The Rural Surgeon

Nobody is happy when a patient needs to be transferred. A patient transfer is an unplanned event for all parties involved: the patient, the family, the surgeon requesting a transfer, and the accepting surgeon or physician.

It’s a fact of life that a rural surgeon will, at times, need to transfer patients to a larger center. The reasons should come as no surprise to any surgeon. Sometimes there are simply not enough ICU beds, ICU nurses, ventilators, or respiratory therapists to care for patients. At times, very complicated surgical patients will present through the ED and sometimes a work-up on a hospitalized patient may reveal a complex surgical problem. Despite the best efforts of a rural surgeon, surgical complications will occur and a transfer can be the wisest choice. Trauma patients, especially those with a neurologic injury, will often need to be transferred. And then there is the exhaustion factor: A long stretch of on-call duty, or a series of difficult, time-consuming patients can deplete the mental and physical resources of a rural surgeon and the next patient who comes in the door with a complicated surgical issue will be transferred.

The transferring of patients from a rural hospital to a larger medical center with higher-level technology on hand is becoming more common. An example of this would be a patient with a blunt splenic injury. In years past, this patient could be carefully followed in a rural hospital, and a splenectomy could be done if necessary. With the ability of interventional radiologists to control splenic bleeding by embolization techniques, some of these patients do better if transferred to a larger center. Some rural hospitals used to operate on patients with a ruptured abdominal aortic aneurysm, but now many of these cases are transferred so that the patient can be treated with endovascular techniques. Some patients with GI bleeding are now transferred for possible treatment with embolization techniques.

In many ways, it has gotten easier in recent years to transfer a patient from a rural hospital. Almost all tertiary hospitals now have a transfer team or transfer coordinator that will determine bed availability, and arrange for a conference call between the rural surgeon and the accepting surgeon and other physicians at the larger hospital. Cell phones have allowed for much quicker communication between physicians. Many rural hospitals are now owned or affiliated with a larger medical center, which can allow for a quick transfer. As a result of Emergency Medical Treatment and Active Labor Act laws, a patient’s medical insurance status should not be a determining factor in a transfer.

Although transfers are easier than they once were, it should be noted that a transfer is not the easy or preferred option for most rural surgeons. Many rural surgeons inwardly groan when they realize that a patient needs to be transferred. Most surgeons can’t help having a feeling of defeat when a transfer is needed. Transfers can be very time-consuming, partly because there is usually no transfer team at a rural hospital and the surgeon has to be involved in making the arrangements and speaking with physicians at the larger center.

Because of the time commitment required for a transfer, it’s very important for the patient and his or her family to make a quick and definite decision about where they’d prefer the patient to be transferred to. Occasionally, after investing time to arrange for a transfer to a larger center, the rural surgeon is told that the accepting hospital will accept the patient, but that there are no open beds, which can mean that the patient can be waiting for several days for the transfer to occur, or that the rural surgeon needs to start the transfer process over again with another center. All this means can mean a further investment of time by the rural surgeon.

Ambulance transfer, whether by ground or air, is another complicating factor in transferring a patient. Medicare will pay the base rate and mileage for a medically necessary ambulance transport to the nearest facility that can care for the patient. Private insurance companies follow suit on this issue. If a patient and the family choose to go to a hospital that’s further away than the closest available facility, the patient will be required to pay for the extra mileage involved in the transfer. During a surgical emergency, patients and their families may have a difficult time with this concept, and it can fall to the surgeon to walk them through the decision and its financial implications. More time devoted to the transfer.

Since the rural surgeon best understands the reasons for the transfer, the rural surgeon should be the one making the phone calls to the larger center, and participating in the conference calls with the accepting physicians. This process should not be delegated to the hospitalist or anyone else. The rural surgeon should also take great care to ensure a complete record is sent with the patient and that pertinent x-ray studies are sent on a CD. The rural surgeon should make it clear to the accepting physicians that he/she will do whatever they can to help care for the patient once the patient returns home.

After the transfer has occurred, the rural surgeon should communicate with the accepting physician periodically to follow the patient’s progress. If the rural hospital and the accepting hospital have the same EHR system, the rural surgeon should follow the progress of the patient and communicate with the accepting physician through the EHR email system or some other means. It’s also very helpful to obtain a cell phone number of the patient, or of a key family member, so that the rural surgeon can communicate with the family after the transfer to monitor the patient’s progress.

There are several important principles regarding transferring patients. First and foremost, accepting physicians at larger hospitals should be treated like gold. A wise rural surgeon keeps a list of accepting physicians that he/she has worked with in the past, as well as their cell phone numbers and email addresses. A good reputation as a surgeon requesting a transfer is very helpful, and part of that is never looking to “dump a patient.” A rural surgeon also must work hard at “networking” to get to know personally as many surgeons and physicians at accepting hospitals as possible. This takes effort, but can be accomplished by being active in the state American College of Surgeons Chapter, regional surgical societies, or state medical society. Personally visiting accepting hospitals, and meeting the surgeons and specialists there, is another great way to develop personal contacts. Every experienced rural surgeon knows that personal connections can pay off in many ways, and in particular, making transfers much easier.

The need for patient transfers from rural hospitals will never go away. Rural surgeons certainly appreciate all the help they receive from larger hospitals when it becomes necessary. As a rural surgeon, I would like to thank all surgeons and physicians at larger facilities that help us care for rural patients. Rural surgeons and physicians at larger hospitals need to continue to work together to achieve the best results possible for patients.

Dr. Puls is a general surgeon in Alpena, Mich. He serves as vice chair of the ACS Advisory Council for Rural Surgery.

Nobody is happy when a patient needs to be transferred. A patient transfer is an unplanned event for all parties involved: the patient, the family, the surgeon requesting a transfer, and the accepting surgeon or physician.

It’s a fact of life that a rural surgeon will, at times, need to transfer patients to a larger center. The reasons should come as no surprise to any surgeon. Sometimes there are simply not enough ICU beds, ICU nurses, ventilators, or respiratory therapists to care for patients. At times, very complicated surgical patients will present through the ED and sometimes a work-up on a hospitalized patient may reveal a complex surgical problem. Despite the best efforts of a rural surgeon, surgical complications will occur and a transfer can be the wisest choice. Trauma patients, especially those with a neurologic injury, will often need to be transferred. And then there is the exhaustion factor: A long stretch of on-call duty, or a series of difficult, time-consuming patients can deplete the mental and physical resources of a rural surgeon and the next patient who comes in the door with a complicated surgical issue will be transferred.

The transferring of patients from a rural hospital to a larger medical center with higher-level technology on hand is becoming more common. An example of this would be a patient with a blunt splenic injury. In years past, this patient could be carefully followed in a rural hospital, and a splenectomy could be done if necessary. With the ability of interventional radiologists to control splenic bleeding by embolization techniques, some of these patients do better if transferred to a larger center. Some rural hospitals used to operate on patients with a ruptured abdominal aortic aneurysm, but now many of these cases are transferred so that the patient can be treated with endovascular techniques. Some patients with GI bleeding are now transferred for possible treatment with embolization techniques.

In many ways, it has gotten easier in recent years to transfer a patient from a rural hospital. Almost all tertiary hospitals now have a transfer team or transfer coordinator that will determine bed availability, and arrange for a conference call between the rural surgeon and the accepting surgeon and other physicians at the larger hospital. Cell phones have allowed for much quicker communication between physicians. Many rural hospitals are now owned or affiliated with a larger medical center, which can allow for a quick transfer. As a result of Emergency Medical Treatment and Active Labor Act laws, a patient’s medical insurance status should not be a determining factor in a transfer.

Although transfers are easier than they once were, it should be noted that a transfer is not the easy or preferred option for most rural surgeons. Many rural surgeons inwardly groan when they realize that a patient needs to be transferred. Most surgeons can’t help having a feeling of defeat when a transfer is needed. Transfers can be very time-consuming, partly because there is usually no transfer team at a rural hospital and the surgeon has to be involved in making the arrangements and speaking with physicians at the larger center.

Because of the time commitment required for a transfer, it’s very important for the patient and his or her family to make a quick and definite decision about where they’d prefer the patient to be transferred to. Occasionally, after investing time to arrange for a transfer to a larger center, the rural surgeon is told that the accepting hospital will accept the patient, but that there are no open beds, which can mean that the patient can be waiting for several days for the transfer to occur, or that the rural surgeon needs to start the transfer process over again with another center. All this means can mean a further investment of time by the rural surgeon.

Ambulance transfer, whether by ground or air, is another complicating factor in transferring a patient. Medicare will pay the base rate and mileage for a medically necessary ambulance transport to the nearest facility that can care for the patient. Private insurance companies follow suit on this issue. If a patient and the family choose to go to a hospital that’s further away than the closest available facility, the patient will be required to pay for the extra mileage involved in the transfer. During a surgical emergency, patients and their families may have a difficult time with this concept, and it can fall to the surgeon to walk them through the decision and its financial implications. More time devoted to the transfer.

Since the rural surgeon best understands the reasons for the transfer, the rural surgeon should be the one making the phone calls to the larger center, and participating in the conference calls with the accepting physicians. This process should not be delegated to the hospitalist or anyone else. The rural surgeon should also take great care to ensure a complete record is sent with the patient and that pertinent x-ray studies are sent on a CD. The rural surgeon should make it clear to the accepting physicians that he/she will do whatever they can to help care for the patient once the patient returns home.

After the transfer has occurred, the rural surgeon should communicate with the accepting physician periodically to follow the patient’s progress. If the rural hospital and the accepting hospital have the same EHR system, the rural surgeon should follow the progress of the patient and communicate with the accepting physician through the EHR email system or some other means. It’s also very helpful to obtain a cell phone number of the patient, or of a key family member, so that the rural surgeon can communicate with the family after the transfer to monitor the patient’s progress.

There are several important principles regarding transferring patients. First and foremost, accepting physicians at larger hospitals should be treated like gold. A wise rural surgeon keeps a list of accepting physicians that he/she has worked with in the past, as well as their cell phone numbers and email addresses. A good reputation as a surgeon requesting a transfer is very helpful, and part of that is never looking to “dump a patient.” A rural surgeon also must work hard at “networking” to get to know personally as many surgeons and physicians at accepting hospitals as possible. This takes effort, but can be accomplished by being active in the state American College of Surgeons Chapter, regional surgical societies, or state medical society. Personally visiting accepting hospitals, and meeting the surgeons and specialists there, is another great way to develop personal contacts. Every experienced rural surgeon knows that personal connections can pay off in many ways, and in particular, making transfers much easier.

The need for patient transfers from rural hospitals will never go away. Rural surgeons certainly appreciate all the help they receive from larger hospitals when it becomes necessary. As a rural surgeon, I would like to thank all surgeons and physicians at larger facilities that help us care for rural patients. Rural surgeons and physicians at larger hospitals need to continue to work together to achieve the best results possible for patients.

Dr. Puls is a general surgeon in Alpena, Mich. He serves as vice chair of the ACS Advisory Council for Rural Surgery.

Nobody is happy when a patient needs to be transferred. A patient transfer is an unplanned event for all parties involved: the patient, the family, the surgeon requesting a transfer, and the accepting surgeon or physician.

It’s a fact of life that a rural surgeon will, at times, need to transfer patients to a larger center. The reasons should come as no surprise to any surgeon. Sometimes there are simply not enough ICU beds, ICU nurses, ventilators, or respiratory therapists to care for patients. At times, very complicated surgical patients will present through the ED and sometimes a work-up on a hospitalized patient may reveal a complex surgical problem. Despite the best efforts of a rural surgeon, surgical complications will occur and a transfer can be the wisest choice. Trauma patients, especially those with a neurologic injury, will often need to be transferred. And then there is the exhaustion factor: A long stretch of on-call duty, or a series of difficult, time-consuming patients can deplete the mental and physical resources of a rural surgeon and the next patient who comes in the door with a complicated surgical issue will be transferred.

The transferring of patients from a rural hospital to a larger medical center with higher-level technology on hand is becoming more common. An example of this would be a patient with a blunt splenic injury. In years past, this patient could be carefully followed in a rural hospital, and a splenectomy could be done if necessary. With the ability of interventional radiologists to control splenic bleeding by embolization techniques, some of these patients do better if transferred to a larger center. Some rural hospitals used to operate on patients with a ruptured abdominal aortic aneurysm, but now many of these cases are transferred so that the patient can be treated with endovascular techniques. Some patients with GI bleeding are now transferred for possible treatment with embolization techniques.

In many ways, it has gotten easier in recent years to transfer a patient from a rural hospital. Almost all tertiary hospitals now have a transfer team or transfer coordinator that will determine bed availability, and arrange for a conference call between the rural surgeon and the accepting surgeon and other physicians at the larger hospital. Cell phones have allowed for much quicker communication between physicians. Many rural hospitals are now owned or affiliated with a larger medical center, which can allow for a quick transfer. As a result of Emergency Medical Treatment and Active Labor Act laws, a patient’s medical insurance status should not be a determining factor in a transfer.

Although transfers are easier than they once were, it should be noted that a transfer is not the easy or preferred option for most rural surgeons. Many rural surgeons inwardly groan when they realize that a patient needs to be transferred. Most surgeons can’t help having a feeling of defeat when a transfer is needed. Transfers can be very time-consuming, partly because there is usually no transfer team at a rural hospital and the surgeon has to be involved in making the arrangements and speaking with physicians at the larger center.

Because of the time commitment required for a transfer, it’s very important for the patient and his or her family to make a quick and definite decision about where they’d prefer the patient to be transferred to. Occasionally, after investing time to arrange for a transfer to a larger center, the rural surgeon is told that the accepting hospital will accept the patient, but that there are no open beds, which can mean that the patient can be waiting for several days for the transfer to occur, or that the rural surgeon needs to start the transfer process over again with another center. All this means can mean a further investment of time by the rural surgeon.

Ambulance transfer, whether by ground or air, is another complicating factor in transferring a patient. Medicare will pay the base rate and mileage for a medically necessary ambulance transport to the nearest facility that can care for the patient. Private insurance companies follow suit on this issue. If a patient and the family choose to go to a hospital that’s further away than the closest available facility, the patient will be required to pay for the extra mileage involved in the transfer. During a surgical emergency, patients and their families may have a difficult time with this concept, and it can fall to the surgeon to walk them through the decision and its financial implications. More time devoted to the transfer.

Since the rural surgeon best understands the reasons for the transfer, the rural surgeon should be the one making the phone calls to the larger center, and participating in the conference calls with the accepting physicians. This process should not be delegated to the hospitalist or anyone else. The rural surgeon should also take great care to ensure a complete record is sent with the patient and that pertinent x-ray studies are sent on a CD. The rural surgeon should make it clear to the accepting physicians that he/she will do whatever they can to help care for the patient once the patient returns home.

After the transfer has occurred, the rural surgeon should communicate with the accepting physician periodically to follow the patient’s progress. If the rural hospital and the accepting hospital have the same EHR system, the rural surgeon should follow the progress of the patient and communicate with the accepting physician through the EHR email system or some other means. It’s also very helpful to obtain a cell phone number of the patient, or of a key family member, so that the rural surgeon can communicate with the family after the transfer to monitor the patient’s progress.

There are several important principles regarding transferring patients. First and foremost, accepting physicians at larger hospitals should be treated like gold. A wise rural surgeon keeps a list of accepting physicians that he/she has worked with in the past, as well as their cell phone numbers and email addresses. A good reputation as a surgeon requesting a transfer is very helpful, and part of that is never looking to “dump a patient.” A rural surgeon also must work hard at “networking” to get to know personally as many surgeons and physicians at accepting hospitals as possible. This takes effort, but can be accomplished by being active in the state American College of Surgeons Chapter, regional surgical societies, or state medical society. Personally visiting accepting hospitals, and meeting the surgeons and specialists there, is another great way to develop personal contacts. Every experienced rural surgeon knows that personal connections can pay off in many ways, and in particular, making transfers much easier.

The need for patient transfers from rural hospitals will never go away. Rural surgeons certainly appreciate all the help they receive from larger hospitals when it becomes necessary. As a rural surgeon, I would like to thank all surgeons and physicians at larger facilities that help us care for rural patients. Rural surgeons and physicians at larger hospitals need to continue to work together to achieve the best results possible for patients.

Dr. Puls is a general surgeon in Alpena, Mich. He serves as vice chair of the ACS Advisory Council for Rural Surgery.

I have been on both ends of the phone call. I began my career at a several-hundred bed community hospital in a town without a university medical center. We took all the local knife-and-gun club incidents, and whatever other surgical emergencies might arise, while receiving phone calls from nearly every point of the magnetic compass. It’s easy to recall the sagging feeling when you realize more serious work is coming in on the helicopter from Podunk, USA, and you’re not off call for another few hours. These memories linger as now I’m the one making the phone calls. When I state that I am the one, I mean the one and only; this is solo general surgery practice and I’m the only general surgeon in my county.

When I do speak with colleagues kind enough to accept our patients, I feel relieved. But the burden of transfer doesn’t travel away with the patient in the ambulance or on the airplane. There always seem to be questions or looks of concern lately, and I don’t just mean from other medical professionals. Maybe it is an Internet thing, but everyone is a critic these days. We are being watched by more than partners and employers, more than payers and agencies, more than our government bean counters. Families, allied health professionals, and even nonclinical staff all have opinions about which patients stay and which leaves our 14-bed, critical access hospital. Gods may have once walked these halls, but nowadays it’s just me!

Of course, any interested party can also criticize my decisions to keep any particular patient; why would anybody restrict their furrowed glare only to transfers? When we keep patients at the edge of our practice, or perform a procedure that is only done rarely locally, we incite more than just the volume debate on the ACS Communities. Goodness – my wife has heard about cases I have done via town chitter-chatter before I even get home!

How does one deal with being whipsawed? This phenomenon is defined in the business world as being subjected to two difficult situations or opposing pressures at the same time. If you transfer, you are criticized. The only thing that changes are the critics if you keep and care for that very same patient! For many rural colleagues, being whipsawed is on the short list of job dissatisfaction drivers; somewhere behind the heavyweight champ of being asked to be in two different places at the same time.

Transferring a patient rarely leads to the lasting criticism that keeping an ill patient locally can. Obviously keeping a patient extends the time period where others can knowingly shake their heads in disbelief. That extra time allows us to educate staff and others as to why a patient with more than simple hernia or appendicitis is being admitted to our little hospital. We can detail why this is a really good thing for everyone – including the patient!

So many of our locals are elderly, and when we keep one for serious surgical illness, so much goes into that decision besides just the patient’s age and comorbid conditions. Immediate family, friends, or existing social support all must be examined and understood. A significant number of geriatric couples are only “independent” together; send one off for surgery a hundred or more miles away and the remaining spouse suffers measurably. Sometimes there is no local family, as nuclear members live in neighboring states or even overseas. I’m always surprised when my patients have trouble even arranging rides to and from our facilities for the routine procedures we do regularly. I think to myself, what will they do when the inevitable happens?

Our geography plays a serious role for those patients who don’t drive any appreciable distances. The mountains to our east are difficult to negotiate and west, well, you’ll get wet rather quickly. Going north and south on Highway 101 can be tricky during summer and dangerous any time in bad weather. I talk to some patients about sending them to Portland and I get looks in response like I’m proposing surgical care in some exotic foreign capital. Urban anxiety, traffic, and unfamiliarity with our largest metropolis make the 300-mile journey untenable for many of our patients; and the TV show isn’t helping our cause! Even cases that define themselves from the get-go as major university referrals return afterward and ask us to assume their postoperative care. Our patients often can’t make the trip to follow-up with the experts who provided their life-saving care.

Stretching our surgical muscles is obviously important for all ACS members. In bigger facilities you can see and sometimes scrub into fascinating cases in other subspecialties, or at least participate in discussions about such in the surgery lounge. I won’t attach a photo of the desk space that serves as my lounge, dictation station, bathroom, and locker. Let’s just say it’s probably not quite the same as many Fellows are used to.

For the rural solo practitioner, a bigger case, done perhaps with a medical student or just scrub technicians, may not be done as slickly as it would be by a surgical team approaching the same at the university. If the case can be done safely though, it pays dividends. After all, it could be tonight when a major car wreck happens, or a hemodynamically unstable abdominal sepsis case presents, and we are forced to do a serious case – perhaps surgery at the edge of my comfort zone or something we don’t do with frequency. Keeping some bigger cases makes those scenarios just a bit less scary.

I have been recruited as an advocate for our College, trying to influence those in our nation’s capital to reexamine the 96-hour rule as it applies to critical access hospitals. A phone call to my senior senator’s staff leads to a conference call and follow-up I remain involved with – a first in my professional career. One issue that resonated with D.C. staffers was recruiting my successor. How do we entice the young surgeon to a rural practice if all we do are lumps and bumps, appendectomies, and inguinal hernias? Regionalization of surgical care may be coming but that can’t excite our younger and future colleagues. In each of the last 2 years my third-year medical students parked here for their first rotation and got hustled into the OR to assist with emergency surgery. The enthusiasm was palpable and energizing, but one was a case that raised some eyebrows: pneumatosis intestinalis requiring two small bowel resections with anastomoses and an open abdomen in an elderly male. This fellow did great; I see him doing his grocery shopping these days. My perspective is that case enabled this year’s day 1 emergency, making the surgery safer here in rural America.

When we call to transfer a patient, please understand real thought and a piece of who we are as surgeons accompanies that patient. Transfer is very rarely a reflex action. Also, realize that not every case we keep is a weak fastball over the middle of the plate; sometimes we do real work here at the limit of our comfort zone, but we do so for myriad good reasons.

Dr. Levine is a general surgeon practicing in coastal southwestern Oregon. Despite growing up in Brooklyn and on Long Island in New York, he has been a practicing rural surgeon since 1999. Folks barely even notice the accent anymore!

I have been on both ends of the phone call. I began my career at a several-hundred bed community hospital in a town without a university medical center. We took all the local knife-and-gun club incidents, and whatever other surgical emergencies might arise, while receiving phone calls from nearly every point of the magnetic compass. It’s easy to recall the sagging feeling when you realize more serious work is coming in on the helicopter from Podunk, USA, and you’re not off call for another few hours. These memories linger as now I’m the one making the phone calls. When I state that I am the one, I mean the one and only; this is solo general surgery practice and I’m the only general surgeon in my county.

When I do speak with colleagues kind enough to accept our patients, I feel relieved. But the burden of transfer doesn’t travel away with the patient in the ambulance or on the airplane. There always seem to be questions or looks of concern lately, and I don’t just mean from other medical professionals. Maybe it is an Internet thing, but everyone is a critic these days. We are being watched by more than partners and employers, more than payers and agencies, more than our government bean counters. Families, allied health professionals, and even nonclinical staff all have opinions about which patients stay and which leaves our 14-bed, critical access hospital. Gods may have once walked these halls, but nowadays it’s just me!

Of course, any interested party can also criticize my decisions to keep any particular patient; why would anybody restrict their furrowed glare only to transfers? When we keep patients at the edge of our practice, or perform a procedure that is only done rarely locally, we incite more than just the volume debate on the ACS Communities. Goodness – my wife has heard about cases I have done via town chitter-chatter before I even get home!

How does one deal with being whipsawed? This phenomenon is defined in the business world as being subjected to two difficult situations or opposing pressures at the same time. If you transfer, you are criticized. The only thing that changes are the critics if you keep and care for that very same patient! For many rural colleagues, being whipsawed is on the short list of job dissatisfaction drivers; somewhere behind the heavyweight champ of being asked to be in two different places at the same time.

Transferring a patient rarely leads to the lasting criticism that keeping an ill patient locally can. Obviously keeping a patient extends the time period where others can knowingly shake their heads in disbelief. That extra time allows us to educate staff and others as to why a patient with more than simple hernia or appendicitis is being admitted to our little hospital. We can detail why this is a really good thing for everyone – including the patient!

So many of our locals are elderly, and when we keep one for serious surgical illness, so much goes into that decision besides just the patient’s age and comorbid conditions. Immediate family, friends, or existing social support all must be examined and understood. A significant number of geriatric couples are only “independent” together; send one off for surgery a hundred or more miles away and the remaining spouse suffers measurably. Sometimes there is no local family, as nuclear members live in neighboring states or even overseas. I’m always surprised when my patients have trouble even arranging rides to and from our facilities for the routine procedures we do regularly. I think to myself, what will they do when the inevitable happens?

Our geography plays a serious role for those patients who don’t drive any appreciable distances. The mountains to our east are difficult to negotiate and west, well, you’ll get wet rather quickly. Going north and south on Highway 101 can be tricky during summer and dangerous any time in bad weather. I talk to some patients about sending them to Portland and I get looks in response like I’m proposing surgical care in some exotic foreign capital. Urban anxiety, traffic, and unfamiliarity with our largest metropolis make the 300-mile journey untenable for many of our patients; and the TV show isn’t helping our cause! Even cases that define themselves from the get-go as major university referrals return afterward and ask us to assume their postoperative care. Our patients often can’t make the trip to follow-up with the experts who provided their life-saving care.

Stretching our surgical muscles is obviously important for all ACS members. In bigger facilities you can see and sometimes scrub into fascinating cases in other subspecialties, or at least participate in discussions about such in the surgery lounge. I won’t attach a photo of the desk space that serves as my lounge, dictation station, bathroom, and locker. Let’s just say it’s probably not quite the same as many Fellows are used to.

For the rural solo practitioner, a bigger case, done perhaps with a medical student or just scrub technicians, may not be done as slickly as it would be by a surgical team approaching the same at the university. If the case can be done safely though, it pays dividends. After all, it could be tonight when a major car wreck happens, or a hemodynamically unstable abdominal sepsis case presents, and we are forced to do a serious case – perhaps surgery at the edge of my comfort zone or something we don’t do with frequency. Keeping some bigger cases makes those scenarios just a bit less scary.

I have been recruited as an advocate for our College, trying to influence those in our nation’s capital to reexamine the 96-hour rule as it applies to critical access hospitals. A phone call to my senior senator’s staff leads to a conference call and follow-up I remain involved with – a first in my professional career. One issue that resonated with D.C. staffers was recruiting my successor. How do we entice the young surgeon to a rural practice if all we do are lumps and bumps, appendectomies, and inguinal hernias? Regionalization of surgical care may be coming but that can’t excite our younger and future colleagues. In each of the last 2 years my third-year medical students parked here for their first rotation and got hustled into the OR to assist with emergency surgery. The enthusiasm was palpable and energizing, but one was a case that raised some eyebrows: pneumatosis intestinalis requiring two small bowel resections with anastomoses and an open abdomen in an elderly male. This fellow did great; I see him doing his grocery shopping these days. My perspective is that case enabled this year’s day 1 emergency, making the surgery safer here in rural America.

When we call to transfer a patient, please understand real thought and a piece of who we are as surgeons accompanies that patient. Transfer is very rarely a reflex action. Also, realize that not every case we keep is a weak fastball over the middle of the plate; sometimes we do real work here at the limit of our comfort zone, but we do so for myriad good reasons.

Dr. Levine is a general surgeon practicing in coastal southwestern Oregon. Despite growing up in Brooklyn and on Long Island in New York, he has been a practicing rural surgeon since 1999. Folks barely even notice the accent anymore!

I have been on both ends of the phone call. I began my career at a several-hundred bed community hospital in a town without a university medical center. We took all the local knife-and-gun club incidents, and whatever other surgical emergencies might arise, while receiving phone calls from nearly every point of the magnetic compass. It’s easy to recall the sagging feeling when you realize more serious work is coming in on the helicopter from Podunk, USA, and you’re not off call for another few hours. These memories linger as now I’m the one making the phone calls. When I state that I am the one, I mean the one and only; this is solo general surgery practice and I’m the only general surgeon in my county.

When I do speak with colleagues kind enough to accept our patients, I feel relieved. But the burden of transfer doesn’t travel away with the patient in the ambulance or on the airplane. There always seem to be questions or looks of concern lately, and I don’t just mean from other medical professionals. Maybe it is an Internet thing, but everyone is a critic these days. We are being watched by more than partners and employers, more than payers and agencies, more than our government bean counters. Families, allied health professionals, and even nonclinical staff all have opinions about which patients stay and which leaves our 14-bed, critical access hospital. Gods may have once walked these halls, but nowadays it’s just me!

Of course, any interested party can also criticize my decisions to keep any particular patient; why would anybody restrict their furrowed glare only to transfers? When we keep patients at the edge of our practice, or perform a procedure that is only done rarely locally, we incite more than just the volume debate on the ACS Communities. Goodness – my wife has heard about cases I have done via town chitter-chatter before I even get home!

How does one deal with being whipsawed? This phenomenon is defined in the business world as being subjected to two difficult situations or opposing pressures at the same time. If you transfer, you are criticized. The only thing that changes are the critics if you keep and care for that very same patient! For many rural colleagues, being whipsawed is on the short list of job dissatisfaction drivers; somewhere behind the heavyweight champ of being asked to be in two different places at the same time.

Transferring a patient rarely leads to the lasting criticism that keeping an ill patient locally can. Obviously keeping a patient extends the time period where others can knowingly shake their heads in disbelief. That extra time allows us to educate staff and others as to why a patient with more than simple hernia or appendicitis is being admitted to our little hospital. We can detail why this is a really good thing for everyone – including the patient!

So many of our locals are elderly, and when we keep one for serious surgical illness, so much goes into that decision besides just the patient’s age and comorbid conditions. Immediate family, friends, or existing social support all must be examined and understood. A significant number of geriatric couples are only “independent” together; send one off for surgery a hundred or more miles away and the remaining spouse suffers measurably. Sometimes there is no local family, as nuclear members live in neighboring states or even overseas. I’m always surprised when my patients have trouble even arranging rides to and from our facilities for the routine procedures we do regularly. I think to myself, what will they do when the inevitable happens?

Our geography plays a serious role for those patients who don’t drive any appreciable distances. The mountains to our east are difficult to negotiate and west, well, you’ll get wet rather quickly. Going north and south on Highway 101 can be tricky during summer and dangerous any time in bad weather. I talk to some patients about sending them to Portland and I get looks in response like I’m proposing surgical care in some exotic foreign capital. Urban anxiety, traffic, and unfamiliarity with our largest metropolis make the 300-mile journey untenable for many of our patients; and the TV show isn’t helping our cause! Even cases that define themselves from the get-go as major university referrals return afterward and ask us to assume their postoperative care. Our patients often can’t make the trip to follow-up with the experts who provided their life-saving care.

Stretching our surgical muscles is obviously important for all ACS members. In bigger facilities you can see and sometimes scrub into fascinating cases in other subspecialties, or at least participate in discussions about such in the surgery lounge. I won’t attach a photo of the desk space that serves as my lounge, dictation station, bathroom, and locker. Let’s just say it’s probably not quite the same as many Fellows are used to.

For the rural solo practitioner, a bigger case, done perhaps with a medical student or just scrub technicians, may not be done as slickly as it would be by a surgical team approaching the same at the university. If the case can be done safely though, it pays dividends. After all, it could be tonight when a major car wreck happens, or a hemodynamically unstable abdominal sepsis case presents, and we are forced to do a serious case – perhaps surgery at the edge of my comfort zone or something we don’t do with frequency. Keeping some bigger cases makes those scenarios just a bit less scary.

I have been recruited as an advocate for our College, trying to influence those in our nation’s capital to reexamine the 96-hour rule as it applies to critical access hospitals. A phone call to my senior senator’s staff leads to a conference call and follow-up I remain involved with – a first in my professional career. One issue that resonated with D.C. staffers was recruiting my successor. How do we entice the young surgeon to a rural practice if all we do are lumps and bumps, appendectomies, and inguinal hernias? Regionalization of surgical care may be coming but that can’t excite our younger and future colleagues. In each of the last 2 years my third-year medical students parked here for their first rotation and got hustled into the OR to assist with emergency surgery. The enthusiasm was palpable and energizing, but one was a case that raised some eyebrows: pneumatosis intestinalis requiring two small bowel resections with anastomoses and an open abdomen in an elderly male. This fellow did great; I see him doing his grocery shopping these days. My perspective is that case enabled this year’s day 1 emergency, making the surgery safer here in rural America.

When we call to transfer a patient, please understand real thought and a piece of who we are as surgeons accompanies that patient. Transfer is very rarely a reflex action. Also, realize that not every case we keep is a weak fastball over the middle of the plate; sometimes we do real work here at the limit of our comfort zone, but we do so for myriad good reasons.

Dr. Levine is a general surgeon practicing in coastal southwestern Oregon. Despite growing up in Brooklyn and on Long Island in New York, he has been a practicing rural surgeon since 1999. Folks barely even notice the accent anymore!

Only last week I thought to myself: an almost perfect surgery day. A few endoscopy cases, a breast case, a parathyroid adenoma, and a gastrectomy. I remind myself from time to time how fortunate I am to have the diversity of cases that I am afforded by my unique rural location and employment in the Indian Health Service (IHS).

Over 2 decades ago with what seemed to be an upheaval in health care, I decided to either leave surgery altogether or find some alternative to the business side of medicine that I was experiencing in the world of my private surgical practice. It was 1993 and the Health Security Act was being formulated with a task force with a paucity of physician input. It looked like medicine was headed to a period of increasing bureaucracy and decreased autonomy.

While thumbing through one of the recruiting magazines, I noticed an article about an internal medicine physician and his wife, an obstetrician/ gynecologist, who together joined the Indian Health Service. I made some inquiries.

I knew nothing about the Indian Health Service. I had a picture in my mind of a remote barren reservation working with doctors who couldn’t get a job in the real world. What I found was the best career I could have imagined.

I landed in a rural community in Oklahoma. The colleagues that I have come to know have been some of the best I have seen anywhere. I have had the distinct privilege of taking care of patients who are for the most part very grateful for the care I can give them.

I can recall during the interview process I was concerned that as a non-Native, I might not be accepted by the patients in this part of the country. My concerns were dispelled. I have felt accepted and appreciated.

What I found was that in many ways, my Native American patients are similar to the rural patients I have had in private practice. In the Native American culture, elders are respected. Family is very important – not just the nuclear family but the extended family, cousins, and multiple generations. Patients are proud of their heritage. There is a sense of interdependence and connection. I have been blessed to be a part of healing ceremonies that have left a lasting influence on my approach to disease, health, and spirituality.

Many of these patients have limited resources and astounding health burdens. Native Americans are disproportionately afflicted with diabetes, cardiovascular disease, and obesity. Because of these health problems, programs that address these specific issues have been developed within our system. We have a diabetic clinic that includes foot care, eye care, nutritional counseling, general medicine, and pharmacy needs as well as extensive education about prevention and disease control. We have also developed a Healthy Eating for Life Program (HELP) involving a multidisciplinary approach to weight loss that includes a cognitive behavioral health program, one-on-one education with a certified bariatric nurse, support groups, nutritional instruction, and for some patients, surgical intervention.

Patients may access the Indian and Tribal Health Systems regardless of insurance status. While our practice is not totally devoid of the business aspects of medicine, most of the time we are unaware of the patients’ insurance status. Procedures or diagnostic studies that cannot be done onsite are sometimes covered through contract health services.

Our facility was built with the intent of providing health care for the adjacent counties, but by the time it was completed the need had already outstripped the resources. While funding has improved over the years, the rising costs of medical care and increases in the volume of the service population have continued to translate into unmet needs, especially for services not directly provided in our facility.

There are many physicians who have come and gone during my tenure. Some have Indian Health Service scholarship paybacks that they fulfill and move on, and others may be in transition from one greener pasture to another. The surgical service has grown from two surgeons to six. We have a good mix of youth and seasoned doctors, with half the group over 40 and half younger. The gender mix is also balanced with three females and three males.

There is a plethora of pathology. Most of us have carved out niches of surgical interest. We average 150 referrals per week, which translates into plenty to do. There are no turf battles. We have not adopted the hospitalist model. The surgeons here round and follow their own patients, which is great for continuity. Our patients appreciate seeing the same doctor. We are not, however, tethered to the facility. The surgeon on call will graciously cover any patients if needed, and we are fortunate in that we all have similar practice styles. Thus, we have cross coverage by surgeons who think and operate similarly.

We have had the pleasure of hosting both fellowship trained surgeons (vascular and trauma) and general surgeons interested in a rural lifestyle and Native medicine. The facility is also a teaching hospital. An array of students including surgical technicians, Certified Registered Nurse Anesthetist (CRNA) students, residents, medical students, and U.S. Army Special Forces all rotate through our operating rooms.

One of the benefits of the Indian Health Service is that you are part of a system. Sometimes one can forget that point amid the daily work. Going to meetings specifically geared toward IHS issues is often very rewarding. You are a part of something much bigger than your own practice. Progress is defined over time – a decrease in amputation rates as hemoglobin A1_C’s improve, a system-wide approach to colorectal cancer screening, the development of a tumor registry that specifically tracks cancer for Native Americans (no longer grouping them under “white” or lost under “other”).

Although we are rural surgeons, we do not work in isolation. All of our providers are board certified. We are currently the only facility in Oklahoma participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

In training, we were encouraged to be aggressive and work independently. It was the era of the pyramid system. No one cared how much sleep you got or when you last ate, and yet there was a team approach among the residents. That same independence is fostered here but in a much more conducive environment.

Many of us sought surgical careers because we truly enjoyed being in the operating room, the haven. We liked the technical aspects, the challenges. We joked that we liked our patients asleep, either on early morning rounds or in the surgical suite.

Where once clinic was a necessary evil, I now enjoy the interaction and find I can often do as much for the patient or family in the clinic as I can in the operating room.

I have also found that with the support of administration, we can have an impact on care beyond the individual level. We can affect the health status of an entire population.

There has been much progress in this system over the last 2 decades and there continues to be room for even more. The key may be in the name: Indian Health Service. I would encourage those who think they might find this type of practice intriguing to explore www.ihs.gov and look under career opportunities. 

Dr. Hope Baluh is an ACS fellow. She serves as chief of surgery at Cherokee Nation W.W. Hastings Hospital in Oklahoma and is a recent graduate from Johns Hopkins School of Public Health.

Only last week I thought to myself: an almost perfect surgery day. A few endoscopy cases, a breast case, a parathyroid adenoma, and a gastrectomy. I remind myself from time to time how fortunate I am to have the diversity of cases that I am afforded by my unique rural location and employment in the Indian Health Service (IHS).

Over 2 decades ago with what seemed to be an upheaval in health care, I decided to either leave surgery altogether or find some alternative to the business side of medicine that I was experiencing in the world of my private surgical practice. It was 1993 and the Health Security Act was being formulated with a task force with a paucity of physician input. It looked like medicine was headed to a period of increasing bureaucracy and decreased autonomy.

While thumbing through one of the recruiting magazines, I noticed an article about an internal medicine physician and his wife, an obstetrician/ gynecologist, who together joined the Indian Health Service. I made some inquiries.

I knew nothing about the Indian Health Service. I had a picture in my mind of a remote barren reservation working with doctors who couldn’t get a job in the real world. What I found was the best career I could have imagined.

I landed in a rural community in Oklahoma. The colleagues that I have come to know have been some of the best I have seen anywhere. I have had the distinct privilege of taking care of patients who are for the most part very grateful for the care I can give them.

I can recall during the interview process I was concerned that as a non-Native, I might not be accepted by the patients in this part of the country. My concerns were dispelled. I have felt accepted and appreciated.

What I found was that in many ways, my Native American patients are similar to the rural patients I have had in private practice. In the Native American culture, elders are respected. Family is very important – not just the nuclear family but the extended family, cousins, and multiple generations. Patients are proud of their heritage. There is a sense of interdependence and connection. I have been blessed to be a part of healing ceremonies that have left a lasting influence on my approach to disease, health, and spirituality.

Many of these patients have limited resources and astounding health burdens. Native Americans are disproportionately afflicted with diabetes, cardiovascular disease, and obesity. Because of these health problems, programs that address these specific issues have been developed within our system. We have a diabetic clinic that includes foot care, eye care, nutritional counseling, general medicine, and pharmacy needs as well as extensive education about prevention and disease control. We have also developed a Healthy Eating for Life Program (HELP) involving a multidisciplinary approach to weight loss that includes a cognitive behavioral health program, one-on-one education with a certified bariatric nurse, support groups, nutritional instruction, and for some patients, surgical intervention.

Patients may access the Indian and Tribal Health Systems regardless of insurance status. While our practice is not totally devoid of the business aspects of medicine, most of the time we are unaware of the patients’ insurance status. Procedures or diagnostic studies that cannot be done onsite are sometimes covered through contract health services.

Our facility was built with the intent of providing health care for the adjacent counties, but by the time it was completed the need had already outstripped the resources. While funding has improved over the years, the rising costs of medical care and increases in the volume of the service population have continued to translate into unmet needs, especially for services not directly provided in our facility.

There are many physicians who have come and gone during my tenure. Some have Indian Health Service scholarship paybacks that they fulfill and move on, and others may be in transition from one greener pasture to another. The surgical service has grown from two surgeons to six. We have a good mix of youth and seasoned doctors, with half the group over 40 and half younger. The gender mix is also balanced with three females and three males.

There is a plethora of pathology. Most of us have carved out niches of surgical interest. We average 150 referrals per week, which translates into plenty to do. There are no turf battles. We have not adopted the hospitalist model. The surgeons here round and follow their own patients, which is great for continuity. Our patients appreciate seeing the same doctor. We are not, however, tethered to the facility. The surgeon on call will graciously cover any patients if needed, and we are fortunate in that we all have similar practice styles. Thus, we have cross coverage by surgeons who think and operate similarly.

We have had the pleasure of hosting both fellowship trained surgeons (vascular and trauma) and general surgeons interested in a rural lifestyle and Native medicine. The facility is also a teaching hospital. An array of students including surgical technicians, Certified Registered Nurse Anesthetist (CRNA) students, residents, medical students, and U.S. Army Special Forces all rotate through our operating rooms.

One of the benefits of the Indian Health Service is that you are part of a system. Sometimes one can forget that point amid the daily work. Going to meetings specifically geared toward IHS issues is often very rewarding. You are a part of something much bigger than your own practice. Progress is defined over time – a decrease in amputation rates as hemoglobin A1_C’s improve, a system-wide approach to colorectal cancer screening, the development of a tumor registry that specifically tracks cancer for Native Americans (no longer grouping them under “white” or lost under “other”).

Although we are rural surgeons, we do not work in isolation. All of our providers are board certified. We are currently the only facility in Oklahoma participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

In training, we were encouraged to be aggressive and work independently. It was the era of the pyramid system. No one cared how much sleep you got or when you last ate, and yet there was a team approach among the residents. That same independence is fostered here but in a much more conducive environment.

Many of us sought surgical careers because we truly enjoyed being in the operating room, the haven. We liked the technical aspects, the challenges. We joked that we liked our patients asleep, either on early morning rounds or in the surgical suite.

Where once clinic was a necessary evil, I now enjoy the interaction and find I can often do as much for the patient or family in the clinic as I can in the operating room.

I have also found that with the support of administration, we can have an impact on care beyond the individual level. We can affect the health status of an entire population.

There has been much progress in this system over the last 2 decades and there continues to be room for even more. The key may be in the name: Indian Health Service. I would encourage those who think they might find this type of practice intriguing to explore www.ihs.gov and look under career opportunities. 

Dr. Hope Baluh is an ACS fellow. She serves as chief of surgery at Cherokee Nation W.W. Hastings Hospital in Oklahoma and is a recent graduate from Johns Hopkins School of Public Health.

Only last week I thought to myself: an almost perfect surgery day. A few endoscopy cases, a breast case, a parathyroid adenoma, and a gastrectomy. I remind myself from time to time how fortunate I am to have the diversity of cases that I am afforded by my unique rural location and employment in the Indian Health Service (IHS).

Over 2 decades ago with what seemed to be an upheaval in health care, I decided to either leave surgery altogether or find some alternative to the business side of medicine that I was experiencing in the world of my private surgical practice. It was 1993 and the Health Security Act was being formulated with a task force with a paucity of physician input. It looked like medicine was headed to a period of increasing bureaucracy and decreased autonomy.

While thumbing through one of the recruiting magazines, I noticed an article about an internal medicine physician and his wife, an obstetrician/ gynecologist, who together joined the Indian Health Service. I made some inquiries.

I knew nothing about the Indian Health Service. I had a picture in my mind of a remote barren reservation working with doctors who couldn’t get a job in the real world. What I found was the best career I could have imagined.

I landed in a rural community in Oklahoma. The colleagues that I have come to know have been some of the best I have seen anywhere. I have had the distinct privilege of taking care of patients who are for the most part very grateful for the care I can give them.

I can recall during the interview process I was concerned that as a non-Native, I might not be accepted by the patients in this part of the country. My concerns were dispelled. I have felt accepted and appreciated.

What I found was that in many ways, my Native American patients are similar to the rural patients I have had in private practice. In the Native American culture, elders are respected. Family is very important – not just the nuclear family but the extended family, cousins, and multiple generations. Patients are proud of their heritage. There is a sense of interdependence and connection. I have been blessed to be a part of healing ceremonies that have left a lasting influence on my approach to disease, health, and spirituality.

Many of these patients have limited resources and astounding health burdens. Native Americans are disproportionately afflicted with diabetes, cardiovascular disease, and obesity. Because of these health problems, programs that address these specific issues have been developed within our system. We have a diabetic clinic that includes foot care, eye care, nutritional counseling, general medicine, and pharmacy needs as well as extensive education about prevention and disease control. We have also developed a Healthy Eating for Life Program (HELP) involving a multidisciplinary approach to weight loss that includes a cognitive behavioral health program, one-on-one education with a certified bariatric nurse, support groups, nutritional instruction, and for some patients, surgical intervention.

Patients may access the Indian and Tribal Health Systems regardless of insurance status. While our practice is not totally devoid of the business aspects of medicine, most of the time we are unaware of the patients’ insurance status. Procedures or diagnostic studies that cannot be done onsite are sometimes covered through contract health services.

Our facility was built with the intent of providing health care for the adjacent counties, but by the time it was completed the need had already outstripped the resources. While funding has improved over the years, the rising costs of medical care and increases in the volume of the service population have continued to translate into unmet needs, especially for services not directly provided in our facility.

There are many physicians who have come and gone during my tenure. Some have Indian Health Service scholarship paybacks that they fulfill and move on, and others may be in transition from one greener pasture to another. The surgical service has grown from two surgeons to six. We have a good mix of youth and seasoned doctors, with half the group over 40 and half younger. The gender mix is also balanced with three females and three males.

There is a plethora of pathology. Most of us have carved out niches of surgical interest. We average 150 referrals per week, which translates into plenty to do. There are no turf battles. We have not adopted the hospitalist model. The surgeons here round and follow their own patients, which is great for continuity. Our patients appreciate seeing the same doctor. We are not, however, tethered to the facility. The surgeon on call will graciously cover any patients if needed, and we are fortunate in that we all have similar practice styles. Thus, we have cross coverage by surgeons who think and operate similarly.

We have had the pleasure of hosting both fellowship trained surgeons (vascular and trauma) and general surgeons interested in a rural lifestyle and Native medicine. The facility is also a teaching hospital. An array of students including surgical technicians, Certified Registered Nurse Anesthetist (CRNA) students, residents, medical students, and U.S. Army Special Forces all rotate through our operating rooms.

One of the benefits of the Indian Health Service is that you are part of a system. Sometimes one can forget that point amid the daily work. Going to meetings specifically geared toward IHS issues is often very rewarding. You are a part of something much bigger than your own practice. Progress is defined over time – a decrease in amputation rates as hemoglobin A1_C’s improve, a system-wide approach to colorectal cancer screening, the development of a tumor registry that specifically tracks cancer for Native Americans (no longer grouping them under “white” or lost under “other”).

Although we are rural surgeons, we do not work in isolation. All of our providers are board certified. We are currently the only facility in Oklahoma participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

In training, we were encouraged to be aggressive and work independently. It was the era of the pyramid system. No one cared how much sleep you got or when you last ate, and yet there was a team approach among the residents. That same independence is fostered here but in a much more conducive environment.

Many of us sought surgical careers because we truly enjoyed being in the operating room, the haven. We liked the technical aspects, the challenges. We joked that we liked our patients asleep, either on early morning rounds or in the surgical suite.

Where once clinic was a necessary evil, I now enjoy the interaction and find I can often do as much for the patient or family in the clinic as I can in the operating room.

I have also found that with the support of administration, we can have an impact on care beyond the individual level. We can affect the health status of an entire population.

There has been much progress in this system over the last 2 decades and there continues to be room for even more. The key may be in the name: Indian Health Service. I would encourage those who think they might find this type of practice intriguing to explore www.ihs.gov and look under career opportunities. 

Dr. Hope Baluh is an ACS fellow. She serves as chief of surgery at Cherokee Nation W.W. Hastings Hospital in Oklahoma and is a recent graduate from Johns Hopkins School of Public Health.

Welcome to a new column about rural surgery! This quarterly feature will be a foray into the world of the rural surgeon by someone who has lived and worked in the rural milieu for many years. I want to bring to you a view of rural surgery from the “front lines.”

“Rural surgery: A view from the front lines” will be the second series about this timely topic published by ACS Surgery News. The first, “The Rural Surgeon” appeared in 2015 and was coordinated by Philip Caropreso, MD, FACS, a prominent and eloquent advocate for rural surgeons. The series was a great success. I was prevailed upon to begin another series. The goal for the new series is to delve into not only the important issues that rural surgeons face, but also to convey to readers who practice far from rural America what goes on in a rural practice.

Dr. Puls is a general surgeon in Alpena, Mich. He serves as vice chair of the ACS Advisory Council for Rural Surgery.

Welcome to a new column about rural surgery! This quarterly feature will be a foray into the world of the rural surgeon by someone who has lived and worked in the rural milieu for many years. I want to bring to you a view of rural surgery from the “front lines.”

“Rural surgery: A view from the front lines” will be the second series about this timely topic published by ACS Surgery News. The first, “The Rural Surgeon” appeared in 2015 and was coordinated by Philip Caropreso, MD, FACS, a prominent and eloquent advocate for rural surgeons. The series was a great success. I was prevailed upon to begin another series. The goal for the new series is to delve into not only the important issues that rural surgeons face, but also to convey to readers who practice far from rural America what goes on in a rural practice.

Dr. Puls is a general surgeon in Alpena, Mich. He serves as vice chair of the ACS Advisory Council for Rural Surgery.

Welcome to a new column about rural surgery! This quarterly feature will be a foray into the world of the rural surgeon by someone who has lived and worked in the rural milieu for many years. I want to bring to you a view of rural surgery from the “front lines.”

“Rural surgery: A view from the front lines” will be the second series about this timely topic published by ACS Surgery News. The first, “The Rural Surgeon” appeared in 2015 and was coordinated by Philip Caropreso, MD, FACS, a prominent and eloquent advocate for rural surgeons. The series was a great success. I was prevailed upon to begin another series. The goal for the new series is to delve into not only the important issues that rural surgeons face, but also to convey to readers who practice far from rural America what goes on in a rural practice.

Dr. Puls is a general surgeon in Alpena, Mich. He serves as vice chair of the ACS Advisory Council for Rural Surgery.

Despite the many changes in medicine over the past century, traumatic injury remains a surgical disease.

Trauma injury is a major public health concern in rural areas, where death rates from unintentional injuries are higher than in metropolitan areas (Am. J. Public Health 2004;10:1689-93). The rural surgeon sees more than his or her fair share of victims of automobile accidents, falls, unintentional firearms injuries, and occupational accidents (think tractor accidents and injuries involving machinery and animals).

Another reality of the rural areas of the United States is that the number of broadly trained general surgeons who can treat a wide variety of trauma injuries is shrinking. Aging and retirements of the “old school rural surgeons” are accelerating and precipitating a lack of surgical coverage crisis, including trauma, in rural areas (Arch. Surg. 2005;140:74-9).

These well-documented developments have combined to reduce the availability of rural surgeons to manage injured patients in planned and consistent ways. Because of the current training paradigm of increasing subspecialization, injured rural patients may be cared for at rural hospitals with reduced capabilities and by rural surgeons with limited trauma training and experience.

What is the action plan to help counteract these developments and to provide the highest-quality patient care at facilities staffed by surgeons who have sworn to “serve all with skill and fidelity”?

The most straightforward and well-established action plan to achieve those goals is the verification process developed by the ACS Verification, Review, and Consultation Program (VRC) in 1987 to help hospitals improve trauma care. The process involves a pre-review questionnaire, a site visit, and report of findings. Verification as a trauma center guarantees that the facility has the required resources listed in the current, evidence-based guide, Resources for Optimal Care of the Injured Patient (2014). If successful, the trauma center receives a certificate of verification that is valid for 3 years.

Most rural hospitals are designated as Level III and IV verified trauma centers on the basis of their available resources. ACS verification confirms that these centers have the commitments and capabilities to manage the initial care of injured patients by providing stabilization and instituting life-saving maneuvers. In addition, verification confirms that protocols and agreements with higher-level trauma centers within a system enable the safe and efficient transfer of injured patients.

During many years of practice in the rural hospitals verified as trauma centers, including being the medical director of a Level II and Level III facility, I provided care to injured patients who presented to the emergency departments (EDs). My experiences confirmed the unequivocal value of practicing in those facilities, and I can attest to the benefits of verification within a system, like Iowa’s state program.

The following case report validates such assertions. A helicopter, unable to complete the transfer to a Level I center for a deteriorating patient with a left chest gunshot wound, landed at my Level III hospital. There was a “Hot Off Load,” which was followed by a full trauma alert for the patient in profound shock. After placing a chest tube during a 20-minute ED stay, the patient transferred to the OR for further resuscitation, and stabilization with required operative treatment. With the patient stabilized and fully resuscitated, according to established agreements, I contacted the Level I center from the OR. After 3 hours, the patient returned to the helicopter and completed the transfer to the Level I trauma center. The patient survived because of the local trauma team’s commitment, organization, and skill brought about by the trauma center verification.

Most research to date has focused on higher-level trauma centers, but recent studies have shown that ACS verification was an independent predictor of survival of trauma patients at Level II centers (J. Trauma Acute Care Surg. 2013;75:44-9; J. Trauma Acute Care Surg. 2010;69:1362-6).

I have firsthand experience with the verification process. Following my involvement with the ACS Committee on Trauma, I became a national site surveyor for the ACSVRC. I became an Advanced Trauma Life Support (ATLS) instructor and then worked as a course director. ATLS is an essential component for trauma center verification. It supports the rural surgeon by giving the local trauma team a format for consistent, life-saving care for the most severely injured patients. I subsequently completed the ACS Advanced Trauma Operative Management course and elected to become an instructor.

I have made site visits to many rural hospitals as a part of the ACSVRC process and have met with a wide range of reactions from “Let’s show off how good we are” to “We really don’t know why we’re doing this” to “Just give us the merit badge and then get out of our hair.” I am gratified to note that ACS Fellows are uniformly supportive. They understand the need for organization, standards, and performance improvement.

Opposition to the ACSVRC process by hospitals and staff is no doubt rooted in cost concerns and general resistance to change. But, as most of us know, demonstrated benefits for patient care can be highly persuasive to most medical professionals.

It is also worth noting that in an effort to decrease stress, the ACSVRC takes significant steps to support facilities that seek verification by eliminating ambiguity from application to on-site visit, by defining criteria deficiencies, and by providing evidence for the entire verification process. The complete VRC program along with an FAQ is available on the ACS website (facs.org/quality-programs/trauma/vrc).

For me, trauma care has always been about what is best for the injured patient. I often ask colleagues this question: “What care do you want for an injured member of your family?” I then answer my own question: “I want the best care possible. That means organized, efficient, and life-saving [care] if needed.” Fortunately, I experienced these benefits at my verified trauma center hospital when my second son was in a rollover motor vehicle crash. He survived.

Verified rural trauma centers do indeed offer the best opportunities for high-quality patient care and for support of the rural surgeons who render that care to “serve all with skill and fidelity.” I know. I have been there.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and clinical professor of surgery at the University of Iowa Carver College of Medicine, Iowa City. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

Despite the many changes in medicine over the past century, traumatic injury remains a surgical disease.

Trauma injury is a major public health concern in rural areas, where death rates from unintentional injuries are higher than in metropolitan areas (Am. J. Public Health 2004;10:1689-93). The rural surgeon sees more than his or her fair share of victims of automobile accidents, falls, unintentional firearms injuries, and occupational accidents (think tractor accidents and injuries involving machinery and animals).

Another reality of the rural areas of the United States is that the number of broadly trained general surgeons who can treat a wide variety of trauma injuries is shrinking. Aging and retirements of the “old school rural surgeons” are accelerating and precipitating a lack of surgical coverage crisis, including trauma, in rural areas (Arch. Surg. 2005;140:74-9).

These well-documented developments have combined to reduce the availability of rural surgeons to manage injured patients in planned and consistent ways. Because of the current training paradigm of increasing subspecialization, injured rural patients may be cared for at rural hospitals with reduced capabilities and by rural surgeons with limited trauma training and experience.

What is the action plan to help counteract these developments and to provide the highest-quality patient care at facilities staffed by surgeons who have sworn to “serve all with skill and fidelity”?

The most straightforward and well-established action plan to achieve those goals is the verification process developed by the ACS Verification, Review, and Consultation Program (VRC) in 1987 to help hospitals improve trauma care. The process involves a pre-review questionnaire, a site visit, and report of findings. Verification as a trauma center guarantees that the facility has the required resources listed in the current, evidence-based guide, Resources for Optimal Care of the Injured Patient (2014). If successful, the trauma center receives a certificate of verification that is valid for 3 years.

Most rural hospitals are designated as Level III and IV verified trauma centers on the basis of their available resources. ACS verification confirms that these centers have the commitments and capabilities to manage the initial care of injured patients by providing stabilization and instituting life-saving maneuvers. In addition, verification confirms that protocols and agreements with higher-level trauma centers within a system enable the safe and efficient transfer of injured patients.

During many years of practice in the rural hospitals verified as trauma centers, including being the medical director of a Level II and Level III facility, I provided care to injured patients who presented to the emergency departments (EDs). My experiences confirmed the unequivocal value of practicing in those facilities, and I can attest to the benefits of verification within a system, like Iowa’s state program.

The following case report validates such assertions. A helicopter, unable to complete the transfer to a Level I center for a deteriorating patient with a left chest gunshot wound, landed at my Level III hospital. There was a “Hot Off Load,” which was followed by a full trauma alert for the patient in profound shock. After placing a chest tube during a 20-minute ED stay, the patient transferred to the OR for further resuscitation, and stabilization with required operative treatment. With the patient stabilized and fully resuscitated, according to established agreements, I contacted the Level I center from the OR. After 3 hours, the patient returned to the helicopter and completed the transfer to the Level I trauma center. The patient survived because of the local trauma team’s commitment, organization, and skill brought about by the trauma center verification.

Most research to date has focused on higher-level trauma centers, but recent studies have shown that ACS verification was an independent predictor of survival of trauma patients at Level II centers (J. Trauma Acute Care Surg. 2013;75:44-9; J. Trauma Acute Care Surg. 2010;69:1362-6).

I have firsthand experience with the verification process. Following my involvement with the ACS Committee on Trauma, I became a national site surveyor for the ACSVRC. I became an Advanced Trauma Life Support (ATLS) instructor and then worked as a course director. ATLS is an essential component for trauma center verification. It supports the rural surgeon by giving the local trauma team a format for consistent, life-saving care for the most severely injured patients. I subsequently completed the ACS Advanced Trauma Operative Management course and elected to become an instructor.

I have made site visits to many rural hospitals as a part of the ACSVRC process and have met with a wide range of reactions from “Let’s show off how good we are” to “We really don’t know why we’re doing this” to “Just give us the merit badge and then get out of our hair.” I am gratified to note that ACS Fellows are uniformly supportive. They understand the need for organization, standards, and performance improvement.

Opposition to the ACSVRC process by hospitals and staff is no doubt rooted in cost concerns and general resistance to change. But, as most of us know, demonstrated benefits for patient care can be highly persuasive to most medical professionals.

It is also worth noting that in an effort to decrease stress, the ACSVRC takes significant steps to support facilities that seek verification by eliminating ambiguity from application to on-site visit, by defining criteria deficiencies, and by providing evidence for the entire verification process. The complete VRC program along with an FAQ is available on the ACS website (facs.org/quality-programs/trauma/vrc).

For me, trauma care has always been about what is best for the injured patient. I often ask colleagues this question: “What care do you want for an injured member of your family?” I then answer my own question: “I want the best care possible. That means organized, efficient, and life-saving [care] if needed.” Fortunately, I experienced these benefits at my verified trauma center hospital when my second son was in a rollover motor vehicle crash. He survived.

Verified rural trauma centers do indeed offer the best opportunities for high-quality patient care and for support of the rural surgeons who render that care to “serve all with skill and fidelity.” I know. I have been there.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and clinical professor of surgery at the University of Iowa Carver College of Medicine, Iowa City. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

Despite the many changes in medicine over the past century, traumatic injury remains a surgical disease.

Trauma injury is a major public health concern in rural areas, where death rates from unintentional injuries are higher than in metropolitan areas (Am. J. Public Health 2004;10:1689-93). The rural surgeon sees more than his or her fair share of victims of automobile accidents, falls, unintentional firearms injuries, and occupational accidents (think tractor accidents and injuries involving machinery and animals).

Another reality of the rural areas of the United States is that the number of broadly trained general surgeons who can treat a wide variety of trauma injuries is shrinking. Aging and retirements of the “old school rural surgeons” are accelerating and precipitating a lack of surgical coverage crisis, including trauma, in rural areas (Arch. Surg. 2005;140:74-9).

These well-documented developments have combined to reduce the availability of rural surgeons to manage injured patients in planned and consistent ways. Because of the current training paradigm of increasing subspecialization, injured rural patients may be cared for at rural hospitals with reduced capabilities and by rural surgeons with limited trauma training and experience.

What is the action plan to help counteract these developments and to provide the highest-quality patient care at facilities staffed by surgeons who have sworn to “serve all with skill and fidelity”?

The most straightforward and well-established action plan to achieve those goals is the verification process developed by the ACS Verification, Review, and Consultation Program (VRC) in 1987 to help hospitals improve trauma care. The process involves a pre-review questionnaire, a site visit, and report of findings. Verification as a trauma center guarantees that the facility has the required resources listed in the current, evidence-based guide, Resources for Optimal Care of the Injured Patient (2014). If successful, the trauma center receives a certificate of verification that is valid for 3 years.

Most rural hospitals are designated as Level III and IV verified trauma centers on the basis of their available resources. ACS verification confirms that these centers have the commitments and capabilities to manage the initial care of injured patients by providing stabilization and instituting life-saving maneuvers. In addition, verification confirms that protocols and agreements with higher-level trauma centers within a system enable the safe and efficient transfer of injured patients.

During many years of practice in the rural hospitals verified as trauma centers, including being the medical director of a Level II and Level III facility, I provided care to injured patients who presented to the emergency departments (EDs). My experiences confirmed the unequivocal value of practicing in those facilities, and I can attest to the benefits of verification within a system, like Iowa’s state program.

The following case report validates such assertions. A helicopter, unable to complete the transfer to a Level I center for a deteriorating patient with a left chest gunshot wound, landed at my Level III hospital. There was a “Hot Off Load,” which was followed by a full trauma alert for the patient in profound shock. After placing a chest tube during a 20-minute ED stay, the patient transferred to the OR for further resuscitation, and stabilization with required operative treatment. With the patient stabilized and fully resuscitated, according to established agreements, I contacted the Level I center from the OR. After 3 hours, the patient returned to the helicopter and completed the transfer to the Level I trauma center. The patient survived because of the local trauma team’s commitment, organization, and skill brought about by the trauma center verification.

Most research to date has focused on higher-level trauma centers, but recent studies have shown that ACS verification was an independent predictor of survival of trauma patients at Level II centers (J. Trauma Acute Care Surg. 2013;75:44-9; J. Trauma Acute Care Surg. 2010;69:1362-6).

I have firsthand experience with the verification process. Following my involvement with the ACS Committee on Trauma, I became a national site surveyor for the ACSVRC. I became an Advanced Trauma Life Support (ATLS) instructor and then worked as a course director. ATLS is an essential component for trauma center verification. It supports the rural surgeon by giving the local trauma team a format for consistent, life-saving care for the most severely injured patients. I subsequently completed the ACS Advanced Trauma Operative Management course and elected to become an instructor.

I have made site visits to many rural hospitals as a part of the ACSVRC process and have met with a wide range of reactions from “Let’s show off how good we are” to “We really don’t know why we’re doing this” to “Just give us the merit badge and then get out of our hair.” I am gratified to note that ACS Fellows are uniformly supportive. They understand the need for organization, standards, and performance improvement.

Opposition to the ACSVRC process by hospitals and staff is no doubt rooted in cost concerns and general resistance to change. But, as most of us know, demonstrated benefits for patient care can be highly persuasive to most medical professionals.

It is also worth noting that in an effort to decrease stress, the ACSVRC takes significant steps to support facilities that seek verification by eliminating ambiguity from application to on-site visit, by defining criteria deficiencies, and by providing evidence for the entire verification process. The complete VRC program along with an FAQ is available on the ACS website (facs.org/quality-programs/trauma/vrc).

For me, trauma care has always been about what is best for the injured patient. I often ask colleagues this question: “What care do you want for an injured member of your family?” I then answer my own question: “I want the best care possible. That means organized, efficient, and life-saving [care] if needed.” Fortunately, I experienced these benefits at my verified trauma center hospital when my second son was in a rollover motor vehicle crash. He survived.

Verified rural trauma centers do indeed offer the best opportunities for high-quality patient care and for support of the rural surgeons who render that care to “serve all with skill and fidelity.” I know. I have been there.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and clinical professor of surgery at the University of Iowa Carver College of Medicine, Iowa City. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

For those who have chosen the surgeon’s path, finding a sustainable work/life balance is challenging. For surgeons with young families and spousal responsibilities, achieving that balance may seem like an unattainable goal. As a rural surgeon with a spouse and children, I am here to say that rural practice has many benefits to those who love their work and also want a balanced life. I recommend that young surgeons, women in particular, consider this path for both the professional and personal advantages it offers.

I always tell the medical students that rotate with me, “When it is 4 o’clock in the morning and you forgot to go home ... be that.” That is to say, whatever rotation they are on when they have that feeling, that is the specialty they should choose. That was us when it came to surgery. When we were students going through surgical rotations we could not get enough. We wanted to see everything, do everything, and we didn’t want to miss anything. Many of our colleagues recommended against choosing surgery. We were told, “You’ll never have a life or a family;” “Your life will be horrible,” etc.

Now, many years later, I still love what I do as a surgeon. But I also love the other half of my life. I chose to practice rural surgery because I sensed that a balanced life would be possible in the rural setting. So I offer the following 10 tips for young surgeons who might be considering a rural practice:

1. Pick a good small town

Sit down and write out a list of all the things you want in a small town. My list, of course, will be different from your list but most importantly, make the list! It is no use taking a job in rural Colorado if you hate to hunt and fish. Consider the town and the job equally. For women surgeons, you may want to look for a place where there are women in upper administrative roles and other female physicians on staff. All small towns are definitely not alike and if you pick one for the hospital or the job without considering your surroundings, you will not likely be happy.

2. Don’t commute

Some people take a job in a small town or a rural setting but choose to live 30 miles away in the next larger town. I suggest living in the town you practice in. If at all possible, live close to the hospital. Every minute that you spend on the road is a minute away from your family. Living far away makes that 2 a.m. call from the ER that much more painful. You also miss out on the opportunity to become a real part of your community.

3. Choose the right partner

Small town physicians are tough to keep. Rural practice turnover is high. One of the most common reasons I hear for why a physician has left the area is because his or her spouse wasn’t happy. No matter how appealing the job seems, no matter how much bonus money they offer, no matter how great the hospital appears, if your spouse doesn’t like it there, you’ll be leaving. You may love your job and back country camping every weekend, but if your spouse pines for Whole Foods and the opera, you will be moving on eventually.

A large part of rural life revolves around events in the school system, and even if you have no young children of your own, it is helpful to make an effort to attend some of these events, if only to support your neighbor’s kids. It goes a long way to establish you as someone who is involved in the community and who cares. Remember, it is the mothers young and old who make many of the health care decisions for their families. Volunteer for events or get involved in the science program at the high school. You may find that you are a unique role model for teenagers in your community.

4. Choose the right partners

Rural general surgery is challenging enough without having to compete with those around you. Surgery in the small town setting becomes infinitely more pleasant when you have good partners. Is the practice set up to help and support each partner, or are you pitted against one another, competing for RVUs? Would your partners tolerate covering your call for 3 months of maternity leave or would this cause resentment? Look for a practice where the surgeons work together and cover for each other, and your small town life will be greatly enhanced.

5. Live within your means

A small town surgical practice can make for a very comfortable life. The cost of living is less, which means that your money goes further, with more left over for expenses such as saving for your kids’ college education. In addition, when you live in rural America, you won’t likely feel pressured to join the super expensive country club, send your kids to an expensive school, or drive a six-figure car. Although we may not make quite as much as the big city folk, when you account for the cost of living, rural surgeons do quite well.

6. Hire help

My husband is a firefighter, and at one point early in our marriage he was working night shift. With me on call and small children at home, that presented somewhat of a problem. But we solved it with a live-in nanny. Some people say, “I don’t want someone else raising my children,” and then they spend all their free time washing baby’s laundry and cleaning house instead of playing with the baby and having family meals and other family time together. How you utilize a nanny or any other help you hire is determined by you. But the idea is to hire help to do the mundane things so that you can do the fun things.

 7. Learn to charm a rock

Small towns can be tough. Make one mistake, make one person angry, and before you eat your breakfast the next morning, the whole town knows about it. A very wise mentor of mine once said, “You catch more flies with honey.” Of course, he was absolutely right. When we work in bigger places, we tend to become numb to our own behavior because outbursts and conflicts are so common that our own little outbursts get lost in the mix. Such is not the case in a small town.

In rural America, people stop their cars to let you pull out. This can be very shocking when you come from New York and your first thought is …am I being carjacked? In a rural town, if you walk around with a Band-Aid on your face, every single person you pass on the street will ask if you are ok. It teaches you to treat other people well, even if you are having an absolutely terrible day. You can’t get away with taking your mood out on other people in a small town.

One very nice thing about working in a rural community is that people are grateful and have a very long memory for whatever you’ve done for them. Whether you’ve cured their colon cancer or removed a lipoma, they will stop you on the street to thank you or tell their friends for years afterward about how wonderful you were.

8. Get a hobby

Although life as a small town general surgeon can seem like a 24/7 occupation, careful time management and household support can create space for a hobby. And you need one. No matter how much we all love surgery, it is essential that we cultivate the ability to leave it be for a time here and there. A hobby (preferably one that helps alleviate stress) can help stave off burnout.

9. Don’t forget to sleep

This much-neglected survival tip is so important. We all have to be on call, some more than others. But most of us also have nights where we are not on call. These should not be the nights where we stay up until 3 a.m. watching every episode of the latest Netflix series. You must resist that temptation. The older you get, the harder it is to recover from a night out operating.

10. Never forget the 4 a.m. feeling

So you may learn to adjust to the small town and then to love it fiercely and protectively. You may even buy your own cow once a year or join a shooting range. You may learn to discuss the fall elk hunt, ice fishing, ranching, and the best place to buy ammunition with your patients. You walk through the hospital and you know every single person you pass in the hallway as well as their kids.

Let us never forget why we chose to be surgeons. Most of us would weather any challenge to continue to do what we love. And choosing a rural practice is one way to practice surgery and also achieve a satisfying work/life balance.

Dr. Long is an ACS Fellow and a general surgeon in rural West Virginia. She is the mother of five and an ironman triathlete. She is currently preparing for her 18th surgical mission trip to Central America in April. Dr. Justine Gavagan and Dr. Catherine O’Connor contributed to this article.

For those who have chosen the surgeon’s path, finding a sustainable work/life balance is challenging. For surgeons with young families and spousal responsibilities, achieving that balance may seem like an unattainable goal. As a rural surgeon with a spouse and children, I am here to say that rural practice has many benefits to those who love their work and also want a balanced life. I recommend that young surgeons, women in particular, consider this path for both the professional and personal advantages it offers.

I always tell the medical students that rotate with me, “When it is 4 o’clock in the morning and you forgot to go home ... be that.” That is to say, whatever rotation they are on when they have that feeling, that is the specialty they should choose. That was us when it came to surgery. When we were students going through surgical rotations we could not get enough. We wanted to see everything, do everything, and we didn’t want to miss anything. Many of our colleagues recommended against choosing surgery. We were told, “You’ll never have a life or a family;” “Your life will be horrible,” etc.

Now, many years later, I still love what I do as a surgeon. But I also love the other half of my life. I chose to practice rural surgery because I sensed that a balanced life would be possible in the rural setting. So I offer the following 10 tips for young surgeons who might be considering a rural practice:

1. Pick a good small town

Sit down and write out a list of all the things you want in a small town. My list, of course, will be different from your list but most importantly, make the list! It is no use taking a job in rural Colorado if you hate to hunt and fish. Consider the town and the job equally. For women surgeons, you may want to look for a place where there are women in upper administrative roles and other female physicians on staff. All small towns are definitely not alike and if you pick one for the hospital or the job without considering your surroundings, you will not likely be happy.

2. Don’t commute

Some people take a job in a small town or a rural setting but choose to live 30 miles away in the next larger town. I suggest living in the town you practice in. If at all possible, live close to the hospital. Every minute that you spend on the road is a minute away from your family. Living far away makes that 2 a.m. call from the ER that much more painful. You also miss out on the opportunity to become a real part of your community.

3. Choose the right partner

Small town physicians are tough to keep. Rural practice turnover is high. One of the most common reasons I hear for why a physician has left the area is because his or her spouse wasn’t happy. No matter how appealing the job seems, no matter how much bonus money they offer, no matter how great the hospital appears, if your spouse doesn’t like it there, you’ll be leaving. You may love your job and back country camping every weekend, but if your spouse pines for Whole Foods and the opera, you will be moving on eventually.

A large part of rural life revolves around events in the school system, and even if you have no young children of your own, it is helpful to make an effort to attend some of these events, if only to support your neighbor’s kids. It goes a long way to establish you as someone who is involved in the community and who cares. Remember, it is the mothers young and old who make many of the health care decisions for their families. Volunteer for events or get involved in the science program at the high school. You may find that you are a unique role model for teenagers in your community.

4. Choose the right partners

Rural general surgery is challenging enough without having to compete with those around you. Surgery in the small town setting becomes infinitely more pleasant when you have good partners. Is the practice set up to help and support each partner, or are you pitted against one another, competing for RVUs? Would your partners tolerate covering your call for 3 months of maternity leave or would this cause resentment? Look for a practice where the surgeons work together and cover for each other, and your small town life will be greatly enhanced.

5. Live within your means

A small town surgical practice can make for a very comfortable life. The cost of living is less, which means that your money goes further, with more left over for expenses such as saving for your kids’ college education. In addition, when you live in rural America, you won’t likely feel pressured to join the super expensive country club, send your kids to an expensive school, or drive a six-figure car. Although we may not make quite as much as the big city folk, when you account for the cost of living, rural surgeons do quite well.

6. Hire help

My husband is a firefighter, and at one point early in our marriage he was working night shift. With me on call and small children at home, that presented somewhat of a problem. But we solved it with a live-in nanny. Some people say, “I don’t want someone else raising my children,” and then they spend all their free time washing baby’s laundry and cleaning house instead of playing with the baby and having family meals and other family time together. How you utilize a nanny or any other help you hire is determined by you. But the idea is to hire help to do the mundane things so that you can do the fun things.

 7. Learn to charm a rock

Small towns can be tough. Make one mistake, make one person angry, and before you eat your breakfast the next morning, the whole town knows about it. A very wise mentor of mine once said, “You catch more flies with honey.” Of course, he was absolutely right. When we work in bigger places, we tend to become numb to our own behavior because outbursts and conflicts are so common that our own little outbursts get lost in the mix. Such is not the case in a small town.

In rural America, people stop their cars to let you pull out. This can be very shocking when you come from New York and your first thought is …am I being carjacked? In a rural town, if you walk around with a Band-Aid on your face, every single person you pass on the street will ask if you are ok. It teaches you to treat other people well, even if you are having an absolutely terrible day. You can’t get away with taking your mood out on other people in a small town.

One very nice thing about working in a rural community is that people are grateful and have a very long memory for whatever you’ve done for them. Whether you’ve cured their colon cancer or removed a lipoma, they will stop you on the street to thank you or tell their friends for years afterward about how wonderful you were.

8. Get a hobby

Although life as a small town general surgeon can seem like a 24/7 occupation, careful time management and household support can create space for a hobby. And you need one. No matter how much we all love surgery, it is essential that we cultivate the ability to leave it be for a time here and there. A hobby (preferably one that helps alleviate stress) can help stave off burnout.

9. Don’t forget to sleep

This much-neglected survival tip is so important. We all have to be on call, some more than others. But most of us also have nights where we are not on call. These should not be the nights where we stay up until 3 a.m. watching every episode of the latest Netflix series. You must resist that temptation. The older you get, the harder it is to recover from a night out operating.

10. Never forget the 4 a.m. feeling

So you may learn to adjust to the small town and then to love it fiercely and protectively. You may even buy your own cow once a year or join a shooting range. You may learn to discuss the fall elk hunt, ice fishing, ranching, and the best place to buy ammunition with your patients. You walk through the hospital and you know every single person you pass in the hallway as well as their kids.

Let us never forget why we chose to be surgeons. Most of us would weather any challenge to continue to do what we love. And choosing a rural practice is one way to practice surgery and also achieve a satisfying work/life balance.

Dr. Long is an ACS Fellow and a general surgeon in rural West Virginia. She is the mother of five and an ironman triathlete. She is currently preparing for her 18th surgical mission trip to Central America in April. Dr. Justine Gavagan and Dr. Catherine O’Connor contributed to this article.

For those who have chosen the surgeon’s path, finding a sustainable work/life balance is challenging. For surgeons with young families and spousal responsibilities, achieving that balance may seem like an unattainable goal. As a rural surgeon with a spouse and children, I am here to say that rural practice has many benefits to those who love their work and also want a balanced life. I recommend that young surgeons, women in particular, consider this path for both the professional and personal advantages it offers.

I always tell the medical students that rotate with me, “When it is 4 o’clock in the morning and you forgot to go home ... be that.” That is to say, whatever rotation they are on when they have that feeling, that is the specialty they should choose. That was us when it came to surgery. When we were students going through surgical rotations we could not get enough. We wanted to see everything, do everything, and we didn’t want to miss anything. Many of our colleagues recommended against choosing surgery. We were told, “You’ll never have a life or a family;” “Your life will be horrible,” etc.

Now, many years later, I still love what I do as a surgeon. But I also love the other half of my life. I chose to practice rural surgery because I sensed that a balanced life would be possible in the rural setting. So I offer the following 10 tips for young surgeons who might be considering a rural practice:

1. Pick a good small town

Sit down and write out a list of all the things you want in a small town. My list, of course, will be different from your list but most importantly, make the list! It is no use taking a job in rural Colorado if you hate to hunt and fish. Consider the town and the job equally. For women surgeons, you may want to look for a place where there are women in upper administrative roles and other female physicians on staff. All small towns are definitely not alike and if you pick one for the hospital or the job without considering your surroundings, you will not likely be happy.

2. Don’t commute

Some people take a job in a small town or a rural setting but choose to live 30 miles away in the next larger town. I suggest living in the town you practice in. If at all possible, live close to the hospital. Every minute that you spend on the road is a minute away from your family. Living far away makes that 2 a.m. call from the ER that much more painful. You also miss out on the opportunity to become a real part of your community.

3. Choose the right partner

Small town physicians are tough to keep. Rural practice turnover is high. One of the most common reasons I hear for why a physician has left the area is because his or her spouse wasn’t happy. No matter how appealing the job seems, no matter how much bonus money they offer, no matter how great the hospital appears, if your spouse doesn’t like it there, you’ll be leaving. You may love your job and back country camping every weekend, but if your spouse pines for Whole Foods and the opera, you will be moving on eventually.

A large part of rural life revolves around events in the school system, and even if you have no young children of your own, it is helpful to make an effort to attend some of these events, if only to support your neighbor’s kids. It goes a long way to establish you as someone who is involved in the community and who cares. Remember, it is the mothers young and old who make many of the health care decisions for their families. Volunteer for events or get involved in the science program at the high school. You may find that you are a unique role model for teenagers in your community.

4. Choose the right partners

Rural general surgery is challenging enough without having to compete with those around you. Surgery in the small town setting becomes infinitely more pleasant when you have good partners. Is the practice set up to help and support each partner, or are you pitted against one another, competing for RVUs? Would your partners tolerate covering your call for 3 months of maternity leave or would this cause resentment? Look for a practice where the surgeons work together and cover for each other, and your small town life will be greatly enhanced.

5. Live within your means

A small town surgical practice can make for a very comfortable life. The cost of living is less, which means that your money goes further, with more left over for expenses such as saving for your kids’ college education. In addition, when you live in rural America, you won’t likely feel pressured to join the super expensive country club, send your kids to an expensive school, or drive a six-figure car. Although we may not make quite as much as the big city folk, when you account for the cost of living, rural surgeons do quite well.

6. Hire help

My husband is a firefighter, and at one point early in our marriage he was working night shift. With me on call and small children at home, that presented somewhat of a problem. But we solved it with a live-in nanny. Some people say, “I don’t want someone else raising my children,” and then they spend all their free time washing baby’s laundry and cleaning house instead of playing with the baby and having family meals and other family time together. How you utilize a nanny or any other help you hire is determined by you. But the idea is to hire help to do the mundane things so that you can do the fun things.

 7. Learn to charm a rock

Small towns can be tough. Make one mistake, make one person angry, and before you eat your breakfast the next morning, the whole town knows about it. A very wise mentor of mine once said, “You catch more flies with honey.” Of course, he was absolutely right. When we work in bigger places, we tend to become numb to our own behavior because outbursts and conflicts are so common that our own little outbursts get lost in the mix. Such is not the case in a small town.

In rural America, people stop their cars to let you pull out. This can be very shocking when you come from New York and your first thought is …am I being carjacked? In a rural town, if you walk around with a Band-Aid on your face, every single person you pass on the street will ask if you are ok. It teaches you to treat other people well, even if you are having an absolutely terrible day. You can’t get away with taking your mood out on other people in a small town.

One very nice thing about working in a rural community is that people are grateful and have a very long memory for whatever you’ve done for them. Whether you’ve cured their colon cancer or removed a lipoma, they will stop you on the street to thank you or tell their friends for years afterward about how wonderful you were.

8. Get a hobby

Although life as a small town general surgeon can seem like a 24/7 occupation, careful time management and household support can create space for a hobby. And you need one. No matter how much we all love surgery, it is essential that we cultivate the ability to leave it be for a time here and there. A hobby (preferably one that helps alleviate stress) can help stave off burnout.

9. Don’t forget to sleep

This much-neglected survival tip is so important. We all have to be on call, some more than others. But most of us also have nights where we are not on call. These should not be the nights where we stay up until 3 a.m. watching every episode of the latest Netflix series. You must resist that temptation. The older you get, the harder it is to recover from a night out operating.

10. Never forget the 4 a.m. feeling

So you may learn to adjust to the small town and then to love it fiercely and protectively. You may even buy your own cow once a year or join a shooting range. You may learn to discuss the fall elk hunt, ice fishing, ranching, and the best place to buy ammunition with your patients. You walk through the hospital and you know every single person you pass in the hallway as well as their kids.

Let us never forget why we chose to be surgeons. Most of us would weather any challenge to continue to do what we love. And choosing a rural practice is one way to practice surgery and also achieve a satisfying work/life balance.

Dr. Long is an ACS Fellow and a general surgeon in rural West Virginia. She is the mother of five and an ironman triathlete. She is currently preparing for her 18th surgical mission trip to Central America in April. Dr. Justine Gavagan and Dr. Catherine O’Connor contributed to this article.

We are currently embroiled in a health care crisis, characterized by the need for malpractice reform, pressures of the 80-hour work week regulations on resident education, and a decreasing interest in pursuing a career in surgery. As we face these difficult problems, we should reflect upon one of the aspects that makes surgery a great profession – namely, devotion to our patients and our craft. As we look forward to the future, I would like to share my personal reminiscences of a rural surgeon from the 20th century who affected my personal development and growth as a general and trauma surgeon.

My father, William J. Baker, M.D., was the first surgeon I ever knew. His effects on me (both as a parent and as a mentor) have been profound and long lasting. Born in Cambridge, Mass., Bill Baker attended Cambridge Latin, Harvard College (BS, 1936), Tufts University (MS in psychology, 1937), and Harvard Medical School (MD, 1941). He then worked as an intern at the Massachusetts General Hospital, where he met Jean “Pinky” Houghton who was working as a scrub nurse for Dr. Robert Linton. Pinky and Bill were married in Hawaii just before he joined the Navy in 1942. He was assigned to a Marine infantry assault division in the Philippines, where he was honored with a Purple Heart and the Silver Star.

>After the war, Dr. Baker returned to Boston where he trained under Dr. Richard Warren at the West Roxbury VA. In 1950 he and Pinky moved to the small town of Laconia in central New Hampshire; he was the first board-certified general surgeon in the State of New Hampshire outside of Dartmouth (which is, after all, almost in Vermont). He performed the first thoracic operation at the Laconia Hospital and brought a high standard of surgical care to the Lakes Region. At the end of his career, he served as Chief of Surgery at the Brockton VA from 1981 to 1985, allowing him to go back to his roots as a Visiting Attending at the West Roxbury VA.

Although Bill Baker did not pursue a career in academic surgery, he made major contributions to surgical care in New Hampshire. He was a charter member of the Northeast Medical Association (NEMA), founded in 1957, which was devoted to improving the care of injured skiers. I remember attending the second meeting at Stowe, Vt., in 1958 (at the age of 10). We both enjoyed our participation in the National Ski Patrol Association, and we were both very proud when I was able to join him as a member of the NEMA in 1984. As a strong advocate for prevention in the area of trauma, Bill Baker spearheaded efforts that led to legislation for the mandatory use of seatbelts and motorcycle helmets in New Hampshire. In the field of breast cancer, he developed an informal but well-organized group of breast cancer survivors (whom he lovingly called his “bosom buddies”). These ladies connected to women who had recently undergone mastectomy for breast cancer. This initiative preceded the Reach to Recovery program that was later sponsored by the American Cancer Society.

As a parent, Bill Baker taught me many things. As a rural surgeon, he evinced a dedication to excellent patient care, a legacy of life-long learning, and a strong commitment to community service and the prevention of injury. He served as President of the New Hampshire Chapter of the American College of Surgeons and was an active member of the New England Surgical Society. As a father, he was a great role model, who taught me the satisfaction that a career in rural general surgery could provide. As the quintessential rural surgeon, Bill Baker made multiple contributions to his community and his adopted state of New Hampshire. His death at the age of 78 was mourned by his family, friends, and the many patients whose lives he had affected as a surgeon, combined with his special mixture of a personal touch and compassion.

Dr. William Baker practiced general surgery from 1950 to 1985, in what some have called “the golden age of medicine.” What insights can be learned from his story for today’s rural surgeon? Rural surgeons today still work in hospitals with fewer resources and lateral support systems than are typically available in larger, urban hospitals. Although these conditions create problems, they mean that the rural surgeon can enjoy closer relationships with patients, nursing staff, colleagues in other specialties, and administrators. And rural surgeons can become influential community leaders and strong advocates for change and improvements in systems of care. The impact of activism is all the greater in rural communities because of the unique role of rural surgeons in the community.

Taking an active role in regional societies is key for rural surgeons. Participation in these societies helps individual surgeons develop networks of like-minded colleagues. Meetings help to “recharge batteries,” both intellectually and emotionally. Knowing that other surgeons are facing similar problems enhances solidarity, leads to creative solutions to issues, and develops bonds of friendship and support. Participation in the state chapter of the ACS can provide resources and leadership opportunities, particularly involvement in the Committee on Rural Surgery. Individuals such as Dr. Phil Caropreso and Dr. Tyler Hughes have been powerful spokespersons for rural surgery with the ACS leadership and their activism has produced results. The Listserve and the ACS Communities that they have developed provide rural surgeons with unprecedented networking and communication channels, the potential of which is only beginning to be understood.

Finally, consider partnering with a regional surgical program so that you can participate in the Transition to Practice program. This could be an opportunity to mentor and welcome energetic young surgeons to rural practice. Although this program is in its early stages, some trainees have decided to remain in those communities and partner with their senior mentor.

As a number of rural surgeons age, they will need to be replaced by dedicated young surgeons. Having interviewed resident applicants for 30 years, I have observed that today’s applicants have a strong commitment to service. Rural surgery can be a challenging career, but the rewards are substantial. One can elevate the standard of care in smaller communities, and the joy of caring for patients and improving their lives with surgical procedures is unparalleled. Living in a small community allows the rural surgeon to maintain a good standard of living and a positive work-life balance, allowing quality time with one’s family. As the son of a rural surgeon, I can personally attest to these advantages.

Dr. Christopher Baker has practiced as a general and trauma surgeon in a number of academic medical centers. He is currently chair of surgery at Carilion Clinic, and professor of surgery at the newly formed Virginia Tech Carilion School in Roanoke, Va. He is proud of the fact that the majority of Carilion’s surgery residents go directly into practice, often in rural settings.

We are currently embroiled in a health care crisis, characterized by the need for malpractice reform, pressures of the 80-hour work week regulations on resident education, and a decreasing interest in pursuing a career in surgery. As we face these difficult problems, we should reflect upon one of the aspects that makes surgery a great profession – namely, devotion to our patients and our craft. As we look forward to the future, I would like to share my personal reminiscences of a rural surgeon from the 20th century who affected my personal development and growth as a general and trauma surgeon.

My father, William J. Baker, M.D., was the first surgeon I ever knew. His effects on me (both as a parent and as a mentor) have been profound and long lasting. Born in Cambridge, Mass., Bill Baker attended Cambridge Latin, Harvard College (BS, 1936), Tufts University (MS in psychology, 1937), and Harvard Medical School (MD, 1941). He then worked as an intern at the Massachusetts General Hospital, where he met Jean “Pinky” Houghton who was working as a scrub nurse for Dr. Robert Linton. Pinky and Bill were married in Hawaii just before he joined the Navy in 1942. He was assigned to a Marine infantry assault division in the Philippines, where he was honored with a Purple Heart and the Silver Star.

>After the war, Dr. Baker returned to Boston where he trained under Dr. Richard Warren at the West Roxbury VA. In 1950 he and Pinky moved to the small town of Laconia in central New Hampshire; he was the first board-certified general surgeon in the State of New Hampshire outside of Dartmouth (which is, after all, almost in Vermont). He performed the first thoracic operation at the Laconia Hospital and brought a high standard of surgical care to the Lakes Region. At the end of his career, he served as Chief of Surgery at the Brockton VA from 1981 to 1985, allowing him to go back to his roots as a Visiting Attending at the West Roxbury VA.

Although Bill Baker did not pursue a career in academic surgery, he made major contributions to surgical care in New Hampshire. He was a charter member of the Northeast Medical Association (NEMA), founded in 1957, which was devoted to improving the care of injured skiers. I remember attending the second meeting at Stowe, Vt., in 1958 (at the age of 10). We both enjoyed our participation in the National Ski Patrol Association, and we were both very proud when I was able to join him as a member of the NEMA in 1984. As a strong advocate for prevention in the area of trauma, Bill Baker spearheaded efforts that led to legislation for the mandatory use of seatbelts and motorcycle helmets in New Hampshire. In the field of breast cancer, he developed an informal but well-organized group of breast cancer survivors (whom he lovingly called his “bosom buddies”). These ladies connected to women who had recently undergone mastectomy for breast cancer. This initiative preceded the Reach to Recovery program that was later sponsored by the American Cancer Society.

As a parent, Bill Baker taught me many things. As a rural surgeon, he evinced a dedication to excellent patient care, a legacy of life-long learning, and a strong commitment to community service and the prevention of injury. He served as President of the New Hampshire Chapter of the American College of Surgeons and was an active member of the New England Surgical Society. As a father, he was a great role model, who taught me the satisfaction that a career in rural general surgery could provide. As the quintessential rural surgeon, Bill Baker made multiple contributions to his community and his adopted state of New Hampshire. His death at the age of 78 was mourned by his family, friends, and the many patients whose lives he had affected as a surgeon, combined with his special mixture of a personal touch and compassion.

Dr. William Baker practiced general surgery from 1950 to 1985, in what some have called “the golden age of medicine.” What insights can be learned from his story for today’s rural surgeon? Rural surgeons today still work in hospitals with fewer resources and lateral support systems than are typically available in larger, urban hospitals. Although these conditions create problems, they mean that the rural surgeon can enjoy closer relationships with patients, nursing staff, colleagues in other specialties, and administrators. And rural surgeons can become influential community leaders and strong advocates for change and improvements in systems of care. The impact of activism is all the greater in rural communities because of the unique role of rural surgeons in the community.

Taking an active role in regional societies is key for rural surgeons. Participation in these societies helps individual surgeons develop networks of like-minded colleagues. Meetings help to “recharge batteries,” both intellectually and emotionally. Knowing that other surgeons are facing similar problems enhances solidarity, leads to creative solutions to issues, and develops bonds of friendship and support. Participation in the state chapter of the ACS can provide resources and leadership opportunities, particularly involvement in the Committee on Rural Surgery. Individuals such as Dr. Phil Caropreso and Dr. Tyler Hughes have been powerful spokespersons for rural surgery with the ACS leadership and their activism has produced results. The Listserve and the ACS Communities that they have developed provide rural surgeons with unprecedented networking and communication channels, the potential of which is only beginning to be understood.

Finally, consider partnering with a regional surgical program so that you can participate in the Transition to Practice program. This could be an opportunity to mentor and welcome energetic young surgeons to rural practice. Although this program is in its early stages, some trainees have decided to remain in those communities and partner with their senior mentor.

As a number of rural surgeons age, they will need to be replaced by dedicated young surgeons. Having interviewed resident applicants for 30 years, I have observed that today’s applicants have a strong commitment to service. Rural surgery can be a challenging career, but the rewards are substantial. One can elevate the standard of care in smaller communities, and the joy of caring for patients and improving their lives with surgical procedures is unparalleled. Living in a small community allows the rural surgeon to maintain a good standard of living and a positive work-life balance, allowing quality time with one’s family. As the son of a rural surgeon, I can personally attest to these advantages.

Dr. Christopher Baker has practiced as a general and trauma surgeon in a number of academic medical centers. He is currently chair of surgery at Carilion Clinic, and professor of surgery at the newly formed Virginia Tech Carilion School in Roanoke, Va. He is proud of the fact that the majority of Carilion’s surgery residents go directly into practice, often in rural settings.

We are currently embroiled in a health care crisis, characterized by the need for malpractice reform, pressures of the 80-hour work week regulations on resident education, and a decreasing interest in pursuing a career in surgery. As we face these difficult problems, we should reflect upon one of the aspects that makes surgery a great profession – namely, devotion to our patients and our craft. As we look forward to the future, I would like to share my personal reminiscences of a rural surgeon from the 20th century who affected my personal development and growth as a general and trauma surgeon.

My father, William J. Baker, M.D., was the first surgeon I ever knew. His effects on me (both as a parent and as a mentor) have been profound and long lasting. Born in Cambridge, Mass., Bill Baker attended Cambridge Latin, Harvard College (BS, 1936), Tufts University (MS in psychology, 1937), and Harvard Medical School (MD, 1941). He then worked as an intern at the Massachusetts General Hospital, where he met Jean “Pinky” Houghton who was working as a scrub nurse for Dr. Robert Linton. Pinky and Bill were married in Hawaii just before he joined the Navy in 1942. He was assigned to a Marine infantry assault division in the Philippines, where he was honored with a Purple Heart and the Silver Star.

>After the war, Dr. Baker returned to Boston where he trained under Dr. Richard Warren at the West Roxbury VA. In 1950 he and Pinky moved to the small town of Laconia in central New Hampshire; he was the first board-certified general surgeon in the State of New Hampshire outside of Dartmouth (which is, after all, almost in Vermont). He performed the first thoracic operation at the Laconia Hospital and brought a high standard of surgical care to the Lakes Region. At the end of his career, he served as Chief of Surgery at the Brockton VA from 1981 to 1985, allowing him to go back to his roots as a Visiting Attending at the West Roxbury VA.

Although Bill Baker did not pursue a career in academic surgery, he made major contributions to surgical care in New Hampshire. He was a charter member of the Northeast Medical Association (NEMA), founded in 1957, which was devoted to improving the care of injured skiers. I remember attending the second meeting at Stowe, Vt., in 1958 (at the age of 10). We both enjoyed our participation in the National Ski Patrol Association, and we were both very proud when I was able to join him as a member of the NEMA in 1984. As a strong advocate for prevention in the area of trauma, Bill Baker spearheaded efforts that led to legislation for the mandatory use of seatbelts and motorcycle helmets in New Hampshire. In the field of breast cancer, he developed an informal but well-organized group of breast cancer survivors (whom he lovingly called his “bosom buddies”). These ladies connected to women who had recently undergone mastectomy for breast cancer. This initiative preceded the Reach to Recovery program that was later sponsored by the American Cancer Society.

As a parent, Bill Baker taught me many things. As a rural surgeon, he evinced a dedication to excellent patient care, a legacy of life-long learning, and a strong commitment to community service and the prevention of injury. He served as President of the New Hampshire Chapter of the American College of Surgeons and was an active member of the New England Surgical Society. As a father, he was a great role model, who taught me the satisfaction that a career in rural general surgery could provide. As the quintessential rural surgeon, Bill Baker made multiple contributions to his community and his adopted state of New Hampshire. His death at the age of 78 was mourned by his family, friends, and the many patients whose lives he had affected as a surgeon, combined with his special mixture of a personal touch and compassion.

Dr. William Baker practiced general surgery from 1950 to 1985, in what some have called “the golden age of medicine.” What insights can be learned from his story for today’s rural surgeon? Rural surgeons today still work in hospitals with fewer resources and lateral support systems than are typically available in larger, urban hospitals. Although these conditions create problems, they mean that the rural surgeon can enjoy closer relationships with patients, nursing staff, colleagues in other specialties, and administrators. And rural surgeons can become influential community leaders and strong advocates for change and improvements in systems of care. The impact of activism is all the greater in rural communities because of the unique role of rural surgeons in the community.

Taking an active role in regional societies is key for rural surgeons. Participation in these societies helps individual surgeons develop networks of like-minded colleagues. Meetings help to “recharge batteries,” both intellectually and emotionally. Knowing that other surgeons are facing similar problems enhances solidarity, leads to creative solutions to issues, and develops bonds of friendship and support. Participation in the state chapter of the ACS can provide resources and leadership opportunities, particularly involvement in the Committee on Rural Surgery. Individuals such as Dr. Phil Caropreso and Dr. Tyler Hughes have been powerful spokespersons for rural surgery with the ACS leadership and their activism has produced results. The Listserve and the ACS Communities that they have developed provide rural surgeons with unprecedented networking and communication channels, the potential of which is only beginning to be understood.

Finally, consider partnering with a regional surgical program so that you can participate in the Transition to Practice program. This could be an opportunity to mentor and welcome energetic young surgeons to rural practice. Although this program is in its early stages, some trainees have decided to remain in those communities and partner with their senior mentor.

As a number of rural surgeons age, they will need to be replaced by dedicated young surgeons. Having interviewed resident applicants for 30 years, I have observed that today’s applicants have a strong commitment to service. Rural surgery can be a challenging career, but the rewards are substantial. One can elevate the standard of care in smaller communities, and the joy of caring for patients and improving their lives with surgical procedures is unparalleled. Living in a small community allows the rural surgeon to maintain a good standard of living and a positive work-life balance, allowing quality time with one’s family. As the son of a rural surgeon, I can personally attest to these advantages.

Dr. Christopher Baker has practiced as a general and trauma surgeon in a number of academic medical centers. He is currently chair of surgery at Carilion Clinic, and professor of surgery at the newly formed Virginia Tech Carilion School in Roanoke, Va. He is proud of the fact that the majority of Carilion’s surgery residents go directly into practice, often in rural settings.

Rural surgeons who provide cancer care face a particular set of challenges. Rural patients tend to be older, sicker, less educated and economically disadvantaged. Rural areas have a higher prevalence of chronic diseases including heart disease and cancer. Rural patients present with more advanced cancers than their urban counterparts. Specific rural regions (i.e., Appalachia) have documented higher cancer incidences and mortality rates.

In addition, there are several barriers to providing cancer care for rural populations. These include poor access to health care services and specialists; geographic barriers preventing access to providers, services, and technology; minimal transportation options for either cancer screening or treatment; limited knowledge of cancer and low participation in screening and other healthy practices; prohibitive costs of screening and cancer treatment; and, in some cases, suboptimal care provided to cancer patients (J. Am. Coll. Surg. 2014;219:814-8; Gosschalk, A. and Carozza, S., “Cancer in rural areas: A literature review,” Rural Healthy People 2010, Vol. 2 [College Station: The Texas A&M University System Health Science Center, 2003]).

Several examples of suboptimal care for rural cancer patients have appeared in professional journals and meetings and in the lay press. Examples of rural cancer care inadequacies include lower use of needle biopsy and sentinel lymph node biopsy techniques for breast cancer patients (Am. J. Surg. 2014;208:382-90; Am. J. Surg. 2013;206:674-81; ACS Surgery News, “Use of minimally invasive biopsy lags in Texas,” February 2013, p. 15); significantly lower rates of radiation treatment in breast lumpectomy patients (USA Today, Nov. 18, 2012); lower rates of adequate lymph node dissection, appropriate chemotherapy, and higher death rates in colon cancer patients (Chow, C.J., ACS Clinical Congress Presentation 2012); higher mastectomy rates and later-stage cancers in breast cancer patients (Jethwa, K., AACR Annual Conference Presentation 2013); higher likelihood of discharge to a skilled nursing facility instead of home in colon cancer patients; and the list goes on and on. These articles all come from academic centers through database studies. It is rare indeed to see data collected and published by the rural centers and providers actually caring for rural cancer patients.

My personal bias is that rural surgeons provide very competent, compassionate, high quality care that allows the cancer patient to remain close to their homes and support systems. This opinion has been reinforced by my involvement with the ACS Advisory Council on Rural Surgery, the rural listserve /ACS Rural Community and through my interaction with surgeons across the country at ACS Chapter meetings and at the Congress.

A study done by Finlayson (Med. Care 1999;37:204-9) documented that nearly 100% of rural patients preferred to receive their care locally, especially if the quality of care was the same as the larger distant hospital. In fact, nearly half of the patients polled would choose to remain local even if the mortality rate at the local hospital was double that of a hospital requiring the patient to travel for care. More recent papers however suggest that patients may be bypassing their local hospitals for care because of concerns about the quality of care provided locally (J. Rural Health 1999;10:70-9; J. Rural Health 2007;23:17-24).

A 2013 ASCO presentation documented that General Surgeons perform a majority of cancer surgeries in the United States (Stizenberg, K.; SSO 66th Annual Cancer Symposium; Abstract 75, March 8, 2013). Only 303 (< 8%) counties in the United States even have a surgical oncologist. A 2014 ASCO presentation estimated a 43% increase in inpatient oncology procedures and a 25% increase in outpatient procedures between 2002 and 2020. By 2025 the total demand for oncology care will rise by 43% (ASCO, “The state of cancer care 2014,” J. Oncol. Prac. 2014;10:119-42). Another study (ACS Surgery News, “Surgeon supply to drop 18% by 2028,” January 2013, p. 1) has estimated that, with predicted future surgeon shortages, general surgeons will be called upon to perform 25% of cases now done by other surgical specialists. General surgeons, both rural and urban, are clearly providing the bulk of cancer care to patients and this trend is on the rise in coming years.

Rural surgeons have certain barriers that prevent them from measuring, documenting, and publicizing the specifics of the care provided to their patients. These surgeons often are in single or small group practices and manage their own businesses. They have no office or hospital staff dedicated to quality endeavors. Financial and time constraints prevent them from being champions of quality care in their communities. Additionally, small numbers of specific cases can result in high statistical complication and mortality rates even if these events happen infrequently. This inability to collect data and assess the quality of care provided can lead to patient outmigration and even “tiering” by third-party payers that forces patients away from their hometown hospitals and providers using financial disincentives.

Rural surgeons can and must now take the lead in collecting, assessing, and reporting data about the care they provide for their communities. This process can be in the form of standardized programs like ACS Rural National Surgical Quality Improvement Program (NSQIP), Surgical Care Improvement Project (SCIP), or Commission on Cancer (CoC) accreditation involvement. Smaller institutions with a single surgeon may not have the financial and staff resources to formally participate but each surgeon can assess what makes up the majority of his or her caseload, whether that is endoscopy or breast or colon cases, and find national benchmarks that can easily be measured. Every endoscopy department can collect data on cecal intubation rates, withdrawal times, adequacy of preps, adenoma detection rates, and appropriate follow-up intervals. Individual surgeons can pick and chose specific benchmarks from NSQIP, Commission on Cancer, National Accreditation Program for Breast Centers (NAPBC), or ACS Committee on Trauma standards documents and use these to evaluate the care they provide. Easy examples might include number of lymph nodes harvested at colon cancer surgery, percentage of breast cancer patients diagnosed with needle biopsy, and percentage treated with conservative surgery and appropriate postop radiation and or chemotherapy, or the percentage of melanoma patients treated per National Comprehensive Cancer Network guidelines. Other ways for institutions to document quality might be to partner with their tertiary referral center for CoC accreditation or just to participate in cancer conferences by videoconferencing. The Commission on Cancer has designated CoC Liason Program Chairs in each state that are available to aid in setting up these types of programs.

It is time for rural surgeons to partner with their hospitals and communities to carry out needs assessments and think of ways to fill those needs. An example might be to work with primary care providers to develop aggressive colon, breast, or lung cancer screening programs in communities with high numbers of late-stage cases. Transparency of the data collected and the care provided in the form of “Quality Reports to the Community” can improve local referral patterns, improve the financial viability of the local hospital, and prove to the community that quality care is being rendered. Pooling the data from a large base of rural surgeons could serve to disprove the academic community notion that rural patients receive suboptimal cancer care.

Dr. Sarap is a practicing general surgeon in Cambridge, Ohio. He is a member of the Advisory Council on Rural Surgery and has been appointed the Commission on Cancer Liaison Program Chair for Ohio.

Rural surgeons who provide cancer care face a particular set of challenges. Rural patients tend to be older, sicker, less educated and economically disadvantaged. Rural areas have a higher prevalence of chronic diseases including heart disease and cancer. Rural patients present with more advanced cancers than their urban counterparts. Specific rural regions (i.e., Appalachia) have documented higher cancer incidences and mortality rates.

In addition, there are several barriers to providing cancer care for rural populations. These include poor access to health care services and specialists; geographic barriers preventing access to providers, services, and technology; minimal transportation options for either cancer screening or treatment; limited knowledge of cancer and low participation in screening and other healthy practices; prohibitive costs of screening and cancer treatment; and, in some cases, suboptimal care provided to cancer patients (J. Am. Coll. Surg. 2014;219:814-8; Gosschalk, A. and Carozza, S., “Cancer in rural areas: A literature review,” Rural Healthy People 2010, Vol. 2 [College Station: The Texas A&M University System Health Science Center, 2003]).

Several examples of suboptimal care for rural cancer patients have appeared in professional journals and meetings and in the lay press. Examples of rural cancer care inadequacies include lower use of needle biopsy and sentinel lymph node biopsy techniques for breast cancer patients (Am. J. Surg. 2014;208:382-90; Am. J. Surg. 2013;206:674-81; ACS Surgery News, “Use of minimally invasive biopsy lags in Texas,” February 2013, p. 15); significantly lower rates of radiation treatment in breast lumpectomy patients (USA Today, Nov. 18, 2012); lower rates of adequate lymph node dissection, appropriate chemotherapy, and higher death rates in colon cancer patients (Chow, C.J., ACS Clinical Congress Presentation 2012); higher mastectomy rates and later-stage cancers in breast cancer patients (Jethwa, K., AACR Annual Conference Presentation 2013); higher likelihood of discharge to a skilled nursing facility instead of home in colon cancer patients; and the list goes on and on. These articles all come from academic centers through database studies. It is rare indeed to see data collected and published by the rural centers and providers actually caring for rural cancer patients.

My personal bias is that rural surgeons provide very competent, compassionate, high quality care that allows the cancer patient to remain close to their homes and support systems. This opinion has been reinforced by my involvement with the ACS Advisory Council on Rural Surgery, the rural listserve /ACS Rural Community and through my interaction with surgeons across the country at ACS Chapter meetings and at the Congress.

A study done by Finlayson (Med. Care 1999;37:204-9) documented that nearly 100% of rural patients preferred to receive their care locally, especially if the quality of care was the same as the larger distant hospital. In fact, nearly half of the patients polled would choose to remain local even if the mortality rate at the local hospital was double that of a hospital requiring the patient to travel for care. More recent papers however suggest that patients may be bypassing their local hospitals for care because of concerns about the quality of care provided locally (J. Rural Health 1999;10:70-9; J. Rural Health 2007;23:17-24).

A 2013 ASCO presentation documented that General Surgeons perform a majority of cancer surgeries in the United States (Stizenberg, K.; SSO 66th Annual Cancer Symposium; Abstract 75, March 8, 2013). Only 303 (< 8%) counties in the United States even have a surgical oncologist. A 2014 ASCO presentation estimated a 43% increase in inpatient oncology procedures and a 25% increase in outpatient procedures between 2002 and 2020. By 2025 the total demand for oncology care will rise by 43% (ASCO, “The state of cancer care 2014,” J. Oncol. Prac. 2014;10:119-42). Another study (ACS Surgery News, “Surgeon supply to drop 18% by 2028,” January 2013, p. 1) has estimated that, with predicted future surgeon shortages, general surgeons will be called upon to perform 25% of cases now done by other surgical specialists. General surgeons, both rural and urban, are clearly providing the bulk of cancer care to patients and this trend is on the rise in coming years.

Rural surgeons have certain barriers that prevent them from measuring, documenting, and publicizing the specifics of the care provided to their patients. These surgeons often are in single or small group practices and manage their own businesses. They have no office or hospital staff dedicated to quality endeavors. Financial and time constraints prevent them from being champions of quality care in their communities. Additionally, small numbers of specific cases can result in high statistical complication and mortality rates even if these events happen infrequently. This inability to collect data and assess the quality of care provided can lead to patient outmigration and even “tiering” by third-party payers that forces patients away from their hometown hospitals and providers using financial disincentives.

Rural surgeons can and must now take the lead in collecting, assessing, and reporting data about the care they provide for their communities. This process can be in the form of standardized programs like ACS Rural National Surgical Quality Improvement Program (NSQIP), Surgical Care Improvement Project (SCIP), or Commission on Cancer (CoC) accreditation involvement. Smaller institutions with a single surgeon may not have the financial and staff resources to formally participate but each surgeon can assess what makes up the majority of his or her caseload, whether that is endoscopy or breast or colon cases, and find national benchmarks that can easily be measured. Every endoscopy department can collect data on cecal intubation rates, withdrawal times, adequacy of preps, adenoma detection rates, and appropriate follow-up intervals. Individual surgeons can pick and chose specific benchmarks from NSQIP, Commission on Cancer, National Accreditation Program for Breast Centers (NAPBC), or ACS Committee on Trauma standards documents and use these to evaluate the care they provide. Easy examples might include number of lymph nodes harvested at colon cancer surgery, percentage of breast cancer patients diagnosed with needle biopsy, and percentage treated with conservative surgery and appropriate postop radiation and or chemotherapy, or the percentage of melanoma patients treated per National Comprehensive Cancer Network guidelines. Other ways for institutions to document quality might be to partner with their tertiary referral center for CoC accreditation or just to participate in cancer conferences by videoconferencing. The Commission on Cancer has designated CoC Liason Program Chairs in each state that are available to aid in setting up these types of programs.

It is time for rural surgeons to partner with their hospitals and communities to carry out needs assessments and think of ways to fill those needs. An example might be to work with primary care providers to develop aggressive colon, breast, or lung cancer screening programs in communities with high numbers of late-stage cases. Transparency of the data collected and the care provided in the form of “Quality Reports to the Community” can improve local referral patterns, improve the financial viability of the local hospital, and prove to the community that quality care is being rendered. Pooling the data from a large base of rural surgeons could serve to disprove the academic community notion that rural patients receive suboptimal cancer care.

Dr. Sarap is a practicing general surgeon in Cambridge, Ohio. He is a member of the Advisory Council on Rural Surgery and has been appointed the Commission on Cancer Liaison Program Chair for Ohio.

Rural surgeons who provide cancer care face a particular set of challenges. Rural patients tend to be older, sicker, less educated and economically disadvantaged. Rural areas have a higher prevalence of chronic diseases including heart disease and cancer. Rural patients present with more advanced cancers than their urban counterparts. Specific rural regions (i.e., Appalachia) have documented higher cancer incidences and mortality rates.

In addition, there are several barriers to providing cancer care for rural populations. These include poor access to health care services and specialists; geographic barriers preventing access to providers, services, and technology; minimal transportation options for either cancer screening or treatment; limited knowledge of cancer and low participation in screening and other healthy practices; prohibitive costs of screening and cancer treatment; and, in some cases, suboptimal care provided to cancer patients (J. Am. Coll. Surg. 2014;219:814-8; Gosschalk, A. and Carozza, S., “Cancer in rural areas: A literature review,” Rural Healthy People 2010, Vol. 2 [College Station: The Texas A&M University System Health Science Center, 2003]).

Several examples of suboptimal care for rural cancer patients have appeared in professional journals and meetings and in the lay press. Examples of rural cancer care inadequacies include lower use of needle biopsy and sentinel lymph node biopsy techniques for breast cancer patients (Am. J. Surg. 2014;208:382-90; Am. J. Surg. 2013;206:674-81; ACS Surgery News, “Use of minimally invasive biopsy lags in Texas,” February 2013, p. 15); significantly lower rates of radiation treatment in breast lumpectomy patients (USA Today, Nov. 18, 2012); lower rates of adequate lymph node dissection, appropriate chemotherapy, and higher death rates in colon cancer patients (Chow, C.J., ACS Clinical Congress Presentation 2012); higher mastectomy rates and later-stage cancers in breast cancer patients (Jethwa, K., AACR Annual Conference Presentation 2013); higher likelihood of discharge to a skilled nursing facility instead of home in colon cancer patients; and the list goes on and on. These articles all come from academic centers through database studies. It is rare indeed to see data collected and published by the rural centers and providers actually caring for rural cancer patients.

My personal bias is that rural surgeons provide very competent, compassionate, high quality care that allows the cancer patient to remain close to their homes and support systems. This opinion has been reinforced by my involvement with the ACS Advisory Council on Rural Surgery, the rural listserve /ACS Rural Community and through my interaction with surgeons across the country at ACS Chapter meetings and at the Congress.

A study done by Finlayson (Med. Care 1999;37:204-9) documented that nearly 100% of rural patients preferred to receive their care locally, especially if the quality of care was the same as the larger distant hospital. In fact, nearly half of the patients polled would choose to remain local even if the mortality rate at the local hospital was double that of a hospital requiring the patient to travel for care. More recent papers however suggest that patients may be bypassing their local hospitals for care because of concerns about the quality of care provided locally (J. Rural Health 1999;10:70-9; J. Rural Health 2007;23:17-24).

A 2013 ASCO presentation documented that General Surgeons perform a majority of cancer surgeries in the United States (Stizenberg, K.; SSO 66th Annual Cancer Symposium; Abstract 75, March 8, 2013). Only 303 (< 8%) counties in the United States even have a surgical oncologist. A 2014 ASCO presentation estimated a 43% increase in inpatient oncology procedures and a 25% increase in outpatient procedures between 2002 and 2020. By 2025 the total demand for oncology care will rise by 43% (ASCO, “The state of cancer care 2014,” J. Oncol. Prac. 2014;10:119-42). Another study (ACS Surgery News, “Surgeon supply to drop 18% by 2028,” January 2013, p. 1) has estimated that, with predicted future surgeon shortages, general surgeons will be called upon to perform 25% of cases now done by other surgical specialists. General surgeons, both rural and urban, are clearly providing the bulk of cancer care to patients and this trend is on the rise in coming years.

Rural surgeons have certain barriers that prevent them from measuring, documenting, and publicizing the specifics of the care provided to their patients. These surgeons often are in single or small group practices and manage their own businesses. They have no office or hospital staff dedicated to quality endeavors. Financial and time constraints prevent them from being champions of quality care in their communities. Additionally, small numbers of specific cases can result in high statistical complication and mortality rates even if these events happen infrequently. This inability to collect data and assess the quality of care provided can lead to patient outmigration and even “tiering” by third-party payers that forces patients away from their hometown hospitals and providers using financial disincentives.

Rural surgeons can and must now take the lead in collecting, assessing, and reporting data about the care they provide for their communities. This process can be in the form of standardized programs like ACS Rural National Surgical Quality Improvement Program (NSQIP), Surgical Care Improvement Project (SCIP), or Commission on Cancer (CoC) accreditation involvement. Smaller institutions with a single surgeon may not have the financial and staff resources to formally participate but each surgeon can assess what makes up the majority of his or her caseload, whether that is endoscopy or breast or colon cases, and find national benchmarks that can easily be measured. Every endoscopy department can collect data on cecal intubation rates, withdrawal times, adequacy of preps, adenoma detection rates, and appropriate follow-up intervals. Individual surgeons can pick and chose specific benchmarks from NSQIP, Commission on Cancer, National Accreditation Program for Breast Centers (NAPBC), or ACS Committee on Trauma standards documents and use these to evaluate the care they provide. Easy examples might include number of lymph nodes harvested at colon cancer surgery, percentage of breast cancer patients diagnosed with needle biopsy, and percentage treated with conservative surgery and appropriate postop radiation and or chemotherapy, or the percentage of melanoma patients treated per National Comprehensive Cancer Network guidelines. Other ways for institutions to document quality might be to partner with their tertiary referral center for CoC accreditation or just to participate in cancer conferences by videoconferencing. The Commission on Cancer has designated CoC Liason Program Chairs in each state that are available to aid in setting up these types of programs.

It is time for rural surgeons to partner with their hospitals and communities to carry out needs assessments and think of ways to fill those needs. An example might be to work with primary care providers to develop aggressive colon, breast, or lung cancer screening programs in communities with high numbers of late-stage cases. Transparency of the data collected and the care provided in the form of “Quality Reports to the Community” can improve local referral patterns, improve the financial viability of the local hospital, and prove to the community that quality care is being rendered. Pooling the data from a large base of rural surgeons could serve to disprove the academic community notion that rural patients receive suboptimal cancer care.

Dr. Sarap is a practicing general surgeon in Cambridge, Ohio. He is a member of the Advisory Council on Rural Surgery and has been appointed the Commission on Cancer Liaison Program Chair for Ohio.

In my recent travels to ACS state chapter gatherings and in my meeting with rural surgeons in a variety of settings, I have heard on many occasions a particular theme of concern: the lack of resources, in particular, personnel resources available in rural hospitals. A shortage of nurses, assistants, and support staff of all kinds has emerged as a serious, continuing challenge for surgeons who work in small communities.

Rural surgery still “gets it done” in spite of resource challenges. Actually, rural surgeons perform more procedures per year with more variety in procedure types than did their urban peers, in spite of limited resources (J. Am. Coll. Surg. 2005;201:732-6).

Courtesy of Dr. Caropreso

Resource shortage for rural practices is a common subject on the rural surgery Listserv. Rural surgeons might exclaim, “We have done so much with so little for so long that we are now expected to do everything with nothing forever!” Nursing and support personnel are key resources that can be in short supply.

The rural surgery Listserv has hosted a contest inviting rural surgeons to complete the following statement: “You know you are a rural surgeon if … (YKYAARSI).” At a recent rural surgery dinner at a scientific meeting, we had a little fun amidst all of the serious topics. The winner surgeon read his winning entry: “You know you are a rural surgeon if your first OR assistant is also the OR director, the director of nursing, the DRG coordinator, the director of QA for the ER, the coordinator of emergency preparedness, the committee coordinator for the annual hospital Christmas party, the chairwoman of the committee for quality measures, the best enema nurse, and the best interpreter of the local jargon, such as ‘casophagus’ (esophagus), ‘whistle’ (penis), ‘physic’ (enema), ‘hepmotoma’ (hematoma ), and ‘toodinitis’ (vaginal infection).” Laughter and cheers followed.

Is this hyperbole? The winning YKYAARSI entry is likely closer to reality for many rural surgeons than might be supposed by those who practice in institutions with abundant personnel resources. In small community hospitals, one dedicated staff nurse can have many roles and many jobs.

Early in my career, I practiced with a true team. Individuals had specific roles. My physician assistants assisted me during operations and on rounds. The OR head nurse “ran the board.” The director of surgical services coordinated all functions of the OR from an office. The emergency room was under the management of a veteran emergency nurse. Patients received outstanding bedside nursing care on the surgical floors and in the ICU. IV teams developed and provided valuable services. Skilled lab techs drew blood. An administrative assistant coordinated social events and fund raising. Clearly, trained individuals focused on their areas of expertise.

Gradually, this structure changed. Individuals had to assume many different roles and fill positions that were otherwise unfamiliar to them. The nursing and support personnel resources available for surgery started to diminish significantly.

Today, the concept of team is reduced to single individuals “wearing many hats.” They have all accepted the additional roles to support their hospitals and then made sincere efforts to perform well. The added responsibilities have stressed these well-intentioned nurses, technicians, and assistants both physically and emotionally. Frequently circumstances prevented them from being resources for surgery, straining surgical performance and patient care. I have experienced such situations firsthand, and I have no doubt many readers have as well.

The YKYAARSI winning entry came to life at my critical access hospital. The OR charge nurse became the director for surgical services, ob.gyn., and the emergency department. Previously, this capable nurse would either circulate my cases or be the first assistant. She also took call. She had the greatest skill starting IVs. With the additional duties outside of the OR, this “resource” nearly disappeared, depriving the practice of her abilities and experience. Providing overall quality care became even more challenging. The new “director of almost everything” also led efforts to raise funds for the hospital building campaign. In addition, she developed and coordinated a half-marathon to lift spirits and get pledges for the hospital. In spite of being encouraged to the contrary by hospital administration, even this smart, determined nurse fell behind, and was no longer a resource for surgery.

Like other rural surgeons in similar circumstances, I persisted and adapted to working with less, but I recognize that this situation is not ideal, and perhaps in the long run, not sustainable.

The root of the problem of limited personnel resources for rural surgery is multifactorial and the topic for another column. If you have experienced a personnel shortage or a situation of critical staff “wearing many hats” and would like to contribute to this discussion, please feel free to e-mail me.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

In my recent travels to ACS state chapter gatherings and in my meeting with rural surgeons in a variety of settings, I have heard on many occasions a particular theme of concern: the lack of resources, in particular, personnel resources available in rural hospitals. A shortage of nurses, assistants, and support staff of all kinds has emerged as a serious, continuing challenge for surgeons who work in small communities.

Rural surgery still “gets it done” in spite of resource challenges. Actually, rural surgeons perform more procedures per year with more variety in procedure types than did their urban peers, in spite of limited resources (J. Am. Coll. Surg. 2005;201:732-6).

Courtesy of Dr. Caropreso

Resource shortage for rural practices is a common subject on the rural surgery Listserv. Rural surgeons might exclaim, “We have done so much with so little for so long that we are now expected to do everything with nothing forever!” Nursing and support personnel are key resources that can be in short supply.

The rural surgery Listserv has hosted a contest inviting rural surgeons to complete the following statement: “You know you are a rural surgeon if … (YKYAARSI).” At a recent rural surgery dinner at a scientific meeting, we had a little fun amidst all of the serious topics. The winner surgeon read his winning entry: “You know you are a rural surgeon if your first OR assistant is also the OR director, the director of nursing, the DRG coordinator, the director of QA for the ER, the coordinator of emergency preparedness, the committee coordinator for the annual hospital Christmas party, the chairwoman of the committee for quality measures, the best enema nurse, and the best interpreter of the local jargon, such as ‘casophagus’ (esophagus), ‘whistle’ (penis), ‘physic’ (enema), ‘hepmotoma’ (hematoma ), and ‘toodinitis’ (vaginal infection).” Laughter and cheers followed.

Is this hyperbole? The winning YKYAARSI entry is likely closer to reality for many rural surgeons than might be supposed by those who practice in institutions with abundant personnel resources. In small community hospitals, one dedicated staff nurse can have many roles and many jobs.

Early in my career, I practiced with a true team. Individuals had specific roles. My physician assistants assisted me during operations and on rounds. The OR head nurse “ran the board.” The director of surgical services coordinated all functions of the OR from an office. The emergency room was under the management of a veteran emergency nurse. Patients received outstanding bedside nursing care on the surgical floors and in the ICU. IV teams developed and provided valuable services. Skilled lab techs drew blood. An administrative assistant coordinated social events and fund raising. Clearly, trained individuals focused on their areas of expertise.

Gradually, this structure changed. Individuals had to assume many different roles and fill positions that were otherwise unfamiliar to them. The nursing and support personnel resources available for surgery started to diminish significantly.

Today, the concept of team is reduced to single individuals “wearing many hats.” They have all accepted the additional roles to support their hospitals and then made sincere efforts to perform well. The added responsibilities have stressed these well-intentioned nurses, technicians, and assistants both physically and emotionally. Frequently circumstances prevented them from being resources for surgery, straining surgical performance and patient care. I have experienced such situations firsthand, and I have no doubt many readers have as well.

The YKYAARSI winning entry came to life at my critical access hospital. The OR charge nurse became the director for surgical services, ob.gyn., and the emergency department. Previously, this capable nurse would either circulate my cases or be the first assistant. She also took call. She had the greatest skill starting IVs. With the additional duties outside of the OR, this “resource” nearly disappeared, depriving the practice of her abilities and experience. Providing overall quality care became even more challenging. The new “director of almost everything” also led efforts to raise funds for the hospital building campaign. In addition, she developed and coordinated a half-marathon to lift spirits and get pledges for the hospital. In spite of being encouraged to the contrary by hospital administration, even this smart, determined nurse fell behind, and was no longer a resource for surgery.

Like other rural surgeons in similar circumstances, I persisted and adapted to working with less, but I recognize that this situation is not ideal, and perhaps in the long run, not sustainable.

The root of the problem of limited personnel resources for rural surgery is multifactorial and the topic for another column. If you have experienced a personnel shortage or a situation of critical staff “wearing many hats” and would like to contribute to this discussion, please feel free to e-mail me.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

In my recent travels to ACS state chapter gatherings and in my meeting with rural surgeons in a variety of settings, I have heard on many occasions a particular theme of concern: the lack of resources, in particular, personnel resources available in rural hospitals. A shortage of nurses, assistants, and support staff of all kinds has emerged as a serious, continuing challenge for surgeons who work in small communities.

Rural surgery still “gets it done” in spite of resource challenges. Actually, rural surgeons perform more procedures per year with more variety in procedure types than did their urban peers, in spite of limited resources (J. Am. Coll. Surg. 2005;201:732-6).

Courtesy of Dr. Caropreso

Resource shortage for rural practices is a common subject on the rural surgery Listserv. Rural surgeons might exclaim, “We have done so much with so little for so long that we are now expected to do everything with nothing forever!” Nursing and support personnel are key resources that can be in short supply.

The rural surgery Listserv has hosted a contest inviting rural surgeons to complete the following statement: “You know you are a rural surgeon if … (YKYAARSI).” At a recent rural surgery dinner at a scientific meeting, we had a little fun amidst all of the serious topics. The winner surgeon read his winning entry: “You know you are a rural surgeon if your first OR assistant is also the OR director, the director of nursing, the DRG coordinator, the director of QA for the ER, the coordinator of emergency preparedness, the committee coordinator for the annual hospital Christmas party, the chairwoman of the committee for quality measures, the best enema nurse, and the best interpreter of the local jargon, such as ‘casophagus’ (esophagus), ‘whistle’ (penis), ‘physic’ (enema), ‘hepmotoma’ (hematoma ), and ‘toodinitis’ (vaginal infection).” Laughter and cheers followed.

Is this hyperbole? The winning YKYAARSI entry is likely closer to reality for many rural surgeons than might be supposed by those who practice in institutions with abundant personnel resources. In small community hospitals, one dedicated staff nurse can have many roles and many jobs.

Early in my career, I practiced with a true team. Individuals had specific roles. My physician assistants assisted me during operations and on rounds. The OR head nurse “ran the board.” The director of surgical services coordinated all functions of the OR from an office. The emergency room was under the management of a veteran emergency nurse. Patients received outstanding bedside nursing care on the surgical floors and in the ICU. IV teams developed and provided valuable services. Skilled lab techs drew blood. An administrative assistant coordinated social events and fund raising. Clearly, trained individuals focused on their areas of expertise.

Gradually, this structure changed. Individuals had to assume many different roles and fill positions that were otherwise unfamiliar to them. The nursing and support personnel resources available for surgery started to diminish significantly.

Today, the concept of team is reduced to single individuals “wearing many hats.” They have all accepted the additional roles to support their hospitals and then made sincere efforts to perform well. The added responsibilities have stressed these well-intentioned nurses, technicians, and assistants both physically and emotionally. Frequently circumstances prevented them from being resources for surgery, straining surgical performance and patient care. I have experienced such situations firsthand, and I have no doubt many readers have as well.

The YKYAARSI winning entry came to life at my critical access hospital. The OR charge nurse became the director for surgical services, ob.gyn., and the emergency department. Previously, this capable nurse would either circulate my cases or be the first assistant. She also took call. She had the greatest skill starting IVs. With the additional duties outside of the OR, this “resource” nearly disappeared, depriving the practice of her abilities and experience. Providing overall quality care became even more challenging. The new “director of almost everything” also led efforts to raise funds for the hospital building campaign. In addition, she developed and coordinated a half-marathon to lift spirits and get pledges for the hospital. In spite of being encouraged to the contrary by hospital administration, even this smart, determined nurse fell behind, and was no longer a resource for surgery.

Like other rural surgeons in similar circumstances, I persisted and adapted to working with less, but I recognize that this situation is not ideal, and perhaps in the long run, not sustainable.

The root of the problem of limited personnel resources for rural surgery is multifactorial and the topic for another column. If you have experienced a personnel shortage or a situation of critical staff “wearing many hats” and would like to contribute to this discussion, please feel free to e-mail me.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

Thanksgiving will soon be here and celebrated joyfully with food, friends, and family in many homes around the country. Football, as well, has become a big part of this tradition on the fourth Thursday of November, an official holiday proclaimed by Abraham Lincoln in 1863. The first Thanksgiving was at Plymouth Plantation in 1621. It is unknown if any rural surgeons were present then. During this holiday, many rural surgeons will be giving thanks for more than food, friends, family, and football.

Twenty-five percent of the population is rural and fewer than 10% of surgeons practice in rural locations. This fact is complicated by the advanced age of the surgeons (~55 y/o) with more than 60% of them planning to retire in less than 10 years. The changes to all aspects of health care today, such as the Affordable Care Act, ACOs, and EMRs, affect the rural health care environment more profoundly and actually promote the deterioration of rural surgical practices. In recent years, rural surgeons have had few reasons to give thanks for the trajectory of their professional situation and fewer yet for the degree of acknowledgment of their challenges by the profession as a whole.

Courtesy of Dr. Caropreso

In the past 2 years, thanks to the tireless efforts of a few activists and enlightened leadership in the College, the ACS is now reaching out to rural surgeons, to recognize and to represent them. An important first step was the establishment of the Advisory Council on Rural Surgery, with its pillars for member services, education, quality, advocacy, as well as communication. The Council is chaired by Dr. Tyler Hughes.

Some critics might conclude that this council is just another group of surgeons more concerned about appearances and prominent positions than making an impact on the professional lives of rural surgeons. But such a conclusion would be wrong. Since its inception, the ACRS has worked relentlessly to identify and address the needs of rural surgeons. Efforts of all the pillars have involved education, along with local and national engagement of rural surgeons with emphasis on training, recruitment, and retention. The ACRS has stressed and promoted the value and quality found in rural surgical practices. Members of the Council have generously given their time and enthusiasm to advance these goals.

One of the major roles played by ACRS members has been contributing articles on the realities of a rural practice for the ACS Bulletin’s regular column, “Dispatches from rural surgeons.” Member services chair Dr. Mike Sarap wrote the initial article “The value of chapter membership: The rural surgeon’s perspective,” detailing chapter membership benefits. It concluded that patient care would benefit from a united, networked surgical community. Local ACS chapters can be a foundation of community and professional support among rural surgeons.

Dr. Mark Savarise, advocacy chair, wrote the feature article, “CPT 2012 brings with it new codes and code changes,” that provided invaluable information to rural surgeons, who otherwise would have struggled to secure it. Recently, Dr. Savarise wrote “ACS intervenes to resolve questions about the 96-hour rule” on an issue of great concern to rural surgeons. These efforts to raise awareness, articulate concerns, advocate for change, and inform members about issues are among the most important tasks of the ACRS.

The ACRS also emphasizes continuing education for rural surgeons. Rural surgery symposiums and skills courses over the years attest to that fact and acknowledge the ACRS connection with the Mithoefer Center, Cooperstown, NY, and the Nora Institute in Chicago, IL. ACRS council member, Dr. David Borgstrom, “Rural surgical practice requires a new training model, offers great opportunities” in another Bulletin rural surgery dispatch. The article describes the existing and emerging training programs, ranging from rural surgery rotations and dedicated rural surgery tracks to immersion and fellowship opportunities. The ACS has hosted a series of regional meetings such as the ACS Surgical Healthcare Quality Forum Iowa in June 2014 to engage the surgical community to share ideas on training and workforce needs, maintenance of quality care, and staff retention. In addition, ACS has introduced the Transition to Practice Program in General Surgery, which has been established in several institutions to help residents move into rural surgical practice. This program offers clinical training but also practice management training tailored to rural surgery.

ACRS quality chair, Dr. Don Nakayama, professor and chair at West Virginia University, Morgantown, has collected standards criteria for rural surgery centers of excellence and is composing a verification document for rural surgical practices. This document will assist rural surgeons and be instrumental in maintaining resources and quality in their practices. Once implemented by the ACS, the verification process for rural surgery, like the well-established program for trauma, will enable the highest standards required for the inspiring quality and for better outcomes. This new verification process and its standards give the rural surgeon a basis for the best practice.

The College has stepped up its advocacy efforts to have an impact on policy and legislation to support all surgeons. The ACS Washington office is vital and Dr. Pat Bailey, ACS medical director of advocacy, has worked with the ACRS to make sure the concerns of rural surgeons are incorporated into the advocacy strategy.

One of the four pillars of the ACRS is communication. The rural surgeons listserv was developed in by the ACRS in 2012 and has been a great success. With more than 1,000 members, and several million emails exchanged, the listserv has become meeting place for the community of rural surgeons. During the numerous rural listserv discussions and threads, many of the emails expressed thanks and appreciation. One rural surgeon volunteered, “This is the most tangible, personally applicable arm of the College I have been exposed to in nearly 40 years as a Fellow.” The conversation continued with this sentiment, “I am terrifically gratified to find that the guilt I have suffered all these years (30+) is misplaced.” As the thread continued, the word thanks appeared multiple times. The communication mission of the ACRS will continue with the development of the ACS Communities platform.

The ACS support for rural surgeons came at an ideal time. And for many in the community, this support is a cause for thankfulness.

In participating in the listserv, rural surgeons identified many topics of interest and some actual concerns to them. Call and locum tenens coverage were the most prominent potential issues. The ACS leadership is aware of both subjects and is currently investigating each one. These matters are vital to rural surgeons, and this publication, ACS Surgery News, invites rural surgeons (or any reader) to respond with any additional information. A productive dialogue could follow and be useful to the ACS. Regardless, the ACS will continue without interruption the process of support rural surgeons.

By its actions, the ACS gives living proof to its motto – “inspiring quality, highest standards, better outcomes” – which now have improved chances for surgeons to continue their work in rural communities. Rural surgeons have experienced the true meaning of ACS Fellowship. Indeed, during this Thanksgiving, rural surgeons will be giving thanks for food, friends, family, and the calling to the surgical profession. Rural surgeons will also be grateful for their College and its personal support of their profession and their practices. Thank you and Happy Thanksgiving to everyone.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

Thanksgiving will soon be here and celebrated joyfully with food, friends, and family in many homes around the country. Football, as well, has become a big part of this tradition on the fourth Thursday of November, an official holiday proclaimed by Abraham Lincoln in 1863. The first Thanksgiving was at Plymouth Plantation in 1621. It is unknown if any rural surgeons were present then. During this holiday, many rural surgeons will be giving thanks for more than food, friends, family, and football.

Twenty-five percent of the population is rural and fewer than 10% of surgeons practice in rural locations. This fact is complicated by the advanced age of the surgeons (~55 y/o) with more than 60% of them planning to retire in less than 10 years. The changes to all aspects of health care today, such as the Affordable Care Act, ACOs, and EMRs, affect the rural health care environment more profoundly and actually promote the deterioration of rural surgical practices. In recent years, rural surgeons have had few reasons to give thanks for the trajectory of their professional situation and fewer yet for the degree of acknowledgment of their challenges by the profession as a whole.

Courtesy of Dr. Caropreso

In the past 2 years, thanks to the tireless efforts of a few activists and enlightened leadership in the College, the ACS is now reaching out to rural surgeons, to recognize and to represent them. An important first step was the establishment of the Advisory Council on Rural Surgery, with its pillars for member services, education, quality, advocacy, as well as communication. The Council is chaired by Dr. Tyler Hughes.

Some critics might conclude that this council is just another group of surgeons more concerned about appearances and prominent positions than making an impact on the professional lives of rural surgeons. But such a conclusion would be wrong. Since its inception, the ACRS has worked relentlessly to identify and address the needs of rural surgeons. Efforts of all the pillars have involved education, along with local and national engagement of rural surgeons with emphasis on training, recruitment, and retention. The ACRS has stressed and promoted the value and quality found in rural surgical practices. Members of the Council have generously given their time and enthusiasm to advance these goals.

One of the major roles played by ACRS members has been contributing articles on the realities of a rural practice for the ACS Bulletin’s regular column, “Dispatches from rural surgeons.” Member services chair Dr. Mike Sarap wrote the initial article “The value of chapter membership: The rural surgeon’s perspective,” detailing chapter membership benefits. It concluded that patient care would benefit from a united, networked surgical community. Local ACS chapters can be a foundation of community and professional support among rural surgeons.

Dr. Mark Savarise, advocacy chair, wrote the feature article, “CPT 2012 brings with it new codes and code changes,” that provided invaluable information to rural surgeons, who otherwise would have struggled to secure it. Recently, Dr. Savarise wrote “ACS intervenes to resolve questions about the 96-hour rule” on an issue of great concern to rural surgeons. These efforts to raise awareness, articulate concerns, advocate for change, and inform members about issues are among the most important tasks of the ACRS.

The ACRS also emphasizes continuing education for rural surgeons. Rural surgery symposiums and skills courses over the years attest to that fact and acknowledge the ACRS connection with the Mithoefer Center, Cooperstown, NY, and the Nora Institute in Chicago, IL. ACRS council member, Dr. David Borgstrom, “Rural surgical practice requires a new training model, offers great opportunities” in another Bulletin rural surgery dispatch. The article describes the existing and emerging training programs, ranging from rural surgery rotations and dedicated rural surgery tracks to immersion and fellowship opportunities. The ACS has hosted a series of regional meetings such as the ACS Surgical Healthcare Quality Forum Iowa in June 2014 to engage the surgical community to share ideas on training and workforce needs, maintenance of quality care, and staff retention. In addition, ACS has introduced the Transition to Practice Program in General Surgery, which has been established in several institutions to help residents move into rural surgical practice. This program offers clinical training but also practice management training tailored to rural surgery.

ACRS quality chair, Dr. Don Nakayama, professor and chair at West Virginia University, Morgantown, has collected standards criteria for rural surgery centers of excellence and is composing a verification document for rural surgical practices. This document will assist rural surgeons and be instrumental in maintaining resources and quality in their practices. Once implemented by the ACS, the verification process for rural surgery, like the well-established program for trauma, will enable the highest standards required for the inspiring quality and for better outcomes. This new verification process and its standards give the rural surgeon a basis for the best practice.

The College has stepped up its advocacy efforts to have an impact on policy and legislation to support all surgeons. The ACS Washington office is vital and Dr. Pat Bailey, ACS medical director of advocacy, has worked with the ACRS to make sure the concerns of rural surgeons are incorporated into the advocacy strategy.

One of the four pillars of the ACRS is communication. The rural surgeons listserv was developed in by the ACRS in 2012 and has been a great success. With more than 1,000 members, and several million emails exchanged, the listserv has become meeting place for the community of rural surgeons. During the numerous rural listserv discussions and threads, many of the emails expressed thanks and appreciation. One rural surgeon volunteered, “This is the most tangible, personally applicable arm of the College I have been exposed to in nearly 40 years as a Fellow.” The conversation continued with this sentiment, “I am terrifically gratified to find that the guilt I have suffered all these years (30+) is misplaced.” As the thread continued, the word thanks appeared multiple times. The communication mission of the ACRS will continue with the development of the ACS Communities platform.

The ACS support for rural surgeons came at an ideal time. And for many in the community, this support is a cause for thankfulness.

In participating in the listserv, rural surgeons identified many topics of interest and some actual concerns to them. Call and locum tenens coverage were the most prominent potential issues. The ACS leadership is aware of both subjects and is currently investigating each one. These matters are vital to rural surgeons, and this publication, ACS Surgery News, invites rural surgeons (or any reader) to respond with any additional information. A productive dialogue could follow and be useful to the ACS. Regardless, the ACS will continue without interruption the process of support rural surgeons.

By its actions, the ACS gives living proof to its motto – “inspiring quality, highest standards, better outcomes” – which now have improved chances for surgeons to continue their work in rural communities. Rural surgeons have experienced the true meaning of ACS Fellowship. Indeed, during this Thanksgiving, rural surgeons will be giving thanks for food, friends, family, and the calling to the surgical profession. Rural surgeons will also be grateful for their College and its personal support of their profession and their practices. Thank you and Happy Thanksgiving to everyone.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

Thanksgiving will soon be here and celebrated joyfully with food, friends, and family in many homes around the country. Football, as well, has become a big part of this tradition on the fourth Thursday of November, an official holiday proclaimed by Abraham Lincoln in 1863. The first Thanksgiving was at Plymouth Plantation in 1621. It is unknown if any rural surgeons were present then. During this holiday, many rural surgeons will be giving thanks for more than food, friends, family, and football.

Twenty-five percent of the population is rural and fewer than 10% of surgeons practice in rural locations. This fact is complicated by the advanced age of the surgeons (~55 y/o) with more than 60% of them planning to retire in less than 10 years. The changes to all aspects of health care today, such as the Affordable Care Act, ACOs, and EMRs, affect the rural health care environment more profoundly and actually promote the deterioration of rural surgical practices. In recent years, rural surgeons have had few reasons to give thanks for the trajectory of their professional situation and fewer yet for the degree of acknowledgment of their challenges by the profession as a whole.

Courtesy of Dr. Caropreso

In the past 2 years, thanks to the tireless efforts of a few activists and enlightened leadership in the College, the ACS is now reaching out to rural surgeons, to recognize and to represent them. An important first step was the establishment of the Advisory Council on Rural Surgery, with its pillars for member services, education, quality, advocacy, as well as communication. The Council is chaired by Dr. Tyler Hughes.

Some critics might conclude that this council is just another group of surgeons more concerned about appearances and prominent positions than making an impact on the professional lives of rural surgeons. But such a conclusion would be wrong. Since its inception, the ACRS has worked relentlessly to identify and address the needs of rural surgeons. Efforts of all the pillars have involved education, along with local and national engagement of rural surgeons with emphasis on training, recruitment, and retention. The ACRS has stressed and promoted the value and quality found in rural surgical practices. Members of the Council have generously given their time and enthusiasm to advance these goals.

One of the major roles played by ACRS members has been contributing articles on the realities of a rural practice for the ACS Bulletin’s regular column, “Dispatches from rural surgeons.” Member services chair Dr. Mike Sarap wrote the initial article “The value of chapter membership: The rural surgeon’s perspective,” detailing chapter membership benefits. It concluded that patient care would benefit from a united, networked surgical community. Local ACS chapters can be a foundation of community and professional support among rural surgeons.

Dr. Mark Savarise, advocacy chair, wrote the feature article, “CPT 2012 brings with it new codes and code changes,” that provided invaluable information to rural surgeons, who otherwise would have struggled to secure it. Recently, Dr. Savarise wrote “ACS intervenes to resolve questions about the 96-hour rule” on an issue of great concern to rural surgeons. These efforts to raise awareness, articulate concerns, advocate for change, and inform members about issues are among the most important tasks of the ACRS.

The ACRS also emphasizes continuing education for rural surgeons. Rural surgery symposiums and skills courses over the years attest to that fact and acknowledge the ACRS connection with the Mithoefer Center, Cooperstown, NY, and the Nora Institute in Chicago, IL. ACRS council member, Dr. David Borgstrom, “Rural surgical practice requires a new training model, offers great opportunities” in another Bulletin rural surgery dispatch. The article describes the existing and emerging training programs, ranging from rural surgery rotations and dedicated rural surgery tracks to immersion and fellowship opportunities. The ACS has hosted a series of regional meetings such as the ACS Surgical Healthcare Quality Forum Iowa in June 2014 to engage the surgical community to share ideas on training and workforce needs, maintenance of quality care, and staff retention. In addition, ACS has introduced the Transition to Practice Program in General Surgery, which has been established in several institutions to help residents move into rural surgical practice. This program offers clinical training but also practice management training tailored to rural surgery.

ACRS quality chair, Dr. Don Nakayama, professor and chair at West Virginia University, Morgantown, has collected standards criteria for rural surgery centers of excellence and is composing a verification document for rural surgical practices. This document will assist rural surgeons and be instrumental in maintaining resources and quality in their practices. Once implemented by the ACS, the verification process for rural surgery, like the well-established program for trauma, will enable the highest standards required for the inspiring quality and for better outcomes. This new verification process and its standards give the rural surgeon a basis for the best practice.

The College has stepped up its advocacy efforts to have an impact on policy and legislation to support all surgeons. The ACS Washington office is vital and Dr. Pat Bailey, ACS medical director of advocacy, has worked with the ACRS to make sure the concerns of rural surgeons are incorporated into the advocacy strategy.

One of the four pillars of the ACRS is communication. The rural surgeons listserv was developed in by the ACRS in 2012 and has been a great success. With more than 1,000 members, and several million emails exchanged, the listserv has become meeting place for the community of rural surgeons. During the numerous rural listserv discussions and threads, many of the emails expressed thanks and appreciation. One rural surgeon volunteered, “This is the most tangible, personally applicable arm of the College I have been exposed to in nearly 40 years as a Fellow.” The conversation continued with this sentiment, “I am terrifically gratified to find that the guilt I have suffered all these years (30+) is misplaced.” As the thread continued, the word thanks appeared multiple times. The communication mission of the ACRS will continue with the development of the ACS Communities platform.

The ACS support for rural surgeons came at an ideal time. And for many in the community, this support is a cause for thankfulness.

In participating in the listserv, rural surgeons identified many topics of interest and some actual concerns to them. Call and locum tenens coverage were the most prominent potential issues. The ACS leadership is aware of both subjects and is currently investigating each one. These matters are vital to rural surgeons, and this publication, ACS Surgery News, invites rural surgeons (or any reader) to respond with any additional information. A productive dialogue could follow and be useful to the ACS. Regardless, the ACS will continue without interruption the process of support rural surgeons.

By its actions, the ACS gives living proof to its motto – “inspiring quality, highest standards, better outcomes” – which now have improved chances for surgeons to continue their work in rural communities. Rural surgeons have experienced the true meaning of ACS Fellowship. Indeed, during this Thanksgiving, rural surgeons will be giving thanks for food, friends, family, and the calling to the surgical profession. Rural surgeons will also be grateful for their College and its personal support of their profession and their practices. Thank you and Happy Thanksgiving to everyone.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.