Contemporary issues in rural surgery
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Contemporary Issues in Rural Surgery Rural Surgery: Deﬁnitions and Current Status The term “rural surgeon” conjures up romantic images of a simple, idyllic practice for some vs an isolated individual with limited resources in a remote, desolate location for others. Obviously, the life of the typical North American rural surgeon lies somewhere in between these 2 extremes. Regardless of one’s perspective, it is widely agreed that rural surgery is in the middle of a worsening crisis.1-4 Although estimates vary, 20% to 25% of the US population live in rural regions, but only 10% to 15% of physicians practice in these areas.1,5-7 Rural patients and their families often live long distances from tertiary care centers and prefer to obtain medical and surgical care close to home. Rural general surgeons in particular appear to be in short supply, especially in small or isolated towns. Thompson and colleagues calculated the number of general surgeons per 100,000 population to be 4.67 in small or isolated rural areas vs 6.53 in urban areas.1 They concluded that “general surgeons form a crucial component of the medical workforce in rural areas of the United States. Any decline in their numbers could have profound effects on access to adequate health care in such areas.” Unfortunately, the trend in the last decade is for surgeons to move away from rural areas, further exacerbating an already existing shortage. In a recent study from the Sheps Center for Health Services Research, the American Medical Association (AMA) Physician Masterfile was used to track changes in physician practice location by US county during the 10-year period from 1996 to 2006.8 Of the 32% of surgeons who moved to a different county during that decade, the overall tendency was to move to locations with more physicians and a better overall economic climate. This disturbing trend parallels work by Lynge and associates who noted that the general surgeon-to-population ratio declined in rural areas from 6.36 per 100,000 in 1981 to 5.02 per 100,000 in 2005.2 Finally, additional data from the Sheps Center have identified 903 US counties in which there was no Curr Probl Surg 2012;49:263-318. 0011-3840/$36.00 ⫹ 0 doi:10.1067/j.cpsurg.2012.01.002
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Curr Probl Surg, May 2012
general surgeon in 2006; one half of these counties did have at least 1 hospital.9 General surgeons are clearly vital to the economic and service line health of rural hospitals. For this and many other reasons, 438 US rural hospitals closed from 1980 to 1998.10 Although the Critical Access Hospital (CAH) Program has resulted in many fewer hospital closures in recent years, many rural hospitals run on the narrowest of margins, require increased philanthropic or community support, and limit services offered based on finance. Currently, of more than 2000 rural hospitals in the United States, 1327 are designated as CAHs and two thirds of these have a general surgeon on staff.9
Definitions Measuring “rurality” of a community has proven to be complicated as it encompasses more than a simple determination of the population. A town of 2500 that is located 10 miles away from a major metropolitan area has far more urban characteristics than a town of 2500 located 250 miles away from the nearest city. The rural vs urban characteristics of each county in the United States have been described by the Office of Management and Budget as metropolitan or micropolitan based on Metropolitan Statistical Areas (MSA). To provide a more granular assessment of “rurality,” the Office of Rural Health Policy in conjunction with the United States Department of Agriculture Economic Research Service and the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) Rural Health Research Center at the University of Washington developed the Rural Urban Commuting Area (RUCA) codes in 1999.1 Based on measures of population density, urbanization, and daily commuting within each census tract (zip code) in the United States, this methodology was used to identify urban cores and adjacent areas that were economically integrated with each of these cores. The 10 main RUCA codes and 23 associated subcodes were aggregated to describe the rural or urban nature of each integrated community.11 Integrated communities were then classified into 4 categories: urban (⬎50,000 population), large rural (10,000-49,999 population), small rural (2500-9999 population), and isolated (⬍500 population) (Table 1). These are the most widely used definitions of rural vs urban in the rural surgery literature.12 For the purposes of this monograph, surgical residencies are classified as university or independent. University residencies include those based at or affiliated with a university medical center. Independent residencies refer to community-based and military residencies. 264
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TABLE 1. Classification scheme for rural versus urban nature of communities by RUCA Codes Classification Urban Large rural Small rural Isolated
Population Range ⬎50,000 10,000-49,999 2500-9999 ⬍2500
Positive Attributes of Rural General Surgery Those who are attracted to a rural surgery career are often from a rural background and wish to live and work in a small town.13 A location that is relatively safe and far away from the complexities and problems of large metropolitan areas is appealing to these individuals. Rural general surgeons are also quick to mention the advantages of unparalleled independence and a broad scope of practice, including a wide variety of procedures as reasons for selecting a rural practice.13 The addition of a general surgeon to a rural hospital may single-handedly raise the level of care and spectrum of services offered. Other positive characteristics of rural practice include immediate leadership roles in the hospital and the community. Rural physicians enjoy very close relationships with their patients and families with informal “postoperative follow-ups” in the local grocery or hardware store. Longitudinal care over time is also professionally gratifying for a surgeon involved in care from birth to death for a given patient or family. Polk and colleagues concluded in a recent review that the “strength of the generalist surgeon lies in continuity of care . . ., in the breadth of expertise . . . surgical services actually provided, and as an advocate for the surgical patient.”14
Challenges of Rural General Surgery Perhaps the most difficult challenge of rural general surgery (GS) is professional isolation. Many rural general surgeons are the sole surgical specialist in their hospital, lacking opportunities to discuss difficult diagnostic dilemmas or operative strategies with surgical colleagues. Mutual review of complications and outcomes is also problematic in a small institution with limited resources and personnel for morbidity and mortality conferences, tumor boards, or quality reviews. Specialtyspecific continuing medical education (CME) may not be locally available. These problems are exacerbated by a lack of call coverage, making for limited opportunities to travel for CME conferences, vacation, or new skill acquisition. Keeping abreast of intellectual and technological advances in surgery is much more formidable in such an environment. Curr Probl Surg, May 2012
Physician reimbursement in rural areas has been much lower for a given procedure than in urban areas even though the rural surgeon is held to the same standards of care. A rural surgeon often has less administrative assistance to negotiate the increasingly complex bureaucracy of billing, coding, medical records, legal matters, contracts, etc. Many rural hospitals have extremely limited budgets, making it difficult to invest in the equipment and personnel necessary to offer expanded or new services. Finally, rural surgeons are extremely vulnerable to volume as a surrogate for quality reviews. Many procedures performed by a rural surgeon are performed in small numbers annually. Based on certain published guidelines, their volume of these procedures will always be judged as low by third-party reviewers. When low volumes are mindlessly equated with low quality, this may affect a rural surgeon’s ability to perform many straightforward operations that they are fully capable of completing in their setting. In an effort to understand the challenges of rural surgery better and to develop rational strategies to reverse the aforementioned trends, this monograph reviews issues concerning workforce, scope of practice, training, recruitment, retention, and maintenance of quality in contemporary rural surgery practice. We conclude with a list of potential solutions for the problems that have been identified.
Workforce Issues: Current Needs, Future Predictors The surgical workforce has been studied now for almost 4 decades. In 1974, the American Surgical Association and the Board of Regents of the American College of Surgeons (ACS) published the Study of Surgical Services in the United States. The study concluded that a sufficient number of surgeons was probably available at that time. The Study of Surgical Services in the United States reported the estimate of the US surgeon workforce to be 6.93/100,000 population.15 More than 20 years later Kwakwa and Jonasson described the ratio of active general surgeons 63 and under as 7.5/100,000. The average age of these surgeons was 47.5 years in metropolitan areas and 48.6 in rural areas. In this study, 92.8% of the surgeons were located in metropolitan and adjacent areas, and only 6.9% were in strictly rural areas.16 Almost a decade later Thompson and colleagues reported on densities of surgeons that ranged from 6.53 per 100,000 in urban areas to 7.71 per 100,000 in large rural areas, to as low as 4.67 per 100,000 in small, isolated rural areas. In these small rural areas, surgeons were more likely to be older than 50 years of age (ie, approaching retirement) and more likely to be an international medical graduate.1 In addition, the Graduate Medical Education National Advi266
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sory Committee predicted in 1980 that the number of board-certified surgeons in active practice would increase from 64,700 in 1980 to 113,000 in 2000. In fact, by 2000 the sum (including colorectal, GS, neurosurgery, orthopedic, ear, nose, and throat, plastic, thoracic, transplant, and urology) was calculated at 66,076, significantly less than the 113,000 predicted. Over this same period the US population had increased from 221 million to 281 million,17 so, although the population increased by 27% over this period, the number of surgeons only increased by 2%. Lynge and colleagues examined the GS workforce over the period 1981 to 2005. They discovered that the number of general surgeons per 100,000 population had declined by 25.9% over this 25-year period. The proportion of general surgeons younger than age 40 dropped substantially from 25.1% in 1981 to 16.2% in 2005. In 1981, 41.7% of active general surgeons were 50 to 62 years of age compared with 46.2% in 2005. Over this same period, the relative distribution of surgeons in urban vs rural practice remained stable with approximately 82% of general surgeons practicing in urban areas and 18% in rural areas. The 4.2% decrease in the absolute number of general surgeons practicing in the United States occurred in conjunction with population growth in the United States from 226 to 292 million between 1981 and 2005, a 29% increase. Over this period, the national general surgeon-to-population ratio declined from 7.68 per 100,000 in 1981 to 5.69 per 100,000 in 2005.2 So, the fact that there have been declining numbers of general surgeons in the face of an increasing population is indisputable. The reasons for this are many. The total number of graduating chief residents in the United States has been constant at about 1030 for 2 decades. During that same period the proportion of GS graduates who pursued fellowship training increased from 55% in 1992 to 70% in 2004.18 Although many of these fellowship-trained surgeons will continue to maintain some portion of their practice as a traditional GS practice, more will not and will tend to focus their practice for reasons of lifestyle or income. We believe that perceptions of a less attractive lifestyle, longer working hours, and decreased income are the main reasons for this gradual decline in the number of practicing general surgeons. This phenomenon has been eloquently described by J. David Richardson, who makes the point that although the professional satisfaction and prestige enjoyed by surgeons is still high, the current efforts of medical schools to diminish the perception of prestige among surgical disciplines has been effective.19 With the increased specialization within all of medicine and, certainly within surgery, there has been a tendency to Curr Probl Surg, May 2012
devalue the “generalist” general surgeon. He also makes the point that there have been marked decreases in income per case over the last decade and that “lifestyle” is the reason most frequently stated by those who decline to pursue a career in surgery. In 2008, a national survey was sent to 5345 categorical GS residents. There was an 82% response rate; 27.5% of respondents expressed concern that they would not feel confident performing procedures independently and 63.8% expressed the opinion that postgraduate specialty fellowship training was necessary to be competitive in the job market.20 Another fact that is clear is that there has been a substantial decline in payments for general surgical procedures during the past century. The combined annual decrease for 5 common general surgical procedures during 1991 to 2006 was 1.4%, or a 21% decline in reimbursements over this 15-year period. All values were held constant to 2006 dollars. This compares to an annual increase in the price of an automobile of 1.25%.21 There are ample data to indicate that the general surgeon workforce is declining in the United States. The reasons are many, including: (1) concern of an unattractive lifestyle; (2) concern about adequacy of training to become a confident, autonomous surgeon; (3) declining reimbursement for the general surgeon; and (4) the need for fellowship training to obtain both increased confidence in the operating room and a competitive edge in the marketplace. In essence, the rural surgeon is the “purest” form of a general surgeon with a broad-based practice that is much broader than the practice of an urban surgeon. In 1 large national study of workloads and practice patterns of 2434 general surgeons recertifying for the American Board of Surgery (ABS) from 1995 to 1997, the practice of urban surgeons was compared with rural surgeons. Forty-six percent of the total number of surgeons lived in MSA of more than 1 million population. This group was compared with the surgeons (19% nationally) living in a MSA less than 50,000. When these groups were compared over this period, rural surgeons performed 470 procedures annually compared with 336 for the urban surgeon. The rural surgeon performed 116 endoscopic procedures annually compared with 31 for the urban surgeon. Rural surgeons also performed more biliary tract procedures and herniorrhaphies, more gastrointestinal procedures, and more laparoscopic procedures. They also performed more gynecologic, urological, and orthopedic procedures, although the difference was slight.22 This national study of recertifying surgeons was recently reproduced and was based on 4968 surgeons recertifying from 2007 to 2009.23 Sixty-eight percent of those recertified in surgery alone GS, and 32% had 1 or more additional certificates (GS⫹) 268
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from the ABS or a certificate from another member board of the American Board of Medical Specialties (ABMS). On average, GS performed 533 procedures per year compared to 401 for GS⫹ (P ⬍ 0.001). Comparing the GS surgeons from 2007 to 2009 to their cohorts from the previous study22 (1995-1997), the 2007 to 2009 group performed a higher average number of total operations (533 vs 398, P ⬍ 0.001). As was documented in the earlier study, rural surgeons performed far more endoscopic procedures than the urban group.23 This dramatic increase in workload for the general surgeon in recent decades is supported by other investigations. Liu and colleagues examined data from the National Hospital Discharge Survey and the National Survey of Ambulatory Surgery from 1996. Collating these data, the total amount of work involved in performing GS operations was calculated and an estimate of work required in 2020 was compared with 2000. This was done with a projected increase in the US population of 18% from 2000 to 2020 and the projected aging of the population with a concomitant expected per capita increase in GS procedures as the population ages. Using this model, a 14.7% increase in surgical work required was projected from 2000 to 2010 and 31.5% from 2000 to 2020. This is partially explained by an estimated increase in the proportion of the population older than 65 years of 14% from 2000 to 2010 and 54.2% from 2000 to 2020 and the increased number of general surgical procedures required to maintain health in an older population.24 Therefore, we are sailing into a perfect storm. Rural surgeons perform more cases than urban surgeons, especially providing endoscopic services to their communities. Rural surgeons are general surgeons in the purest sense. The number of graduates of United States surgical training programs is static at approximately 1000 to 1030 annually. Fewer of these young surgeons are staying in GS, with about 80% currently seeking specialty fellowship training.25 Multiple studies show a declining number of rural surgeons in relationship to their population base.1,2,15,17 The total volume of surgical procedures required by the population is increasing.24 Reimbursement for general surgeons is declining.21 Finally, to make matters worse for the rural communities, there is evidence that rural surgeons are leaving rural areas to move to higher physical density areas. Data from the AMA Physician Masterfile show that many counties in the rural south, Appalachia, the Midwest, and rural southwest have no surgeons at all (Fig 1). In addition, for general surgeons, the number of counties without a general surgeon is even greater, 1138 vs 958 (Fig 2). Curr Probl Surg, May 2012
FIG 1. Map indicating total surgeons per 100,000 population by county in the United States, 2009. (Reprinted with permission from Gaul K, Poley ST, Ricketts TC III, et al. Mapping the supply of surgeons in the United States, 2009. Chapel Hill, NC: American College of Surgeons Health Policy Research Institute. Available at: http://acshpri.org/documents/SurgeonAtlas_BOOK.pdf.) (Color version of figure is available online.)
Goodman described the increase in overall physician-to-population ratio from 207 per 100,000 national population in 1980 to 296 per 100,000 in 2000 and demonstrated a reduction in physician workforce variations during this period.26 He opined that as physician numbers increased overall there was a gradual shift across the board (with 1 exception) from physicians practicing in areas of large hospital referral regions to smaller hospital referral regions. In other words, physicians tended to move from high physician supply areas to areas where physician supply was less. The 1 exception in Goodman’s study was GS, in which the number of surgeons per 100,000 population dropped by 15% during the 20-year period. There was also a reverse trend of general surgeons moving between higher and lower physician density areas compared with all other types of physicians (ie, general surgeons tended to move from the lower physician density areas to the higher physician density areas and most likely from the more rural areas to less rural areas).26 Doty and colleagues conducted a national survey of a selected sample 270
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FIG 2. Map indicating total general surgeons per 100,000 population by county in the United States, 2009. (Reprinted with permission from Gaul K, Poley ST, Ricketts TC III, et al. Mapping the supply of surgeons in the United States, 2009. Chapel Hill, NC: American College of Surgeons Health Policy Research Institute. Available at: http://acshpri.org/documents/SurgeonAtlas_BOOK.pdf.) (Color version of figure is available online.)
of 233 rural hospital administrators. To create the sample, using the American Hospital Association (AHA) Healthcare Database, they selected 2166 rural hospitals nationally that were identified for inclusion by being located in towns with RUCA codes between 4 and 10 (excluding 4.1, 5.1, 7.1, 8.1, and 10.1). They then randomly selected 233 hospitals. They had a 48% response rate; 59% of the respondents were from CAHs, and the median population service area for each hospital was 25,000. These responding hospitals had a median of 2 full-time surgeons on staff, with a median of 1 full-time board-certified general surgeon on staff. Thirty-four percent of these hospitals reported a surgeon leaving in the next year and 36% reported they were actively recruiting a surgeon. The responding hospitals reported a median of 12 months required to recruit a surgeon. Twelve percent of these hospitals stated that if they lost the surgery program, the hospital would be forced to close.7 If we extrapolate the finding that 36% of these rural hospitals were actively recruiting a Curr Probl Surg, May 2012
general surgeon, across the 2166 rural hospitals in the original sample that met the RUCA codes (36% ⫻ 2166), this indicates that at that time in the United States it is likely that there was an immediate need for 780 rural surgeons nationally. We are only graduating 1030 GS residents per year and 80% of them are pursuing subspecialty training and thus would be unlikely to consider practice in a rural setting. Thus, for the purposes of discussion, we can estimate that only 206 (0.20 ⫻ 1030) new graduates per year are produced to fill 780 potential spots in rural surgery, even if all of those graduates chose a rural location. A similar study performed in Tennessee was recently reported. Using identical RUCA code inclusion criteria to Doty’s study, 80 rural hospitals were identified in the state of Tennessee, and 36% responded to a very similar survey instrument as that administered by Doty. Fifty-four percent of those hospitals were actively recruiting a surgeon with a mean recruitment time of 11.8 months.27 If we extrapolate these data (54% ⫻ 80), there were 43 rural surgery jobs available in Tennessee. The combined GS training programs in the state graduate 28 GS residents per year with only 6 (0.20 ⫻ 28) available for GS jobs, leaving at least 37 jobs unfilled in rural hospitals looking for a surgeon in Tennessee alone. The fact that there is a declining GS workforce that especially impacts the supply of the rural surgeon is indisputable. The economic impact of this phenomenon is enormous on rural and community hospitals. The pressing question at this point is what can be done to reverse this trend. It is our belief that another principal cause of this shortage, in conjunction with the reasons listed previously, is that most of our trainees are in university or university-affiliated residency programs, in which the exposure of the surgical trainee to any general surgeon, especially one in rural practice, is extremely limited or absent. The trainee’s mentors are almost all fellowship trained (hepatobiliary, surgical oncology, vascular, breast, etc), and with the possible exception of the acute care surgery services, residents are never or rarely exposed to a surgeon with a broad-based GS practice. This must be remedied. Programs must be encouraged to rotate their residents away from urban universities into private practice settings in the community, or better still, into rural practices.14 Although this creates some potential issues with Medicare funding of graduate medical education, the benefits can be enormous, especially in obtaining the requisite endoscopic training for the surgical trainee. At the UTCOM-Chattanooga GS residency, all residents rotate for a 3-month period to a rural hospital 50 miles from the main campus. They are mentored by a handpicked group of 3 surgeons, all of whom trained in Chattanooga. Housing is provided by the group free of charge. 272
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One primary benefit is that the average resident performs approximately 40 esophagogastroduodenoscopies and 80 colonoscopies in a concentrated 3-month period and then returns to the main campus as an experienced endoscopist.28 Another huge benefit is that the resident is completely exposed to the pros and cons of a rural “pure” GS practice and is thereby able to make an informed decision regarding their desire to practice in this setting. The decision is made based on data and personal experience, and not on perception or hearsay of what is involved in a rural GS practice. Even though this rotation in Tennessee does an excellent job in providing critical endoscopic training, the graduates of the program still pursue postgraduate fellowship training at approximately the national rate. Perhaps this is because the main campus is a university training program, with the great majority of the faculty in a subspecialty practice. Consequently, although the residents do have a valid rural surgical experience, the fact that most of the rotations are spent with subspecialty mentors may shape their future career plans. In contradistinction to this program is the curriculum at Gundersen Lutheran in La Crosse, Wisconsin. This program is an independent residency program with no ABMS-approved surgical subspecialty fellowships, and 9 rural surgeons at 10 locations, together with 14 teaching faculty at the main campus. In their program since 1974, 11 (24%) graduates have pursued fellowship training and 35 (76%) have directly entered GS practice, one half of these in small rural locations. All graduates are board certified. This trend is the reverse of the national trend.29 As suggested by Richardson, we should pay attention to the devaluation of surgery as a discipline, particularly in our medical schools. We must expose students to our discipline early in their medical school education. We must become better mentors of our students and residents and focus on the “good” and stop whining about the “bad.”19 Perhaps 1 of the most important, but problematic, solutions is changing the fundamental structure of reimbursement for all general surgeons and rural surgeons in particular. Residents have to see that the practice reimbursement of general surgeons is at least roughly equal to other surgical specialties to justify the less attractive lifestyle. Finally, there is the innovative model described by Huffstutter in which his rural practice in Arkansas focuses on mentoring local high school students by establishing a formal “White Coats” program, which exposes these students to the joys of surgical practice and consciously not discussing practice business, hospital politics, or government controls. As Curr Probl Surg, May 2012
these students enter college, they are encouraged to return to work at the rural hospital during the summer, as well as asked to discuss any issues concerning their education with their mentors. Of approximately 70 of these students, 10 have completed medical degrees; 6 of those have become general surgeons, with 4 of the 6 becoming partners in the rural surgery practice.30 Effective mentoring by surgeons in rural communities, in medical school, and in residency training may be part of the ultimate solution.
Rural Surgery Scope of Practice Describing the scope of practice for the typical rural general surgeon has proven to be challenging. The precise makeup of a rural surgeon’s practice is similar to the definition of a liquid—its shape is defined by its container. The case mix in each situation depends on (1) the experience and interest of the surgeon, (2) the presence or absence of other surgical specialists, and (3) the available resources and commitment of the rural hospital. Location of the practice is also a factor as proximity to another medical center may influence greatly the relative volume of available operations. Much of our knowledge of the rural surgery scope of practice has come from publications that detail a single surgeon’s experience. Broader studies of rural surgery case mix have often been limited by methodologic constraints. Case log analyses have been hampered by failure to include minor procedures, outpatient surgery, and surgical subspecialty operations not traditionally performed by urban general surgeons. Several studies have focused on only the procedures most frequently performed by rural surgeons, ignoring the wide variety of cases performed with an annual volume of less than 5. Added all together, these less commonly encountered cases account for a significant proportion of a rural surgeon’s caseload.
Operative Procedures Several recent studies have elucidated the types of procedures commonly performed by rural general surgeons. Landercasper and associates published the experience of 7 rural general surgeons working at 9 small rural (⬍10,000 population) community hospitals as part of a Midwestern US Regional Health System.6 A total of 2420 procedures were recorded in a prospective registry of consecutive cases over an 18-month period. The most frequently performed operations were endoscopic (28%), gynecologic (21%), hernia (10%), colorectal (8%), biliary (8%), Caesarean section (5%), breast (5%), orthopedic (5%), and carpal tunnel release (3%). More recently, Harris and colleagues examined the surgical 274
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procedures performed by all North Dakota and South Dakota surgeons during 2006.31 Current procedural terminology codes from 46,052 clinic, outpatient, and inpatient procedures were analyzed. All the surgeons were classified using RUCA codes to stratify by rural vs urban locations. They found that rural surgeons performed an average of 1071 procedures per year, including endoscopy (39.8%), GS (25.6%), minor surgery (17.9%), and surgical specialty (12.3%) procedures. When large rural surgeons were compared to their colleagues in small rural areas, they performed fewer overall cases, but their case mix included more vascular, thoracic, and urological operations. Surgeons in small rural areas performed more endoscopy, minor surgical, obstetrical/gynecologic, and orthopedic procedures. Ritchie and colleagues at the ABS examined the surgical operative case logs of 2434 general surgeons without additional ABMS fellowships who applied for recertification from 1995 to 1997.22 These surgeons were then classified as rural or urban based on MSA methods created by the Office of Management and Budget. Rural surgeons averaged 470 annual cases vs 336 for urban surgeons. Rural surgeons performed nearly 4 times as many endoscopic procedures as their urban counterparts and also performed more biliary tract, hernia, alimentary tract, laparoscopic, gynecologic, urological, and orthopedic operations. Urban surgeons performed more vascular, thoracic, transplant, and pancreatic operations. Valentine and coworkers recently analyzed the surgical operative logs of 4968 ABS board-certified surgeons who had applied for recertification from 2007 to 2009.23 Surgeons were stratified by RUCA Codes. The average number of cases performed annually was 466 for urban surgeons, 644 for those in large rural areas, 681 for small rural, and 555 for isolated areas. Rural surgeons performed far more endoscopic procedures and fewer abdominal, alimentary tract, and laparoscopic procedures than their urban counterparts. The mean percentage of endoscopic procedures for rural surgeons was 46% of their total caseload. Because minor procedures and many surgical specialty cases were not able to be recorded on the surgical case log forms that were used by the ABS, the degree to which these operations contributed to a rural surgeon’s practice was not measured. Heneghan and colleagues reported the results of a survey sent to US rural and urban surgeons (the distinction was based on the MSA designations determined by the Office of Management and Budget).32 Rural surgeons performed more procedures of a greater variety than urban surgeons. Rural surgeons reported higher volumes of endoscopic, gyneCurr Probl Surg, May 2012
cologic, obstetrical, and urological operations. Urban surgeons reported higher volumes of abdominal, laparoscopic, and vascular operations. VanBibber and coworkers performed a retrospective comparison of inpatient general surgical procedures performed at US hospitals using the Nationwide Inpatient Sample database.33 Hospitals were classified as rural vs urban using RUCA Codes. General surgical procedures constituted 42% of all inpatient operations in rural hospitals vs 25% in urban hospitals. Operations on the bowel, appendix, and gallbladder comprised 61% of all GS operations performed in rural hospitals compared to 46% in urban hospitals. There were many fewer operations on the stomach, esophagus, liver, pancreas, spleen, and thyroid performed in rural hospitals. Finally, these authors estimated that a broadly trained general surgeon with obstetrics and gynecology experience could perform 66% of all inpatient operations done in a rural hospital. The addition of simple vascular, head and neck, and urological skills could increase that proportion to 71%. Putting all of this information together, what does it tell us about the procedures that rural surgeons are performing in the United States? Rural surgeons are performing a significant number of open and laparoscopic abdominal procedures, including operations on the biliary tract, small bowel, colon, and appendix. They are also busy with open and laparoscopic hernia repairs. A large portion of a rural surgeon’s practice consists of endoscopic procedures and minor operations on the skin and repair of wounds. Surgeons in small rural areas are very likely to perform a large volume of obstetrical and gynecology operations as well as moderate numbers of urological and orthopedic procedures. Surgeons in large rural areas are more likely to perform vascular, thoracic, and head and neck procedures. The precise surgical subspecialty case mix for a rural surgeon is clearly affected by the presence or absence of subspecialty services in a given rural hospital. In many locations, rural surgeons are required to perform a wide variety of cases that they perform only once or twice per year.
Trauma Management Trauma care remains an integral part of a rural general surgeon’s practice. Furthermore, rural general surgeons are key components of trauma systems in states with large, sparsely populated areas. Bintz and colleagues described the experience of a single, rural surgeon in a town of 5500 people with 84 trauma patients treated over a 7-year period.34 Although, 64% of patients were transferred to a regional trauma center for definitive care, 31% of patients were admitted to the community hospital. 276
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These authors concluded that the roles of the general surgeon in trauma management at a rural hospital are (1) to coordinate trauma care, (2) to perform urgent procedures in the emergency department to achieve optimal resuscitation and stabilization, (3) to prioritize patients rationally for transfer to a regional trauma center after assessment of patient injuries and institutional capabilities, and (3) to provide definitive care for a select subset of patients with no need for specialty surgical intervention. In another study of referrals of trauma patients from level III hospitals to a level I trauma center, Ball and colleagues discovered that the vast majority (91%) of definitive GS procedures could have been performed by general surgeons at level III hospitals were it not for the presence of associated injuries that required surgical subspecialty care.35 The value of a rural surgeon in a state-wide trauma system was the focus of a study that surveyed all rural general surgeons in Wyoming.36 The survey consisted of 8 trauma patient scenarios and demonstrated surprising commitment to the definitive care of trauma. Presented with a hemodynamically stable 16 year old with an isolated splenic injury, 95% of survey respondents would admit the patient to their rural hospital for nonoperative management. Similarly, 95% would elect to perform an emergent splenectomy on a hemodynamically unstable 20 year old with an isolated splenic injury. With an unstable young adult who had a precordial penetrating wound, 57% of these rural surgeons would perform a thoracotomy followed by transfer to a trauma center. Rural surgeons are leaders for trauma care in their region; many are active instructors for Advanced Trauma Life Support (ATLS) and Rural Trauma Team Development Course (RTTDC) courses. Committed rural general surgeons are essential in helping institutions prepare themselves as part of state-wide systems designed to provide optimal care to patients in vast geographic regions of North America.
Critical Care/Nutritional Support The rural general surgeon is frequently the critical care physician for their rural hospital either alone or in partnership with primary care physicians. For critically injured trauma patients or critically ill surgical patients, the rural surgeon is the attending physician and must be capable of managing difficult airway problems, hemodynamic instability, shock from all causes, transfusion reactions, and a host of internal medicine derangements. In addition, the rural surgeon is the proceduralist for all critically ill patients at the rural hospital and either performs or assists with endotracheal intubation, arterial lines, central venous catheters, chest tubes, and endoscopic procedures on these individuals. The management Curr Probl Surg, May 2012
of parenteral and enteral nutrition for all hospital patients often defaults to the rural surgeon as well.
Anesthesia Services The predominant anesthesia providers in rural areas of North America are certified registered nurse anesthetists who function independently without an anesthesiologist.37 This often means that the rural surgeon is called on for assistance with difficult airway problems, drug interactions, hemodynamic instability, and other anesthetic emergencies. Many rural surgeons are also responsible for the administration of conscious sedation techniques, which are frequently used with outpatient clinic procedures.
Wound Care Rural surgeons are the wound specialists in their community hospitals. This includes management of acute wounds, such as burns, bites, and stings, lacerations in all locations, including to the hands, as well as degloving injuries. In addition, management of chronic wounds, such as venous stasis ulcers, arterial ulcers, wound infections, and malignant ulcers, is coordinated by the rural surgeon. He/she must have experience with plastic surgical techniques, such as debridement, cosmetic wound closures, skin grafting, and simple tissue flaps. Finally, in the absence of an enterostomal therapist, the rural surgeon may be responsible for stoma care in their community.
Preoperative Risk Assessment and Optimization Although many rural hospitals have excellent primary care physicians, the preoperative evaluation and postoperative management of most surgical patients are provided by the rural surgeon. It is unlikely that cardiology, pulmonary medicine, and nephrology consultants are immediately available in these settings. Therefore, the rural surgeon must be self-reliant in the ordering and interpretation of preoperative screening tests. This activity may be essential in the determination of which patients are able to receive their surgical procedures safely in the rural hospital instead of requiring transfer to a tertiary center for preoperative optimization, monitoring, and postoperative critical care. Similarly, the rural surgeon is responsible for postoperative care of a large variety of surgical patients in a setting in which there are few medical specialists available for consultation. In these settings, a close partnership with primary care providers and development of subspecialty expertise are important to assist in the treatment of common postoperative complications.38 278
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Primary Care Most rural surgeons practice in a community in which there is a cadre of primary care physicians who serve as both the referral base and the medical specialists for the surgical practice.38 However, in areas of extreme physician shortages, rural surgeons may provide primary care for many of their patients, especially those in whom ongoing surgical follow-up is necessary. Another model of care has been documented by Rossi and colleagues in which general surgeons double as the primary care providers in a CAH.39 These authors describe surgeons as both generalists and specialists in the provision of unparalleled continuity of preoperative assessment, intraoperative technique, and postoperative care. Understanding that the scope of practice for rural surgeons includes a wide variety of procedures as well as expertise in many nonsurgical fields has important implications for optimal training in preparation for rural surgery practice.
Training the Rural Surgeon—Essential Components Training rural surgeons might seem to be a straightforward task. “Rural surgery” has often been equated with “general surgery” and it has been assumed that standard GS training should therefore be adequate. In fact, several studies reviewing rural surgeon case logs demonstrate a significant volume of subspecialty surgical procedures.6,32,40,41 Furthermore, it has become evident over the past decade that resident preparation for and exposure to rural surgery during training are important factors that may make it more likely that graduates choose a rural practice.13 Most research that supports current training models is based on reviews of practicing rural surgeon operative logs and rural surgeons’ opinions. A multitude of variables (individual ability, individual motivation, and regional variation) makes an optimal rural track difficult to determine precisely and institutional variables, such as size, location, and the presence of other learners, make uniform exposure very difficult to standardize. The core of current training structure is focused on “general surgery”; however, as subspecialty practice becomes more prevalent and the spectrum of GS becomes less diversified, defining “general surgery” is a moving target. Breast, endocrine, biliary, hernia, splenic, soft tissue, and all elements of gastrointestinal surgery are fundamental to rural GS operative practice and should serve as the basis of resident preparation. Exposure should occur throughout residency with graduated responsibility. As surgery residencies become increasingly prone to isolated “subspecialty” GS rotations, such as endocrine, colorectal, vascular, and Curr Probl Surg, May 2012
breast rotations, attention must be focused on assuring well-balanced exposure to broad-based GS throughout training. Rural surgeons typically perform a wider variety and greater volume of surgical cases, which includes more subspecialty cases than urban surgeons. Heneghan and colleagues surveyed 421 urban and rural surgeons to determine variability in practice patterns, factors in choosing practice location, and educational needs.32 Eighty percent of rural surgeons reported that they were well prepared for practice compared to 93% of urban surgeons (P ⫽ 0.0009). Rural surgeons reported significantly higher volumes of endoscopic, gynecologic, obstetrical, and urological procedures and also performed more orthopedic, otolaryngologic, plastic, and hand procedures. The authors concluded that rural surgeons required additional training in gynecology, Caesarean sections, urology, thoracic surgery, endoscopy, orthopedics, and plastic surgery.32 In a study of rural general surgeons from Iowa, Breon and colleagues noted that nearly one third of all operations performed in practice were procedures not required by the Accreditation Council for Graduate Medical Education (ACGME) for graduating surgical residents. They also reported greater operative volumes and case diversity among rural surgeons when compared to urban surgeons. The authors determined that focused training in urology, orthopedics, and gynecology would be beneficial. They stressed the importance of exposure to rural surgery during residency by way of established rural rotations to enhance both experience and recruitment.41 In a survey of West Virginia surgeons, Gates and colleagues demonstrated an increase in both case volumes and diversity by general surgeons in smaller communities when compared to urban settings. Gynecologic, urological, orthopedic, and otolaryngologic procedures made up 27% of operative volumes for rural surgeons compared to 5% for urban surgeons.40 Burkholder and Cofer surveyed GS program directors to assess rural surgery training. Only 36% of programs had incorporated rural surgery into their curriculum. Those program directors who believed that training rural surgeons was part of their mission were more likely to have a rural surgery track. Respondents reported the need for training in obstetrics, gynecology, orthopedics, otolaryngology, and urology. The authors underscored the importance of identifying programs that have a rural surgery commitment so that medical students who have a rural interest can select training more easily in a conducive environment.42 280
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Surgical Rotations Abdominal and Anorectal Surgery. A multitude of abdominal operations are pertinent to preparation of the rural surgeon. Cholecystectomy, appendectomy, colectomy, inguinal and ventral hernia repair, splenectomy, small bowel resections, and antireflux surgery are all common operations well within the capabilities of well-trained rural surgeons. The rural surgeon must be well prepared to deal with “acute care surgery” conditions (diverticulitis, perforated viscus, small bowel obstruction, incarcerated paraesophageal, inguinal, or ventral hernia, mesenteric ischemia, and soft tissue infections). In addition, common anorectal procedures, such as abscess drainage, hemorrhoidectomy, sphincterotomy, and the management of fistula-in-ano, are within the scope of rural surgery. Minimally Invasive Surgery (MIS). The volume of MIS accomplished by general surgeons has increased substantially over the past 10 years.23 The fact that it has become intertwined with “general surgery” generically leads to a lack of standardization in what a resident can expect during GS rotations. Residents at the authors’ institutions may accomplish laparoscopic adrenalectomies, abdominal perineal resections, laparoscopic or open hernia repairs, mastectomies, laparoscopic colectomies, and thyroidectomies during the same rotation. Certainly, if rural surgeons are to remain competitive and up to date with current trends in surgical practice, a solid foundation of MIS is imperative. Protected skills laboratory time is important throughout training as data mount about the benefits of simulation training. Basic laparoscopic skills are well within the ability of most postgraduate year (PGY) I residents with advancement in skill development throughout training. Level-appropriate MIS procedures at the authors’ institutions are summarized in Table 2. Trauma. Management of the trauma patient is absolutely critical for the rural surgeon, who may serve as the first contact in designated or nondesignated trauma centers. Rural surgeons serve as community leaders to coordinate trauma care, provide necessary procedures and techniques to accomplish resuscitation and stabilization, triage patients for transfer to trauma centers, and provide definitive care when appropriate.34,36 Trauma experience should occur throughout training with graded responsibility. Initial assigned roles in assisting senior residents and attending physicians with patient assessments and procedures adds to resident confidence. ATLS instructor certification with subsequent teaching opportunities is an outstanding adjunct to overall training and the maintenance of proficiency. In addition, residents should focus on Curr Probl Surg, May 2012
TABLE 2. Minimally invasive surgery (MIS) experience by postgraduate year (PGY) level in the authors’ surgical residencies
Diagnostic laparoscopy Laparoscopic appendectomy Laparoscopic umbilical hernia repair Laparoscopic cholecystectomy Laparoscopic incisional hernia repair Diagnostic thoracoscopy Endoscopic procedures (PEG, polypectomy) Laparoscopic antireflux surgery Laparoscopic assisted colon resection Laparoscopic transcystic common bile duct exploration Thoracoscopy with pulmonary resection Laparoscopic colon resection Laparoscopic splenectomy Laparoscopic inguinal hernia repair Endoscopic procedures (advanced polypectomy, control of UGI hemorrhage) Laparoscopic adrenalectomy Laparoscopic bariatric surgery Laparoscopic-assisted esophagectomy
PEG, percutaneous endoscopic gastrostomy; UGI, upper gastrointestinal.
acquiring experience with orthopedic injury, genitourinary trauma, and trauma in pregnancy when opportunities are present in preparation for a rural environment where subspecialty care may not be available. Endocrine Surgery. Endocrine surgery, to include thyroid, parathyroid, and adrenal procedures, remains at the core of GS training. Although adrenalectomies are performed infrequently based on the overall incidence of adrenal pathology, management of thyroid and parathyroid disease is more common. Availability of ultrasound (surgeon or radiologist directed) is an important aspect of thyroid and parathyroid surgical planning. Ultrasound is generally available to rural surgeons. Ruby and colleagues noted that 95% of rural surgeons in Wyoming had access to ultrasound.36 Concordance of imaging with clinical presentation in the development of patient care plans is a guiding principle. Breast Surgery. Care of patients with breast pathology is an essential component of GS. Individual surgeons increasingly focus on breast care and siphon this patient population away from general surgeons in urban settings. However, there are not enough breast subspecialists to serve rural America and the skill sets required remain well within the realm of GS residency without fellowship training. Clearly the most important factor in providing breast care is the concordance of clinical presentation and imaging in the development of a care plan for these patients.43 282
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Well-established clinical care guidelines are readily available and familiarity with these guidelines allows the rural surgeon to provide contemporary breast care. Obstetrics/Gynecology. The GS resident’s ability to learn gynecologic procedures is aided immensely by experience with open and laparoscopic general surgical procedures. Specific rotations in obstetrics and gynecology should focus on an adequate volume of laparoscopic or open salpingo-oophorectomy, dilation and curettage, hysterectomy, tubal ligation, and Caesarean sections. In addition, exposure to the outpatient management of common gynecologic conditions should be provided. The authors have found increased exposure to Caesarean sections during the chief year before graduation to be very helpful in preparation for this aspect of rural surgical practice. Endoscopy. Endoscopic procedures may constitute up to 50% of a rural surgeon’s practice and exposure during residency is compulsory. There is current debate about what experience should be mandated during training for credentialing. The ABS and several leading gastroenterology societies are collaborating to develop objective criteria for assessing competence in the performance of endoscopy as opposed to relying on case numbers. Exposure should occur at junior levels to introduce basic principles, gain experience with conscious sedation, and perform procedures. At senior levels, endoscopic skills can be developed further and proficiency accomplished. Endoscopic simulators have been demonstrated to play a role in preparation. This may save time and reduce the number of procedures needed to obtain competency.44,45 Training can be directed by general surgeons or gastroenterologists. Collaboration between departments has been beneficial in the author’s institution.29 Rural Rotations. Exposure to rural surgery during medical school and residency is an important predictor of an individual’s decision to pursue rural practice.13 Experience during the PGY I year theoretically could serve as a recruitment tool for those who have not had exposure to rural care in the past. We have found that exposure during the PGY III or PGY IV year is most valuable given the fact that basic skill sets have been mastered, patient management skills are mature, and senior residents can be relied on more by rural surgeon mentors. This experience gives surgery residents a realistic immersion experience in rural living and practice. Although the authors believe that exposure to rural surgery practice is essential, the optimal duration is variable based on the spectrum of training received during other residency rotations. Rural electives in international settings have the potential to serve an important role as well. Exposure to procedures less common at most Curr Probl Surg, May 2012
training programs, such as open cholecystectomy, a variety of plastic surgical procedures, and thyroidectomies for goiter, all provide residents with experience they may value as a rural surgeon.46 In addition, introductions to resource allocation and team management gained during these experiences are important for rural practice. Recently, these experiences were granted approval on a rotation-by-rotation basis by the ABS and the ACGME-Surgery Residency Review Committee (RRC). Vascular Surgery. With a shift toward vascular fellowship training, which is focused on endovascular techniques, and a reduction in surgical resident exposure to open vascular procedures, there is concern that development of vascular skills that may be needed in a rural environment is declining. Several authors have highlighted the importance of rural surgeon competence in vascular procedures, such as vascular access, amputations, venous surgery, and the management of vascular trauma.32 Certainly with regard to vascular emergencies, it is essential to have well-qualified individuals and systems to manage or stabilize patients initially in rural regions where long transport times may increase mortality or inclement weather may be a barrier to timely patient transfer.38 Orthopedics. Exposure to orthopedic surgery seems to be important early in training with reinforcement during senior resident years. Management of fractures, common hand injuries, and carpal tunnel syndrome have been identified as most likely to be encountered in rural surgery practice.6 Otolaryngology. Depending on training program settings, exposure to otolaryngology may be integrated. Procedures to include tonsillectomy/ adenoidectomy, tracheostomy, management of the solitary neck mass, cervical lymphadenopathy, Zenker’s diverticulum, and branchial cleft abnormalities are all valuable. Plastics/Burn Surgery. Plastic surgery techniques are valuable adjuncts for the rural surgeon. Management of difficult wounds, removal of skin cancers, skin grafting, and tissue handling are important parts of rural surgery practice. Rotations at both junior and senior levels provide a broad spectrum of exposure and experience. Rural surgeons are called on to manage patients with burn injuries. Initial triage, resuscitation, stabilization, and preparation for transfer or definitive care depending on the severity of the injury should be reinforced. Urology. Advanced techniques of urinary catheter placement to include cystoscopy and suprapubic tubes should be mastered. Rural surgeons frequently perform cystoscopy, vasectomy, orchiectomy, orchiopexy, and hydrocoelectomy. 284
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Nonsurgical Rotations Anesthesiology. We have maintained an anesthesiology experience for our PGY I residents. Residents gain important exposure to airway management, arterial and venous access, monitoring, regional blocks, general anesthesia, conscious sedation, and intraoperative fluid management. Rural surgeons often serve in a supervisory role for certified registered nurse anesthetists. Critical Care. Critical care experience throughout training is important for the rural surgeon who may be the only local provider capable of managing patients with respiratory failure, hemodynamic instability, sepsis, and renal insufficiency in a rural hospital. A rural surgeon can provide endoscopy, invasive monitoring, and nutritional support in this environment for medical and surgical patients.34 Experience with procedures, such as tracheostomy, placement of arterial and venous lines, tube thoracostomy, and management of temporary abdominal closure, are all useful. Nutrition. Didactic and clinical nutrition education is essential for any GS resident. Although most large hospitals have adopted multispecialty nutritional support teams, the rural surgeon may be the only one available to offer this service at rural hospitals.34 We have found that classroom education and use of the Fundamentals of Surgery Curriculum in addition to a focus on clinical scenarios during critical care rotations provide well-rounded exposure during residency. Formal rotations in nutrition and assuring that residents are able to work directly with a nutritional team in the care of surgical patients are valuable experiences. Practice-Based Learning. Rural surgeons need to have the knowledge, resources, and familiarity with processes to follow their patient outcomes. This will become increasingly important as pay-for-performance programs and third-party quality reviewers proliferate. Demonstration of personal surgical outcomes is also required for Part IV ABS Maintenance of Certification activities. It is essential for the rural surgeon to be able to analyze the surgical literature critically. Multiple resources are available to facilitate this process. Evidence-Based Reviews in Surgery sponsored by the ACS is an excellent resource for the development of these skill sets. Journal clubs with attending surgeons and residents are extremely beneficial. Research Experience. The requirement for research responsibility during residency is important to expose residents to the mechanisms and intricacies of research studies and promotes self-learning. Presentation and writing skills can be refined during focused research electives or Curr Probl Surg, May 2012
TABLE 3. Practice-based management curriculum components for GS residency Practice-based management curriculum components 1. Coding and documentation 2. Billing 3. Malpractice insurance and risk management 4. Business operations and management 5. Insurance processing 6. Types of practice (private, multispecialty group, etc) 7. Contracts (review of employee and recruitment parameters) 8. Investment and financial planning
full-year experiences and residents going on to rural practice can gain experience that will enable them to design and interpret studies as well as to contribute to the scientific literature. System-Based Practice. The development of leadership and team management skills in hospital settings is very important for the future rural surgeon who often serves as an administrative leader in smaller hospitals. Resident participation on patient care pathway and graduate medical education committees promotes development of these skills while also providing an opportunity for the residents to give feedback with regard to patient care concerns, system improvements, and areas of educational enhancement. Practice Management. Curriculum with a focus on the “business” side of medicine has expanded over the past several years. In the past, a high percentage of surgical residents reported being unprepared for various aspects of office management to include documentation, coding, malpractice insurance, contracts, electronic medical records, finances, and insurance processing.47 Jones and colleagues reported their approach to this process, which involves a series of lectures provided by hospital administrators, meetings with documentation and coding specialists, and feedback based on chart reviews for the concordance of documentation with coding.48 They noted significant improvement in documentation and coding accuracy with implementation of this strategy among residents and attending physicians. These topics are clearly essential for all surgery residents but rural surgeons in particular have fewer support staff to facilitate these processes. Important topics to be included in a practice management curriculum are listed in Table 3. A proposed rural surgery track is presented in Fig 3. The schedule meets ABS and ACGME requirements, provides sufficient exposure to surgical subspecialties, provides ample time for ACGME required operative volumes, and fosters the broad-based training required to prepare the graduate for a successful rural practice. In addition, the authors feel that 286
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FIG 3. Proposed surgery residency block curriculum for residents interested in rural surgery preparation. (Color version of figure is available online.)
this type of exposure would not limit a resident’s ability to pursue fellowship training and would sufficiently prepare them for GS practice in any clinical setting. The recent textbook publication, Rural Surgery: Challenges and Solutions for the Rural Surgeon, provides an excellent outline for a didactic approach to rural surgery training.49 In summary, preparing surgery residents for rural surgical practice presents many challenges and “standard” GS training fails to provide adequate exposure to a variety of subspecialty procedures that are common to a rural surgeon’s practice. Broad GS, MIS, endoscopy, trauma, and vascular surgery should be complemented by subspecialty experience in gynecology, urology, and otolaryngology. Additional exposure to nonsurgical patient care as well as life-long learning and practice management principles is essential to complete the preparation of the rural surgeon.
Training the Rural Surgeon—Different Institutional Models Despite a well-established need for rural surgery preparation, there are relatively few programs in the United States that have initiated rural surgery tracks or have maintained the breadth of training that is thought to be optimal for adequate preparation. Several institutions have developed successful models of rural experience during surgical residency. Doty and colleagues sought to identify GS programs with an interest in rural surgery. First, they searched the Fellowship and Residency Electronic Interactive Database and identified GS training programs with a Curr Probl Surg, May 2012
rural surgery training track. Second, they searched each GS residency Internet site for any reference to rural surgery training to identify those programs with an interest in rural surgery. Third, they used RUCA codes to classify residency programs situated in rural areas. They identified 25 surgery residency programs (10% of total) that met at least 1 of these 3 criteria and were considered likely to produce rural surgeons. The authors then queried the AMA Physician Masterfile to identify residency programs in which current rural surgeons have graduated in an attempt to establish a ratio of the number of graduates practicing in rural areas to the number of chiefs who graduate annually from their program.50 The authors reported that graduates of programs in the midwestern US were more likely to practice in a rural area when compared to graduates of programs in the northeastern and western states. Independent residency programs were more likely than university programs to have graduates in rural settings. The authors noted barriers in the ability of medical students with a rural interest to identify residency programs to meet their needs and called for development of a consortium of GS residencies with a common interest in the training of rural surgeons. Finally, they identified specific programs that were successful in graduating surgeons to practice in large rural, small rural, and isolated rural areas.50 All considered, there is not a standardized curriculum for rural surgery but several models have been described and are reviewed. Most of these models involve broad-based training with additional exposure to subspecialties and options for rural surgical experiences. Others offer standard surgery training but include devoted rural surgery tracks over a substantial amount of time to provide exposure. It is also clear that some graduates from GS residencies without a focus on rural surgery will choose to practice rurally. Several of the residency programs with graduates in rural practice identified by Doty and colleagues were programs that do not claim a rural surgery interest.50 This clearly suggests that other factors are involved. Although specific preparation for rural surgery is thought to be important, it is not the only avenue to rural practice.
Basset Healthcare, Mithoefer Center for Rural Surgery, Cooperstown, New York51,52 Established in 2004, the center was designed to confront rural GS shortages. The center “is committed to developing comprehensive solutions that benefit rural citizens, rural surgeons and rural hospitals.”52 The program focuses on recruitment of high school and undergraduate college students who have opportunities to shadow surgeons and establish an 288
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interest in a health care career. Medical student experience is divided between a metropolitan setting (first 18 months) and a rural setting (final 30 months). Surgery residents are afforded a broad-based GS experience with no competing fellowships or subspecialty residents. Extensive exposure to gynecology, obstetrics, endoscopy, otolaryngology, plastic surgery, and hand surgery is offered to surgery residents throughout their training. The residency program offers dedicated junior and senior electives in Saranac Lake, New York (population, 4769) where a true rural surgical experience is accomplished. Additionally, the program offers postresidency mini-fellowships in rural surgery for graduates who need more exposure to surgical subspecialties. The fellowships are of variable length and are “needs” driven based on applicants’ desires and future goals.
Gundersen Lutheran Medical Foundation, La Crosse, Wisconsin29,53,54 Preparation for rural surgery practice is accomplished throughout the training experience. GS is the only surgical specialty to sponsor a residency and a 1-year bariatric/MIS fellowship is the only postgraduate fellowship offered at this institution. The surgery residents work one-onone with subspecialty staff in orthopedics, otolaryngology, plastic surgery, urology, emergency medicine, anesthesia, and cardiothoracic surgery during PGY I and II rotations, which foster relationships that enhance senior level exposure to additional subspecialty operations and conditions. Focused senior rotations in endoscopy, obstetrics and gynecology, and cardiothoracic surgery guarantee further skill acquisition and maturation in these essential areas. Residency graduates perform more than 25 Caesarean sections and 20 hysterectomies in addition to other gynecologic procedures. Residents who anticipate performing obstetrics and gynecologic procedures are able to hone their skills during the chief year. Residents graduate with more than 150 colonoscopy and 50 upper endoscopy procedures. PGY III and IV electives in rural surgery are offered within the Gundersen Lutheran system in Prairie du Chien, Wisconsin (population, 6047) and Decorah, Iowa (population, 7944). Residents live in these rural communities and live the life of rural surgeons with call responsibilities and participation in a large volume of endoscopy, obstetrics, gynecology, and GS under the tutelage of committed rural attending general surgeons. Rural surgery electives at other rural hospitals have also been accomplished with similar exposure to procedures. An international elective provides the opportunity for residents to gain exposure to operations infrequently encountered in standard Curr Probl Surg, May 2012
US training programs, such as open cholecystectomy, various plastic surgical procedures, and thyroidectomies for large goiters.46 The importance of comprehensive patient care with outcomes analysis, evidencebased literature reviews, required research experience, and practice management education are paramount to the resident’s preparation for rural practice. Approximately two thirds of program graduates practice GS and one half of these graduates choose to serve small, rural populations (⬍10,000 population).29
Oregon Health Science University, Portland, Oregon Deveney and Hunter have previously reported their approach to rural surgery training.55,56 They initiated a program in 2002 in which a PGY IV resident can elect to replace their required research year with a year in Grants Pass, Oregon (population, 23,000). The hospital has a full GS staff and multiple subspecialists but no competing residencies. They developed a curriculum with broad exposure to gynecology, urology, orthopedics, otolaryngology, endoscopy, and GS. They have since been approved for 2 residents per year at this training site and have published their outcomes. Of the first 6 participants, 2 are practicing in rural or international settings, 3 are practicing GS in small urban communities, and 1 is practicing a subspecialty in an urban setting.
University of North Dakota, Grand Forks, North Dakota57 The program was designed in 1982 and since that time has maintained a broad exposure to GS and surgical subspecialties throughout the resident’s experience. Dedicated rotations on anesthesiology, pathology, plastic and reconstructive surgery, orthopedics, otolaryngology, and urology have been maintained. The absence of other surgical residencies in the entire state is advantageous for senior GS residents, who incorporate subspecialty procedures into their daily routine. Endoscopic experience is acquired in the senior years at a Veteran Administration Medical Center. A rural surgery experience is offered during the PGY I and II years in Park Rapids, Minnesota, where residents may perform more than 100 surgical cases, including a variety of laparoscopic procedures. Individual resident needs (eg, Caesarean delivery) are tailored for intended future practice. The incorporation of medical student teaching and exposure is integral to the program. Residents typically graduate with more than 250 endoscopic procedures. Antoneko reported that as of June 30, 2008, 41% of graduating residents have maintained practice in smaller community or rural settings.58 290
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University of Tennessee College of Medicine, Chattanooga, Tennessee59 This is a 6-year, hybrid independent/university program that offers broad exposure to GS and surgical subspecialties. Citing a recognized need to expose their surgery residents to a rural surgery operative mix and to increase interest in rural surgical opportunities, a rural rotation was developed.28 All residents spend 3 months on a rural surgery rotation during the PGY III year in Athens, Tennessee (population, 13,220). General surgeons at this site are responsible for mentoring the residents who gain significant endoscopy experience and exposure to endocrine surgery, colorectal surgery, breast surgery, urology, and otolaryngology. The endoscopic experience is thought to be most significant because resident opportunities for this experience are limited at the main university campus. At the rural site, residents gain both diagnostic and therapeutic endoscopic expertise and additionally spend office time dedicated to the evaluation of gastroenterologic conditions. The full immersion of living in a rural community provides a genuine experience, enabling an individual to make an informed decision whether to practice in a rural setting. The residents take home calls, which better demonstrate the responsibilities of rural surgeons and allow residents to develop this skill during their training. Giles and colleagues surveyed their residents and noted several positive findings.28 Residents rated the experience as highly valuable with ample autonomy and devoted teaching faculty interest and felt that more time should be allocated to this rotation. Residents felt fully capable of incorporating endoscopy into their future practice based on this experience alone. Following the rural rotation, they viewed rural surgery more favorably and were more likely to consider rural surgery as a career.28
University of Utah, Salt Lake City, Utah In response to a call by the Utah Medical Education Council to increase medical student and resident exposure to rural practices, the University of Utah established a 1-year rural surgery fellowship. The program was piloted for 3 months in 2007 and has been maintained since then as a full-year program after the PGY III year for 2 residents per year. They established a curriculum consisting of specific rotations on anesthesia, gynecology, obstetrics, orthopedics, urology, gastroenterology, thoracic surgery, plastic surgery, otolaryngology, pulmonology, emergency medicine, trauma, and GS. The 1-year fellowship was accomplished in lieu of a research year. The authors stress the importance of the crossover Curr Probl Surg, May 2012
between the fellow and a family practice residency with joint conferences, clinical responsibilities, and teaching opportunities. The fellow keeps a comprehensive portfolio of patients and procedures thought to be critical for future credentialing in subspecialty procedures. The setting is unique in being a large suburban hospital with a strong GS department and subspecialty providers but no competing subspecialty residents. Longterm success with placement of these fellows in rural environments is anticipated.60 In summary, there are several models in both independent and university residency programs for rural surgery practice preparation. Wellbalanced exposure to surgical subspecialties throughout training, shortterm (3 months or less) isolated rural surgical experiences, long-term (greater than 3 months) rural surgical experiences, and postresidency fellowship training are all contemporary strategies. Some common themes among the programs reviewed are the absence of competing surgical subspecialty trainees (either residents or fellows), dedicated experiences with subspecialty rotations, and the provision of a full immersion rural surgical experience.
Recruitment: Who Goes into Rural Surgery? Successful recruitment of rural surgeons is multifaceted. Identification of individuals who are likely to practice in rural settings would be advantageous to help address the worsening shortage of rural surgeons. An immediate response to the rural surgery workforce shortage is to try to identify factors that influence an individual’s decision to practice rurally. Several authors have studied characteristics of those individuals who choose to practice rurally. In addition, there have been a multitude of factors identified that correlate with the decision to practice rurally. A significant study identifying disturbing data concerning the choice to practice rurally was reported by Rosenblatt and colleagues.61 They used the 1991 AMA Physician Masterfile to study the practice locations of US medical school graduates over a 10-year period. They discovered that 12.6% of medical school graduates between 1976 and 1985 were practicing in rural areas and more than 50% of these graduates were practicing family medicine, general internal medicine, and pediatrics. Only 17.5% of general surgeons were practicing in nonmetropolitan areas and only 4.6% of surgical subspecialists were practicing in rural locations. Male physicians were more likely than women to practice rurally in all disciplines (13.8% vs 8.8%). Of general surgeons, 18.2% of men were practicing rurally compared to 12.5% of women. Rosenblatt identified significant variations in the production of rural physicians by US medical 292
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schools, with a range of 2.3% to 41.2% of graduates in rural practice locations. In addition, 12 of 125 medical schools (9.9%) produced 25.6% of rural physicians. Conversely, 61 (48.8%) of 125 medical schools produced less than 25% of rural physicians. They further identified that the magnitude of Medicare educational subsidies and National Institutes of Health funding that a medical school received was inversely proportional to the school’s production of rural physicians. They postulated that the source of medical school funding directly affected graduates’ decisions of where to practice. A school with funding from rural state legislatures with support for rural training was more likely to produce graduates who chose rural practice.61 These findings suggested that 1 avenue to improve recruitment of rural surgeons was to focus funding on new or current publicly owned medical schools in rural states. Although not unique to recruiting rural surgeons, the importance of enthusiastic mentoring of high school, college, and medical students cannot be overemphasized. Huffstutter reported his experience with the development of a “White Coats” program, a 2-week summer elective for junior and senior high school students in a rural location. Participants took tours of the hospital and observed different departments in operation. Throughout college, the students were invited to work at the hospital and gain further experience. The importance of a “genuine interest” in mentoring, designing the mentorship to meet the students’ perspectives and needs, and emphasizing the multiple positive aspects of a rural surgical career were stressed by Huffstutter. The results of the program were impressive. Ten of 70 students (14%) completed medical school; 6 became general surgeons, 4 of whom joined the author in a rural surgery practice.30 Participation in a rural experience during medical school or residency has clearly been associated with the decision to practice rurally. Brooks and colleagues determined that rural rotations were a significant factor in the retention of rural family practitioners.62 Rabinowitz and associates noted that growing up in a rural environment was the strongest predictor of practice in a rural setting for all providers.63 For surgery residents, senior level rural electives have been associated directly with the decision to practice rurally.64 Doty and colleagues sent surveys to resident graduates from Bassett Healthcare and reviewed surgical resident operative logs. They reported that 83% of the surgeons who were practicing in rural areas had grown up in a rural environment.65 In addition, these residents gained broad spectrum operative exposure during their training when compared with surgical graduates nationally. This was felt to have prepared those who Curr Probl Surg, May 2012
chose rural practice better for the diversity of procedures he or she encountered. Jarman and colleagues identified individual factors that were correlated with the decision to practice GS in rural locations. They surveyed graduates from the 4 GS residencies (2 university and 2 independent) in Wisconsin over a 15-year period (1994-2008). The questionnaire was written to interrogate personal and spousal/partner background, medical school and residency experiences, hobbies and extracurricular activities, and practice characteristics. A survey response rate of 45% was achieved. Attending high school or college in a rural area and having a partner or spouse who grew up rurally were significantly associated with practice in a rural area. Seventy-nine percent of rural surgeons participated in a medical school rural clerkship compared to 37% of urban surgeons (P ⫽ 0.001). Completing surgical residency at a program with a stated commitment to rural training was a significant factor in rural surgery practice selection. Recreational activities associated with rural surgery practice location were hunting large game or birds. Rural and urban surgeons reported similar rates of medical student teaching opportunities but urban surgeons were more likely to teach surgery residents. A “broad scope of practice” was more often cited by rural surgeons as the reason for selecting their current practice. Finally, 60% of urban surgeons had completed fellowship training vs 11% of rural surgeons (P ⫽ 0.001). The importance of a connection with a rural setting before residency was demonstrated by the fact that 89% of the rural surgeons surveyed reported such experience.13 One potential strategy to attract general surgeons to rural surgery is to increase the number of GS residency positions. Unless these new positions are focused on individuals who are going to practice rurally, this would be unlikely to have a substantial impact on rural shortages. Given that 80% of graduating surgery residents choose fellowship training and assuming that most of these individuals go on to practice in urban or metropolitan settings, it would be difficult to create enough residency positions to meet the current rural surgery demand.25 Creating specialized positions or rural surgery tracks in surgery residencies specifically geared toward rural surgery preparation would seem to more reliably supply the rural communities. We know that surgery residents graduating from programs with a commitment to rural training are more likely to practice rurally,13 but only 10% of GS residencies have been identified with this commitment.65 Perhaps increasing the resident complement in these programs or developing new residencies in rural locations would be of benefit. 294
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Complicating the situation is the unpredictable effect of “personal choice” that may evolve during residency and renders it difficult to rely on an increase in residency positions or an individual’s background to meet rural surgery demands. Residents entering a GS residency want to have a variety of options on completion of training. The authors have certainly trained individuals who considered rural surgery but chose to pursue postresidency fellowship and now practice a surgical subspecialty in an urban setting. In an attempt to produce more interest in rural practice, several medical school programs have been created to introduce students to rural practice with anticipated retention of resident graduates in rural areas. The focus of these preparatory programs has primarily centered on family medicine but spillover to rural GS has been noted. The Mithoefer Center for Rural Surgery (est. 2004) developed the “Shadow a Surgeon Program” for high school and undergraduate students who are considering a medical career. Teaching faculty, residents, and nurses work with these students for a dedicated period to provide exposure to medicine, establish mentorship opportunities, and “inspire students to practice in a rural environment.”51 The program also offers a fourth-year medical student rural surgery elective with similar goals.52 The University of Colorado initiated the Rural Health Scholars Program in 1999, which is a nonprofit residence-based science and medical program primarily designed for rural high school students interested in pursuing health science careers. Medical students, teaching faculty, and staff support and direct the program, which occurs for 3 weeks each summer.66 Additionally, the University of Colorado School of Medicine has recently developed a Rural Track for medical students. Students identified as having an interest in practicing rurally are supported with rural experiences throughout their 4 years of training. The students are exposed to a rural curriculum that includes opportunities and challenges of rural practice and exposure to technical skills that they will require later in training. The program graduated their first class in 2009 and currently recruits 12-15 students per year.67 The WWAMI regional medical education program was established in 1971 and has been integral in addressing physician workforce demands in rural and underserved areas in the northwestern United States. Summer enrichment programs are provided for high school students to encourage them to explore health care careers in rural settings. Medical students who are admitted to the program have the opportunity to participate in a rural/underserved observation elective before beginning medical school. Medical students spend their first year in 1 of the partner states and their Curr Probl Surg, May 2012
second year in Seattle at the University of Washington and have the opportunity to complete their required and elective clerkships during the third and fourth years throughout the WWAMI region. Program results have been favorable, with nearly 50% of graduates choosing primary care in rural areas.68 The importance of one-on-one preceptorships during third- and fourth-year medical student surgery rotations in community settings was recently reported by Tatum and colleagues. These students scored better on postrotation standardized examinations when compared to students rotating at university centers. In addition, postrotation evaluations were notable for more time spent with teaching faculty, improved overall clerkship quality, and a higher overall contribution to the medical student’s medical education.69 The impact of these findings on those individuals’ practice location decisions are not known. The University of Minnesota Rural Physician Associate Program is a long-standing program (est. 1971) that offers 9-month community-based rotations to third-year medical students with rural family practitioners.70 Since its inception, 67% of former students remained in Minnesota to practice. Additionally, two thirds of students went on to practice in rural locations, 80% of whom are primary care providers. One big advantage of the program is that medical students observe unparalleled continuity of patient care. During the 9-month family medicine rotations, these medical students often have their first exposure to rural surgeons as they follow their primary care patients from surgical referral to the operating room. This contact has influenced many of these students to consider a career in surgery— often in rural settings. In addition, the students are able to live in and become a part of the communities in which they serve. Additionally, the program established a self-recruiting tool by offering a Rural Observation Experience for first- and second-year medical students so they can shadow rural providers over 2- or 3-day experiences. The University of Wisconsin School of Medicine and Public Health initiated the Wisconsin Academy for Rural Medicine program in 2008.71 Residents of Wisconsin admitted to the program are required to demonstrate an interest in rural practice. A rural core curriculum is integrated during medical school with dedicated rural clinical opportunities throughout each year. The program has worked to develop third-year core clerkships in GS and fourth-year electives in surgical subspecialties at community hospitals in Wisconsin. The University of North Dakota School of Medicine (UND) has recognized the importance of medical student exposure to surgery. The GS residency takes an active role in medical student curriculum. Surgery residents teach gross anatomy to first-year medical students and proctor 296
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case discussions for the second-year, patient-centered learning blocks. A surgery interest group for first- and second-year medical students to provide exposure to GS was established. During the third and fourth years, medical students participate in one-on-one preceptorships throughout the state. They are required to participate in surgery morbidity and mortality conferences and attend surgery grand rounds via video conferencing during this time. From 2006 to 2009, 11.5% to 15.1% of UND medical school graduates chose GS residency. Antoneko reported that this model has accounted for a high proportion of medical students who pursue rural practice after graduation. Nearly 50% of UND medical school graduates who completed the UND GS residency chose rural practice.58 In Wisconsin, the 4 surgery residency programs (2 university and 2 independent) have recently worked together to form a consortium to provide desired experiences for surgery residents seeking training opportunities that may not be available within their home institutions. In the past year, 2 residents from the University of Wisconsin-Madison who wanted more rural surgery experience participated in an established rural surgery rotation at a small rural hospital associated with the Gundersen Lutheran Medical Foundation surgery residency. The authors feel that the provision of experiences such as these could encourage individuals’ decisions to practice rurally. Similarly, residents interested in a subspecialty not offered by their independent program could participate in a rotation sponsored by a university residency. Individual residency programs have been identified with a rural surgery focus. These programs are highlighted in the “Training the rural surgeon— different institutional models” section. The programs vary in their approach to rural surgery preparation but all provide exposure to a rural surgery curriculum, which is believed to better prepare individuals for rural surgical practice and serve as a recruitment tool to these underserved areas.
Recruitment Incentives Successful recruitment of a general surgeon to a rural practice often depends on fostering relationships with candidates that begin in high school, college, medical school, or residency. Most rural surgeons today are physician employees, hired by the rural hospital or a larger health care network.2 Employment contracts with these organizations offer more competitive salaries and more comprehensive benefit packages. Loan forgiveness, signing bonuses, and/or salary guarantees are frequently written into agreements, which commit the surgeon to a specific minimum Curr Probl Surg, May 2012
duration of employment. Informal or formal contracts may also codify arrangements for call frequency and time off for vacations and CME activities. The simultaneous recruitment of a general surgeon and primary care providers has been recommended to assure that an adequate critical mass of providers has been assembled to improve the chances of successful practices in rural hospitals. Finally, some have advocated for governmental agencies to designate rural general surgeons as primary care providers who might therefore be eligible for health care shortage recruitment and reimbursement incentives. Currently, the National Health Service Corps continues to receive financial support to address the problems of geographic distribution of primary care physicians.8 Sheldon has proposed that the National Health Service Corps be available to all physicians to alleviate shortages among all providers in rural areas.4 In summary, several factors have been correlated with the decision to pursue rural GS practice. A number of programs have been identified that provide high school, college, and medical students with rural opportunities to generate or maintain their interest in pursuing rural practice. Consideration of establishing rural surgery tracks in new or current residency programs and collaboration of current surgery residencies to provide exposure to rural surgery opportunities would be advantageous.
Retention of Rural Surgeons There is a paucity of data in the literature regarding retention of general surgeons. We first focus on the generic issue of retention of all “rural physicians” and postulate that these data can be extrapolated to shed some light on retention of general surgeons in rural practice. Brooks and colleagues reported an analysis of 21 quantitative articles that analyzed recruitment and retention of primary care physicians in rural areas from 1990 to 2000.62 Six of these articles analyzed premedical school factors, 15 considered medical school factors, and 6 analyzed residency factors related to rural recruitment and retention. The results of this analysis were variable. Specific conditions that contributed positively to “retention” were as follows: (1) longer National Health Services Corps obligations were associated with higher rural retention, (2) specialized medical school curriculum for applicants with rural backgrounds or expressed rural intentions increased rural retention, (3) both students and preceptors in a decentralized rural experience fostered rural retention, and (4) residency rural rotations and residencies that emphasized underserved area health care improved retention. Preparedness for small town living also increased retention. In their discussion of these results, the authors 298
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concluded that the presence and duration of rural rotations in residency appeared to be the best predictor of retention in rural areas, a finding that was likely because of students being better prepared for what awaited them in practice. They also pointed out that although the study focused on the issues of selection of candidates and their formal training, there were also other important factors in retention. These included local factors, such as professional lifestyle and financial issues. Also, problems with professional isolation, long work hours, lack of specialty support, lack of educational opportunities, and lower financial reimbursement rates were important factors that impacted on retention.62 Another article reported on the results of a survey that the Canadian Medical Association sent to 2400 physicians in rural areas and 400 who moved from rural to urban areas. This study reported that important professional factors involved in the decision to move from rural to urban areas included long work hours, lack of professional backup, lack of specialty services, need for additional training, need for expanded hospital services, unavailability of CME, and improved earning potential. Family and personal reasons for leaving a rural practice were children’s education, spousal job opportunities, recreation, cultural opportunities, and retirement. This study demonstrated that the highest priority factors that might have retained physicians in their rural practice were additional colleagues, locum tenens coverage, an opportunity for group practice, specialist services, alternative compensation, CME, improved facilities, and emergency transportation. The author summarized the key modifiable factors in dealing with the problem of retention as (1) educational (medical school, residency, and availability of CME), (2) group practice opportunities (local hospitals building and subsidizing group practice clinics), (3) improved hospital facilities, (4) reasonable working conditions (dealing with long “on call” hours, locum tenens), and (5) financial incentives (pay rural physicians a premium for what they do).72 So is retention of rural surgeons a problem in our society today? Previous sections of this monograph have discussed the critical nature of having surgical services in a rural hospital. One national survey of rural hospitals demonstrated that in 2005, 27% of hospitals in small rural areas and 48% of hospitals in large rural areas were losing a surgeon within the next 2 years.7 A similar study performed in the State of Tennessee from 2008 to 2009 demonstrated that 15.4% of small rural hospitals reported that a surgeon would be leaving in the next 2 years, and 37.5% of large Curr Probl Surg, May 2012
rural hospitals reported a surgeon leaving in the next 2 years.27 There is clearly a worsening problem with retention of surgeons in rural practice. The Advisory Council for General Surgery, a standing committee of the ACS, recognized the problem of retention of general surgeons in rural practice. The Advisory Council formed a Subcommittee on Rural Surgery.12 This committee has identified several issues of concern to rural surgeons. First, liability and case volumes are of concern. The debate over case volumes presents a particular threat to surgeons in small volume hospitals. The implication that certain surgical procedures should only be performed in large volume centers, and the increased medical liability that can ensue if that principle is not followed, is a threat to rural surgeons. Rural surgeons can have more logistical difficulties with the incorporation of new technology and maintenance of skills and competence. If practicing surgeons do not have access to new technologies, they may be forced to abandon significant segments of their practice. The needs of rural general surgeons must be met by developing programs with the hospital that consider such issues as expense, time away from practice, and need for practice coverage so the rural surgeon can leave for advanced surgical training. Disparities in reimbursement and the difficulty in recruiting a new partner are also significant issues in retaining a rural surgeon.73 A survey of surgeons who moved from rural to urban areas was recently completed by the ACS Health Policy Research Institute based at the Sheps Center at the University of North Carolina. Based on AMA Physician Masterfile data, they identified 1147 surgeons who moved from a rural setting to an urban setting. These surgeons were invited to participate in a web-based survey to define key factors in the decision to move. There were 51 respondents and two thirds were general surgeons. Among these rural to urban relocators, changes in practice characteristics were (1) notable shift from solo practice to hospitalist or locum tenens, (2) drop in work hours (60 to 54), (3) dramatic drop in call days (4.4 to 2.4), and (4) an increase in surgical volume (10 to 13 procedures/week). These same surgeons detailed the most effective incentives that had been offered to them as inducements to relocate. Fifty-seven percent reported a more favorable work/call schedule, and 48% reported an improvement in surgical equipment or facilities. Only 30% of this group reported a bonus payment as a top incentive. This survey concluded that policies facilitating favorable call schedules may provide the best possibility for retaining rural surgeons. Another strong conclusion in successful retention of a rural surgeon is empowering a rural surgeon to feel that he/she is able to provide high-quality surgical care, and this is closely linked to availability 300
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of surgical facilities, equipment, and support staff (Dr Anthony Charles, personal communication, 9/14/2011). One of the key solutions to retaining general surgeons in rural practice is to deal with the negative impact on lifestyle imposed by onerous call schedules and professional isolation. Many hospitals have looked to locum tenens surgeons to provide call coverage for rural surgeon vacations, meetings, and weekends. Other rural surgeons have developed informal arrangements with nearby hospitals, clinics, or individual surgeons to provide mutual call coverage, skilled operative assistance, quality reviews, and clinical advice. More formal, organized networks of regional health care that are common in the midwestern United States are able to offer even more support to participating rural surgeons. An example of a mature, regional network is the Gundersen Lutheran Health System in La Crosse, Wisconsin. Gundersen Lutheran is a multispecialty group practice that was established in rural southwestern Wisconsin in 1891. In 2011 this fully integrated, physician-led health care system includes nearly 500 physicians and more than 6000 employees working at the main campus in La Crosse, Wisconsin (population, 51,000) and at 25 regional sites in 19 agricultural counties of Wisconsin, Minnesota, and Iowa. The Department of Surgery comprises 14 full-time teaching faculty in La Crosse and 9 rural surgeons who practice in 10 small rural or isolated towns with community hospitals; 7 are CAHs (Fig 4). A guiding principle of the organization is to empower the rural, regional surgeons to practice the full scope of surgery consistent with their training and the capabilities of their community hospital. When these capabilities are exceeded, patients are referred to the tertiary care center in La Crosse for care by members of the same department of surgery. The regional surgeons have access to the same electronic medical records, digital radiology images, and distancelearning technology as the main clinic surgeons, making for relatively seamless transitions of care and the ability of surgeons at all locations to participate in morbidity and mortality and other CME conferences. Administrative assistance for regional surgeons is available for legal, business, credentialing, coding/reimbursement, and quality review initiatives. A department-wide surgical case registry allows each surgeon to track their outcomes and rural surgeons have coauthored several recent research projects.6,34 New skill acquisition can be learned in the skills laboratory or operating rooms of the main clinic and teaching faculty have proctored rural surgeons in the performance of new techniques. The rural surgeons form the backbone of the southwestern Wisconsin regional trauma system and many are ATLS course instructors. Finally, the rural Curr Probl Surg, May 2012
FIG 4. Rural surgeons and rural surgery locations in the Gundersen Lutheran Health System and Wisconsin 2011. Each star indicates a home location for Gundersen Lutheran regional surgeons with the number within each star indicating the number of surgeons based in that town. Circles indicate other hospital locations in which Gundersen Lutheran regional surgeons perform operations. Contracted surgical coverage is also provided in Black River Falls, WI.
surgeons have been able to organize themselves by geographic areas to share call coverage. This network has allowed Gundersen Lutheran to support regional surgeons in an effort to provide surgical care to patients in their communities. It has also resulted in very stable rural surgery 302
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practices with low rates of surgeon attrition. Over the past 25 years, only 2 (12.5%) of 16 regional surgeons have left the Gundersen Lutheran Health System prior to retirement. Although this health system entirely comprises physician employees, the principles may be applicable to less formal networks of care. We have described the current issues in the retention of surgery in rural practice. The problems are many, and there are many possible solutions. Public policy decisions that would strengthen the fiscal condition of small rural hospitals could provide funds to improve facilities, increase retention (providing for locum tenens and training programs for their staff), and support multispecialty clinics. Surgical residency training could be adjusted to focus on the development of “rural subspecialty” training to encompass broader training in the varied surgical procedures that small rural hospitals need their surgeons to provide. Rural hospitals could develop collaborative relationships with large, regional tertiary medical centers to facilitate easy transfer of complicated surgical cases without the claims of “dumping.”7 Although many issues of concern have been described, perhaps the most pressing issue in solving the problems of retention is dealing with the overwhelming issues of workload and reimbursement. To maintain a reasonable quality of life, the rural surgeon and his/her family must have some time off. A practice of 2 or, better, 3 surgeons must be established, or significant competent locum tenens provided. If there is no scheduled opportunity for time away from work provided, burnout will ensue and the surgeon will leave, looking for greener surgical pastures. Closely related to this work hours/quality-of-life issue is the issue of reimbursement. If a surgeon in a rural setting is making less money for more work than their urban counterparts,22,23 this will lead to eventual dissatisfaction and increased burnout and result in surgeon relocation. In summary, additional efforts must be made by society, professional organizations, and the local health care systems to decrease the unequal workload and increase reimbursement, or retention of rural surgeons will continue to be a problem.
Importance of Rural Surgery to Health Care Systems: Consequences of Failure We feel that there is indisputable evidence that a healthy, financially viable rural hospital is very important to the health of the rural community. The economic survival of a small rural hospital is based on many factors. However, it is clear that 1 of the major driving forces in economic survival is being able to provide surgical services. In many Curr Probl Surg, May 2012
ways, a general surgeon is the economic engine that runs the rural hospital. The loss of surgical services may lead to economic failure and even to the closure of the hospital. In 2005 a survey of 68 rural hospitals was conducted in the State of New York. These 68 hospitals were designated as “rural” by the Health Care Association of New York. A 13-item survey instrument was mailed to the administrator of each of these hospitals. There was a 69.1% overall response rate. Nine of the 47 respondent hospitals were excluded because those hospitals were either of a size greater than 100 beds or located in towns with populations of greater than 50,000 people. This left 38 hospitals for final analysis.74 At the time of the survey 42.1% of the hospitals were actively trying to recruit a general surgeon. Of these, 16 (64.3%) hospitals had been looking for a general surgeon for more than 1 year, and 21.4% had been looking for more than 2 years. The vast majority, 86.8%, of these hospital administrators stated that the GS program was critical to their hospital’s financial viability. Nearly 40% of the administrators stated that if the hospital lost its GS program, the hospital would be forced to close. In summary, the results of this study indicated that hospital administrators perceive GS as an important program that makes a substantial contribution to the financial health of their rural institution.74 Using similar methodology, a national survey of rural hospitals was conducted. Using RUCA codes based on data from the 2000 National Census and 2004 zip codes, 2166 rural hospitals were designated from towns located in RUCA codes between 4 and 10 (excluding 4.1, 5.1, 7.1, 8.1, and 10.1, which are urban focused areas). Two hundred thirty-three of these 2166 hospitals were randomly selected for this national survey. The survey was administered in 2005 and had an overall response rate of 48%. Fifty-nine percent were CAHs. Responding hospitals reported they had a median of 2 full-time surgeons and a median of 1 full-time board-certified surgeon on staff. In addition, the median number of any surgeon older than 50 years of age was 2. Thirty-four percent of these hospitals indicated a surgeon was leaving in the next 2 years and 36% of the hospitals were actively recruiting a general surgeon. Eighty-three percent of these 111 hospitals indicated that the surgery program was very important to their hospital’s financial viability and would reduce services if they lost the surgery program. Twelve percent of these hospitals stated that if they lost the surgery program the hospital would close.7 Based on this national survey, a survey of rural hospitals was conducted in the State of Tennessee from 2008 to 2009. Identical methodology was used as that by Doty and colleagues.7 One additional item was added to 304
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the survey in an effort to define the economic worth of a general surgeon. Using this same methodology, 80 hospitals were identified as appropriate for inclusion by the Tennessee Hospital Association. There was a 36.3% overall response rate. In these Tennessee hospitals, more than 44% of the surgeons were older than 50 years. Also, 41.4% of these hospitals had a salaried surgeon. Just more than one fourth (27.6%) of these hospitals anticipated that a surgeon would be leaving in the next 2 years, and 53.6% of the hospitals were recruiting at least 1 surgeon with an average recruitment time of 11.8 months. All hospital administrators felt that having a surgical program was important to their hospital with 97% of respondents stating that it was “very important” to the financial viability of their hospital. When asked what would happen if their hospital lost surgical services, 11% stated they would be forced to close, and 89% stated they would need to reduce services. These hospitals reported that the mean estimated net revenue generated for a hospital by 1 general surgeon was $1,765,680; the median was $1,400,000, with a range of $325,000 to $6,555,938. This study demonstrated that large hospitals had greater revenue as each hospital bed, on average, contributed $1.4 million in gross revenues. An unexpected finding of this study was that whenever a hospital had more gross revenues than expected based on bed size, it had more surgeons than expected. Whenever a hospital was underperforming relative to bed count, it usually had fewer surgeons than expected. This strongly suggests that the number of surgeons is a primary driver of income relative to that which would be expected based on hospital size. Between 2 hospitals of equal size, the 1 with the greater number of surgeons will likely have greater revenues.27 In another study, looking at the impending crisis in the GS workforce, the worth of a general surgeon in annual net revenue to a hospital was estimated at between $1.1 million to $2.4 million per year.3 A successful hospital is crucial for successful community economic development in a rural county. In many rural communities the rural hospital is often the second largest employer, second only to the rural county’s school system. If the total impact of the hospital on employment is calculated (including hospital employees, physicians, pharmacies, etc), health-generated employment is often approximately 10% of a rural community’s employment. One study that examined a rural hospital in Perry, Oklahoma in 1997 demonstrated that (1) approximately 9% of all employment is directly working in the health sector and (2) approximately 14% of all employment is attributed to the health sector (direct and secondary). This analysis concluded that the economic effects of the health sector on these counties were profound. Additionally, to attract Curr Probl Surg, May 2012
industrial firms, businesses, and retirees to any rural community, it is crucial that the area has a high-quality health system. The total impact of the health sector on the economy of the county of this 1 hospital in Perry, Oklahoma was 363 jobs, $7,064,881 in income, $2,319,464 in retail sales, and $63,585 in sales tax.75 Another study examined the difficulty a rural hospital has had, in the past, surviving financially while caring for Medicare patients. Rural hospitals often have a larger percentage of patients in the Medicare age groups. The authors examined a rural hospital in Stigler, Oklahoma (45 hospital beds, 43 full-time equivalent employees, county population 2600, and year 1988). They estimated that if the hospital closed in 1988, by 1992 the county would have lost 154 in county population, 78 jobs, $1,742,800 in income, $452,000 in retail sales, and $9100 in sales tax collection.76 Data such as these helped stimulate legislation to create the designation of CAHs that accept certain restrictions and are reimbursed 101% of cost from Medicare. This legislation was designed to ensure the financial viability of small rural hospitals. It is estimated that, by 2004, 959 small rural hospitals (more than 40% of all rural hospitals) had opted out of the Medicare Diagnosis Related Prospective Payment System and converted to a CAH.76 Currently, of more than 2000 rural hospitals in the US, 1327 are designated as CAHs. In another effort to study the impact of rural hospital closures on community economic health, Holmes and colleagues examined longitudinal data on all counties in the nation from 1990 to 2000. Hospital data regarding hospitals that closed were obtained from multiple sources, such as the AHA’s Annual Survey of Hospitals, the Centers for Medicare and Medicaid Online Survey Certification and Reporting System, the HHS Office of the Inspector General, and others. They identified 134 counties between the years of 1990 and 1999 that had 140 hospital closures. The mean population in these counties was 26,766 and per capita income (1990) was $14,119. Forty-two of these 140 hospitals that closed were the only hospital in the county. They demonstrated that if the hospital that closed was the only hospital in the county, the closure had a direct negative effect on the economic health of the county. Counties losing their only hospital experienced a long-term decrease in real per capita income of roughly $703 in 1990 current dollars and an increase in the unemployment rate by 1.6% (P ⬍ 0.05). They concluded that the closure of a rural county’s sole hospital decreased the economic well-being of the community and likely placed the local economy in a downward spiral that may be very difficult from which to recover. This effect was statistically 306
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significant. They estimated a long-term decrease in the annual per capita income of these counties of 1.5%.77 Probst and colleagues performed a comparative analysis between 103 small rural counties in which a hospital closed between the years of 1984 and 1988 with a matched group of counties in which no closure took place.78 “Comparable” counties were selected based on 7 scales that measure the similarity between a “closure” county and the “comparable” counties. Three scales examined population and economic characteristics in the year before closure; 2 scales measured change throughout a 3-year period preceding closure, and 2 scales measured changes throughout a 5-year period after closure. The rural hospitals were selected from a list provided by the AHA identifying rural hospitals that closed between the years of 1980 and 1992. There were 108 rural hospital closures in the final analysis. There were 3 comparison counties selected for each closure county. Examination of estimated income changes in “closure” and “comparison” counties across the pre- and postclosure periods suggests that hospital closure may have depressed income growth in closure counties. In the 5 years after closure, comparison counties exhibited a pattern of steady growth in earned income averaging an estimated ⫹1.3% per year. Earned income in closure counties declined for the 3 years after closure and then it began to increase again, averaging ⫹0.3% per year. Labor force in closure counties dropped 1.5% during the closure year and continued to decline at approximately ⫺0.1% per year. Comparison counties experienced workforce growth averaging ⫹0.5% per year throughout the period studied.78 Other data indicate that a rural hospital contributed income to the local rural economy of $54,739 per bed per year.79 We have demonstrated that a financially viable rural hospital is a crucial component of a healthy rural economy. The hospital serves as a major employer in the rural community, providing jobs and revenue to the community. Also we have demonstrated that an active surgical service is vital to the economic health of a rural hospital. Surgical services are crucial to provide revenue that keeps the hospital open and also to provide a wide range of services for their community. Without GS services, a family physician would not be able to practice obstetrics safely without surgical backup. In addition, no endoscopy service could be available. There would possibly be no one to provide critical care services. Finally, unstable trauma patients might succumb to potentially salvageable injuries because of inadequate resuscitation and stabilization in concert with long transport times to definitive care. Motor Curr Probl Surg, May 2012
FIG 5. Relationship of density of surgeons to geographic likelihood of mortality from motor vehicle crashes. (Reprinted with permission from Sheldon GF.4) (Color version of figure is available online.)
vehicle crash mortality has been shown to decrease in areas where surgical services are available (Fig 5). The critical shortage of GS providers has been discussed elsewhere in this monograph, but it is obvious that a shortage of surgeons threatens the financial viability of rural hospitals and that the collapse of these hospitals can have a dramatic negative effect on their respective communities. In many ways the economic health of rural communities is tied to the presence and health of these hospitals, which is tied to the ability to provide surgical services. The ongoing crises in the national GS workforce can be expected to have a dramatic negative impact on the economic health of our rural communities unless this trend is reversed.
Maintenance of Quality in Rural Surgical Practice The 2 reasons most often cited by surgeons selecting a rural practice location are their personal or family rural background and a strong desire to maintain a broad scope of practice. In reality, regardless of location, most surgeons perform only 10 to 20 “high-volume” procedures.23,80 308
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Rural surgeons perform endoscopy and common abdominal operations in relatively large numbers, but are called on to perform a large variety of procedures in low volumes (fewer than 5 cases per year). Maintenance of this broad scope of practice depends on a foundation of broad-based training in residency, developing methods for new skill acquisition, support of the hospital for equipment and personnel, and an objective method to demonstrate good outcomes. Surgical outcomes measurement ranges from informal to comprehensive assessment. By virtue of its active, invasive nature, surgery makes surgeons feel accountable for any adverse outcome. General surgeons are often “scarred by their most recent bad result” or “buoyed by their most recent success.” A rural surgeon often lacks surgical peers in their own institution and must therefore rely on themselves to serve as their “own greatest critic” as well as “their own greatest fan.” The interplay between these 2 extremes is what defines many surgeons as good or bad. Careful, honest self-assessment of performance may be a very powerful quality control mechanism. However, in a climate of many third-party judges and imposition of “volume as a surrogate for quality” initiatives, the rural surgeon is particularly vulnerable. Common barriers to quality assessment of a rural surgeon’s practice include lack of surgical peers, limited institutional resources, low surgical case volumes in many categories, and adverse characteristics of rural populations.81 The proliferation of centers of excellence, regionalization of care, and volume/quality assessments are particularly threatening to rural surgery. In reality, the operations for which the associations between volume and outcomes are strongest (pancreatectomy, esophagectomy, gastrectomy) are not often performed in rural hospitals presently.82 Because of this, the effect of regionalization of these uncommon operations would have minimal impact on the volume of surgery done in rural hospitals.83 However, expansion of volume/ outcome criteria into more common procedures, such as colectomy, breast surgery, biliary tract surgery, and hernia repair, would have tremendous repercussions on rural surgical practices. For this reason, as well as to demonstrate honest personal surgical results that may be shared with patients and their families, there is building pressure on rural surgeons to participate in on-going quality assessment. Tracking results and demonstrating equivalent outcomes are clearly the most effective measures to protect against bureaucratic application of measures that purport to equate low volume with low quality. Regionalization of surgical care as a solution to variations in quality has some distinct disadvantages, including long travel distances for patients, resultant hardship for families, poor continuity of care, and obvious Curr Probl Surg, May 2012
TABLE 4. Options for performance improvement and outcomes assessment for rural surgeons Personal registry of cases/outcomes ACS National Surgical Quality Improvement Program Classic Essentials Small and rural ACS Practice-Based Learning for Surgeons (case log system) Centers for Medicare and Medicaid Services Surgical Care Improvement Project ACS registries Trauma Oncology State-wide quality consortiums Washington (Surgical Care Outcomes Assessment Program) Tennessee (Tennessee Surgical Quality Collaborative) Regional networks ACS, American College of Surgeons.
negative economic impact on rural hospitals and their communities. Regionalization based on volume alone has even less credibility. Finlayson has determined that volume is an ineffective surrogate for quality at small rural hospitals.81 More successful approaches to quality assessment in these environments include (1) focusing on processes of care, (2) developing quality consortiums with other providers and regional hospitals, and (3) determining the appropriateness of care instead of trying to develop outcome measures for operations in which the sample size is so small that no meaningful statistical results can be reached.81 As an example of the utility of quality assessment using measures of processes of care, Cronen and colleagues recently reported the results of a study of surgical time-out procedures at 4 small to midsized hospitals in Kentucky and southern Indiana.84 They reported that smaller hospitals were able to react more quickly than larger hospitals to ideas for improvement and were able to demonstrate equivalent surgical process measures as larger institutions. Demonstrations of surgical outcomes are also possible by participation in regional or national projects in which an individual’s results can be benchmarked against a larger, diverse group of surgeons (Table 4). The most sophisticated of these efforts is the National Surgical Quality Improvement Program (NSQIP) of the ACS. ACS-NSQIP is a widely accepted quality improvement program based on a risk-adjusted data collection mechanism that collects and analyzes outcomes data. ACSNSQIP Classic is an extensive surgical quality improvement program that depends on collection of 69 clinical variables by specially trained data 310
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managers. It is both expensive and labor-intensive, making it prohibitive for most small rural hospitals and rural surgeons. ACS-NSQIP Essentials uses a reduced set of 46 clinical variables to identify areas of concern and measure quality improvement. ACS-NSQIP Small and Rural is a new program designed for institutions with low surgical case volume or those located in rural areas as defined by RUCA codes. This program uses the collection of the same set of variables as ACS-NSQIP Essentials. The ACS also offers its Practice-Based Learning for Surgeons case log system. Using this program, a rural surgeon can track cases and outcomes in a confidential registry that can then be used to develop current benchmarks based on aggregate results recorded by the participants. Finally, the ACS sponsors national registries for trauma and oncology patients. The Centers for Medicare and Medicaid sponsors the Surgical Care Improvement Project. This national program emphasizes easily measured processes of care in an effort to improve quality by increasing compliance with standards of care. Other options for practice quality assessment include collaboration with other surgeons or hospitals as part of many networks doing this work.85 Examples of state-wide efforts at quality improvement and cost-effective care are Washington state’s Surgical Care Outcomes Assessment Program and the Tennessee Surgical Quality Collaborative. Regional health systems of care can also promote quality initiatives. Surgical quality initiatives currently in place at Gundersen Lutheran Health System in Wisconsin include participation in ACSNSQIP, a system-wide surgical case registry, ABS Maintenance of Certification activity tracking, system-wide access to morbidity and mortality conferences using distance learning technology, and ad-hoc procedure outcomes peer review. Excellent surgical outcomes are not achieved by surgeons working in a vacuum. Commitment of the rural hospital to quality is also vital. This means that adequate resources are allocated for the purchase and maintenance of specialized equipment, the training and CME of operating room personnel, and provision of an appropriate facility. Hospitals must not push surgeons to perform procedures that they are uncomfortable doing in that environment. Conversely, rural surgeons must not push hospitals to perform procedures for which they are not properly equipped or trained. A healthy partnership between the rural hospital and rural surgeon is necessary to engender an environment in which the scope of practice can be maintained as broadly as excellent outcomes allow. Curr Probl Surg, May 2012
Potential Solutions The practice of GS in a rural area can be very rewarding. To reverse the current trends in workforce shortages and to enhance the quality of life for rural surgeons, innovative but thoughtful solutions will be necessary. There is no question that the 2 most powerful disincentives— demanding lifestyle and lower compensation—must be addressed first and foremost. Based on our review of the topic, it is our opinion that several issues might be solved with a multifaceted approach to improving rural surgery.
Expanding Rural Surgery Workforce Recently a panel of surgical leaders convened to discuss the growing crisis of shortfalls in the GS workforce.14 They concluded that the following actions might increase the number of general surgeons produced each year: (1) increasing the overall number of GS residency positions in the United States to augment throughput of general surgeons into practice; (2) more training in community hospitals, exposing the residents to role models and mentors who are actually general surgeons; and (3) selection of residency candidates by likely interest in a GS career. Although predicted to have only a modest impact, these steps would increase the number of potential general surgeons, some of whom would select a rural practice location. Other methods to build interest in rural surgery might include high school and college mentoring or “reality” programs. Medical school rural preceptorships and full immersion rural surgery rotations during residency should be expanded— especially in states with rural physician shortages. Urban residencies without a rural rotation could partner with another residency in their geographic area that does offer a rural experience to sponsor their resident on a rural rotation. Finally, a clearinghouse of information about residencies with a rural commitment should be developed for residency applicants interested in rural surgery.
Preparing Residents for Rural Practice Rural general surgeons need training in all the essential components of GS. They need particular emphasis on abdominal surgery with excellence in minimally invasive techniques to be competitive. A rich experience in esophagogastroduodenoscopy and colonoscopy is absolutely essential. Rural surgeons must be well versed in critical care, nutrition, and trauma management. Formal exposure to gynecology and surgical obstetrics at a senior resident level is preferable. Rural surgeons must be comfortable managing vascular emergencies and complex wounds. Exposure to other surgical subspecialties, such as orthopedics, otolaryngology, urology, and 312
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thoracic surgery, is location-dependent, based on the needs, resources, and subspecialty coverage for the rural hospital. Increased flexibility in the final 2 years of residency as allowed by the ABS should make acquisition of these additional skill sets possible. Practice management topics, practice-based learning techniques, and leadership training are also important. For those surgeons wishing to acquire subspecialty training after residency in preparation for a transition in their careers to another location, postresidency mini-fellowships must be made available.
Recruitment of General Surgeons to Rural Areas Much of the success in recruitment centers around a competitive, attractive financial package for the rural surgery applicant. This compensation package may include many components—salary, benefits, signing bonus, loan forgiveness, salary guarantees, and contract provisions. Lifestyle issues are also fundamental with rational approaches needed for call coverage and time off for vacations, CME activities, and new skill acquisition. Administrative assistance to help navigate an increasingly complex bureaucracy is vital. Creative recruiting techniques need to be developed, such as linking searches for rural surgeons and primary care physicians in a collaborative fashion to ensure that the requisite critical mass of providers is assembled to allow adequate mutual volumes of patients and referrals. Finally, consideration should be given by governmental agencies to designate rural general surgeons as primary care providers or providers in health care shortage areas who qualify for rural health recruitment and reimbursement incentives.
Retention of Rural General Surgeons Success in retention also revolves around compensation and lifestyle issues. In addition to competitive salaries, rural surgeons want to be able to maintain an interesting mix of cases. This depends on the ability to keep up with advances and to acquire new skills. It also hinges on a commitment by the hospital to support new technique development with appropriate investment in resources, equipment, and training for hospital personnel. The acquisition of new skill sets has been 1 component of a recent rural surgery symposium sponsored by the ACS. To ameliorate professional isolation, rural surgeons can be connected with colleagues at surgical meetings or through Internet-based resources such as the ACS web portal for rural surgeons. CME must be made possible with call coverage for meeting attendance as well as with on-line resources. To minimize the impact of volume/quality initiatives, rural surgeons must have the tools available to track their personal outcomes to compare to Curr Probl Surg, May 2012
published benchmarks. Administrative help to deal with legal, financial, credentialing, and information technology issues is increasingly important. Practice networks (formal or informal) may alleviate many of the burdens of rural surgery practice by provision of call coverage, administrative assistance, technology investments, new skill acquisition, communication methodology, and ease of system-wide referrals.
Consequences of Failure to Preserve Rural Surgery Loss of rural surgery practices translates into closure of rural hospitals or significant curtailment of services. Without a local hospital, rural patients and families will be forced to travel long distances for care. Many of these patients will simply fail to seek care or be subject to delays in treatment. Regional systems of care, such as state-wide trauma systems, may collapse or require major redesign in states with large rural areas. Regional tertiary surgery centers will likely be inundated with high volumes of poorly evaluated patients inappropriately referred to subspecialty surgeons for treatment. Preservation of active and successful rural surgery practices will require implementation of many of the potential solutions above in an effort to maintain excellent surgical care for more than 60 million rural Americans.
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