I guess it depends on what you consider rural. Do you have a city size example for me? Like I interviewed at Geisinger which is super rural but their hospital is also a fortress capable of nearly anything. Most places that have a general surgery residency aren't *that* rural. Compared to a major city, sure. I did my residency in the suburbs of Philadelphia north of Temple. We did a rural-esque rotation to a hospital an hour North with a population of 16k and maybe at best a 100k catch radius. I would say the pace of life is dramatically different, surgical techniques can be 5-10 years behind the curve and a lot of that can be due to equipment. Its not economical for smaller/rural hospitals to have lots of expensive specialized equipment. Doesn't mean that surgeons have bad outcomes or do the wrong operations, quite the contrary. They often have better anatomical knowledge because they've been doing true general surgery their entire career. But don't be surprised to see older techniques and bigger incisions. The pace of life is MUCH slower and more laid back. The complexity of the patients is generally lower. The acuity is not. There's stuff you have to transfer. And you will usually need to do away rotations at high volume places for things like peds, trauma, transplant, HPB. (This is common even in larger programs).
Surg onc fellowship lifestyle varies by program. Mine is probably, honestly, the easiest. I'm in a massive quaternary system that was originally a more of a giant health conglomerate (still is) but has really embraced its GME stuff and was such high volume they felt they could really deliver a unique experience in surgical oncology. Because of that we have a veritable army of PAs that do all of the "work" you would normally think of - orders, paperwork, discharges, dealing with floor stuff, pages, even consults. As fellows we are essentially treated as attendings. We have full autonomy for decision making, ordering studies, talking to patients and giving them direction of their care, path, calling families. Pretty much the only thing we don't do is the time out for legal reasons. In the operating room at my fellowship I have way more autonomy than I did in residency (and in residency I already had a ton of autonomy in my community program) - my attendings will often even let me go through with things they disagree with which predictably usually results in me making a minor mistake and making a vein bleed that they then expect me to fix. They're very invested in making sure once I leave fellowship, if I'm practicing alone, I have sound judgement, can get myself out of trouble, know when to call for help, and can learn from mistakes to become a better surgeon once I'm no longer under the training umbrella. Hours are better but again that's largely due to the PAs that were in place before the fellowship started. Volume at my program is too much for the fellowship to even begin to capture because we have no residents. We capture all of HPB/surg-onc/sarcoma, but only get about 1/12th of colorectal, head and neck, breast, etc etc. pick your sub-rotation. Could probably support at least 4 fellows (we have two) if not six because of not having residents. I have six months of fellowship to go, am actively not chasing cases anymore and focusing on what I find interesting, and have 350 cases in 1.5 yrs of fellowship. Minimum volume is 170 and I exceeded all of the categories probably like 9 months into fellowship. They also have done an excellent job teaching me complex robotics and I've done a couple skin to skin robotic whipples solo with the attending regaling us all of his exploits on his hunting trips. (Short version - he can't shoot a shotgun to save himself and never gets anything. He would die in the zombie apocalypse.)
