Skeletonize or Modernize: Which Approach Will Define the Future of Rural Surgery?

Overhauling rural surgery is a challenging task. Multiple solutions have been entertained, and they boil down to two strategies that hinge on whether to transfer the patient to surgical care at larger hospitals or make the care available locally.

The first strategy—transferring the surgical patient to a larger hospital—is centered on reducing surgical services in rural hospitals or skeletonizing, thus eliminating the costs of necessary infrastructure as well as the ongoing costs associated with less frequently performed inpatient operations. This approach suggests that smaller hospitals should perform only minor, straightforward surgeries.

When care is not urgent or emergent, the patient transfer approach could result in long waiting lists, and rural patients would be required to travel several times for the initial visit, workup, surgery, and follow-up. It also is important to note that there is extremely limited public transportation in many smaller communities, and rural patients sometimes cannot afford to fill their car gas tanks.

With some patients, including geriatric patients, the financial burden is even greater as the families need to pay for accommodations while losing days of work.

In emergency situations, transportation is not always reliable. The delay can result in the progression of the surgical disease, which has the potential of increasing morbidity and necessitating a long list of consultations, interventions, possible protracted hospital stay, and increased cost.

When transferring the patient is not possible due to the lack of surgical beds at the larger facility or transportation is unavailable, rural patients with surgical emergencies such as viscus perforation or ischemic bowel could die.

The second strategy—modernizing—focuses on the provision of surgical care within the patient’s local community through a variety of modalities, such as telehealth, minimizing travel to larger hospitals.

This approach promotes performing advanced or cutting-edge surgeries locally by well-trained rural surgeons who act as one-person teams that do not rely on consults, thus saving a substantial amount of money.

Another important benefit is that patients can receive visits from family without traveling long distances—this aspect of care and its impact on healing should not be underestimated.

Experiences of Aspirus Iron River Hospital

The data from the 2020 US census showed a reduction of rural populations from 2010 to 2020; however, these numbers predate the COVID-19 pandemic and do not take into account seasonal population variation.

Rural areas provided a sanctuary during COVID-19 pandemic for rural and urban individuals. The observed lockdowns were easily relaxed in these low-population areas as social distancing was already in place, a circumstance that seemed to attract people to live in rural areas. One of the prerequisites for choosing rural areas is the availability of a local hospital with optimal surgical services.

However, recruiting rural surgeons to perform outpatient surgery exclusively, without the ability to address their own complications in their hospitals, is an unappealing proposal. Unfortunately, this approach could lead to hospital closures and catastrophic economic consequences for the community. The astronomical cost of rebuilding collapsed rural services will eclipse the money necessary to support current services.

My hospital, Aspirus Iron River Hospital in Michigan, is a prime example of making surgical care available to patients locally. This critical access hospital is located in the Upper Peninsula of Michigan, in a town with a population of approximately 3,000 people. Our core belief is that rural patients deserve surgical services comparable to their urban counterparts.

In addition to bread-and-butter surgeries, the hospital provided specialized foregut procedures—a rewarding decision that produced excellent outcomes for new procedures with long follow-up.

We initially attracted patients from nearby communities, and then—in a reversal from the typical rural-to-urban patient travel—more urban patients from different states traveled to our rural hospital to have their antireflux procedures performed. This practice ensured financial stability before and during the COVID pandemic.

The hospital established an antireflux program in a stepwise fashion over 8 years, evaluating approximately 1,100 gastroesophageal reflux disease (GERD) patients.

Patients received a comprehensive diagnostic workup with endoscopy, wireless pH studies, endoFLIP, and manometry. We also performed endoluminal (the Stretta procedure and transoral incisionless fundoplication) and laparoscopic/revisional antireflux operations. Some of these procedures were completed locally in large numbers prior to their implementation in larger hospitals.

Aspirus Iron River Hospital recently added sedation-free, robotically controlled capsule endoscopy. It is one of only eight hospitals in the US, and the only critical access hospital, using this new technology (see photo). The capsule can be maneuvered with robotic assistance to thoroughly examine the stomach without the need for sedation, preoperative lab work, or discontinuing anticoagulants.

Using the technology, we were the first hospital in the world to visualize antireflux valve (transoral incisionless fundoplication [TIF]) in the collapsed normal position without being stented by a gastroscope.

This breakthrough has the potential to allow surgeons to examine the dynamics of the gastroesophageal junction in an awake GERD patient without endoscopy. We presented this discovery at an emerging technology session of the Society of American Gastrointestinal and Endoscopic Surgeons 2023 annual meeting.

My hospital is one of many inspiring examples of rural centers that embraced modernizing or even revolutionizing surgical services. Using robots in rural hospitals and establishing local niches in general and orthopaedic surgery is promising.

Proponents of this approach are not opposed to judicious cuts in particular services or supplies; however, they acknowledge that rural hospitals simply cannot cut their way to success. It is growth and expansion that ensures a hospital's financial survival.

In summary, skeletonizing the scarce resources of rural hospitals has theoretical advantages, which evaporate with the realization that it may result in the malfunction, and possible collapse, of both the rural and urban health systems.

A better investment is to modernize and train surgeons to have thriving careers in rural America where they can serve the rural patients in their own communities.

Until serious strides are made, every rural surgeon should ask themselves one question: What services do I provide that will make patients bypass other hospitals to come to me? 

Disclaimer

The thoughts and opinions expressed in this viewpoint article are solely those of Dr. Fanous and do not necessarily reflect those of the ACS.

Dr. Medhat Fanous is a general surgeon at Aspirus Iron River Hospital in Michigan.