Rural surgical practice requires new training model, offers great opportunities

Surgical care for rural America is at a crossroads. The average age of a rural general surgeon is 55 and increasing. The rural population is growing and aging as well. More than 50 million Americans live in rural America, hours from major metropolitan medical centers.*† These people want and deserve optimal care in their communities.

Fiscal uncertainty is everywhere, including in rural America. Financial viability is razor-thin for many health care systems. It is a well-recognized fact that surgical services are critical to the financial viability of rural hospitals and quite often to the communities they serve because the hospital and schools are typically the largest employers in these towns. They provide stable, high-paying jobs for an educated workforce.

The good news is there is an increasing interest among medical students in developing the skill set necessary for providing surgical care in rural America. These students are tech-savvy, have clarity of long-term vision, and are interested in diverse training opportunities. Further, an increasing number of opportunities for that training are now available.

The American College of Surgeons’ (ACS) Advisory Council for Rural Surgery (ACRS) is developing a repository of opportunities for training to optimize the skill set of a surgeon to competently and safely enter practice in rural America. Practicing surgery in a rural setting requires a more diverse skill set than is needed to practice in urban areas because small communities are often unable to support surgical specialists, such as otolaryngologists, plastic surgeons, urologists, or even obstetrician-gynecologists (OB-GYNs). Rural surgeons need to be capable of providing emergency care for specialty surgical problems as well as for general surgery conditions. Fortunately, several types of educational opportunities are available for residents to develop these added skills. Although this column by no means provides a comprehensive list of all available programs, it does help to begin a conversation about different program types that are available.

Rural surgery rotation

One rural training model is a rural surgery rotation. Many general surgery programs offer residents the opportunity to do a rural surgery rotation, either as an elective or as a required component of training. Residents spend anywhere from one to three months away from the primary urban teaching center in a community setting where they get concentrated focus on general surgical experience and on a variety of subspecialty cases as well. In many of these settings, endoscopy experience is emphasized. These opportunities are available at East Carolina University, Greenville, NC; East Tennessee University, Johnson City; University of Nebraska, Lincoln; University of Tennessee at Knoxville; and University of Tennessee at Chattanooga, as well as other programs.

Dedicated track

Another model of training is a dedicated rural surgery track. One example of this model is a program available at the University of North Dakota, Grand Forks. This program includes nine months of training with surgical subspecialty and rural surgery rotations in postgraduate years (PGY) 2, 3, and 4. These rotations include endoscopy, OB-GYN, urology, otolaryngology, and orthopaedic surgery, as well as additional exposure to rural surgical cases. This program’s defined track is available through the National Residency Matching Program (NRMP) as a distinct, separate entity.

Immersion approach

Another model for rural training is an immersion approach. At Oregon Health Sciences University, Portland, and the University of Utah, Salt Lake City, residents have the opportunity to spend an entire year in a rural community in lieu of the usual year of research in the middle of residency. The residents spend the year immersed in the community, where they work alongside surgical subspecialists, have their own morbidity and mortality conferences and journal clubs, and participate in local educational opportunities and county medical societies. Typically, these residents have a high volume of operative experience, including endoscopy.

Several programs in the U.S. have a more broadly defined general surgical experience intrinsic to their general surgery residency. Gundersen Lutheran Medical Center in La Crosse, WI, and Bassett Medical Center in Cooperstown, NY, are programs in smaller communities that have no competing fellowships or subspecialty residents. The lack of competing learners allows for a much broader collaborative experience with subspecialty faculty throughout the entirety of the surgical training program. Dedicated rural electives are available in both, as well as subspecialty-specific rotations. These programs provide great opportunity for collaboration in subspecialty operative and perioperative care opportunities throughout the entirety of the five-year residency program.

Fellowships

Fellowship opportunities are also available, such as the program at The Mithoefer Center for Rural Surgery in Cooperstown, which has pioneered a flexible fellowship experience that allows a surgeon in practice or at the completion of his or her residency to spend additional time in a focused experience—for example, endoscopy—to better develop the skill set necessary to go into practice in rural America. These programs have typically been collaborative efforts with the ultimate site chosen as a stepping stone to develop the specific skills needed to succeed in the new location.

The ACS has recently developed a Transition to Practice Program in General Surgery. This program is intended for residents finishing their general surgery training who would like additional experience in practice development, subspecialty exposure, and rural surgical care. To date, the ACS Transition to Practice Program in General Surgery is offered at the following institutions: Eastern Virginia Medical School, Norfolk; Gundersen Lutheran Health System; Mercer University School of Medicine, Macon, GA; Ohio State University, Columbus; University of Louisville, KY; and the University of Tennessee at Chattanooga.

The interest level in providing opportunities for young surgeons to undergo the training necessary to provide optimal care to surgical patients in rural America is on the rise. At the same time, medical students, residents, and surgeons-in-practice are often looking for a change in practice type. Exciting opportunities to introduce young surgeons to the joys of rural surgery are emerging all over the country, and rural general surgeons are in great demand.

The ACRS and ACS as a whole are committed to promoting and enhancing these opportunities. The advisory council recognizes that the list of programs that will provide appropriate training in this field is far from comprehensive and is making further efforts to develop a more detailed list of programs offering this educational opportunity. Directors of programs not mentioned in this article who would like to submit information to the ACRS about their training models should send details to Karen Deveney at deveneyk@ohsu.edu.


*Stevermer JJ, Supattanasiri GJ, Williamson H Jr. A survey of general surgeons in rural Missouri: Potential for rapid decrease in work force. J Rural Health. 2001;17(1):59-62.
Shively EH, Shively SA. Threats to rural surgery. Am J Surg. 2005;190(2):200-205.

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