Smaller hospitals often fear that “market share” will be devoured by larger organizations. Rural communities frequently fear that they will lose their local hospital altogether, which is often their largest employer. In reality, by fostering both higher volume and higher-acuity care in rural affiliates, larger systems can reduce congestion evolving in urban ORs. There simply isn’t enough space for all of the work that needs to be done to have it all be done in urban facilities, when routine surgery could be done safely in rural affiliate hospitals. The 60-120 million rural Americans are not always willing nor able to go to urban surgical settings for routine procedures. As the surgical needs of the boomers reach their apex, it is critical that rural hospitals increase the acuity of care they deliver, while simultaneously increasing the volume of care they deliver to avoid a crisis of surgical congestion in urban settings. This is not only financially best for rural hospitals, it is likely safer for older patients to receive the care they need closer to their homes.

“The cultural expectation of being ‘ever-accessible’ was a feature of the training of a post-World War cohort that is neither necessary, nor desirable, in the presence of clinical supports such as hospitalists and advanced practice office staff physician extenders. Nonsurgical management demands should be reduced by these supports, but are those supports present?”

Ironically, rural facilities frequently have more available OR time than can be used by the available providers. Younger and more recently trained surgeons may not wish to practice in smaller settings. Merritt Hawkins, a nationwide physician search firm, conducted a survey in 2017 of final-year residents which concluded that only 3% of the respondents would prefer to practice in a community of 25,000 or less (asamonitor.pub/3pyJxsF). The obstacles that interfere with care delivery in rural settings are probably worst for general surgery. The aging and retirement of general surgeons in rural settings is causing a crisis of rural general surgery provision, according to many surveys and assessments of needs (asamonitor.pub/3pJqEmQ). It is common for older general surgeons to be willing to be “on call” more often than is acceptable to recently trained graduates. To some extent, this reflects that younger surgeons are more likely to have younger children requiring parental participation in school, sport, and other social events. But the cultural expectation of being “ever-accessible” was a feature of the training of a post-World War cohort that is neither necessary, nor desirable, in the presence of clinical supports such as hospitalists and advanced practice office staff physician extenders. Nonsurgical management demands should be reduced by these supports, but are those supports present?

The trends continue to worsen. Rural general surgeons are older than their urban peers (J Rural Health 2021;37:762-8). In 2019, 59.4% of the general surgeons in small/isolated rural areas were 50 years of age or older, compared to 48.8% in urban areas. Between 2001 and 2019, the per capita supply of general surgeons in the U.S. decreased by 18% overall and by 29.1% in rural areas (J Rural Health 2021;37:762-8; asamonitor.pub/43dCaEE; asamonitor.pub/44hH7h3). A survey of rural hospital administrators in 2008 revealed that 34% of rural hospitals had a surgeon leaving within the next two years, more than one-third of rural hospitals were searching for a surgeon at the time, and the total number of general surgeons practicing in rural communities is decreasing approximately 0.5%-1.0% annually (Surgery 2008;143:599-606). As is felt to be true for anesthesiology, training to the setting is thought to increase recruitment of new surgeons: “[A]t the department of surgery at the University of Wisconsin (UW) School of Medicine and Public Health, the rural general surgery residency track is (sic) helping fill the need for surgeons in underserved parts of the state, giving students the training necessary to serve patients in rural and community practices” (asamonitor.pub/3PQx51Z). Pediatric general surgery is especially difficult to maintain in rural settings. A 2020 survey published by the American College of Surgeons revealed that “… a cadre of surgeons trained at a time when they became comfortable taking care of some children …” but “… many surgeons lack a succession plan, and their respective hospitals will need either to recruit a replacement with similar expertise, which seems unlikely, or send all of the (pediatric) patients to a regional center” (asamonitor.pub/3pF8iTN).

Otolaryngology is another important service in rural settings. Children in need of myringotomy, adenoidal, and tonsillar surgeries face barriers to access. Dwight T. Jones, MD, Chair, Department of Otolaryngology at the University of Nebraska, describes his department’s experience in expanding rural care services. They established an extensive telehealth program with our patients who were driving two to seven hours to see us. This included wound checks, tonsillectomies, sinus care, and patients with head and neck cancer patients” (asamonitor.pub/3NNZFyr). In the Canadian health care system, “Rural patients experience more barriers to care and travel longer distances compared to their urban counterparts,” Dr. Jones said. “…travel to urban centers in order to access (pediatric ENT) care … requires an average travel distance of 496 km (317 miles)” (asamonitor.pub/3pIfa2S).