Surgeons who treat patients in rural areas are a unique group, distinct from other surgeons because of scope of practice, environment, and resources. These surgeons address a vast range of surgical problems, work in relative professional isolation, and have fewer resources available to get the job done. Nevertheless, these physicians play critical roles in their profession and are irreplaceable assets in their communities.
Although poorly defined, often misunderstood, arguably unfairly characterized, and inadequately documented, surgery has a long distinguished history and tradition in rural communities.
What are the main challenges faced by rural surgeons and what can be done to strengthen their practices, professional lives, and longevity in the field? Rural patients are more likely than urban patients to be elderly and poor and have chronic illnesses (J. Am Coll. Surg. 2014;219:814-8). The average age of rural surgeons suggests that many will retire in the coming decade. Who will replace them and care for 60 million citizens who reside in rural America? How will the gradual decline of residents choosing general surgery and rural practice affect patient care?
This new monthly column, Rural Surgeons Speak, focuses on these questions and searches for answers. Rural Surgeons Speak will introduce to all readers the voices, concerns, questions, and opinions of surgeons practicing in the small towns and rural regions of the United States. Although many of the challenges faced by rural surgeons are unique to this group, there is overlap with issues encountered by urban surgeons and those in academic settings. In spite of problems ranging from a shift from independent practice to hospital employment and to treating the poor with pronounced chronic illnesses, rural surgeons are dedicated and committed. Although these matters are common to all surgeons, rural surgeons’ experiences tend to be singular because of the high percentages of such patients and fewer institutional resources.
I have practiced surgery in small and large rural locations for 37 years. Rural surgery is not a specialty. My case log, filled with endoscopies, laparoscopies, laparotomies, and breast operations, may be even more varied than the logs of urban colleagues. In my early years of practice, I did orthopaedic surgery and gynecology. As a conscious choice, I practiced surgery where I wanted, and how I wanted. My choice was not by default. When I started, I sought a location that would allow me to “have a more complete life with less tension, excellent schools, opportunity for economical living,” and a fulfilling surgery practice. Unknown to me, Dr. Edwin F. Cave, ACS president, made those statements about rural surgery in the Daily Clinical Bulletin for the 37th Annual Clinical Congress decades before I started.
Like other rural surgeons, I wanted to embrace and be embraced by my community. I also saw opportunities for personal advancement (involvement with ACS), and for the development of my surgical talents (lasers, laparoscopies, endoscopies). I live just a mile from the hospital. I know my patients by their first names. They speak to me on the telephone. My number is in the book. When they meet me in church or at the grocery store, I am “Doc.” Occasionally a PEx is performed in such locations. It is personal. It is comfortable. There is a real sense of community and of belonging. I am involved. I provide an invaluable service “right at home,” where my patients want to be treated. In return, I am valued and supported.
After becoming a FACS in 1979, I involved myself in many activities of the ACS. Most recently, I participated in the rural surgery renaissance from its beginning. As part of my participation, I routinely contacted rural surgeons around the United States and gained intimate and detailed knowledge about their practices, successes, and concerns. I bring insights from my background to the writing of this column.
While glamour is at a minimum in rural America, personal satisfaction for many of these surgeons is at a maximum. Unfortunately, isolation is a given in most rural practices, and therein lies the problem. In spite of offering much to their patients and, in turn, to the profession, rural surgeons are easy targets of negative assessments, ill-conceived policy changes, and misunderstandings.
Despite their vital role in treating patients, rural surgeons often regard themselves as unrecognized and unappreciated by their peers. There is a subtle bias in the profession against a surgeon who would choose this life of relative isolation, alleged nonspecialized surgery, and overwork in communities with fewer cultural resources and fewer employment options for spouses. Yet their work is essential to the health of millions of people who live in rural areas. Thankfully, the profession as a whole has stopped ignoring rural surgery in recent years as the ACS leadership has stepped in and begun to increase support for rural surgeons.