Students need exposure to the joys of rural surgery

“I want you to know that Dr. Tate is a good man. He did my gallbladder 15 years ago, his daddy did my C-section, and his daddy birthed me. You understand? He’s a good man.”

The patient, who I will call “Rose,” a spunky North Carolinian in her mid-70s, was referring to William C. Tate III, MD, FACS, a general surgeon in the town of Linville, NC. It was in my first week as a fourth-year medical student on a sub-internship in rural surgery. Rose’s eyes twinkled through her bifocals as she reminded me again how lucky I was to be working at the Tate Clinic. Today, her daughter had driven her to this small practice for a biopsy of a suspicious lesion on her left arm.

Dr. Tate knocked and then unceremoniously walked into the exam room. He greeted Rose with a kiss on her cheek and a warm hug. The visit began with an update on his mother’s health, followed by discussion of the renovations going on at the local church. It was a good few minutes before the conversation turned to medicine. I reported a quick history and physical exam to Dr. Tate, and a biopsy was done. Rose left with another hug from Dr. Tate and some more advice for me.

“You remember that Bill Tate is a good man, you hear?” She grinned at Dr. Tate as she shook her finger at me.

My four weeks as a sub-intern in rural surgery were inspiring. Dr. Tate’s grandfather came to Linville in 1910 as the town’s first general surgeon. Later, his son took over the practice, and now his grandson runs the clinic with his partner, Thomas Matthews Haizlip, Jr., MD, FACS. As general surgeons in the truest sense, they have served the citizens of western North Carolina expertly. I had the opportunity to first-assist on a range of cases, including amputations, hemi-colectomies, skin grafts, cholecystectomies, and endoscopies. More importantly, for those four weeks, I felt like part of the town. I saw how their kindness, humanity, and investment in the community have positively affected patients’ lives.

Opportunity leads to inspiration

But what spurred my interest in rural surgery? It certainly was not my upbringing. I was born and raised in the Washington, DC, metropolitan area and have spent most of my adult life in the suburbs of Chapel Hill, NC. However, in the last two years, I have taken a 180-degree turn. I completed my third year of medical school in a program that emphasizes rural care in western North Carolina. I am currently finishing my master’s thesis on the effects of federal and state policies on a rural hospital system in the region. As a general surgery applicant, I have sought out residency programs that have an academic and clinical focus on rural disparities.

I would not have followed this trajectory had it not been for the opportunity to learn in a rural environment with engaging mentors. During my first two years at the University of North Carolina (UNC) School of Medicine, I was assigned to five “community weeks” in a pediatrics office in the northwest corner of the state. This experience was my first foray into medicine outside the academic and urban environments. I immediately appreciated how invested the physicians were in the community. They knew their patients on a personal level. Thus, I chose to complete my entire third year in Asheville, NC, where I trained under a group of superb mentors.

Almost everyone reading this column likely has had at least one mentor in surgery. Somewhere in our careers, we met a clinician who was a leader and pushed us to be better. We seek to emulate such mentors, and they often influence us far more than we realize. Dr. Tate is one of those people for me, as is Dr. Haizlip. These clinicians have shown me how to be a surgeon committed to both the patient and the community. They are the ones who made the case for my decision to embark on a career in rural surgery.

Pointing the way

Approximately one-quarter of the U.S. population lives in rural areas, yet only 15 percent of the American physician workforce provides services in these regions. The shortage of rural surgeons is even more worrisome: only one of every 10 U.S. surgeons practices in a rural community.1 Unfortunately, this workforce shortage is expected to worsen over the next decade, as nearly half of all rural general surgeons are more than 50 years old.2,3 More than 80 percent of general surgery residents are now pursuing fellowship training, which is negatively correlated with a career in rural practice.1,4 Lack of exposure to rural surgery in medical school and residency and worries regarding heavy caseloads, isolation, and diminished resources also are barriers to recruitment.1,5 The American College of Surgeons Advisory Council for Rural Surgery has been charged with finding ways to overcome some of these recruiting obstacles.

As someone who is still in training, I do not have a silver bullet to fix these issues. However, I do believe, rural surgeons and medical schools can take a few actions right away. These suggestions stem from my own experience and current evidence on rural care.

  • Become a mentor. Rural surgeons should become closely involved with local and state medical schools, taking students under their wings. Without caring clinicians like Dr. Tate, I would never have heard Rose’s story regarding how important his practice was to her and her family.
  • Expose students earlier to rural care. It is nearly impossible to recruit general surgeons to rural areas if they have not had exposure to the field. For this reason, undergraduate medical education students should have the opportunity to serve in rural communities. They should have clerkships in the third and fourth years that require them to move beyond academic wards and into new environments. Schools should offer sub-internships at rural clinics and encourage students to participate. If medical students never experience the joy of being part of a close-knit community, how can we expect them to join one after residency?
  • Recruit more students from rural backgrounds. The statistics suggest that my story would be an exception. Most physicians who work in underserved rural areas are from similar backgrounds.1,3 Medical schools must emphasize recruitment of students from these communities to increase the number of physicians who will choose to return to underserved rural areas. At UNC, efforts already are under way to attract students from rural areas.

These recommendations can be implemented easily, and they would make a significant difference in the career choices of medical students and residents. However, all stakeholders must make a concerted effort, starting from the ground up. Caring for patients in a small community is an honor and a life-changing experience, but no one will know it without living it first.


References

  1. Jarman BT, Cogbill TH, Mathiason MA, O’Heron CT, Foley EF, Martin RF, Weigelt JA, Brasel KJ, Webb TP. Factors correlated with surgery resident choice to practice general surgery in a rural area. J Surg Educ. 2009;66(6):319-324.
  2. Cofer JB, Petros TJ, Burkolder HC, Clarke PC. General surgery at rural Tennessee hospitals: A survey of rural Tennessee hospital administrators. Am Surg. 2011;77(7):820-825.
  3. Milligan JL, Nelson HS Jr, Mancini ML, Goldman MH. Rural surgery rotation during surgical residency. Am Surg. 2009;75(9):743-745.
  4. Adra SW, Trickey AW, Crosby ME, Kurtzman SH, Friedell ML, Reines HD. General surgery vs fellowship: The role of the independent academic medical center. J Surg Educ. 2012;69(6):740-745.
  5. Chipp C, Dewane S, Brems C, Johnson ME, Warner TD, Roberts LW. “If only someone had told me…”: Lessons from rural providers. J Rural Health. 2011;27(1):122-130.

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