It was a great honor to attend the American College of Surgeons (ACS) Clinical Congress 2018 in Boston, MA, to receive the Nizar N. Oweida, MD, FACS, Scholarship for surgeons who serve small communities. The generosity of the family of the late Dr. Oweida gave me the opportunity to share my experience at different events at the conference. My main goal was to remind my fellow rural surgeons to focus on the advantages of working in small hospitals and to inspire them to provide specialized care locally. Given the scarcity of research originating in rural areas of the U.S., rural surgeons have a unique opportunity to generate quality research projects that reflect the characteristics of their patients.
Research in a small community
I was fortunate to graduate from the Carilion Clinic, Roanoke, VA, residency program. The program director, John Ferrara, MD, FACS, emphasized the goal of transferring the skill and medical care to the patient. When I started working at Aspirus Iron River Hospital, Iron River, MI, in a town of approximately 3,000 people, I quickly realized the challenges our patients and their families endure when they are transferred to tertiary hospitals. My top priority became developing a plan to safely manage our patients locally—a goal that can only be achieved with the assistance of a committed team.
My first year of practice was slow, and I was concerned about losing my surgical skills. I started visiting nursing home residents and managing their wound care. The community appreciated my commitment to providing this care, as it prevented multiple trips to outpatient clinics and unnecessary emergency room visits and did not disturb the routine of these frail patients.
In my second year, I decided to develop a structured anti-reflux program that encompasses all diagnostic workup, uses cutting-edge laparoendoscopic approaches, and collects objective outcome data. I received overwhelming support from the administration and clinical leadership while establishing the program. Equipment was ordered in a timely manner and all staff involved received appropriate training. Over three-and-a-half years, we evaluated approximately 620 gastroesophageal reflux disease (GERD) patients and performed more than 280 antireflux procedures, ranging from endoluminal procedures, such as transoral incisionless fundoplication or Stretta to laparoscopic repair of type IV hiatal hernias and revisional antireflux surgery.
We presented our data at regional, national, and international conferences. We also established novel techniques such as diaphragmatic crural eversion and the use of extracorporeal sliding arthroscopic knots in optimizing hiatoplasty. We developed extensive experience in laparoscopic hiatal hernia and concomitant endoscopic fundoplication.
The contributions of our program coordinator, operating room staff, dietitian, radiologists, pharmacists, and inpatient and outpatient staff allowed us to provide our patients with an excellent experience. Patients insisted on meeting Connie Koutouzos, chief executive officer of Aspirus Iron River Hospital, to compliment her on advancing local health care “the old-fashioned way.”
Advantages of rural research projects
A notable dilemma facing rural surgeons is to demonstrate that they have outcomes that are comparable to tertiary hospitals, despite low surgical volume. Our experience is different—we are clearly a high-volume program with comparable outcomes and original research activities. We believe that academia is a mindset and is not associated with a place or position.
Our research output is unique in many aspects. First, it avoided fragmentation of care of GERD patients, as we performed the diagnostic and therapeutic procedures. This approach gave us unfiltered access to GERD patients and enabled us to evaluate the entire spectrum of GERD. Second, our research is focused purely on rural patients. Third, these patients are more likely to attend clinic visits at their local hospital and to comply with local postoperative protocols, which have the potential to deliver long-term follow-up data.
A wonderful opportunity
I greatly appreciate that the ACS recognized this clinical and research output through the Nizar N. Oweida Scholarship. I was given the honor to be a stage participant in the Opening Ceremony of the ACS Clinical Congress and to hear the vision of Ronald V. Maier, MD, FACS, FRCSEd(Hon), FCSHK(Hon), FCCS(Hon), 2018–2019 ACS President. I also attended the Martin Memorial Lecture, The National Institute of Hope, delivered by Francis Collins, MD, PhD, head of the National Institutes of Health. It was inspirational to envisage the effect of more “Institutes of Hope” on patients’ welfare through patient-centered care and research.
It was a great honor to receive the Nizar N. Oweida Scholarship certificate from the 98th ACS President, Barbara Lee Bass, MD, FACS, FRCSEng(Hon) FRCSI(Hon), FCOSESCA(Hon). This award is not only for me, but also for my team of amazing individuals who embraced change, adapted new strategies for growth, and moved outside the established comfort zone to provide excellent care in our local community. This energetic team comprises the entire staff of the Aspirus Iron River Hospital, which transformed it from a critical access hospital to a critical access site of hope.