EPISODE 53
How to Think About a Surgical Career (While You’re Still in Med School)
Episode Transcript
Dr. Randy Lehman (00:00:00):
Welcome back listener to the Rural American Surgeon. I'm your host, Dr. Randy Lehman, and I'm joined today by Isabelle and Ev, who are two students at Baylor, and I really appreciate you guys coming on. They wanted me to talk to their pre-surgical, basically med student group about rural surgery, and I figured that if they had some questions that there may be some other listeners who had similar questions and so we thought we'd just record it and put it out as an episode of the show. Thanks a lot for joining me guys. Tell me about the Baylor College of Medicine Student Surgical Society.
Ev (00:00:38):
Yeah, sure. So I can cover that. So I'm I'm MS three. I'm one of the co-presidents of Student Surgical Society at PCM and pretty much what we do is we're student org and our main mission is to get students involved in surgery and interested in surgery. And how we do that is we hold events mostly with faculty residents. They may give a background on their subspecialty or subspecialty or some part of surgery residency applications. We'll also do faculty or resident or peer to peer mentoring. We'll have research opportunities coordinated. And then what else? We'll hold SIM lab events as well, get students plugged in with the clinical skills and practice that early on. So overall, just getting students involved here at Baylor, how many students per class do you have at the Baylor College of Medicine? Probably around two 40, including both Houston and Temple Campus.
Dr. Randy Lehman (00:01:36):
Yeah. And what's the interest in going into surgery?
Ev (00:01:39):
I think this year is one of the biggest years we've had in terms of residency applicants. I think the current fourth years have at least a dozen students applying into surgery, so I've heard, especially given Baylor's history with surgery, I think there's a strong interest.
Dr. Randy Lehman (00:01:55):
You guys are both MS Fours? Threes, threes, okay. Sounds good. Isabella, how do you want to do this?
Isabella (00:02:02):
I think a good place to start would maybe be talking a little bit about specifically what drew you to rural medicine, but then specifically to rural surgery and then a little bit maybe about your practice currently or how it's evolved over the years and then maybe you talk a little bit about training.
Dr. Randy Lehman (00:02:20):
Sure. So I knew that I wanted to go back to my hometown before I knew that I wanted to be a doctor. So that's the draw. I'm back now living on the farm that I grew up on. I have cows and pigs and a go-kart for my kids and land my helicopter in the backyard and do whatever I want. It's like as far away from society as I possibly can get, but yet I could go farther, but it's not the farm I grew up on. So what happened is I went to series of events happened that we've talked about before on the show, but for the sake of you guys is that I got a scholarship to go to college and then I went to Purdue and I sort of chose pre-pharmacy because it seemed like a good idea at the time, a number of reasons.
(00:03:12):
And then I hated it and had four semesters of declining GPA and didn't get into pharmacy school. And then I had all this pre-health stuff and more or less went to medical school out of spite and then of course got great grades after I made that mental shift. And then it was actually like, oh yeah, this is what I'm supposed to be doing. I thought though, when I went to medical school I was going to do ER and then I fell in love with surgery and I remember being a third year medical student, you have to make your decisions being in Cincinnati Children's Hospital making this pros and cons list and in order for a specialty to make it on to the pros and cons list, it needed to be something that was needed in my hometown. So I put er general surgery family med on the list basically, and I was considering all of em, but I think I kind of knew what I wanted to do and I made the list, but I remember first it was just too much clinic, family med.
(00:04:20):
Now being family med in a rural place, you can be a lot more procedurally based and do a lot of skin lumps and bumps and procedures like that and you could do lots of little office procedures, colonoscopies and EGD's and the days of the family med doctor doing appendectomy are probably gone. But that used to be done in my hometown. The family med docs used to do surgery and they used to do anesthesia for each other with poke, fall, anesthesia, general anesthesia, inhaled anesthesia, endotracheal, everything just for pure family though. But I mean that was 40 years ago and I don't know of anybody that's practicing like that anymore. Then I imagined somebody coming to the ER with appendicitis and then being an ER doctor and calling the person who gets to go fix it basically. And I wrote as a con under ER will not be a surgeon.
(00:05:21):
And so then I'm like, okay, as all the cons under surgery are, well, it's a five-year residency instead of three, it's a longer harder training. That's mainly what it is. It's not really an afterwards thing. I mean maybe you could say it's better to have shift work and be in the ER and then you could be all the way off. You could have that I think as a surgeon if you really wanted it, which I don't, and that doesn't really bother me that much. I mean I grew up on a farm. If the cattle need water, they're always your responsibility if they get out, they're always your responsibility and it's like that with your patients. And if you do a good job mending fence and managing your cows in a way where you don't run into emergencies, meaning you can minimize your complications and choose to appropriate patient selection and also bundle things up and if you manage your practice in a certain way, it really doesn't have to just kill you either.
(00:06:22):
So anyway, I said to myself at that point, suck it up, do the training and do the job that you ultimately want to do. The other thing that I would say for the students is when you go through your rotations, don't think about how the rotation made you feel when you're making your decision. And do not look at the residents, just look at the attending on the rotation and say, do I want their job and do I want to do that for the rest of my life? Because a lot of the other stuff, how you feel can be just based on personality and who you get along with. And then the residents, there's a huge amount of variability. Some of them are not in the right place anyway, they're not even supposed to be doing the thing that they're doing and maybe they end up switching. And so you just look at the actual job and if you love that, then you're on the right track.
Isabella (00:07:18):
I take it kind of how you chose to go back, number one, to go back to the place that you grew up and to provide care to that community and then to choose surgery. Maybe you could talk a little bit about your training and then the transition from your training to your current practice and maybe how that's changed over the years.
Dr. Randy Lehman (00:07:41):
Yeah, so I'm five and a half years out of residency and I went to Mayo Clinic in the rural surgery track. So at that time in third year when I discovered, I mean I made the decision, I definitely want to be a surgeon, I definitely want to go back home. Then I realized that there's a huge amount of activity about the topic of rural surgery nationally in American College of Surgeons and then also in the programs. There are these programs that are developing rural surgery training tracks and they're very vastly different from each other. So you have to ask a lot of what exactly you're getting in general, trying to trade a broad based general surgeon in five years and get 'em out and meeting the needs where we're short in rural America on surgeons. And so after I identified that, then I was like, I want to go to one of those types of programs, but I was kind of late to the game when I identified it.
(00:08:41):
And so I ended up interviewing 16 places, only three of which had a rural surgery track and I ranked them 1, 2, 3, got my number two, which is Mayo Clinic, which is the message is trust the match because the nice part about the match is anywhere that you end up going, you know that they wanted you to. So it's not about getting your number one or whatever, it's more about the computer matching everybody up so that you get a place that you're really happy with and they are too. So anyway, I went there and the difference in my track was that in fourth year I had dedicated rotations in ortho urology, ENT, plastics and OB GYN. There were mostly a six week rotations, I can't remember the four or six weeks. And then I was taking general surgery Q2 call at that all the way through in a smaller hospital but not a rural hospital.
(00:09:41):
It was, I don't want to say there's 10 ORs. I know that, and I don't know, maybe there's 70 beds or something maybe way off of that, but it's like a real hospital with an ICU and IR and GI and specialty stuff. It's not like a critical access hospital I work in now. But the benefit is that there's no competing residents except for we had a third year resident doing a general surgery rotation there. So it worked out. We would just take every other call for general surgery and then I would go preferentially, I would go do those subspecialty things, plus it was extremely irrelevant. And then I would always go do general surgery all the way through because I was at the same hospital for a long period of time and everybody gets to know you, then they trust you and invite you into the operating room and then it just kind of works out great. And most of residencies kind of like that. You get out of it what you put into it. So in Mayo we would have, with the research residents and everything, we would have 75 residents at a time because there's people going in and out of the lab and everything and you can very much hide for all of your residency if you really wanted to.
(00:10:58):
Or in the afternoon when you are done and there's still cases going on, you can just go down and be an or rat and just look around for something to do because sometimes the staff is running a second room on their own or there's fellows that are, they don't really care about that case necessarily. The more resident level case, maybe you do it with them, maybe they did have coverage for the room, but it's a fellow and they're fine. They're like, you can just do it and I'll just chill. It's all about relationships and being aggressive about it. And so it's amazing how much you are in control of your own training as a resident I guess. And you can get drastically different. The average Mayo Clinic resident graduates with 950 cases and I graduated with 1600 and COVID wiped out the last three months of my training.
(00:11:52):
So to give you an idea, but that doesn't tell the whole story either because there may be some I may have done, I definitely did more rotations outside of the big house, so I still got plenty of experience operating on the pancreas and liver and whatnot. But I had these other days where I'd do seven, eight cases of gallbladder attorneys all day long, which a lot of the other residents didn't get a chance to do. So that's the one thing I loved most about my training was that I got a lot of places you'll go interview at. They'll say, yeah, we're logging 1600, 1800 cases and they make us stop logging our cases at the end because otherwise we're going to have questions from the ACGME
(00:12:38):
But then I asked this question at one place that I interviewed, I said, well, how are your Whipples? And they're like, well, there's five minimum to graduate. So we all just double or triple scrub if there's a pancreas case and then we all just log it as surgeon junior. So you don't want to have 1600 and not actually do the big cases, but you don't want to necessarily have eight, 900 and come out and really need a fellowship to be able to operate, which only comes through enough volume and enough autonomy and also early as you can get in the operating room to make your skills as good as possible before you get there. Obviously know how to tie, know how to suture, know how to handle yourself for the basic things. Then when the opportunity presents itself shine and then get yourself better and get in there and make mistakes as early and as often as possible because the more that you can do that, it just builds on itself.
(00:13:38):
There's just an improvement curve where you can change where you start and you can also change the slope of your curve relative to your peers. And a lot of people they don't do. I mean you would think everybody in surgery would be really aggressive about their own training, but it's kind of amazing how many people just kind of, I don't know, show up and go through it and maybe they expect to get spoon fed or something, but it's not really how it's, so take care of your own education would be my advice. Now that's kind of residency and that's not even really what you asked about, but the transition out of residency and into practice. I don't know what stage, I know you guys are MS threes, but if there's anybody else that were to listen to this, I mean if you can avoid taking out loans for your living expenses, that's ideal.
(00:14:32):
And in college, applying for all scholarships, maybe working through college, maybe working even in residency or I mean in medical school, which I did work your way through it, and there's synergistic things. So for example, I taught for the mcat or you can teach anatomy lab or something some way that you can kind of pitch in. I also kind of house hacked, bought a house and rented out the rooms to roommates and just kind of kept my living expenses low. Had a lot of friends that they were living like doctors while they were medical students. And what I mean is they would rent a fancy town home and then they're paying for that on a loan, which means that they're really paying for it three times over. So they're really renting for like $7,500 a month. That's how I thought about everything that I bought when I was residents.
(00:15:23):
It's times three, do I want this $5 coffee? It's really 15 type of thing. And so I minimized that as much as I could, but I still got out with about 150,000 in loans, which was less than the total overall cost of tuition, but it was still bothering me a lot. I knew there were some student loan repayment options in rural America and I called my hometown hospital where I wanted to go back and they didn't really want to talk to me because I was trying to do this when I was a junior resident, like a one or even the summer before my first year. And I knew where I was going, but I think they were part, they sold and they were part of a chain. And the chains, they don't really want to deal with you until you're like a four or five and that's 20% of surgery residents switch out of surgery, they drop out.
(00:16:17):
So I mean to be fair, they could do a whole bunch of work with a first year resident and then it doesn't work out well. Anyway, with me, I knew that it would couldn't get them to do anything. I kind of gave up for a bit and then a number of dominoes sort of fell where I got married, my intern year, we got pregnant, had a baby my second year and we knew that we were, she's from my hometown too. And so I went and called all the hospitals around the area and the two that were independent offered me a contract immediately. So that's the lesson is there was three that were part of a chain and they all said, call us back when you're a four or five. The two that were independent said, here's the deal, we'll give you a whatever. Here's lesson number two.
(00:17:10):
So nationally, there's one surgeon per 19,000 that is underserved. And I read at least one study that said there should be one surgeon per 14,000 population and I buy that. But the question is also if you're rural or urban, if you're rural in some ways there's a lot of things you're not going to do. And so you may be giving up the higher level things like trauma, esophagectomy, whipple, pancreas surgery, liver surgery, rectal surgery. But you may be given that up if you're in the city anyway because a specialist might claim it. But at the same time in rural America, you take care of things that you wouldn't in the city. So for example, scopes is a huge one. It's about 50% of an average rural general surgeons practices, scopes, and I would say can be, and if you don't want it to be, it doesn't have to be, but it ends up being kind of breathing air, it's just ubiquitous and you just, it's no big deal.
(00:18:25):
It's not stressful because you're good at it and you can just knock it out. And it's also something you may not appreciate now, but you can just do on a Friday and then you don't have to worry about calls through the weekend and you sleep well. And I personally don't really like scopes, but if you can learn to, it can be a great part of your practice. And then it feeds obviously your hiatal hernias and your colon cancers and diverticulitis and there's just a lot of everybody that's 40 or older that has appendicitis that they kind of need to get a colonoscopy. So you find a lot of people that need it anyway and then you just, you're able to offer that scopes is a big one. And I told you before that when I trained, I did all these subspecialty rotations and I had no visibility at that time into what the incidents of these surgeries would be, B.
(00:19:23):
So I'm like, yeah, of course I'm going to do parotids, so I got to go with the ENT as much as I can and do the parotids and I mean it's on the board, there's questions about the parotids on the board. So it's not even out there for a general surgeon to do is like a one in a hundred thousand thing and then you're going to have facial paralysis on somebody and I dunno, I'm at a point now where I'm not actually doing thyroids or parathyroids much less broad. I've never had a need to do a parotid. Maybe I've had one in five and a half years. I'm not adding a ton of value to my community by offering them. So I thought when I was in training it's like all these things seemed equal value, but then you find out through experience what is and and it also depends where you end up landing what specialists they already have. But what happened with my practice, I will tell you what cases I do too in a minute, but to help make that make sense, what happened with my practice is that I went to a town of 12,000 where there were two other surgeons already there.
(00:20:35):
So I just said one surgeon per 14,000 is a good number. And I went to a town of a county of 12,000, town of 1200. So there was nothing for me to do and my volumes were very slow. And so I went to my hometown county, which is the next county over made friends with all the primary care docs and started getting referrals. I was doing things like varicose veins that nobody had been doing there before. So that's kind of makes you busy. Then you meet all these people and they still aren't up to date on their colonoscopy because they've been refusing. And so you kind of talk 'em into it and you can find things to do. But still the average general surgeon does 6,500 RVs per year and everything that you do gets broken down into a five digit CPT code. And here's another crazy stupid thing that you should know that I didn't know how, I didn't know this, but when you log your cases into the A-C-G-M-E case log, you're choosing a CPT code. But I didn't know that I was choosing a CPT code until I was a fourth year resident.
(00:21:45):
So you can look at these coding books and it's always a five digit code and that's how you get paid for the rest of your life. This all happened in the eighties before that surgeons just bill reasonable and customary bills and then they come out like a MA, I don't know who all did it, but basically they came out with this and now everybody uses CPT codes. Each CPT code has a value, a clinic visit, it has a CPT code, which they start with nine nine, any of what we call e and m, so like ER consultation, floor consultation, clinic visit, those are all, they have a value. And then surgeries have values and make things more complicated. There's modifiers. So if you do two things on the same day, you have to put a modifier and stuff, but don't worry about that too much right now.
(00:22:33):
But that gets you kind of started. But if you want to think about it when you're a resident, you can look at your own CPT codes and you can look up online like what an RVU is for a given CPT code. For example, a gallbladder's roughly 10 and a clinic visit might be like two, but there's a variability between a level 2, 3, 4, 5 just to give you an idea. And anyway, I was doing maybe, I dunno, first year like 4,000 or something, RVs not very much. And then it took off later and I don't think it was was demographics more than anything else. And so a series of other things happened where my hometown hospital went ahead and got privileges and then they had a surgeon had an unfortunate medical problem and then they needed help soon. And so then I went to my first job and I always had in my mind, I'm going to work here at this first job. I want to be in my hometown, I'm going to work here for four years and then I'm going to go and I'm just going to be in one place. You don't have to do that. That was a big misunderstanding in my own brain. And so if you want to be in two places, you can negotiate whatever you want as an employee, but it's easier as an independent. And so basically I went over to my hometown as an independent with permission from my job. Have you ever heard this story before?
Isabella (00:24:09):
I think I've heard bits and pieces of this, but I don't think I've heard the whole thing.
Dr. Randy Lehman (00:24:13):
Not a great story. I mean it's good. It's good to not, but it's good for you to know because are you guys entrepreneurial in any way?
Ev (00:24:22):
I'm not. I wouldn't call myself an entrepreneur now, but it's always interest to me.
Isabella (00:24:26):
I similarly do not think I am very entrepreneurial, but I do think there are a lot of people who are particularly in the relation of medicine and business and it's a good thing to know if nothing else.
Dr. Randy Lehman (00:24:40):
Yeah. So you guys both think that you'll have a job as a surgeon.
Isabella (00:24:45):
Fingers crossed fingers, fingers crossed
Dr. Randy Lehman (00:24:48):
Probably working for a hospital. That's what 85% of new grads do is they take a job and it's what I did. It becomes burdensome to have the nurse with the clipboard looking over your shoulder. So there's reasons that for autonomy of yourself, that's the number one reason that I had a desire to be independent and I just wanted to sort of work for my patients and that's it. But you find out that you're actually working not just for your patients, but you're still working for the hospital in some ways, even if you're independent and you're working for your referring doctors too. And at the same time you're kind of working for the insurance companies as well, helping to take care of their patients if you will. I mean you're fighting against them at the same time, but if you're independent you have to contract with them.
(00:25:43):
So if you're not in network with them, you won't get their patient, you just won't be able to take care of those patients. So you have multiple bosses kind of, even if you're independent. But I mean it's okay. It's how it is. So I bought a building, hired all my staff, did billing and coding, bought my own EMR, bought all my supplies and equipment and had a independent surgery practice at the same time that I had my W2 job. And part of the problem was it was a part-time surgeon with full-time overhead, but I was losing a ton of money. My overhead at the peak was about 600,000 a year and my income was between myself and a nurse practitioner was three 50. So I was losing 20 grand a month funding it out of my other job. It was not a good situation and something had to change and it's a very long story I have recorded in other shows, but basically I ended up contracting it to the hospital and that worked.
(00:26:53):
And then I had a couple other doctors from surrounding hospitals come and reach out and ask if I could go there and I said, yes, but under this model and now I have four hospitals but I'm going down to three that are in this contracted model where I kind of see what they need and then I kind of meet their needs so that the benefit for the hospital is that they don't have to hire a full-time surgeon. All the benefits, they would have a hard time getting over that hump, but they can just contract with me for we started both of the second two places two days a month and it was what I could justify doing at the time and they could handle it. And then quickly that becomes 4, 6, 8. Now we're at one place where we're up to, my nurse practitioner comes there one day a week as well, and I go there two days a week.
(00:27:55):
So we're up to basically 12 days a month at one place and we're kind of able to grow together. Now how would you do that just straight out of residency? You sort of almost have to have something going first. And I guess the big tip for a person considering rural surgery is to know that you're in demand and to understand that you have to work with a hospital in some way because the money is flowing through the hospital because the professional fees for you to do a gallbladder are less than half of what they were 20 years ago.
(00:28:34):
That's like unthinkable. But it is. Why are you getting paid less than half of what the same surgeon was getting paid for the same operation 20 years ago? It's a big problem and it's because the hospitals have big lobbies and the doctors don't is why. And it's because the people running the show and rolling out the Affordable Care Act and things are saying that their intention is for affordable Care Act to increase vertical integration in healthcare, meaning doctors being employed, that's what they want because it's government and government wants control of people. So obviously good government doesn't want that, but if you ever hear of government talking about having control, it's not good government. But that being said, it's where we're at. I think that we'll either tip to a point where doctors will, the market will take over and we'll probably end up having two things would be my guess, where we'll have a public health system that will be extremely long wait times and slow care people will die on wait lists, but it is what it is and it's free.
(00:29:48):
And then you'll have private healthcare as a separate arm and it's already happening in Indiana now. There's a surgery center that's been doing this for quite a while, like 20 years in Oklahoma and in Indiana they just started one in the past probably four or five years where it's just cash pay surgery center. We'll tell you, we advertise right on our website what the price is for lap chole because a lot of people have high deductible plans and they still care about it. Definitely endoscopy, things like that. But for rural surgery right now, and I would say the foreseeable future critical access hospital structure continues to exist, which is a small hospital that is at least 30 miles away from any other hospital. It has to have a 24 7 ER, has to be a hospital that it can admit people and it has to have 25 beds or less.
(00:30:43):
And those hospitals get reimbursed at cost plus 1% from Medicare. So they have a thing called a cost report of which your salary can go on to and they can basically be insured to not lose money on Medicare patients. And the idea is that you're making a little bit on commercial payers and then the hospital stays alive and that's a bipartisan, I think axing critical access hospitals is very politically for both Democrats and Republicans. And so I think that it will continue for a while now you got to be ready to change. So we are talking about how to prepare yourself to be able to be skilled enough to be fighting the professional isolation and handle it and be a good surgeon. That's one problem. But the other problem is how do you structure it? And basically if you're not, my opinion would be if you're not making more in rural America than your urban counterparts saying you're doing it wrong in 2025 or 2026 because basically most surgeons don't want to go out there and you're more in demand in rural America.
(00:32:07):
So I would say the jobs are there and the pay is there and everything. I kind of rambled around, but I think I got most of the points at least made that I wanted to make about that. And then now I'm at a point with my practice where I hired another surgeon to come help me and I hired, I've got two nurse practitioners and actually a family med doc that does a couple days a month of scopes for me. And we sort of grown, but I don't think most people aren't going to do that. They're not going to grow a actual business. But if every single step along the way meets with my mission, which is, I'll say this. One last thing before we move on is you as a rural surgeon, do you guys both want to be rural surgeons or just want to be general surgeons? Not just, but
Ev (00:33:00):
I'm not particularly rural for me, but the topic has always fascinated me for sure. Great. My grandfather practiced rural surgery in Jefferson City. Not exactly rural, but he had a lot of his caseload was from the surrounding area and it was a small city at the time. So where's Jefferson City? It's the capital of Missouri, but that was back in the fifties, forties, fifties, Missouri. Okay, got
Dr. Randy Lehman (00:33:23):
It. Okay. And by the way, this is EV sugar baker and he is related to the sugar baker repair
Speaker 4 (00:33:32):
Among
Dr. Randy Lehman (00:33:33):
Other things, right? So that's awesome. And Isabella, what about you?
Isabella (00:33:39):
I am interested in rural surgery. I think I went to medical school kind of knowing I wanted to work with underserved populations. And in medical school you hear a lot about urban underserved and certainly there are a lot of urban underserved people, but I think grew up a little bit more rural, not super rural, but a little bit more rural and really was struck by the need out there for care and care close to where people live.
Dr. Randy Lehman (00:34:08):
Okay? If you are a surgeon in an urban environment, you are usually a number and you're very replaceable. I mean you're valued, don't get me wrong, but you don't have very much personal impact on your city. Does that make sense? But if you're a rural surgeon, then you create 25 jobs in your county just by choosing to practice there. And that actually impacts a county when you're talking about a county of 20,000 people because those are good jobs with decent pay and good benefits from a very stable entity, which is the hospital. And usually in most rural counties, your three biggest employers are actually, it's all like everybody's working for the government basically. But you got the courthouse, the school system and the hospital, those are usually three. And then you may have a smattering of businesses and maybe have one big factory or something.
(00:35:18):
Ideally there's a little bit of diversification. And then there's agriculture and the small businesses, but the big businesses, hospitals a big one and it's stabilized by the federal government and through Medicare, you're bringing these jobs to this community, which are like I said, decent jobs. And then those people choose to live there and they buy houses there and they pay property taxes there and they buy groceries there. And the great irony of the whole thing is that the actual payers are not the patients usually themselves. The payers is Anthem and United and Medicare and Medicaid, all entities that are outside of your county that you cause money to flow into your county where normally people kind of live there and there's a problem with the rural brain drain. So the best and the brightest leave and go to the city and it kind of perpetuates itself.
(00:36:24):
And a lot of times people leave to go to the mall or they go to buy their cars or buy things on Amazon or whatever and they're leaving to buy things and there's not a way to bring revenue into your town and you as a surgeon have a big way to be able to do that. So yeah, it's great to take care of the one patient that's in front of you and if you don't get satisfaction out of that, then you got to question yourself. You should. But when the urban surgeon takes care of that one patient from 'em, that's like the end of their mission now, except for an academic surgeon who's going to publish things and change everybody else's outcomes down the road, which there's a place for that and people should do that. Somebody has to push the envelope, so that's great.
(00:37:18):
I'm not saying that definitely don't want to take anything away from that. We stand on the shoulders of giants and if it wasn't for everybody behind us, we wouldn't even be able to have this conversation. But after you do that one care of that one patient that you allow them to not have to travel the burden of travel for the patient who's either one of three things, they're either old or they're poor or they're busy. Every single person that I take care of is one of those three things and all of them want to stay local because of their thing, whatever it is. And you decrease that burden of travel, let them stay there, create the jobs for the people that are around them, the money flows into the county. And then on top of that, when a business thinks about coming to a town, they look at your town and they say, oh, there's a functioning hospital there has something going for it.
(00:38:13):
And your hospital becomes a point of pride and you're helping keep that hospital open and something the whole community can be proud of. So that's kind of the way I think about myself as a rural surgeon and what really keeps me excited and going because there are obviously there's stresses with it too, and you got to have something to be able to, and for me, I also think that financial independence is a very valuable thing and I think everybody should be pursuing that as aggressively as possible because once you hit your financial independence number, then you're only doing what you want to do and it makes you more of who you already are and then you can shed the things that you hate and become this almost more altruistic person but a person that you just love to be. The problem though is that once you hit that, if you got to have something else that drives you, besides money obviously, and I'm there now just five and a half years out of residency due to basically pretty extreme frugality and really hard investing. And now if I didn't want to work I wouldn't have to, but I definitely want to and I want to go until I'm in my seventies and it's just an awesome job, but then it's probably going to lead to just more opportunities and you never know where it's going to end up. So that's sort of the mission and purpose of the rural surgeon. What's the next set of questions that you had?
Isabella (00:39:52):
I think it would be really interesting to know what types of cases you do. We talked a little bit about the scopes. I imagine the bread and butter of general surgery is alive and well everywhere in general surgery. I think I would personally be curious to know what types of cases you do from a more specialty perspective, do you feel like you are able to be more broad in your role as a general surgeon or does just the realities of having the hospital system be what it is in a critical access hospital versus one that has a really strong surrounding care component, does that somewhat limit what you're able to do safely? Those types of questions I think would be particularly interested. I would be particularly interested in ev. I don't know if there's anything you want to add.
Dr. Randy Lehman (00:40:40):
laOkay, so people always ask me, what's your favorite surgery to do? Actually I do have something that I really love, which is laparoscopic common bile duct exploration. And the thing I love about it is that not every general surgeon knows how to do it. And by me doing it in my small town, I saved the person a trip for an ERCP. And I think if I had a capable surgeon, if I had choledocholithiasis and I had a capable surgeon who was willing to do laparoscopic common bile duct exploration, I would prefer that over an ERCP followed by lap chole because I would save myself two procedures, I would have less risk for pancreatitis and I wouldn't have to have a sphincterotomy. So I think it's actually better now.
(00:41:28):
It's not like it's standard of care better, everybody has to do it and ERCP still has a role, but it's definitely not worse in my opinion. It's better and then definitely in your community when you can save somebody that trip. So I love that. But really the way I like to answer the question is I don't really have a favorite operation. I have a type and my favorite type of operation is a case that takes me 30 to 90 minutes and the patient has no complications and I fix a problem for them. And if they can sleep in their own bed that night, that's even better. So that is what I do a lot of. And now that I've been in four different small hospitals, what you find is some places have really good urology coverage and other places have none, and some places have really good ortho coverage and other places has none.
(00:42:29):
When I was talking before about not knowing as a resident, the relative value of each thing scopes is number one, C-sections is number two, but it's geographically dependent. And I'm talking about in terms of your value, especially in terms of what you can get paid. If you're a general surgeon that's willing to do C-section call, you'll get paid twice as much basically. And that's true on the locum circuit, but I think a lot of rural hospitals have shut their OB programs down already and a lot of times they'll close down an OB program and they'll make more money the next year or make money the next year and then 10 years later they barely have a hospital. That's kind of a common thing is you buy the family by delivering the baby, but OB always loses money. And so if you lose money on OB eventually you get it shut down.
(00:43:36):
And I actually talked to his hospital CEO from the first hospital that I worked at a retired CEO and he told me, I told him that I think OB is important, and we were in the middle of shutting down the OB at that place at that time, and I'm generally against that, but they were down to 60 deliveries per year and there were some COVID and there staffing issues post COVID and there's also some quality questions. And so anyway, long story short, I do think it was actually right for them to shut down their OB department, but I was talking to this old CEO and he said, I told him our story, my wife's story and I, so basically we went to a small hospital and delivered our babies in Minnesota, not at big house Mayo Clinic, but the small place where we felt more in with the people and it just was more like us.
(00:44:29):
We both ended up establishing primary care there and our kids did. I went and saw a consultation there, my wife had a surgery there. And then we go back to Indiana and my wife has a different surgery and she goes back to Owatonna, Minnesota to have her surgery because that's where her doctors are and that's where she's comfortable. And they bought our family by delivering our baby. I told this to the CEO and the CEO O said, that's a great story, but there's nobody like you and all the people that are delivering babies in our county are on Medicaid and we don't want 'em anyway.
(00:45:05):
And I was like, okay buddy, I'm glad you're not here anymore. But there's an element of financial facts at the end of the day and you have to make things work. But I do think that right now if you were going to just take two extra skills that are not core general surgery would be scopes and C-sections that will give you a lot of value. Now I do a lot of things that are not that, so let's go one by one through the specialties. So urology, I do vasectomies, circumcisions like adult thrombosis, babies two, I guess I'm more comfortable with an abscess in the scrotum, that kind of thing. I thought maybe I would do low grade, I don't and I wouldn't at this point. I'm not saying you can't. There was also a period where I was actually asked to do stones shortly before residency ended and I had done some and the scope for doing ureteroscopies is the same scope that I use for common bile duct exploration.
(00:46:11):
It's the litho view. You just have to go laser and you can be selective and it's really not that hard. I do if I want to put up my own ureteral stents. So I got all that on the urology thing, but that would be just for resections. But anyway, I went and spent all this extra time spending time with the urology guys before the end of residency to get more exposure to stones and I came back and I set up a three day thing where I went down to IU with a guy that does a lot of stones and he was willing to sort of be a resource and let me call him and then send him things that whenever the stone's in a bad spot or whatever.
(00:46:59):
And then after that, this is another interesting point for your students is I did not understand how the privileging process works. Do you guys know that? Have you heard about it? You have to request privileges at a hospital in order to do procedures there and there's a credentialing board that gives you those privileges, grants you those privileges. So there's usually a general surgery core and you kind of request that and it has a lot of things in general surgery. But then if you're going to do other things outside your core, you have to read through what all it is and then you have to say what you want to do. So it would behoove you to start making a list of the things that you want to do so that you're prepared and then have somebody that's willing to vouch for you from your residency program because the credentialing committee can go back to your residency program and say, do they really know how to do this?
(00:48:00):
And if you come with a letter that says, yes, he's good to do this, or you have these contexts, these are things I had no idea. And so I just thought if I said I could do it, obviously it's my own malpractice and I'm the one that's like you would think a doctor would basically not do something that they didn't know how to do it. But I think that first off, there are some doctors that have done things in the past that don't know how to do it and there is a role for this credentialing committee. But I'll tell you that I had a lot of problems when I first started because the same person who asked me to go be able to do stones later made a bunch of roadblocks so that I couldn't do them.
(00:48:47):
It was really weird and very political. And so I guess I don't need to talk anymore about that necessarily. Just to say that there's problems in front of you that you have no idea about and if you get close towards the end, second half or residency, just start asking your mentors about their first job and what were the hiccups to starting their first job and stuff like that. Alright, so anyway, urology is like vasectomies, circs. I would do a torsion, but I haven't had to take care of a torsion. I thought I would do, I did peds and spent a bunch of time like maybe an undescended testicle. I don't think I would at this point to do an orchiopexy, hydrocele. I've aspirated some taking out the hydros seal sac, you can do it. Most of the time it's just a pain and I just send 'em to urology kind, make it their problem.
(00:49:40):
Osee, same deal like clipping varicoceles and whatnot. I think that I just send those to urology. Now, plastics. So if you can get a good plastics rotation, that's like bread and butter plastics, not like face transplant at the Mayo Clinic, okay, that's a waste of time. But learning flaps, skin cancer is one of the most common things that I take care of. Not just melanoma, mostly basal and squamous cell skin cancer. And I've seen some crazy things like a huge squam that on the top of the head that was invading all the way through the skull into the dura guy that obviously is hosed at that point. He came in, he wanted me to excise it in clinic that day. I'm like, no buddy. We're getting MRI. And I sent to the oncologist who's from India, and she's like, this is not something I should see in the United States.
(00:50:33):
I should be seeing this in India. I'm like, yeah. So flaps, nasolabial flap, that's a good one. Split thickness skin graft. Extremely good tool to have in your back pocket. You can try full thickness skin graft. I've had some work, some don't take some skin from the back of the ear and you can put it somewhere. Rhomboid flaps, V-Y flaps, I'll do a little A to T flap here. I've done that several times. You can take a pretty good size chunk here and make it almost imperceptible by hiding it in their forehead line with a little vertical extension.
(00:51:17):
And keystone flap is an extremely robust, it's a very, looks pretty crazy with all the incisions you're making with the keystone flap, but it'll never die. So that's great. And then you can do your melanomas and then also all these other skin cancers, obviously lots of skin lesions, lumps and bumps and stuff like that. So that's where plastics comes in really handy. I make it clear that I don't take care of rashes, I just take care of masses and lesions. And then lipomas, I mean little subcutaneous masses, basically. They will just keep you busy and pay your bills and then you do 'em all local. You get to know the patients, they get to know you and then they become your biggest fan. So oh, ear two, helical, rim advancement flap. Don't be scared, you just make the ear a little bit smaller, but make sure you go and find half a dozen of them in residency and then just be able to offer that to your community.
(00:52:17):
It's like tons of skin cancer right here on the top of the ear. So urology, plastics, ortho, I don't really do any fractures. I know people used to pin hips and stuff and I thought maybe I would if there's old lady in the nursing home, mostly bedridden, but she just falls out of bed and you're not really going to be messing up how she walks and somebody just needs to pin her. But we actually have pretty good ortho coverage and so it's not really something that I need to do, but what I'll do is a lot of hand stuff. So if you can get a hand rotation, do it carpal tunnel trigger finger ganglion cyst, what's the cyst at the edge of the fingernail OID cyst at the fingernail. You can do a little bilobed flap to close that. It's like a beautiful little, you can put your loops on if you want to.
(00:53:13):
So it's mostly hand in ortho and I thought maybe I would be managing clavicle fractures, non-op and stuff like that, but that hasn't really been a need. Anything in OB GYN, that's benign. I'll basically do. So hysterectomy if they have the most common indications for hysterectomy would be dysfunctional, uterine bleeding, and then prolapse and fibroids. So you got to know the indications. So if you can go find, you got to learn how to do the case and know the indications and then manage the complications afterwards. And the way that I do, if you're going to have a robot, then you can just do 'em on the robot and it'll be no problem. But a ablation is usually required for dysfunctional uterine bleeding, so like A D&C and ablation, maybe a hysteroscopy as part of it, and then a lot of times solves it and they don't need a hysterectomy, they need permanent sterilization.
(00:54:11):
So like doing a laparoscopic bilateral salpingectomy easy case, great thing to offer for sterilization for them and it decreases their ovarian cancer risk. Also, ovarian torsion, dermoid cyst, big recurrent ovarian cyst you know that you want to do a cystectomy on. Don't worry about it. Don't forget that your ovarian arteries come straight down from the infundibulopelvic ligament. So don't take adhesions on the top side of the ovary like superiorly. A lot of that stuff you can do, but not if you've not done any training, you have to go seek out a special rotation and ideally have some friends that in my show I always say there's a segment called the resources for the busy rural surgeon and everybody always says your cell phone should be your biggest resource. I mean that's by far the most common answer. In residency, I was networking, but not really as much as I should have been. I wish I networked more, so that's GYN oh, like a Bartholin gland abscess or cyst managing that. I did do a VIN III vulvar intra epithelial neoplasia. I would not do that again. First off, my repair kind of fell apart. And secondly, it's just at the edge of cancer, so I'm not doing cancer stuff and I make that clear.
(00:55:38):
I'll biopsy for sure if somebody has a mask down there, just get a little piece of it and get 'em pointed in the right direction. But it's not your problem. Don't make it your problem. There's another specialty. I did a rotation on, what was it? Ortho neurology, ENT. Funny part is I stopped doing thyroids. You don't have to do that by any means, but I just had to kind of pick and choose because I ended up kind of running out of time and I had great training. I did multiple blocks of endocrine and I graduated probably 50 or 60 thyroids and parathyroids, but I didn't have a nerve monitor and it was like you have to decide what you're going to ask them to buy for you. And then the volume just wasn't there.
(00:56:26):
I would get one or two a year of thyroids and parathyroids and I don't have parathyroid hormone monitoring. And then meanwhile, I was scoping these people and I'm finding all of these neglected reflux and big hiatal hernia patients, and so I was like, that's something that I actually do quite a lot of right now in my practices fixing all these hiatal hernias that have been left for decades. And there was a 0.3 years ago where I wrote down, I'm like, if I'm not doing at least six a year of thyroids, then I'm going to stop doing it. Within a couple months after I wrote that down, I said I stopped because there wasn't a path to doing that volume. I also wrote down, if you're not doing six hiatal hernias a year, then don't do them in three years. Give yourself some time to build a practice and you're not going to just forget everything overnight, but you don't want to go on forever either.
(00:57:33):
Last week I did three hiatal hernias, so now it's become clear what the practice can and can't be. And then from a general surgery perspective, I guess from ENT, I don't do tubes or tonsils. You could if you want to, tubes and tonsils, the tonsils, they bleed and stuff. And we had a family member that I wasn't even alive yet, but he bled to death and I just personally a little have PTSD because of my family, so I just don't do that above the neck like lymph node biopsy and stuff. You're more comfortable because you get that exposure. From a general surgery perspective, the biggest cases I do would be like for gut hidal hernia stuff, I've taken out a gist. And then colon resections, of course you got your bowel obstructions, there's going to be bowel resection with that. And then obviously gallbladder, laparoscopic, common bile duct exploration, your AEs and all your hernias, and I've done several component separations, but that's not a very common thing.
(00:58:40):
And then you'll figure it out like who's supposed to get an operation in your hands in your hospital and who's not, for example, hernia when it's been recurrent and how to tactfully say no. I've gotten myself into some sticky situations that you just have to be able to get yourself out and two times the hand-sewn colon anastomosis has bailed me out, so make sure you know how to do that. I had this one patient who had a previous Whipple and I had to do a colectomy on him and I could have sent, and maybe if that's your first year, maybe send that patient. It wasn't really my first year, but it was hard and I just didn't have any reach. I ended up having to do a hand zone and I bailed myself out that way. Other situations where you can call people in the middle of the case, you can scrub out and make a phone call.
(00:59:36):
You don't want to do that regularly, but I've maybe done it three or four times, maybe once a year where one situation I had this lady supposed to be a sigmoid cancer that was sent to me, my GI doctor who scoped and tattooed and I went in for a sigmoid colectomy and there was no tattoo and there was no mass. And I went up and there were some adhesions at the splenic flexor. So I farted around taking those down. I thought maybe it was high but it wasn't, was actually down in the rectum. So then after I got that all freed up, then I go down, I'm looking, and then you get this hint way down in the rectum of this tattoo. And so I have a buddy of mine that's in Indie who trained with me at Mayo Clinic, and I actually FaceTimed him during the operation and I told him, I'm like, look, I don't really want to do a proctectomy today.
(01:00:38):
And I don't think she's really correctly staged and I think that we should, I feel like closing up, but just closing up and leaving the operating room, that's never on your multiple choice test that you're taking right now. Because the right answer is, I guess don't get yourself in that situation, but it can happen and you can be a good surgeon, you can care a lot. You can try really hard, you can be diligent and you can still find yourself in a situation. And don't forget that slowly backing away isn't always an option. So the issue with rural surgery is that you are isolated. That's the number one issue. It's professional isolation. That's why I'm telling you these things like how to bail yourself out, how to have friends that you can call so that you can fight that professional isolation and push through it and patient selection and stuff like that too.
(01:01:39):
But I mean, if we have to code a patient during a case, if you're at Baylor, you just push a blue button on the wall and all of a sudden there'll be 12 anesthesiologists in the room and one's getting an A line, a nurse's place fully, somebody else is messing around with the ET tube and then everyone's there. And if you have to code 'em, there's a limitless. You only have to take one turn at doing compressions. If I have to code somebody, there's one CRNA in the county and they're doing that case with me and it's me and them. And what we would do is we would call the ER doctor down and they would help us and whoever is available from a nursing perspective, but there's nobody else. And so that drives your risk management decision making. And not every hospital is exactly like that.
(01:02:35):
Maybe there's more than one anesthesia provider, but most of the places I'm at, that's how it's, so I tell the patient that in their pre-op thing, if I have to say no because they're too sick, I'll say, look, your EF is 20%. It's a non-zero chance that something goes wrong and I don't want you. It's not that I don't know what to do, it's just that it will completely overwhelm us and you would not get as good of care if something went wrong with your heart. And I tell them, it's just me and one anesthesiologist and we would literally be calling the ER doctor to come help us run the code and we wouldn't be able to take care of you afterwards if we had to keep you in an ICU. So we do everything we can to not have cardiac problems or respiratory problems where we can't get 'em off the vent because we can't really keep a vent overnight either. I'll give you one other story. Example. I had a 90-year-old patient who came in with lady who had a strangulated umbilical hernia, pretty simple, bright cherry red and CT shows ischemic bowel.
(01:03:42):
And so what are you going to do? I mean, you're going to put her in a helicopter and go flyer somewhere where there is a cardiac ICU and a cardiologist or is it right to go straight and just get that problem fixed? So I went straight and did it was a quick bowel resection and fixed the hernia, and then she had chest pain and she had rising troponins. And so then we transferred her afterwards. And that's not too hard of a call because you can easily explain that. Now, if that was an elective repair, very different, very much less accept. You should not accept that from yourself. I mean, if it happens once, okay, but it shouldn't happen very often because you should be asking them about their functional status. And if they're like, I can't walk across the room without getting short of breath, then you just get a stress test and you say, we don't want your surgery to be your stress test. And that's how you minimize those risks. And also you can do inguinal hernias under spinal and you can also do inguinal hernias under Mac local. And then there's very much less risk to the heart and lungs than doing general anesthesia. So consider all those things as well.
Isabella (01:05:04):
I think the utility of local or some kind of regional block is I have come to appreciate it in my training and in listening to stuff like this. It seems very useful for cases where you need it.
Dr. Randy Lehman (01:05:21):
I've done hemorrhoidectomies in the clinic under straight, local.
Isabella (01:05:25):
Yeah,
Dr. Randy Lehman (01:05:26):
I mean it's crazy what you can do if you have the right person.
Isabella (01:05:29):
Let's see. So we've talked a little bit about mostly everything I think that people had submitted just in terms of previous questions and then in terms of questions that I know people have had. And thank you for your time. I'm sensitive. I think we're coming up to about an hour and a half and I don't know what people's bandwidth is for the rest of the time. Did you have anything in particular that you wanted to ask about?
Ev (01:06:02):
I think everything that I had, the of this was answered, but if you had something that you wanted to get to for sure, we can go to that. Yeah,
Dr. Randy Lehman (01:06:11):
Maybe one last wrap up thing. Every time on my show I have a guest on and we talk about how I do it because I'm a tips and tricks kind of a guy, and I love to hear how other people are doing technical little things. And I just have a few things that I picked up in residency that I think most people graduating even side by side me didn't necessarily know. I had a little list of 'em and so I'll run through maybe some of 'em. But basic things before we start is there's no reason that you ever have to sow backhand pretty much see a lot of students loading their needle backwards intentionally and then going, you need to turn your body. That's the answer. Okay, so rather than throwing backhand, turn your body 90 degrees and turn that into a forehand throw. If you ever find yourself throwing a backhand throw, load your needle forehand and ask myself, how can I turn my body and do that?
(01:07:11):
That's number one. Number two, little paddle, little buzz. So the Bovie even would do a lot of dissecting with the Bovie, just a little paddle moving the Bovie back and forth. And then buzz the bands in between. Tension and counter tension being a core concept in surgery, basically tying around a clamp. So if you go to tie around a clamp, you can just, if it's all up in your face and your assistant is showing you the clamp, don't pass the tie around the clamp, just push the tie down on the clamp. Let go with your right hand, your index finger and sweep it around and pull it down. That's how you load it around the clamp. Okay, so push it down against the clamp, sweep it by letting go with your hand and with that same finger, pulling it through. And then if you're deep in the pelvis, a lot of people will try to line it up on their fingertip.
(01:08:09):
They'll line their tie up on their fingertip and then push it down and then try to slip it underneath the clamp. Don't do that. Put it on the back of your nail and push it down on the back of your nail and let your pad of your fingertip find the tip of the clamp and then just roll your finger over and it'll snap right underneath the clamp. So that fingertip trick, that was by the best technical surgeon I've ever worked with, Dave Nagourney. And it happens very quick with him because he leaves two clamps open on the mayo stand and they'll grab two clamps at the same time with one hand and clip 'em onto a vessel and fold 'em open and be screaming at the resident to cut before you know what even just happened. So that was good. Another one is an exercise that you can do.
(01:09:02):
And if you take a pop can, you should practice tying on the tab of a pop can. It's a very good, nice little stable thing for you. And then you drink your pop can so that you can get your energy to continue to keep practicing and then tie on it empty without moving the pop can. And once you master that, where that pop can, that empty pop can will stay there. And you can just keep tying, tying, tying, put it inside of a coffee cup like as big of a coffee jug as you can and tie down inside there. And then when you get good at that, and I'm not joking about this, take that whole coffee cup and put it down inside your washing machine and tie and don't move the pop can. And if you can do that, then you can tie on a tiny little pancreatic branch without it tearing and your staff will be very happy and your patients will thank you.
(01:09:56):
So that's a good exercise. Obviously having a clamp in your pocket and running it all the time and never stick your fingers into the clamps is another good one. When you're positioning, when you're a student, you don't know, but when you're a staff, you're in charge of the positioning. You do not want your shoulders to be like this. It'll kill you like elevated shoulders if you're not watching video. So you don't want your shoulders to be up and then you're operating the whole case. So you need to either get the bed down or you need to be up on a step so that your shoulders can be relaxed at your sides when you're doing laparoscopic surgery. Primarily laparoscopic surgery. Oh, one good one on the appy that I learned about halfway through residency was just a lot of people, when you're doing your api, go for your base first for sure.
(01:10:42):
I think most people will know that. But then a great move is to put, once you can get a hole underneath the base, put your other instrument alongside it and spread straight ap. So one goes straight down to the floor, the other one goes straight up to the ceiling. And some staff, some people will give you a hard time about that because they think that it's going to create a bunch of bleeding, like bluntly dissecting the mesentery. If it's causing a lot of bleeding, you're not doing it right. And just keep practicing that move and try and do it in a different way. You're kind of trying to go along parallel the vessels and just, you got to sort of have a sixth sense about when it's going to actually cause bleeding. But if you can do that real quick, just a little move, then you bring your stapler in for your base and obviously don't put the big fat side of the stapler through, put the thin metal side through. It'll just slide right in. Bam, you carry on. And then however you take your ary staple is how I do it.
(01:11:45):
It'll go a lot quicker and slicker and easier. Last thing. So realize that there's a one-handed and a two-handed tie and that you can do both of them with each hand and know when it's right to do each one. So a two-handed throw, you can get that done with less suture. So if you have a tiny tail, do your two-handed throw and you can still get your knot tied. Most of the time I do one-handed throw with my right hand, but when you're doing a one-handed throw, you're pulling your own same suture through. So if you have a needle, you don't want to pull your needle through your loop. A knot is basically making a loop between two strands and bringing the tail through it. Okay, so you're going to bring through the one that you're holding with your time, with your right hand, then you're going to bring the one that's in your right hand through.
(01:12:47):
So you want to put your needle in your left hand to do a one-handed right tie. And if your needle ends up in your other hand, that's when it's really good to be able to do quickly and easily the one-handed throw with your other hand or you just do a two-handed throw with your right hand because it's opposite for the one-handed and two handed. So the best way for you to probably practice this in your mind's eye is to tie some tie with a needle on a string sometimes with your practice, and then make sure you're never pulling it through and make sure you're always doing all four types of those throws, one handed left and right and two handed left and and then you'll really understand what you're doing. And then when it's in the moment, like when you're a third or fourth year resident and you're doing the really high level deep work, you don't have to figure it out then so sooner the better on all that.
(01:13:54):
Other than that, yeah, I'm so tickled that you guys called me up and wanted to talk about rural surgery, and if something else comes up, feel free to you or your other students or anybody that's listening to this, feel free to interact with me on the Rural American Surgeon Facebook page is one place or there's an email at the rural american surgeon.com and I do check those, and it's a very niche podcast that I'm running here where we don't really have that many listeners. It's very intimate. It's just me and one listener at a time. That's one thing that I love with their earbuds in, and I love it. I'm tickled whenever somebody writes in. So if you guys have other questions or need something else, feel free to reach out.
Ev (01:14:40):
Sounds awesome. Thank you so much, Dr. Layman.
Dr. Randy Lehman (01:14:42):
This has been the Rural American surgeon and we've been here with the Baylor Student Surgery Club. So thank you guys so much again for joining me, and we'll see you on the next episode of the show.
