The rural surgeon: an endangered species.

From the time I was a small child, I had a burning desire to become a surgeon. In those days, in Iraq, surgeons were few and were direly needed to practice a wide spectrum of procedures. The fruit of their work was my inspiration. But I had a premonition that by the time I would be ready, I might not be able to satisfy my professional desires. In 1976 I took my first step when I became a medical student at the University of Baghdad School of Medicine. By graduation, things were already different; highly specialized surgeons were returning home from abroad. Their predecessors became known as general surgeons. Nevertheless, the need was tremendous and the nation’s capabilities were no match. Surgeons continued to practice as desired, guided by their level of comfort. My professional dreams were still viable. No need to stick to monotonous operations of a narrow field. Just imagine yourself doing only hernias, gallbladders or breast cases all day long, day in and day out. But the winds did not blow in the direction I hoped for. Because the country was at war, my plans were shelved as I was drafted into the military. Most of the time, administering first-aid or treating general illnesses was all I could do on the frontlines. Yet I vividly remember having to do some chest tubes, surgical airways, splinting of fractures, and even some limb amputations to save a life or two. The looming future and the uncertainty were reasons enough for me to flee Iraq. Becoming a general surgeon in America required a leap of faith that led to a story of its own. Needless to say, it was very hard for a foreign graduate to find a spot in a surgical residency program. ‘‘Better lucky than good’’ was how I found a preliminary position in a surgery residency program at Kern Medical Center in Bakersfield, California, a small program affiliated with the University of California, San Diego. I was skeptical at first because it was not a prestigious program and, then, it was placed on academic probation; but ‘‘beggars can’t be choosers.’’ Before long, I realized that my program was not only fulfilling but truly meaningful. It taught me everything about something and something about everything, providing far more than what is offered at many university-based programs. My chairman and program director practiced general and vascular surgery in addition to thoracic surgery. The two other attending general surgeons were his trainees. Residents also covered all subspecialty services. The absence of specialty-residencies ensured wide exposure and excellent hands-on experience for everyone. The clinical training was reinforced by the creation of a three-month rotation under rural surgeons in the small town of Delano, on the outskirts of Bakersfield. There I was introduced to the concept of rural surgery, a practice of old-time, non-specialist surgeons who were able to manage a wide range of surgical problems with very limited resources. By the time I finished my residency, I felt confident functioning independently, something I had always longed for. ‘‘But,’’ one may ask, ‘‘what is a rural surgeon?’’ According to the Office of Management and Budget and the Bureau of the Census, a metropolitan area is an outlying county with a commuting threshold of 25% or more. All other areas are described as rural. Accordingly, some 50 million people live in rural America, representing some 20% of US population and occupying about 75% of total US land mass. Any surgeon who practices in a rural area is, by definition, a rural surgeon. It has been estimated that only 10% of general surgeons now practice in rural areas, half of the needed workforce. With the expected increase in the population over the age of 65 as Baby Boomers age, the workload for general surgeons can be expected to increase almost threefold, putting rural areas at a further disadvantage. The great need and the wide scope of practice offered by rural surgery led me to consider taking a job as a rural surgeon, but there were too many hurdles. Most of the 2006 by the Societe Internationale de Chirurgie World J Surg (2006) 30: 267–268 Published Online: 13 February 2006 DOI: 10.1007/s00268-005-0465-3