Episode 1

Life in Rural Surgery

Episode Transcript

Welcome folks. This is the very first episode of the Rural American Surgeon Podcast. This is something I've been wanting to do for a long time, since probably my first or second year of residency eight or nine years ago. 

I'm passionate about rural surgery because I grew up on a farm in northwest Indiana, and it's been in my blood since I was a little kid, running around listening to my parents travel over the countryside singing songs about our heartland, such as the Great American Farmer and This Land Is Your Land, watching a slideshow in the early 1990s with pictures of waving fields of grain and American flags and red and green tractors. So I think I was fed a large amount of propaganda when I was a child that has really shaped my background and upbringing.

But I truly believe that rural America is a very special place with very special people with values that still need to be preserved. And rural surgery practice has a lot to offer as well. Rural surgery truly is different than surgery that you would see in an urban counterpart, or especially in the ivory tower where you have so many resources available to you. You have to still be a doctor to be a rural surgeon. You have to think critically about the patients. You have to think about what you can and can't do in rural America.

And then there may be things outside of a normal general surgery specialty, which includes pulling from some other surgical subspecialties like orthopedics or OBGYN or urology, which makes your practice actually more diverse, while at the same time you're giving up some of the breadth of general surgery, such as esophagectomy or Whipple or liver resection, which usually wouldn't be appropriate. 

And you probably not going to afford the $250-$500,000 worth of equipment that's required for vascular surgery and endovascular techniques these days. So that won't be sitting in your closet outdating in a critical access hospital, for example.

So my goal for this podcast is every episode I'll interview a guest, really that I want to talk to. These are leaders in the forefront of rural surgery. They're colleagues of mine that I've came in contact with in our national meetups. They might have been someone that helped me along the way through my training. And most importantly, they all care and have a special passion for rural surgery, as do I.

My background after leaving the farm was I went to college and then medical school at Cincinnati, and when I was in Cincinnati, I discovered the field of rural surgery. I gained a mentor and then I found there are special training tracks currently that have been developed over the last 10 to 15 years, mostly in the United States, training a rural surgeon. And I ended up matching at the rural surgery track in the Mayo Clinic in Rochester, Minnesota. 

Spent five years up there with a lot of great teachers and mentors and I feel like I got excellent training with the goal of coming back home to my hometown in northwest Indiana and able to offer a broad-spectrum, high-quality care to the patients that are close to me. And we can keep care close to home so they don't have to travel to the city, but yet offer them the same quality that they would get if they were, for example, traveling to the Mayo Clinic.

The segment of my podcast that I'm most excited about, especially as I start out, is one called How I Do It. There may be people listening to this show that are not rural general surgeons. You may or may not find this segment interesting, but I want to dive very deeply into the exact minute details of how my guest does one case every week. 

I think this will be useful for new surgeons in practice, it'll also be useful for residents. And most importantly, it's just fun to hear that there's not just one way to do things and we can talk about the pros and cons and maybe you'll find something for your practice.

Now, there may be people listening to this show who are not general surgeons. Maybe they're orthopedic urologists, plastic surgeons, OBGYNs that are practicing in rural America. Maybe they're medical specialists or primary care physicians. And if you want to tune out during that episode, that's fine. But you might also pick something up as to what your general surgeon is thinking about when you're, say, referring a patient to them, and what sort of things would change their management or even operative technique.

There may also be people listening to the show that are nurses or nurse managers or administrators or CEOs of small hospitals, or even people that are interested in healthcare policy. And I think we'll touch on some of those things, including rural lifestyle. We'll talk about practice models, and no doubt we'll have some opportunity to talk about government assistance or interference in the rural surgery practice.

[00:05:27] But those things are all essential and important to just have an understanding about. And you'll also get a mindset into when we're at our best as general surgeons. What are the good things that motivate us and keep us going so that we can all avoid that stuck feeling. And I won't use the buzzword that everyone's talking about, but that feeling where what you're doing is not really getting you anywhere and it's not really what you want to be doing anymore.

I think that professional isolation is a big problem in rural practice, not just surgery, but others. And I hope to fight that by building a community. With this podcast, we'll have ways to connect, and I'll talk about resources and other groups, particularly Northern Plains Rural Surgical Society and the American College of Surgeons with their rural surgery interests. 

Those are probably the two leading American groups to have a focus on rural surgery, and we can talk with people from those groups and interest you, I think, with some resources that will become hopefully a useful adjunct to your practice.

If you have something that you'd like to talk about, please don't hesitate to interact with us on the show. Reach out to me and we'll try to chase down what interests you. But as I start the show, it's basically a show where my audience is myself. I'm getting the questions answered that I want to talk about, and we'll see where it goes from there. 

I also have an interest in personal finance, and I feel like financial independence is an important process that it's good for everyone to go through to learn the concepts of frugality and also of charity. And I think that those things help to eliminate money as a motivator, and it helps us to get back to our altruistic roots.

And so this podcast is definitely not going to be dominated by that. It's mostly going to be the nuts and bolts of rural general surgery practice. But I will have a financial corner where I'll ask my guests if you have any particular tips or even a money mistake that you made that, say, you were talking to a medical student or resident or a young attending that you would want to share to help them have success and not need to focus on money so much in their lives, as they have so many other much more important things to worry about.

We'll also talk about rural lifestyle, and there's a section of the podcast that I think will be very popular, which is going to be classic rural surgery stories. And I'm imagining, you know, maybe there's somebody who traded surgery for a chicken. You know, that's what comes to mind. 

However, I don't know if we'll have something that dramatic, but for me, I know my very first case was a gallbladder, and my second case was an appendix. And it sounds pretty bread and butter, but the gallbladder I actually saw back this past week, and it turned out to be gallbladder cancer.

The patient was sent for a segment 4b5 resection portal lymphadenectomy. I put a port in later, they did their chemo, and the margin on the liver was positive. Several lymph nodes were positive in the porta. And the patient's alive. And what did I see them for this past week but to remove their port? So that's insane to be involved in that.

I never would have thought I would have expected that person to have less than a year of life expectancy. But that's where your most common operation is. Your first operation that turns out to be like a 1 in 100,000 type of diagnosis of gallbladder cancer. The second case, the appendix, was the father of my new babysitters.

So I'm talking about appendix this and that in the operating room or in the emergency room with the patient. And I get done, and the patient's wife looks up to me and says, "Do you know so and so and so and so?" And I said no, because I didn't even know who they were. My wife had set it all up. And then she said, "I think they're your babysitters." And then everything and the ice was broken.

That's rural practice immediately in real life. So when you have a town of 1,200 people, like I was practicing in a county of 12,000, you can't avoid operating on people that you know. Now, you still have to have boundaries. You know, things that you would do for your immediate family members are probably different than the rest of the community, but it becomes very personal very quickly.

And the other thing about that appendix is it was a 9-centimeter appendiceal mucocele. So again, when your common operation becomes the one in a thousand diagnosis, and of course, I'm calling my buddies that are doing HIPEC at Mayo and trying to make sure that I do right by this guy. 

I ended up deciding to do an open appendectomy for my first appendix to prevent the terrible, dreaded complication of pseudomyxoma peritonei, or "Jelly Belly" if you would rupture an appendiceal mucocele. And he's also doing great. And he wrote me a song afterwards called "Dr. Randy." And, you know, it's just how life goes in rural America. It's different.

[00:10:39] That's how the practice is different. It's much more personal. Call really is less of a burden, but there's more of it. On a general call week for me, I might get four consults. And so that's something that's a little bit more manageable, but it's more about resource management, team management. That's true for any surgeon, but really true for a place when you have, say, five nurses and four CSTs that work in your whole department.

And that's your call team, and you have one CRNA, that's your anesthesia team at a time in town. And so then you're thinking about cases in the middle of the night, managing your surgery list on your call days. And if you're not done for the day, but then you have to call somebody back in and it's the same crew that was there with you all day, you have to be thoughtful about those kind of things in a way that you don't have to when you're, like I said, at the ivory tower of the Mayo Clinic.

So I'm really glad you're here. I hope that you enjoyed getting to know a little bit more about me. I have a team and a crew that's helping me produce this podcast, and they've suggested that I just introduce myself for the first couple episodes before we get into the guests. 

But I'm going to talk a little bit more about my background and my family maybe in the next episode. And then shortly thereafter, we'll be getting into the guest interviews and talking about the nuts and bolts of rural general surgery practice. Hope you have a great day.