By Riann B Robbins, MD
Imagine practicing rural surgery in the dense mountains of western Montana. For nearly a year, I immersed myself in subspecialty and rural surgery training through the Kalispell Regional Medical Center Rural General Surgery Fellowship. During this time, I worked at a regional medical center and multiple critical access hospitals, defined as centers with 25 beds or less. Here I share some of the lessons learned through this unique experience.
Unfortunately, we currently do not meet the critical surgical workforce needs of this country. Twenty-five percent of the US population live in rural locations while only 15% of physicians practice in these areas. Despite a 27% increase in rural population size between 1980 and 2000, the general surgery workforce increased by only 2%. Consequently, a significant maldistribution of surgeons exists between urban and rural areas and only two thirds of critical access hospitals have an available general surgeon on staff. Rural surgeons are more likely to be over age 50, graduates of international medical programs, and nearing retirement. One national study of 233 rural hospitals reported 34% had a surgeon who planned to leave within the year, 36% were actively recruiting, and 12% would be forced to close if they lost their surgery program. This surgical workforce crisis is not addressed by current training models, leaving a large segment of society without adequate access to surgical care.
Graduating general surgery residents increasingly pursue fellowship training. In 2004, 70% of graduating residents pursued fellowship compared to 55% in 1992. When asked about the decision to pursue fellowships, residents cite lack of confidence to perform procedures independently, the belief that fellowship training is necessary to remain competitive in current job markets, the lack of exposure to rural and subspecialty training experiences, and the misconception that current training inadequately prepares them to enter practice independently. Furthermore, one third of procedures performed by rural surgeons are not required by ACGME for graduation and are typically not taught to general surgery residents at large academic training institutions. Dedicated rural surgery tracts may increase trainee confidence to pursue independent general surgery practice after graduation and combat these previously held misunderstandings in critical ways.
Operating in rural hospitals provided me with exposure to the basic procedures of surgical subspecialties including urology, OBGYN, orthopedics, otolaryngology, and even interventional radiology. Without this unique opportunity, I would not have been exposed to these types of procedures at my urban, academic training institution. Through this experience, I gained more operative independence in the OR, enhanced my surgical decision-making in a resource-limited environment, and gained insight into a viable but often overlooked career path. Now I strongly value the contribution our rural surgery colleagues make to our collective surgical community.
Our current surgical training model can be modified in ways that support the goal to prepare, recruit and retain more residents to meet the general surgery workforce needs of America. I encourage training institutions to evaluate how they can incorporate experiences that facilitate exposure to rural surgery as we collectively strive to meet the surgical workforce needs in our country.
Riann B Robbins, MD is a fourth-year General Surgery resident at the University of Utah. In lieu of a dedicated research year, she recently completed the Rural General Surgery Fellowship through Kalispell Regional Medical Center in Kalispell, Montana under the guidance of Randall Zuckerman, MD and David Sheldon, MD. Her professional interests include trauma and emergency general surgery, surgical critical care, and surgical education. She is currently completing the Surgical Education Research Fellowship through the Association of Surgical Education. Her non-academic interests include yoga, exploring national and state parks, and spending time with her growing family. You can find her on Twitter @riann_robbins.
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