ACS Bulletin - October 2016

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