Episode 68

Training Miniseries 1: Dr. Mel Johnson and Dr. Lauren Dudas

Episode Transcript

Dr. Randy Lehman (00:00):

Welcome back to the Rural American Surgeon. I'm your host, Dr. Randy Lehman. I'm doing a miniseries that highlights rural training across the country. We are going to dive into real programs, real paths, and how to become a high level broad scope surgeon serving communities that need you the most across rural America. I'm going to be joined by a co-host, which is a MS three who's interested in rural surgery, Jacob Steffan, and we're going to be interviewing programs that we've identified or that self-identify as training rural surgeons, and we're going to get the answers that you need in terms of the hard hitting questions, what makes their program different, and how can you apply if you're a medical student. And even if you're not a medical student, maybe you're interested in hearing how the next generation of rural surgeons are trained. And so we're going to put together several episodes and crank through as many as we can, and we've already had several programs that have reached out to us to connect, so I will see you on the inside of the show. Welcome back, listener to the Rural American Surgeon Podcast. I'm so pleased to bring back onto the show, Dr. Melissa Johnson from Gunderson. Dr. Johnson, thanks for joining us.

Dr. Mel Johnson (01:17):

Thank you so much for having me, Dr. Lehman. It's a pleasure to return.

Dr. Randy Lehman (01:21):

Yeah, and we have Jacob Steffan, who is an MS three from IU in the rural track. Is that correct, Jacob? Am I saying that right?

Jacob Steffen (01:30):

Yeah, rural track in iu.

Dr. Randy Lehman (01:32):

So it's nice to have a med stud with us, and we are going to be starting our series about training programs in the United States that focus on training a rural surgeon. One of the first ones that comes to mind for me and actually the place that I ranked number one, which I love to tell everybody at Mayo about that is Gunderson in La Crosse, Wisconsin. And so Dr. Johnson is not only our president for the North American Rural Surgical Society, she's the program director. She for Gunderson, she lives and breathes basically training a rural surgeon and thinking about that all the time, she just got back from the A PD, what is it? A

Dr. Mel Johnson (02:15):

PS Association of Program Directors in Surgery where

Dr. Randy Lehman (02:19):

We all

Dr. Mel Johnson (02:20):

Put together.

Dr. Randy Lehman (02:21):

So she is the person for training a rural surgeon. And so I'm just so glad that you took the time to come back on the show to talk about Gundersen and if you could maybe just give us an introduction of what your program's all about, maybe its history, where it is now, where it's trying to go, and what kind of person you're looking for in your program.

Dr. Mel Johnson (02:44):

Excellent. Thank you, Randy. So the Gunderson Foundation General Surgery Residency Program has been in place now for 70 years. So long running program, really one of the first ones in the nation that was specifically designed to train surgery residents to go directly into general surgery practice and with many of those selecting to go into rural general surgery practice. So that was the purpose, that was why it was founded, and we have maintained that identity throughout all of these years. And just to give an illustration, if you look at all general surgery residents across the nation, approximately 80% of those that complete a residency program go on to fellowship training. If you look at our statistics over the past decades, approximately two thirds of our graduates go directly into general surgery practice, and if you look at that group, half of them go rural and half go urban.

(03:41):

When you make that distinction, oftentimes we use 50,000 as the population cutoff for rural versus urban. So if you look at our graduates that go to urban general surgery practice, we're talking about places like Bismarck, North Dakota. Yes, indeed that would be urban, but our goal is to place people into general surgery positions really throughout more of what we would say rural America. One third of our graduates do go on to pursue fellowship training, but many of those, if you look at where they end up in practice actually end up in rural areas, but perhaps bring a new skillset to that rural area. That could be trauma critical care coverage, it might be colorectal surgery, could be MIS bariatric. Those are just some examples. But I looked over the last six years and I had six residents go on to fellowship training and two of those six are now practicing in rural areas so we can even recapture those.

(04:37):

But again, our rate of approximately 30% of residents going on to fellowship training versus the national rate of 80%, we are seriously helping the national crisis and shortage of general surgeons by training surgeons. The way that we do at Gunderson, more specifics about my program and how we do that. Part of it has to do with the rotations that we have set up for our residents. They do rotate through obviously general surgery, trauma surgery, vascular surgery, but then we also have subspecialty training available to them, things like urology, ENT, gi, interventional radiology and obstetrics and gynecology. And now you may think, well, why would we need to train a rural general surgeon in subspecialty areas? Well, many rural general surgeons actually have to do procedures from those subspecialties. And I would say what's different about Gundersen is that we don't have any competing residencies. So when our residents rotate with urology, they're working one-on-one with the urologists.

(05:40):

Same with ENT, same with OB GYN. So we have no competition for things like training our general surgeons on how to do C-sections. I had a recent graduate do over 100 C-sections in her time at Gunderson, and she specifically sought out a rural general surgery job that included C-section coverage. So a lot of it's just designed within our rotations. To give you a little background on where Gunnerson is located, it is in La Crosse, Wisconsin, which is a population of approximately 52,000, but a metro catchment area of about 130,000. So technically speaking, we are urban, not by most people's standards if you ask anyone from the coast or a large city, but we are a big tertiary referral center. We have access to all specialties really within our hospital because of that, we also have started a rural general surgery rotation in the PGY three year at Tooma, Wisconsin, which is right down the road, and which Dr.

(06:41):

Lehman also provides services at Tooma, which is outstanding. That simply gives the residents a feel for what it would be like to be in more of a critical access hospital. So even though all five years are really dedicated towards training them to become an incredibly well-rounded general surgeon, we are also giving them a taste of what that would feel like to work and live in that area. In addition, we also have elective rotations including an elective rotation in Fairbanks, Alaska, which again, Fairbanks in and of itself is considered urban for Alaska, but they serve patients from all across the state, including Indian Health Service. We also have elective rotations available in places such as Nepal and Kenya, and you may think, well, why would you want to send a rural surgeon overseas while working in underserved areas globally really gives the resident a flavor for what it's like to be in an under-resourced area and how to make the most of what you've got available to you, which is what the rural surgeon has to do on a regular basis.

Dr. Randy Lehman (07:45):

So I love that. So basically you can graduate a program, a person from your program that can do C-sections immediately.

Jacob Steffen (07:54):

Correct.

Dr. Randy Lehman (07:55):

You can graduate somebody that can go to a fellowship if they choose. They're broad trained. Do any of your graduates do some of the things that they learn on ENT and urology?

Dr. Mel Johnson (08:13):

Absolutely. I'd say the number one from urology that they do is cystoscopy and stents. So many of our graduates will want to be doing colorectal surgery when they get to these rural areas. And the chances of having a urologist to place stents before, for instance, let's say they're doing a colon resection for chronic sigmoid diverticulitis, a case where you would want a ureteral stent, there's no chance that they're going to have access to urology so

Jacob Steffen (08:40):

They

Dr. Mel Johnson (08:40):

Can get several repetitions and get signed off on cysto and stents from the standpoint of ENT, our ENT physicians work with them on thyroid and parathyroid surgery, which are well within the purview of a rural general surgeon tracheostomies. And then even we have an upcoming graduate. She's currently a PGY four planning to return to her small hometown in very northern Minnesota, and she would have the opportunity to do tonsils and ear tubes as well because there's absolutely no access to ENT in her region. Minnesota,

Dr. Randy Lehman (09:15):

I have one specific question. I know that Gunderson just merged with Bellin and is forming Amplify Health. Does that make any changes for your program?

Dr. Mel Johnson (09:23):

Great question, and it really has not impacted it at all. Bellin Health System is located in Green Bay, so across the state from us, and they do not have a general surgery residency program and they don't intend to have one. So it really is more of a, it's a merger of the healthcare systems and the insurance product, but really not impactful on our residency. We happen to have some graduates that work at Bellin Health System, and so we have been in talks about the possibility of having our residents do elective rotations out there if they would like to see what a more urban general surgery practice looks like, because Green Bay, again would be considered urban.

Dr. Randy Lehman (10:02):

Very good. So my quick bent on training a rural surgeon is a lot of times people, well, there's a lot of different ways you can do it. One is you can just train 'em in a regular program and they can have a one month rotation to a rural place to be an exposure thing. That's fine. There's nothing wrong with that, but this whole immersion into training a person to basically fix the five, be ready to operate when you're done, be able to do the breadth of general surgery and then some. That's kind of what I think is, and the no competing residence, but being at a place that is a tertiary referral center is kind of like the holy grail to training a surgeon well, and so if you are a medical student listening to this, that's my bent on it. I think that Gunnerson obviously is a great program and we'll talk about a few more things very specific. So I think Jacob, if you had a few questions from a medical student's perspective, we should just shift and go to them now.

Jacob Steffen (11:05):

Yeah, sure. So I have a couple of basic medical school questions that probably everybody wants to know, and then as we go, I can get a little bit more specific. But my first question is what is the number one thing that you want prospective medical students to know about your program?

Dr. Mel Johnson (11:23):

I would expect them to absolutely know that our passion and our mission is to train broad general surgeons, many of whom elect to go into global and rural surgery practice. That is our mission. I certainly six through hundreds of applications every year. I would say one of my frustrations is that because we are a community-based program is that sometimes some applicants see us as a safety program, meaning, well, if I don't get into Harvard, then I'll go to Gunderson. We're not the same and I have nothing. I love the people at Harvard and Yale and Duke and all of those places, but we train a very different product. So I certainly am expecting that all medical students will have researched our program and know exactly who we are. I would never consider us a safety program. If I can give that message out to the medical students.

(12:25):

I get hundreds of applications, I select 40 people to interview, and then I select four people for my program. And out of this year's application class, I got four out of my top seven choices. So if you're thinking of using us as a safety program, I would probably apply somewhere else. And Jacob, one of the things I look for the most, especially within the personal statement of the applicant's Aris application, would be a passion for general surgery, a passion for rural or global surgery, a passion for working with underserved patients. I also look for academic all stars. And the great news is there are just absolutely fantastic applicants out there that bring together the entire package deal. So if med students want to know what they need to bring to the table, that would be it. But again, and very frank, when I do interviews, if an applicant says, well, I really want to be a liver transplant surgeon, you shouldn't come to my program. We don't do transplant at Gunderson at all, and that's okay. There's incredible transplant programs that you can train at throughout the nation. So we're not the best program for everyone.

(13:46):

We're very truthful about what we train and what our goals are, and that is truly what I'm looking for in applicants. If I can give any advice to you yourself, are entering your fourth year medical school, I be honest, be honest with who you are, be honest with what you want to be when you grow up. And I am honest a hundred percent about what we train and what I'm looking for. If we're all honest and we stop trying to gain the system, then the match can be a really, really beautiful thing. So I would say just bring absolute honesty into your fourth year as you contemplate where you would like to train.

Dr. Randy Lehman (14:26):

This is why Dr. Johnson's a perfect guest because she not only answered your question, but she answered the second question on your list, the third question on your list and the fourth question on your list already. So that's perfect. And you didn't even have to say the question. Nice job.

Dr. Mel Johnson (14:42):

He gave me the questions ahead of time, so I may or may not have

Dr. Randy Lehman (14:45):

Prepared

Dr. Mel Johnson (14:46):

A bit.

Dr. Randy Lehman (14:46):

Oh, okay. Okay, I see.

Jacob Steffen (14:49):

Yeah, so I think that's great. Great. And it's definitely something for us medical students to think about because right now I'm starting to think about community versus academic and what that means and how the training programs differ. I think a year or two years ago when I started med school, that wasn't really even on my radar, not something that you think about so much, but it is a very important distinction because there's a different training program that fits everybody's needs, and there's just a lot of differences between not only community programs but within different community programs. There's even differences between what people are doing because there's community programs in the big city that are doing all of the big transplants and all that stuff. So there's just a wide array. So I would encourage my fellow classmates to start thinking about what you want to do with your life. So my next question for you is does your program do any didactics and what do your didactics look like if you do?

Dr. Mel Johnson (15:51):

Yes, we use the same didactic program as approximately 96% of general surgery residency programs across the nation, and that's called the score curriculum. So that really has become, I would say the gold standard for curricula for general surgery programs. Now we have a dedicated time set aside, so every Wednesday afternoon my residents spend two hours in didactic conference and there is a rotating list of topics that they cover scores designed to cover all of the general surgery topics in a two year span. And score is great, it's available online, plus they create lectures out of it. You can create quizzes, you can do customized work with it, but it really is a fantastic system and I do not work for or get paid by score, but I would say that's what you'll find in most programs. In addition to that, we also have a weekly morbidity and mortality conference.

(16:48):

We have monthly grand rounds. We have a monthly journal club where we get together typically at an attending's home in the E thing and discuss three or four pertinent journal articles, other elements. We have an academic day each year at Gunderson where many of the residents will present the work that they may have already presented at the regional or national stage. And we also have a research requirement. So for all of our graduates, they must have presented regionally or nationally twice and also published twice in a peer reviewed journal. We don't have dedicated research years. So as a future applicant, that's something you'll want to look for. If research, especially the basic science research is something that's important to you and you think you'd like to add a couple of years onto your residency, then you want to make sure that you look for programs that offer that. We do not offer dedicated research years. We just have our research requirement. But I would say many of our research projects tend to be more clinically based because again, we don't have those dedicated years that you would need to spend in a basic science lab. We do allow our residents to take elective research months. So for instance, if they need to really buckle down and write some manuscripts, they can take an elective month to work on that.

Jacob Steffen (18:05):

Yeah, that's great. I've never heard of score before, so that's probably a really good thing for a medical student to do a little bit of research on and what that looks like for different programs. You said it's two years, so do you start that intern year and then complete that your second year?

Dr. Mel Johnson (18:23):

It's just, it's a rolling curriculum, so it just covers really all the topics within general surgery within two years. So we just

Jacob Steffen (18:32):

Set

Dr. Mel Johnson (18:32):

Out our curriculum for that two years. So you'll see it, everyone will see it at least twice within your five years, but those topics just keep rolling through, so it doesn't really matter which one you start out at. There's not really a beginning and an end. There's just a huge volume of information that you've got to learn as a general surgery resident. And for you as an MS four, just so you know, score launched a curriculum for incoming interns as well. So as soon as we, and we have bought into that also with our program, so as soon as we match someone in March, we are able to get them into their score account and start utilizing those resources. And there's a prep course essentially for new surgery interns. So it really is a comprehensive program.

Jacob Steffen (19:19):

So I know that a hot topic among medical students applying through ERA a s is signaling, so can you explain to us how signaling works and what your program looks for?

Dr. Mel Johnson (19:30):

Absolutely. I sit on an A PDS committee on resident recruitment, and part of that is we actually set the number of signals that any given applying that of the students can use in that process. So for those that don't know what signaling is, each residency program across the United States, each specialty has a certain number of signals that an applicant can give as they're applying to programs. A signal I would describe as like a golden ticket. It's a way of indicating to a certain number of programs, you are my favorite program. So it really doesn't give us any more information than that. We just know because within general surgery, our number of signals currently is 15, that number is not going to change. So it's important for upcoming applicants to know that as well. For right now we're sticking with 15. There are lots of conversations nationwide about how to use those signals and should you game your signals, you if you rotate at program, then do you not need to signal them if you apply at your home med school program?

(20:37):

Do you not need to signal them? The clear message we give from AP DS is that you should signal every program that is one of your top 15 programs. Do not use it to try to game the system. This goes back to honesty within that application process. So you need to decide after you come up with your entire list of places to apply, which are your top 15. And again, don't try to game it. The system doesn't work that way. We're looking for honesty and frankly, I've got to tell you, in the last two years since we moved to 15 signals, I get approximately 120 applications that have signaled my program. I only do 40 interviews so far and away. If you want an interview at my program, you essentially have to list me in your top 15. I'm not saying it's impossible for me to not go outside of that, but when there's that many people that are that interested in my program, why would I look at hundreds of others where I don't land in their top 15? And I would say that's,

Dr. Randy Lehman (21:44):

Let me ask you a follow up to that. So a signaling is a thing within Aras?

Dr. Mel Johnson (21:48):

Correct.

Dr. Randy Lehman (21:49):

And it didn't exist apparently when I was applying.

Dr. Mel Johnson (21:52):

That is correct. It's

Dr. Randy Lehman (21:53):

Only

Dr. Mel Johnson (21:54):

For four years. We used five signals for the first two years and that really wasn't enough. Like orthopedics uses 30, we landed on 15 for the past two years, and that seems to be the number that gives the programs many more signals than they have interviews available. So it's not impossible to match it a program that you have not signaled, but it is definitely more difficult.

Dr. Randy Lehman (22:20):

So you put the signal in before you interview?

Dr. Mel Johnson (22:22):

Correct.

Dr. Randy Lehman (22:24):

So it helps to get you an interview basically.

Dr. Mel Johnson (22:26):

Correct. And there are talks, we just had these talks at A PDS of should we have post-interview signaling where you can again send another signal afterwards because maybe your list has really changed after you've interviewed. There are some programs like ob, GYN uses gold, silver, and bronze signals. So back in my day, if you applied to a program that was your signal to the program that you liked them,

Dr. Randy Lehman (22:53):

But now people are applying to what? 50 programs? I mean Jacob, how many programs do you think?

Jacob Steffen (22:58):

Yeah, I believe the average from last year was 70 programs in that area.

Dr. Randy Lehman (23:02):

Right?

Dr. Mel Johnson (23:04):

It's gotten and part of the signaling and the reason that we have, we've continued with it, is it decreasing the number of applications that people are putting out there because they're realizing if they really are not in one of my top programs, my chance of an interview is less. That's a good thing for applicants. Applicants, I'd say post COVID we're applying to over a hundred programs and they have to pay for all of those applications.

Jacob Steffen (23:28):

So

Dr. Mel Johnson (23:28):

It was just flooding the market. Your top tier people with the highest scores were taking up all the interview slots because there were just so many applications on the market. So I would say use your signals very truthfully and now we'll help you the most.

Dr. Randy Lehman (23:47):

Great summary.

Jacob Steffen (23:48):

Okay. So my next question for you is what is the average number of cases that an intern at your program completes and how does the case volume change over the years?

Dr. Randy Lehman (23:59):

And one more thing on that too, also maybe total volumes at the end.

Dr. Mel Johnson (24:03):

Okay, excellent. Average volume for a graduating PGY five from our core REM is well over 1100. I would say 1100 is sort of the low number I'd say out of the past couple of years. A high number I've seen is in the high 13 hundreds for total cases. When you come in as an intern, the A-C-G-M-E has built this into the case log because there were some issues nationally with interns and second year residents really not getting into the operating room. They'll being used more for floor work. So they actually set a minimum. So you have to be in the operating room a minimum of 250 times in the first and second year, and that's a requirement. It's built into the case log for the A-C-G-M-E, our typical numbers at the end of second year are around 550 to 600 for individual cases spent in the operating room.

(24:56):

So most of our interns actually make that 250 mark by the end of intern year. Now that doesn't mean they've been the operating surgeon for all of those cases. That counts everything. So if you come in as a first assistant, like let's say you scrub a big pancreas case, you're obviously not the one doing the cases an intern, but if you're there, you're assisting, you're doing courts of it, you're the first assistant. The other cases that count would be called surgeon junior. So let's say you come into the operating room, do an umbilical for knee repair with me, and you do all critical components of the procedure that would be called Surgeon Junior. So if you take first assistant plus surgeon junior by the A-C-G-M-E, it must be 250 by the end of the second year. And again, we average over 550.

Jacob Steffen (25:43):

Yeah, thank you. I appreciate that. Do you have any general advice for any medical students that are interested in rural surgery?

Dr. Mel Johnson (25:53):

Yes, there are many things you can do to investigate that path even before you get to the application process. I would say number one, I'm putting in a shameless plug for the North American Rural Surgical Society. It is the only rural surgical society in the United States, and I do happen to be the president of the head currently preach.

Dr. Randy Lehman (26:12):

But

Dr. Mel Johnson (26:12):

It is a great opportunity if you have an interest in rural surgery, I would encourage you through your med school to even do research in rural surgery. And North American Rural Surgical Society is a great forum to present your research and it also gives you a pathway to potentially publishing in the American surgeon, which is the dedicated journal of, I'll call it nars so I don't have to keep saying North American Rural Surgical Society. So I would say membership in NARS is key. If you come to the annual meeting, you'll have access to all of really the thought leaders in the United States in rural surgery, and you'll be sitting down and having dinner with them. People like Dr. Tyler Hughes, he's sort of like the father of rural surgery in the United States. Champions for rural surgery like Dr. Mary Fett who's a pediatric surgeon, but who is really pushing nationally to return pediatric surgical care to the rural setting. That's just an example. There are those types of leaders at every single table. So I encourage you to join, check out our website, and again, really dive into if you can do some rural surgery research in your own program,

(27:26):

That would be great. That looks great on your application as well. Even if you're just doing a project, don't feel like you have to get a publication out of it, but just become involved. As

Dr. Randy Lehman (27:36):

I'm kind of thinking about this, I'm thinking about myself and what really helped me the most. And I think it was finding a mentor.

Dr. Mel Johnson (27:45):

Yes.

Dr. Randy Lehman (27:46):

Were you going to say that?

Dr. Mel Johnson (27:48):

I wasn't, but I'm glad you brought that up. I was thinking about though, as I talked about getting into rural surgery research, is that if you find your rural surgery mentor, that is how you make those things happen. So if you can go and even if you have a rural rotation of any kind within your medical school program, you can reach out to them because you also could do, if there's not research available in rural surgery, you could also do anything within rural medicine. And I would say most medical schools have some sort of rural or underserved rotation. So I think finding a mentor is absolutely key. And then start investigating programs. Where do you look? I wish I could say that there's a huge clearing house where you could just go to one website and I would show you every rural surgery training program in the us and that is on my very short bucket list.

(28:38):

And I sit on an a CS committee called the Rural Surgery Collaborative, and that is probably our number one push over the next five years is to try to create a database of rural surgery training programs. It's hard to define a rural surgery training program because Randy, as you mentioned earlier, it might just be a one month rotation. It might be dedicated months in a rural surgery location, or you might be one of the newer programs out of West Virginia, which I can't think of the name off the top of my head, but they are actually embedded within a rural setting. So their entire program is located in a very small town. Many,

Dr. Randy Lehman (29:19):

I think you're talking about Marshall, right?

Dr. Mel Johnson (29:20):

Yes. Thank you. There can be many different ways to train someone in rural surgery, and I think that's why it's so hard to find that information as an applicant right now. So places you can look is the A CS Rural Surgery Advisory Council. They have a website through the American College of Surgeons that gives a partial list, Frida, which is a database available to medical students. You can tease out some of that information there. We have partner programs through North American Rural Surgical Society. So those partners are listed on our website, but probably the number one place you need to look to really see what a program means by having a rural surgery training program is each individual program's website, which that's a lot to do. There's over 370 training programs in the US again someday. My dream is there will be one website you can go to for that information. And then not only will we track those programs, but we'll have the outcomes of all of those programs as well. So you can see are they actually producing rural surgeons in their graduates? But that's a dream, but we're pushing for that over the next five years.

Dr. Randy Lehman (30:28):

Nice. Yeah, that's something that we just personally had to go through the challenge of doing because we're trying to find all the rural surgery programs to offer them an opportunity to share on the podcast. So we feel that same pain. And if you can make some progress there, that would be awesome. And just thank you again for taking all this time. One last question is where should a interested applicant go to learn more or to apply to your program?

Dr. Mel Johnson (30:52):

To learn more about our program, please go to our website. So if you just type in Gunderson Foundation General Surgery Residency program, we have a pretty comprehensive website that shows you things like block schedules, it shows you even videos of lacrosse. So if you have never been to lacrosse Wisconsin, you can get an idea of our community. And it really talks about the philosophy of our program too, having just come back from this national meeting. It sounds like a lot of med students go to Reddit. I certainly am not putting out any content on Reddit, so take that for what it is. But I actually sat through a seminar yesterday talking about how to make your program more visible to the Gen Z generation. So it looks like I've got some work to do because I am a Gen Xer, so I need to get a bit more savvy with my social media. But I would say the most reliable place right now would be each individual website.

Dr. Randy Lehman (31:52):

Perfect. Well, thanks again for taking all this time. I really appreciate it. Everything that you're doing up there, everything you're doing nationally and just for coming back again and being on the show, it's always great to talk to you.

Dr. Mel Johnson (32:03):

Thanks to both of you.

Dr. Randy Lehman (32:05):

I'm here again with medical student Jacob Stefan, and today we welcome program director from West Virginia in Morgantown, Dr. Lauren DOAs. Thank you for joining us. Thanks

Dr. Lauren Dudas (32:16):

For having me. I'm excited to talk about our program.

Dr. Randy Lehman (32:19):

So Dr. DOAs is a program director for four years at WVU and she enjoys working with the residents. She completed a critical care fellowship and her program is one of the programs that doesn't necessarily have say, a full dedicated year to rural surgery or a rural surgery track necessarily, but has a keen interest in supporting the rural surgery delivery in West Virginia in particular. And so therefore is also interested in training a broadly based, highly skilled general surgeon that can help meet those needs. And so with that sort of introduction, perhaps you could give us just a more detailed overview of what your program would offer to a person considering training as a rural surgeon.

Dr. Lauren Dudas (33:06):

Sure. So we're in Morgantown, West Virginia and our five-year academic program with a focus on serving the population of West Virginia. So we really try to toe the line between supporting our residents that want to go into academic practice and fellowship training after residency, or those who want to go directly into general surgery practice and often in remote or rural or resource limited locations. We have a focus really on training, really well-rounded general surgeons with a broad exposure to all types of surgery cases and a one month surgery rotation at Jefferson Medical Center, which is a rural location in West Virginia where they follow one surgeon in kind of an apprenticeship model. Beyond that, for our residents that want to go into general surgery practice, I have elective set up in urology or gynecology, even podiatry, we try to get some extra exposure to gi. So those residents are fully prepared to be potentially even the only surgeon in their location or have limited practice.

Dr. Randy Lehman (34:06):

Have you had any residents that graduated your program and did anything sort of outside of what is the 2026 general surgery core, if you will?

Dr. Lauren Dudas (34:14):

I don't think outside the core, but we do have some that have to push the boundaries of training because they might not have another surgeon or another hospital or other limited resources, like I said, for quite a distance.

Dr. Randy Lehman (34:29):

So for those subspecialty things, it's like would a resident graduate putting their own stents up for colon surgery, for example?

Dr. Lauren Dudas (34:37):

Yeah, that was one of our focuses. So I worked with our urology group to figure out what would be most beneficial for the residents after training, and they figured if they can do a hundred cystos during their experience with the urologist, that they would give 'em a certificate so they can get privileges when they go on to practice that they can do their own stents.

Dr. Randy Lehman (34:55):

Have you had any other specialties like that with any other certificates?

Dr. Lauren Dudas (34:58):

No, we haven't seen the need really for privileges. Mostly when residents have gone to apply for privileges after training, they haven't had any difficulty was the biggest robotic surgery would be the other one. But all of our residents are able to train and get their robotic certificate if they want at the end of training.

Dr. Randy Lehman (35:14):

This specific thing I'm thinking of would be C-sections. Anybody ever interested in that or would you be able to accommodate that? I

Dr. Lauren Dudas (35:21):

Think we would be able to accommodate it, but we have not had anyone who's had the need. But our gynecologists do ask me specifically if there's a need for that. I think our hospital has grown really rapidly over the past couple of years, but we still have a relatively community feel as far as everyone knowing each other. And so that's made it really easy to have that flexibility for the residency training.

Dr. Randy Lehman (35:41):

And I came down there and interviewed at Morgantown, and that is a beautiful place of the country. What's the lake called? That's in your

Dr. Lauren Dudas (35:47):

Cheat lake? Yes,

Dr. Randy Lehman (35:48):

Man, that thing I was just, and then I had to go to Rochester, Minnesota of all places. It's like, but you got to make these decisions in your life,

Dr. Lauren Dudas (35:58):

Right?

Dr. Randy Lehman (35:59):

So tell me just a little bit more about that one month rotation.

Dr. Lauren Dudas (36:03):

Sure. So they are about an hour and a half actually outside of dc, but hidden in a little area of West Virginia that has a critical access hospital. So critical access hospital. The length of stay is supposed to be limited to four days. We have family medicine providers that provide most of the medical care and we actually help consult if they need any additional higher level care with their family medical providers. But really there's just a few surgeons at the location and they really practice anything from submandibular abscesses. They do have access to a robot and do robotic colectomies, do the ovarian torsion cases. So really full spectrum general surgery. Our residents take home call at the same time as the surgeon that they follow. And then the surgeon there has been really flexible in trying to see patients in the clinic and then book them during the same month so our residents can get the full spectrum of care for that patient.

Dr. Randy Lehman (37:01):

Nice. Can I ask you about a specific case?

Dr. Lauren Dudas (37:03):

Sure.

Dr. Randy Lehman (37:05):

This past, actually, Tuesday two days ago I had a case, I'm in a critical access setting. I'm the only surgeon there. I have a patient came through the er, happened to be while we were there, otherwise we don't necessarily do call there who had appendicitis on CT scan.

Jacob Steffen (37:25):

They

Dr. Randy Lehman (37:25):

Had right lower quad pain, but it was a little more generalized than maybe you would expect, and it was kind of subtle and appendix was dilated and it was called some free fluid and some perineal training. And it was CT suspicious for early acute appendicitis. But I had my spidey sense up as I went into it. Well, I went in and the other thing is three months prior she had a RUI gastric bypass, had had 60 pounds of weight loss. So I went in and did lap api, but the appendix didn't. It was a little dilated and there were multiple little fecal lifts visible, but it wasn't like fi exudate really didn't look that inflamed. The appendix was white in color rather than being,

(38:05):

But there was a fair amount of fluid that was sero kind of dark, no clot or anything, and almost brownish. And that was mostly in the pelvis. So I took the appendix out and then I just explored the rest of the abdomen. The patient had had a hysterectomy for prolapse in the remote past couple decades prior, and supposedly they'd only left one ovary, but it looked like maybe it had been sort of manipulated because it, it looked like two almost, but they were both over on the left side and the one part of the ovary had a cyst and there's fluid all around it, but it didn't see a rupture or a hole in the cyst or anything. And then there were several brown areas over the ovary that I thought could possibly be endometriosis, but there were no implants in the pelvis anywhere else that I saw in.

(39:11):

The other thing in my mind for differential was maybe it's blood product from her surgery three months ago that had kind of settled down there and it's just kind of staining it still, but there really wasn't anywhere else. And so I kind of thought, well, maybe this is going to be endometriosis and maybe this, and the cyst was kind of dark, but it didn't really look like a textbook chocolate cyst. And maybe I'll stop my story there and if you want, you could tell me what I should do or I can just continue and tell you what I did

Dr. Lauren Dudas (39:46):

Well, I would take out the appendix regardless in there for that. And it's dilated and it has append. And then if you're able to send the fluid for sample, that would probably be my plan. Tell me what you did.

Dr. Randy Lehman (40:01):

What I ended up doing is the cyst was kind of exophytic off the ovary and I just wedged it off with the LigaSure and I sent that for path and I took every little spot that was brown that was, and I just picked it off with a grasper. So as far as volume of the ovary, much less than 10% removed. And then I just sent it. And then PATH is still pending. Patient did discharge the next day and she said she felt a lot better. Her pain was down to two out of 10, but she came in, it was 10 out of 10 and I guess I'll have to close the loop on a future episode. We'll let the path actually came back as, but to me it was if it was some endometrial tissue still there since when she had her hysterectomy, who knows.

(40:46):

The other thing that I've seen several times since I've been out is endometriomas in the abdominal wall that come to me complaint like it's a hernia, but it turns out you talk to the patient and it comes and goes every 28 days and it really hurts. But then other times it doesn't hurt at all and I've taken out several of them, so I just use their scar mostly it's in a C-section scar. I just open it up, go down, cut it out, and try to make sure I get all the way around it and it's usually palpable. So that's kind an interesting rural surgery thing that maybe if you were at WVU, you'd probably call an O OB GYN, but I would call A-B-G-Y-N, but I don't one to call.

Dr. Lauren Dudas (41:23):

I do tell my residents, don't be afraid of ovaries with the LigaSure. You can do what you need to do.

Dr. Randy Lehman (41:27):

Yeah, the LigaSure is the way to go and harmonic's. Okay too. Okay, great. I easily distracted here. So I just had a couple more questions then we can let Jacob ask maybe one or two, but I just want to know what kind of resident thrives in your program?

Dr. Lauren Dudas (41:44):

I really look for someone who is prepared to be an adult learner. I think medical training does have a bit of handholding nowadays, so I'm looking for someone who has been proactive in getting themselves engaged in different experiences or research opportunities and is comfortable with what they want to do in the future. Five years is a lot of time. You do have a lot of time to figure out exactly what you want to do, but I think I focus on those with, like I said, some experience already and grit. I think that's important for any surgery resident.

Dr. Randy Lehman (42:20):

Nice. So you like that book that Angela Duckworth book?

Dr. Lauren Dudas (42:22):

It's on my bookshelf.

Dr. Randy Lehman (42:23):

There you go. Yeah, that's a good book. Alright, I love it. Jacob, you have any questions for us?

Jacob Steffen (42:29):

Yeah, I have a couple of questions from a medical student perspective. So my first question is what would be your number one thing that you wish you could tell all medical students that are applying to your program

Dr. Lauren Dudas (42:41):

Be genuine in your interviews? We actually just had a resident student forum at our state American College of Surgery meeting and I said the whole point of doing interviews is so that the program can find a good fit for them, but you also want to find a good fit for yourself. So that's going to give you the best success during residency is if it's a place where you fit well. And everyone always says that they're looking for a good fit, but I think there are a lot of students that get into the interview and they're trying to just sell themselves, but sell your true self, otherwise you're going to set yourself up for failure.

Jacob Steffen (43:16):

Yeah, that's a really good point. And you're kind of the second person now that I've told us a similar story where out of

Dr. Randy Lehman (43:23):

Two.

Jacob Steffen (43:24):

Yeah, so the first person, Dr. Johnson told us not to kind of lie in your interview or when you're communicating because programs communicate with each other. So that's a good little tidbit to know. So yeah, my next question would be what qualities in an applicant, you kind of touched on this a little bit already, but what qualities in an applicant do you think that stand out to you when you see them?

Dr. Lauren Dudas (43:50):

So I don't want to put my interview questions out there completely, but what I'm looking for is am my questions really is someone who can think in the moment and the focus is on patient care and how they would deal with different situations. So I guess my qualities are a little bit of problem solving, but also underlying, I'm really trying to figure out what are their genuine focuses. I also ask if people have been in the hospital at night because there are a lot of programs where people have not seen the hospital at night because they don't have to do any night call or night float or anything. And as a surgeon, especially as a trauma surgeon, we're in the hospital a lot at night. So I do think if you've never seen the hospital at night and you're applying for surgery residency, you should probably go do a 24 hour shift somewhere.

Jacob Steffen (44:38):

Yeah, I like that answer. I don't think anybody has told me about the night thing and it's kind of interesting to think about. I think there's a lot more, at least at my program, there's a lot more night things happening during fourth year, so it's something to watch out for. What is the average number of cases that an intern completes at your program and how does that evolve over the next four years after that?

Dr. Lauren Dudas (45:01):

So I just did our case numbers. Right now most of our interns are at about 50 for major cases. The A-C-G-M-E requirement is that they do 250 procedures by the end of second year. So if you count bedside procedures, it's quite a bit higher. But our residents right now have about 50 major cases that they can count. Most of them will get to probably between 60 on the higher end, 70, and then by second year, that number,

Dr. Randy Lehman (45:28):

You brought it up,

Dr. Lauren Dudas (45:29):

My husband is going to love that. And then by second year, that number has almost tripled. So they're in the operating room a lot more as a second year, and then third year they'll probably put on about another a hundred cases. Our residents graduate with 1200 to 1500 cases, so we're in the process of trying to expand, but we have pretty high volumes as far as autonomy or what they're actually doing in those cases. There's a lot of services that we worked. We transition to a night float system so that the residents don't have post-call days. So for all of our elective scheduled services, they're there Monday through Friday and we try to get off days on the weekends. So that's helped increase our case volume a little bit. And then even at night float, sometimes the interns can get in, but lots of times they're busy managing floor stuff and consults.

Dr. Randy Lehman (46:20):

I like to jump in with a couple questions. How much penetrating trauma do you get in Morgantown?

Dr. Lauren Dudas (46:24):

So I think our number is probably between 10 and 15%. It's pretty low, but it has increased in the past couple of years.

Dr. Randy Lehman (46:31):

And then what category of cases is hardest for your residents to get their numbers in?

Dr. Lauren Dudas (46:41):

It actually, surprisingly used to be appendicitis because we had so many rural hospitals that they would do the appies but then they wouldn't do some of the other stuff. But that's not the case. Actually, that's changed right now. I would say the open thoracic numbers are a little more challenging, but we haven't had anyone struggle to actually get their case numbers. It's just that those are the cases I'll be tracking as a PGY five

Dr. Randy Lehman (47:07):

And liver and pancreas, no problem,

Dr. Lauren Dudas (47:09):

No problem. We do lots of liver and pancreas.

Dr. Randy Lehman (47:12):

This is a classic sort of academic case mix and everything. That's funny that you say that about the appendix, but you don't need to stress about it. If you can do an extended right hepatectomy, you can do an appendix. So, all right. Did you have any other questions, Jacob, or,

Jacob Steffen (47:29):

Yeah. So my last question for you would be where can a medical student go to learn more about your program?

Dr. Lauren Dudas (47:35):

Our website, I take pride in keeping our website really up to date. It shows our schedule, the resident schedule right on there. Our curriculum, it emphasizes our cadaver training, which is I think one of the highlights of our program. It's built right into our curriculum. Our residents do it every single year, twice a year, but our website's pretty up to date. We do have two residents that try to keep our social media up to date, but since I'm old, I can't do that part. But you'll see some pictures of our residents doing things outside the hospital on there.

Dr. Randy Lehman (48:02):

Nice. We'll put a link to that in the show notes. It looks like, do you have an Instagram too?

Dr. Lauren Dudas (48:07):

We do.

Dr. Randy Lehman (48:09):

Nice.

Dr. Lauren Dudas (48:10):

You said

Dr. Randy Lehman (48:10):

My at WVU surgery for your Instagram handle, and then you even have some good general surgery, WVU YouTubes and things. Great resources. Awesome. Is there any final thing that if you wanted to highlight something about your program that you think is something everybody should know or maybe even a thing that people misunderstand about your program?

Dr. Lauren Dudas (48:35):

Sometimes West Virginia, I can get forgotten. It's just like a state in the middle. Like I mentioned in the beginning. I think we have residents that are successful going into really competitive academic fellowships and practices thereafter, and also directly into general surgery practice. So I as program director, really focus on trying to make sure whatever your goal is, that we can meet that need. So I think that's something to consider. Just don't forget about us here in Morgantown.

Dr. Randy Lehman (49:01):

Very nice. Yeah, it's a wonderful, wonderful place. And if you like college football

Dr. Lauren Dudas (49:07):

That's right.

Dr. Randy Lehman (49:09):

I love you have that view from your hospital right down into the football stadium. It's so cool. Yeah. And plus Jerry West is from West Virginia. That's

Dr. Lauren Dudas (49:16):

Right. Amazing.

Dr. Randy Lehman (49:17):

They

Dr. Lauren Dudas (49:18):

Will win again.

Dr. Randy Lehman (49:21):

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