Diamonds in the rough—a case for rural surgery rotations

It is 6:30 am. My gaze shifts from my textbook to the westward facing window overlooking the water of Michigan’s Long Lake. I wrench my attention back to the final paragraph in the text, which is the vascular chapter. One final bite of my apple, and then it’s book closed, shoes on, and out the door to make my way to Alpena Regional Medical Center, MI. The drive to the hospital reminds me of a Thomas Kinkade painting. Trees line the 10-mile stretch into town, dotted with houses and small businesses. I pull into the parking lot at 6:45 am and am greeted by several nurses and staff on my way into the operating room (OR) lockers.  This moment is the most at ease I have been during residency. Granted, three and one-half years of general surgery training is not an eternity, but here I have a sense of peace that transports me outside of time.

A day at Alpena

We start the day with a carotid endarterectomy. Our patient is a pleasant 81-year-old woman who has lived in Alpena her entire life. She did not want to have to drive the two and one-half hours into the city, which, as I recall, was likely Flint, MI, in order to have her operation without the support of her friends and family. Her carotid surgery went off without a hitch and she did well postoperatively. Next on the docket are two cholecystectomies, followed by two colonoscopies, and an emergent appendectomy that we managed to squeeze in before lunch. Rounds after lunch are punctuated by conversations with the nursing staff as well as several hospitalists. These exchanges are not idle chatter—they are conversations of consequence regarding patients, with genuine interest in the lives of all involved.

Throughout the day, the hospital staff is welcoming. Most of the staff are aware that a resident is on-site for a one-month rotation (May 2016), and those who are not aware of my presence seem to be keen to have a resident in-house. Between cases, after my postoperative notes and orders are written, I sit at the OR charge nurse station or at the work desk in preoperative or post-anesthesia care unit areas, where everyone seems to be interested in the details of my life and how I am enjoying my time at Alpena.

The staff members exhibit appreciation for the opportunity to live in northern Michigan and a devotion to the hospital and their colleagues that allow them to live and work in their idyllic home. Although challenges such as limited resources and access to specialists arise, everyone works together with a cooperation born of mutual happiness. It is a state of mind reinforced by personal satisfaction, strong work/life balance, and collegiality.

I knew that this life existed; I knew it was possible. But the blindfold of stress, the pressures of residency, and the impulse to keep my head down had prevented me from looking up and looking forward specifically in this direction.

The environment in Alpena was not what I was familiar with, as I did not grow up in the Midwest, but rather in a small mountain town—Rifle, CO. Rifle is an example of a modern rural town, where seemingly everyone knows everyone else; Sunday church is sacred; and once, in high school, a student rode his horse to class. This was my upbringing and a piece of my soul that I had abandoned when I left for college. Living and working in Alpena gave me the opportunity to be back in a small town environment.

Stemming the workforce shortage

Numerous articles have been written on the shortage of rural physicians, specifically surgeons. Many of these authors have focused on strategies for reducing rural workforce shortages. However, the personal experiences I describe in this column provide a resident’s perspective on rural surgery rotations and are intended for four distinct audiences.

Residents from rural areas

For those of us from small towns and rural settings, residency has a peculiar way of making us forget the joys of our hometown and our upbringing. Whether it’s the work hours, the stress of passing boards, or just keeping our heads above water, we tend to lose sight of what we once had. Budding surgeons need to choose surgical programs near large population centers to ensure the case mix and volume needed to hone their craft is available, but this urban environment can wear down even the toughest farm kid.

Program directors

I would encourage program directors to offer a rural surgery rotation. The surgeon workforce shortage in rural America is a problem that can be tempered, and rural surgery rotations provide the opportunity to train in a variety of cases with unique practice patterns.

Residents training in a rural rotation typically have the opportunity to experience what it would be like to practice in their hometown or someplace like it. Consider offering a rural surgery rotation, even if your hospital is landlocked. Partnerships with hospitals and surgery groups benefit both the residents seeking this experience, as well as the hospitals and surgeons with which they work, bringing cutting-edge techniques and new and different approaches to problems we all hold in common.

Practicing rural surgeons

Experienced rural surgeons possess a wealth of knowledge and wisdom. Consider hosting a resident at your practice. There is no better way to give back to your profession than training the next generation, and this partnership may even provide you with new insights for providing optimal care. And who knows—during this processes you may be meeting your future partner and colleague.

Rural hospital systems

I encourage rural hospitals to explore the possibility of hosting surgical residents. The surgical residency learning environment is carried along with a visiting surgical resident, who will likely reveal to your colleagues new techniques as well as current research findings. Not only will your current surgical staff benefit from the presence of a resident, but the OR staff, floor nurses, and even nonsurgical services will likely gain a new point of view. Residents who have a rewarding experience at your institution may be convinced to pursue rural surgery as a career, and your hospital will likely be first on their list of desired places to work.

A win-win opportunity

I urge residents, program directors, rural surgeons, and rural hospital leaders to take advantage of the benefits that come with implementing a rural surgery rotation. I encourage surgery residents to seek out rural hospitals and groups that are eager to give back to the profession. Step out into the wild and encounter a side of surgery most haven’t experienced. All parties involved will benefit, and we might even ease the burden of care on America’s rural hospitals along the way.

Residents, program directors, surgeons, and hospitals that are interested in participating in or hosting a rural surgery rotation are encouraged to contact Michael Sarap, MD, FACS, Chair, and Mark Puls, MD, FACS, Vice-Chair, ACS Advisory Council for Rural Surgery. Dr. Sarap can be reached at, and Dr. Puls at

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