Spe­cial re­port: Ru­ral mar­kets suf­fer­ing from short­age of sur­geons

Large sec­tions of ru­ral Amer­ica con­tinue to suf­fer from a drought of gen­eral sur­geons

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An arid-like land­scape con­tin­ues to creep across vast sec­tions of the coun­try. But this isn’t a ge­o­graphic phe­nom­e­non tied to cli­mate change, it’s a cul­tural and pro­fes­sional one known as a sur­gi­cal desert. Re­sult­ing from a dearth of in­ter­est on the part of sur­geons prac­tic­ing in ru­ral ar­eas, sur­gi­cal deserts are cre­at­ing health risks for res­i­dents in the com­mu­nity and mak­ing it dif­fi­cult for hos­pi­tals to care for them, in­dus­try ex­perts are warn­ing.

“A sub­stan­tial por­tion of our coun­try can be char­ac­ter­ized as sur­gi­cally un­der­served, de­spite sev­eral pro­grams de­signed to help sus­tain health­care ser­vices in un­der­served com­mu­ni­ties through en­hanced re­im­burse­ment,” wrote the au­thors of a 2009 re­port from the Amer­i­can Col- lege of Sur­geons Health Pol­icy Re­search In­sti­tute. “For many places, these ini­tia­tives may not be suf­fi­cient to sup­ple­ment a sur­gi­cal prac­tice.”

The prob­lem has not im­proved since those num­bers were col­lected. “What­ever (the sit­u­a­tion) was in 2009, I sus­pect that the trend line is only get­ting worse,” says Jonathan Sprague, pres­i­dent of Rocky Coast Con­sult­ing, a Ban­gor, Maine, firm spe­cial­iz­ing in health­care ser­vices.

Like the dif­fi­cul­ties ru­ral pri­mary-care op­er­a­tions face in at­tract­ing doc­tors to work for them, ru­ral surgery pro­grams are strug­gling to at­tract sur­geons. Most newly minted gen­eral sur­geons go into spe­cial­ties—which aren’t in high de­mand in ru­ral ar­eas be­cause of smaller pop­u­la­tions—and those that do re­main in gen­eral surgery for the most part are elect­ing to work in or near cities, where the avail­able pro­fes­sional re­sources are more abun­dant and com­pa­ra­ble to what they had in med­i­cal school.

As a re­sult of this lack of in­ter­est in work­ing out­side of ur­ban regions, more than 900 mostly ru­ral coun­ties in the coun­try have no ac­cess to a lo­cal sur­geon, cre­at­ing sur­gi­cal deserts for about 9.5 mil­lion Amer­i­cans, ac­cord­ing to an ACS study, “Sur­gi­cal Deserts in the U.S.: Places with­out Sur­geons.”

“This is not a bro­ken sys­tem, but it is a sys­tem in­creas­ingly fac­ing a cri­sis,” Sprague says. There are many ru­ral hos­pi­tals pro­vid­ing ex­cep­tional surgery ser­vices, but go­ing for­ward “it’s go­ing to be very dif­fi­cult,” Sprague says.

It’s the fall­ing num­ber of sur­geons rel­a­tive to the pop­u­la­tion that is driv­ing the prob­lem, and although ur­ban ar­eas also have been hit with a drop in gen­eral sur­geon cov­er­age, ru­ral ar­eas lack them the most.

A study pub­lished in the Archives of Surgery in 2008 found there were 5.69 gen­eral sur­geons for ev­ery 100,000 pop­u­la­tion in 2005, down 26% from 7.68 in 1981. In ru­ral ar­eas, in­clud­ing coun­ties that are ad­ja­cent to ur­ban coun­ties and those that have cities with at least 10,000 to 50,000 res-

idents, the ra­tio was 5.02 sur­geons per 100,000 pop­u­la­tion, a de­crease of 21% from 6.36 in 1981.

The num­bers are worse, though, look­ing at less-pop­u­lated coun­ties not ad­ja­cent to an ur­ban area and with­out a city of at least 10,000 peo­ple, a type of re­gion highly de­pen­dent on gen­eral sur­geons for emer­gency care, ac­cord­ing to the study, ti­tled “A Lon­gi­tu­di­nal Anal­y­sis of the Gen­eral Surgery Work­force in the United States, 19812005.” Such coun­ties had only 4.31 sur­geons per 100,000 in 2005, down 16% from 5.15 in 1981.

Sur­geons are not at­tracted to the ru­ral life­style for a num­ber of rea­sons. Af­ter typ­i­cally get­ting trained in a more ur­ban en­vi­ron­ment, nascent gen­eral sur­geons have grown ac­cus­tomed to med­i­cal tech­nol­ogy that of­ten isn’t avail­able in ru­ral set­tings, says Jess Judy, se­nior vice pres­i­dent of provider re­la­tions at Lifepoint Hos­pi­tals, a for-profit chain based in Brent­wood, Tenn., with a high con­cen­tra­tion of ru­ral and sole com­mu­nity hos­pi­tals.

Lifepoint is work­ing to be creative in at­tract­ing sur­geons to its ru­ral fa­cil­i­ties, try­ing to em­ploy them di­rectly to re­move some of the un­cer­tainty of join­ing or form­ing a prac­tice. One ap­proach the com­pany is con­sid­er­ing is the cre­ation of a hos­pi­tal­ist-like role for sur­geons, pos­si­bly to be called a “sur­gi­cal­ist,” though the specifics are far from be­ing def­i­nite, says Melissa Waddey, se­nior di­rec­tor of strate­gic re­source group at Lifepoint.

Hav­ing ac­cess to cap­i­tal for med­i­cal tech­nol­ogy is one of the ways 101-bed Natchez (Miss.) Com­mu­nity Hospi­tal, owned by for-profit hospi­tal chain Health Man­age­ment As­so­ciates, Naples, Fla., tries to cre­ate an en­vi­ron­ment that would be more at­trac­tive to sur­geons con­sid­er­ing a ru­ral prac­tice, says Donny Rent­fro, the hospi­tal’s for­mer CEO. Natchez re­cently added a sur­gi­cal ro­bot to its reper­toire and also per­forms com­mu­nity out­reach to try to build busi­ness for its sur­gi­cal ser­vices, he says.

In­deed, res­i­dents in ru­ral com­mu­ni­ties have be­come more aware of avail­able tech­nol­ogy, but some still seem to pre­fer met­ro­pol­i­tan providers for that care, fur­ther hurt­ing prospects for ru­ral sur­gi­cal-care providers. Health­care con­sumers are be­com­ing more ed­u­cated on health­care is­sues and are rec­og­niz­ing that the higher vol­ume of pro­ce­dures tak­ing place at ur­ban providers gen­er­ally are as­so­ci­ated with bet­ter out­comes, says Robert Gift, a di­rec­tor for Chadds Ford, Pa.-based IMA Con­sult­ing, which spe­cial­izes in health­care. And as larger ur­ban hos­pi­tals and sys­tems have af­fil­i­ated with ru­ral hos­pi­tals, the sur­gi­cal ser­vices of­ten end up be­ing per­formed in the ur­ban hospi­tal, Gift says.

The role of the gen­eral sur­geon also has changed. Be­fore sur­gi­cal spe­cial­iza­tion be­came so com­mon, a ru­ral sur­geon might have per­formed a lot of vas­cu­lar surgery, whereas to­day that type of op­er­a­tion would most likely go to a vas­cu­lar spe­cial­ist in a more ur­ban set­ting, says Arthur Blank, pres­i­dent and CEO of 25-bed

Mount Desert Is­land Hospi­tal, Bar Har­bor, Maine, a state with no sur­gi­cal desert coun­ties. Ru­ral sur­geons to­day might do more en­doscopy pro­ce­dures, some­thing they weren’t nec­es­sar­ily trained to do as a gen­eral sur­geon, but can learn, he says.

Mount Desert is mov­ing to­ward an em­ploy­ment model for its sur­gi­cal pro­gram, which gets heavy traf­fic in sum­mer months from nearby Aca­dia Na­tional Park and has most of its C-sec­tions per­formed by gen­eral sur­geons, Blank says. Fam­ily-prac­tice physi­cians and nurse mid­wives han­dle most of the vagi­nally de­liv­ered ba­bies.

The de­mand side of the ru­ral surgery equa­tion also has been af­fected, with pro­por­tion­ately fewer peo­ple liv­ing in ru­ral ar­eas. The ru­ral pop­u­la­tion con­tin­ues to grow, but at a much slower rate than pre­vi­ously.

The ru­ral pop­u­la­tion grew 4.5%, or about 2.2 mil­lion peo­ple, be­tween 2000 and 2010, bring­ing its to­tal pop­u­la­tion to 51 mil­lion, ac­cord­ing to a re­cent anal­y­sis of cen­sus data con­ducted by the Carsey In­sti­tute, which is part of the Univer­sity of New Hamp­shire at Durham. The ru­ral pop­u­la­tion had grown by 4.1 mil­lion in the pre­vi­ous decade, while the ur­ban pop­u­la­tion growth rate in 2000-2010 was 10.8%, ac­cord­ing to the in­sti­tute.

The slow­down in pop­u­la­tion growth was driven by shift­ing trends af­fect­ing ru­ral ar­eas, par- tic­u­larly those not close to met­ro­pol­i­tan cen­ters.

“The slower pop­u­la­tion growth in ru­ral Amer­ica oc­curred be­cause mi­gra­tion con­trib­uted far less to the ru­ral pop­u­la­tion in­crease than it had dur­ing the 1990s,” wrote the au­thors of the Carsey In­sti­tute anal­y­sis ti­tled “Ru­ral De­mo­graphic Change in the New Cen­tury: Slower Growth, In­creased Di­ver­sity.”

“Para­dox­i­cally, nat­u­ral in­crease (more births than deaths) re-emerged as the pri­mary de­mo­graphic force fu­el­ing ru­ral growth, not be­cause of a surge in ru­ral births, but be­cause mi­gra­tion to ru­ral Amer­ica has sharply di­min­ished,” the au­thors wrote.

Just too small?

Some regions sim­ply might not be big enough to sup­port a sur­geon. A com­mu­nity needs at least 15,000 to 20,000 res­i­dents to sup­port a sur­geon eco­nom­i­cally speak­ing, says Ger­ald Doek­sen, di­rec­tor of the Na­tional Cen­ter for Ru­ral Health Works, part of Ok­la­homa State Univer­sity at Still­wa­ter. But in com­mu­ni­ties that size there are qual­ity-of-life is­sues that make it harder to at­tract sur­geons to live and work there.

“The prob­lem is they’re of­ten on-call, an aw­ful lot,” says Doek­sen, who also is a pro­fes­sor and ex­ten­sion econ­o­mist for the Ok­la­homa Co­op­er­a­tive Ex­ten­sion Ser­vice at Ok­la­homa State. The ideal sit­u­a­tion can sup­port two sur­geons and would there­fore have a pop­u­la­tion of about dou­ble that size, Doek­sen says. Gen­er­ally speak­ing, the ar­eas served by crit­i­cal-ac­cess hos­pi­tals are too small to sup­port a gen­eral sur­geon, he says.

Ru­ral com­mu­ni­ties are des­per­ate to at­tract ru­ral sur­geons so that sur­gi­cal ser­vices can re­main, for eco­nomic and qual­ity-of-life rea­sons. “These hos­pi­tals are very pas­sion­ate about re­main­ing in their com­mu­nity,” says Amy Dore, as­sis­tant pro­fes­sor at Met­ro­pol­i­tan State Col­lege of Den­ver.

In a sur­vey of ex­ec­u­tives at “tweener” hos­pi­tals con­ducted by Dore, re­spon­dents expressed con­cern about the dearth of gen­eral sur­geons in ru­ral ar­eas. Ru­ral hos­pi­tals known as tween­ers are too large to qual­ify for crit­i­cal-ac­cess hospi­tal cost-based re­im­burse­ment but too small to pro­vide ef­fi­cient prospec­tive pay­ment sys­tem care.

Ac­cord­ing to Dore’s sur­vey, which she con­ducted for her doc­toral dis­ser­ta­tion, ex­ec­u­tives strongly agreed with the state­ment, “If the sur­gi­cal ser­vices were dis­con­tin­ued at my hospi­tal, the hospi­tal would suf­fer sig­nif­i­cantly fi­nan­cially,” as well as the state­ment, “I con­sider the short­age of ru­ral gen­eral sur­geons in the United States to be crit­i­cal.”

Dore adds that she found a re­la­tion­ship be­tween the suc­cess of a ru­ral surgery pro­gram and the num­ber of sur­gi­cal sup­port staffers em­ployed, which may have im­pli­ca­tions re­lated to the re­ten­tion and at­trac­tion of ru­ral sur­geons.

There are broader eco­nomic ben­e­fits to hav­ing a surgery pro­gram, ac­cord­ing to re­search from the Na­tional Cen­ter for Ru­ral

CRISTINA JAN­NEY

Dr. Tyler Hughes, who prac­tices at Mcpher­son (Kan.) Hospi­tal, warns of the risks posed by the lack of sur­geons in some regions.

MOD­ERN HEALTH­CARE GRAPHIC

Source: Amer­i­can Col­lege of Sur­geons Health Pol­icy Re­search In­sti­tute

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