Episode 3

Navigating Global Rural Surgery with Dr. Lauren Smithson

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. But 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 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, or primary care, or simply someone interested in healthcare for rural America, I'm glad you're here. Now, let's get into the show.

Lauren Smithson is here with us, and she is the chair for the Advisory Council for Rural Surgery. Thank you so much for joining the Rural American Surgery podcast, Lauren.

Dr. Lauren Smithson: [00:00:55] Yeah, no problem. Thanks, Randy, for having me.

Dr. Randy Lehman: [00:00:58] It's great to see you. I got the honor to meet you in January at what is now the North American Rural Surgical Society and was the Great Plains Northern Plains Rural Surgical Society. You were telling us all kinds of crazy things about an experience that you had across the pond, which maybe we'll touch on today. But first, let's do a little introduction of you. So you're practicing in, is it Nova Scotia?

Dr. Lauren Smithson: [00:01:23] No, actually Newfoundland, which is another of the Canadian Atlantic provinces, just actually north and east of Nova Scotia, which you have to access by ferry or plane.

Dr. Randy Lehman: [00:01:36] Now, that's rural. So what got you to where you are? What's your practice like now, and where are you going?

Dr. Lauren Smithson: [00:01:43] All right, well, I don't know how much detail you actually want, but I'm a Caribbean medical grad. So I went down to St. Martin to do my medical degree and did all of my rotations over in the UK in Blackburn, and then came back and did my electives in the States and Canada because I wanted to get as much exposure as I could to places to do residency.

And I ended up doing my residency in Providence Hospital, which is in Southfield, Michigan, and a bit of a stint in the Buffalo SUNY program as well before I graduated. When I finished, I wanted to come home to Canada because I've always felt like I wanted to practice in rural Canada, but there didn't appear to be any jobs.

So I was looking at international options like Abu Dhabi and Dubai on this international job website. And at the bottom of the list was St. Anthony, Newfoundland. And I'd never heard of it, but I knew that Newfoundland was Canadian, and I thought, what a great adventure, let's go somewhere new. So I chose to go to St. Anthony, Newfoundland.

And when I got there, in our small 2,000-person town, 11 hours away from the tertiary center, I found out that it was also the Viking landing site in North America in the year 1004, which happens to be my secondary passion. So I was totally gung ho and ended up moving there in 2015 and have been practicing there for the last almost nine years in a remote community.

But combining that with a lot of advocacy and national and international work on promoting rural medicine, both for trainees as well as for practicing general surgeons, and trying to work towards national licensure in Canada, advocating for rural medicine down in Australia, and then doing a two-year rural surgical fellowship in Scotland that I just finished in July of this past year included learning orthopedic procedures, obstetric urology, ENT, and traveling around to the remote sites in Scotland to see how they implemented rural training for their surgical trainees.

Dr. Randy Lehman: [00:03:45] What a great experience. And so I'm glad that you're so involved in advocacy, and I can see your fingerprints obviously all over ACS. And we're bringing you to the Northern Plains. It was so interesting to hear about your training program. Maybe we'll talk about that in just a little bit. But first off, I wanted to ask, as I do with most guests: Why is rural surgery special to you? You can have a job anywhere you want. What's so special about rural surgery?

Dr. Lauren Smithson: [00:04:14] Well, I grew up rural, so I fit the appropriate criteria for people who usually go back to rural communities to work. That was one thing. But I've always liked to live in the middle of nowhere and have space around me. And I've always loved the idea of being a part of a community, and I tend to find that you do that very well when you're rural.

I also did not want to be pigeonholed in my career. I like challenges, I like variety. I wanted my day to be a bit of a surprise in terms of what I would be doing. I didn't want to have to go to work and be told that I would be doing all gallbladders, all hernias. You know, as a general surgeon who did not feel the need to follow up with any fellowship, I didn't want to be a city surgeon who was focusing specifically on simple procedures—or I guess I shouldn't say simple procedures, but the basic general surgery procedures. I wanted the option to do the colorectal, I wanted to be able to do the breast oncology. I wanted to be the trauma surgeon. And when you work in a rural area and you are a bit more isolated, you tend to have that option.

Dr. Randy Lehman: [00:05:14] So from where you're at now, if you wanted to go to a referral or your patient needed to go to a referral center, how far is that and what's available there? And then also what's available at your institution in terms of your resources?

Dr. Lauren Smithson: [00:05:26] So we'll start with ours. You know, St. Anthony in Newfoundland actually has a really great medical history associated with it. So it's very well resourced at the moment for the size of the town that it works in. It usually actually serves about 15,000 people in the region, including some people on the coast of Quebec who come across to Newfoundland for their specialty care. But the town itself only has 2,000 people in it.

The hospital currently is only running about 24 to 30 beds because a lot of patients are long-term care patients. But in the past, this site was originally established in 1905 by Wilfred Grenfell, who was a missionary doctor from the UK who came over to minister basically to the deep-sea fishermen and provide them with medical care as well as proper nutrition, more social enterprise, orphanage care for children who were being abandoned, and a lot of tuberculosis in the area. So that was the origin of medicine in that region.

And then as time went on, it became a hospital that was affiliated with the province. And obviously we have socialized medicine, so we had provincial healthcare that took over. But through the time period before it became a provincial center, it was a hospital where a lot of doctors came up from the US to work and to provide specialty care. So there were a lot of Harvard doctors. And it had a very strong affiliation which was called the International Grenfell Association. And that's why it was such a prominent hospital in the region.

So we actually have pretty good history, which is why we had pretty good services when I was there or, you know, while I'm there. So we provide a lot of things. There's actually three general surgeons working there, an orthopedic surgeon, two gynecologists, an ENT surgeon, and ophthalmologists, dental. Usually there's two to three anesthesiologists at any given time, and then there's family practice and pediatrics. At one point we had an ultrasound technician who did echocardiography, so we could kind of do our preoperative testing in the region as well. So it was a very well-supplied small rural hospital.

And unfortunately, as time has gone on and the focus in the province has shifted, we're losing a lot of those services and they're not being replaced. When I started, this is what we had—internal medicine, everything was available.

So that was what we have in St. Anthony. The tertiary center, which is St. John's, Newfoundland, is a population of about 250,000 people, and that's the biggest city in the province. The second-largest city only has about 20,000 people and it has a hospital, but they also send their more serious cases to St. John's. And that is an 11-hour drive. It is a one-hour and a bit fixed-wing flight and it's a two-hour search-and-rescue helicopter flight. So it's quite a remote hospital and quite isolated.

So the services that we provide surgically are actually quite advanced, I would say. We have breast cancer care. We do send them out for stereotactic biopsies, but we don't really do breast-conserving therapy yet, though we're working towards that as the new magnetic equipment comes. We do laparoscopic colons. I was doing laparoscopic Nissen procedures. We do everything from thyroids to toenails. I think the only things we don't do are probably heart surgery and brain surgery. But the general surgeons who are working there basically cover everything that needs to be done.

Dr. Randy Lehman: [00:09:03] Yeah. So for me, you know, rural—I had a mentor of mine who was told by a mentor of his, "You can do carotids or C-sections, but not both." So either you're in a rural enough place that you can do some of this subspecialty thing, or you're in a big enough place where you can do the breadth of general surgery, which may include Whipples and pancreas surgery, liver resection, esophagectomy, carotids. This is at that time. But if you're in that place, then you're going to have a for-sure OB-GYN and you're going to have all these other subspecialists, so you probably won't do as much of that. Now there's—that's not a rule, it's just a general guideline. So you're at a place where it sounds like you don't have a radiologist that would do a wire localization for you?

Dr. Lauren Smithson: [00:09:46] No, no radiologists. The radiology reads come from the tertiary center.

Dr. Randy Lehman: [00:09:50] Okay.

Dr. Lauren Smithson: [00:09:51] But what we did recently start is having a magnetic seed placement, so I would inject that. And so we were able to do sentinel nodes with—because obviously we didn't have the facility to use the gamma radiation either. So we were doing sentinel nodes with just methylene blue, having pre-warned the patients that this is not ideal, that your best option for care is the tertiary center, that there's a higher likelihood of axillary dissections because these nodes may be missed. And so instead of having two methods of finding your sentinel node, we were only using methylene blue and we had pretty good results with that. But obviously it's not standard of care. It was, however, what patients would choose because most people would choose that over traveling. So we were doing that for a majority of my practice, but then recently started doing the additional probe testing with the magnetic seed. So it was great.

Dr. Randy Lehman: [00:10:51] And then the other question I had, ICU-wise, do you guys have an ICU and who runs it?

Dr. Lauren Smithson: [00:10:56] So we do. We have a five-bed ICU, and when I started, we had some really highly competent nurses and we still have really good nursing team now, although a lot of the old guard retired during COVID. So we have a lot of new faces working in the ICU, and that does decrease during the summer when we have summer slowdowns. And our patients, we don't have as much ICU care basically because of staffing reasons. The ICU is run by an in-house respiratory therapist who lives in the region, is from the region, and probably doesn't intend to leave.

But when he does, we may no longer have respiratory therapy taking care of our ventilators. So anesthesia does a lot of it. However, with our surgical training, unlike the UK, it's usually the surgeons who are doing the ICU care and the trauma critical care components rather than the anesthesiologists, which is how the model works in the UK. So we have the ability to trade off. We have specialists, we have intensivists or anesthesiologists who can do the critical care, and then we have the surgeons who can do some critical care. So we kind of trade, and our call schedule sort of alternates who's covering ICU based on who's on call.

Dr. Randy Lehman: [00:12:06] Gotcha. So you described what was there when you came, and then you said there's been some things that have been left that have kind of disappeared and not been replaced. My next question—you also said you went to Scotland and did this training. So I also trained at Mayo Clinic in the rural surgery track, and I had dedicated rotations as a fourth-year in Ortho, Urology, OB-GYN, Plastics, and ENT. And I think it very much depends on the place that you're at, what of that you could use. But my question is, have you lost any of those specialties specifically? And have you been able to bring in some of the subspecialty work as a result of your fellowship training?

Dr. Lauren Smithson: [00:12:46] Well, yeah, I've been doing—I did a few of the C-sections, but we still do have gynecology in place. So it's kind of more like I was just keeping my skills up rather than helping to take over a service that was lost.

Urology, we only have a visiting urologist who comes every couple of months or every three months or so. We did do a lot of urology in our practice as well, which was quite common in the rural and remote areas in the UK. Up in Shetland, the general surgeons there do prostate biopsies, ultrasound-guided prostate biopsies, they do cystoscopies, they do bladder stone removal and things like that. Obviously if it gets more complicated, it goes out, but that's a flight to Aberdeen. So that was a big deal.

They would do a lot of the flow interpretation for lower intestinal tract or lower urinary tract symptoms and stuff like that in clinic, which was new for me because I've never really looked at that before too. So that was a pretty interesting experience. But I would say that we probably don't do as much urology as I was seeing in the rural areas in my fellowship. But we do do some of the urology and especially the follow-up from when the urologists are visiting. However, if there were any cancer problems or any other issues, they would be going down to the tertiary center.

In terms of other things that were lost, we lost internal medicine. So we have a visiting internist who comes from another province every once in a while, and sometimes we have locums and sometimes we don't. But what it really truly affects is a lot of pre-operative assessments. When you don't have echocardiography, you don't have stress testing—we can do treadmill stress testing and EKGs, but now we don't have echo and we don't have dobutamine stress tests. So the patients have to go out for any cardiac workup. Losing internal medicine was huge because they also were quite helpful with the more severe medical problems. And so now the ICU for the medical patients is really being run by GPs.

Dr. Randy Lehman: [00:14:45] Let's get into the "how I do it" section, and this is something where it may be for all levels of trainees. So there might be medical students, residents, early attendings listening to this, and it might just be fun for seasoned attendings to listen. But I'm really wanting—my goal with the segment is to dive in deep on fine points of the technical aspects of the surgery and how exactly you do it. There's not, as you know, not a right or wrong way on how to do it. But if, say, you've never done it before, you know, then it's a useful thing to actually talk through step by step. Since we were talking about breast surgery and you do mastectomies as part of your practice, we could talk about mastectomy and sentinel node, which we've already briefly discussed. Let's go briefly through the workup of getting the patient to the operating room, but maybe not dwell on it, and then get ourselves quickly to where we've got a patient prepped and ready.

Dr. Lauren Smithson: [00:15:36] Yeah, for sure. I think it's interesting—I think it's really important to point out when you're talking about rural surgery that you have to be much more flexible in the way that you're going to deal with the situation. Because you as a surgeon can know what the standard of care is and know how you want to approach things, but that's not always what's going to happen when you see a patient for the first time or you're working them up.

We had to send our patients out if we wanted to do neo-stereotactics. So stereotactic biopsy for anything smaller than a centimeter that we couldn't hit with an ultrasound-guided core biopsy would have to go five hours away. And then we had cross-hospital politics where people would not want to do a biopsy based on the read of another radiologist from another hospital. So we'd have to put in a consult form—it was messy, but it was the best option for patients with small breast cancers.

However, with our patients, if we gave them the option of going to town, which required getting a place to stay, taking time off work, finding someone to take care of your kids, paying for a hospital, paying for the drive—it was hard for patients to go down to town to have things done. But if we gave them the option between having breast-conserving therapy and having to have six weeks of radiation in town, or doing a mastectomy and most likely not having to have the radiation, almost everybody chose mastectomy, even for stage one cancers.

So that meant that we were doing a lot of mastectomies in the region. And like I said earlier, early on, most of what we were doing was just methylene blue and finding sentinel nodes that way. We have an in-house pathologist, which he's been there for quite some time, so that was quite fortunate. So when frozen sections were a thing for nodes, we were doing them. Only now we've kind of transitioned based on a lot of the papers that suggested that you could do radiation for positive lymph nodes in the axilla and such. Now we don't do the frozen sections quite so much. If we have to go back and do an axillary clearance, we'll do it that way.

But we also recently introduced Magseed into our practice. And so now having the Magseed really does make a difference in terms of being able to localize a sentinel node with two different types of materials. Not that you need it with Magseed, but you know, for our own sake, because it was new for us, we were doing Magseed and methylene blue and we were getting really good results with that. And the surgeries were ending quicker, and we are getting good harvest and excellent pathological results.

Dr. Randy Lehman: [00:18:04] Specific questions on two of those things you talked about technically. Okay, so some surgeons aren't doing any of their own ultrasound-guided core biopsies.

Dr. Lauren Smithson: [00:18:13] Yeah.

Dr. Randy Lehman: [00:18:14] What device do you use and technically, how do you do your ultrasound-guided core biopsy?

Dr. Lauren Smithson: [00:18:22] Well, the benefit for me is that I also do a lot of thyroid biopsies. So I have a fair amount of practice using ultrasound to do a lot of my guided biopsies. Even though the thyroid is FNA and the breast is core, I'm very happy doing core biopsies without ultrasound when you can do a palpable lump. The ones that are harder when you get smaller.

So we're very particular about how we go about getting diagnosis because if you have a non-diagnostic specimen, you're really delaying somebody's care. And with a suspected cancer, that's not ideal.

So what we usually do is after you've localized a palpable mass, then you would make a mark on the skin, you would do an injection of some local anesthetic, and you would place your core biopsy through a little nick in the skin and then you would fire a handheld. So we had two options: You had the handheld core biopsy, which you would fire using the mechanism itself that just kind of pushed into the tumor and then pulled out a core. And you would take 10 of those specimens, put them on a little slip of absorbable paper and put them in formalin.

Or you could have a handheld gun which is just kind of like it pulled back with a trigger, and then you fire through the mass and you do about 10 different passes through that and make sure that you have tissue that isn't just fatty tissue before you send it off for specimen.

So that's what we would usually do if something was palpable or we thought we'd get a good specimen, but if we really didn't think that we would—if it was something suspicious for DCIS microcalcifications on a mammogram—then we would send them for stereotactics in Corner Brook, which is about a five-hour drive away. If we were in the in-between, so maybe we would be able to get a good specimen, we felt quite confident that this was accessible, then you could do it with an ultrasound.

So you place the ultrasound on top of the mass. You center the core biopsy in the same way, so the gun or the manual from the center of the ultrasound, holding the ultrasound in your left hand and firing with the right, if you're right-handed. Or you can have a technician—actually an ultrasound tech can hold the probe as well—and then you can brace the breast and fire through the lesion that you felt.

Dr. Randy Lehman: [00:20:32] How does that differ from—I hate to jump off—but thyroid FNA biopsy? So what size gauge needle are you using for that? And are you always—you're not always using ultrasound if it's a big palpable nodule as well?

Dr. Lauren Smithson: [00:20:46] Yeah, I mean with palpable nodules, I think it's just always better to use ultrasound because you can clearly see the needle going into the mass. And even then you get a lot of non-diagnostic specimens. But I use a 25-gauge needle on a 10cc syringe. So then you would have the syringe pulled out. You don't have to use lidocaine—I did. I would numb up the area because I was going to do multiple passes and it can just be a little bit uncomfortable for people.

Then I would have the ultrasound tech localize the nodule in question that had been previously read by the radiologist. And then we would make multiple passes with each needle, moving the needle up and down and trying to negatively apply pressure on the syringe so that you could draw some more cells up into the needle. And then there was a pathology technician in the room as well at the same time who would prepare the slides right on site. So then we would know if it looked like it was just clear fluid from a cystic mass or if it was actually cellular debris, so that we kind of had a better idea if we were going to be getting a positive specimen or not. So that's—but FNA is different than core biopsy.

Dr. Randy Lehman: [00:21:52] You do six of those, or how many of those do you do?

Dr. Lauren Smithson: [00:21:55] So I take three needles, and I would do multiple passes through each of the nodules with each needle. So if there were two nodules, I would do six syringes. But if there was one nodule, it would be three syringes, which is usually adequate.

Dr. Randy Lehman: [00:22:07] Okay, well, thanks for letting me dive off into that topic. And then so now you say you did a—you had a palpable mass and you did your own core biopsy, and it's positive for ductal adenocarcinoma.

And you've got discussion with the patient where you explain the sentinel node process, which we will talk about in detail here. And then the patient chooses that they want to have a mastectomy with you. And they're going to be one of your first patients you're using dual tracer on. So you go to the operating room—how do you position the patient and drape the patient and prep them for surgery? And what kind of anesthesia are you using?

Dr. Lauren Smithson: [00:22:44] So the Magseed we would also inject the night before, and you could inject longer than that. The Magseed stays in place for a while, but we usually did it because patients would be traveling to the hospital and they would arrive the day before. So we'd inject the night before. And then you don't have to massage the breast during surgery like you do with methylene blue to get it to follow the lymphatics into the axilla.

So the patient had already been injected for the Magseed for the sentinel node, and then we would position them on their back. In the surgery, you can do the positioning of the arm in multiple different ways. There's no right or wrong, and I'm not overly consistent with how I do things. Some people will actually raise the arm and have it hanging from a semi-bar over their head, and then have it hanging by the wrist so that the axilla is kind of open and loose. Some people do an arm extension. Some people rotate the shoulder backwards so that the arm is in an L shape.

But you just have to be cautious of keeping people in certain positions for long periods of time and padding areas that are going to be exposed to the table. So if you know your elbow is going to—like the Olecranon process is going to be lying on something hard, you might want to put a gel pad underneath it. I usually just do an arm extension. So I don't bend the elbow or hang the arm, and pretty much straight.

Dr. Randy Lehman: [00:24:05] Out on an armboard. But not circumferentially prepped?

Dr. Lauren Smithson: [00:24:09] I always position on an armboard.

Dr. Randy Lehman: [00:24:10] But not circumferentially prepped. And you're not using a stockinette?

Dr. Lauren Smithson: [00:24:14] No.

Dr. Randy Lehman: [00:24:15] So that you can leave the arm—

Dr. Lauren Smithson: [00:24:16] If you want to move the arm around.

Dr. Randy Lehman: [00:24:18] So most of the time you just let the arm be strapped down?

Dr. Lauren Smithson: [00:24:21] Yeah, I do, because I don't usually manipulate it. And I've never had any difficulty finding nodes that way.

Dr. Randy Lehman: [00:24:26] Yeah. And one more question about the Magseed. So when you inject, is it retroareolar location?

Dr. Lauren Smithson: [00:24:31] So actually the subareolar space, so the needle actually goes in. And then you'll find—like just as if you were injecting into the TAP plane, if you were doing a TAP block, for example—you'll find that the injector goes in easily into the space and spreads out. So you can feel the right place to have that going, as opposed to, you know, in a retroareolar or too deep or anything like that, where you're going to feel the pressure as it fills up. It just fills up really easily in the subareolar space.

Dr. Randy Lehman: [00:24:59] Okay.

Dr. Lauren Smithson: [00:25:00] It's about 1cc worth of volume that goes in.

Dr. Randy Lehman: [00:25:04] Okay. So then you've got them prepped and you timed out. And so do you mark with a marking pen your incisions, and then how do you make your incisions?

Dr. Lauren Smithson: [00:25:14] Yeah, so I usually mark out the axilla. So I do the pectoralis, I do the latissimus dorsi. I draw the line through where the axillary vein will be. And then I actually draw where the hair-bearing area is at the bottom. And usually where there's a cross of those lines, that's where I'm going to want to make my incision.

But the nice thing about using Magseed is that the magnetometer—because that's a great word to say on television or podcast, whatever, it's not going to come out right the next time I say it. Anyway, you do that before you even make an incision. So first you assess the level of the response to the instrument on the skin. And so you kind of know if you're in the right area or which direction you need to go with your incision.

And so you do that first before you do anything else, before you even prep the patient. And then you kind of mark it with a skin marker and you go from there. So that's where your incision will be. And that's changed my practice a bit because I used to do it more by landmarking. And now I do a combination of landmarking and see if my landmarks meet the same place where the magnetic tracer is going to show to be the most likely to find a—

Dr. Randy Lehman: [00:26:20] A node, usually probably anterior and inferior. Right in the axilla.

Dr. Lauren Smithson: [00:26:24] Yeah.

Dr. Randy Lehman: [00:26:25] A low kind of incision. Yeah, sure.

Dr. Lauren Smithson: [00:26:27] Yeah, yeah. So it goes right—usually it's right along that hair-bearing line.

Dr. Randy Lehman: [00:26:31] Right.

Dr. Lauren Smithson: [00:26:31] To be honest, yeah. So once we've done all that and then we prep the patient, I don't separate the axilla from the breast. I keep both in the same field, but definitely down the midline, a little bit off the midline to allow more space in my field, and then up to the clavicular line as well. And I kind of do a triangular thing, so I'm coming down along the shoulder and then around the arm to kind of leave that space open. And then obviously, the last sterile towel is almost underneath the patient in a way so that the axilla is in a sterile space and so is the breast.

In terms of marking for your breast incision, because I do all my markings first before we start, you want to include your biopsy site into your incision whenever you're doing breast surgery. Hopefully if you've had a biopsy that you've done, you've kept it to an area where you can minimize the amount of tissue you need to resect. And that's also different based on the size and shape and ptosis of the breast as well. So if you have a very large breast, you might get away with a bigger incision. If you have a smaller breast, you might want to try to do something that's more like breast conserving, so skin-sparing surgeries to make it easier for reconstruction afterwards.

These are all discussions you would have with the patient beforehand. There's actually a really good paragraph or chapter in the Rural Surgery book by Dr. Halverson, edited by Dr. Halverson, that goes through different skin-sparing techniques for rural surgeons for breast surgery, and that has images and everything about different kinds of incisions. So inframammary, or around the nipple, or whatever you're choosing to do.

Dr. Randy Lehman: [00:28:08] Do you have a relationship with a plastic surgeon that you like to use? And how many of your patients end up going? Do you recommend it to everybody? And then how many of them end up going and talking to somebody?

Dr. Lauren Smithson: [00:28:17] Yeah, because again, you're back to the same situation of travel. So the plastic surgeons are in St. John's. I've been working to try to get plastic surgeons up to St. Anthony to do clinics and to do a couple of operative days. It didn't work out in the long run because people are quite busy. But yeah, we do referrals to the plastic surgeons in town.

Dr. Randy Lehman: [00:28:38] Can you just call them and talk to them? I mean, do you have that kind of relationship?

Dr. Lauren Smithson: [00:28:42] Or I'll send an email or I'll send a referral. But yeah, typically speaking, that's how we work.

Dr. Randy Lehman: [00:28:47] And then some of the patients, no doubt they're going to decline reconstruction and you're going to—those patients are going to get simple mastectomies. Is that pretty much?

Dr. Lauren Smithson: [00:28:56] Yeah, yeah, it's a simple—well, it's a modified radical mastectomy technically, or that's for the axillary clearance. But then you're doing a mastectomy with a sentinel lymph node biopsy for a lot of them.

Dr. Randy Lehman: [00:29:09] But then if they say to you pre-op, "I don't want to go see a plastic surgeon pre-op, but I might want reconstruction," then what is the operation of choice that you're doing?

Dr. Lauren Smithson: [00:29:21] I usually do skin-sparing mastectomies where I can. So try to keep the incision around the nipple-areolar complex as small as possible and then tunnel up—like, you know, you make your flaps all the way up and you're working in a much smaller space. It also leaves better skin bridges if you have an incision for your axillary node and you have an incision for your breast, rather than having one giant incision that includes both, which is another way of doing it. But I try to keep my incisions fairly small when I operate.

Dr. Randy Lehman: [00:29:48] Okay. And there's no immediate placement of a tissue expander or anything?

Dr. Lauren Smithson: [00:29:52] So that's an interesting question because oncoplastic breast surgery is another component of it, and that's seen a lot in breast fellowships. But there's no reason why general surgeons can't also learn the same techniques. So you can do oncoplastic surgical techniques as a course. You could do some work where you go out and train with a plastic surgeon who does oncoplastics and you can learn those techniques and take them back to your practice for your patients.

That's not an issue whatsoever. And actually, in the UK, breast surgery has always included the oncoplastic component. So the plastic surgery, reconstruction and reduction of the opposite breast or augmentation, placement of expanders—that all fell in the purview of the breast surgeon, rather than a plastic surgeon and a breast surgeon working together.

So it's kind of interesting. It basically means that you can tailor your practice to do whatever it is that you want to do. I have not done any placement of expanders apart from doing rotations. So I don't do my own placement of expanders. I'd rather patients had a chance to kind of heal before, and most people don't choose to have any reconstruction anyway. So the number of times that I would do it would be very limited.

Dr. Randy Lehman: [00:31:05] So I would love to walk through that skin-sparing mastectomy in a little bit more detail. So how long is your incision? Your nipple-areolar complex—but you're getting all the way around the areola. And then sometimes you're using extender extensions on either side?

Dr. Lauren Smithson: [00:31:22] Yes. You have to include your biopsy site. So the skin where the needle went through for your core biopsy, it has to be included in your incision.

Dr. Randy Lehman: [00:31:30] That crossing your mind when you do the biopsy, then? When I do my own biopsies—

Dr. Lauren Smithson: [00:31:34] Yes. Which always makes it different when someone else does your biopsy for you.

Dr. Randy Lehman: [00:31:37] Yeah. It's like doing your own colonoscopy. Right. So then you're dissecting the breast all the way around circumferentially before you come underneath. And you're coming down to the—like to the muscular fascia in each direction first?

Dr. Lauren Smithson: [00:31:50] So it's still pretty standard. Like, when you're doing the mastectomy, you follow the rules, which is basically to dissect superiorly to the clavicle, medially to the sternum, laterally to the edge of the pectoralis, and then inferiorly to the inframammary fold. So that whole area has to be removed in order to take all of the breast tissue out. Okay. You keep your flap less than a centimeter. So people suggest, you know, point or like 0.5 to 1. But you want to limit how thin you make it so that you're not buttonholing or creating skin-necrosis in your flaps. That's what I generally tend to do, but I think that there's a lot of change that's still going on in terms of literature and practice, in terms of the thickness of the flap, and then the likelihood of leaving residual cancer and the likelihood of not.

So tips for doing that: Always keeping your hands on the flap, making sure that you're not—you're pinching the flap, you're making sure that flap isn't getting too thin or too thick. So that's one way of doing it, is manual palpation for each of the flaps that you're working on. The other way to do it is that there actually is a plane that separates the breast tissue from the fat tissue. And if you can find that plane, it should just easily dissect down.

So a lot of retraction and counter-retraction when you're doing your flaps. And that really allows those tissues to separate on their own. Always more difficult when you're dealing with the elderly who have much different, much finer, much more fragile tissue. And also different with smokers, where you won't find those planes easily because everything is generally stuck to itself. And then obviously, inflammatory reactions caused by the cancers themselves changes the way that the flap planes work.

But if you can find that flap—and one of the tricks that a surgeon that I worked with from South Africa taught me was to actually use a dilator to create the flap, because a blunt dilator will not go through the skin. It will not go through any of the tissue, but it will go through the plane. So you take that dilator, you retract the breast tissue down, and you punch that dilator through the fatty tissue and into the plane that separates the breast tissue from the fat tissue. And that actually gives you something really easy to work with.

And then you're just using cautery to kind of zip through whatever small attachments are left, and the breast falls away from the skin, and you end up with a perfect flap. So there's a few different ways to do it. It's just a matter of figuring out which one works for you. But to do that circumferentially, take the breast from wherever it's most easy to access that clavi-pectoralis fascia and separate the fascia and the breast off of the chest muscle.

Dr. Randy Lehman: [00:34:38] And so are your assistants holding an Army-Navy or—I mean, I know you're handling the flaps.

Dr. Lauren Smithson: [00:34:43] You'll change up what you're using for retraction as your flaps get larger. So usually I start with cat's-paws—so they're really tiny little three-pronged hooks, or even skin hooks for that matter, for retraction. And you retract straight up. And then you just use your own hand with a sponge to create counter-traction. Right. And then you can find your plane. Once they're done with the cat's-paws or the hooks, and that's not big enough, then you can go to the larger hooked retractors, or you can use Army-Navys, or you can use Richardsons.

Dr. Randy Lehman: [00:35:17] Have you had the opportunity to try out any of those lighted retractors? Which lighted retractors? Okay. I'm imagining down in—

Dr. Lauren Smithson: [00:35:23] I use the lighted retractor when I'm in somebody's pelvis, but I haven't really needed it for being in someone's breast tissue.

Dr. Randy Lehman: [00:35:29] Sure. All right, very good. And so then you take the tissue off of the—do you take the pectoralis fascia with the breast, or do you take it right off the pectoralis?

Dr. Lauren Smithson: [00:35:40] Yes, usually try to incorporate the fascia, because then, you know, if the fascia has been compromised by the tumor—so then obviously chest wall involvement is one reason for radiation after a mastectomy. So you'd want to know that. So I try to include that in my resection margin.

Dr. Randy Lehman: [00:35:57] Yep. Love it. And then when you're going into—so after you've injected the blue dye, we kind of missed that. But you injected that after they're asleep?

Dr. Lauren Smithson: [00:36:04] In the retroareolar space with your Magseed, which Magseed says you don't have to. But we were just—because we wanted to see if we could peg those nodes and get the blue dye. It was interesting because some of the nodes that were positive with the Magseed were not blue. So I guess methylene blue just didn't travel down those channels.

It was kind of—we just wanted to see what we were getting because it was such a new technology for us. But if you were using methylene blue and gamma-radiation for it, then you inject into the subareolar space, or you inject in four quadrants around the tumor, and then you gently massage that for about five to ten minutes before you do your prep and before you do your incision. I usually did it and left it and would go out and scrub and get ready so that it had time to migrate.

Dr. Randy Lehman: [00:36:54] Okay. Well, I think that's probably enough talking to details about your breast operation for the sake of trainees and all kinds of people that are interested in rural surgery. One little section that—

Dr. Lauren Smithson: [00:37:07] Don't forget to mark your specimen! So you have your left, your laterals and your medials and your superior margins when we're talking—

Dr. Randy Lehman: [00:37:14] So this is your—

Dr. Lauren Smithson: [00:37:15] Your breast—

Dr. Randy Lehman: [00:37:15] Your breast specimen. When you're taking your mastectomy, you've got the skin on there, so you've got an anterior marking, but you're doing—what do you do? Like long, short, superior? You know, it's orientation. It's got to be the life. Yeah, exactly.

Okay, great. So the next section of our show is called "Financial Corner," and I just am interested in the financial literacy piece and financial independence for physicians. Of course, in Canada, you guys are on socialized salaried medicine, right?

Dr. Lauren Smithson: [00:37:46] Not everyone is. It should—like, it does seem like that would be the case, right? Like, you've got a national healthcare system, so obviously you're getting salaried from your hospital. But it's actually more complicated than that. We could get into those, but I don't think anybody really cares about why the Medical Act of 1966 resulted in people being privatized. Doctors who have to bill—anyway, that's another whole story. But some people are salaried from their hospital system, and some people can bill. And what you do is you bill the government just the same way that you would bill an insurance company. It's actually very similar.

Dr. Randy Lehman: [00:38:18] Sure. So maybe instead of diving into that, do you have any tips for personal finance? So it doesn't really matter what your income is—if you're spending every dime of your paycheck, then you're essentially not making any progress. Have you had the ability to make some progress in your life? And any tips to your former self, like 10, 20 years ago that you would say, do or don't do this? Or how to manage loans, anything, anything of that nature?

Dr. Lauren Smithson: [00:38:47] So I got some really good—I think there was some really good advice coming out of residency. I mean, number one, people said don't buy a new house right away. You know, like, save your money. It's kind of hard when you move out of residency and finally you feel like you're actually making a proper paycheck. And you're like, "I'm going to be fine. I'll get a mortgage, it'll all be good. I'll get a new car, I'll get a new house." And you tend to jump into these things because all of a sudden your paycheck just looks so good, right? But it's better to hold off, wait, build up a little bit of credit and capital before you jump into those things. I would suggest—I certainly didn't jump into buying a house. I lived in rented accommodation after I graduated and I drove an old beater until it died. So I still drive an old beater. But that has more to do with, you know, environmental reasons than not. But I don't like waste.

Dr. Randy Lehman: [00:39:39] What did you do with your money if you weren't spending it on these luxury spending items, or were you just doing more things?

Dr. Lauren Smithson: [00:39:45] Yeah, that's an interesting thing. Another thing—so my friends and I decided to open a brewery in a very small remote town in the middle of nowhere during COVID. So I would not suggest that as an appropriate use of money. I ended up buying a very large 12,500-square-foot derelict clock tower that had been there since 1935. And then we invested further in buying new brewing equipment, updating the place and putting in a tap room. And we own Ragnarok Northern Brewing Company in St. Anthony, Newfoundland. So you can look it up online if you wish.

Dr. Randy Lehman: [00:40:22] I think we can put the link into the show notes. Probably there's some people I'm sure that are going to be interested.

Dr. Lauren Smithson: [00:40:27] Ragnarokbrewing.com—and it was a great adventure. I'm really glad that we did do it. But financially speaking, I just said don't buy a house and I invested in a brewery. So, you know, it's kind of two-faced to say that.

But I think people do really well, you know, as long as you're aware of the fact that this is a career that doesn't offer you a pension. Right? You have a large debt to pay off coming out of medical school—most of us do, especially Caribbean grads. And then you have to live and you have to, you know, pay for kids or school or whatever it is that you choose to do. And then you have to have a pension for yourself for when you're done.

Because, I mean, some of us might want to work until we fall over at the table, but most of us don't. You know, like you want this job to have a lifespan and you want to be able to walk away from it when you're still healthy enough to do the things that you enjoy outside of medicine. So keeping those things in mind, it's better to focus your investments on paying yourself first. So invest in RRSPs or whatever they use in the States to help you set up for a pension for the future and pay that first. Then work on your loans, and then if you have money left over for the fun stuff, then do the fun stuff.

Dr. Randy Lehman: [00:41:47] That's Personal Finance 101. Very beautiful thoughts there. So I wish it worked.

Dr. Lauren Smithson: [00:41:52] But anyway, it's good advice.

Dr. Randy Lehman: [00:41:56] Do as I say, not as I do.

Dr. Lauren Smithson: [00:41:58] Exactly, 100%.

Dr. Randy Lehman: [00:41:59] The next section of the show is called "Classic Rural Surgery." So do you have an experience where you could—it sounds like you have a whole host of them, but one particular case that stands out. It's like, this is classic rural surgery. Nobody around. Normally, the ivory tower general surgeon would not need to be anywhere near this case, but here I am.

Dr. Lauren Smithson: [00:42:23] In any case—I think in any situation, any rural surgeon that you talk to, it will come in waves of things that happen to you that you're like, "Okay, well, I'm covering call by myself in a rural area in the winter for the next 10 days. What could possibly go wrong?" Everything. Everything does go wrong in that situation. And then when there's three people around and everyone's twiddling their thumbs and you've got a full complement of nursing staff, nothing happens. Right?

So I think probably the first year that I was working, I was alone at Christmas for a 10-day stint. And it started out with a necrotizing pancreatitis who I had to—he had 100% RANSON criteria, so 100% mortality rate. But did get him down to the tertiary center. We stabilized him, we got him on oxygen, we made sure that he was properly hydrated, and it was gallstone pancreatitis.

Got him down to the tertiary center. He did live. He lived in the hospital for a year. He was in ICU for something like five months, and then he was in rehab for the seven months after he got discharged from the hospital. Finally got home.

So he came in, and then that was followed by a woman who'd gotten in a car accident and been hit in the face with her husband's oxygen tank. So she had shredded her entire face, and I had to sew that back together in the middle of the night. And then a man showed up the next day with a goose bone in his rectum. I had a lot of bones in rectums. And it actually was—you think that it can't go all the way through your GI system, but I actually think that it can. I don't think it's going up the other way. People are eating stews with animal bones in them.

Dr. Randy Lehman: [00:44:07] How big are these goose bones?

Dr. Lauren Smithson: [00:44:09] Well, that was fairly large. I think it was probably about a 1½ to 2 inch, maybe like 5 centimeter goose bone that was sticking in his skin inside the rectum. Anyway, the GP called me from home, and at this point, I'd been doing all these overnights and I was exhausted. And she's like, "He's got an abscess." And I was like, "My gosh, can't you just take care of it?" And she's like, "No," she's like, "I can't." And I was like, "Fine." So she's like, "I got a CT scan. You can look at it if you want."

So I came in and looked at the CT scan, and it was not an abscess. It was a necrotizing pelvic infection. The whole entire pelvis was gas-gangrene. So I was like, well, the only thing you can do with this is pretend it's like an extraperitoneal rectal penetrating trauma. Which, fortunately, in my training in Buffalo and Detroit, I did actually see a few of those.

And so it was basically dealing with what was a horseshoe abscess. Cleaning out all of the black necrotic tissue in the pelvis, diverting him with a laparoscopic diverting-ostomy, and placing drains. So he had three drains. And so we just managed to get him stabilized and then transferred him to St. John's as well for his tertiary care.

But what was really interesting with his case was he came back with bilateral upper arm paralysis that turned out to be some form of Guillain-Barré that had only affected his upper limbs. So I spent a lot of his recovery time talking to neurologists, trying to figure out what had happened to this guy. And the best line was the neurologist saying to me, "I have no idea why a general surgeon is calling me about a case." That is rural medicine for you.

Dr. Randy Lehman: [00:45:52] That's perfect. Man, what a crazy 10-day stint you had. But that sounds about right. Last time I was on call, I had a fishbone in the vallecula. That was a similar deal. And my takeaway from that, for anybody who's ever going to have to deal with it, if you haven't already, is just put the patient to sleep and do a DL. I tried to fart around with the GlideScope, I tried to use numbing medication. The problem is the patient couldn't get IV access, and there were reasons why it was hard and we were trying to do that, but it's a piece of cake if you just put them to sleep, do your DL like you're putting in your breathing tube, there's the bone, and then wake them back up. Very good.

So that's classic rural surgery. And lastly, the last segment is "Resources for the Busy Rural Surgeon." And we have iPhones, our computers, our bookshelves, and then there's groups and organizations—all these different ways that we can take some resource, maybe something sitting on the back of our toilet seat. And what's the most important thing? Maybe not most important, but just one or two things that have been very useful to you that you think every rural surgeon should know about.

Dr. Lauren Smithson: [00:47:07] I would say that your number one important thing for resources is networking. I mean, you can have all of the books that you want on hand, but when the things come in that you've never seen, you've never read about, and you know there's something wrong, but you don't even know what it is, then knowing who to call and them knowing who you are is probably your most important resource.

Dr. Randy Lehman: [00:47:29] And so that's networking at your main referral center, which—

Dr. Lauren Smithson: [00:47:33] Yeah, or anywhere. Like your colleagues from when you were a resident. You know, if you have somebody who is a really good helper, trainer, mentor, you know, stay in touch—they can offer you some advice in cases. Anyone that you've met at a meeting, anybody that you have spoken to when you're doing courses, you know, anyone that you think might be able to help.

I remember I had one guy with a stage-four undiagnosed primary who we thought was probably neuroendocrine. Well, I'd met an oncologic surgeon from Montreal, which was another province away. And you know, I called him up and I said, "I've got this guy, he's young, we don't know what to do with him. Could you help take over his care or offer us some suggestions what to do?" And he was 100% responsive in terms of emailing back and forth, getting the right tests, getting this gentleman into the clinic over there, and trying to sort out what had caused a stage-four cancer in a 48-year-old. So it's really helpful.

Dr. Randy Lehman: [00:48:37] Yep. Yeah, I use resources like that all the time. I couldn't agree more. The professional isolation is what you're kind of getting at in rural surgery. And it can be kind of debilitating and intimidating for people. So don't forget that your contact list is one of your best resources.

Dr. Lauren Smithson: [00:48:55] Yeah, don't let yourself be isolated. I mean, it's something that you can feel isolated, but if you set yourself up, you don't have to be isolated, especially not in today's society.

Dr. Randy Lehman: [00:49:07] Not in 21st century, maybe back when the surgeon was establishing the Newfoundland center that you're working at now, right? And then all you could do is send a letter. Yeah, that's a problem. But are you sitting in Newfoundland right now?

Dr. Lauren Smithson: [00:49:22] Exactly.

Dr. Randy Lehman: [00:49:23] You're in Newfoundland and I'm in Ontario right now. Oh, okay.

Dr. Lauren Smithson: [00:49:26] Yeah.

Dr. Randy Lehman: [00:49:27] Well, still, I mean, this is—you're still quite a ways away and the technology is so fantastic. So anything else that you'd like to talk about or cover today, Lauren?

Dr. Lauren Smithson: [00:49:38] No, I think—I mean, anyone you're going to talk to who's a rural surgeon is going to put in a plug for rural surgery, especially at training. And I think one of the hardest things for trainees is getting program directors and trainers in academic centers to pay attention to them when they're asking to be properly trained to go out into practice after the five years, rather than having to then go on and do a fellowship or feeling that they need to do a fellowship in order to be employable.

You will be able to get the skills that you need and the resources that you need to work in a rural center by doing your five years of residency if you work towards that goal from the beginning. So if that is something that you know that you want—and I knew from medical school that that was what I wanted. I knew I didn't want to live in a city. I knew that I wanted a life that was in a community. So I knew what I needed to do to get there.

And it's actually why I was in two residency programs. So I went to Buffalo first, and it was a large city center that was focused on large city practice, and there was a lot of trauma, which was really good for me, but I wanted to be in a community program.

So I transferred into a community program in Detroit in order to get more autonomy and to learn to operate on my own, as opposed to having multiple people in the operating room all the time and always working with a fellow, always working with a lead surgeon. So if you know what it is that you want, you need to work really hard with your program director in a program that is focused on rural training in order to get the skill set that you need. But you can walk out of a five-year surgical residency program and operate and be very good at what you do.

Dr. Randy Lehman: [00:51:19] You sort of described right there, if you're in the middle of your program getting good training in one way, but you want something slightly different, and you did a pivot. That's interesting. But what might be better is matching into that program in the first place. And so talk to the interviewing medical student that's going to surgery residency—what questions do they need to ask on the interview trail of the programs to ensure that they get the kind of training you're describing?

Dr. Lauren Smithson: [00:51:47] Well, you know, that's a good question. Number one, there are a few good resources that have come out. Paper written by Isolina Rossi, as well as the ACS website will show certain programs that have rural track. Those are really good programs to talk about—or to talk to and to try to go to those programs to do your residency. In terms of the other thing you said like, well, here's—

Dr. Randy Lehman: [00:52:15] Let me give you an example. I went to a program, a community program where they were bragging about how many cases they did—1,600 average graduating. And they said they have to stop logging their cases towards the end of their training or else they'd be under the microscope by the ACGME. And so if I asked a few more questions and then I found out—actually I said, "Well, how many pancreas cases did you do and how many esophagus and liver cases did you do?" And then you find out that they're actually double and triple scrubbing on the Whipples and counting them and just getting five enough to graduate.

Right, and that's—I mean, yeah, they came out and they could crank out the hernias and gallbladders no problem. But it was city bread-and-butter general surgery. And that was just high volume all the time of that. And so they can do their ports and their hernias and their gallbladders, and that's much different than what I got, which was a lot—I mean, I had 19 pancreas and 19 liver. And that was nothing that I did as an intern or anything like that. Those were all in the first assist. Those are like, it was me and a staff and there was no fellow in the room, and I didn't count anything that wasn't legit.

And then I still managed to graduate with 1,600 cases with COVID knocking out the last three months of my training, and I still got all the extra—well, the nice part about my training was I was able to be at the ivory tower in Rochester, see the high-level stuff, but then kick out to the Mayo Clinic health system where there's no competing trainee. And then I was able to get high volume of that stuff that the community program was offering at the same time and then also had the subspecialty things. So I was very happy with my training. I don't think I could have been better prepared for the job that I got.

I know there's other programs out there like that. And so I guess my encouragement to medical students is ask those tough questions. And I don't know if you'll get the right answer from the program directors as much as you'll get it from the residents, would you say?

Dr. Lauren Smithson: [00:54:31] Yeah, the other residents are very helpful resource too. Reputation—program reputations are quite important when you're going forward. I think where it does fall down is for residents who have a little bit less freedom of choice, or I should say medical students. So Caribbean grads will always have a tougher time—at least hopefully not always, I said, but currently probably will have a few less interviews, a few less, you know, a little bit less freedom of choice. So in that case, you may not really be able to choose the program that you want to go into rural surgery.

But when you're in it, try to work with your program director to make it what you want. Like, be very clear about your goals, be very clear about what you'd like to achieve, how you can achieve it, and try to establish electives, if your program allows for that, that will provide you with some additional endoscopy if you're going to an endoscopy-heavy area or will let you do an ENT or an orthopedic rotation, if those are relevant.

And then obviously foreign grads are also going to have a limited amount of exposure. So people who are on a visa, like Canadians or foreign nationals coming in—those people have a little bit more difficulty getting into programs, so they may have to find an alternate way of doing it. But you are right: getting information from the residents and the staff about what that program has to offer is quite important during the interview trail, no matter where.

Dr. Randy Lehman: [00:56:05] You end up, more than almost anything in the world, the mantra that "you get out of it what you put into it" is very, very true for general surgery residency. And rich kind of get richer. If you start and you're eager as an intern and you get your hands busy and you're practicing at home and you're tying your knots down inside of a coffee can and then put that down inside of your washing machine and you're tying in a hole, you're working on your skills, it's going to come back to you as a two, three, and then when you're coming out as a four and a five and you've got that reputation that the attendings all trust you, then it's that next level autonomy. So the little things that you do early on feeds to this skill and confidence and quality of training later on, too. So, anyway, thanks for touching on that a little bit.

Dr. Lauren Smithson: [00:56:55] Good.

Dr. Randy Lehman: [00:56:55] All right. Well, I really appreciate the chair of the ACS Advisory Council for Rural Surgeons coming on two months postpartum and taking time out to speak with us at the Rural American Surgeon podcast. I really appreciate it. I look forward to seeing you at some of the national meetings and everything and just keep up the good work with everything you've been doing. Thanks a lot for it.

Dr. Lauren Smithson: [00:57:18] Thank you so much for having me. It was really a pleasure. I really believe in what I do, and I really think that being a rural surgeon is a great life. And you not only have a great life, you can have a pretty financial or pretty successful career doing a bunch of different things and getting involved at the national and international level. So never feel like you're going to be limited being a rural surgeon because if anything, it just opens up your opportunities more.

Dr. Randy Lehman: [00:57:42] No doubt. And thank you to the listeners. We'll see you next time at the Rural American Surgeon podcast. Take care.