Episode 32

The Art of Adaptability in Rural Surgery with Dr. P.J. Reddy

Episode Transcript

Dr. Randy Lehman [00:00:11]: Welcome to The Rural American Surgeon. I'm your host, Dr. Randy Lehman, a general surgeon from Indiana. This show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics such as practical surgical tips, rural lifestyle, finance, training, practice models, and more. We have a segment called Classic Rural Surgery Stories, where you'll get a feel for how practice in the country differs from the city. If rural surgery is your passion, this show is for you. So now that the chloraprep has dried, let's make our incision. Welcome back to The Rural American Surgeon. I'm joined today by Dr. P.J. Reddy, and he has a wealth of experience from a long history as a rural surgeon in Kansas. So thank you very much for joining us today, Dr. Reddy. Thank you very much.

Dr. P. J. Reddy [00:01:04]: I appreciate, you're so kind. My name is P.J. Reddy. I graduated from medical school in India, and I did one year of what's called house agency, that means internship, you know. At least in those days, they wouldn't give you a certificate until you do an internship also, which I did. So, after finishing one year of internship in India, I came to this country. I came in 1967, and after coming here, I did one year internship in New York. After that, I did residency in surgery for four years in New York. And after finishing surgical residency, I also did a one-year fellowship in plastic surgery. That was done in upstate New York, that means Syracuse. Syracuse, New York, now is there for one year. And then I was thinking of going into practice. You know, I wanted to practice for a few years before going back to India. In those days, people either went into group practice or solo practice. In my case, I was not sure if patients would come to see me or not since I come from a foreign country and I do not have white skin. Then I saw an advertisement in a medical magazine. There is a small town in northwest Kansas called Hill City, and they were looking for a doctor. So, I wanted to be employed. Instead of going into practice, I decided to go to a place where I'm employed.

Dr. Randy Lehman [00:03:01]: Sure.

Dr. P. J. Reddy [00:03:02]: So I flew from New York City to Kansas City, Kansas City to Salina, Salina to Hays, which is 55 miles from Hill City. I landed in Hays, Kansas, and to my surprise, the CEO of the hospital came to receive me. The CEO of the hospital took me from Hays to Hill City. In Hill City, I had an interview with the board of directors, hospital board. They looked at my CV and all that, and they asked me to sign a contract on the spot. Yeah, on the spot. So I signed a contract for two years. It didn't take too long for me to find out that patients do not care much about your skin color. They care about what kind of treatment and management you give. And it didn't take too long to have my schedule full. Within a few days, or within a week or two, my schedule was full. And at the end of two years, they asked me to sign for three more years. I signed a contract for three more years. Then the CEO of the hospital showed some figures to me: "Doc, we are paying you this much salary, but if you go on your own, you'll make more money." So he recommended to me to go on my own in Hill City. I said, all right. So I went on with another doctor, and the two of us had our own practice. The thing is, the roots get deeper and deeper as you stay longer.

Dr. Randy Lehman [00:05:11]: Right.

Dr. P. J. Reddy [00:05:12]: My first child was a year and a half at that time, and they started going to school there. Then we had two more children after that, and they started going to school. So people naturally wanted me to stay. You may not believe it, but I was there in that small town for more than 40 years. Wow, 41 years.

Dr. Randy Lehman [00:05:46]: That's incredible.

Dr. P. J. Reddy [00:05:49]: My two sons and one daughter both became doctors. They went to school in Hill City, and then they went to college, and then they went to KU Medical Center. So one of my sons is a neurologist, and the other son is an oncologist. My daughter graduated in speech therapy, but her husband is an oncologist. So my two sons, my daughter, and my son-in-law are all physicians.

Dr. Randy Lehman [00:06:27]: That's a beautiful story.

Dr. P. J. Reddy [00:06:29]: Thank you. After practicing for so long, I thought of retiring, and so we moved to Wichita, Kansas. In Wichita, my older son and my daughter live, so to be closer to children and grandchildren, we moved to Wichita. After coming here, I was kind of getting bored. I wanted to do some work. There is what is called Western Medical Center in Wichita, and there they have a wound care clinic. They wanted somebody to take care of patients in the wound care clinic.

Dr. Randy Lehman [00:07:16]: Yeah.

Dr. P. J. Reddy [00:07:16]: Since I'm a surgeon, they took me right away.

Dr. Randy Lehman [00:07:21]: So overqualified.

Dr. P. J. Reddy [00:07:24]: It was a part-time job, of course. So I did work part-time for two years.

Dr. Randy Lehman [00:07:31]: Okay.

Dr. P. J. Reddy [00:07:32]: Wound care clinic at the Western Medical Center.

Dr. Randy Lehman [00:07:37]: Sure.

Dr. P. J. Reddy [00:07:37]: Then the COVID-19 pandemic came. Everything was closed, so I quit working after that.

Dr. Randy Lehman [00:07:50]: That's quite the story.

Dr. P. J. Reddy [00:07:52]: One more thing. I did some volunteer work. There is a clinic here called Mayflower Clinic.

Dr. Randy Lehman [00:07:58]: Okay.

Dr. P. J. Reddy [00:07:59]: At the Mayflower Clinic, it's meant for people without health insurance. I volunteered there for a few years.

Dr. Randy Lehman [00:08:09]: Sure.

Dr. P. J. Reddy [00:08:10]: They gave me an award also for working there.

Dr. Randy Lehman [00:08:16]: That's very nice. So I did a little web search on Hill City, Kansas, and it says that the population's around 1,600 people. Does that sound about right to you?

Dr. P. J. Reddy [00:08:28]: It went down. It used to be 3,000 when I was there. The count was about 5,000.

Dr. Randy Lehman [00:08:35]: Okay.

Dr. P. J. Reddy [00:08:36]: We used to get patients from neighboring towns and for the whole county and sometimes from the neighboring counties also, so they all kept me busy.

Dr. Randy Lehman [00:08:49]: Yeah. So when you started there, you were the only surgeon in town?

Dr. P. J. Reddy [00:08:54]: Yeah.

Dr. Randy Lehman [00:08:55]: And were you the only surgeon the whole time?

Dr. P. J. Reddy [00:08:58]: That's right.

Dr. Randy Lehman [00:08:59]: Were they able to replace you after you retired?

Dr. P. J. Reddy [00:09:02]: No, not really.

Dr. Randy Lehman [00:09:04]: How's the hospital doing since then?

Dr. P. J. Reddy [00:09:06]: Well, you know, they have a surgeon coming to Hill City, I think, once in two weeks. If there's an emergency, then they transfer the patient to a neighboring town.

Dr. Randy Lehman [00:09:20]: Sure. Yeah. That's a common story. But basically, the hospital recognized your value, and the CEO came out to meet you, took you straight to the board, and they gave you a job offer on the spot. I think that's still happening in the small towns that have managed to remain independent. You know, a lot of these small hospitals have been purchased by a bigger system who then no longer, like, maybe they bought the hospital thinking that they could buy the stream of referrals, not so much thinking about how they could offer more services here in this small town. So, is the Hill City Hospital still independent, or have they been conglomerated?

Dr. P. J. Reddy [00:09:58]: That's a good question. You know, I found out that after I left, the income has gone down for the hospital.

Dr. Randy Lehman [00:10:05]: Sure.

Dr. P. J. Reddy [00:10:06]: Because they were not doing any surgery and all that, the income has gone down. The hospital CEO, a lady, she's a CPA. There is what is called a community hospital, something like that. It became a cohort community hospital. By that, Medicare will pay. If you lose money, Medicare will reimburse the hospital. If you make money, you have to pay it back to Medicare.

Dr. Randy Lehman [00:10:43]: Are you talking about a Critical Access Hospital?

Dr. P. J. Reddy [00:10:45]: Yeah, currently CAH.

Dr. Randy Lehman [00:10:46]: There you go.

Dr. P. J. Reddy [00:10:49]: So the hospital became CAH, Critical Access Hospital, after I left. I think maybe when I was there also, they started the CAH, you're right.

Dr. Randy Lehman [00:11:01]: Yeah. That's a very...

Dr. P. J. Reddy [00:11:03]: Since CAH, they didn't have to close the hospital.

Dr. Randy Lehman [00:11:08]: Did you say they will never close the hospital?

Dr. P. J. Reddy [00:11:10]: Because I say CAH, as you know, when it's CAH, then they get the money from Medicare.

Dr. Randy Lehman [00:11:18]: Yeah. So they get paid basically at cost, so they'll never close the hospital unless the CAH program goes away. Right. So now they're extremely dependent on that. We've lost a lot of...

Dr. P. J. Reddy [00:11:36]: That's what I heard. You know, if you make more than you spend, you have to pay the money back to Medicaid.

Dr. Randy Lehman [00:11:44]: Sure.

Dr. P. J. Reddy [00:11:45]: But if you make less, then you'll get the money back from Medicare.

Dr. Randy Lehman [00:11:53]: Yep. Very good. Well, that is just a great introduction and I wanted to just say thank you for being involved on the rural surgery listserv. That's a—I would say a small group, but it's always fun to hear different perspectives. I actually met you through the listserv, and you were talking about your rural practice and sort of saying some inspirational things to a young rural surgeon, and I appreciated that. So I invited you to come on the show, and I'm really thankful that you did so. The first question that I ask every guest is, why is rural surgery special to you?

Dr. P. J. Reddy [00:12:32]: Well, one thing is they kept me busy. You know, rural surgery kept me busy. If I'm in a big city, I do not know how busy it will be. It depends. There are so many surgeons, and I was the only surgeon there. They kept him busy. I think I also did OB-GYN.

Dr. Randy Lehman [00:12:56]: So we're going to talk about how I do it for the show, and today we're going to be talking about colonoscopy. So we're going to talk about specific tips and tricks, but also have a focus on how you learned this skill after your residency training. Tell me what your exposure was to colonoscopy in residency. I am sitting actually in the building that I went to for my eight-day well-child visit and found my paper chart in the basement. It's a clinic that I was able to purchase and start a practice out of. That's a long, complicated story, but long story short, I guess what I'm trying to say is there are a lot of medical textbooks from some of the previous doctors that used to work here. They're still here in the building. One of those books was a book on colonoscopy from the late 1980s. I just cracked that book and was looking through it, just wondering where the perspective was at that point. I remember reading that it says colonoscopy is a good tool for certain circumstances, maybe for high-risk people for colon cancer. You could consider using it for screening, but it should never be offered for screening or for the entire population due to the cost and the technical difficulties. You know, there's limited access. So that's where we were like in the late 1980s. Obviously, now screening colonoscopy is for everybody multiple times throughout your life, starting at 45 now. You finished med school and came over here in the late 1960s, and you've witnessed insane change during that time. So what year did you actually go to Hill City?

Dr. P. J. Reddy [00:14:45]: 1973.

Dr. Randy Lehman [00:14:47]: Okay. And so you're there for 41 years. Did colonoscopy even exist? Like when did it start? I can't remember.

Dr. P. J. Reddy [00:14:58]: Well, you know, that's a good question. I think it started in the late 80s, '88, '89, in that time. I started doing it in 1995.

Dr. Randy Lehman [00:15:10]: Okay.

Dr. P. J. Reddy [00:15:11]: I think 19... I think I wrote somewhere here. I think in '95, maybe, I did the first scope. Well, I heard about this colonoscopy. I think I told you. Well, there is a town called Salina. Salina is about maybe an hour and a half drive, maybe two hours drive from Hill City. There's a gastroenterologist over there. So I went to the gastroenterologist. I saw him how he does the colonoscopy and also gastroscopy, both.

Dr. Randy Lehman [00:15:51]: Okay.

Dr. P. J. Reddy [00:15:52]: Then I met—you know, I went to Wichita, Kansas, and I met a gastroenterologist. He gave me a video on how to do colonoscopy. I took it home, looked at that video, and all that. Then I started doing colonoscopy in Hill City.

Dr. Randy Lehman [00:16:15]: Okay.

Dr. P. J. Reddy [00:16:16]: So that's how I learned.

Dr. Randy Lehman [00:16:18]: What kind of volume did you have to watch in order to see? Did you have anybody come to Hill City with you or did you touch any actual patients? Were you able to actually do any colonoscopy somewhere else?

Dr. P. J. Reddy [00:16:30]: No, I did it myself alone. I mean, we had a nurse anesthetist coming and giving anesthesia to the patient. Then I did the scope. I think I did more than 500 scopes, colonoscopy, and more than 500. I also, I think I told you, did gastroscopy. Also, I think more than 1,000 gastroscopes.

Dr. Randy Lehman [00:17:06]: Yeah. Just doing a little quick CoPilot web search here. What I'm finding is, you know, they always say, oh, the history of colonoscopy dates back to the 1800s. Right. But it doesn't really. Modern colonoscopy started in the late 60s, leading from some upper scope successes, and then by the 70s, it was standard to diagnose colon cancer. Of course, I told you about the book from the 80s. So gradually, throughout the 80s and 90s, it became important for screening now and preventative care. I also found that, and I'm not sure if this is—somebody might have to fact-check me on this, but what I'm seeing is that the flexible endoscopy curriculum started only in 2017, which sounds right. That's when I was in training. But I'm sure the numbers for training were before that. You just didn't have to do the FES curriculum.

Dr. P. J. Reddy [00:18:05]: You mean flexible sigmoidoscopy?

Dr. Randy Lehman [00:18:08]: Yeah, like there's a specific curriculum. You know, there's Fundamentals of Laparoscopic Surgery and then there's now Fundamentals of Endoscopic stuff such as colonoscopy. So we use a trainer and everything. And so, to graduate residency, you only need 50 colonoscopies and 35 upper scopes in order to graduate. But if you're a surgeon and you're technically capable, you're doing bronchoscopies and other things using scopes, I guess I see that as maybe a minimum number to have an exposure. But I don't know if I would do 50 and 35, and if I was bare minimum coming straight out, I probably wouldn't be ready to navigate some of the difficult colons that I see in practice. I'm just wondering how that was for you to get through your first couple dozen and become more technically proficient over time. Like, that seems intimidating to me. I'm wondering how your perspective practice makes perfect.

Dr. P. J. Reddy [00:19:12]: As you keep doing, the more you do, it takes less time.

Dr. Randy Lehman [00:19:16]: Yeah, yeah, that makes sense. And then in terms of trying to not create complications, how did you manage that early on? Just take your time.

Dr. P. J. Reddy [00:19:26]: Fortunately, I didn't have any complications. But, you know, I think in a couple of cases, I was not able to put the scope into the cecum. I think there was pressure stricture in the sigmoid colon or something like that, and I didn't go through. In another case, I couldn't go through the phrenic flexure. There are a few cases where I was not able to go through into the cecum, you know, and when that happens, I send the patient to another surgeon in a neighboring town, like Hayes or Salina.

Dr. Randy Lehman [00:20:11]: And they were usually able to get through.

Dr. P. J. Reddy [00:20:14]: Yeah. You know, I think, if I remember right, in one case, the patient had maybe cancer, something like that, and a large tumor, you know?

Dr. Randy Lehman [00:20:30]: Sure. Very good. So, if you were teaching somebody else, hey, I learned this or that trick for colonoscopy, what were some of the best tricks to your technique that helped you get through a difficult one?

Dr. P. J. Reddy [00:20:43]: Well, you know, I tell them just go slow. Don't push the scope in too fast. You know, just go slow and try to manipulate it.

Dr. Randy Lehman [00:20:59]: Yeah, sometimes when you're pushing in, you're actually kinking on the inside and dragging the scope with you. When you pull back, it actually straightens the whole thing out, and you can see the lumen and fall in a little bit easier. It's kind of like pushing your sleeve up on your shirt, you know, but it's not totally intuitive, and I think it's a different skill set than surgery entirely. It's kind of like, I don't know, riding a bike and riding a skateboard. Just because you can do one doesn't mean you can necessarily do the other.

Dr. P. J. Reddy [00:21:27]: Yeah.

Dr. Randy Lehman [00:21:29]: Not that I know much about skateboarding, but very good. Anything else about colonoscopy that you'd like to share with my listener?

Dr. P. J. Reddy [00:21:39]: Well, you know, you see some diabetic lesions as you do the procedure and you deal with polyps, you know, diverticular and polyps. Most of the time, as you know, the polyps are benign. But we never know until we do the biopsy and excise them, you know. It depends on the type of the polyp. If it is a pedunculated polyp, you can put the wire around it and then get the whole thing out— the polyp, I mean.

Dr. Randy Lehman [00:22:20]: Sure.

Dr. P. J. Reddy [00:22:21]: Pedunculated, yes. Otherwise, if it is flat on the surface and then you do a biopsy, sometimes you can have perforation of the colon. So you need to be really careful when doing the biopsy. Another thing is, when it comes to the hepatic flexure, you'll have to be cautious with the scope. You don't want to go into the liver at the hepatic flexure.

Dr. Randy Lehman [00:22:53]: Sure.

Dr. P. J. Reddy [00:22:55]: I can tell you, I mean, go slow and see what you can do.

Dr. Randy Lehman [00:23:00]: Yeah. So I would say that I've seen two different types of complications. I've seen a lot of different complications, both as a resident managing other people's complications and some in my own practice. You know, you can do a lot of damage with traction; like, you can cause a splenic capsule or tear. You know, when you're talking about perforation, it could happen, yeah, when removing a large polyp. But one potential complication is actually perforating with the end of the scope by applying too much pressure. Or if you're pushing through a big loop, you can actually perforate out the side of the sigmoid colon, and hopefully you'll catch that on the way back. They used to do X-rays like live fluoro when colonoscopy was first coming out, but now there's actually a device called the scope guide. Have you ever heard of the scope guide?

Dr. P. J. Reddy [00:24:06]: No. I heard about a CT scope.

Dr. Randy Lehman [00:24:10]: No, this is different. This is non-radiating. It's magnets that are within the scope. I'm not really sure how it works, but there's a little flat panel that sits on a cart and can go over the patient, and you can see down in the corner. It looks like a fluoro. You can see the shape of your scope, and there are pressure sensors too. If you're feeling a lot of pressure at one spot, it'll turn yellow and show you. I think that's a good trick. If somebody is considering adding colonoscopy, first off, finding mentors and doing courses. Then consider using the scope guide because it'll show you that picture. You'll see when it's looping; then you pull back and have the nurse hold pressure to pass it through straight. You'll see if it's working or if it's starting to form a loop. Just an idea. Yeah, yeah. Why don't we move on from colonoscopy— as much as we love talking about it— and let's go to the next segment of the show called our Financial Corner. So I was wondering if you had a money tip for our listeners.

Dr. P. J. Reddy [00:25:12]: Many students have $100,000, $200,000 loans, you know, something like that. So once they start doing residency, they have to think about paying the loan back, you know?

Dr. Randy Lehman [00:25:28]: Yes.

Dr. P. J. Reddy [00:25:29]: Fortunately, in my case, that was not the problem, and my children also did not have that kind of problem, you know.

Dr. Randy Lehman [00:25:43]: But what would you do if you were graduating? I think actually the average is now like $250,000 or $300,000. That's the average, meaning some people have $400,000 or more. So what if you're graduating medical school right now, going to residency with $300,000 of student loan debt, what would you do?

Dr. P. J. Reddy [00:26:01]: Well, you know, the best thing is to spend less. I mean, don't buy a Lexus car.

Dr. Randy Lehman [00:26:17]: Yeah, that's a good start.

Dr. P. J. Reddy [00:26:21]: I don't think they should spend money on alcohol or things like that, you know.

Dr. Randy Lehman [00:26:25]: Yeah. Eliminate your vices.

Dr. P. J. Reddy [00:26:29]: When I started doing my internship, my salary was $6,000 per year. $6,000, wow. In residency, it was $10,000 for the first year in those days. But now residents, from what I've heard, I think residents make $60,000— something like that.

Dr. Randy Lehman [00:26:57]: It's probably close, yeah.

Dr. P. J. Reddy [00:26:58]: Yeah. So maybe they can use 25% of it to pay off their loan.

Dr. Randy Lehman [00:27:09]: Sure.

Dr. P. J. Reddy [00:27:09]: The thing is, how much interest do you have to pay for the loan? You know, there are some loans with interest rates of 8%, 9%. Some loans you have to pay that high interest, you know. Maybe it's better to sit with a financial advisor and see what they recommend.

Dr. Randy Lehman [00:27:38]: I'm just doing some quick math. Say you graduated with $300,000 student loan debt and it was federal debt, so it's at 6%. A lot of people are probably in worse situations. That's $18,000 of interest only. So if you have a $60,000 salary and you paid a quarter of that for your loan, then you're paying $15,000 a year. Right. So you're actually getting behind on the interest during each one of those years. So I'm not sure that they can solve it. You know, there's a lot of different strategies. What I love about your answer is you started by saying, stop spending, stop the madness, okay? That's not the time for you to buy the Lexus car. You didn't say like, here's a big stock tip so you can get rich quick. Speaker A: And you didn't even mention public student loan forgiveness, which is a program that probably should be used by some of these people where you work. You work for a nonprofit or government entity of some sort, and you can get loan repayment. You also could sign on with the military. But you didn't mention those specific tricks you started with, like the fundamentals, like if you don't control your spending, you're never going to get out of debt.

Dr. P. J. Reddy [00:28:58]: Right, because that's a good point. You know, the thing is, in the state of Kansas, if you do work in a rural area, then they'll pay off the loan, some of it or all of it, something like that. I know some doctors here in Kansas who work in a rural area for three years.

Dr. Randy Lehman [00:29:21]: Yeah.

Dr. P. J. Reddy [00:29:22]: You know, if they work for three years, then the loan is paid off. That is something to keep in mind.

Dr. Randy Lehman [00:29:28]: Yes. And that's where I was hoping we were going to go because it is a rural surgery podcast, after all. So I think going to work in a rural area, whether it's through an official government program or just a hospital recruitment strategy where there could be some student loan repayment as part of an exchange for time, is a great strategy. I think there's a huge need in rural America, and if you can work that to your advantage, go for it. But I would say one more thing about this topic. I think if I would have gone back to being a medical student and maxed out my student loans for living expenses and everything that I possibly could have the whole entire time, and then invested that money, on the backside done public student loan forgiveness, I think I would have been actually money ahead. But the only reason is because I went to Medical School in 2011. Right. So coming out of the big recession, I was part of a time in which was one of the longest sustained bull markets in history. That's not guaranteed, but there is a sense of security in not having any debt. And student loan debt is... I had some, you know, but it's gone now, and it's non-secured debt. So, like if you have a debt on a property, at least you can sell the property as long as you have enough of an equity cushion. But you can't sell anything to pay off your student loan debt. It's just there, and the only thing you have is you. You need to work it off because it was for you to get the education that you got. So, I guess my advice would be to minimize your debt. Even though, like in looking back, I probably could have been money ahead borrowing money at 6% and investing it, I think that would have been a poor choice, and I'm glad I didn't. I encourage you not to do that as well, you know, just minimizing the debt in the first place.

Dr. P. J. Reddy [00:31:36]: Yes, I am. Maybe it's better to talk to the financial advisor, you know, I don't know.

Dr. Randy Lehman [00:31:44]: I think that's a good point to say that this is more or less an entertainment podcast, and I'm not a financial advisor. I agree that you should talk to somebody that's a fiduciary and who is licensed and all that stuff. But some of the core concepts of what we're saying, like don't take out debt, I mean, that's not like a stock tip, you know. I think it's fine to tell people that. Alright, I love it. Let's move on to the next segment of our show called Classic Rural Surgery Stories. So these are stories that your urban counterpart just wouldn't believe. Do you have any stories like that that you could share in a neighboring town?

Dr. P. J. Reddy [00:32:24]: There's a surgeon there, I used to call him to assist me in major cases. That surgeon used to come to assist me. So we were two doing major surgeries, colon resection, you know, things like that. So that was helpful. And I told you that I was doing OB/GYN also. So my colleague, a family practitioner, he was assisting me for, you know, C-sections, you know, things like that. So I used to get some help from other people also.

Dr. Randy Lehman [00:33:08]: Any particular stories from any of those surgeries that really stands out to you as something you would never believe?

Dr. P. J. Reddy [00:33:16]: Well, you know, fortunately, I did not have that many complications. Well, you know, two patients, two cases, laparoscopic cholecystectomy; there was damage to the common bile duct. So I had to send them to another hospital for that due to the perforation of the common bile duct.

Dr. Randy Lehman [00:33:52]: And so how did you identify that? How did you identify that?

Dr. P. J. Reddy [00:33:59]: Well, you know, you do lab chole, you send the patient home, the next day the patient comes back, "Doc, I'm still having pain," you know, and then the abdomen is swollen, tender, things like that. Then you do a CAT scan. When you do a CAT scan, it shows some fluid near the ascending colon, you know.

Dr. Randy Lehman [00:34:25]: Yeah, that's a giveaway.

Dr. P. J. Reddy [00:34:27]: That means, you know, there's bile leaking.

Dr. Randy Lehman [00:34:29]: Sure.

Dr. P. J. Reddy [00:34:30]: And then send them to tertiary bigger.

Dr. Randy Lehman [00:34:34]: Hospital and then ERCP to follow that with stenting. And that solved the problem.

Dr. P. J. Reddy [00:34:40]: Well, you know, the ERCP stenting, I had one case, I was doing a gastroscopy. There was a perforation of the distal esophagus, and I had to send the patient to a bigger tertiary hospital. They put a stent, and that was there for six weeks or something like that. So everything went well. No problems at all.

Dr. Randy Lehman [00:35:11]: Yeah. How about the bile duct injury, though? Was there a. Yeah, bile duct injury.

Dr. P. J. Reddy [00:35:17]: I think the patient... They did a choledochoduodenostomy.

Dr. Randy Lehman [00:35:22]: Okay.

Dr. P. J. Reddy [00:35:22]: Choledocojejunostomy, like that, you know.

Dr. Randy Lehman [00:35:25]: Yeah, yeah, that sounds good. Well, thank you for those stories. The last segment of the show is resources for the busy rural surgeon. Do you have one resource that you used regularly that you think every rural surgeon should know about?

Dr. P. J. Reddy [00:35:44]: Rural surgeons should be familiar with, you know, DNC, hysterectomy, you know, C-section, things like that. In a rural area, we never know. I would like the residents to get some training in OB/GYN also. And also they should learn how to do tonsillectomy, you know, TNEA and all that in a rural area. TNA, you know, they can rotate through the ENT department and learn to do TNA and maybe thyroidectomy, parathyroidectomy. I did all those cases, you know. And, you know, in general, general surgeons do only, you know, abdominal surgery and mammography and breast cases. Of course, you know, I don't think they do that much, you know, ENT, so they should learn all these surgeries also. And the other thing was, I had many textbooks of surgery at home, and if I have a patient for a parathyroidectomy, I read the night before.

Dr. Randy Lehman [00:37:10]: And.

Dr. P. J. Reddy [00:37:11]: Look at the anatomy and all that and see how to do parathyroidectomy or for thyroidectomy and all that, you know, I think it's a good thing to have the books at home. Surgical books, operative procedures. I mean.

Dr. Randy Lehman [00:37:30]: Yeah, yeah. And now in the days of laparoscopic and robotic surgery, you know, there's an element of video, too, that you can watch video. Okay, so that's good. I do the same thing with textbooks. Now, I want to ask, is that a habit that you started in training to read from the textbooks the night before to prepare for your cases?

Dr. P. J. Reddy [00:37:53]: In the training room? I did not do that many cases. That's why I bought the books, you know, operative procedures. I can show you if you want me to. There's one right here.

Dr. Randy Lehman [00:38:11]: Yeah, sure.

Dr. P. J. Reddy [00:38:11]: Well, you know, this is about Atlas.

Dr. Randy Lehman [00:38:17]: Of Color, Atlas of Human Anatomy by. Who is the author? McMinn and Hutchings.

Dr. P. J. Reddy [00:38:26]: And then I had surgical procedures also. Yeah, I had surgical procedures. And I also had, you know, CSAP.

Dr. Randy Lehman [00:38:35]: Sure. And so, Dr. Reddy, how old are you now?

Dr. P. J. Reddy [00:38:41]: What's your guess?

Dr. Randy Lehman [00:38:43]: Well, let me do some math. If in '67 you came here and you're already done with med school, you had to be at least 20, something like, say, 24. And then 41 years practice, and then two years after that. And then that was Covid and it ended. So. So let me see. 48 plus 24. I'm going to say you're. You're 82.

Dr. P. J. Reddy [00:39:05]: 82, you're right.

Dr. Randy Lehman [00:39:07]: Wow. Geez. I think I should be a detective, quit the surgery and the podcasting business to be a detective or a mathematician.

Dr. P. J. Reddy [00:39:14]: You're right.

Dr. Randy Lehman [00:39:16]: All right, well, it's a beautiful picture of an 82-year-old surgeon that's still academically involved. At least you're involved in our society. You're never not a surgeon. It's very similar to being a pilot. You might not, you might give up your license, you might give up your medical, you might not be board, you know, give up your board certification, may not be practicing, but you're always a surgeon. And I appreciate you taking the time to share that experience and that knowledge with me and with the younger generation today. It just, it's really meaningful to me. So I really appreciate it.

Dr. P. J. Reddy [00:39:55]: Thank you. You know, I still have the medical license and there is an osteopathic School of Medicine here in Wichita. And sometimes they call me to teach the students how to suture, you know, suturing. And so I do that and so I keep myself active. You know, I read before that empty mind is devil's mind.

Dr. Randy Lehman [00:40:26]: Thank you for joining us for this episode of The Rural American Surgeon podcast. We appreciate you being a listener. It's been my pleasure and honor. It's been nice to have Dr. Reddy to show us what a great career in general surgery can look like. So thanks again for joining us and we'll see you on the next episode of The Rural American Surgeon podcast.

Dr. P. J. Reddy [00:40:50]: Same.