By Shan S. Lansing, MD
Access to healthcare has been an increasing concern in the United States for the last several decades. Since 2010, over 130 US rural hospitals have closed, most commonly due to financial non-viability. A 2016 report from the National Rural Health Association predicted that one-third of all rural hospitals in America were at risk of closing within 10 years; this represents 673 hospitals in 42 states that serve as the primary access to healthcare for 11.7 million people. The rural hospital closure crisis is driven by a combination of factors, including lower hospital volumes as well as higher percentages of uninsured patients. Ultimately, it is estimated that local hospital closure increases the community mortality rate by 5.9%. In 2009, the life expectancy in rural American was close to 3 years shorter than that in metropolitan America. The unfortunate reality at this point is that a person’s zip code can have as much of an effect on their health as their genetic code.
Surgeons have a unique role in rural healthcare, both as an integral component of community health systems, as well as an important part of small hospital viability. First, rural general surgeons are important for the health of patients living in rural communities. If we are ever going to alleviate rural health disparities, rural patients must have access to a general surgeon for their undifferentiated and potentially-surgical concerns. Second, in a much bigger picture, rural general surgeons are important for the financial stability of small hospitals, which in turn plays a significant role in the overall economy of the rural community.
Rural surgeons can provide a number of primary-care services for their communities. Though scope of practice varies depending on training, location, hospital resources, and many other factors – it is suggested by the American College of Surgeons Advisory Council for Rural Surgery that optimal rural surgery training includes full-scope general surgery care, upper and lower endoscopies, surgical obstetrics, and even basic thoracic, plastic, and orthopedic surgery. For the average rural general surgeon, it is estimated that up to one-eighth of a one’s practice consists of subspecialty procedures in vascular surgery, obstetrics/gynecology, orthopedics, urology, otolaryngology, and thoracic surgery.
From a personal perspective, AWS-member Dr. Nikita Machado shares her experience as rural general surgeon in Conneaut, OH:
“Rural surgery faces a number of challenges in the United States. A lot of these hospitals, a significant number of which are designated as critical access, are located in remote areas. As a result, they have less resources and access to other consulting specialties, making it more challenging to provide the multidisciplinary care we are used to at larger centers.
However, this is offset by the sheer variety of surgical practice. It is not unusual for rural surgeons to perform a variety of different cases every week, including general surgery, endoscopies, thoracic and in some places gynecological cases. Rural surgeons inevitably find creative solutions to help their patients, and the advent of tele-health has made it easier to obtain second opinions and consultations when needed. Patients are extremely grateful to be taken care of in their hometown, avoiding the need for hours of travel for surgical care. It’s not uncommon for them to treat their surgeons and other members of the healthcare team as part of their extended family, which makes this a very rewarding career.
A combination of broad-based surgical training during residency, along with improved access to more specialized centers for appropriate escalation of care when needed, can result in a successful rural surgical practice.”
Trainees interested in rural surgery can find a list of residency programs with rural tracks in a recent publication by Rossi et al.
To hear more on access to surgery in rural America, join the AWS Communications Committee in the upcoming Tweetchat on May 17 at 8pm Eastern Time. We will be guided by our moderators Drs. Isolina Rossi, Annie Dunham, Adrian Diaz, and Shan Lansing to discuss the importance of rural surgery, as well as challenges and potential solutions to rural health disparities.
To participate, follow @womensurgeons and moderators, then tag your tweets with the hashtag #AWSChat. Be sure to keep an eye out for Tweets from members of the AWS Communications Committee who helped to organize this TweetChat: @altierim1, @machado_nikita, @niti12, and @LenaETrager. If you haven’t participated in a tweetchat with us before, check out this tutorial written by Dr. Heather Yeo (@heatheryeomd) to know more!
Tweetchat moderators:
Dr. Annie Dunham (@adunhamable) – General Surgery chief resident in the University of Wisconsin Rural and Community Surgery track with a passion for teaching and connecting community and academic surgeons through state-wide surgical collaborations.
Dr. Adrian Diaz (@DiazAdrian10) – General Surgery resident at The Ohio State University and fellow at the IHPI Center for Healthcare Outcomes and Policy (CHOP), interested in health policy research, with a focus on optimizing access, quality and value of care health systems deliver to patients.
Dr. Isolina Rossi (@rossi_isolina) – PGY3 general surgery resident at the Carolinas Medical Center in Charlotte, NC. She has published on the details of ACGME rural surgical training while also leading the development of a rural surgery track within her own program. She plans to return to her hometown of Hopedale, IL to practice rural surgery after training.
Dr. Shan Lansing (@ShanSLansing) – Incoming general surgery intern at Oregon Health & Science University, interested in advocating for policies and educational programs aimed at increasing rural access to surgical care.
Tweetchat questions:
- How does rural surgery differ from a general surgery practice near a metropolitan center?
- What are some ways that rural surgeons can stay connected while caring for (and living in) an isolated community? Are there further training options and/or ways to get second opinions in real time during difficult cases?
- Though there are many, what do you think is the greatest challenge that rural surgeons face?
- Telehealth is often touted as a solution to physician shortages in rural areas. In what ways is telehealth useful or not useful in rural surgery?
- What changes do you anticipate will occur within the field of rural surgery over the next 10-15 years?
- What are things trainees should consider if they are interested in rural surgery? What should they look for in a residency or transition-to-practice program?
Shan Lansing, MD is a recent graduate from The Ohio State University College of Medicine, and incoming General Surgery intern at Oregon Health & Science University. Originally from a small town in southern Oregon, she attended Oregon State University to earn a dual Bachelors in Chemistry and Biohealth Sciences. She continued at Oregon State University for a Masters of Science in Analytical Chemistry where her thesis focused on optimization of a fluorescent biosensor for detection of microRNA as it relates to cancer diagnostics; though she was able to find the art to micropipetting, she felt a calling to care for underserved populations. Her current academic interests include advocating for policies that mitigate rural health disparities. Ultimately, Shan seeks to pursue a career in rural general surgery, aiming to provide comprehensive surgical care for an underserved community. In her free time she enjoys running, cooking, and cross-stitching. You can find her on twitter at @ShanSLansing.
Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.