Job as General surgeon in critical access hospital

[drsender]

I am entering my fifth year of general surgery residency and have started looking for jobs for next year. I have always planned to end up in either a rural area or smaller city. A lot of the more heavily advertised jobs in these areas are for small critical access hospitals in rural areas. They typically have more frequent call and relatively high compensation.
Having never rotated at a place like that (our “rural” rotation is not all that rural), I would really like to hear what it is like to work in that type of position. Is call really as slow as advertised? Do you end up having any time off for family & recreation? I would love to hear from someone with experience. Thanks!

---

Members don't see this ad.

 

[Lem0nz]

Can only speak from locums work but I would make sure you know the answers to a couple things:

1) Are you willing and able to do hysterectomies and c-sections, and if not, who is going to? Will you have a senior partner who can teach you? (They are not hard and if you're willing to learn, no big deal). This can be a requirement in many places.
2) If its just you how are they going to handle vacation and time off?
3) How comfortable are you with vascular and the like (amputations, fistulas perhaps, smaller things) and what are your hard nos?
4) ...what are your hard nos?
5) You ready to do a lot of upper and lower endoscopies? 😀

I think question 4 probably the most important to be able to answer and be up front about. Most places will work with whatever you say no to. The pace of life in my experience has been very slow, yes. Usually 3-4 minor cases, major cases tend to be transferred/referred out. You are on call 24/7 but the threshold to transfer is so incredibly low that it usually isn't that bad, and realistically you just don't have that many people to take care of. If you're super into the community you're living in they will MAKE time for you and your family. The few times I had to actually operate when I was doing locums they're like "soooo when do you want to do this. The call team will wrap around you so like if you want to get breakfast with the girls and then come in, or do it first thing, or wait until mid afternoon, you just let us know boss."

 

[ACSurgeon]

What’s your motivation here?

going back to your hometown where you want to be part of the community and happy to stay in town most weeks of the year? You can probably find a way to make this work.

money? You can make plenty of money as a surgeon in a normal to large size city. Be careful not to start at a critical access hospital and let your skills decline as you become increasingly antsy to leave town every day off you have.

breadth of skills? Probably look for a mid to large size rural hospital with good support and ability to do real cases. Fine, maybe you have to do the breadth of general and open vascular surgery but you’ll have resources.

finally, I wonder if surgeons at critical access hospitals get pigeoned holed in that line of work and become suspicious for ones who “couldn’t do better”.

 

[drsender]

Thanks for the replies!

I do not have any experience with C-sections beyond assisting but would be willing to learn. I would like to practice a reasonable scope of general surgery. I don't have any desire to take on big cases or reach beyond my skill set, especially in a resource limited area. I would be comfortable with AV fistulas but not any more complicated vascular procedures. I've done a lot of endoscopy in residency and would be happy to do more in practice.

Regarding motivation, l am from a small town but do not plan to return there. I love the outdoors and have always wanted to live in the country. I am just not a city person and I think working in a small hospital would suit my personality. I don't aim to be ultra productive or take on super complicated cases. I want to live somewhere where I can provide a good service to the community, operate a fair amount and be proficient at what I do. Compensation is less important to me than free time. My main concern with a small critical access hospital is work life balance. Will I have time off to spend with my kids and for recreation? I guess what I'm trying to figure out is how the lifestyle will compare to a more traditional general surgery practice.

Thanks again for your input!

 

[Lem0nz]

Thanks for the replies!

I do not have any experience with C-sections beyond assisting but would be willing to learn. I would like to practice a reasonable scope of general surgery. I don't have any desire to take on big cases or reach beyond my skill set, especially in a resource limited area. I would be comfortable with AV fistulas but not any more complicated vascular procedures. I've done a lot of endoscopy in residency and would be happy to do more in practice.

Regarding motivation, l am from a small town but do not plan to return there. I love the outdoors and have always wanted to live in the country. I am just not a city person and I think working in a small hospital would suit my personality. I don't aim to be ultra productive or take on super complicated cases. I want to live somewhere where I can provide a good service to the community, operate a fair amount and be proficient at what I do. Compensation is less important to me than free time. My main concern with a small critical access hospital is work life balance. Will I have time off to spend with my kids and for recreation? I guess what I'm trying to figure out is how the lifestyle will compare to a more traditional general surgery practice.

Thanks again for your input!

I rotated at a ‘rural’ (not that rural but 30 minute drive from the edge of the suburbs, 60-90 from center city) hospital, probably served about 50,000 people and they supported four general surgeons at a single hospital for the community that worked with the lifestyle and scope that you have described. I would say that’s probably what you want. It is close enough that you can transfer OB and Gyn, but still live in the country (another fifteen minutes from that is farmland and forest). If you went more rural, I would probably try to find somewhere with a population around 50,000 and a partner.

Others can offer different insight, I may off as I was just rotating there for a couple months but that also generally lines up with my rural locums experience too with the difference being that if you’re >2 hours transfer distance than those OB and Gyn skill sets (again, just simple hyster and crash c section) can be extremely marketable and worthwhile.

A 5-15k population town with a small to medium hospital would still be critical access and realistically probably serves at least 20-30k when you count its radius and should more or less give you that pace of life. My n of 1 experience is that one general surgeon per 10k depending on the transfer network seems about right in real life.

 

[TypeADissection]

3) How comfortable are you with vascular and the like (amputations, fistulas perhaps, smaller things) and what are your hard nos?
4) ...what are your hard nos?

Gonna be real honest, at first glance I read that as "...what are your hard ons?" And then I thought you doubled down and asked what his hard ons were again. I was thinking, kind of personal but I kind of like where this is going... And then was disappointed in my illiteracy.

Anyway, in my residency we did a 2-3 rotations per year at a critical access hospital for our "rural surgery" rotation. We worked with 3 general surgeons and the majority of our rotation by volume was: Endoscopy >>> Hernias > Breast > Gallbags > Appys >>> Colons (mostly right, the left colons got referred to a bigger city 20 miles up the road where a CRS did all of that). We also did a lot of PEGs in the GI suite.

Each guy had a half day a week that they all used for golfing. They were honest about their salaries and made a shade under $400K. But each guy was out of the office by 1630 most days. We took call for them while we were there and it was the easiest call compared to what we were doing at the mothership. No traumas. Very little floor calls. Each guy had a reason for being there and most of it was because family was nearby and they wanted a good lifestyle yet still operate. It was a really fun rotation and I think a lot of my colleagues got turned onto the idea of rural surgery because of it. Our surgeons at the mothership made more but not that much more to justify the kind of nonsense that we were doing routinely. Cheers.

 

[Lem0nz]

Gonna be real honest, at first glance I read that as "...what are your hard ons?" And then I thought you doubled down and asked what his hard ons were again. I was thinking, kind of personal but I kind of like where this is going... And then was disappointed in my illiteracy.

Anyway, in my residency we did a 2-3 rotations per year at a critical access hospital for our "rural surgery" rotation. We worked with 3 general surgeons and the majority of our rotation by volume was: Endoscopy >>> Hernias > Breast > Gallbags > Appys >>> Colons (mostly right, the left colons got referred to a bigger city 20 miles up the road where a CRS did all of that). We also did a lot of PEGs in the GI suite.

Each guy had a half day a week that they all used for golfing. They were honest about their salaries and made a shade under $400K. But each guy was out of the office by 1630 most days. We took call for them while we were there and it was the easiest call compared to what we were doing at the mothership. No traumas. Very little floor calls. Each guy had a reason for being there and most of it was because family was nearby and they wanted a good lifestyle yet still operate. It was a really fun rotation and I think a lot of my colleagues got turned onto the idea of rural surgery because of it. Our surgeons at the mothership made more but not that much more to justify the kind of nonsense that we were doing routinely. Cheers.

TAD.

1) AAAs? Carotids? Thoracic Outlet Syndrome? What are your hard ons?
2) ...what are your hard ons TAD?
3) ...TAD... bruh... your hard ons... *wink*

 

[TypeADissection]

TAD.

1) AAAs? Carotids? Thoracic Outlet Syndrome? What are your hard ons?
2) ...what are your hard ons TAD?
3) ...TAD... bruh... your hard ons... *wink*

 

[drsender]

TypeAdissection: Thanks for your experience! That's really good to hear. I was, however, very disappointed to learn that critical access hospitals are not, in fact, super interested in knowing my hard-ons.

 

[wholeheartedly]

Our rural critical access facility has two general surgeons that visit for a week or two at a time, M-F. so no call and no emergent surgeries (though they’ve both made themselves available to the ED for consults when in town). They do endoscopy, choly, appy, hernia’s, lump and bump type stuff etc. They are higher volume/broader scope at their primary shops. Works well for our facility.

(We also have full time Ortho, 1 week urology, variable gyn as needed. They are trying to get OB going. glad i won’t be around for that goat rodeo)

 

[Surgeon D.O.]

Gonna be real honest, at first glance I read that as "...what are your hard ons?" And then I thought you doubled down and asked what his hard ons were again. I was thinking, kind of personal but I kind of like where this is going... And then was disappointed in my illiteracy.

Anyway, in my residency we did a 2-3 rotations per year at a critical access hospital for our "rural surgery" rotation. We worked with 3 general surgeons and the majority of our rotation by volume was: Endoscopy >>> Hernias > Breast > Gallbags > Appys >>> Colons (mostly right, the left colons got referred to a bigger city 20 miles up the road where a CRS did all of that). We also did a lot of PEGs in the GI suite.

Each guy had a half day a week that they all used for golfing. They were honest about their salaries and made a shade under $400K. But each guy was out of the office by 1630 most days. We took call for them while we were there and it was the easiest call compared to what we were doing at the mothership. No traumas. Very little floor calls. Each guy had a reason for being there and most of it was because family was nearby and they wanted a good lifestyle yet still operate. It was a really fun rotation and I think a lot of my colleagues got turned onto the idea of rural surgery because of it. Our surgeons at the mothership made more but not that much more to justify the kind of nonsense that we were doing routinely. Cheers.

Are there any vascular trained guys/gals in these rural places? I knew of one who was CT trained and handled the (minor) thoracic and vascular.

Just curious if you have 1.) the general surgeons doing the vascular and possibly even minor thoracic stuff 2.) hiring someone else to do it or 3.) ship them off.

Slight interest in rural so just just curious what's out there.

 

[TypeADissection]

Are there any vascular trained guys/gals in these rural places? I knew of one who was CT trained and handled the (minor) thoracic and vascular.

Just curious if you have 1.) the general surgeons doing the vascular and possibly even minor thoracic stuff 2.) hiring someone else to do it or 3.) ship them off.

Slight interest in rural so just just curious what's out there.

The problem with a modern day vascular practice is that it requires modern day infrastructure. You need a functioning vascular lab and a hybrid room to do your cases and then have appropriate follow-up. Most rural hospitals don't have the ground-up infrastructure to even recruit for a vascular surgeon that is trained to do the full gamut within our specialty. So that means you're going to have general surgeons creating fistulas, doing bypasses, and sometimes carotids if they're comfortable. The problem is that the postop surveillance is usually poor and a lot of things that could be done endo or hybrid end up with big incisions and big complications when it fails.

Just recently I recanalized native SFA and Pop on a patient with a non-healing foot wound who had a failed AK Pop (10 years ago) and BK Pop (5 years ago) bypass done by a general surgeon initially for claudication. Neither bypass stayed open more than a year. I can't remember the last time I ever had to do an AK Pop bypass for claudication, since that can be done endo nowadays. So back to your question, yes and no. I have vascular buddies that have taken jobs in rural Kentucky, Alabama, etc. But the common denominator is that all of them did have a hybrid room and working vascular lab.

One of my buddies in residency is down south and there is no vascular surgeon within 50 miles of his hospital and he recently did an open SMA embolectomy out of pure necessity. During our rural surgery rotation, there were 2 vascular surgeons at the mothership of that health system 20 miles up the road and all the referrals would go to them. None of the general surgeons we worked with had any remote interest in doing anything vascular related. Hope this helps. Cheers.

 

[LucidSplash]

The problem with a modern day vascular practice is that it requires modern day infrastructure. You need a functioning vascular lab and a hybrid room to do your cases and then have appropriate follow-up. Most rural hospitals don't have the ground-up infrastructure to even recruit for a vascular surgeon that is trained to do the full gamut within our specialty. So that means you're going to have general surgeons creating fistulas, doing bypasses, and sometimes carotids if they're comfortable. The problem is that the postop surveillance is usually poor and a lot of things that could be done endo or hybrid end up with big incisions and big complications when it fails.

Just recently I recanalized native SFA and Pop on a patient with a non-healing foot wound who had a failed AK Pop (10 years ago) and BK Pop (5 years ago) bypass done by a general surgeon initially for claudication. Neither bypass stayed open more than a year. I can't remember the last time I ever had to do an AK Pop bypass for claudication, since that can be done endo nowadays. So back to your question, yes and no. I have vascular buddies that have taken jobs in rural Kentucky, Alabama, etc. But the common denominator is that all of them did have a hybrid room and working vascular lab.

One of my buddies in residency is down south and there is no vascular surgeon within 50 miles of his hospital and he recently did an open SMA embolectomy out of pure necessity. During our rural surgery rotation, there were 2 vascular surgeons at the mothership of that health system 20 miles up the road and all the referrals would go to them. None of the general surgeons we worked with had any remote interest in doing anything vascular related. Hope this helps. Cheers.

Will say you can do a number of basic endovascular procedures with a Carm or in the cath lab. It is a giant PITA but I know several people who will do some, including myself when my partner is using our hybrid room. No issues doing fistulagrams like this on a portable fluoro bed/table (I use what my OR calls the “pain table” though I strongly suspect that is not the intended spelling). I also do bypasses on this table and do completion angio with Carm because doing bypass in my 12-year-old hybrid room is miserable on my back. I know plenty of people who do basic EVAR using carm like at some VA where there is no hybrid room.
Can do peripheral Endo down in the cath lab but I prefer not to at my hospital because they don’t keep much of what I need down there and have to bring from OR ahead of time in a guessing game, and also not designed to get down to foot so I end up doing some ridiculous angles and bending the knee to see it if I can. And I know of cardiologists who do EVARs in cath lab but don’t get me started on how inappropriate I think that situation is.

But anyway, it is all a PITA without a hybrid room. But you could do more than people realize without a hybrid room. But I would never go to work at a hospital like that without a promise of building a hybrid room within a few years or significant access to the cath lab with suitable machines. And you run the risk, if in the cath lab, of having to stop and transport patient emergently to OR if need to go open. So there is no vascular surgeon who will tell you that is their preferred method out in a rural place.

 

[Lem0nz]

My residency had two vascular surgeons who alternated traveling to the remote hospital an hourish away with the rural general surgeons and would do the minor to moderate procedures described above. There was an IR suite and they were allowed to use/share it like two days out of the month which was enough. Anything bigger they brought back to the main hospital.

Like TAD said - very few general surgeons want to do vascular. Honestly, if you don't like vascular, you usually kind of hate vascular. I say seriously and without reservation that vascular surgeons are the most talented, amazing, important doctors in the entire hospital system. Because since they exist, I don't ever have to do vascular. God bless them.

 

[TypeADissection]

Will say you can do a number of basic endovascular procedures with a Carm or in the cath lab. It is a giant PITA but I know several people who will do some, including myself when my partner is using our hybrid room. No issues doing fistulagrams like this on a portable fluoro bed/table (I use what my OR calls the “pain table” though I strongly suspect that is not the intended spelling). I also do bypasses on this table and do completion angio with Carm because doing bypass in my 12-year-old hybrid room is miserable on my back. I know plenty of people who do basic EVAR using carm like at some VA where there is no hybrid room.
Can do peripheral Endo down in the cath lab but I prefer not to at my hospital because they don’t keep much of what I need down there and have to bring from OR ahead of time in a guessing game, and also not designed to get down to foot so I end up doing some ridiculous angles and bending the knee to see it if I can. And I know of cardiologists who do EVARs in cath lab but don’t get me started on how inappropriate I think that situation is.

But anyway, it is all a PITA without a hybrid room. But you could do more than people realize without a hybrid room. But I would never go to work at a hospital like that without a promise of building a hybrid room within a few years or significant access to the cath lab with suitable machines. And you run the risk, if in the cath lab, of having to stop and transport patient emergently to OR if need to go open. So there is no vascular surgeon who will tell you that is their preferred method out in a rural place.

Great point. We are currently under construction for a second full-time hybrid room. Currently splitting time w/ IR for the main hybrid, but we usually win the time allocation because they can just as easily take cases to the EP/Cath lab for their procedures, whereas our hybrid cases require more setup from the open and IR teams. I have done quite a bit of work w/ the c-arm especially for bypass completion shots or traumas. It definitely can be done, but it is a huge PITA. Mostly because not everything is near the OR and thus if they need stuff, they're always scurrying out to grab something else. But I definitely would not have signed on if there wasn't a hybrid room already up and running. Especially bc I'm doing so many hybrid cases now.

 

[TypeADissection]

...very few general surgeons want to do vascular. Honestly, if you don't like vascular, you usually kind of hate vascular. I say seriously and without reservation that vascular surgeons are the most talented, amazing, important doctors in the entire hospital system. Because since they exist, I don't ever have to do vascular. God bless them.

This is also spot on. Most of my colleagues in residency who are now in practice hate vascular surgery with a passion. Think about how much Michael Scott hates Toby. Multiply that by 100 and that is most of my colleagues from residency.

Amongst your various adjectives describing vascular surgeons, you forgot "incredibly good-looking," "winsome," and "extraordinarily humble."

 

[Lem0nz]

This is also spot on. Most of my colleagues in residency who are now in practice hate vascular surgery with a passion. Think about how much Michael Scott hates Toby. Multiply that by 100 and that is most of my colleagues from residency.

Amongst your various adjectives describing vascular surgeons, you forgot "incredibly good-looking," "winsome," and "extraordinarily humble."

Gonna be honest I've met some hot vascular chicks, no doubt at all, but the guys tend to be video game nerds who are like "the hybrid room is like xbox!". Or they're dinosaurs. There seem to be very little in betweens there... and a vascular surgeon with a y chromosome on average is not a looker. XD

 

[LucidSplash]

Gonna be honest I've met some hot vascular chicks, no doubt at all, but the guys tend to be video game nerds who are like "the hybrid room is like xbox!". Or they're dinosaurs. There seem to be very little in betweens there... and a vascular surgeon with a y chromosome on average is not a looker. XD

As I am a woman, I’m just gonna take the compliment and run with it. 😂

 

[BigRedBeta]

I am entering my fifth year of general surgery residency and have started looking for jobs for next year. I have always planned to end up in either a rural area or smaller city. A lot of the more heavily advertised jobs in these areas are for small critical access hospitals in rural areas. They typically have more frequent call and relatively high compensation.
Having never rotated at a place like that (our “rural” rotation is not all that rural), I would really like to hear what it is like to work in that type of position. Is call really as slow as advertised? Do you end up having any time off for family & recreation? I would love to hear from someone with experience. Thanks!

Not a surgeon, and only did a few weeks with a general surgeon while in between MS1 and MS2, but it was super rural and a unique experience in my education and training.

From what I gathered, what @TypeADissection says is very true.

Surgeon was in a town of about 7500 at the bigger hospital in the region. Had 2 half days/wk at the next town down in size (2500) that was about 30
minutes away. Spent other 2 other 1/2 days on a rotating schedule during the month at a few other hospitals up to about an hour away. We'd round on patients at the "big" hospital in the morning, then drive to another hospital, do a couple cases/clinic visits, stop for lunch, drive back and have clinic or an ED consult and be done around 1645. Or on days where just at the big hospital, cases in the morning, a few clinic appointments and be done by 1430. They had a PA who did almost all the post-op visits and would just come grab him from the OR if there was something she needed.

LOTS of endoscopy. Lots of breast. Lot of choles/appys. But also saw a few thyroidectomies, colons, nissens, and a student after me said she saw a Whipple (not sure if I believe her now 15 years after the fact).

The lifestyle for someone used to small town living looked great. The community was always insanely appreciative in a way I don't think could happen in bigger places. His vacation time was handled by the network of surgeons at the referral centers a little over an hour away in a couple different directions (towns of 50-300k). It's definitely different but sounds like you are familiar with what it's like more than some others might.