Rural surgery

[ParachuteAdams]

Would love to hear people's experiences of training and/or practicing in rural areas. I've been toying with the idea of working in a critical access hospital up in the mountains one day.

What is the scope of practice like for general surgeons out in the boonies? What is life like for specialists? Are you satisfied with your job? Do you feel valued in the community?

What is the job market and starting salary like? Level of autonomy?

Are you always on call since there's nobody else? Do you work more or less hours than your urban counterparts?

Thanks in advance.

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[anatomist_surgeon]

I'm a gen surg resident who's interested in community/rural practice and did an extended rural surgery rotation in medical school so I can provide something of an answer to this but obviously the answer will vary by practice setting and attending. The attending I worked with was in a 25 bed critical access hospital, nearest larger facility was ~2 hours away by road during good weather. Scope of practice in a rural setting is often as wide as you and your hospital feel comfortable with. With that surgeon we did the usual bread and butter general surgery stuff (hernias, appy's, gallbladders) as well as thyroids/parathyroids, dialysis access, and colons. Also a high volume of endoscopy which seems typical for most rural practices. He also did some hand surgery (carpal tunnel release, trigger fingers, etc) and ENT stuff like tonsils and adenoids and ear tubes. He also first assisted the FP/OB on c-sections fairly frequently. He seemed very satisfied with his job and was very valued by the community and hospital. A busy general surgeon can often be the difference between a hospital operating in the red or black for the year which comes with some respect and appreciation by hospital administration that may not be found in a bigger hospital/practice. There is significant demand for general surgeons in rural areas and these jobs often pay better than jobs in larger urban centers. The downside: if he was in town he was on call. The hospital hired locums coverage to allow him to have two weekends off a month as well as 4 weeks of vacation/year but he was basically on call the remaining time. He rarely got called in during that time but still, if he was needed he was available. Trauma obviously isn't as frequent as at a busy county hospital but rural people still have the occasional gunshot wound and car accidents and he was the first point in the chain of care so he needed to be able to care for those things when they came in. We also still had plenty of gallbladders and appy's coming in through the ER but most of those got admitted to the hospitalist overnight and added to the OR schedule for the morning without requiring the surgeon to come in. Schedule was 4 days per week (M-Th), scopes or OR in the morning, clinic in the afternoon. Flexibility to add cases on for Friday when the surgeon was bored but not required. Because he was the only surgeon there, he had flexility to start cases when he wanted and so usually started at 8 am. He'd roll into pre-op at 7:45, do cases, round on inpatient's if present in between cases during room turnover. Seemed like he was typically in the hospital from 7:45 am - 5:30 pm M - Th and from 8 - 10 am on Fridays for 2-3 colonoscopies unless something was happening in the ED. Which, again, he was on call 24/7 except as mentioned. Overall didn't seem like a bad gig if you can tolerate being attached to your pager and ready to come in that often.

 

[Billroth_III]

I'm a gen surg resident who's interested in community/rural practice and did an extended rural surgery rotation in medical school so I can provide something of an answer to this but obviously the answer will vary by practice setting and attending. The attending I worked with was in a 25 bed critical access hospital, nearest larger facility was ~2 hours away by road during good weather. Scope of practice in a rural setting is often as wide as you and your hospital feel comfortable with. With that surgeon we did the usual bread and butter general surgery stuff (hernias, appy's, gallbladders) as well as thyroids/parathyroids, dialysis access, and colons. Also a high volume of endoscopy which seems typical for most rural practices. He also did some hand surgery (carpel tunnel release, trigger fingers, etc) and ENT stuff like tonsils and adenoids and ear tubes. He also first assisted the FP/OB on c-sections fairly frequently. He seemed very satisfied with his job and was very valued by the community and hospital. A busy general surgeon can often be the difference between a hospital operating in the red or black for the year which comes with some respect and appreciation by hospital administration that may not be found in a bigger hospital/practice. There is significant demand for general surgeons in rural areas and these jobs often pay better than jobs in larger urban centers. The downside: if he was in town he was on call. The hospital hired locums coverage to allow him to have two weekends off a month as well as 4 weeks of vacation/year but he was basically on call the remaining time. He rarely got called in during that time but still, if he was needed he was available. Trauma obviously isn't as frequent as at a busy county hospital but rural people still have the occasional gunshot wound and car accidents and he was the first point in the chain of care so he needed to be able to care for those things when they came in. We also still had plenty of gallbladders and appy's coming in through the ER but most of those got admitted to the hospitalist overnight and added to the OR schedule for the morning without requiring the surgeon to come in. Schedule was 4 days per week (M-Th), scopes or OR in the morning, clinic in the afternoon. Flexibility to add cases on for Friday when the surgeon was bored but not required. Because he was the only surgeon there, he had flexility to start cases when he wanted and so usually started at 8 am. He'd roll into pre-op at 7:45, do cases, round on inpatient's if present in between cases during room turnover. Seemed like he was typically in the hospital from 7:45 am - 5:30 pm M - Th and from 8 - 10 am on Fridays for 2-3 colonoscopies unless something was happening in the ED. Which, again, he was on call 24/7 except as mentioned. Overall didn't seem like a bad gig if you can tolerate being attached to your pager and ready to come in that often.

Do you think most surgeons coming out of general surgery are equipped for rural surgery where you are doing basically "everything"? I've heard that doing and acute care or surgical critical care fellowship can better prepare you?

 

[Smurfette]

Do you think most surgeons coming out of general surgery are equipped for rural surgery where you are doing basically "everything"? I've heard that doing and acute care or surgical critical care fellowship can better prepare you?

There are programs that have rural surgery specific training pathways, as well as community programs that have large percentage of grads going into rural areas. I would recommend this type of set up over a CC fellowship. Rural surgery will be doing large percentages of endoscopy and perhaps also need to do c-sections; these programs know that and incorporate it more heavily in your training. Most traumas and complex critically ill patients (like what ACS fellowships train you for) are going to be transferred out in the rural setting as critical access hospitals don't have the resources to deal with those.

 

[deleted50541]

Most traumas and complex critically ill patients (like what ACS fellowships train you for) are going to be transferred out in the rural setting as critical access hospitals don't have the resources to deal with those.

Agreed. Just because you have the training to take care of those patients, doesn't mean you have the same resources at hand to help you keep them alive as you would at a tertiary center. The surgeons/physicians I know at such critical access facilities know their limitations very well and don't hesitate to call for a transfer. So unless you have a specific location in mind where ACS/CC training might be of added benefit, I don't think it's necessary for a rural surgeon with solid general surgery training.

Community programs are great for folks interested in a general surgery career in a rural setting. That said, I trained in a large academic program and three of my peers went directly into rural practices after graduation. We could tailor our 5th year toward our areas of interest. So for instance, they spent extra time doing endoscopies with our colorectal surgeons knowing it would be a big part of their rural practices. One resident even spent some time with a neurosurgeon since she was expected to learn how to do burr holes at her rural hospital.

They all seem pretty satisfied in their jobs. I wouldn't say they necessarily felt they could "do everything", but they had a skill set from residency that allowed them to be flexible and adapt to the needs of the hospital/surgical group.

 

[longhaul3]

I'm a gen surg resident who's interested in community/rural practice and did an extended rural surgery rotation in medical school so I can provide something of an answer to this but obviously the answer will vary by practice setting and attending. The attending I worked with was in a 25 bed critical access hospital, nearest larger facility was ~2 hours away by road during good weather. Scope of practice in a rural setting is often as wide as you and your hospital feel comfortable with. With that surgeon we did the usual bread and butter general surgery stuff (hernias, appy's, gallbladders) as well as thyroids/parathyroids, dialysis access, and colons. Also a high volume of endoscopy which seems typical for most rural practices. He also did some hand surgery (carpel tunnel release, trigger fingers, etc) and ENT stuff like tonsils and adenoids and ear tubes. He also first assisted the FP/OB on c-sections fairly frequently. He seemed very satisfied with his job and was very valued by the community and hospital. A busy general surgeon can often be the difference between a hospital operating in the red or black for the year which comes with some respect and appreciation by hospital administration that may not be found in a bigger hospital/practice. There is significant demand for general surgeons in rural areas and these jobs often pay better than jobs in larger urban centers. The downside: if he was in town he was on call. The hospital hired locums coverage to allow him to have two weekends off a month as well as 4 weeks of vacation/year but he was basically on call the remaining time. He rarely got called in during that time but still, if he was needed he was available. Trauma obviously isn't as frequent as at a busy county hospital but rural people still have the occasional gunshot wound and car accidents and he was the first point in the chain of care so he needed to be able to care for those things when they came in. We also still had plenty of gallbladders and appy's coming in through the ER but most of those got admitted to the hospitalist overnight and added to the OR schedule for the morning without requiring the surgeon to come in. Schedule was 4 days per week (M-Th), scopes or OR in the morning, clinic in the afternoon. Flexibility to add cases on for Friday when the surgeon was bored but not required. Because he was the only surgeon there, he had flexility to start cases when he wanted and so usually started at 8 am. He'd roll into pre-op at 7:45, do cases, round on inpatient's if present in between cases during room turnover. Seemed like he was typically in the hospital from 7:45 am - 5:30 pm M - Th and from 8 - 10 am on Fridays for 2-3 colonoscopies unless something was happening in the ED. Which, again, he was on call 24/7 except as mentioned. Overall didn't seem like a bad gig if you can tolerate being attached to your pager and ready to come in that often.

There are programs that have rural surgery specific training pathways, as well as community programs that have large percentage of grads going into rural areas. I would recommend this type of set up over a CC fellowship. Rural surgery will be doing large percentages of endoscopy and perhaps also need to do c-sections; these programs know that and incorporate it more heavily in your training. Most traumas and complex critically ill patients (like what ACS fellowships train you for) are going to be transferred out in the rural setting as critical access hospitals don't have the resources to deal with those.

Great posts. Stupid question: does the general surgeon who does the C-section have to make the call that the C-section is indicated? i.e. how much obstetrical knowledge/training goes into developing that competency vs. just learning how to do the case when someone tells you it's indicated? On the one hand I would assume that if there's someone else there who is trained to make the call, that person could just do the case, but on the other hand it also seems like a lot of additional training for a general surgeon to take on to be independently competent as an emergency obstetrician. It's hard for me to picture a general surgeon crashing a patient to the OR based on a fetal heart tracing. Maybe the GS would only do the slam-dunk cases while the more obstetrically complex patients get transferred out? Or do they call an obgyn somewhere to consult over the phone?

 

[Med0123]

Great posts. Stupid question: does the general surgeon who does the C-section have to make the call that the C-section is indicated? i.e. how much obstetrical knowledge/training goes into developing that competency vs. just learning how to do the case when someone tells you it's indicated? On the one hand I would assume that if there's someone else there who is trained to make the call, that person could just do the case, but on the other hand it also seems like a lot of additional training for a general surgeon to take on to be independently competent as an emergency obstetrician. It's hard for me to picture a general surgeon crashing a patient to the OR based on a fetal heart tracing. Maybe the GS would only do the slam-dunk cases while the more obstetrically complex patients get transferred out? Or do they call an obgyn somewhere to consult over the phone?

in several centers (at least in Canada), an hospitalist/FM is making the call for a C/S to be done, and the surgeon is purely technician.

 

[Smurfette]

Great posts. Stupid question: does the general surgeon who does the C-section have to make the call that the C-section is indicated? i.e. how much obstetrical knowledge/training goes into developing that competency vs. just learning how to do the case when someone tells you it's indicated? On the one hand I would assume that if there's someone else there who is trained to make the call, that person could just do the case, but on the other hand it also seems like a lot of additional training for a general surgeon to take on to be independently competent as an emergency obstetrician. It's hard for me to picture a general surgeon crashing a patient to the OR based on a fetal heart tracing. Maybe the GS would only do the slam-dunk cases while the more obstetrically complex patients get transferred out? Or do they call an obgyn somewhere to consult over the phone?

No, it's the FP who does their own OB deliveries' decision. They just call when the pt needs a C/S.