Behind the Knife Rural Surgery Series: Ep. 2 - Rural Surgery Training

residency. And as a fellow of the American college of surgeons, Dr. Brad Muncy is from Dingus, West Virginia, went to undergrad at Marshall University in medical school at the same place I trained, which was West Virginia University School of Medicine. And like I said, is a current PGY 2 resident in Marshall's Rural General Surgery Residency. Thank you guys for taking the time to chat with us today. So to jump into things, can you give us a little bit of background about both of your upbringings, what brought you into medicine and eventually surgery and into rural surgery specifically? Oh, I'm old, so that may take a while. We got all the time in the world. I don't ever remember wanting to be anything other than a doctor. Growing up and nobody thankfully told me I couldn't. So, off I went to Marshall and I didn't want to go far from home which is why I stayed there for medical school. And they were big into

training primary care and rural doctors at that time even. And financially the, we were a little concerned, my parents were, and Logan Regional sort of sponsored me. They paid for my medical school, which was great, and so, I stayed at Marshall for training, of course, like you said, and when I finished there the hospital was in some bankruptcy proceedings and was being sold, and they wanted me to, you know, get be private practice while they, quote, would take care of me. And my chairman, Dr. David Denning, who is big on training bread and butter rural surgeons, came up with the idea of, what if you go down there and work for me? And he asked the dean. The dean said yes. We talked to the administrators at Logan and they said, well, they had no problem as long as I'm on their campus. And six years later, they brought me a contract contract. paid in full. So I was lucky enough

to come to be at Logan where I've been for 22 years debt free. That's a long story. Brad, what attracted you to rural surgery residency and eventual rural surgery career? So I, as you can tell, I grew up in Dingus, West Virginia. Any place named has to be a rural small town, right? I had the pleasure, actually, of shadowing as an undergrad when I was deciding, you know, what route I was going to take as far as a career, I'd landed on the fact that I think I wanted to be a doctor. Wasn't really sure it hadn't had a lot of exposure into different specialties within medicine. I actually met Dr Cisco here at a oddly enough, I was in a play with her daughter. So that we met up and I got the opportunity to shadow her and that was the first time I was ever in an O. R. First time ever seeing a surgery was in Logan Regional Medical Center. I remember at that time, too, she said, you know, I want to have read, I think I said something to the line of, well, let me know when you get it. And

lo and behold, several years later, I, Get the, Hey, we have it now. So that it's kind of a full circle thing for me to be in Logan. That's one aspect of it being closer to my family. And then just working in a rural population, I find it a little bit more rewarding than the hustle and bustle of some of your tertiary care centers. You get to develop good relationships with patients, and then not only that, but you, you get a unique opportunity with this program to, one, get early operative experience with it being new. That was something that was attractive to me at this program. And then the other was the fact that you get training in some subspecialties that you wouldn't get otherwise. For example, we Scrub with orthopedic surgery we scrub and do C sections, some gynecologic procedures, and you know, hopefully we can take some of those more basic procedures out into rural communities where there's a need for it and be able to perform them. So I thought that was cool. Absolutely. Similar

to you, Brad, I would not be a surgical resident if it weren't for the rural general surgeon in my hometown who I happened to shadow in high school and told myself that whatever I had to do to one day find myself in similar shoes as his is what I was going to do. Didn't know it entailed a bunch of. Residency training and medical school and all that stuff. But here we are nonetheless So we talked about marshall a little bit generally Can you talk to kind of start things off about the program a little bit about? marshall's residency program and its relationship with The rural server residency that y'all have. Can you just kind of give us a high level overview of the training program there and the environment. So our curriculum is the exact same is actually modeled after the curriculum in Huntington when we, when they decided to do this, that made the most sense to us. The, the other thing that we do is we we remain in this program is we continue to support

them as they go through their current program and then in the future in the, these next few semesters, we hope to bring them back into the program as well. So that was that was just a story for us, but you know, kind of the integrity of surgery program. Actually encompasses several hospitals in the Huntington area. So there are multiple health system or the hospital systems there that the general program works within. So, this was kind of just adding another hub to that. It's just a little bit further of a drive. Fair enough, we participate in like M and M, for example, we participate virtually from Logan when we're there. So we all share the same M and M grand rounds and I've actually taken the privilege with our didactic. Being with the education chief in Huntington to make sure that the topics match from week to week. So no matter if I'm going back and forth between Logan or if I'm in Huntington, it's not like I get repeat topics discussed in didactics or I miss a topic. It's all very fluid. That's great.

And Dr. Cisco Goff, maybe you can talk about this a little bit. Can you speak a little bit about what the impetus was behind starting a rural surgery residency specifically and maybe get into some of the nitty gritty logistics of starting a program like a rural surgery residency? Well, like I've already said, Dr. Denning's goal is to For years has been to train a good bread and butter surgeon and the trend is now for everybody to specialize. So we've had a lot of conversations about how do we get Residents to want to be rural surgeons or I don't want to say just general surgeons, but a general surgeon and you know, for years, we've talked about it. There is a shortage in 2019, 60 percent of rural areas did not have an active general surgeon and everybody realizes there's a shortage, but nobody's doing anything about it. So, we decided finally to do something about it

and Dr. Weiner, who is our DIO in Huntington, she started with medical students and realized that wasn't the way to go. She wanted to follow it up with a resident based sort of program. So, she made a call to Dr. Denning and said, Hey, I want to do a real surgery residency. What do you think about that? Will you support that? And she said his answer was yes. And he hung up on her. So, from that conversation, and, and, you know, me begging for years with the, program directors to just send them to me so they could see what it was like. All this happened there was of course a lot of work done behind the scenes. I was fortunate to have, you know, this good sized university medical school behind me and the big GME office and one particular lady, Joanne Raines, who apparently is a, Professional at grant writing and she secured a couple grants that gave

us the money to Do the things that we needed to do to get the program up and going And I would imagine it was y'all's gme office at marshall that kind of helped with the acgme stuff getting accredited and all those Good things. Yes, we um um There was hours and weeks where we had to figure out a way to count cases You You know, which is something people in my little hospital didn't routinely do. So we had to kind of do it the hard way to make sure that we had enough volume and enough cases to satisfy all the requirements. And I learned a lot during that process. There's a lot of little things that you're Details that, things you have to have, like 24 hour access to food, and a refrigerator for breast milk, and just weird locks on certain doors. So, it was a process, but those guys, I think Dr. Wehner has, How would she say today?

29 fellowships and residencies that she takes care of. So, you know, this was, this was old hat to them. I was the, the green one. Fair enough. And so you talked about it a little bit, but were there any major hurdles or challenges that you encountered when trying to set up this unique training program that maybe you anticipated or didn't necessarily anticipate? Yeah, we, the. We anticipated this. It was housing. Because these guys sort of have to have two homes, basically. Some of them have families, some of them don't. Some of them chose to buy homes in Logan and rent in Huntington. But financially, we realized that was going to be difficult. Our community is very much behind us. But the landlords also like to collect rent and you know, the money we secured couldn't be, can't be used for things like that. So, we're currently in a process that

involves So many people that I'm not even going to call them all out by name because it's become much bigger than me, but some federal money has been granted. The city of Logan has gotten involved with some vacant buildings. And we're just in the process of developing a white coat community for not just our residents, but for medical students who rotate through for locums, doctors who may come in. So the city of Logan has a vision. We have a vision, the hospital would love to see it happen too, but it is a process. I can believe that and see that in your face. But it goes to show, go ahead. No, that's been our only hiccup so far. It just goes to show that, you know, all the support that y'all are getting locally from the community members, I feel like that in and of itself just encapsulates what having great health care services looks like in a rural community and kind of

the community that that builds in doing that jumping back into kind of, you know, the training paradigm at multiple institutions, rural tracks within general surgery residencies. Is that a distinctly different experience than what y'all are getting your residents in the rural surgery residency program, or are those more similar way to think about those two? I would say they're they're distinctly different. I mean, granted, I've never participated in a rural track before. This is the only residency that I know. But that said, you know, we spend 51 percent of our time in a rural hospital setting we mainly it's where we do most of our bread and butter, general surgery, and then, like I said, some of those sub specialties that we have the privilege of scrubbing. And then when we go to our our sister program, and Huntington is where we get most of our. subspecialty training, our vascular we travel to UK, I think, for transplant, and we do all the same

training that a standard general surgery residency does, with the exception of we do more actually. But, you know, back to the question, question. I think a rural track definitely gives you a little exposure, but I think in order for you to fully appreciate what it means to be a rural provider, you kind of have to immerse yourself in a way that these rural tracks don't allow you to. You just need more time there. Makes sense. For sure. From what I understand is the amount of time. Yeah, the biggest difference she's saying is this the time difference. That makes sense. So, would I be right in operating under the assumption that, Brad, you and I are taking the same ab site every year that we know and love well, same written and oral general surgery boards, all that good stuff, and at the end of our training, we're both going to be, general surgeons, but we don't necessarily spend similar amounts of time in the same in practice setting, I guess, is that correct?

And I, you know, I think that highlights a bigger point too, that you know, it was a big topic of discussion at ACS clinical Congress. I think you were there as well for these talks, but you know, there's a whole field of rural surgery out there that, that looks very different than what you think of when you think of general surgery at the university setting. And, you know, people find niches within their community that they're able to feel as a general surgeon, sometimes fall under other subspecialties, that kind of thing. So, you know, it, it's there, there's been talk of, you know, is, is rural general surgery or this kind of community general surgery, its own thing, should it be its own fellowships that you can practice more broadly, like those kind of talks have been brought up and in meetings like that. For sure. Sure. And so. We can also safely assume the same thing in the sense, I know you have an interest, Brad, in colorectal surgery specifically. We can, you can be a rural surgery resident and if you desire some extra subspecialty training that you maybe will eventually take out to that rural community,

you can apply all the same for a colorectal surgery fellowship, for a trauma critical care fellowship, for a vascular fellowship. Is that correct? Accurate. That's correct. Yeah. I, and you know, I think there's, there are fellowships and different subspecialties that I think would be more amenable to a rural setting than others, obviously, you know, some high acuity vascular or cardiothoracic surgery. I don't really see sitting well in a community hospital just because you lack the resources you know, to be able to support that post operatively even. But Yeah, I think that there are definitely some subspecialties out there that would be beneficial even in a rural setting. Colorectal is the one that I have a passion for and comes to mind for me, but trauma, critical care, those things, I mean, those are all good tools to have in your pocket no matter what hospital you're working in. Makes sense. And so a surgical oncologist at Logan several years ago, and he did a lot of general

surgery, but ultimately, this is the, this is the, the opposite end of that. Ultimately, he chose to, to go somewhere bigger because we didn't have the radiation therapist and all that kind of stuff that he needed to go along with his specialty. So, unfortunately, he chose to, to leave. So you'll have that too. So, in your mind, Dr. Siskogoff, does this training pathway, a rural surgery residency specifically that's, Brad kind of highlighted the distinct differences between what y'all have there and some of the kind of designated rural surgery tracks within general surgery residency. In your mind, does a residency program like yours prepare people clinically better for rural practice or? Is it the case that you get that exposure and ingratiation within a rural community as part of your training as well that kind of

prepares you both personally and professionally for what rural life looks like, or is it both? It's both. It's both of those things. I think, of course I'm going to say this, but I think these guys are going to be more prepared than the traditionally trained general surgeon. I know when I came out, Right, of a relatively traditional program and came to Logan, I found myself going, Ugh, nobody told me about this, right? Nobody told me that I had to learn how to package up a really bad trauma and get it an hour and a half away, right? So, these guys, I use trauma as an example. They learned how to punt. In Logan, and then they learn how to receive in Huntington. So I think they're getting a broader based education that will serve them well in that community that, you know, where they want to be immersed and develop those personal

relationships and things. Yeah, we definitely get a very unique perspective. Like she said, being on the sending and receiving end of things like traumas, for example, like you, you start to appreciate things from like an injury pattern standpoint differently, what you can keep, what you need to send. And then not only that, but Going from a larger place where you're more of a cog in a greater machine to being one of the couple people that you know that is the Department of Surgery in a small place, you get a view, a thousand foot view, so to speak, as a resident that you normally wouldn't get when it comes to Systems based things within hospitals, how to operate with other specialties and medical teams within the hospital, how to communicate with administration about different instruments you may need or different equipment you may need. And I think that's something unique to this that I don't think other residents typically get in a, in a larger setting.

And you very well may be the, the trainee that gets to scrub the operative trauma for the general surgery problem as well as the fixation of whatever fractures they may have and do the bladder injury repair, all those things. You get all of those clinical experiences, which I think is really cool and unique as well. Cause at the bigger centers, it's call ortho, call Euro, call all these folks. Right. I think part of our curriculum ought to be like a whole day on the what. What not to keep. You have to learn what, what not to do also. And I will say too, to your point, like the the other attending surgeons in like OB GYN, ortho, what have you, have adopted us with loving arms. It's been really nice to, you know, get, go in and learn how to do a carpal tunnel release or you know, learn how to do cystoscopy or a few c sections under your belt, just in case you might have to do so, one in the, in the place where you're practicing eventually, like it,

And they're awesome about not amusing you too. This is true. That's good to know for any prospective residency applicants. In that vein though, So, Dr. Siskogoff, can you maybe share a little bit about what you're looking for in a rural surgery applicant and then chase that with Brad, can you talk about kind of your decision making between going to the program you're at versus a traditional general surgery residency or a general surgery residency that has a rural track? We have the U. D. It's a task of, you know, in a 10 minute conversation virtually, trying to figure out who will simply fit in a program like this, because the way we go through the match process now, there's a lot of people who probably really aren't interested in, in, in rural surgery. So first we have to weed out those, those folks. And then, you know, it is just a gut feeling on

who's going to fit in. Right, so because everybody's got the scores and the research and the papers and all that stuff, but I think for the most part, we're looking for the, the fit on my end. As far as deciding this alluded again to just the broad training that I'm getting the early operative experience. Like, those are all big pluses to me. My, my mother's home is around 20 minutes from the hospital that I work at. So that was convenient for me as well. And then one thing that I may take for granted sometimes is, you know, the relationship that you can build with your attendings in these areas. You know, I'm very close to Dr. Cisco, Dr. Paul. And you know, I think that's invaluable because they're just a call away. Always. I can call them, ask them anything. I'm not afraid to ask him. There are no stupid questions. And I've learned a lot by having the kind of relationship that I do with my attendings. So that was, and I knew Dr. Cisco even coming into this. So that was also a big draw to

this program for me. Absolutely. I could see that being the case. So if there are interested potential applicants out there in the world listening to this episode or interested surgeons who are passionate about rural as well and would want to replicate this program, are there any resources on Marshall's? training websites or any resources out there that y'all could point them in the direction of to learn more about your program specifically in rural surgery training. Yeah, so a quick Google search for Marshall General Surgery Residency, Rural General Surgery Residency. We have our own page within there. It's, it's along with all the other residency programs offered at Marshall. So that has all the information on, you know, traditionally you'll see schedule outlines, just kind of a basic information about applying. We do go through the same exact match process as everyone else. We just are the first program to ever actually have the designation of rural. We're

very proud to be the first separately accredited rural general surgery program. As a fellow West Virginian, I'm proud to just even be associated with you guys and the work that you're doing. And I truly mean that. So to close, one thing that I've been doing in this series when I chat with folks, because rural surgeons just have such an awesome practice variety. Can you share an interesting or cool case that you've taken care of recently that might be a surgical problem that a typical non rural or community surgeon Takes care of or a surgical sub specialist that doesn't routinely deal with this problem. Maybe each of you could share a cool case We talked about that this question for a minute actually and you know It's not that there's any particular special cases that happen It's just the fact that you know with what we do we some days we come in and we may be doing an excision of a cyst from an area we don't typically work in, or, you know, we may

have, right yesterday. It's just very broad. We're doing APRs. We're doing breast surgery. We're doing a lot of, you know, subspecialty surgery, but it's just, that's our bread and butter in oral surgery. You kind of take care of what's in front of you. Probably the coolest thing is how Sick our patients are. Like the things we handle sometimes it's not so much. Oh my gosh. It's this case. It's this colon It's oh my gosh This person left this like this for this long and and here we are trying to trying to fix it And sometimes we have to fix it because they can't get anywhere else you find yourself in that situation going Well, this conversation has been awesome, it's been particularly in enlightening for me, who's got an interest in rural surgery, but also I'm sure the listenership of

people who, whether they are surgeons in their very niche and specific practice who have no semblance of what rural surgery is actually like to medical students who may be interested in joining y'all in your program. So greatly appreciate you taking the time to chat with us on behind the knife. Well, thank you for having us and dominate the day.