Friday, January 2, 2009

Rural Surgery

A nice article from the Washington Post (via KevinMD) last week about the impending general surgeon shortage in rural America. Here are some choice tidbits:

*In 1980, 980 general surgeons were trained in the the USA. In 2008, the number has reamined constant despite an increase in population by 79 million.

*Today there are only 5 general surgeons per 100,000 people

*Most rural general surgeons are over the age of 50

So this a good thing if you're a young general surgeon, right? There's going to be a huge demand to replace the retiring generation of surgeons and hospitals will need to reconstitute its forces. Because let's face it, surgeons are vital to a rural hospital's bottom line. The lucrative procedures that a local general surgeon can bring in often makes the difference between profitability and a hospital closing. Check out this power point presentation from the AAMC on rural surgery. Surgical services can potentially provide up to 30% of hospital revenue in the rural setting. Every time Podunk Hospital has to ship out an appendectomy or a hip fracture or a colon cancer because of surgeon unavailability, that's money lost.

But before we lose ourselves (we being young general surgeons) in rapturous expectations, there are some cold hard facts to digest. Namely, that in order to be a rural general surgeon, this means that you have to convince your spouse that it would be a great idea to move to Otsego, New York or Platteville, WI. You actually have to live in these towns. This isn't necessarily a bad thing, but you better be damn sure living the small town American life is what you really want. Secondly, rural surgery requires that one is comfortable performing certain procedures that most residents in training these days are not exposed to, i.e. setting minor fractures, hysterectomies, and ceasarean sections. Finally, although the hospital benefits enormously from successfully recruiting a general surgeon and will pay handsomely up front to do so, it can be difficult to maintain a suitably busy practice if you live in a town of 10,000. What happens is, the hospital will entice you to their sleepy hamlet with a seemingly exorbitant guaranteed contract (most general surgeons receive a steady deluge of junk emails from headhunters promising $350,000 a year or more guaranteed for the first three years, maybe with a large signing bonus on top of that). But when the guarantee runs out, you're on your own. And if you live in a town with, say, three primary care practices, it's going to be hard to maintain the sort of volume that will sustain your previous income level. You may find you are only doing 5 or 6 cases a week without a reasonable expectation of growth (given the population) and your income falls by 50% or more. It happens. And the hospitals don't care because they're still racking in the procedural profits from the cases you do book.

So be careful. Be wary of those glossy post cards that come in the mail with a picture of a moose and some mountains and a burbling stream in the background promising half a million bucks to start if only you come to this "quaint little midwestern bedroom community" that is only "a short drive to a major metropolitan area" (i.e. 3 hours to Dayton, OH) and is perfect for the "hunting and fishing enthusiast."

I think the answer to the problem is two-fold:

1. Loan forgiveness for surgical residents willing to commit to the backwoods of America (much like I propose loan forgiveness as a way to increase the number of medical students who opt for a career in primary care).

2. The creation of a dedicated specialty of "rural surgery" where more attention is given to the learning of OB/Gyn, endoscopy, and orthopedics. We have fellowships for "advanced laparoscopy" that didn't exist five years ago. The field of "trauma surgery' has become so non-operative that now trauma surgeons are looking to cherry pick late night emergency cases. Surgical training is constantly in flux. Rural surgery is the obvious next field for potential growth....


Andrew_M_Garland said...


Young surgeons are lured to rural towns by promises of 3 years x $350,000 salaries, but must then cope with possibly reduced earnings in a too-quiet environment.


Young surgeons commit to working in a rural town in exchange for their education loan. The initial term of service is by law, say 3 years, with suitable protections and proficiency requirements.

Their specialty of Rural Surgeon is administered by the Department of Homeland Health, which sees them as a unique asset, and expresses its dissatisfaction that such physicians would ever move back to cities where their publicly supported skills would be wasted.

The Rural Surgeon Support Act specifies subsidies and salaries for small towns, reviewed and reset yearly by the relevant boards within Homeland Health. Homeland Health plans to extend this working model to other needs and specialties, according to future legislation.

"Private Pay" medical education becomes increasingly expensive at rates far higher than inflation, offset only by Homeland Health programs to supply forgivable loans and grants in preferred "directed" specialties and career tracks.

Anonymous said...

On the plus side, Medicare seems to be on the path of relaxing the HPSA (Health Provider Shortage Area) payments. An extra 10% never hurt anyone's bottom line.

Bongi said...

i think i have the best of both worlds. where i work is still pretty rural, but we service a large enough area to make it quite sustainable. we also have an abundance of gynaes so no hysterectomies for me thank you very much. (also more incisional hernias)

Anonymous said...

Just make sure you are employed on a salary with tail coverage and forget the guarantee and the problem is solved. Don't buy the biggest house in town and if they cut you loose you're a free agent.

Anonymous said...

I'm enjoying your blog very much and wanted to comment on this older post.

As a medical student who was a nurse before med school, I'm wondering about whether Family Practice could accommodate some of these procedures. I'm more interested in General Surgery myself, but have worked a lot with FP docs as a nurse and know that at least in California, quite a few of the FP residencies in rural areas involve quite a bit of surgical and critical care training.

I also worry that FP (at least in urban areas) has become too interested in social problems and less interested in medicine. (I also saw this in my recent outpatient pediatrics assignment). Perhaps you could attract young docs into rural family practice by enhancing the surgical training during rural FP residencies with the goal of them being independent with some elective general surgery procedures.

Having proposed this, I hope to not be offending anyone. I do understand that General Surgery is a 5-6 year residency and do not mean these comments to imply that that experience can be easily replicated or substituted.

Anonymous said...

(most general surgeons receive a steady deluge of junk emails from headhunters promising $350,000 a year or more guaranteed for the first three years, maybe with a large signing bonus on top of that).


Headhunters read your blog. =( what we do isn't junk.

If fact I'm pretty much the only headhunter I know (hah!) that reads every medical blog I can get my hands on so I can see what Doc's really think about everything. (Well at least everything they write about)

Jeffrey Parks MD FACS said...

What you do isn't junk; it's actually a very useful service. But the mass, unsolicited emails I receive in my inbox on a weekly basis is technically "junk mail". Wouldn't you agree?

drcunningham said...

Please do not encourage the subspecialty of rural surgery as a distinct title...that role is already frowned upon enough by the ivory towers and the college is enjoying dividing up our specialty into nooks and crannies that are not financially sustainable and most not proven cost effective. A definite specialty in rural surgery is ridiculous sounding. Get program directors to REALLY train general surgeons that what the residents are there for and increase awareness among residents as to the skills they need for a rural surgical career so they can take their own initiative during training which is completely feasible. The next thing you know the college will have different MOC and Recert. exams for rural vs urban surgeons.