Rural surgery: framing the issues.

Many rural residents have limited access to surgical care. Although this problem has been ongoing for the past few decades, several factors threaten to exacerbate the situation. The narrowing of general surgery practice, workforce shortages and inappropriate distribution of surgeons, changes in how surgeons are trained, and increasing health care costs contribute to the problem. Creative approaches to address these issues are needed to provide high-quality surgical services to the approximately 50 million Americans living in rural communities.

General surgery contributes to the financial health of rural hospitals and communities.

Rural hospitals and communities often profit from the ability to provide surgical services. There can also be substantial financial costs for individuals, hospitals, and communities associated with not having access to surgical care in rural areas. Despite these advantages, limitations that include a shortage of rural general surgeons and other surgical staff and financial constraints prevent some rural institutions from offering surgical services. Few concrete data are available on this subject, and more research is needed to confirm anecdotal reports regarding the positive economic impact derived from general surgical services. It is especially important to examine and quantify the direct and indirect financial contribution that a general surgeon makes to a rural hospital and community.

Are general surgery residency programs likely to prepare future rural surgeons?

BACKGROUND: Too few surgeons practice in small rural areas of the United States. Many newly graduating surgeons choose not to practice rurally because they feel unprepared for rural practice. Family medicine residencies have a track record of placing graduates in rural settings. Their experience shows that having a stated interest in training rural physicians, a rural-focused curriculum, and rural practice exposure opportunities are successful elements for graduating physicians who practice rurally. OBJECTIVE: To describe the extent to which general surgery residency training is likely to prepare future rural surgeons using criteria cited in reviews of rural family medicine residency programs. METHODS: Three criteria were used to assess whether general surgery residency programs are positioned to produce rural surgeons: rural location, rural-focused curriculum, and self-identified interest in rural training. Several search strategies were employed to identify residency programs that meet the criteria. Additionally, data extracted from the American Medical Association's Physician Masterfile was used to determine demographic characteristics of residency programs that have trained surgeons who currently practice rurally. RESULTS: Overall, 25 general surgery residency programs meet at least 1 of the 3 criteria. This finding represents approximately 10% of all residency programs in the United States. Residency programs located in the Midwest and the South have generally been more successful in graduating surgeons who are practicing rurally than those situated in the Northeast and West. CONCLUSIONS: Although a few general surgery residency programs have been successful in graduating surgeons who practice rurally, there has not been a coordinated effort among programs to accomplish this goal. Our findings suggest a need for organization and coordination among those programs committed to training surgeons for rural practice. The creation of a consortium of general surgical residency programs with an interest in training rural surgeons could be a useful first step in this process.

Use of locum tenens surgeons to provide surgical care in small rural hospitals.

BACKGROUND: Too few general surgeons practice in rural American communities, and many hospitals in the smallest rural areas do not have a surgeon. Therefore, it is likely that some small rural hospitals are using alternative arrangements to provide surgical care, including hiring locum tenens surgeons. We describe the degree to which small rural hospitals are using locum tenens surgeons to provide surgical services. METHODS: Administrators at 129 small rural hospitals were surveyed by telephone. The survey instrument was comprised of questions asking whether the hospital provides surgical services, if the hospital has recruited a surgeon, whether the hospital uses locum tenens surgeons and if so for what purposes. RESULTS: A total of 76% of surveyed rural hospitals have offered surgical services during the past 5 years. In all, 56% of hospitals providing surgical care have recruited a surgeon during the past 5 years. Of those who have been unsuccessful in their search, 30% have considered using a locum tenens surgeon, and 20% have done so. CONCLUSIONS: Given the difficulty of recruiting surgeons to practice in rural America, it is critical to develop strategies to address this problem. Although using locum tenens surgeons may allow rural hospitals to offer surgical services, the quality of surgical care could be compromised. Other means for delivering surgical services at rural hospitals that cannot recruit or retain a surgeon should be explored to ensure that rural residents have access to high quality surgical care.

How does degree of rurality impact the provision of surgical services at rural hospitals?

CONTEXT: Rural residents frequently have decreased access to surgical services. Consequences of this situation include increased travel time and financial costs for patients. There are also economic implications for hospitals as they may lose revenue when patients leave the area in order to obtain surgical services. Rural communities vary in size and distance from more populated centers. Since rural hospitals are located in varying types of rural communities, they likely differ with regard to the provision of surgical care. PURPOSE: To describe the differences between hospitals located in smaller versus larger rural areas regarding the provision of surgical care. METHODS: A 12-item survey instrument based on one previously used in a pilot study was mailed to a national random sample of rural hospital administrators (n = 233). Rural location was determined using rural-urban commuting area codes. FINDINGS: One hundred and eleven surveys were received, yielding a 48% response rate. Hospitals in larger rural areas had an average of 9 surgeons compared to 1 at hospitals in smaller rural areas. More administrators at hospitals located in larger rural areas viewed the ability to provide surgical care as very important to the financial viability of their hospital. CONCLUSIONS: Among rural hospitals located in communities of varying sizes there are significant differences in how surgical services are delivered and the financial importance of providing surgical care. Administrators at hospitals located in larger rural areas, more than in smaller ones, report financial reliance on their ability to offer surgical care and have significantly more resources available to do so.

General surgery at rural hospitals: a national survey of rural hospital administrators.

BACKGROUND: Many rural residents have limited access to surgical care. Rural hospitals frequently struggle to provide surgical services due to workforce shortages and financial constraints. The purpose of this study is to describe rural hospital administrators' perceptions regarding the state of their general surgery programs and the impact that providing surgical services has on their hospitals' financial viability. METHODS: A 12-item survey was mailed to a random sample of national rural hospital administrators (n=233). One hundred and eleven surveys were completed, yielding a response rate of 48%. In addition to overall descriptive analyses, comparisons were made between hospitals located in large versus small rural communities. RESULTS: Eighty-three percent of rural hospital administrators perceived their surgical program to be very important to the financial viability of their hospital and stated that they would reduce services if the hospital were to lose its surgery program. Thirty-four percent of hospitals have a surgeon leaving within the next 2 years and more than one-third of hospital administrators are currently searching for a surgeon. CONCLUSIONS: Surgical care is a vital component of the health care services delivered by rural hospitals. Surveyed administrators' view the ability to provide surgical services as crucial to the financial viability of their rural hospitals. A shortage of general surgeons is a potential major threat to these rural hospitals.

Rural versus non-rural differences in surgeon performed endoscopy: results of a national survey.

The ongoing decline in the number of general surgeons practicing in rural areas of the United States is concerning. Existing data show that rural surgeons perform a broad spectrum of cases including procedures that are not considered to be in the repertoire of most general surgeons. In particular, rural surgeons seem to be performing a sizeable number of endoscopic procedures. A sixty-item survey was mailed to 1700 rural surgeons while a random sample of 154 urban surgeons were telephoned and administered the same questionnaire. The general surgeons were identified using a list obtained from the American Medical Association Masterfile. The response rate was 25 per cent and 74 per cent among rural and nonrural surgeons respectively. Seventy four per cent of rural surgeons performed more than 50 flexible endoscopies a year in contrast to 33 per cent of nonrural surgeons (P < 0.05). Approximately 42 per cent of rural surgeons reported doing more than 200 procedures annually, whereas only 12 per cent of the nonrural surgeons did so. Additionally, 63 per cent of rural surgeons wished they had further training in endoscopy before starting practice as compared with 46 per cent (P < 0.05) of nonrural surgeons. Rural surgeons perform flexible endoscopy at a much higher rate than their nonrural counterparts. The majority of rural surgeons feel they would have benefited from additional flexible endoscopy training before entering practice.

Starting a general surgery program at a small rural critical access hospital: a case study from southeastern Oregon.

CONTEXT: Surgical services are frequently unavailable in rural American communities. Therefore, rural residents often must travel long distances to receive surgical care. Rural hospitals commonly have difficulty providing surgical services despite potential economic benefits. PURPOSE: The purpose of this project was to identify the key challenges and describe the initial outcomes experienced by Harney District Hospital (HDH), a rural critical access facility in Oregon, as it develops a surgical program. Since few models exist, this information will be valuable for those considering offering surgical services in a rural setting. METHODS: This project employed a single case study design. Qualitative information was gathered from semi-structured interviews, a focus group, reviews of historical documents, and informal observations. Quantitative data sources included HDH financial and utilization records, US Census records, and economic and demographic statistics from the state of Oregon, Harney County, and the city of Burns. FINDINGS: HDH is learning that initiating a change such as expanding surgical services within an organization is a challenging process requiring collaboration among the administration, staff, and community. Preliminary findings indicate that the new surgical program has resulted in significant financial gains for the hospital. CONCLUSIONS: While starting a rural surgery program is a complex undertaking, there are benefits for the hospital. If a rural hospital is to be successful in this mission, collaboration and adaptability must be key components of the process.

Is a broadly based surgical residency program more likely to place graduates in rural practice?

BACKGROUND: There is a shortage of general surgeons practicing in rural America. Rural surgical practices differ from those in urban settings encompassing a broader case mix with a larger percentage of time spent performing abdominal, alimentary, gynecological, genitourinary, and orthopedic procedures. Present graduates of many general surgical residencies do not obtain the range of experience necessary to practice effectively in this environment. We hypothesize that general surgical residents undergoing broadly based training are more likely to practice in a rural location. METHODS AND MATERIALS: We conducted a survey of graduates from the Mary Imogene Bassett Hospital's (MIBH) broadly based surgical residency program in 2004. Additionally, the surgical resident logs from the Accreditation Council for Graduate Medical Education (ACGME) and the residency program were reviewed for years 2001-2004. RESULTS: Of the 56 surveys sent out, 42 (75%) were completed and used in the analysis. A majority of the general surgeons who were raised in a rural environment reported that they are residing and practicing in a rural setting. Graduates of the MIBH residency program, on average, performed more cases as residents in the following subspecialty areas: genitourinary, plastics/hand, gynecology, neurosurgery, and orthopedics than national residency graduates. CONCLUSIONS: Based on our findings, surgical residents graduating from a broadly based training program appear more likely to practice in a rural setting.

General surgery programs in small rural New York State hospitals: a pilot survey of hospital administrators.

CONTEXT: Hospitals play a central role in small rural communities and are frequently one of the major contributors to the local economy. Surgical services often account for a substantial proportion of hospital revenues. The current shortage of general surgeons practicing in rural communities may further threaten the financial viability of rural hospitals and communities. PURPOSE: To describe hospital administrators' perceptions regarding the current state of general surgery programs at small rural hospitals in New York State, including the impact that surgical services have on hospital financial viability. METHODS: A list of hospitals belonging to the rural hospitals group of the Healthcare Association of New York State was obtained to determine prospective survey recipients. Sixty-eight administrators at each of the identified hospitals were subsequently surveyed and 38 respondents met all inclusion criteria. FINDINGS: Approximately 87% of hospital administrators perceive that the general surgery program is critical to the hospital's financial viability. Forty percent of respondents report that they would be forced to close the hospital if the surgical program was lost. Among the 42% of administrators trying to recruit a general surgeon, almost two thirds have been searching for more than 1 year. CONCLUSIONS: According to the perceptions of hospital administrators, the financial viability of rural hospitals in New York State depends in large part on their ability to provide surgical services. Additionally, general surgeons appear to be in high demand at a significant number of the surveyed institutions.

North American Guidelines for Children's Agricultural Tasks: five-year assessment and priorities for the future.

BACKGROUND: The North American Guidelines for Children's Agricultural Tasks (NAGCAT) are a safety resource created to assist parents in selecting safe work for their children 7-16 years of age. Since their release in 1999, a growing body of scientific evidence has accumulated regarding NAGCAT. The purpose of this project was to assess the current scientific and programmatic evidence regarding the efficacy and utilization of the NAGCAT resource in order to determine the priorities for the next 5 years. METHODS: A systematic, evidenced-based method was employed to accomplish the project objectives. Our data sources included results from a survey of agricultural safety practitioners and researchers, a comprehensive synthesis of the peer-reviewed literature, and recommendations from a priority-setting meeting. RESULTS: Five main priorities were identified: to address the perceptions and barriers associated with the use and non-use of the NAGCAT resource; to revise and re-format a core set of the guidelines; to develop a NAGCAT resource dissemination/marketing plan; to provide training and support for agricultural safety professionals and parents using NAGCAT; and to conduct further research to facilitate accomplishing these priorities. CONCLUSIONS: This assessment and priority identification process was successful in outlining the next steps for the NAGCAT resource. As we move toward 2010, those involved in pediatric agricultural injury prevention will have a blueprint to ensure that NAGCAT are an effective and widely used resource for preventing work-related injuries.