EPISODE 60
Selection, Systems, and Outcomes in Rural Whipple Surgery with Dr. Cate Straub
Episode Transcript
Dr. Randy Lehman (00:06):
Welcome back listener to the Rural American Surgeon Podcast. I'm your host, Dr. Randy Lehman, and I'm so pumped to have Dr. Cate Raub with me today. Thank you, Dr. Raub for joining me. Thank
Dr. Cate Straub (00:16):
You.
Dr. Randy Lehman (00:17):
And Dr. Raub is a associate professor with the University of Washington and Washington State University where they have a rural surgery program and she serves as a medical student, clerkship director. She's also a governor for the American College of Surgeons, and she will be moderating a session about challenges on rural surgery transfers out there in Washington DC this fall. She has a lot of things going on, a very interesting and exciting and unique rural surgery practice. So I'm so pumped to have you on for today's show and thanks again for joining me.
Dr. Cate Straub (00:51):
Thank you so much. It's a pleasure to be here. Absolutely. My love of rural surgery is something I've kind of grown into in my career. I wouldn't say it's been a passion of mine from the get-go. I wish I could say that, but it totally wasn't. I grew up about as far away from rural America as you could imagine. I grew up just off an exit ramp on Long Island and never contemplated rural medicine. There was about five different hospitals within five miles of me. So it was really actually after I graduated from college and decided to take a couple of years off volunteering with AmeriCorps that I became really interested in what even rural America was. And I learned after doing a year of disaster relief work in rural South Carolina and Louisiana, that when you help rural communities, the hospitality and the love you get back is multiple fold above and beyond.
(01:50):
And still wasn't sure that that's where I wanted my practice to go. But ended up at the University of Utah for residency and fell in love with the great outdoors and there's no better place to continually experience the great outdoors than a smaller hospital system in the middle of a beautiful place. And that's kind of how I landed myself in Wenatchee, Washington, which is if you look at the state of Washington, we're kind of smack dab in the middle of it just on the east side in the foothills of the mountains, a part of Washington that most people don't think of because it's very dry, it is very sunny, and it is very, very, very rural. So our catchment area here is about a quarter of the state falls within the catchment area of my hospital system, but is the most rural parts of the state kind of go from here in the middle all the way up to Canada as far as our catchment area goes for our hospital system.
Dr. Randy Lehman (02:47):
Wow.
Dr. Cate Straub (02:48):
Yeah, it's really, when I speak nationally on rural surgery and rural medicine, I have a picture of Washington and I kind of show where the med schools are on either side, where the residency programs are kind of dotted around the edges, where the trauma centers are, and then we're right smack dab in the middle of nothing in the middle of that for the whole state.
Dr. Randy Lehman (03:10):
Yeah, that's the thing about rural surgery. So how do you define it? That's always a challenge. And what is rural is the first question then what is rural surgery? And I have people that I know that are in Lafayette, Indiana, which is a place to me would be like the referral center, 200,000 community and everything, and they consider themselves rural surgeons. And then there's me who's 45 minutes from a place like that, two hours from Indy, two hours from Chicago. And I consider myself a rural surgeon, neither of which matches up with what you do or holds a can of that. And
Dr. Cate Straub (03:48):
At the same time, I think that the only type of rural surgeon that is really well-defined is the critical access hospital surgeon because that is to be considered a critical access hospital. To be able to get that funding is a very, very, very specific definition. But I think that a lot of it has to do with no matter what size your hospital is or what you're capable of doing there is how far you are from the next available thing. And what patient populations are you serving and how far do people come to you? I think when I started this job, I knew I was a community surgeon. And I've realized since then that there are so many different community surgeons. There's community surgeons as defined as just not academic surgeons that are hugely specialized. And then there are those bread and butter surgeons that are a hop, skip and a jump away from the tertiary center.
(04:38):
And then there's the general surgeon more like me who is far away from a tertiary center and yet is sort of considered a bit of a regional referral for all those critical access hospitals. And then there's the true critical access surgeon. And so I shied away from saying that I was a rural surgeon for a really long time for that reason because people do seek us out and send things to us. But the thing is that the struggles that we have with our patient population, the rural patient as well as the transfer dilemmas and as well as trying to be a hospital system that needs to really pick and choose what they're willing to bring in and not because we don't have endless sources of money and we can't do everything, so we have to decide what we're going to do and what we're not going to do. I think that's something that a lot of larger hospital systems just don't have to think about.
Dr. Randy Lehman (05:28):
Yeah, that's perfect. And you've sort of touched on this, but I usually like to ask the guests what is so special about rural surgery and why should we even care? Is it relevant in 2026 and why?
Dr. Cate Straub (05:41):
I think it's relevant because just so much of our country lives in rural America. It is really easy when you live in a big city to think that everybody is willing to drive to you to get their medical care, but not only are some people unwilling or unable to do that, but there are geographic challenges in between you. I'm two hospital, I'm sorry, I'm two mountain passes away from Seattle, and there are times of the year that that is just physically impossible to cross. We had horrible storms earlier this year that knocked out one of the two ways over the mountain passes for four months and then we had fog that kept us from being able to fly anybody out for over a month. And so you can't just abandon rural America by saying they need to be able to get to a big city.
Dr. Randy Lehman (06:32):
Yeah, 100%. And of course for me, I moved back to the farm that I grew up on. It's personal, but there's different reasons that people find themselves serving this population. And I think everybody listening to this show has pretty much already bought in.
Dr. Cate Straub (06:46):
Yeah, I mean the same reasons that I discovered when I was working in South Carolina and Louisiana, also the most thankful patients on the face of the earth and you get the most random presence from them.
Dr. Randy Lehman (07:01):
Tell me more.
Dr. Cate Straub (07:02):
What's the most random present? Oh, this is a great one. If we're going to get down to classic rural surgery moments. Okay, let's just jump ahead eventually. I have so, so many, but just about three weeks ago, a gentleman on a farm outside of town was trying to wrestle one of his boars away from a female pig. It was trying to get it on and he wasn't supposed to and he got gored through the leg with the boar's tusk and I saw him in the er. He was doing well, but ortho and I were going to take him to the OR because he had err his joint and I was going to take care of the soft tissue stuff. He relayed to me that he would love nothing more than to give me some of the meat of the boar because he had said his neighbor had shot the boar to get it away from him.
(07:47):
And he's like, and again, exit ramp on Long Island. I don't know much about this stuff, but he was like, the only problem is if I don't bleed the boar out soon, the meat will lose its taste and you're not going to want it. And I said, well, they just put me on hold on getting you back to the or do you think I could bleed out your pig in the next 30 minutes? And it didn't end up working out, but that's the sort of thing that you end up doing around here. And his wife was like, if you come over here, I'll give you the equipment and we can do it together. And then the neighbor's like, no, no, no. I actually didn't shoot the boar yet. I just put it back in the cage. It's not dead yet. So I went on with the case instead.
Dr. Randy Lehman (08:28):
Nice. But
Dr. Cate Straub (08:29):
It sounds
Dr. Randy Lehman (08:30):
Like you're going to get some pork out of it.
Dr. Cate Straub (08:31):
Yeah, I am definitely getting pork out of it, but they've already given me a couple dozen eggs to make up for the lack of pork.
Dr. Randy Lehman (08:37):
Yeah, that's fantastic. Now
Dr. Cate Straub (08:39):
Are
Dr. Randy Lehman (08:39):
You living in town?
Dr. Cate Straub (08:41):
I do live in town actually. I live walking distance to the hospital, walking distance to downtown. I walk everywhere.
Dr. Randy Lehman (08:48):
So you haven't went full prepper whatever yet, but that's okay. There's still time for you. No, but there's nothing better than going
Dr. Cate Straub (08:59):
Where you, I live in a bustling metropolis that is Wenatchee Washington, which is not very big. Yeah.
Dr. Randy Lehman (09:04):
So what is Wenatchee? It's population wise,
Dr. Cate Straub (09:07):
It's about 30,000 people and then East Wenatchee add another 20, 30,000 people. And then our catchment is probably about 250,000 people from here to Canada.
Dr. Randy Lehman (09:17):
Yep. Yeah, very good. So then tell me just before we get into the how I do it, your hospital, is it the only hospital in town then? Yeah. So what services do you guys have because of catchment area of 250,000? Do you have ir?
Dr. Cate Straub (09:36):
Yep, we do. Ideally we have ir, gi, most surgical subspecialties, but things get harder as it gets harder to hire people into rural communities, harder to keep people in rural communities and as physicians start recognizing that they just can't take call all the time, they can't always cover 24 7 with is one or two partners. So we're seeing, even though we have these capabilities, the exact availability of it gets stripped away. I think most of rural America struggles to have 24 7 ERCP capabilities and neurosurgery capabilities and IR capabilities and things like that. I have neurosurgery Monday through Thursday seven to five and Friday seven to noon. That's the way ENT goes and things like that as well.
Dr. Randy Lehman (10:26):
Yeah, very good. So you don't get called on to do C-sections?
Dr. Cate Straub (10:31):
No, I do not. I am lucky in that regard is that, no, I don't have to do C-sections,
Dr. Randy Lehman (10:39):
But yet you probably do almost probably bigger spectrum of general surgery than what I do because for me, I'm in three critical access hospital, actually four count Tooma Wisconsin. And the funny part is you say that critical access practice is defined. It's not the same practice for me at all the four sites that I'm at because the hospitals have different resources.
Dr. Cate Straub (11:02):
Yeah,
Dr. Randy Lehman (11:02):
I
Dr. Cate Straub (11:03):
Think I mentioned that the government description of what a critical access hospital is defined,
Dr. Randy Lehman (11:09):
But then even within that there's variation. So I want to know one more question and then I want to get to our topic and this is going to lead directly into it. Are there any specialties at your hospital that would come out of general? What we currently think are the specialties that come out of general surgery? For example, colorectal, thoracic?
Dr. Cate Straub (11:34):
No, we do have two cardiac surgeons and we do have part-time vascular surgery coverage and that's it. We don't have colorectal or anything like that.
Dr. Randy Lehman (11:45):
Okay. So
Dr. Cate Straub (11:46):
As
Dr. Randy Lehman (11:46):
Far as the spectrum of general surgery goes, tell me about the breadth of your practice.
Dr. Cate Straub (11:51):
Yeah, so I mean largely at this point in my career do acute care and trauma though we're going to talk a lot about my pancreatic work as well. I have a feeling and we just get called for everything. There's not a tube line or drain that is placed in this hospital that we don't get called to help manage. There's very few belly pains that we don't get consulted on. There's very few. You get called to evaluate every abnormal x-ray and CT scan, I swear. Just what's your opinion of that? And so we do pediatrics, we do cancer surgeries, we do trauma surgeries. We do the vast majority of pleural based thoracic disease. I do the decortication and things like that. I got called to a crash C-section, not to help with the C-section, but because the 22 week infant was coding and they couldn't get an umbilical artery catheter in. And I did that for the first time in my career just a couple weeks ago. You get called, they don't know what to do. You're the one that they call.
Dr. Randy Lehman (12:55):
Yeah. What an inspiration first off, thank you for what you're doing. Are you hospital employed?
Dr. Cate Straub (13:01):
No, I work for the Wenatchee Valley Medical Group, which is one of the largest physician owned groups in the world. Sorry, in the country. Take that back.
Dr. Randy Lehman (13:09):
Okay. It
Dr. Cate Straub (13:10):
Might be in
Dr. Randy Lehman (13:11):
The world.
Dr. Cate Straub (13:11):
It might be. We are well over 200 physicians that work both within Wenatchee as well as surrounding satellite clinics in our catchment area. And we have a contract through our hospital system for us to work there.
Dr. Randy Lehman (13:25):
Okay. So how many other general surgeons work at that hospital?
Dr. Cate Straub (13:29):
There are seven of us total.
Dr. Randy Lehman (13:32):
Are you all in the same group?
Dr. Cate Straub (13:34):
Yep.
Dr. Randy Lehman (13:34):
Okay.
Dr. Cate Straub (13:35):
There's no other general surgeons anywhere nearby. The next set is about oh, 30, 40 miles north.
Dr. Randy Lehman (13:42):
Okay. Well that sounds like a pretty good setup. You mentioned a few things, peds cancer. Tell me about that peds, what do you do? I mean, my buddy's wife just texted me again,
(13:57):
Hey, they don't like doing the vitamin K shot on their newborn baby and they like to do the traditional eight day circumcision and everything. They go to my church and whatnot. So they had a baby a couple years ago and I did a circ. It was all great experience and then she just texted me again, Hey, had another baby, you're still doing that. Okay, so that's fine. I thought I might do more peds than I do, but then now it becomes an anesthesia thing for me more than anything. So now it's hard to do a 13-year-old appy, but much less a pyloric stenosis or whatever. Now I've done some spitz nevus thing, like skin things and I am willing to do things, but it's less than what I thought it would be. But what is your
Dr. Cate Straub (14:49):
Practice?
(14:50):
So thankfully our anesthesiologists are willing to anesthetize kids six months and older here. So the appies for sure, obviously a fair number of kids are getting cholecystitis and complications from biliary disease as well. I do pediatric inguinal and umbilical hernias. I've done a handful of emergent intussusception cases and I don't do CRCs, those definitely, or tonsils and things like that. We have urology and ENT for the majority of those. The other day, just as interesting cases you get called on. This was actually two days ago, the ER called me with an 8-year-old with prune belly syndrome who had an ostomy and appendicitis and I was like question that. And I kind of went into the medical record and looked back at what had been done at Seattle and it said he had a Mitrofanoff tube, and I think a lot of your listeners know, but that's when you actually utilize the appendix to create a connection between the bladder and the umbilicus so that the child can cath.
(15:55):
So that's part of being a rural general surgeon that's willing to do pediatrics is not necessarily doing all the operations, but understanding the intricacies of what can go on in challenging congenital cases and sort of set the ER on the correct path. And so I said it's impossible for him to appendicitis because his appendix is being used as this conduit. And if your ultrasonographer found an appendix in the right lower quadrant, they were probably looking at something else. And ultimately the child underwent a CT scan that just showed severe constipation and he was able to be discharged home. So sometimes it's not so much what you get to operate on, but the knowledge you get to instill to other people about what's going on with these cases.
Dr. Randy Lehman (16:38):
Yeah, for sure. And cancer wise, just real quick, what types of cancer are you talking about?
Dr. Cate Straub (16:45):
Oh yeah. We have a robust breast cancer group here and breast cancer group such as medical oncology, radiation oncology, and just a lot of breast cancer patients. We manage melanoma patients, the sentinel lymph nodes for that. We do routine colon cancers, segmental. And then obviously I've kind of started my own practice doing pancreatic work while another one of my partners took on esophageal work. So I have a partner that does esophagectomy and I do Whipples.
Dr. Randy Lehman (17:19):
Yeah, and you didn't do an HPB fellowship?
Dr. Cate Straub (17:23):
Did not.
Dr. Randy Lehman (17:24):
And your partner that doesn't esophagectomy didn't do a thoracic fellowship?
Dr. Cate Straub (17:28):
He did not. He didn't MIS fellowship, but no, he did not do and did a fair amount of foregut in that, but yeah.
Dr. Randy Lehman (17:35):
Yeah. And then what do you guys do from a vascular perspective? I know you said that you have the vascular surgeon, but before we get into the Whipples and how I do it
Dr. Cate Straub (17:44):
Pancreas
Dr. Randy Lehman (17:45):
Stuff, but does anybody do carotids out of the seven of you?
Dr. Cate Straub (17:49):
No, we don't do carotids. No, we don't do the vast majority of vascular work. I've done a handful of shunts and things like that, or I've worked with other surgeons when we haven't had vascular available to help with patients that couldn't be transferred. But we don't do formal vascular work.
Dr. Randy Lehman (18:06):
Vascular
Dr. Cate Straub (18:07):
Access,
Dr. Randy Lehman (18:07):
I'm sure you do tons.
Dr. Cate Straub (18:08):
Well, tons of ports and central lines. Yeah, sure. Who
Dr. Randy Lehman (18:11):
Does the AV fistulas
Dr. Cate Straub (18:13):
Vascular.
Dr. Randy Lehman (18:14):
And who does the varicose veins?
Dr. Cate Straub (18:16):
Vascular.
Dr. Randy Lehman (18:17):
Okay.
Dr. Cate Straub (18:18):
Do you do varicose veins and fistulas?
Dr. Randy Lehman (18:21):
I do a ton of veins. I came out prepared to do fistulas, but what I think is happening is I think a lot of the patients in my geographic area that develop end-stage renal disease are just dying.
Dr. Cate Straub (18:37):
That's
Dr. Randy Lehman (18:37):
What I think is happening because I went around and asked a lot of the primary care doctors, I was like, where do your patients go for dialysis? There's no dialysis in any of those towns. And they're like, well, I dunno. I don't have very many people on dialysis. And I'm like, well, you should have a certain percentage of patients on dialysis because I don't say this to them, but I feel like they may be moving closer to a dialysis center, but probably more likely it gets overwhelming and they just die.
Dr. Cate Straub (19:10):
I think a lot of that speaks a lot to the communities. People present a little bit later whether or not it's just in general not going to the doctor as much or just not knowing when to go to the doctor as much. You're just having lives that don't allow them to go to the doctor as much. And so a lot of things from end stage renal disease to pancreas cancer get diagnosed late. I mean, I see, yeah, liver disease,
Dr. Randy Lehman (19:35):
The same thing.
Dr. Cate Straub (19:36):
Yeah, I see a huge number of patients that are unresectable and already metastatic. And honestly, this isn't really a joke, but I used to say that a lot of patients around here that turn yellow would rather die than drive to Seattle to figure out what's going on.
Dr. Randy Lehman (19:54):
Yeah. Okay. Well, let's get to how I do it segment because I do not talk very often in the rural surgery how I do it about pancreas surgery. But I'd love to know first how you decided to do that and logistically like a program, how did that happen? And then I want to talk about the most common indications for surgery. And then I want ask you the stupid questions on the exact technical details just because I like nerding out on surgery.
Dr. Cate Straub (20:24):
I was going to say, knowing that you wanted to talk about this in particular, I thought I'm not coming on this podcast to teach people the technique of how to do a Whipple at all. We can talk about it, but I think it's more important to discuss why and is it safe and how do you make it safe for your patients to be able to do big surgeries in smaller places like this? So first you have to identify, and then we identified a need. We kind of looked at how many patients were being transferred and what that meant, and we realized that a lot of patients were being transferred. We did not have advanced GI coverage. So once somebody needs an ERCP or an endoscopic ultrasound, if they go to a larger center for that, they're not going to come back to you for the surgery.
(21:08):
They kind of get enveloped into that system. And so we recognized that we actually had a fairly robust group of people that were being sent to Seattle for workup and management and pancreatic cancer, but I didn't have a way to work them up here. You can't do it without an advanced endoscopist. So the administration said they wanted me to do something like this. Well, they want somebody in our group too. And I had had at the University of Utah, a very robust HPB training, and I said, well, if we're going to do this, we have to do it soon. I'm not going to get too far out from residency not doing these surgeries. And I said, I'm going to need mentorship and I'm going to need support and I'm going to need marketing. And so I started talking to Dr. Adnan at Virginia Mason, and I said, if I do this, will you be kind of my accountability buddy? I'm going to collect my data and I want you to review it and I want to be able to run every case past you and I want to be able to shadow you and come to Virginia Mason and watch you do cases.
(22:12):
And that worked. Beautiful. Virginia Mason
Dr. Randy Lehman (22:14):
Is in
Dr. Cate Straub (22:15):
Virginia? It's in Seattle. It's in Seattle. Okay,
Dr. Randy Lehman (22:16):
Sorry.
Dr. Cate Straub (22:18):
That's all right.
(22:19):
Believe me. As somebody who went to the University of Virginia, that confused me a lot moving out this way as well. Got it. And his mentorship was invaluable, but I think as a non fellowship trained community or close to rural surgeon, you do feel a bit of an imposter syndrome. Should I even be allowed to take on these bigger cases? Should I be, am I qualified to do it? Is everybody in the tertiary center is going to be kind of talking about me? Why is she doing this? Is it okay for her to do this? And having his support and having him sort bring me into the fold and invite me to start attending conferences and things like that under the auspices of being a pancreatic surgeon was incredibly helpful to help build the respect around here. So then my marketing department took me on a whirlwind tour to every clinic between here and Canada, and I just handed out cards and my cell phone number, and I basically said, you don't need to know how to work these patients up.
(23:20):
If your patient turns yellow, if they have a mask, just call me. I'll take it from there. I'll figure out where they need to go. You don't need to guess which cases are going to be surgical or not or what imaging to get. Just let me know. And then we hired an advanced endoscopist, and now I have two. And we decided that we still needed greater oversight to these cases. So obviously I present every case at our cancer conference, but on top of that, we created a separate pancreas conference that meets every other week. And it's just me, the GI docs and radiologists, and just reviewing everything from which cysts are concerning to be pre-cancerous. How do we manage complex, complex pancreatitis? How do you figure out if something truly is a choledochal cyst and what needs to be done by that? And I spent a lot of that conference saying, this person needs to be referred to Seattle or Spokane or wherever's best.
(24:14):
But it was a great way of me picking up cases. We were starting to identify cancers before they were getting out of control, before they were becoming locally advanced, and it was allowing me to operate on cancers in pre-cancerous lesions under the best possible circumstances, which is normal anatomy, and it allowed me to expand my practice. The next question was like, how many cases do I have to do a year to be safe and what do my outcomes have to be? Obviously the concept of a high volume institution is a pretty hot button issue. And just floating that term out there keeps a lot of community docs and oral surgeons from wanting to take on things because somebody's going to say, you're not a high volume institution. Thankfully, the numbers for pancreas work are pretty low. In general, if you're doing about 12 to 15 major pancreatic operations a year, you fall into that definition of a high volume center in the literature. And so I said, if I can't maintain those numbers, then I shouldn't be doing this. And I have routinely for the past about 14 years, been doing between 12 and 15 major pancreatic resections a year, sometimes a little more
Dr. Randy Lehman (25:23):
For the past, how many years I missed?
Dr. Cate Straub (25:24):
About 14 years I've been doing this. Wow.
(25:31):
But at the same time, you kind of have to be picking on your patients. You have to maintain good numbers, you have to be safe. And so how do you be picky and keep the patients that you are going to be able to have good outcomes with while still maintaining those numbers? And there have definitely been times when I just wasn't getting the referrals, I wasn't really seeing the patients, and I thought maybe it's just not safe for me to do this anymore. But just about then we kind of expanded what our advanced endoscopists were able to do as far as identifying precancerous lesions. And I saw my numbers pick up again, just last week I did an open cystgastrostomy because the endoscopist couldn't reach a cyst. And I did a pancreatic necrosectomy through an open cystgastrostomy. And I mean, I haven't done it since residency, but why not?
(26:19):
And so I collected data for the first five years, and I looked at every single patient I even saw in clinic where they ended up getting referred to and what their outcomes were. I compared them to mine for the cases that I kept here. I looked at negative margin rates, I looked at leak rates, pancreatic fistula rates, and I looked at overall survival. And then I had the team at VM evaluate my stats and compare it to their own and find that my outcomes probably because a little choosier about my patients were actually better than their outcomes. And they came and presented to our oncology team and said that not only is Cate a safe surgeon, but you should actively be referring your patients to her.
Dr. Randy Lehman (27:01):
What if
Dr. Cate Straub (27:01):
Your outcomes were
Dr. Randy Lehman (27:02):
Slightly worse than theirs?
Dr. Cate Straub (27:05):
And that happens when you have a low end. You can have a bad couple of months, and suddenly your outcomes look a lot worse. And you have to critically evaluate that and decide what to do with that information. So yeah, if my outcomes were worse, I'm pretty sure my hospital system would've asked me to keep doing it, and I think I would've evaluated whether or not I had means of improving my outcomes. Is this a systems issue? Is it a me issue? How can we improve that? And if there was no way for me to thoughtfully improve my outcomes, I'd have to stop.
Dr. Randy Lehman (27:39):
I don't know.
Dr. Cate Straub (27:41):
I think
Dr. Randy Lehman (27:41):
I'm asking. It depends, like I said, slightly. So that makes a big difference.
Dr. Cate Straub (27:46):
It does. And when your numbers are low, when your N is low, it takes one bad outcome to make your outcomes worse than a lot of other people's. And
Dr. Randy Lehman (27:54):
I don't know how you exactly say that. What is the standard deviation of these surgical outcomes that you're talking about? You can say you're slightly better, but are you actually outside of a standard deviation better? Because I would say definitely if you're within one standard deviation worse or better, that's basically the same thing. Basically you're doing the thing, you're participating in the bell curve. And so then I try to do in my practice where if I can look the patient in the eye and say that you are not getting a better operation somewhere else,
Dr. Cate Straub (28:33):
That's
Dr. Randy Lehman (28:33):
Kind of a, I don't know, a threshold or whatever. Which for the most part, I've told this story several times, but basically it was very ironic to have the person fly in on their private 7 47 from Abu Dhabi into Mayo Clinic land at Rochester International and go through customs and come over and have the second year resident fix their umbilical hernia flying over thousands of capable surgeons on the way there. But the point is, at the end of the day, better, worse, the same, most people I think are more of the same. You're kind of getting the standard of care. I mean, there may be the thing where Lake Wagan, where whatever all the children are above average, but everybody kind of thinks they're above average. But if you're average, so what's wrong with that? But then you have these people where you're living, sometimes they refuse to go somewhere else.
Dr. Cate Straub (29:46):
And
Dr. Randy Lehman (29:46):
I have found myself in sort of tricky situations, having conversations with patients where it's like, I mean, I've said no flat out, no sometimes, but sometimes I'm like, well, they're
Dr. Cate Straub (29:57):
Willing to roll the dice on this. Yeah,
Dr. Randy Lehman (29:59):
I get your point. And the same thing happens with the patients that are borderline surgical candidates, but they're, heck, my grandpa had a redo turp, and so I'm living it from the other side, watching him say what he wants to say in his nineties, 94 years old, I, I need to redo. I understand the risk of general anesthesia or whatever. And he went for it and it went fine, but even if it didn't go fine, he was okay. And I also like to say the surgeon takes risks. I mean, the patient takes risks, not the surgeon. So
Dr. Cate Straub (30:30):
End of the day,
Dr. Randy Lehman (30:32):
It
Dr. Cate Straub (30:32):
Doesn't always feel that way though.
Dr. Randy Lehman (30:34):
No, it doesn't. And you have to, can't burn yourself out with too big of a surgeon's graveyard. And if you think it's really the wrong thing to do, obviously don't do it. But there are these patients that are borderline from a medical perspective, and you try to explain to them what the real risks are. Some people given that exact circumstances and a good understanding will say, I don't want to do it. And some of them will say I do. And then I feel like at that moment I leave it up to them. But to take that amount of time, talk about risks and benefits of every patient's kind of hard.
Dr. Cate Straub (31:15):
Oh, it is. It is. But I mean, I think especially with pancreatic surgery, you can't really discuss anything short. There's no quick discussion in that regard. So I mean, we're already buying in for a long-term relationship the moment you enter my office. So I mean, to that end where you're talking about patients that will just flat out refuse to go anywhere else, I mean, I even had a patient who I did do a whip on a month or two ago who developed a very low grade leak and it was being managed perfectly by a drain, and he was going to go home with the drain. I could never get him to come down out of his canyon for me to evaluate that drain. Thankfully, he was MyChart ready and he was sending me weekly tallies of how much was coming out. And then I didn't hear from him for a weekend. And on Monday I get a MyChart message. It just says, nothing came out this weekend. I pulled out the drain myself and I was like,
Dr. Randy Lehman (32:11):
Nice.
Dr. Cate Straub (32:12):
Yeah,
Dr. Randy Lehman (32:13):
I was over it, so don't worry about it.
Dr. Cate Straub (32:15):
I got it. He's apparently doing fine.
Dr. Randy Lehman (32:17):
That's awesome. How did you have the conversation? Well, what was the very first pancreas surgery that you did outside of residency?
Dr. Cate Straub (32:26):
Oh yeah, that's a good question. The very, very first one was an open distal pancreatectomy that I did with one of my partners. I had a couple senior partners that had been kind of doing the one-off occasional pancreatic surgery. Maybe they were doing one or two a year. My older partners, and they were very encouraging of me getting this practice up and going. So yeah, I remember her name. I'm sure they were. I remember everything about this patient. But yeah, I did an open distal pancreatectomy and splenectomy for a T one and zero pancreas cancer. And shortly thereafter I did a Whipple with another one of my partners. And then it was kind of fits and spurts, convincing GI and oncology and local people to refer to me. So that first year was pretty low volume.
Dr. Randy Lehman (33:13):
How did the conversation go with the first patient? When you explain, did you tell 'em, this is my first pancreas surgery since pregnancy? I would pitch it. Maybe I would tell him that, but I'd say, but I'm doing it with my partner who's done many, well,
Dr. Cate Straub (33:28):
I mean that's a hundred percent what I did. And actually she came to me through my partner's clinic and they said, we just hired this young buck surgeon who came from this big university program and she's done a bunch of these there. And she was just like, sweet, sign me up. I mean, rural patients for the most part are just remarkably trusting. They trust you so implicitly from the get go. And I think that is something that you deal with a lot when you're taking on. I don't know, being a rural surgeon in general is like they trust you and you got to feel deserving of that trust. You have to have the confidence in yourself to be able to do what they already trust you to do. Why
Dr. Randy Lehman (34:08):
Do you think it wasn't so much
Dr. Cate Straub (34:09):
Convincing them,
Dr. Randy Lehman (34:10):
Right? Why do you think rural patients are more trusting?
Dr. Cate Straub (34:20):
I think that that is a really, really good question. I think because they know that you're the option, they have that if they don't want you, they're going to have to go elsewhere. And so they just want to trust in their local hospital system probably more. They're not just like, well, if I don't like her, I can just go down the street and get someone else. So they're a little more likely to just inherently want to trust you because they don't want to go to mountain passes away.
Dr. Randy Lehman (34:45):
Do you think
Dr. Cate Straub (34:45):
Rural people
Dr. Randy Lehman (34:46):
Are more trustworthy than urban people?
Dr. Cate Straub (34:50):
Ooh, trustworthy. I don't know. What do you think?
Dr. Randy Lehman (34:58):
Well, I have an opinion.
Dr. Cate Straub (34:59):
Of course you do. And I'm asking it.
Dr. Randy Lehman (35:06):
I don't want to necessarily dominate our conversation by any means with this, but
Dr. Cate Straub (35:10):
You're not. It's
Dr. Randy Lehman (35:11):
Just something that it flashed through my brain. So I think that there is, part of why I like to practice in rural America is I went back to high school. When I moved back home, I found this paper that I wrote when I was in high school, and the title of paper was The American Farmer, the Moral Backbone of the United States or something like that. So obviously I had an opinion on this topic for a long time. But FFAI was an FFA four H, great clubs. My dad says, he told me a story about he left his wallet on top of the
Dr. Cate Straub (36:05):
Pump
Dr. Randy Lehman (36:06):
At the gas station, and it just showed up in his mailbox. Nothing missing, of course. And nobody even, he doesn't even know who gave it to him. Nobody's even asking recognition. They just saw this, ID went to his house, dropped it. And I've also read article. I don't want to be too much bias that I don't look at the truth. And I've read articles that say things like Rural America is the new inner city with poverty and drugs, and
Dr. Cate Straub (36:33):
I
Dr. Randy Lehman (36:34):
Know the other side of some crazy things that happen still in rural places, but I'm scared to go to the city and I hate going to the city, and I feel very safe in my small town. And we just got kind of internet scammed, and I just, to me, can't believe that somebody would do that. So I think that to a certain degree where I was going with the question is, it's possible that these people are projecting how they are on other people because they have high integrity, which I think comes from being rooted and grounded in a community where there's a lot of not autonomy. There's a lot of accountability because you're going to have to look at the people that are around you and you're going to have to live with them. And your reputation sort of matters. If you're in the city, you can be, I mean, there's a lot of people that are depressed and feeling alone and isolated in the city of 10 million people because there's so many people, but they're not actually connected.
(37:40):
Whereas if you're in a town of 5,000 people, you actually know, I mean, have so many touch points. Every single patient that I see, I have to play the connections game with them to somebody that we both know. And literally almost every single patient, I do that. And that builds a lot of trust. The other thing is that they're not so far removed from their belief in the Judeo-Christian God. And I think that if you think that you exist by chance, then what really matters? If you lie, the only reason it matters is for selfish reasons, because it's going to come back to hurt you because your reputation's going to suffer. The only reason you're truthful is for social reasons. But if there actually is an absolute authority over your life and you actually believe that, and you believe that you're created for a purpose and all this, then you may still lie. You may still do the wrong thing sometimes, and you may still sin, but you wish you didn't and you try not to. And so I wonder if people are more Christian, if you will, and actually believing it and then living it out and then projecting that back on their surgeons. That's where I was going with it.
Dr. Cate Straub (39:01):
Okay. No, I can definitely see all of those points, especially your points just about, there's just a lack of anonymity in rural America because you all know each other. Like you said, I can't go to the grocery store out to dinner without running into virtually everybody. I was at my kids' math athletes competition the other night, and I could barely get into the bleachers because I kept getting stopped. And people trying to talk to you about things, you're like, oh, I know you. And then it's sort of even mastering the knowing glance of we do know each other, but we're not sure how we know each other
(39:38):
That you kind of do all over the place. And I think a lot of people don't like rural medicine because of that. But I love it. I mean, growing up on Long Island, everything was anonymous. Nobody knew anybody. Kids didn't know each other in their high schools. And the next high school is just down the street. And this is just lovely. I just love being part of a community in which everybody knows each other. And I think once you've been doing it for a while in a given place, a lot of the trust just comes from, well, you took out the appendix of my neighbor's son's best friend from high school, so you can take out my pancreas cancer. They just feel like they'd rather you are this known quantity, and you do things within the community because you love your community. They see you out doing things like marching for women's rights, or I do a heart dissection with children in town every year, and it always makes it into the papers. And then you're like, oh, then you're that surgeon that five different kids remembered me from that. And so it's this community-based referral practice rather than needing to know the doctors in the area.
Dr. Randy Lehman (40:51):
Yeah, I love it. So those are all the same things that I love and enjoy in my practice. So welcome to the rural American surgeon, the echo chamber for you and me.
Dr. Cate Straub (41:05):
It is absolutely fantastic. I agree. There's a three degrees of every patient in your office, and I've learned to just walk in and say, you look really familiar to anybody in that room, whether it be the patient, and then I say, jokingly, did I operate on you? And then they'll be like, no, but they almost feel famous because I thought that. And then the conversation goes from there, and we usually figure out how we know each other at some point in there.
Dr. Randy Lehman (41:29):
Yeah, I do that too. But then a lot of times I did actually operate on them. It's like, shame on me for not remembering.
Dr. Cate Straub (41:35):
Or sometimes it'd be like, yes, you did. And then that kind of did I do a good job? And then it gets on.
Dr. Randy Lehman (41:41):
Love it. Alright. I had a couple of questions before we go more to technical. So when you determine a need for something, I guess you had an idea of the volume that you wanted to have on the backend and technically how did you determine that the need was there? Is that mainly population size and catchment area, and then how common these
Dr. Cate Straub (42:06):
Things are?
Dr. Randy Lehman (42:06):
Or actually you said you looked at how many cases are being sent out, some of that seems like it would be hard to track down.
Dr. Cate Straub (42:13):
It is. It is. And in fact, we've looked at that with a variety of other cancers and different groups try to tell you they can calculate how much is being sent out. Intuitive loves to tell you how many of your colon cases are being sent elsewhere and make you want to get all those patients back. And so what we really looked at is because we have a really good oncology group here, even if you go elsewhere for your Whipple, you tend to come back for your chemotherapy. So I asked our oncology group to look at the past year and just see how many patients they're actively taking care of because almost every pancreas cancer is going to get chemo either upfront or afterwards or both. They were able to give me those initial numbers as far as how many they were sending away. I didn't realize how much of my practice was going to end up being benign or precancerous lesions. I actually get the vast majority of my practice from those we've started. We have a good program for evaluating pancreatic cysts and putting them sort of on a surveillance program of MRIs and cts and just picking those up as those subtle changes, those high risk stigma to start forming has become a huge part of my practice.
Dr. Randy Lehman (43:28):
That was going to be my next question is of the 12 to 15 that you're doing per year now, how many of those came to you as incidental finding on imaging for other reasons versus actually being a symptomatic lesion?
Dr. Cate Straub (43:44):
Yeah, I would say, I joke that I should be paying the urology department for all of their referrals from kidney stones that have incidental pancreatic cysts. It is CT ips at the beginning of the vast majority of my referrals. So yeah, it hopefully comes from incidental findings. Those are the ones that can help. Once you're symptomatic, it gets a lot harder. So
Dr. Randy Lehman (44:14):
You would say most of them at this point, they probably were an incidental, because the thing is, if you go to all the clinics from where you are to Canada and you tell 'em to send you all the yellow patients, really you should be telling 'em to send you the incidental pancreas lesions. Right?
Dr. Cate Straub (44:31):
Well, yeah. Yeah. And that we ended up having to work on was doing a better job communicating in the verbiage of those cts, like what they should be doing with these findings.
Dr. Randy Lehman (44:40):
Yeah.
Dr. Cate Straub (44:41):
Did you ever
Dr. Randy Lehman (44:41):
Go to radiology departments and tell them to send you the incidental?
Dr. Cate Straub (44:46):
Well, the vast, vast majority of films are being read down at our institution. So thankfully I could keep a lot of that. But then it was education to the primary care doctors about what to do with those findings as well. But yeah, now if you have a pancreatic cyst, we delineate who's the referral pattern is and exactly how often they should be getting repeat imaging.
Dr. Randy Lehman (45:10):
Yeah, very good. So what would be the most common, well, should we do Whipple?
Dr. Cate Straub (45:19):
Yeah,
Dr. Randy Lehman (45:20):
What's the most common reason you do a Whipple now?
Dr. Cate Straub (45:23):
I would say still the most common reason I do a Whipple is probably still a pancreas cancer, but it's almost 50 50 with side branch.
Dr. Randy Lehman (45:32):
Okay. So say I'm a go high level, say I'm a patient almost. Well, my sister-in-law had pancreas cancer. She was dead in three months. What good does an operation do? Who gets an operation versus not?
Dr. Cate Straub (45:55):
Do you mean you present to me as somebody with pancreas cancer and you're making that?
Dr. Randy Lehman (45:59):
Sure. Yeah. That
Dr. Cate Straub (46:00):
Argument to me,
Dr. Randy Lehman (46:00):
Something like that. Why? How does, well, she had an operation and she died anyway. And how do you know if the operation's going to help you
Dr. Cate Straub (46:11):
Don't, pancreas cancer is a bastard. I start every consult on it with that. We're just going to keep going back to this pancreas, cancer sucks, and here's what we can do and here's what we know. But I have to tell you, even if we do our absolute best work, if you tolerate all of your chemotherapy upfront, if it looks like your tumor is shrinking, your CA 19-9 responds and I do the best possible operation for you and get it all out, there's still a 50 50 chance that your cancer is going to be back in a year. I mean, that's just a fact of life with things like pancreas cancer.
(46:50):
And I have to tell you, when you go through everything that's required in a Whipple, nobody really explains what a Whipple is. Like a surgeon GI is like, oh, they're just going to take it out, just go talk to you in oncology. He's just like, yeah, that's fine. You draw the pictures and you show them, I have to cut here, here, here, here. And then I have to put Humpty Dumpty back together again. And then you kind of go through why it's so risky, why general surgeons don't love cutting things apart and putting them back together. And the pancreas is a soft spongy organism that makes enzymes that digest things, and then I'm going to poke it with a needle a bunch of times, and you can word it in a way in which they get the severity of it. And especially when I'm seeing patients for pre-cancerous lesions, some are just so terrified at the idea of pancreas cancer that they just want it out sooner than later.
(47:36):
And then you present the Whipple and they're like, oh, maybe I'll put the pause on that and we'll kind of see if this actually grows. But once you have a patient with a cancer, they come in and say, I don't care how bad it is. I want this out. The vast majority of the time, and especially for younger, more healthy patients, they sign up for it 99% of the time. But I do think that whenever you're going to take on something like this, a lot of your practice kind of becomes palliative care too. You have to tell the 90-year-old that they shouldn't have their Whipple or the 75-year-old with horrible COPD and horrible diabetes, and you just have to say, this isn't for you. Let's talk about what life would be like if you didn't do it. Every pancreas cancer conversation is, this is what it could be like if you do sign up for this, but let's also talk about what it would be like if you don't. What would your life look like and what can you expect from that?
Dr. Randy Lehman (48:33):
Sure. So tell me if the patient goes, they go forward with operation if they're a cancer patient, they've all undergone neoadjuvant.
Dr. Cate Straub (48:49):
Yeah. I mean, it's a rare head of pancreas cancer that does not have neoadjuvant upfront.
Dr. Randy Lehman (48:54):
And
Dr. Cate Straub (48:55):
The
Dr. Randy Lehman (48:55):
Idea is you're selecting the patients that are going to advance anyway.
Dr. Cate Straub (48:58):
Yeah, I mean, I tell patients the reason for that is kind of threefold. One is to hopefully, well should improve my margin negative freight. Neoadjuvant chemotherapy has been shown to have improved R zero resections. And if I say if I leave any cancer behind, I haven't done you much good, but it does also select out for those patients that are going to met out, the cancer is going to spread because pancreas cancer is a bastard. And it doesn't mean that I should have operated upfront. It means that your cancer was just going to be a bastard no matter what. And then thirdly, it also helps select out the patients. The surgery is big surgery and chemo can be really challenging, and if you don't do well with chemo, you weren't going to do well with surgery. So sometimes that helps to select out patients that no longer want surgery.
Dr. Randy Lehman (49:45):
Yeah. What are the most common regimens that, if you can speak to at least a little degree of pre-op
Dr. Cate Straub (49:56):
Chemo? Well, there's still, unfortunately though we are seeing some advances in pancreas cancer treatment. There's still really just two chemo regimens for the vast majority of cancers. And it's either gem, abraxane or folfirinox. And it kind of depends on your performance level. If you're a young healthy person, you're going to get FOLFIRINOX. If you have some challenges in regard to age and comorbidities, you're going to get gem abraxane.
Dr. Randy Lehman (50:21):
And then if you don't know this's fine. But I don't How long, what should the patient expect on both of these? So they're both IV chemotherapy, and so you got to have a port ahead of time. And how long does it take and how many times a week?
Dr. Cate Straub (50:42):
I mean, ideally, well, what I tell them is that chemotherapy is a recipe. That recipe is determined by your oncologist and that I do not speak fully as to the exact regimen, but in an ideal world, you'll be getting IV chemotherapy. And I don't say how often or how many times a week, but it would be for about three months. And then we would reassess things. And that chemo, in ideal world, you get six months of chemo for pancreas cancer. It can be all upfront or it can be sandwiched in between. And it really just kind of depends on how you're doing and how your tumor's responding. And when we want to do surgery, and when you're done with the chemo, we give you six or so weeks to sort of buck up, get your nutrition back up, get your health back up and proceed with surgery. And then hopefully you're back on chemo in between two and six weeks after surgery.
Dr. Randy Lehman (51:29):
Now, when you're placing ports, you don't
Dr. Cate Straub (51:33):
Think
Dr. Randy Lehman (51:33):
About that. You just go straight to chemo some days the same day, right?
Dr. Cate Straub (51:37):
Yeah, yeah.
Dr. Randy Lehman (51:38):
You
Dr. Cate Straub (51:39):
Certain time
Dr. Randy Lehman (51:40):
Leave them accessed and send them downstairs or whatever.
Dr. Cate Straub (51:42):
You certainly can. Yeah, I do that a lot. I do. I mean, obviously as part of my pancreas practice, the most common surgery I do is a diagnostic lap in port. I mean, that's just like bread and butter almost every week.
Dr. Randy Lehman (51:54):
And the diagnostic lap and then going straight to chemo the same day or the next day is in the problem for wound complications or anything? No. Okay. Alright. And so they got a negative diagnostic lab, they went and got their neoadjuvant and now they're ready for a Whipple.
Dr. Cate Straub (52:14):
And
Dr. Randy Lehman (52:14):
Do you do most of those open?
Dr. Cate Straub (52:17):
Yeah, I do all whipples open. I mean, even in the state of Washington, there isn't anybody doing robotic whipples right now. And laparoscopic whipples have kind of gone the way of the dodo. You either do 'em open or robotically. I do my distal pancreatectomy robotically if it's indicated.
Dr. Randy Lehman (52:34):
So talk to me about positioning then and we'll just jump ahead to that. There's probably a thousand other things we need to be thinking about preoperatively, but unless you want to say something else preoperatively. I mean,
Dr. Cate Straub (52:46):
No, I, it's the usual discussion of a big surgery epidural or no epidural, do they meet with anesthesia beforehand? And a bit of preconditioning if you've just gone through chemo and then you meet with me, I'm going to talk a lot about making sure you're up, moving around eating well, we're checking labs, making sure your albumin's up and whatnot. And depending on the degree of pancreatic resection, sometimes if you meet with your PCP or endocrinologist about diabetes management, it's very hard to get in with endocrinology around here though. And so positioning, it's just supine arms out. We always start again with another diagnostic lap to make sure things haven't changed. And then we move on to an upper midline incision. And as I explained to my med students when they're there with me, the pancreas is a deep, dark organ. It's closer to the spine than it is to the abdominal wall.
(53:43):
And so the majority at the beginning of the surgery is just bringing a very retroperitoneal structure up to where you can actually work with it and just sort peeling away those layers, stomach up, colon down, duodenum up, and you're just kind of making this into an organ that can actually be dealt with. And then dealing with all the anatomy below the pancreas, identifying your SMV and all of its tributaries and freeing up your uncinate process from that, making your window under the pancreas over top of the portal vein. And then switching to on top of the pancreas, your chole cystectomy, uncovering your whole port, and then identifying your arterial anatomy, doing your lymphadenectomy and sweeping it down towards the specimen. And then that's kind of where you take a deep breath and you say, this actually can come out. And then you just start stomach folded away, bile duct folded away, pancreas folded away, and then go down below and pull up your jejunum to make four. So hours of operating sound horribly simple.
Dr. Randy Lehman (54:40):
Yeah. Alright. Let me walk you through some of those steps. So what retractor do you use?
Dr. Cate Straub (54:47):
I put a wound protector in and then I use book wall retractor. It's just what I've used my entire life and I love it.
Dr. Randy Lehman (54:54):
And first step is after diagnostic lab and everything is elevating the stomach?
Dr. Cate Straub (55:01):
Yeah. Well, I start with a good Kocherization, so I open up, I get the duodenum freed up from its retroperitoneal attachments and then sort of follow that all the way under over top of the IVC and get pretty much all the way over to the aorta posteriorly. And as you do that and you're kind of coming around the sweep of the duodenum, you kind of naturally start taking down the hepatic flexor and start dropping that portion of the colon down as you get to the backside of the ligament of Treitz from the right hand side of the body. Okay. Do you
Dr. Randy Lehman (55:35):
Normally tilt the bed at all while you're doing that Kocherization? Kind
Dr. Cate Straub (55:37):
Of depends on the depth of the patient. Do you stand usually I'm on the patient's right for the whole case and my assistant is on patient left. Sometimes I actually have to tilt the patient towards my assistant and I use an RNFA for all these cases now. I used to use partners, but I've trained up some RFAs to help me.
Dr. Randy Lehman (55:58):
Okay. And then so you get to coker maneuver, and where exactly on the duo do you start your coker maneuver?
Dr. Cate Straub (56:06):
Superiorly or the most lateral part of it? And then I work up and down as I kind of go back on that, and then usually tend reach instruments. Are
Dr. Randy Lehman (56:16):
You using while you do that?
Dr. Cate Straub (56:18):
Most of the time, hands? Yeah. I mean, it's mostly DeBakey and cautery and yeah, just regular cautery for that. I think that cautery does a brilliant job of dividing along natural anatomic planes. I certainly use a lot of ligature later on in the case, but for everything that should be the way sort embryology intended it. As you're kind of dividing things you should be able to do with cautery and blunt dissection.
Dr. Randy Lehman (56:49):
Right. So you don't do a lot of dissecting between a right angle, have your assistant buzz like you would
Dr. Cate Straub (56:56):
Able resume? No. In fact, I was going to mention that there's definitely, it's a very big difference between operating when you're dealing with residents and attendings than when it's you and a first assist or you, and in other cases, like just you and a scrub tech, scrub techs are only allowed to do certain things. Obviously they're not my assist during Whipples, but being a rural surgeon, you just get used to having people that aren't allowed to manipulate tissue or burn tissue or as we call it, severed tissue as part of their scope of practice. So R NFAs are obviously allowed to do more, but I think my entire, how I operate here has just become to be not reliant on needing those techniques. And so my assist is just a lot of really good retraction and exposing that plane for me. And then I kind of do the dissection myself.
