American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Advanced Skills Course for Rural Surgeons

The mission of the Nora Institute is to support surgeons in their pursuit of exceptional patient care. One path to this goal is to support surgeons in maintaining knowledge and excellent technical skills. The Nora Institute identified a need among rural surgeons for increased access to continuing professional development that matches the rural surgeons’ broad scope of practice. Unlike their urban colleagues, rural surgeons often have a broader scope of practice that requires them to address a wider array of clinical problems, including emergency gynecology, emergency urology, orthopedics, and more.

The Nora Institute Advanced Skills Course for Rural Surgeons brings together rural surgeons from all over the country and provides them with expert mentoring in a variety of disciplines. The course uses a blended learning format that consists of an e-learning component for knowledge acquisition followed by a hands-on mentored skills session. Amy Halverson, MD, FACS, and a team of rural surgeons and adult learning experts have developed 11 distinct learning modules.

The 2014 Nora Advanced Skills Course for Rural Surgeons was held October 25 in San Francisco in conjunction with the American College of Surgeons Clinical Congress. This year’s course welcomed 38 participants, the highest enrollment in a Nora Institute skills course to date. The curriculum focused on endoscopic procedures including foreign body removal, advanced polypectomy and stricture dilation and stent placement. We also presented a session on endoscopic management of hemorrhoids. 

ACS Conducts a Regional Skills Course for Rural Surgeons

ACS held a regional skills course, Advanced Endoscopic Skills Training for Rural Surgeons, on May 8, 2015. This pilot course explored the feasibility of offering smaller, regional courses in order to increase accessibility to surgeons practicing in rural areas. Course participants came from North Dakota, South Dakota, Montana, Illinois, and Winnipeg, Manitoba. The curriculum covered the topics of advanced polypectomy techniques, endoscopic dilation and stent placement, management of upper gastrointestinal hemorrhage, and removal of esophageal foreign bodies.

NDSD Course

NDSD Course

NDSD Course

We previously conducted a needs assessment for rural surgeons across the country to assess the practice patterns and knowledge and skills gaps among surgeons in rural practice. Recognizing that there may be regional variation, we repeated a needs assessment among the surgeons practicing in rural regions in North Dakota and South Dakota. We asked them what procedures they most commonly perform and what topics they would be most interested in learning more about during a hands-on course. As expected a session on advanced endoscopy ranked among the most useful topics. This course utilizes a blended learning model where participants review online didactic material prior to the course for knowledge acquisition. This design allows the faculty and participants to focus the on-site activities to hands-on skill practice. The course was held in conjunction with the annual meeting of the combined North Dakota and South Dakota ACS chapters.

General surgeons practicing in rural areas face unique challenges. These include lack of access to continuing professional development activities and a sense of professional isolation. The rural surgeon’s scope of practice is broader than their urban counterparts; they have the responsibility to cover urgent procures that in other locations would be managed by surgical specialists. Endoscopic procedures make up approximately 50 percent of the procedures performed by rural surgeons, and many communities do not have gastroenterologists. Given their remote locations, rural surgeons may not have the opportunity to interact with colleagues to keep up to date with new technology. New surgical technologies, devices, and practices are continuously being introduced into clinical practice. Exposure to continuous skills training will help clinicians maintain high-quality and robust safety of care. While individuals may acquire knowledge through independent study—for example, web-based study, seminars—technical skills, including those required by clinicians in surgical disciplines, are best acquired by mentored, experiential skills training.

Recognizing the need to improve access to ongoing skills training, the College developed the Advanced Skills Course for Rural Surgeons. Since 2011, the annual course is held in conjunction with the ACS Clinical Congress. While the rural skills course has consistently high attendance, the number of surgeons participating in this course has been relatively limited. Surgeons often cite time away from practice as a significant impediment to attending continuing professional development programs.
Looking forward, ACS will continue to evaluate educational strategies for continuing professional development. By creating course content and learning materials and providing technical support for regional courses, the College can facilitate institutions and regional ACS chapters in providing valuable learning opportunities to surgeons in their local areas.

Rural Surgery Learning Modules

  1. Leadership and communication
  2. Advanced endoscopy
  3. Emergency gynecology
  4. Emergency urology
  5. Facial plastic surgery—lesion excision
  6. Facial plastic surgery—laceration repair
  7. Breast ultrasound
  8. Ultrasound for central line insertion
  9. Management of fingertip amputation
  10. Laparoscopic common bile duct exploration
  11. Anesthesia skills

What Surgical Skills Rural Surgeons Need to Master
Halverson AL, Hughes TG, Borgstrom DC, et al. J Am Coll Surg 2013, Nov; 217(5):919-23.

Participant Comments

“I have applied the skills I learned in my working relationships as well as my personal relationships.”

“I never used the ultrasound until recently. At this time I feel that it is probably bad practice not to use it.”

“I had a patient with a neglected avulsion of the tip. I used the technique of dyeing the matrix to be certain I removed it all. I found this very helpful, as the anatomy was distorted. Yet with this technique, I was able to identify and remove the entire matrix and got an excellent functional result. Thanks!”

“I reconstructed a huge facial lac/scalping injury from the eyelid across the forehead to the back of the scalp, which turned out beautifully!”

“Not only did I gain a couple of useful techniques, especially ultrasound for central line placement and the trick with the nail matrix, but, more importantly, I had knowledgeable people watch how I was doing things and either affirm that what I was doing was correct or make helpful suggestions. I have been in solo practice most of my career with no other surgeons on staff. It is always great to have a proctor look over your shoulder and make useful suggestions. I wish I had had this course available to me 34 years ago when I started my practice. Thank you.”