Barriers to Surgical Health Care Access in Rural Communities

Introduction

Unfortunately, lack of access to medical care, especially specialists such as surgeons, is becoming more common. This lack of access is seen in our country’s most and least populated areas. Rural communities continue to have diminishing populations, leading to closures of clinics and hospitals in those areas, enhancing the problem. In 2012, 42 rural hospitals closed, leaving a shortage of access to inpatient surgery services for these patients. ¹ With this ongoing decrease in access, patients often need to drive hours to reach a surgeon. In addition, both ends of the spectrum experience higher disparities in health care outcomes. Some might find this scenario unattractive as a possible career goal as a surgeon. However, the need for surgeons in these communities is undeniable and requires specific recruiting and retention strategies to improve access to surgical care.

Rural Community Needs

Despite the growing trend of subspecialization, rural surgery is still vital and necessary. The need for rural general surgeons has increased over the last several years. The current workforce in these rural areas is aging. Currently, there are more rural general surgeons over the age of 50 than under the age of 40. ² The American College of Surgeons Advisory Council on Rural Surgery defines rural surgery as practicing in a city with a population of less than or equal to 50,000. ³ According to most recent census data, more than 2000 counties in the United States fall within that definition. Given that a substantial amount of the American population, almost 20%, is in rural areas, the diminishing surgical workforce in those areas is of mounting concern.

The rural hospital depends on the general surgeon’s work as their cases can generate up to 40% of the hospital’s revenue. This surgeon “can generate $4.4 million in payroll, and the same practice creates 26 jobs in a community.” ⁴ Given their value to the hospital, administrators tend to be much more supportive of rural surgeons, and these surgeons tend to have board memberships and be more involved in decision-making at the hospital compared to their urban counterparts. In addition, the surgeon would be someone of great respect in the community with long-standing personal and professional relationships. Rural surgeons often care for multiple generations of a family and form life-long partnerships with their patients and families. For reasons like these, they are vital to their close-knit communities. ⁵

The drawbacks of working in less populated areas include a more frequent call burden, difficulties in recruiting partners, and often needing more technological advances. Some rural surgeons complain of a lack of respect from their urban counterparts, especially when attempting to transfer patients for a higher level of care. Lack of supportive staff and associated tasks that they perform tend to land on the surgeon themselves. Nonetheless, there are benefits of working as a surgeon in rural areas. These include increased autonomy of practice, performing a wider variety of surgeries not typical in the urban setting, the decreased cost of living commonly seen in nonurban areas, ⁶ and more satisfaction with work-life balance. ⁷

The Issue at Hand

There is currently a shortage of surgeons nationwide, and the demand is projected to continue increasing. Studies have shown that in 2032, there will be an approximate deficit of 23,000 surgeons in the United States. ⁸ The rural parts of the country are significantly affected by the shortage of surgeons, having only 4.67 surgeons per 100,000 people. ⁸ This deficiency causes a barrier for patients to receive routine surgical care and emergent life-saving care. ⁹ The low number of surgeons compared to patients also places strain on the present workforce and could cause decreased quality of care as professionals are stretched further to accommodate the demand. This diminished workforce requires patients to travel further to get care, and hospitals and clinics with sufficient technology may also be further away.

There have been several reasons cited that have contributed to the lack of surgeons in the rural setting. The most important factors are the number of newly trained surgeons that need to keep up with the growing patient demand, subspecialization into different specialties, and the aging of the current workforce that provides care for rural patients.^10,11

The number of categorical training positions for residents coming into surgical training had historically stayed within 900-1200 since 1997, when the Balanced Budget Act took effect. This Act placed a limit on the amount of federal funding there is for graduate medical education. With this limited funding, residency programs are less able to expand, and it is more difficult for new programs to be created due to the costs of operating a program. The limited funding has effectively translated to a limit on the number of surgical training positions in the United States. ¹² The number of surgical training applicants has steadily risen. Still, there needs to be more positions to match the rise in applications.

In the 2024 Main Residency Match, 38,494 first-year positions were available for 66,818 applicants across all specialties. This left 28,324 more applicants than positions available in the 2024 Match process. ¹³ A similar trend is seen in the general surgery subgroup of the 2024 Match. 1717 categorical General Surgery positions were available for 3164 total applicants. ¹⁴ These statistics emphasize the pool of potential surgeons that could contribute to increasing access to care in rural settings but are limited due to the low number of training positions.

Another issue that compounds the effect of fewer new surgical providers is the diminished workforce caring for the rural population in the United States. Most rural surgeons are older than 50 and plan to retire in the next 10 years. When these providers retire, they also take their many years of experience with them. The pool of rural providers is diminishing at baseline, and it is also not being replenished or growing at a rate to match the need throughout the country. ¹⁵

Subspecialization of providers into niche fields in surgery also poses a challenge for rural surgery. When providers subspecialize, they tend to close themselves off from practicing general surgery. As a result, this creates a smaller pool of general surgeons for rural communities. Almost 85% of recent general surgery residency graduates subspecialize for many reasons. ¹⁶ Reasons include pursuing fellowship to achieve a perceived increased value in the health care market, providers believing fellowship is needed for a successful career, and, most interestingly, some have decreased confidence in practicing independently.^16,17 This makes sense, given that recent general surgery graduates do not have the same diverse training as previous graduates. In addition, they may feel less equipped to care for different issues that may be needed in the rural community without the help of a specialist, for example, an OBGYN or orthopedic surgeon.^18,19

Solutions

So, how do we address this growing depletion of rural surgeons? A refinement of the pipeline that produces rural surgeons needs to be done. Possible future surgeons can be identified from those from rural areas and people interested in working in those communities. Identifying the potential pool of future providers starts before medical school. It should begin in rural communities by exposing youth to the field. Structured and maintained involvement and communication from appropriate personnel should be developed to provide potential surgeons with information and experiences with rural surgeons. Starting in the community is a great place to begin combatting the lack of surgeons. Next, we can identify medical students from rural backgrounds interested in rural medicine by utilizing interest groups and shadowing experiences. In addition, identifying a rural surgeon as a mentor for said interest groups and shadowing experiences could give a realistic view of rural practice. ²⁰ On the residency level, establishing more rural track programs to allow interested residents to examine the breadth of the practice could increase the rural surgeon population. Incentives, such as loan repayments during and after residency if committed to practicing in a rural community, would also help recruitment efforts. For example, incentives such as the National Health Service Corps Rural Community Loan Repayment Program have already been employed, and different specialties of healthcare professionals have been successfully recruited to rural areas. These programs agree to pay large portions of loans or all loans in return for service in areas of need.^17,21

Training a rural surgeon requires a broad scope of practice, including endoscopy, gynecology, obstetrics, vascular, urology, and orthopedic procedures. Surgeons need this range of experience and rotations because surgeries often done by specialists in urban settings are more commonly executed by general surgeons in rural settings. Evidence of this trend lies in a 2015 cross-sectional study that examined the procedures performed in urban and rural hospitals in 24 states and established that obstetric-gynecologic and orthopedic procedures were much more commonly completed by general surgeons in rural areas as opposed to their urban counterparts. ⁹ It has also been consistently shown that in these small communities, surgeons serve as the primary providers for endoscopy, with 40% to 60% of their practice consisting of endoscopy. ¹⁸ The training of a rural surgeon would be much different than those who want to stay in an urban environment or subspecialize. Residents planning to practice in rural settings should be afforded the opportunity to rotate in all the previously mentioned specialties to make them well-rounded and prepared for the work ahead. The exposure needed for a rural practice may not be possible in the current residency paradigm. ²² Current residency programs do not train residency with the same broadness that previous graduates received. ²³ This deficit could be bridged through specialized rural tracks in residency, the transition to practice, or rural fellowship.^24,25 Other initiatives that have been used include required and elective rural surgery rotations in residency. ³ Continued implementation of this additional training will lead to better-prepared resident physicians and expose them to rural surgery as a possible career.

Additionally, with more programs and rotations for rural surgery, there is still the critical issue of competing learners. Rural surgery necessitates training and exposure to subspecialty procedures and diseases that commonly fall upon the general surgeon in the rural setting. ²⁶ These experiences are vital. Unfortunately, the presence of other residents and fellows in those subspecialties dilutes the amount of exposure and the learning experience general surgery residents receive.^27,28 This poses a challenge for learners because other residents and fellows are often given priority when assigning operative cases. Programs and electives with fewer competing learners should be prioritized when assessing opportunities to create learning experiences.

Once a rural surgeon has joined a community, the work to retain that surgeon begins immediately. Recent graduates need guidance coming out of residency, and having a partner available for assistance can aid in the surgeon’s comfort. In addition, partnerships with larger institutions such as academic centers could lead to better patient outcomes. For instance, educational conferences available for the surgeon to attend virtually could keep them up to date with the current literature and obtain CMEs. In addition, these relationships could ease the transfer of patients to a higher level of care. More recently, graduating surgical residents have been looking for places with advancing technologies. Healthcare systems should be open to investing in these technologies, such as advanced laparoscopic surgery and robotic surgery.^29,30 Furthermore, one of the benefits of living in a smaller community is integrating the surgeon into the community. By virtue of their jobs, that surgeon is considered a leader and the respect it garners. ⁵

Conclusion

Access to surgical care in rural communities is a growing problem requiring specific solutions. Hospital and surgeon availability is diminishing as surgeon subspecialization is increasing. In addition, residency program spots have only minimally increased over the last 30 years. Governmental and residency training programs are actively working to increase the rural workforce with loan repayment programs and unique residency tracks to expose and train future rural surgeons. These rural communities and hospital systems are vital in the continued development of the surgeon and retention in the area.