Wanted: General Surgeons in Rural Regions

A dearth of specialists and a generation of surgeons approaching retirement age are together, a growing cause for concern in some rural regions.

There's a general surgery crisis in rural America, suggest preliminary research findings from the Washington-Wyoming-Alaska-Montana-Idaho (WWAMI) Rural Health Research Center.

The problem is twofold. First, although the number of general surgeons is declining around the country, the shortage is more acutely felt in rural areas.

"In urban areas, much of that decline can be offset with general surgery subspecialists," Mark Doescher, MD, MSPH, director of the WWAMI Rural Health Research Center, said in an interview. "But in rural areas where you don't have the population density to support the specialists, that impact becomes much more significant because there isn't an easy way to offset some of those services."

Moreover, the research points to a lack of training among newly minted general surgeons in obstetrics/gynecology and orthopedics. According to Doescher, they're less likely to do "in-a-pinch" c-sections and other basic procedures that general surgeons a generation ago would have performed.

"We're producing general surgeons who are probably not comfortable practicing in rural environments based on the skill set they have," he says. "There needs to be a wakeup call that there is still a need for people with some general skill sets."

Although there's a perception that rural general surgeons need to be prepared for every kind of surgery under the sun, the preliminary study findings actually show that "rural hospitals concentrate on relatively narrow set of low complexity inpatient procedures performed on relatively low?risk patients."

"In reality most of what's being done are, if you will, the bread-and-butter general-surgical types of procedures," says Doescher. "The take-home message from the study is that in rural locations compared to urban locations, general surgeons focus actually on the most common types of procedures."

According to Doescher, the findings suggest a need for training within general surgery residencies that equips general surgeons in rural areas to perform not only general surgery procedures, but also the basics of other specialties, too.

"Really we need an emphasis on training tracks that can produce rural general surgeons with this bread-and-butter type of skill set, with the addition of things that currently fall outside of general surgery training," Doescher says.

For example, after completing a program like this, Doescher says general surgeons should also be able to perform basic obstetrics procedures such as c-sections; orthopedics procedures such as pinning a hip after a hip fracture; and possess good endoscopic skills in the outpatient arena.

If that happened, he says "you'd actually be producing a very viable, rural, general surgery workforce."

Although much of this shift needs to happen at the medical-school and residency level, Doescher says it's an issue that should also be top-of-mind for rural hospital executives.

"If it isn't, they need to be thinking about it," he says. "This is a big issue because it ties in with the attractiveness of primary care in rural hospitals. If you don't have the surgical backup it's harder to get primary care providers. It ties in with the trauma system in rural areas; it ties in with the financial viability of services provided."

He believes that rural hospital administrators should take the lead in thinking about what "they need to produce locally and what would better fit within a more standardized referral network." For example, executives might consider using traveling surgeons to perform scheduled procedures and local surgeons who are available for emergency back-up. In addition, he says rural hospital executives should work closely with referral hospitals about coordinating care.

"What I have is a small piece of a bigger puzzle, which is: How do you produce the workforce that's needed in rural areas, and how do you create the right climate to attract surgeons in rural settings?" says Doescher. "A lot of that's medical education overall, but the rural hospitals have a big piece on trying to figure out how that make that a manageable career choice."