Rural surgery: High pressure but rewarding

What is it like to be a surgeon in rural America? Many laypeople and even some of our colleagues may have the notion that is idyllic—perhaps “Doc Hollywood”-like. They may imagine lazy days spent fishing and tending to occasional patient in the hospital—a simple, maybe even boring, life.

However, those of us who have chosen to practice in rural areas will tell you that the life of a rural surgeon can be one of high pressure and professional isolation. As one rural surgeon commented on the American College of Surgeons (ACS) rural surgery listserv, “Non-rural clinicians get only a fraction of this pressure. After 20 years in my community, almost every case now is someone I’ve known or previously treated. No question that this causes us to question every decision we make, and it’s just not the same as when I was a big city doctor. If I could just get a patient over their hospitalization [when I practiced] in the city, it was very unlikely I would ever see them again, compared to my practice now where I never rotate off the service.”

At the same time, rural practice can be incredibly fulfilling. Can this paradox be explained?

Your patients are your neighbors

Some surgeons would consider many aspects of rural surgery to be disadvantages. Rural surgeons know almost all of their patients. A small town affords no anonymity, no ability to leave work at work. The rural surgeon may operate on their grocery clerk or someone else that they see in town every week. In the big city, referrals may depend on insurance networks, one’s professional colleagues, or whoever shows up at the emergency room. In a small town everyone’s mother, brother, and cousin knows you. This can be a good thing or a bad thing. In contrast to life in a bigger city, the rural surgeon truly lives in a fishbowl. Your every move is under scrutiny. As one surgeon noted on the rural surgery listserv:

How about returning to your rural hometown that you grew up in to practice general surgery? Over 20 years of operating on countless friends, classmates, teachers, and so on—making them better, giving them bad news, and dealing with bad outcomes. I have a guy coming in tomorrow who tried to pick a fight with me in high school. I’ve also had people avoid me because of something I did 35 years ago. Forget trying to go out and having a beer. Everyone knows you and watches [your] every move.

Of course, knowing everyone in town can have its advantages as well. One rural surgeon made the following comment on the listerv: “Just when you think the pressure is too much, someone tells you how much they appreciate you. I had a lady tell me this week that she prays for me every night because I saved her life several years ago. She wants to buy an autographed picture of me. There are so many highs and lows it’s hard to figure out which end wins.” Another surgeon noted the following:

“(1) You know you’re a rural surgeon when the family of the kid whose spleen you removed for trauma pays you in cash and blueberry pies (really, really good blueberry pies); (2) You know you’re a rural surgeon when you can’t get through the produce section at the grocery without doing a consult or inspecting a wound; (3) You know you’re a rural surgeon when, before you ask about medications, you ask ‘parlor or stanchion?’ (which, for those of you who didn’t know, are methods of milking cattle); and (4) Lastly, you know you’re a rural surgeon when you go to a garage sale and end up crying with a family over their relative you operated on, but who is gone now. There’s just no greater calling. I am grateful.”

Providing myriad services with limited resources

Another thing about small towns that can make rural practice challenging is that people don’t like to wander away from their homes, farms, or businesses. Rural surgeons are pressured to treat patients in their hospitals, to keep them close to home so their families can avoid traveling to visit and care for them. But the fact is, rural patients are more likely than urban patients to be elderly and poor and to have chronic illnesses, which means they may need more resources than are available at the community hospital.*

Although rural areas often are resource poor, that doesn’t limit the cases that come through the doors. Rural surgeons constantly need to be able to figure out if they can solve a problem with the resources they have or if it would be better for a patient to go elsewhere. The perception at some of the larger referral centers is that rural surgeons ship people out so they can go play golf. Quite to the contrary—rural surgeons do everything they can to keep their patients close to home, but they have to think each problem through to its conclusion and decide whether they have the equipment, skilled nursing staff, anesthesia services, diagnostics, and so on, to complete the job successfully. Many times, the surgeon may have the skills necessary to treat the problem, but the facility is not equipped to provide high-level recovery and follow-up care. In these cases, it is in the patient’s best interests to be transferred to a better-equipped facility.

24-hour availability

Most rural surgeons are on call every other night or every third night, and some are on call every night. People may think that we are not called very often. However, the potential for interrupted sleep every night can be very stressful. Never being able to turn off the phone or travel more than 30 minutes away from the hospital requires a tremendous commitment on the part of the surgeon, as well as his or her family. Furthermore, our institutions sometimes work from the perception that the more you do, the more you can do. In other words, if you can take call every other night, why can’t you take call every night? Administrators and practitioners who have never taken every-night call don’t understand how stressful it is to always be on. Even if the phone rarely rings, the rural surgeon always has to be available. And inevitably, if you go on vacation, someone you know will get appendicitis, and when you return they will come to you saying, “I was sick and you weren’t here.” Try to go to a movie or a graduation ceremony and not be able to turn off your phone. In bigger cities, where call is one in three or four days, the call day may be busy, but the other three days the phone can be silenced.

Professional isolation

Despite their vital role in treating patients, rural surgeons may feel that their peers overlook or don’t appreciate them. A subtle bias runs through the profession against a surgeon who would choose this life of relative isolation, apparent non-specialized surgery, and overwork in communities with fewer cultural activities and fewer employment options for spouses. Yet rural surgeons are essential to maintaining the health of millions of rural Americans.

A breadth of skills

Another source of pressure is the need for a broad range of skills. In rural hospitals, surgeons must be able to perform a wide variety of procedures and to do them in times of need. A urologist may not be available to provide care if a patient has a bladder or ureter problem. A gynecologist may not be available if a suspected appendicitis turns out to be an ovarian problem.

Because the training paradigm for general surgeons is becoming narrower and narrower, rural surgeons often have to develop some of these skills on their own. Graduate medical education programs are configured in such a way as to encourage subspecialization and do not prepare young surgeons adequately for rural practice. This challenge, in addition to work hour restrictions, has made it more difficult to train surgeons who are prepared to practice in rural areas. Gone are the days when general surgery residents came out of residency with a broad set of surgical skills. Mentorship and rural surgery fellowships will become increasingly important as the supply of adequately trained rural surgeons dwindles in the next decade.

It’s the life we love

Those of us who have chosen rural surgery wouldn’t trade it for any other type of practice. We are deeply invested in our communities and find our practices very rewarding. Is the life of a rural surgeon an easy one? Maybe not. Is it a fulfilling one? Absolutely.

*Nakayama DK, Hughes TG. Issues that face rural surgery in the United States. J Am Coll Surg. 2014;219(4):814-818.

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