The University of Alabama at Birmingham Surgery Community Network: Tackling the Challenges of Rural Surgery.

Over the past 5 years, The University of Alabama at Birmingham (UAB) Department of Surgery has taken a keen interest in the practice of surgery in rural Alabama and has established the UAB surgery community network. Our goal is to improve the delivery of surgical care in rural areas through active recruitment of rural surgeons, the development of research around rural surgery practice, and the expansion of a surgery network throughout the state. Here, we will present the challenges faced by rural surgery, our early work to address these challenges, and offer a plan for moving forward.

Examining the Surgical Life.

Debriefing after a major event is a key component in ongoing improvement in performance. Likewise, reflecting on one's career at the time of leaving the operating room environment is an opportunity to transmit the lessons learned from decades of surgical practice. The authors, recently retired from daily operating and leaders in American surgery, reflect on the impact of surgical life on surgeons and their personal lives. Observations regarding selection of medical students, surgical trainees and practice models are presented from this perspective.

Current surgeon practices for postoperative activity restrictions after abdominal surgery vary widely: A survey from the communities on the ACS website.

BACKGROUND: Surgeons often impose restrictions on patient activities after an abdominal operation in an effort to prevent complications such as incisional hernia. This study addresses the current recommendations concerning the restriction of activities given by a diverse group of surgeons to their patients after abdominal surgery. METHODS: A 14-item survey was posted on surgeon-specific social media platforms, primarily the American College of Surgeons Communities. This survey included questions about demographics, practice type, and activity recommendations after open and minimally invasive abdominal surgery. Descriptive, multivariable, and qualitative analyses were performed. RESULTS: A total of 420 surgeons completed the survey. The majority of respondents identified as general surgeons (76.2%). Practice types included private (37.6%), academic (34.3%), underserved (10.1%), and Veterans Affairs (5.6%). After an open laparotomy, the majority of respondents (53.1%) recommended that patients refrain from heavy lifting or strenuous activity for 6 weeks. For a minimally invasive abdominal operation, recommendations were even more variable, restricting activity for 2 weeks (34.4%), 4 weeks (23.8%), 6 weeks (15.5%), or no restrictions (12.6%). On average, participating surgeons recommended an earlier return to activity by 2.3 weeks for patients undergoing minimally invasive surgery compared with an open operation (95% confidence interval 2.1-2.5, P < .001). Qualitative analysis provided additional information regarding surgeons' rationale for decision making. Only 23.8% of the respondents indicated that their recommendations were based on evidence in literature. CONCLUSION: This survey on surgeon recommendations for convalescence after an abdominal operation indicates the wide variation in practices with insufficient evidence to guide decision making. Future clinical trials examining various durations and intensities of postoperative restrictions will be important to determine a safe and patient-centered approach for recovery after an abdominal operation.

Is the American College of Surgeons Online Communities a safe and useful venue to ask for surgical advice?

BACKGROUND: Many surgeons rely on the American College of Surgeons (ACS) Community Forums for advice on managing complex patients. Our objective was to assess the safety and usefulness of advice provided on the most popular surgical forum. METHODS: Overall, 120 consecutive, deidentified clinical threads were extracted from the General Surgery community in reverse chronological order. Three groups of three surgeons (mixed academic and community perspectives) evaluated the 120 threads for unsafe or dangerous posts. Positive and negative controls for safe and unsafe answers were included in 20 threads, and reviewers were blinded to their presence. Reviewers were free to access all online and professional resources. RESULTS: There were 855 unique responses (median 7, 2-15 responses per thread) to the 120 clinical threads/scenarios. The review teams correctly identified all positive and negative controls for safety. While 58(43.3%) of threads contained unsafe advice, the majority (33, 56.9%) were corrected. Reviewers felt that a there was a standard of care response for 62/120 of the threads of which 50 (80.6%) were provided by the responses. Of the 855 responses, 107 (12.5%) were considered unsafe/dangerous. CONCLUSION: The ACS Community Forums are generally a safe and useful resource for surgeons seeking advice for challenging cases. While unsafe or dangerous advice is not uncommon, other surgeons typically correct it. When utilizing the forums, advice should be taken as a congregate, and any single recommendation should be approached with healthy skepticism. However, social media such as the ACS Forums is self-regulating and can be an appropriate method for surgeons to communicate challenging problems.

Are online surgical discussion boards a safe and useful venue for surgeons to ask for advice? A review of the International Hernia Collaboration Facebook Group.

BACKGROUND: Social media is a growing medium for disseminating information among surgeons. The International Hernia Collaboration Facebook Group (IHC) is a widely utilized social media platform to share ideas and advice on managing patients with hernia-related diseases. Our objective was to assess the safety and utility of advice provided. METHODS: Overall, 60 consecutive de-identified clinical threads were extracted from the IHC in reverse chronological order. A group of three hernia specialists evaluated all threads for unsafe posts, unhelpful comments, and if an established evidence-based management strategy was provided. Positive and negative controls for safe and unsafe answers were included in seven threads and reviewers were blinded to their presence. Reviewers were free to access all online and professional resources (except the IHC). RESULTS: There were 598 unique responses (median 10, 1-26 responses per thread) to the 60 clinical threads/scenarios. The review team correctly identified all seven positive and negative controls. Most responses were safe (96.6%) but some were unhelpful (28.4%). For sixteen threads, the reviewers believed there was an established evidence-based answer; however, only six were provided. In addition, 14 responses were considered unsafe, but only four were corrected. CONCLUSIONS: The vast majority of responses were considered helpful; however, evidence-based management is typically not provided and unsafe recommendations often go uncontested. While the IHC allows wide dissemination of hernia-related surgical advice/discussions, surgeons should be cautious when using the IHC for clinical advice. Mechanisms to provide evidence-based management strategies and to identify unsafe advice are needed to improve quality within online forums and to prevent patient harm.

When rural is no longer rural: Demand for subspecialty trained surgeons increases with increasing population of a non-metropolitan area.

BACKGROUND: Surgery in larger, non-metropolitan, communities may be distinct from rural practice. Understanding these differences may help guide training. We hypothesize that increasing community size is associated with a desire for subspecialty surgeons. METHODS: We designed a mixed methods study with the ACS Rural Advisory Council. Rural (<50,000 people), small non-metropolitan (50,000-100,000), and large non-metropolitan (>100,000) communities were compared. Quantitative and qualitative data were analyzed. RESULTS: We received 237 responses, and desire to hire subspecialty-trained surgeons was associated with practice in a large non-metropolitan community, OR 4.5, (1.2-16.5). Qualitative themes demonstrated that rural surgeons limit practices to align with available hospital resources while large non-metropolitan surgeons specialize according to interest and market pressures. CONCLUSIONS: Surgery in rural versus large non-metropolitan communities may be more distinct than previously understood. Rural practice requires broad preparation while large non-metropolitan practice favors subspecialty training.

Rural surgeons' perspectives on necessity of post-residency training are stable across generations.

BACKGROUND: Training future rural surgeons is critical, but training needs are unclear. We hypothesize perspectives on necessity of subspecialty training differ among rural surgeons by generational cohort. METHODS: An online survey was sent to ACS Rural Surgery Listserv subscribers. Closed-ended elements were analyzed using bivariate testing and logistic regression. Purposively-sampled respondents participated in qualitative interviews analyzed using principles of grounded theory. RESULTS: Generation was irrelevant to respondents' hiring preferences, but older surgeons were more likely to state subspecialty training was ideal for any future rural surgeon. Controlling for practice context, younger rural surgeons were less likely to favor hiring a subspecialty-trained surgeon (p = 0.019). Themes emerged from qualitative analysis emphasizing broad training and the importance of practice context. CONCLUSION: Across generations, rural surgeons' perceptions about the training needed for rural surgery are largely stable. Considering practice context will allow educators to better prepare future rural surgeons for rural practices.

Training for a Career in Rural and Nonmetropolitan Surgery-A Practical Needs Assessment.

OBJECTIVE: The current shortage of surgeons in rural and smaller communities is predicted to get worse. In this study, we solicited practicing rural surgeons' opinions about the skill set needed in a rural practice in order to inform curriculum development for general surgery residents who intend to embark on rural careers. DESIGN: We developed an online survey consisting of demographic questions and closed- and open-ended questions regarding current practice environment and scope of practice. Priorities for training were identified using descriptive analyses of both the quantitative and qualitative data, including frequency of responses regarding specific skills training. PARTICIPANTS: We surveyed currently practicing surgeons who subscribe to the American College of Surgeons Rural Surgery listserv. RESULTS: 237 surgeons from 49 states and 1 Canadian territory responded; 60% of participants had been in practice for 20 or more years, and 70% did not pursue subspecialty training. Valuable skills identified for rural surgeons were: endoscopy, advanced laparoscopy, and basic non-general surgery subspecialty procedures. Regardless of years of practice or setting, respondents felt that rural experience during residency was highly valuable (82%) and overwhelmingly supported training future rural surgeons at residency programs with broad general surgery experiences and high case volumes with no or few fellows. CONCLUSIONS: Practicing rural surgeons identify endoscopy, basic non-general surgery subspecialty procedures, and advanced laparoscopy as key components of their current practice. These skills may not be strongly emphasized in traditional general surgery training programs. Surgical educators should focus on developing curricula that emphasize these areas in order to prepare residents for careers in rural surgery.

Association of Hospital Critical Access Status With Surgical Outcomes and Expenditures Among Medicare Beneficiaries.

IMPORTANCE: Critical access hospitals are a predominant source of care for many rural populations. Previous reports suggest these centers provide lower quality of care for common medical admissions. Little is known about the outcomes and costs of patients admitted for surgical procedures. OBJECTIVE: To compare the surgical outcomes and associated Medicare payments at critical access hospitals vs non-critical access hospitals. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional retrospective review of 1,631,904 Medicare beneficiary admissions to critical access hospitals (n = 828) and non-critical access hospitals (n = 3676) for 1 of 4 common types of surgical procedures-appendectomy, 3467 for critical access and 151,867 for non-critical access; cholecystectomy, 10,556 for critical access and 573,435 for non-critical access; colectomy, 10,198 for critical access and 577,680 for non-critical access; hernia repair, 4291 for critical access and 300,410 for non-critical access-between 2009 and 2013. We compared risk-adjusted outcomes using a multivariable logistical regression that adjusted for patient factors (age, sex, race, Elixhauser comorbidities), admission type (elective, urgent, emergency), and type of operation. EXPOSURES: Undergoing surgical procedures at critical access vs non-critical access hospitals. MAIN OUTCOMES AND MEASURES: Thirty-day mortality, postoperative serious complications (eg, myocardial infarction, pneumonia, or acute renal failure and a length of stay >75th percentile). Hospital costs were assessed using price-standardized Medicare payments during hospitalization. RESULTS: Patients (mean age, 76.5 years; 56.2% women) undergoing surgery at critical access hospitals were less likely to have chronic medical problems, and they had lower rates of heart failure (7.7% vs 10.7%, P < .0001), diabetes (20.2% vs 21.7%, P < .001), obesity (6.5% vs 10.6%, P < .001), or multiple comorbid diseases (% of patients with ≥2 comorbidities; 60.4% vs 70.2%, P < .001). After adjustment for patient factors, critical access and non-critical access hospitals had no statistically significant differences in 30-day mortality rates (5.4% vs 5.6%; adjusted odds ratio [OR], 0.96; 95% confidence interval [CI], 0.89-1.03; P = .28). However, critical access vs non-critical access hospitals had significantly lower rates of serious complications (6.4% vs 13.9%; OR, 0.35; 95% CI, 0.32-0.39; P < .001). Medicare expenditures adjusted for patient factors and procedure type were lower at critical access hospitals than non-critical access hospitals ($14,450 vs $15,845; difference, -$1395, P < .001). CONCLUSIONS AND RELEVANCE: Among Medicare beneficiaries undergoing common surgical procedures, patients admitted to critical access hospitals compared with non-critical access hospitals had no significant difference in 30-day mortality rates, decreased risk-adjusted serious complication rates, and lower-adjusted Medicare expenditures, but were less medically complex.

Evaluation of a blended learning surgical skills course for rural surgeons.

BACKGROUND: Rural surgeons have unique learning needs not easily met by traditional continuing medical education courses. METHODS: A multidisciplinary team developed and implemented a skills curriculum focused on leadership and communication, advanced endoscopy, emergency urology, emergency gynecology, facial plastic surgery, ultrasound, and management of fingertip amputations. RESULTS: Twenty-five of 30 (89%) rural surgeons who completed a follow-up course evaluation reported that the knowledge acquired during the course had improved their practice and/or the quality of patient care, particularly by refining commonly used skills and expanding the care options they could offer to their patients. The surgeons reported incorporating changes in their communication and interaction with colleagues. CONCLUSIONS: This course was successful, from participants' perspectives, in providing hands-on mentored training for a variety of skills that reflect the broad scope of practice of surgeons in rural areas. Attendees felt that their participation resulted in important behavior and practice changes.

What surgical skills rural surgeons need to master.

BACKGROUND: As new technology is developed and scientific evidence demonstrates strategies to improve the quality of care, it is essential that surgeons keep current with their skills. Rural surgeons need efficient and targeted continuing medical education that matches their broader scope of practice. Developing such a program begins with an assessment of the learning needs of the rural surgeon. The aim of this study was to assess the learning needs considered most important to surgeons practicing in rural areas. STUDY DESIGN: A needs assessment questionnaire was administered to surgeons practicing in rural areas. An additional gap analysis questionnaire was administered to registrants of a skills course for rural surgeons. RESULTS: Seventy-one needs assessment questionnaires were completed. The self-reported procedures most commonly performed included laparoscopic cholecystectomy (n = 44), hernia repair (n = 42), endoscopy (n = 43), breast surgery (n = 23), appendectomy (n = 20), and colon resection (n = 18). Respondents indicated that they would most like to learn more skills related to laparoscopic colon resection (n = 16), laparoscopic antireflux procedures (n = 6), laparoscopic common bile duct exploration/ERCP (n = 5), colonoscopy/advanced techniques and esophagogastroscopy (n = 4), and breast surgery (n = 4). Ultrasound, hand surgery, and leadership and communication were additional topics rated as useful by the respondents. Skills course participants indicated varying levels of experience and confidence with breast ultrasound, ultrasound for central line insertion, hand injury, and facial soft tissue injury. CONCLUSIONS: Our results demonstrated that surgeons practicing in rural areas have a strong interest in acquiring additional skills in a variety of general and subspecialty surgical procedures. The information obtained in this study may be used to guide curriculum development of further postgraduate skills courses targeted to rural surgeons.