A comparison of future recruitment needs in urban and rural hospitals: the rural imperative

An audit on surgery cancellation in a teaching hospital

Background

Operative procedure cancellations are a dilemma for the healthcare system as well as for the patients. It causes increased workload and cost to our system. For patients, it has major financial, psychological as well as medical consequences. We aim to self-identify the causes of cancellations for efficient operation room management.

Methods

We performed a retrospective chart review in a tertiary academic medical center for the last 66 months of operative records. Subsequently, we performed thematic coding to categorize causes into distinct categories.

Results

Our records showed 5153 cancellations which represent (7.3%) of the total booked procedures. Of these cancellations 91% were ordered before the day of surgery, compared to 9% for same-day cancellations. Cancellations were 58% female patients and 40% male patients. The number one reason for cancellations for both same-day and prior cancellations is the unavailability of the surgical consultant.

Conclusion

Surgical procedure cancellations profile is unique among our settings and has changed over time. Over the last 5 years, the number one reason is unavailability of the surgical consultant. Efforts should be made to identify and correct the underlying reasons to improve patient outcomes in our evolving healthcare system.

What Is the Geographic Distribution and Density of Orthopaedic Advanced Practice Professionals in Rural Counties? A Large-database Study

BACKGROUND

Advanced practice professionals, including physician assistants (PAs) and nurse practitioners (NPs), play an important role in providing high-quality orthopaedic care. This role has been highlighted by projections of nationwide shortages in orthopaedic surgeons, with rural areas expected to be most affected. Given that approximately half of rural counties have no practicing orthopaedic surgeons and that advanced practice professionals have been shown to be more likely to practice in rural areas compared to physicians in other medical disciplines, orthopaedic advanced practice professionals may be poised to address orthopaedic care shortages in rural areas, but the degree to which this is true has not been well characterized.

QUESTIONS/PURPOSES

(1) What percentage of rural counties have no orthopaedic caregivers, including surgeons and advanced practice professionals? (2) Is the density of advanced practice professionals greater than that of orthopaedic surgeons in rural counties? (3) Do orthopaedic advanced practice professionals only practice in counties that also have practicing orthopaedic surgeons? (4) Are NPs in states with full practice authority more likely to practice in rural counties compared with NPs in restricted practice authority states?

METHODS

We identified orthopaedic surgeons and advanced practice professionals using the 2019 Medicare Provider Utilization and Payment Data, as this large dataset has been shown to be the most complete source of claims data nationwide. Each professional's ZIP Code was matched to counties per the US Postal Service ZIP Code Crosswalk Files. The total number and density of physician and advanced practice professionals per 100,000 residents were calculated per county nationwide. Counties were categorized as urban (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) or rural (micropolitan and noncore) using the National Center for Health Statistics Urban-Rural Classification Scheme. Comparisons between rural and urban county caregivers were conducted with the chi-square test and odds ratios. Population densities were compared with the Wilcoxon rank sum test. A bivariate density map was made to visualize the nationwide distribution of orthopaedic caregivers and determine the percentage of rural counties with no orthopaedic caregivers as well as whether orthopaedic advanced practice professionals practiced in counties not containing any surgeons. Additionally, to compare states with NP's full versus restricted practice authority, each NP was grouped based on their state to determine whether NPs in states with full practice authority were more likely to practice in rural counties. We identified a group of 31,091 orthopaedic caregivers, which was comprised of 23,728 physicians, 964 NPs, and 6399 PAs (7363 advanced practice professionals). A total of 88% (20,879 of 23,728) of physicians and 87% (6427 of 7363) of advanced practice professionals were in urban counties, which is comparable to nationwide population distributions.

RESULTS

A total of 39% (1237 of 3139) of counties had no orthopaedic professionals (defined as orthopaedic surgeons or advanced practice professionals) in 2019. Among these counties, 82% (1015 of 1237) were rural and 18% (222 of 1237) were urban. The density of advanced practice professionals providing orthopaedic services compared with the density of orthopaedic surgeons was higher in rural counties (18 ± 70 versus 8 ± 40 per 100,000 residents; p = 0.001). Additionally, 3% (57 of 1974) of rural and 1% (13 of 1165) of urban counties had at least one orthopaedic advanced practice professional, but no orthopaedic surgeons concurrently practicing in the county. There was no difference between the percentage of rural counties with an NP in states with full versus restricted practice authority for NPs (19% [157 of 823] versus 26% [36 of 141], OR 1.45 [95% CI 0.99 to 2.2]; p = 0.08).

CONCLUSION

As advanced practice professionals tended to only practice in counties which contain orthopaedic surgeons, our analysis suggests that plans to increase the number of advanced practice professionals alone in rural counties may not be sufficient to fully address the demand for orthopaedic care in rural areas that currently do not have orthopaedic surgeons in practice. Rather, interventions are needed to encourage more orthopaedic surgeons to practice in rural counties in collaborative partnerships with advanced practice professionals. In turn, rural orthopaedic advanced practice professionals may serve to further extend the accessibility of these surgeons, but it remains to be determined what the total number and ratio of advanced practice professionals and surgeons is needed to serve rural counties adequately.

CLINICAL RELEVANCE

To increase rural orthopaedic outreach, state legislatures may consider providing financial incentives to hospitals who adopt traveling clinic models, incorporating advanced practice professionals in these models as physician-extenders to further increase the coverage of orthopaedic care. Furthermore, the creation of more widespread financial incentives and programs aimed at expanding the experience of trainees in serving rural populations are longer-term investments to foster interest and retention of orthopaedic caregivers in rural settings.

Predictors of hospital bypass for rural residents seeking common elective surgery

BACKGROUND

Surgical bypass occurs when rural residents receive surgical care at a nonlocal hospital. Given limited knowledge of current bypass rates, we evaluated rates and predictors of bypass for common procedures.

METHODS

We used 2014 to 2016 all-payer claims data from the Healthcare Cost and Utilization Project State Inpatient Databases to study rural patients from 13 states who underwent 1 of 11 common elective surgical procedures. Bypass was measured by whether a patient received elective surgical care at the closest hospital offering the requested procedure or another nonlocal hospital. Bypass probability was then modeled as a function of patient-level and hospital-level characteristics.

RESULTS

Of the 121,297 rural elective surgery visits in our sample, 78,268 (64.5%) bypassed their local hospital. Bypass rate was greatest for coronary artery bypass graft or valve replacement (74.8%) and lowest for laparoscopic cholecystectomy (53.7%). In addition, average bypass rate was greatest for surgeries with the highest risk of intraoperative blood loss and postoperative complications. The probability of bypass significantly (P < .001) increased for patients who were younger, privately insured, and lived farther from the closest hospital. In addition, the probability of bypass significantly (P < .001) increased for patients whose local hospital had fewer full-time equivalents, lower operating margin, and fewer recommendations from previous patients.

CONCLUSION

Among rural patients seeking elective surgery, bypass of the local hospital was common among both low-risk and high-risk procedures. These findings suggest that there is a substantial amount of bypass, which may negatively impact a hospital's financial performance and, hence, wellbeing of the local community.

Resident Perspectives on the Value of Rural General Surgery Rotations: It's Not Just About the Cases

PURPOSE

Understand the scope of cases that residents participate in during rural general surgery rotations and the value residents and program directors find in such rotations. In turn, our goal is to add to the ongoing conversation the value exposure to rural surgery brings to surgery training.

METHODS

Qualitative study analyzed reviews of residents' self-reported case lists and field notes from exit interviews with the site director.

RESULTS

Trainees participated in an average of 105 cases during the rotation, including basic and advanced endoscopy along with exposure to a wide array of surgical cases. Residents had exposure to the rural facility and its staff and participated in a busy outpatient surgical clinic, the hospital, and community activities. We received overwhelmingly positive qualitative feedback from residents regarding how this rural rotation advanced their skills, helped prepare them for life after residency, and for some confirmed their plans to practice in a rural location.

CONCLUSION

With the decline in the number of rural general surgeons and projected continuance of this trend, it is important to understand how trainees view their residency experiences and how those experiences may be shaping their outlook on career choices. Our single-site, qualitative study showed that a rural general surgery rotation during residency has broad importance and value in general surgery resident training. Having a rural rotation also allowed residents to gain understanding of a rural lifestyle, workflow, and the social fabric including the rural surgeons' connections with their communities.

Creating a Rural Plastic Surgery Practice: Social and Financial Impacts

In the United States, 25 million people are without reasonable access to a plastic surgeon. Previous studies have demonstrated that rural populations have limitations to healthcare, and these limitations result in poor quality of life and poor outcomes. New research points to the importance of rural plastic surgery, but still lacks clarity of what the creation and development of a rural plastic surgery practice may entail. Our aim with this study was to discover both the surgical compilation and financial impact of a single rural plastic surgeon’s practice. We reviewed the first 1.5 years of a single surgeon’s plastic surgery practice from its beginnings in a rural community at a critical access hospital with no previous plastic surgery presence. During the study period, the surgeon completed 2062 clinic visits and 305 surgeries. The practice involved approximately 70% hand surgery and the remaining general plastic surgery. The practice generated approximately $8 million in charges and $3.5 million in collections. Collections were broken down by $2.6 million in surgical procedures, $560,000 from clinical practice, and $330,000 from downstream revenue. A rural plastic surgeon’s practice may have noted positive impacts on medical care and financial bottom lines in rural communities.

A Survey of Musculoskeletal Disorders in the Orthopaedic Surgeon: Identifying Injuries, Exacerbating Workplace Factors, and Treatment Patterns in the Orthopaedic Community

Introduction:

As demand for orthopaedic care increases, the orthopaedic community must preserve access to skilled physicians. Workplace hazards and related injuries or conditions contribute to musculoskeletal (MSK) stress on orthopaedic surgeons, which can lead to undesirable medical leaves of absence or early retirement. The purpose of this study was to identify and characterize work-related and non–work-related MSK conditions that affect orthopaedic surgeons and differential injury patterns among male and female surgeons. This study hypothesized that MSK conditions would be exacerbated by work, correlate with age, and show gender-based disparities. Identifying MSK conditions and associated workplace hazards may ultimately help guide preventive or protective efforts.

Methods:

Following IRB and society approvals, a modified 15-question physical discomfort survey was emailed to a randomized selection of American Academy of Orthopaedic Surgeons (AAOS) members and all Ruth Jackson Orthopaedic Society members. Data were deidentified and merged by AAOS; analyses were performed by the authors.

Results:

Most surgeons reported at least one MSK condition (86%; 95% male versus 82% female, P = 0.317), with an average of two conditions per surgeon. Low back pain (56%) and neck pain (42%) were the two most common conditions reported. Male surgeons were more likely to report medial epicondylitis (P = 0.040), lateral epicondylitis (P ≤ 0.001), low back pain (P = 0.001), and lumbar radiculopathy (P = 0.001); however, male respondents were significantly older than female respondents (57 versus 43 years, P ≤ 0.0001), and some conditions were age-correlated. Most respondents reported at least one work-attributed MSK condition (64%; 68% male versus 62% female, P = 0.806). Caseload was not associated with an increased number of work-related MSK conditions; yet, 60% of surgeons reported that work worsened symptoms. Surgical treatment was sought most often for lumbar radiculopathy (6%) and carpal tunnel syndrome (6%). Sixty-nine leaves of absence were reported; most less than 1 month (55%). Exacerbating workplace factors included positioning (patient/surgeon), instruments, and personal protective equipment.

Discussion:

Work-related MSK conditions are common among orthopaedic surgeons. Greater awareness of potential workplace-related hazards and conditions is needed to address and mitigate negative MSK health effects on orthopaedic surgeons.

The association between operating margin and surgical diversity at Critical Access Hospitals

Context

Surgical volume is correlated with increased hospital profitability, yet many Critical Access Hospitals (CAHs) offer few or no inpatient surgical services.

Objectives

This study aims to investigate the impact of the presence of different inpatient surgical services on CAH profitability.

Methods

The study design was a cross-sectional analysis of financial data from the most recent fiscal year (FY) of 1299 CAHs. Multiple linear regression was utilized to assess how the operating margin was affected by the number of different inpatient surgical services offered per hospital. Covariates known to be associated with hospital profitability included occupancy rate, case mix index (CMI), system affiliation, ownership status (public, private, or nonprofit), and geographic region.

Results

The regression model for the CAH operating margin returned an R2 value of 0.18. Each additional inpatient surgical service corresponded to a 1.5% increase in operating margin (p=0.0413). Each 10% increase in occupancy rate and 0.1 increase in CMI corresponded to a 0.9% increase in operating margin (p=0.0032 and p=0.0176, respectively). The number of surgical services offered per CAH showed positive correlations with occupancy rate (r=0.23, p<0.0001) and CMI (r=0.59, p<0.0001).

Conclusions

A positive correlation exists between operating margin and the diversity of inpatient surgical specialties available at CAHs. Furthermore, providing surgery allows CAHs to accommodate higher occupancy rates and case mixes, both of which are significantly and positively correlated with CAH operating margin.

An Examination of General Surgery Residency Programs with a Rural Track

BACKGROUND

There is a steady decline in the general surgery workforce in rural areas of the United States. In response, some surgery residency programs have developed rural tracks to encourage rural practice and adequately prepare trainees for this setting.

OBJECTIVE

To compare the practice type and location of graduates from general surgery residency programs with and without a dedicated rural track between 2011-2020.

METHODS

General surgery residency programs with and without a rural track were identified using the American Medical Association Residency and Fellowship Electronic Interactive Database and the Rural Surgery Program list from the American College of Surgeons. Graduates of these programs who entered general surgery practice between 2011-2020 were subsequently identified from individual residency program websites and tracked to their current practice setting using a Google search of first and last name and residency affiliation. Practice location was identified by zip code or county name and coded by Rural-Urban Continuum Codes (RUCC, Economic Research Service, USDA).

RESULTS

We identified 2,582 general surgery residency graduates from 2011 to 2020 across 66 residency programs. Of these graduates from programs without a rural track, 23.6% entered general surgery practice without additional fellowship training, compared to 34.0% from residency programs with a rural track (p = 0.019). Community or University-based program designation was not associated with decision to enter general surgery practice over fellowship training (p = 0.420). Proportion of graduates entering rural practice as defined by RUCC groups 7-9 was not associated with having a rural program track or with community or university-based program status.

CONCLUSION

Residency programs with a rural track produce a higher proportion of graduates entering general surgery compared to fellowship, though they are no more likely than programs without a rural track to produce graduates who ultimately practice in rural areas.

Workforce Issues in Urology

The future supply of urologists is not on pace to account for future demands of urologic care. This impending urologic shortage sits on a backdrop of multiple other workforce issues. In this review, we take an in-depth look at several pressing issues facing the urologic workforce, including the impending urology shortage, gender and diversity concerns, growing levels of burnout, and the effects of the coronavirus pandemic. In doing so, we highlight specific areas of clinical practice that may need to be addressed from a health care policy standpoint.

Current Trends in Surgical Procedures Performed in Rural General Surgery Practice

BACKGROUND

The procedures that rural general surgeons perform may be changing. It is important to recognize the trends and practices of the current rural general surgeon in efforts to better prepare general surgeons who desire to enter a practice in a rural environment. The aim of this review is to detail the recent operative case volumes of 6 rural locations in the upper Midwest where general surgery is practiced.

METHODS

The Enterprise Data and Analytics department of Sanford Health compiled all surgical procedures performed within the Sanford Health System between January 1, 2013 and August 31, 2018. Procedures performed by a total of 58 general surgeons in locations of under 50 000 people are included in this review.

RESULTS

From January 1, 2013 to August 31, 2018, 38 958 surgical procedures were performed in rural locations. Endoscopic procedures made up 61.6% of a rural general surgeon's practice. Cholecystectomy (6.3%), hernia repair (6.3%), and appendectomy (3.7%) were the principle nonendoscopic procedures performed by rural surgeons, comprising 16.3% of the case volume. Added together, endoscopy, cholecystectomy, hernia repair, and appendectomy made up 77.9% of the rural general surgeon's caseload. Vascular procedures (2.5%), breast procedures (1.8%), obstetrics (0.4%), and urology procedures (0.2%) are also included in this review.

CONCLUSIONS

Rural general surgeons are vital to the surgical workforce in the United States. Recognizing a trend that rural general surgeons perform less subspecialty procedures and more endoscopic procedures will provide direction for those interested in pursuing a career in rural general surgery.

Rural Surgical Training in the United States: Delineating Essential Components Within Existing Programs

BACKGROUND

Rural access to surgical care has reached crisis level. Practicing in rural America offers unique challenges with limited resources and specialists. Most training programs do not provide enough exposure to the endoscopic or the surgical subspecialty skills to prepare a resident for an isolated rural environment. As awareness has increased, many programs have modified curriculum to address this need. The Advisory Council on Rural Surgery (ACRS) of the American College of Surgeons set out to delineate important components of rural training programs and measure to what degree the existing heterogeneous programs contain these components.

STUDY DESIGN

The ACRS identified 4 essential components of rural surgical training based on literature and expert opinion. These components included rotations in a rural setting, broad exposure to surgical specialties, endoscopy experience, and lack of competing specialty learners. A list of Accreditation Council for Graduate Medical Education programs from a prior publication was updated with the 2019 Fellowship and Residency Electronic Interactive Database self-identified "rural track" programs, reviewed, and categorized.

RESULTS

We identified 39 programs that self-identified as having a rural emphasis. Depending on the extent of which 4 essential components were included, programs were categorized as either "Broad" (12 programs), "Basic" (20 programs), or "Indeterminate" (7 programs).

CONCLUSION

The ACRS described the optimal components of a rural surgical training program and identified which components are present in those surgical residencies which self-identified as having a rural focus. This information is valuable to students planning a future in rural surgery and benefits programs hoping to enhance their curriculum to meet this critical need.

Physician workforce planning and allocation model using agent-based modeling: A case study in Thailand

OBJECTIVE

To address the physician workforce challenges in Thailand using Agent-Based Modeling (ABM). Physician planning and allocating have been modeled with the life cycle framework starting from medical school intakes, residency training, and career retirement.

METHOD

This study proposes a systematic approach to physician planning and allocating which are modeled with a framework starting from medical school intakes, residency training, and career retirement.

RESULTS

The ABM can estimate physician levels for provincial government hospitals (OPS-MOPH) and other sectors. The model can demonstrate any geographical imbalance issues at the provincial level under the existing rural recruitment program implementation. Based on the ABM simulation result, although person per physician ratios reached the target of 1800:1 at the national level in 2019, Bangkok is the only province that reached the target. For other provinces, the ratio of OPS-MOPH is far from the target. It will need 10 more years to reach the target, and a geographical imbalance will still exist. A solution of modified rural recruitment program with the limitation of hometown jobs has been proposed to reduce the geographical imbalance. With the proposed modified rural recruitment program, the model predicts that all provinces will reach the target in 2036.

The State of Vascular Surgery Interest Groups in North America

BACKGROUND

Vascular surgery interest groups (VSIGs) raise awareness and attract medical students to the specialty. There has been a plateauing of applicants interested in integrated programs. The goal of this survey was to assess the activities of VSIGs and identify factors associated with matriculation into vascular surgery residency.

METHODS

A survey was administered to members of the association of program directors in vascular surgery. It inquired about the presence of a VSIG at the corresponding medical schools. The program directors at institutions lacking VSIGs were asked about possible hurdles in establishing one. The rest of the survey focused on the different activities of the VSIG. The VSIGs were divided into low enrollment if less than 10% of the students in that group pursue vascular surgery training and high enrollment if greater than 10% of the students pursue vascular surgery. Chi-squared test was used for comparison.

RESULTS

There were 65/123 programs that responded (53% response rate). The responses came most commonly from programs in the Northeast (36.9%). Only 37% (n = 24) had a VSIG at their institutions. Lack of time (65.2%) and lack of a student champion (60.9%) were the most common hurdles encountered by the program directors who considered establishing a VSIG. Comparing the 2 groups of VSIGs, there was no difference in terms of the training paradigm, experience of program director, or geographical location. The VSIGs had comparable duration of activity, number of students, and meeting frequency. There was no difference in clinical exposure outside the curriculum between the 2 groups with observation on the wards and in clinic being most common. Endovascular simulation was significantly (P = 0.01) more common in low enrollment (83.3%) compared with high enrollment (33.3%) VSIG. There was a trend in the high enrollment group for more vascular anastomosis training (75% vs. 66.7%) that did not reach statistical significance (P = 0.65). There was no difference between the 2 groups in career development opportunities and education activities. Most VSIGs (75%) operated with a budget of less than $1,000 based on divisional or departmental funding (low enrollment = 66.7% versus high enrollment = 41.7%, P = 0.22).

CONCLUSIONS

Only one-third of the vascular surgery training programs have an associated VSIG. Vascular surgery training programs should promote VSIG formation with equal emphasis on endovascular and open surgery, thus providing medical students an early exposure to the specialty.

The continued urbanization of American surgery: A threat to rural hospitals

BACKGROUND

In 2011, we predicted that surgeon shortages for rural hospitals would contribute to closures of rural hospitals. Here, we update population trends, the distribution of rural and urban hospitals, and surgeon supply to estimate surgeon demand for rural and urban hospital settings by 2040.

METHODS

Surgeon supply was based on new certifications for general surgery, orthopedic surgery, and obstetrics and gynecology adjusted for retirement. Surgeon demand from 2020 to 2040 was projected based on the US Census and published practice ratios: general surgery 10.7/100,000, orthopedic surgery 7.9/100,000, and obstetrics and gynecology 13.0/100,000.

RESULTS

The US population grew from 309 million in 2011 to 327 million in 2017 with rural populations unchanged at 56 million. By 2040, the US population will be 374 million (urban 85% and rural 15%) creating shortages of general surgery (-31.5%), orthopedic surgery (-34.3%), and obstetrics and gynecology (-25.3). Future hiring needs for urban hospitals will be 5 times greater than rural hospitals. Urban hospitals will likely recruit most newly certified surgeons.

CONCLUSION

Increases in surgery trainees will not meet the demand. The continued urbanization of American surgery may push rural hospitals into a vicious financial cycle leading to additional closures of rural hospitals and worsening issues of access. An alternative training paradigm for the rural surgeon is recommended to meet the unique demands of rural hospitals.

The Surgical and Anesthesia Workforce and Provision of Surgical Services in Rural Communities: A Mixed-Methods Examination

PURPOSE

Rural-urban disparities in the surgical and anesthesia workforce exist. This mixed-methods study describes the distribution of the surgical and anesthesia workforce and qualitatively explores how such workforce and other factors influence rural hospitals' provision of surgical services.

METHODS

We calculated provider counts by county from the Area Health Resource File. Using American Hospital Association survey data, we sampled rural hospitals, stratified by critical access status and state policies. We conducted qualitative semistructured interviews with administrators at 16 hospitals and performed directed content analysis of factors influencing surgical services provision at rural hospitals.

FINDINGS

Within rural counties, 55.1% of counties had no surgeon, 81.2% had no anesthesiologist, and 58.1% had no Certified Registered Nurse Anesthetist (CRNA). Administrators reported that rural hospitals struggled to provide many surgical services given lack of subspecialty surgeons and adequate postsurgical care. Rural hospitals likely struggle to generate volumes necessary to support safe and profitable subspecialty surgery programs. Anesthesia services were not reported as a current limitation given that CRNAs in particular had strong, diverse skills sets and many hospitals allowed high CRNA autonomy. However, meeting anesthesia needs for emergency surgeries and 24-hour obstetrics posed significant challenges.

CONCLUSIONS

While rural hospitals reported meeting community needs for elective and noncomplex surgeries, rural hospitals continued to face significant challenges providing subspecialty surgeries, emergency surgeries, and 24-hour obstetrical services.

Women surgeons and the emergence of acute care surgery programs

BACKGROUND

In parallel to women entering general surgery training, acute care surgery (ACS) has been developing as a team-based approach to emergency general surgery (EGS). We sought to examine predictors of women surgeons in EGS generally, and ACS particularly.

METHODS

From our national survey, we determined the proportion of women surgeons within EGS hospitals. We compared the proportion of women surgeons based on hospitals characteristics using chi-squared tests, then used regression models to measure odds of ACS relative to the proportion of women.

RESULTS

779 (50.4%) hospitals had zero women surgeons. These hospitals were more likely non-ACS and non-teaching with <200 beds. ACS had a higher median proportion of women surgeons (17%) compared to non-ACS (0%).

CONCLUSION

Our study highlights the dearth of women representation within EGS hospitals nationally and illuminates some of the underlying characteristics of ACS that may draw women: urban, academic, and staffed by more recently trained surgeons.

SUMMARY

Using a national survey of Emergency General Surgery (EGS) hospitals, we sought to examine predictors of women surgeons in EGS generally, and acute care surgery (ACS) particularly. We found that 779 (50.4%) hospitals had zero women surgeons. Women were more likely to be among EGS surgeons at hospitals with ACS models. Our study highlights the dearth of women representation within EGS hospitals nationally and illuminates some of the underlying characteristics of ACS that may draw women: urban, academic, and staffed by a higher proportion of newly trained surgeons.

When rural is no longer rural: Demand for subspecialty trained surgeons increases with increasing population of a non-metropolitan area

BACKGROUND

Surgery in larger, non-metropolitan, communities may be distinct from rural practice. Understanding these differences may help guide training. We hypothesize that increasing community size is associated with a desire for subspecialty surgeons.

METHODS

We designed a mixed methods study with the ACS Rural Advisory Council. Rural (<50,000 people), small non-metropolitan (50,000-100,000), and large non-metropolitan (>100,000) communities were compared. Quantitative and qualitative data were analyzed.

RESULTS

We received 237 responses, and desire to hire subspecialty-trained surgeons was associated with practice in a large non-metropolitan community, OR 4.5, (1.2-16.5). Qualitative themes demonstrated that rural surgeons limit practices to align with available hospital resources while large non-metropolitan surgeons specialize according to interest and market pressures.

CONCLUSIONS

Surgery in rural versus large non-metropolitan communities may be more distinct than previously understood. Rural practice requires broad preparation while large non-metropolitan practice favors subspecialty training.

Macroeconomic trends and practice models impacting acute care surgery

Acute care surgery (ACS) diagnoses are responsible for approximately a quarter of the costs of inpatient care in the US government, and individuals will be responsible for a larger share of the costs of this healthcare as the population ages. ACS as a specialty thus has the opportunity to meet a significant healthcare need, and by optimizing care delivery models do so in a way that improves both quality and value. ACS practice models that have maintained or added emergency general surgery (EGS) and even elective surgery have realized more operative case volume and surgeon satisfaction. However, vulnerabilities exist in the ACS model. Payer mix in a practice varies by geography and distribution of EGS, trauma, critical care, and elective surgery. Critical care codes constitute approximately 25% of all billing by acute care surgeons, so even small changes in reimbursement in critical care can have significant impact on professional revenue. Staffing an ACS practice can be challenging depending on reimbursement and due to uneven geographic distribution of available surgeons. Empowered by an understanding of economics, using team-oriented leadership inherent to trauma surgeons, and in partnership with healthcare organizations and regulatory bodies, ACS surgeons are positioned to significantly influence the future of healthcare in the USA.

Training for a Career in Rural and Nonmetropolitan Surgery-A Practical Needs Assessment

OBJECTIVE

The current shortage of surgeons in rural and smaller communities is predicted to get worse. In this study, we solicited practicing rural surgeons' opinions about the skill set needed in a rural practice in order to inform curriculum development for general surgery residents who intend to embark on rural careers.

DESIGN

We developed an online survey consisting of demographic questions and closed- and open-ended questions regarding current practice environment and scope of practice. Priorities for training were identified using descriptive analyses of both the quantitative and qualitative data, including frequency of responses regarding specific skills training.

PARTICIPANTS

We surveyed currently practicing surgeons who subscribe to the American College of Surgeons Rural Surgery listserv.

RESULTS

237 surgeons from 49 states and 1 Canadian territory responded; 60% of participants had been in practice for 20 or more years, and 70% did not pursue subspecialty training. Valuable skills identified for rural surgeons were: endoscopy, advanced laparoscopy, and basic non-general surgery subspecialty procedures. Regardless of years of practice or setting, respondents felt that rural experience during residency was highly valuable (82%) and overwhelmingly supported training future rural surgeons at residency programs with broad general surgery experiences and high case volumes with no or few fellows.

CONCLUSIONS

Practicing rural surgeons identify endoscopy, basic non-general surgery subspecialty procedures, and advanced laparoscopy as key components of their current practice. These skills may not be strongly emphasized in traditional general surgery training programs. Surgical educators should focus on developing curricula that emphasize these areas in order to prepare residents for careers in rural surgery.

How Competitive Is Plastic Surgery? An Analysis of the Canadian and American Residency Match

Background

Plastic surgery (PS) is considered to be one of the most competitive specialties. As a result, some students are discouraged from applying, reducing the overall number of PS candidates. Still, much of what we know of the match is based in conjecture.

Objective

To examine the Canadian PS match data from 1997 to 2016. To our knowledge, this is the first long-term analysis of the Canadian PS residency match.

Method

We examined the Canadian Residency Matching Service reports from 1997 to 2016, extracting key match statistics, including available positions, number of applicants, positions filled, positions unfilled, and gender-specific match results. To examine competitiveness, the ratio of total applicants per quota per year (CR) and the ratio of applicants who chose PS as their first-choice specialty per quota per year were calculated (FC-CR). The National Residency Matching Program data were used to assess the American integrated PS match over the past decade and served as a comparison.

Results

The CR of Canadian PS programs declined over the last 20 years (P < .001), indicating fewer applicants applied to the program per available position. Similarly, the FC-CR also declined over the last 20 years (P < .001). The number of females matching to their first-choice discipline of PS increased from 1997 (P < .001). There was no significant change in the number of males matching to their first-choice discipline of PS (P = .15). There was no significant change in the competitiveness (CR) of the American integrated PS match over the last decade (P = 0.087).

Conclusion

Encouragingly, today PS has more training positions and more female residents; yet, the overall number of applicants has remained relatively static over the past 20 years. This analysis serves as a valuable reference for PS programs and should assist in developing strategies to encourage the best applicants to apply.

Factors Associated With Medical School Graduates' Intention to Work With Underserved Populations: Policy Implications for Advancing Workforce Diversity

PURPOSE

Given projected U.S. physician shortages across all specialties that will likely impact underserved areas disproportionately, the authors sought to explore factors most correlated with medical school graduates' intention to work with underserved populations (IWUP).

METHOD

Data from the 2010-2012 Association of American Medical Colleges Medical School Graduation Questionnaire (n = 40,846) were analyzed. Variables (demographics, career preference, debt burden, intention to enter loan forgiveness programs) were examined using chi-square tests and logistic regression models.

RESULTS

Respondents included 49.5% (20,228/40,846) women, 16.6% (6,771/40,837) underrepresented minorities (URMs), and 32.4% (13,034/37,342) with primary care intent. The median educational debt was $160,000. Respondents who were women (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.49, 1.70), URMs (aOR 2.50, 95% CI 2.30, 2.72), intended to enter loan forgiveness programs (aOR 2.44, 95% CI 2.26, 2.63), intended to practice primary care (aOR 1.65, 95% CI 1.54, 1.76), and intended to emphasize nonclinical careers (aOR 1.23, 95% CI 1.11, 1.37) had greater odds of reporting IWUP. Among those who chose specialties and careers with a nonclinical emphasis, and among those with greater burdens of educational and consumer debt, URMs were nearly twice as likely as other minorities and whites to report IWUP.

CONCLUSIONS

Findings suggest physician characteristics that may be associated with filling workforce gaps in underserved areas. Restructuring financial incentive programs to support physician leaders and specialists with characteristics associated with IWUP may complement similar policies in primary care and could have key impacts on health equity in underserved areas.

Surgical deserts in California: an analysis of access to surgical care

BACKGROUND

Areas of minimal access to surgical care, often called "surgical deserts", are of particular concern when considering the need for urgent surgical and anesthesia care. We hypothesized that California would have an appropriate workforce density but that physicians would be concentrated in urban areas, and surgical deserts would exist in rural counties.

METHODS

We used a benchmark of six general surgeons, six orthopedists, and eight anesthesiologists per 100,000 people per county to define a "desert". The number and location of these providers were obtained from the Medical Board of California for 2015. ArcGIS, version 10.3, was used to geocode the data and were analyzed in Redivis.

RESULTS

There were a total of 3268 general surgeons, 3188 orthopedists, and 5995 anesthesiologists in California in 2015, yielding a state surgeon-to-population ratio of 7.2, 6.7, and 10.2 per 100,000 people, respectively; however, there was wide geographic variability. Of the 58 counties in California, 18 (31%) have a general surgery desert, 27 (47%) have an orthopedic desert, and 22 (38%) have an anesthesiology desert. These counties account for 15%, 25%, and 13% of the state population, respectively. Five, seven, and nine counties, respectively, have none in the corresponding specialty.

CONCLUSIONS

Overall, California has an adequate ratio of surgical and anesthesia providers to population. However, because of their uneven distribution, significant surgical care deserts exist. Limited access to surgical and anesthesia providers may negatively impact patient outcome in these counties.

Students to Surgeons

Introduction. Our nation suffers from a shortage in surgeons. This deficiency must be addressed at the medical student level. Increasing faculty and resident interaction with junior students augments surgical interest. Our surgical interest group has recently redefined its role to address these concerns. Methods. A multifocal approach has been implemented to increase interest in the surgical specialties. Each academic year, senior students recruit first and second year students to our group to establish early exposure. Members receive didactic presentations from surgical faculty, addressing various topics, on a biweekly basis. In addition, scrubbing, knot-tying, and suturing workshops address technical skills throughout the semester. Membership and match data were collated and analyzed. Results. Over the past 5 years, the enrollment in the student interest group increased significantly from 112 to 150. Accordingly, we have observed a parallel increase in the number of students who have successfully matched into surgical residencies. A record number of students (37) from the class of 2013 matched into surgical specialties, representing an 85% increase over the last decade. After creating bylaws and electing societal officers, the group has been recognized by the school’s Student Council and given financial support. At present, the group is fiscally solvent with support from the institution, surgery department, and faculty. Conclusion. As the demand for surgeons increases so too does the need to increase student interest in surgery. Our school has been successful because of our surgical interest group, and we encourage other schools to adopt a similar approach.

Are self-identified "disadvantaged" students less likely to enter surgical residencies? A single-institution study

BACKGROUND

Given more emphasis on training primary care physicians for underserved areas, we hypothesized that students self-identifying as "disadvantaged" would be less likely to pursue surgical training.

METHODS

We retrospectively reviewed medical school data on students graduating 2005-2014. Students were stratified into "disadvantaged" and "nondisadvantaged". Data were recorded on age, grade point average, Medical College Admission Test (MCAT), gender, surgery grade, United States Medical Licensing Examination step 1 score, and residency match into a surgical field. A comparison of the proportion of students matching into a surgical field was assessed with chi-square test. Multivariate logistic regression was performed to assess the factors that predict the choice of general surgery versus another surgical field.

RESULTS

Of the 1140 students who graduated during the study period, 219 (19.2%) students self-identified as "disadvantaged". Of all students, 158 (13.9%) chose a surgical field. The disadvantaged group was older at entry and had lower grade point average and total MCAT scores. Twenty-seven (12.3%) disadvantaged students chose a surgical residency versus 130 (14.1%) nondisadvantaged students (P = 0.56). On multivariate logistic regression, female gender (odds ratio [OR] = 3.9; 95% confidence interval = [1.9-8.3], P < 0.01), disadvantaged status (OR = 2.8 [1.1-7.1], P = 0.03), and United States Medical Licensing Examination step 1 score ≥ 227 (OR = 0.43 [0.21-0.88], P = 0.02) were significantly associated with matching into general surgery versus another surgical specialty.

DISCUSSION

Although the disadvantaged cohort was older and had lower undergraduate GPAs and MCAT scores, the proportion of disadvantaged students matching into a surgical residency was not statistically different. To address the future shortage of general surgeons in underserved areas, increasing enrollment of "disadvantaged" students may alleviate the "surgical desert".

Meeting Increasing Demands for Rural General Surgeons

Dynamic assessment of the effective surgical workforce recommends 27,300 general surgeons in 2030; 2,525 more than are presently being trained. Rural shortages are already critical and there has been insufficient preparation for this need. A literature review of the factors influencing the choice of rural practice was performed. A systematic search was conducted of PubMed and the Web of Science to identify applicable studies in rural practice, surgical training, and rural general surgery. These articles were reviewed to identify the pertinent reports. The articles chosen for review are directed to four main objectives: 1) description of the challenges of rural practice, 2) factors associated with the choice of rural practice, 3) interventions to increase interest and preparation for rural practice, and 4) present successful rural surgical practice models. There is limited research on the factors influencing surgeons in the selection of rural surgery. The family practice literature suggests that physicians are primed for rural living through early experience, with reinforcement during medical school and residency, and retained through community involvement, and personal and professional satisfaction. However, more research into the factors drawing surgeons specifically to rural surgery, and keeping them in the community, is needed.

Longitudinal rural clerkships: increased likelihood of more remote rural medical practice following graduation

BACKGROUND

Extended rural clerkships clearly increase the likelihood of rural practice post-graduation. What has not been determined is whether such rural interventions increase the likelihood of graduates practicing in more remote, versus inner regional, locations.

METHODS

The Australian Health Practitioner Regulation Agency database was used to identify the current workplace of every graduate of the Medical School of Western Australia, 1980 to 2011. There were 324 graduates working in a primary practice location defined by the Australian Standard Geographical Classification as inner regional to very remote. They were divided into 3 groups - 200 graduates who entered medical school before commencement of the Rural Clinical School of Western Australia (RCSWA), 63 who entered after the RCSWA had started, but not participated in RCSWA, and 61 who participated in the RCSWA. The RCSWA offers a longitudinal rural clinical clerkship throughout level 5 of the MBBS course.

RESULTS

The two groups not participating in the RCSWA had 45.5% and 52.4% of subjects in outer regional/very remote locations, respectively. In comparison, 78.7% of those who had participated in the RCSWA were currently practicing in outer regional/very remote locations. When the 3 groups were compared, the significant predictors of working in a more remote practice compared to working in an inner regional area were being female (OR 1.75 95% CI 1.13, 2.72, P = 0.013) and participating in the RCSWA (OR 4.42, 95% CI 2.26, 8.67, P < 0.001). In multivariate logistic regression that corrected for gender and remoteness of rural address before entry to medical school, participation in the RCSWA still predicted a more than 4-fold increase in the odds of practicing in a more remote area (OR 4.11, 95% CI 2.04, 8.30, P < 0.001).

CONCLUSION

Extended rural clinical clerkship during an undergraduate MBBS course is related to a much greater likelihood of practicing in more remote, under-serviced rural locations.

Does surgery residency prepare residents to work at critical access hospitals?

BACKGROUND

Operations performed by surgeons working at Critical Access Hospitals (CAHs) and surgery residents have not been compared.

METHODS

Procedure codes logged by general surgery residents graduating from our institution in 2013 and 2014 were obtained. Procedure codes were obtained for all CAHs in our state for 2012 to 2013. Clinically relevant categories were compared among residents and general surgeons at CAHs.

RESULTS

A total of 34,246 procedures logged by general surgeons at CAHs were compared with 31,977 procedures logged by surgery residents. Endoscopy comprised 56.1% of cases done by general surgeons versus 9.1% of cases by residents (P < .001). Excluding endoscopy, rural surgeons had higher percentages in hernia, skin/soft tissue, cholecystectomy/common bile duct, rectal/anal, and breast cases. Residents who completed a rural surgery rotation had higher numbers in small/large bowel, hernia, breast, and endoscopy.

CONCLUSIONS

Surgery residency provides less exposure to endoscopy compared with a general surgery practice at CAHs. A rural rotation increases endoscopic exposure.

Workforce shortage for general surgeons: results from the Society for Surgery of the Alimentary Track (SSAT) surgeon shortage survey

BACKGROUND

Population shifts among surgeons and the general populous will contribute to a predicted general surgeon shortage by 2020. The Public Policy and Advocacy Committee of the Society for Surgery of the Alimentary Tract designed and conducted a survey to assess perceptions and possible solutions from important stakeholders: practicing surgeons of the society, general surgery residents, and medical students.

RESULTS

Responses from 1,208 participants: 658 practicing surgeons, 183 general surgery residents, and 367 medical students, were analyzed. There was a strong perception of a current and future surgeon shortage. The majority of surgeons (59.3 %) and residents (64.5 %) perceived a current general surgeon shortage, while 28.6 % of medical students responded the same. When asked of a perceived general surgery shortage in 20 years, 82.4, 81.4, and 51 % said "yes", respectively. There were generational differences in responses to contributors and solutions for the impending shortage. Surgeons placed a high value on improving reimbursement, tort reform, and surgeon burnout, while residents held a strong interest in a national loan forgiveness program and improving lifestyle barriers.

CONCLUSION

Our survey offers insight into possible solutions to ward off a surgeon shortage that should be addressed with programmatic changes in residency training and by reform of the national health care system.

Effect of insurance expansion on utilization of inpatient surgery

IMPORTANCE

Enhanced access to preventive and primary care services is a primary focus of the Affordable Care Act, but the potential effect of this law on surgical care is not well defined.

OBJECTIVE

To estimate the differential effect of insurance expansion on utilization of discretionary vs nondiscretionary inpatient surgery with Massachusetts health care reform as a natural experimental condition.

DESIGN, SETTING, AND PARTICIPANTS

We used the state inpatient databases from Massachusetts and 2 control states (New Jersey and New York) to identify nonelderly adult patients (aged 19-64 years) who underwent discretionary vs nondiscretionary surgical procedures from January 1, 2003, through December 31, 2010. We defined discretionary surgery as elective, preference-sensitive procedures (eg, joint replacement and back surgery) and nondiscretionary surgery as imperative and potentially life-saving procedures (eg, cancer surgery and hip fracture repair).

EXPOSURE

All surgical procedures in the study and control populations.

MAIN OUTCOMES AND MEASURES

Using July 1, 2007, as the transition point between the prereform and postreform periods, we performed a difference-in-differences analysis to estimate the effect of insurance expansion on rates of discretionary and nondiscretionary surgical procedures in the entire study population and for subgroups defined by race, income, and insurance status. We then extrapolated our results from Massachusetts to the entire US population.

RESULTS

We identified a total of 836 311 surgical procedures during the study period. Insurance expansion was associated with a 9.3% increase in the use of discretionary surgery in Massachusetts (P = .02). Conversely, the rate of nondiscretionary surgery decreased by 4.5% (P = .009). We found similar effects for discretionary surgery in all subgroups, with the greatest increase observed for nonwhite participants (19.9% [P < .001]). Based on the findings in Massachusetts, we estimated that full implementation of national insurance expansion would yield an additional 465 934 discretionary surgical procedures by 2017.

CONCLUSIONS AND RELEVANCE

Insurance expansion in Massachusetts was associated with increased rates of discretionary surgery and a concurrent decrease in rates of nondiscretionary surgery. If similar changes are seen nationally under the Affordable Care Act, the value of insurance expansion for surgical care may depend on the relative balance between increased expenditures and potential health benefits of greater access to elective inpatient procedures.

Acute care surgery: now that we have built it, will they come?

BACKGROUND

Concern over lack of resident interest caused by the nonoperative nature and compromised lifestyle associated with a career as a "trauma surgeon" has led to the emergence of a new acute care surgery (ACS) specialty. This study examined the opinions of current general surgical residents about training and careers in this new field.

METHODS

A 36-item online anonymous survey regarding ACS was sent to the program directors of 55 randomly selected general surgery (GS) training programs for distribution to their categorical residents. The national sample consisted of 1,515 PGY 1 to 5 trainees.

RESULTS

Response rate was 45%. More than 90% of residents had an appropriate understanding of the components of ACS as generally described (trauma, surgical critical care, and emergency GS). Nearly half (46%) of all respondents have considered ACS as a career. Overall, ACS ranked as the second most appealing career ahead of surgical critical care and trauma but behind GS. Most residents believed that ACS offers better or equivalent case complexity (88%), scope of practice (84%), case volume (75%), and level of reimbursement (69%) compared with GS alone. Respondents who answered ACS had a better scope of practice (61% vs. 36%), lifestyle as an attending surgeon (77% vs. 34%), or level of reimbursement (83% vs. 38%) compared with GS were twice as likely (p < 0.0001) to have considered ACS as a career. Overall, 40% of the residents believed that ACS offers a worse lifestyle in comparison with GS.

CONCLUSION

These results suggest that there is notable interest in the emerging specialty of ACS. The level of resident interest in ACS as a fellowship and career may be increased by marketing those aspects of practice, which are viewed positively and addressing negative perceptions related to lifestyle. It may be appealing to add an elective GS component to certain ACS practice options.