The Rural Surgical Workforce: Current and Future Challenges (2019)

Background: The discourse about the rural health care workforce in the US has typically focused on the need for primary care physicians. There is a growing body of research on the characteristics of rural general surgeons although it is much smaller and less sophisticated than that on rural primary care physicians. There is growing concern that the aging of the rural surgical workforce and the continuing trend towards specialization will create or worsen shortages of surgical providers in rural areas. A number of proposals to slow or reverse this trend have been made including opening up National Health Service Corps loan repayment to surgeons who chose to practice in rural areas. Methods: a systematic review of the literature (dating from 2000) identified major themes such as the importance of general surgeons to rural health care delivery, workforce characteristics of rural general surgeons (demographics, practice patterns), and program innovations that encourage residents to consider careers in rural areas. These themes formed the basis for in-depth interviews with eight key informants: five surgeons and three non-surgeons to formulate systematic arguments about the most important factors in recruitment and retention of surgeons in rural areas. Areas of inquiry included the nature of rural surgical practice, the reality of personal and professional isolation, how surgeons choose rural practice, the potential benefit of making surgeons eligible for NHSC (National Health Service Corps) loan forgiveness and how rural surgeons contribute to social capital in their communities. Results: the informants agreed that the rural surgical workforce is under stress and that more must be done to recruit general surgeons to rural areas. Infrastructure and a perception that rural areas are less desirable than urban areas as living and work environments were seen as major impediments to recruitment. There was also strong agreement that rural is very different in different parts of the US and that this complicates the question of determining how best to supply surgical care to rural areas. A majority of the informants believed that medical students and residents from rural areas or small towns were more likely to choose rural practice. Creating the opportunity for relationships (via rural rotations) between residents or medical students and practicing rural surgeons was proposed as a way of bringing new surgeons into rural areas. Informants were divided on the question of NHSC loan forgiveness in part because two were unaware of the program’s existence. One informant proposed that surgeons currently practicing in urban areas who were interested in relocating to rural areas be given economic support for transferring their practices. The three informants who had practiced or were currently practicing in rural communities described the importance and benefits of their involvement in the life of their communities. Conclusions: rural areas in the US have difficulty recruiting and retaining general surgeons. The diversity of what constitutes rurality in the US and uncertainty as to the appropriate level of service for rural areas make it difficult to determine how many surgeons are needed to provide adequate care for rural areas. Future research on the rural general surgical workforce would benefit from rigorous evaluation of rural surgical training programming that currently exists at the medical student and resident level, investigation of why surgeons come to or leave rural areas, and what economic incentives are most likely to be effective.