Monday, March 17, 2014

A med student asks about rural surgery training

Lionel, a first-year med student at a US school, writes

I'm really passionate about rural surgery and the idea of having a wide variety of procedures that you have to be able to take care of—ortho, c-sections, urology, ENT, abdomen, etc. But the thing is, everyone I talk to says this is an unreasonable expectation to have going forward as current training isn't conducive to learning all those things in 5 years, given the number of fellows present and the general trend towards super-specialization these days. Yet, I read about massive needs for rural general surgery. It doesn't quite add up. 

What is your take on this? Also, how do I go about pursuing a career as a rural surgeon in this academic/training environment? Community program? Academic program? I know Cooperstown, Oregon and Gunderson have rural surgery fellowships but I haven't heard anything about them or how to determine if you need to pursue this extra training.

Good questions.

An email exchange yielded more background information. He went to college in a rural area, has worked in an orphanage on a farm, and spent some time with physicians in rural Africa.

He has thought things through very well and seems quite committed to becoming a rural surgeon.

In medical school, he plans to do one elective in rural surgery and another at a hospital that serves as the primary clinic/surgical center for 160,000 people in a poor African country.

He is also going to spend a summer doing research at an academic center just to get an idea of what that is like.

I sent him some links to papers on the subject of rural surgery most of which he had already seen.

Here is what I think.

If you choose the right program, you would not have to take an extra year of fellowship to become a competent rural surgeon. For example, the Oregon program includes a year of rural surgery in their five-year curriculum for those who wish to do it.

There are some other programs besides the ones you named, and there may be more by the time you are ready to choose a residency. You might also think about programs with international rotations.

If you are truly committed to becoming a rural surgeon, a pure academic program is probably not for you. You are not likely to get enough diversified subspecialty experience in such a place. A community hospital program that offers a chance to rotate on some of the subspecialties and OB would be better, and there will be few or no fellows competing for cases.

I hope that some readers will contribute other perspectives to the discussion.


  1. Rural surgery practice in the US is very rewarding, but quite different from 'general surgery' in the developing world. In my first job in rural Oregon, I did C-sections, upper GI scopes for bleeding, emergency salpingectomy for bleeding ectopic, suprapubic cath placements for retention, but we had full ortho coverage. Working with Doctors Without Borders in Sudan, ortho made up a quarter of my cases. I think a program with rural focus is the best choice, but you'll still be learning ortho and neuro from books at point of care. I don't expect think an academic program has any advantages for a future rural surgeon - may have disadvantages, in fact.

    1. Chris, thanks for the comments. It's good to hear from someone who has had some experience on the front lines.

  2. I did a community general surgery residency in a large city, then practiced as an urban general surgeon for a few years, and then relocated to a tiny critical access hospital. I now practice solo. My transition to rural practice was stressful and painful. I found almost nobody willing to help me. Cooperstown in particular wouldn't give me the time of day (I think that the receptionist threw my application in the trash.) Somehow I managed to pick up C sections, endoscopy, and minor interventional procedures.
    Lionel will probably have a much easier time of it, provided he goes to a residency program tailored towards training rural surgeons. Nevertheless, rural surgeons in the US are held to a national standard of care. Dabbling in bariatrics, Whipples, pulmonary lobectomies, vascular, laryngectomies, and joint replacements at small institutions with limited capabilities is a way to destroy your reputation and get yourself sued out of existence. Remember, also, that visiting specialists in urology, ENT, orthopedics, gynecology, etc, will be happy to come through your area q 2-4 weeks and skim off the elective cream.
    Solution? Do a good 5 year residency program geared towards rural surgery. Do international rotations. Even more so, rub shoulders with actual rural surgeons and see what is feasible out in the sticks. When you finish training, join a (good) rural surgeon who is what you aspire to be, who wants a junior partner, and who can continue to teach and mentor you. (I am a decade out and learn new things every day, but unfortunately have to do it by myself.)

    1. This seems like excellent advice. Thanks.

  3. I am currently a solo surgeon in a rural practice. I did my residency at a community program followed by a minimally invasive fellowship. All that training was still not adequate for this experience and it has been a difficult transition for me and a daily learning experience. It is rewarding in its own way but competing for results with large centers is not easy. The American college of surgeons has a very active rural surgery forum that has a large contributing membership of rural surgeons.There is also a residents liaison for rural surgery through the Residents and associate fellows society. (RAS-ACS).

    I believe a community program without fellowships and an apprenticeship with a rural surgeon for a year would be ideal for such training. Not only that there are more programs that are offering rural surgery tracks:

    The Mithoeffer center for rural surgery from basset healthcare has avery nicely organized website and shadowing program and that may help in understanding and planning your career.

    Good Luck!

  4. Fella, thanks so much for the comments and the links. This should be very helpful.