Rural surgery: The road less traveled

According to the U.S. Census Bureau, rural areas cover more than 90 percent of the nation’s land mass but contain 19.3 percent of the population—approximately 60 million people.* To flip those statistics, the other 270 million residents occupy less than 10 percent of the landscape.

For the most part, rural America is spread over large regions of isolated, empty space where traveling to a tertiary care hospital usually means trekking long distances. I have used a different definition when describing the isolation of my rural Oregon surgery practice—the distance to a Walmart Supercenter, which is 3.5–4 hours depending on snow conditions over mountain passes.

When putting it in these terms, I usually represent the most isolated surgery practice in the room at a surgical conference; that is, until recently when I spoke with a surgeon from Guam, whose practice is a 10-hour flight to a Hawaiian Walmart Supercenter.

How did I get here?

I was born and raised in Chicago, IL. I trained in urban New York and New Jersey metropolitan tertiary teaching hospitals, then spent the first 13 years of practice in the New York State Tri-City Area, consisting of Albany, Schenectady, and Troy. In fact, the smallest town I ever lived in was Champaign-Urbana, with 50,000 other undergraduate and graduate students at the University of Illinois.

So, how did I get here—how did I end up in rural Oregon? It started the day I had an epiphany after logging almost 300 miles during a long weekend call. My surgery group covered a large multispecialty medical group with privileges at multiple hospitals in all of the New York tri-cities. Because five or six of us were in the group (depending on the year), we were responsible for a large portion of those individual hospitals’ emergency room (ER) unreferred (code for uninsured) surgical call days. If 20 surgeons were on staff at a given hospital, we covered one-fourth of the call. This situation added up to being on ER call somewhere across the region most days of the month and, many times, at more than one hospital on the same day, which led to my day of epiphany.

The opportunity to see many types of cases was great for a newly trained, green general surgeon, and it was just what I signed up for. I like to think the residents considered our group the “young guns”—young enough to remember what it was like to be a resident but old enough to have the experience to avoid or get out of trouble.

But as the years passed, I realized that I was spending more hours in my car traveling back and forth to these multiple hospitals for ER or operating room consults and rounding than I spent with my family. My wife, who is from rural Iowa, is a nurse administrator and happens to be my clinic manager. She suggested that we make a change and that a rural practice might be a better fit. As residents, we went by the motto of “every other day call causes you to miss half the good cases,” and I carried this belief into my surgical practice, where running in circles was the norm. But enough was enough, and though I continued to love what I did, I soon discovered a more rewarding way of life.

My wife and I went about researching rural hospitals in our favorite part of the country—the Northwest—and found that there, as in most of the U.S., general surgeons were and are needed, especially in small towns. We interviewed at multiple hospitals and chose our small critical access hospital in John Day, OR, over four other choices in Northern California, Oregon, and Washington State. This decision was driven mostly by the welcoming community, plus the trust we found in the hospital administrator.

What keeps me here?

Since that decision 14 years ago, I have been the only general surgeon in Grant County, OR. My practice has a catchment area of fewer than 10,000 people. My scope of practice includes a breadth of bread-and-butter general surgery procedures, and I pride myself on the use of the most up-to-date minimally invasive approaches. In my previous metropolitan practice, many of the operations I had been trained to perform were slowly being siphoned off to specialty care, which meant fewer endocrine, breast, colorectal, and foregut operations.

As a broadly and well-trained surgeon, I have not only been able to reintroduce these cases into my practice, but I’ve also been able to add other procedures by necessity. Urologic cases—like cystoscopy, urethral stents, and vasectomies, along with gynecological operations, including open and laparoscopic hysterectomies—are all part of my repertoire. As the hospital gastrointestinal specialist, I also perform hundreds of both diagnostic and therapeutic upper and lower endoscopies each year. In polling my rural brethren, many of us also perform caesarean sections, although I do not. I am, however, often called by my capable family medicine, obstetric-trained physicians during times of a difficult entry or to “stop the bleed.”

Neighbors and friends

In my New York practice, I rarely saw any of my patients outside of the office or the hospital. In my rural practice, I see my patients every day at the bank, tire store, hardware store, or at one of the two fast-food restaurants in town. I’ve also been here long enough to know most of the county’s population by name or at least by family. Special relationships with my patients—like the World War II veteran who brings me his favorite beer and photos from his time overseas—are priceless and positive aspects of this familiarity.

But sometimes this closeness can be too much. For example, when I was shopping in the frozen food section of the grocery store, one of my patients said, “Doc, I know I have an appointment next week, but could you take a look at this mole on my back now?” as he proceeded to pull up his shirt. My wife does all of the grocery shopping now.

Unlike many fast-paced urban areas where patients have begun to lose respect for our specialty, small-town patients usually are appreciative of your help and time. Even though you’ve spent three or four sleepless nights taking care of someone’s grandma, that same urban family is the first to complain when their appointment is five minutes overdue. In my rural practice, my patients are rarely anything but grateful, and I appreciate that.

24-hour availability

One challenge for rural surgeons is the need for 24-hour availability balanced by a much lower volume. When I’m away, I am covered by the helicopter, which transports patients to Bend, OR; Boise, ID; or Portland, OR. Prior to my transition to a small town, I really didn’t understand the concept of surgeon workforce shortages, which much of the U.S. deals with every day. In New York, I would sometimes get calls from upstate rural hospitals wanting to transfer a patient for something as simple as an appendectomy. The discussion would go something like this: “What do you mean you don’t have a surgeon today? What kind of hospital are they running?” Fast-forward to my small, critical access, 24-bed, rural, isolated hospital that may need to transfer that same patient when I am unavailable. Now, I understand.

Be the inventive surgeon you were trained to be

I would swear that the spork was invented by a rural surgeon since we often are called to be innovative and make do, while maintaining quality and standards of care. Rural surgeons also wear many hats. In my hospital, I am not only the sole general surgeon, but also chief of staff, trauma medical director, and emergency medical services medical director, responsible for covering 5,000 square miles of cattle country. But whether at a rural or urban hospital, surgeons are usually the backbone for the revenue stream and leadership of the medical staff.

A day in the life

One day, several years ago, I was seeing an old rancher to remove a skin lesion. In my office, I was reading his chart, and my medical assistant was helping our patient get undressed while his unimpressed and oblivious wife sat reading a magazine across the room. I soon heard a clamor from the room as I saw my wife emerge from and then reenter the room. I entered the room only to see our patient with his overalls halfway down, my wife trapping a multicolored gecko under a Tupperware container, and my medical assistant trying to sweep up a twitching detached lizard tail. It seems that while my assistant was helping our elderly patient undress, a lizard emerged from his pants and ran across the room. Apparently, this type of lizard detaches and throws its tail as a distraction when threatened. Meanwhile, my patient and his wife remained calm and cool. His wife looked up from her magazine long enough to explain that he had just come from haying and “was always getting those damn lizards in his pants.”

Will the real general surgeon please stand up?

It has been said that rural surgery is the last bastion of true general surgery practice. The life of a rural surgeon may be difficult at times, but it is extremely rewarding. I feel like I’m able to be a real general surgeon, the surgeon I trained to be. Combine that with the patient relationships that I’ve developed, and I can say that I wouldn’t have changed my experience here for the world.

As for those young surgeons contemplating a rural practice, give me a call. I’ll be happy to help you with directions on this “road less traveled.”


*United States Census Bureau. New census data show differences between urban and rural populations. December 8, 2016. Available at: www.census.gov/newsroom/press-releases/2016/cb16-210.html. Accessed June 7, 2019.

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