During my M4 year, I did a rural general surgery rotation.
Surgery, by its nature, does require at least a moderate sized town/infrastructure to support a hospital--you need ORs, ancillary staff, an ICU (or a way to transport sick people out of there, ie. helicopter). The hospital I was at served parts of northern Arizona and most of southern Utah. The population included old ranchers, suburban families, wealthy "snowbirds," and polygamists (interesting bunch, by the way). The pathology that sits around in the sticks, waiting to come to the hospital, because it's 5-6 hours away, is pretty impressive.
At any rate, the doctors I worked with (3 in the group) worked like dogs, but they had a very broad practice. They were all technically very good, did lots of open and laparoscopic cases. They did general sugery (including endoscopy), vascular, and non-cardiac thoracic. There was also one vascular surgeon in town, but the number of cases was more than just one person could handle. There were no CT surgeons. These guys took a ton of call--call for the group (responding to calls from discharged post-op pts. and covering the hospital), ER call, and vascular call. In addition, once a week, one of them would drive over to the other side of the state and have clinic, where he'd do small procedures (excise lipomas, etc.) and scope a few colons--stuff people weren't likely to drive 4 hours to have done.
What I saw as the pros and cons:
Pros=you have a very broad practice; these surgeons loved living where they did (I hated it--but I can't stand small towns), if you want to really be involved w/your patients, they're also your neighbors, your barber, your banker, your grocery bagger, etc; you see a lot of interesting pathology, often in late stages; not a lot of subspecialists around--you're the one running the show (better know your stuff!)
Cons=you work like a dog; you work like a dog; you work like a dog--if one of your partners goes out of town, you work even harder; not a lot of subspecialists around, so not a lot of brains to pick for consultation; if something goes wrong, how far is it to the nearest tertiary care center--can you get your patient there in time?; living in a small town got painfully tedious, and the responsibility to your patients, when you are the ONLY show in town felt really overwhelming
Just my perspective--I had to do the rotation as part of my school's curriculum, not because I had any interest whatsoever in rural surgery.
