The Real Economics of Rural Surgery with Dr. Randy Lehman

In this episode of the BOSS Business of Surgery Series, host Dr. Amy Vertrees sits down with rural surgeon Dr. Randy Lehman for a wide-ranging conversation about rural surgery, financial freedom, and the future of surgical practice. Dr. Lehman shares his unconventional journey, from growing up on a farm in northwest Indiana to becoming a national advocate for rural surgery—complete with a helicopter commute between hospitals.

Together, they explore what makes rural surgery uniquely fulfilling, why independent practices struggle in today’s healthcare economy, and how financial independence can transform a surgeon’s career options and impact.

What You’ll Learn in This Episode

Dr. Lehman’s Path to Rural Surgery

Growing up on a farm, switching from pre-pharmacy to pre-med, and discovering a passion for rural surgery at Purdue and UC Medical School. He describes the unexpected doors that opened and closed along the way, eventually leading him to Mayo Clinic’s rural surgery track and a broad, high-volume surgical experience.

What Rural Surgeons Really Do

Rural surgery offers a broad scope of practice and the ability to care for patients of all ages—often with higher compensation for lower-acuity operations. Dr. Lehman shares examples from his own practice, which spans carpal tunnels to hysterectomies to skin cancer flaps, as well as why he avoids highly complex cases that require tertiary-care resources.

Training That Prepares You for Everything

He explains the difference between simply rotating through a rural hospital and completing true rural surgery training, which requires high volume across multiple specialties. His own training included over 1,600 cases—far above the national average.

The Hard Truth About Practice Models

Dr. Lehman opens up about the highs and lows of his post-residency years, including:

• Pursuing a job at his hometown hospital after it was sold

• Building a dual-location practice between two small hospitals

• Attempting an independent practice with $600k annual overhead and only $350k collection

• Writing $20–30k checks every few weeks just to keep the doors open

The takeaway: in today’s economic environment, hospitals subsidize surgeons because they recoup facility fees—while most independent practices cannot survive on professional fees alone.

Understanding the Economics: RVUs, Overhead, and Reality

He breaks down why his independent practice collected only $57 per RVU versus over $100 per RVU when employed—and what that means for surgeons who dream of autonomy. Dr. Lehman and Dr. Bertrand discuss the impact of decreasing reimbursement, increasing overhead, and the future risk of efficiency adjustments and bundled CPT payments.

Financial Freedom as a Career Strategy

Dr. Lehman's philosophy is simple and powerful: live on very little early in your career, invest wisely, and achieve financial independence fast.
He shares:

• How buying an $86,000 home allowed him to reach financial freedom within two years

• Why minimalism amplifies your negotiating power

• The role of real estate in accelerating independence

• How financial freedom allows him to give away hundreds of thousands of dollars each year

• Why money magnifies your character—good or bad

Building “The Rural American Surgeon” Podcast

Despite costing nearly $50,000 per year to produce, his podcast is a passion project aligned with his goal of becoming a national rural surgery leader. He shares why telling these stories matters for rural hospitals, local economies, and the future surgical workforce.

Entrepreneurial Thinking in Medicine

Dr. Vertrees and Dr. Lehman close with a powerful discussion on why physicians must think like entrepreneurs—not simply RVU generators. They explore how surgeons can reclaim autonomy, redefine their value, and build careers with freedom, flexibility, and mission at the center.

Chapters

• 00:00:00 – Dr. Randy Lehman’s Background and Journey

• 00:03:47 – The Scope and Benefits of Rural Surgery

• 00:06:00 – Rural Surgery Training and Case Volume

• 00:13:18 – Practice Models After Residency: Wins and Struggles

• 00:20:04 – The Real Economics of Surgical Practice

• 00:29:56 – Financial Philosophy & Becoming Independent Early

• 00:42:07 – Creating The Rural American Surgeon Podcast

• 00:47:56 – Entrepreneurial Mindset and Physician Autonomy

Action Items & Takeaways

• Seek a true rural surgery training track, not just rural exposure.

• Prioritize high-volume operative experience during residency.

• Buy a modest first home to accelerate financial independence.

• Practice generosity early, regardless of income.

• Explore rural surgery as a deeply rewarding and high-impact career path.

• Connect with Dr. Lehman at ruralamericansurgeon.com for more resources.