For many years, rural surgeons had felt isolated, unrecognized, underrepresented, and neglected. In a word, rural surgeons described themselves as “underdogs.” These feelings were expressed to the American College of Surgeons (ACS) Board of Regents in February 2012, and in June of that year, the ACS established the Advisory Council for Rural Surgery (ACRS).
The need to communicate with rural surgeons and to connect them as a group with the ACS leadership was immediately apparent, but surveys failed to identify the best means of enhancing communication. Although rural surgeons were acquainted with many social networking modalities, ACRS leaders chose to use a listserv, if for no other reason than simplicity, even though the listserv may be considered the underdog of social networking. Because the ACS was looking at ways to improve its networking techniques, however, the rural listserv was considered sufficient as a stop-gap measure.
How it works
Dr. Caropreso working on the listerv.
Listserv technology became available in 1986, when Eric Thomas, an engineering student, developed automated software to manage mailing lists, which, until then, was a manual, cumbersome, and labor-intensive process.* Applied to e-mail, listserv software allows for the automatic distribution of e-mails to all members of a group. E-mails go to a single address, in this case acsrural@listserve.facs, and all subscribed members receive the correspondence. Discussions of subjects can then take place as list members respond.
A listserv is either completely automated, or it can be moderated by an individual(s). The rural list has two moderators—the author, Phil Caropreso, MD, FACS, and Tyler Hughes, MD, FACS, Chair of the ACRS—who review subjects and content. Only subscribers may participate in the group.
An introductory e-mail was sent on August 12, 2012, to 1,700 rural surgeons identified from the College’s member database. Following the Clinical Congress, the rural listserv debuted with the posting of the first official communication on October 23, 2012. The initial e-mail from the listserv stated:
[T]he work of the ACRS on your behalf is just beginning. Your participation in that work is vital to provide direction to the fulfillment of the ACRS’s mission. Without your involvement, the identification of the challenges of rural practice will merely be guesswork. With that thought in mind, the College has established a listserv for rural surgeons’ communications.
In his Presidential Address at the 2012 Clinical Congress, A. Brent Eastman, MD, FACS, FRCSEd(Hon), FRACS(Hon), FRCSI(Hon), proclaimed his “calls to action” for the next 100 years, which included renewed focus on challenges in rural surgery. In November 2012, Dr. Eastman contributed to the rural list, referring to the ACRS and to the listserv. This was the first communication from an ACS President specifically to College members who practice in rural areas.
Listserv comes of age
In the months that followed, the rural list went through a period of adjustment, which led to a fully formed and stable electronic mailing list with approximately 1,000 members. The rural list accomplished the goal of improving communication among and with rural surgeons. The figure on this page demonstrates the gradual increase in the number of contributions.
Rural Listserv e-mail volume
Approximately 4 million e-mails have been exchanged through the rural listserv. Currently, each e-mail goes out to all 1,000 subscribers, and an average of more than 600,000 e-mails are exchanged monthly. Notably, a discussion in January regarding call coverage galvanized the rural surgeons, propelled list participation, and worked to ease listserv e-mail fatigue.
With rare exceptions, the e-mails have been civil and informative. In a word, the activity on the rural list has been “professional.” The moderators, who spend hours on their computers and smartphones to authorize up to 100 e-mails per day, have withheld only two e-mails. Before posting some e-mails, the moderators have contacted the surgeon privately to clarify content, and those exchanges have always been collegial.
The topics presented have been broad, interesting, and educational. The table on page 50 features the most common general discussion categories as well as some of the topics presented in threads on the rural list.
Clinical surgery topics and generic case presentations posing the question, “What would you do?” have generated supportive and educational replies within hours. Discussions about the current health care environment and daily practice are often vigorous, and calls for advocacy support have resulted in positive responses from rural surgeons who recognize the ACS’ commitment to its Fellows.
Success
The rural listserv has fulfilled the goal of improving communication, and it has connected rural surgeons as a group while also engaging them with the ACS leadership. The following comments from rural surgeons are a few examples that illustrate the perceived benefits of the rural list:
- Extremely valuable. I definitely feel more connected with surgeons who do what I do.
- I enjoy the rural listserv for the sense of connectedness with other rural surgeons.
- One of the great things about listserv is relief from the isolation we all feel as rural surgeons.
- The list is the most tangible, personally applicable arm of the College I have been exposed to in nearly 40 years as a Fellow.
- It is more exciting to have a voice with the College.
- I am encouraged to attend the rural activities at the ACS [Clinical] Congress.
The ACS’ leaders support the rural list and recognize its success. Patricia L. Turner, MD, FACS, Director, ACS Division of Member Services, recently stated in an e-mail communication, “The rural listserv is an effective way to engage those who may be geographically isolated in conversations about what we do every day as surgeons. The community and camaraderie of the ACS transcends locale, and the rural surgery listserv provides a structure for some of those conversations. As part of the new ACS website, Web-community functionality will bring a wealth of new ways to interact even more actively.”
In addition to the accomplishments of improved communication and engagement of rural surgeons with the College, the listserv has yielded other tangible benefits. One achievement has been the creation of a forthcoming document, Resources for Optimal Rural Surgery, which will address the common problems associated with developing the infrastructure necessary to support a rural surgical practice. The success of the rural listserv will lead to achieving key goals by addressing such topics as call coverage, locum tenens services, and the preservation of rural surgery.
The rural listserv is having an impact outside of its own boundaries. For example, Dr. Eastman has challenged surgeons operating in tertiary hospitals to create programs with a two-way exchange—not only updating education and training, but also preparing surgeons for rural life and working independently. Given its success, Dr. Eastman believes the rural listserv can serve as an example for fostering meaningful consultations and important referral relationships throughout surgical communities. The rural listserv will continue to evolve and could become a source for continuing medical education and routine video conferencing.
A new community
The rural listserv will evolve into a new group—the rural surgeon community, one of the many communities that will be formed as part of the College’s redevelopment of the member side of the ACS website. The ACRS is optimistic that this online community will retain the benefits of the rural list, while creating a new Web-based community that will be exciting, modern, and successful.
The ACS communities, which, at press time, are scheduled to launch this summer, will serve as a professional social media platform that provides all members of the College with opportunities to share information and foster collaboration. Once logged in, rural surgeons may expand their communication efforts by exchanging documents, audio, and video. Community members also have the opportunity to communicate sensitive or confidential information in private, secure networks—without the continuous moderation currently available in the listserv. In addition, Fellows will be able to specify the frequency with which they receive notifications from the various communities to which they belong.
The ACS rural listserv began as an “underdog” project, but rural surgeons responded strongly to this initiative. The effort became a success by recognizing, connecting, and engaging rural surgeons. With the establishment of the ACRS and the rural listserv, rural surgeons have an effective voice and representation in the ACS, and the perception of the neglected rural surgeon has been largely eliminated. The unique challenges of being a rural surgeon continue, but the future of rural surgery looks a little brighter because of the underdog victory of the ACS rural listserv.
Discussion categories and thread topics on rural listserv
| Surgery | Practice | ACS |
| Common bile duct exploration | Call | ACS resources |
| Cholecystectomy | Electronic health records/standardization | Regents input/support |
| Breast surgery | Work hour restrictions | ACS President communications |
| Appendectomy | Recruitment | Advocacy |
| Colon surgery | Retention | Washington Office support |
| Rectal stump complication | Contracts | ACRS/pillars contributions |
| Impactions | Retirement | 96-hour rule |
| Hollow viscus perforation | Interactions with administration | Two-midnight rule |
| Pneumothorax | Credentials/privileges | American Board of Surgery director input |
| Laparoscopy | Proctoring/mentoring | Residency program directors input |
| Thoracoscopy | Decreased reimbursement | Advanced Trauma Life Support® |
| Colonoscopy | Employed vs. private practice | Maintenance of Certification |
| Polyps | Patient’s gratitude | Rural film project |
| Right lower quadrant mass evaluation | Telemedicine | Annual rural dinner |
| Biliary enterostomies | Tertiary centers relationships | Clinical Congress rural surgery sessions |
| Skin cancer surgery | Transfers | Rural symposium |
| Thyroid surgery | Medical Group Management Association guidelines | Rural surgery training |
| Journal articles | Stark Law | Surgeons as institutional employees |
| Fatigue | Continuing medical education | |
| Assistants | Funding for critical access hospital (CAH) CAH admission restrictionsScope of practice |
L-Soft. History of LISTSERV. Available at: http://www.lsoft.com/corporate/history-listserv.asp. Accessed May 19, 2014.
