Surgery Training for Rural America Fourth Rural Surgery Symposium May 17, 2009 David Borgstrom, MD, FACS Mary Imogene Bassett Hospital Cooperstown, New York

Surgery in Rural America n What is rural? n Scope of the Problem n Possible Solutions

What is Rural? n urban > 50,000 n large rural 10,000 to 50,000 n small rural <10,000

Defining Rural n Rural-Urban Continuum Codes –Rural Urban Commuting Area Codes n more continuous n county and municipality n secondary flow to UA and UC n % flow out

RUCA Codes

Non Metro Areas

Population Density 2000 Census

The Problem-Rural America n older, sicker, poorer, less educated n higher infant and injury related mortality n less insurance, fewer physicians n 20-30% less medical service n financial stability of rural hospitals is dependent upon general surgeon.

The Problem n 60 million (22.4%) live in rural America n 6.40 GS per 100,000 nationally n 4.67 GS per 100,000 in small rural n 20.8% of GS practice in rural areas n 9% in small or isolated rural n 19% projected to fill need

The Problem n 65 and older fastest growth –GS workload 3X greater –30% over next 15 years –25% increase in lap chole by 2020 Shivley and Shivley, Threats to Rural Surgery, Am J Surg, Aug 2005

The Problem n Less than 40% of residents choose GS n 13% selected rural location in 1980s n decrease in student interest n male/female disparity

The Problem n General surgeons in rural America –male –> 50 years old –IMG –earlier retirement n Solo practice –continuing education –vacation/call

The Problem n economic issues –lower reimbursement –technology n liability issues –increased cost –costs of diversity n spouse/family concerns –education/ culture/ diversity

The Problem n Rural America deserves optimal care n surgery drives rural healthcare n workforce is diminishing n less interest among students and residents

The Solution n Make it appealing n Training

The Solution make it appealing n community/hospital commitment –FP model in medical school n tuition payment n debt assumption –Liability support n broad based care –C-sections increased cost

The Solution make it appealing n Provide support n technology –laparoscopy –radiology n nuclear medicine n mammography n teleradiology

The Solution training n Medical education n GME n Post graduate education

The Solution training n Medical education –AAMC - Council on Graduate Medical Education (COGME) n 3,000 new medical students by 2015 –increase class size –new medical schools (very hard) –affiliated campuses

The Solution training n Rural residencies –rural location –rural tracks n reputation for rural connection –residency lifestyle –workforce preparation

Surgery for Rural America n significant number in need –surgeon numbers in decline n education reform –different needs n national support/promotion n creativity to make it appealing –partnership