Episode 6

PAs and the Power of Collaborative Care

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

Welcome back to the Rural American Surgeon. This is a unique episode. We get a special place to record. It seems like we're in the backwoods of northern Wisconsin. However, we're on the set of Area Community Theater in Tomah, and my guest today is a PA, Jerry Fushianes. He's going to talk to you about how you could implement a PA or nurse practitioner into your practice. We'll see you on the show.

Welcome back to another episode of the Rural American Surgeon. I have with me today Jerry Fushianes, a PA that works in Tomah, Wisconsin. I have some personal experience working with him, and thanks a lot for joining the show, Jerry.

Jerry Fushianes: [00:01:26] Absolutely. Thank you for having me.

Dr. Randy Lehman: [00:01:27] And thanks for this awesome set that we have behind us as well. So, it might look like we're in a cabin in the northern backwoods of Wisconsin; however, we're actually on the set of the upcoming play at Area Community Theater that Jerry is directing. The show is called what, and what's it about?

Jerry Fushianes: [00:01:45] Well, it's Escanaba in the Moonlight. It's a Jack Daniels comedy. Escanaba is a city in northern Michigan, and they really do think they're from Wisconsin there. But it's a comedy about deer hunters and aliens, and it's a pretty funny show.

Dr. Randy Lehman: [00:01:58] Can't wait. I think I might have to make the three-state trek just to come see the show in a couple of weeks. Thanks for having us here. This is great lighting and a fantastic place for us to record.

We're going to stick to mostly the usual script, but Jerry has an interesting model that he uses where the PAs and nurse practitioners are working as hospitalists, doing some clinic work, wound care, and assisting in surgeries with multiple surgical specialties. I think this will be valuable information for a practicing rural surgeon who might be interested in starting that sort of program. I can also mention how, in Indiana, I’m using my nurse practitioner, who’s been a lifesaver for me as well.

We'll get into that in a minute, but first, let's introduce Jerry. Jerry grew up and trained in Detroit. He was originally a paramedic and then went to PA school. Tell me about the transition from PA school to primary care. How did you find yourself in rural Wisconsin?

Jerry Fushianes: [00:03:01] Well, it's kind of an interesting story. I guess everyone has their “how do I pay my student loan” story, but mine was unique. Prior to 9/11, I had joined the Army Reserve under the Health Loan Repayment Program in hopes that I could get my student loans taken care of. Then 9/11 happened, and everything changed.

I was in family practice for a few years, and then I was sent to Fort McCoy in central Wisconsin during Operation Enduring Freedom. The thing that my family and I noticed was that a small community was a lot more family-friendly. We felt this would be a better place for us to stay, so after the deployment, we decided to settle here in Tomah.

Dr. Randy Lehman: [00:03:44] Yeah, so this kind of brings us into why I love rural surgery.

Dr. Randy Lehman: [00:03:52] So there's a ton of ways to answer that question.

Jerry Fushianes: [00:03:52] Yeah.

Dr. Randy Lehman: [00:03:52] One can be the practice itself. Two can be the people, the pressures, the micromanagement in the city by the hospital corporate administration, which may not be as burdensome in rural America. There are reasons not to love it: professional isolation, resource limitations. So take that where you want. But if you had to pick a few of those things—like exactly why did you choose? You said it was about your family and that this is a great environment, and I agree. But what other things do you love about rural practice?

Jerry Fushianes: [00:04:25] You know, I think it's kind of a... maybe it's just unique to me. But what I found different—and that I learned to really respect—was accountability. Practicing in a small community, you're going to run into these people again. They're going to see you, and your reputation and your relationship with them… you don't get to hide.

So it… I want to say that we treat everybody wonderfully, but it does weigh on you that I'm gonna—I'm gonna be seen again, and I can't just blend into the background. They're gonna know who I am. So it did—it made me feel that I needed to just do a little bit better. And truly, that clearly made me a better PA.

Dr. Randy Lehman: [00:05:06] I love that. And the reason I'm laughing and smiling is it's not the first time I've heard exactly what you're saying. So this is… welcome to the echo chamber, like I said.

Rather than doing how I do it, with this episode, we're going to talk about how I do it if I want to set up a successful program using—we'll call them advanced practice providers—because nurse practitioners and PAs both can fill this role. First, tell me, how did you start here in the role? How did it change over time? Where are you at now? And then maybe I'll pepper in some specific questions.

Jerry Fushianes: [00:05:41] Well, in starting out here, the thing was, when I was on active duty, I first had the chance to walk through the hospital that I worked for. I remember the HR person walking me through, and I was looking around going, "Boy, I should probably moonlight while I'm out here."

"Oh, we would never hire a PA. You know, we're physician-driven." I figured, challenge accepted. So I kept hammering them and being persistent, and eventually, I was given a part-time weekend job in the ER. On Saturday mornings, I would come in and help them out. That eventually grew and grew.

I spent 10 years in the ER, and we were right at that growth phase where we were moving out of the current hospital into a larger one. We realized there was going to be a surge—there always is when you go from a smaller facility to a new one. There's going to be more patients. I don’t know why, but it seems to be true.

So we were trying to plan in advance. One of the things that happens is that physicians who work in our facility generally work for one of the larger hospitals but are on staff with us. Our PAs and nurse practitioners, who work for our facility, had the unique opportunity to be the conduit between those physicians—who might not be here every day but provide a valuable service—and the local team. They may not know all the nuances, like, "Who do I call for this?" or "How do I handle this?"

So the PAs, for lack of a better term—and I apologize to my nurse practitioner colleagues because I know this always offends—the mid-level providers, or associate providers, fill that role. What we’ve started to think is, what if we, because PAs are uniquely trained across specialties—we're not trained in one thing; we're trained to duplicate services for the physicians we work with.

Jerry Fushianes: So today, I could be working in general surgery. Tomorrow, Thursday, I could be in the ER, but I'm still providing the same service. I'm just providing it for a different licensed physician to match their practice style.

So we thought, what if we took that model and applied it to how all of our surgery works? In essence, I could follow a patient from the ER to admission, to the OR, back to the floor, and finally to discharge—allowing the physicians to focus on their specialties while the associate provider focuses on the overall care.

For example, this patient came through with these comorbidities. How do we ensure follow-up care? How do we make sure that if they have a question after discharge, it’s answered in the way the physician would want? This is where we saw the value of developing a strong associate provider program. It makes it easier for physicians to come out here, knowing they can lean on associate providers to fill those gaps.

That’s one of the most frustrating things for a locum, I think—coming in and trying to figure out, “How do you guys do this?”

Dr. Randy Lehman: [00:08:34] Yeah. And then there are multiple state barriers, figuring out pre-op orders the first few times, post-op orders, follow-ups—all that stuff is very painful until you get it hammered out. It’s still painful.

Jerry Fushianes: [00:08:50] Sure. When we get a locum here, one of the things I hear about our facility is that we really try to make it better for them because we want them to come back. And we usually do get a lot of them to return because we’re able to fill that gap.

In other places, locums might just show up and be told, “Well, you’re getting paid premium dollars. Figure it out.” We’d rather avoid that because when we do, patients get better care.

Dr. Randy Lehman: [00:09:15] Sure. Maybe I should tell the audience what I’ve been able to do in my career so far. I’m a little over four years in, and I have an employed job in Indiana. My dream, however, was to start an independent practice in my hometown.

I did that with the permission of the hospital I was employed at, but it led to building an enterprise with $600,000 overhead and gross collections of $350,000 a year. Essentially, I was negative $20,000–$30,000 a month. That $600,000 doesn’t include paying myself anything—it was a true loss. I gut-checked it for 18–24 months and proved to myself that private practice in that model, where I was, is essentially dead in 2024.

Then, I found ways around it. I created win-wins for the community, the hospital, and myself. I contracted that business to the hospital and expanded that contract to a couple of other places.

In the middle of all this, I had extra vacation time from my W-2 job. Everyone gets all these emails about coming to the "Middle of Nowhere." Maybe this podcast will inspire some people to call a few more of those recruiters back and check out what all the fuss is about.

Jerry Fushianes: [00:10:43] I’m sensing you’re going to get a new sponsor here soon, right?

Dr. Randy Lehman: [00:10:46] Yeah. This episode brought to you by…

Dr. Randy Lehman: So anyway, I actually have a great relationship with my Locums organization. About a year out, I started going to a different town in Wisconsin that I was familiar with just because I had flown over it so many times in training. It’s on the Mississippi River, and I loved it there.

It was, you know, it just… everything has to work for you and your family at the time based on what you need and what the hospital needs. I was filling a gap while they waited for a permanent hire. I was there for about two years, off and on, during that time. Supposedly, the next guy was coming, but then, oh no, he’s not—and everything changed. When they finally did hire someone, Dr. Minus passed away. Dr. Minus was a beloved general surgeon here.

Jerry Fushianes: [00:11:51] Absolutely.

Dr. Randy Lehman: [00:11:51] Yeah. The timing just worked out because you guys had a need through the same parent organization and Locums company. They pitched it to me, asking if I’d be willing to fill the role. That was about a year ago. I’ve been coming here for a few weeks here and there, essentially using my vacation from my regular job to come up. That’s how I got to know you and this model.

I essentially cover ER call when I’m here. Locums is a great way for a surgeon interested in rural practice to dip their toe in the water. Maybe come to Tomah, Wisconsin—there’s a plug for you guys. Oh, yeah. There are organizations we’ll probably talk more about in future episodes.

Now you know my backstory and how I ended up here. My locums work is very limited—just a handful of weeks a year. I have one hospital as my primary employed position, where I’m a W-2 employee. Then I have three other hospitals in Indiana where I do 1099 contracted work. Essentially, I’ve transitioned my private practice into that model.

I think people will be interested in hearing more about this, and I’ll talk about it in other episodes. There are a lot of different ways to set up your practice, unrelated to resource limitations in critical access settings. You have a patient in front of you with a condition, and it’s not about the city or the one-to-one patient—it’s about how you structure your practice. We’ll talk more about that as we go on.

But now, as we shift back to what you’ve been able to do here, what does an average week look like for you in Tomah, Wisconsin?

Jerry Fushianes: [00:14:08] Well, surgically, as a critical access hospital, we do have limitations, as you pointed out. Sometimes, those limitations are challenging to explain because they aren’t just about the physical capability of the facility but also about ancillary resources like CRNAs.

Our facility doesn’t employ anesthesiologists, so there’s a different comfort level with a CRNA compared to an anesthesiologist. There may be cases where the surgeon is perfectly comfortable doing the procedure, but we can’t proceed because the ancillary services feel the case might be too complex.

Even if it’s not too complicated for the surgeon, it could be for the facility, nursing staff, or CRNA services. So, we see variability depending on who’s available at any given time.

Jerry Fushianes: Yeah, depending on who's on, the confidence level is one of the challenges we see when a locum comes into our facility. One of the best tools they can bring is the question, "How do you guys do it? How do I make what I do fit into that?"

When they approach it this way, they have a much better chance of success than if they come in saying, "This is how I do it." That approach might work for them, but in a small community that’s always done it a certain way, it creates barriers that work against them.

When I teach young PA students, one of the things I always tell them is that the best thing you can do is be approachable. Be positive, approachable, and open to questions, even if they seem dumb. Often, those questions are the ones that prevent mistakes.

Now, as a PA, my job is to protect the supervising physician and ensure they’re not exposed to liability. When we talk about our model, you come in as a contractor or locum through another hospital system. When we hire locums directly, one of the discussions we’ve had is, “Why can you do this now but not then?”

Dr. Randy Lehman: [00:17:27] Where would you start?

Jerry Fushianes: [00:17:28] Exactly.

Dr. Randy Lehman: [00:17:29] Somebody has to go to the ivory tower and come back.

Jerry Fushianes: [00:17:31] Exactly. When the physician is employed by a second hospital, we don’t have the same relationship to build on. But for one of our local physicians, like Robertson, for instance, at two in the morning, he might call and say, “Admit that patient for me, put them on the floor, get them prepped.”

So, our job is to prepare that patient so all he has to do is come to the OR in the morning, see the patient, and leave again. We handle pre-op orders, post-op orders, and rounding. He’s available if something isn’t right, but we’re trained to duplicate his services to the point that we know when to alert him.

This setup works well for surgeons covering multiple hospitals. They know, for example, that Bob at one hospital has the skills to handle specific tasks. It allows surgeons to move between hospitals, providing services efficiently. It’s not just about billing—although it can increase revenue—it’s about providing more services to the community.

Ultimately, we provide excellent care in this small community because surgeons like you are willing to come here and deliver the level of care you were trained to give. If we had to grow this ourselves, we wouldn’t be able to.

Dr. Randy Lehman: [00:17:43] Yeah.

Jerry Fushianes: [00:17:43] Otherwise, gosh, you know, we have a robot as a small community hospital, which is kind of unusual. But in getting it, we realized every time we’d interview a young surgeon, they’d ask, “Do you have a robot?” If we didn’t, we’d lose them.

Many young surgeons are only trained on robots. They might know open surgery or robotics, but not laparoscopic techniques. If we told them they’d have to do it laparoscopically, they might agree to try, but often within a couple of months, they’d say, “I got a better offer,” and leave. So, we invested in a robot.

Jerry Fushianes: Because then we get surgeons of a different caliber. That’s not to say that surgeons who don’t use robotics don’t do good work, but when you're a small community trying to recruit someone full-time, if you want a young surgeon to come here, you need a robot.

Dr. Randy Lehman: [00:18:25] Good to hear that. I don’t have a robot anywhere I go, except for here. And I don’t use it here because I’m not here very often. So, you don’t have to have it?

Jerry Fushianes: [00:18:34] No. When you do, it’s one more tool, one more thing in your quiver to offer. It’s not as important for locums because, like you said, the amount of effort they’d have to go through to prove they’re qualified might not be worth it. But to get a young surgeon to come here and have someone they can see in the clinic today and put on the robot tomorrow—whereas at another hospital, it might take three months to get access—here, we can do it in a day.

Dr. Randy Lehman: [00:19:00] That’s a great point, too. So, how many advanced practice providers are in your group?

Jerry Fushianes: [00:19:06] We currently have six, and we just hired our seventh. They’ll start in December.

Dr. Randy Lehman: [00:19:09] What’s unique to me is that you’re covering multiple service lines in your hospital. What surgical services do you support? Ortho, general, and…

Jerry Fushianes: [00:19:19] OB. We’re on call for C-sections and other OB surgeries. If there are two surgeons available, one works with the OB surgeon. But sometimes, there’s not a second surgeon on or within range. In that case, the first-assist PA steps in to assist.

The surgeon performs the surgery, and the first-assist PA supports. That’s what makes this work—we assist no matter the type of surgery. I hold things, I close. If we ever get to the point where you need me to figure out how to take the gallbladder out, something has gone terribly wrong.

Dr. Randy Lehman: [00:19:50] Yeah, right.

Jerry Fushianes: [00:19:51] My job is consistent. Whether it’s a C-section, ortho, or general surgery, my role remains the same. Even with ortho cases, while the setup might differ, the support and care we provide are constant.

Dr. Randy Lehman: [00:20:20] Do you also work shifts in the ER?

Jerry Fushianes: [00:20:23] Well, we provide backup for the ER. Since there are five of us, we usually have a float person available. If the ER gets overwhelmed, that float person steps in.

Dr. Randy Lehman: [00:20:37] Go down there and see the same patients?

Jerry Fushianes: [00:20:39] We just help clear them out if needed. It’s a crowd-pleaser. It shows people we’re working and helping, instead of just sitting around while the ER is slammed.

Dr. Randy Lehman: [00:20:47] I get it.

Jerry Fushianes: [00:20:47] And sometimes those patients turn out to need surgery. We might think, “This could be surgical,” call in the surgeon, and it turns into a case.

Dr. Randy Lehman: [00:20:55] Yeah. So, tell me about wound care.

Jerry Fushianes: [00:20:58] Wound care is actually something our nurse practitioners excel at. We have three wound-care-certified nurse practitioners who specialize in it.

Jerry Fushianes: So what we saw was a need in our community where the wound care being provided wasn’t state-of-the-art. As a critical access hospital, we were able to access certain resources, such as live tissue products, that even larger hospitals couldn’t obtain. Because of how funding works, we could access these products, which are typically used at university hospitals, but not as readily available at mid-range hospitals.

Our nurse practitioners, along with our general surgery service, developed a robust wound care program that now sees about 300 patients a month.

Dr. Randy Lehman: [00:21:39] Is it a hospital outpatient department?

Jerry Fushianes: [00:21:41] It is.

Dr. Randy Lehman: [00:21:42] Okay. And that’s important.

Jerry Fushianes: [00:21:43] It is, and we think it is. We also have an outlying clinic that doesn’t do wound care, but the specialty clinic within the four walls of the hospital does. It piggybacks on our surgery service.

Dr. Randy Lehman: [00:21:56] Yeah. And then you’re also part of the hospitalist group, rotating through and seeing medical admissions, not just surgical patients?

Jerry Fushianes: [00:22:06] That’s correct. That setup gives our team the ability to admit patients when the hospital is nearly full. If you really want to do a case, you can admit the patient, and the associate provider uses their medical background to support you. They’re admitted under you, but we provide the medical support and prepare the patient. We can consult internal medicine if needed, but we ensure they’re admitted and ready for you.

Dr. Randy Lehman: [00:22:34] Let me talk for a second about how I’ve used my nurse practitioner, Taylor, in Indiana. To develop a system like yours, you need the right volume and hospital support. Even for me, it’s overwhelming to consider starting something so complex.

Jerry Fushianes: [00:22:57] Right.

Dr. Randy Lehman: [00:23:00] I was referred to Taylor by a close friend who connected us. She’s from my town, graduated from the same high school as me, and I was friends with her older sister. She’s a year younger than me and has the perfect personality for her role—calm, no-nonsense, and no drama.

Jerry Fushianes: [00:23:33] And you found the one—we’ve been looking for someone like that.

Dr. Randy Lehman: [00:23:36] Exactly. You need the right person. I found Taylor through a referral, but recruitment is a big question.

Jerry Fushianes: [00:23:46] We figured out a system that works well for us. We contacted the universities we liked and offered ourselves as a preceptor center. We told them, “Send us your best students because we want to hire them.” This way, we created a farm system. We observe the students during training, handpick the ones we want, and work hard to keep them. That’s how we built our team.

Dr. Randy Lehman: [00:24:14] Is anyone in your group originally from this area or have family here?

Jerry Fushianes: [00:24:19] Yes. One of our nurse practitioners, Heather—you’ve met her—was born and raised here locally. But that’s it. The others have all relocated from other areas.

Dr. Randy Lehman: [00:24:28] With Taylor, she had moved away but later returned to live in Rensselaer, Indiana. She didn’t want to move again and wanted to stay there.

Dr. Randy Lehman: It was very easy to sell her on the mission that was in my head, which is: I’ve just been gone for the last 13 years getting the training with this place in mind.

Jerry Fushianes: [00:24:53] Right.

Dr. Randy Lehman: [00:24:53] Rensselaer, Indiana. And I’m back. Now, I want to offer surgical services at the highest quality right here, close to home. I don’t want these people to have to leave town. I want them to stay for all the reasons. Number one, it’s convenient and extremely high quality for that one patient in front of me.

Jerry Fushianes: [00:25:13] Right.

Dr. Randy Lehman: [00:25:14] But beyond that, it keeps our rural hospital open so that my family and I can depend on it for care. It also has economic value—it raises all ships. Rural hospitals are often top employers in a county, providing great jobs and supporting the community. When a hospital closes, it’s devastating for the area.

Jerry Fushianes: [00:25:45] Absolutely.

Dr. Randy Lehman: [00:25:46] So, for me, it’s about hospital viability. Rural hospitals are closing, and that’s a huge problem. Anyway, Liberty Clinic is my independent practice, and Taylor is completely on board with this vision. She’s able to come to the OR, scrub with me, hear me, and talk to me about patients. At this point, we’re walking in lockstep. I believe in her completely. I never question her motives, and she doesn’t question mine. She even starts to think like me—her notes look just like mine.

Jerry Fushianes: [00:26:22] She’s a PA? You said nurse practitioner.

Dr. Randy Lehman: [00:26:24] She’s a nurse practitioner, but I often think of her as functioning like a PA. She’s a family nurse practitioner, but when she started, she had just graduated from NP school. Before that, she worked as a resource nurse for eight years, which means she essentially worked in every facet of the hospital.

Jerry Fushianes: [00:26:43] That’s a great point because people often ask me about the difference between a PA and a nurse practitioner.

Dr. Randy Lehman: [00:26:48] Sure.

Jerry Fushianes: [00:26:49] I’m fortunate that I’m married to a nurse practitioner who makes sure I know the right answer to this. The big difference is in their training models. RNs are certified by competency, not by degree. An LPN, ADN (associate degree nurse), BSN (bachelor’s), or MSN (master’s) are all RNs—they share the same core training.

PAs, on the other hand, are trained in a competency-based medical model. There are still a few associate-level PA programs, but most PAs today have a master’s degree, and some have transitioned to a doctorate. However, the doctorate is primarily academic and doesn’t affect clinical practice—though that’s another discussion about PAs and the title “doctor.”

The key difference is that nurse practitioners build on their RN training when they become NPs. Their training depends heavily on their previous experience and the rotations they completed. PAs, however, are uniformly trained in the medical model by physicians and PAs. Every PA has the same core rotations. If I meet a PA, I know what their training included. When I meet a nurse practitioner, I don’t always know that.

Jerry Fushianes: So the challenge is that nurses have seen sick patients before—they know what sick patients look like. So they have that advantage, but they don’t always have the background that we do. We have basic sciences, anatomy, physiology, cadaver labs, and training from physicians to duplicate their services.

Nurse practitioners, especially those just starting out, don’t always have that background. Like you said, you had a nurse practitioner who just came out of school. You had the advantage of taking her knowledge and shaping it the way you wanted.

Dr. Randy Lehman: [00:28:46] Yeah. Not just that, but I also taught her how to continue learning.

Jerry Fushianes: [00:28:49] Well, there you go.

Dr. Randy Lehman: [00:28:50] If she doesn’t know something, she looks it up. The thing that makes her really good—and if there are any NPs or PAs listening, take note—is that she finds the balance between two extremes. On one end, you have someone who’s overly confident, makes decisions quickly, and is sometimes wrong. That’s bad. On the other extreme, you have someone who has no idea what to do, doesn’t know how to find answers, and calls for everything without investigating.

Taylor is in the middle. She assimilates all the information, forms her own judgment, and, if she doesn’t know the answer, looks it up. She almost always comes to the right conclusion. Then she calls me to confirm when it’s appropriate.

Jerry Fushianes: [00:29:51] Excellent.

Dr. Randy Lehman: [00:29:52] That’s ideal.

Jerry Fushianes: [00:29:53] Exactly. What you’ve described is what we try to achieve in our training. We call it “stop points.” When you encounter something new, you need to know what you don’t know. That’s key.

There’s confusion now, especially as PAs and nurse practitioners move into the doctorate realm. Some people misunderstand the difference between an educational doctorate for PAs or NPs and a physician’s doctorate. The title “doctor” isn’t a protected title, but “physician” is. These days, almost every pharmacist, physical therapist, and even some housekeepers hold doctorates.

When I first started, the physician who hired me—a guy back in Michigan named Ansar—was an incredible mentor. I just saw him recently. He used to say, “I don’t care if you’re a PA, an NP, a DO, or an MD. I want you to be a healer.”

Dr. Randy Lehman: [00:30:49] Yeah.

Jerry Fushianes: [00:30:49] He wanted us to walk into a room, know enough to help the patient, and know when to involve him. He’d say, “If I need to get involved, I’ll teach you what you need to know. If you can’t learn it, then we have a problem.”

That type of mentorship was fantastic. He had a way of balancing support and independence. He’d tell us, “Bring me two legitimate references for what you want to do. Don’t bring me Mad Magazine or Ladies’ Home Journal—give me real sources.” That type of confidence, knowing he had faith in me, but also knowing I wouldn’t be left out on a limb, really helped me grow into a strong associate provider.

Jerry Fushianes: Somebody can work with you because, ideally, if that person does a great job for you for 10 years but then exposes you to one bad lawsuit, any gains you’ve had might be lost. So, when you describe how not only she has those talents, but that you trust her, that’s what all of us should be trying to achieve—figuring out how to duplicate the services the physician provides while knowing when to step back.

Here’s an example. Robertson, one of the surgeons I work with the most, appreciates when I point out concerns. When I tell him, “I don’t think we should do this,” he doesn’t dismiss it outright. He’ll stop and ask why, to see if there’s something he can address to build confidence in moving forward. My job as a PA isn’t to decide whether we should or shouldn’t proceed with a surgery—it’s to point out potential issues. If the decision is made to move forward, my role is to make that surgery as successful as possible.

Dr. Randy Lehman: [00:32:29] Are you doing any surgery consults outpatient?

Jerry Fushianes: [00:32:32] Outpatient.

Dr. Randy Lehman: [00:32:33] Outside of the hospital? Like, does somebody come to you directly for an elective referral?

Jerry Fushianes: [00:32:38] Oh, you mean down in the specialty clinic?

Dr. Randy Lehman: [00:32:39] Yeah.

Jerry Fushianes: [00:32:39] Yes, we get those.

Dr. Randy Lehman: [00:32:40] So, not the surgeon seeing the patient directly?

Jerry Fushianes: [00:32:45] We’ll see them first.

Dr. Randy Lehman: [00:32:47] Then does the surgeon meet the patient the day of surgery?

Jerry Fushianes: [00:32:50] No, not necessarily. Sometimes, we get consults from the ER. The ER might call us and say, “Can you see this patient? We’re thinking about referring them to the surgeon, but we’re unsure.” That’s an important point. By having me available, we save the surgeon from having to drop everything and go down to the ER every time there’s a question.

This way, we capture more business because we can prioritize. Some patients need to be seen right away, while others can wait a week or more. We sort that out for the surgeon.

Dr. Randy Lehman: [00:33:17] Well, both my kids had tonsillectomies last year.

Jerry Fushianes: [00:33:21] Yeah.

Dr. Randy Lehman: [00:33:22] In both cases, they were seen pre-op by an APP.

Jerry Fushianes: [00:33:25] Yeah.

Dr. Randy Lehman: [00:33:26] We were told, “You’ll get your tonsils out, and it’ll be one of these five doctors performing the surgery.”

Jerry Fushianes: [00:33:34] Oh.

Dr. Randy Lehman: [00:33:35] And they said, “We’ll call you to let you know who and when.”

Jerry Fushianes: [00:33:39] In larger systems, that’s common. In our smaller setting, we’re still a bit more personal.

Dr. Randy Lehman: [00:33:44] Honestly, I felt very comfortable with the process. If it’s that routine, it works. Much of what I do is also that routine.

When my nurse practitioner first started, she didn’t want to give up primary care. I was drowning in wound care and needed help.

Jerry Fushianes: [00:34:02] Sure.

Dr. Randy Lehman: [00:34:02] She wanted to work four days a week and live in town. It was a win-win. She took one day a week for wound care and three days for primary care. She worked out of my office, which was awkward because I didn’t want to collaborate on primary care—I’m not trained for it.

Dr. Randy Lehman: A good primary care friend that I know and trust basically paid someone to collaborate with her. That worked out fine. She handled that aspect while I collaborated with her on wound care. But eventually, I started drowning in clinic work.

Jerry Fushianes: [00:34:45] Yeah.

Dr. Randy Lehman: [00:34:46] I was getting all these referrals for colonoscopies, and it’s pretty straightforward. What I needed was someone to handle the medical side of things.

Jerry Fushianes: [00:34:56] Right.

Dr. Randy Lehman: [00:34:57] My problem was, I’d see patients and have to decide if they needed the procedure or not. Yes or no, then move them to the schedule. What really needed to happen, especially in a small town, was proper cardiac risk stratification—looking at the patient as a whole medically. I can do it, but am I as good as an anesthesiologist or internist at it? Probably not.

Jerry Fushianes: [00:35:26] Well, if you are, you’re in the wrong business. Right?

Dr. Randy Lehman: [00:35:29] Exactly. Especially for colonoscopies, it’s really about making sure the patient is ready. If the primary care doctor wants a colonoscopy or EGD, I’ll do the test. But cardiac fitness and risk stratification need to be handled first. If a patient has a cardiac issue, they can be sent for clearance. I don’t handle that directly.

Jerry Fushianes: [00:35:56] Sure.

Dr. Randy Lehman: [00:35:56] So, I asked her to start seeing colonoscopy patients pre-op, and eventually post-op too.

Jerry Fushianes: [00:36:03] Yeah.

Dr. Randy Lehman: [00:36:05] It’s the same process repeatedly.

Jerry Fushianes: [00:36:08] What you mentioned is something we’re moving toward because many of our competitors are already doing it.

Dr. Randy Lehman: [00:36:12] Yeah.

Jerry Fushianes: [00:36:12] Currently, a patient might be referred from the VA. They see their primary care doctor, get referred to us, have a visit with the surgeon, then get sent for a pre-op physical before finally coming back for the procedure. That’s four visits for one colonoscopy. We realized we were losing business to competitors, so we recently launched a pilot program. Now, patients referred to us have the pre-op, counseling, and teaching done on the same day. They meet the surgeon on the day of the procedure. It’s reduced to two visits.

Dr. Randy Lehman: [00:36:47] That’s how I handle it too. I meet them on the day of surgery. I do an updated H&P but don’t charge for it.

Jerry Fushianes: [00:36:52] Okay.

Dr. Randy Lehman: [00:36:52] Some people charge for it, but I don’t have a strong opinion on that. After that worked well, I asked Taylor to handle gallbladder cases.

Jerry Fushianes: [00:37:08] Yeah.

Dr. Randy Lehman: [00:37:09] Gallbladders are straightforward. If there are stones, we proceed. If there’s nothing, we do a HIDA scan. For biliary dyskinesia, I set specific criteria. Now, we’ve reached a point where I can discuss choledocholithiasis, bile duct stricture, and laparoscopic common bile duct exploration with her, and she knows exactly what I mean.

Jerry Fushianes: [00:37:30] And she’s been in these cases with you, right?

Dr. Randy Lehman: [00:37:32] Yeah, absolutely.

Dr. Randy Lehman: So, she can now work up a common bile duct issue. She has advanced far beyond where she started.

Jerry Fushianes: [00:37:37] Yeah.

Dr. Randy Lehman: [00:37:38] But it all began with her seeing that first patient. Then, I met my first gallbladder patient on the day of surgery. I hadn’t been involved earlier, but the notes looked as though I had.

Jerry Fushianes: [00:37:50] Sure. That model works. We’re not at that point yet because our volume still allows for the surgeon to be more directly involved. But the relationship you’ve described between the PA or nurse practitioner and the surgeon—having that confidence level where they are walking in lockstep—is critical.

That all comes back to the training at the beginning. When hiring a mid-level provider, whether it’s a PA or an NP, you have to determine if their background aligns with what’s needed. Nurse practitioners, upon graduation, often excel at working with patients—they’ve seen sick patients before and know what that looks like. Some PAs, depending on their background, have similar experience. But typically, it takes about five years for both professions to reach the same level of competency.

Dr. Randy Lehman: [00:39:51] It’s so obvious.

Jerry Fushianes: [00:39:52] Yeah.

Dr. Randy Lehman: [00:39:52] There’s a difference between her and me.

Jerry Fushianes: [00:39:54] Right.

Dr. Randy Lehman: [00:39:54] She knows it, and I know it. So, why even talk about it?

Jerry Fushianes: [00:39:58] Exactly. What I’ve noticed in your description of your relationship with her is that there’s no ego involved.

Dr. Randy Lehman: [00:40:02] My goal is to make her…

Jerry Fushianes: [00:40:04] As successful as she can be. That’s why you’ve developed a strong working partnership. While not a surgical partner in the traditional sense, she’s a partner in delivering excellent patient care.

Dr. Randy Lehman: [00:40:19] Two things I don’t want to forget. First, do you have any CME programs you’d recommend for a nurse practitioner or PA working in a rural general surgery practice?

Jerry Fushianes: [00:40:31] All of our nurse practitioners, since they’re trained differently, take a program called NIFA—the National Institute of First Assisting. It’s comprehensive and covers a lot of essential skills.

Jerry Fushianes: PAs aren't required to take it in our facility because, during our rotations, we complete a surgical rotation that's very similar.

Dr. Randy Lehman: [00:40:52] Is it just about the surgical aspects?

Jerry Fushianes: [00:40:55] That's all.

Dr. Randy Lehman: [00:40:55] What about pathology?

Jerry Fushianes: [00:40:56] That’s correct, yeah.

Dr. Randy Lehman: [00:40:57] Okay, that's great. So, we'll put a link to that in the show notes.

Jerry Fushianes: [00:41:01] Sure.

Dr. Randy Lehman: [00:41:01] Is there anything specifically pathology-related to general surgery?

Jerry Fushianes: [00:41:05] You know, for me, the biggest learning curve was from Doc Robertson. I don’t know if he’ll like me sharing this, but he reboards every two years and goes through all these articles. During my first year, I thought, what am I—his library? But then it hit me—this is exactly what I need to know. So, I started going to the American College of Surgeons website to see what they recommend reading. I focus on those materials.

As a critical access hospital, our scope is limited. We don’t do everything. For example, during COVID, we did a splenectomy, which isn’t common for us. Most of our cases are gallbladders, hernias, appendices, small bowel obstructions—things like that.

Dr. Randy Lehman: [00:41:47] So, you’re still doing colectomies?

Jerry Fushianes: [00:41:49] Yeah, we’re doing those too. My focus is on learning the same materials as the surgeons. Even if I can’t fully digest it immediately, I aim to ask informed questions. Coming from family practice and ER before this role, seeing the full circle of medicine has been enlightening. It’s the closest experience to residency for a PA.

When recruiting PAs or NPs, I emphasize the unique experience here—you follow a patient through the entire process, from admission to surgery to discharge and follow-up. It’s a full 360-degree view.

Dr. Randy Lehman: [00:42:36] That’s a great point. So, here’s the other thing I wanted to share. I spoke with a surgeon in the lounge who criticized how I’m using Taylor.

Jerry Fushianes: [00:42:51] Sure.

Dr. Randy Lehman: [00:42:52] They told me, “In our group, nurse practitioners have never seen a patient without me seeing them the same day, co-signing the note, and documenting that I was present. You’re going to face liability issues someday.” So, I asked, “How long have you been practicing?” They said, “Seven years.” Then I asked, “So, you’ve experienced this issue firsthand?” They admitted, “No.” I said, “Then why are you limiting their role? We’re facing a massive shortage, and anything that extends my capacity is essential.”

Jerry Fushianes: [00:43:38] I understand the concern, and it’s valid. That’s why it’s crucial to choose the right person, provide proper support, and ensure they feel comfortable coming to you with questions. This builds mutual confidence. I often emphasize that one liability event can have consequences beyond lawsuits. As someone who reviews cases as an expert witness, I see it firsthand.

Dr. Randy Lehman: [00:44:00] Most of them are garbage.

Jerry Fushianes: [00:44:01] Yeah, most of them are.

Jerry Fushianes: But when I look at these things, the issues that PAs are tagged for generally aren’t something obvious. Like you said, really? Who could have caught that? I don’t think, you know, even someone like Dr. House would have caught that. Unfortunately, though, that’s not how modern medicine works.

Sometimes, it’s also about reputation. If that PA’s temperament, skill set, or overall approach doesn’t match how you want to be seen in the community, that can be an issue. Robertson, one of our surgeons, always says, “Start your shift by going down to the ER, say hi to the ER team, and let them know, ‘Hey, Robertson’s on today, and I’m working for him, so call me if you need something.’” He believes that connection is critical. That’s how he gets business. And no question is a bad question, but it works better when he has me to go down there and make those introductions.

Dr. Randy Lehman: [00:44:53] We have a rule: don’t be invisible to the ER.

Jerry Fushianes: [00:44:59] Exactly, let them know you exist. For Robertson, that’s his only referral source. So yeah, he’s got me down there, “trolling,” as he calls it. He doesn’t want to be doing it himself, but I go down, connect with the team, and sometimes find patients who could be referred to wound care or other specialties. The goal is to build respect at the same level as the surgeon because maintaining that respect reflects well on the whole team.

That isn’t always taught to younger PAs, but it’s something we emphasize. Personally, I don’t apologize for being a PA. I’m proud of it. It’s provided me with a great career, and I love the flexibility. I can change specialties at any moment as long as I have a supervising—or as we now call it, collaborating—physician. My role is important, and I aim to perform at the top of my skills. That’s what you described with Taylor.

I hear your colleagues’ concerns about liability. I wouldn’t say be worried, but be aware. When I started, I remember working for a general surgeon in Detroit, who was also the president of the College of Surgeons at the time. One day, I tried to refer a patient, but his office staff said, “We don’t take calls from PAs.”

Dr. Randy Lehman: [00:45:35] Wow.

Jerry Fushianes: [00:45:36] So, tail between my legs, I went to my family doc boss, Dr. Ams, and told him what happened. He calmly said, “Don’t worry about it. I’ll handle it.” He then picked up the phone and called the surgeon’s office, saying, “Tell Bob I won’t make it to golf Friday—I’m looking for a new surgery office for my patients.” He hung up and told me, “You’ll get a call in five minutes.” It was less than that.

The surgeon called me back, apologizing, “Jerry, I thought they said medical assistant! Tell me about your patient.” Afterward, he invited me to sit with him at the next hospital med staff meeting to introduce me to others. That taught me the value of standing up for the team while building professional connections.

Jerry Fushianes: He goes, "What you have to understand is that I refer a lot of patients to him, and I refer quality patients to him. You now work for me, so I’m referring patients to him through you." He just needed to be reminded, and I appreciated how he handled it. He didn’t put me in a spot where I felt like I did something wrong. It worked, too, because from that point on, that surgeon became one of my best friends. He’d go out of his way to introduce me, and if anybody messed with me, they had to deal with him.

Dr. Randy Lehman: [00:47:38] That has to do with a lot of intrinsic factors.

Jerry Fushianes: [00:47:40] Yeah. But I was the first PA in that community.

Dr. Randy Lehman: [00:47:43] Yeah. As you mentioned earlier about the CRNA versus anesthesiologist dynamic, there’s definitely a spectrum.

Jerry Fushianes: [00:47:57] Yeah.

Dr. Randy Lehman: [00:47:57] There’s overlap, too. I’d say, in general, you’re correct that the average PA or CRNA might handle less complex cases compared to the average MD anesthesiologist. But there’s such a spectrum. I’ve had MD anesthesiologists refuse cases that CRNAs handled capably and competently.

Jerry Fushianes: [00:48:26] That’s true. Now that you mention it, many of the colleagues we work with—especially those with military training—have exposure to cases that significantly increase their comfort level. Unfortunately, though, you’re often working to the lowest comfort level of the group. For instance, one provider might clear a patient for surgery tonight, but the person on tomorrow might cancel the case.

Dr. Randy Lehman: [00:49:07] I’ve already voiced my frustrations with anesthesia.

Jerry Fushianes: [00:49:09] I know.

Dr. Randy Lehman: [00:49:11] Anyway, let’s switch gears. I want to discuss something unique—a financial topic.

Jerry Fushianes: [00:49:17] Sure.

Dr. Randy Lehman: [00:49:18] A money tip. A lot of people say things like, "Don’t buy that house yet," but I hear you’ve got an interesting investment.

Jerry Fushianes: [00:49:30] Yeah.

Dr. Randy Lehman: [00:49:31] Tell me how it’s going for you. What have you been doing?

Jerry Fushianes: [00:49:37] Well, as you mentioned at the start of the podcast, we’re here in the community theater in central Wisconsin. Dr. Amsler, who’s been a mentor, always told me, "You’ve got to have something outside of work that brings you joy." Work isn’t always fulfilling, and sometimes you won’t even like it. You need something else to keep you grounded.

So, with some of my extra money, I’ve invested in this local theater. It’s a community space where we’ve started writing TV shows, plays, and hosting writing groups. It’s been a great outlet for creativity and connection.

Dr. Randy Lehman: [00:50:24] How many years have you been doing this?

Jerry Fushianes: [00:50:25] We started during COVID because we couldn’t put shows on the stage. So a group of us got together—a couple of guys from the local TV station, a couple of actors, and a few people who thought they were writers. For me, I’m none of those things. I’m a little bit of each. But when you get in a room with people that creative, it’s fun.

So we started writing TV, and you know, we tried to sell it. It’s still sitting on someone’s desk. We’ve also done our first play, which will debut this Christmas here at this theater and in Cedarburg, Wisconsin. And now we’ve completed our first full-length movie, which is about to be pitched. So we’re having fun.

Dr. Randy Lehman: [00:51:01] How much money does it cost to produce one of these things?

Jerry Fushianes: [00:51:04] For a small community theater show, you might spend about $2,000 to $3,000, and the return is maybe $5,000 or $6,000. So you’re not making much. You’re doing it because you enjoy it.

When we make money, we don’t return it to ourselves. We reinvest it into the community theater. For the movies, when we start making money, those profits will come back to us, but we’ll still reinvest in the community.

Dr. Randy Lehman: [00:51:28] How much does it cost to produce a movie?

Jerry Fushianes: [00:51:30] Well, it depends. For the one we started with, which was our largest production, we crowdfunded $125,000. We brought in national actors to this tiny town and shot a whole pilot episode over a week.

Dr. Randy Lehman: [00:51:51] This is for a TV series?

Jerry Fushianes: [00:51:53] Yes, it’s for a TV series called Man Out the Way for King. The pilot is out there, but the series hasn’t been picked up yet. We’ve written six seasons.

Dr. Randy Lehman: [00:52:07] Six seasons?

Jerry Fushianes: [00:52:08] We’ve got six episodes for season one, and then six seasons total. COVID was long, so we had a lot of time. We also worked on Camp No Phone, Running with Scissors, and Canceling Christmas.

Canceling Christmas is completed. It’s in the box and will be staged this year. It’s like a Hallmark movie—you sit there, smile, maybe don’t laugh hard, but you enjoy it. It’s the kind of show people in a small community theater will appreciate. We plan to stage it here, sell it to other community theaters, and make it a revenue stream.

Dr. Randy Lehman: [00:52:45] How much does one theater pay for royalties per show?

Jerry Fushianes: [00:52:49] It varies. For what we’re doing, it’s probably about $120 to $250 per show.

Dr. Randy Lehman: [00:52:57] For the pilot you’ve created, if someone bought it and made the series, do you think they’d use your pilot?

Jerry Fushianes: [00:53:09] No, I don’t think so. The reality is, in this business, the people who succeed are the ones who don’t care about credit. They just want the project to move forward. Pay me and move it along.

Dr. Randy Lehman: [00:54:06] Because there’s no doubt that even the stories we think are the best, when they get to a studio, they’re going to be rewritten. And if they rewrite more than 33% of it, you’re no longer the head writer. Somebody else becomes it.

So, they guarantee if they give it to someone else, they’re going to rewrite that much because they want it to be someone who’s recognized. I’m a writer, and I’m a head writer—that’s unique. But I don’t think I have enough time on this rock to get there. The time I do have, we’re spending writing stories we love telling people about. And we hope someone else, if they take it, will make it better. I might think it’s fantastic, but if you can make it better, let’s do it.

Dr. Randy Lehman: [00:54:06] What’s a beautiful little intimate theater. Brittany and I came and watched a play, and we just loved it. So, I think we’re going to have to make a trip back up here and watch your upcoming one.

Jerry Fushianes: [00:54:18] Please do. We’ll buy you popcorn.

Dr. Randy Lehman: [00:54:19] All right. So, the last thing. We talked about resources for the busy rural surgeon, and we talked about several things, like your PA. You want a...

Jerry Fushianes: [00:54:29] Sharp scalpel and a good PA, right?

Dr. Randy Lehman: [00:54:32] But let’s do the last segment, which is classic rural surgery stories.

Jerry Fushianes: [00:54:37] Okay.

Dr. Randy Lehman: [00:54:37] You have a unique one with the base right next door. Tell me how your town’s population essentially doubled or tripled overnight, and what did you do about it?

Jerry Fushianes: [00:54:51] Well, as we said earlier, we’re near Fort McCoy, Wisconsin, which is a mobilization platform for the Army Reserve and Army Guard. When the U.S. pulled out of Afghanistan, there was an influx of refugees.

There were basically two points where they went, one of which was Fort McCoy. Our town has just under 10,000 people, and their top number was about 12,000 refugees at one point. Along with that, we had up to 8,000 support staff to care for those individuals.

Well, along with that came patients at all different stages of the disease process. Some showed up with flash drives containing their medical records. Others not only didn’t speak the same language but didn’t have any traditional medical care history.

Dr. Randy Lehman: [00:55:51] Ever.

Jerry Fushianes: [00:55:52] Yeah. I remember one specifically at the beginning. This woman came in, and we were convinced she had a gallbladder problem. We were about to go in and take it out because transferring patients at the start of COVID was impossible. But while talking to her, the translator kept saying she mentioned a heart problem, and that’s all we could get.

Dr. Randy Lehman: [00:56:16] Yeah.

Jerry Fushianes: [00:56:17] So, our CRNAs were hesitant. They knew it wasn’t the same-day kind of deal, but it was a big question. What are we doing here? We tapped the brakes for a couple of days, cooled her off with antibiotics, and tried to figure it out. Finally, we got a hold of a friend of a friend, who connected us with her brother-in-law in Virginia, and he spoke English better than I did.

Jerry Fushianes: [00:56:46] And it was, she had been told by somebody local—someone not professionally trained—that she had a heart problem. She carried that belief her whole life, saying, "I have a heart problem." Fortunately, with that context, we felt a little more comfortable moving forward, and nothing horrid happened.

But those types of situations showed us we weren’t prepared. You know, a lot of us do mission trips, but this was like the mission trip came to us. We spent a good 12 months treading water, with some of us working two to three days straight with only short breaks because we were a small hospital.

In spite of everything, we were seeing diseases we wouldn’t normally encounter. The public health department sat in our hospital, asking us to order tests I’d never even heard of. It was a wonderful opportunity to learn, but in my nearly 20 years here, it was one of the proudest moments.

Our small community came together—not just the community, but the hospital, our physicians, and our OB surgeon. They were sometimes delivering five or six babies a day in the ER because we couldn’t get upstairs. It was the best of times, it was the worst of times. Someone’s going to write about that one day.

Dr. Randy Lehman: [00:58:00] It sounds like a great opening line, doesn’t it? Especially for some kind of movie or play.

Jerry Fushianes: [00:58:05] I think it would be wonderful.

Dr. Randy Lehman: [00:58:07] Is there anything else the audience could do to help you in any way, or is there anything else we can do for you?

Jerry Fushianes: [00:58:13] Well, I’d say, find something in your community to invest in. Don’t just invest your money—invest your time. For example, with community theater, we’ve had surgeons invest both their time and money. It’s helped the community, and it’s helped us expand what we can do.

And of course, if there’s anything else, hire a PA or a nurse practitioner. Hire one of us.

Dr. Randy Lehman: [00:58:46] Hey, thanks for coming on. And thanks for tuning in to this episode of the Rural American Surgeon podcast. If there’s a surgeon or anyone interested in rural healthcare or rural surgery, please like and share this. Give us a review online, and share it with your contacts. I’ll see you on the next episode of the Rural American Surgeon.