Why Rural Surgeons Can’t Afford to Be Too Specialized (Part 1)
Stuart Ferguson, a consultant general surgeon in Scotland’s remote Shetland Islands, joins The Rural American Surgeon to discuss what it takes to practice surgery 200 miles into the North Sea and why he deliberately built his career around becoming a broad surgical generalist.
Stuart shares his training journey from Glasgow and Northern Ireland to colorectal surgery, global health work in Zambia, and Scotland’s Rural Surgical Fellowship. He explains how the fellowship allowed him to build additional skills in urology, orthopedics, trauma, and obstetrics specifically for the needs of Shetland.
The conversation also explores what surgical practice looks like for a population of roughly 22,000 served by three consultant general surgeons. Stuart describes a practice divided between general surgery, urology, trauma, and orthopedics, along with endoscopy and emergency procedures that would typically be divided among several specialists in larger hospitals. The episode concludes with a look at how he developed the urology skills needed to practice independently in such an isolated setting.
00:00 Why Rural Surgery Creates a Broad Skill Set
00:45 Meeting Stuart Ferguson and the UK Tradition of Calling Surgeons “Mr.”
05:42 Stuart’s Surgical Training in Scotland and Northern Ireland
07:30 Going From Colorectal Training Back to Generalist Surgery
08:00 Scotland’s Rural Surgical Fellowship
08:38 Building Skills in Urology, Orthopedics, Trauma, and Obstetrics
09:21 How Many General Surgeons Serve the Shetland Islands
11:51 What “Rural” Means in an Extremely Isolated Community
17:01 Shetland’s Scandinavian History and Culture
18:33 Serving 22,000 People With One Hospital and Three Surgeons
19:32 Stuart’s Mix of General Surgery, Urology, and Orthopedics
20:45 The Bread and Butter Procedures of a Shetland Surgeon
21:17 Managing Complex Cases and Surgical Emergencies
22:33 Endoscopy Without a Gastroenterologist
31:09 How Stuart Built His Urology Skills After General Surgery Training
32:08 Using the Rural Surgical Fellowship to Prepare for Shetland
33:13 Training for Independent Urologic Practice 200 Miles Into the North Sea
Resources Mentioned
● British Society of Gastroenterology
Episode Transcript
Dr. Randy Lehman (00:44):
Welcome back listener to the Rural American Surgeon podcast. I am your host Dr. Randy Laman with me today I have Dr. Stuart Ferguson from Scotland. I have been looking forward to this episode for so long. Thank you for joining us. Is Doctor or Mister the right word?
Dr. Stuart Ferguson (00:59):
Well, in in the UK, Mr. Yeah But um when I've worked elsewhere in the world, I'll be doctor.
Dr. Randy Lehman (01:06):
Okay So, but but a mister is just a mister too, like any other man? Or is mister like denoting a certain thing?
Dr. Stuart Ferguson (01:14):
Well, uh by convention it'd be when you've got your surgical exams. So your more junior surgical exams, membership of the Royal College of Surgeons, then you tend to be mystified, um or mystified. Yeah.
Dr. Randy Lehman (01:28):
Well, because I mean I was Mr. Randy Layman the day I was born. Do they say that over in Scotland or not so much? They hang on to that until you pass your...
Dr. Stuart Ferguson (01:38):
Um, I was, yeah, um I guess I was proud of my doctor title when I got it. Um, I enjoy surgical history and culture and for us it's part of culture, um to use the doctor title, yeah.
Dr. Randy Lehman (01:52):
go back. So, I've been to that museum in Edinburgh, the Surgeon Museum. I assume you've been there?
Dr. Stuart Ferguson (01:58):
I actually was based in the University of Edinburgh for a couple of years as an anatomy tutor, yeah. Yeah, I mean that is
Dr. Randy Lehman (02:07):
quite the museum and about the the history of the barbers and the development of surgery back in the days of, I don't know, surgical greats that we still have instruments named after them.
Dr. Stuart Ferguson (02:18):
Yeah, yeah, absolutely. And that's where the master comes from is the um the fact that um those who did surgery evolved more from barbers and those who weren't afraid to tackle practical problems and the the doctors were the physicians, but these days we need we need a bit of old school types really, not just practical.
Dr. Randy Lehman (02:42):
especially a rural surgeon needs to be a doctor and a barber if you will, I guess. So they were the ones that had the correct tools of the day and that's how that, you know, came to be, right?
Dr. Stuart Ferguson (02:56):
Yeah, that's right. Yeah, they were the ones that you would you would trust if you did have a a practical procedure needing done.
Dr. Randy Lehman (03:03):
Yes Who who cuts your hair?
Dr. Stuart Ferguson (03:07):
Well, that's an interesting question. Um, so where where I live is the town of Lerwick, which is the main administrative town in the Shetland Islands. Um, we're an archipelago of twenty-three thousand people spread out across, um, I think about fifteen inhabited islands. Most of us on the Shetland mainland, so-called. Um, we're about two hundred miles north of the top of mainland UK. And um, sometimes there are disadvantages of being far, far north and um, it can be trickier to find specific things.
Dr. Stuart Ferguson (03:47):
and one thing is actually hairdressers, it can be quite hard finding someone to to cut your hair up here.
Dr. Randy Lehman (03:52):
So you have to do it yourself or you
Dr. Stuart Ferguson (03:54):
occasionally spouse do it or something? Yeah, my wife has prevailed upon an occasion.
Dr. Randy Lehman (03:59):
Yeah
Dr. Randy Lehman (04:00):
My wife's been doing the haircuts for me recently and I love it, but when I travel, actually one of the things I like to do is find a barber shop wherever and then like we have picture I have pictures of myself getting haircuts, you know, all over the world 'cause it's like something you're gonna need anyway and so you can kind of
Dr. Stuart Ferguson (04:17):
Yeah.
Dr. Stuart Ferguson (04:18):
My wife is a general practitioner, or you would you would see family doctor. Um, and she is very happy to be the other side of the the red line. Some theatres of this red line, you must wear your scrubs. Um, and she is very happily on the other side and um, practical things of much less appeal including cutting hair.
Dr. Randy Lehman (04:41):
Got it. But you've had your hair cut and I assume you've had your neck shaved with a straight razor before.
Dr. Stuart Ferguson (04:47):
I guess so.
Dr. Randy Lehman (04:48):
Yeah, and you you know, I'm just I can't get my neck shaved with a straight razor without thinking of the history of surgery, basically at this point, you know, it's just it's so cool. So,
Dr. Stuart Ferguson (05:02):
It's incredible watching how my hairdressers hold their their scissors and wonder about those basic surgical skills that I've taught many times to to folk. But using your instruments well, being ergonomic. It's interesting how they stand, they manage their bodies well.
Dr. Randy Lehman (05:18):
Yep. It's a great point. Move that chair. Move the move the patient. Don't uh move your body.
Dr. Stuart Ferguson (05:24):
Yeah.
Dr. Randy Lehman (05:24):
Basically.
Dr. Randy Lehman (05:25):
So very good. Uh we sort of got into uh everything hairdressing here before we got a proper introduction to you as a person and as a uh your life working through training and what you're doing now. Uh first off, how did you grow up?
Dr. Stuart Ferguson (05:42):
Um, so I I grew up in and around Glasgow, the largest city in Scotland, and went to university there. Um, graduated, spent my early years training around Glasgow and then decided that uh surgery was going to be the most enjoyable route for me. And the the first two years of my surgical journey were in Northern Ireland. Um, so I lived in Belfast and commuted around the province and it was a great grounding.
Dr. Stuart Ferguson (06:16):
Even at that point, I actually was fairly set in the idea of ending up in a generalist rural practice.
Dr. Stuart Ferguson (06:25):
and I was fortunate to be able to get back on, um, higher surgical training in the west of Scotland. Um, I took a few breaks along the way. So, I, I was two years in Edinburgh doing research, teaching anatomy, clinical surgery, and then later on I took a year out in a post that was, uh, called a clinical leadership fellowship. And it was a, a post that was, that was run by our, our Scottish government and by the national training organization here, NHS Education for Scotland.
Dr. Stuart Ferguson (07:03):
And it was a way of, um, hoisting clinicians a few rungs up the ladder, seeing what it's like at the top, um, giving us some insights into the the difficult choices that face leaders and managers and an insight into the question of how you affect change. And then came to the end of of general surgical training. In the UK you have to choose your sub-specialty and mine was colorectal. And then from that point, I generalized more rather than specializing.
Dr. Stuart Ferguson (07:39):
I spent another six months with a an upper GI colleague and then spent another um half year with my wife volunteering in Zambia in a remote rural mission hospital. And when I was out there, I got the chance to apply for a consultant job here in the Shetland Islands. This is uh for anyone who's watching the the images, the picture behind me is uh Tombola, a raised beach um that connects one of the small outer islands. So I applied for a job here in the Shetland Islands and they allowed me to apply with
Dr. Stuart Ferguson (08:18):
an additional two years of training which was called a rural surgical fellowship. The rural surgical fellowship is funded nationally by the Scottish Government and it allows a bespoke opportunity that's designed for the context you'll you'll find yourself in, filling in gaps. And for me, it was mainly learning urology, doing significant upskilling in orthopedics and trauma, and then getting snippets of experience in obstetrics. I delivered about 30 babies.
Dr. Stuart Ferguson (08:52):
um did a couple of burr holes, opened some chests, um buzzed some tonsils. Um a few of these diverse things. Uh because Shetland is unique in the UK in terms of its health service in how isolated it is. 200 miles into the North Sea and we have to be capable but we're small. We're never going to have all the specialties here. So, that's a potted summary of my
Dr. Randy Lehman (09:22):
How many general surgeons are in Shetland?
Dr. Stuart Ferguson (09:24):
So currently we have three consultant general surgeons and we have anesthesiologist specialist and one hospital
Dr. Randy Lehman (09:32):
Okay. And uh you were saying sorry?
Dr. Stuart Ferguson (09:35):
Yeah, yeah, so and we also have a number of consultant physician colleagues and as of the last few years, we have an obstetrician and gynaecologist based in the island at any one time, but only one of them. So we would quite frequently be assistants for caesarean sections. And if anything goes wrong, which it can, then we need to be able to step up. One of our obstetricians had an MI, um, at the point of closing the uterus, having delivered the baby, headed off to ED to have his thrombolysis. And uh the general surgeon really needed to know how to close a uterus.
Dr. Stuart Ferguson (10:16):
So, you you are exposed here, you have to be able to adapt and step up regularly, slightly beyond your comfort zone.
Dr. Randy Lehman (10:25):
I understand. I I'm not sure. Are you aware at all of so you see my cow here?
Dr. Stuart Ferguson (10:30):
Oh yes.
Dr. Randy Lehman (10:32):
Yeah.
Dr. Randy Lehman (10:33):
So, my uh travel to Scotland, did I say much about it? No. I don't know, the listener might not might find it interesting too because they kind of know me now. Um, so let's see, ten years ago, yeah. We got married, my wife and I, and we went on a babymoon immediately got pregnant, of course, and then we went on a babymoon, our wife was seven months pregnant in September, I think, of 2016. I somehow convinced my program to pay for a a course through the Royal College of Surgeons in Edinburgh for actually in Dundee.
Dr. Randy Lehman (11:11):
and it was in Dundee, which is a course of vascular exposure, I think it was, on a cadaver. And mostly the surgeons that were there were like, uh, for example, I remember a breast surgeon, but he was going to go work like in a rural place and he may or may not get called upon and they may or may not be able to get transport in and out, and so he was kind of refreshing some of these things. Some of the other people I feel like they were just kind of there. They're like, yeah, I'm not really going to use this, you know.
Dr. Randy Lehman (11:42):
And it was quite an ordeal. Well, I grew up on a farm in Indiana. So, the county I live in is actually about 33,000, but of course, right to the other side there's another county with, you know, 20,000 and 20,000 the other direction and two hours north is Chicago, you know. So, and two hours south is Indianapolis. Um, so I'm rural, but that's the thing about rural is there's rural that's Shetland. You're like geographically so isolated. There's Newfoundland, there's Africa, Central America, there's Wyoming, and uh my my dad just went on vacation.
Dr. Randy Lehman (12:19):
he said he drove on a state highway up there that was like a gravel road but you could only fit one car through it at a time but it was yet it was a state highway it was going out and watching a rodeo and stuff it was crazy
Dr. Randy Lehman (12:30):
But uh there's a huge diversity. I feel for sure like I'm a rural authentic person, you know, I grew up on a farm and we had cattle and pigs and everything. And I moved back to the farm that I grew up on, actually, got the opportunity to do that. And my whole dream was my dad had a herd of cattle, uh half black half red, and there's one white one. And so that was naturally my favorite, you know, because it's the unique one. So then I had this dream and I have found written down have a herd of white cattle when I get whatever, when I've made it. And so I thought I was going to breed Charolais, that's a white breed of cattle.
Dr. Randy Lehman (13:09):
but then I got talked out of it by some vets. They said, "These are huge animals and we don't like going to service their herds and stuff." And then I was like, "Okay, what do you do?" Then I'm starting to have start my little family. And then we went on this trip to Scotland. And my wife found this Scottish Highland cow, and of course, they're becoming popular in culture as well at this time. And she said, "Can we get these cows?"
Dr. Randy Lehman (13:31):
and and I'm like, yeah, uh, sure, why don't I look into it? So I look into it. Turns out there's actually seven different colors of Highland cows, uh, officially, um, for purebreds. And they have two of them that have white hair. There's one that has a pink nose and that's called a white, and one that has a gray nose and that's called a silver. And so then over the next five, six years, I'm like learning about these things and finally I I set my mind that I'm going to build a s- I like the silver because the contrast between the muzzle and the coat. And I just think they're visually beautiful.
Dr. Randy Lehman (14:08):
And um so we started we decided we're having a herd of silver Highland cattle and that's what we're doing. We've we've now been doing it for four years and then I'm going to show you this if you can see it. Oh, please focus.
Dr. Randy Lehman (14:23):
That is now the daughter that was in my wife's belly when we took our trip to Scotland. Nine years old, dragging around a 750-pound heifer and then she got the reserve champion at the Indiana State Fair like four days ago as of this recording. So, it's crazy, you know, you see the full circle and what I'm saying is we're in love with Scotland.
Dr. Randy Lehman (14:47):
like
Dr. Randy Lehman (14:48):
it's a special place in our heart, and now we've been back and we're and we're going again this fall. And uh last time we went, we went to a cattle show in Oban and a sale and everything. And I talked of course to them and I said, "What do you think about silvers?" They say, "Oh, no," and they use a few choice words, you know. And they're like, "Those are the ones, they're destined for the meat market."
Dr. Randy Lehman (15:09):
you gotta get rid of those. I'm like, oh come on.
Dr. Stuart Ferguson (15:12):
Yeah, fashions come and go and um I think the the kind of classic vision of a Highland cow is red.
Dr. Randy Lehman (15:21):
Click
Dr. Stuart Ferguson (15:22):
And um I mean you'll know much more than I, uh, but um I think it was Queen Victoria had decided that that was quite the shade to have. It's her favorite. That's where rocket is personality.
Dr. Stuart Ferguson (15:34):
Yeah. She enjoyed Scottishness as well.
Dr. Randy Lehman (15:38):
And the royal family has a fold of, they call them a fold, not a herd, of Scottish Highland cows. And apparently at some of the, I don't know if it's at every castle, but at least at like one castle, all they eat is Highland beef when they're there.
Dr. Stuart Ferguson (15:53):
A sustained musical note.
Dr. Randy Lehman (15:54):
So it's all about tradition.
Dr. Stuart Ferguson (15:56):
Mhm Okay.
Dr. Randy Lehman (15:58):
Okay, I don't know how I got on that. So, but are there are there Scottish Highland cows in Shetland, Manny?
Dr. Stuart Ferguson (16:04):
No, there's there's not much of um of a beef herd or dairy herds in Shetland. There are some. Um so you can buy Shetland cream and butter and milk, but um actually it's Orkney which is our archipelago neighbor to the south that is the place for dairy herds. And there's quite an interesting history with that. Um Orkney was the site of an absolutely massive Royal Navy base during the World Wars. And um during the the war period they had this massive surge in population.
Dr. Stuart Ferguson (16:42):
you know, almost doubling the local population and they needed to drink milk. So, the Orkney land is pretty suitable for cattle and when I was visiting my sister in Canada, the good quality cheese I could get was Orkney cheddar. But Shetland is a land of of seafarers, of fishermen who might occasionally farm. The Orcadians are farmers who occasionally fish.
Dr. Randy Lehman (17:05):
Mmm. And and both of them more heavily influenced by Scandinavian culture than maybe by definitely by English culture, right? But more more by
Dr. Stuart Ferguson (17:14):
Yeah
Dr. Randy Lehman (17:15):
a little bit of Scottish but more Scandinavian, right?
Dr. Stuart Ferguson (17:17):
Yes, that's right. Yeah, the place names are much more recognizably Nordic and Shetland has only been part of Scotland for 550 years or so. And before that, it was part of the Kingdom of Norway. It's um, yeah, the story is a defaulted mortgage payment, something like that. The Scandinavian king at the time didn't have much money to scrape together for a dowry, so he gave Shetland and Orkney to the King of Scotland, um, on the understanding that he would buy it back at some point and he never got round to it. So it's been Scottish ever since.
Dr. Randy Lehman (17:55):
That's incredible. I know there's more sheep than than people in Scotland, right?
Dr. Stuart Ferguson (18:01):
Uh, almost certainly, yes. Yeah.
Dr. Randy Lehman (18:03):
five and a half million people in Scotland. Indiana for reference has seven million people, just in my state. Um, but yeah, it feels like when we went to on that vacation and we were driving through, just the signs that say, you know, tractor crossing, cow crossing, feels like home to us. So that's that's one of the things.
Dr. Stuart Ferguson (18:23):
in Shetland there are some signs that will say otters crossing.
Dr. Randy Lehman (18:29):
Otters
Dr. Stuart Ferguson (18:30):
Yeah, it's one of the best places in in the world to see otters.
Dr. Randy Lehman (18:34):
Yeah, that's that's fantastic. So, why don't we um talk about your practice a little bit? Um so now that you're there, we're getting a picture, it's 22,000 people. You can check it out on the map, it's unbelievable how isolated and remote the Shetland Islands are just north of Orkney, north of Scotland. And then um one hospital, three surgeons. You're on call one in three then?
Dr. Stuart Ferguson (18:57):
Yeah, that's right. At least during the week, we our health board do pay for us to get a locum one in four weekends. So, I'm only working one in four weekends, but one in three or if somebody's away, one in two.
Dr. Randy Lehman (19:11):
C
Dr. Randy Lehman (19:11):
Well, it sounds like I need to get privileges over there and then, uh, come help you out every once in a while. Sure. So, that's awesome. And then at least you get a little more breathing room for one and four on on the weekends. But what's your actual practice look like? I know you sent it to me and I reviewed, uh, some of your case logs, but compared to say a general surgeon in the city, how's your practice different?
Dr. Stuart Ferguson (19:32):
Well, I suppose one of the things that's mentioned is that of the three colleagues we have here consultants in the island, all of our practices are slightly different. Um, but my personal practice would be about uh 40% general surgery, 40% urology and 20% trauma and orthopedics. Um, so as I mentioned before, my UK training route was general surgery with a colorectal subspecialization.
Dr. Stuart Ferguson (20:02):
So I do tackle colonic resections, um certainly laparoscopic open or open right hemicolectomies. Um I've done two or three high anterior resections, the more straightforward forward end of perineal work. Um I'll do about one lap coly a month and then the usual mix of hernias, bits and pieces. Um urology, I tackle transurethral resection of prostate and of bladder tumors.
Dr. Stuart Ferguson (20:43):
all of my colleagues will do circumcisions, hydroseals, the so-called groinery, um of urology. And uh and and then we also all do minor cold orthopedics, percutaneous needle fasciotomies, trigger fingers, carpal tunnel releases, that sort of thing. So that that would be our elective bread and butter. We we've made a point of keeping a hold of a two-bed high dependency unit that our anesthetic colleagues run. And that's one of the things that allows us to tackle slightly trickier things.
Dr. Stuart Ferguson (21:18):
And we have a history of of hosting surgeons from our tertiary referral center which is Aberdeen, who'll come and do cases with us. So I've done a couple of
Dr. Stuart Ferguson (21:31):
alongside a colorectal specialist colleague who's doing them regularly in a higher volume center. And then emergencies will be, you know, whatever the front door throws at you. Uh one of my former colleagues was here 20 years and over that time he did four craniotomies. We do get occasional trauma laparotomies, um and very occasionally have to open a chest.
Dr. Stuart Ferguson (21:59):
and lots of small bits and pieces, reducing dislocations, fractures. Uh, I personally do um cemented hip hemiarthroplasties and all of us do dynamic hip screws for extra capsular fractures. We would tackle selected ankle orifices, occasionally repair tendons, etcetera.
Dr. Randy Lehman (22:23):
Man, see there's so much that I want to talk about. We got to we're going to focus on the urology piece of it today, but uh I mean you're doing it. So who does endoscopy at your hospital?
Dr. Stuart Ferguson (22:33):
We don't have a medical gastroenterologist. And I suppose it would look different if we did, but all three of us consultant surgeons are fully accredited for gastrointestinal endoscopy. Um it's the British Society of Gastroenterology who rule GI endoscopy in the UK and they have standards of accreditation. And my colleague and I who have been through the training system more recently have duly filled out log books, um done all the requisite training and so I do about a hundred colonoscopies a year, about a hundred OGDs a year.
Dr. Stuart Ferguson (23:12):
And we do do occasional selected trickier therapeutics. I am pretty comfortable banding varices, uh deleting esophaguses, tackling slightly larger polyps.
Dr. Randy Lehman (23:27):
Mm-hmm. Band hemorrhoids
Dr. Stuart Ferguson (23:29):
Yeah, that's right. Yeah.
Dr. Randy Lehman (23:32):
Who do you do Bronx?
Dr. Stuart Ferguson (23:33):
We don't, no, we don't do bronchoscopy. And uh two of us do cystoscopy, lots of cystoscopy.
Dr. Randy Lehman (23:40):
Is there somebody in Shetland who does Bronx?
Dr. Stuart Ferguson (23:44):
like for your...
Dr. Randy Lehman (23:46):
You called it something not an ICU but you called it something else.
Dr. Stuart Ferguson (23:49):
high dependency unit
Dr. Randy Lehman (23:50):
Yeah. And so if they got to the point where they needed that, then they would be transferred.
Dr. Stuart Ferguson (23:56):
Yes, that's right. Yeah.
Dr. Stuart Ferguson (23:58):
So, if anyone in Shetland needs intubated for any length of time, it absorbs essentially all of our theater capacity. I imagine you might have a similar setup, but when I start my weekend, I start my weekend together with the theater crew for the whole weekend and they they do on calls in the way that I do. Which actually is kind of links into one of the things I like about rural surgery is you feel in the same team because actually everyone wants to get the job done, um, and get away and get a rest. Nobody's waiting for the night shift. They they are the night shift.
Dr. Randy Lehman (24:34):
You are preaching to the choir on that. And that kind of segues us right into like the first real segment of the show even though we've been talking for like quite a while, is uh why rural surgery? So like what is it about that practice that you just described that attracted you?
Dr. Stuart Ferguson (24:50):
I think that medicine needs generalists and specialists. And it needs some people at either extreme of that continuum. You need the person who's got an intense interest in this molecule and this disease and they're really going to make progress. And then you occasionally need people who are at the extreme end of generalism. And arguably, we should have more people towards the generalist end than we do. And I like the sense in generalism that it's, um, I think often a particularly holistic way of looking at a patient.
Dr. Stuart Ferguson (25:29):
I like the fact that you're applying your your judgment in a concentrated way to an individual rather than focusing in a specialist system or area. I feel like patients get a good deal from it and it's satisfying to do things that you believe in. It's very disheartening to work in a system where you feel like a a cog, um always doing the same thing, always making the same decision. So it's personally satisfying, I think generalism is good for patients. And I think there's something very satisfying about the feeling of stepping up for your community.
Dr. Stuart Ferguson (26:07):
Because if you talk to rural communities about what makes them confident to stay in a rural community, to put down roots, um, one of the top things they'll say is feeling like they can access good quality healthcare. Um, so there's a a vocational feel to it, which I imagine you can strongly relate to. Um, where you care about rural communities, you feel like they should be getting a good deal. Um, they shouldn't be getting a second-class service from people who can't get jobs elsewhere. They should be served by people who really want to be there, who are well-trained and motivated for the environment.
Dr. Stuart Ferguson (26:47):
So
Dr. Stuart Ferguson (26:48):
there's a almost a missional aspect to it, a vocational, a strongly vocational aspect. While for some people the idea of being in a fishbowl, in a small pond is pretty off-putting, for me, I don't mind being known. There's been a lot of getting used to, but I enjoy the feeling that I'm strongly part of a local community and they own me and respect me.
Dr. Stuart Ferguson (27:16):
that experience of being part of a small community is is something that suits me personally very well.
Dr. Randy Lehman (27:22):
Yeah, it depends on the community, but I mean it's it can be keeps you honest for one. You can't hide. But at twenty two twenty two thousand people in all the Shetland Islands, I mean they all have to know who you are.
Dr. Stuart Ferguson (27:35):
Yes, absolutely. Yeah, that's right. Yeah, you're very noble.
Dr. Randy Lehman (27:40):
What are the uh what are the main industries in Shetland Islands? Is fishing and agriculture or is there tourism?
Dr. Stuart Ferguson (27:48):
Shetland is economically a pretty successful region within the UK. In the 70s, when North Sea oil was being developed at massive scale, the technology at the time wouldn't have allowed for oil to be extracted other than via Shetland. Um, the pipelines had to land here. So we had, I don't know if it still is, Europe's largest oil terminal at Solvang. In its heyday, there were massive ships in and out all the time.
Dr. Stuart Ferguson (28:24):
As I said before, Shetland is very much sea-facing, um rather than having so much arable land, so fishing industries are huge. The Shetland fishing fleets land more seafood than all of England and Wales and Northern Ireland put together.
Dr. Stuart Ferguson (28:43):
it's a big, big industry. Uh, we produce 80% of Scotland's mussels, produce I think uh a large proportion if not the majority of farmed salmon. So there's industry here, um that's successful, relatively low unemployment. Um the council is the biggest employer. We have lots of islands so we need lots of ferries, lots of services. The NHS is the is the next biggest employer. Um and yeah, tourism is a thing, but we are slightly off the beaten track. Um so we get lots of cruise ships, something like 150,000 cruise ship visitors visitors will pass through a year.
Dr. Stuart Ferguson (29:23):
Um, and there's a bit of a stream of them to the hospital, but it's a bit expensive to get here, a bit awkward, and that means that we're never going to have mass market tourism.
Dr. Randy Lehman (29:35):
Sure. Now, the Shetland pony. Is that from the Shetland Islands?
Dr. Stuart Ferguson (29:38):
Yes, yeah, genuinely is, yeah. So the the
Dr. Randy Lehman (29:42):
is a pony, right?
Dr. Stuart Ferguson (29:44):
Yes, that's right, particularly renowned for being stocky, reliable, very resistant to disease, robust, and uh common with a lot of Shetland wildlife is just a bit lower to the ground because we're a very windy place. Sixty days of gale-force winds a year in Shetland. Highest ever uh summer temperature recorded, 22 degrees Celsius, which I think is about 72 degrees Fahrenheit. So it's cold and windy. Yep. You wouldn't move here for the weather.
Dr. Randy Lehman (30:16):
No
Dr. Stuart Ferguson (30:17):
it's pretty amazing.
Dr. Randy Lehman (30:18):
I remember comparing Scotland and and like my hometown weather is like, wow, that that high is so much higher but the low is so much lower in the winter and then also the percentage of sunny days. It's like, I actually, there's a island off of Oban called Inch Island and it was for sale. It was like, when I was there visiting last year, I was not too bad. I think it was a 90-acre island for like 600,000 pounds or something like that. Like it's really not that bad when you but it's kind of just a rock, you know, it's it's green but it I don't think that it's got a lot of topsoil.
Dr. Randy Lehman (30:57):
So I'm like, maybe I can put some Highland cows out there and make it into a destination, but uh long story short, I think it sold. But then if the weather was a little better, that would have probably pushed me over the edge.
Dr. Stuart Ferguson (31:10):
Yeah.
Dr. Randy Lehman (31:10):
So, let's uh carry on to the next section of the show which is normally my favorite, but in this case, probably not, uh because we've been talking about such odd things for me on this show just from the fact of of where you live and everything, but but I am excited to hear about your urology practice. So, maybe before we get into it, how you kind of talked about it, but please tell me again how you learned how to do this after general surgery training.
Dr. Stuart Ferguson (31:40):
Sure.
Dr. Stuart Ferguson (31:41):
Um, I didn't have any urology jobs through my general surgery training. Um, but I knew I wanted to be a renal surgeon. In the UK, general surgical training is a minimum of eight years. And throughout that time, if I did have spare sessions, I would use them to accrue additional skills. So, I did go along to quite a few cesarean section lists and I went along regularly to cystoscopy lists or I went along to lists where I might be doing circumcisions, hydroceles, etcetera. So, I was already able to do a cystoscopy for sure.
Dr. Stuart Ferguson (32:17):
But I was privileged to have this two-year rural surgical fellowship. Um this centrally funded bespoke opportunity to be supernumerary and design a program around what I needed. So, I don't know...
Dr. Randy Lehman (32:34):
How many people per year do that fellowship in Scotland?
Dr. Stuart Ferguson (32:37):
A maximum of two. A maximum of two, not very many.
Dr. Randy Lehman (32:42):
And this is not the same thing that Lauren Smithson did.
Dr. Stuart Ferguson (32:45):
It is. Yeah, Lauren did this as well. Yeah.
Dr. Randy Lehman (32:48):
She did it for two years? I thought it was one, but maybe it's
Dr. Stuart Ferguson (32:50):
She she only did it for one. C
Dr. Randy Lehman (32:52):
Oh, okay.
Dr. Stuart Ferguson (32:53):
you can do it for a maximum of two and well you could you could have any kind of minimum really, but uh probably to make it worthwhile you you'd have to do six months or so. And I went into that fellowship with a consultant job in the Shetland Islands. So there was a very specific end product that was required and I had one colleague here at the time in Shetland who was doing all of the stuff that I wanted to be able to do. So there was a there was a clear end goal. He was, as I said, doing TURP, he was doing TUR bladder tumors.
Dr. Stuart Ferguson (33:31):
um and I wanted to be independently competent to be doing that 200 miles into the North Sea, able to dig myself out of a hole. And I have to thank the urology department at Aberdeen Royal Infirmary because they invested in that vision, um as well, and felt that I could do it. Um the trainees were very accommodating and allowed me to absorb some of their training opportunities. And I focused heavily on becoming credentialed in the specific skills that I knew I would deploy.
Dr. Stuart Ferguson (34:06):
and I I was careful to make sure that I was documenting that competency. So we we have a program in the UK, the Intercollegiate Surgical Curriculum Project, that defines levels of competence that has specific assessments. So I made sure that I was collecting assessments from urology consultants saying I had attained independent level competency in these procedures so that I could evidence my practice and and feel like I was offering people an equivalent quality. And since I started in practice,
Dr. Stuart Ferguson (34:46):
I had a mentor at the time who was doing it. He's now retired, but I've made return visits uh to that same department in Aberdeen to consolidate skills, check that I was still doing everything right.
Dr. Randy Lehman (34:58):
How long have you been at Shetland?
Dr. Stuart Ferguson (35:01):
I've been a consultant here now three years.
Dr. Randy Lehman (35:04):
Okay. And so then how many times have you been back to Aberdeen?
Dr. Stuart Ferguson (35:08):
uh I've been at least twice, yeah. Um and and I've done a mixture of orthopedics and neurology. So, I've gone along and and had them watch me do a hip hemiarthroplasty and seen some people doing DHSs, uh done some TURPs and just sort of checked and made sure that I was maintaining standards.
Dr. Randy Lehman (35:29):
Great. So, what specific, you know, we've kind of I said I wanted to talk about urology, but should we? I know what I do from urology perspective is basically I'll do a cysto and put my own stent up for a colon resection and then just pull the stent out at the end. There was a period at the end of my training where I was sort of asked would I be able to come and do stones and then I did the all this jumping around through hoops and I got a lot of extra experience but spent a lot of extra time, came pretty much ready to do it and then there's all this political stuff when I landed. Then I went to Indie, I found somebody that was going to be willing to kind of like help out and um anyway this
Dr. Randy Lehman (36:09):
I'm sort of moaning, I guess, at this point. I spent all this extra time and then then like the credentialing body at the hospital ended up saying, "eh, we don't actually want you to do this." Uh, it's kind of irritating. Um, but I do at least sisto drop my own stent in, but and maybe if a difficult Foley catheter placement if they call, you know, call me for that.
Dr. Stuart Ferguson (36:28):
Mhm.
Dr. Randy Lehman (36:29):
But um now my practice has gotten sort of so busy with the other things and more of like there's really a big catchment area that needs to be covered and so just to do like the general surgery for that area, endo is a huge thing for us. Um and so I'll do carpal tunnels and cerfs and things like that.
Timecode:
00:44 Introducing Dr. Stuart Ferguson
00:59 Doctor or Mister? Surgical Titles in the UK
01:52 Edinburgh, Barber-Surgeons, and Surgical History
03:03 Haircuts, Barbers, and Surgical Ergonomics
05:25 Stuart's Path to Rural Surgery
07:39 Zambia and the Move to Shetland
08:18 Scotland's Rural Surgical Fellowship
09:22 Surgical Staffing in the Shetland Islands
10:33 Randy's Scotland and Highland Cattle Story
16:04 Farming, Orkney, and Shetland Culture
18:34 Practicing Surgery in One of the UK's Most Remote Communities
19:11 Call Coverage and Rural Surgical Practice
19:32 Stuart's General Surgery, Urology, and Orthopedic Practice
22:23 Endoscopy in Shetland
23:58 High Dependency Care and the Rural Team
24:34 Why Rural Surgery?
27:40 Shetland's Economy and Major Industries
29:35 Shetland Ponies and Island Weather
31:10 How Stuart Trained in Urology
32:17 Inside the Rural Surgical Fellowship
33:31 Documenting Competency and Training in Aberdeen
34:58 Maintaining Skills After Fellowship
35:29 Randy's Experience With Urology Credentialing
36:29 Randy's Current Urology Practice
