EPISODE 69

Training Miniseries 2: Dr. Mariela Rivera

Episode Transcript

Dr. Randy Lehman (00:00):

Welcome back, listener to the Rural American Surgeon Podcast. I'm your host, Dr. Randy Lehman. I'm very excited today. This is part of our miniseries about training a rural surgeon where we're interviewing program directors from across the United States that have a specific track or an interest in training rural surgeons. In this interview is from my home program, Mayo Clinic in Rochester, Minnesota. We have the program director, Dr. Mariella Rivera with us. Thank you, Dr. Rivera for joining us.

Mariela Rivera (00:32):

Thank you so much for having me today. Excited about this opportunity.

Dr. Randy Lehman (00:37):

Yeah. Dr. Rivera is a trauma critical care general surgeon at the Mayo Clinic, and she has been in the program director role for three years. Before that, she was critical care fellow program director, and so she knows all about the GME and things that are required. And specifically now we're going to be talking about the one spot per year where you have a specific rural general surgery track. And so if you could just give us sort of a 20, 32nd intro into what that program's all about.

Mariela Rivera (01:09):

Fantastic. So the program, as you very well said, one position out of 11 positions soon to be 12 positions because we are growing from a residency standpoint. The track, the first year you start within Mayo, Rochester, we have our main campus, which is Rochester, but we have this amazing health system that Mayo has continued to grow, which gives opportunity for the rural track resident to go and train in the rural or community setting. So the Mayo Clinic rural track resident gets to be trained both at the main registered campus and the health system and which I believe it is really the beauty of it because you can benefit and learn from both worlds.

Dr. Randy Lehman (02:02):

Yeah, perfect. And so when does the resident spend most of their time out in the Mayo Clinic health system?

Mariela Rivera (02:07):

I would say between years three and four, that's going to be more than 50% of the time it is going to be in the health system. PGY one and PGY five, our corners are going to be mainly on the registered campus. PGY two is a little bit of a 50 50,

Dr. Randy Lehman (02:26):

And so I was the first resident to go through that program. And of course I don't have a lot of visibility into what has happened to it since I left, but maybe I could talk a little bit about what I experienced since I went there and then you could catch me up on some. I'm sure there's modification changes that occur over time, but what I remember from what I didn't black out is that we had endo rotation as a two and then we were basically good to go able to perform endo by the time we were done with our endoscopy rotation. And then I had an elective as a two, but that was based on my own input in OB GYN. Nice part about that for me is I was able to deliver my first child while I was on that rotation and we were waiting

Mariela Rivera (03:20):

To

Dr. Randy Lehman (03:20):

Find out if it was a boy or a girl. So I was the very first person to know as a three, let's see, I think I did Red Wing and then as a four in Red Wing, we went over to, what's that critical access hospital up on 52 straight north of Town

Mariela Rivera (03:36):

River Aus or Belize? Is that what you're thinking?

Dr. Randy Lehman (03:40):

No.

Mariela Rivera (03:40):

Or Cannon Falls.

Dr. Randy Lehman (03:42):

Yeah, cannon Falls. I stopped over there and did a couple things and then as of four I went to Mankato Eau Claire and a bunch of rotations in lacrosse, which included ob, G-Y-N-E-N-T, plastics, urology, ortho, and then as a five, I was supposed to do a chief rotation back out in lacrosse for three months, but then that got canceled because of COVID and then I had to go back and do chief service again. So killing me. So in what ways has it changed since then?

Mariela Rivera (04:20):

I love that, Randy. Thank you for that. So a few things have changed based on the feedback of the rural track resident year after year after year. So from one of the few things that you said that elective that you did as a PGY two, we have kind of formalized that every rural track resident can have an elective either PY three or four. And that's the same way that we're doing for the non-rural track resident. Now, what is different for the rural track resident is what we call the flexible, and this is semantics, but you said OB GYN, for example, because that was an interest you had, or at least other residents have expressed their interest in training in OB GYN. Then that will be a flexible because not everybody wants that experience. Other residents have asked for experience more on the red wing for scopes for endoscopies and colonoscopies because they see that practice or ERCP because they know that their practice will require that skill.

(05:31):

So we have integrated two flexibles plus the elective. So there's three rotations during the years that you can choose so that your experience is somewhat flexible thinking of training what you need for the next step in a rural practice. So that will be a change ran. Another things that we have done a little bit different is that to standardize what to expect in a year, 2, 3, 4, 5. And the reason that we went for standardization is because I want to make sure that the rural track knows how much time they're going to be away from Rochester because that matters from a personal standpoint. It matters when you're traveling. Our longest side is Eau Claire and it's about and brand, you did that more than me, but probably like three, four hours, especially in those winter months, that can be hard. So the other side are a little bit closer and we provide housing and all that, but I think it matters for the rural track resident to know, oh, okay, this is going to be my reality. This is going to be the amount of time that I'm going to be outside of the main campus in planning, right, in planning life. So that has been also a change based on the residents feedback.

Dr. Randy Lehman (06:52):

That makes a lot of sense. So what do you think? One of the strengths I remember is getting to these other sites, you have such a massive system. So first off, I felt like it was easy to get. It was like a playground. You could get anything you wanted because if you wanted that high volume bread and butter, you're going to get that when you go to those other sites because there's no competing resident. You can just sit in the OR and you can just go and go and go. But at the same time, it's easy to get all of your other case numbers for all the other categories because you have dedicated six at that time, thoracic surgeons doing all this foregut and all this chest surgery, and you have the HPP guys that has all this pancreas and all this liver and stuff. So it was like, in my opinion, the best of both worlds. Would you say that that is a major strength or are there others to the program that kind of stand out to you?

Mariela Rivera (07:52):

I think that continues to be our mayor strength. Randy, exactly as you defined it. The health system is designed to survive or to work at its capacity and best quality and patient safety, et cetera, without a resident. So when a resident visits the health system sites, they do have that flexibility of rotating with different surgeons going after cases that they require, which is a little bit different when you are rotating in Mayor Rochester. The practice is designed to live with a resident. The resident is integrated into the practice and into the rotation. So it is the best of both worlds because there is some flexibility. I'll tell you that there is so much of a strength that the non-rural track residents have asked more and more and more to rotate in the health system. I've been able to provide that to the non-rural track residents and without affecting their rural track experience.

Dr. Randy Lehman (09:02):

What kind of resident thrives in your program and what would a good applicant show you that are intangible traits about themselves?

Mariela Rivera (09:12):

They're still coming to train at the Mayo Clinic residency. So there's some characteristics that I'm looking in every single resident, let's just put it that way, that will make the resident thrive. And I think one of those things is you have to be a fast learner, Randy here. You need to read for the book, you need to read for the test, and then you go to the, and then you learn how this amazing surgeons are doing the future, what's going to be in the books in the future. So you have to have that flexibility of learning in a quick way and being able to gather all that information in a very short period of time. That's key. I think another quality, look, this is kind of my philosophy. I'm looking for humans that take care of humans. I want the people that can pass the test.

(10:10):

But more important is I want the people that can have those. I can create connections and that care and that take ownership and that there is that purpose and passion and their why is the patient and I still in 2026 believe that that's the best or the grade surgeon and that will make it, I think I can train everybody, Randy. I still believe that. And between a series of simulations and nons simulations and a bunch of things that we're doing here, Mayo, but the numbers are there, the faculties are there, the outside of the OR experiences there. So I'm really looking for that human from a rural track specific. I want the person that has a vision of what they want to do next that are committed with the rural world. And Randy, you are and the perfect model you wear and you still are where you were very clear what your practice was going to be. Cherry has changed and it might keep changing, but you still represent that rural track surgeon and that's what we want to do. We want to train the rural tracks of the world and of this nation that there's such a need. So I think it's that conviction, that emotional intelligence of what you want to do so that you can grab the experience here and make it your own and will then be what you need for your practice in the future. So I think that's what I'm really looking into that real track application.

Dr. Randy Lehman (11:48):

Yeah. Perfect. Very specific. Thank you. Yeah, I was sitting in the basement of the building, the clinic building where I went for my eight day well child visit. And when I bought this building, I found my paper chart in the basement and then I've got my podcast studio set up here and everything. That's awesome. So yeah, I had a very long-term vision. Not everybody has to know exactly that, but I definitely walked in on day one saying, Hey, I asked Dr. Cholera, Hey, when I'm, when this AAA comes into the hospital that I was born at, what am I going to do? And it's helpful because you burn it in your brain a little bit better if you can kind of visualize yourself in certain situations in the future. So hey, Jacob has a couple questions for you, so why don't you take it away, Jacob?

Jacob Steffen (12:31):

Yeah. So my first question for you would be what is the number one thing that you wish you could tell prospective medical students that are looking at your program?

Mariela Rivera (12:41):

Oh, the number one thing is that yes, we are in the middle of nowhere. We are in Rochester, Minnesota. There's a lot of corn fields around it. It's a little bit larger, Randy, than when you were here, I'll tell you that. But it is a fantastic experience and residency, even though it's long, I don't want to make it feel that it's not. It is still a lot of your time when you look at five years plus to your fall. I'm a life as a surgeon. It's really for a short period of time. So the other thing I would say, we are Mayo Clinic, but we are open to everybody that wants to come and train here. Don't think that we have a set of people that we want to come in now. We are trying to even expand that vision and bring in the highest quality learners. So don't be shy to look at our program. Don't be shy to ask questions. Send me an email and learn more about us.

Jacob Steffen (13:50):

Yeah, thank you. It kind of sounds like the town that I grew up in, small town in the middle of Iowa, so that's great. What is the average number of cases that an intern completes at your program and how does that evolve over the rest of the years?

Mariela Rivera (14:06):

So I would say the average is going to be around 200 for an intern year, which is pretty high obviously, if you can imagine those cases are going to be basic cases, but they're there and the autonomy is going to be limited, but they are going to have hands-on experience for the rural track and the non-rural track. We have one faculty that only work with a PGY one, and that's in the endocrine surgery world. Randy, what it used to be, the Farley rotation on your times. We have continued with that because we believe in that experience of one-on-one, even as a PGY one, every other day you're in the OR with one surgeon doing their cases. So is

Dr. Randy Lehman (15:04):

That a particular surgeon doing that or they take turns?

Mariela Rivera (15:07):

No, it's a particular surgeon has been Dr. Foster TR Foster. He came after he was an IS, not MIS, sorry, endocrine surgery fellow and then stayed with us. He came from Yale. He's one of my associate program directors too. So very dedicated to education. So since day one he got just a PGY one in his Do

Dr. Randy Lehman (15:28):

You have a rural specific A PD?

Mariela Rivera (15:30):

I do. Rob went, which,

Dr. Randy Lehman (15:32):

Oh yeah, that makes sense. Of course,

Mariela Rivera (15:34):

Yes. That is something I added to when I became a program director. I felt that need, I needed somebody that would have the knowledge that I don't have. I was trained here, trained elsewhere, and then the fellowship here. So I don't have eyes to the rural track, but, so that was one of the first thing I did. And Rob has been a fantastic addition.

Jacob Steffen (15:56):

So we kind of know that at Mayo and Rochester, there's a lot of other training programs outside of surgery, but specifically at your outside hospitals where the rural track residents go to train, what other training programs that exist in those hospitals and are there any other fellowships or anything else, any other programs going on at those outside hospitals?

Mariela Rivera (16:19):

Yeah, thank you for that. So there's going to be fellowships, a few fellowships, for example, colorectal and GI fellows will go through the health system because of the numbers of endoscopies and colonoscopies that are done in there and the experience. So those will be a few that I can think about really that there's not other fellowships that I'm aware of. It's just our own people going to the health system. There has been discussions and I think it will happen. I don't don't want to state anything that I don't know for sure, but there's been discussion under orthopedic residency in the health system, but I don't know details on that. So that might be coming up.

Jacob Steffen (17:07):

Yeah, thank you for that. I think it's important to get a picture of what other training programs are, because that can kind of influence what your training looks like as well. So I was reading about your program and researching online. I found something that sounded pretty fun and interesting about the surgery Olympics. So can you touch on the surgery Olympics?

Mariela Rivera (17:26):

Okay, so the surgery Olympics is an assessment. Don't be scared. It's a fun assessment we use with simulation and we do that in the first weeks. As you start as a general surgery resident, you mainly you as a learner with us know what you don't know and know what you know. And then after that we give you the feedback. We say, Hey, this is the bar, this is where we want you, not right now during the year, let's work on it. And these are resources that you can work on it and it is to guide yourself, directed feedback, residency, the majority of it, it's going to be self-directed feedback. I am not with you a hundred percent of the time telling you what you're going to learn. You have to learn based on the experiences. So this is a way to guide that because it can be very overwhelming of everything that you're supposed to know, especially in that first year.

(18:28):

We do it again six months later and then it's once again, what have you learned? What have you not learned? What are the things that you still need to work on? And once again, we call Olympics because there is some competition. We do give this year our associate program director for simulation, Dr. DM Boo, shout out to her. She gave actually fake medals to those high performers. It's a recognition and we will be recognizing them again during our graduation. It's hard work, right? It's hard work and it is an objective way of assessing you. That is what Olympics are. We have a similar mindset for PWAs two to five, we just call it in a different way, X games and they're meant to also, what are the skills I want you to have for next year? Let's test you at the beginning of this year. Set the bar. You have a full year to get there. These are important skills and they're going to be based on where the residents rotate, the faculty expectations and things like that. So it's a simulation based assessment to tell you what you know, what you don't know. That's a little bit of a competition.

Jacob Steffen (19:47):

So where can a medical student go to learn more about your program?

Mariela Rivera (19:51):

Yes, website. Our website may just type in rural track. Mayo Clinic, Rochester, Minnesota. That's the important thing because we do have other two programs, general street programs, one in Arizona and one in Florida. Jacksonville, to my knowledge, they do not have a rural track yet.

Jacob Steffen (20:12):

Okay. That's great to know. Well, thank you Dr. Rivera for coming on the show. This has been our Rural American Surgeon podcast and our subsegment of rural training tracks in the United States. So thank you Dr. Rivera, and thank you to our listener. Thank

Mariela Rivera (20:31):

You so much for having me. Thanks

Dr. Randy Lehman (20:32):

For joining us on this episode. We look forward to seeing you on the next episode where we interview several other programs from across the country. If you have specific questions that you want to hear, don't hesitate to reach out to us. Join us at theruralamericansurgeon.com and you can submit your requests there. I appreciate all of the feedback and things that I've seen already from so many of you that have sent emails. I really appreciate I get to read every one of 'em and I look forward to hearing from more of you as time goes on. So thank you very much for joining us on this episode of The Rural American Surgeon. I'm your host, Dr. Randy Lehman, and I will see you next time.