Joey Wahler (Host): It addresses a wide variety of medical issues, so we're discussing general surgery. Our guest is Dr. Danielle McMillen, a general surgeon with Iowa Specialty Hospitals and Clinics.

This is the ISH Dish Podcast. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. McMillen. Welcome.

Dr. Danielle McMillen: Hi.

Host: So first, can you tell us briefly what made you go into medicine and specifically general surgery? What first peaked your interest?

Dr. Danielle McMillen: I was heart-set on engineering because my dad was an engineer when I was in high school. And then, I took an anatomy and physiology class in my high school. And my dad told me that I was never as excited talking about engineering as I was talking about what I was learning in that class. So, he said I should really look for an interest in something in medicine. My mom was a nurse. So, I shadowed with an ENT and fell in love. I wanted to be able to do something in healthcare and surgery just fit. When you go through your rotations in med school, you see so many different things, but you find your people.

Host: Absolutely. So, kudos to your dad for supporting your interest in doing something other than what he did.

Dr. Danielle McMillen: Exactly. He, I think, was a little upset about it. But then, my brother is finishing his senior year of engineering school, so he got it in the long run. He just had to wait a little bit.

Host: Okay. So, he was rewarded for his support. Yeah, my dad was an engineer as well, and I chose a completely different path too. So, what are the most common types of procedures performed by general surgeons like yourself?

Dr. Danielle McMillen: It can vary depending on where you are practicing. Anywhere from hernias to gallbladders to colon resections. Also, endoscopy, a lot of general surgeons still do scopes, especially for someone like me who works in a rural area, bringing outreach to clinics where it's a couple hours to the next city. Surgeons are able to bring a variety of different procedures in general surgery. So, big ones for us are lump and cyst removals, gallbladders, hernias, colon cases. But depending on your specialty, you can go anywhere from those to bariatrics or some specialize in some upper GI kind of stuff. It all depends.

Host: Gotcha. What would you say are a few of the biggest recent advancements in technology that have improved the surgeries that you do? Robotic surgery, of course, has now touched just about every branch of medicine, right?

Dr. Danielle McMillen: Yeah. That's the first one that comes to mind. There's a lot of things in medicine that have changed, from even just wound care to different technologies and meshes we use for surgeries. But the robot has definitely been a game changer for treatment of patients. It makes it a lot easier on them for healing time and pain postoperatively. And with robotics, it helps the surgeon. I mean, it's a lot better ergonomics for us in the way that we operate and makes cases overall quicker so they have less anesthesia time.

Host: And it enables surgeons like you to be more precise in what you're dealing with, right?

Dr. Danielle McMillen: Absolutely. Laparoscopically, we have those same small incisions, which is great for healing and pain control, but the robot gives you a wrist, which really just changes your ability to handle tissue and see what you need to, and it's something where the surgeon controls almost everything. You control where your camera is, you control where all of your retraction is by it all being something that you can just change with the pedals and the robot. It gives a lot of different choices and different instruments that you can have and changed out quickly without delaying different parts of your procedure and, like I said, just having a wrist when you're trying to operate in tight spaces like a gallbladder or up into the upper part of the abdomen, really just the visualization is bar none compared to anything else.

Host: Yeah, absolutely. How about the key differences between open surgery and minimally invasive techniques, and what factors typically influence whether you choose one or the other for a given case?

Dr. Danielle McMillen: Depending on what case you're doing and why you're doing it can help you decide. Also, the patient's own history. In an elective surgery, if it's somebody who's had quite a few surgeries in the past, so they weren't somebody that we can always trial robotics or minimally invasive, laparoscopic approach. But if we get in, there's just too much scarring to where we don't feel that we can see what we need to safely, then we convert to open. Some procedures, if it's a plane, for example, a robotic inguinal hernia, sometimes we aren't able to get into that plane nicely robotically or laparoscopically. If they've had a prostatectomy in the past or sometimes radiation or things where that plane's already been entered, it's hard to get those dissection planes again that can lean you toward doing an open procedure or just the patient's overall health. If it's not something they can tolerate having insufflation into their abdomen, then we lean toward open.

Host: Understood. How about the key for general surgeons in managing patient care before, during, and after surgery to ensure optimal recovery outcomes? What would you say is your overall approach to be as effective as possible?

Dr. Danielle McMillen: Preoperatively, I think it's being very upfront with patients that even if we do a laparoscopic or a robotic case where the pain is smaller than an open procedure, it doesn't mean that there will be no pain. It still wouldn't be sore, you're still having surgery. And being honest about that upfront helps patients understand what they're going to go through in the long run, but also being prepared and having them be in their best physical shape that you can get them to, trying to get patients to stop smoking, getting blood sugars under control, working with their primary to get them in an optimal health situation before we take them, work on getting their physical endurance higher, getting them to exercise more if they weren't prior, those kind of things, or even helping with nutrition before big surgeries. Sometimes we'll start nutritional shakes prior to a big surgery to help boost their nutrition.

Host: Interesting. So, it's about much more than just the surgery itself, clearly.

Dr. Danielle McMillen: The surgery itself is an important part, but only a small piece into everything that goes into the patient care. It's definitely a team approach. I can't manage all of the the medical comorbidities patients can have. So, hats off to primary and they do a great job of helping us really get patients ready for surgery in that regard.

Even physical therapy, some will go to a rehab center, like a prehab kind of thing where they get to help with their strengthening before they undergo a big surgery. And then, postoperatively, with followup and having a really good support staff that takes care of the patients, Nursing to have their pain controlled, letting us know if there's any big changes, because nurses are definitely at the bedside more frequently than doctors are able to be. So, they're a great eyes and ears resource that helps us a lot with taking care of the patient as a whole picture, not just as an appendix or as a hernia.

Host: Yeah. Nurses are often an underrated, undernoticed part of what's obviously a great team effort. How about the biggest misconception or two that you find from your experience about general surgery and how can patients be better informed so they don't have those?

Dr. Danielle McMillen: I think a big misconception for general surgery is what general surgeons do, what procedures they're able to do. It used to be common practice depending on where you lived, that general surgeons did a lot of endoscopy or did a lot of scopes. That depends on a practice. Some practices don't have surgeons do scopes. But that is something that many, especially like myself who are coming out of training, who learned a lot of that, to have an extra resource, an extra set of hands that can help with our overwhelming GI and endoscopy needs. I get a lot of, "Well, you just do hernias or you just do lumps and bumps as a general surgeon in a small hospital," and that is definitely a misconception. We are able to do far more than that as general surgeons from obviously hernias and gallbladders, but also I was trained to do colon resections and small bowel resections and big open belly surgeries.

So, general surgeons are trained in a wide array of things. And then, if we go into a subspecialty, it's further training into one subspecialty, but one that we had usually touched a base on during our training.

Host: Yeah, I've often thought of general surgeons being akin,-- of course, at a much higher level, if you will-- to a cook in a diner. You sometimes go to a diner and you look at the huge menu and you wonder, "How does the guy or gal back there at the grill know how to make all these different things on a given day?" And it's kind of the same for you, right? Like, you really have to know a lot. There's the old saying that knowing a little about a lot of different things. You have to know a lot about a lot of different things, don't you?

Dr. Danielle McMillen: Yeah. And that was something that you understood going into training, but really didn't understand coming out of medical school, because you learn a lot about a lot of things. And then you go into surgical training, and there's a lot of other things about all of those other things that you know that you had to learn and intricate pieces to that, and they may not be things that I'll continue to treat after training, but it's an important knowledge to keep to help with patients, at least to help guide where they need to go even if I'm not what they need.

Host: Absolutely. Couple of other things. In terms of preventative care and awareness for patients, since that's a big part of what you do, how significantly does that contribute to community health? I mean, people think of general surgeons as just performing procedures as you touched on, but since there is so much else involved, how much does that help contribute to the community's health at large, do you think?

Dr. Danielle McMillen: I think it helps quite a bit. I didn't grow up in Iowa, I grew up in Pennsylvania. So, I grew up where the healthcare systems are very different and I didn't understand that until I came here for training. Iowa is one where they are very tight to their communities in small towns and getting patients to come to Des Moines or Iowa City or the big city. Getting patients to come there can be difficult because it's a far drive for them or they don't have transportation to get them there. And having the resources only be in a big city makes it difficult for patients to get that preventative care. So by the time they sometimes present, or presenting to us while I was in training, they were much further along. It's something we could have found sooner had they had the resources to get their preventative care. And general surgeons can sometimes be the person that catches that. They don't go to doctors frequently, but they have a hernia that pops up that bothers them or they're having gallbladder problems. And then, they show up to my clinic, but I ask about all of the questions: do you follow with your primary? Have you gotten your colonoscopies? And really rule out broad scopes because those are things that matter as a patient as a whole before just fixing what they came for.

Host: And so, having said that, Doctor, would you say that that kind of education and promoting that awareness with patients in a rural, underserved community like the one you deal with, is that really the biggest key to treating people effectively in an area like that?

Dr. Danielle McMillen: I think it's a part of it. And I think another part is just understanding their ties to their community. They're very proud of the small towns they come from. And part of fears of hospitals is you go to the hospital, and if you have surgery, but if you're there for a few days and you're two hours from home, you're there alone through a lot of it. We saw that a lot with COVID where we couldn't have families come in, but that's something that's common from small towns to bigger cities, is families can't just drop everything and drive a couple hours every day to come be with a family member who had surgery farther away. So, being able to bring resources to their community, so for the things that we can take care of, they can be close to home. They can't have family there to speak with us and understand what we're going through, see how their progress, and really be able to talk to the family. It's going to help take care of them directly. And that helps overall with their patient care, both before, after, and during surgery.

Host: And when you talk about those types of logistical issues, because of the kind of area that it is, those are things that obviously in many parts of the country that are complete non-fact. And so, they become an additional part of the care that you offer, and I'm sure people are relieved and appreciate that that's available.

So, speaking of which, in summary here, Doctor, what would you say is the one most important thing you want those joining us to know about the general surgery services at Iowa Specialty hospitals and Clinics?

Dr. Danielle McMillen: I would want them to know is that we have a great variety of resources in our general surgery clinic. We have three surgeons practicing through here, and myself being full-time with Iowa Specialty; that I would want them to know that they can get these procedures done here, not to kick the can down the road, because they don't want to be out for a long period of time. We have a lot of advances in our treatments now where you don't necessarily have to be down for weeks or months like you had in prior. And that the resources, even just for preventative care, are here to rule out things like a colon cancer and getting your screenings and mammogram screenings.

We just came out of October. Those are huge to get your breast cancer screenings and that we have all of those resources here with mammography, and both that and endoscopy so that we can start our preventative care and then take care of you from there with whatever we find, from something as small as you have a lipoma you want removed or a lump to something as big as needing a colon removal or something like that that came with a diagnosis.

Host: Yeah, I'm sure those joining us are relieved to know that all of those things are available within reach, logistically under one roof, so to speak. So, folks, we trust you are now more familiar with general surgery. Dr. McMillen, I don't know how you got to know so much about so many different things, but I'm sure the public is glad to know that you and yours do Keep up all your great work and thanks so much again. I marvel at what general surgeons are able to do.

Dr. Danielle McMillen: I think we get a lot of credit, but I marvel at what other specialties are able to do. I know a lot in surgery, but I don't know a lot of what primary care knows. I would say they probably know more than I do, because there's so much more in primary care.

Host: Everyone, of course, contributing greatly in their own way. Now, for more information, please do visit iowaspecialtyhospital.com. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for being part of the ISH Dish Podcast.