EPISODE 47

Why This Family Doctor Does C-Sections with Dr. Brogan Bahler

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, listener, to The Rural American Surgeon. Today, my guest is Dr. Brogan Baylor, and he's a family practice doctor. Thank you so much for joining us. We're going to be talking today about OB/GYN topics.

Dr. Brogan Bahler [00:00:59]: All right, thanks for having me.

Dr. Randy Lehman [00:01:01]: All right, so tell us a little bit about your background and your authority to be able to speak on such topics as C-sections before we begin.

Dr. Brogan Bahler [00:01:12]: Yeah, for sure. Yeah. I have a weird background, I guess a little atypical for a family doctor. So, I guess going back to medical school, I had landed pretty much on thinking I was going to do real general surgery. So. And during my third year, end of my third year, I had my first son. And when I was doing my sub-I's and everything in fourth year, that kind of, I think, changed my perspective on a lot of things in life, you know, and focusing on my family and trying to weigh all that stuff out.

I had one sub-I in trauma surgery, which I really enjoyed. And I really liked all things surgery. And I had one in family medicine, and it was with a private practice doctor, which I think I had, like, this very, I don't know, perfect experience with this person that is very hard to recreate. But I think that's what pulled me into family medicine. And I, you know, I read these stories or heard these things of like, you know, like the old school family doctors that just were like, did everything. Like, maybe they even did appendectomies or they did C-sections, they delivered babies, they worked in the ER. They did all this stuff.

And I just kind of decided that that's what I was going to be. And so, I mean, with that in mind, I really, really was selective at which programs I was willing to consider and, you know, voiced what I wanted to do long term and made sure that that was something that they had. Residents had graduated and were doing similar things like that.

Dr. Randy Lehman [00:02:43]: Yeah, very good. So do you feel like you got the training that you needed?

Dr. Brogan Bahler [00:02:46]: Yeah, I would say for the most part I did. I guess the other odd thing again is, you know, I do full spectrum, including surgical obstetrics. And, as my career has progressed, I've actually leaned even more and more into that, where that's my main focus now. But I didn't do an F-MOB fellowship, and I was able to. I went to Ball Memorial in Indiana and had fantastic training there.

With my three years, I had somewhere around like 300 deliveries, which for family medicine, it's pretty exceptional. In three years, obviously for OB/GYN, they have numbers that exceed that, but just a tremendous amount of primary C-sections. And the big thing was that it was really just, you know, all of my surgical obstetrics was taught by MFM and OB/GYN surgeons. And so, they kind of were like, if you're in my OR, you're gonna, we're going to train you like we would train an OB/GYN resident. And if you can't handle that expectation, then, you know, you may not be cut out for this. And so they had the intensity of a surgery residency, I feel, within our family med residency.

Dr. Randy Lehman [00:04:01]: So how many C-sections does somebody need to do to be competent?

Dr. Brogan Bahler [00:04:06]: Yeah, that's a great question. A lot of training programs have used either the number 100 or 150. Some of them have tried to steal what is in ABOG ACGME criteria to graduate from an OB/GYN residency. The hard thing with that is that, you know, I think we kind of do know how many C-sections an OB/GYN resident, who is also doing hysterectomies and oophorectomies and these other abdominal surgeries, needs to do to be competent. But that may not be the same number as somebody that the only surgery they do is a C-section, if that makes sense, which for most family doctors, they're not really getting into the OR and doing maybe any other surgery other than that.

So, I do think that there probably is a number close to around 150 primary C-sections. Obviously not just observing C-section C-sections or, you know, it's hard to say with like assisting, you know, how involved an assist is. But I think, you know, when you're doing 150 primary C-sections, most people are reasonably competent to handle the majority of cases. Now, I don't know if that means that you can handle a fourth or a fifth repeat C-section or a BMI, you know, of 60. I mean, you're a surgeon; you know, like, there are certain cases that when you get out, you know, you're really comfortable with your bread-and-butter normal cases, but as you progress, even outside of training, I think you get more comfortable with those more complicated cases.

Dr. Randy Lehman [00:05:46]: Yeah, that's a great way to put it. There's. It's a bit of a trap question, of course, because, like, competency is not a number, right? But how do you determine it? That's one of the things that we have to do. So if somebody wants to do C-sections, sometimes general surgeons in rural areas are called upon to do C-sections, participate in a call pool. Usually, they are not at all involved in the laboring. Usually, the decision on who the C-section happens to is already made for them. And so it's more of knowing the steps and technically how to do the operation.

Obviously, you need to understand the difference between repeat and also someone that's been laboring for a while, also the different presentations. But do you think that 150 C-sections for an otherwise fully trained general surgeon is the right number or. And again, it's not a number. That's the trick. But do you think that it's. When you're saying it might be a higher number for a family med resident, should it also be a lower number for a general surgeon?

Dr. Brogan Bahler [00:06:58]: I think you got to think about the surgery itself and where you're like, where do you get stuck? Like, what are the hard parts? Like the cruxes of the surgery? So like, you know, you go down through your steps. Like, are you gonna have trouble getting through skin? No, like, I mean, like, but like the first area you really get stuck is, you know, with a repeat lysis of adhesions. Those, like, you're going to be fully competent in that with no additional training. Right? I mean, like, you're

Dr. Brogan Bahler [00:07:29]: the person that is going to get called in for lysis of adhesions if you're on like the bowel, if you have bowel attached to uterus, like, if you, you know, just sometimes it's just one big block of like, you know, it's like, okay, where are my planes? You know, you're not going to need so many C-sections other than like, I mean, getting comfortable with the Pfannenstiel approach. Like, that's going to take five surgeries, you know, for you to kind of like know, okay, this is like where we typically do these type of surgeries. Now the next part of

Dr. Brogan Bahler [00:07:59]: where you get stuck, I would say the most common it would be actually delivery of the baby. And that's going to be the harder part for a general surgeon, I think, you know, a standard breech delivery, it's usually not that complicated, but, like, you probably do need to see, I would say, a minimum of like, five where you actually have your hands on and do them.

And the hard part is even if you scrub into, you know, 30 cases, how many of them are going to be breached? Yeah, I don't know. I mean, obviously, that's

Dr. Brogan Bahler [00:08:30]: a standard reason for delivering by C-section. In the US at least, you know, we're not doing scheduled vaginal breach deliveries very often. But if it's belly side up, you know, there you can have awkward presentations. You can have a breach that's labored, and the feet are in the vagina, and the arm presents out and it pops out of your hysterotomy. And now you're like, okay, well, I can't do any of my maneuvers that I'm supposed to do. And so I, you know, I think

Dr. Brogan Bahler [00:09:01]: in a lot of these things, you can't prepare for everything, obviously. The one thing that I had, an OB-GYN once, that we were just, like, stuck in this case where we couldn't get the baby out of a C-section. So, I mean, even she'd had enough that the scar tissue is tight. And even with the hysterectomy, like. And it was vertex, like, it should have been easy. And I remember as the resident, I said, hey, get the

Dr. Brogan Bahler [00:09:31]: vacuum. And she just said, no. And she J-ed the uterus at, like, big time J. Like, bandage scissors went up, and she goes, I'm a surgeon. I know how to fix a mom. I don't know how to fix a baby. And OB-GYN said that an OB-GYN did. But I. But I mean, the same thing I think for you is, like, is your approach maybe going to be a little bit different at times? Like, I think it is, but at the. I think you're probably going to be able to deliver a mom safely by surgically. Right. You know, but. But there's

Dr. Brogan Bahler [00:10:02]: probably going to be some things with the baby specifically where you just aren't as, you know, versed and comfortable with as a general surgeon.

Dr. Randy Lehman [00:10:12]: Yeah, I think it's a big. It's a big need. In the United States right now, we're losing rural hospitals. A lot of the rural hospitals that are closing do not have general. They don't have surgery programs. Almost none of them have labor and delivery programs either. Um, but a lot of times what happens is you lose the labor and delivery program. The next year, your numbers look better because. Because you're like, in the black. Cause you were losing money on the labor and delivery. But then

Dr. Randy Lehman [00:10:42]: 10 years later, you pretty much don't have a hospital because you buy the family by delivering their babies. So in rural America, if a general surgeon can participate and be competent and comfortable helping out with some OB-GYN stuff, including C-sections, it's a huge value. It's also financially valuable. I have done, you know, maybe about four weeks or so of locums per year each. Each year for like the past five years

Dr. Randy Lehman [00:11:13]: since I've been out of residency, which has been kind of really nice to be sort of enlightened and have an eye open and see how things are done in other places. It was also nice because I had a bit of a bug-out bag early on when I wasn't sure how. I was kind of stressed out with my practice and just to have another option. Yeah, I would encourage anybody. I mean, it's kind of like moonlighting in residency. It. It's like cross-training, you know, because I work those shifts in

Dr. Randy Lehman [00:11:43]: the ER. In residency, I'm a much better doctor, and I think the moonlighting did that for me. But, you know, it just depends what you're. What you're going to do. But anyway, my point of saying that is that working for the locums companies, if you're a general surgeon that can, can do C-sections, that is a super in-demand thing. Oh, yeah, it's. And it's not just for locums. It's for obviously permanent positions. Take your pick. You know, name your

Dr. Randy Lehman [00:12:14]: price and take your pick. I would encourage general surgeons to not be scared of it and try to educate yourself. We'll talk about C-section today. We will also talk about resources, about C-section, you know, and if you, if you have an opportunity if you're still a resident, to go scrub in with as many different people and learn as many different techniques as you possibly can and how to get yourself out of a bind and ask those questions and write them down in little books because you're going to forget and have that to go back to

Dr. Randy Lehman [00:12:44]: when the adrenaline's pumping and you're called on to do your first C-section. Um, I, I just want to encourage, I guess, the, the rural surgeon in America to not totally throw in the towel on that because you can really help not just the mom and the baby of that situation but your whole community, your hospital viability by choosing, you know, to give of yourself and offer that and I had one more question for you because you, you said just about your

Dr. Randy Lehman [00:13:14]: background, you talked about how you've went to having a larger portion of your practice be OB-GYN. So tell me how you've done that and what I guess is would you do it all exactly the same if you had to do it over again?

Dr. Brogan Bahler [00:13:35]: That's a good question. So I guess I'll touch on a couple of the points that you made, kind of, and answer that question as well. So going back, I guess to my training again, one of the things I did was I did a ton of moonlighting in the ER. Like, I mean, a lot. I. And it was at a single coverage. I actually had privileges at three different ERs, but they're all critical access hospitals, all single coverage. Pretty much I only did night and weekend shifts.

Dr. Brogan Bahler [00:14:06]: And so I was the only doctor there. And that was as a second and third-year resident. And that was actually one of the reasons too that I picked the residency went to, not just because they allowed it, but that they had mechanisms in place to prepare you before you went out and, you know, make sure that you're going to be able to do that, you know, reasonably safely. And it, it's weird because like, going back to that question that you asked about like, how many does a general surgeon need to do? It's like, well, you wouldn't think that working in the

Dr. Brogan Bahler [00:14:36]: ER would have correlations to me being able to do C-sections, but it does. Right? You know, it's like you just get more comfortable, one, with being uncomfortable, two, with handling critical trauma situations, and also even adds in like getting back, would I do it the way I did it? No. But is there advantages of the way I did it? Yes. So I'm going to talk on that too. I think that'd be at least something fun to talk about. So, like, you know, I think that in a

Dr. Brogan Bahler [00:15:07]: postpartum hemorrhage, you have like that OB-GYN mindset when you're thinking, like, okay, what are my medications, like, my Hemabate, my oxytocin, you know, you're thinking about like surgical things like your Bakri or, you know, a D&C, all those different things. Right, right. So like you have, like, that mindset and kind of an algorithm that you follow. But then if you've done ER, you also have done ATLS, right.

Dr. Brogan Bahler [00:15:38]: So then you're kind of thinking of like, okay, like you're two large-bore IVs and like this resuscitation protocol, and you have a better knowledge of blood products, and all of that was beneficial for me, you know, and just having an idea of like a critical patient. And I think in general surgery, you know, you spend some time in the SICU/ICU and you have sick post-op patients that you take care of. Family

Dr. Brogan Bahler [00:16:08]: doctors. We spend, at least when I was in residency, I had to do one month of ICU and then a bunch of months of inpatient hospitalist medicine. But like that ER actually getting out there and doing it was a huge thing for me. So that answers some of the questions as far as like how did I get there?

Dr. Brogan Bahler [00:16:39]: After I completed my three years of residency, I gave my pager number to every OB-GYN in town, every ER doctor, and to about three general surgeons. I said, "Hey, these are the things I want to be able to do by the time I leave. Page me at any time," even when I wasn't on call, even if I was post-call. I apologize if I broke work hour rules; I probably wasn't supposed to mention that. But I just went in, right? You kind of have to say, "Hey, it's a three-year residency; it's not supposed to be a fun time. It's supposed to prepare you for the rest of your career."

Dr. Brogan Bahler [00:17:10]: Plenty of times, a general surgeon paged me like, "Hey, I have a chest tube. Do you want to come in? It's not emergent, but it'll be in the next hour." I would just drive in. We actually had a C-section pager we could carry. If no one was on duty overnight, they would page whoever had it. I frequently went in at three in the morning or five in the morning to do C-sections. Our program was also different in that if you did the section, you were expected to round on that person until they were discharged, which was a lot of extra work.

Dr. Brogan Bahler [00:17:40]: However, some issues with training, like our work hour restrictions, mean you don't "own" the patient. You're often not following up on everything. I think I really got to realize the consequences of my actions. For instance, if a patient's hemoglobin dropped, I'd think through my actions: Do I need to get a CT? Do I need to treat the hemoglobin? All those different things.

Dr. Brogan Bahler [00:18:10]: After residency, I worked at a critical access hospital in Indiana for three years, where it was truly full scope. I pulled shifts in the ER, acted as the hospitalist, and had my own clinic. When I was a hospitalist, I would round on everyone before starting my clinic. I was on 24/7 call for all my obstetric patients and did C-sections. The biggest advice I would give is not to ask hospital administrators if something is possible, but if they have people currently doing it.

Dr. Brogan Bahler [00:18:42]: Residents I work with often talk to administrators who are excited about their plans to do it all, but then find out no one else is doing it. It becomes an uphill battle for credentialing with inevitable naysayers. Luckily, a senior physician, a family doctor doing all the things I wanted to do, was already established. He did around 100 deliveries a year, hysteroscopies, D&Cs, ablations. With his mentorship, I was able to do the same.

Dr. Brogan Bahler [00:19:13]: I had general surgeons who were supportive of my surgical work in family medicine and knew when to ask for help without judgment. They helped me through cases rather than taking over. Being confident in my skills meant I was more likely to call for help because I prioritized patient care. Sadly, many places shut down OB departments; this happened where I was. I realized that OB was what I loved most about family medicine.

Dr. Brogan Bahler [00:19:43]: Other aspects were enjoyable, but I never got upset about delivering a baby at three in the morning. I couldn't say the same about other calls that felt unnecessary. For me, OB was a passion. There was a place in Illinois that had shut down its OB department. When they did, three private practice OB-GYNs quit. A single FQHC midwife stepped up, providing essential prenatal care.

Dr. Brogan Bahler [00:21:15]: This midwife was amazing, supporting the community by enabling travel to Peoria for delivery. I interviewed to direct an OB-GYN department with one board-certified OB-GYN in Peoria. Moving here, I practice outside of Peoria focused on obstetrics. We went from 100 to 350 deliveries annually, recruiting FMOBs, midwives, and a women's health nurse practitioner across three clinics.

Dr. Brogan Bahler [00:21:46]: My role is split between administration and 100% clinical obstetrics and gynecology. It's a rewarding path. Though credentialing posed challenges, it's fascinating how flexible family medicine is. With its Swiss Army knife approach, family doctors adapt to community needs, developing expertise in critical areas.

Dr. Brogan Bahler [00:24:25]: And then I found this community that really needed somebody to focus on obstetrics and gynecology, and my depth of knowledge in that has just expanded so much over the last several years. Now I'm able to take care of really complicated obstetrics and gynecology patients and have earned the trust of the board-certified OB-GYNs at the hospital I deliver at, where they've allowed me to do more and more. Now my practice is really no different than theirs, you know? Being part of an FQHC, often I'm taking care of the most complicated patients with the highest risk pregnancies. Yeah.

Speaker A: And you know what's funny about that phrase? The full phrase is "A jack of all trades is a master of none, but oftentimes better than a master of one." That's actually the phrase, and it’s used out of context in the wrong directions to make it sound like it's bad to be a jack of all trades. But I think that cross-training is extremely valuable, and it's relevant to a rural surgeon too because we're basically the Swiss army knife of surgery. So, the next question for the show normally is, why is rural surgery special to you? But is there a particular reason that rural OB-GYN is special to you?

Speaker B: Yeah, I think that with rural surgery, obviously there's that community bond; there's a mission. I think there's a continuity of care.

Speaker A: And.

Speaker B: That's probably true for all practices and all different specialties that practice in rural settings. The scope of practice, I think, is what drew me in. That was unique, like, how many Level 1 trauma centers are family doctors allowed to do the surgeries I do? I'm doing hysteroscopies and D&Cs, and I'm doing C-sections. As a family doctor, I got my wings to do all of that during my residency training to prove that I had the numbers. Now I have actually been able to get privileges at much larger hospitals. But it was a huge uphill battle. So, I think that scope was one of the things that really drew me, being able to do the surgeries that I like to do.

Speaker A: Got it. Well, if we don't get to how I do it, we never will. So obviously we're going to do "how I do it" for C-section. Usually, we go into extreme detail about each step of the operation, starting with the positioning. Maybe, actually, maybe let's talk about indications for surgery just briefly. The most common indications for C-sections are what? Repeat C-sections and then failure to progress. You tell me.

Speaker B: Yeah, so you have your standard repeats. That, as an indication, is starting to really change because, you know, VBACs after one C-section, there are some calculators to look at their likelihood of having a successful VBAC. But now there are some institutions that are even doing VBACs after two C-sections. So that's a big change. But yeah, for sure, just a standard repeat. Very common breech presentation. We alluded to earlier. Failure to progress or non-reassuring fetal heart tones are your other really common indications. Sometimes fetal intolerance of labor gets used, but that's pretty synonymous with the non-reassuring fetal heart tones.

Speaker A: Where are we at with twins?

Speaker B: So, most larger institutions, you can deliver twins as long as your baby A, or the lower one, is vertex. Even if your second one is breech, many people will deliver. I'm a big fan of those needing to be in the OR. So, I actually think that the vaginal portion of it, ideally both are born vaginally but should be in the operating room. Once you know you're, you can labor your patient up until maybe they're like 8 cm or close to delivery, but then they need to be moved into the operating room for delivery. That's not, to my knowledge, a national standard. Some hospitals do have that as an institutional standard. Then, with your second one, some OB-GYNs will choose and feel that it's reasonable to deliver the second one breech after that first one has paved the pathway, so to say. I usually will do an internal version. That means that I put one hand actually in and then the other on the outside and invert the baby to turn it vertex. In some situations, you do have to convert to a C-section, even if you get the first one out vaginally. Sometimes you have to convert to a C-section for your second baby. That's why it really needs to be in the OR. There's just enough that can go wrong that you really need to be able to have everything totally ready, you know, the kit, everything totally open, your C-section case.

Speaker A: So, we have a segment of the show called Resources for the Busy Rural Surgeon. But I'd like to just throw it in now because you mentioned the Green Journal and the guidelines that you referenced. Where could somebody find those in the Green Journal?

Speaker B: If you're an ACOG member, then you get it every single month. That also gives you digital access to every single publication. ACOG makes these practice guidelines, and generally, like a lawyer is going to reference them if you're ever in a lawsuit. ACOG practice bulletins or guidelines—all of that's accessed with your ACOG membership. You actually don't have to be an OB-GYN to get membership to ACOG. If you're doing a large volume of obstetrics, regardless of your specialty, it probably behooves you to have it so you can reference those guidelines.

Speaker A: You can't reference the guidelines without the membership.

Speaker B: Not to my knowledge. Which is crazy, right? If it's like national guidelines and you can't get them unless you're a member. So, it's not the best situation right there. Otherwise, you're like going to UpToDate or just asking whatever local person, right?

Speaker A: Yeah, sure.

Speaker B: And there are huge deviations in local standards of care. So it is always good to know your local standard of care. But for a lot of stuff, your standard definitions, like what is preeclampsia or whatnot, are going to be on these guidelines and standard treatments and those things. They have some specifically, you know, on VBACs that have come out recently, talking about that two C-section limit. These are big changes, right? So, it is hard to stay up to date if you're not having a membership. It stinks because it's expensive, but for me, it's worth it.

Speaker A: Sure. Well, now that you're a hundred percent OB-GYN. Sure. Especially.

Speaker B: Yeah.

Speaker A: All right, very good. Well, thank you. Do you have anything else to add to either of those segments?

Speaker B: The biggest thing for me, I would say, is we've talked about the three A's before: you and I have, like, affability, availability, ability. That's not just with your patients; I think it's also with your colleagues. The biggest thing is knowing your specialist and your backup, like your safety net in all those different layers. That's your real resource: knowing all the people and being affable with them and being available when they need you. If you are available when they need you, then they're going to be available when you need them. That's probably been my biggest key to success, how I've gotten here—I've just made friends, like, in my local network. I'm just really good friends with many of the OB-GYNs here where I'm at.

And like they've helped me out a lot and like, you know, when I've been in a tough situation, like they've been able to help me, whether that's by phone or, you know, one or two times, like even calling them to the OR for help, you know, and so that's important. And so yeah, I think like a mentoring chip, like network and like that's important.

Dr. Randy Lehman [00:31:52]: Yep.

Dr. Brogan Bahler [00:31:53]: And then I, I don't. Did. Did we talk about. I think you said financial corner too.

Dr. Randy Lehman [00:31:57]: I know we didn't really hit all that bounce back. So the, the other two ones are classic rural surgery in the financial corner. So why don't we go financial corner? What do you think? Money tip for our listener that you might have.

Dr. Brogan Bahler [00:32:09]: That's where family medicine actually did win over. Which is weird because I think like the stereotype is that, you know, family medicine, like financially is like the worst decision or like so underpaid and it's like I get it. Yeah. If you do outpatient only and you work from nine to five and you take no call and you work four days a week in clinic, you're not going to get paid. Super great. But the big thing is it's a three-year residency. So I started, you know, earning the income of attending multiple years early compared to a general surgeon and one year early compared to an OB-GYN. So that was huge financially.

The other big thing is that I had time to be able to do moonlighting. So like I made quite a bit more while I was in residency. Actually, the pay for family med residents, when I looked at it back when I went through residency, was actually a little bit higher just to get people to go in. And I actually had a sign-on bonus for residency. Isn't that weird? Like I think it was like five grand or something to go to family med residency.

On top of that, in Arkansas, I trained at University of Arkansas for med school. They had a, I don't know if it was, I think it was for like pediatricians and family doctors and maybe internists that you could get a loan that was separate from like the regular FAFSA loan. It had zero percent interest for like the first five years and then it went to whatever like the normal rate was. And so like, and I, it was only for like the first 20k or something a year, but I was able to basically do just that for all of mine. So I had zero percent interest on my student loans just because I was a family doctor. Right. So that's huge financial.

And then when you look at, there's a lot of programs like the National Health Service Corps where I'm working right now, they offer that and we have a really high HRSA rating. And so pretty much everybody that comes here generally gets that loan repayment. That one is very different because it is actually tax-free. So you get like 50k a year, I want to say, but you don't have to pay any taxes on it, which is the only one like that that I'm aware of.

And that's a big financial. I think the thing that people don't realize and that they don't prepare for is that they don't realize when those get paid off, you know, when they're forgiven, that you have to pay taxes on them when they're forgiven. Right. And like people run into big problems with that because they're not prepared for that huge amount on their tax bill.

There's also the Public Service Loan Forgiveness or PSLF. There is a lot of, you know, I remember like, I think Colorado had one specific for family doctors, it was like an extra 20k or 50k, something like that if you came there. And I just got a huge sign-on bonus to be able to do family medicine and rural. And I found that generally speaking, most family medicine jobs have pretty good sign-on bonuses. When I've talked to my OB-GYN colleagues, they're like, what are you talking about? We don't get those. And I'm like, oh, for family medicine and like especially rural. And I imagine if an OB-GYN really went rural, they probably would still get it. Right. Probably right.

But like family medicine, I don't, I don't know like any family doctors that aren't getting some type of sign-on bonus for where they're going. And so yeah, I guess like quick summary was like access to loans and loan repayment services, short residency definitely has benefits and then sign-on bonuses when you get out. And then after that, you know, if you have an RVU contract or whatever, it usually the pay per RVU is not like dramatically, dramatically different from a family doctor to an OB-GYN. And so if you're doing actually the same workload as them, you're actually getting paid the same amount.

Right. It's just that the reason why family doctors don't always get paid as much as one not taking all the call in the workload, but also that they usually don't do the procedures and procedures usually have a better reimbursement and RVU. Well, like I do tons of procedures and so like as far as that's concerned, like I've not had a problem where I feel that I'm just treated terribly financially, you know, like I think that I'm treated fair.

Dr. Randy Lehman [00:36:17]: Yeah, great. That is a new financial tip for the rural American surgeon listener. Do family medicine. That's okay. Basically, you make a compelling argument, I'll give you that much. And I think that there's a lot of ways to kind of get to where you want to go. The other thing that came to my mind is in 2021 with the changes to coding, there's basically a 30% bump in value for all the EM codes too.

Dr. Brogan Bahler [00:36:50]: Oh yeah.

Dr. Randy Lehman [00:36:51]: Which blew my mind when it came when that change happened because all of these clinic-based specialties that are on RVU-based contracts essentially got a 30% bump in their bonus, you know. And how does that, like, I don't know how. I never heard of a bunch of people like having their contracts be renegotiated or whatever. But it's, it is the reality and it does make clinic relative to procedures more valuable for both the specialist and for the clinic-based person.

Dr. Brogan Bahler [00:37:24]: So yeah, I mean that. And then I guess the other thing is that many rural hospitals are rural health clinics, you know, and so rural health clinics and FQHCs actually get paid per encounter. Yeah. And so OB-GYN is actually phenomenal for clinic encounters because they're generally pretty efficient, I guess is a good word.

Dr. Randy Lehman [00:37:48]: Quick.

Dr. Brogan Bahler [00:37:49]: Yeah. I mean, a prenatal or a postpartum, if you can get paid the same amount for that encounter as you do for somebody that has like, you know, heart failure, kidney failure, is 90 years old, is like, you know, this like complicated family med patient. If you're getting paid the same amount or the hot elite, you may now be. The clinic's getting paid the same amount. Right, but that's part of your negotiation. Right. You do have to negotiate your contract to get your fair shake of the pie. And usually like my. A lot of FQHCs or rural health clinics, they may actually have contracts that are based on the encounter rather than RVU, which there's a. That's a whole. I mean, we could talk for an hour just on that about whether that's right or wrong. But, you know, they want to have you to have the same incentives as they have and not. So that way you're not able to game the system. Right. Anyways.

Dr. Randy Lehman [00:38:41]: Yeah, no, that's great. Little financial corner for you guys. Did you have a story that was just classic rural surgery now? I understand you kind of have an. I mean, would you. You're not really a rural practice. You have one rural clinic now, but your practice is actually quite urban, from what I understand.

Dr. Brogan Bahler [00:39:00]: Yeah, yeah, it is. It has changed a lot over the years.

Dr. Randy Lehman [00:39:04]: But the idea behind the classic rural surgery stories is a story that your urban counterpart just wouldn't believe. So really, any crazy surgery story counts.

Dr. Brogan Bahler [00:39:16]: Well, I can give you one pretty big then. I'm gonna give you two. One's not surgical, but it's just funny. And that's from my time in rural practice. And then one's a crazy surgical story from my current time, actually. So one that I just loved, and this is classic rural medicine, is that I had this, like, 80-90-year-old lady. We'll just call her Betty. She comes in and she's got...

Dr. Randy Lehman [00:39:39]: Like, she presented for a C-section.

Dr. Brogan Bahler [00:39:41]: She's like in the office, you know. Yeah. My, she's AMA, right? Advanced Maternal Age. So, and she's got like the paper with just tons of stuff written on it, which you like. I mean, everybody knows how you actually feel. We don't have to say it when somebody has that just huge paper. I mean, it was like filled out full. Full page. And I'm like, hey, Betty, it looks like you got a lot to talk about. Right. You know, and she's like, oh, yeah,

Dr. Brogan Bahler [00:40:11]: I got a lot to talk to you about today, Dr. Baylor. She says it slowly, and then she's like, so how's your wife? And she knows my wife's name, says my wife's name. And I'm like, oh, she's doing good. And I give this little minute line. She keeps on asking these more leading questions about my wife, and I keep on going. And then she's like, and your firstborn, his name is... She knows his name. And I'm like... She's going on about him, right? And then she's like, and you have what, a three-year-old, right? And you just had a baby, right? And so she's going on.

Dr. Brogan Bahler [00:40:42]: At this point, it's been like, I'm not joking, over 15 minutes. And I'm like, Betty, I really just appreciate you. Yeah. I'm like... I wanted to be like... And I go. I said, but you have that list. Can we get to some of that? And she goes, oh, that was just about it. That was her list. She wrote down all of my family's names. She wanted... She had nothing medical to talk about at all. And I was like, I don't know. Like, what do I even do with this? Like, therapeutic counseling? Like, I don't know. Right? So

Dr. Brogan Bahler [00:41:12]: that's great. So just loved it. And that's like the stuff you miss, right? Like in... Same lady would, like, bring me in, like, blueberry pies and, like, stuff from her garden. Like, that stuff was amazing. So classic surgery story, though. So they're, like I said, the hospital where I'm at is... They shut down, actually, the OB unit here. So there is no OB unit in that rural clinic. But there was a time that somebody showed up in labor,

Dr. Brogan Bahler [00:41:43]: had had... I think when the report was, she'd had like seven prior C-sections. And there was this report that, like, she had gotten to complete. So they were having her push, but then it sounded like maybe lost station, you know, so the baby had gone back up. It was... And they had called multiple OB-GYNs, and nobody could come out there. And... But then EMS refused to transfer because they felt like the patient was too unstable. And so I got a call and just said, like, will you

Dr. Brogan Bahler [00:42:14]: come in there? Like, they just said, we have an emergency. It's obstetric. Can you come? And I'm like, okay, I'm coming now. And I just left. I had, like, four people in my clinic waiting on me, and I just left. I didn't even know. And I had actually never been to this hospital. I had to put it in my... Like, like, hey, Siri, give me directions to this hospital. And I drove there, like, pulled in. I just walked in through the ER and on the way, I called the CMO of the whole hospital system. I was like, hey, I need emergency privileges

Dr. Brogan Bahler [00:42:44]: at this hospital. And they were like, yes, you have it, granted. And so, like, I just showed up there and I asked for an ultrasound and put it on the mom. And so it's compounded. She was, like, under the influence of endless, like, combative swinging. And I put the ultrasound on, the baby's heartbeats like, 50. And I just, like, instinctively, like, go to the OR now. And so, like, I'm having somebody, like, basically hold me by the hand,

Dr. Brogan Bahler [00:43:15]: drag me to, like, where the scrubs are. I don't even know what floor the OR is. I don't know where anything is. And, like, I get there and I'm like, hey, we need a Betadine splash. Like, we need... We're going to have to go under general. And then I'm like, do you have a C-section kit? They're like, no. And I'm like, well, I just need a scalpel, like, thinking, like, legitimately, technically, that's all you need. But then as, like, the case started, I was like, retractors, like, bladder blade. And they're like, we don't have any of that. And I'm like, oh.

Dr. Brogan Bahler [00:43:45]: They're like, all of those are very expired and we do not have them. So I'll save the details of, like, everything that progressed throughout the surgery, but it ended up being just this, like, she ended up having a uterine rupture, you know, and mom and baby both did great, and they're both doing well today. And, you know, so it's just a big case that at minimum, I'd say the baby would have died had I not been called and been able to get there. And maybe even the mom,

Dr. Brogan Bahler [00:44:16]: I don't know what outcome she would have had. And so, you know, that's like the type of stuff that I... I think the non-surgeon, like, those are the stuff that break you, like, and you're like, this is why I never want to do this. And those are, like, the stuff for me. I was like, this is why I did all the training that I did and why I want to keep doing it, right? Like, you're like, this makes me want to do it for another 10 years, you know. So.

Dr. Randy Lehman [00:44:40]: Yeah, how many people did you have scrubbed in with you?

Dr. Brogan Bahler [00:44:45]: A lot. It was like, all of the nurses from the whole hospital, I feel like, showed up. Right. You know, so. Yeah.

Dr. Randy Lehman [00:44:51]: And again, you had anesthesia.

Dr. Brogan Bahler [00:44:54]: They had a CRNA. Yeah. And so, yeah. And ironically, again, like, small town, like, again, like, this rural. So one of the circulating nurses... So I had a patient in Peoria that's laboring, and she, like, only wants me to deliver. She's 10 centimeters, first baby. And she, like, progresses to complete during all of this. And they, like, tell her, like, hey, it's time to push. And she's like, well, I'm waiting for Dr. Baylor to show up. And, like, my colleague even shows up, and it's like, well, I guess I'll just stay here until he's available because, like, and we obviously, HIPAA. We can't tell this patient this information. Well, it turns out that, like, that laboring patient's... It was like her, like, sister, I don't even know, like, was a nurse at this other hospital and in the OR with me and is like, hey, so and so is 10 cm and she's waiting for you. Like. And I'm like, oh, my gosh. Like, during all of, like, to add...

Dr. Randy Lehman [00:45:53]: On top of the same case.

Dr. Brogan Bahler [00:45:54]: During that crazy case. Yeah, my. Yeah. So you asked, like, how many people were there. Like, not... There was, like, abundance. There were plenty enough. But, like, it's like, literally, like, one of my other... Yeah. It's just crazy. So. And I don't... I probably can't share any more than all of that just for HIPAA, because it's like, you know, you get too into the details, and it's probably discoverable or whatever, but it's... It was a big case and yeah, I just was happy I could help out the... and that I serve in. Right. So.

Dr. Randy Lehman [00:46:21]: So not, like, what was the baby's name, but what would be a great baby name for a baby that showed up with a rupture like that? Because this is what I heard.

Dr. Randy Lehman [00:46:41]: I heard there was a baby that was born as a twin that wasn't known about.

Dr. Brogan Bahler [00:46:42]: Oh, yeah.

Dr. Randy Lehman [00:46:43]: And the first baby had some normal name, and the second one was named D. apostrophe Extra. The extra.

Dr. Brogan Bahler [00:46:53]: The extra.

Dr. Randy Lehman [00:46:53]: The extra. So what would be a good baby name for a, you know, rupture? I got one other one. There was, you know, I have a farm, and I have cattle and pigs and everything. There's a boar in a boar stud, which, you know, that's how they breed with AI and everything, that was born by C-section. And the boar's name is Out The Side.

Dr. Brogan Bahler [00:47:18]: Out the side.

Dr. Randy Lehman [00:47:19]: Because they did these actually. You know, there's got to be some good...

Dr. Brogan Bahler [00:47:23]: A convertible top. Right. Just take it out the convertible top.

Dr. Randy Lehman [00:47:26]: Right. So the internal experience.

Dr. Brogan Bahler [00:47:29]: Yeah. I don't know. I mean, it's—I think just—it's being its seventh baby, too. Right. You could just—I mean, maybe that's it right there. Seven, like we just said. At some point, you just run out of names, and you start numbering them.

Dr. Randy Lehman [00:47:42]: Just come on. Come on in. Supper time. All right, perfect. Well, this has been a great conversation. Thank you so much for taking us through an important operation for maternal health in rural America—the C-section. Is there anything else that you'd like to share with the audience?

Dr. Brogan Bahler [00:48:02]: I just appreciate you having me. And, I mean, I'm sure we could talk for several more hours, but we'll keep it stopped here at an hour. Right.

Dr. Randy Lehman [00:48:09]: Well, we'll have to have you back sometime and see if there's anything else that we can chat about. So thank you so much for joining us, and thank you to the listener for being here on this episode of The Rural American Surgeon. And we'll see you on the next show.