1. RURAL HOSPITAL TERTIARY CARE LINK Thomas H. Cogbill, M.D. Gundersen Lutheran Medical Foundation La Crosse, Wisconsin

2. Challenges of Rural Surgery Professional Isolation Acquisition of New Technology/Skills Call Coverage Reimbursement Administrative Duties Education/CME Requirements Research Opportunities Volume-Based Quality Initiatives

3. Gundersen Lutheran Health System Fully Integrated Physician-Led 453 Physicians 6159 Employees

5. Main Clinic – La Crosse, Wisconsin (population 51,000) 12 General Surgeons Branch Clinics – 25 Locations 9 General surgeons

8. Regional Surgeon Operations Endoscopy28% Gynecology21% Hernia10% Colorectal 9% Biliary Tract 8% Orthopedic 7% Cesarean Section 5% Breast 5% Other 7%

9. Communication Med-Link Telephone System Distance-Learning Sites Admission/Referral Nurse E-mail

10. Transportation Med-Link Helicopter System Ground Transportation 3 States, 19 Counties All Levels of Care

11. Call Coverage Main Clinic – Skill Set Mismatch Other Regional Surgeons

12. New Technology Acquisition Surgical Skills Laboratory Main Clinic Case Participation On-site Proctoring

13. Administrative Help Salary and Benefits Coding and Reimbursement Patient Satisfaction Surveys Department-Wide Registry of Cases Maintenance of Certification

14. Education CME Opportunities Surgical M & M Conference Distance Learning

15. Teaching Rural Surgery Elective ATLS Instructors RTTDC Courses Residency Lectures

16. Research Landercasper et al: Spectrum of rural general surgery, Arch Surg 1977 Bintz et al: Role of rural surgeon in trauma, J Trauma 1997 Callahan: Experience of rural general surgeon, JACS 1994