Rural surgery 3

Hello, behind the knife listeners. This is Cody Mullins. I'm one of the surgery education fellows with behind the knife. And today we're capping off our rural surgery series with another conversation with a rural surgeon, Dr. Randy Lehman. Dr. Lehman was born and raised in Rensselaer, Indiana. He went to undergrad at Purdue.

medical school at the University of Cincinnati and matched at the Mayo Clinic for his general surgery training, where he trained in the rural surgery track and graduated in 2020, and has since relocated back to Northwest Indiana since finishing his training. Dr. Lehman, thanks for joining us. Hey, thanks for having me.

Looking forward to it. So you've gone back to Northwest Indiana where you grew up. Can you talk a little bit about how you found yourself in rural surgery practice and also maybe share what you love the most about it? Yeah. So my whole dream was to come back to my hometown and be the surgeon in my hometown.

That dream sort of morphed over time, but I thought that I had a great upbringing and I loved the small town. I loved the atmosphere, the mentorship that I got. Very. Passion about rural America,

I kind of think that that was propagandized to me from my parents because my dad was a singer, had a little singer songwriter gig on the side with my mom.

And when I was very little, they got this seed corn company deal where they traveled and did a bunch of Christmas programs or whatever. And so I mostly remember this from pictures and probably my, My unconscious psyche in the back of my head where it's been burned in there. But basically I remember toddling around and seeing my parents singing this land is your land and the great American farmer and these slideshows of like wheat fields and red and green tractors and barns and stuff.

And so to me, like, and I grew up on a farm. There, I think there still is sort of like a just a moral good value thing first off about working the dirt, living out and seeing nature and, and seeing agriculture is a very healthy

way to exist from a mindset perspective. I mean, also from a health perspective.

And so I just. I always wanted to be back home. And I liked it there. I thought about farming. I thought about a lot of things. I'm a sort of entrepreneurial person. But there was a the Lily foundation gave me a scholarship to go to college and I remember sitting down in that interview and telling them.

I am going to come back home and make a difference at that time. I didn't know that I was going to be a surgeon. I didn't actually know, I didn't really want to go to college. I, my parents made me apply for the scholarship. So then I get the right full ride. It's like, okay, you better go. So I ended up going to Purdue only because my buddy was going there and I ended up going to pharmacies.

pre pharm only because it was, it, they have a top three pharmacies program. And my, my principal's wife was a pharmacist, right? So these little things happen to you. It happened to me anyway. And and I had four semesters of declining

GPA and hated it and did not get into pharmacy school. And I knew that I just had, you know, slept through my anatomy exam and like, literally wasn't.

I was not trying or applying myself. And so I, I said, well, I'm gonna go to med school, you know, and I'm basically went to med school out of spite. And I remember my, my counselor telling me, don't, you don't want to do that. You know, you look at your grades, you're not going to make it, you're not cut out.

And of course, then I switched and then I got straight A's and then I, you know, got 96 percent on the MCAT and just, you know, it wasn't for lack of ability. It was just for lack of trying. Then went to medical school, thought I might do ER. But I didn't really know I got there. It wasn't long before I fell in love with surgery.

And then I remember being at university of Cincinnati children's hospital, my pediatrics rotation as a third year. And like, really, that's when you got to commit. So I made a pros and cons list. And on that pros and cons list, it said I had, I had written down the different specialties and

if it wasn't something that was needed in my hometown, it wasn't on the list.

So I had basically family med, er, general surgery. And. There's other things you could do, but those would be the most in demand things in rural America by far. And so I remember just imagining somebody coming in with appendicitis, diagnosing it as an ER physician, and then calling the surgeon to fix it.

And that was what's going through my head. And I wrote as a con under ER will not be a surgeon, you know, and so at that moment, it's like all the cons for surgery. It's a longer residency. It's a harder residency, you know, the perceived potential call burden and things like that. It was like, suck it up.

This is a job that you want. And so then I just did it. And one more thing about that is that I also took some, I don't know where it was with like an aptitude test online specific for medical students deciding what specially they want to do. And I remember I took the test twice because I wanted to sort of make sure that it was

valid on different moods, you know, but it said, I like to do.

I do not like to do longterm. Care for a patient, like I like to do episodic care where I see them for a problem, fix it, dismiss them. So rheumatology was the lowest, right? Because rheumatology never fixes anybody. They just manage a condition forever, which makes sense for my personality. And then it also said you really like to do procedures, but you don't love those like six, seven hour make a wax, you know?

So things like cardiac surgery thoracic surgery, those kind of things. Things were like down a little ways. General surgery was kind of like hovering in there. But the funny part was ENT, ortho, urology, OBGYN, those were really high. And those are more kind of quick, easy, you know, general surgery, you can take it multiple different ways.

But then after I made that commitment to general surgery, then I discovered that, Hey, there's all this

information out there and interest in rural surgery, specific rural surgery training. And I kind of discovered it at the 11th hour. And I ended up interviewing at 16 places for general surgery, three of which had a rural surgery track.

And I ranked them one, two, three. The practice that I now have is All of those things, ortho, urology, ENT, plastics, OBGYN, but out of general surgery, and it's all the quickest, and easiest, and lowest morbidity things, which is the most appropriate surgery to be done in this small town. And so it really, for my personality, I, I, When I tell you that story, it's not hard for you to imagine that I actually believe that that God had a role in opening and closing doors for me.

And that's how I ended up. And I sort of have to tell you that story before I just like, boom, hit you with that. But that's really what I believe. And I, I'm loving it. And then there's been some challenges and things along the way.

But I was able to move back to the farm that I grew up on. I have Highland cows and spot pigs and, you know, Rhode Island reds, and my kids are loving it out there.

You know, we shoot deer off our own property. And I know a lot of the patients, a lot of them can't help, but call me Randy. Cause they like literally wipe my butt and things when I was a kid and it is everything that I sort of dreamed that it would be, except for maybe wrestling with the corporate medicine, but you know, that's just sort of a reality of today.

Yeah, absolutely. So you started to zoom in to kind of where your current setting is. Can you talk a little bit more about the town that you work in, which is the town you grew up in? I hope I got it right when I said Rensselaer. Yeah, Rensselaer. You nailed it. Nailed it. Can you talk a little bit about the town as well as the hospital and the resources that you have to work with?

Yeah, actually, if You think most of your audience is a trainee? I think so. So if you're a trainee

and you're listening to this because you're interested in practicing in rural America as a surgeon, first off, if you have student loans first off, you're very needed in that area. And It's a great practice, and it can be a great lifestyle, and even though call could be every other or every third, it, first off, it doesn't have to be, and secondly, it's not that much of a burden, because the calls are so few and far between, so about 1 percent of every ER visit needs a doctor.

Surgery console so that there's some numbers for you, like a small town hospital might have four to 10, 000 E. R. Visits a year. And so you can quickly back into the numbers, even if it's 10, 000 visits a year. You know, maybe only a that works out to be a hundred, you know, of those need a surgery consult, which is like one every three days.

And some of those aren't going to be appropriate for your facility anyway. So, you know, maybe

you have, that's a pretty busy rural ER and maybe that means 50. appropriate consults per year or something. So don't be scared by that. The reason I'm phrasing it this way is that there are, there's potential for some student loan repayment or some sort of incentive for you to come and pay is actually pretty good.

It's better in rural America than it is in the cities for the most part. Sort of probably depends on what exactly you're doing. But I wanted to come to my hometown hospital. And that town is now 6, 000 people, 30, 000 people in the county. There was a county hospital called Jasper County Hospital, and that's where I was born, on the second floor.

That hospital sold to Franciscans. It's the, I don't know, Franciscan Alliance or whatever. That's the chain. In 2015, which is also the year that I went to residency. So I called in July, like June, July. I'm like, I'm going to be home for like a month in between med school and residency. Do you want to meet?

Well, the County hospital was actively being

sold at that time. So the old CEO told me, we got to figure this out. We got to get you back home. But unfortunately, this is what's happening and we're selling to the Franciscan. So you have to talk to them. So I contacted them, radio silence, nothing, nothing, you know, finally, I kept messaging them back and then they were like, yeah, you could come.

Actually, that'd be great. You could meet our physician recruitment team. They're in Indianapolis, right? It's two hours away. And then I'm like, okay. Okay, you guys have no idea who you're talking to, what I can bring, you do not understand this hospital. And it's the only critical access hospital that they have, and actually I was right, they don't understand it.

Now, ironically, it's the only profitable hospital in the region last year, which is kind of funny. But basically what happened is, they said call us back when you're a four or a five, and we'll talk about You know, a job or whatever. Well, I had student loans and I knew that I could get loan repayment and stuff.

And I wanted to get them paid off as soon as possible.

And I just, at the time, I just said, okay, fine. And I sort of let it be. But then I went to Honduras on a mission trip for second time with my mentor and they had, he's from Campbellsville, Kentucky, Eugene Shively. And they have a educational stipend down there.

So he said to his CEO after we came back from hunters second time, we got to try and recruit Randy to come down here. So, they offered me that deal, which forced me then to kind of think about it again. And this is as an intern. And I then contacted Merritt Hawkins, that's a physician like a recruitment firm.

There's lots of physician recruitment firms you could call. Found another place in Missouri where, but all of these places I was planning on going to work for a four year contract and then come back home and start an independent practice in my hometown. That was my dream. Pay off my loans, save up some money, come back home, be independent.

Well, we also got pregnant, I got married intern year and then we

got pregnant immediately. And a lot of things, kind of one thing led to another. And then after my daughter was born, especially it became real obvious that I wanted to come back home. So I went on Google Maps and I zoomed out of Rensselaer and I searched for a hospital and there was like five hospitals, sort of like a five dice.

And I called all those hospitals. And what I learned from that is if it's an independent hospital, they know your value and they want you and they're willing to pay. to set up some terms that are mutually beneficial and be flexible and, you know, whatever you need. Like if, if you have a spouse that needs a job, you know, that's also in healthcare or, you know, relocation, or there's some sort of a, Like a stipend that I had or whatever, like they were very flexible with me.

And two of those hospitals were independent hospitals. And I had contracts from both of them. The other three that were part of a chain said, call us back when you're a four or five. So, so that's my lesson to your listener. If you're a resident and you're early stage and you are considering doing something like this.

The other thing is if you. If you want to sign a contract early and get some sort of student loan repayment, I think that's a very smart idea and you have the potential, even if four years kind of changes things and you want to do something else, some other hospital potentially would buy that. out as well.

So, I mean, you've got to know what you're wanting to do, really. I don't, I'm not advising you just sign some contract and not intend to do it. But I don't think you lose that much by making that commitment. As opposed to maybe like a military thing, you're not going to get bought out of that. But something private like that could be bought out.

So I did that and I went to the next county over from my hometown, which is Pulaski County. Took a job there, a W 2 employed job that everybody can understand. My loans paid off in four years. So, my plan was to go there and then go to my hometown and be independent. And I carved it out of my non compete and all this

stuff.

Then another series of things happened. So my first off, I was not that busy because the county I went to is a county of 12, 000 people. Count of, you know, 1200 people. There were three surgeons there. I mean, third, I think they thought that maybe one of the surgeons will be gone before I got there or something.

Who knows? But they just, again, recognize my value and hired me. So, so, I wasn't super busy right out the gate, and it was 2020, so that's when I started. So, privileging took a while, and this is another thing they don't tell you in residency, and you should definitely know about, is call your hospital before you get there, That you're going to be operating at in like, as soon as abcite's over, okay?

Basically on your chief year, or whatever, call them and ask for the credentialing department and say, what needs to happen so that I'm credentialed

with payers so that on day one I can see patients and operate? That being said, it was blessing in disguise because, you know, of course, I just kind of had a chill summer and spent a lot of time with my family and decompressed and still got paid.

So that was nice. But then I got, I went ahead and got credentials at my hometown hospital, just planning ahead. That's what, that's all I was planning on doing. And as I was doing that, there's a surgeon that was operating here who had an unfortunate Really severe stroke. And I was becoming friends with him and he actually signed a thing that said he would like take care of my patients if I died or whatever, you know.

But then he ended up kind of having that happen to him. And he was doing wound care two days a week at that, at my hometown hospital. And then that became sort of like an emergency. They, they had another surgeon doing general surgery, but nobody for, for wound care. So they asked if I could do that. And then I went to my hometown, to the hospital that I was working at.

Next. County over and I explained the situation and again, like I said, they were

flexible and they let me start an independent practice on the side while I was still employed with them, like a limited independent part time practice and their, I think their goal, first off, aside from just being great, was just to help me see that I could do both, like, so that I could be more of a longterm solution and that, The way that all plays out is I ended up signing a renewal with them, which I'm now in my second contract with them with this independent practice on the side.

And so then I, there's a bunch of other stuff. I could really tell a long, longer story than this, but basically a building came available. I bought it. I, I built a brick and mortar practice from the ground up and I had overhead Overnight of 600, 000 a year and I had I hired a nurse practitioner I I had overall gross receipts coming in of 350, 000 a year so I was losing like 20 to 30 grand a month

Just to keep the bill bills paid and not paying myself anything with my genius private practice thing I would not recommend doing that In 2024.

I had to learn this for myself. I also didn't really look up what I was going to get paid for anything that I was going to do, but I didn't realize essentially everyone is now being subsidized on your professional fees by the hospitals. They're paying you everything that they're collecting on you.

And then some and then you're So in order for you to make the same amount of money, I mean, it's impossible to make the same amount of money when you're out on your own because you have overhead and then you're going to be paid less for the actual work you do. So it's, you know, that's totally stacked against you.

You could work harder, but it, the numbers are so ridiculous in my situation that if I quit my other job and, and came here independent, I thought I probably would. Make money, but it would be about a quarter of what I was making at my employed job. So that's so

silly. So that was a very stressful period of time that I learned from, and hopefully you don't have to make the same mistake.

And then it worked out again, serendipitously, where I contracted my business to the hospital that I grew, that I was working at that was in that town. And now I go into that hospital as a. 1099 independent contractor. I pay for my malpractice, but essentially not much else except for I've got some admin staff that they do a lot of things for me though, you know, like, yeah, it's mostly my practice, but, but anyway, I go in and I use the hospital's nurses and their computer system and their supplies and equipment and scalpels and bandages and Even for the clinic procedures and then obviously use their operating room and at very little cost to me.

And now they bill for me as well. And then they just keep the collections and pay me a daily rate that's got a kicker on it. And that works out much better. So I had a great year last year.

And then I ended up having two people in two adjacent counties who came to me that are both doctors. That I knew professionally.

And they said, we know your passion about rural surgery. We have no surgeon in our small town hospital. Would you come to our hospital too? Now for one of them is IU, one of them is Ascension. So these are big chains that normally control and own. Surgeons, right? They want to but they were very in a small town.

They're very willing to say, okay, what's your model? And I said, I'm going to do it this model, or we're not going to do it. Okay, fine. You know, and now I have a daily rate. It's actually very low risk for them because if I don't show up, if I'm not working there, it doesn't, I don't cost them anything. But when I show up, they, they bring in.

You know, it's really, really good for the hospital viability. And so now I'm in four places. The central one is sort of my hometown. But it's been quite an experience for four and a half years to have that kind of like business experience. You know, the practice itself is almost the easy part.

Although

there are challenges, but each hospital has something a little different. And so some of the hospitals have a 24 hour call. Only one has a 24 hour call team. So I generally do my bigger cases there. And then the other places I'm doing mostly elective outpatient surgery, I actually don't get bothered from the ER at almost any of those places unless it's setting something up for the clinic because they know that I can't take care of anything.

Unless if I'm going to be there the next day, then I'll let the ER know. And if they have like an appy overnight, they'll hold it over and I'll do it the next morning or whatever. So from a lifestyle perspective, it's not too bad. And then the travel is not too bad either because the hospitals all just let me land my helicopter right on their helipad and then drag it off to the side.

And then I just travel like that for my farm. So it's only like. You know, 16, 18 minutes to each place. So, you know, what could be better than that? Not too shabby at all. So I think one thing that trainees may appreciate hearing from a practicing rural surgeon, you know, it sounds like you're

doing a lot of different things at a number of different places.

Can you zoom in a little bit and tell us a little bit about the breadth and the depth of your clinical practice? So, you know, people hear about rural surgery and they're like, Oh, I don't want to go. Take a job where I'm doing like 75 percent scopes, you know, talk about the actual breadth of your your practice.

Cause I know you're doing carpal tunnels, you're doing basic urology, ENT, you mentioned it, ortho, all sorts of things. So tell us a little bit about that. Yeah. First thing would be, what did I think when I was a trainee? And then what is the reality? And I think you can take your practice a lot of different ways.

And it's what you stand up at medical staff or at med ed, or just in a conversation with the referring doctors and you tell them what you have an interest in doing, it will show up. And if you tell patients that you can. You know, the things that you want to do, like, a lot of times people don't know what general surgery is that they asked me what general surgery is, and

then I can say whatever I want.

Well, I usually say it's gallbladders, hernias, appies, and it's from a cancer perspective. It's colon cancer, breast cancer. I do a lot of skin cancer. As soon as I say skin cancer, like, oh, I got this weird mole, you know, and that's how you can like. Make yourself available so people can actually know what you're capable of doing close to home.

And then you take care of those little things and and then they'll come back for everything else. But you gotta be able to post it, you know, and say like, what, this is what I do. So I, most of the training tracks You know, I'm thinking the old school general surgeon. So there's no specialist in town, just a general surgeon or a surgeon, and they do all kinds of surgery.

So I went and did a track where at Mayo in fourth year, we had dedicated six week rotations in ortho urology, ENT, plastics. And OBGYN, all of which I was at a place where general surgery was going on

with limited competition. And I was Q2 general surgery call the whole time all the way through. But everybody knew that I was being pulled in multiple directions.

And I was also the kind of resident that like they knew I wasn't leaving the OR till the lights were turned off. And so nobody ever questioned You know, if he's not here, is he, I don't think people care either. You know, that's the way residency is it's up to you to go get that experience. And you can hide for the majority of residency and do very little and come out and not be very well trained.

But I also at the I was at lacrosse Wisconsin at the Mayo Hospital there for all those rotations. And that's by design because there's no competing residents there and the types of cases they're doing there are like bread and butter cases like tonsils, you know, rather than Going and being ENT in Rochester doing all these big head and neck crazy cancer resection that doesn't make any sense It's not relevant

to a rural surgery practice.

So I did kind of get Conceptually a little bit of that in residency, but then I got out and I realized the you know 80 20 rule like 80 percent of your value in rural surgery at some places is the difference is c sections and scopes. So there's huge demand for that right now. If you're a general surgeon that would be willing to participate in C section call and could get trained to do that and, or do scopes, you have 1200 job options right now in the United States, you know, or more, I don't know, but that's not necessarily why I went into the rural surgery track.

And I actually never really liked scopes and I've gotten into it a little bit with sort of my mentor. My, my mentor told me that scopes are, You know, he's like, they carried us through a lot of bad times. And it's, you know, it's something you can do on a Friday and you don't ever have any calls over the weekend and you don't have to worry about it.

And you're adding a great service because there's no GI doctor

there and patients don't have to travel for this very basic thing. Fine. You know, plus, you know, you find your colon cancers and your hiatal hernias and things that you can fix and bad reflux disease you can fix surgically and whatnot.

So if somebody likes to do scopes, I really do not want to discourage them. Because it is a great service that you're providing, but I'm, I am trying to work my way out of it, sort of. And so if there had a partner that, you know, was, loved them, that'd be great. What I actually did is I ended up hiring a family med doc who does some scopes, and she comes down two days a month right now and does them for me at my hometown hospital, because I've gotten to the point where if my, if I didn't have my nurse practitioner and her doing the scopes, there's more than 30 work days.

Happening with Liberty Clinic providers right now, it's bigger than me, you know, and I'm growing to that. I'm going to bring in another person. That's going to do some scopes and another person that's going to do some wound care. And I'm really actually looking at this point for a surgical partner. So

it's a little early for a plug, but you know, maybe we put a thing in the show notes or whatever, how to reach out to me.

And if you're interested in a practice, like what I'm describing or even mentorship, but. By me, you know, and doing that, I seriously in the next immediately I'm looking for somebody and in the next few years, but what am I actually doing now after getting that training? So I, I do not. do any fracture management.

I thought I would. I did a lot of rib fractures, even, even non op management of clavicle fractures. They don't come to me. I do almost no trauma, literally almost none. We don't have a level trauma center and everything just gets shipped from the field if it's serious trauma. And if it's not serious trauma, then it doesn't need a surgeon.

So I From ortho, basically what I do that I'd say is the highest value if you want to try to catch this and bring it into your practices is generally hand stuff. So trigger finger

release, carpal tunnel, I do not do like, Dupuytren's contracture release. I wouldn't necessarily do that, but it's nice to see a few of those if you can get time with ortho.

You know, and lumps and bumps and ganglion cysts and things like that of the hands and wrists are very common. And those you know, cysts at the base of the nail, did a little cute bilobed flap, stuff like that is, is very easy and good stuff for a surgeon to be able to do and a patient not have to be able to travel.

From ENT thought I would do tonsils. I don't I haven't done any for four and a half years. And at this point, if somebody came in, I'd just say no, because the thing is mostly it's kids. Your CRNA is uncomfortable. You're down in their mouth, in the back of their throat. And you know, they, if they're going to have a complication, it's going to be a dramatic one in the middle of the night.

So, and it, the values just, I don't know, I don't think it's there, but it just depends on where you're practicing. Cause if you're six hours from anywhere by fixed wing aircraft and you have no ENT,

it's, It's an easy case and you can do it especially if you have better anesthesia support or, you know, good anesthesia support and but I, I just don't, I thought I would do parotids, haven't of course seen one, I wouldn't do one at this point matter of fact, thyroids, which I did like 50 on my ENT rotation I just was having like one show up a year, a parathyroid, I don't have nerve monitor, I don't have I don't have IO PTH.

And so I actually gave that up about a year ago. For the time being, of course, I didn't give up my privileges or anything, but because I had my hiatal hernia practice sort of growing and bread and butter general surgery practice growing because of more locations, I said, this doesn't make a lot of sense.

I don't feel, I'm not excited about when I see one of these on it's kind of stressful, but it, that's something that I would love to bring. And do close to home. If I had maybe a junior partner, we scrub them together.

And yeah, that try, try to get the volume because you have to be able to do a certain number of volume to, to be able to be good at.

So ENT ortho urology I do, you know, circs, vasectomy I would manage a torsion if it showed up I, I had a great urology experience. A lot of it, I don't know, I, I've, you know, humongous hernia where there's, it's an old, older guy and an orchiectomy is a common sense type of thing. I very comfortable doing that.

I thought I might manage testicular masses like the low grade seminar, grade one seminomas and stuff like that. But made that decision shortly after I got out. That didn't really make sense. Okay. OBGYN, that's probably one where I do, I would say the biggest spectrum. I do tons of tubules, which I do as a laparoscopic salponjectomy, which decreases the risk of ovarian cancer.

Ovarian torsion, large symptomatic cysts, which you know, most of the time, you know, you can try ovarian sparing, it just depends on the patient's age

and how you're going to do it. Like if they're just going to chomp it out with a harmonic or ligature or you know, just do a unilateral salpingo oophorectomy.

I did see sections at the first job, but then they closed the OB department. And so I. I still have privileges to C section at several places, my, every other place the OB department has closed. My hometown hospital OB department has closed. That's sort of a professional goal of mine to get that restarted, but it's a really, really uphill battle.

So ask me in five to 10 years, how I'm doing on that. And I would definitely participate in C section call if we get to that point, but I also do hysterectomy, which I generally do as an LAVH which I would do for benign conditions. You know, abnormal uterine bleeding being most common. I also do you know, as a step in that basically my nurse practitioner places IUDs if those are what the patient desires, or I could do it in clinic.

And then also doing like NovaSure ablations because, you know, that's a necessary step

or a recommended step and sometimes required by insurance instead of hysterectomies as they're trying to like keep people from getting hysterectomies or whatever. So those are, and then plastics. So I had a really nice rotate, a couple of really nice rotations with some great rural plastic surgeons.

And what I picked up is, you know, how, how do you do a rhomboid flap? How do you do a Keystone flap? How do you do a bilobed flap? And you know, how to handle tissue, how to do, you know, your closures. And I do a ton of skin cancer. And so that's something that, you know, keeps you busy. And again, low morbidity, you get to do a lot of it under local.

So patients get to know you because you're talking and I'm telling my story just like this. And by the time we're done, they're like, man, I wish I had something else that you could do because I believe in what you're, what you're trying to do here. And so that's the specialty stuff. And then from general surgery, do you want to talk about that too?

So again, like this one might be easier for you to hear what I don't

do. You know, I don't do esophagectomies. I don't do whipples. I don't do any kind of pancreas surgery. I probably would do a spleen in a certain like hematologic condition or something. If the hematologist asked me to, but I haven't had to in four and a half years, I would not do a liver resection.

I don't do any rectal surgery. I've done several. chest cases but they're kind of uncommon and I would not do a lobectomy. So I have done a couple blebectomies and I've done a decort on an old guy from the nursing home attached to the hospital, you know, where it's like, yeah, we could send you somewhere, but he doesn't really want to, and he's got an empyema a lot of thoracentesis, paracentesis.

you know, tube management stuff like that. From a vascular perspective, I don't do any bypass surgery. I don't do any stenting either. So, you know, fistulas. So I would do fistulas, but there's no dialysis centers in any of these towns. And that's something else I'm kind of working on. I think fistulas would be a great practice to, you know, To have in a small town but

basically from vascular, what I do is varicose veins, ports, central lines theoretically, AB fistulas.

You use the robot when you're doing mineraline based surgery or are you straight sick? Yeah, I don't have any robot at any of the places and I feel like I got great laparoscopic surgery training and I think the robot would slow me down and I like to go fast, I guess. And you know, it's, it adds a lot of cost that at the end of the day doesn't really add a lot of value.

There's a few, you know, ventral hernias that I'd like to have them on. I would, I would use it if I had it on inguinals and on on hysterectomies for sure, probably would use it on hiatal hernias, but man, I do my, I do my vaginal cuff closure with the endo stitch for the vicral. And then I do my, you know, hiatal hernia closure with a.

on a endo stitch and it's fast and easy. And I think your bites are the same and it's just as effective. So for me I'm,

I'm fine without it for the time being. We'll see where we're at 10, 15 years again, down the road, in terms of does the cost come down, what can be proven in terms of outcomes? If there ever was, then I would.

You know, definitely be considering that, but right now I feel like I'm giving the patients the same operation. So I feel totally fine doing a straight stick. It's great. So let's change gears a lot now. And you have a podcast that's called the rural American surgeon podcast. Can you tell us a little bit about the impetus behind starting it as well as kind of what you've learned from the experience of talking to all these different rural surgeons and People who may not be a rural surgeon, but are guests on your show that are just big proponents and advocates of rural health.

Rural surgery for me is, has become very much a central core passion that I identify with, you know, this cause that I want. And it, it works well for

me because surgery is a passion, but like I described earlier, rural America is a passion of mine. And so that at that intersection, there's great need right now.

And and also great opportunity. And so as I've gone through training about it, I, I feel like there's, there are people talking about it. It's great to see the energy, but there's also, I like listening to podcasts and there's no podcast on rural surgery. And it was a professional goal of mine for many years to, to, you know, To start this podcast about rural surgery and just sort of share my story because I, you know, it's not like, the listenership is a very niche.

Okay. It's not like we're going to have millions of listeners, but for those people that want to hear this story, they don't have a surgeon's lounge where there's other people that they can chit chat about. It's mostly like, we've got a few buddies and we've got our text threads that we're keeping in touch that way.

But I think there's people that are passionate about this topic. So I wanted to start a podcast and I just it's been a lot of fun the, the,

the people tell the same story it, it's funny how similar the stories are but it almost never gets old because there's little nuances for each town.

But it, but it's basically the rewards of general surgery in a rural area are. The appreciation that you get by the patients and the administration, even that's probably, I would say the number one takeaway, sort of on the spot coming up with it. And then also, what it's, it's, it's a lifestyle.

It's whether you want to live in the community. Where everybody knows you, you know, it's the same person that is going to church with you, you know, teaching, your kids working at the school, at the, at the hospital with you, those are the people that you're taking care of. And it makes it a lot more personal.

And it also, your your reviews it's.

It's word of mouth. That's your reviews, you know, a lot of people. I mean, if you're in the city, like, how do you know the surgeon that you're seeing much about them, but people know and you've heard of the three a's of surgery. Okay. So ability, affability, and Ability.

Ability. Yeah. So those are the three. That's not a great one for me to have left out, but. No, but that's, that, the worst part about it is that's the least important one in terms of having a busy practice. And it's the only one we care about. It's the one we care most about and we should. But at the end of the day, if you're just there.

That generally is a great way to have a practice. If you're friendly, then you're, then you're golden. But you still should care about your quality metrics, and then that's on you, you know, more than anybody. But other people, if, if you're kind of present there, willing and, and, you

know, And friendly, that's a large portion of your battle.

And once you've kind of done that, and then you get the opportunity, people trust you and they give you the opportunity to kind of prove yourself and then it can, the rewards practicing in rural and rural America are great. That's awesome. Dr. Lehman went off on a tangent to talk about how great rural practice is again, which just underscores how passionate he is about it.

But as a. An actual listener of his podcast, I can tell you guys that it's a great listen for anybody who's interested in potentially pursuing a career in rural surgery or just have an interest in learning more about it and kind of what different folks practice patterns look like. He has a bunch of different segments on the podcast that include tell me if I'm missing any Dr.

Layman, but you have the financial corner how I do it, which is always like. Some great clinical discussion of commonly encountered general surgery issues and also classic rural surgery, which usually entails an awesome and funny and unique story. Am I missing any of the other segments? Yeah. So there's resources for the

busy rural surgeon and, you know, more or less just an intro.

So, and while, you know, intro involves while of rural surgery, but yeah. And I actually stay more focused on my podcast than I am on yours. So, and I have to, by design, I put those segments for a reason, and then we got to get through it because otherwise I can't have every episode being two hours, you know?

That's fair. You know, as we've already talked about, there are a lot of current listeners to the Behind the Knife podcast who are trainees, whether that be medical students who are interested in surgery or general surgery residents. What is your plug for why somebody should consider becoming a rural surgeon?

And maybe your partner one day who, and maybe you'll offer to. Fly them to work with you on your helicopter and do fire roads with you as long as they like some scopes. Sure. Yeah. The main reason is that I think rural surgery is a great place with values that are still beautiful. My

dad forgot his wallet.

On the top of the gas station you know, kiosk or whatever on the pumps and it showed up in his mailbox. No note or anything you know. The trans, the, the small size leads to maybe more transparency and accountability. The the space around you. I don't, I'm trying to hypothesize why but you know, the space around you and nature around you and the.

Tying into agriculture, I think, is a very sort of, like, faith building sort of, environment, and I just think that you know, the skyscrapers, and the cubicles, and the squares in the city man, I couldn't live that way, and I gotta have sunshine, and, and trees, and fresh air, and that's what I get, so, you know.

Because of that, I just love rural America

and the people that are out there and they are now underserved. And so there's a need. So that would be my pitch. And if, if you want to come out for the money, okay, that's fine too. You can, but. It's probably not going to last. If you believe what I just said, you'll go out there and kind of experience it for yourself and you'll be like, there's no way I'm ever going back to the city.

It's sort of like a country mouse, city mouse thing. You're one or the other. Country mouse can't sleep in the city. City because of all the noise and the sirens and things like that and the city mouse can't sleep in the country because of all the silence So so that's why I think and but there are other reasons selfish reasons that you can go like like I said pay is one but you know, even the fact that I Generally don't have my census is usually zero my inpatient

census It's typically zero.

And most of what I do, I can have a very busy practice. Last year I did 10, 000 RVUs. Average surgeon is 6, 500 RVUs. So you can have a very busy practice, but doing those. high volume, low acuity things where patients go home and they all do really well and you have very few complications, even though you're busy and doing tons of surgery.

To me, that's awesome practice to other people doing doing three whipples a week. Is a more awesome practice and the bigger the incision, the bigger the surgeon or whatever, bigger the, you know, I don't know if you want to do that. I'm glad that there are people that like to do that and there should be, but that's not the type of practice I want to have.

And so I'm able to be really flexible with my schedule spend a lot of time with my family. Live in the place that I kind of want to live. And, and it works out for

me on multiple. I was just hits all these different things all at once. So we'll close this episode the way we've closed our other episodes in the series and the way you often close your show.

And so I'll turn it around on you with a one 80 and ask you if you can share us share with us a classic rural surgery story, as you say, on your podcast. Yeah, you have a great one. So, my first surgery was a gallbladder, and my second surgery was an appendix. But, the first gallbladder surgery turned out to be gallbladder cancer.

And the appendix was a nine centimeter meat. It's nine centimeter appendix. Seal mucous seal. So that's how it is. And that was on my babysitter's dad, new babysitter's dad. Right? So that's how rural practice all of a sudden. It's. There's a lot of the common thing,

but I have now done three gallbladder cancers in, or seen three gallbladder cancers in four years.

And it's just some of the weirdest stuff is out there, and I think it's just because you're seeing all of it. That you get the sort of opportunity to see the weird things. It's the confluence, yeah. When I started that first off the gallbladder cancer first one was not obvious while I was operating.

It was just kind of like the cystic duct was sort of frail and I had to kind of like chase it back down and you know, get it clipped and then ended up being that it was because there was cancer. In that area, and it was the way most gallbladder cancer is diagnosed, which is just you did a surgery for what you thought was acute cholecystitis or something else.

And then it ends up being instantly diagnosed. I did have another one which was read as acute cholecystitis on imaging presented like acute cholecystitis, but ended up being gallbladder cancer. It was invading into the duodenum. That was a

tough one. Yeah. And then let's see, I had another one that I think was a, the other one was incidental.

I can't remember the details of it right now, but I know I've done three. But anyway, it's basically rural surgery is where the common thing suddenly becomes uncommon. And it's just, it's been like that over and over. The other thing that I do a lot of that I, that I just wanted to mention is You know, get good at those esophageal food impactions because they happen more than you would think to and if you're going to take scope call, your GI bleed management, just like have a real good algorithm before you leave residency and turns out most of the GI bleeds that I see are GI bleeds that weren't.

And by the time you get there, they're stable. And it's one of these things where if they're unstable, well, they need to be resuscitated and scope them in the morning. And if they're stable, well, then they're stable enough. You can say, yeah, I know, I know GI's notes and we consult them. So, but it's actually sort of the

reality.

And obviously once you do enough scopes, you realize there's really not a lot of point to scoping an unprepped colon, you know, either. So, yeah, awesome. Well, Dr. Lehman, this has been great. Greatly appreciate you taking the time to come on on behind the knife and share your perspective on rural surgery to plug again, Dr.

Lehman has a great podcast, the rural American surgery podcast, and he also may be looking for a partner in the next couple of years, so we will make sure to include a lot of stuff for you to be able to learn more from Dr. Lehman and contact him in the show notes. Dr. Lehman, where is your podcast streaming on what platforms?

Yeah, we're on all the platforms. So if you Spotify, Apple, or wherever you find your podcasts, and if you want to watch video, they're on YouTube. I also have a Facebook account where I put a lot of really cool shorts that I think are sort of more fun to watch. So find us on the Facebook too. It's the rural American surgeon, and you can.

Subscribe to our podcast and please share it with people that are in your network that

you know that are passionate about rural surgery. The other thing I'm, I'm not, you're probably already talked about this, but if you're interested in rural surgery, you need to join. The North American Rural Surgical Society.

It is the premier group and it is growing like crazy. And we, we've been meeting in Denver every January. You would love it. It's very relevant to my practice. And so strongly consider that I'm not in any way affiliated with them, except for being a member. I guess I'm presenting this year, but it's.

It's a really great time and very relevant. Nothing to do with American College of Surgeons, although most people are overlap their members in both. And the last thing I would say yeah, just on my need for a future partner. Actually, it's a, it's an acute need. So if, Your listener wants to reach out to me.

I can put my email is our layman, L E H M A N at mylibertyclinic. com and feel free

to shoot me a message on there or send me a CV or even just a contact. If there's somebody, you know, that might be interested. I could, and I could even take You know, some, some independent contracted part time help too.

So, you know, since you, you had the, had me on, I figured I might as well plug that, but I really do appreciate the opportunity to talk to your listeners and what you guys are doing. I mean, you've done a wonderful job with this podcast. Well, we appreciate it again and I will hand it back off to Dr.

Lehman one more time so that he can give a sign off to the viewer or the listeners. Well, I'm just hoping that if you have any interest in rural surgery at all, that you never forget to dominate the day.