Rural surgery and the volume dilemma
by Patrick L. Molt, MD, FACS
Another 3:00 am phone call eft me struggling toward wakefulness. This time it
was the obstetrician. He went
on too long, explaining how he
had produced a large laceration
in a patient’s bladder in the
course of performing a cesarean
delivery. Finally awake enough
to interrupt, I said, “Whatever
it is, I’ll take care of it.” For
general surgeons in small rural
hospitals, this is what we do—
we take care of it, whatever it is.
Growing demand for
rural surgeons
In the approximately two-
thirds of the 1,300 critical access
hospitals (CAH) located across
the U.S. where general surgeons
still operate, we engage in a
scope of practice that has largely
disappeared in metropolitan
areas. As one contributor to the
American College of Surgeons
rural listserv wrote, “You know
you are a rural surgeon when
your OR [operating room] list
for the day would require five
subspecialists in a larger hospital.”
In light of the decline in
general surgeons practicing in
rural areas (an estimated 8. 1
per 100,000 population in 1981,
declining to 5 per 100,000 in
2005, and likely even fewer
today), there is no shortage
of patients in need of surgical
services. 1 In comparison with
their urban counterparts, of
whom there are approximately
7. 7 per 100,000 patients, rural
surgeons take responsibility
for 50 percent more lives. 1 Case
loads are higher for surgeons
practicing in both small and
large rural hospitals by a similar
proportion, as documented by
analysis of the American Board
of Surgery (ABS) recertification
case logs. 2 Analysis of the Dakota
Database for Rural Surgery
yielded an average of 1,071
surgical procedures annually
among the 43 rural surgeons
participating. Case distribution
included 48 percent of cases
considered general surgery,
40 percent endoscopy, and
12 percent subspecialty. 3 When
it comes to the volume part of
the volume/outcome equation,
overall number of cases is rarely
an issue for rural surgeons.
Unfortunately, outcomes
research evaluating a variety of
medical diagnoses has shown
poorer results in CAHs than in
larger hospitals. Surgical services
suffer from guilt by association.
Several recent publications have
confirmed that as rural surgeons,
we do well those procedures
we do regularly. Gadzinski and
colleagues, in a 2013 publication
from the University of Michigan
Center for Healthcare Outcomes
and Policy, Ann Arbor, compared
results using administrative data
sets from 1,283 CAHs and 3,612
non-CAHs for eight common
procedures in general surgery,
obstetrics and gynecology,
and orthopaedics, including
the following: appendectomy,
cholecystectomy, colorectal
cancer resection, cesarean
delivery, hysterectomy, knee
replacement, hip replacement,
and hip fracture repair. 4
Length of stay was statistically
significantly shorter at CAHs
for four procedures and risk-adjusted mortality rates were
OCT 2016 BULLETIN American College of Surgeons
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DISPATCHES FROM RURAL SURGEONS