Rural surgery 1

Hello, Behind the Knife listeners. My name is Cody. I'm one of the surgery education fellows. Today, I have the opportunity to chat with Dr. Brett Autry, who's a rural surgeon and going to be kicking off our series that we're doing on rural surgery. Dr. Autry has some background on him. He grew up in Concordia, Kansas, a small town in north central Kansas, went to undergrad at William Jewell College in Liberty, Missouri, which he then followed medical school in Kansas City at Kansas City University College of Osteopathic Medicine and then came back to Michigan for his general surgery training at Michigan State University College of Human Medicine in Lansing.

After his general surgery training, he went to the northern part of Michigan in a town, Ludington, Michigan, and was in private practice for about 10 years, after which he sold his practice and became employed at what is now Corwell Health in 2016. And he's now been in rural surgery practice for about 18 years.

Not to date you, Dr. Autry, but thank you so much for taking the time to chat with us and for coming on the

podcast. No problem. Thanks for inviting me to start things off. Can you just give us a little bit of background about the town that you work in Ludington, Michigan, as well as the hospital that you work in?

Yeah. So Ludington is a town of about 8, 000 people. That's our year round residence. We are quite a tourist town because we're right on the coast of Lake Michigan, beautiful, beautiful area. Our hospital draw technically or historically has been around 30, 000 year round people that does expand to about 30, 000 people in the town and about, you know, 60 to 80, 000 people in our draw area during the summer months.

We have a lot of snowbirds that go south for the winter time. And a lot of people come in from other cities to just come in and spend a week on the, on the coast. Our hospital is right in the, I think it's actually 56 beds technically, but about 50 beds. We've got OB coverage, 24 seven OB coverage.

Our surgical specialties are general surgery. We have orthopedics, kind

of have some ENT coverage at times. And we do have ophthalmology that is in the area that does some cases at our hospital. Really. 24 seven type of call is only general surgery and OB. We've got two orthopedic surgeons here, so they take about two thirds of a month of call.

So probably about 20 days a month there that's covered. So, we do have a hospitalist support for admissions in the hospital and then we outpatient services, we've got pediatrics, family practice internal medicine and a private practice, a dermatologist that is actually in town. So that's kind of our.

medical area, so to speak. Awesome. I, as somebody who also lives in Michigan, while I haven't been to Ludington specifically, I can strongly endorse the the beautiful coast and Northern Michigan. And it's a really fun place to go and spent in the summertime, especially. So how did you find yourself? In a rural surgery practice, it seems like you've been in Ludington since you finished up your training.

So can you share with us how you found yourself in

that practice and what you love most about it? Yeah. So it was kind of interesting about my third year of residency, my wife and I were talking and about where we kind of wanted to end up. And I grew up in small towns in Kansas. She grew up in.

In a bigger area in Bakersfield, California, and we both decided we had plans for family and things. We both decided we kind of wanted to raise our Children and in a smaller area, kind of counterintuitively. Kind of gives the kids a little bit more opportunities to do things because they can be involved in so many different things and I have to pigeonhole themselves into one little thing.

So, you know, my kids are involved in varsity athletics and very accomplished musicians and in the, you know, they do plays and they do quiz bowl and all sorts of other stuff. So, we kind of decided that we wanted to. be in a place like that for to practice. And the other thing is that, you know, before I decided I wanted to be a surgeon, you know, when I grew up I

decided that I was going to be, I wanted to be a family practice doctor.

And the nice thing about rural surgery is that it does give me that opportunity to have those longer, lasting relationships with patients. And so that's kind of one of the things that I really love kind of come back to this as one of the most difficult experiences, but also a wonderful experience.

When I, right after, right after I started practice, I got a a consult from somebody for a, one of the primary care docs for a young gal 25 years old with what they said was a rectal mass. So my first instinct and first thought was, hemorrhoid cause that's what a 25 year old would have. Well, no, she had a rectal mass and I.

told her on her 26th birthday, which was about a week later when I did her colonoscopy, that she actually had metastatic rectal cancer, which was difficult to discussion to have right out of right into practice. But the cool part and the kind of the longevity part of that was 10 years later, her son, who was five at the time turned 16 and needed to get his

First screen colonoscopy.

And so on the same day I did his mom's cause she was still alive at the time did hers as well as his first one. And, you know, you don't get that, that experience in a lot of places. And that was a really special relationship and, you know, those types of relationships really are priceless.

When you're seeing people for a long time and helping them do something, that's pretty, pretty substantial like that. That is a strong endorsement, not just of rural surgery practice, but rural surgery lifestyle as well. So you started the diving into it a little bit. Can you share with the listeners kind of what your case mix currently looks like?

What's some of the most common operations that you do and how it has evolved over time? Yeah. So Lots of bread and butter stuff. You know, we do a ton of good general surgery stuff, hernias, gall bladders you know, lumps and bumps skin cancers, breast surgery, colon surgery. I do anti reflux surgery.

So Nissen's toupees. You know,

fundoplications as well as big hiatal hernia repairs. And we also, all of us do thyroids and parathyroid surgeries. The main thing is probably you don't get at a at a bigger practice or bigger hospital, is we do lots and lots of endoscopy which is, which is nice because you are the one that's finding the colon cancer, so you know exactly where it's at.

And you can mark it, you know, exactly how you marked it in order to do the surgery. So those are, that's probably the biggest thing that we do. And then as far as how my practice has changed, when I first started practice, as you said, 18 years ago, as I'm aging myself, I kind of brought advanced laparoscopic surgery to our, to our little hospital.

They had done gallbladders laparoscopically, and that was about it. So I started doing hernias and colon resections and the dissonance and parasophageal hernias and, and all that type of stuff you know, with a straight stick, you know, laparoscopic things early on. And then over the

past, probably four or five years our hospital system decided to put robots and in all of the regional hospitals and things.

So I was staunchly against it at first. And my because I wasn't gonna add anything to my practice as far as I wasn't gonna do any new surgeries with it. But my wife being much smarter than I am said I don't need to, I'm too young to do the old fuddy duddy and I need to learn how to, how to use the robot.

So I did that. And so that's probably the biggest change in my practice has been kind of converting everything that I had been doing, you know, laparoscopically over to to robotic type of surgery. You know, we do have a huge right. And just earlier today, I did let's see, I did a. Incisional, recurrent incisional hernia, robotically and inguinal hernia robotically, a robotic gallbladder, a total thyroidectomy endoscopy and a lap epi.

That was my, that was my surgery day today. So kinda a lot of fun stuff. Yeah. That's awesome.

But yeah, just, just a little bit of everything and just a, just a great, yeah. It's not all like that every week, but you know, today something happened to be a good week. So you didn't do the thyroid with a robot, did you?

No, I didn't. I didn't. I think some people are doing something like that with it, but I that's beyond my pay grade. So fair enough. Fair enough. And I'm sorry, I forgot to ask earlier, how big is your group of general surgeons there in Ludington? And can you share, you started talking about the robot a little bit.

So what cases, if any, nowadays are you doing with straight six laparoscopically? Oh, so, there's three of us. We have three general surgeons here in Ludington. And let's see, I've got my Dr. Vandenduel. She was hired probably about seven, about eight years ago. seven years ago. And then Dr.

Langlois has been about six years. And the two of them have been with us and, and things. So there's three of us, which makes it, you know, 10 calls a month, one, one in three, every

third weekend. It's, it'd be kind of challenging at times, but as far as the things that we're doing, straight sticks, you know, it depends, still do a lot of gallbladders.

straight laparoscopically, especially if somebody else is using a robot. You know, acute gallbladders, a lot of times just adding it on, we may not have access to it because either one of the OBGYNs or one of my partners is using it. I'd still do, I do my appies straight sticks just cause it's, it's easier.

And a lot of times just, you know, the setup in the middle of the night, I know some places are doing them robotically and are having really good success with it. And that may change as. You're getting new scrubs and they're not getting the techniques of holding still with the camera while you're trying to operate.

That, that is challenging at times, but that as of right now, we're still doing that every once in a while. I'll have a, a big. You know, something that needs to be, you know, retroperitoneal mass or something like that, that needs to be biopsied. And I'll do that with straight sticks as well.

Again, just trying to fit something in from a schedule standpoint. So the next thing I want

to talk about with you, a lot of people hear about rural surgery and are like, Oh, those surgeons are doing the C sections. They're doing basic ortho, they're doing urology. It sounds like you've got, you know, OBGYN coverage 24 seven there.

And you know, rural is different in different places. So do you do any clinical work in your practice outside of the basic tenants of what we understand as being general surgery as a rural surgeon? I probably I think probably the closest thing to that is going to be just a lot of endoscopy. I think we get because we don't have any G.

I coverage at our facility. And so a lot of times I'll manage pretty easy to manage. You know, inflammatory bowel disease stuff if they're easy to manage with some oral stuff, and I don't have to put them on biologics and things. I can manage those long term. Most of those, though, I'm sending down to you know, see a gastroenterologist from that standpoint.

So that's a lot of, a lot of the realm is it falls into that

GI. standpoint. I do have lots of friends that are, that are in rural areas that, you know, you know, there's a few of them that are doing some basic, you know, hypertension and diabetes management and things as well, mainly because they just don't have the primary care docs there to, to do that.

I don't, I was, I kinda, We when I started here and when I was looking for a position, one of the things I was really looking for is a place where I didn't have to do OB. I didn't want to do c sections have that be a requirement of the job. The main reason was because I don't know, I'm not trained in the indications of when somebody needs to go, you know, to to have a c section and I'm old school and I don't want somebody else telling me when I have to operate.

And so that. That to me was was a kind of a hard stop. I know there's a lot of people that still do see sections and love that part of part of the practice is probably one of the cool things about rural surgery is that you can

kind of, you can kind of put that Add some of those things, you know, when you want to, when you need to kind of tailor where you, where you go or your practice that you do.

I do help out with a lot of C sections and sometimes I get called in if there's been a bad C section where they're having a lot of bleeding. It was probably about a year and a half ago, maybe two years ago. Now I got called in for, you know, one where there was just. Couldn't control the bleeding. And I needed, then they asked me to come in and, you know, stop stuff.

And I was able to do that. Luckily I had a lot of gynecology experience on on my residency. And so, you know, in the anatomy and things, even though your center is a little tighter than normal it's, you still have the ability to fall back on that to, to actually. You know, do what's right for the patient at that time.

So, so I've already broken the ice and mentioned to the listeners that you're 18 years into practice. And so, as somebody who's mid career, can you share a little bit of perspective about what the transition was like from

residency? into rural practice and then also talk about kind of the mentorship model that you and your group have, as you've recruited new members that are junior to you into your practice and the support that you provide them in their adaptation to attending life.

Yeah, absolutely. So when I started, you know, back a long time ago I started basically in a solo private practice. I had a cost sharing agreement with another surgeon that had been in practice for about 30 years. And so we were, you know, the old eat what you kill model where, you know, you didn't get paid if you didn't work and all that type of things.

We just office staff in a facility. And he was very good at Having, you know, he would answer questions if I had them, but didn't really have a good, I felt isolated a lot of times mainly because he was doing things, you know, 30, he was still coming in the middle of the night to take an appendix out.

It was not ruptured in a

nonseptic patient and things. And he thought it was, you know, malpractice that I would wait till the morning to do that. You know, in that, in that regard that changed as he got along, but Anyway, you know, he was very busy. And so I felt isolated quite a bit. And, and my biggest thing when after he retired and we brought him Kelly in and, and then and then Keith my two partners now, my biggest thing was to make sure that they did not feel isolated.

So I did whatever I could to make sure that, you know, the first times they're on call, I'm still in town, I'm not going anywhere. You know, I have open door type of policy to make sure that we, chat about cases, they can run things by me whenever they wanted to and, and things. And the bad thing was, is that my practice didn't slow down at all when they started.

So trying to find, you know, trying to find the time to actually spend it, it would probably be very good if there was a, if we had a true mentorship program. But I think that the biggest thing is just, just trying to have this open, open door type of policy. We

still sit down and go over cases together and stuff.

I'll bounce things off of them. They'll bounce things off of me as, as far as you know, what to do. And sometimes we do get into a situation where you can't do exactly what you want to do or what you were trained to do because we don't have that capability. You know, we don't have Interventional radiology most of the time in our hospital.

So draining abscesses and things can sometimes be very difficult or is a laparoscopic abscess drainage as opposed to a percutaneous I. R. drainage because of the just because of the logistics from that standpoint, but having that openness and having that kind of open door ability to just really look for, Make sure that they don't feel that isolation, that same isolation that I felt for starting practice.

Cause that was pretty, that was pretty scary at times. I can totally see that being the case. So you started to touch on a little bit with IR availability and things like that at your

hospital. When you're in rural practice at a hospital that has kind of. Some limitations from like a subspecialty availability standpoint, bandwidth within the hospital for regular beds as well as ICU capabilities.

What are some of the unique considerations that you have to have as a surgeon there about procedures that you. Will versus will not offer patients or, you know, patients with certain profiles of comorbidities that they have or don't have. What are kind of some of the bandwidth things that you have to think about as a rural surgeon when you know that technically you may be able to do a case, no problem, but maybe you worry about like the availability of some colleagues to be able to help in another specialty or the bandwidth that the hospital has to take care of that patient post operatively.

Can you talk a little bit about that? Yeah, absolutely. We deal with this all the time. Especially as our our population is an older population. And it's getting older and sicker just like most rural areas are.

Biggest thing that we we have is we don't have cardiology inpatient cardiology available.

We have a kind of a visiting cardiologist that comes up occasionally. And so that's that's the biggest thing from our standpoint. If we have somebody that's at a high cardiac risk for post operative issues and things, you know, the better part of valor. A lot of times is especially if it's an elective type of Procedure you know, better part of valor sometimes is to have them go down to, you know, down to Grand Rapids to where they've got those type of facilities and those type of specialties to do things.

Where it gets difficult is when we've got a emergent or a, you know, emergency or an urgent type of situation. You've got somebody that's at a high risk or moderately high risk, but they've got another issue and they, we can't transfer or we can't get people out. And so that's when we do have to kind of really have the discussion of, of how do we.

How comfortable do we feel extending our capabilities? Sometimes that ends up being,

you do the surgery and then you ship them, you know, as soon as you can, you know, post op for the, for the ICU care. I hate doing that because I like to take care of my patients post operatively. But that sometimes is a, is a possibility that we have to do just because of the, of the issue, right?

You know, you run into transfer issues as well as those things. So I do have a lot of conversations with our our hospitalist group and who's going to be on for a few days. During the expected post optic period for our elected patients that are at higher risk, as well as talking with their anesthesia providers for that as well to see if they feel comfortable with that.

And most of the time we're able to accommodate them. You know, we've got a very sharp group of people and having that little bit of optimization beforehand and just making sure everybody's aware of what's coming in. We can usually take care of a lot of things that, you know, we may not be able to otherwise, but, you know, it has changed a little bit back when we had the, you know,

primary care in our internals taking, you know, rounding in the hospital and taking care of their patients while they were in the hospital.

You know, I did some, I did some laparoscopic, you know, resections here and would bring them in and you get ICU, you know, they get central into the ICU the night before and get tanked up on fluids and get their central lines and art lines and all that type of stuff in and then do the surgery the next day and, you know, had everybody management and everything went really well.

But now we just don't have that. Just in part of that was because they were so familiar with it with their patients. They've seen all the time outpatient. We don't have that familiarity. So those type of things we don't do quite as often. But They were fun when we did them. I can totally see that being a challenge and frustrating at times, right?

Like you, you know, Hey, I can do this operation. I want to own my patient, but sometimes the best thing is to transfer them when you, when you need to. But there are obviously bandwidth constraints to that as well. So in that vein, kind of taking a

step back, one of the other hats that you wear is you're a committee member on the advisory council for rural surgery at the American college of surgeons.

So can you. Share a little bit about some of the current challenges that you see facing the rural surgeon that you may be directly experiencing as a rural surgeon and also at a higher level that the college is experiencing whether it be Rural hospitals that are closing converting to rural emergency hospitals and you know shutting down their inpatient services Workforce recruitment and retention things like that Yeah.

Yeah. All of those things are issues. We have a situation here in Ludington where the hospitals to the north of us stopped doing inpatient care and, and kind of went towards that rural emergency hospital model. And, and that, you know, kind of puts us in the center of a almost a 90 mile radius, not quite 90 miles to the south, but close to it.

A radius where you can get to some of inpatient

care and, and 90 miles may not seem like a lot, but. In February in northern Michigan, that can be just the same as, you know, 1000 miles almost, you know, the ground transportation can't go and the air traffic is not not flying. So that's a that's an issue that is kind of putting a lot of strain on some of your small to, you know, small to mid size kind of hospitals, I think, is trying https: otter.

ai And it's difficult for the community as well when that happens, because now they're inpatient care, which could just be a couple of days is now going to have to be 60 miles away and most of these rural areas are not flush with cash. And so these, these patients are, you know, on the lower end of the socioeconomic spectrum and that 60 mile drive or a 30 mile drive or 45 mile drive may be something that's unattainable for them to visit their family members.

Or even to just pick 'em up and bring them back from the

hospital and bring them home. And so those are lots of big issues that, that we're doing. Obviously workforce issues are, are a big issue. Luckily, we're fully staffed here in Ludington and and that's great, but that is not the case throughout the country, especially in rural areas.

So. People going to going into general surgery in general and then going into general surgery in rural areas has really decreased over the In the past several years. Lots of us are getting older like me. I'm not quite to retirement age, but you know, eventually I will be and and you know, having that those those young surgeons up and ready to take over is going to be important.

You know, with the workforce studies that, you know, that came out back in, was it March or April earlier this year? I mean, it's, it's that's going to be tough. You know, some of the shortages that we're seeing coming up And so I think it is kind of start young medical school. And I think even earlier than medical

school to get people interested in rural surgery and knowing what it involves.

I'm just starting a program with our local high school. It was one of the other hats I wear, as I said, of our local school board. And so I'm working with don't do that by the way I work with our, I'm working with our, our local college and career readiness person trying to get kind of a intro to rural surgery for future positions.

People that are interested in actually this. We have lots of nursing programs and allied health initiatives through our local community college, but nothing for physicians because those kids are too busy taking a P classes and or doing dual enrollment and stuff like that. So they're not doing those, those type of classes.

So, reaching out to them and trying to get some shadowing experience and some other things. So really hitting some roadblocks, but we're trying to do that. So I think that getting that yeah. Out there is, is is really Is really big thing. I think the other things really affecting real surgery and I heard this a lot at the at

the last college meeting in October of transferring patients and getting people to the bigger hospitals.

If it's something that you can't take care of, or if it's or you just don't have the room or anything like that, getting the bigger hospitals don't have the capacity necessarily to take care of all of our patients. And. You can't get them there. There's a significant shortage in transportation, E. M. S.

Services. And the ability to get people there. I'm running into that issue almost on a weekly basis here where we're having issues with either, either at our hospital or one of the other hospitals, regional hospitals in our system, just you know, the local EMSs are, are almost you know, They're understaffed, overworked, just like everybody from that standpoint, but so that's another big big issue that we have as far as challenges, but they're

not insurmountable challenges.

They're just, we have to look at them in a different, a different viewpoint than, than you do at a bigger institution at times. Makes total sense. We'll change gears here a little bit, and there are lots of current listeners to Behind the Knife who are trainees, whether they be medical students, residents, fellows.

What is your plug for why somebody should consider a career in rural surgery? I think it's probably the coolest thing, to be honest with you. I love being a rural general surgeon. I truly love it. And I love it for all the, the things that we talked about before, the variety of the practice that I do, the ability that I had to do the things that, that I, that I enjoy.

And that, that connection and that ongoing connection and, and that I get with my patients is, is just wonderful. That to me is, is the pinnacle of being a, being a physician, being a doctor

and, and that is probably the thing that I just love the most is, is those relationships. I will say it's not for everybody.

You know, there's, I cannot go to the grocery store. without seeing, you know, several of my patients. I've had patients that have just been up for closed, hold their pants down to show me incisions that I've made on their, their body to make sure, you know, say, does that count for my postdoc visit? No, it doesn't, you know, in, in the aisle of a grocery store or, or out and about.

And so I really liked that having that connection to the community and being involved in the community like that. Some people may not like that. It. And so if that's not where you would, you know, where you see it, that's probably not the thing for you. But I truly do think that this is for a person that wants to have that community involvement.

to have that ability to to have the breadth of practice that you that you have and can have

in a rural area to be involved with. You're expected to be involved with hospital leadership. You're expected to be on the med exec committee. You're expected to be in all these things to help to help move your hospital forward.

You're also expected to help do some things with your community as well. Being on foundation boards and all sorts of other things are just kind of, you get that real sense of belonging. And to me, that is that's priceless and something that I just, just really, really loved. So I, I think in that regards, that's, that's probably the, you know, the best thing you can take gallbladder out anywhere.

You know, but to take the Bob lighter out and have somebody that comes and tells you, you know, every, every week when they see you checking out the grocery, they feel so much better. Because you did that for them. You know, that type of, that type of interaction and stuff is, is, is priceless. That's awesome.

And can you share one more time? What, what cases you did today? I mean, when you outlined

the beginning of our, our chatting, I was like, oh my goodness, I did a, I did a robotic recurrent incisional hernia, a robotic inguinal hernia, robotic gallbladder, a total thyroid ectomy for, a bunch of big thyroid nodules that were suspicious.

I did an laparoscopy. You're not going to get that practice variety anywhere other than in rural surgery. That's awesome. Yeah. So to close things out, can you share with the listeners, maybe one interesting or cool case that you'd taken care of that may be the typical community, non rural general surgeon or surgical sub specialist doesn't routinely deal with that comes to mind?

Yeah. You know, I was thinking about this and I I actually was looking back at this probably about a year and a half ago. I had a, I had a gal that came in, actually was up visiting from, from another larger city came in and had a had a gastric volvulus, an incarcerated gastric perisophageal hernia with

a gastric volvulus.

So, and you know, I mean, I've done lots of perisophageal hernias repair, repairs and stuff like that, but not one that was acutely incarcerated where, you know, the stomach was, you know, three times the size of my head and in the chest and she was short of breath and all that type of stuff. And so, I went in and actually was able to fix that, fix it robotically, was able to get everything down get at least enough of the straightened down with men's YouTube down and drain her stomach.

Which made a big difference and then getting the rest of it down and reducing it, repairing the hernia actually put in a piece of mesh to reinforce the occur there and, and, you know, didn't have any, any studies for, for things. So just basically did a gastropexy and I think I did a anterior little dora fundaplication to help us.

I shouldn't have so much reflux on it, but. She was so appreciative. And, you know, in a bigger institution that would probably go to thoracic. That would go to, you know, your core gut specialist. That would, that type of stuff would go there. And so something like that was really cool to be able to do here.

You

know, things like, you know, even just Several months ago, I was able to take one of my partners through a bleeding duodenal ulcer. You know, that was that was, you know, bleeding pretty bad. They'd never done one in residency because they go to IR for embolization and things like that. And so we were able to go and we got it cleaned up.

Got it sewed off. Everything went great patient, you know, did wonderfully and, and things like that, and then the bigger institution that would probably be done by your acute care surgeons or, you know, or, or IR or GI would try to do some, some things, you know, and so those types of things are, are pretty, pretty slick.

Now they don't happen every day. Thank goodness. But they are but they are kind of cool when they did. And when they do happen and you're able to really, really make a difference for for, for people. So. That's awesome. Well, Dr. Autry, thank you so much for taking the time to talk with us about your perspective and rural surgery.

We greatly appreciate it. I think the listeners

are going to be enlightened to what rural surgery practice and lifestyle can really look like. So, we appreciate you taking the time and I will turn it over to you to tell the listeners too. Oh, the only way to do it is really in the rural practice, but you know, dominate the day.