Commentary: ACS Advisory Council tackles rural surgery crisis


The Advisory Council for Rural Surgery will be 2 years old in June 2014. Its creation resulted from the realization of ACS Leaders such as J. David Richardson, Brent Eastman, Patricia Numann, and the Board of Regents that a crisis was in process regarding surgical access in rural America.

The recognized crises in rural surgery are of interest to all surgeons. The core of therural surgical crisis is not just the access to surgical care for the estimated 60 million people of North America living in rural environs, but the role and sustainability of general surgery as a specialty in itself. General surgery, the parent of almost every specialty, has suffered a gradual attrition of its field through abdication or specialization.

Dr. Tyler Hughes

While not universal, the shift from surgical training to creating specialist surgeons who take care of limited areas of anatomy leaves the American public facing a fragmented surgical world and, in those places where there cannot be multiple surgical "superspecialists," patients’ lives and well-being will depend on well-trained general surgeons in small communities and rural areas.

The Rural Council is wrestling with these large and fundamental questions. How do we train and support surgeons who must work in geographically or temporally isolated areas? Of the 1,200 residents graduating from ACGME-accredited general surgical residencies, only 30% seek broad-based practice, which amounts to 360 surgeons per year. Of those 360, about 10% –-– 36 surgeons – will practice in rural areas. More than 500 hospitals are deemed Critical Access and do general surgery. On the ACS rural listserv, there are 1,000 rural-based surgeons; 52% of rural surgeons are within 10 years of retirement (not to mention attrition from other sources such as health or burnout). A simple calculation proves that not enough surgeons will be there for those rural patients. A helicopter or runway does not equal surgical access. It takes the cognitive skills of a general surgeon to know who truly requires surgical care and what type.

Given these facts, new approaches to retaining surgical access in rural areas are coming either through proactive planning by surgeons or as a result of other parties with other interests "solving" the crisis.

Centralization is attractive to policy makers, but not to the rural patient 50-100 miles away on a snowy night. In the Affordable Care Act legislation, the ACS was able to procure a 10% increase in reimbursement for surgeons in underserved rural areas, which is appreciated. However, the motivation to practice in rural locales is not and will not be driven solely by money, for the joy of rural practice lies in the fulfillment of doing a difficult job well for an entire community in which one becomes an integral part. Finding ways to make that sort of surgical life possible to young men and women is the best answer.

The Advisory Council for Rural Surgery therefore is touching many areas of surgery and the ACS. Like the rest of the College, we function in five pillars – Education, Optimal Care/Quality, Membership Services, Communications, and Advocacy. Each pillar is actively engaged. Education, under Karen Deveney, is working on templates for rural tracks in general surgery residency programs in alignment with ABS and RRC requirements as well as medical student and postresidency surgeon education. Optimal Care, under Don Nakayama, is developing infrastructure standards for rural hospitals as well as research mechanisms for rural surgeons to develop their data. Membership Service, under Mike Sarap, works on recruitment and retention of rural surgeons, call relief strategies, and community-based services on oncology issues. Advocacy is well guided by Mark Savaris, who in particular is working on repeal of the infamous 96-hour rule that threatens surgical access in some of our most-remote hospitals. The Communication pillar, under Phil Caropreso, has made enormous strides through the development of a rural listserv, which allows rural surgeons to communicate in real time on subjects ranging from case review to practice management. Through Dr. Caropreso’s tireless efforts, 1,000 surgeons communicate approximately 20-100 times a day. In total, more than 5 million e-mails have been distributed in 18 months. Soon, this will morph into the Rural Surgical Community, with much-improved software, which also will be used by the rest of the College Fellows in their respective fields of interest.

Rural surgeons, like most surgeons, pride themselves on being individualists who can solve problems with limited resources. The Advisory Council for Rural Surgery is helping these individuals find a common place for education, advocacy, quality care, communication, and fellowship. Rural surgery is transforming from disparate surgeons in isolated areas to a common group of Fellows dedicated to the highest principles of the American College of Surgeons.

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