The Rural American Surgeon

Randy Lehman
  • 4.9 (23)
  • Science
  • Weekly

Welcome to ”The Rural American Surgeon,” a podcast series dedicated to providing insights, resources, and a community for the surgeons of rural America. Your host, Randy Lehman, is an established authority on the multifaceted aspects of rural surgery—from the unique professional benefits and challenges, rural surgical training paradigms, current reimbursement landscape, and how to create triple win opportunities for sustainable rural surgery in partnerships with hospitals and rural communities. This podcast is designed for both rural general surgeons and rural surgical specialists who are seeking not just advice and guidance on practicing in rural areas, but also inspiration to foster valuable partnerships across our great land. Each episode is a deep dive into topics such as mastery of rural surgery, the rural lifestyle, fighting professional isolation, building a system to ensure surgical services are offered at a high level, using scarce resources wisely, achieving personal financial freedom, accessing a wealth of outside surgical resources, and inspiration at a high level of why what we do is important.

  1. 5d ago

    He Was Performing Esophagectomies in a Small-Town Hospital

    We're revisiting a conversation from The Rural American Surgeon archives with Dr. Gary Timmerman, exploring what it takes to perform complex surgery in a rural hospital, including the preparation, surgical judgment, and technical skills required to take on major operations. In this How I Do It episode, host Dr. Randy Lehman and Dr. Timmerman take an in-depth look at esophagectomy, including transhiatal and Ivor Lewis approaches, open versus robotic surgery, reconstruction techniques, and why every surgeon needs a backup plan when things don't go as expected. How do you know when you're prepared to perform a complex operation in a rural setting? Dr. Timmerman shares how he developed an esophageal surgery practice in Watertown, South Dakota, and why he waited four years before performing his first esophagectomy. He discusses the extensive preparation involved, from continuing surgical education and mentorship to documenting outcomes and establishing relationships with larger medical centers, including Mayo Clinic and the University of Minnesota. The conversation then moves into the surgical techniques themselves. Dr. Lehman and Dr. Timmerman compare transhiatal and Ivor Lewis esophagectomy, discuss open and robotic approaches, and examine the challenges of operating without the same resources and immediate specialist support available at major academic hospitals. They cover stomach mobilization, gastric conduit creation, cervical anastomosis, lymph node dissection, and alternative reconstruction techniques, including colonic and small bowel interposition when the stomach isn't a suitable conduit. Dr. Timmerman also shares his experience with early robotic esophagectomy in South Dakota and explains why he continued reviewing multiple operative approaches before every case, even after years of experience. For rural general surgeons who may never perform an esophagectomy, the conversation also provides practical insights into esophageal cancer diagnosis, Barrett's esophagus surveillance, biopsy decisions during upper endoscopy (EGD), and laparoscopic jejunostomy (J-tube) placement. Throughout the discussion, one message remains constant: practicing in a rural community is no excuse for compromising surgical standards. Whether performing a routine procedure or tackling a complex operation, surgeons must be prepared to make sound decisions, recognize their limitations, and provide the best care possible for their patients. Key Takeaways 00:00 Rural Surgery Requires High Standards 00:29 Introducing the How I Do It Series01:08 Taking on Esophagectomy in Rural Practice02:53 Building Support From Larger Centers03:34 The Responsibility of Complex Surgery05:29 Learning Multiple Esophagectomy Approaches06:19 Transhiatal vs Ivor Lewis Esophagectomy08:21 Early Robotic Esophagectomy Experience09:46 Always Have More Than One Surgical Option11:25 Preparing Patients Before Esophagectomy12:44 Transhiatal Esophagectomy Step by Step16:12 Mobilizing the Esophagus and Neck18:56 Creating the Cervical Anastomosis21:47 When the Stomach Cannot Be Used22:14 Colonic Interposition and Alternative Conduits25:49 Hand-Sewn Anastomosis Technique27:09 Biopsy and Barrett’s Surveillance30:04 Holding Rural Surgery to the Same Standard30:44 Feeding Access and J-Tubes32:27 Laparoscopic Jejunostomy Technique36:24 J-Tube Risks and Internal Hernias37:25 Open Surgery vs Minimally Invasive Techniques Resources Mentioned American Collegeof Surgeons:https://www.facs.org/ ACS ClinicalCongress:https://www.facs.org/for-medical-professionals/conferences-and-meetings/clinical-congress-2026/ Mayo Clinic:https://www.mayoclinic.org/ University ofMinnesota: https://www.umn.edu/ Da Vinci SurgicalSystem: https://www.intuitive.com/en-us/products-and-services/da-vinci

  2. Oct 22

    When Skin Cancer Surgery Gets Complicated: Mohs & Skin Grafts

    We're revisiting a conversation from The Rural American Surgeon archives that tackles some of the most practical decisions general surgeons face when treating skin cancer. Dr. Konstantin Grigoryan joins host Dr. Randy Lehman for a discussion about skin cancer management, Mohs surgery, reconstruction, biopsies, and referral decisions in rural practice. Dr. Grigoryan shares his path from engineering to dermatology and Mohs micrographic surgery, as well as his experience caring for patients across Northern California, including many rural and medically underserved communities. The conversation begins with the basics of Mohs surgery, including how complete margin evaluation differs from standard excision, which patients benefit most, and why head and neck tumors, aggressive pathology, immunosuppression, and younger age can influence the decision to refer. Dr. Grigoryan also explains how reconstructive options range from secondary intention and primary closure to advancement, rotation, transposition, and interpolation flaps. We then get into the practical details rural surgeons often face: when standard excision is reasonable, how to think about positive margins, when frozen section may help, biopsy selection, melanoma staging, full-thickness skin graft technique, closure materials, and how to manage infected cysts. We also discuss delayed presentations and neglected skin cancers, including cases where squamous cell carcinoma extended into bone and deeper structures. The episode closes with a broader point about rural surgical practice: keep appropriate cases local when it benefits the patient, but avoid becoming a “cowboy.” We also emphasize the value of having trusted referral relationships and colleagues who can help with borderline or complex cases. KEY TAKEAWAYS 00:00 Welcome and Introduction01:25 Dr. Grigoryan’s Path to Dermatologic Surgery03:39 Mohs Surgery in Rural California05:31 What Patients Can Expect From Mohs07:11 Which Skin Cancers Benefit Most09:41 Choosing the Right Patient for Mohs11:36 Nodular vs Infiltrative Basal Cell Cancer12:24 Reconstructive Flaps After Skin Cancer Excision16:13 Full-Thickness Lip Reconstruction17:06 Full-Thickness Skin Graft Technique19:05 Closure Techniques and Suture Selection21:47 When Rural Surgeons Should Keep Skin Cancer Local23:26 Positive Margins and Frozen Section Decisions25:16 Gray Areas in Skin Cancer Management28:37 Shave vs Punch Biopsy29:42 Biopsy Strategy for Melanoma32:11 Dermoscopy and Skin Lesion Evaluation34:04 Financial Corner: Slow and Steady Investing35:13 Classic Rural Surgery: Advanced Skin Cancer37:17 When Mohs Reveals Much More Disease40:05 Managing Exposed Bone and Skin Grafts41:42 What to Do With Unexpected Positive Margins43:32 Avoiding the “Cowboy” Approach45:18 Dermatology Resource for Rural Surgeons45:50 Managing Infected Skin Cysts48:36 Final Thoughts RESOURCES MENTIONED DermNethttps://dermnetnz.org/ National Comprehensive Cancer Network (NCCN)https://www.nccn.org/ American College of Mohs Surgeryhttps://www.mohscollege.org/ American Academy of Dermatologyhttps://www.aad.org/ UC Davis Healthhttps://health.ucdavis.edu/ U.S. Department of Veterans Affairshttps://www.va.gov/

  3. Oct 15

    Why This Experienced Surgeon Never Used Nerve Monitoring in Thyroid Surgery (Part 2)

    Dr. Ronald Weigel returns for Part 2 of his conversation with host Dr. Randy Lehman on The Rural American Surgeon. The discussion continues with a practical look at what cancer care rural hospitals can safely keep local, when patients should be referred, and how smaller hospitals can build sustainable surgical programs even without 24/7 general surgery coverage. Dr. Weigel explains that common cancers such as breast cancer, colon cancer, melanoma, and some prostate cancers may be appropriate for rural treatment depending on the surgeon’s experience and the hospital’s capabilities. The conversation then moves into patient-centered breast cancer care, including mastectomy, reconstruction, rural patient preferences, and why treatment decisions should reflect what individual patients actually want rather than assuming every community has the same priorities. Dr. Weigel also discusses how Commission on Cancer accreditation, tumor boards, rural-specific quality metrics, and participation in the National Cancer Database can help improve care and generate better data about cancer treatment in rural communities. Later, Dr. Lehman and Dr. Weigel get into the nuts and bolts of rural surgery, including recurrent breast abscesses, lumpectomy incision placement, margin techniques, thyroid and parathyroid surgery, and operative exposure. The episode culminates in a direct discussion about whether rural surgeons should perform thyroid surgery without nerve monitoring. Dr. Weigel shares why he has not routinely used nerve monitoring in his own thyroid practice, while emphasizing careful identification of the recurrent laryngeal nerve, surgeon judgment, appropriate patient selection, and knowing which procedures belong in each individual rural practice. Key Takeaways 00:00 Welcome Back to Part 2 00:17 Cancer Care Without 24/7 Call 02:02 What Cancer Should Stay Local? 03:22 Investing in Rural Surgical Capability 04:14 Breast Cancer and Reconstruction 06:09 Understanding Rural Patient Preferences 10:14 Accreditation and Surgical Standards 10:57 Tumor Boards and Continuing Education 11:26 Building Rural Cancer Quality Metrics 13:01 Why Rural Cancer Data Matters 14:19 ACS Rural Cancer Resources 15:45 Building Trust With Rural Patients 21:13 Rural Surgical Case Decisions 22:24 Managing Recurrent Breast Abscess 25:09 Lumpectomy Incision Techniques 29:03 Using Shave Margins 32:42 Thyroid and Parathyroid Surgery Pearls 35:09 Bringing Endocrine Surgery Back Locally 36:29 Is Nerve Monitoring Necessary? 38:28 Parathyroid Surgery Without Intraoperative PTH 41:25 Deciding What Stays Local 41:53 Final Advice for Rural Surgeons Resources Mentioned American College of Surgeons https://www.facs.org/ ACS Commission on Cancer https://www.facs.org/quality-programs/cancer-programs/commission-on-cancer/ ACS National Cancer Database https://www.facs.org/quality-programs/cancer-programs/national-cancer-database/ ACS University of Iowa https://uiowa.edu/ uiowa.edu American Board of Surgery https://www.absurgery.org/ ACS Rural Cancer Programs https://www.facs.org/quality-programs/cancer-programs/

  4. Oct 8

    Can Rural Hospitals Really Provide the Same Quality Cancer Care? (Part 1)

    Dr. Ronald Weigel joins host Dr. Randy Lehman on The Rural American Surgeon to discuss the American College of Surgeons Commission on Cancer’s new rural accreditation pathway and what it could mean for hospitals, surgeons, and cancer patients in rural communities. Dr. Weigel shares his path from engineering and surgical training at Duke to cancer research, leadership at the University of Iowa, and his current role as medical director of cancer programs for the American College of Surgeons. The conversation then turns to the challenges of delivering cancer care in rural America, where patients may face long travel distances, limited access to general surgeons and oncology specialists, and fewer hospital resources. Dr. Weigel explains how the Commission on Cancer Rural Accreditation track was designed to adapt established cancer-care standards for smaller hospitals while helping more patients receive high-quality, guideline-concordant care closer to home. Dr. Weigel also walks through the accreditation process, including cancer leadership, multidisciplinary care, registrars, data collection, site visits, and building referral networks when services such as medical oncology or radiation therapy are not available locally. We also discuss how accreditation can strengthen rural cancer programs, increase patient volume, attract specialists, and reinforce the role of broad-spectrum general surgeons in maintaining viable rural hospitals. Key Takeaways 00:38 Introducing Dr. Ronald Weigel and Rural Cancer Accreditation 02:08 From Engineering to Medicine and Surgery 02:44 Training at Duke and Lessons From Surgical Mentors 03:51 Developing a Leadership Style in Surgery 07:58 Surgical Training, Cancer Research, and Stanford 09:10 Becoming Chair of Surgery at the University of Iowa 10:16 Joining the American College of Surgeons Cancer Programs 12:37 Why Rural Cancer Accreditation Matters 14:18 Understanding the Needs of Rural Patients 17:12 Cancer Disparities in Rural Communities 17:31 How the Rural Commission on Cancer Accreditation Track Works 19:30 The Accreditation Process and Timeline 21:13 Building Multidisciplinary Cancer Care in Rural Hospitals 21:37 What Hospitals Need to Meet Accreditation Standards 24:46 Building Cancer Care Networks Without On-Site Oncology 26:13 How the ACS Supports Rural Hospitals Through Accreditation 27:51 Is Any Rural Hospital Too Small for Cancer Accreditation? 29:10 How Accreditation Can Strengthen Rural Surgical Programs 30:28 Supporting Multiple Surgeons in Rural Communities 31:22 The Broad Scope of Rural General Surgery Resources Mentioned American College of Surgeons https://www.facs.org/ ACS Commission on Cancer https://www.facs.org/quality-programs/cancer-programs/commission-on-cancer/ ACS National Cancer Database https://www.facs.org/quality-programs/cancer-programs/national-cancer-database/ ACS University of Iowa https://uiowa.edu/ uiowa.edu American Board of Surgery https://www.absurgery.org/

  5. Oct 1

    The Rural Surgeon’s Guide to Treating Pilonidal Disease

    Dr. Levi Smucker joins host Dr. Randy Lehman on The Rural American Surgeon to discuss his path to rural general surgery, from growing up in Pennsylvania and training at Bassett Healthcare in Cooperstown to building his practice in Goshen, Indiana. He shares how a close knit group of six surgeons has given him strong mentorship, broad operative experience, and the opportunity to develop his own areas of expertise while serving multiple hospitals. Dr. Smucker also takes a practical look at pilonidal disease, walking through patient presentation, conservative management, the Gips procedure, excision, wound healing, and the Bascom cleft lift. The conversation explores how he approaches recurrent and complex cases, technical considerations for different procedures, and the importance of choosing treatment based on the individual patient. They also discuss cost sharing within local Plain Church communities, an unusual rural surgery case involving an esophageal food bolus, preparing for challenging cases without letting anxiety take over, and why mentorship remains so important for the next generation of rural surgeons. Key Takeaways 00:38 Meet Rural General Surgeon Dr. Levi Smucker 01:20 From Pennsylvania to Rural Surgery in Indiana 02:18 Why Bassett Healthcare Was the Right Place to Train 02:52 Building a Career in a Supportive Rural Surgery Practice 04:21 Resources and Capabilities Across Three Hospitals 05:09 Finding a Surgical Niche in Rural Practice 05:52 Bringing Vascular Surgery Into General Surgery Practice 06:25 The Broad Spectrum of Rural General Surgery 08:30 Why Rural Surgery Still Matters 09:15 Understanding Pilonidal Disease 11:27 Evaluating Patients After a Pilonidal Abscess 12:09 Treatment Options for Pilonidal Disease 13:05 How the Gips Procedure Works 15:02 The Bascom Cleft Lift Procedure 16:43 Technical Approach to the Gips Procedure 18:13 Choosing the Right Treatment for Complex Cases 20:48 Performing the Bascom Cleft Lift 24:52 Creating an Off Midline Closure 26:03 Coding Considerations for Pilonidal Surgery 27:42 Lessons From Plain Church Communities and Cost Sharing 29:10 A Classic Rural Surgery Case 30:06 Preparing for Difficult Cases Without Burning Out 32:46 Why a Culture of Mentorship Must Be Passed On Resources Mentioned Bassett Healthcare https://www.bassett.org/ Gehrig Surgical Associates https://www.gerigsurgical.com/ Critical Access Hospitals https://www.cms.gov/medicare/health-safety-standards/certification-compliance/critical-access-hospitals

  6. Sep 24

    What Rural Surgeons Need That Most Residencies Don’t Teach

    Dr. Joon Shim, program director at Bassett Healthcare in Cooperstown, New York, joins host Dr. Randy Lehman and Jacob on The Rural American Surgeon to discuss how Bassett prepares residents for the realities of rural general surgery. Dr. Shim explains how residents begin gaining operating room experience from day one and train across a broad spectrum of surgical cases without competing with surgical fellows. The conversation explores what it takes to thrive in rural surgery, including adaptability, resilience, emotional intelligence, and the ability to provide excellent care when patients face challenges with transportation, insurance, and access to specialists. Dr. Shim also shares what she looks for in residency applicants, Bassett’s approach to leadership development, and why rural surgeons must be prepared to think independently, operate confidently, and care for the entire community. Key Takeaways 01:21 How Bassett’s Rural Surgery Residency Is Structured 01:54 Building Independence From the First Day in the OR 03:35 What Makes a Resident Thrive in Rural Surgery 04:25 Why Adaptability Is Essential for Rural Surgeons 05:30 How Rural Healthcare Can Improve Continuity of Care 06:26 Providing Excellent Care Despite Patient Resource Limitations 07:15 Adapting Treatment for a Patient With Limited Access to Care 08:22 The Extreme Cases Rural Surgeons Can Encounter 09:56 What Dr. Shim Looks for in Residency Applicants 11:25 Teaching Emotional Intelligence and Leadership 12:42 How Much Operative Experience Interns Can Get 14:27 Training Across Specialties Without Surgical Fellows 15:38 Where Bassett Surgery Graduates Go to Practice 16:46 How Medical Students Can Learn More About Bassett 17:28 Training Surgeons Who Are Technically Driven and Deeply Human 17:48 Thinking Independently and Leading Compassionately 18:54 Connecting With the Rural Surgery Community 19:59 How to Choose the Right Residency Program 20:35 Dr. Shim’s Journey From Major Trauma Centers to Rural Surgery Resources Mentioned AO Foundation https://www.aofoundation.org/ Bassett Healthcare Network https://www.bassett.org/ Bassett General Surgery Residency Program https://www.bassett.org/medical-education/residency-fellowship-programs/general-surgery-residency-program Bassett Surgery Residents on Instagram https://www.instagram.com/bassettsurgeryresidents/ North American Rural Surgical Society https://www.northamericanrss.org/

  7. Sep 17

    Why Rural Surgeons Can’t Afford to Be Too Specialized (Part 2)

    Stuart Ferguson returns for part two of his conversation on The Rural American Surgeon to explore the practical realities of providing urologic and general surgical care in the remote Shetland Islands. Stuart discusses the limitations that come with practicing in a small island hospital, including equipment decisions, limited critical care capacity, weather that can prevent patient transfers, and the need to know when a case should be referred. He then walks through his approach to transurethral resection of the prostate, including patient selection, equipment, safety landmarks, difficult catheter placement, and how elective urology experience helps when managing emergencies. The conversation expands beyond the operating room as Stuart shares his approach to charitable giving and how he and his wife make global health work in Zambia a regular part of their careers. He explains how rural surgery gave him the broad skill set needed to work in low resource environments and shares a case that demonstrates the value of being a generalist who can see the whole patient rather than a single problem. The episode concludes with practical resources for rural surgeons and an introduction to the Viking Surgeons Association. Key Takeaways 00:00 Returning for Part Two With Stuart Ferguson 00:48 Managing Kidney and Bladder Stones in Shetland 01:37 How Often Stuart Performs TURPs 01:48 Operating Rooms, Endoscopy, and Critical Care Capacity 02:26 Patient Transfers and Scotland’s Retrieval Service 02:54 When Weather Makes Transfer Impossible 03:32 Selecting the Right Patient for a TURP 05:14 Equipment and Safety Principles for TURP 06:15 Cystoscopy and Identifying Key Landmarks 07:33 Managing a Difficult Urethra 08:19 Difficult Foley Catheter Placement and Guidewire Techniques 09:23 Using Urology Skills to Manage Severe Hematuria 09:59 Stuart’s Approach to Tithing and Charitable Giving 10:50 Automating Giving Through a Separate Account 11:27 Supporting Global Health Work in Addition to Giving 13:05 Faith and Community in Shetland 14:31 The Viking Surgeons Association and Rural Surgery Community 16:09 Randy’s Path Into Rural Surgery 18:44 Training Specifically for a Rural Surgical Career 20:29 Creating Change Within a Small Rural Health System 21:31 Making Time for Global Health Work in Zambia 21:54 Stuart’s Connection to Rural Surgery in Zambia 23:30 How Global Health Work Maintains Surgical Skills 26:13 Why Rural Surgery Transfers Well to Low Resource Environments 28:20 The Value of Being a Holistic Generalist 29:30 Connecting Multiple Medical Problems Across Specialties 30:18 Recognizing When the Patient’s Greatest Need Is Something Else 32:45 Resources for the Busy Rural Surgeon 33:24 AO Surgery Reference for Unfamiliar Procedures 33:54 Primary Surgery for Low Resource Settings 34:54 The Viking Surgeons Association Resources Mentioned  AO Surgery Reference  Viking Surgeons Association  Royal College of Surgeons of Edinburgh  Faculty of Remote, Rural and Humanitarian Healthcare  NHS Shetland

  8. Sep 10

    Why Rural Surgeons Can’t Afford to Be Too Specialized (Part 1)

    Stuart Ferguson, a consultant general surgeon in Scotland’s remote Shetland Islands, joins The Rural American Surgeon to discuss what it takes to practice surgery 200 miles into the North Sea and why he deliberately built his career around becoming a broad surgical generalist. Stuart shares his training journey from Glasgow and Northern Ireland to colorectal surgery, global health work in Zambia, and Scotland’s Rural Surgical Fellowship. He explains how the fellowship allowed him to build additional skills in urology, orthopedics, trauma, and obstetrics specifically for the needs of Shetland. The conversation also explores what surgical practice looks like for a population of roughly 22,000 served by three consultant general surgeons. Stuart describes a practice divided between general surgery, urology, trauma, and orthopedics, along with endoscopy and emergency procedures that would typically be divided among several specialists in larger hospitals. The episode concludes with a look at how he developed the urology skills needed to practice independently in such an isolated setting. 00:00 Why Rural Surgery Creates a Broad Skill Set 00:45 Meeting Stuart Ferguson and the UK Tradition of Calling Surgeons “Mr.” 05:42 Stuart’s Surgical Training in Scotland and Northern Ireland 07:30 Going From Colorectal Training Back to Generalist Surgery 08:00 Scotland’s Rural Surgical Fellowship 08:38 Building Skills in Urology, Orthopedics, Trauma, and Obstetrics 09:21 How Many General Surgeons Serve the Shetland Islands 11:51 What “Rural” Means in an Extremely Isolated Community 17:01 Shetland’s Scandinavian History and Culture 18:33 Serving 22,000 People With One Hospital and Three Surgeons 19:32 Stuart’s Mix of General Surgery, Urology, and Orthopedics 20:45 The Bread and Butter Procedures of a Shetland Surgeon 21:17 Managing Complex Cases and Surgical Emergencies 22:33 Endoscopy Without a Gastroenterologist 31:09 How Stuart Built His Urology Skills After General Surgery Training 32:08 Using the Rural Surgical Fellowship to Prepare for Shetland 33:13 Training for Independent Urologic Practice 200 Miles Into the North Sea Resources Mentioned ●  NHS Shetland ●  Royal College of Surgeons ●  British Society of Gastroenterology

See All (81)

Trailer

4.9
out of 5
23 Ratings

About

Welcome to ”The Rural American Surgeon,” a podcast series dedicated to providing insights, resources, and a community for the surgeons of rural America. Your host, Randy Lehman, is an established authority on the multifaceted aspects of rural surgery—from the unique professional benefits and challenges, rural surgical training paradigms, current reimbursement landscape, and how to create triple win opportunities for sustainable rural surgery in partnerships with hospitals and rural communities. This podcast is designed for both rural general surgeons and rural surgical specialists who are seeking not just advice and guidance on practicing in rural areas, but also inspiration to foster valuable partnerships across our great land. Each episode is a deep dive into topics such as mastery of rural surgery, the rural lifestyle, fighting professional isolation, building a system to ensure surgical services are offered at a high level, using scarce resources wisely, achieving personal financial freedom, accessing a wealth of outside surgical resources, and inspiration at a high level of why what we do is important.

Information

You Might Also Like