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A comprehensive analysis of surgical procedures in rural surgery practices
The American Journal of Surgery (2010) 200, 820 – 826
A comprehensive analysis of surgical procedures in rural surgery practices Joel D. Harris, M.D., M.P.H., Clint C. Hosford, Ph.D., Robert P. Sticca, M.D., F.A.C.S.* Department of Surgery, University of North Dakota, School of Medicine and Health Sciences, Grand Forks, ND, USA KEYWORDS: Rural surgery; Procedures; Practice patterns; Caseload; CPT codes
Abstract BACKGROUND: Data regarding the practice patterns of surgeons are derived from indirect information and may not reflect practice patterns in rural surgery. The aim of this study was to analyze all procedures performed by rural surgeons in North Dakota and South Dakota in 2006. METHODS: All surgeons in the Dakotas were identified by state American College of Surgeons databases. Rural urban commuting area codes were used to identify rural surgeons. Current Procedural Terminology codes from clinic, outpatient, and inpatient procedures performed during 2006 were obtained. RESULTS: Data were obtained from 81% of rural surgeons. A total of 46,052 Current Procedural Terminology procedure codes were analyzed. Rural surgeons averaged 1,071 procedures/year, composed of 25.6% general surgery, 39.8% endoscopy, 17.9% minor surgery, and 12.3% surgical specialty procedures. Surgeons in small and large rural communities differed in total procedures per year (1,346 vs 988). Significant differences existed in the types of procedures performed by surgeons in large and small rural communities (P ⬍ .001). CONCLUSIONS: Rural surgeons perform a high volume of procedures, with endoscopic and minor surgical procedures comprising over 55% of their practices. Understanding rural surgeons’ caseload will help guide the training of rural surgeons. © 2010 Elsevier Inc. All rights reserved.
Approximately 1 in 5 Americans reside in a rural area. Much has been written about the demographics and distribution of surgical services provided by surgeons who treat rural populations.1 Efforts to characterize rural general surgery practice have previously relied on national databases and individual surgeon or small samples of pooled surgeon case logs (⬍8 surgeons).2– 4 These methods have provided some insightful analysis, yet they fail to comprehensively characterize rural surgery practice. In prior reports, the American Medical Association master file and American
* Corresponding author. Tel.: 701-777-3067; fax: 701-777-2609. E-mail address: [email protected] Manuscript received March 6, 2010; revised manuscript July 1, 2010
0002-9610/$ - see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2010.07.029
Board of Surgery recertification logs have been used to characterize rural surgery practice patterns. These databases include inpatient and outpatient procedures but are generated retrospective by self report.5,6 Analysis of these databases have led to the conclusion that rural surgeons perform, “substantially more total procedures than did urban ones . . . endoscopic procedures accounted for much of this disparity.”6 General surgeons practicing in rural areas were found to perform a variety of surgical subspecialty procedures that are routinely performed by obstetricians, otolaryngologists, urologists, and other surgical subspecialists in urban areas.6 The Nationwide Inpatient Sample and Medicare databases have been used to describe surgical experience in
J.D. Harris et al.
Surgical procedures in rural surgery practices
rural areas, yet these databases do not include office or same-day surgical procedures. Studies using samples from these databases have concluded that there are significant differences in the type and volume of surgical procedures performed in rural areas. VanBibber et al7 concluded that general surgical procedures make up 42% of rural inpatient procedures compared with 25% of inpatient procedures in urban hospitals. Rural surgeons were found to perform fewer procedures on the esophagus, stomach, large bowel, spleen, liver, pancreas, and thyroid compared with their urban counterparts.7 Developing a rural training curriculum as a part of surgical residency has been suggested as a means of “optimizing the training of surgical residents” who desire to practice in rural areas.2 However, until rural surgical practice is better characterized, such a curriculum would be based on hypothesized need. We sought to more accurately characterize rural surgery practice by creating a comprehensive database of all procedures performed by rural general surgeons in North Dakota and South Dakota during the calendar year 2006.
Methods All general surgeons practicing in North Dakota and South Dakota were identified by the respective American College of Surgeons databases in February 2007. Rural urban commuting area (RUCA) codes were assigned to each surgeon on the basis of the area code of his or her primary practice area. RUCA codes were developed by the Rural Health Research Institute to stratify ZIP codes into urban, large rural, small rural, or isolated rural on the basis of commuter flow in and around each ZIP code (Table 1). Exclusion criteria were surgeons whose primary practice areas were located within an urban RUCA code and surgeons performing ⬍50 procedures annually. Rural surgeons were contacted by telephone and permission was requested to obtain all Current Procedural Terminology (CPT) codes logged in calendar year 2006. A comprehensive collection of CPT codes was solicited from all clinic, outpatient and inpatient procedures during the study period. Data were provided by a member of each provider’s coding or billing staff. Surgeons were guaranteed that their
Table 1 codes
Definitions of rural classification based on RUCA
821 Table 2 CCS code assignment for general surgical procedures General surgery procedure
CCS Codes
Trachea Esophagus/stomach Small and large bowel
34, 35 71, 74, 93, 94 72, 73, 75, 78, 79, 92, 95, 96 77, 81 80 66, 67 84 245, 246 10–12 85, 86 165–167, 174, 175 168–173 68–70, 76, 82 87–90, 97, 99
Rectal/anal Appendix Spleen/lymph Cholecystectomy/common bile duct Liver/pancreas Endocrine Hernia Breast Skin/soft tissue Endoscopy Other abdominal
individual data would be aggregated to a RUCA category and could not be traced retrospectively to individual surgeons. Microsoft Excel 2002 (Microsoft Corporation, Redmond, WA) was used to create a database consisting of surgeon RUCA code, CPT code, and procedure volume (number of procedures for each CPT code). Clinical Classification Software (CCS) was used to condense the CPT codes into clinically relevant categories for analysis. CCS was developed by the Healthcare Cost and Utilization Project and consists of 244 unique codes.8 There were no CCS codes specifically designated for liver or pancreas procedures, so these procedures were reclassified into 2 new CCS codes. Code 245 was assigned to liver procedures (CPT codes 47000 – 47130 and 47300 – 47399), and pancreas procedures were assigned code 246 (CPT codes 48000 – 48548 and 48999). CCS codes were collapsed into 14 categories comprising procedures that are classically performed by general surgeons (Table 2). Surgical specialty procedures were defined as a group of procedures within a surgical specialty that are often performed by general surgeons in rural areas but are not typically considered “classic” general surgery procedures. Surgical specialty procedures collectively made up 8 categories (Table 3). Analysis of the data was performed using SPSS version 17 (SPSS, Inc, Chicago, IL). Chi-square analyses were used to compare frequency distributions between small and large rural areas, and the Mann-Whitney U test was used to assess for differences between surgeons’ overall practice patterns.
Categorization Definition Isolated rural Small rural Large rural
Population ⬍2,500 without commuter flow to a larger area Population 2,500 to 9,999 or census tracts with commuter flow to such an area Population 10,000 to 49,999 or census tracts with commuter flow to such an area
Results Fifty-eight rural general surgeons were identified in North Dakota and South Dakota after applying RUCA codes to the North Dakota and South Dakota American College of Surgeons database. Attempts to contact all 58
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Table 3 CCS code assignment for surgical specialty procedures Specialty procedure
CCS Codes
Orthopedics
142, 143, 145–148, 152, 153, 155–164 119–132, 134, 137, 140 100, 104, 106, 109–112, 114–118 51–57, 59–61, 63 23, 25–27, 30–33 3–9 36–42, 44, 48, 49 19
Obstetrics and gynecology Urology Vascular Otolaryngology Neurosurgery Cardiothoracic Ophthalmology
surgeons revealed that 3 had retired or relocated outside of the Dakotas. Four surgeons refused participation or did not respond to multiple phone calls, faxes, or e-mail contacts. Three surgeons were nearing retirement or primarily providing family practice medical care in their communities and performing ⬍50 procedures per year. Six surgeons desired participation, but their procedure data could not be accessed by their coders or was not permitted to be released by their hospital administration. One additional surgeon was identified who met study criteria but was not listed in the American College of Surgeons database. Data were obtained from 43 of 53 surgeons who met the inclusion criteria (an 81% response rate; Fig. 1). A total of 46,052 procedures were performed in calendar year 2006 by the 43 surgeons who contributed CPT codes to create the Dakota Database for Rural Surgery (DDRS). Surgeons practicing in isolated (population ⬍ 2,500) and
Figure 1
small (population ⬍ 10,000) RUCAs were combined into 1 category (small rural) because there were very few (3 surgeons) who practiced in isolated rural areas. The collected data revealed that 10 surgeons practiced in small rural areas, whereas 33 surgeons practiced in large rural areas. All rural surgeons performed a mean of 1,071 (median, 863) procedures in 2006. The 10 surgeons practicing in small rural areas performed a mean of 1,345.8 (median, 930.5) procedures, compared with 987.7 (median, 863) procedures performed by their counterparts in large rural areas. Despite these sample differences, results of the Mann-Whitney U test indicated that the differences were not significant (U ⫽ 159, P ⫽ .86, r ⫽ ⫺.26). When analyzed by the categories of general surgery and surgical specialty procedures, the small rural area surgeons performed a mean of 1,172.2 (median, 824.5) general surgery and 173.6 (median, 52.5) specialty procedures, whereas large rural area surgeons performed 868.6 (median, 757) and 119.1 (median, 87) general and subspecialty procedures, respectively. These differences also were not significant (U ⫽ 155, P ⫽ .77, r ⫽ ⫺.044 and U ⫽ 138, P ⫽ .44, r ⫽ ⫺.12 respectively). Endoscopy made up 39.8% of rural general surgeon caseload, with surgeons in small rural areas performing a higher percentage (41.7%) than surgeons in large rural areas (39%). Minor surgical or skin and soft tissue procedures composed an additional 17.9% of rural surgeons’ caseloads, also representing a larger portion of the small rural surgeons’ practices (23.2% vs 15.7%). When combined, endoscopy and minor surgery procedures constituted most rural surgeons’ case production, with a 10.2% predominance in small rural versus large rural practices (64.9% vs 54.7%). Significant differences were identified in procedure
Flowchart identifying potential study participants.
J.D. Harris et al. Table 4
Surgical procedures in rural surgery practices
823
Surgical procedures performed by surgeons practicing in small and large rural areas
Procedure
All surgeons procedure frequency*
Small rural surgeons (n ⫽ 10)
Appendectomy Bowel (small and large) Breast Cholecystectomy/CBD exploration Endocrine Endoscopy Esophagus/stomach Hernia Liver/pancreas Other abdominal Rectal/anal Skin/soft tissue Spleen/lymph Trachea Specialty procedures Total
1,030 1,507 2,278 2,891 126 18,307 740 2,841 175 651 1,252 8,240 329 19 5,666 46,052
204 384 326 517 10 5,611 61 687 26 180 531 3,118 62 5 1,736 13,458
(2.2%) (3.3%) (4.9%) (6.3%) (.3%) (39.8%) (1.6%) (6.2%) (.4%) (1.4%) (2.7%) (17.9%) (.7%) (.04%) (12.3%) (100%)
Large rural surgeons (n ⫽ 33)
(1.5%) (2.9%) (2.4%) (3.8%) (.1%) (41.7%) (.5%) (5.1%) (.2%) (1.3%) (3.9%) (23.2%) (.5%) (.04%) (12.9%) (100%)
826 1,123 1,952 2,374 116 12,696 679 2,154 149 471 721 5,122 267 14 3,930 32,594
(2.5%) (3.4%) (6.0%) (7.3%) (.4%) (39.0%) (2.1%) (6.6%) (.5%) (1.4%) (2.2%) (15.7%) (.8%) (.04%) (12.1%) (100%)
P†
OR (95% CI)
⬍.001 .001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 .374 ⬍.001 ⬍.001 ⬍.001 .780 .012
1.69 1.21 2.57 1.97 4.80 .89 4.67 1.32 2.37 1.08 .55 .62 1.78 1.16 .93
(1.45–1.97) (1.08–1.37) (2.28–2.89) (1.78–2.17) (2.52–9.17) (.86–.93) (3.59–6.08) (1.20–1.44) (1.56–3.60) (.91–1.29) (.49–.61) (.59–.65) (1.35–2.35) (.42–3.21) (.87–.98)
CBD ⫽ common bile duct; CI ⫽ confidence interval; OR ⫽ odds ratio. *Percentage is based on total frequency of general and specialty procedures. †Based on 2-sided 2 test.
volume in several categories of procedures when comparing surgeons practicing in small and large rural areas (P ⬍ .05). Rural surgeons practicing in small rural communities performed a statistically greater number of endoscopy, anal or rectal, skin and soft tissue, and specialty procedures. Surgeons in large rural areas performed statistically more procedures in the following categories: appendectomy, bowel, breast, gallbladder or common bile duct, endocrine, esophagus or stomach, hernia, liver or pancreas, and spleen or lymphatic (Table 4). Specialty operations constituted the third largest category of rural general surgeons’ caseloads, making up 12.3% of the procedures (Table 5). Vascular and obstetric and gynecologic procedures made up 56.3% of the specialty procedures performed by rural general surgeons. Statistically significant differences were identified when compar-
Table 5
ing specialty procedures performed in small and large rural areas (P ⱕ .015). Surgeons in small rural areas performed more obstetric and gynecologic and orthopedic procedures, whereas surgeons in large rural areas performed more cardiothoracic, urologic, neurosurgical, and vascular procedures.
Comments The current practice and future role of general surgery in rural areas is an often debated topic, with few supporting data to guide the discussion. The DDRS, containing ⬎46,000 procedures, is the most comprehensive database on rural general surgery practices that has been generated to
Specialty procedures performed by rural general surgeons practicing in small and large rural areas
Specialty procedure
Procedure frequency*
Small rural
Large rural
P†
OR (95% CI)
Cardiothoracic Neurosurgery Obstetrics and gynecology Ophthalmology Orthopedics Otolaryngology Urology Vascular Total
624 212 1,063 28 857 240 517 2,125 5,666
152 49 642 11 437 69 130 246 1,736
472 163 421 17 420 171 387 1,879 3,930
⬍.001 .015 ⬍.001 .32 ⬍.001 .517 .004 ⬍.001
1.42 1.49 .20 .68 .36 1.10 1.35 5.55
(11.0%) (3.7%) (18.8%) (.5%) (15.1%) (4.2%) (9.1%) (37.5%) (100.0%)
(8.8%) (2.8%) (37.0%) (.6%) (25.2%) (4.0%) (7.5%) (14.2%) (100.0%)
(12.0%) (4.1%) (10.7%) (.4%) (10.7%) (4.4%) (9.8%) (47.8%) (100.0%)
(1.17–1.72) (1.08–2.06) (.17–.23) (.32–1.45) (.31–.42) (.82–1.46) (1.10–1.66) (4.78–6.44)
CI ⫽ confidence interval; OR ⫽ odds ratio. *Percentages shown in “Procedure Frequency” column are based on total procedures, general and specialty. Other percentages are based on specialty procedures only. †Based on 2-sided 2 test.
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date. This is due to the inclusion of (1) all clinic, outpatient, and inpatient surgical procedures during 1 calendar year and (2) 81% of eligible practicing rural surgeons’ data, an inclusion rate that has not previously been attained. This study is the first to analyze procedure volume by RUCA code and compare surgical practice in small and large rural areas. We feel that these direct data from the majority of the rural surgery practices in North Dakota and South Dakota provides an accurate view of a rural surgeons’ practice in the upper Midwest. Analysis of the DDRS demonstrated that a high volume of surgical procedures were performed in rural areas, averaging 1,071 procedures per surgeon. This is consistent with previous studies suggesting that rural surgeons maintain a high procedure volume.2,6,7 Procedure volume and category varied when comparing small and large rural practice. Surgeons in small rural areas performed a larger number of procedures, on average 358 more than large rural surgery practices. Much of this difference can be attributed to the greater number of endoscopies (small, 561/yr; large, 385/yr) and minor surgical procedures (small, 312/yr; large, 155/yr), indicating that rural surgeons in small rural communities are often the only surgical providers and perform all types of minor surgical procedures as well as most of the gastrointestinal endoscopy. In addition, surgeons in small rural areas performed 55 more specialty procedures per year than those in large rural areas (174 vs 119, respectively). In our database, there were 10 rural surgeons practicing in small rural areas compared with 33 surgeons in large rural areas. This is expected, because small and isolated rural areas are less likely to support hospitals and surgical practices. In addition, surgeons are less likely to settle in areas where there is not a minimum population available to support a surgical practice. Classic general surgery procedures made up 87.7% of rural surgeons’ caseloads. Endoscopy and skin and soft tissue procedure categories accounted for 57.7% of procedure volume. Our results also agree with those of previous published studies showing large numbers of endoscopic procedures in rural surgery practices. We also found that this trend was inversely related to the size of the community of the rural surgery practice. Endoscopy made up 41.7% of rural surgeons’ caseloads in small rural areas and 39.0% in large rural areas. Given the large number of procedures in our study, this difference was statistically significant. This finding supports the recent change made by the Accreditation Committee on Graduate Medical Education to increase the graduation requirement for general surgery residents to a minimum 85 endoscopic procedures. Diagnostic and therapeutic endoscopy experience should be pursued even more aggressively by residents intending to practice in a rural area. These procedures are frequently performed on an outpatient basis and consequently have been underappreciated in most previous studies.
The makeup and volume of specialty procedures performed by rural general surgeons is the topic of greatest speculation in recent literature. Specialty procedures made up 12.3% of rural general surgeons’ caseloads. A high degree of variability in the type of specialty procedures performed in small and large rural areas was identified. In part this is dependent on the availability of specialists within the rural communities. In small rural areas, obstetric and gynecologic and orthopedic procedures made up 62.2% of specialty procedures, compared with 21.4% of the specialty procedure volume of surgeons practicing in large rural areas. This difference is likely due to the increased availability of surgical specialists in large rural areas. In large rural areas, vascular and cardiothoracic procedures were more commonly performed. These categories made up 59.8% of surgeons’ specialty procedure caseloads in large rural areas, compared with 23% in small rural areas. Basic vascular and cardiothoracic procedures are taught in general surgery residencies but were classified as specialty procedures in our study and previous studies because they typically are deferred to fellowship-trained specialists in urban areas. Surgeons in small rural areas are often capable of performing advanced general surgery and specialty procedures but may elect not to perform these procedures, because hospital support in the form of intensive care units, respiratory therapy, and other support services may not be available. A rural surgery track has been suggested and developed by some general surgery residency programs to more competently train surgeons who desire to practice in rural areas. Expecting that general surgery residents can competently perform all types of urologic, obstetric and gynecologic, orthopedic, and other specialty procedures by adding 6 to 8 months of specialty rotations to their training is virtuous but unrealistic. However, through further analysis of the specialty procedure categories, it may be possible to identify the commonly performed specialty procedures. A rural surgery curriculum could then be developed on the basis of these findings. These data demonstrate that in many ways, rural surgeons are the only true general surgeons remaining. It is unusual to find general surgeons in urban or academic communities who still perform the whole spectrum of general surgical procedures as well as provide some aspects of surgical specialty care. In these environments, the readily available specialists often relegate general surgeons to basic intra-abdominal procedures, with most complex abdominal procedures and even some basic procedures being referred to fellowship-trained specialties, such as colorectal, breast, endocrine, vascular, surgical oncology, and others. Although we feel that these data provide a very accurate view of a rural surgeon’s practice in the upper Midwest, there may be variation of surgical caseloads in rural surgery practices in other areas of the country due to several factors, including proximity to a tertiary referral center, availability of specialists, established practice patterns in the area, and the capabilities of the hospital in the community. For these
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reasons, generalization of these results to rural surgeons in all areas of the country may not be appropriate. Furthermore, data were collected retrospectively, and it is possible that some procedures were not identified by the surgeons’ billers and/or coders and subsequently not included in the DDRS. This is less likely as a source of variation, because most surgical practices go to great lengths to record all billable procedures to increase reimbursement.
Conclusions This study is the first to comprehensively describe the diverse inpatient and outpatient practice of rural general surgeons on the basis of firsthand procedural data. Rural surgeons perform a high volume of procedures, with endoscopy and minor surgical procedures constituting ⬎55% of their practices. Significant differences exist in the type and volume of procedures performed by surgeons practicing in small and large rural areas. Understanding rural general surgeons’ caseloads is necessary to guide the training of the next generation of rural general surgeons and develop a framework for delivering effective surgical care to rural populations.
References 1. Thompson MJ, Lynge DC, Larson EH, et al. Characterizing the general surgery workforce in rural America. Arch Surg 2005;140:74 –9. 2. Landercasper J, Bintz M, Cogbill TH, et al. Spectrum of general surgery in rural America. Arch Surg 1997;132:494 –7. 3. Tulloh B, Clifforth S, Miller I. Caseload in rural general surgical practice and implications for training. ANZ J Surg 2001;71:215–7. 4. Sariego J. Patterns of surgical practice in a small rural hospital. J Am Coll Surg 1999;189:8 –10. 5. Heneghan SJ, Bordley J IV, Dietz PA, et al. Comparison of urban and rural general surgeons: motivations for practice location, practice patterns and education requirements. J Am Coll Surg 2005;201:732– 6. 6. Ritchie WP Jr, Rhodes RS, Biester TW. Work loads and practice patterns of general surgeons in the United States, 1995-1997. A report from the American Board of Surgery. Ann Surg 1999;230:533– 43. 7. VanBibber M, Zuckerman RS, Finlayson SRG. Rural versus urban inpatient case-mix differences in the US. J Am Coll Surg 2006;203: 812– 6. 8. Agency for Healthcare Research and Quality. Clinical Classification Software (CCS) for ICD-9-CM. Available at: http://www.hcup-us.ahrq. gov/toolssoftware/ccs/ccs.jsp. Accessed September 26, 2010.
Discussion Ed Kimm, M.D. (Denver, CO): Disparities in health care has become a very popular topic nowadays, especially in the context of the ongoing health system reform, and nowhere is this concern greater than access to health care in rural areas. Although 20-25% of the population lives in rural areas, fewer than 15% of physicians practice there and only 10% of general surgeons. How to address this problem has
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been a topic of interest to both surgical educators and policy makers. There are three areas of focus: recruitment, proper training, and retention of surgeons in these underserved areas. It is felt by many that designing more targeted rural surgery training in residency programs will better prepare young surgeons to be successful in rural practice. To effectively train these “rural track” residents, it is important to know what rural surgeons actually do and how their practices differ from their urban counterparts. With this paper, Dr Harris’ group from North Dakota have added to the growing body of literature that tries to accurately assess what rural surgeons are really doing. They compiled one years’ worth of cases from 43 general surgeons in North and South Dakota that practice in nonurban areas and then compared the practices of large rural surgeons to those of small rural surgeons, the latter group including surgeons practicing in “isolated rural areas”. Although they show many statistically significant differences between these two groups, more importantly they show once again that rural surgeons do a significant amount of GI endoscopy and they do a significant amount of subspecialty work, primarily in Obstetrics, Gynecology, and Orthopedics. This echoes many previous reports and certainly supports the concept that surgeons entering rural practice need to have solid training in the core competencies of general surgery as outlined by the American Board of Surgery, but also need to spend a reasonable amount of time on subspecialty rotations, especially in OB/GYN and orthopedics, and clearly need to be well trained in endoscopy. I have three questions. First of all, do you really believe that rural surgeons’ practices are similar enough to have a standardized “rural surgery curriculum” or even the choice between a “large rural track” and a “small rural track”, or do you think residents would be better served to have the flexibility in their final year or two to acquire a customized skill set based on the needs of their specific practice location? For example, a surgeon joining a small community where there is an active orthopedic surgeon might find as much benefit from an orthopedic rotation as one on the Transplant Service. Secondly, for some time now, there has been much discussion of changing the format of surgical training, for example the 4⫹2 model. It is not hard to imagine that someone will be championing the idea of four years of “basic” general surgery followed by a two year “rural surgery track”. Do you think this structure would encourage or discourage individuals from pursuing a career in rural surgery? Finally, and perhaps most important, even if we can develop the perfect model for the training of a rural surgeon, how do you propose we identify and recruit those medical students that are likely to thrive in a rural general surgical practice? I enjoyed your presentation and I appreciate the privilege of discussing the manuscript. Joel D. Harris, M.D. (Grand Forks, ND): Thank you very much Dr Kim. You have some great questions. The first question: I think the way the rural tracks developed have been by identifying that rural surgeons need a special-
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ized skill set. But I think the way that we are going about it, and this is my own bias, might be a little bit incorrect. Instead of just sending surgeons to spend a couple of months with either a surgeon in a rural area to attempt to learn these procedures, or to follow an OB/GYN and expect that after two months, they will be able to acquire the skill set that that OB/GYN has spent their career trying to attain is the wrong way to go about this problem. I think instead, we should take, for example, the OB/GYN category, and break the procedures down that the rural surgeons are currently performing. We may find that 80% of the OB/GYN procedures rural general surgeons are performing are Csections, hysterectomies, and oopherectomies. Just like we have minimal competencies in general surgery, it would be appropriate to state that “X” amount of these OB/GYN procedures should be performed to demonstrate competence. If a resident was planning to go into a rural general surgery practice, over the five years or 4⫹2 program he/she would need to somehow work with OBs to meet these criteria. Again, we first we need to study exactly what
procedures are being performed in rural areas and that was the focus of our research. This approach will lead to more effective training towards that rather than simply working with a specialist for a couple of months. Regarding the 4⫹2 question, I think that would encourage additional training and may promote training of rural surgeons. This would allow surgeons to continue taking general surgery call during the additional 2 years of training. Frequently it has been stated that fellowship trained surgeons feel less comfortable stepping back to general procedures because they have been focused on their specialty for a few years. Finally, the topic of how to recruit is actually one of the issues that we have addressed in our rural surgeon survey paper, the 24 questions survey manuscript that I spoke about. One of the major aspects is recruiting medical students who are from rural areas because they are the ones that will most likely return to rural areas. Finding people with early interest, and providing exposure to rural medicine, specifically surgery, at a very early time in their career has been found to make them continue to have interest in that field.
A comprehensive analysis of surgical procedures in rural surgery practices Joel D. Harris, M.D., M.P.H., Clint C. Hosford, Ph.D., Robert P. Sticca, M.D., F.A.C.S.* Department of Surgery, University of North Dakota, School of Medicine and Health Sciences, Grand Forks, ND, USA KEYWORDS: Rural surgery; Procedures; Practice patterns; Caseload; CPT codes
Abstract BACKGROUND: Data regarding the practice patterns of surgeons are derived from indirect information and may not reflect practice patterns in rural surgery. The aim of this study was to analyze all procedures performed by rural surgeons in North Dakota and South Dakota in 2006. METHODS: All surgeons in the Dakotas were identified by state American College of Surgeons databases. Rural urban commuting area codes were used to identify rural surgeons. Current Procedural Terminology codes from clinic, outpatient, and inpatient procedures performed during 2006 were obtained. RESULTS: Data were obtained from 81% of rural surgeons. A total of 46,052 Current Procedural Terminology procedure codes were analyzed. Rural surgeons averaged 1,071 procedures/year, composed of 25.6% general surgery, 39.8% endoscopy, 17.9% minor surgery, and 12.3% surgical specialty procedures. Surgeons in small and large rural communities differed in total procedures per year (1,346 vs 988). Significant differences existed in the types of procedures performed by surgeons in large and small rural communities (P ⬍ .001). CONCLUSIONS: Rural surgeons perform a high volume of procedures, with endoscopic and minor surgical procedures comprising over 55% of their practices. Understanding rural surgeons’ caseload will help guide the training of rural surgeons. © 2010 Elsevier Inc. All rights reserved.
Approximately 1 in 5 Americans reside in a rural area. Much has been written about the demographics and distribution of surgical services provided by surgeons who treat rural populations.1 Efforts to characterize rural general surgery practice have previously relied on national databases and individual surgeon or small samples of pooled surgeon case logs (⬍8 surgeons).2– 4 These methods have provided some insightful analysis, yet they fail to comprehensively characterize rural surgery practice. In prior reports, the American Medical Association master file and American
* Corresponding author. Tel.: 701-777-3067; fax: 701-777-2609. E-mail address: [email protected] Manuscript received March 6, 2010; revised manuscript July 1, 2010
0002-9610/$ - see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2010.07.029
Board of Surgery recertification logs have been used to characterize rural surgery practice patterns. These databases include inpatient and outpatient procedures but are generated retrospective by self report.5,6 Analysis of these databases have led to the conclusion that rural surgeons perform, “substantially more total procedures than did urban ones . . . endoscopic procedures accounted for much of this disparity.”6 General surgeons practicing in rural areas were found to perform a variety of surgical subspecialty procedures that are routinely performed by obstetricians, otolaryngologists, urologists, and other surgical subspecialists in urban areas.6 The Nationwide Inpatient Sample and Medicare databases have been used to describe surgical experience in
J.D. Harris et al.
Surgical procedures in rural surgery practices
rural areas, yet these databases do not include office or same-day surgical procedures. Studies using samples from these databases have concluded that there are significant differences in the type and volume of surgical procedures performed in rural areas. VanBibber et al7 concluded that general surgical procedures make up 42% of rural inpatient procedures compared with 25% of inpatient procedures in urban hospitals. Rural surgeons were found to perform fewer procedures on the esophagus, stomach, large bowel, spleen, liver, pancreas, and thyroid compared with their urban counterparts.7 Developing a rural training curriculum as a part of surgical residency has been suggested as a means of “optimizing the training of surgical residents” who desire to practice in rural areas.2 However, until rural surgical practice is better characterized, such a curriculum would be based on hypothesized need. We sought to more accurately characterize rural surgery practice by creating a comprehensive database of all procedures performed by rural general surgeons in North Dakota and South Dakota during the calendar year 2006.
Methods All general surgeons practicing in North Dakota and South Dakota were identified by the respective American College of Surgeons databases in February 2007. Rural urban commuting area (RUCA) codes were assigned to each surgeon on the basis of the area code of his or her primary practice area. RUCA codes were developed by the Rural Health Research Institute to stratify ZIP codes into urban, large rural, small rural, or isolated rural on the basis of commuter flow in and around each ZIP code (Table 1). Exclusion criteria were surgeons whose primary practice areas were located within an urban RUCA code and surgeons performing ⬍50 procedures annually. Rural surgeons were contacted by telephone and permission was requested to obtain all Current Procedural Terminology (CPT) codes logged in calendar year 2006. A comprehensive collection of CPT codes was solicited from all clinic, outpatient and inpatient procedures during the study period. Data were provided by a member of each provider’s coding or billing staff. Surgeons were guaranteed that their
Table 1 codes
Definitions of rural classification based on RUCA
821 Table 2 CCS code assignment for general surgical procedures General surgery procedure
CCS Codes
Trachea Esophagus/stomach Small and large bowel
34, 35 71, 74, 93, 94 72, 73, 75, 78, 79, 92, 95, 96 77, 81 80 66, 67 84 245, 246 10–12 85, 86 165–167, 174, 175 168–173 68–70, 76, 82 87–90, 97, 99
Rectal/anal Appendix Spleen/lymph Cholecystectomy/common bile duct Liver/pancreas Endocrine Hernia Breast Skin/soft tissue Endoscopy Other abdominal
individual data would be aggregated to a RUCA category and could not be traced retrospectively to individual surgeons. Microsoft Excel 2002 (Microsoft Corporation, Redmond, WA) was used to create a database consisting of surgeon RUCA code, CPT code, and procedure volume (number of procedures for each CPT code). Clinical Classification Software (CCS) was used to condense the CPT codes into clinically relevant categories for analysis. CCS was developed by the Healthcare Cost and Utilization Project and consists of 244 unique codes.8 There were no CCS codes specifically designated for liver or pancreas procedures, so these procedures were reclassified into 2 new CCS codes. Code 245 was assigned to liver procedures (CPT codes 47000 – 47130 and 47300 – 47399), and pancreas procedures were assigned code 246 (CPT codes 48000 – 48548 and 48999). CCS codes were collapsed into 14 categories comprising procedures that are classically performed by general surgeons (Table 2). Surgical specialty procedures were defined as a group of procedures within a surgical specialty that are often performed by general surgeons in rural areas but are not typically considered “classic” general surgery procedures. Surgical specialty procedures collectively made up 8 categories (Table 3). Analysis of the data was performed using SPSS version 17 (SPSS, Inc, Chicago, IL). Chi-square analyses were used to compare frequency distributions between small and large rural areas, and the Mann-Whitney U test was used to assess for differences between surgeons’ overall practice patterns.
Categorization Definition Isolated rural Small rural Large rural
Population ⬍2,500 without commuter flow to a larger area Population 2,500 to 9,999 or census tracts with commuter flow to such an area Population 10,000 to 49,999 or census tracts with commuter flow to such an area
Results Fifty-eight rural general surgeons were identified in North Dakota and South Dakota after applying RUCA codes to the North Dakota and South Dakota American College of Surgeons database. Attempts to contact all 58
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Table 3 CCS code assignment for surgical specialty procedures Specialty procedure
CCS Codes
Orthopedics
142, 143, 145–148, 152, 153, 155–164 119–132, 134, 137, 140 100, 104, 106, 109–112, 114–118 51–57, 59–61, 63 23, 25–27, 30–33 3–9 36–42, 44, 48, 49 19
Obstetrics and gynecology Urology Vascular Otolaryngology Neurosurgery Cardiothoracic Ophthalmology
surgeons revealed that 3 had retired or relocated outside of the Dakotas. Four surgeons refused participation or did not respond to multiple phone calls, faxes, or e-mail contacts. Three surgeons were nearing retirement or primarily providing family practice medical care in their communities and performing ⬍50 procedures per year. Six surgeons desired participation, but their procedure data could not be accessed by their coders or was not permitted to be released by their hospital administration. One additional surgeon was identified who met study criteria but was not listed in the American College of Surgeons database. Data were obtained from 43 of 53 surgeons who met the inclusion criteria (an 81% response rate; Fig. 1). A total of 46,052 procedures were performed in calendar year 2006 by the 43 surgeons who contributed CPT codes to create the Dakota Database for Rural Surgery (DDRS). Surgeons practicing in isolated (population ⬍ 2,500) and
Figure 1
small (population ⬍ 10,000) RUCAs were combined into 1 category (small rural) because there were very few (3 surgeons) who practiced in isolated rural areas. The collected data revealed that 10 surgeons practiced in small rural areas, whereas 33 surgeons practiced in large rural areas. All rural surgeons performed a mean of 1,071 (median, 863) procedures in 2006. The 10 surgeons practicing in small rural areas performed a mean of 1,345.8 (median, 930.5) procedures, compared with 987.7 (median, 863) procedures performed by their counterparts in large rural areas. Despite these sample differences, results of the Mann-Whitney U test indicated that the differences were not significant (U ⫽ 159, P ⫽ .86, r ⫽ ⫺.26). When analyzed by the categories of general surgery and surgical specialty procedures, the small rural area surgeons performed a mean of 1,172.2 (median, 824.5) general surgery and 173.6 (median, 52.5) specialty procedures, whereas large rural area surgeons performed 868.6 (median, 757) and 119.1 (median, 87) general and subspecialty procedures, respectively. These differences also were not significant (U ⫽ 155, P ⫽ .77, r ⫽ ⫺.044 and U ⫽ 138, P ⫽ .44, r ⫽ ⫺.12 respectively). Endoscopy made up 39.8% of rural general surgeon caseload, with surgeons in small rural areas performing a higher percentage (41.7%) than surgeons in large rural areas (39%). Minor surgical or skin and soft tissue procedures composed an additional 17.9% of rural surgeons’ caseloads, also representing a larger portion of the small rural surgeons’ practices (23.2% vs 15.7%). When combined, endoscopy and minor surgery procedures constituted most rural surgeons’ case production, with a 10.2% predominance in small rural versus large rural practices (64.9% vs 54.7%). Significant differences were identified in procedure
Flowchart identifying potential study participants.
J.D. Harris et al. Table 4
Surgical procedures in rural surgery practices
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Surgical procedures performed by surgeons practicing in small and large rural areas
Procedure
All surgeons procedure frequency*
Small rural surgeons (n ⫽ 10)
Appendectomy Bowel (small and large) Breast Cholecystectomy/CBD exploration Endocrine Endoscopy Esophagus/stomach Hernia Liver/pancreas Other abdominal Rectal/anal Skin/soft tissue Spleen/lymph Trachea Specialty procedures Total
1,030 1,507 2,278 2,891 126 18,307 740 2,841 175 651 1,252 8,240 329 19 5,666 46,052
204 384 326 517 10 5,611 61 687 26 180 531 3,118 62 5 1,736 13,458
(2.2%) (3.3%) (4.9%) (6.3%) (.3%) (39.8%) (1.6%) (6.2%) (.4%) (1.4%) (2.7%) (17.9%) (.7%) (.04%) (12.3%) (100%)
Large rural surgeons (n ⫽ 33)
(1.5%) (2.9%) (2.4%) (3.8%) (.1%) (41.7%) (.5%) (5.1%) (.2%) (1.3%) (3.9%) (23.2%) (.5%) (.04%) (12.9%) (100%)
826 1,123 1,952 2,374 116 12,696 679 2,154 149 471 721 5,122 267 14 3,930 32,594
(2.5%) (3.4%) (6.0%) (7.3%) (.4%) (39.0%) (2.1%) (6.6%) (.5%) (1.4%) (2.2%) (15.7%) (.8%) (.04%) (12.1%) (100%)
P†
OR (95% CI)
⬍.001 .001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 .374 ⬍.001 ⬍.001 ⬍.001 .780 .012
1.69 1.21 2.57 1.97 4.80 .89 4.67 1.32 2.37 1.08 .55 .62 1.78 1.16 .93
(1.45–1.97) (1.08–1.37) (2.28–2.89) (1.78–2.17) (2.52–9.17) (.86–.93) (3.59–6.08) (1.20–1.44) (1.56–3.60) (.91–1.29) (.49–.61) (.59–.65) (1.35–2.35) (.42–3.21) (.87–.98)
CBD ⫽ common bile duct; CI ⫽ confidence interval; OR ⫽ odds ratio. *Percentage is based on total frequency of general and specialty procedures. †Based on 2-sided 2 test.
volume in several categories of procedures when comparing surgeons practicing in small and large rural areas (P ⬍ .05). Rural surgeons practicing in small rural communities performed a statistically greater number of endoscopy, anal or rectal, skin and soft tissue, and specialty procedures. Surgeons in large rural areas performed statistically more procedures in the following categories: appendectomy, bowel, breast, gallbladder or common bile duct, endocrine, esophagus or stomach, hernia, liver or pancreas, and spleen or lymphatic (Table 4). Specialty operations constituted the third largest category of rural general surgeons’ caseloads, making up 12.3% of the procedures (Table 5). Vascular and obstetric and gynecologic procedures made up 56.3% of the specialty procedures performed by rural general surgeons. Statistically significant differences were identified when compar-
Table 5
ing specialty procedures performed in small and large rural areas (P ⱕ .015). Surgeons in small rural areas performed more obstetric and gynecologic and orthopedic procedures, whereas surgeons in large rural areas performed more cardiothoracic, urologic, neurosurgical, and vascular procedures.
Comments The current practice and future role of general surgery in rural areas is an often debated topic, with few supporting data to guide the discussion. The DDRS, containing ⬎46,000 procedures, is the most comprehensive database on rural general surgery practices that has been generated to
Specialty procedures performed by rural general surgeons practicing in small and large rural areas
Specialty procedure
Procedure frequency*
Small rural
Large rural
P†
OR (95% CI)
Cardiothoracic Neurosurgery Obstetrics and gynecology Ophthalmology Orthopedics Otolaryngology Urology Vascular Total
624 212 1,063 28 857 240 517 2,125 5,666
152 49 642 11 437 69 130 246 1,736
472 163 421 17 420 171 387 1,879 3,930
⬍.001 .015 ⬍.001 .32 ⬍.001 .517 .004 ⬍.001
1.42 1.49 .20 .68 .36 1.10 1.35 5.55
(11.0%) (3.7%) (18.8%) (.5%) (15.1%) (4.2%) (9.1%) (37.5%) (100.0%)
(8.8%) (2.8%) (37.0%) (.6%) (25.2%) (4.0%) (7.5%) (14.2%) (100.0%)
(12.0%) (4.1%) (10.7%) (.4%) (10.7%) (4.4%) (9.8%) (47.8%) (100.0%)
(1.17–1.72) (1.08–2.06) (.17–.23) (.32–1.45) (.31–.42) (.82–1.46) (1.10–1.66) (4.78–6.44)
CI ⫽ confidence interval; OR ⫽ odds ratio. *Percentages shown in “Procedure Frequency” column are based on total procedures, general and specialty. Other percentages are based on specialty procedures only. †Based on 2-sided 2 test.
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date. This is due to the inclusion of (1) all clinic, outpatient, and inpatient surgical procedures during 1 calendar year and (2) 81% of eligible practicing rural surgeons’ data, an inclusion rate that has not previously been attained. This study is the first to analyze procedure volume by RUCA code and compare surgical practice in small and large rural areas. We feel that these direct data from the majority of the rural surgery practices in North Dakota and South Dakota provides an accurate view of a rural surgeons’ practice in the upper Midwest. Analysis of the DDRS demonstrated that a high volume of surgical procedures were performed in rural areas, averaging 1,071 procedures per surgeon. This is consistent with previous studies suggesting that rural surgeons maintain a high procedure volume.2,6,7 Procedure volume and category varied when comparing small and large rural practice. Surgeons in small rural areas performed a larger number of procedures, on average 358 more than large rural surgery practices. Much of this difference can be attributed to the greater number of endoscopies (small, 561/yr; large, 385/yr) and minor surgical procedures (small, 312/yr; large, 155/yr), indicating that rural surgeons in small rural communities are often the only surgical providers and perform all types of minor surgical procedures as well as most of the gastrointestinal endoscopy. In addition, surgeons in small rural areas performed 55 more specialty procedures per year than those in large rural areas (174 vs 119, respectively). In our database, there were 10 rural surgeons practicing in small rural areas compared with 33 surgeons in large rural areas. This is expected, because small and isolated rural areas are less likely to support hospitals and surgical practices. In addition, surgeons are less likely to settle in areas where there is not a minimum population available to support a surgical practice. Classic general surgery procedures made up 87.7% of rural surgeons’ caseloads. Endoscopy and skin and soft tissue procedure categories accounted for 57.7% of procedure volume. Our results also agree with those of previous published studies showing large numbers of endoscopic procedures in rural surgery practices. We also found that this trend was inversely related to the size of the community of the rural surgery practice. Endoscopy made up 41.7% of rural surgeons’ caseloads in small rural areas and 39.0% in large rural areas. Given the large number of procedures in our study, this difference was statistically significant. This finding supports the recent change made by the Accreditation Committee on Graduate Medical Education to increase the graduation requirement for general surgery residents to a minimum 85 endoscopic procedures. Diagnostic and therapeutic endoscopy experience should be pursued even more aggressively by residents intending to practice in a rural area. These procedures are frequently performed on an outpatient basis and consequently have been underappreciated in most previous studies.
The makeup and volume of specialty procedures performed by rural general surgeons is the topic of greatest speculation in recent literature. Specialty procedures made up 12.3% of rural general surgeons’ caseloads. A high degree of variability in the type of specialty procedures performed in small and large rural areas was identified. In part this is dependent on the availability of specialists within the rural communities. In small rural areas, obstetric and gynecologic and orthopedic procedures made up 62.2% of specialty procedures, compared with 21.4% of the specialty procedure volume of surgeons practicing in large rural areas. This difference is likely due to the increased availability of surgical specialists in large rural areas. In large rural areas, vascular and cardiothoracic procedures were more commonly performed. These categories made up 59.8% of surgeons’ specialty procedure caseloads in large rural areas, compared with 23% in small rural areas. Basic vascular and cardiothoracic procedures are taught in general surgery residencies but were classified as specialty procedures in our study and previous studies because they typically are deferred to fellowship-trained specialists in urban areas. Surgeons in small rural areas are often capable of performing advanced general surgery and specialty procedures but may elect not to perform these procedures, because hospital support in the form of intensive care units, respiratory therapy, and other support services may not be available. A rural surgery track has been suggested and developed by some general surgery residency programs to more competently train surgeons who desire to practice in rural areas. Expecting that general surgery residents can competently perform all types of urologic, obstetric and gynecologic, orthopedic, and other specialty procedures by adding 6 to 8 months of specialty rotations to their training is virtuous but unrealistic. However, through further analysis of the specialty procedure categories, it may be possible to identify the commonly performed specialty procedures. A rural surgery curriculum could then be developed on the basis of these findings. These data demonstrate that in many ways, rural surgeons are the only true general surgeons remaining. It is unusual to find general surgeons in urban or academic communities who still perform the whole spectrum of general surgical procedures as well as provide some aspects of surgical specialty care. In these environments, the readily available specialists often relegate general surgeons to basic intra-abdominal procedures, with most complex abdominal procedures and even some basic procedures being referred to fellowship-trained specialties, such as colorectal, breast, endocrine, vascular, surgical oncology, and others. Although we feel that these data provide a very accurate view of a rural surgeon’s practice in the upper Midwest, there may be variation of surgical caseloads in rural surgery practices in other areas of the country due to several factors, including proximity to a tertiary referral center, availability of specialists, established practice patterns in the area, and the capabilities of the hospital in the community. For these
J.D. Harris et al.
Surgical procedures in rural surgery practices
reasons, generalization of these results to rural surgeons in all areas of the country may not be appropriate. Furthermore, data were collected retrospectively, and it is possible that some procedures were not identified by the surgeons’ billers and/or coders and subsequently not included in the DDRS. This is less likely as a source of variation, because most surgical practices go to great lengths to record all billable procedures to increase reimbursement.
Conclusions This study is the first to comprehensively describe the diverse inpatient and outpatient practice of rural general surgeons on the basis of firsthand procedural data. Rural surgeons perform a high volume of procedures, with endoscopy and minor surgical procedures constituting ⬎55% of their practices. Significant differences exist in the type and volume of procedures performed by surgeons practicing in small and large rural areas. Understanding rural general surgeons’ caseloads is necessary to guide the training of the next generation of rural general surgeons and develop a framework for delivering effective surgical care to rural populations.
References 1. Thompson MJ, Lynge DC, Larson EH, et al. Characterizing the general surgery workforce in rural America. Arch Surg 2005;140:74 –9. 2. Landercasper J, Bintz M, Cogbill TH, et al. Spectrum of general surgery in rural America. Arch Surg 1997;132:494 –7. 3. Tulloh B, Clifforth S, Miller I. Caseload in rural general surgical practice and implications for training. ANZ J Surg 2001;71:215–7. 4. Sariego J. Patterns of surgical practice in a small rural hospital. J Am Coll Surg 1999;189:8 –10. 5. Heneghan SJ, Bordley J IV, Dietz PA, et al. Comparison of urban and rural general surgeons: motivations for practice location, practice patterns and education requirements. J Am Coll Surg 2005;201:732– 6. 6. Ritchie WP Jr, Rhodes RS, Biester TW. Work loads and practice patterns of general surgeons in the United States, 1995-1997. A report from the American Board of Surgery. Ann Surg 1999;230:533– 43. 7. VanBibber M, Zuckerman RS, Finlayson SRG. Rural versus urban inpatient case-mix differences in the US. J Am Coll Surg 2006;203: 812– 6. 8. Agency for Healthcare Research and Quality. Clinical Classification Software (CCS) for ICD-9-CM. Available at: http://www.hcup-us.ahrq. gov/toolssoftware/ccs/ccs.jsp. Accessed September 26, 2010.
Discussion Ed Kimm, M.D. (Denver, CO): Disparities in health care has become a very popular topic nowadays, especially in the context of the ongoing health system reform, and nowhere is this concern greater than access to health care in rural areas. Although 20-25% of the population lives in rural areas, fewer than 15% of physicians practice there and only 10% of general surgeons. How to address this problem has
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been a topic of interest to both surgical educators and policy makers. There are three areas of focus: recruitment, proper training, and retention of surgeons in these underserved areas. It is felt by many that designing more targeted rural surgery training in residency programs will better prepare young surgeons to be successful in rural practice. To effectively train these “rural track” residents, it is important to know what rural surgeons actually do and how their practices differ from their urban counterparts. With this paper, Dr Harris’ group from North Dakota have added to the growing body of literature that tries to accurately assess what rural surgeons are really doing. They compiled one years’ worth of cases from 43 general surgeons in North and South Dakota that practice in nonurban areas and then compared the practices of large rural surgeons to those of small rural surgeons, the latter group including surgeons practicing in “isolated rural areas”. Although they show many statistically significant differences between these two groups, more importantly they show once again that rural surgeons do a significant amount of GI endoscopy and they do a significant amount of subspecialty work, primarily in Obstetrics, Gynecology, and Orthopedics. This echoes many previous reports and certainly supports the concept that surgeons entering rural practice need to have solid training in the core competencies of general surgery as outlined by the American Board of Surgery, but also need to spend a reasonable amount of time on subspecialty rotations, especially in OB/GYN and orthopedics, and clearly need to be well trained in endoscopy. I have three questions. First of all, do you really believe that rural surgeons’ practices are similar enough to have a standardized “rural surgery curriculum” or even the choice between a “large rural track” and a “small rural track”, or do you think residents would be better served to have the flexibility in their final year or two to acquire a customized skill set based on the needs of their specific practice location? For example, a surgeon joining a small community where there is an active orthopedic surgeon might find as much benefit from an orthopedic rotation as one on the Transplant Service. Secondly, for some time now, there has been much discussion of changing the format of surgical training, for example the 4⫹2 model. It is not hard to imagine that someone will be championing the idea of four years of “basic” general surgery followed by a two year “rural surgery track”. Do you think this structure would encourage or discourage individuals from pursuing a career in rural surgery? Finally, and perhaps most important, even if we can develop the perfect model for the training of a rural surgeon, how do you propose we identify and recruit those medical students that are likely to thrive in a rural general surgical practice? I enjoyed your presentation and I appreciate the privilege of discussing the manuscript. Joel D. Harris, M.D. (Grand Forks, ND): Thank you very much Dr Kim. You have some great questions. The first question: I think the way the rural tracks developed have been by identifying that rural surgeons need a special-
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ized skill set. But I think the way that we are going about it, and this is my own bias, might be a little bit incorrect. Instead of just sending surgeons to spend a couple of months with either a surgeon in a rural area to attempt to learn these procedures, or to follow an OB/GYN and expect that after two months, they will be able to acquire the skill set that that OB/GYN has spent their career trying to attain is the wrong way to go about this problem. I think instead, we should take, for example, the OB/GYN category, and break the procedures down that the rural surgeons are currently performing. We may find that 80% of the OB/GYN procedures rural general surgeons are performing are Csections, hysterectomies, and oopherectomies. Just like we have minimal competencies in general surgery, it would be appropriate to state that “X” amount of these OB/GYN procedures should be performed to demonstrate competence. If a resident was planning to go into a rural general surgery practice, over the five years or 4⫹2 program he/she would need to somehow work with OBs to meet these criteria. Again, we first we need to study exactly what
procedures are being performed in rural areas and that was the focus of our research. This approach will lead to more effective training towards that rather than simply working with a specialist for a couple of months. Regarding the 4⫹2 question, I think that would encourage additional training and may promote training of rural surgeons. This would allow surgeons to continue taking general surgery call during the additional 2 years of training. Frequently it has been stated that fellowship trained surgeons feel less comfortable stepping back to general procedures because they have been focused on their specialty for a few years. Finally, the topic of how to recruit is actually one of the issues that we have addressed in our rural surgeon survey paper, the 24 questions survey manuscript that I spoke about. One of the major aspects is recruiting medical students who are from rural areas because they are the ones that will most likely return to rural areas. Finding people with early interest, and providing exposure to rural medicine, specifically surgery, at a very early time in their career has been found to make them continue to have interest in that field.