Editor’s note: This is the first in a series of columns written by members of the American College of Surgeons (ACS) Advisory Council for Rural Surgery.
The American College of Surgeons (ACS) is celebrating 100 years of excellence at the same time I am celebrating 25 years of surgical practice in a rural community. I practice in a town of 15,000 in southeastern Ohio and serve a population of 50,000 or more. A total of seven counties in this part of Ohio have no health care facilities and two others have only critical access hospitals.
As a rural surgeon, I perform a wide variety of general, vascular, laparoscopic, endocrine, pediatric, and thoracic procedures. My caseload also includes diagnostic and therapeutic endoscopy, pillcam, endoscopic retrograde cholangiopancreatography, carpal tunnel release, and pacemaker insertion. Caring for a small community using all the knowledge and broad surgical skills gained from a general surgery training program is incredibly rewarding and fulfilling.
Challenges in rural surgery
The challenges of rural surgery have been documented in several recent surveys and articles.1-3 Some of the less favorable aspects of rural practice that have been cited include excessive call coverage, difficulty recruiting and retaining young associates, problems accessing educational programs, malpractice issues, and professional isolation. Many rural surgeons are nearing retirement age and only 12 percent of surgical residents are entering general surgery practice after their five years of training.4 Critical shortages of surgical manpower have developed in rural America.
I trained at Marshall University in West Virginia. I did have the good fortune to have an excellent mentor as a senior partner when I began my practice in Ohio. And while I have experienced alternating periods of sharing call with one or two other surgeons, I have also experienced the challenges of not being acquainted with other surgeons trained in this state, and who are practicing in the area.
Benefits of chapter membership
Fortunately, I discovered an organization in my state that not only helped me meet the challenges of a small-town practice, but also encouraged involvement in leadership, advocacy, and surgical collegiality. The ACS Ohio Chapter is a dynamic organization composed of an incredible mix of dedicated academic, large community, and rural surgeons from all four corners of the state.
The networking opportunities for members of this chapter are limitless. My practice partner and I were able to arrange temporary help with our call coverage through interaction with a group of chapter members in another community. In addition, interaction with a group of academic surgeons facilitated our recruitment of a newly trained resident; no recruiting firm was needed.
The Ohio Chapter has close ties with the state ACS Committee on Trauma, the Commission on Cancer® (CoC), the Association of Women Surgeons, and the American Cancer Society, and these groups contribute to the chapter’s meeting agenda. Annual chapter meetings offer opportunities for members to earn continuing medical education credits, and to learn about ways to improve one’s practice, with renowned experts from across the country speaking on various pertinent topics.
Perhaps the most important benefit of attending the chapter meetings is the networking opportunities and collegiality of the participants. It is routine for a surgical chair or trauma director from a university program, a solo practitioner from a tiny town, and an endocrine or oncologic surgeon from a major institution to share a meal. The group has attended a professional baseball game, dined on a riverboat, and mingled in a planetarium. These social activities foster an incredible bond between Ohio surgeons from all walks of life and can lead to big improvements in the provision of quality care.
Benefitting patient care
Professional isolation often means not knowing where to send patients with complex conditions that are beyond the capabilities of a small hospital. Rural surgeons sometimes worry that residents or tertiary surgeons will denigrate the care rendered prior to referral and thereby give rise to malpractice litigation and the loss of professional credibility. Statewide collegiality and social relationships between surgeons allow rural surgeons to more confidently transfer difficult patients to tertiary surgeons who are familiar with and understand the limitations small-town surgeons face.
Greater familiarity and better communication between surgeons translates into better patient care and fewer misunderstandings between all parties involved. These relationships also lead to a greater referral base for the new academic surgeon looking to build a practice. Through my chapter contacts, I can call specialists at any center in Ohio for a second opinion about a complex case, advice in the operating room, or transfer support when patients require advanced or additional care. I can also offer local follow-up care for those patients referred to subspecialists in distant cities. Both the rural surgeon and the tertiary surgeon benefit from the bonds forged through chapter membership.
The chapter’s involvement with other areas of the College has proven beneficial as well. As an example, the CoC Cancer Liaison meeting is part of our annual chapter meeting. Interaction with this group helped me earn two CoC Cancer Liaison Physician Outstanding Performance Awards.
Involvement with the state Committee on Trauma, which also meets during the Ohio Chapter annual meeting, led to the formation of relationships with adult and pediatric trauma centers, which facilitates our ability to provide lifesaving, initial care to unstable trauma patients and immediately transfer them to Level I facilities for definitive care. I have spoken about the need to improve communication and cooperation between tertiary and community surgeons at statewide trauma conferences and during Surgical Grand Rounds at Ohio State University, Columbus. These experiences have afforded me access to major centers to observe new surgical techniques and develop important contacts.
Tertiary surgeons also reap the benefits of these relationships, including an expanded referral base and trusted assistance in the provision of ongoing follow-up care. In addition, rural surgeons typically perform many endoscopy procedures and may be useful in training surgical residents in the provision of these services.
Community surgeons can also offer surgical clerkships for medical students. Telemedicine opportunities could be developed with small towns to improve patient care statewide, decrease inappropriate transfers, and generally facilitate better communication between facilities. We are doing this in our small community for stroke care and pediatrics and are in the process of extending it for burn care.
United surgical community
Lastly, and most importantly, the Ohio Chapter has made me a better citizen of the surgical community. I started travelling to the annual meeting to attend the cancer and trauma sessions and stayed for the entire program. I participated in the social events and met established members. Instead of ignoring an unknown, young attendee, many chapter members engaged me in their conversations and dinner groups.
The ACS Ohio Chapter also drew me into and educated me about advocacy efforts, in which every surgeon should actively engage. In 2009, after serving as chair of the Community and Rural Surgery Committee for a few years, much to my surprise, I was nominated to be President of the Ohio Chapter. This group was asking a rural surgeon from a tiny community to lead an organization representing all the surgeons in Ohio.
Clearly, ACS state chapters represent all facets of the statewide surgical community and all surgeons need to participate and contribute. The educational, social, and professional benefits are limitless, particularly for rural surgeons.
- Fischer JE. The impending disappearance of the general surgeon. JAMA. 2007;298(18):2191-2193.
- Broughnan TA. Surgical endoscopy. SAGES 2007 rural surgery panel. 2008;22(7):1579-1581.
- Mithoefer Center for Rural Surgery. Available at: www.centerforruralsurgery.org. Accessed August 24, 2012.
- Personal communication with Tyler Hughes, MD, FACS, American Board of Surgery, June 2012 meeting.