up with me. And I also do, we don't have any ERCP and I do laparoscopic common biotic exploration. So I want people to be comfortable and not be this big fuss about getting the tubing when we need to do it. Okay. And I'm not saying that I'm for sure going to do this forever, but now most of the time I do a cla gram literally adds 90 seconds to the case. And I am talking about from the time I ask for the clip to clip the gallbladder side until the time I am pulling the thing out and the picture has been taken.

(42:43):

And I mean, I saw things in residency where people try to get Klan grams and couldn't get it done. So if you can make it that easy just by kind of reps, and then what we're able to do is sometimes quite complicated things. Scope the bile duct, pulling stones out with baskets and stuff. And then when I have to shoot a clan gram five times during this interval back and forth thing, and each time it only takes me a minute and a half, it's much better. And so I find it worth it. And I've also found things

Dr. Jesse Van Maanen (43:22):

Oh yeah, that you would not have

Dr. Randy Lehman (43:24):

Expected. Yes, incidental things, incidental stones in the duct and whatnot.

Dr. Jesse Van Maanen (43:29):

Yeah, no, I love that. I think that's the whole point that we're making, right? Is it get good at the thing when it's not that hard, so that when it is hard, you're not learning for the first time or for the second time even. So that's a perfect point that you make. We are not yet doing common duck exploration, but it is in the budget to purchase the items.

Dr. Randy Lehman (43:53):

And so

Dr. Jesse Van Maanen (43:53):

We did 'em in residency but haven't brought the service to us yet, but really are having a hard time sometimes getting patients out for ERCPs when they need them. So when we get that up and running, I may be talking to you again for some tips and tricks on how to navigate some of those tricky cystic ducts.

Dr. Randy Lehman (44:10):

Yeah, I've got some pictures and stuff, and that's, patient selection is a big one on that one. So short, fat cystic duct is the ideal, obviously anatomy. And then if you can just save that one person, I mean they'll never appreciate it. They don't really know. They'll just say, oh, Dr. Van Monen took my gallbladder out, but you know what you did, so it's all good. You know what you saved them from. Let's move on to the next segment of the show, the Financial Corner. Do you have a financial tip for our listener by Low so high?

Dr. Jesse Van Maanen (44:41):

I'm going to speak about it. As a recent grad, I've only been in practice maybe four years or so, four and a half. You are in med school and you're paying an inordinate amount of money and then you're in residency and you're making just enough to buy the off-brand Wheaties. You get to be an attending and it feels great because you've finally made it. My tip is live like a resident who just got a nice bonus for a little while. I mean, don't live like a resident. Don't scrape food off the floor necessarily because you've earned it. You've made it here. I can't speak as someone who's been in practice for 10 or 15 years and has built some inordinate amount of wealth, but the money starts flowing in as a surgeon. And if you budget well, if you still think about your finances, if you don't go buy a boat and a brand new house and a second house and a third house and three new cars, you are going to set yourself up for success later.

Dr. Randy Lehman (45:49):

Love it.

Dr. Jesse Van Maanen (45:50):

I can only say about that much because I'm four years in. I live comfortably as we all do as physicians. There's no doubt about that. There's no beating around that bush. But stuff is stuff. And honestly, if I'm going to spend money on something, I'd rather go somewhere and experience a life event than necessarily have another toy. Not to say that I don't like toys or don't have 'em, but I like memories more than things.

Dr. Randy Lehman (46:18):

It's beautiful. It all goes back in the box. You heard that six foot box at the end? Yeah. Alright, great. I love it. Now, did you come prepared with any sort of classic rural surgery story that your urban colleagues just wouldn't believe by chance or anything happen crazy lately?

Dr. Jesse Van Maanen (46:42):

I don't know about crazy, but here's an example that goes back to the coordination of care and how rural hospitals can really pull weight for patients where in a larger institution and not to knock them again, but you may have a longer wait time for something. So I don't know, maybe six months ago or so I was on call and the emergency department called me. You could just

Dr. Randy Lehman (47:07):

Say six, seven months ago if you want.

Dr. Jesse Van Maanen (47:10):

Did I say that?

Dr. Randy Lehman (47:12):

You can say six seven, that's acceptable on this show. No, you said six months, but I'm just letting you know it's okay. You say six months old, say six, seven. Yeah,

Dr. Jesse Van Maanen (47:21):

My son does this, so I do understand it. I know understand it, but I

Dr. Randy Lehman (47:28):

Alright, sorry to interrupt. Carry on.

Dr. Jesse Van Maanen (47:31):

So I'm on call and the ER is asking me to come see a mid twenties year old healthy female with this massive pleural effusion. She had kidney stones and came in for kidney stone troubles, has a history of those. And so they did a CT without contrast and again found her stone. But of course the CT catches the bottom part of her lung fields and no one understands why she would have a pum or a hydro thax. She is young and healthy and active. So they went ahead with a CT scan and she had a, I would call a football sized tumor in her anterior mediastinum, entirely incidental, no idea it was there had felt a little puffy in her neck and upper extremities in the last couple of months and maybe a little tired but not losing weight. Totally incidental, thank you kidney stone for discovering this massive mediastinal mass. So I went ahead and did a thoracentesis for her that day to relieve some of the effusion, set that for cytology. And then she had a CT guided biopsy of this mass and it was lymphoma. And so within one night, and this is an example of a rural surgery success story. One night she gets an incidental CT scan and thoracentesis, two days later she is having a mediastinal biopsy by our radiologist

(49:02):

Three days later because PATH came back. You're pushing the port. I put in the port, I put in the port three days later. Exactly, because she's already seen oncology in our hospital and they're going like, we have path back. They called us and you get a port in the next day. So within I think it was eight days time, she had been diagnosed, discovered, diagnosed, worked up, seen medical oncology port in getting chemo within a

Dr. Randy Lehman (49:30):

Week. That's amazing.

Dr. Jesse Van Maanen (49:31):

A day or two, right? Because I have the oncologist cell phone number, they have mine. I called radiology and it wasn't all me. I played a very small role in this whole thing. She's had staging imaging workup later and is entirely complete pathologic response. I mean within months.

Dr. Randy Lehman (49:51):

But the Canadians aren't even listening to this show. They should be.

Dr. Jesse Van Maanen (49:57):

It was a really cool thing to see from an entire hospital perspective to say, I can walk down the hallway 20 feet and talk to my oncologist. I know the guy. Yeah,

Dr. Randy Lehman (50:06):

That's awesome.

Dr. Jesse Van Maanen (50:08):

And that's an example of a rural surgical success, success story where you can do more if you're a smaller, to some degree, you can't do more necessarily procedurally, but for the patient and what it means for 'em, you can coordinate better. I should say flex. You can flexibility better. In a small town. You don't nimble, you don't have to answer to somebody, and you certainly don't have to send them to somewhere 3, 4, 5 hours away to have a consult to then come back and have a port placed. I just saw the morning of the port. So that's an example of something that went well because we were able to coordinate and communicate well that you don't always get elsewhere.

Dr. Randy Lehman (50:49):

Yep. Great job. Hey, last segment of the show is resources for the busy rural surgeon. Before you tell me just whatever resource you think might be a good recommendation that every rural surgeon should know about, I want to know if you're going to send something for cytology on a thoracentesis, what do you send it for? And before you say that, is this just in your head or do you go to a resource to look up what you're going to send the fluid for

Dr. Jesse Van Maanen (51:19):

In terms of full fluid analysis?

Dr. Randy Lehman (51:22):

Yeah.

Dr. Jesse Van Maanen (51:23):

Yeah. I originally, when I first, so we have Epic, that's another crazy small town critical access hospital sort of how in the world do you do that? We are a partner, so although we are an independent hospital, we have a community connect site of Epic through a larger institution that we're not owned by or governed by, but they have gifted us their epic at a discounted rate.

Dr. Randy Lehman (51:52):

Your hospital should be a case study because it's a perfect, you have just enough volume flowing in that you can have a robot in Epic and then you can recruit young capable surgeons because you have those things. So really it ends up actually being a sort of a numbers game. To have that success, you got to be small enough that you're still critical access, but just big enough that you can still do these other things. And then even if you do that, you can have some incompetent people running it or some crooks involved in the mix or whatever, and next thing you know it doesn't work, but you kind of have to have those other things or else you end up fizzling out. But anyway, I digs,

Dr. Jesse Van Maanen (52:36):

I got, I'm talking about Thora.

Dr. Randy Lehman (52:38):

Where

Dr. Jesse Van Maanen (52:39):

I was going with that is with most EMRs, but Epic is because I know it. I essentially built a smart phrase or an automatic order set that pulled in every possible thing I may need from a thoracentesis or a separate paracentesis evaluation, and I just type the words thoracentesis labs in, hit enter twice and then uncheck what I may not need. So if I'm not looking for a Kyle leak, I'm not going to look for that. If I'm thinking about infection or if I'm not, I'm going to uncheck those boxes. So I kind of cheat. To be fair, at one point in time I had all of these 18 things memorized and I never want to forget because as soon as the specimen is spent now you can't get it back. But I built these phrases and then I select what I think I need.

Dr. Randy Lehman (53:30):

When you first came out and you had all that stuff memorized and you're at your first day on a job and you're building your thoracentesis dot phrase, what resource did you originally primarily get that information from? Or is it multiple UpToDate?

Dr. Jesse Van Maanen (53:49):

Mostly.

Dr. Randy Lehman (53:50):

Okay. Very good. But what you just gave us is an extremely practical tip of how to actually do it in your practice. I think it's good for medical students and residents listening to the show to understand that these are the life hacks because it's a recurring problem. It's a problem once, it's going to be a recurring problem, how can you set yourself up so that you can just hammer through it the next time and without having to just memorize it? Because sometimes the problems, they don't actually just happen. It's not like you're running a chest service at St. Mary's Hospital or thoracic surgery or whatever, but you're still going to be called on to do it and you should do it confidently. Well, so anyway, any other resources for the busy rural surgeon that you would like to share with us?

Dr. Jesse Van Maanen (54:39):

Well, obviously the Rural American Surgeon Podcast.

Dr. Randy Lehman (54:42):

There you go. Yeah, I don't think that this is your main CME or at the moment when you have to do a gallbladder, you're going to come back and listen to this episode. Although

Dr. Jesse Van Maanen (54:56):

Maybe someone will put the retracting arms the way I do

Dr. Randy Lehman (55:00):

Sometimes. I have listened to some of these. If I've got an unusual case in a few of the episodes, I'm like, I don't remember some good trick, what was going on. But anyway, sure. Yeah. Thanks for the nod, and I do appreciate it.

Dr. Jesse Van Maanen (55:15):

Well, and it is been good to get to know you through North American Rural Surgical Society. I would say, again, that's not a type of, if I can put a plugin for them, I don't think that that's necessarily a place that I go for UpToDate in the minute information. But a group of rural surgeons across the country and even abroad who are committed to and in some similar ways working rural, although as we've talked about rural means a lot of different things. Being able to come together, collaborate, get to know each other, see everybody annually and talk actually, rural surgery and what works for my hospital and what works for yours, and how are we different, but how are we the same has been one of my favorite community building things as a rural surgeon,

Dr. Randy Lehman (56:02):

Come out to San Diego next February. It's a good place to be. That's right. Awesome. Well, Dr. Van Manen, thank you so much for joining us and we will go ahead and take it out for me. Randy Lehman, your host of the Rural American Surgeon. I will see you on the next episode of the show.