From the 5th grade, ACS Regent Gary Timmerman, MD, FACS, knew he wanted to be a physician.
“I was going into medicine, and I wanted to be a surgeon,” he said from the University of South Dakota Sanford School of Medicine, where he is chair of surgery.
A fan of M*A*S*H, a television series about an American surgical hospital in Uijeongbu, South Korea, during the Korean War, he was inspired by the commitment to helping patients against all odds. “I wanted to be like Hawkeye,” he said, referring to Alan Alda’s character.
“My older brother, who was also a surgeon and just recently retired, decided to get into medicine when I was in high school. He’s the one who told me, ‘If you’re going to do it, start now’,” Dr. Timmerman recalled.
As he made his way through high school, he worked hard and did well, leading him to a pre-med track as a chemistry major.
“I worked as a scrub tech over the summers, too,” he said. “I helped take out my first appendix when I was 18 years old. It speaks to how much the earliest parts of your life can have a profound influence on your career.”
After studying, scrub teching, and practicing, he made his way to medical school, 2 years at the University of South Dakota, then graduating from Washington University in St. Louis, Missouri. Shortly after, he matriculated to Chicago, Illinois, for residency at Rush Presbyterian—St. Luke's Medical Center.
“I always knew I wanted to come back to South Dakota and serve people there,” he explained.
After 5 years in Chicago, which included a 3 month stop in Washington, DC, at Children's National Hospital for pediatric surgical training, he did just that.
Back Where It All Began
Watertown, South Dakota, had a population of 18,000: “I brought a lot of new skills to the community there, but I also learned a lot,” he said. “In Chicago, I did 3 months at John H. Stroger Jr. Hospital of Cook County, where I saw a lot of knife and gun injuries. In Watertown, it was car and farm accidents.
His experience at a large, urban public access hospital allowed him to have significant influence over getting care to patients.
“ATLS and trauma leveling was just catching on in the mid-1980s. We didn’t have a statewide trauma system. We didn’t have ER physicians. So, I was able to help them rewrite how to identify a seriously injured patient,” he explained.
Dr. Timmerman helped set up minimum requirements for looking after patients. Nurses, often the first point of contact, could take vitals and call trauma codes if needed. It was a new mobilization concept, which eventually led to the establishment of a full-time emergency room.
A True General Surgeon
For cancer care, he was able to provide the same transformative approach.
“I knew what I wanted to achieve,” he explained. “In 1989, there were only two radiation centers in the whole state of South Dakota.”
Dr. Timmerman performed the lumpectomy for breast cancer patients and then transferred their care to radiation centers in Sioux Falls or Aberdeen with hotel partnerships for the length of their stay.
“Executive committees didn’t understand there were different modalities for cancer care, but through this work, we were able to move the hospital's cancer care forward,” he said.
During his time in Watertown, Dr. Timmerman was able to apply everything he learned throughout his training. “I stayed in general surgery, and some specialists knew I was going to do that, so I was able to learn a lot from them,” he said.
“I did about 300 c-sections, probably more,” he recalled. “I did urological procedures, ortho, dialysis catheters, any major internal organ resections, esophageal and lung procedures, pacemakers, and pediatrics. There was only one other pediatric surgeon, and he was in Sioux Falls,” he said.
His practice was defined by what he felt comfortable doing, especially with open procedures. As laparoscopy took over in 1989, Dr. Timmerman and his team traveled to Chicago to get trained.
Leading to Create Change
After 10 years in Watertown, Dr. Timmerman moved to Sioux Falls to work with Sioux Valley Hospital—now Sanford Medical Center—and The University of South Dakota Sanford School of Medicine, where he remains today.
In South Dakota, there was no surgical residency program established, but Dr. Timmerman knew the ACS had vested interest in creating new generations of surgeons.
“We are rural, but the hospital has 500 beds. We were doing 25,000 surgeries a year, but we weren’t training anyone,” Dr. Timmerman said of the lack of a general surgery residency program.
As Chair of the Board of Governors, he turned to the ACS for help mitigating the problem. “The College was hugely supportive of letting me spearhead a rural general surgery program. They recognized the need,” he said.
In 2012, the chair of surgery at the University of South Dakota retired, and Dr. Timmerman knew that to get this residency program off the ground, he needed to be in a position of leadership.
“I applied for and became chair because I needed the authority to take the next steps necessary to help create a surgical residency. I had a clinical appointment, but not academic. We started the program in 2014 with three residents per year (six total the first year), and now we’re up to four per year,” he said. “We have a 100% board pass rate, and 53% immediately go into rural general surgery practice. We are doing our best to replenish the depleting rural surgical workforce.”
Advocating for Patients
South Dakota was one of the last states to adopt the Affordable Care Act (ACA), because it is not solely dependent on marketplace insurance. The state has a high Medicare rate due to the relative age of the population and has South Dakota Urban Indian Health, a blended insurance program with federal backing, for Native Americans.
The issue most faced in South Dakota is one immovable social determinant of health: distance to care. This is significant hurdle when dealing with acute events like heart attack or trauma, which can be secondarily influenced by extreme weather.
“There are small critical access hospitals, but they couldn’t deal with acute problems. Even at the turn of the century, when you get west of the Missouri River, which cuts South Dakota in half, there were huge areas with historically no 911 service,” Dr. Timmerman said.
But Dr. Timmerman has a knack for being in the right place at the right time.
“Around 2002, I was at a basketball tournament with my family, and we got snowed in by a blizzard. Governor Mike Rounds (now Senator) was at the same tournament, so I brought him a cup of coffee and asked if I could talk to him,” he said.
Dr. Timmerman noted the lack of 911 coverage and brought the governor the idea of a statewide trauma system. A few weeks later, he was alerted it would be in the state budget and was able to help write it.
“There were 54 hospitals in the state, and 47 of them were critical access,” he said. “So, we made them all trauma centers. State law mandates they have training, real-world experience, and continuing education.”
Since then, trauma related deaths in South Dakota for those who make it to any hospital have dropped to national levels, on par with major cities like Atlanta and Chicago.
Sanford Health, the largest rural healthcare system in the nation, created Sanford Medical Education (SME), where Dr. Timmerman serves this as one of the medical directors.
Through this initiative, SME has established Sanford funded residency programs staffed by educators throughout the Sanford footprint. These programs now exist throughout the rural upper Midwest like North and South Dakota, Minnesota, and Wisconsin. Residencies now include emergency medicine, two cardiac fellowships, GI fellowship, neurology, family medicine, pediatrics, oncology, and surgical critical care.
“This all involves advocacy and speaks to the value of the ACS, our medical schools, and Sanford Health. Without this initial support, we wouldn’t be here,” he said.
Staying Focused
“My good friend L. D. Britt [MD, FACS,] has always said there is no excellent surgical care without access,” Dr. Timmerman said. “To be front and center with people who make decisions is important—you have to put yourself there sometimes.”
The ACS and its Division of Advocacy and Health Policy in Washington, DC, fights for patients every day, in ways that don’t always feel immediately obvious. But that’s part of doing the work.
“So much of what we do isn’t the big wins, it’s the things we prevent. Those are often bigger disasters,” Dr. Timmerman noted. “The ACA might be a bigger issue in cities than rural communities—$5 billion has been allocated to assist rural healthcare—but we must take care of each other no matter where we practice.”
Dr. Timmerman, who also counts Senate Majority Leader John Thune as a close friend of more than 35 years, knows what access to the right people can do. He is clear, though, that there is more than one way to have an influence—we must all run in the same direction, regardless of who is on Capitol Hill.
“We are all on the same team. That’s why I go to Washington, DC, to fight. Get yourself in the room, and don’t give up on your patients.”
