Rural General Surgeon - Any thoughts?

[Dr JPH]

I am getting ready to begin my surgical internship in just a few months.

More and more I am drawn to general surgery.

I am also considering a rural or semi-rural area to practice...possibly some place that will also offer partial loan repayment options.

I realize my salary will be compromised because of this, but I think the benefits will outweight the negatives for me.

Beyond GS training, what else would be beneficial? I have considered Colorectal, Trauma and Vascular. Of the three, Trauma is the most appealing to me.

Does anyone here currently practice general surgery in a smaller, rural environment? A few of the hospitals I have looked at are 100-200 bed facilities, but dont seem to be lacking in technology.

Is it hard to get cases at these hospitals?

Are there salaried positions at places like this?

Anyone know where I can look to get more information on this topic?

Anyone have any thoughts?

Thanks.

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[Pilot Doc]

I am getting ready to begin my surgical internship in just a few months.

More and more I am drawn to general surgery.

I am also considering a rural or semi-rural area to practice...possibly some place that will also offer partial loan repayment options.

I realize my salary will be compromised because of this, but I think the benefits will outweight the negatives for me.

Beyond GS training, what else would be beneficial? I have considered Colorectal, Trauma and Vascular. Of the three, Trauma is the most appealing to me.

Does anyone here currently practice general surgery in a smaller, rural environment? A few of the hospitals I have looked at are 100-200 bed facilities, but dont seem to be lacking in technology.

Is it hard to get cases at these hospitals?

Are there salaried positions at places like this?

Anyone know where I can look to get more information on this topic?

Anyone have any thoughts?

Thanks.

There are a few rural surgery fellowships. They provide a wide exposure to basic ob/gyn, ortho, ENT and urology procedures. Oregon and Cooperstown, NY have them - perhaps others.

If you practice somewhere the managed care penetration is low, your salary may be good, especially compared to the local cost of living. (e.g. 6000 sq ft brick house on 10 acres for $250K.)

A trauma/critical care fellowship is probably not a good fit for a rural surgeon. You will be plenty well trained as a general surgeon to handle all the trauma you can manage. Even if you're a trauma hotshot, the institutional requirements and subspecialty expertise in other disciplines to handle serious trauma won't exist in your rural hospital.

I don't think vascular or colorectal would be a good fit either. Again, for the cases you'll be doing, you should be adequately trained as a general surgeon. Vascular is increasingly diverging from general surgery with specialized endovascular techniques. The things that a colorectal surgeon can do that a GS can't - lap J-pouches, etc - aren't going to be high volume in rural surgery.

Bascially, the things you need to learn are more non-GS surgical procedures.

In terms of job market/caseload, there are TONS of jobs out there and plenty of patients if you want to work in a small town.

The Bulletin of the Am Col Surgeons has articles of rural surgery on a fairly regular basis. I think there's also a rural surgeons section of the ACS.

And finally - I'd be careful about advertising your interest in rural surgery. It doesn't get much respect among academic attendings.

 

[Dr JPH]

There are a few rural surgery fellowships. They provide a wide exposure to basic ob/gyn, ortho, ENT and urology procedures. Oregon and Cooperstown, NY have them - perhaps others.

Is there a listing of these somewhere? I had no idea such a fellowship existed.

If you practice somewhere the managed care penetration is low, your salary may be good, especially compared to the local cost of living. (e.g. 6000 sq ft brick house on 10 acres for $250K.)

The numbers that I have crunched seem to show that I would be coming out pretty close as far as numbers go, once cost of living/loan reimbursement/malpractice are all factored in.

A trauma/critical care fellowship is probably not a good fit for a rural surgeon. You will be plenty well trained as a general surgeon to handle all the trauma you can manage. Even if you're a trauma hotshot, the institutional requirements and subspecialty expertise in other disciplines to handle serious trauma won't exist in your rural hospital.

I don't think vascular or colorectal would be a good fit either. Again, for the cases you'll be doing, you should be adequately trained as a general surgeon. Vascular is increasingly diverging from general surgery with specialized endovascular techniques. The things that a colorectal surgeon can do that a GS can't - lap J-pouches, etc - aren't going to be high volume in rural surgery.

Bascially, the things you need to learn are more non-GS surgical procedures.

Understood. Thank you for the detailed response!

In terms of job market/caseload, there are TONS of jobs out there and plenty of patients if you want to work in a small town.

I guess thats why the hospitals I have looked at are recruiting so hard.

The Bulletin of the Am Col Surgeons has articles of rural surgery on a fairly regular basis. I think there's also a rural surgeons section of the ACS.

I am going to check that out now!

And finally - I'd be careful about advertising your interest in rural surgery. It doesn't get much respect among academic attendings.

Really? Now that suprises me a bit. I would think that they would look at it as being noble or (excuse the term) "ballsy". Any thoughts on why this is?

Thanks!

JPH

 

[Winged Scapula]

Is there a listing of these somewhere? I had no idea such a fellowship existed.

There is not a centralized database (ie, on FREIDA or NRMP) that I am aware of, but a Google search does find some.

I guess thats why the hospitals I have looked at are recruiting so hard.

Its supply and demand. Not many people want to work in rural communities - you are often the "only game in town" which means on call every night, no coverage if you want to take vacation, meager specialty resources, lack of job opportunities for spouse, substandard schools/shopping/entertainment outlets, etc. So while the money will be great, you will work your arse off.

Bear in mind that many of these hospitals will tempt you with obscene salary offers (ie, $400/year and up) but they cannot and will not sustain that offer more than a year or two, and will shackle you with an agreement to stay for a few years to pay that salary guarantee off. So while these jobs sound great up-front they always come with a trade-off (ie, saw a job in Nevada for $600/year - but you were the only surgeon in town; if you're on call every night, you don't have much opportunity to spend the money, besides the fact that I'm sure that salary guarantee is not forever).

Really? Now that suprises me a bit. I would think that they would look at it as being noble or (excuse the term) "ballsy". Any thoughts on why this is?

You have to understand academic medicine. Now the osteopathic world and some community programs may be different, but in the academic world there is a tendency to look down upon the general surgeon, rural or not, and favor fellowship trained surgeons/specialtists. I agree with PilotDoc - there just isn't much love for general surgery, especially rural general surgery, among academic types and "advertising" it, especially early in your career, can cause problems down the road. Same tends to go for Plastics - general surgery residents thinking about plastics get labeled as uninterested in "real" surgery and I've been told, get less teaching. Obviously my experience is that of just two programs and the word of friends in others, but I don't know anyone who thinks general surgery is "noble" and while they may think doing rural general surgery is "ballsy" its not because you are doing something noble but rather because:

a) you are choosing a location which makes the lifestyle for you and your family tough
b) you are choosing a career path (ie, lots of call, little vacation or time off) which most others wouldn't
c) it can be a risky proposition if you aren't happy

Academic surgeons tend to be a snobbish crowd and look down on many things outside of their realm; I feel somewhat shunned for even considering private practice.

 

[46&2]

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.

 

[Dr JPH]

Thank you for all the comments and feedback thus far.

This is an idea that I have been kicking around, but I obviously have a while to decide.

Maybe I should shoot for plastics AND rural surgery. Just because you dont live in the big city doesnt mean you should have access to implants!

Another option would be to go a community hospital, not necessarily rural...perhaps more small town feeling.

I guess I can see the thought behind pushing for specialization, but the osteopath in me leans towards the general surgeon who does a little of everything.

Some of the best surgeons I have worked with, and smartest, were general surgeons who spent some or most of their career at large academic centers and then opted to "slow down" and go to a community hospital...only to fine MORE work. All of them have said they were happy in their decision.

I love to teach, I love technology...and part of me wants to take that motivation to the small community and see how it goes. I also want to bring an aspect of osteopathic medicine to the profession in the form of manual medicine (did I just lose all support from this forum? 🙂 )

I could care less about what others in the academic setting think of my decision...afterall, I CHOSE a DO school over an MD school...but I dont want to be red flagged or labeled so I might play it close to the vest.

I love the city. Being in Philadelphia for the last 10 years has been great, but I dont know if I want to work in a major metropolitan area. I dont even know if I want to work in a semi-major metropolitan area!

Any more opinions, comments, websites, first hand stories...all is much appreciated.

 

[Dr JPH]

Did I frighten everyone off with my osteopathic comments? 😕

🙂

 

[Winged Scapula]

Buehler? Buehler?

 

[maxheadroom]

I've heard great things about the Cooperstown program. I know someone who rotated there because of an interest in surgery. He ultimately went into FP with a focus on international health. He thought that it would be great training for someone who was interested in missionary medicine.

 

[dawg44]

Kimberli made some great points.

As with all things but especially in a small town you have to know your contract in and out. If you don't like something, time commitment, noncompete, whatever it is have them remove it. You are the commodity. You are RARE. A surgeon that WANTS to live in a rural community. Get a skilled attorney in contract negotiations. Mine was $500 flat fee and I tell you it was the best money I ever spent. Don't own anything and treat the contract as short-term. Don't buy an 800,000 dollar house in a town of 8,000. Don't let them lock you in with a salary guarantee pay off like Kimberli stated. Make no mistake the hospital makes a bundle off of your work. They wouldn't be recruiting you if it was otherwise. They will use every tool in their disposal to keep you there and the salary guarantee with length of payback is just one. I would recommend a straight salary with production bonuses. When you are mobile you hold the cards and you can take your ball and go home if it doesn't fit you. As far a call and leaving town. You can leave town if you have no patients in the hospital. Everything through the E.R. gets shipped downstream like it did before you were there.

 

[flashman]

A friend of mine who just graduated from my program is a DO and chose like you a rural practice. He just called an attending of mine and they were discussing their practices. One thing discussed among surgeons in practice is how many cases are done per week or month. Many academc surgeons will average about 10 cases/wk. My friend in rural practice just finished 90 cases last month, so the work is certainly there. A recent plumb case was a laparoscopic heller myotomy, in which he was assisted by his experienced senior partner. Hence the opportunity exists to do whatever you want. Having discussed with prior graduates of my program it seems that the people in rural practice say that about half of their cases are endoscopy, which is a nice buffer: easy, well reimbursed, elective cases.

Just a few thoughts...

 

[Dr JPH]

I really appreciate all of the feedback and suggestions. This is actually making me more excited about exploring this more.

Im going to keep bumping this thread to get more and more first hane experience info!

Thanks again

 

[dawg44]

I don't want to make it sound like a bad thing either from my previous post. There are alot of positives in going to a rural community.
You are instantly a big fish. Its hard to stand out when you are the 15th general surgeon in a 600 bed hospital but by going to a smaller town, you are it. You have instant standing in the community. You are much more likely to have "pull" in matters around the hospital. What you say actually might matter when compared to being a junior attending in a large group. The cost of living is usually significantly less. Some like the school systems better some less. That in and of itself is an entire debate. If you want to live on a large piece of land it is far far easier in a smaller town. The cases are there and are bread and butter. And if you don't want to do something, you ship it. And seriously call is not that big of an issue as far as being busy its just more time with a pager. Most residents are used to Level 1 or II centers and let me tell you a rural hospital isn't even close.

 

[cabinbuilder]

I am from Alaska and if you were to go there as a general surgeon (that's what I plan to do eventually) I tell you the cases are there, the money is there. No taxes, No HMO's. Major reimbursement. Bear in mind too that the general surgeons in Fairbanks do a lot that you wouldn't see elsewhere. Currently there are no colorectal surgeon, no GI, No urology, No cardiology, No vascular, No Neuro, No Nephrology. Just the basics. Other general surgeons here in the states tell me that their practice is a dying art, not so if you go rural. I would not ever worry about getting cases. You do so much more as a rural surgeon and the patients are grateful that you are there for them. This sense of entitlement you see he with Welfare folks just isn't happening. Places like Wyoming, Montana, the Dakotas, Idaho, all are in need of surgeons.