Episode 75

What Rural Surgeons Need That Most Residencies Don’t Teach

Dr. Joon Shim, program director at Bassett Healthcare in Cooperstown, New York, joins host Dr. Randy Lehman and Jacob on The Rural American Surgeon to discuss how Bassett prepares residents for the realities of rural general surgery.

Dr. Shim explains how residents begin gaining operating room experience from day one and train across a broad spectrum of surgical cases without competing with surgical fellows. The conversation explores what it takes to thrive in rural surgery, including adaptability, resilience, emotional intelligence, and the ability to provide excellent care when patients face challenges with transportation, insurance, and access to specialists. Dr. Shim also shares what she looks for in residency applicants, Bassett’s approach to leadership development, and why rural surgeons must be prepared to think independently, operate confidently, and care for the entire community.

Key Takeaways

01:21 How Bassett’s Rural Surgery Residency Is Structured
01:54 Building Independence From the First Day in the OR
03:35 What Makes a Resident Thrive in Rural Surgery
04:25 Why Adaptability Is Essential for Rural Surgeons
05:30 How Rural Healthcare Can Improve Continuity of Care
06:26 Providing Excellent Care Despite Patient Resource Limitations
07:15 Adapting Treatment for a Patient With Limited Access to Care
08:22 The Extreme Cases Rural Surgeons Can Encounter
09:56 What Dr. Shim Looks for in Residency Applicants
11:25 Teaching Emotional Intelligence and Leadership
12:42 How Much Operative Experience Interns Can Get
14:27 Training Across Specialties Without Surgical Fellows
15:38 Where Bassett Surgery Graduates Go to Practice
16:46 How Medical Students Can Learn More About Bassett
17:28 Training Surgeons Who Are Technically Driven and Deeply Human
17:48 Thinking Independently and Leading Compassionately
18:54 Connecting With the Rural Surgery Community
19:59 How to Choose the Right Residency Program
20:35 Dr. Shim’s Journey From Major Trauma Centers to Rural Surgery

Resources Mentioned

AO Foundation
https://www.aofoundation.org/

Bassett Healthcare Network
https://www.bassett.org/

Bassett General Surgery Residency Program https://www.bassett.org/medical-education/residency-fellowship-programs/general-surgery-residency-program

Bassett Surgery Residents on Instagram
https://www.instagram.com/bassettsurgeryresidents/

North American Rural Surgical Society
https://www.northamericanrss.org/

Show Transcript

Dr. Randy Lehman (00:00):

big ulcer in the middle. And he just said he just wants it out right then and there, you know, in clinic. And it's like fixed. I said, no, dude, I'm pretty sure this thing's literally connected to your skull. So I got an MRI. And it's invading not only into his skull, through his skull and meninges and into his brain. I sent it to oncology and she's from India. She said, this is what I'm supposed to see in India when I go back home in the third world, not what I'm supposed to see in the United States. But you can't make up some of these situations we see in rural America. Welcome back, listener, to the Rural American Surgeon Podcast.

Dr. Randy Lehman (00:36):

I am your host, Dr. Randy Lehman, and I have with me today Dr. Joon Shim from Bassett Healthcare in Cooperstown, New York. She's a program director. She has been the program director for six years. She's a PGY-20 Army veteran, two tours in Afghanistan, has seen it all, done it all, and is now a teacher of teachers. I'm just so, obviously, your program has a long history of training rural residents and rural surgeons, and I'm so honored that you took the time to be on the show with us today.

Dr. Joon Shim (01:08):

Thank you for having me.

Dr. Randy Lehman (01:11):

That's wonderful. I think the first thing we'll start with, we have lots of questions about your program, but if you could just give us a 30-second intro, what your program is all about.

Dr. Joon Shim (01:21):

Okay. Well, our program has been in existence since the 1930s. It's a long established rural program. We're a large geographic region in central New York. My residents gain huge exposures to an incredibly wide spectrum of surgical pathology in rural training. We're not a track. We're embedded. In a village of less than 2,000 people with a large catchment area. We're a level three trauma center. Now the structure of our training is intentionally progressive. Interns build a very strong foundation from day one. They go to the operating room. We do not have any surgical fellows, and our residents are guided sort of with independent decision-making by having the patients follow the residents.

Dr. Joon Shim (02:15):

Unlike other training programs where you have different service lines, colorectal, bariatrics, trauma, not at Bassett. The patients follow the residents. So each service, each team will have patients that have had a Whipple, a fem-pop bypass, trauma, bariatrics. And we do that longitudinally for five years because I am prioritizing an education of longitudinal experience for my surgeon.

Dr. Randy Lehman (02:49):

That's very different than anything that I've heard. How big are these services by the time a resident is a five?

Dr. Joon Shim (02:55):

So we have just increased our resident chief resident complement. It used to be from two to three, and now we're at four chiefs a year. And I will finally graduate. By two years from now, four chiefs. And we're doing it in a stepwise fashion to make sure the volume meets their education. With that said, we have three teams because each team is covered by a chief. And it's anywhere from 20 to 25 patients per team, depending on the weeks to months.

Dr. Randy Lehman (03:28):

Very cool. And so then what kind of resident really thrives in a program like yours?

Dr. Joon Shim (03:35):

I think that's a very complex question. I sort of want to think about it before I just answer it. For me, it's about the person, the spirit of rural surgery, what that means for them. Some of them have a purpose. They know, like you, Dr. Lehman. Want to go back to Indiana and practice in the town that I grew up. But there are others where they land differently. They didn't think rural surgery was for them, but they end up here and they realize it's their new mission. So I think that I have super flexibility in where the student is and where the student who becomes a resident wants to go.

Dr. Joon Shim (04:16):

I think when I think back on the people who thrive in this program, you have to embrace and feel good with limited resources, what it means to be a community surgeon at the heart of it, and what it looks like when patients have very poor access to care in a rural atmosphere. So I think If those residents are on board, they adapt. And I use that word adaptable because I think that's the heart of being a rural surgeon. They excel in the training.

Dr. Randy Lehman (04:48):

Yeah, I've had both my grandpas were admitted. My grandpa and my wife's grandpa were admitted at the hospital across the street from where I'm currently sitting. I think it was last summer and right across the hall from each other, you know, and so we're in the building. Like in the town, going to see both of them every day, right. If they have to go up and down the highway, they're going to land at different hospitals, different systems, different places. Probably the chance that I go is extremely low. Your care can't be, you say resource limited, but it can't be like a lower quality care.

Dr. Randy Lehman (05:24):

It has to be kind of the same operation that they're getting, kind of same equipment, same opportunities, same medicine, you know, which it is. You know, it's like a lot of times it's even the same doctors. Sometimes in our situation, hospitalists come up from out of town. But the funny part is that the care in the rural setting. Sometimes ends up being better care because of the family involvement and the follow-up plan. And then people don't get lost and fall through the cracks. It's kind of like the same medicine, the same operation, but then they kind of know where they're going afterwards.

Dr. Randy Lehman (05:55):

And the people that are discharging them understand the lay of the land and how the home health works and how the nursing homes work and things like that. Do you guys get into that with your residents? Like, I think it's very common for people to graduate residency and say, oh, they never taught us this in residency. Things like coding and billing and practice management and some of these things. Do you guys have any sort of curriculum to, this is kind of off the made up question, but talk about those sort of things that you're going to experience, especially in a small town after residency?

Dr. Joon Shim (06:25):

Yeah, I think our residents live it here. There are times where because of access, transportation, money, we have to be creative in solving the problem for the patient. I just have a patient coming up who has malignant melanoma and there are things that I want to do with him, but there's also limitations because of resources for him, not the hospital. And so as a rural surgeon, I have to adapt, understand my patients and still execute and give them excellent care. So the residents see that because this is a very personalized program because it's so small that it's a lived experience yearly for the resident.

Dr. Randy Lehman (07:07):

Yeah. Can you be real specific about like that situation? What do you want to do with that person? And what are you going to end up doing with them and why?

Dr. Joon Shim (07:15):

This guy has a six by eight tumor on his left shoulder that's ulcerating and bleeding. The reason he waited this long is he used to work for a company that closed down in a rural part of central New York. He lost his health insurance and now he finally got Medicare. And so he was able to see me for him. I want to biopsy him, but he. Can't come to clinic because he doesn't have a ride. So logistically planning and he says, I just can't make it. And he's been waiting for nine months for this to come out. So I'm thinking to myself right now, what can I do? What's my low hanging fruit to make things move for this guy?

Dr. Joon Shim (07:54):

So number one, I'm probably going to do a palliative excisional biopsy just to get the tissue and get it going and do a two-stage where he may need to see plastics and even get his sentinel nodes. You know, having this multidisciplinary discussion with plastics and surgical oncology, I don't want this waiting where we're waiting for open ORs for different times and different specialists, but someone has to do something actionable for this patient. And that's what I mean by rural surgery.

Dr. Randy Lehman (08:22):

Yeah, that makes me think of a patient I had who she had a, oh, it was probably about the exact, about the size you're saying, like six-, seven-centimeter, right in the center of her chest, big black, you know, ulcerated thing draining. She shows up in my clinic and just says she just wants it off today, you know? Okay, let's do this in a stepwise fashion, but that happens. And then I've seen other ones. I had one that was a squamous cell carcinoma on the back of the head.

Dr. Randy Lehman (08:47):

this guy had a biopsy excision like a couple years before but then kind of like let it go and then i guess he was seeing some wackadoo guy doing ozone therapy onto the you know just made up garbage thing somebody should really be going to jail for and uh it's just by the time he sees me it's as big as a dinner plate covering the whole back of his skull and big ulcer in the middle and he just said he just wants it out right then there in clinic. And it's like fixed. I said, no, dude, I'm pretty sure this thing's literally connected to your skull.

Dr. Randy Lehman (09:18):

So I got an MRI and it's invading not only into his skull, through his skull and meninges and into his brain. I sent it to oncology and oncology, she's from India. She said, this is what I'm supposed to see in India when I go back home in the third world, not what I'm supposed to see in. In the United States. But you can't make up some of these situations we see in rural America. So I think Jacob has some questions for you, too. So you want to take it away?

Jacob Steffen (09:43):

Yeah, sure. First of all, it's nice to meet you. And thanks for coming to talk to us. So my first question for you is, what's the number one thing that you wish you could tell all medical students who are considering your program?

Dr. Joon Shim (09:57):

I think when we interview applicants interested in rural surgery, especially we are one of the only rural surgery programs in the Northeast, we're looking for more than just scores and CV accomplishments. I really look for within the application, adaptability, resilience, humility, and that genuine commitment. To patient-centered care. I really look for applicants, especially in a rural atmosphere that's team-oriented. The emotional intelligence is vital. And people who are excited, the way Dr. Lehman and I are talking about some of these cases, excited about broad-spectrum surgery. And I also am committed to medical students who are wanting that deep connection with their communities and being comfortable leaning into the discomfort, managing complex cases with limited resources.

Dr. Joon Shim (10:56):

And I guess as a program director reflecting, I really value curiosity and ownership.

Jacob Steffen (11:05):

Yeah, I love that answer. And actually, that's not something that I think is talked about a lot, especially with emotional intelligence and things like that. So it's great to hear somebody that out there that's valuing that side of medicine. It's very important.

Dr. Randy Lehman (11:18):

Let me hop in here. Is there if somebody wants to work on their emotional intelligence, would you have any resources you recommend for them?

Dr. Joon Shim (11:25):

I think that also it depends on the person, their background, their life experience. But one of the things I've been doing for the last seven, eight years that's unique to this program is I have a leadership longitudinal course. It's an application base. We meet once a month in a small group. Talk about emotional intelligence within the leadership realm. This is the first time in, I think this is my seventh or eighth time I've been doing this. I started this in Ohio when I worked at Wright State as a professor. And I brought it here as a program director where I have eight residents involved in this and they even log on while they're on vacation. That's how important this program is to them.

Dr. Joon Shim (12:05):

But this is the first time I had four surgery residents and four internal medicine residents because in a rural atmosphere, you have to work multidisciplinary, interdisciplinary. I think. That has enhanced their learning on emotional intelligence as a leader.

Dr. Randy Lehman (12:23):

That's great. It's like, where can I apply? No, I'm just kidding.

Jacob Steffen (12:25):

Yeah, exactly. Very cool. So we touched a little bit earlier, you kind of talked about interns jumping right into the OR at your program. So can you talk a little bit about the average numbers of cases that interns complete and then how that evolves over the next couple of years?

Dr. Joon Shim (12:43):

Thank you for that. I think that I always want to critically think about my answers because I don't want to just answer for the sake of. First and foremost, it depends on the resident. It always does. Some residents, you know, need space to be upstairs and do the clinical work because, you know, they're catching up on maybe some of the things that they didn't get as medical students, if you will. And some are just. Done and they want to double scrub, triple scrub with a senior resident and a junior resident. We don't have PAs and NPs double scrubbing in our cases. This is a resident driven education.

Dr. Joon Shim (13:17):

And so the residents who are the most aggressive, I've seen numbers at the end of the year, I'm doing end of the year evaluations right now. 120, 130 cases. So there are cases to be done where they're actually progressing in their autonomy because it's them and then attending. No one else.

Dr. Randy Lehman (13:35):

Are you saying 120 logged as a surgeon junior or first assist? Everything.

Dr. Joon Shim (13:40):

Operative experience.

Dr. Randy Lehman (13:42):

Okay.

Dr. Joon Shim (13:43):

I think we have to be careful when people log Surgeon Junior, what exactly are they doing, especially in July and August and depending on the case, but experiential where it's you and the attending over a hundred cases at the end of intern year. I'm not sure a lot of programs can say.

Jacob Steffen (14:01):

Yeah, I love that answer. I like your adaptability. We kind of touched a little bit about it, but being able to adapt to what the resident needs. And what their learning needs are is really great as a program. I'm really glad that you can be able to do that, provide that for your residents. So what other residents, I think you already mentioned internal medicine. What other residents and fellowship training programs exist at your main site?

Dr. Joon Shim (14:27):

Thank you for that question. So we have zero surgical fellows in our program. The priority is general surgery residents. So our residents, because there's no fellowship, they have vascular cases, plastics, CT surgery, OBGYN, because there's no surgical residency here. Now, we have another residency, internal medicine. That's it for residencies. And then we have a transitional year where those transitional year interns definitely rotate through surgery and medicine. So it's a very unique opportunity. And we have one fellowship under internal medicine, which is cardiology.

Jacob Steffen (15:04):

Yeah, I love that. I don't think very many programs kind of talk about what other training programs, but it does, it can influence kind of what you're doing and limiting the amount of other specialties that are there can widen your experience a little bit, which I think is great. So where do your graduates end up? I think that there's a... Page on your website that kind of talks a little bit about this and you have a spreadsheet, but is there like a certain geographic location or setting that you see your residents kind of gravitating towards?

Dr. Joon Shim (15:38):

I actually did that. And it's part of my slide when I do the orientation or the recruitment with the medical students. In the last 10, 15 years, We represent pretty much a wide variety of locations within the United States. It's not northeast. We have a lot of people going into Idaho, Michigan, Montana. We also have five residents that went to Alaska and they practiced together. And actually, one of the former Bassett alums is the first robotic Whipple in Alaska just in 2022. But all of them are practicing together in a very broad spectrum kind of practice. And I also have residents practicing in California. So it's really a wide array.

Dr. Joon Shim (16:24):

In the last five years, I would say it's mostly Wisconsin, Idaho, rural Maine. I have two residents that are practicing together in rural Maine. It's a lot of critical access hospitals.

Dr. Randy Lehman (16:35):

Oh, that says a lot. Jacob, you have maybe one more question or are you finished? Yeah,

Jacob Steffen (16:40):

so my last question for you is where can a medical student go to learn more about your program?

Dr. Joon Shim (16:46):

I think we've worked a lot on our website. We try to be as transparent as possible. And my whole mission of the website is to help a medical student. So when I work backwards, I ask myself, what's the whole point of the website? And I think of the third and fourth year medical students who are thinking about where they want to train. So the website's super helpful. Number two is our Instagram. You know, the Instagram is controlled by my residents. But of course approved by GME. But that really shows you the life of a resident.

Dr. Joon Shim (17:16):

And then I think the most important thing is if a resident is truly interested in knowing and getting curious about Bassett, just touching base, emailing us, you know, we can try to have residents talk to them. You know, it's a very open and personalized atmosphere here. And I really believe in that. Because I'm committed to personalizing the approach of the education. We all learn differently. It is a very personal program since we have no other learner. And I'm looking for residents who are technically driven, but who are also deeply human. That matters to me. And so I'm finding that kind of alignment. And my end product for a resident, no one is an end product.

Dr. Joon Shim (17:56):

There's still, there's a lot of growth opportunities as an attending, and the learning never stops. But someone who can critically think independently, operate confidently, lead compassionately, and care for the entire community, not just the individual, that is really at the center of rural surgery.

Dr. Randy Lehman (18:15):

That's beautiful. That's like 100% what I'm about. And I did concentration public health when I was in undergrad. And it turns out, you know, you're being a rural surgeon is basically being a public health advocate, you get the pleasure of doing surgery, but the surgery is almost incidental to all this other change that you're enacting. So and it looks like that Instagram handle is @bassettsurgeryresidents. We'll put a link to that in the show notes. We'll put a link to your website also in the show notes. I had one last question. I know there are some people from Bassett that show up at North American Rural Surgical Society.

Dr. Randy Lehman (18:44):

I went to the website for North American Rural Surgical Society and I didn't see you as a residency member, but are you planning on doing that?

Dr. Joon Shim (18:55):

Funny that you mentioned that. I wasn't aware of it because we're not in that region. And I met with Tav, who is the program director at South Dakota, who I know very well because we traveled to Sri Lanka together to teach surgeons in Sri Lanka. So I've known him for several years personally. And he said, June, how come you're not in this? And I said, I had no idea. And he said, well, so I think we will be joining. Thanks to him. Perfect.

Dr. Randy Lehman (19:20):

yeah you should and it's not you know used to be northern plains but now it's really north american because we have people from not even just our country but from canada and every part of the us now that are showing up um i don't know where the meeting's always going to be like they just moved it to san diego but i think that's for weather you know i mean it's far from you but yeah the residents they have debates and great place to do presentations, especially about rural surgery, where you've got like, you know, a couple hundred people in the room that really care about what you're talking about. So yeah, I would encourage you to do that.

Dr. Randy Lehman (19:50):

And also to the listener, if you're not a member in North American Rural Surgical Society, I mean, I think I've said it enough, but you should be. So is there anything else that you want to add to the program? I really appreciate your time.

Dr. Joon Shim (20:00):

I think that the most important thing for a student is to know yourself, and it's hard because we're evolving, but knowing how you learn. It's not just about the name or you think this is what I should do. It's about investigating yourself and saying, hey, do I learn better at a bigger university or do I learn better at a smaller program, liberal arts, if you will, because Bassett is basically liberal arts. And then you can start tapering down to what is the atmosphere and what is the community that I want to serve or I'm actually interested or maybe it's something I never considered, but maybe this is something I should consider. You know, I can speak for myself. I didn't grow up rural.

Dr. Joon Shim (20:36):

I grew up right across from New York City all my life. And where I trained, I trained at level one trauma centers, big universities, but I landed here and I'm leading a program. As a surgeon educator. Because of my time in the military, I lived and worked in Kentucky and Tennessee, and it resonated with me. So these can shift and change as long as our medical students continue to have a broad, open mind about their growth and how they want to serve a surgeon.

Dr. Randy Lehman (21:05):

Yeah, it's amazing how your career can go throughout your life. So I'm excited for you and your residency and your program, and I just really appreciate it. And to the listener, also, thank you for joining us on this episode of The Rural American Surgeon. We are in the middle of our mini-series about residency programs here to train a rural surgeon. And we will see you on the next episode of the show.

Timecode:

00:00 Cold Open: Rural Cases You Can't Make Up

00:36 Introducing Dr. Joon Shim

01:11 Inside the Bassett General Surgery Residency

02:15 A Longitudinal Model of Surgical Training

03:28 What Kind of Resident Thrives at Bassett?

04:48 Why Rural Care Can Be Better

06:25 Teaching Residents to Work Around Real-World Barriers

07:15 A Melanoma Case That Defines Rural Surgery

09:43 What Medical Students Should Know Before Applying

11:18 Building Emotional Intelligence in Surgical Training

12:25 How Early Do Interns Get Into the OR?

14:27 No Surgical Fellows Means More Cases for Residents

15:38 Where Bassett Graduates End Up

16:40 How Medical Students Can Learn More About Bassett

17:56 What Bassett Wants Its Graduates to Become

18:44 The North American Rural Surgical Society

20:00 Know How You Learn Before Choosing a Residency

21:05 Closing