The North Dakota Rural Surgery Support Program: Providing surgical services to communities in need

Dr. Aaland with a patient at a rural hospital in Jamestown

Dr. Aaland with a patient at a rural hospital in Jamestown

Approximately 20 percent of the U.S. population lives in rural areas. In comparison with metropolitan locations, rural communities often are understaffed with health care providers. Most rural patients would prefer to receive their medical care in their own communities whenever the services are available. Unfortunately, for many rural communities, surgical care is very limited or nonexistent. The demand for general surgeons in rural locations is projected to be among the highest of any medical specialty in the next decade.1,2

To help ensure that surgical patients in the state have access to the care they need, the University of North Dakota School of Medicine and Health Sciences (UND SMHS) launched a Rural Surgery Support Program (RSSP) in July 2014. This column outlines the rationale for starting the RSSP, explains how it works, and describes the initial effects of the program.

Need for rural surgeons

Rural communities often have a difficult time recruiting and retaining general surgeons due to several factors, which are listed in Table 1.3,4 Indeed, rural general surgery practices offer unique advantages and challenges. As the plight of the rural surgeon becomes increasingly apparent, health care leaders continue to search for solutions to some of the major problems associated with rural surgical practice.

Table 1. Impediments to rural surgery recruitment/retention

  • Professional/social isolation
  • Lack of practice coverage for vacations, attendance at continuing medical education programs, new skill training
  • Lower reimbursement/increased expenses
  • Limited resources and capabilities of rural hospitals
  • Call coverage and lifestyle concerns
  • Administrative requirements for practice maintenance
  • Increasing regionalization of medical care
  • Difficulty in recruitment and retention
  • Decreased interest in broad-spectrum general surgery practice
  • Increasing subspecialization in general surgery
  • Lack of broad-based training for rural surgery practice

Many rural hospitals rely on their surgeon(s) for financial viability. Many small rural communities have only one general surgeon who is often tasked with providing a broad spectrum of surgical services, both in general surgery and other surgical specialties. In many critical access hospitals, the population and volume of surgical procedures can only support one surgeon who is often on call 24/7 for weeks at a time, leading to the most common problem for rural surgeons—surgeon burnout. Burnout and professional dissatisfaction can occur in response to the need for continuous coverage as well as multiple other challenges that face the typical rural surgeon.

Retention of rural surgeons is also adversely affected by the number of surgeons leaving rural practice after only a few years because of burnout. When a rural surgeon leaves a community, he or she leaves behind a huge gap in access to health care for patients in that area, which can affect the ability of the hospital to continue to offer inpatient services. The loss of regular surgical services also affects the retention of other core staff who are tied to the provision of regular surgical services, including certified registered nurse anesthetists, operating room nurses, surgical assistants, surgical technicians, and other ancillary personnel.

In North Dakota, surgeon shortages almost always happen in the smaller communities due to the premature departure or retirement of a rural surgeon (see insert RSSP Success in a Rural Community, above). Before the RSSP was established, the only alternative for the rural hospital was to hire locum tenens surgeons, which often resulted in sporadic coverage, sometimes of questionable quality, and was an expensive option that was ultimately a losing proposition for the facility. As the average age of rural surgeons continues to increase, surgeon shortages will continue to plague rural hospitals and communities, exacerbating the need for rural surgery coverage.

UND RSSP Program

In recognition of the challenges facing rural surgeons in North Dakota, the department of surgery at UND SMHS developed the RSSP to aid rural hospitals and surgeons in the state. The purpose of the program is to stabilize surgical coverage in rural communities in need. The guiding principle is to meet the specific needs of the rural community, which are determined by invested community leaders, their surgeon(s), and the representatives from the RSSP. The program is flexible and can provide a range of support depending on the needs of each community (see Table 2).

Table 2. UND SMHS RSSP: Existing and Planned Services


  • Practice coverage—Two-week maximum
  • Recruitment support and advice
  • Continuing education in surgery and trauma

  • Surgical credentialing
  • Quality programs, including the American College of Surgeons National Surgical Quality Improvement Program
  • Peer review


Several unique aspects of the medical environment in North Dakota necessitated and facilitated the development of this program. North Dakota is a rural state, and 87 percent (39 of 45) of the hospitals are classified as rural. Of the rural hospitals, 80 percent (31 of 39) are critical access hospitals, and 67 percent (26 of 39) have or would like to have the resources to provide surgical care (see map).

North Dakota hospitals and critical access hospitals (Reprinted with permission)

North Dakota hospitals and critical access hospitals (Reprinted with permission)

The UND SMHS is the only medical school in North Dakota, and it is sponsored by the state. The people of the state and their elected officials expect the medical school to develop programs to support the health care needs of rural communities. For many years, the rural communities of North Dakota have had difficulty recruiting and retaining general surgeons to rural hospitals. In its initial phase, the RSSP has provided practice coverage for rural surgeons, helped in the recruitment of a permanent surgeon for the community, and improved educational opportunities for hospital staff and physicians. Other activities are planned as the program matures (see Table 2).

Program initiation

The RSSP program was established July 1, 2014, with initial startup funding from the UND SMHS and the North Dakota State Legislature. The program was designed to be financially self-sufficient within one year. A division of rural surgery was established within the department of surgery at UND, and a director, Mary Aaland, MD, FACS, a co-author of this column, was hired to develop the program. Dr. Aaland visited all rural hospitals in the state to explain the program and its benefits to rural hospitals. She received an overwhelmingly positive response from both hospital administrators and the rural surgeons. Initial coverage assignments were scheduled in October 2014 and have increased as the program has gained recognition.

Program structure

The program is administered by the department of surgery, with all contracts and revenues channeled through the department. Participating hospitals may sign up for a specific time period or implement an open-ended contract that will take effect when the need arises. An established fee structure is in place, which is based on length of coverage and services provided. The RSSP does not bill for any clinical activities or procedures that the covering surgeon provides. Clinical billing is the responsibility of the home institution, which retains all revenues from clinical services. The RSSP surgeon guarantees to provide and complete all necessary documentation to maximize clinical revenue for the institution. The only responsibilities of the home institution are the daily or weekly fee and the provision of appropriate housing for the RSSP surgeon. All other costs, including liability insurance, meals, and administrative expenses, are the responsibility of the RSSP program and calculated into the fee structure. The fees typically are 30 percent to 50 percent lower than at most locum tenens agencies, a savings that benefits the home hospital administration.

Initial experience

In the year since the RSSP began, both the initial response and the requests for use of the program have been impressive, reinforcing the authors’ belief that programs of this type can be very helpful and in some cases critical to stabilize rural surgery practices.

Our experiences have identified some key components of the program that have resulted in benefits to rural surgery (see Table 3). In areas with competing health systems, the neutrality of the sponsoring organization can be critical, as institutions are often leery of working with a program from a competing institution. Our community-based medical school serves well in this function because it does not have a hospital and works with all hospitals in the state to educate our physicians for the future.

Table 3. Key components and advantages of the RSSP

Key components Advantages
Dedicated surgeon recognized and credentialed at participating institutions Mutual familiarity between institution and covering surgeon, improved continuity of care
Neutrality of sponsoring organization Elimination of concerns about competition between institutions or health systems
Cost Significant savings for participating institutions
Availability In-state availability of a surgeon familiar with patients and hospital systems
Credentialing The covering surgeon’s credentials are obtained and maintained by administrative support, eliminating tedious and costly credentialing process for each assignment
Recruitment Recruitment advantages for single-surgeon hospitals that are able to guarantee a specific number of weeks off for recruited surgeons

The ability to have coverage provided by a surgeon who is known, licensed, and credentialed in the state has also been very valuable. The perception of that surgeon as someone who wants to help and preserve rural surgery practices and is available for post-assignment follow-up conversations has also been well received. In its first year of operation, the RSSP has scheduled assignments that will occupy almost the entire next year for Dr. Aaland, and we are now considering hiring another surgeon to meet the needs of the participating institutions.

In summary, the RSSP has been well received by rural hospitals that have been affected by the many challenges associated with maintaining rural surgical services. We anticipate that the program will continue to provide needed coverage and other services to help rural hospitals stabilize and maintain their surgical capabilities in North Dakota.

Newspaper clipping from the September 26, 2014, Adams County Record

Newspaper clipping from the September 26, 2014, Adams County Record

RSSP success in a rural community

Hettinger is a rural community in southwest North Dakota with a population of approximately 1,200, and the West River Regional Medical Center is the sole medical facility in the county. The only general surgeon, who practiced for more than 30 years, announced his intention to retire in 2009. Despite years of recruitment efforts and many offered incentives, the community was unable to replace its retiring surgeon, who left in 2013. Most of the recruited surgeons shied away due to lack of coverage for time away from the practice. With the advent of the RSSP in July 2014 and the ability to guarantee eight weeks of coverage per year, the medical center was able to recruit a full-time surgeon within two months, stabilizing the much-needed surgical services in this health care facility and the community.



  1. Williams TE Jr, Satiani B, Ellison EC. A comparison of future recruitment needs in urban and rural hospitals: The rural imperative. Surgery. 2011;150(4): 617-625.
  2. Lynge DC, Larson EH. Workforce issues in rural surgery. Surg Clin North Am. 2009;89(6):1285-1291.
  3. Cogbill TH, Cofer JB, Jarman BT. Contemporary issues in rural surgery. Curr Probl Surg. 2012;49(5):263-318.
  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):1007-1012.

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