Hello readers, I hope everyone had an enjoyable summer and is off to a smooth start of the academic/fiscal (depending on your practice setting) year. This month, we welcome an ASA member from New England and an expert on rural medicine, Dr. Shaan Alli. Dr. Alli will enlighten us on the different challenges and altered goals that arise as we venture further from metropolitan areas, leaving behind a heavily industrialized, well-established support system. All would agree that the world feels smaller today due to media and technology, but is it truly smaller? Dr. Alli will help us figure that out.
Dr. Alli, thank you for joining us. Please describe your current position and responsibilities.
I am honored to showcase the exciting world of rural anesthesiology practice. I serve as the chair of anesthesiology at a rural hospital in Vermont. I oversee the day-to-day operations of the department, which includes ensuring that there is adequate anesthesiology coverage for the operating rooms, non-operating room sites, and our (unpredictable) obstetrics suite. Given the current shortage of health care workers, this requires some creativity. The administrative structure of our operating room includes an “Operating Room Governance Committee” that is charged with not only the daily operations but also with strategizing for the future. Operational planning includes implementation of new service lines as well as expansion/contraction of existing service lines.
Another component of my position entails implementation of policies and procedures to ensure that we are in alignment with current standards of anesthesiology practice and are meeting regulatory requirements. However, my favorite part of my current position is providing direct patient care. My clinical responsibilities include providing both solo anesthesia care as well as supervising anesthesiology assistants, for a variety of cases, e.g., obstetrics and gynecology, orthopedics, general surgery, podiatry, and otolaryngology (which includes pediatrics). My department also assists with central line/arterial line placement, intubations, and acute interventional pain management.
How do you define/delineate the concept of “rural”? And what got you interested in rural practice?
During my residency, some of my favorite attendings were incredibly versatile. They were the types of physicians who were comfortable doing a variety of cases, including pediatrics and obstetrics. What these attendings had in common was that they had all worked in smaller private practices for some time before returning to academics. They were comfortable providing solo care and doing many cases that some of the more “specialized” attendings were not comfortable with. I appreciated that level of versatility and wanted to emulate that in my own practice.
My wife and I would take weekend trips to Vermont for hiking, camping, biking, skiing, etc., and we thought it would be great to live close to those activities. Our rural town is much more affordable than the city we left at the end of my fellowship, which allowed me some leeway in paying back student loans. So, the idea developed as we spent time in rural areas. Rural practice seemed as though it would be a great fit for the lifestyle I envisioned for myself and my family, along with being more affordable. In truth, it has been much better than I could have imagined.
Technically, any area that is not urban is considered rural by the government’s (specifically HHS) Health Resources and Services Administration. The next closest hospital to my own is about an hour away, which speaks to the sparseness of the community. In much of my hospital’s catchment area, patients needing a Level I trauma center have to be airlifted. A simple illustrative concept: “You might be in a rural area if… you routinely see farm animals on the way to work.”
What aspect of rural practice is most different from urban/suburban practice?
The biggest difference between urban/suburban and rural practices is the availability of resources. This includes technology, educational resources, and perhaps our most important asset, available staff. My group consists of four physicians and five anesthesiologist assistants, so our team is not large enough to have multiple physicians on call. The CAAs take backup calls in the event there is an ongoing OR case and a concurrent emergency that needs to be attended to. This means that the physician anesthesiologist on call is providing solo care without in-house backup. On this basis, I always have advanced airway equipment in the room in case I encounter a difficult intubation, and I think through the difficult airway algorithm before taking any patient to the operating room, as help can be 30 minutes away. This situation can be very intimidating to a new attending. I live five minutes from the hospital, so I let my colleagues know that they can always call if they need help in a pinch. So, in that sense, I am perpetually on call.
What is most challenging about the structure of perioperative medicine in rural settings?
The daytime operations of the operating room are mostly predictable. However, the late afternoons and evenings present a bigger challenge. As we have only one anesthesia team and one nursing team, this leaves us vulnerable to multiple and/or simultaneous emergencies. This usually occurs in the obstetric suite, but potentially in the ICU and ER also. Communication with the OB team is paramount. Our surgeons are very cooperative and understand that OB is given priority, and therefore their case may be postponed/delayed if there are active patients on labor and delivery. Implementing and calling a second team can sometimes be necessary. Another aspect of this structure is to consider your personal limitations before initiating care of a patient. A second anesthesiologist is not immediately available, so anticipation of what can go wrong is important, as is calling for backup as early as possible. As mentioned, our CAAs serve as the first option for backup; calling another physician or second CAA is the next step. Regardless, your backup can be up to 30 minutes away.
What do you find most rewarding about working in a rural setting?
There are many aspects of working in a rural area that are incredibly rewarding. Practicing in an area where there is a shortage of physicians is truly an honor. Patients and staff alike often thank me for providing service in this area, so the care I provide feels genuinely appreciated. Another rewarding aspect is that our hospital is truly a “community” hospital in every sense of the word. It’s not unusual to take care of a neighbor or a family/friend of a staff member. Patients feel very comforted being cared for in their own community. The hospital network is seeking new ways of keeping patients in our care network and expanding our service lines.
Which services are most crucially affected by ruralness/remoteness: obstetrics, trauma, cardiothoracic, etc.? And how do you manage these obstacles?
It’s difficult to pick a single service, as most services are affected. One of the most obvious services that is greatly impacted by living in a rural community is obstetrics. There have been many reports of rural hospitals closing their obstetrical units over the last few years, forcing families to drive great distances to deliver. Consider the stress of driving someone in labor to the hospital in the treacherous winter weather in the northern states. For hospitals that do provide obstetric services, the care may be limited to those with low-risk pregnancies. Various types of surgeries can also be limited because of the level of postoperative care that is needed. For example, we do not have intensivists on site in our hospital, only telehealth ICU coverage.
I assume there is a shortage of physicians in rural areas disproportionate to that seen in urban areas. Can you comment on this?
This is true for primary care as well as specialists. Applicants are often concerned about “losing skills” if they take a job in a rural hospital that does not offer thoracic, cardiac, or neurosurgical cases. This is a legitimate concern. However, there are many other types of skills that are gained by practicing in this setting. In many rural practices, the anesthesiologist might care for a laboring patient, pediatric patient, and perform regional blocks or place a thoracic epidural, all on the same day. In larger hospitals, anesthesiologists are often limited in the types of cases they perform. As an example, many large departments only use specialized teams for obstetrics, so, in that scenario, an anesthesiologist could actually lose those skills.
Is there a role (due to necessity) for increased scope of practice for “generalists” in rural settings, whether in anesthesiology or other specialties?
The general training offered by anesthesiology residencies is actually reflective of what is expected to be performed in a rural hospital. In many parts of this country, “generalist” anesthesiologists can be called upon to manage ventilators in the ICU and perform chronic pain procedures in addition to providing anesthetic care for surgical cases.
What is the most unusual thing you have encountered in your practice thus far?
Surprisingly, I have not encountered anything really strange. There are certainly things that you would not see in an urban environment, such as a hunter injured by falling out of a tree stand or having a tree fall on someone who was cutting it down, but nothing absurdly out of the ordinary.
Any advice for trainees considering a career in a rural setting?
Residents interested in practicing in a rural setting should do a rotation in a rural hospital. ASA has a Rural Access Scholarship that helps residents fund a rotation in a rural hospital (asamonitor.pub/3ofUTxa). Many residents have inflexible curricula and may not have time for an additional rotation, so e-mailing one of the mentors on the list would be another starting point. Finding a good mentor, as any new attending anesthesiologist should, is hugely important. Trainees should also be aware that many smaller community hospitals are affiliated with networks containing larger hospitals. These health systems can provide an alternate/additional practice venue that is non-rural, thereby helping mitigate concerns of losing certain skills.
What do you like to do in your spare time?
My wife and I chose a rural setting because we wanted to be closer to nature. We chose to live in a state that many people visit for vacation, and we take advantage of the great skiing, mountain biking, and hiking that is available close to our home. We have pollinator gardens that we tend to and also own a horse. This would not have been possible in an urban area.
Any parting words for our readers?
There is a great need not only for physician anesthesiologists but also for all specialties of medicine in rural areas. It is relatively easy to create a satisfying career and a great lifestyle in a community that aligns with your values, given the vastness and diversity of this country.