Michael Sarap, MD, FACS, and Alisha D. Reiss, MD, FACS
Michael Sarap, MD, FACS, Former Chair, ACS Advisory Council for Rural Surgery, and Alisha D. Reiss, MD, FACS, President-Elect, ACS Ohio Chapter, discuss the reasons why rural surgery is a rewarding practice.
Nearly 60 million people reside in rural America, while only 10% of US general surgeons are providing care for these individuals. Rural patients are generally older, have a higher prevalence of chronic diseases, are less well-insured and educated, and present with more advanced disease. Access to care is problematic because of socioeconomic, geographic, and health system barriers. Surgeons in rural areas are hindered by lack of technical and human resources and expertise, difficulties in keeping skills updated, and lack of specialty support.
Rural communities derive significant benefits from surgical practices in their areas. The economic worth of a general surgeon working in a hospital is $1.05 to $2.7 million/year and they contribute as much as 40% to a small hospital’s revenue. A busy general surgeon can generate $4.4 million in payroll and the same practice creates 26 jobs in a community.
The scope of practice of the rural surgeon depends not only on the ability and training of the surgeon, but also the characteristics of the community served, local resources, geographic barriers, staff and specialty support, and privileging issues. Multiple studies have indicated that significant percentages of the workload of the rural surgeons includes endoscopy, biliary, hernia, venous access, and gastrointestinal cases with varying amounts of subspecialty cases depending on the community and the surgeon.
Multiple challenges exist to guarantee the appropriate surgical care for all rural Americans. Demographic trends, workforce shortages, issues with surgical training, rural hospital closures, and economic pressures all threaten to limit access to surgical care in the near future. Demographic data reveals that the rural population of America is declining as the urban rates are climbing every year. The per capita supply of US general surgeons declined 18% from 6.4/100,000 to 5.2/100,000 from 2001 to 2019. Rural areas declined by 29.1% and small and isolated rural areas declined by 32.6%. In addition, 48.8% of urban general surgeons are over 50 years of age as compared to 55% in large rural areas and 59.3% in small rural areas. In 2019, 60.1% of nonmetropolitan counties had no active general surgeon. The prospects for filling the vacancies for retiring general surgeons and hospitals without a surgeon are dismal. Less than 20%—and perhaps as low as 12%—of general surgery residents enter practice after 5 years of training (120/year). Most enter specialty fellowships, which decrease their chance of seeking a rural position after training. An estimate of 12 graduates per year end up in a rural setting and there are an estimated 1700 jobs available. Fischer, Cofer, Burns, Sheldon, and many others began to sound the alarm about surgical workforce shortages over 15 years ago.
Rural areas have been experiencing hospital closures for decades, including 460 general hospitals in the 1990s. The rate of rural hospital closures is accelerating. Since 2010, 136 rural hospitals have closed with 2020 setting a record with 20 hospital closures. The reasons are complex and varied but the main factors involve the individual hospital, the regional market, demographics, and economic factors. A hospital closure results in longer travel times for care and higher mortality rates for several emergency conditions. Loss of a local hospital also often leads to a significant downturn in the local economy of the community.
On a local level, individual surgeons often struggle with decisions about which cases to do at their facility specifically in terms of the volume/quality debate and the concerns about litigation in cases with a bad outcome. Additionally, the increased awareness about physician wellness makes it more difficult to recruit surgeons willing to take 1:3 or 1:2 call. The hassle factor associated with call in rural areas could be an issue for some. Reasons for this include the number of after-hours calls, resistance in some facilities to verbal orders, and the erosion of the willingness of nurses and other support staff to making independent clinical assessments and decisions. In terms of call relief, hospitals are very resistant to provide call relief to single or small group practices due to the high costs of locums coverage.
The initial and ongoing training of the rural surgeon remains incompletely understood. There is currently not a solid or confirmed curriculum for successfully training an individual with the necessary knowledge or skill set to master a rural surgical practice. Multiple curricula and training programs are being tried but no long-term results exist to validate a best approach. Rossi and others identified 4 essential components of rural surgery training based on literature and expert opinion. These components included rotations in a rural setting, broad exposure to surgical specialties, robust endoscopy experience and a lack of competing specialty learners.
There can be significant financial, social, professional, and lifestyle rewards from life as a rural surgeon. Depending on the specific practice, the combination of a broad-based general surgery practice, a strong endoscopic caseload along with whatever other specialty cases are included in a surgeon’s repertoire, can insure a steady and protected income that may outpace urban practices. Many rural surgeons have significant caseloads involving dermatology, endocrine, foregut, vascular, and oncologic patients. The lack of surgical specialists and the surgical needs of the population fosters the expansion of the types of cases done by rural surgeons. Recognition and respect in the local community along with long-term patient and family relationships are true benefits that serve to offset the administrative hassles of all surgical practices and decrease the risk of burnout. Property and home values and cost of living expenses are significantly decreased in comparison to urban areas and there are more opportunities for outdoor recreation of all types in rural areas.
There are also significant benefits from being able to work at 1 facility that is only minutes from home instead of taking call at several facilities to financially make ends meet in the urban practice. Emergency cases are often less than in urban areas so that rural surgeons can usually attend their children’s school and athletic activities while taking calls from the hospital and emergency room. This would also include the ability to go golfing or fishing while on call because everything in rural areas is in close proximity to the centrally localized hospital in most towns.
General surgeons in smaller facilities are generally well-regarded by hospital leadership who understand their value to the hospital and the community. They are tasked with leading teams and joining medical staff leadership ranks early in their careers. This relationship can facilitate less restrictive privileging requirements, better financial support, hospital board membership, and, generally, more influence in the major decisions made at the highest levels.
Rural surgeons may feel more respected by their patients and more appreciated in smaller communities. Even after a long discussion and education about treatment choices, many rural patients respond with “Whatever you think is best, Doc.” It can be very rewarding and refreshing to earn that kind of respect.
Rural surgeons usually carry a heavier burden of call than rural counterparts and many have feelings of inadequate support and technology. As reported above, the surgeon workforce shortage results in difficulties recruiting and retaining associates. Support staff shortages—especially since the COVID pandemic—have made it extremely difficult to staff offices and rural hospitals with nurses, medical assistants, biller/coders, and other clerical help. Rural surgeons have less support to fulfill administrative, regulatory, and insurance tasks and hurdles. Lesser numbers of medical and other specialists force the rural surgeon to deal with medical, social, and economic issues that rarely fall to urban surgeons. There is an ever-increasing difficulty in transferring critically ill or clinically challenging local patients to tertiary centers and specialists, and the pandemic made the situation even worse.
The American College of Surgeons (ACS) has recognized the plight of rural surgeons and the organization has done much to acknowledge and help rectify the problem. The ACS Advisory Council for Rural Surgery was formed over a decade ago and has helped to communicate the needs of rural surgeons. The leadership of the ACS and the ACS Regents have recognized and embraced rural surgeons as true members of the family of surgery. Rural surgeons are routinely involved in all College activities including the Clinical Congress, where many rural surgeons act as moderators or panel experts every year, and many rural surgeons serve in leadership positions as officers of the College and leaders of the Board of Governors and Board of Regents.