Integrated health system builds collegial network of rural surgeons

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Two-way relationship with referral center is key

The rural surgeon needs some financial assurance, a reasonable call schedule that allows him/her time away from the job without compromising the care of patients in his/her town, regulatory relief, and a relationship with a “mother ship” referral center that is a true two-way street. The days of the independent private solo practitioner are numbered, and the statistics bear this out. The convergence of declining reimbursement, increasing burden of scrutiny and documentation placed by payers and the government, and an emerging workforce that values work-life balance all contribute to the need to develop programs like this one at Gunderson to maintain the surgical workforce in our small towns. Rural surgery comes with a great deal of intrinsic reward, which makes it an excellent career, if these obstacles can be overcome.

Mark Savarise, MD, FACS, is a general surgeon practicing in South Jordan, Utah, and is clinical associate professor of surgery at the University of Utah, Salt Lake City. He has no disclosures.


Recruiting and retaining general surgeons is a longstanding problem for rural hospitals. A regional medical system in the Upper Midwest tackles this challenge by integrating small-town general surgeons into the network and emphasizing professional development, fair compensation, and a sustainable call and leave schedule.

The Gundersen Health System (GHS) is a physician-led, nonprofit health care network that operates in 19 rural counties in parts of Wisconsin, Minnesota, and Iowa, with its main campus in La Crosse, Wis. The network, established over a period of almost 40 years, is a mix of larger GHS medical centers, community hospitals, medical clinics, and GHS-managed and independent critical access hospitals (CAHs).

Dr. Thomas H. Cogbill is a general surgeon who practices at Gundersen Health Clinic.
Dr. Thomas H. Cogbill
Two surgeons practicing at Gundersen – Thomas H. Cogbill, MD, FACS, and Marilu Bintz, MD, FACS – conducted a seven-question survey of the general surgeons in their regional network to collect data on the demographics of this group, the surgeons’ work profiles, and their reasons for taking and for remaining in their positions. Currently, there are nine GHS-employed general surgeons practicing in the small towns around La Crosse. These general surgeons provide care at critical access hospitals both within and outside the GHS network. The study, published in the Journal of the American College of Surgeons (2017 Jul;225[1]:115-23), provided some lessons on successful strategies based on responses to the survey and the experience of Gundersen over the past 38 years.

A sustainable model

“It is clear that the older paradigm of a single rural surgeon providing care 24/7 to an isolated community is vanishing. Design of a more sustainable model involves small groups of rural surgeons working together to provide general surgery and some subspecialty care locally, but who are also part of a larger network for administrative and clinical support,” said Dr. Cogbill in an interview.

Dr. Marilu Bintz is a general surgeon who practices at Gundersen Health Clinic.
Dr. Marilu Bintz
The Gundersen Health System involves a cooperative and collaborative relationship between the surgical services on the main campus in La Crosse and the GHS-employed general surgeons in smaller communities in the surrounding region. The emphasis is on competitive salaries, reasonable call and leave schedules, administrative support, and adequate case variety and volume. The objective is to develop collegial, mutually supportive relationships, not only between GHS and the rural general surgeons it employs but also among the community surgeons.

Lessons learned

Dr. Cogbill said, “Our 38-year experience with rural surgery in our region has taught us many lessons. The strategy of trying to place a solo general surgeon in every small town with a CAH within our service area was not sustainable nor practical. The development of several rural centers of care within our region has allowed us to be more successful in the recruitment and retention of rural general surgeons who are hired to be part of a small group (optimally three) who provide care to their home community as well as outreach surgical care to several outlying CAHs near their home CAH. This has made it possible to offer a reasonable call schedule, mutual assistance, and the chance to build adequate case volumes. Connectivity to the health system should not mean ‘send all the great cases to the main campus,’ but instead should support the rural surgeons in performing appropriate cases locally.”

The survey respondents were aged 36-55 years, five were male, and all were graduates of U.S. medical schools. Eight are board certified and seven are either fellows or associate members of the American College of Surgeons. Their tenure in the GHS system averaged at least 7 years, ranging from 2 years to more than 20. Their surgical logs for a recent 1-year period show a case mix of endoscopy (63.8%), general surgery (26.7%), and obstetrics (6.1%). Mean annual relative value units for the group were 3,627 (range 2,456-5,846).

One goal of the confidential survey was to explore the reasons behind these surgeons’ choice of a rural practice. Their primary motivations were a preference for a rural lifestyle and a desire for a broad scope of practice. Loan forgiveness motivated some (37.5%), and the influence of a mentor was important for others (25%). The opportunity to join an integrated health system such as GHS was deemed extremely important to seven of the respondents.

Retention of rural surgeons

The most important factors mentioned by survey respondents for remaining in their positions were lifestyle (87.5%), family (75.0%), relationship with patients and colleagues, and scope of practice (75.0%), and compensation (62.6%).

Reasons to consider leaving were call burden (37.5%), relationship with the local hospital (25.0%), and compensation (25.0%).

The survey also looked at potential retention of these general surgeons in the coming 5 years: 37.5% said they were somewhat likely to remain, 25% said they were very likely to remain, and 37.5% said they were extremely likely to stay.

Two successful strategies have been promoting a satisfactory case mix and comanagement of patients who are referred to the main campus. The surgeons from the small towns are encouraged to come to La Crosse to assist in procedures on referred patients, to teach in the surgical residency and the Transition to Practice General Surgery fellowship programs at Gundersen, to participate in clinical research activities, and to engage in a variety of professional activities that strengthen the bonds between GHS and rural surgeons. These interactions help minimize professional isolation, a serious problem for surgeons working on their own in small communities.

Communication is maintained electronically. “Our system includes the use of a common EMR across the entire system allowing mutual access to both inpatient and outpatient records, including full access to digitized diagnostic imaging. GHS has established a number of distance-learning telemedicine links between the main campus and the rural communities that permit real-time patient consultations as well as participation in teaching conferences including Morbidity and Mortality Conferences.”

Reducing burnout in rural surgeons

The GHS model may have some impact on burnout among the rural surgeons in the system, said Dr. Cogbill. “Rural surgeon employment as part of a fully integrated regional network has the potential to reduce the magnitude of burnout by providing administrative assistance to help navigate bureaucratic complexities, easy access for subspecialty consults with colleagues who are known entities, and a model of rural surgery involving pods of three colleagues who can share call, mutual assistance, and case volumes.” Fair and competitive compensation and some degree of loan forgiveness have been in the mix of factors that have helped with recruitment. Administrative assistance from the main campus eases the clerical burden the surgeons face. Guaranteed free time for vacations and educational meetings, as well as a reasonable call schedule, are all built into contracts; this has had a big impact on recruitment. GHS has concluded that three general surgeons in a community is the optimal number to maintain call coverage and mutual assistance. Dr. Cogbill said, “The call schedule is managed by each “pod” of rural general surgeons themselves. With a full complement of three rural surgeons in a pod, they maintain an every third night call schedule. In towns in which there are fewer than three surgeons, the GHS surgeons often share call with surgeons who are not part of GHS to maintain a reasonable/sustainable call schedule.”

The retention track record at GHS is impressive. Since 1978, 19 rural general surgeons have been employed by GHS. Four (21%) rural general surgeons have retired 10 (53%) continue to practice in the network; only 5 (26%) left prior to retirement. Six rural general surgeons practiced in one location for over 20 years.

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