I am not a rural surgeon per se. I admit it up front. I have resources and great partners. Nonetheless, I deal with delivering complex care in Montana—one of the nation’s most rural states—on a daily basis. I train residents who want to be rural surgeons in a focused year of surgery skills that will prepare them for success in rural surgical practice. I also frequently drive 200–300 miles back and forth to critical access hospitals (CAHs) in our state to help with operations and to see patients.
At Kalispell Surgical Specialists (KSS)—founded in 2013 as a service of Kalispell Regional Healthcare—my partners and I regularly think about the workforce shortage in rural surgery and its effect on our patients. KSS is a cohesive bunch of subspecialty-trained surgeons with a common goal of providing tertiary surgical care to Montanans. I was recruited to Montana in 2009 to create a surgical oncology service line in the Flathead Valley, which quickly grew to a statewide referral program, the first of its kind in this state. This program has evolved into the Montana Rural Surgery Support System (RS3) to better help rural surgeons provide complex surgical care with limited resources. I was asked to explain our program in this column and to provide a road map for other rural surgeons who want to help improve local access to surgical care.
Montana’s surgical landscape
Montana is a large state geographically, encompassing more than 147,000 square miles.* We have approximately 50 geographically dispersed CAHs, staffed by solo rural surgeons or small groups.* The closest quaternary care is out of the state—and in some cases too far for helicopter support, making fixed-wing transfer of complex surgical patients necessary.
The enormous distances and geographic barriers to delivering care in Montana are daunting. Imagine driving from the Upper East Side of New York, NY, in a snowstorm, to have a re-do Nissen in Richmond, VA. Stupid, right? But travel of this distance for care is a daily occurrence in Montana.
Our regional referral system comprises three hospitals with a staff of more than 300 physicians in Flathead Valley, a picturesque area of Northwest Montana. All surgical services, except for transplantation, are present on the KSS campus. We enjoy a visionary, supportive hospital administration that endorses our notion that no matter where episodic care is delivered in the state, as long as the patient has access to quality care and stays in Montana, the program, as a whole, has value. Enormous geographic barriers to competition (such as distance, topography, and weather) have resulted in isolation of our hospitals in the state, and it has also delayed the growth of subspecialty surgical care due to the small population base of each system.
At present, slightly more than 1 million people reside in Montana, and it makes little sense for every population base of less than 100,000 people to have a pediatric surgeon, cardiothoracic surgeon, or surgical oncologist. However, it does make sense for all those systems to share that subspecialty resource and deliver care that is appropriate for the venue when possible and to manage more complex or resource-intense episodes of care in a regional referral center equipped to manage them. This premise is the basis for our program to provide direct support for surgical needs in rural Montana hospitals.
Over the last several years, by necessity, we developed RS3, a clinically integrated network that was conceived, developed, and implemented by surgeons. The beauty of the program is its simplicity. All rural surgeons in Montana are well trained, but limited access to resources and quality support personnel, as well as hospital size, may constrain their scope of practice. To overcome these barriers to surgical care in a rural setting and to keep patients in Montana, we now directly support rural or solo surgeons in their locales, so they can handle cases as they see fit in their community hospital or CAH. These collaborative relationships improve the scope of services and the quality of care provided by our fragile rural surgical practices.
For instance, if a case that needs to be done locally is slightly more complex than usual, but the rural surgeon has the skill set to manage the patient’s care, we will travel to that hospital and lend an experienced hand, so the patient can stay local. A common situation is an obese patient with sigmoid diverticulitis, maybe with a colovesical fistula, who is predicted to have a technically difficult laparoscopic colectomy. The patient wants to remain near family and community for the elective operation. When we travel to the patient and directly support the surgeon’s practice, the surgeon, the hospital, the patient, and the community all benefit. For the solo surgeon, having an experienced second surgeon available to assist is deeply satisfying, allowing them to acquire up-to-date laparoscopic skills, and helps the CAH maintain its viability by keeping the patient in town. We provide these services throughout Montana on a weekly basis. You really only need a receptive administration that sees how these efforts keep the facility in the black and some courtesy privileges to make this program work. We are happy to bring our fly rods, of course, and enjoy a good meal.
In more complex situations, when a surgical problem arises that the rural surgeon is well trained to manage, but the CAH may not be the best site for that episode of care, we extend courtesy privileges to the surgeon to bring the patient to KSS, perform the procedure in our hospital with our assistance, and then co-manage the postoperative care. When appropriate, patients return to their hometown for postoperative care. For example, a fairly straightforward distal pancreatectomy or low-anterior resection of the rectum might be managed this way. On average, we host a rural surgeon in this manner about once every month. The biggest barrier to this management strategy ends up being coverage at the CAH while the rural surgeon is away. We are exploring a model of reciprocal call coverage by our group to stimulate more use of this service.
Even more complex cases, such as tertiary thoracic, hepatopancreaticobiliary, and pediatric cases, and cases with complications, are directly transferred for management in KSS. It is comforting to us to know that on the other end of that case, maybe hundreds of miles away, is a competent and collegial surgeon who is going to partner with us for postoperative care and management of complications. We bring patients in from around Montana several times a week, and herein lies the benefit that our administration now realizes. Until the development of the RS3 collaborative model, these patients would have left Montana, leaving behind distressed families and strained CAH bottom lines. We view our program, RS3, as an extreme value—a win-win-win-win for the solo surgeon, the patient, the CAH, and our program. The solo surgeon has established lines of support, the patient can stay close to home, the CAH is buoyed by the patient retention and is a referral line, and we get to practice tertiary, complex surgery on our terms in a collegial environment.
Easy to reproduce model
Our administration concurs that by directly supporting rural surgery practices, we contribute to the viability not only of the surgeon in that community, but the hospital that serves the community, and to the quality of surgical care in Montana. The model is easily reproduced and can be applied to almost any surgical subspecialty. This program is not outreach, where you travel to a clinic sparsely attended in some remote location and bring the patients to your hospital for care. That model is of minimal value to the CAH, and only serves to drain patients from their system. The RS3 fosters a partnership amongst practices and administrations. Old models of competition are obsolete in Montana and collegial professional relationships that benefit our population are replacing them (see Figure 1). Our view is that this model of care will make rural surgery practice in Montana appealing and sustainable for years to come, and we have noted successful recruitment of young surgeons in the state, at least in part due to the established support networks.
Figure 1. Collaborative patterns of patient care in Montana
Note: Relative size of red circles represents numbers of patients managed in concert with local facilities at Kalispell Surgical Specialists
How do you make it work? First, you must have some good partners who see the greater good in such a program. By no accident, my partners all have the same vision. You must have a “just say yes” policy, which essentially means that any case the solo surgeon needs help with, for any reason, is dealt with promptly regardless of whether the patient is insured, uninsured, addicted, experiencing postop complications, and so on. The bottom line is that if a surgeon is calling (or texting, nowadays), he or she needs help.
Your institutional administrators might need some education and likely some eye opening before implementing a similar program. But aside from institutional buy-in and support, the solo rural surgeons must want your support and ask for help when needed. If you boil it all down to what is best for the patient, irrespective of money, the answer is clear.
I welcome your comments, criticisms, or questions and can be reached on the Rural Surgery ACS Community listserve or directly via e-mail at email@example.com.
*Rural Health Information Hub. Montana. September 12, 2016. Available at: www.ruralhealthinfo.org/states/montana. Accessed June 1, 2017.