I spent a month with a surgeon in a town of 10,000 people in central Texas as part of a 'rural' surgery rotation. He had been an attending at a university hospital, having done a colorectal fellowship and contributed to a paper describing laparoscopic colectomies for colon cancer published in NEJM. He grew sick of being the low man in the academic totem pole, taking trauma call, and being away from his family. So he quit academics and headed west.
He's now in a semi-rural area, unsalaried, and in a lawyer-unfriendly town. He's much happier now. Has several kids who he can occassionally drop off at school or see at lunch. Lives on top of 'doctor's hill' where several other physicians live and has a great view of the surrounding community. Trauma gets sent to San Antonio, about 60-90 minutes away. He continues to perform lap colectomies, but hernias, gallbladders, and breat biopsies typify his practice. Another big aspect of his practice are colonoscopies due to the elderly populace. In many areas gastroenterologists dominate this procedure, but he sought out a place where surgeons usually did it (very profitable, simple, helpful procedure). Twice a month, he also goes to a smaller town (5,000) about an hour away to have clinic. That town's hospital doesn't even have an OR (got flooded out a year ago), but he can do scopes there.
Two other surgeons also practice there, one is a vascular surgeon. For the larger cases like an APR, a family practice physician (former urologist) assists him. For a large ovarian mass removal, he assists the OB/ Gyn. He's got a nurse (soon to be NP) helping him the majority of the time. About 1.5 days a week are dedicated to the OR, another day to colonoscopies. Call is Q3, but once again trauma goes elsewhere and not every case of appendicitis coming in at 2 AM needs an operation immediately.
You'd think being only an hour or so from a large health center would cause a local specialty train surgeon to suffer. But while you won't be doing as many large procedures as those in academics, you can get enough to stay compentant. The patient's viewpoint is largely limited to the preop and the postop. My father lives an hour away from MD Anderson, but when he had prostate cancer they treated him so bad during his clinic visit he had the local urologist perform his prostatectomy. Still cancer free, no complications.
So I don't think you'll have any problems getting cases in a rural area, espeically since that's where they lack surgeons. As far as fellowships, trauma may be the least useful. Level I trauma requires a lot of resources like neurosurgery, so a lot of cases go to the big city. The compensation for trauma is awful as well, and some of the patients can really run up the costs. Hence, unsalaried physicians plus small rural hospital really can't afford major trauma. Plus, if you're constantly taking trauma call, your patients and practice during the day will suffer as well.
Another thing to look at are the same-day surgery centers erupting across the country. These seem especially beneficial to the rural surgeon who does so much day surgery; get paid more for the same operation. Legislation may limit their creation/operation, however, as they seem to cause the local hospital to suffer (surgery brings in the money, not pneumonia).
Here's a link to the Oregon rural surgery page, the two articles are well done:
http://www.ohsu.edu/surgery/UGS/RESIDENCY/RuralSurgeryIndex.htm
Oh, and rotations overseas are also an option to look into. Stanford and Carolinas Medical Center, for example, will let you do a month in Central America. You'll really be doing everything there.
