Care Transitions: Why the Critical Window in Cancer Care Lies Between Appointments

Episode Contents

• 00:00 NovaNav Introduction
• 01:02 Guest Introduction: Dr. Lisa Attebery
• 02:43 What clinicians often miss between appointments
• 06:40 Common post-op issues patients face at home
• 08:52 How technology can support patients before and after surgery
• 11:54 Why delays in care can worsen outcomes
• 15:43 Reducing unnecessary ER visits with better guidance
• 18:18 Redesigning the space between appointments
• 20:33 The first days after diagnosis: delivering news with hope
• 22:05 Biggest friction points in the cancer journey
• 24:58 Access challenges, workforce strain, and rural care realities
• 28:08 Mobile mammography and meeting patients where they are
• 29:13 The role of families and caregivers in cancer care
• 32:27 What it means to care for breast patients for life
• 35:11 Closing Remarks

Key Takeaways

They explain why the standard discharge instruction model fails, how 48-hour biopsy windows correlate with patient outcomes, and why post-operative ER visits often signal gaps in structured follow-up rather than true emergencies. This episode offers a clinical operations perspective on patient navigation, caregiver coordination, and the friction points that health systems can address without adding headcount.

Transcript

Hello. I don't know if you're on, you're on mute, but I don't know if you're. Oh, there you go. I can't hear you but I'm here whenever you're ready.

Wait a minute. One second. Sorry Lisa one second. I'll be right back.

Hi Lisa Can you hear me. I can. How are you. I'm sorry we had a little I was just speaking with Amrit we had a little bit with two links.

Circulating. Okay, sorry. That's okay. Are you, are you good with, with the questions I sent over.

Yeah, I'm good. Yeah. Okay, probably hit me with anything so hit me. Okay, awesome.

Well I want to hit you with the things that you with the things that you want to speak with you, you find most valuable you know what I mean so like without knowing you and just kind of having some discussions with others in terms. I just was thinking, this is my, my first good guess that what we might be, and I just want to make sure you're like no that Lisa, this is the area that I love to speak about, you know what I mean. No, you did well and so I've invited some colleagues on there Dr. Dupree is going to hop on I see is a friend of mine from Oklahoma who's a breast radio radiologist so I'm glad I invited some other people to.

Awesome. So how do you want me to handle that then I have your is your bio okay. My bio is yeah perfect. Yep.

Okay, I may have. It's, it's luminous right luminous. So I was the chief of luminous and now I'm looking into other opportunities. Yeah.

I did for other options. Yeah, I did says served I did put it in, I noticed that so perfect. I'll wait till the others come on. You can do whenever, whenever you want to go.

Okay, well we can start I just didn't want. So, I guess everyone will jump in as needed if somebody gets I'm right was going to, I'm going to jump in as well so do you mind if I call him real quickly. Sure, you can do. This is your interview you could really do anything you want.

Well, it's you. Okay. We'll jump in. All right, great.

Um, do I, Dr. Dupree, I'm not going to mention or should I mention it or she's just a, she's a good yeah so she's a great breast radiologist so we're pretty good. She lives in Oklahoma so we've been talking and so I said hey I'm going to be on a podcast if you'd like to listen so. Oh, listen, cool, Dr.

Dupree if you want to jump in I'd love to have another voice in there. Okay. I don't know. Come on, yes she does.

She may have. It's very very cool that would have like a voice in here so yeah, I think I'm in car line so I might get distracted. Just pick it up. I may not give you the big intro but what I can do is post we can do I can get your bio and I can do something post podcast so just excuse me if I don't introduce you formally.

No worries. I can fix that. Listen to you that Dr. Dupree sneaking into my podcast.

I know right. All right, I have to. I have a settings I turn off my settings. Okay, cool.

Somehow or another I'm on a team thing and it's stinging me. Okay, we're ready to go. All right. Okay.

So welcome to the surgical journey, Nova NAS podcasts on all things pre post up all through the patient surgical journey. Today, I welcome Dr. Lisa Atterbury to our podcast, Dr. Atterbury thank you for being here.

Thank you for having me. I'm very happy to be involved in this project. Excellent. And we have Dr.

Dupree on the call as well. And she will jump in into the discussion, and I welcome her as well. Dr. Atterbury is a board certified general surgeon and breast surgical oncologist with more than 18 years of experience in both private practice and employed healthcare settings.

Throughout her career she has built an expanded best programs across multiple institution combining clinical excellence with strategic leadership. She was the third surgeon in the US to adopt sent a mag wireless technology for non palatable breast cancers and the first surgeon on the East Coast for nipples bearing and mastectomies in 2006. Her advanced surgical expertise includes many techniques, different implant reconstructions and balances procedures and allowing her to provide comprehensive and highly individualized breast cancer care. She has served as chief of breast surgery at luminous health where she led breast programs across two campuses and seven surgeons recruited to rebuild and strengthen service lines.

And she's known for her collaborative leadership style and commitment to teamwork, and has consistently worked to align surgical innovation with patient centered program development. We are very excited to have you here today. Your work reflects a deep commitment not only to surgical excellence but to building programs and really having a strategic vision and serving patients. So with that, welcome, and we will start the discussion.

When you think about cancer patients, what happens to them in the weeks between appointments that most clinicians do not fully see or appreciate? And the reason why I started with that question, I actually was speaking to somebody who was really thinking about this in an innovative way because a lot happens in between. And so I was really looking forward to hearing what you had to say based on actually that discussion I had a few weeks ago. Sounds a great question.

It's probably the highest, I think, stress point for a patient. So, you know, the normal pathway we would like to see if they have an abnormal mammogram, ideally would love to see a surgeon within 24 to 48 hours or get the biopsy within 24 to 48 hours. I think the unknown is worse for a patient than knowing, right, that unknown is just what's going to happen. They're hopping on Dr.

Google, you know, they're fixing their will. And that is the worst time. So when you get them and then you kind of get them settled and then you get a biopsy. And then when you the goal is to have a biopsy result within about 48 hours.

So if you look at standards across the country, the metrics with it. So those anxious times and then, you know, there you try to bring them in the office. Right. The goal is always 48 hours, no matter what, bring them in to kind of calm them down and go through that.

I think that is something that providers don't get. You know, you have an abnormal mammogram. A lot of surgeons are like, whatever. I just want to see a cancer diagnosis.

Right. But if you establish that care first, that is so anxiety provoking for those patients. You know, they've talked to everybody. Like I said, they think they're going to die.

They have 15 stories of, you know, people that have bad outcomes. And so when you get them and then they start to settle, you realize how much this disrupts their entire life. Right. If they have kids, if whatever it may be, it's a horrifying time.

And unless they have it, I always say like a touchstone. I feel like I'm a touchstone for my patients. Right. I meet them at like one of the worst times.

Dr. Slack, Dr. Price, sorry, is a radiologist. So she does biopsies as well.

She knows this, but they want a touchstone. So as soon as they have somebody that is a soft landing pad, that's where you really help a patient out. Right. You ground them.

You go through things. You let them know that, you know, breast cancer is treatable, curable. Now it's turning into a chronic disease. You know, there are certain disease types or breast cancer types that are very difficult to manage.

But that is a lot where the physicians don't know. They had no idea of that. You know, they could have a mammogram and don't have a biopsy for four weeks later, four weeks. Those patients are dying a slow death.

They are anxious. Their life is completely disrupted. And so I think that is the part that is really valuable. And having had two aunts that have gone through it has made me a little bit more attuned to it.

And also I think I just had really great parents that, you know, made me empathetic and understand where we're missing out. And so I think that's the biggest time where people totally miss the boat. You know, they hang up the phone. OK, they're going to wait for the phone call.

What happens to the patient? They freak out. And so I think that is a hard time that people really don't understand physicians, clinicians, whatever it may be. I would never thought you would have answered that, but that's a great answer.

Thank you. I mean it in the sense that it is the time. I have my own little mini story, but everything kind of worked out. But it's true that first 24, 48 hours, you're right.

Like that's really that you're you really are a loss. And it's so true. I didn't anticipate that. But from my experience and others, it is the most.

Uncertain, your mind is racing, you really you really don't know what's going on. I love the way you said that you become a touch point or you become somebody that really is stable for them. So I think that's fantastic. That's really so true.

It's years of experience and really just sitting and listening. Surgery may be a little bit challenging, but the easiest part is to listen to a patient and they'll teach you. Right. Yeah, that's incredible.

After surgery, once a patient leaves your direct line of sight, what are the most common issues that emerge at home care that could have been prevented with guidance or follow up? That's a that's a that's a painful thing. So, you know, you even though you educate a patient about their surgery, whatever it is, a lumpectomy, lymph node testing, mastectomies, reconstruction. You know, we have such an antiquated system where, you know, the hospitals, the EMRs, you type out instructions of which nobody reads because, you know, they're still focused on their cancer.

So what happens is when they go home, you get the phone calls the next day. What do I do with this drain? I didn't get my instructions. They did get their instructions.

They just didn't read them. Right. And so then I have the nurses calling. And so once they're out of that purview until I mean, I may function a little differently.

I will usually see patients within two weeks. I call them. But that being said, if they're reconstruction, I see them earlier. But there's a nebulous kind of liminal space for these patients.

Right. There's stuff coming out of their dressings. They're having fevers. They don't know if it's normal.

Their pain and all these questions that, you know, you can't be there 24 hours a day to answer them, nor can you have, you know, their personal nurse or M.A. So during that first couple of weeks, you're trying to keep them as close as possible. But it's impossible to be with them every second of the day, which is what they need and probably want. Right.

You know, it's an unknown of what's going to happen. And so that when you get that first appointment, you can answer some questions and things start to settle down. But those two first two or three weeks are just brutal for everybody. The patient, the provider, the staff, the phone calls, the nurse navigators.

It's very, very challenging time because surgery is not a pedicure. I always say I'm like, you know, you go in. What is normal? I don't know what normal is because I don't know how your body is going to behave.

So that's where we really lack. And like I said, nobody reads a piece of paper and you can't have it. It's just our society doesn't want that. They need it right now.

And then once again, they hop on Google and they're like having a fever. And the next thing they know, they think they're septic and going to be in the ICU when it's, you know, just they haven't gotten out of bed or walked around. So that's a very challenging time as well. And so we kind of get into a rhythm of that.

How do you see technology in that? You know what you just talked about seems as though technology can play a really important role. Yes. I'm just going to say, like, the Novan app, I think, is a brilliant over its overdue idea.

So when you everybody has a cell phone, even my patients that are 80, they have a cell phone. They may not use it well, but they probably have 10 grandkids or whatever family members that you can. Something that's a little bit more tangible that they pick up every day. Who doesn't pick up their phone 500 times a day?

Right. There's an app on there, you know, tailoring something to them like, OK, it's two weeks before surgery. You know, Miss Smith, you're going to have to come off your coumadin on, I don't know, Tuesday, whatever that may be. Whatever.

I don't even know what day we're today. The 9th. You know, every day, a step up of two weeks to tell them what they should be doing. You know, we don't have your cardiac clearance.

Right. We need this to do. I need you to call the cardiologist or that those kind of things to to rein in so we don't miss the last thing we want to do is miss a surgery, delay a surgery. Studies have demonstrated when you get further out, the outcomes get worse.

The efficacy of surgery, of chemo, of immunotherapy dropped dramatically. So when you start getting out 30 days, that's a very stressful time. So having something that patients can follow, I think, is huge. And it's not going to be a piece of paper because they shove it in their car or who knows where it is.

So technology is that place. We know AI is booming. Not really sure how AI is going to fit into the surgical world in general. But, you know, having the ability of an app is something that follows us preop and also postop, you know, letting us know, OK, your postoperative day one from bilateral nipple sparing mastectomy is direct implants.

Here's what you should expect. Right. Here's our normal findings and have those ten normal things and then go, OK, so here's your things that we're concerned about that we don't want a phone call. So that way we're avoiding the trips to the ER where they go to the ER and they get admitted and then they're on a medicine service and then nothing good happens at that point.

So as they have somewhere to go and then say, look, if not call our office. But if they have that, patients are so much calmer versus not, you know, not finding the pain like, wait, I have a fever of 100. No, fever is not really this. You need to get up and, you know, a walk around.

I think that's a huge area that we need. You know, we practice antiquated medicine a lot of the time, maybe not surgery wise, but in care, I think we do. So getting it to the next level of having, you know, electronics, phone apps, all these, I think it's a great thing to have. You said a lot and we're going to stay on this question.

So thank you. I do want to mention the paper. I agree because I get things from paper, you know, it's like in your car or, you know, like for sure I knew where I put it. And I agree it's, you know, it's somewhere and I had a relative who had come out of the ER and I know for sure there was a CT scan performed.

They couldn't find it. It was just, it was just, you know, looking for pain or going to the floor or trying to download the paper. I agree that it's been antiquated. But you mentioned something really interesting.

And I was actually doing research a couple of months ago about delays in surgeries, but you mentioned it in a different context. I was looking at it from a stressor, like delays actually cause stress for the patient. There's studies in that. So you mentioned something really interesting that delays actually worsen the outcomes.

And breast cancer is absolutely the time from diagnosis to the time from surgery, or let's say they're going to get chemotherapy up front or immunotherapy as we call neoadjuvant therapy. When that gets, starts to push out, you know, you start to see a decline in disease-free survival, you know, all these things start to get impacted. So outside of the stress of, you know, every patient's like, I want the cancer out and I want it out now. Right.

And that's not always possible at that moment in time. They need, may need a CAT scan, an MRI, another biopsy. But as we push that out, the anxiety is worse. And now all these studies are demonstrating it.

Like we're failing on a lot of this because of all the way our systems are set up. And, you know, some of it's driven by our healthcare system, but some of it's driven by, you know, just getting a patient into the OR or they missed the appointment for the cardiologist. Right. They, they took their Coumadin the day before surgery or, you know, they come in and they have an infection, you know, whatever it is.

And so all those things start to add up on top of just waiting to have a surgery is like you said, anxiety. And if you're not anxious as me as a surgeon walking in, I'm anxious because then you've made me uncomfortable. I want you to be a little bit anxious, but the waiting is horrible. And now even more so with having these delays, having worse outcomes for breast cancer patients is very concerning and it's happening across the country.

So we have to figure out in my world to shorten that. It really gives a different perspective on our cardiac clearance, really. And that's one isolated situation of how important it is to get that clearance or how important it is to do what you say, stop taking this medicine. Then that puts it into perspective, really.

Ozempic now, you know, those meds, you know, we have to stop them earlier for surgery. They have gastroparesis. All these things are delays. And so it's a delay for the patient.

It's a delay for the surgery. It has all those impacts that are downstream that you have to be on. And it's really hard to be on it. That's where I think, you know, we can use technology to bring that in and make it concise for a patient and go, oh, my gosh, I am on Ozempic.

I've got to stop it. And it says, I don't know, stop it on February 1st for my surgery on the 14th. That's a no brainer. You check the box.

And so I do think there's a huge need for that. You also, I agree with you, not sure where AI lands in surgery, but I do think AI is completely applicable for reducing admin burden. It's completely applicable, you know, maybe in analytics, you know, like, you know, just predictive analytics, things like that. So I agree there, 100 percent.

I think it is. I mean, a study just came out with AI and mammograms and for a long time. And Dr. Slack might get me on this one, Dr.

Dupree. But, you know, when AI first came out with mammograms, they were looking at densities and a lot of radiologists pooh-poohed it because they're like, oh, it's not good. But now studies have demonstrated that it's better picking up progressive densities that are hiding some of these interval cancer, breast cancers that are more aggressive than the regular. So there is a role for it, for sure.

It's like how to integrate it, how to integrate it safely. So I do think there is a role for a surgeon, you know, in the OR. I'm not so sure about that, but I think that surrounding it to make us more efficient, to give better care to the patient, you know, to let them know that they're not sitting at home and nobody cares about them. And, you know, they're thinking, oh, my gosh, I got to run to the ER every five minutes or I've got a call.

It does help everybody. It takes some strain off the health care system. It takes a strain off the patients, which ultimately that's our goal, right? I always say if you're more worried about your income than your outcome, you're in the wrong field.

If you do the right thing by the patient and you take care of them, whatever it may be by this, then that's a win. That's a win win for everybody. I'm going to put that down. Post-op unnecessary ER visits.

I think that's also such a great conversation or application because you do panic. You say, let me just go to the ER. I've heard people say it. I've heard my parents say, oh, let's just go to the ER.

No, wait a minute. That's not the way to manage this. You know, you may not need to go to the ER. But I love how you talked about like almost being so specific, like these are the reasons you would go.

These are reasons to call me. These are the reasons don't go. And this is what would get up and walk or do so and so. And I think patients actually probably want that, too.

Right. I mean, they want to be like, if I fall into this bucket, I feel better. We are very much a driven society of, you know, like to check a box. Right.

They'll check their tick tock or whatever they have 8000 times a day. So to check that and to go, OK, this is normal. This is what I need to do. And a lot, you know, they want to hear from us.

But really, if you put it there and they have a plan, everybody wants a plan. Right. Everybody needs a plan, whether it's a plan coming out of my mouth, my nurse's mouth, my M.A.'s mouth, or it's coming from, you know, technology. If you have a plan, the anxiety lessens.

OK, this is normal. Right. I don't need to make a phone call. I don't need to go to the E.R.

where they're full because of covid and flu. And I'm going to see somebody who has no idea what I had. And right. And then all those things.

So a plan is a beautiful thing for a patient. And accessibility to it, I think, is key. Would be like that accessibility, because that's really what that is. It's whether it's discharge instructions or your specific your care plan.

It really is that plan. And people do follow plans. Right. And it's easily accessible to them.

And my mom will be 90 this year. She's still on her iPhone. I love her. I like her already.

I know. I love her. I like it. So there's no barrier, like, oh, they won't use an iPhone.

I'm like, oh, they actually do use an iPhone. And they'll be the best ones that follow. Right. You show them the app and they're like, OK, I'm on it.

I'm checking it off. Right. It's, you know, the 20 year olds and 30 year olds that go, you know, willy nilly. You know, they check on Google first or their friend who's running some video on Instagram that tells them to drink vinegar and we'll fix whatever.

But the older patients are really good. I mean, they're like on it. Boom. Checking the list.

Checking the list. Haven't done it on it. They're the best ones. I agree.

Not for this, not for this podcast, but you brought up a good point with all this information. You must drive me crazy a little bit with too much. One thing is to understand and want to research. But the other is the alternative treatments that really probably you just.

I mean, that's a whole separate subject, but I'm sure you are faced with that. That's a yeah, that's a good one for sure. No doubt about it. Yeah, that's an interesting one.

So if you could redesign the space between appointments, I know we talked a little bit about that earlier, but it's the space between appointments. Maybe it had therapies, you know, how you probably are doing that already, obviously. But what would be, again, probably in the context of technology, right? I mean, do you find that space challenging for you?

Like someone comes in. I don't know the span. I'm sorry, Dr. Everett.

Is it between four weeks? I don't know when patients might come in between treatments. But do you find that space like, oh, yeah, we should have known that. Well, she would have told me really or something that does that happen or not happen every day?

Absolutely. I mean, so, you know, when you meet a patient for the very first time, you know, they're hyper focused on one thing. Right. Because that's in our world could be a mammogram, MRI, abnormal genetics.

So a lot of things go out the window besides that hyper focus. Right. And then they come in with a cancer diagnosis. That's their next focus.

So, you know, they forgot that, you know, they have a fib, you know, or they see a cardiologist or they have sleep apnea or they have diabetes that's out of control. So, you know, you try to gather that as much as you can as you move forward. But, you know, sometimes things move fast or sometimes they drag a little bit. But there's a lot of unknowns.

So you start peeling it back. And like I said, patients will fill out some of the documents, but then they forget. Oh, yeah, I am on Oseptic. I forgot about that.

So it gets lost in the weeds because of the goal is, you know, whatever it may be. I'm going to have my knee replaced. I've got to have whatever my gallbladder surgery. I've got to have this cancer.

That is the primary focus. And so everything else kind of falls by the wayside. And other things, you know, women, the number one killer is cardiac disease. You know, when I give lectures, they're talking about breast.

I'm like, they're talking about genetics and someone will raise their hand and say, hey, my mom had breast cancer. I'm going to get it. I'm like, only five to 10 percent of breast cancers are genetically driven. I'm more worried about someone in the back row who goes, I don't have a family history.

I'm like, that person gives me more stress than anything else. But above and beyond, cardiac is the number one killer of women and men. It just is what it is. And so, you know, but cancer is a different world.

So, like, it's all different. Yeah. Yeah, that's a great answer. Thank you.

I'm going to give Dr. Dupree an opportunity. Anytime you want to jump in. You there, Dr.

Dupree? Thanks. No, I think you guys bring up good points. The first few weeks after a diagnosis, these patients are terrified.

And as a breast imager, I'm usually the one that is telling them, yes, I think this is suspicious. I think we need to biopsy it. And it's paramount getting them in, you know, within two, three days to get this biopsy done. And if I think it's a cancer, I go ahead and tell them that because I certainly don't want to call somebody up out of the blue and just, you know, bam.

You have breast cancer without them having time to absorb it. And as a breast imager, because we're usually the first point of contact, even if it's multicentric cancer or metastatic cancer, you still have to deliver that news with kid gloves and still give them some sort of hope. And like Dr. Atterbury said, you know, breast cancer is very treatable.

You know, in some instances, you know, I will say curable, but in those bad cases, you know, just saying it's treatable, I think gives them something to hold on to and some sort of hope to sort of shape their, you know, their journey through their cancer. Yeah. Thank you. It's true.

Again, I go back to the first question. I hadn't really thought of it, that that being probably one of the most critical times and how you both as, you know, clinicians look at that, you know, for a patient. And I think I really hadn't thought about that. It's probably one of the most challenging times in the whole process for a patient and for how you, like you said, deliver the message or really become that touch point.

So, you know, something that, like I said, I hadn't thought about as much, but it really is. And I guess, you know, just letting them know and being realistic and just being there is probably, you know, very important. If you could remove one friction point from the cancer journey for your patients, and that's for both doctors here. So we'll start with Dr.

Atterberg. What would that be? I think the delays really is what we're seeing, you know, access is a challenge. Health care is a challenge right now, for sure, getting that.

Those are big friction points and getting the patients on that track, right, getting them the study, getting them the diagnosis, you know, having that conversation of putting those plans. Those are some of the friction points. It sounds really simple. And if somebody who has, you know, health care or health insurance, and they're highly educated, they'll navigate it pretty well.

But there's the rest of the society that they don't, they have a really hard time of navigating that, right, the mammogram, nobody calls them, you know, you get them three weeks later, you're doing a biopsy in the office, you're calling them back. And it's, those are the friction points you get. Once you get a patient on path, you know, you get a diagnosis and you talk, they seem to settle, right? Now you're building a community, right?

They've met the radiologist. Now you're, I, like I said, my touch, I'm their touchstone. And so, like Dr. Dupree may call somebody for a biopsy, I call as well.

They will never forget the day that they have that phone call. I've called patients in Mexico, and I will still see them and they'll tell me about it. And so, but once you start to get their plan together and their team, right, you get a medical oncologist on board, a radiation oncologist, you know, those, it gets a little bit easier for the patient once that plan is in place, but getting to that spot can be really, really difficult. Getting to the diagnosis and the plan.

I mean, it can go from, you know, if it's great, you're in four days. Sometimes it's a month and a half and it's just a patient, like, I couldn't get in to get my mammogram. I couldn't get my ultrasound. I couldn't get in to see you.

You know, you've got centralized scheduling, which is difficult to manage. And then, you know, I tried to call your nurse and they never called back because, you know, they're overloaded. So all those front loading things are friction points. And then, you know, afterwards we can, like I said, get into a groove where things settle down with it.

But that's what I would say is the biggest part, hardest part for sure. Yeah, I agree. The dissemination of information and getting the patient into the clinic. We try to, if we're having a call back on a screening mammogram, we try to get them in within five days.

But we are a huge network and, you know, we're struggling to find breast radiologists and we have one breast surgeon. And so, you know, as well as we try to schedule, sometimes it takes longer and that's just frustrating. Our lab, you know, Dr. Atterbury said 24, 48 hours.

Our lab is 72 hours. And so it's just the time to get everything wrapped up is frustrating. Thank you. I appreciate that.

Something I hadn't thought of initially before this interview, I'm going to ask a couple more questions. You know, I think we know about the Rural Transformation Fund and how there's so much money that's going to rural hospitals. I would imagine that's probably a great place for what you both, you know, where you serve in terms of that, those communities to help, if everything I'm listening, really helping the rural communities with their cancer care. Sometimes probably have to travel long distances or connect, they're a bit more challenging.

I mean, you would probably know that better than I would. You see those challenges in rural areas. It's interesting how you define rural areas. I mean, before I had come to Annapolis, I was in Connecticut, right?

So, you know, Connecticut is a very small state. Connecticut, New Hampshire and Rhode Island have the highest incidence of breast cancer in this country. And so everything is, it's not really rural. It's just trying to navigate it.

I mean, I practiced right in the middle of Connecticut. Yale was 45 minutes down the road, right? And then along the coast, you know, you had Norwalk, Hospital, Stanford, Brigham and Young, not far. So, you know, it's not even a rural component to it.

It's just getting access. I mean, Dr. Dupree is in, I think, Tulsa, Oklahoma. So it's not like she's in the middle of nowhere.

Well, she kind of is, but even in Annapolis, you know, it's a wealthy area. You have the Naval Academy and you have patients that are 30 minutes down the road, but getting access, it's just getting in a car or getting the availability, right? And so making the phone call, sure, they make the phone call, our first available is six weeks. And so we have a crisis going on in the United States in our healthcare.

Physicians are leaving medicine in droves. And my personal feeling like a lot of it is the administration until you appreciate your physicians as physicians and everyone else, even the person that greets you at the door, cleans the floor, everybody plays such an important role. But when you don't treat people well, you lose it. And I always say, and I've said it to every CEO I've worked for, I said, nobody's coming to the hospital for your CEO.

They're not. They're coming because of the reputation that's built on the ground. It's the boots on the ground that are bringing patients. And so rural could be, you know, just accessibility.

They just 10 minutes down the road from a major metropolitan area. So there are initiatives for rural. I know in Maryland on the Eastern shore, University of Maryland is building a hospital and it's funded. So that's great.

But, you know, we are also facing situations where, you know, the Affordable Care Act, you know, those are threatened to be pulled. If those are pulled, that puts 15 million people on Medicaid. So where are those patients going to go? These hospitals really don't want to take Medicaid.

You know, it's not a financial win. And so these patients are in limbo. It's hard. It's hard accessing even so, you know, the, the wealthier patients.

Sure. Absolutely. They're easy. They're a no brainer, but it's the people that, and even the middle class.

I mean, are you going to, you know, pay your insurance bill or are you going to feed your family or get your medications or elderly too? So the system is very strained. So I don't know if it's really rural. It's just hard access right now for everybody.

And when you don't have enough providers, like Dr. Dupree said, it gets worse. What a great answer. Totally.

Like, no, but it was to the, it was to the, you, you nailed it. I agree on a hundred percent. I love how you answered that question. Thank you.

We do have an access issue. We do have issues that need to be addressed. That is a great point. I actually practiced in Oklahoma city at OU, the rest health network.

And you know, it's over a million people here, so it's not exactly rural, but we have two mobile coaches and we're waiting on a third. And so we actually traveled a state and actually go out to, you know, nowhere, Oklahoma. But in addition, we also go locally, you know, to Hobby Lobby, we park in the parking lot, we go to high schools, we go to Amazon because, you know, we're open from seven to five. Well, that's what these people are working.

And so they really can't leave work or maybe, you know, they don't have transportation to go get their mammogram. And so, you know, we bring breast imaging to them. Wow. That's fantastic.

And so interesting that you go into, you know, different places, right? And like you said, you know, a specific company. That's, that's great. I knew there were mobile, I am from New York, and I know there's a lot of mobile resources there, but I love that you go to different places like an Amazon, like Hobby Lobby and places like that.

And during the hours that they're there to the, I want to talk a little bit about families and your, you know, your insights into the caregiver role and for both doctors, again, please. How do you, do you, do you see that there's breakdowns here? How do you see family members working together? I know, again, I'll step in as a, you know, I care for my mom.

So I'm, I'm really there and highly involved. But there's, there's some points where, you know, that can't always be. And I just don't know your perspective as doctors in terms of caregivers and how their role might be. It's, um, I would say the majority of the time, I'll see family members step up during the initial phases, right?

They'll come in and they may have a significant other, you know, brother, sister, kid. And so initially, you see it, you kind of see him through that beginning part of it. I do think it dwindles a bit. I always say, you know, they must be comfortable when they stop coming to the appointments.

Right. So they kind of peel off a little bit, but it can be very strained. I mean, there are people that don't have, I've had patients that like, look, I have no family, you know, you come out of the OR and you say, what, you know, beforehand, who would you like me to call? No one, I don't have anyone.

So we're, you know, arranging them to get home. And so those are challenges our society is facing. And, you know, with the advent of COVID, you know, that more isolation came into impact for people as well. And so it is a challenge.

And then you do have the extremes where you, you know, you have people that come in and they have the most wonderful friends, you know, you get to pick your friends, not your family, which is always a bonus in cases. And so they step in and help. And so I think the majority of time you, they do rally a group. It is heartbreaking when someone comes in by themselves and, you know, there's no one, they don't want to talk to anybody.

They don't have anybody. And that's a really hard situation for me to be in just, I mean, I come from a very large family, which can be good and bad. A lot of friends, but yeah, it can be hard, but most of the time you do see, but the strain on a healthcare giver is hard. I mean, if you look at dementia patients, 40% of healthcare givers die before the patient does.

It's true. That is true. Yeah. Yeah, because the stress, it's a stress.

And so, you know, when you're caring for somebody in my world of surgical, most of the time, you know, even if they go through chemo or immunotherapy, when they get on immunotherapy, they're kind of flying, but, you know, chemo can be tough, right? You know, they may not be able to work. They may not be able to get a bed. So some people don't have anybody, but that will usually get better.

But you wouldn't look at the stats of dementia. I mean, it's, it's, you know, in the frontal dementia is now the number one dementia. I mean, that's, yeah, 40% of healthcare givers or the healthcare person will die before the person does of the disease. That's a lot of stress with it.

And so, yes. Yeah, that's, I didn't realize that was so high. So, Dr. Dupree, in your work, how do you see the caregiver role for maybe those breakdowns in communication or support?

I mean, it comes in all sizes and shapes. I mean, the majority do have a support system, either a daughter, daughter-in-law, husband, etc. But in the cases where they don't, I think it's very important that your nurse navigator get involved. And there's a handful of patients that I've diagnosed, you know, over the years that, you know, I gave them my personal cell phone because they needed somebody.

And, you know, we're still in touch to this day. I mean, you just need one person, just one good person to count on. You're touched on, right? That's right.

My last question, you teed this up perfectly. I was speaking earlier today with Raj, Martine and Amrit. One of the things that came up to her as a question is, you typically will have a patient for life, right? Yeah, yes.

So that's very different than most physicians. And so I was like, oh, that's really a great point. So the wording that Raj used, I don't know if you've met Raj, but it's almost as if you've said it in this podcast all the way throughout, the same spirit, is that you're really, you're kind of wrapping your arms around them the entire time. And that's what he used.

I thought that was interesting. But really, if you really have a patient for life, and it seems as though from just our conversation, that you really are making this as a seamless and wonderful, I don't want to call it experience, but it is, you know, this is a patient care experience. And so you're really, you know, how do you think about that in the context of having a patient for life? It's, um, yeah, I have med students that will rotate or residents and, you know, their opinion of a surgeon, and probably most people is, you know, arrogant, it's a one time thing.

And they don't realize, you know, you meet somebody at this situation. And these are dedicated patients. I mean, they follow you. I've had patients come from all over the country, parts of the different world to be followed.

And, you know, there's no greater honor, as I tell them to, to be on this journey with them, you know, to get them to the other side, and to learn their family. And so, and, and Dr. Dupree, and I know, because when I was practicing Delaware, my patients were moving to Oklahoma. So I gave her a call, and essentially gave her the handoff, right?

It's no greater honor than to know them and to follow them. And they call you, I mean, even when I stepped away from my current, they're finding me at my house, they're sending, you know, that to be to be a someone surgeon, there's no greater honor for someone than to give them your life. And that's the way I feel about it. They are dedicated.

I have patients, I mean, I see them every year for annual mammography or more frequently if they have a diagnosis. But, you know, like I have one that she's a beekeeper, and she brings me fresh honey every year. And another one brings me strawberries, and you know, pictures of their grandkids, and they're just lovely. So we are the lucky ones.

We are. We're very fortunate to be in this spot. And so, like I said, it's an honor. I really love this time that we have to talk and get to meet you, Dr.

Avery and Dr. Cree. Thank you. This was really an amazing podcast, I have to tell you.

And thank you very much for, you know, just the great answers and just the discussion. I mean, it's very enlightening, both from a clinical perspective, but I actually think from a, which is everything that I've read about, you know, culturally and how you lead and, you know, you can feel it. In this discussion, so it was really great. Thank you very much.

My pleasure. Thank you very much. Thank you for having me.