Rural surgery and surgical education

Abstract

The number of general surgeons practising in small rural communities has dwindled over the past few decades. Patients, hospitals, and the rural community have been negatively impacted by the shortage of rural surgeons and resulting decreased access to surgical care. Many rural hospitals financially rely on the ability to provide surgical care, as they may generate up to 30% of their revenue from surgical services. A rural general surgeon’s practice is unique in a number of ways, aside from being located in a nonurban setting. Surgeons practising in rural communities typically perform more surgeries and a broader scope of subspecialty procedures compared to their urban and suburban counterparts. Obstetrics and gynecology, orthopedics, urology, plastic surgery, hand surgery, otolaryngology, and especially endoscopy cases are among the most commonly performed procedures. According to several sources, endoscopy, including colonoscopy, comprises approximately half of a typical rural general surgeon’s caseload especially if there is no gastroenterologist practising in the area. In addition, rural surgeons can experience a sense of professional isolation as they may be the only surgeon in a community located a significant distance from colleagues. Personal concerns such as compatibility with rural life and the frequency of being on-call also impact many surgeons’ decisions regarding whether they will settle or stay in a rural community. Despite our knowledge of the differences between rural and urban surgical practices, the current surgical education system is not structured to prepare surgeons to practise rurally. Evidence from the primary care literature shows that a rural training track system that provides experience in managing the typical cases seen in rural practice and allows residents to develop a sense of what it is like to work and live in a rural community can impact future rural practice. Unfortunately, just 5% of all general surgery residency programs are either located in a rural area or offer a rural training track. Confirming the magnitude of the problem, results of a recent survey of general surgery program directors by Burkholder and Cofer (2007) [1] showed that fewer than 9% of residency programs had a rural surgery curriculum. Clearly more needs to be done in order to prepare surgeons for a rural practice and ultimately increase rural citizens’ access to surgical care. From the surgical education standpoint, a rural surgery curriculum should be developed to guide the training process ensuring that residents obtain adequate subspecialty experience and spend a significant amount of time practising and living in rural settings. Since rural communities differ greatly from urban areas, surgical residents that are trained in urban settings will not be exposed to the unique features of a rural practice and lifestyle and will be less likely to choose a rural practice location. Ultimately, developing a sense of what it is like to practise in a rural area is likely one of the most important influencing factors in preparing future rural surgeons.