Episode 74
Why Rural Surgeons Can’t Afford to Be Too Specialized (Part 2)
Stuart Ferguson returns for part two of his conversation on The Rural American Surgeon to explore the practical realities of providing urologic and general surgical care in the remote Shetland Islands.
Stuart discusses the limitations that come with practicing in a small island hospital, including equipment decisions, limited critical care capacity, weather that can prevent patient transfers, and the need to know when a case should be referred. He then walks through his approach to transurethral resection of the prostate, including patient selection, equipment, safety landmarks, difficult catheter placement, and how elective urology experience helps when managing emergencies.
The conversation expands beyond the operating room as Stuart shares his approach to charitable giving and how he and his wife make global health work in Zambia a regular part of their careers. He explains how rural surgery gave him the broad skill set needed to work in low resource environments and shares a case that demonstrates the value of being a generalist who can see the whole patient rather than a single problem. The episode concludes with practical resources for rural surgeons and an introduction to the Viking Surgeons Association.
Key Takeaways
00:00 Returning for Part Two With Stuart Ferguson
00:48 Managing Kidney and Bladder Stones in Shetland
01:37 How Often Stuart Performs TURPs
01:48 Operating Rooms, Endoscopy, and Critical Care Capacity
02:26 Patient Transfers and Scotland’s Retrieval Service
02:54 When Weather Makes Transfer Impossible
03:32 Selecting the Right Patient for a TURP
05:14 Equipment and Safety Principles for TURP
06:15 Cystoscopy and Identifying Key Landmarks
07:33 Managing a Difficult Urethra
08:19 Difficult Foley Catheter Placement and Guidewire Techniques
09:23 Using Urology Skills to Manage Severe Hematuria
09:59 Stuart’s Approach to Tithing and Charitable Giving
10:50 Automating Giving Through a Separate Account
11:27 Supporting Global Health Work in Addition to Giving
13:05 Faith and Community in Shetland
14:31 The Viking Surgeons Association and Rural Surgery Community
16:09 Randy’s Path Into Rural Surgery
18:44 Training Specifically for a Rural Surgical Career
20:29 Creating Change Within a Small Rural Health System
21:31 Making Time for Global Health Work in Zambia
21:54 Stuart’s Connection to Rural Surgery in Zambia
23:30 How Global Health Work Maintains Surgical Skills
26:13 Why Rural Surgery Transfers Well to Low Resource Environments
28:20 The Value of Being a Holistic Generalist
29:30 Connecting Multiple Medical Problems Across Specialties
30:18 Recognizing When the Patient’s Greatest Need Is Something Else
32:45 Resources for the Busy Rural Surgeon
33:24 AO Surgery Reference for Unfamiliar Procedures
33:54 Primary Surgery for Low Resource Settings
34:54 The Viking Surgeons Association
Resources Mentioned
● Royal College of Surgeons of Edinburgh
● Faculty of Remote, Rural and Humanitarian Healthcare
Episode transcript
Dr. Randy Lehman (00:00):
We're back with part two of our interview with Mr. Stuart Ferguson. In Scotland and in the UK, doctors become doctors, and then surgeons eventually give up their doctor title and go back to Mr., and it's a sort of a point of pride and a reference back to before. the earliest surgeons in England and Scotland who basically were barbers. So I think that you've enjoyed, if you got to this point, the first episode and you can understand why I was so excited to interview Mr. Stuart Ferguson. I really appreciate him taking the time and let's talk about the second part of the show.
Dr. Stuart Ferguson (00:47):
But i don't really do any TURPs for sure or kidney stones um do you do kidney stones i wouldn't do kidney stones no we've really just got a bladder stone crusher um which is fine if you've got a small stone but once it gets beyond a certain size you really need to a laser or lithotripter style device so we did have some thought about whether it'd be worth us having a laser so that we could tackle ureteric stones and larger trickier bladder stones but the economics of it didn't really work out for us yeah i mean you start thinking demographically 22 000 times how many times you're gonna have to crack out the laser so those are the things that
Dr. Randy Lehman (01:30):
are very relevant to rural surgeons. So TURPs, how many TURPs are you finding that the community needs annually?
Dr. Stuart Ferguson (01:37):
It will be around about 15 a year.
Dr. Randy Lehman (01:40):
And why don't we just talk about your setup for that? So how many operating rooms do you have in Shetland?
Dr. Stuart Ferguson (01:47):
We've got two operating rooms, which we use for all of our endoscopy work as well. We don't have a separate endoscopy suite.
Dr. Randy Lehman (01:55):
Okay. Now, what I understood you say earlier is the advanced care, I'm still blanking on that term.
Dr. Stuart Ferguson (02:03):
A high dependency unit.
Dr. Randy Lehman (02:05):
High dependency unit. Is that in the operating room as well, or it just ties up the anesthesia person?
Dr. Stuart Ferguson (02:11):
um that would tie up our anesthesia person but it's in another room if necessary yeah it's it's a part part of our surgical ward okay so you can how many patients can you have ventilated at a time then uh ventilated really essentially one you know in scotland we have a a pretty well-organized national retrieval service called ScotSTAR who will bring a mobile intensive care team and will take your your intubated patient away from you or have a lower level transfer for unstable or stable patients to the tertiary center elsewhere but if it's one of the 60 days where you have gale force winds Absolutely. Yeah, you've got it. Where sometimes fog, winds, etc. mean that you're absolutely stuck.
Dr. Stuart Ferguson (03:01):
And then you just absolutely have to do your best. And the reality of it is that sometimes bad stuff is going to happen because you can't have every possible skill set. Yeah. I have one patient who I did an end colostomy for after many years of colonic irrigation following his delayed treatment of his cauda equina syndrome because he couldn't get off island. So yeah, bad stuff sometimes happens. You can't solve every problem.
Dr. Randy Lehman (03:32):
Okay. So you're taking your patient though with your, that has a benign. prostatic hyperplasia to the operating room and you're setting them up. And what are the key components of the TURP for a general surgeon in America? So we can hear about it.
Dr. Stuart Ferguson (03:49):
Sure. Well, like any operation, you need to make sure you're doing the right operation for the right patient. TURP may not be appropriate. If a patient is particularly comorbid and is not going to cope with a complication, in UK practice at the moment if your prostate is heading towards 100 mils or more in volume then you're probably better off having a HoLEP, holmium laser enucleation of your prostate so i wouldn't tackle them i would refer them on You want to be sure that you're operating in a patient who's got a proper obstructive uropathy and you're not going to do the TURP and they're going to have exactly the same symptoms because their main problem is detrusor underactivity or overactivity.
Dr. Stuart Ferguson (04:42):
So you have to have a threshold of when you might want to send your patient for urodynamics, we don't have the wherewithal to do that for every patient. Uroflowmetry at minimum, accepting that a maximum flow rate of less than 12 mL per second will indicate an obstructive uropathy. So you want to be sure that you're operating on the right patient. You need a lot of irrigation fluid. I go through liters and liters. We have a bipolar resectoscope setup. It's an Olympus instrument, which is the same that they use in Aberdeen. Follow
Dr. Stuart Ferguson (05:23):
stay beyond the verumontanum make sure you're not damaging anything else stop when you're seeing the capsule and be context appropriate so if you're doing a channel TURP facilitating prostate radiotherapy you're being a lot less radical and You know, you can tailor how radical you are according to the age, the comorbidity of the patient, trying to make sure that they get a good outcome, regardless of whether you're going to have to bring an early end to the operation or not.
Dr. Randy Lehman (05:59):
Very good. So. some of these uh i have questions where i ask like really practical how you hold your instruments and things like that um i think i'm going to take this a little different direction do you ever have a heart so the first thing you do is you go all the way into the bladder with your instrument right yes and then you kind of come back and you're gauging everything
Dr. Stuart Ferguson (06:18):
Yes, that's right. Yeah, you do a thorough diagnostic cystoscopy because your patient might not have had a cystoscopy beforehand. And if you saw an unexpected bladder tumour, for example, then in UK practice, I think we would unfortunately have to stop and have a further discussion with the patient. So you would do your diagnostic cystoscopy. Some urologists like to mark landmarks with coagulation diathermy, a little mark about a centimeter in from the ureteric orifices. I personally quite like doing a circumferential mark beyond my verumontanum so I've got a clear stop point. I will use my left hand to try and
Dr. Stuart Ferguson (07:04):
give myself a clear understanding and space of where my verumontanum is so that you're being efficient in your swipes with your loop diathermy efficiently removing tissue and stopping at that key safety point to minimize your chance of a sphincter injury okay so when you're going in with your systo
Dr. Randy Lehman (07:26):
Do you ever have a really hard time because it's so pinpoint getting through the prostate?
Dr. Stuart Ferguson (07:33):
Not really through the prostate, no, because the prostate is really spongy and you can push through it. So much more common would be the need to do a procedure to widen your bulbar or penile urethra and there's different schools of thought on that. The instrument that we have and use quite often is Clutton's sounds or you could use Hegar dilators. We've got Clutton's or an Otis urethrotome. appropriately as a safe instrument. And some physiological urethras that might admit a diagnostic 22 French rigid scope will not admit a larger resectoscope. So you occasionally have to do urethrotomies even for a physiological urethra.
Dr. Randy Lehman (08:19):
Okay. So the reason I'm asking this It's something that everybody might encounter, which is difficult Foley catheter placement. So I'm wondering if there's any particular skills that you're maybe picking up and you're next level on from doing the TURPs. that would apply to if somebody has a, like, positioning or feeding things through that difficult Foley catheter placement would also apply.
Dr. Stuart Ferguson (08:51):
Yeah, sure. I guess a flexible cystoscope is going to do almost all the time, isn't it? You're almost always going to get a decent enough view to get a guide wire with a soft tip in the bladder and then railroad your catheter on top. Occasionally having a rigid cystoscope as well will be useful. Well, I think in general surgical practice, one of the things that I find TURP and TURBT skills have given me is an ability to more confidently deal with a really troublesome hematuria. You know, I've been irrigating the patient via a three-way catheter for a day or two, not making any progress.
Dr. Stuart Ferguson (09:30):
comfortable to put in a rigid cystoscope because sometimes you're just not going to get a view otherwise you're not going to clear the clot without a rigid cystoscope and I'll have the confidence to apply diathermy or resect tumor if I were to see it. So that's definitely one scenario where having that background of elective practice can be useful in an emergency setting.
Dr. Randy Lehman (09:54):
Anything else that you'd like to add to this, how I do it before we move on to the next section?
Dr. Stuart Ferguson (09:58):
No, that's good.
Dr. Randy Lehman (09:59):
Yeah, thank you. I think that was just one of the most unique ones that we've done. So next section of the show is the financial corner, and we just keep it quick and sweet. But is there any one practical money tip that you would have that maybe you wish you knew before or something that's worked for you for the listener to learn from?
Dr. Stuart Ferguson (10:18):
So I would say that one financial principle I follow is to tithe or thereabouts regularly. Selfishness is pretty hardwired into us. And I think if you have a systematic commitment to giving.
Dr. Randy Lehman (10:35):
So tithe means tenth. Yeah,
Dr. Stuart Ferguson (10:38):
I would give a bit more than a tenth, but yeah.
Dr. Randy Lehman (10:41):
that's the idea. Maybe when you're a surgeon, you might give a bit more than a tenth. So, but you said systematic. So exactly how do you do it? Because I mean, I can say how I do it.
Dr. Stuart Ferguson (10:50):
Sure. Well, I've got a separate current account with my bank that is purely money that's going elsewhere, will never be spent on my priorities, but will go to charities or individuals or causes that I think are important.
Dr. Randy Lehman (11:07):
Yeah. And so does that automatic, do you get paid every week, every two weeks or how do you get paid? yes i'll get paid every month so i've got a standing order set up so i don't need to think about it it's happening automatically next thing you know you've got a certain amount of money there and uh you have to spend it on somebody else yes absolutely now is that the are those the funds that you use to uh to go work in zambia No,
Dr. Stuart Ferguson (11:33):
we would do that in addition. So that money is for what I would use and on other causes. But essentially, my wife and I do donate a fair amount of our time, unpaid leave and travel expenses, etc. to the global health work that we do.
Dr. Randy Lehman (11:50):
So there's some doctors that I know that they need every penny of what they make to live.
Dr. Stuart Ferguson (11:55):
Sure.
Dr. Randy Lehman (11:57):
You don't need every penny that you make to live?
Dr. Stuart Ferguson (11:59):
No, fortunately not.
Dr. Randy Lehman (12:01):
See, that's, I think, the most, well, maybe not the most powerful, but one of the most powerful parts of the tithe is that, number one, it's not your money. It makes you feel like everything that you have is not your money. Number two, it opens your eyes to, I don't need it all. And no matter what you're living on. you could live on 90% of what you're getting.
Dr. Stuart Ferguson (12:24):
Absolutely. That's a really good way to express it. And yeah, I have a faith perspective. I believe everything I have, all skill, talent, resource, et cetera, comes from God. And it's a small way of indicating that I believe that.
Dr. Randy Lehman (12:42):
yeah no that's a beautiful thing i mean i feel the same way we talk about that a lot on the show too so it's a beautiful way to live and uh the main thing is i actually think it's true i mean how can you look at the things that we're able to see and and view it any differently i guess people do but it's it requires too much space for me to believe anything different absolutely so um
Dr. Stuart Ferguson (13:07):
do you go to the church of scotland we my family and i we go to a local baptist church um there's pretty much every flavor of of christianity and various other faiths represented in shetland you know for for all that it's geographically isolated it's culturally reasonably diverse it's for many hundreds of years been this um meeting point trading posts in the middle of the north sea and with the coming of oil and massive injection of resource and people it's a place that's really used to newcomers and some rural places you'll never really feel like you belong and shetland is fortunately not like that
Dr. Randy Lehman (13:49):
Yeah, I cannot wait. So the spoiler alert, I guess for the listener is that I have recently bought my tickets. And so we are going over to the Viking Surgeons Association, which is going to be just south of Shetland in Orkney this year. So I'm taking my family on a family vacation to a town of 7000. That's the kind of vacation we love is just kind of dive in and see and we'll stick around a little bit longer than the association meeting. And then it sounds like I'm going to be talking to them about my experience speaking with rural surgeons here in the United States and how things may be same, different and otherwise. So it's going to be so cool sometime.
Dr. Randy Lehman (14:35):
Maybe you should come to the North American Rural Surgical Society too, because that's essentially the counterpart on the other side of the pond. And it's a growing group. How many members do you have? Yeah, we have like, I think roughly around 150 to 200 members. But that's got its own story. I've talked about it several times on the show, but it was a... organization for vascular surgeons in a few states in Central America who were general surgeons, but also doing vascular. And then slowly they became less and less people that were doing vascular and they were going to shut it all down, but they still wanted to get together.
Dr. Randy Lehman (15:14):
And so one of the surgeons suggested, why don't we just change it to the Rural Surgeons Association? And it was Northern Plains Rural Surgical Association, but then it grew so much, they didn't even want to call it the American. They call it the North American Rural Surgeons Association, which of course is, I mean, if they just said American, then it's, you know, it becomes American Rural Surgical Association. It's kind of like ARS. So you don't really want to say that, you know, NARS is bad enough. But Lauren was presented to us. So we have Canadian members and members not just from the United States as well.
Dr. Randy Lehman (15:54):
And it's a now since they made that change, which was, I think, about 10 years ago, it's been a slow growth where before it was a slow decline of the group numbers.
Dr. Stuart Ferguson (16:04):
Was that an important part of you forming your identity as a rural surgeon?
Dr. Randy Lehman (16:09):
Um,
Dr. Stuart Ferguson (16:09):
it complemented it.
Dr. Randy Lehman (16:12):
So basically I didn't want to go to college and I just wanted to go to business for myself and I got a scholarship. So I was like, what the heck? I'll go to college. So I went to Purdue. One thing led to another. I decided to go pre-pharmacy, just little doors opening and stuff. I hated it. I had four semesters of declining GPA and I didn't get into pharmacy school after the two years. So then I had all these pre-health classes and I knew I wasn't trying and I wasn't applying myself. And so then I more or less out of spite decided I'm going to go to medical school
Dr. Randy Lehman (16:52):
And of course, at that point, then I was heavily motivated, got straight A's, crushed the MCAT, got into pharmacy school the next year, and then turned them down. And what it really was, is it was God directing my path and using my own selfish motives and whatnot. It only makes sense 10 years later when you're looking back, but. that's what I really think is providential. And because I would not have signed up for 13 years of training outside of after high school, you know, I'd rather like, you know, thrown trash or something. But anyway, I did it. And then I go to medical school. And always my plan was to come back home. And I wanted to improve my home community.
Dr. Randy Lehman (17:35):
And then I I mean, my choice of specialty only had to do with what did they need here in Rensselaer, Indiana, Jasper County. And I had made a pros and cons list of family medicine, general surgery, and ER. And I actually was thinking when I went to med school, I would do ER, but then I just fell in love with surgery. And at that point, the only cons on the surgery list were the training is longer and harder, call responsibilities, things like that. But it's kind of like overcome it because I put as a con under emergency medicine will not be a surgeon. And at that moment, it's like, okay, just suck it up.
Dr. Randy Lehman (18:17):
Do the training that you need to do because I'm imagining diagnosing somebody with appendicitis and then calling the surgeon to come fix it. So, and then I discovered that there is, mostly in like third year of medical school, I got a mentor. There's this field of rural surgery that is sort of a specialty in its own right, really actually a hot topic and a lot of development about training. And then I found out there are specific training tracks for it, applied broadly. But then I got interviews at three places that had a rural track and I ranked them one, two, three, and then matched at the Mayo Clinic in the rural surgery track.
Dr. Randy Lehman (18:54):
And then from day one, I told them where I was going. So same deal. My training was augmented and enhanced by the fact that I could envision myself there doing it. I didn't have a person there that I was going to model after, but I still sort of understood. And then actually, you get a better training from the attendings because they're really invested in you because you're not just. taking up a spot on their rotation until you go do your fellowship. There are pieces of every rotation that I'm doing. And so then they're trying to explain that to me.
Dr. Randy Lehman (19:33):
And even like when I would go through vascular and thoracic and different rotations that I don't do much of the spectrum, but I still do some, they would. help me through. So that's my long story of how I got to, and I've been out six years and that since I got out, I took a job the next county over. Then I started an independent practice and then I ended up contracting to the hospital. So I've been through a lot, but I've grown my practice to right at this moment, it's me. And I hired another surgeon last year and I have two advanced practice providers too, that help with clinic and wound care. Now it's more than me.
Dr. Randy Lehman (20:10):
It's a team, which makes my life... I don't know. I enjoy the entrepreneurial aspect of it, which I don't think there's a lot of that in the NHS.
Dr. Stuart Ferguson (20:18):
No, there's not. There are some entrepreneurs, but they won't tend to thrive in the NHS, maybe by having a parallel private interest.
Dr. Randy Lehman (20:31):
But you can still get a lot of professional purpose and mission out of enacting change and advocating for the right thing. And you can still have a voice, right?
Dr. Stuart Ferguson (20:41):
Absolutely. And if you're in a small organization like NHS Shetland, then you have a... disproportionately large voice and we have a board culture that does welcome innovation and that's that's really positively inclined towards change and new ideas yeah that's refreshing yeah and for us that's included for example around contract flexibility so when i was appointed to my post i was appointed in such a way that they they called it a global citizenship interest um and the post was advertised as having up to 10 weeks a year of paid leave possible within it, in addition to the standard NHS leave, which I think is probably a bit more generous than in North America.
Dr. Stuart Ferguson (21:32):
So my wife and I... in the end have taken six weeks of unpaid leave each year. And I've had really warm health board support in doing that. And we've used that to mainly visit Zambia and a rural hospital there.
Dr. Randy Lehman (21:51):
Yeah. So this is a great time. Tell me about Zambia.
Dr. Stuart Ferguson (21:55):
My wife has worked three and a half years on and off in Zambia before she met me, and my sister was a missionary in Zambia for about 10 years, so I had visited the country a number of times. And a particular medical link was with a mission hospital called Chitokoloki, Chitokoloki Mission Hospital, which is in the upper stretches of the Zambezi River. And since about 2001 has had as its anchorman a northern... Irish missionary surgeon called David McAdam. I visited him earlyish on in surgical training and was completely inspired and really wanted to return. And my wife and I got a chance after I'd finished all of my residency. We went together for half a year in the midst of COVID.
Dr. Stuart Ferguson (22:50):
escaped a lot of restrictions and it was a huge part actually of building my independence and a sense that I had actually accrued quite a lot of useful skills that might be deployed in situations that were uncomfortable or unfamiliar and we've returned to that particular place. every year and we've got a really rich set of friendships there we understand the context we're not spending a lot of time trying to work out how the place runs or where stuff is we can go and be useful and for both my wife is that what you said
Dr. Randy Lehman (23:29):
yeah yeah i found it on the map very
Dr. Stuart Ferguson (23:32):
Sure. Yeah, it's a very refreshing experience. And one thing I would say in Shetland is that although I have a very broad practice and it really interests me and motivates me, I don't do an awful lot of major procedures with a high degree of technical challenge. And Chitokoloki is the opposite, where, in common with many similar scenarios, pathology is often very advanced, very difficult. It maintains your surgical confidence and sharpness, I think, because you will legitimately be the best placed person to help them there. You're not disadvantaging them by failing to transfer because there often is no practical way to transfer. It's personally refreshing, professionally rewarding and helpful, integrating global health as I do into an NHS career.
Dr. Randy Lehman (24:29):
Now your wife doesn't scrub in with you when you're over there?
Dr. Stuart Ferguson (24:32):
Definitely not. No, she's very reluctant to cross that red line. Although when we went, she discovered that the tea room was the other side of the red line. And there was a big culture of buns and coffee at 10 a.m. So she was prevailed upon.
Dr. Randy Lehman (24:50):
And it's right on the airport, it looks like.
Dr. Stuart Ferguson (24:53):
Yes, that's right. Yeah, there's an airstrip that's part of it, part of the mission station.
Dr. Randy Lehman (24:57):
Do you fly in there or do you drive in?
Dr. Stuart Ferguson (24:59):
We've very largely flown in because it saves a huge amount of time. The roads aren't particularly fun either.
Dr. Randy Lehman (25:07):
Sure. Yeah, I've been to Kenya on a surgical mission trip, but primarily I go to Honduras. and as i sort of my first time i ever took a mission trip i was 13 years old i turned 13 in haiti i guess i was 12. now haiti is total mess right now and it's like not even really safe to even show up um because of all the gangs and stuff but if as i became more medical and then as i became more surgical my trips became more medical it originally was like construction humanitarian became more medical, then became more surgical.
Dr. Randy Lehman (25:42):
And so obviously now if I'm going to do a mission trip, I'm going to go do surgery because that's the need and that's the skillset that I have. So there's a place that I go in central Honduras for, it's, they have it set up where there's, there's follow-up, you know, cause you don't want to do surgery and abandon or anything like that. um part of a bigger system that can have longitudinal care and then you plug in with your skill set at this particular time it's been working out um pretty well but yeah i love that i would say that one of the attractions of rural surgery for me
Dr. Stuart Ferguson (26:18):
when i was at the very beginning point of career with lots of options before me was the sense that it would give me a very general skill set that was applicable in low resource environments elsewhere because i was very motivated by the the thought of that kind of work and that has been true um you know we are able to tackle things a lot wider i knew it was going to be rural so i about a year and a half of breast surgery within my training and i'll regularly do difficult mastectomies one essentially toilet mastectomy i did a couple of years ago um occasional bits of vascular work um one really satisfying case was a lady who came with a nine-year history
Dr. Stuart Ferguson (27:04):
of non-healing ulcer on her leg which i looked at and realized was um going to be helped by dealing with her varicose veins so we managed to find a stripper um tied off for a long saphenous and within a week um she was well in her road to recovery and incredibly grateful i've had a couple of those in indiana so sometimes you see things in
Dr. Randy Lehman (27:27):
Like where I live, too, though, that like one patient had a squamous cell on the back of the head that he just let go and it was invading into his brain. And I said to oncology, because I'm like, you know, what are you going to do? And she said, she's Indian. And she said, this is what I'm supposed to see when I do missions in India. I'm not supposed to see this in Indiana, you know? Yeah,
Dr. Stuart Ferguson (27:48):
yeah. I had patients with really, really advanced neglected pressure sores here and pretty familiar with it from spinal injuries patients in Zambia.
Dr. Randy Lehman (27:59):
You've shared several stories, but the next true segment of the show is classic rural surgery stories. Do you have any other stories that kind of come to mind? Something that your urban colleagues just wouldn't believe?
Dr. Stuart Ferguson (28:10):
I should have taken more time to think of a really good case.
Dr. Randy Lehman (28:14):
You're permitted to come back on the show another time. We can save it. It's okay.
Dr. Stuart Ferguson (28:21):
I'll talk about one case. Sorry, you'll want to edit out probably a bit of that.
Dr. Randy Lehman (28:26):
Yeah, we'll touch it up.
Dr. Stuart Ferguson (28:28):
Yeah. I would think of one case that I think illustrates the value of being a holistic generalist quite well. And it's a lady that I saw with several different complaints. But because I was the key link person who was seeing them for all of those problems, I was able to join the dots and ultimately, I think, help her much more than anyone who maybe had more niche ability in all of these areas might have achieved. So I met this. lady in the midst of a pregnancy where she had a marginally positive qFIT test. I presume you're using qFIT regularly and had to discuss with her a colonoscopy or not. And we ended up negotiating not, but she was pretty anxious about it.
Dr. Stuart Ferguson (29:20):
I saw the same individual a few months later, where she arrived absolutely petrified with a palpable axillary lump. And I examined her, and because I had had about a year and a half's worth of breast experience, I was able to pick up that these were the ones that I was most concerned about. were not standard kind of cancer nodes they were definitely enlarged but they had a funny kind of rubbery texture to them and i noted that she had bilateral breast implants so i presumed that she probably had axillary silicosis and the fact that i was able to talk her through that
Dr. Stuart Ferguson (30:00):
give her a bit of perspective and it did ultimately prove to be the correct diagnosis was really helpful and we interacted in a few other things. I think I saw her as her urologist as well and we ultimately diagnosed her with a PUJ obstruction.
Dr. Stuart Ferguson (30:16):
chronic that she's awaiting surgery for but in being the one generalist who saw her for all of this what was really apparent was that the greatest issue for this lady was paralyzing health anxiety and she had very irresponsibly tried to seek help was doing the right things and just making no progress and the fact that I had built all of this rapport across multiple different specialty areas meant that I felt far more able to strongly advocate for her for her to get the psychological help that would make a difference and it was extremely gratifying receiving feedback that she had made huge progress in that. I've seen her subsequently and she was extremely grateful.
Dr. Randy Lehman (31:09):
Yeah, that is cool. I've had several experiences like that myself, where a patient comes back for a completely unrelated issue, and then you're like, you really feel like you're connected with them. I had a similar situation, however, at the county fair recently, where a patient that I diagnosed with colon cancer is like actually a friend of mine's father. And it was actually rectal, low rectal cancer, so I don't do that.
Dr. Randy Lehman (31:30):
So I coordinated, but I think I placed this port and uh did his colonoscopy he got his resection i did his follow-up colonoscopy and things i see something i was like what's that on your arm as i'm talking to him in the stands at the pig show you know and he says oh it's melanoma yeah i'm like oh okay so i'll be seeing you for that he's like no no i got it all set up to do surgery at like so-and-so other place i'm like
Dr. Randy Lehman (31:58):
you know i do like all things skin and and skin cancer and melanoma too but you do that what if i would have known that you did and it's like okay how do you get the word out to people of like because people always ask i say i'm a general surgeon oh oh just uh okay general surgeon okay and they don't want to even ask but you have to explain soft tissue everywhere you know, think of me, but whatever.
Dr. Stuart Ferguson (32:24):
There's, there's some things I wish that I could pass the buck on, um, chronic back pain, uh, not really a favorite topic. Um, yeah, diabetic feet, et cetera. I mean, it's, uh, it's not too bad getting to do the above or the below knee amputation, but all of the, the workup and care and inpatient management is a bit less fun.
Dr. Randy Lehman (32:47):
All right. Well, this is awesome. So the last segment of the show is the resources for the busy rural surgeon. So if there's a resource that you would recommend somebody that's interested in doing rural surgery, do you have one?
Dr. Stuart Ferguson (32:59):
I don't know if anyone has mentioned the AO app on the podcast before.
Dr. Randy Lehman (33:06):
I don't think so.
Dr. Stuart Ferguson (33:07):
So AO is a Swiss organization that's quite an authority in trauma care. And let me see if I can show you. I don't know whether it will all focus similarly. Is there? Yeah,
Dr. Randy Lehman (33:23):
we'll put a link to the app in the show notes too.
Dr. Stuart Ferguson (33:26):
AO Surgery Reference, and it's totally free and it's got great diagrams a description of various surgical approaches with levels of difficulty for things that you might tackle not very frequently if you're as isolated as me and you just sometimes have to go on with it yeah that's great for a rural or mission surgeon that may find themselves in lots of different I presume that others might have recommended primary surgery.
Dr. Randy Lehman (33:52):
Tell me about that one. I don't think I've heard that one either.
Dr. Stuart Ferguson (33:55):
Primary surgery is, there's a second volume available, trauma and non-trauma, and it's written for surgeons in... lower resource settings and lower income settings so it's not really written for a shetland type environment but if you're a generalist having to do something really unfamiliar in a hurry then it's a fantastic resource if you want a really practical approach to you know you've got somebody who's got a placenta previa they're bleeding you're needing to do a caesarean section it's not something you've done very much of it is a fantastic resource primary surgery the second and current edition was edited by Mike Cotton who's formerly a surgeon in Zimbabwe I found that.
Dr. Randy Lehman (34:48):
We'll put a link to that as well in the show notes. This is wonderful. Love those resources. Is there anything else that you'd like to share with the audience today, Stuart?
Dr. Stuart Ferguson (34:56):
Feel free to come and visit the Viking Surgeons Association anytime. So we're a bit smaller than your outfit. We would typically have 50 people. along at a meeting. It's an association of UK and Nordic surgeons formed in 1973 and the focus is an annual meeting. We've been all over the UK, we've been to Iceland a number of times and the program is always uniquely useful for a general surgeon in a rural area we've almost always got urology updates and trauma and orthopedics occasional ENT and you can find some archived material on the Royal College of Surgeons of Edinburgh website where we linked in with their Faculty of Remote, Rural and Humanitarian Healthcare, you can find some sessions there.
Dr. Stuart Ferguson (35:51):
And we have a website, vikingsurgeons.net. And as you've advertised already, we're in Orkney, the Orkney Islands this year, we'll be elsewhere the following year.
Dr. Randy Lehman (36:02):
Yeah. If you're going to Orkney and you join, send me something through the website and then we'll connect too if one of the listeners heads over there. All right. This has been awesome. Thank you so much for all of your time and just sharing. This is one of the most legitimate rural surgery practices that I have come across. And that's saying something because that's like my whole thing. I interview rural surgeons. So I just appreciate you taking the time, Stuart. And I look forward to seeing you in a couple months.
Dr. Stuart Ferguson (36:31):
That'd be brilliant. Thanks, Randy.
Dr. Randy Lehman (36:34):
Yes, thank you. And thank you to the listener for joining us for this episode of the Rural American Surgeon. It has been a pleasure. We'll see you on the next episode of the show.
Timecode:
00:00 Part Two Introduction
00:47 Kidney Stones, TURPs, and the Limits of Rural Urology
01:40 Operating Rooms and the High Dependency Unit
03:32 TURP for the Rural General Surgeon
06:18 Diagnostic Cystoscopy and TURP Safety Landmarks
07:33 Urethral Dilation and Difficult Access
08:19 Difficult Foley Catheter Placement
08:51 Hematuria and Emergency Urologic Skills
09:59 Financial Corner: A Practical Money Principle
10:18 Tithing and Systematic Giving
12:24 Faith, Stewardship, and Giving
13:07 Faith and Community in Shetland
13:49 The Viking Surgeons Association and Orkney
14:35 The North American Rural Surgical Society
16:04 How Randy Became a Rural Surgeon
20:41 Innovation and Flexibility in NHS Shetland
21:51 Global Health Work in Zambia
23:32 Why Global Surgery Sharpens Rural Skills
25:07 Randy's Surgical Mission Experience
26:18 Why Rural Training Transfers to Low-Resource Settings
27:59 Classic Rural Surgery Stories
28:28 The Value of Being a Holistic Generalist
31:09 Long-Term Relationships With Rural Patients
32:24 The Cases Rural Surgeons Can't Pass Off
32:47 Resources for the Busy Rural Surgeon
32:59 AO Surgery Reference
33:55 Primary Surgery
34:56 Viking Surgeons Association
36:02 Closing
