Responding to the need for rural general surgery training sites: A how-to

The rural general surgeon is an endangered species. Although studies of current and future surgery workforce needs reach varying conclusions based on the methodology and assumptions applied, most researchers agree that a marked maldistribution of surgeons exists and that rural areas in particular lack sufficient general surgeons to provide adequate surgical care.¹ The shift of surgery trainees toward specialization compounds the deficit of rural general surgeons and may further threaten the availability of rural surgical care.

Although residents are turning away from rural general surgery practice for multiple reasons, notable concerns include a lack of exposure to general and rural surgery in training; lack of exposure during residency to a wide breadth of services and skills that rural general surgeons are expected to deliver, including basic orthopaedic, urologic, hand, gynecologic, therapeutic endoscopic, and otolaryngologic procedures; perceived challenges of on-call requirements; and limited opportunities to engage in lifelong learning. Research has shown that nearly 50 percent of a rural surgeon’s practice is composed of basic and complex endoscopic procedures, with another 12 percent centered on subspecialty procedures, including obstetrics and gynecology, orthopaedic, otolaryngology, urology, and thoracic.^2-4

A variety of independent and university residency programs have a history of training surgeons who enter rural practice directly after residency. More recently, an increasing number of program directors have demonstrated a renewed commitment to meet the needs of the rural populace, especially if these programs are located in states with a significant rural population. Specifically, program administrators are exploring the addition of rural sites or tracks to their residencies. Whether the residency is already established and seeks to add an opportunity for a rural training experience or the administrator is developing a new general surgery residency program with a rural focus, key steps can be taken to establish a successful program. There are several existing models that can be employed to facilitate the process.

Existing models

Some highly successful models for training a broadly competent rural general surgeon are exemplified by programs such as those at Gundersen Medical Foundation, LaCrosse, WI; Mary Imogene Bassett Hospital, Cooperstown, NY; and the University of North Dakota School of Medicine and Health Sciences, Grand Forks. These residency programs all share certain characteristics, including few or no competing surgical specialty residency programs, the presence of both specialty faculty and general surgeons, and close relationships with rural hospitals. These institutions have designed their programs to meet the educational and training needs of general surgery residents who plan to practice in a rural environment. New academic programs, such as the one established in 2014 at the University of South Dakota Sanford School of Medicine, Sioux Falls, have adopted this model.

In the past few years, several university programs that are located in states with significant rural populations have developed independent rural residency tracks to which medical students apply directly. Among these are the University of Wisconsin, Madison, and the University of North Dakota. Other programs, such as the one at Oregon Health and Science University, Portland, have embedded a rural track in their general surgery residency, which does not require a separate application.

Another model employed by general surgery residencies is to offer an elective or required rural rotation at one or more levels of training. These experiences are universally popular, as they offer the opportunity for residents to connect with a rural surgeon mentor, to perform a broad range and large volume of procedures, and to develop a sense of being part of the practice and of the community. Programs that offer rural surgery rotations include the University of Tennessee at Knoxville and Chattanooga; the University of West Virginia, Morgantown; Gundersen Health System; and the University of Louisville, KY.

Factors to consider

All of these models are effective in exposing residents to the exceptional nature of rural general surgery practice. Nonetheless, each is unique with respect to the availability of rotation sites, approaches to funding, the availability of suitable faculty, and the duration of assignments. Several factors need to be taken into account by the surgical programs and rural communities that are interested in developing rural surgery sites, tracks, or programs.

The first and most critical consideration is selecting the appropriate site or sites for the training to take place. The ideal rural training site has a case volume that is large and varied enough that the residents will gain adequate experience. A balance of smaller office or ambulatory procedures, larger inpatient procedures, and endoscopic procedures is ideal, with an approximate volume of 30–50 cases per month. The goal of the program should match the available resources of the rural site with the need for the residents to gain experience in specific types of cases.

If the purpose of the program is to provide residents with the skills needed to practice surgery in an isolated rural setting with no surgical specialists, then it is imperative that the trainee be adequately exposed to cesarean sections, fracture management, urologic and otolaryngologic emergencies, and surgical conditions of the hand; a hospital with infrequent cases of these types may be a poor match. Almost all rural sites will offer a rich experience in gastrointestinal (GI) endoscopy, as this procedure is a hallmark of rural general surgery. GI endoscopy experience alone, however, will not provide the resident with adequate exposure to the breadth of skills a rural surgeon must possess.

It is important that the rural hospital administration, the surgical attendings, and the nursing and ancillary staff be unified in their commitment to host a trainee. Visits to the site by the program director, the department chair, and a surgical resident to meet with all constituencies, learn about the program, and to pose questions are highly recommended. The surgeons selected as mentors must be American Board of Surgery-certified or have specialty qualifications that are acceptable to the Residency Review Committee (RRC) for surgery; should be Fellows of the American College of Surgeons or another professional surgical society; and must be highly regarded in the region for their refined surgical skill, clinical decision making, and ethics.

The surgeons at the rural practice must agree with the parent program about the optimal length of the rotation and the appropriate resident level (postgraduate year). Faculty members who have extensive prior experience working with residents may be more willing to entrust their patients to a junior learner. Both the faculty and administration of hospitals that participate in rural surgery training can reap many potential benefits, including the exposure of their surgeons and surgical staff to the educational milieu, improved surgeon and staff satisfaction, exposure to leading-edge surgical techniques and procedures, and an advantage in recruiting surgical partners who had previously rotated there as residents.

The details of the proposed rotation must be thoroughly discussed with the hospital administration and faculty surgeons. Compliance with all Accreditation Council for Graduate Medical Education (ACGME) regulations, including those pertaining to duty hours, supervision policies, and educational sessions (such as weekly morbidity and mortality conferences) must be ensured. Curricular goals and objectives should be clearly delineated. Methods and details of formative feedback and summative evaluation of the residents must be established.

Terms of funding for the rotation must be defined, including benefits and housing details. The resident’s salary may be provided by either the parent institution or the rural site. Some programs have secured state funding or grants. The parent institution and rural site must identify appropriate housing in proximity to the rural hospital and decide which institution is responsible for its cost. The issue of which institution provides medical liability insurance also must be determined.

All of the previous details of the program must be included in the program letter of agreement and master contract between institutions before the program begins. The parent program must apply to the ACGME RRC for surgery in advance of any new program or rotation of six months or more in length. Shorter elective or required rotations do not necessitate advanced approval, although the rotation must still comply with all ACGME regulations.

The ACS intervenes

The American College of Surgeons (ACS) offers several resources to help establish rural surgical programs, training, and sites. One type of experience that may have relevance for the future of rural general surgery is the ACS Transition to Practice (TTP) Program, which is designed to help better prepare new graduates of surgical residency for independent practice. These programs may be customized for a graduate who has a specific type of future practice location in mind and are ideal for preparing a new graduate to enter a rural practice. TTP fellows are best placed in independent hospitals without a general surgery residency program, to avoid any erosion of surgical resident case volume or operative experience.⁵ Details about the TTP Program are available on the ACS website.

In addition, the members of the Education Committee of the ACS Advisory Council for Rural Surgery are available to consult with any institution interested in developing a rural site or track. Interested parties should contact Karen Deveney, MD, FACS, at deveneyk@ohsu.edu for further information.

Rural surgeons also are encouraged to contact the program director of the general surgery training program in their state to express their interest in serving as mentors to surgical trainees and helping to ensure the future of rural general surgery.

Finally, medical students with an interest in rural general surgery as a career can locate a list of general surgery residency programs that provide rural surgery experiences in residency online.

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References

1.  Etzioni DA, Finlayson SR, Ricketts TC, Lynge DC, Dimick JB. Getting the science right on the surgeon workforce issue. Arch Surg. 2011;146(4):381-384.
2. Ritchie WP, Rhodes RS, Biester TW. General surgery workloads and practice patterns in the United States, 2007–2009. Ann Surg. 2011;254(3):520-525.
3. Harris JD, Hosford CC, Sticca RP. A comprehensive analysis of surgical procedures in rural surgery practices. Am J Surg. 2010;200(6):820-825.
4. Sticca RP, Mullin BC, Harris JD, Hosford CC. Surgical specialty procedures in rural surgery practices: Implications for rural surgery training. Am J Surg. 2012;204(6):1007-1013.
5. Richardson JD. ACS Transition to Practice Program offers residents additional opportunities to hone skills. Bull Am Coll Surg. 2013;98(9):23-27.