EPISODE 70

Training Miniseries 3: Dr. Frank Wood and Dr. Barclay Stewart

Episode Transcript

Dr. Randy Lehman (00:00):

Welcome back, listener to the Rural American Surgeon Podcast. I'm your host, Dr. Randy Lehman. I'm very excited today. This is part of our miniseries about training a rural surgeon where we're interviewing program directors from across the United States that have a specific track or an interest in training rural surgeons. In today we have a guest, Frank Wood, he's an assistant professor of surgery. He's the assistant program director for a newly formed general surgery rural track at University of Oklahoma, and he's a trauma surgeon, but he's actually from a small town in rural Oklahoma, which is Lone Grove. So this is all very near and dear to his heart and he's basically been the driver for this new track. So we are so honored and thankful that you've taken the time to join us today. Thanks, Dr. Wood.

Dr. Frank Wood (00:50):

Thanks Dr. Lehman. I appreciate the opportunity to come here and speak.

Dr. Randy Lehman (00:55):

Yeah, so tell us about this. So why does Oklahoma need a rural surgery track?

Dr. Frank Wood (01:02):

So our biggest opportunity is about two thirds of our state's population resides in a rural community. So we're still actually an agrarian state at this point in time, and we have actually lack of physicians throughout the entire state of Oklahoma, even some of our urban areas. We have a lack of surgeons, but it's especially hard hit in our rural areas. And so that's one of the reasons. Several years ago, the Department of Surgery looked around, realized that honestly a large number of our rural surgeons are trained at the University of Oklahoma, but as those are getting older and starting to retire, we should really focus on and trying to work to place surgeons back in those small communities to keep them open and operating.

Dr. Randy Lehman (01:48):

Yeah, that's a recurrent driver. Hear that a lot. And now do you have one of the newest programs in the nation? And so tell me what is different for this resident that's going to come through your rural surgery track? How does it look different than your regular program?

Dr. Frank Wood (02:02):

Difference from a regular program is that they will spend 18 months in the rural environment. They spend nine months, or excuse me, six months as a third year resident in Lawton, Oklahoma at Comanche County Memorial Health System. And then they spend as a fifth year their entire fifth year. So a total once they complete their general surgery residency of 18 months at that location.

Dr. Randy Lehman (02:29):

And I see that there's also training in subspecialty experienced orthopedics, OB, GYN, urology, endoscopy. You have a great explanation. We'll put the link to your page in our show notes for the listener if you want to join and see more. But how is the resite going to get that exposure?

Dr. Frank Wood (02:46):

So when they're down in Lawton rotating with, there's a faculty of six surgeons there at that institution, the endoscopy experience that you highlighted is primarily done with the general surgeons that are there. There's also an OB grooves. There's orthopedics in that hospital as well. So what we do is we have our rural residents take the opportunity to go to cases in the other areas such as urology and so forth in order to gain that experience and exposure. We've specifically decided that we wanted to have that exposure at Lawton because there's no other surgical residencies there, so there's no competition as opposed to the hypothetical scenario of having our residents rotate on obstetrics or urology here, well then they might be competing with other trainees and we wanted to avoid that. And also it allows to broaden the experience of our residents when they're in the rural community about to other surgeons as well, people they potentially might be working with in the future.

Dr. Randy Lehman (03:48):

Where do you expect the resident to live during the 18 months? In Lawton?

Dr. Frank Wood (03:52):

The housing is provided by the hospital system there. So they have an apartment that they rent out and it is just for our resident that they have has dining capabilities, washers, dryers and so forth. We've gone through several iterations of that. We responded to the residence before we were times, we were originally at a previous location and then decided to transition to something new based on resident feedback. We're very receptive to those things and I think that the hospital system and Lawton is equally as receptive. We appreciate that.

Dr. Randy Lehman (04:25):

Yeah. Now I've heard in University of Cincinnati back in the day, okay, my mentor, he's in his eighties, he told me, I kid you not that they were not allowed to, I don't think even date when they were a residence and they definitely weren't allowed to be married. And on the last day of residency or when you graduate your chief from your seven year program and all this stuff, you were taken to the Cincinnati debutante ball and essentially set up all right, but things are changed. So you got enough room at that housing for a small family or something?

Dr. Frank Wood (05:02):

We do actually about 50% of our residents are married and amongst those, the 50% are married, have children as well. So about a quarter of our residency. And that tends to be more as you spread throughout the upper levels. And there have been times where because in Lawton, not only do our rural residents go down there, but our urban residents rotate through for a month each so that they could each get exposure to a rural environment. And with that, because of on the weekends if they're on call or overnights, if they have family that otherwise doesn't have commitments, there have been times where they take their family and their children with them down there.

Dr. Randy Lehman (05:43):

Yeah. Yeah, that's great. I'm not sure if you really aware of this, but I trained in the rural surgery track at Mayo Clinic and I actually rotated through Eau Claire Mankato lacrosse, Owatonna Red Wing. So I did rotation at a lot of these different sites and that housing, I mean you just have to have the right person. You have to know going into it, what you're signing up for, what you're describing is actually a lot more stable than what we did. I mean, I had actually two kids during residency and my wife was super flexible and awesome, and so we just kind of considered it an experience and it sure was.

Dr. Frank Wood (06:18):

Yeah. That was one of the things we specifically wanted to be in tune with was trying to group this amount of time together so that the resident isn't constantly moving back and forth long in Oklahoma City are about 90 miles apart. So it is theoretically feasible if you're not on call overnight that you could get up in the morning and drive in or something. And I have had one of our rural residents actually do that. He tends to live on the southern side of the metropolitan area. We wanted to not have them moving so frequently it would disrupt their family life as well. And you mentioned now the other sites we are looking at, so we may have to consider this differently, but we are looking at potentially expanding to three other sites and maybe even expanding the residency, the numbers of residents in those spots. So meaning right now we have six, what I would say traditional urban residents and one rural track resident in the long-term, five to 10 year plan, we like to move that closer to two rural residents and six urban or categorical residents.

Dr. Randy Lehman (07:22):

Yeah. I obviously personally strongly support you doing that because we need rural surgeons across the United States. And the other thing is if you get the opportunity to go to more than one hospital as a resident, there is a lot that I learned because you see that there isn't a right or wrong way to do a lot of these things. I mean, there are wrong ways, but there are multiple wrong ways and there's also multiple right ways. Absolutely. Then when you get to your hospital and they have a certain piece of equipment, I mean really once I got to my hospitals, I mean most of the equipment I had seen before because, but if I would've stayed all at Mayo, Rochester, I wouldn't have. But since I had rotated around and saw all these different things, it added to my training a little bit. But Jacob's got some questions for you. Why don't we let you take it away, Jacob?

Jacob Steffen (08:08):

Yeah, sure. First of all, thank you Dr. Wood for coming on to talk to us. We appreciate it and it's nice to meet you.

Dr. Frank Wood (08:14):

It's nice to meet you as well, Jacob.

Jacob Steffen (08:16):

So what's the number one thing that you wish you could tell all medical students who are interested in applying to your program?

Dr. Frank Wood (08:25):

I think some of the things we've already discussed, I think the expansion of this track in the future and how we're trying to look at adding more sites. One thing that I would put in there is that if you look up the population of Lawton, it's not the smallest town. One of the things that we're trying to do with our expansion to other facilities is to get into the towns that are below the 30,000 or less population threshold as well in order to kind of broaden that rural experience. One other thing to tell potential residents that I think the University of Oklahoma is very invested in resident education, if anything within our education realm is the gemstone of what we have. It is our resident education. We're very, very proud of it, and so we're always looking to make it better. This was one of those initiatives to try to not just settle for status quo.

(09:21):

And as such, when problems arise, I think that the program leadership and the entire department of surgery is very responsive to needs and to things like I mentioned with Dr. Lehman briefly, I mean realistically with our living situation, we were an apartment, an above garage compartment complex for several years. We at that time had more males rotating through the program, and then there was some issues that developed with some of the, essentially they didn't feel that it was as safe as otherwise could be for some of our other residents. And when that was brought up, I think we moved housing within seven days to a whole new facility. And so I think both us as well as Lawton, both really want to see this work. A lot of the attendings that we work with when we go to these other sites, not all of them, but a representation of them are graduates of our program.

(10:19):

So there's that tie in that and a vested interest in our rural surgeons wanting not just from, oh, I want future partners perspective, but that tie into their relationship to the university and making sure that we turned out a well-trained, well-rounded resident. And our other thing is that we have, because we do 18 months, we try to make sure and preserve time here on this campus for surgical oncology, trauma, pediatrics, all those sorts of things because at the end of the day, what's important to me specifically is that I want a well-trained surgeon no matter which track they go through. I want when wound as a trauma surgeon and one of the gunshot wound of the chest comes in and needs to be open, I want them to feel comfortable and to see them and say, well, I've done this before many times,

Dr. Randy Lehman (11:09):

I have a little sidebar here because this is very much MySpace and I'm very passionate about it. So I think that the focus for training is exactly what you're doing. It needs to be at a place with no competing residents, but big enough place that you have high volume and big enough that you have all the subspecialists like ob, GYN, ortho, urology, ENT, plastics, those kinds of things. And then you can be busy as a resident with general surgery and then you can find time to learn some of those other things that you specifically want to take to your practice. For example, I do carpal tunnel, I do trigger finger, some hand stuff, a lot of skin flaps and skin cancers, GYN, hysterectomy, tubal ligation, vasectomy, circumcision, all those things with great comfort and ease because I was able to be at a place just exactly like you're describing.

(12:01):

It's good to kind of see the smaller place, but you don't want that necessarily to be your main spending a ton of time training at the low volume. I would never, it's great for somebody to come to a rotation with me now with my practice just to have exposure and they will get some hands-on training, but you wouldn't want five years of that because the volume for each particular thing, you can get a lot higher somewhere else. And the other question I had is Lawton, they're not an OU hospital I don't think. Right. So what's in it for Lawton?

Dr. Frank Wood (12:34):

So from their perspective, when we approached them, so while we've had the rural track now just in the last few years, we've been rotating in Lawton since roughly 2019. And at that point was for our urban or our traditional residents to go down there, six of them rotating for six months at a time or one month each, essentially a half FTE, what's in it for Lawton when we approach them because they have to afford part of the funds for funding. The residency S slot during that time was they did a cost benefit analysis and they estimated that if this would mitigate part of their physician recruitment and they estimated that they would probably pick up one surgeon every decade out of the program. And that would offset more than the cost of the salary line is less than 10 years worth of physician recruitment. And within I think four years, don't quote me four or five years, we already have one of our graduates as one of their new faculty members.

Dr. Randy Lehman (13:38):

Cool. Plus it's also a better recruit because you had a longitudinal interview process for them. So that makes a lot of sense. I was just wondering how that exactly works. So thank you. Go ahead Jacob.

Jacob Steffen (13:51):

Yeah, that makes sense. I also like how you've shown to adapt and stuff based on feedback from your residents, which I think all medical students and residents can come to appreciate. My second question for you is what are some unique things or features on an application that makes you kind of go, oh wow, I think we should really consider this person.

Dr. Frank Wood (14:14):

I would say showing a level of interest in rural underserved populations. I think the thing is is because our rural track is a separate NR MP match code, so it appears like a completely different residency program. Although the interview process for either track is the same interview, you can select both and you interview once and then we rank you on different lists. We'll rank you potentially on both of those lists. But when we're talking about rules specifically what I like to look at when going through applications, is this person actually interested in returning to a rural community or are they just hedging bets to try to maximize their match rank? Which I understand we all have done that and I have nothing negative towards that approach. But from my perspective, my long-term goal is that we have surgeons actually returning to rural communities as such someone who's vested in that comes, you don't have to be from a small town, but it does seem that that's the largest group of that population that's interested. Showing some level of interest in that already before you get to the application process is beneficial.

Dr. Randy Lehman (15:36):

I'd like to piggyback on that. If you think back to some of the most successful residents in your program, rural or not, what traits did they have that caused them to be that standout in your program?

Dr. Frank Wood (15:53):

In our program, and this is a great question because I get asked this pretty much every interview season and what I tell residents what we're looking for is someone who is hardworking and someone who can get along well with the other residents and is a team player because everyone who comes and applies generally is a certain level of intelligence. And it's like, I dunno if you've ever read the book Outliers, that probably should be a plug. But Malcolm Gladwell kind of addresses this and we've also here at the University of Oklahoma done research looking at some of this stuff too. And there's a threshold event when you're looking at intelligence. Then after that, how successful people are is up to them and the time that you invest in them. And what we're looking for is someone who comes in, fits in well with a resident culture.

(16:44):

We don't want someone who comes and doesn't enjoy being with their co-residents because that's their family for the next three and a half to five years depending on which track you're in. And if you don't get along well with others, then you won't succeed to your maximum potential either. And then no one else around you does either. And then you have increased risks of attrition, increased risks of depression and so on and so forth. And so it's about finding the right culture fit. And so teamwork, working well with others are the primary things that we're looking for

Dr. Randy Lehman (17:24):

And being a hard worker. So I have another weird question. Do you have kids?

Dr. Frank Wood (17:28):

I do actually. I

Dr. Randy Lehman (17:29):

Have a

Dr. Frank Wood (17:30):

2-year-old son.

Dr. Randy Lehman (17:31):

How old?

Dr. Frank Wood (17:33):

He's about two and a

Dr. Randy Lehman (17:34):

He two. Okay. So I have a 7-year-old and a nine year-old. So we're kind of like getting into this. Are these traits like inborn or how can a parent pass those traits that you're talking about off to their kids if you want to take it, this is my show. We can say whatever we want to.

Dr. Frank Wood (17:56):

I think that it's 50 50. I think there's a certain level of burn looking at my son, there's aspects of his personality that are unique to him and have manifested since shortly after he was born. There's also things that you pouring into people to make them into a certain individual. So what can we do? I think loving our children is one of the most important things that we can do, and showing that level of support because that's the biggest thing that we can pour into them. And then I think also just almost like we do with residents, certain level of graduated responsibilities, expectations and not being overly harsh when they're not met, being understanding, but also still having an expectation that I expect you to not hit the little kid in class. That's not the right thing to do, but it's also a reflection on how we approach it.

(18:55):

And I think we can approach that event when our children don't do something quite like we wanted it to happen. If we overreact to that situation, if we blow up too much, it creates within them a doubt that persists. And instead what we have to do is come at that situation with a level of both love and respect, but also I'm disappointed this happened. I think you can do better in this. To be honest with you, that's sort of how I approach residency. I was just having this conversation this morning with someone and I said, there's two ways to approach it. You can either blow up and get mad or and fly off the handle, which I don't really like. I never have. Or you can come at someone and say, Hey, I'm disappointed this happened. I had a lot of trust in you that X, Y, and Z was going to happen and I'm disappointed this happened. And I have found in my teaching of others and also the teaching of me, that the worst thing that someone can say to me is, I'm disappointed in you. And I think when we're talking about our children, we want to create in our children the same concept where they want the respect of others, but they're also unique individuals that can work through disappointment also.

Dr. Randy Lehman (20:18):

Yeah, I love it. What if you're doing a low anterior resection? Somebody takes in the circular stapler and they put it in upside down with the hook down and it's a that's working with you. Are you going to fly off the handle on that one? No,

Dr. Frank Wood (20:33):

I don't. I get quiet actually since I don't actually do that procedure. The better example for me is when something bad happens in the trauma bay and I'm standing at the foot of the bed and I walk away, I take a brief moment, I get quiet, I walk away about 30 feet or so, and I've been told this too, I wasn't even quite self-aware of this until when I was a fellow. Some of the residents that were not on my service tease me and they said, oh, there it is, the head shake of disapproval. And I walk away and I shake my head no to the floor and I take a big deep breath and I come back and I stand at the foot of the bed and instead of yelling, but in sort of a normal voice, sometimes even quieter than I normally speak, say, so what were we going to do differently this time? And that's not uncommon in the trauma bay because honestly, we're dealing with very exceptional learners

Dr. Barclay Stewart (21:29):

And

Dr. Frank Wood (21:31):

If you come back, most of them already can tell you what they would do differently. You don't have to get mad. Most of 'em actually already know. Most of them have already. And I think in individuals as let's say it was someone who didn't know they put the stapler in and they had no idea, well then that's my fault because part of this is my responsibility to take a step back and go, do I really know that? Did they know how to put that in? I'll be mad internally, but I just get quieter.

Dr. Randy Lehman (22:02):

Yep. Yeah, that's so mature. But that's something I saw in residency once and I was like, oh my goodness. But now I don't have anybody else helping me. Right with the low anterior, so actually last LARI did is about 10 days ago, and actually the charge nurse ran the stapler. Usually I uns scrubb one of my hands and I reach down and I'm firing it like this way and then I go do it. But she did it and she did an awesome job, but I definitely talked to her about the curve

Dr. Frank Wood (22:33):

When I was a resident, one of our more senior colorectal faculty. What I learned from him was that he had an exceptionally good way of simplifying it where he'd talk about and he would take a medical student, just push it in your hands, lower your hands higher. And rather than trying to tell 'em how to move the end of the scope where your hands need to be and sort of those events allow you to do a better job, I think teaching too.

Dr. Randy Lehman (23:04):

Yep. I love it. Jacob, maybe you have one more question for us.

Jacob Steffen (23:07):

Yeah, sure. So I have a really quick technical question for you. You said that your rural track has a separate an r and p code. So I'm wondering through era a s, do you signal both programs or just one or what should you do for somebody who's interested in both the rural track and your program in general?

Dr. Frank Wood (23:30):

Signal's a very interesting topic and I think they're very interesting as well. It can be an entire conversation of itself. Realistically I would say signal the track that you are interested in. If you're interested in both equally, then you would signal both. But I think of the two, you signal the one that you like the most. That's probably the best advice I can give. The reality is, Jacob, is that we've just in the last few years, gone to big signaling and having even come back from the Surgical Education Week conference, every program is still sort of figuring out how they're going to use them. So the advice I'm giving is dynamic, and so it's again showing I think signals provide a lot of use if you're signaling us. The thing is is that if you signal one or the other, our interview process is the same. We're going to see on one list or the other that you've signaled or we'll see it on both if you signal both. But either way, you will interview once and if you get an interview, you're still interviewing for both tracks if you want. Some people will apply only to one and then they're only applying for that one. But if you're offered an interview and you applied to both tracks, then you're still interviewing for both of 'em.

Jacob Steffen (24:49):

Okay, that makes sense.

Dr. Randy Lehman (24:51):

There's also a question that Jacob usually ask, but we probably should before we wrap it up here, and I want to take two parts. Mainly we're going to want to know about case volume, but before that, how many applicants do you have for each arm, like the regular general surgery, and then for your rural arm?

Dr. Frank Wood (25:13):

We have about a little over a thousand applications per year. It varies now that we've gone to big signaling, we've had as many, somewhere I think about most recently, between 1100, 1500 applications a year

(25:27):

Off the top of my head. For our rural track, we're in probably the triple digits we're in, I would say between 30 and a hundred and for new, that number has doubled from one year to the next. I think it'll keep going up as word kind of gets out there that we have this program, we end up ranking, we end up interviewing about 75 to a hundred total applicants in general. Of those, we end up having about 25 to 40 interested in the rural track that we interview. Now they make dual applicants to one track or the other.

Dr. Randy Lehman (26:04):

So last question then on case volume, what do your residents graduate with and how much of that do they get? Early operative exposure, like in the first or second years of residency?

Dr. Frank Wood (26:14):

So total case volume first, most of our graduates are graduating with over a thousand cases, somewhere between 1100 and the upper ends of 1300 cases per year. We are able to meet all of our areas regularly every year. As for the first and second year, I will be honest with you, those tend to be lower than the rest of it. It's very graduated. We're probably in the double digits by the end of the first year and probably into the still double digits, maybe to a hundred by the end of their second year. Our third year is where things really take off. They'll finish their third year with several hundred cases, I think off the top of my head, between three and 400 cases at that point. And it grows on that as a fourth year. There's a ton of experience with our trauma programs and stuff like that. And likewise, it's our fifth year. Our fifth year tends to be very heavy on the complexity of cases at that point. That's generally what we're looking at.

Dr. Randy Lehman (27:18):

Yeah. Thank you so much. Is there anything else that you'd like to share before we close it out?

Dr. Frank Wood (27:24):

I really appreciate the opportunity to come talk about our program. We're really excited about it and we'd be happy to talk to other people. If other people have thoughts or questions, I'm happy to answer any of those as well offline or through email and so forth.

Dr. Randy Lehman (27:39):

Yeah, sounds like you're off to a great start. We have University of Washington faculty, Barclay Stewart, who's going to talk to us about the rural training programs that they have available up in the Pacific Northwest. So thanks for joining us.

Dr. Barclay Stewart (27:53):

Thank you. It's our pleasure. And again, thanks for all the effort behind this Real Surgery podcast, so we're excited to see where it goes.

Dr. Randy Lehman (27:59):

You bet. That's my pleasure. So why don't you start by just giving us a background to what is available at your institution.

Dr. Barclay Stewart (28:06):

Sure. At the University of Washington, we have a really unique relationship with the Pacific Northwest. Our medical school runs a program out of what's called the Whammy Region or Washington, Wyoming, Alaska, Montana, and Idaho Medical student trainees experienced the Wyoming region, both for their didactic portions of their medical school as well as their clinical tracks. And they move all over the region actually. And it provides 'em with a really unique insight into how care is delivered both in rural settings and smaller metropolitan areas, as well as how care is coordinated across the Pacific Northwest. With that in mind, our training program historically was really focused on patients both in Seattle and then tertiary and quaternary care for patients in our region. And we realized that we were missing a really important part of our training mandate, which was to ensure that Pacific Northwest gets populated, which really high quality surgeons practicing in rural areas.

(28:55):

So we had the goal of developing a program that exposes trainees to the complexities and the nuances of providing care in more rural healthcare settings and how to coordinate care across regions which include and Pacific Northwest, rural, remote, and frontier communities, particularly up in Alaska. Additionally, many of the problems that we are trying to solve in rural health like access and equity, resource responsive models of care and sustainable capacity building are all analogous to those in global health. Therefore, we aligned our rural and global health programs into one called Progress or the program for rural and global surgery that ensures trainees benefited from the learning and exposure in these shared domains, both in the rural and global environments. We have iterated on multiple tracks generally. We settled on a couple opportunities for residents. The first is for rotations as R twos, R threes and elective R four rotations at Alaska Native Medical Center, a really special mission-driven hospital in Anchorage, San Alfonso and Boise, and then the Billings Clinic and Billings, Montana.

(30:00):

There. They experience the breadth of general surgery, really culturally competent care and a market different health system than what they experience here in Seattle. And for residents that are really interested in having rural surgery be part of their career and also academic pursuit, frankly, we have year long clinical and research experiences at Alaska Native Medical Center and at the Billings Clinic in Montana, as well as the critical access hospitals that they serve in Montana and Wyoming. And there they rotate through general surgery, endoscopy, orthopedic surgery, obstetrics and gynecology, urology, neurotrauma. So they can be fluent with the multiple specialties of care and the indications and have an understanding of the procedures required for often emergency care in those specialties. They also take part in local or regional QI initiatives and perform research on rural health and rural surgery.

Dr. Randy Lehman (30:53):

Well, that's quite a lot to kind of digest. And so Oregon though, they're kind of like, no thanks. We don't want to be part of whammy. We'll do our own thing.

Dr. Barclay Stewart (31:04):

Yeah, they've had a very long commitment for a long time to rural surgery, so we actually learned a lot from how they did it and really have great respect for what they've been able to do for many years at OHSU.

Dr. Randy Lehman (31:15):

Nice. Yeah, me too. And we've had some of their leaders on the show, so obviously really appreciate them. So tell me a little bit about what kind of a resident excels in the program that you're talking about.

Dr. Barclay Stewart (31:29):

I mean, generally speaking, I mean I think of all across the country, applicants in medical school now are just on a different level than they were when I feel like I was going through. So we get exceptional applicants here at the University of Washington all the time,

Dr. Randy Lehman (31:42):

Says the MD PhD mph, extremely well spoken and obviously intelligent Barkley Stewart. But yes, carry on.

Dr. Barclay Stewart (31:52):

Yeah, we have great residents. Then everyone who's applying generally we're looking for people who are just eager to learn, eager to serve, and they'll be mission driven. It's just part of the ethos of the hospitals that we work at here and certainly in the whammy region. While some are focused on a specific specialty from the start that might not necessarily lean toward rural surgery, others don't know or want to learn about the potential careers and practice types that they could work toward in rural surgery and in our region and beyond. And what's really important to us, our values like service for people and developing systems of care, being innovative and how care is organized and delivered, having compassion for people regardless of where they live or their life circumstance and certainly being respectful of different people and cultures and ways of life and importantly, care environments care just looks differently all across the country. It doesn't mean that it's better or worse. So for the residents or the students listening, if that sounds like you, we'd certainly love to see you on interview day. And fortunately there's a lot of residents who fit here from many different paths before medical school and even during medical school. And we don't necessarily track people directly into a world surgery track or program. We want the flexibility built into the program to ensure that all people get what they need when they go through our residency.

Dr. Randy Lehman (33:08):

It's a little bit more ambiguous than some of the programs that we have interviewed so far. And you're admitting that and telling me that, and you are obviously, I strongly agree. I do mission surgery as well. The skillset for a rural surgeon is very similar for an international mission-driven surgeon like that. I think that obviously part of not part my main mission is actually increasing access to care right here in this town of 6,000 people in Indiana where I grew up, but there's a need everywhere. I want to hear a little more about the brass tacks of what the resident actually does and where they physically go, but also then where are they ending up? What's the track record of people are done, where are they landing and what kind of job are they doing?

Dr. Barclay Stewart (33:57):

Yeah, so I mean the brass tacks generally, our junior residents often predominantly go to Alaska, the native medical center and increasingly to St. Alfonso in Boise really focused on general surgery, acute care surgery, and obviously Anchorage and Boise are not small towns. They are smaller cities, but they really care and coordinate care across their own regions and it's a really important part of that service delivery model. They do a lot of endoscopy, a lot of mans endoscopy and kind of an older school if you will, breadth of general surgery to include lots of thoracic and obviously all the acute care surgery breast and a lot of soft tissue work. And they're really excellent surgeons and teachers and have created great training programs that we're really fortunate to be partnered with for r fours as the elective rotation, they can go to either Billings or Boise or Alaska Native Medical Center.

(35:00):

And there it's a little bit more focused on operative experience, not just managing a service in a patient load. And then for a year long folks at Alaska Native Medical Center or at the Billings Clinic, it's really focused on thinking about how to incorporate rural surgery into practice and lifestyle, being part of a community doing projects, focusing on quality improvement issues on that access like I mentioned. And then the billings clinic's done a really phenomenal job about having a really, really wide training opportunity for patients or for our residents across multiple specialties. As you mentioned, it's not meant to make obstetricians out of general surgeons. It's meant to help them understand the difference between an emergency problem that needs to be managed quickly and then one that might be able to mitigated and referred on a less selective basis how to do important emergency procedures when you're called upon to do so. And that sort of mentality being fluent about the indications and some of the techniques, not necessarily obviously to be a urologist or an obstetrician, but

Dr. Randy Lehman (36:07):

Yes. But yes, so in my practice, I mean I do hysterectomy, tubal ligation, vasectomy, circumcision, C-section, ectomy, Varian, torsion, things like that. And so there are places in the United States where they would need a 0.2 OB GYN,

(36:31):

Or they have a OB program and they can't get three OB-GYNs to cover all the call and they have to rely on general surgeries to do C-sections or in other places maybe they're not doing ob, but they still have that GYN stuff, but they just can't get a part-time GYN and a rural surgeon to me is like general surgery plus. So yeah, there's things that I don't do esophagectomy or Whipple or liver resection or really much thoracic outside of just some minor stuff, but I've added carpal tunnel and these other things and a lot of skin cancer and it's really a neat, if you look at the community, what the community actually needs, you keep a vast majority of these things close to home, creating jobs close to home, keeping rural hospitals open or losing 10 every year, respond I guess to that. Could your resident graduate doing that sort of a practice or would they need something else?

Dr. Barclay Stewart (37:29):

Yeah, I think I totally acknowledge and admire that scope. My thought on this for our trainees is that I want them to be exposed and fluent and understand what they do and don't know. And certainly when they graduated, even from our world surgery track, we want a really close mentored experience and that breadth of general surgery where they went, I don't think that our residents would be ready to be independently practicing in that environment, but certainly would be very well prepared to be mentored, to be very successful in an exact environment like that. And that's our goal. We want to create surgeons like you and have them around our region to ensure that people get care close to home. And as you mentioned, keep hospitals open, prevent a lot of the rural emergency hospital designations from ticking over. That's certainly the goal, but it's hard to train residents completely like that in this day and age, but we want to make sure that they are max prepared to be able to explore and be mentored in that practice once they graduate.

Dr. Randy Lehman (38:35):

Yeah, love it. Jacob, do you have some questions?

Jacob Steffen (38:38):

I think you have a five year program and then you have a five plus two and the billings year long rotation. So what is kind of the difference between all of those lengths of time?

Dr. Barclay Stewart (38:51):

The five year programs are for folks that don't want to do professional development years, which can be time at one of our rural partner hospitals could be doing research domestically or internationally. Some people get graduate degrees and focus on a specific topic and others want clinical for their clinical experience and others just want research experience. So our goal at the University of Washington is to provide residents with a tailored experience as close to their passions and purpose on this planet as possible. The pros in that is that we are able to be really flexible and adaptable and give people what they want as they go through their training. And the cons are that it is a little bit, I forgot the word you use Randy, I think nebulous or something, but it is a bit our amorphous. We do have to kind of create some structure around it for the individual when that time comes.

(39:42):

For people that want to make the science of access or implementation or health services research part of their career, the five plus two with a focus on a rural track is a great option for them. For instance, those that want to do global health, being able to spend a year with the Billings clinic team, expanding their scope of understanding of surgical practice and then spending a year at one of our training sites in Ghana or Burkina Faso or Nepal is a really wonderful opportunity for them. But for folks who would want to go straight to practice in a rural and rural community after residency, a five year program with our rotations in their second, third and fourth years at our rural partnership sites also is an excellent opportunity for them. So we try to be flexible. We want multiple avenues and we want people that there's some life changes during residency, so you might sign up for one track and decide to do something else, and we want to make that possible. And part of that is not having such a rigid system that we can't move residents around to make sure that they get what they need and want.

Dr. Randy Lehman (40:49):

You have all these sites, I assume housing is, you figured that out somehow. And have you had residents go through with families and the families go with or how does that work?

Dr. Barclay Stewart (40:58):

Yeah, each of the sites provide housing, transportation to and from the site. We provide a transportation stipend for our residents who are in Alaska and they get their normal salary and benefits and insurance all through the University of Washington ultimately supported by the partnership sites, but the same pathway that they would normally get their salary and benefits when they're here. We have had a couple residents bring family, a loved one, particularly not necessarily children. We are ensuring that there is space and opportunity for that to happen when that comes when a resident wants to bring their entire family and including pets, which is obvious severely a bit of a tricky thing with some housing complexes. But yeah, we want to make it possible for people to experience what living in a community is like with their families because ultimately that has to network for the whole family unit and not just for the individual surgeons. So we want that shared experience. The program in Boise has been really helpful and understanding about that need and want, and they're working with us to make sure that we have a spot for residents that want to bring their families.

Jacob Steffen (42:14):

So it sounds like your program is very adaptable and malleable to what experience the resident wants to get out of it, which I think everybody can kind of appreciate and we applaud you on being able to adapt and teaching your residents what they want to learn, which is great. My next question is what is the number one thing about your program that you wish you could tell all medical students who are interested?

Dr. Barclay Stewart (42:43):

I was a resident here, a fellow here, and I've stayed on a Harborview Medical Center for a number of reasons. One is the culture that we've created with our faculty and residents is a really extraordinary thing and it's hard to beat going to work with your family and for a shared mission and caring for people of all walks of life in our region. It really is the lifeblood of what we do here at the university, and it also trickles down all the way to certainly the patient care and to our training program, which is why we're trying to again, reinvigorate rural surgery in the whammy region and make it a really core part of our identity as a residency program.

Jacob Steffen (43:25):

Yeah, I love that. Sounds great. Can you talk about the number of cases that you do as an intern in your program and how that evolves over the years?

Dr. Barclay Stewart (43:36):

Our residency is like many large academic residencies is pretty top heavy, obviously. We meet our requirements for caseloads each year. Our first year is really learning how to work within a system, how to manage patients in the acute care services, learn basic surgical skills or our two year focuses is more on critical care, being a consultant, learning a bit of more complex general surgery. And then with our three, four, and certainly five years, it's increasing exposure to complex procedures, to specialty specialty cases. And frankly, I include rural surgery care delivery as a specialty case and how that's performed. And then our four and five years are certainly leadership development and team management and service management. So we have a very graduated program. We're very careful with ensuring that no one feels unsafe or outside of their comfort zone, but we do want to push them just enough to where they have to be very thoughtful and careful safe surgeons as they go throughout their training.

Jacob Steffen (44:42):

Yeah, I love that. Do you notice any difference in case volume between the different pads that you guys provide?

Dr. Barclay Stewart (44:49):

There is some difference in case volume, and part of it's the way that the hospitals are organized. Some of our partner hospitals rely on residents as part of the workforce, and some have a large advanced practice provider group that does a lot of the work that residents often have to also do for the practices that have lots of apps. The residents do a lot more cases and less care work. I feel that important part of learning how to be a doctor is how to deliver care in different environments. And some of that is when you are the only surgeon in a group, you also have to do all parts of care, which is not just operating. So I want to be sure that residents have that exposure to different practice types and different models of how practices are built and not just one that relies solely on providing surgery. The Billings Clinic is really unique in that they have a group that provides surgical care at critical access hospitals across Montana and Wyoming. So the residents spend time with him at these critical access hospitals doing backlogs of small general surgery cases and screening endoscopies for instance. So each is a little bit different in how they deliver care and residents, I think benefit from seeing those multiple different care models.

Jacob Steffen (46:08):

Yeah, I love that there's two sides of the coin. You got to learn both how to operate and how to take care of people. So it's important to be comfortable on multiple those things. At the Billings clinics specifically, I'm assuming at your main site there's all sorts of different residencies and fellowships and stuff. What other residencies and fellowships exist at the Billings Clinic for your students that go there?

Dr. Barclay Stewart (46:33):

At the Billings Clinic and at Alaska Native Medical Center, the University of Arizona residents also share space and time with our group, and they've been wonderful distant partners in this, if you will, and the residents have kind of created a community of what it means to be a world surgery engaged resident. And that's been a fun side effect of doing all this that we didn't anticipate really for a short time away from oftentimes their family or their second homes, their training programs. It's nice to have colleagues nearby that understand what being a resident is and that sort of thing. So that's been wonderful. And then also the differing experiences, I think of the home residencies have allowed each of the partner sites to understand how different residents need to be educated and where they are in their journey in residency. And that's led to I think, more versatile educators, which has certainly benefited both programs.

Jacob Steffen (47:29):

Yeah, that's kind of a unique experience of getting two residency programs together. It's like a crossover episode or something like that. Exactly. So yeah, I think that's great. And something that you maybe wouldn't get at other places. Do you notice a trend of where you are for specifically the residents who do the rural track or the one year in billings? Do you notice there's a trend or where do you see those graduates ending up in all of United States and kind of in your area or where do they like to go?

Dr. Barclay Stewart (48:06):

Yeah, our first ones are graduating basically as we speak, and they've been offered positions and are likely going to take them at, I don't want to give anything away, but in the region they trained here in the AMI region, which is I think obviously the ultimate sign of success. And we're really proud, excited by that. We have a couple of our combined rural global surgery trainees who are now doing really incredible work internationally and plan to make that their career. And they're really technically extraordinary surgeons because of their experience too. So I think it's doing what we intended to do the program is we just hope we continue populating our region with surgeons who want to provide great care in people's communities.

Jacob Steffen (48:54):

Yeah, it sounds like you're meeting all of your end goals, which is awesome. Get people in the whammy region to operate, so that's great. My last question for you is where can a medical student go to learn more about your program?

Dr. Barclay Stewart (49:09):

They can certainly go to our Department of Surgery website. I'm also happy to share my email and if people want to contact me about how to apply more information, more details, I'm happy to take direct communications for applicants. And then we also have listening days as part of our interview process, which we give lots of details about each of the different tracks, research programs, the clinical programs that our institution.

Dr. Randy Lehman (49:39):

So we'll put a link to your email, is that fine in the show notes and also to your department of surgery website. That sounds good. And then just one very technical point for me before we wrap up. So if someone is applying through Aras, is there just one code or are there multiple codes for each of these tracks

Dr. Barclay Stewart (49:59):

For interest? We've talked lots about what's the best way to do this, and because we've had people switch both into and out of multiple tracks over the years, we've decided to make it a general application to the program. And then we help people identify a track while they're an intern, so they don't have to pre-specify a track, but feel free to explain, but it's been tricky for us to decide that.

Dr. Randy Lehman (50:23):

Yeah. Did you have multiple NRMP codes in the past?

Dr. Barclay Stewart (50:28):

We didn't. That was our intention to switch to that, but then we started realizing how many times people switch out of tracks and we didn't want people to feel pigeonholed. We want to make people to feel inspired and passionate and do what they want to do. That's when people succeed. And if we felt like people get locked in, then it doesn't make space for people to switch in and doesn't make people, they can't switch out as easily. So we haven't done that.

Dr. Randy Lehman (50:54):

That makes sense. How many total programs, how many total applicants to the program do you have each year then? Now, I'm sorry, not applicants. How many people get in? You could tell me how many applicants too, but how many total spots?

Dr. Barclay Stewart (51:09):

We match eight residents and we get hundreds of applicants.

Dr. Randy Lehman (51:16):

Sure. But it's eight applicants, but over multiple states.

Dr. Barclay Stewart (51:20):

Oh, basically the country.

Dr. Randy Lehman (51:22):

Yeah. Does everybody, that's an applicant. Everybody that gets in, do they kind of start by getting an apartment in Seattle or they all kind of have a home base there in Seattle?

Dr. Barclay Stewart (51:34):

Yeah, a home base. And they all rotate for all of our Seattle, Seattle and area hospitals and rotations. And then again, those who want to spend time away get to spend longer time, and those who just want to understand or be part of the Miami region, we have those electives and where we have an opt out system, so it's technically not mandatory for all residents to go to different sites, different programs, community partners if you will, but almost everyone elects to do so. It's usually an extenuating family circumstance where people decide not to,

Dr. Randy Lehman (52:13):

Yeah, they have to stay or whatever. That has been a excellent intro into what you guys are doing in whammy in Pacific Northwest, rural and global, and also academic and any other track that you want to go into general surgery training. And it sounds awesome, and I hope you keep up the good work, and I just really appreciate you coming on to share all this with our listener.

Dr. Barclay Stewart (52:35):

Yeah, thanks. And thanks for all y'all are doing. I look forward to seeing where this goes all together.

Dr. Randy Lehman (52:40):

Thank you. And thank you also to the listener. This has been the Rural American Surgeon. I'm your host, Dr. Randy Layman, and we'll see you on the next episode of the show.