Unsupported Browser
The American College of Surgeons website is not compatible with Internet Explorer 11, IE 11. For the best experience please update your browser.
Become a member and receive career-enhancing benefits

Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

Become a Member
Become a member and receive career-enhancing benefits

Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

Membership Benefits

The Need to Prepare More Surgeons for Rural Practice Is Urgent

Jim McCartney

Jim McCartney

March 6, 2024


Dr. Gary Timmerman trains Dr. Shaye Brummet on the Fundamentals of Laparoscopic Surgery Trainer.

A shortage of surgeons in rural areas of the US has been building for years. Combined with impending surgeon retirements and a lack of new surgeons being prepared for rural practice, the healthcare of an estimated 60 million people living in rural areas throughout the country is threatened.1

Rural counties, many of which are in the central US, are defined as having populations of less than 50,000. Access to care is dramatically compromised in these areas due to the long distances (and sometimes challenging weather conditions) that patients need to overcome to see a surgeon. While optimal access to surgical care is generally accepted to be 7.5 general surgeons per 100,000 patients, in 2019, the urban ratio was down to 5.44 general surgeons per 100,000, and the rural ratio decreased to 3.15 per 100,000.2 Of the rural counties in the US, 60% were without surgical care in 2019.

“We’re not talking 20 minutes to go to the doctor. We’re talking anywhere from 2 to 6 hours to find a doctor,” said ACS Regent Gary L. Timmerman, MD, FACS, professor and chair of the Department of Surgery at the University of South Dakota (USD) Sanford School of Medicine in Sioux Falls.

And the problem is about to get much worse. The rising demand created by an aging patient population cannot be met by the shrinking supply of surgeons, many of whom are approaching retirement. In rural areas, 55%–60% of surgeons are over 50 years old (versus less than 50% in urban areas).2 Only 200–300 new surgeons are added every year to fill the void of thousands who are retiring, according to Dr. Timmerman.

Brent E. Nykamp, MD, FACS, a general surgeon in Orange City, Iowa—a town of 6,200 people approximately 45 miles southeast of Sioux City—also acknowledged that training programs have not been able to keep up with the demand.

“As a rural surgeon, you become a general practitioner who does surgery as well.”

Dr. Lauren Smithson

The Health of the Rural Community

What’s at stake in the fate of the rural surgeon is not just the healthcare of rural patients, but the health of rural communities. Rural communities derive significant benefits from surgical practices in their areas. The general surgeon brings an estimated $1.05 million to $2.7 million per year to a small hospital, contributing as much as 40% to the overall revenue. If the general surgeon has a busy practice, he or she can generate $4.4 million in payroll and create 26 jobs in the community.3

“We bring financial stability and viability that keeps these hospitals open,” Dr. Nykamp shared. “Aside from the patients who end up in the operating room, surgeons manage many patients nonoperatively, such as those with bowel obstructions, diverticulitis, and pancreatitis. These are patients who primary care providers may not be as comfortable managing on their own.”

Dr. Nykamp and his partners provide caesarean section services, which allows the facility to have a robust full-service family practice.

In addition, communities depend on surgeons—who often bring distinct perspectives and life experiences—to be leaders, whether it’s serving on boards, at schools, in churches, or helping with other community activities.

Challenges to Building a Rural Surgeon Workforce

Besides demographics, issues that have led to the shortage of rural surgeons include increasing specialization among general surgery residents, the desire for work-life balance, and limited resources in rural hospitals.

Trend Toward Specialization

General surgery residents are increasingly specializing or even subspecializing in areas of surgery once considered traditional elements of general surgery, such as breast, colorectal, vascular, pancreatic, and biliary surgery. In fact, fewer than 20% of general surgery residents enter practice after 5 years of training.4 As a result, they may not be good candidates to be rural surgeons, which requires a more generalist approach.

“All of these were part of the general surgery umbrella that I trained under,” Dr. Timmerman said. “I was expected to know something about and have proficiency in all of them.”

Specialists often aren’t trained in fundamental general surgery services, such as delivering babies or performing vasectomies, he added. One reason is that the increasing demands of training residents in new technologies, including advanced laparoscopy, therapeutic endoscopy, and robotic surgery, make it difficult to teach these fundamental skills. As a result, even residents who don’t specialize may not get all the training they need to practice in a rural setting.


Dr. Gary Timmerman (left) helps Dr. Eastan Marleau as he performs a colonoscopy using the Fundamentals of Endoscopic Surgery Trainer.

Another factor to consider is that many residents hesitate to become rural surgeons due to the lack of surgical volume. Rural surgeons rarely have the steady stream of surgical cases that they might expect in larger settings, and they will not be performing complex oncological surgeries or Whipple procedures, Dr. Nykamp said. Rather, they will focus on standard “bread-and-butter” general surgery, such as hernias, gallbladders, breast cancers, appendectomies, trauma, and colon cancers. They also must be prepared to have a heavy volume of nonsurgical procedures like endoscopies.

“One of the hardest things I found coming out of residency was that my concept of being a general surgeon is not actually what you do,” shared Lauren E. Smithson, MD, FACS, who practices in Saint Anthony, a small port on the Great Northern Peninsula on the island portion of Newfoundland and Labrador in Canada. “As a rural surgeon, you become a general practitioner who does surgery as well. You end up managing a lot of functional gastrointestinal cases or managing medical problems that are complex but not necessarily surgical.”

In addition, rural surgeons must be prepared to go it alone because they often do not have nearby colleagues with whom to consult. When they encounter unexpected challenges, such as a ruptured appendix, they may end up having to transfer the patient to a larger center because resources, such as interventional radiology, intensivists, or overnight imaging critical to safely treating the patient, are not available.

Surgical residents coming out of training who are concerned about such isolation may prefer the safety of hospitals even if they like a rural setting. “We need to better train surgeons to have the courage and confidence to go out and practice on their own,” Dr. Timmerman said.

Desire for Work-Life Balance Is Real

Just as new rural surgeons need to better understand their role, rural hospitals have to understand that young surgeons may not be willing to take on the heavy workloads of their predecessors. And that could exacerbate the rural surgeon shortage.

Today’s young workforce places a high value on work-life balance. Many graduates of surgical residency programs may not be willing to be on call 24 hours a day, 7 days a week, according to Dr. Smithson. Rural hospitals need to embrace this change in culture and understand how it affects their staff.

“We won’t have solo surgeons anymore,” she said. “You may need to hire and pay two surgeons for every one leaving.”

Lack of Resources

Although all hospitals are facing a pinch of financial resources, many rural hospitals face extinction because of a lack of resources. “There’s a real pressure to treat hospitals and doctors and medicine like businesses, and that can make it quite difficult for some of the smaller hospitals and critical access hospitals to stay open,” Dr. Smithson said.

But it’s not just about money. Small rural hospitals may not have adequate blood banks, support staff, or technology to attract the volume of patients that would support a robust surgical practice.

“There are cases we don’t want to take because things may come up that are going to be a problem with the limited resources that we have,” Dr. Nykamp shared.

Surgical residents are trained in new technologies, so they understand the advantages for the patient, the hospital, and their own practices. Unfortunately, rural hospitals often do not always have the latest technology, and that may deter graduates.

Take robotic surgery. When USD’s new rural surgical residency program began, Dr. Timmerman thought there was little purpose in training his rural surgical residents on surgical robots because it was unlikely they would ever have access to one where they practiced.

Instead, he found that rural hospitals are striving to acquire robots. Research shows that robotic surgery has advantages over laparoscopic surgery and that patients often recover faster, Dr. Timmerman explained. In addition, robotic surgery can add to a hospital’s financial bottom line.

“Small town hospitals know that it may take a robot to get surgeons to practice there,” he said.

Many rural hospitals also lack surgical staff necessary to support surgeons, which limits their ability to care for certain patients. For example, Dr. Smithson’s hospital does not have an intensivist, nor does it have overnight or weekend ultrasound technicians. Her hospital has mammography, but no stereotactic biopsies for small breast lesions, so patients must drive 5 hours to have this performed.

Within the province itself, even in the tertiary center, recruiting radiation technicians in the radiation oncology program has proven difficult. As a result, rectal and breast cancer patients must travel off the island—requiring a flight or ferry—to Toronto or Halifax for radiation therapy.

“This really changes your scope of practice,” she said. “You can be the best surgeon in the world, but you can’t work without a team.”

Dr. Timmerman spent a decade in Watertown, a small city in northeast South Dakota, where he was limited in what surgical services he could provide due to a lack of support staff, such as specialty nurses.

It’s not just support during the operation that is the challenge. Lack of postoperative support also can scuttle an operation, Dr. Nykamp said.

Dr. Smithson said that treating pediatric patients in rural areas can be limited when the postoperative nursing staff is not comfortable in managing pediatrics or does not have Pediatric Advanced Life Support certification.


Dr. Lauren Smithson debrides and grafts a diabetic foot ulcer (left) and in her spare time, chops wood in Newfoundland.

How to Build a Rural Surgical Workforce

There are a variety of approaches that could help ease the shortage of rural surgeons. Some of the more promising ones include:

Tapping a Homegrown Resource

Building up the rural surgical workforce starts with doing a better job of drawing from a ready market for rural surgery: medical students who grew up in rural areas and now want to work there. Drs. Timmerman, Smithson, and Nykamp all were born in rural areas and wanted to return to a rural area to practice surgery.

“It’s a lot easier to work with students who want to go into rural, community, or even missionary general surgery,” Dr. Timmerman said. “The younger you get them and try to imprint on them the value of a smaller community, the greater the likelihood they’ll take a second look at practicing in a small community.”

Dr. Nykamp explained that the process of attracting students to rural care should start even before medical school.

According to Dr. Timmerman, it also should include sending medical students to train for a while in a small town so they get an immersive experience of what it’s like to be a rural surgeon.

“We need to train from the ground up,” Dr. Smithson said. “We know from research that exposure to rural rotations in medical school and residency really increases the likelihood that someone will return to a rural area.”

Rural Track Training Programs Emphasize Rural Immersion

To support those who want to practice in a rural setting, medical schools need to better train and prepare surgical residents for that practice, Dr. Timmerman said. There’s an effort backed by the ACS called “Fix the Five” in which surgical residency programs offer rural surgery opportunities as electives within 5–7-year training  programs; 1–3-month rotations in a rural community; and international or missionary care opportunities.

Some programs offer a rural surgery track with up to 6–9 months of rural training. According to Dr. Timmerman, other programs offer residents an immersion approach that could include 1–2 years in a rural community in lieu of “research years” or a fellowship following their 5-year residency. “It gives them the opportunity to know what they’re getting themselves into.”

In 2013, Dr. Timmerman helped create South Dakota’s first new general surgery residency program in decades. Since there was a cap on the number of federally funded residency slots, it was funded by an initial $2 million grant from Sanford Health.

“These are kids who knew they wanted to go back to the Midwest or return to their small hometown in Wisconsin or Iowa, and they’ve done that,” he said.

One of the goals of the program is to train students in a set of surgical skills broad enough to practice in the rural setting. The program has graduated three residents per year since the first class graduated in 2018. Of the 20 graduates, 11 (55%) went into general surgery while nine (45%) decided to specialize. All of them practice in communities that have populations of less than 200,000, Dr. Timmerman said.

Other successful rural track programs include:

  • Oregon Health & Science University (OHSU): In 2003, OHSU established a rotation for senior-level residents at Asante Three Rivers Medical Center in Grants Pass, Oregon, becoming one of the first universities to train general surgeons to serve in rural communities. The university has since added a second rotation at Bay Area Hospital in the coastal town of Coos Bay, Oregon.
  • University of North Dakota: The medical school has a rural track in which its students spend a few months training in smaller communities. 
  • University of Minnesota: Third-year medical students in the rural physician associate program go to live and work in a small community; some of them go on to become rural surgeons. 
  • University of Washington in Seattle: The university has a rural surgery training program that enables residents to do a rotation at a rural clinic in Billings, Montana.5

The Need for More Rural Surgeons

Telemedicine Can Help

Telemedicine offers significant support to patients and providers at rural hospitals. In fact, one of the upsides of the COVID pandemic was that the power of telemedicine was on display. This technology was able to fill in effectively when in-person patient visits, consultations, and training were not options.

For example, telemedicine allows a doctor in a different city to consult on a patient or even watch and help guide an operation. “This helps reduce one of the big drawbacks of rural surgery, which is isolationism,” Dr. Timmerman said.

Surgical patients who need to come in the office to have their wounds checked can do this over their smartphone or personal computer, allowing them to avoid a lengthy trip.

“Since we have Zoom, imaging, and a camera to look at wounds, telemedicine reduces travel time, cost, and inconvenience, and increases the likelihood that people will keep their follow-up visits,” Dr. Smithson explained, adding that she has patients on the south coast of Labrador and Quebec who live in small communities with no doctors available, and they need to take a ferry to her remote hospital. Telemedicine can reduce the burden on patients and their families that is associated with postoperative care.

Although restrictions on the use of telemedicine were loosened during COVID-19, the proven benefits of telemedicine for rural health should be considered as efforts are made to tighten these restrictions once again.

Incentives to Build the Rural Surgeon Workforce

Since rural surgeons earn significantly less than their counterparts in cities, there are efforts to draw more surgeons into rural practice by offering financial incentives, such as bonuses or student loan forgiveness programs. Organizations such as the Accreditation Council for Graduate Medical Education support government initiatives and grants that would help provide these incentives.

But not everyone agrees that this is the right approach. Dr. Nykamp worries that surgeons who take a rural job to get their student loans paid or receive a bonus will not have a long-term commitment to practicing there.

“We’ve seen different student loan repayment programs where somebody shows up for 3 years, meets the requirements, and they’re off to the next spot,” Dr. Nykamp revealed. “In the long run, that’s not helpful.”

He would rather see financial aid go to help small hospitals buy new technology that can attract more patients and providers. In fact, helping a resource-strapped rural hospital buy a robot could increase the hospital’s revenues and help cut costs. A recent presentation at the Northern Plains Rural Surgical Society meeting showed evidence that adding robotic surgery significantly increased a rural hospital’s revenues, Dr. Smithson said.

In addition, robotic arms can help with retraction during an operation, requiring fewer staff members, Dr. Timmerman shared.


Dr. Brent Nykamp (center) is a general surgeon in Orange City, Iowa, along with junior partner Dan Locker, MD (left) and senior partner Steve Locker, MD (right). Dr. Dan Locker, the son of Dr. Steve Locker, is an example of how some surgical practices hope to “grow their own replacements.”

Look to Private Funding for Training

Although government funding for residency programs hasn’t increased in years, in 2021, the Consolidated Appropriations Act attempted to address disparities in funding for rural graduate medical education, including 1,000 new slots devoted to rural healthcare over 5 years starting in 2023, according to Dr. Timmerman. Unfortunately, many of the initial slots went to hospitals in New York (18), Georgia (9), Florida (7), and California (6), with only a few slots going to the Central states Iowa (2), Kansas (2), South Dakota (1), North Dakota (1), and none for Nebraska or Minnesota, he added.

“The intention was good; the outcome was not,” Dr. Timmerman said.

In lieu of more government funding, another potential source of funding for residency slots are hospital systems and their foundations, he explained. In 2021, USD Sanford School of Medicine pledged $300 million to transform rural healthcare delivery, including eight new graduate medical residencies and fellowships in critical specialty areas.

“What better way for a foundation to help advance medicine than to help promote the education of people who want to give back to that institution?” Dr. Timmerman asked.

The challenges for rural surgery have increasingly become the focus of many organizations, including the ACS. The College has added advisory groups and supported legislation to help address the shortage, including efforts to restructure the National Health Service Corps Scholarship and Loan Repayment Programs that help surgeons who choose to practice in rural or underserved areas.

“The ACS has really gone to bat for rural surgeons,” said Dr. Timmerman, who, as an ACS Regent, helps represent the voice of rural surgery.

Jim McCartney is a freelance writer.

  1. Ellison EC, Bhagwan S, Way DP, Oslock WM, Santry H, Williams TE. The continued urbanization of American surgery: A threat to rural hospitals. Surgery. 2021;169(3):543-549. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0039606020304207. Accessed February 22, 2024.
  2. WWAMI Rural Health Research Center. The Distribution of the General Surgery Workforce in Rural and Urban America in 2019. Policy brief, March 2021. Available at: https://familymedicine.uw.edu/rhrc/wp-content/uploads/sites/4/2021/03/RHRC_PBMAR2021_LARSON.pdf. Accessed February 22, 2024.
  3. Sarap M, Reiss AD. Rewards and Frustrations of Rural Surgery Practice. American College of Surgeons. Available at: https://www.facs.org/for-medical-professionals/practice-management/private-practice-small-business/rural-surgery-practice/#:~:text=Rural%20communities%20derive%20significant%20benefits,to%20a%20small%20hospital%27s%20revenue. Accessed February 22, 2024.
  4. Sarap M, Reiss AD. Rewards and Frustrations of Rural Surgery Practice. American College of Surgeons. Available at: https://www.facs.org/for-medical-professionals/practice-management/private-practice-small-business/rural-surgery-practice/#:~:text=Rural%20communities%20derive%20significant%20benefits,to%20a%20small%20hospital%27s%20revenue. Accessed February 22, 2024.
  5. Rural Surgery Training Program. UW Medicine Department of Surgery. Available at: https://uwsurgery.org/rural-surgery-training-program/. Accessed February 22, 2024.