To support and promote rural surgery, the American College of Surgeons (ACS) Board of Regents established the ACS Advisory Council for Rural Surgery (ACRS) at its June 2012 meeting. On creating the ACRS, the Regents said:
The mission of the ACRS is to identify, investigate, and rectify the challenges associated with rural surgical practice. To address these complex issues, the ACRS will work to develop broad-based training through rural residency tracks and to improve recruitment, retention, mentoring, and post-residency education for rural surgeons. All of the council’s efforts reflect the College’s commitment to ensuring that the nation’s 60 million rural patients have access to high-quality surgical care and to addressing the challenges facing rural surgeons.1
ACRS members have been actively working to fulfill the goals set forth by the Regents. This column describes the current activities of the ACRS.
Development of rural surgery training programs
ACRS members have identified and promoted general surgery residency training programs that emphasize specific training for rural surgeons or have a rural surgery track in their program.2 Furthermore, the ACRS has encouraged the development of a rural surgery track within current general surgery residency programs.3,4
For example, ACRS member and Past-Chair, ACS Board of Governors Executive Committee, Gary Timmerman, MD, FACS, a general surgeon at University of South Dakota Sanford School of Medicine and Sanford Medical Center, Vermillion, helped create an entirely new general surgery residency program at that institution. This training program places primary emphasis on graduating rural and community general surgeons. Unique to the program is that no other competing surgical specialty programs or fellowships are in place.
Furthermore, the ACRS has been an active supporter of the ACS Transition to Practice in General Surgery (TTP) program for residents who have completed their general surgery training. R. Phillip Burns, MD, FACS, a Past First-Vice-President of the ACS and Past Vice-Chair of the ACRS, has been instrumental in the development of the TTP program.5 Several of the hospitals that are participating in the TTP program have a strong rural focus in their training programs.
Spreading the word
To help better inform the surgical community about the issues facing rural surgeons, ACRS members have given presentations at ACS chapter meetings, Clinical Congress, and at large regional meetings.
In addition, the ACRS has been working with the Rural Surgeons Film Project, which produced the video The Calling of Rural Surgery. This six-and-a-half-minute video showcases the great need for rural surgeons in the U.S. and clearly depicts the satisfaction that rural surgeons find in their work. The video was previewed at Clinical Congress 2015 and can be accessed online.
Educating medical students and residents
Many members of the ACRS and rural surgical community have arranged regular rotations with medical students and residents, exposing them to a rural surgical practice. In addition, Lauren Smithson, MD, FACS, a former ACRS member and a rural surgeon in St. Anthony, Newfoundland, developed the Society for Young Rural Surgeons (SYRUS). SYRUS, an international community of rural and global physicians, aims to promote interest in rural surgery among medical students, residents, and young practitioners. (View more information on SYRUS.)
Members of the ACRS have been actively working with the ACS Division of Advocacy and Health Policy, the American Medical Association, the American Hospital Association, the National Rural Healthcare Association, and representatives from the Centers for Medicare & Medicaid Services (CMS) to address concerns regarding the pending 96-hour rule legislation. The 96-hour rule, which concerns payment to critical access hospitals (CAHs) for Medicare patients, is of crucial importance for the financial viability for these facilities. ACRS members have been involved in conversations with CMS administrators on the subject and have advised members of Congress who serve on key committees regarding alternatives to the current rules and proposed legislation.6
CMS recently indicated it would begin enforcing a long-forgotten rule requiring that physicians who admit patients to CAHs certify that each patient can reasonably be expected to be discharged or transferred within 96 hours. Previously, CAHs had been operating under a similar but separate condition of participation that required patient stays to be less than 96 hours on average. The recent action by CMS will result in surgeons without the ability to admit patients for procedures routinely performed in CAHs, and inpatients will be forced to go further from home for treatment.
To address the issue, Rep. Adrian Smith (R-NE) and Sens. Pat Roberts (R-KS) and Jon Tester (D-MT) introduced the Critical Access Hospital Relief Act (H.R.169/S.258) to eliminate the certification requirement for admitting physicians while maintaining the long-enforced 96-hour average stay requirement. The ACS has endorsed the bill.
ACRS members also have been actively working with the ACS Division of Advocacy and Health Policy regarding changes in reimbursement for colonoscopies and have responded to CMS’ request for information regarding the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act that was enacted in April 2015. Specifically, the ACRS addressed CMS’ questions regarding technical assistance to small practices and practices in Health Professional Shortage Areas as they face implementation of the new law. Furthermore, ACRS members have worked with the ACS Division of Advocacy and Health Policy staff to provide comments on the meaningful use of electronic health records and the specific challenges facing small practices.
Publications regarding rural surgery
A monthly column, “The Rural Surgeon,” is published in ACS Surgery News and addresses issues in rural surgery. In addition, this column, “Dispatches from rural surgeons,” is published quarterly in the Bulletin. Both of these publications highlight the great support the ACRS has consistently received from the ACS leadership in solving problems related to rural surgery. Furthermore, several ACRS members have published articles or editorial/opinion pieces in various journals and in the lay press.7
ACRS members Amy L. Halverson, MD, FACS, and David C. Borgstrom, MD, FACS, have written a book, Advanced Surgical Techniques for Rural Surgeons, published in November 2014, which provides content covering topics relevant to surgical care in rural areas, with a focus on the surgical diseases that are often treated by surgical subspecialists in the urban setting.
In addition to these publications, ACRS members are currently active in writing the rural surgery topic for Selected Readings in General Surgery, which will be published in 2016.
The rural listserv has been an active online form of communication for rural surgeons. Since launching in August of 2012, more than 14.5 million e-mails have been exchanged between 750 participants.8
The success of the rural listserv helped inspire the development of the ACS Communities. Tyler G. Hughes, MD, FACS, Chair of the ACRS and ACS Governor, is the Editor of the ACS Communities. The Rural Surgery Community is the fourth most active ACS Communities page.
Clinical Congress activities
Since its inception, the ACRS has sponsored or cosponsored various Clinical Congress Panel Sessions, open forums, and Town Hall Meetings related to rural surgery issues, including an Advanced Skills Training for Rural Surgeons Postgraduate Course. These courses always have been well-received and well-attended. In 2015, an Advanced Skills Training for Rural Surgeons course was offered at the ACS North Dakota/South Dakota Chapter meeting. Consideration is being given by the ACS and the ACRS is considering holding Advanced Skills Training for Rural Surgeons courses at other chapter meetings.
In addition, rural surgery has been designated as a dedicated track at Clinical Congress, and Dr. Borgstrom has served as the Clinical Congress Program Liaison for the ACRS. He is now a member of the Clinical Congress Program Committee.
Five ACRS-cosponsored panel sessions have been accepted for the Clinical Congress 2016.
Another educational program that the ACRS has in development is the Rural Surgery Symposium, a biennial meeting devoted to rural surgical issues.
Lastly, the ACRS has sponsored a Rural Surgeon’s Dinner at Clinical Congress since 2012. Averaging more than 100 attendees, these dinners have provided a great opportunity for rural surgeons to network.
Development of standards
The ACRS is working with the ACS to develop a set of standards for use in establishing the infrastructure and practices required to optimize rural surgical care across the nation. These standards could also serve as a template for other nations to consider.
On call/locum tenens issues
ACRS member Robert P. Sticca, MD, FACS, chairman and program director, department of surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks, has developed the North Dakota Rural Surgery Support Program, which provides a general surgeon for locum tenens coverage at local rural hospitals.9
Members of the ACRS are working with the ACS to develop a system for locum tenens coverage for rural hospitals on a national basis.
Cancer patient care
One of the authors of this article, ACRS member Michael D. Sarap, MD, FACS, a surgeon in Cambridge, OH, has been working with leadership of the Commission on Cancer and the National Accreditation Program for Breast Care. This effort is aimed at making it easier for lower volume rural hospitals that provide quality care to attain Commission on Cancer accreditation, or at least recognition, as well as to develop methods for these hospitals to measure their quality.10
ACRS members have been engaged in several efforts to coordinate international rural surgery activities. Examples are as follows:
- ACRS member Nadine Caron, MD, FACS, a surgeon at the University of Northern British Columbia, Prince George, has been involved in numerous programs in Canada to improve the care of native populations.
- Dr. Hughes, as the ACRS Chair, has traveled to New Zealand and Scotland to participate in rural surgery conferences.
- In 2016, Drs. Hughes and Timmerman will participate in the Royal Australasian College of Surgeons annual meeting in Brisbane, Australia. They will discuss the subject of rural practice in Australasia in an effort to learn how each area of the world responds to the challenges of rural surgery.
- The ACRS will support The Lancet Commission on Global Surgery as that project continues to move forward.
Many members of the rural surgical community across the country have expressed great appreciation for the College’s commitment to support and promote rural surgery. Members of the ACRS will continue to strive to fulfill its mission to identify, investigate, and meet the challenges associated with rural surgical practice.
- American College of Surgeons. New Advisory Council for Rural Surgery offers several programs during Clinical Congress. Bull Am Coll Surg. 2012;97(9):80.
- American College of Surgeons. Rural surgery program. Available at: www.facs.org/education/resources/residency-search/specialties/rural. Accessed November 23, 2015.
- Deveney K, Jarman B, Sticca R. Dispatches from rural surgeons: Responding to the need for rural general surgery training sites: A how-to. Bull Am Coll Surg. 2015;100(4):47-50.
- Borgstrom DC. Dispatches from rural surgeons: Rural surgical practice requires new training model, offers great opportunities. Bull Am Coll Surg. 2013;98(7):55-56.
- Richardson JD. ACS Transition to Practice Program offers residents additional opportunities to hone skills. Bull Am Coll Surg. 2013;98(9):23-27.
- Savarise MT. Dispatches from rural surgeons: ACS intervenes to resolve questions about the 96-hour rule. Bull Am Coll Surg. 2014;99(10):40-43.
- Nakayama DK, Hughes TG. Issues that face rural surgery in the United States. J Am Coll Surg. 2014;219(4):814-818.
- Caropreso P. Dispatches from rural surgeons: ACS rural listserv—An “underdog” success story. Bull Am Coll Surg. 2014;99(7):48-51.
- Sticca RP, Aaland MO. Dispatches from rural surgeons: The North Dakota rural surgery support program: Providing surgical services to communities in need. Bull Am Coll Surg. 2015;100(7):58-62.
- Sarap MD. The rural surgeon: Rural cancer care—if you build it (and measure it!) they will come. ACS Surgery News. 2015;11(1):3.