College leaders answer the question, “Why is rural surgery an important issue now?”

The American College of Surgeons (ACS) is a scientific and educational association dedicated to improving the quality of care for the surgical patient. The College is involved in many activities, such as surgical education, cancer programs, trauma care, volunteerism, political advocacy, and so on. Recently the College’s Board of Regents chose to place new emphasis on the issue of rural surgery, and with the Board’s support, an Advisory Council for Rural Surgery was formed in June 2012. It is the first new Advisory Council that the ACS has established since 1988.

Considering the fact that the practice of rural surgery has been a part of the profession since the advent of surgery, what motivated the ACS leadership to start focusing attention on this important issue now?

Rural roots

In an effort to determine why the practice of rural surgery has become a top priority for the College, I interviewed the current ACS President, A. Brent Eastman, MD, FACS; Immediate Past-President Patricia Numann, MD, FACS; and the Past-Chair of the Board of Regents J. David Richardson, MD, FACS.

It quickly became apparent that all three of these College leaders had personal ties to rural America and rural surgery. Dr. Eastman grew up in Evanston, WY, a town with a population at the time of approximately 3,000. At age eight, he developed nausea, vomiting, and abdominal pain. An appendectomy was performed, but his symptoms persisted, and the appendix was found to be normal. He was referred to a surgeon in Ogden, UT, who ordered an intravenous pyelogram, which showed bilateral ureteral obstruction due to an anomalous renal artery. Two urologists performed a ureteropyeloplasty, which Dr. Eastman said, “Really saved my life, because I was destined for chronic pyelonephritis.”

Dr. Numann grew up in upstate New York, in the town of Denver, which had a population of 82. Her family was poor. “Much of our medical care was really given to us by those doctors who never seemed to make an issue of it in any way,” she said. “We always received good care.”

As a surgical resident, Dr. Numann was driving home late on Christmas Eve. When she was about 10 miles from home, she fell asleep at the wheel, and “went through three guard rails and a tree.” After extricating herself from the car and waking up the family at a nearby residence, she was taken to the local hospital. She had an extensive scalp laceration, and her hematocrit was found to be 17 percent. She is very appreciative of the care she received from the rural surgeon and the rural hospital.

Dr. Richardson also has a rural background and, in fact, was born in a one-room house in the small town of Morehead, KY. At the age of 10, he developed acute appendicitis with perforation. “I had to go to Lexington, which was nearly a two-hour ride in my dad’s truck, and it was not pleasant. That left an impression on me,” recalled Dr. Richardson, which may explain why access to surgical care has always been an important issue to him.

Although having three College leaders with ties to rural surgery likely helped to draw attention to the issue, there are other reasons why the College is placing greater emphasis on this topic. One reason is the change that has occurred within the College leadership and the Board of Regents. According to Dr. Eastman, “The leadership in the ACS has in recent years increased our efforts to facilitate two-way communication with our Fellowship and hear from the ‘surgeons in the trenches.'”

Dr. Numann added that the composition of the Board of Regents has changed and that the Regents “understand because they have been the workers in the field. They have walked the walk. I think it’s making a difference, and it’s going to make the College more relevant to everyone.”

Access issues

The College has always been concerned about access to surgical care and that is an issue of particular concern in rural America. An estimated 59 million citizens live in rural America.1 One-third of the land mass of America is defined as rural.2 Although 24 percent of Americans live in small rural communities, only 10 percent of general surgeons practice in those communities.3 Trauma literature has shown that a higher density of surgeons is associated with a significant reduction in deaths from motor vehicle crashes.4 The lack of proximity to a trauma center or to the appropriate level of care results in a higher death rate for motor vehicle traffic accident victims, and the death rates are higher in areas that have a lower number of surgeons per county.5

Given that access to high-quality surgical care is “part of the overall mission of the ACS,” according to Dr. Numann, it should be no surprise that improving the availability of surgical care in rural areas has become a priority for the College. As Dr. Richardson said, “We have to refocus our efforts to really make sure that quality care is available for all of our people. It’s [a matter of] getting a good surgeon out to where the people are.”

Workforce shortages

The College is particularly aware of the shortage of general surgeons and its impact on rural surgery. Although the number of general surgery residents completing residency each year has remained constant, the U.S. population continues to rise. The number of residents choosing to specialize is also growing. Due to these two factors, the overall number of general surgeons per 100,000 population has decreased by 25.91 percent between 1981 and 2005.6 Fewer general surgeons are practicing in rural areas relative to urban areas. Lynge and colleagues have shown that there are 4.67 general surgeons per 100,000 population in rural areas, compared with 6.53 general surgeons per 100,000 population in urban areas.7 Critical access hospitals, which serve as the sole support for many rural areas, are having difficulty recruiting general surgeons. Of the 1,294 critical access hospitals, 365 (28.2 percent) have facilities with operating rooms, but do not have a general surgeon residing in that county.1

Furthermore, the current rural surgical workforce is aging. General surgeons in small or isolated rural areas are more likely than their urban counterparts to be 50 years of age or older.7 In a survey of hospital administrators from 111 rural hospitals, one-third reported that they are actively recruiting a general surgeon, and one in 10 hospitals reported that they would be forced to close if they did not recruit general surgeons.3

Surgical training and education

From its origin, the College has always been concerned about surgical training and education. This issue also affects rural surgery. All three surgeons interviewed for this column expressed concern that the Halsted model of surgical training may no longer be the best model. And according to Frank R. Lewis, MD, FACS, executive director, American Board of Surgery, the failure rate for the oral exam of the American Board of Surgery has increased from 16 percent in 2006 to 27 percent in 2012 (personal communication with Dr. Lewis, November 14, 2012). These, and other factors, may continue to raise questions regarding the overall quality of surgical training today.

There also is a very real trend for residents to pursue surgical specialization, which decreases the pool of general surgeons who are available to practice rural surgery. The percentage of general surgery residents that choose to do a fellowship after residency has increased from slightly more than 50 percent in 1992, to 78 percent in 2010.8,9 This percentage has increased further to 80 percent in 2012 (personal communication with Dr. Lewis, November 14, 2012).

Residents choose to specialize for many reasons. One reason may be that the current model for residency training may not adequately train residents to practice in a broad-based general surgical practice. In a survey of general surgery residents, 27.5 percent reported being concerned that they would not feel confident performing surgical procedures by themselves before they completed training.10

The College’s leadership is concerned about surgical education issues. “The College actually was founded to look at the quality of the hospitals that residents were trained in to be sure that they had sufficient services to support the proper training of surgical residents. Isn’t it ironic that here we are 100 years later, and maybe we need to look at that again,” said Dr. Numann.

“For the American College of Surgeons to be relevant to the people practicing in the rural environment, the ACS needs to be involved from the beginning in setting standards for training and continuing education to support our rural surgeons,” Dr. Eastman added.

As the data cited previously in this article clearly demonstrate, rural surgery is an endangered area of general surgery. Approximately 1,000 general surgery residents complete their training annually.11 About 80 percent of these residents will go on to complete a fellowship, and if all of these residents then specialize, only 200 new general surgeons will enter the workforce each year, which leaves just four new general surgeons per state annually.

Perhaps rural surgery is the “canary in the coal mine” for general surgery. If there aren’t enough replacements for rural surgeons, how long will it be before there aren’t enough replacements for general surgeons?

Establishing the Advisory Council

As Chair of the Board of Regents, Dr. Richardson invited two rural surgeons, Tyler Hughes, MD, FACS, and Philip Caropreso, MD, FACS, to address the Board of Regents in February 2012. Dr. Hughes practices in McPherson, KS, and is on call every other night. Dr. Caropreso has practiced general surgery for 36 years, and works in Keokuk, IA. Dr. Caropreso is trying to retire but is having difficulty finding a surgeon to replace him. During the meeting, both surgeons described why they chose to practice rural surgery and made it clear that they derive great personal satisfaction from that decision. They also described challenges related to rural surgery, including workforce issues, such as an aging surgeon population, burnout, call issues, fatigue, difficulty with recruitment and retention, and training issues. Drs. Hughes and Caropreso warned of the possible extinction of rural surgery if these issues are not addressed.

“I think it would be no understatement to say that to me it was one of the most compelling things I’ve ever listened to in my life. I think we all felt that way,” recalled Dr. Richardson.

Dr. Eastman described the presentation as a “seminal moment,” provoking the Board to convene a business meeting on the issue of rural surgery. Drs. Eastman, Numann, and Richardson all stated that this meeting was very brief due to the unanimous support for rural surgery. The Board of Regents agreed that action needed to be taken immediately to support rural surgery and recommended the formation of an Advisory Council for Rural Surgery. By the June 2012 meeting, the membership and leadership of the Advisory Council on Rural Surgery was in place. Dr. Eastman said, “I don’t think that I’ve ever seen anything in my time as a Regent for nine years, or as President–Elect, or now as President, move through the machinery of governance of the Board of Regents as fast. I think that spoke to [the] leadership [of] David Richardson, and I think that it spoke to a strong, well-presented message from the rural surgeons that provided the reasons why the College should be interested in this [issue].”

The leadership of the College has always been concerned about the issues of access to quality surgical care, surgical education, and surgical workforce issues, including those specific to rural surgery. Through leaders with personal ties to rural America and rural surgery, this topic became a top priority for ACS leadership, particularly as the result of an excellent presentation given to the Board of Regents. This presentation crystallized and personalized the issues involving rural surgery, and made it clear that rural surgery is a modern-day concern, particularly for members of the College. The real key in the events leading up to the formation of this Advisory Council is the rapid response of the leadership of the College. They not only heard the message, but they chose to act accordingly, responding to the needs of both Fellows and patients. With the help of the ACS, rural surgeons will continue to be able to, in the words of the College’s motto, “serve all with skill and fidelity.”


References

  1. Sheldon GF. Surgical practice in rural areas. Introduction. Surg Clin North Am. 2009;89(6):xvii-xix.
  2. Lynge DC, Larson EH. Workforce issues in rural surgery. Surg Clin North Am. 2009;89(6):1285-1291.
  3. Frangou C. Rural hospitals feel the pinch of general surgeon shortage. General Surgery News. 2008. Available at: www.generalsurgerynews.com/ViewArticle.aspx?d_id=69&a_id=9929. Accessed November 20, 2012.
  4. Chang DC, Eastman AB, Talamini MA, Osen HB, Cao HST, Coimbra R. Density of surgeons is significantly associated with reduced risk of deaths from motor vehicle crashes in US counties. J Am Coll Surg. 2011;212(5):862-866.
  5. Eastman AB. Scudder Oration on Trauma. J Am Coll Surg. 2010;211(2):153-168.
  6. Lynge DC, Larson EH, Thompson MJ, Rosenblatt RA, Hart LG. A longitudinal analysis of the general surgery workforce in the United States, 1981–2005. Arch Surg. 2008;143(4):345-351.
  7. Thompson MJ, Lynge DC, Larson EH, Tachawachira P, Hart LG. Characterizing the general surgery workforce in rural America. Arch Surg. 2005;140(1):74-79.
  8. Sheldon GF. The evolving surgeon shortage in the health reform era. J Gastrointest Surg. 2011;15(5):1104-1111.
  9. Sheldon GF. Access to care and the surgeon shortage. Ann Surg. 2010;52(4):582-590.
  10. Yeo H, Viola K, Berg D, Lin Z, Nunez-Smith M, Cammann C, Bell RH Jr, Sosa JA, Krumholz HM, Curry LA. Attitudes, training experiences, and professional expectations of US general surgery residents. JAMA. 2009:302(12):1301-1308.
  11. Fischer JE. The impending disappearance of the general surgeon. JAMA. 2007;298(18):2191-2193.

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