What medical students need to know about training for a career in rural surgery

I love being a rural surgeon. My critical access hospital is in Hopedale, IL, a town of 850 people. I was born in the hospital where I practice. I could look out my office window in between cases and see my kids playing during recess. Everybody knows everybody, and frequently, the patients are relatives of the emergency medical services volunteers, nurses, ancillary staff, and physicians. I love the broad scope of my practice, from primary care to vascular surgery. I endure no traffic lights or road rage when I commute to satellite offices, but I remain vigilant to avoid hitting deer, raccoons, and opossums.

Rural rotations often expose medical students to aspects of general surgery and personalized patient care that they would rarely see in a larger metropolitan teaching hospital. In this respect, I find rural surgery is an “easy sell” to the eager first- or second-year medical student formulating career plans.

Help wanted

Rural America is in dire need of surgeons. A small community hospital cannot thrive without us, and lifesaving surgical skills are needed in all rural areas to ensure optimal trauma and acute care surgical coverage.

The American College of Surgeons (ACS), primarily through the Advisory Council for Rural Surgery (ACRS), as well as many practicing rural surgeons and educators are stimulating more and more interest in rural surgery among medical students. Through its medical student outreach, the ACS has created a forum for medical students to interact with surgeons of all walks of life, including rural surgeons—and it is working. These students are now asking, “If I want to become a rural surgeon, which residency programs should I apply to?” It is a great question, and like so many other great questions, it has no easy answer.

Wouldn’t it be wonderful if we could direct these students to an up-to-date list of all of the general surgery residency programs in North America that have a dedicated training program for rural surgeons? At present, this list does not exist, but the ACRS is trying to make this resource a reality. The good news is that more and more residency programs are stepping up and trying to fill this rural niche, and they are discovering that these programs are popular among applicants because of the broad-based surgical training they provide.

Identifying rural surgery training programs

The ACRS recently sought to update the list of rural surgical residencies and published its results in the article “Reap what you sow: Which rural surgery training programs currently exist, and do medical students know of their existence?”* Electronic surveys were sent to all 261 Accreditation Council for Graduate Medical Education (ACGME)-accredited general surgical training programs in North America. Programs that did not respond received follow-up phone calls. Program directors or chairs were asked if their institution had a specific rural surgical track, and if so, how it was designed.

We also consulted the American Medical Association’s Fellowship and Residency Electronic Database, filtering out general surgical residencies as “rural surgery.” Next, we cross-referenced these lists with the published list of 12 verified rural surgical residencies compiled and published on the ACS website (see sidebar).^† All told, we found that 44 of the 261 (16.9 percent) ACGME-accredited general surgery residencies reported having a rural training scheme in place. Verifying that these programs are all, in fact, robust rural training tracks has proven difficult, as there is a great degree of variation in their curricula. Nonetheless, we did expand the list of possibilities significantly. I encourage all surgical program directors and division and department heads to assist us in our future attempts to contact you to better identify and categorize these rural training paradigms. We plan to make a regularly updated list available on the ACS web page.

Where are you headed?

What should a medical student look for in a rural general surgery residency? A broad-based curriculum is critical. Heavy endoscopy exposure is a must because this procedure commonly represents more than 40 percent of the rural surgeon’s caseload. Working with a rural surgeon mentor in a small community for one to three months is optimal, and attaining familiarity with primary care is best achieved in this setting as well. Subspecialty training may be obtained with three to six months of unopposed rotations in a rural or larger community hospital.

Subspecialty exposure

The key is to avoid competing with other specialty residents or fellows for cases. Ideally, the subspecialty exposure will be broad but also designed around the needs of the community to which the surgeon will be headed after training. The community hospital rotations should generally result in 30 days or fewer away from the main teaching facility and usually occur during postgraduate years two through four. Some programs will insert an entire year of rural and subspecialty training in place of a research year. Other models include a fellowship year or a Mastery in General Surgery program, which follows completion of a general surgery residency.

Subspecialty exposure optimally will include anesthesia, burns, critical care, endoscopy, neurosurgery, obstetrics-gynecology, orthopaedics, otolaryngology, plastics, thoracic, trauma, urology, and vascular surgery. Again, every effort should be made to tailor the subspecialty training to the expected needs of the surgeon and target community. For example, a surgeon heading to a remote location without continuous obstetrics coverage likely will want to be facile with cesarean sections and perinatal complications. Avery and Wallace have published a review of the five different models of rural surgical training programs and cite examples of each.^‡ I highly recommend this article for any medical student or surgeon interested in the training of the rural surgeon.

In summary, rural surgeons love their broad scope of practice and the ability to live in a small community, which can lead to a special physician-patient relationship—the sort of professional relationship that is near extinction in the corporate model of health care delivery that one finds in the metropolitan setting. These are the factors that attract the medical student aspiring to be a rural surgeon. The resident seeking to practice in a rural setting requires a much broader skill set than one who will be moving on to subspecialty fellowship training. Unfortunately, the days of the “rotating internship” are apparently gone; however, with some creativity and effort, we can still train a general surgeon to care for “the skin and its contents.”

*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 Ed. 2018;75(3):697-701.

^†American College of Surgeons. Rural surgery program. Available at: facs.org/education/resources/residency-search/specialties/rural. Accessed November 11, 2018.

^‡Avery DM, Wallace JC. Rural surgery training programs in the United States: A review of the literature. Online J Rural Res Policy. 2016;11(3). Available at: https://doi.org/10.4148/1936-0487.1078. Accessed November 21, 2018.