February 1, 2022
By Medhat Fanous, MD, FACS, ACS Advisory Council for Rural Surgery
Academia and research are often associated with a scientific title or rank in a prominent institution. Rural surgeons do not meet this definition and are largely excluded from this academic status. I would like to use my research experience at a critical access hospital in the Upper Peninsula of Michigan to examine seven common perceptions of rural surgical research.
This is a myth. Rural surgeons are keen to critically analyze their outcomes and compare them with the national standards. The irony is that these standards were established by major centers with ample resources.
This is a fact. Rural surgeons lack the personnel to conduct research. They are excluded from numerous research grants and scholarships available to surgeons at recognized academic institutions. Rural surgeons must be motivated to conduct research projects because they typically do not get rewarded with promotions or incentives for their research output.
This is a myth. The pathology does not stop at the gate of rural hospitals. Rural surgeons have unexpected intraoperative events that they handle skillfully without help from other specialties. They present their experience as informative case reports. The data of rural retrospective studies are entered manually. Rural surgeons are familiar with the patients' details, producing meaningful data. Replicating this accuracy is impossible in large databases that rely on the electronic abstraction of Current Procedural Terminology codes and have an inherent inability to probe beyond surface-level observations. In fact, they may even contribute to mislabeling of diseases and inaccurate conclusions.
This is a myth. One in 5 Americans live in rural communities. Specialized rural centers attract patients who prefer to stay close to home. We have evaluated approximately 1,000 GERD (gastroesophageal reflux disease) patients and have published multiple articles involving hundreds of subjects.
This is a myth. Rural research is original and innovative. For example, where I practice, we started using EndoFLIP 2 years ago to assess the dynamics of gastroesophageal junction. Our experience with almost 400 procedures enabled us to characterize EndoFLIP use in the surgical management of GERD. We found that the outcomes of performing partial fundoplication based on preoperative EndoFLIP versus manometric findings are comparable. We now are applying EndoFLIP in the preoperative, intraoperative, and postoperative settings, which will enhance our understanding of the best use of EndoFLIP in antireflux surgery.
This is partially true. However, rural patients face the financial and logistical burden of traveling to major centers, which affects compliance with postoperative visits and may result in shorter follow-up than what urban patients experience. Rural patients often ask if the local surgeon can manage them postoperatively. It remains to be seen whether telemedicine will affect this practice.
This is a fact. I had about 20 rejections prior to publishing my first article. This was mainly due to the unfamiliarity of the reviewers with rural surgery. A reviewer once criticized me for repeating the EGD, which the referring gastroenterologist already performed. Unfortunately, no mechanism was available to respond and inform the reviewer that I function as a gastroenterologist and a surgeon and that I was the endoscopist who performed the initial EGD. I am grateful that the journal of The American Surgeon is becoming the platform of rural surgeons.
Rural surgeons may lack academic titles, but many possess a scholarly and inquisitive mindset. They pursue research despite limited resources and a lack of professional incentives. Perhaps it is time for the ACS to allow rural surgeons access to research grants available to existing academic centers and judge the research project based on its merits - not on the institutional credentials of the author(s).