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/

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/

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

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/

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

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

Dr. Amiri, program director at Marshall University, and fourth year surgery resident David Kanarowski join The Rural American Surgeon to discuss Marshall’s dedicated rural general surgery residency and how it prepares surgeons for independent practice in rural communities.

They explain how residents spend roughly two thirds of their training at rural hospitals, gaining early operative experience without competing with other residents for cases.

The conversation covers the broad skills rural surgeons may need, including C-sections, endoscopy, orthopedics, and procedures shaped by the resources available in their future communities.

Dr. Amiri and David also share what Marshall looks for in applicants and why a genuine commitment to rural life matters. The episode concludes with a practical discussion of Dr. Amiri’s approach to robotic right colectomy.

01:07 Why Marshall Created a Rural Surgery Residency

02:26 Spending Two Thirds of Training in Rural Hospitals

03:09 Preparing for a Career in a Small Town

05:27 Tailoring Training to Future Rural Practice

06:48 How Marshall’s Rural Residency Is Structured

07:49 What Marshall Looks for in Rural Surgery Applicants

09:03 Case Volume and Early Operative Experience

09:53 Taking Call in a Rural Hospital

10:43 Housing and Rural Rotation Sites

11:56 Training with OB/GYN, Orthopedics, and Other Specialties

13:59 Endoscopy and C-Sections in Rural Practice

16:14 Finding Residents with a Rural Mindset

17:02 Training General Surgeons Rather Than Specialists

18:29 Fellowships That Can Benefit Rural Surgeons

20:11 How Dr. Amiri Performs a Robotic Right Colectomy

22:33 Medial to Lateral Dissection and Pedicle Ligation

24:28 Using ICG to Identify the Middle Colic

26:55 Bowel Transection and Stapling Technique

29:05 Creating the Anastomosis

30:44 Postoperative Care and Early Discharge

31:26 Adapting the Technique Without a RobotResources Mentioned

● Marshall University

Dr. Anne O’Rourke, program director at the University of Wisconsin, joins The Rural American Surgeon to discuss how UW’s rural surgery track prepares general surgery residents for independent rural practice.

She explains how the five-year program combines training in Madison with recurring rural rotations, giving residents experience with the broad skill set rural surgeons need, including endoscopy, C-sections, trauma stabilization, and general surgery.

Dr. O’Rourke also shares what the program looks for in applicants and why courage, confidence, resilience, and exposure to practicing rural surgeons are essential for preparing the next generation of rural surgeons.

00:45 Training the Next Generation of Rural Surgeons

01:56 Why Wisconsin Created a Rural Surgery Track

03:09 The Five-Year Rural Surgery Pathway

06:58 How Rural Rotations Are Structured

09:32 What UW Looks for in Rural Surgery Applicants

11:16 Courage, Confidence, and Resilience in Rural Practice

13:58 Training in C-Sections and Other Rural Surgical Skills

16:03 Endoscopy, C-Sections, and Trauma Stabilization

17:36 Preparing Residents for Independent Practice

19:09 Why Exposure to Rural Surgeons Matters

20:41 Why Surgeons Choose Rural Practice

24:34 The Importance of Providing Care Close to Home

Resources Mentioned● University of Wisconsin Rural Surgery Track

● Wisconsin Surgical Collaborative

● North American Rural Surgical Society

● University of Wisconsin Rural OB/GYN Track

● NRMP Match