The rural general surgeon delivers a range of services, including trauma, critical care, obstetrics, gynecology, orthopaedic, vascular, urology, and head and neck procedures, in small hospitals. Given the range of procedures performed in this setting and the advances in surgery and surgical technology, rural surgeons need efficient and targeted continuing medical education (CME) that matches their broad scope of practice. Furthermore, rural surgeons have relatively limited opportunities to interact with other surgeons and to participate in CME activities. Barriers to these activities include the need to travel long distances and the difficulties of leaving a practice with no clinical coverage during the surgeon’s absence. Responding to the need for specialized CME opportunities, the College introduced the first rural surgeons’ skills course in 2011. The Nora Institute Advanced Skills Course for Rural Surgeons has since been presented at the annual Clinical Congress of the American College of Surgeons (ACS).
The Nora Institute Advanced Skills Course for Rural Surgeons provides a multidisciplinary curriculum that is customized to meet the unique learning needs of rural surgeons. Course participants can hone their endoscopic and laparoscopic skills and learn new surgical procedures, such as facial reconstruction, breast ultrasound, and the management of a partially amputated finger. In addition, the curriculum covers the management of urologic, gynecologic, and vascular emergencies. At present, 10 modules are rotated annually (see Table 1). Participants are provided with Web-based learning materials to review before attending the in-person session in order to maximize the time spent in hands-on, mentored skills practice. Content experts contribute to and teach each course module.
Table 1. The Nora Institute Advanced Skills Course for Rural Surgeons curriculum modules
|Leadership and communication||Emotional intelligence—organizing and communicating effectively with team members|
|Emergency urology||Cystoscopy and ureteral stent insertion, management of testicular torsion, suprapubic tube insertion, ureteral repair|
|Emergency gynecology||Laparoscopic management of ovarian torsion and ectopic pregnancy|
|Facial plastic surgery||Lesion excision, local flap reconstruction, eyelid laceration repair, lip laceration repair|
|Ultrasound||Breast ultrasound and ultrasound for central line insertion|
|Anesthesia||Conscious sedation, management of difficult airways|
|Hand trauma||Repair of fingertip amputation, extensor tendon repair|
|Laparoscopic common duct exploration||Cholangiogram, transcystic and transcholedochal exploration|
|Advanced endoscopy||Endomucosal resection of polyps, foreign body removal, stent placement, hemostasis techniques|
|Vascular surgery||Placement of temporary shunt after traumatic injury, management of acute arterial occlusion, management of venous disease|
Origins of the course
The inspiration for the rural surgeons skills course is rooted in the vision of the late Paul F. Nora, MD, FACS. Dr. Nora generously committed time and finances to the College to establish a program to further the College’s efforts to promote patient safety. This dedication resulted in the establishment of what is now known as the ACS Nora Institute for Surgical Patient Safety.
In considering how to expand the College’s existing efforts in the area of patient safety, Dr. Nora supported outreach to rural surgeons. Ruth Shea, Dr. Nora’s long-time assistant and a former ACS employee, suggested contacting Tyler G. Hughes, MD, FACS, who had authored a Bulletin article on rural surgical practice.* In early 2009, I called Dr. Hughes, then an ACS Governor and general surgeon from McPherson, KS, and asked him how the College could better support rural surgeons. Dr. Hughes invited me to Cooperstown, NY, to attend a rural surgery symposium led by David C. Borgstrom, MD, FACS, who at the time led the Mithoefer Center for Rural Surgery, Mary Imogene Bassett Hospital, Cooperstown, and who at present is a general surgeon at West Virginia University in Morgantown. It was at this symposium, through numerous conversations with rural surgeons, that the idea for a skills course emerged.
The Nora Institute Advanced Skills Course for Rural Surgeons was developed by a team of rural and academic surgeons, as well as individuals with expertise in adult education. Initial planning for the course involved numerous one-on-one and group discussions with rural surgeons in an effort to develop suggestions for the course content. A needs assessment questionnaire was designed based on these discussions as well as a review of the literature and rural surgeon case logs.† Results from this needs assessment guided the content development. Once the content was determined, we worked with subject experts to develop training models and assessment tools.
Value of the course
In the course of their careers, surgeons may need to learn new skills or retool current practices. The development of new technology and improved quality of care strategies necessitate keeping our technical skills up-to-date. Furthermore, some surgeons may want to broaden their scope of practice, which requires refreshing old skills or attaining new ones. While some knowledge may be learned from independent study, technical skills are best acquired through hands-on, mentored training using cadaver, porcine, and simulated models.
Past participants have reported improved confidence and patient care after attending a course, examples of which can be seen in the following comments:‡
- “Not only did I gain a couple of useful techniques—especially ultrasound for central line placement and the trick with the nail matrix—but, more importantly, I had knowledgeable people watch how I was doing things and either affirm that what I was doing was correct or make helpful suggestions [for improvement]. I have been in solo practice most of my career with no other surgeons on staff. It is always great to have a proctor look over your shoulder and make useful suggestions. I wish I had had this course available to me 34 years ago when I started my practice. Thank you.”
- “I reconstructed a huge facial lac/scalping injury from the eyelid across the forehead to the back of the scalp which turned out beautifully!”
- “I had a patient with a neglected avulsion of the tip. I used the technique of ‘dyeing’ the matrix to be certain I removed it all. I found this very helpful, as the anatomy was distorted. Yet with this technique, I was able to identify and remove all of the matrix and got an excellent functional result. Thanks!”
The key limitation to the implementation of new skills is primarily the practice patterns unique to the local community. For example, if another urologist or orthopaedic surgeon is in town, these cases will get referred. Additionally, after the ultrasound course, several surgeons reported pushback from radiology departments when using diagnostic breast ultrasound or ultrasound for central line placement.
With this feedback in mind, the College has begun offering the Nora Institute Advanced Skills Course for Rural Surgeons at the regional level to increase accessibility. In 2015, the ACS hosted the first regional skills course in conjunction with the North Dakota Chapter and South Dakota Chapter joint annual meeting. Future courses are planned for Utah, New Mexico, and Alabama.
The ACS Nora Institute for Surgical Patient Safety looks forward to making this program available and accessible to surgeons throughout the rural U.S.
*Hughes TG. Rural surgical practice: A personal perspective. Bull Am Coll Surg. 2007;92(2):12-17.
†Halverson AL, Hughes TG, Borgstrom DC, et al. What surgical skills rural surgeons need to master. J Am Coll Surg. 2013;217(5):919-923.
‡Halverson AL, DaRosa DA, Bogstrom DC. Evaluation of a blended learning surgical skills course for rural surgeons. Am J Surg. 2014;208(1):136-142.