The Rural American Surgeon

E42: ERCP Up Close: A Fellow’s Guide to Advanced Endoscopy | Dr. Benji Smith

What happens when you're learning one of surgery's most technical procedures from a living legend?
 
Dr. Benji Smith, an advanced endoscopy fellow training under the renowned Dr. Vitale in Louisville, joins host Dr. Randy Lehman to share his journey from general surgery residency to mastering ERCP. 
 
The two discover a surprising connection to the same medical mission in Guaimaca, Honduras before diving into the nitty-gritty of procedures most surgeons only hear about in referral notes.
 
From scope positioning and sphincterotomy techniques to stent placement and EUS biopsies, Dr. Smith breaks down what makes this specialty so challenging and so critical. 
 
Plus, find out why he actually enjoys treating pancreatitis patients (yes, really!) and a perspective shift that might change the way you think about collaborating with advanced endoscopists.
 
0:00 Introduction
1:03 Dr. Smith's Background
7:09 What We Have In Common
9:33 How I Do It: ERCP
22:26 How I Do It: EUS
38:54 Financial Corner
43:21 Classic Surgery Stories
53:21 Resources for the Busy Rural Surgeon
Resources Mentioned
 
🌐 ERCP Fellowship Program, University of Louisville: https://louisville.edu/medicine/departments/surgery/fellowships
🌐 Guaimaca Medical Mission, Honduras: https://www.honduranmission.org/
🌐 PRISMA Health Upstate General Surgery Program: https://academics.prismahealth.org/graduate-medical-education/residencies/general-surgery-greenville

E41: Money Miniseries 3: Investing

What if the biggest ROI isn’t measured in dollars, but in freedom?
 
In this third installment of his finance miniseries, Dr. Randy Lehman unpacks what it really means to invest—beyond the usual “just put it in a 401(k)” advice.
 
From real estate and business ownership to tax liens and even cattle, Dr. Lehman pulls back the curtain on investment opportunities most professionals never hear about. This episode isn’t just about growing wealth—it’s about understanding risk, stewarding wisely, and building a life that money alone can’t buy.
 
With personal stories of loss, faith, and lessons from the parable of the talents, Dr. Lehman invites you to rethink what it means to truly invest—in assets, in people, and in yourself.
 
0:00 Introduction
3:45 Beyond Stocks and Bonds: The Full Investment Spectrum
8:20 Understanding Risk
15:30 Risk Tolerance Through Life Stages
22:15 Personal Stories of Loss and Faith in Investing
35:40 The Biblical Foundation of Investment Strategy
42:10 From Debt Elimination to Asset Building
48:25 Real Estate
55:30 Business Ownership and Alternative Investments
1:02:15 Cash Flow vs. Appreciation Strategies
1:08:45 The Freedom That True Wealth Provides

E40: Bringing Robotics to Rural Alabama with Dr. Quince Gibson

What happens when you bring cutting-edge robotic surgery to one of the poorest regions in America?
 
Host Dr. Randy Lehman welcomes Dr. Quince Gibson, a UAB-trained general surgeon serving rural Alabama's Black Belt region. Born in Jamaica and shaped by a life-changing encounter with poverty in inner-city Baltimore, Dr. Gibson made the bold decision to leave a successful business career to pursue medicine. His mission: bring quality surgical care to communities where 31% of residents live below the poverty line.
 
Dr. Gibson shares his remarkable journey of establishing trust in a community skeptical of healthcare, the challenges and triumphs of implementing robotic surgery in a critical access hospital, and why the robot ultimately couldn't be sustained with just one surgeon. From managing post-operative bleeding without call coverage to performing emergency surgery with limited resources, he reveals the stark realities of rural surgery in America's most underserved regions.
 
Discover the three A's of surgical success, learn the technical details of robotic ventral hernia repair, and understand why sometimes the most advanced technology isn't the answer to healthcare disparities.
 
0:00 Introduction
1:16 Dr. Gibson's Background
5:25 Why Rural Surgery Is Special to You
29:40 How I Do It: Robotic Ventral Hernia Repair
54:02 Financial Corner
1:00:32 Classic Rural Surgery Stories
1:17:28 Resources for the Busy Rural Surgeon
Resources Mentioned
 
📚 “Atomic Habits” by James Clear: https://a.co/d/dV7BWeH
📚 “The Talent Code” by Daniel Coyle: https://a.co/d/fxzAOVU
 
🌐 UAB Rural Surgery Program: https://www.uab.edu/medicine/home/education/md-program/rural-medicine/rural-medicine-program

E39: Money Miniseries 2: Freedom in Frugality

Beyond the 'why' of money lies the 'how'—and it starts with a practical paradox most doctors never hear: the less you need, the richer you become.
 
What if the secret to true wealth isn't earning more, but spending less? In episode two of his finance miniseries, host Dr. Randy Lehman reveals why frugality is the unsung hero of wealth building. This isn't about pinching pennies or living like a monk—it's about buying back your freedom. 
 
Dr. Lehman shares his remarkable journey from a negative $150,000 net worth in residency to positive $400,000 by graduation, achieved through four strategic moves that most doctors never consider. From his $83,000 house two blocks from the hospital to the 12-unit apartment deal that taught him everything about real estate investing, Dr. Lehman demonstrates why your spending dictates your freedom more than your income ever will.
 
Discover the 4% rule, learn why minimalism is the upgrade to frugality, and understand how living below your means creates the margin needed for true financial independence.
 
0:00 Introduction
2:45 The FIRE Movement and 4% Rule
8:30 Frugality vs. Scarcity Mindset
12:15 The $83,000 House Story
18:20 Minimalism as an Upgrade
22:10 Four Ways to Build Net Worth in Residency
35:45 The 12-Unit Apartment Deal
42:30 Why Nothing is Permanent
44:15 From Saving Phase to Growth Phase

E38: The Colonoscopy Chronicles with Dr. Dan Margo

What happens when you're the only surgeon for hundreds of miles and every decision matters?
 
Host Dr. Randy Lehman welcomes Dr. Dan Margo, a seasoned rural surgeon from northern Minnesota, who has spent decades mastering the art of surgical practice in isolation. Dr. Margo shares hard-won insights from his years serving remote communities, including the unique challenges of being a visiting surgeon and the critical importance of collegiality in rural practice. 
 
They dive deep into colonoscopy techniques–including abdominal pressure maneuvers and advanced lesion removal strategies–while exploring everything from Miralax prep protocols to pre-anesthesia evaluation timing. Dr. Margo demonstrates why rural surgeons must be master diagnosticians, skilled technicians, and compassionate caregivers all rolled into one.
 
Tune in for an inspiring episode filled with practical surgical wisdom from the frontlines of rural healthcare, where innovation is born from necessity and every patient interaction truly counts.
 
0:00 Introduction
2:58 Dr. Margo's Background
5:22 Why Rural Surgery Is Special to You
23:52 How I Do It: The Colonoscopy
1:35:40 Financial Corner
1:37:06 Resources for the Busy Rural Surgeon
Resources Mentioned:
🌐 Foregut Disease Foundation course: https://foregutdiseasefoundation.org/2025-course
🌐 North American Rural Surgical Society: https://www.northamericanrss.org/
🌐 American Society for Gastrointestinal Endoscopy (ASGE) Guidelines: https://www.asge.org/home/resources/publications/guidelines
🌐 Cologuard test (alternative screening method for colorectal cancer): https://www.cologuardtest.com/

E37: Money Miniseries 1: What's the Point? Why Money Means Nothing Without Purpose

Introducing a new miniseries on money—starting with the question beneath the dollars: What’s the point?
 
Before we talk finance, we’re digging into foundations. In this episode, Dr. Randy Lehman shares an unexpected conversation with ChatGPT about evolution, intelligent design, and the meaning of existence—revealing why, for him, the evidence points to faith over chance.
 
But this isn’t just about science. It’s about worldview—how what you believe about life shapes how you handle money.
 
Dr. Lehman pushes back on the pursuit of wealth for its own sake, arguing that without a higher purpose, money is meaningless. He challenges listeners to redefine what it truly means to be “rich”—and why, in the end, the means are the ends.
 
This episode sets the stage for the entire series: exploring money as a tool for freedom, purpose, and lasting impact.
 
0:00 Introduction
2:15 The Most Important Question
3:30 A Conversation with ChatGPT About Evolution and Design
15:40 Why Darwin's Finches Don't Prove Macroevolution
18:55 The Cultural Fallout of Teaching We're Cosmic Accidents
25:30 ChatGPT's Stunning Response
31:20 From Utilitarian Thinking to Faith-Based Purpose
34:10 Money as Freedom vs. Monument Building
36:05 Redefining “Rich”
 

E36: Saving a Dying Hospital with Dr. Manu Kaushik

What happens when a rural hospital loses its only surgeon and faces closure?
 
Host Dr. Randy Lehman welcomes Dr. Manu Kaushik, who stepped in to save a dying critical access hospital in Greenville, Alabama. After 40 years of service, the hospital's longtime surgeon retired, COVID hit, and the OR shut down completely - threatening the entire community's access to care. 
 
Dr. Kaushik shares his incredible journey of rebuilding surgical services from scratch, training staff, fixing broken equipment, and literally buying his own instruments to keep patients from having to travel hours for basic care. 
 
They dive deep into his innovative modified Smead-Jones hernia repair technique, discuss IPOM and component separation procedures, explore the transition from laparoscopic to robotic surgery, and cover everything from inguinal repairs to emergency trauma management.
 
Tune in for an inspiring episode filled with practical surgical techniques and unforgettable stories from the frontlines of rural healthcare.
 
0:00 Intro
1:54 Dr. Kaushik's Background
6:43 Why Rural Surgery Is Special to You
11:00 How I Do It: Ventral Hernia Repair
20:22 How I Do It: Smead-Jones Stitch
28:23 How I Do It: IPOM Technique
35:13 How I Do It: Robotic Inguinal Focus
43:51 How I Do It: Mesh Placement in Hernia Repair
55:48 Financial corner
1:06:06 Classic Rural Surgery Stories
1:23:18 Resources for the Busy Rural Surgeon
Resources Mentioned
 
🌐 American College of Surgeons (ACS) Rural Trauma Development Course: https://www.facs.org/quality-programs/trauma/education/
 
🌐 ACS Stop the Bleed Program: https://www.stopthebleed.org/
 
🌐 ACS Rural Surgery Resources: https://www.facs.org/for-medical-professionals/education/programs/so-you-want-to-be-a-surgeon/section-iii-surgical-specialties/rural-surgery-program/
 
🌐 MGMA (Medical Group Management Association) Data: https://www.mgma.com/mgmadata

E35: Carotid Endarterectomy Mastery with Dr. Michael Roskos

How do you perform a carotid endarterectomy with confidence while ensuring patient safety in a rural setting?
 
Host Dr. Randy Lehman welcomes Dr. Michael Roskos, his former program director for the rural surgery track at Mayo Clinic, to dive deep into this critical procedure. They explore patient selection criteria, detailed surgical techniques, and the evolution of vascular surgery practice over the decades. 
 
Dr. Roskos shares his experience practicing in La Crosse, Wisconsin, and his weekly surgeries in the small town of Arcadia, where he operated on patients whose families he'd known for generations.
 
Tune in for an in-depth discussion where technical mastery intersects with the unique demands of rural healthcare.
 
0:00 Introduction
1:52 Dr. Roskos’ Background and Path to Rural Surgery
4:11 Why Rural Surgery Is Special to You
6:08 How I Do It: Carotid Endarterectomy
29:30 Financial Corner
33:49 Classic Rural Surgery Story
39:30 Finding The Right Surgical Volume Balance
43:21 Resources for The Busy Rural Surgeon
45:03 Outro
Resources Mentioned
 
🌐 Rural surgery listserv: https://gaggle.email/join/distribution-list@rural-surgery.ca
🌐 National Comprehensive Cancer Network Guidelines (NCCN): https://www.nccn.org/guidelines/
🌐 UpToDate - Medical Resource recommended by Dr. Rosko: https://www.uptodate.com/

E34: Rural Surgery on the Cutting Edge with Dr. Greg Gerrish

What does it take to bring advanced foregut surgery to a rural hospital?
Host Dr. Randy Lehman sits down with Dr. Greg Gerrish, a third-generation surgeon practicing in South Dakota, to talk shop on the real-world challenges and wins of rural surgical care. From Barrett’s esophagus to emergency thoracotomies, Dr. Gerrish brings both technical depth and day-to-day experience to the conversation.
They cover Dr. Gerrish’s approach to laparoscopic hiatal hernia repair, his reasons for avoiding bougie-assisted intubation, and how he selects patients for LINX procedures. He also walks through a high-stakes trauma case that required fast thinking and decisive action. 
 
This episode offers a look into the kind of surgical work being done far from academic centers—but with no less precision or purpose.
 
0:00 Intro
3:23 Dr. Gerrish's Background
10:25 Why Rural Surgery Is Special To You
13:46 How I Do It: Laparoscopic Foregut
1:03:48 Financial Corner
1:04:49 Classic Rural Surgery Story
1:12:21 Closing Thoughts
 
Resources Mentioned:
🌐 Foregut Disease Foundation course: https://www.forgutdiseasefoundation.org/
🌐 Comprehensive General Surgery Review Course (Mayo Clinic): https://ce.mayo.edu/surgery/content/comprehensive-general-surgery-review-course-2024

E33: Bariatric Breakthroughs in Rural America with Dr. Kabir Mehta

What happens when Mayo Clinic precision meets small-town grit?
Dr. Randy Lehman sits down with Dr. Kabir Mehta, who never expected to land in Hazard, Kentucky–population 5,000–but now finds deep purpose in bringing advanced bariatric care to a region where patients used to drive hours for a specialist. 
This honest doctor's lounge conversation covers the real stuff: Dr. Mehta’s surgical strategies for handling bariatric emergencies, how he earned trust in a town where everyone knows everyone, and what it takes to not just survive but thrive in rural practice.
They dig into technical hurdles, financial realities, and those 2 AM moments when you’re the only one on call. But it’s not all struggle–there’s something powerful about practicing medicine where you know your patients’ stories and see the difference you're making every day.
0:00 Intro
5:11 Dr. Mehta's Background and Practice
14:42 How I Do It: Bariatric Emergencies
26:28 Managing Internal Hernias in Bariatric Patients
48:13 Embracing Failure and Learning from It
59:30 Missed Shuttle Story
1:08:48 Closing Thoughts
Resources Mentioned:
🌐 White Coat Investor: https://www.whitecoatinvestor.com/
▶️ Dr. Kabir Mehta's YouTube channel: @KabirMehtaMD