Association for Academic Surgery (AAS)

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RESIDENCY TRAINING IN RURAL SURGERY

The experience of a rural surgeon is unique in both its rewards and challenges compared to those in an urban or academic setting. Many rural surgeons have written about the joys of building lasting patient-physician relationships, maintaining a broad operative skillset, and cultivating a practice that supports their community1. Unfortunately, the potential for rural surgical practice may go unrecognized by many medical students whose urban academic institutes do not offer rural rotations. Here we will highlight the field of rural surgery, share our experiences as rural surgical trainees, and provide insight to medical students who may be interested in rural surgery training.

WHAT IS RURAL SURGERY?

The American Board of Surgery defines rural hospitals (RH) as those that serve a population of fewer than 50,000 people. Surgeons in RH must have a toolbox of vast procedural capabilities, covering the full range of “bread and butter” general surgery operations from carotid endarterectomies to colectomies. Their role often encompasses the primary care needs of their patients, including colonoscopies, medical management of bowel disease, and procedures outside the scope of modern general surgery such as carpal tunnel release and cesarean section. The wide spectrum of care provided by rural surgeons highlights the great importance of rural surgeon availability for the care of these populations. However, a shortage of more than 23,000 rural surgeons is expected in the next five years2. In response, residency programs across the country are working to provide rural training for their residents.

WHY TRAIN IN RURAL SURGERY?

Dr. Lake, the first resident selected for the Medical College of Wisconsin’s Rural Track, was driven to pursue rural surgery by the opportunity to make big differences close to home. Throughout her training in college and medical school, universal interest in global surgery was rising. She was drawn to the concept put forth by the Lancet Commission – “universal access to safe, affordable surgical and anesthesia care…[to]…save lives, prevent disability, and promote economic growth.” She realized shortly thereafter that she could pursue this mission without traveling outside of the country. Similar health disparities in access to surgical care exist in most rural regions of the United States. The unique challenges of providing safe and reliable surgical care in low-resource areas as well as the problem-solving skills necessary to overcome them are what drew Dr. Lake into rural surgery.

For Dr. Fredrickson, who grew up in a small Wisconsin city, the interest in medicine was initially sparked by rural physicians and the unique relationships that they formed with patients. In her medical school rotations at an academic institution, she noticed patients and providers often emphasized subspecialty expertise more than building holistic patient-provider relationships. As a result, she was in search of a residency program that offered community-based rotations where she could gain more insight into the type of career that she wants to build once her training is complete. The Medical College of Wisconsin had just begun the rural surgery program where she would have the benefits of both an academic center experience, where she would work with excellent subspecialty surgeons as well as annual rural rotations learning from surgeons with broad-based practices. In her experience so far, she has found added advantages of working in a rural hospital which provides a diverse operative experience and exposure to new mentors with distinct views on healthcare. Most of all, she is developing a well-rounded perspective of the infinite career options that surgeons have.

The many benefits of rural surgery training are supported by research. Trainees in rural hospitals have reported more operative confidence, hands-on experience, and patient care continuity3. Undurraga Perl et al. demonstrated that residents who completed a year of rural rotations reported higher case volumes in nine surgery categories compared to counterparts who did not4. When it comes to choosing a career after graduation, Klingensmith et al showed that most residents who chose general surgery over fellowship had an influential mentor in practice and 26% had an influential rotation during their training5. These studies support that rural rotations are beneficial not just for resident learning but also for career development.

WHAT TRAINING IS AVAILABLE IN RURAL SURGERY?

There are many ways to gain rural experience as a surgical trainee. A recent article by Mercier et al separates programs into two categories: those which are intrinsically rural, where primary training is completed in RH, and those that offer rotations in RH2. Immersion in a rural program offers constant training and mentorship with surgeons who have practices representative of a career in rural surgery. More commonly, however, residency programs offer RH rotations to expose trainees to this type of practice within the typical training regimen of an academic-affiliated institution. Most often programs provide one to three months of elective RH rotations where residents have reported distinctly different operative and clinical experiences from other rotations2,3.

Dedicated rural surgery tracks, such as the one offered at the Medical College of Wisconsin, commit more time to rural training than short elective RH rotations. The obvious advantage of a built-in rural curriculum is that we get consistent experience in both settings throughout residency. As an example, the hospital where we complete most of our training has a Level 1 Trauma Center that admitted over 2,700 patients in 2018 alone. Working in a busy trauma center affords invaluable experience managing operative and non-operative traumatic injuries. Many of these patients present as transfers after being stabilized and triaged by smaller hospitals, including the one where we work during our rural rotations. Seeing the perspective of both the referring and receiving facilities, we have learned a great deal about the decisions that must be made when patients present with traumatic injuries, including whether their needs can be met by the hospital resources. Our training is more comprehensive because we have opportunities like this to care for patients in diverse care settings.

WHICH PROGRAMS OFFER RURAL SURGERY?

It is an exciting time to apply to general surgery as opportunities for rural training are increasing, However, it can be difficult to find and compare available programs. Articles by Mercier et al and Rossi et al highlight several U.S. programs that exemplify the different types of rural programs available2,6. During our residency searches and applications, we used the AMA-affiliated FREIDA database, which contains a list of programs that can be filtered to include community-based programs and those with rural track options7. Ultimately, residency websites and program coordinators are the best sources for applicants to gain information about what rural opportunities are offered.

In conclusion, there is a growing need for community-based rural surgeons. This need emphasizes the importance of providing rural surgery training to introduce residents to this type of practice. Furthermore, rotations in rural hospitals have been shown to provide valuable educational opportunities for surgical trainees. We know that our experiences training in a rural hospital have broadened our perspective and skillset and have made us stronger surgeons.. We encourage those interested in rural surgery to fully explore the available options for incorporating rural training into their surgical residency.

 

REFERENCES

  1. Dispatches from rural surgeons. Bulletin of the American College of Surgeons. Available at: https://bulletin.facs.org/category/dept/for-your-profession/dispatches-from-rural-surgeons/. Accessed May 6, 2020.
  2. Mercier PJ, Skube SJ, Leonard SL, McElroy AN, Goettl TG, Najarian MM, Termuhlen PM, Chipman JG. Creating a rural surgery track and a review of rural surgery training programs. J Surg Educ. 2019 Mar-Apr;76(2):459-468. https://doi.org/10.1016/j.jsurg.2018.09.004
  3. Hao S, Johnson HM, Celio A, Frye L, Bayouth L, Joseph J, Walsh DS. Rural general surgery experience as a valuable adjunct to an academic based general surgery residency. J Surg Educ. 2020 May-Jun;77(3):598-605. https://doi.org/10.1016/j.jsurg.2019.11.007
  4. Underraga Perl V, Diggs B, Ham B, Schreiber M. Does surgery residency prepare residents to work at critical access hospitals? Am J Surg. 2015; 209:828-833.
  5. Klingensmith ME, Cogbill TH, Luchette F, Biester T, Samonte K, Jones A, Lewis FR, Malangoni MA. Factors influencing the decision of surgery residency graduates to pursue general surgery practice versus fellowship. Annals of Surg. 2015;262(3) 449-455.
  6. Rossi IR, Wiegmann AL, Schou P, Borgstrom DC, Rossi MB. Reap what you sow: Which rural surgery training programs currently exist and do medical students know of their existence? J Surg Educ. 2018 May-Jun;75(3):697-701. https://doi.org/10.1016/j.jsurg.2017.09.029
  7. American Medical Association. Available at: https://freida.ama-assn.org/Freida/#/. Accessed May 6, 2020.