Shortage of rural surgeons: How bad is it?

Rural America encompasses 72 percent of the nation’s land mass, and 46 million people, or 15 percent of the U.S. population, live in rural communities.¹ So, are there enough rural surgeons to care for America’s rural population? What will the need be for rural surgeons in America in the future? A look at the data shows that answers to these questions can be difficult to ascertain.

Data supporting a shortage of rural surgeons

Proportionately fewer surgeons practice in rural America. Lynge and colleagues showed that in 2005, the ratio of general surgeons per 100,000 population was 5.85 in urban counties and 4.31 in small rural counties (counties not adjacent to a metropolitan county and with the largest city in the county comprising less than 10,000 people).¹

A survey of rural hospital administrators by Doty and colleagues showed that 34 percent of rural hospitals have a surgeon leaving within the next two years and that more than one-third of rural hospitals were searching for a surgeon.²

Many rural counties don’t have a surgeon. A 2006 study by Belsky and colleagues showed that 30 percent (925 out of 3,107) of U.S. counties were without a surgeon. Of the counties without a surgeon, 50 percent have a hospital.³ In all, 7 percent of U.S. counties lost their general surgery coverage entirely in 2006–2011.⁴

Shortage of rural surgeons likely to increase in the future

Not all physicians would consider a rural practice. Merritt Hawkins, a nationwide physician search firm, conducted a survey in 2017 of final-year medical residents. This survey showed that only 3 percent of the respondents would prefer to practice in a community of 25,000 or less.⁵

The rural surgery workforce is aging. The study by Lynge and colleagues studied physician data from 1981 to 2005. The number of general surgeons in rural areas that were ages 50–62 increased from 39.5 percent in 1981 to 52 percent in 2005.¹ This study also showed that rural areas experienced a decrease in the number of general surgeons younger than 40 years old, from 24.5 percent in 1981 to 13.6 percent in 2005.

Many general surgery residents are choosing to become surgical subspecialists. Because of the Balanced Budget Act of 1997, the number of new graduating allopathic general surgery residents has remained stable for more than 25 years, with only a modest increase in recent years from approximately 1,000 to about 1,050 new allopathic general surgeons per year.⁶ Of these newly graduated general surgery residents, an increasing percentage are choosing to pursue a surgical fellowship following their residency, which means that many of them would never consider rural surgery as a career. Data show that up to 77 percent of graduating surgical residents are entering a fellowship program.⁷

A study by Williams and colleagues states that each rural hospital in America will need to recruit two general surgeons in the period from 2011 to 2030.⁸ They estimate that the U.S. has 1,998 rural hospitals. If you do the math, these rural hospitals would need to recruit 3,996 (1,998 × 2) new rural surgeons over the next 20 years. In that time, if the number of newly graduating general surgery residents remains at 1,050 a year, 21,000 (1,050 × 20) new general surgeons would be produced. If 77 percent of those residents chose to do a fellowship and do not become general surgeons, 4,830 new general surgeons would be produced over the next 20 years (21,000 × 0.23). If the assumptions of the authors are correct, 82.7 percent (3,996/4,830) of the new general surgeons would have to enter rural surgery to meet the needs of rural hospitals.

Data show some areas are doing better than others

Not all rural areas are experiencing a shortage of surgeons. Although the study by Lynge and colleagues showed that the number of general surgeons per 100,000 population in small rural counties in 2005 was low at 4.31, the same study showed that the ratio for large rural nonadjacent counties (counties not adjacent to a metropolitan county and with at least one large city of 10,000 to 50,000 population) was 7.68, which was higher even than the ratio of 5.85 in urban areas.¹

Proponents of the Dartmouth model for evaluating the physician workforce have long argued that the physician supply issues in our nation are rooted in a maldistribution of physicians, rather than a shortage of physicians.⁹ Studies in the Dartmouth Atlas of Health Care have shown that patient outcomes are not better in regions with a large supply of physicians.¹⁰ Patients who live in regions with more care available report being less satisfied with their care than patients in regions that spend less.¹¹

The number of rural hospitals in America is decreasing. In data presented by Pink and colleagues in 2017 from the North Carolina Rural Health Research Program, 122 rural hospitals closed between 2005 and 2016, with 53.3 percent of these closures (65/122) occurring in the years 2013−2016.¹¹ iVantage Health Analytics published a study in 2016 using a vulnerability index to assess the probability of a rural hospital closing. By comparing data from recently closed rural hospitals with other rural hospitals, they calculated that an additional 283 rural hospitals are at risk of closure.¹² Obviously, if there are fewer rural hospitals in the future, fewer rural surgeons will be needed.

Finally, the rural population of America declined by nearly 200,000 people between 2010 and 2016, the first recorded period of population decline.¹³ Although the drop is a small one, if the rural population continues to decline, the need for rural surgeons in the future will also decrease.

Difficulties in interpreting the data

Much of the data regarding surgeon shortages uses the ratio of general surgeons per 100,000 population. This method may not be the best way to evaluate the presence of a surgeon shortage, especially when comparing urban areas with rural areas. In rural areas, where general surgeons do a large number of endoscopies because of the absence of gastroenterologists and have broad-based practices because of the absence of surgical subspecialists, a higher number of general surgeons per population would be needed to meet the surgical needs of the community. In urban areas, which generally have many surgical subspecialists and gastroenterologists, a lower number of general surgeons per population would be needed. Because of the differences in the practice of urban and rural surgery, comparing general surgeons to 100,000 population ratios is not comparing apples to apples.

As noted earlier, many rural hospitals are searching for a surgeon. Just because a rural hospital is looking for a rural surgeon doesn’t mean that it has the hospital infrastructure or medical community to support a rural surgeon. Eilrich and colleagues in 2010 showed that a rural general surgeon can generate $1.34 million dollars per year for the hospital from patient activity.¹⁴ Just because a rural hospital would like to have a rural surgeon generating this revenue stream doesn’t mean it can truly support a rural surgical practice.

Conclusions

As these data demonstrate, there is a lot of conflicting information regarding the degree of shortage of rural surgeons. It can be difficult to draw conclusions and come up with a real answer to the question of how many rural surgeons are needed now and in the future. The real answer is probably somewhere between the extremes in the data mentioned previously.

Undoubtedly, many rural communities are in desperate need of a rural surgeon now. Even though the number of rural hospitals in America is decreasing, there is still a lot of concern about having enough rural surgeons in the future. When the following facts are considered, the evidence points to a very real shortage of rural surgeons in the future: the increasing age of rural surgeons, the high number of graduating general surgery residents who choose to do a fellowship and most likely will become surgical subspecialists, and the low number of graduating residents who would be willing to live and work in a rural community. Accurately quantifying the degree of shortage of rural surgeons now, and in the future, is what’s difficult.

Potential solutions

How can we quantify the degree of shortage of rural surgeons now and in the future? Perhaps if it were known how many surgical procedures are likely to be needed in a specific community based on its size and that number were compared with the actual number of surgical cases performed based on data from Medicare, Medicaid, and private insurers, a real answer could be determined to assess whether the area has a rural surgeon shortage.

Perhaps if data could be collected that would show how easy or difficult it was for residents of a specific rural community to obtain quality surgical care, it would be possible to determine whether that rural community has a surgeon shortage.

Another potential solution could come through the passage of the Ensuring Access to General Surgery Act of 2017 (H.R. 2906/S. 1351). This bill would direct the Secretary of the U.S. Department of Health and Human Services (HHS), through the Health Resources Services Administration, to conduct a study of general surgery workforce shortage areas. It also would grant the HHS Secretary the authority to provide a general surgery shortage area designation. The American College of Surgeons Division of Advocacy and Health Policy has made passage of this bill a priority for several years.

Although the data on the degree of shortage of rural surgeons are somewhat conflicting and difficult to assess, there is no doubt that determining an accurate estimate of the degree of rural surgeon shortage is important. More study of this issue is required. With accurate information, surgical leaders and policymakers can work together to strategically meet the surgical needs of rural America.

References

1. Lynge DC, Larson EH, Thompson MJ, Rosenblatt RA, Hart LG. A longitudinal analysis of the general surgery workforce in the United States, 1981–2005. Arch Surg. 2008;143(4):345-350.
2. Doty B, Zuckerman R, Finlayson S, Jenkins P, Rieb N, Heneghan S. General surgery at rural hospitals: A national survey of rural hospital administrators. Surgery. 2008;143(5):599-606.
3. Belsky D, Ricketts T, Poley S, Gaul K, Fraher E, Sheldon G. Surgical deserts in the US: Places without surgeons. American College of Surgeons Health Policy Research Institute. Available at: facs.org/~/media/files/advocacy/hpri/surgicaldesertsinus.ashx. Accessed February 10, 2018.
4. Nakayama DK, Hughes TG. Issues that face rural surgery in the United States. J Am Coll Surg. 2014;219(4):814-818.
5. 2017 survey: Final-year medical residents. Merritt Hawkins. Available at: www.merritthawkins.com/uploadedFiles/mha_2017_resident_survey.pdf. Accessed February 10, 2018.
6. Skeptical scalpel. A shortage of general surgeons: Coming soon? Physician’s Weekly. August 13, 2012. Available at: www.physiciansweekly.com/general-surgeons-shortage/. Accessed February 10, 2018.
7. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: Longterm data from the American Board of Surgery. J Am Coll Surg. 2008;206(5):782-788.
8. Williams TE, Satiani B, Ellison EC. A comparison of future recruitment needs in urban and rural hospitals: The rural imperative. Surgery. 2011;150(4):617-625.
9. The physician workforce. The Dartmouth Atlas of Health Care. Available at: www.dartmouthatlas.org/keyissues/issue.aspx?con=2940. Accessed February 10, 2018.
10. Dartmouth Institute for Health Policy and Clinical Practice. Supply-sensitive care. The Dartmouth Atlas of Health Care. Available at: www.dartmouthatlas.org/keyissues/issue.aspx?con=2937. Accessed February 10, 2018.
11. Pink GH, Thomas SR, Kaufman BG, Holmes GM. Rural hospital closures and finance: Some new research findings. Presented at American Hospital Association 30th Rural Health Care Leadership Conference, Phoenix, AZ. February 7, 2017. Available at: www.healthforum-edu.com/rural/PDF/2017/RL17_pink.pdf. Accessed February 10, 2018.
12. iVantage Health Analytics. Vulnerability to value: Rural relevance under healthcare reform 2015. Available at: https://nosorh.org/wp-content/uploads/2015/11/2015-Rural-Relevance-Study_iVantage.pdf. Accessed February 10, 2018.
13. U.S. Department of Agriculture. Rural America at a glance: 2017 edition. Available at: www.ers.usda.gov/webdocs/publications/85740/eib-182.pdf?v=43054. Accessed February 10, 2018.
14. Eilrich FC, Sprague JC, Whitacre BE, Brooks L, Doeksen GA, St. Clair CF. The economic impact of a rural general surgeon and the model for forecasting need. National Center for Rural Health Works. September 2010. Available at: http://digitalprairie.ok.gov/cdm/ref/collection/stgovpub/id/24192. Accessed February 10, 2018.