Episode 11
The Value of Surgical Mentorship with Dr. Eugene Shively
Episode Transcript
Dr. Randy Lehman: [00:00:07] Welcome to The Rural American Surgeon. I'm your host, Dr. Randy Lehman. On this show, you'll receive powerful insights and resources for rural surgeons. I'm a general surgeon in northwest Indiana, and this show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics ranging from practical surgical tips to a host of others, including rural lifestyle, finance, training, practice models, and more. We'll also have a segment called Classic Rural Surgery Stories where you'll get a feel for how practice in the country differs from the city. Whether you're a surgeon, other specialist, primary care provider, or simply someone interested in healthcare for rural America, I'm glad you're here. Now, let's get into the show.
Dr. Randy Lehman: [00:00:46] Welcome back to another episode of The Rural American Surgeon. I'm here with one of my greatest mentors, Dr. Eugene Shively, from Campbellsville, Kentucky. I met him as a fourth-year medical student when I was at the University of Cincinnati. I went and told the chair of the Department of Surgery that I wanted to be a rural surgeon. He said, "If you want to be a rural surgeon, you have to rotate with Eugene Shively, essentially the godfather of rural surgery." So, Dr. Shively, thank you so much for coming onto the show.
Dr. Eugene Shively: [00:01:13] You're welcome.
Dr. Randy Lehman: [00:01:15] So, we've got a lot to talk about today. We may have to bring you back as another guest another day, but there are so many stories. I’d like to start with an introduction. Tell us a little bit, just briefly, about your training and what your career has been like throughout the years.
Dr. Eugene Shively: [00:01:32] Well, I graduated medical school in 1970 from the University of Louisville. I did a rotating internship at the University of Cincinnati. I wasn't exactly sure what I wanted to do, and then I was in the Air Force as a flight surgeon with a C-130 outfit for two years. Afterward, I came back to the University of Louisville, where I graduated from medical school, and completed a surgical residency under Dr. Polk.
Dr. Randy Lehman: [00:02:01] And then you came essentially very close to your hometown, right? Campbellsville was your hometown. And then you practiced there for how many years?
Dr. Eugene Shively: [00:02:12] Well, I've been here 46 years. I stopped doing surgery just before COVID.
Dr. Randy Lehman: [00:02:20] So, you're how old now?
Dr. Eugene Shively: [00:02:23] I'm 80.
Dr. Randy Lehman: [00:02:24] And now we're recording this in 2024. So, just before the pandemic in 2020, then. I want to talk about the rotating internship in Cincinnati. You've told me before that the rotating internship was one of the best things that made you a well-rounded doctor. You’ve also told me some crazy stories. I want you to share the parathyroid story and maybe the trach story.
Dr. Eugene Shively: [00:03:02] At the University of Cincinnati, Dr. Altamaier was the chairman. That was an additional surgery program. You worked there very hard—many times, every other night. It was a six-year program, and you got certified in general and thoracic surgery. You were not allowed to be married. At the end of your residency, you were invited to debutante balls, a tradition Dr. Altamaier upheld.
Dr. Altamaier scrubbed in on every parathyroid case. Once, we had a parathyroid adenoma. The chief resident started the case and dissected out the parathyroid adenoma. Then, Dr. Altamaier scrubbed in. The chief resident covered the thyroid back over the adenoma and said, "Dr. Altamaier, I'm having a little trouble finding this parathyroid adenoma. Can you help me?" Dr. Altamaier pulled it up and said, "Here it is, Henry." Henry replied, "Thank you so much." Dr. Altamaier scrubbed out, and that was the end of the case after closure.
Dr. Randy Lehman: [00:04:29] That’s fantastic. It just sounds like a totally different world.
Dr. Eugene Shively: [00:04:33] It was a totally different world. It was a male-dominated, very rigorous, demanding program that required a tremendous amount of resilience. But I enjoyed my internship there, and I'm glad I did a rotating internship because I think it taught me a lot. It made me a better surgeon. I understood medicine better, and even OB-GYN and pediatrics.
Dr. Randy Lehman: [00:05:14] So, a question I like to ask everyone early in the show is, why is rural surgery special to you?
Dr. Eugene Shively: [00:05:22] Well, I came back to Louisville because I wanted to get closer to home, and my parents were getting older. I had the option of staying in the Air Force and going down to Austin to do a residency, but I decided to come home. I wanted to practice where I was raised. I felt that there was a huge need in rural America at that time.
The family doctors did a lot of surgery. There was only one surgeon in Campbellsville, and there were no other specialists. Some of the family doctors did quite a bit of surgery—they would do cholecystectomies, hysterectomies, appendectomies, and some orthopedics like closed reductions. The general surgeons surrounding Campbellsville were real general surgeons.
There were three general surgeons in Lebanon, Kentucky, 20 miles away. They did fractured hips and all types of surgery. It was the same way in two other nearby towns. In Greensburg, there was a surgeon who performed all types of general surgery, including OB-GYN. They didn’t always do obstetric deliveries, but they performed C-sections when family doctors needed them to.
In Columbia, Kentucky, there was another surgeon who handled all those cases. They didn’t routinely do thoracic surgery, but if a patient needed a chest tube or a thoracentesis, they would do it. I know one surgeon who even drained an epidural hematoma once because it was an emergency, and they couldn’t transport the patient. They provided phenomenal care.
I wanted to be involved in that, and I decided family practice wasn’t the best fit because I knew family doctors wouldn’t continue doing surgery. Surgery was exciting and very rewarding.
Dr. Randy Lehman: [00:07:56] Yeah. So, let’s move to the "How I Do It" section of the show. We decided ahead of time—and I should probably mention—that we’re here in Campbellsville. I came down to record this podcast and spend some time with you. We’re in your cabin. The cabin is really cool. Tell us the story about it.
Dr. Eugene Shively: [00:08:18] Well, when I first moved back, a friend of mine liked to tear down log cabins, number the pieces, and sell them. He talked me into buying two log cabins. One of them is now about 200 years old, and the other is approximately 150 years old. After I bought them, he told me, “By the way, you’ve got to put these cabins back up. If you leave them on the ground, they’ll rot.”
I got some college students to start reassembling them, but they didn’t know what they were doing. So, I hired a guy who lived down the road and had experience assembling log cabins. He helped with the project. The next summer, we built an A-frame between the two cabins.
Not knowing much about construction, I didn’t realize that one cabin was three feet higher than the other, and neither was square. The room in between required a special carpenter and took about four months to complete. We have a stone in here from an old slave fence, and another stone my wife found when she saw a guy hauling rocks. She asked him what he planned to do with them, and he wasn’t sure.
Dr. Eugene Shively: [00:10:23] And so he decided that we should buy that. Some of the materials on the outside are very, very heavy. The guys who put that up had to lay the mortar and let it set for at least five minutes before placing the stone on top. It was extremely difficult work, but it turned out remarkable.
Dr. Randy Lehman: [00:10:23] Yeah, yeah, it's really cool. So essentially two cabins, one's 200 years old, one's 150 years old, and then this A-frame built connecting the whole thing. We're sitting in the atrium, and it's decked out with all kinds of animals, some of which belong to your son-in-law. And then you've got a moose that you say is older than you.
Dr. Eugene Shively: [00:10:43] Yes, most of it was killed out in Wyoming, actually during World War II. You can see the moose there. And then there are two deer—not mule deer, but Kentucky deer—that came from out west. They were also killed during World War II.
Dr. Randy Lehman: [00:11:09] So anyway, that's where we're coming from and why we're in this unique setting—not the usual one. But let’s move on to the "How I Do It" segment. We’ve decided to talk about something that’s not done very commonly anymore but might be interesting to my audience, which is essentially just me. And that’s an exploration of the common bile duct.
I do an exploration of the common bile duct a little differently, so that might be something we can talk about. First off, who’s the patient that needs an exploration of the common bile duct?
Dr. Eugene Shively: [00:11:46] Well, it’s a patient who has stones in the common bile duct. When I started off, I routinely did cholangiography, even during open surgeries. I began performing laparoscopic cholecystectomies in 1990—there’s a story to that as well.
When we found common duct stones, we would usually open, explore the common duct, and place a T tube. Nowadays, everyone thinks that’s a sin, but it’s actually a very good operation. The patients do quite well. There’s nothing wrong with opening and exploring the common duct. You can take care of most problems that way—remove the stones, place a T tube, and monitor the patient.
One advantage is that if you have a patient with multiple stones and you leave one behind, about a month to six weeks later, you can scope the patient through the T-tube tract and perform choledochoscopy to remove the stone. That’s something most people don’t know about. Choledochoscopy isn’t hard to do. Anyone who can perform bronchoscopy can do it. It’s easy to remove stones that way. You can also dilate the common duct or place a stent if needed.
Dr. Randy Lehman: [00:13:24] Yeah, there’s a lot to unpack there. Let’s start with the actual exploration of the common duct. Let’s assume we’re doing an open cholecystectomy, and you’ve done a cholangiogram and found a stone. What do you use to shoot the cholangiogram? For this part of the podcast, assume you’re talking to a resident or young general surgeon who’s never seen this but has a general idea of what you’re talking about.
Dr. Eugene Shively: [00:14:01] You mean for an open procedure?
Dr. Randy Lehman: [00:14:02] Yeah, sure.
Dr. Eugene Shively: [00:14:03] Well, they make a cholangiocatheter—several types are manufactured—that you can place in the cystic duct. You secure it with a hemostatic clip and then shoot your X-ray.
When we started, we didn’t have the advanced X-ray machines where you could see the image immediately. The technician had to take the film, develop it, and bring it back. Only then could we see if there was a stone or not.
Dr. Eugene Shively: [00:14:55] But now, of course, we have fluoroscopy, so we can do it right away. We can even use fluoroscopy during the procedure while taking out a stone. It makes things a lot easier.
Dr. Randy Lehman: [00:14:55] Yeah, that’s great. So, you do that, you identify a stone. Presumably, these patients didn’t necessarily have symptoms beforehand. But if someone has elevated bilirubin, particularly direct bilirubin, and a dilated bile duct, you’d be suspicious, right?
Nowadays, I would do an MRCP if I suspect a common bile duct stone. Sometimes you can pick it up on a CT scan or ultrasound, but if both are negative and I’m still suspicious, I’ll use MRCP to confirm that the stone is in the duct. That wasn’t an option for most of your career, was it?
Dr. Eugene Shively: [00:15:54] That’s correct. We probably started using MRCP once MRI became widely available, which was around 2005 or so.
Dr. Randy Lehman: [00:16:10] Okay. So, you have an obvious stone on cholangiogram. What’s your next step for common bile duct exploration?
Dr. Eugene Shively: [00:16:20] You make a longitudinal incision on the bile duct. First, you can try irrigating the duct to remove the stone. After that, you can use a choledochoscope to examine the duct proximally and distally.
If the scope passes into the duodenum, you’ve likely cleared the stone. If not, you try pushing the stone through with irrigation or a catheter. During laparoscopic cholecystectomy, I’d always try pushing the stone through first. If that didn’t work, I’d use the choledochoscope through the cystic duct and try removing it with a basket.
If that failed, I’d use a laser to fragment the stone on several occasions. Then I’d irrigate and push the fragments through. We always performed a completion X-ray to ensure no stones remained.
If it was a laparoscopic procedure, we didn’t need to place a T tube. We’d simply clamp the cystic duct and finish. For open procedures, we placed a T tube and a drain. About six weeks later, we’d perform a T-tube cholangiogram. If it was clear, we’d remove the tube. If not, we’d perform a percutaneous choledochoscopy to address any remaining stones.
Dr. Randy Lehman: [00:18:15] Tell me about the longitudinal incision you made on the common bile duct. I assume it was anterior, avoiding the 3 and 9 o’clock positions where the blood vessels are?
Dr. Eugene Shively: [00:18:32] Yes, I’d usually make the incision near the cystic duct unless the cystic duct was in an abnormal position.
Dr. Randy Lehman: [00:18:35] And the choledochoscope you used—it’s essentially like a bronchoscope. Did you actually have a choledochoscope, or did you use a ureteroscope?
Dr. Eugene Shively: [00:18:48] We actually had a choledochoscope, but you can use a ureteroscope as well.
Dr. Randy Lehman: [00:18:54] Okay. And you used that with a pressure bag for irrigation?
Dr. Eugene Shively: [00:19:00] Yes, that’s correct.
Dr. Randy Lehman: [00:19:04] And did you ever infuse glucagon to relax the sphincter?
Dr. Eugene Shively: [00:19:04] Frequently.
Dr. Randy Lehman: [00:19:07] You used 1 milligram?
Dr. Eugene Shively: [00:19:09] Yes.
Dr. Randy Lehman: [00:19:09] Of glucagon? Yeah. And then you’d let it circulate and try to flush it through. You scoped proximally and distally with your choledochoscope, which functions like a bronchoscope, as you mentioned. It’s equipped with continuous flow irrigation, so you can see the inside of the duct.
This is a very small scope, but it has a working channel where you can run a basket down—like a nitinol basket with four wires—to grab a stone and pull it out or push it through. That makes sense. And every time you did that, you always placed a T tube, correct?
Dr. Eugene Shively: [00:19:42] If it were open, yes.
Dr. Randy Lehman: [00:19:43] If it were open. What about laparoscopic cases?
Dr. Eugene Shively: [00:19:44] Obviously not.
Dr. Randy Lehman: [00:19:49] What if you had a chronically obstructed duct that was really large, like 1.5 centimeters? Would you ever stitch it up primarily and leave it, or did you always place a T tube?
Dr. Eugene Shively: [00:20:02] I always placed a T tube, but there were surgeons who would repair and sew it up.
Dr. Randy Lehman: [00:20:08] I had a case like that during residency. It was a 1.8-centimeter duct, and we managed it laparoscopically but stitched it up afterward.
Dr. Eugene Shively: [00:20:14] Yes.
Dr. Randy Lehman: [00:20:16] That was a cool case. Okay, moving on to the laparoscopic era—I’ll describe what I do, which sounds very similar to your approach.
Dr. Eugene Shively: [00:20:26] Let me just say one thing. The reason we started doing this was that we didn’t have ERCP available. This method allowed us to manage complex choledochal surgery without needing ERCP.
Some surgeons believe this procedure is just as safe—if not safer—than ERCP because it avoids the risk of severe pancreatitis. And you’ve seen how severe pancreatitis can be after ERCP.
Dr. Randy Lehman: [00:21:07] Yeah, I’m one of those surgeons. That might be a minority opinion, but I feel strongly about it. It’s definitely better for the patient. The only problem is patients rarely understand what we’ve done. I try to draw diagrams and explain, but they just say, “Dr. Lehman took my gallbladder out,” and that’s it.
Dr. Eugene Shively: [00:21:25] I recorded all my cholecystectomies and gave the patients a copy of the video. Some people thought this could lead to malpractice suits, but I disagreed. Patients loved it. They’d watch the video at home and come back for their post-op visit saying, “That was pretty neat!” It was also great marketing.
Dr. Randy Lehman: [00:22:00] How were you recording these surgeries when you first started? Was it digital?
Dr. Eugene Shively: [00:22:05] That’s correct.
Dr. Randy Lehman: [00:22:06] So, you were using discs?
Dr. Eugene Shively: [00:22:08] Yes, but the first cameras were terrible. You could barely see anything. It’s amazing we didn’t have more problems. People talk about injuries to the common bile duct, and I think part of the issue early on in laparoscopic cholecystectomy was the poor quality of the equipment.
It’s interesting how I started doing laparoscopic surgery. I attended the SAGES meeting in September 1989. There was a doctor from France—his name escapes me—who presented laparoscopic cholecystectomy. At that time, SAGES was more of an endoscopy club, and very few people paid attention to him.
Dr. Eugene Shively: [00:24:31] Within just a few months, Eddie Reddick started teaching a course on laparoscopic cholecystectomy in Nashville, and it exploded in popularity. I had scheduled a class with him for June 1990, but they called me and said, "We have an opening in January. Why don’t you come down?" I told them I was too busy and put it off.
In those six months, I was already behind. We started doing laparoscopic cholecystectomies in July 1990. I had a gentleman who had just finished his residency in Louisville, and we began performing them together. We always worked together to ensure safety, and that’s how we got started. Looking back, I made a mistake by not going to Nashville in January with Eddie Reddick.
It was interesting—Reddick gave all his patients a copy of the video. Not only did he record the procedure, but he also added audio commentary, explaining what he was doing to the patient during the surgery.
Dr. Randy Lehman: [00:24:31] Wow, that’s amazing. It’s incredible to think about standing on the shoulders of giants. It’s hard to fathom how far we’ve come.
Maybe next time we record, we can discuss Jane Todd Crawford and her story. For now, I’d like to wrap up the laparoscopic portion of the common bile duct exploration. You mentioned placing the choledochoscope in the cystic duct, so laparoscopically, you never made an incision on the common bile duct, right?
Dr. Eugene Shively: [00:25:00] That’s correct—I never did. Some surgeons, including one of my partners, would do that if they couldn’t access the duct through the cystic duct.
Dr. Randy Lehman: [00:25:22] Did you often have to dilate the cystic duct with a balloon?
Dr. Eugene Shively: [00:25:22] Yes, frequently. Sometimes it would pass through, but other times we had to dilate the duct before threading the scope into the duodenum.
Dr. Randy Lehman: [00:25:22] For those wanting to succeed with this approach, my main tip is to be selective. I’ve had good success clearing ducts and avoiding ERCP and transfers from critical access hospitals to referral centers, which can be a big hassle due to ERCP availability.
I don’t attempt this if the cystic duct is tiny and tortuous. Fortunately, most patients with choledocholithiasis have anatomy conducive to this procedure—a short, wide cystic duct. Chronic or partial obstruction often creates favorable anatomy.
I perform a trans-cystic laparoscopic common bile duct exploration. I insert an extra 5-millimeter port in the right upper quadrant and pass a disposable ureteroscope, specifically the LithoVue scope, through it. This avoids the cost and fragility of permanent ureteroscopes, which are about $100,000. If I break a disposable one, I don’t feel as bad.
I use a pressure bag for irrigation. After performing a cholangiogram, I advance the scope distally, locate the stone, and try to push it through. If that fails, I use a nitinol basket to retrieve it. Smaller stones are pulled completely out through the cystic duct and the 5-millimeter port.
If a stone is too large, I retrieve it through the 10-millimeter port. This approach has been very successful. While patients may not fully grasp the benefit of avoiding ERCP and transfers, they are generally grateful.
Dr. Randy Lehman: [00:28:18] I usually keep patients overnight, then get LFTs in the morning before discharging them the next day. That’s been a technique that works for me. I think it’s something that should continue to be discussed, especially in rural surgery circles where we don’t have ERCP readily available. I believe it’s a real service to patients if you can offer this.
Thank you for your time discussing that. I have another segment of the show I’d like to transition to, called the Financial Corner. I didn’t ask you about this ahead of time, but do you have a money tip for residents or junior attendings? Perhaps something that worked for you or something you wish you had done differently?
Dr. Eugene Shively: [00:28:18] Things have changed radically since I started practicing. Just to give you an example, I started practicing in 1978. Back then, for an open cholecystectomy, we got paid $1,400 to $1,500. Now, for a laparoscopic cholecystectomy, most surgeons get paid between $500 and $600, not accounting for inflation.
All we had to do was perform the surgery, send the bill, and we got paid. There was no back-and-forth hassle, no pre-authorization requirements—none of that. These days, very few surgeons are in solo practice. Almost everyone I know in Kentucky works for a healthcare system, a hospital, or a group.
For those finishing residency, I’d recommend working for a hospital or a group practice rather than going into solo practice. Working solo, without a partner or backup, can be overwhelming. I did it for a year and wouldn’t recommend it now.
The most important financial decision I made was starting a defined benefit retirement plan with my first partner. We contributed a significant amount of money to it, and it accumulated tax-free over time. The downside is that you have to contribute an equal percentage for your employees, but in the long run, it pays off.
Start planning for your retirement from day one. If you don’t, you might find yourself unable to retire comfortably or live the way you want.
Dr. Randy Lehman: [00:30:58] Those are great tips—thank you. One more thought on laparoscopic exploration of the common bile duct. As you know, there’s CPT 47562 for a laparoscopic cholecystectomy, 47563 for a lap chole with IOC, and 47564 for a lap chole with common bile duct exploration.
I didn’t realize until about six months ago that there’s a separate code for choledochoscopy, and I hadn’t been using it for years. That was lost potential. Make sure to look up the code for choledochoscopy and use it if you perform one. It’s important to keep your coding as accurate as possible.
When you started practicing, there was no CPT system, right?
Dr. Eugene Shively: [00:31:56] That’s correct.
Dr. Randy Lehman: [00:31:57] It’s hard to imagine. Everything was based on usual and customary charges. Then CPT codes were introduced, allowing for more precise billing and identification of procedures. It’s a completely different system now. I wonder where we’ll be in 25 years—it’ll probably look just as different as it does now compared to 25 years ago.
Dr. Eugene Shively: [00:32:18] I hated coding. Later in my practice, one of the surgeons in our group took over most of the coding responsibilities and trained our future office manager to handle it. From that point on, I stopped coding entirely—they managed all of it for me.
Dr. Eugene Shively: [00:33:26] Most hospitals now have coders. At the hospital where I practice, they have people who handle all the coding. I have a friend who works for the University of Kentucky. He’s a retired surgeon involved in finance and coding there.
He tells me that doctors and surgeons probably shouldn’t be doing their own coding because it has become so complicated. That’s another big issue in medicine—it’s getting more complicated, and it’ll eventually have to be addressed.
Dr. Randy Lehman: [00:33:26] I think you still need to be aware of coding, at least for the things you routinely do. Having a coding book simplifies your life when handling coding queries. It ensures you write the necessary information in your notes, which minimizes follow-up questions that can be frustrating.
Plus, your payment depends on accurate coding. I keep track of all my codes, write them on my charge sheet, and give them to the office. The coders confirm everything, which works well for me.
Dr. Eugene Shively: [00:34:02] I agree—you need to know some of it because it’s related to reimbursement. Unfortunately, coding has become way too complicated.
Dr. Randy Lehman: [00:34:16] I have a section of the show called Classic Rural Surgery. This is where I ask you to share a story that exemplifies rural surgery—something you’d encounter in a small town but not in a city. Does anything come to mind?
Dr. Eugene Shively: [00:34:43] What comes to mind are cases a general surgeon would never see in a city but are common in rural areas. For example, tubal pregnancies. We were frequently called for those.
When I started practicing, you needed knowledge of gynecology. We performed a lot of gynecological procedures, including hysterectomies, before we had a gynecologist. I worked closely with one after he joined, and we often performed surgeries together.
We also collaborated with a urologist who specialized in pelvic relaxation and third-degree cystoceles. For example, I’d perform the vaginal hysterectomy and posterior repair, while he’d handle the anterior repair or bladder suspension. These surgeries were common, and we had good success rates.
In a small town, peer review happens within the community. Everyone knows your outcomes, so your reputation depends on your performance, not someone in a big city reviewing your charts.
Dr. Randy Lehman: [00:36:17] That’s very relevant to what I’m doing. There’s no OB-GYN in any of the critical access hospitals where I work.
The other week, I handled a large paratubal cyst laparoscopically. The CT scan showed it was likely coming from the tube rather than the ovary. The patient had peritonitis and was in significant pain.
During surgery, I decompressed the cyst with a needle, followed it to the stalk, and found it was torsed. I used the LigaSure to seal and cut the stalk. The entire case took 12 minutes. I removed the cyst, sent it for pathology, and saw the patient during follow-up. She was doing great.
This isn’t something a general surgeon should feel intimidated by. You just need a resource or someone you can consult if necessary.
Dr. Randy Lehman: [00:37:16] GYN cases show up often, and many can be handled in a small-town setting.
Dr. Eugene Shively: [00:37:16] If you’re in residency and planning to go into rural surgery, it’s essential to plan accordingly, especially in your last year or two. Think about where you’ll practice and what skills you’ll need.
For example, will you need to perform C-sections or emergency gynecological procedures? If so, you should train for those. At the University of Louisville, I was fortunate to take rotations on non-general surgical services. I spent three months focused on gynecology rather than obstetrics and another three months on orthopedics. That training was invaluable when I started practicing, and I continued doing those procedures for many years.
Dr. Randy Lehman: [00:38:23] That’s a great tip. You even stayed a bit longer after residency, right, to get additional experience?
Dr. Eugene Shively: [00:38:30] Yes, I stayed an extra three months. I spent two months on endoscopy. By the way, I don’t think you can practice rural surgery without doing endoscopy. While Randy has someone doing them for him, most rural surgeons find that at least a third of their practice involves endoscopy.
This doesn’t include ERCP but does involve colonoscopies and EGDs. We also performed advanced endoscopic procedures, such as dilating strictures in the distal esophagus. It was common to encounter patients with food stuck in the esophagus, which we routinely removed. Endoscopy is an essential skill.
I also spent two extra months in orthopedics. I handled fractured hips, performed closed reductions, and referred complex cases to the university. Additionally, I did a couple of months in thoracic surgery. One thoracic surgeon I worked with was interested in pacemakers, which were just becoming common.
I began placing pacemakers at my hospital and did so for many years. One of my partners, who I trained, now performs about 60 pacemaker placements annually. It’s a valuable service that keeps patients from having to travel out of town.
We didn’t handle defibrillators, but we always consulted with cardiologists for pacemaker cases unless it was an emergency, like severe bradycardia with a heart rate in the 20s. Having reliable pacemaker representatives was critical—they were incredibly helpful throughout my career.
Dr. Randy Lehman: [00:41:06] I forgot you did pacemakers! I remember seeing one when I rotated here as a fourth-year medical student. That’s not something I’m doing in my practice, but it’s something to consider.
The last segment of the show focuses on resources for busy rural surgeons. You’ve already done a great job discussing training for residents—how they can acquire skills that add value to their communities.
Ultimately, it’s about keeping care local so people don’t have to leave town. This helps keep hospitals viable, supports jobs in the community, and ensures patients get safe, high-quality care close to home.
With limited resources, rural surgeons often pick up subspecialty skills. For example, I perform carpal tunnel releases, hysterectomies, and some GYN procedures. These are straightforward cases where patients typically do very well.
Dr. Randy Lehman: [00:42:21] They’re great cases for rural surgery. Thanks for sharing that. I also want to discuss resources for the busy rural surgeon. I know you’re a big advocate for the American College of Surgeons, and you’ve also mentioned the importance of having a network outside your small town. Can you comment on both of those or share any additional advice for rural surgeons?
Dr. Eugene Shively: [00:42:21] I think it’s essential to be active in the American College of Surgeons. They do an outstanding job in training and continuing medical education. I don’t think there’s any organization that does a better job.
They’ve done a wonderful job with their annual conference in the fall and other educational resources, like CSAP. Additionally, networking with a regional medical center is critical. For example, I worked closely with the University of Louisville. I was on their clinical staff and had a strong working relationship with them.
I knew everyone there, and they knew me. If I referred a patient to them, they communicated with me about the case. Sometimes they sent the patient back to me for post-op care. If I had a challenging case I didn’t feel comfortable handling, I could call them, and the patient would be seen right away.
It’s crucial to have this type of collaboration. Even if you’re by yourself or your partner is unavailable, you should never hesitate to ask for another opinion.
Dr. Randy Lehman: [00:43:59] So who would you call for backup—general surgeons or specialists?
Dr. Eugene Shively: [00:44:07] It depends on the problem. I had a strong relationship with a vascular surgeon in Louisville. We trained together—he was an intern when I was a chief resident—and we maintained our friendship. He went on to complete a vascular surgery fellowship.
Later in my practice, I did a lot of wound care, especially during the latter part of my career. Wound care often involves vascular issues, so I became skilled at working up those patients. If a patient had a vascular problem, I referred them to him. We communicated effectively, which made a huge difference.
For example, if I called him on his cell phone about a post-op issue, he would address it immediately. That’s beneficial for both the patient and the referring surgeon.
Dr. Randy Lehman: [00:45:10] I do something similar. I call general surgeons for some problems and colorectal surgeons for others. I don’t typically handle rectal surgeries, but I still perform colon cancer surgeries. Having a consistent referral pattern allows me to ask questions about my cases and ensure quality care.
For vascular cases, I oversee a wound care clinic. I met with the vascular surgeon I work with most at the nearest referral center. I brought my nurse practitioner along to meet his team. We discussed how he wanted vascular disease cases worked up—whether he preferred duplex imaging, CTA scans, or other diagnostics.
We coordinated our approach: I manage wound care and simpler cases, like varicose veins, in my practice, while more complex cases—like those requiring multiple stents or bypasses—go to his center. It’s a collaborative system that works well.
Dr. Eugene Shively: [00:46:22] Exactly. Communication with the vascular surgeon is critical.
Dr. Eugene Shively: [00:48:01] Say you have a patient with wrist pain, diabetes, and renal failure. Do you really want to do a CTA on that patient? Or would it be better to send them directly to the vascular surgeon, let them perform an ultrasound, and potentially do an angiogram in a hybrid room? That way, the patient avoids receiving a double dose of IVP dye.
Another critical area for rural surgeons is learning how to manage rectal conditions. For example, anal fissures, fistulas, and perirectal abscesses are common and can be easily treated, but many general surgery residents aren’t trained in managing them. You need to make a special effort to learn these skills.
You should also know how to manage hemorrhoids—understanding which hemorrhoids require surgery and which don’t. I performed many hemorrhoid bandings in the office and managed thrombosed hemorrhoids by draining them. These are skills that general surgery residents often miss unless they actively seek out training.
Dr. Randy Lehman: [00:48:01] Yeah, and it’s not that difficult. You could connect with a colorectal surgeon during your training and do oral boards a few times on hemorrhoid-related cases. Most cases come in labeled as “hemorrhoids,” but they might actually be fistulas, abscesses, fissures, prolapse, rectal cancer, or even fungating tumors that no one has properly examined.
Dr. Eugene Shively: [00:48:29] Exactly.
Dr. Randy Lehman: [00:48:30] So you never know. They’re all billed as hemorrhoids, but you need to prepare for a variety of conditions. Should we do a bonus “How I Do It” section on this?
Dr. Eugene Shively: [00:48:43] A bonus?
Dr. Randy Lehman: [00:48:44] Too late.
Dr. Eugene Shively: [00:48:47] You mentioned rectal prolapse—I treated those as well. I had great success with the procedures I used and saw many cases over the years.
Dr. Randy Lehman: [00:49:01] Let’s do a rapid-fire bonus “How I Do It” for perianal conditions. Let’s start with hemorrhoids. If you have internal hemorrhoids that are prolapsing or bleeding, and there are no external hemorrhoids, what do you do?
Dr. Eugene Shively: [00:49:21] I usually treat those conservatively with anesthetic suppositories and Sitz baths. Most patients improve with that approach. If they don’t, then I consider hemorrhoidectomy. Toward the end of my career, I started using the Harmonic scalpel for hemorrhoidectomies, and it worked very well.
One thing I want to emphasize is that many general surgeons don’t fully understand how to use local anesthesia effectively. I learned this during my residency at the Trover Clinic in Madisonville, Kentucky. They performed all their hernias under local anesthesia.
Since the introduction of Marcaine, I’ve mixed it with xylocaine to achieve excellent, long-lasting anesthesia—up to six to eight hours. If you stop the immediate throbbing pain, patients tolerate surgery better, and you can significantly reduce narcotic use.
I applied this technique to abdominal surgeries as well. I always infiltrated the incision site with Marcaine and xylocaine before starting the procedure.
Dr. Eugene Shively: [00:51:26] It’s very important to administer Marcaine and xylocaine preemptively at the start of the operation, rather than waiting until the end. Now, with transabdominal Marcaine, such as in a TAP block, the anesthesia is even more beneficial, and patients require fewer narcotics.
Dr. Randy Lehman: [00:51:26] Yeah, you’re talking about a TAP block. So, how are we doing with our rapid-fire perianal conditions here? Not very well for me. For internal hemorrhoids, I typically do banding. For external hemorrhoids, I perform a hemorrhoidectomy.
Dr. Eugene Shively: [00:51:38] Banding works well.
Dr. Randy Lehman: [00:51:41] And external hemorrhoids are where I perform a hemorrhoidectomy.
Dr. Eugene Shively: [00:51:44] You can’t band external hemorrhoids.
Dr. Randy Lehman: [00:51:46] Right. If they’re below the dentate line, then they require surgical intervention.
Dr. Eugene Shively: [00:51:48] You can do that in the office. I’ve done it in the office many times.
Dr. Randy Lehman: [00:51:52] Okay. When you do the hemorrhoidectomy with the Harmonic scalpel, do you close the wound?
Dr. Eugene Shively: [00:52:01] You don’t have to.
Dr. Randy Lehman: [00:52:02] I’ve stopped closing the wound as well.
Dr. Eugene Shively: [00:52:04] Exactly. It seals on its own. If it reopens, it’ll still heal. Many surgeons don’t close hemorrhoidectomy wounds; they leave them open.
Dr. Randy Lehman: [00:52:14] Okay, very good. That’s hemorrhoidectomy in a nutshell—of course, trying fiber and conservative management first. Let’s move on. You do an exam in the office or under anesthesia and find a posterior midline fissure. There are no hemorrhoids. What’s your approach?
Dr. Eugene Shively: [00:52:31] If I find it under anesthesia, I wouldn’t do anything at that moment, other than an anoscopy. If I find it in the office, I’d treat it with Sitz baths and nitroglycerin ointment. If it doesn’t heal, then I’d proceed with a lateral internal sphincterotomy.
At first, I was hesitant about performing sphincterotomies, but I found they work very well. Patients often experience instant pain relief. You still want to use a lot of Marcaine for these cases. If a patient presents to your office with severe rectal pain, it’s almost always an anal fissure.
Dr. Randy Lehman: [00:53:18] Yep, I agree. Let’s talk about local anesthesia. For every perianal case I perform, I use an Exparel field block. Did you use Exparel during your career?
Dr. Eugene Shively: [00:53:32] Occasionally, but I think it’s an excellent option.
Dr. Randy Lehman: [00:53:35] Exparel is liposomal bupivacaine.
Dr. Eugene Shively: [00:53:37] Right. It’s a long-acting local anesthetic.
Dr. Randy Lehman: [00:53:42] Marcaine lasts six to eight hours, but liposomal bupivacaine lasts 48 to 72 hours.
Dr. Eugene Shively: [00:53:49] That’s a great idea. I didn’t use it much during my career, but I think it’s something surgeons should be familiar with.
Dr. Randy Lehman: [00:53:55] It’s becoming more affordable as it goes off-patent and becomes generic.
Dr. Eugene Shively: [00:54:02] Cost was one of the reasons we didn’t use it as much.
Dr. Randy Lehman: [00:54:05] All right. Let’s move on to abscesses. How do you diagnose a perirectal abscess—CT scan?
Dr. Eugene Shively: [00:54:23] No, you don’t need a CT scan to diagnose a perirectal abscess. Unfortunately, I’ve seen many patients who underwent unnecessary CT scans for what was clearly a perirectal abscess. Often, it’s obvious.
Dr. Randy Lehman: [00:54:47] So what’s your approach? Make an incision over the maximum point of fluctuation, like any abscess?
Dr. Eugene Shively: [00:54:52] Exactly. And you, obviously, want to…
Dr. Eugene Shively: [00:55:12] You’ve got to know where the abscess is. You don’t want to cut through both the internal and external sphincters. You can cut through the internal sphincter, but if you cut through both, you might cause rectal incontinence. If that’s the case, put a seton in.
Dr. Randy Lehman: [00:55:12] Yeah. So I was always told to make the incision as close to the anal verge as possible to shorten a fistula if it happens. Do you agree with that?
Dr. Eugene Shively: [00:55:24] Yes.
Dr. Randy Lehman: [00:55:25] Okay. Nowadays, I don’t think seton placement at the time of drainage is commonly needed because most abscesses will heal on their own without becoming a fistula. But setons are still useful, right?
Dr. Eugene Shively: [00:55:41] I’m just talking about cases where you’ve got an extensive abscess, and you have to cut through both the internal and external sphincters.
Dr. Randy Lehman: [00:55:48] Yeah, okay. Or like a horseshoe abscess. I agree—don’t be scared of it. I do order a lot of CT scans, probably more than you’d want, but they serve as a surgical roadmap for me. I can see if there’s a horseshoe component or other complexities. But if there’s a clear physical exam finding of an abscess, I agree that the patient will feel relieved if you can just drain it.
I tell my patients that about one-third of abscesses turn into a fistula after drainage. Do you think that’s a fair number?
Dr. Eugene Shively: [00:56:19] I think that number might be a little high, but I don’t know the exact data.
Dr. Randy Lehman: [00:56:23] Some abscesses will become fistulas requiring treatment. If a patient has persistent drainage after six to eight weeks post-drainage, I suspect a fistula. What’s the best way to diagnose it—MRI?
Dr. Eugene Shively: [00:56:46] I typically use a probe in the office. I numb the area and probe to see where the tract leads. Sometimes the tract goes straight to a hole in the mucosa, but not always. Usually, you can tell where it’s draining. Then you perform a fistulotomy, depending on its location. If the tract goes high into the rectum and through the sphincters, I would place a seton, but I didn’t have to do that very often.
Setons can be difficult for patients. They cause pain, especially when tightened. Patients often have to come to the office weekly for adjustments.
Dr. Randy Lehman: [00:57:28] So you’re using the seton to cut through the tissue?
Dr. Eugene Shively: [00:57:31] Right.
Dr. Randy Lehman: [00:57:32] Is that a silk stitch?
Dr. Eugene Shively: [00:57:34] You can use silk, but I usually use a small Penrose drain.
Dr. Randy Lehman: [00:57:38] Okay. A tight Penrose drain will work to cut through?
Dr. Eugene Shively: [00:57:41] Yes, but you have to tighten it every week or two.
Dr. Randy Lehman: [00:57:44] Got it.
Dr. Eugene Shively: [00:57:44] I would pull on the Penrose drain while a nurse held it, then tie a silk suture around it.
Dr. Randy Lehman: [00:57:52] Okay. I find setons useful when there’s a residual abscess that needs to collapse into a small tract. For cutting setons, I’d typically use 2-0 silk. There’s also the LIFT procedure and plugs, though plugs seem to go in and out of favor.
Dr. Eugene Shively: [00:58:19] You use plugs?
Dr. Randy Lehman: [00:58:20] I don’t use plugs.
Dr. Eugene Shively: [00:58:21] I’ve never used them.
Dr. Randy Lehman: [00:58:23] There’s also some testing of stem cell injections for fistulas.
Dr. Eugene Shively: [00:58:27] Stem cells?
Dr. Randy Lehman: [00:58:28] Yeah, but they don’t seem very effective.
Dr. Eugene Shively: [00:58:29] Isn’t that expensive—using stem cells?
Dr. Randy Lehman: [00:58:32] That’s why it’s experimental. All right, let’s talk about rectal prolapse. How do you treat rectal prolapse? You mentioned Dr. Altemeier earlier today.
Dr. Eugene Shively: [00:58:41] Yes, I usually performed the Altemeier procedure. It works very well, but those cases are very rare. I might do one or two a year.
Dr. Randy Lehman: [00:58:53] Have you ever done a sigmoid colectomy with rectopexy?
Dr. Eugene Shively: [00:58:59] Yes, I have.
Dr. Randy Lehman: [00:59:00] How do you decide between the Altemeier procedure and a sigmoid colectomy with rectopexy?
Dr. Eugene Shively: [00:59:05] It depends. If it’s just a mucosal prolapse, one option is to use rubber band ligation. For elderly patients, especially those who are high-risk, an Altemeier procedure is appropriate, especially if the prolapse is limited to 4 or 5 centimeters. For younger, healthier patients, I would consider a sigmoid resection with rectopexy. However, most of the patients I saw were elderly, and I preferred to avoid major operations in those cases.
Dr. Randy Lehman: [00:59:50] That makes sense. I’ve had similar cases. For a 40- or 50-year-old patient, I’d perform a laparoscopic sigmoid colectomy with rectopexy. But for an 85-year-old nursing home patient, an Altemeier procedure under spinal anesthesia works well.
Dr. Eugene Shively: [01:00:07] Absolutely. I’ve done that many times. Well, not many—maybe one or two a year. Rectal prolapse isn’t very common, but with an aging population, we may see it more often.
Dr. Randy Lehman: [01:00:24] True. Although with declining birth rates, it’s hard to predict future trends.
Dr. Eugene Shively: [01:00:29] I believe constipation plays a significant role in rectal prolapse.
Dr. Randy Lehman: [01:00:34] Agreed. Let’s talk about anal condyloma.
Dr. Eugene Shively: [01:00:39] First, confirm the diagnosis with a biopsy. Then, I usually use a Bovie to coagulate the lesions. Some people use lasers, but I think that’s an expensive solution for a benign problem.
Dr. Randy Lehman: [01:00:58] And you may need to bring the patient back to clean up residual lesions, right?
Dr. Eugene Shively: [01:01:00] Yes, absolutely. I always inform patients that they might need follow-up treatments.
Dr. Randy Lehman: [01:01:05] Hopefully, the Gardasil vaccine will help reduce these cases.
Dr. Eugene Shively: [01:01:08] It should, but unfortunately, not enough people are getting vaccinated. While the incidence of cervical cancer has decreased, it hasn’t dropped as much as we hoped. That said, it’s still much better than it used to be.
Another practice I had that seems to be falling out of favor is performing pelvic exams and Pap smears in the office. I think it’s important to ensure the uterus, ovaries, and rectum are healthy before surgery. You don’t want to be mid-operation and discover an issue you’re not prepared to address. For example, if you’re removing a gallbladder but find a uterine or ovarian problem, it could mean a second surgery, which is avoidable with a thorough preoperative exam.
Dr. Randy Lehman: [01:03:01] That’s a good point. Physical exams in general seem to be falling out of favor.
Dr. Eugene Shively: [01:03:01] Exactly. Even rectal and pelvic exams under anesthesia are less common now because explicit patient consent is often required. I used to perform them routinely without specific permission, but times have changed. Still, as a general surgeon, you should know how to conduct a proper pelvic exam and understand what you’re dealing with.
Dr. Randy Lehman: [01:03:01] I agree. Well, this was great. Did I miss anything for perianal conditions? I did this all from memory, so we might need to turn it into a bonus episode.
Dr. Randy Lehman: [01:05:00] I think we did pretty well. Covered it pretty thoroughly. Thank you so much for your time. I really appreciate it. And thank you for everything. We first met a decade ago this coming fall, and I just want to say thanks for all the mentorship over the last decade.
Honestly, the main message from this episode is to find yourself a mentor or a set of mentors. Look for people who won’t throw you under the bus—someone you can call to ask stupid questions, and they’ll just give you the answer without making you feel stupid.
I was fortunate during my training to go to Honduras on a mission trip with Dr. Shively. After I did a rotation with him in my early fourth year, I went to Honduras during my late fourth year and continued going during residency to Guaymaca, Honduras. It was incredible because now, as an attending staff volunteer, I’m running my own room there.
All the people on that team and at the location have watched me progress through my surgical training. Coming back year after year, doing 40 cases in a week with the same team, really enhanced my training. It’s also built trust over time. I did this during my vacation as a resident. So even if you only get a small vacation, go operate during that time.
Not only was it a blast and helped others, but it also made me a more confident and capable surgeon. I owe you so much—not just for today’s episode or pulling me on water skis, but for everything. You’ve become one of my best friends, and I truly appreciate you. Also, you’re not allowed to die, so don’t do that. Come back for another guest episode, please.
Dr. Eugene Shively: [01:05:21] I strongly recommend that medical students and residents go on medical missions. You learn so much. For example, you’ll realize you can be a great surgeon even without CT scans. You’ll improve your physical examination skills, learn how to do open hernias, and so much more.
This is an extremely important learning curve, especially for rural surgeons. It’s not only beneficial to your profession, but it’s also incredibly rewarding. You’ll be helping people in drastic need, providing services they wouldn’t get otherwise. It’s fulfilling and reminds you why you pursued surgery in the first place.
Dr. Randy Lehman: [01:06:17] Thank you. Is there anything else you’d like to share with my audience? If they want to get in touch with you, I know you have a podcast. We can include the link in the show notes. Can you tell us briefly what it’s about?
Dr. Eugene Shively: [01:06:35] My podcast focuses on the U.S. healthcare system. I’m a retired surgical oncologist and have been doing this for about three years now. We cover various topics about the U.S. healthcare system, including its costs, inefficiencies, and unique practices.
For instance, we’ve discussed for-profit health insurance, private equity in healthcare, and the cost of pharmaceuticals. Did you know the U.S. is one of the few countries that allows pharmaceutical advertising? We’ve also interviewed trauma surgeons, surgical oncologists, and others. It’s been exciting, and I’ve learned a lot.
Dr. Randy Lehman: [01:07:41] That sounds great. Everyone, check out the podcast. The link will be in the show notes. I think that’s a wrap for us. Thank you for joining us, and don’t forget to like, subscribe, and share this with all your rural surgery friends. Join us and interact with us on our Facebook page. It’s been a pleasure. We’ll see you next time. Thank you.
