Improving access to surgical care in rural America: An interview with J. David Richardson

On October 4, J. David Richardson, MD, FACS, professor of surgery and vice-chairman, department of surgery, University of Louisville School of Medicine, KY, will be installed as the President of the American College of Surgeons (ACS). Dr. Richardson has always been concerned with the issue of access to surgical care, and he recently shared his views on the subject with me.

Rural upbringing

Dr. Richardson was born and raised in Morehead, a small rural town in eastern Kentucky. “Everybody, to some extent, is a product of their own upbringing. Being raised in a small town where we had no access to hospital or surgical care until I was 18 made me aware of the access problems in acquiring surgical care,” Dr. Richardson noted. In fact, he experienced the lack of local surgical care first-hand at an early age. “I can remember when I had a perforated appendix at age 10 and had a two-and-a-half hour ride to Lexington [KY] in a pickup truck in the pre-interstate highway days, and I can say that really did make an impression on me. I always remembered how scared I was and how uncomfortable it was,” he said.

In his second year of surgical residency at the University of Kentucky, Lexington, Dr. Richardson returned to Morehead for a three-month surgical rotation at the local hospital, St. Claire Regional Medical Center, which then had approximately 41 beds, and worked with the local general surgeons. “I did some orthopaedics, and I did a lot of gynecological surgery. I did [cesarean sections] with some of the physicians there, and just a ton of general surgery, as well as some trauma,” Dr. Richardson recalled. “It was a great experience for me.”

Although he has devoted his career to academic surgery, Dr. Richardson has maintained close ties with the Morehead area. “I have a brother who runs an insurance agency there, as well as nieces, nephews, and cousins. I have relatives in the really deep mountains of eastern Kentucky where the access to surgical care, quite honestly, is an issue,” he said.

As a result, Dr. Richardson has made many return trips to Morehead and has seen the St. Claire Regional Medical Center grow to a 159-bed regional referral center. He is well aware of the positive impact that locally available health care has had on the community. “We really have an excellent local hospital in my home town. There is outstanding surgical care. We’ve got specialty surgeons now. We’ve got four general surgeons, and they do a great job. For those [patients] within that five-county service area, the drive would be 30 minutes at the most. Over the course of my lifetime, we have gone from having no care to having high-quality emergency surgical services and can provide for a wide variety of sophisticated elective procedures. I’ve been able to see what good care can really do for a whole community and for a region. That means people don’t have to drive two-and-a-half hours to find out if they’ve got appendicitis or not,” he said.

Need for local access

“I think access to care in the rural areas is something that is extremely important. It is my understanding that one out of every six people in the [U.S.] still lives in what could be classified as a rural area,” Dr. Richardson said, adding that he strongly believes that the availability of local care is important for a patient who has abdominal pain that needs evaluation. “You really need to be able to take care of those patients locally. Patients deserve that,” he said.

He also believes that patients with chronic illnesses and with diseases that require a long course of treatment should be able to receive care close to home. “I did a lot of breast cancer work years ago, and many of our patients simply could not drive the many miles required to do the radiation therapy for six weeks, as an example. It just wasn’t an option in their life. They had grandchildren to take care of or they didn’t have a car. The poor people who were disadvantaged and often remote and isolated really needed to have local care,” Dr. Richardson said.

“I believe that the difficulty in access to rural surgical care is a crucial societal problem that has not received adequate national attention,” he added. “I have marveled for years that it has not been more of a political issue, that people in rural areas haven’t demanded better access to health care of their elected representatives.”

“The other thing that I’ve been really impressed with through the years is the kind of work that people do at a local level,” Dr. Richardson noted. “I am tremendously impressed at the quality of surgical care that we have in many rural areas, how thoughtful and how caring surgeons are, and how good they are. In my opinion, many leaders of academic surgery really don’t understand the tremendous quality of surgery that goes on in many areas of private practice both in urban settings, and certainly rural settings as well.”

Creating awareness among ACS leadership

As a Regent, Dr. Richardson attended an informal breakfast meeting at the 2011 Clinical Congress with a group of approximately 12 rural surgeons. The discussion centered on rural surgical issues. Included in the group of rural surgeons were Phil Caropreso, MD, FACS, from Keokuk, IA, and ACS Governor Tyler Hughes, MD, FACS, from McPherson, KS. “I enjoyed [the meeting] very much; so the one thing I promised was that if I ever had an opportunity to advance the cause of rural surgery, I would do so,” he said. That opportunity presented itself when Dr. Richardson was elected Chair of the Board of Regents at the conclusion of the 2011 Clinical Congress. He invited Drs. Caropreso and Hughes to the first Board meeting under his chairmanship in February 2012.

“I don’t mean to sound naïve when I say this, but it was one of the most touching things I’ve ever witnessed in my life. You couldn’t have found two people to have made a case for something any better than they did, and I’m telling you that it moved people to the point of emotion. I can’t state that strongly enough, really how powerful the message was. There was unanimous Regent approval to do something, and the Advisory Council for Rural Surgery [ACRS] arose out of that,” Dr. Richardson said, noting it was the first new Advisory Council of the ACS to be established in 40 years.

Since its formation, the ACRS has created greater awareness among the ACS leadership of the problems that rural surgeons face. “I don’t think there’s any question that the level of awareness of rural surgical issues has increased markedly. I do not mean to be dismissive of prior efforts by the College leadership, but the awareness of current problems is now more front and center,” Dr. Richardson said.

How the ACS can help to improve access

Now that ACS leadership is more aware of the issues in rural surgery, Dr. Richardson said, “We have some responsibility to at least educate in terms of what our workforce needs are. The College has done numerous workforce studies under the leadership of the late George F. Sheldon [MD, FACS]. Dr. Sheldon coined the term ‘surgical deserts’ for places that needed general surgeons and simply didn’t have them. What the country needs are general surgeons right now.¹ There is very little evidence that we need more surgical specialists. Right now we have a serious disconnect between what we’re producing and what the country needs, in my opinion, and I feel that very strongly. I think that the College can help get that message out,” he said.

“It’s hard to separate the rural surgery problems from the general surgery problems. When so many people are doing fellowships and wanting to designate themselves as something other than general surgeons, then clearly you are going to have problems in rural areas. So I think until we get more general surgeons, it’s going to be really hard for rural surgery to have the workforce that it needs,” Dr. Richardson added.

With regard to general surgery training, the College “certainly has been taking the position that we can’t cut general surgery funding.” However, Dr. Richardson also feels that the ACS can help to solve rural surgical issues by helping to promote better training in general surgery. “I think part of what the College needs to do, and what I want to try to emphasize, is that we need to improve core general surgical training. If people don’t feel that they are prepared to handle the broad breadth of practice in general surgery, then the thought that they are going to go out into a small community by themselves or into a small group practice can be very daunting.” Furthermore, he added, “I think the general surgeon’s training needs to be better and I think the College needs to become more involved in the verification of that training.”

In addition, Dr. Richardson noted that the College has formed a group called “Fix the Five,”² which is working to improve residency training, as well as a Transition to Practice (TTP) program.³ “Although the TTP program is not rural surgeon specific, we have several programs in fairly rural places,” Dr. Richardson said. “Many of those programs are really trying to produce rural surgeons and prepare them for practice in that environment.”

Dr. Richardson believes that the ACS Division of Advocacy and Health Policy has sought to address the issues facing rural surgery. He participated in the April 2015 ACS Leadership & Advocacy Summit in Washington, DC, and noted that “the big push that our group made in Kentucky was the importance of critical access hospitals, the 96-hour rule,⁴ and support for Sen. Pat Robert’s (R-KS) bill S. 258,⁵ trying to protect small hospitals. That was the major theme of that entire episode, so to me, that is one thing that the College did or has already done that’s very concrete in terms of trying to help rural surgeons,” he said. “I think that the legislative team clearly is very attuned to the things that could impact rural surgery and is trying hard to intercede on behalf of rural surgeons.”

Dr. Richardson also mentioned that Ajit K. Sachdeva, MD, FACS, FRCSC, Director of the ACS Division of Education, has been very interested in enhancing the portability of medical licensure across state lines, which will ensure easier access for locum tenens coverage and coverage when rural surgeons take vacations.

To enhance the College’s efforts to improve rural access to surgical care, Dr. Richardson said he believes the nation needs a National Surgical Health Service. At present, “we have a National Health Service that provides people to do obstetrics, dentistry, and primary care. If the political awareness arose to the desperate needs of rural surgeons, then the idea of a ‘surgical health service’ might be politically palatable. This could take the form of loan forgiveness for years of service to rural communities and the like,” Dr. Richardson said. “To me, that’s a big idea that, down the road, people need to be pursuing because I don’t know that market forces alone are going to solve the problem. This is a long-term process, but initial steps should be started at a political level by those who live and work in rural communities. “

There is no question that Dr. Richardson has never lost his belief in the need for access to surgical care in rural areas. “If you want to be a leader in surgery, you really do need to look at other people’s point of view, their obstacles as well as their strengths in terms of rendering good patient care,” he said. “I’ve just tried to do that for rural surgery.”

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References

1. Belsky D, Ricketts T, Poley S, et al. Surgical deserts in the U.S.: Places without surgeons. ACS/HPRI Institute Factsheet. July 2009. Available at: www.facs.org/~/media/files/advocacy/hpri/surgicaldesertsinus.ashx. Accessed August 18, 2015.
2. Hoyt DB. Executive Director’s annual report. Bull Am Coll Surg. 2014;99(12):19-34. Available at: bulletin.facs.org/2014/12/2014-executive-directors-annual-report/. Accessed August 10, 2015.
3. Richardson JD. ACS Transition to Practice program offers residents additional opportunities to hone skills. Bull Am Coll Surg. 2013;98(9)23-27. Available at: bulletin.facs.org/2013/09/acs-transition-to-practice-program-offers-residents-additional-opportunities-to-hone-skills/. Accessed August 10, 2015.
4. Savarise MT. Dispatches from rural surgeons: ACS intervenes to resolve questions about the 96-hour rule. Bull Am Coll Surg. 2014;99(10):40-43. Available at: bulletin.facs.org/2014/10/acs-intervenes-to-resolve-questions-about-the-96-hour-rule/. Accessed September 14, 2015.
5. S.258—Critical Access Hospital Relief Act of 2015. Summary. Available at: www.congress.gov/bill/114th-congress/senate-bill/258. Accessed September 14, 2015.