If you follow health policy in this country, you will have noticed that a common topic of discussion is the looming general surgery workforce shortage. This imminent shortfall, particularly among broadly trained general surgeons, will particularly affect surgery in rural America.
In response to the impassioned and reasoned pleas for help with this critical issue from two leading rural surgeons—American College of Surgeons (ACS) Governor Tyler Hughes, MD, FACS, a general surgeon in McPherson, KS, and Phil Caropreso, MD, FACS, a general surgeon in Keokuk, IA—the College’s Board of Regents established an Advisory Council for Rural Surgery. This council is charged with studying the issue and advising the College on solutions to this impending crisis. Emphasizing the importance of this problem as well as the College’s commitment to helping to resolve it, A. Brent Eastman, MD, FACS, ACS President, included rural surgery as one of the four pillars of emphasis for the ACS in his Presidential address. In addition, the Bulletin of the American College of Surgeons has established this quarterly column to better highlight the challenges facing our colleagues in rural America.
As the Regental liaison to the Advisory Council for Rural Surgery, I have been asked to discuss my past experiences as a practicing rural surgeon and potential solutions to the challenges facing rural surgical care.
My time as a rural surgeon
As a medical student and as a resident, I had the privilege of observing two master rural surgeons in the small Georgia mill town of Thomaston. I quickly became enamored with the quantity and quality of their work, as well as their total dedication to the community. As I was completing a vascular fellowship and searching for a place to make a difference, it became apparent that I could make a contribution in this community and quickly accepted an offer to join their practice. An important contributing factor in that decision was that one of the sister communities that this practice served—Culloden, GA—was the boyhood home of the great Alfred Blalock, MD, FACS.
As a confirmed city boy who believed that urban sprawl and carbon monoxide were aphrodisiacs, as well as an ardent Kennedy Democrat, it quickly became apparent that some cultural adjustments were in order if I was going to live harmoniously in my new home. I was surprised by the warm community welcoming, shocked by how well-versed people were with almost every detail of my unaccomplished life, and struggled constantly to answer the all-important question, “Where do you go to church?” As time went on, I adjusted and came to realize that their insatiable curiosity about my daily life was motivated more out of sport than malice, I kept my liberal ideology to my closest confidants, and went to church with everyone.
Despite my magnificent training and a spectacularly successful first case—repair of a leaking aortic aneurysm—it rapidly became apparent that I was woefully unprepared for the breadth of clinical problems that a busy rural surgeon treats. This deficiency became painfully obvious when I was first confronted with a full office. Not only was I scheduled to see patients with the standard, garden-variety problems, but also a large number of patients needing tonsillectomies, carpal tunnel releases, circumcisions, and rotational flaps for significant skin lesions. I was horrified and shocked at my newly discovered shortcomings, but through the guidance of my masterful partners and a strong motivation to learn, I slowly became a real rural surgeon.
One of the joys and satisfactions of practicing in a rural setting is that surgeons are instantly recognized as important and critical members of the community. With these accolades come an expectation of community involvement and leadership. I quickly found engaging with the community in this manner an unexpected reward of rural living, which markedly enhanced my sense of satisfaction and fulfillment. The opportunities for such involvement are legion and diverse and simply require an expressed interest and commitment to the role. I quickly became involved with many service organizations, the chamber of commerce, tutoring programs, and a child abuse prevention organization. I also served a term as a county commissioner.
Probably the most rewarding part of rural practice was the intimate relationships I developed with my patients and the community. I found tremendous satisfaction and sense of purpose in resecting a colon cancer in the wife of a running buddy, treating my children’s teacher’s breast cancer, removing the tonsils of the school superintendent’s children, repairing the ruptured aneurysm of my yardman’s mother, treating the carotid dissection of the director of the local chamber of commerce, and repairing the subclavian injury of a hometown U.S. Marine hero, to name but a few cases. Using my skills to care for neighbors in need was extremely humbling and fulfilling. It provided a level of satisfaction and reward that I have been unable to replicate in the urban environment, with its transient and varied demographics.
Challenges of rural surgery
Currently, 60 million Americans live in rural areas, which are defined as communities having a population of less than 50,000. Data from studies that the American College of Surgeons (ACS) Health Policy and Research Institute has conducted indicate that an estimated 925 U.S. counties have no surgeon, and of these regions, 57 had populations of more than 25,000.* Currently, only 7 percent of all U.S. surgeons practice in rural settings. These physicians tend to be mostly male with an average age of 58, and fully 50 percent plan to retire in the next 10 years. Most are in one- or two-person practices, are frequently employed, and all report significant difficulty in attracting future partners, according to the College’s surveys of rural surgeons.
Factors contributing to the challenges in recruitment include decades of deteriorating demographics and economic and cultural contraction. Rural communities tend to have a lower tax base, making investments in required medical technologies difficult and often impossible. The population’s characteristic low per capita income and high number of indigents translate into low physician reimbursement, adding to the difficulty of attracting young surgeons with significant school debt.
Many rural surgeons complain of feeling professionally isolated, with insufficient call backup, limited and shallow medical and subspecialty consultative services, and a lack of tertiary care support. Increasing demands for Maintenance of Certification and continuing medical education (CME), as well as investment in electronic health records, are particularly burdensome for small, marginally capitalized practices. Recent generational shifts and the trend toward producing narrowly trained surgical specialties that afford predictable lifestyles further limit the recruitment pool.
Rural community limitations, the imminent retirement of a large portion of the surgical workforce, and a lack of qualified or interested replacement surgeons are converging to create an imminent crisis in rural surgery. This perfect storm, if you will, will have disastrous effects on community economics and the overall wellness and safety of rural Americans.
Potential solutions
Like all complex problems, the salvage, stabilization, and re-invigoration of rural surgery has no simple answer and will require a comprehensive understanding of all the important variables driving this crisis. Reason would suggest that this problem may be pragmatically broken down to issues of recruitment, training, and support.
Recruitment
It is critical that we enhance and expand efforts to expose aspiring young surgeons to rural health systems. It is widely known that two of the most important factors that influence a young surgeon’s interest in rural practice are being raised or having lived a part of one’s life in a rural community and exposure to rural surgery during training.
Local communities can effectively participate in this process by identifying promising young students, setting up surgical shadowing and mentoring programs, and providing health care scholarships. Medical school rural clerkships and resident rural rotations, as well as rural surgical faculty mentors, provide key exposure to this type of work. Also, databases listing rural communities with workforce needs should be developed and made available to interested residents.
Financial incentives are a key component of recruitment. With the staggering debt residents now face and the low remunerative potential of rural practice, it is going to be imperative to offer loan forgiveness to finishing residents. In addition, a supportive hospital administration offering competitive and stable employment contracts will be essential for both recruitment and retention of young surgeons.
Training
Unfortunately, many of the newly minted surgeons are ill-prepared to practice broad-based general surgery, especially in an environment with limited support from partners, subspecialists, technologies, and tertiary care. New paradigms are needed to produce broadly trained general surgeons with added competencies in endoscopy, urology, orthopaedics, gynecology, and plastic surgery. Additionally, this group will need to have a good general knowledge of internal medicine and be facile in the management of common medical problems. The famed John Arlie Mansberger, MD, FACS, used to call this type of surgeon “an internist that operates.” We need to recreate this type of surgeon for rural America.
The ideal training program would be based in a major medical center with a large and diverse patient population with active divisions representing the broad-based components of general surgery. The program should be resident-centric with few subspecialty fellowships and no minimally invasive fellowship programs. There should be a strong commitment to adequately train residents in endoscopy and to provide residents with opportunities to attain appropriate, needed skill sets in many of the other surgical disciplines as well. There should be extensive immersion at the junior resident level in the major medical disciplines.
For residents completing their training and feeling unprepared for the challenges of rural practice, the availability of a one-year fellowship dedicated to these principles would be extraordinarily helpful. With the near universality of fellowship training today, I think this would be acceptable to many trainees and should be a fellowship with distinction such as “Master in Surgery” or other appropriate accolade. Along these lines, the College is developing an ACS Transition to Practice Program in General Surgery, which will be pilot tested at five institutions beginning July 1: University of Louisville School of Medicine, KY; Gundersen Lutheran Medical Center, La Crosse, WI; University of Tennessee, Chattanooga; Ohio State University, Columbus; and Mercer University School of Medicine, Macon, GA. Eastern Virginia Medical School will launch a program in 2014.
Support
As stated previously, the challenges of rural surgery are protean, resources are limited, and economies are lean. For the heroes who choose rural surgery as their life’s mission, adequate support structures must be in place to make practice tenable and retention possible.
The local community must offer an unwavering commitment to adequately supporting a surgical service that is feasible given the available resources. Inherent to that commitment is the development and maintenance of a strong primary care system, an investment in technology and training, and available employment situations that offer a competitive salary and benefits package. Innovative approaches to the often onerous call schedules and limited time off should be developed and may include the expanded use of allied health personnel, locum tenens, and the creation of a registry of recently retired, credentialed surgeons willing to provide periodic respite coverage.
Feelings of professional isolation may be lessened with the development of strong relationships between the rural community and a local sister medical center. This relationship can provide access to relevant CME, new skills acquisition, consultative services, as well as a dependable conduit for timely patient transfer.
Finally, it is imperative that both the ACS and the American Board of Surgery continue to strive to understand the unique challenges of rural surgery and to provide the support needed for rural surgery to thrive.
Final perspective
One afternoon during my residency, I found myself in the presence of the great W. Dean Warren, MD, FACS, while he was holding court. During this monologue of high-minded musings, he posed a question that significantly influenced my future surgical career: “Who do you fellows think is the best surgeon in America today?” After a period of awkward silence, he said, “I will tell you who he is. I don’t know his name, but I know where he works. He or she lives in some rural town using all their resources with minimal support, inadequate pay, little time off, and devoid of professional recognition, dedicating their life to the care of their people. This selfless physician is the greatest surgeon in America.”
I’ve had the rare life’s privilege of working with two such surgeons—William M. Dallas, MD, FACS, and Michael W. Oxford, MD, FACS—doing just what Dr. Warren held in esteem. I can’t say I don’t miss it. We must do what is necessary to preserve this niche in surgery for all of America’s future great surgeons and the people who will need them.
*Belsky D, Ricketts T, Poley S, Gaul K. HPRI data tracks: Surgical deserts in the U.S.: Counties without surgeons. Bull Am Coll Surg. 2010;95(9):32-35. Original data available at: www.acshpri.org/documents/ACSHPRI_FS2.pdf. Accessed March 3, 2013.
