Looking for an oasis

An arid-like landscape continues to creep across vast sections of the country. But this isn't a geographic phenomenon tied to climate change, it's a cultural and professional one known as a surgical desert.

Resulting from a dearth of interest on the part of surgeons practicing in rural areas, surgical deserts are creating health risks for residents in the community and making it difficult for hospitals to care for them, industry experts are warning.

“A substantial portion of our country can be characterized as surgically underserved, despite several programs designed to help sustain healthcare services in underserved communities through enhanced reimbursement,” wrote the authors of a 2009 report from the American College of Surgeons Health Policy Research Institute. “For many places, these initiatives may not be sufficient to supplement a surgical practice.”

The problem has not improved since those numbers were collected. “Whatever (the situation) was in 2009, I suspect that the trend line is only getting worse,” says Jonathan Sprague, president of Rocky Coast Consulting, a Bangor, Maine, firm specializing in healthcare services.

Like the difficulties rural primary-care operations face in attracting doctors to work for them, rural surgery programs are struggling to attract surgeons. Most newly minted general surgeons go into specialties—which aren't in high demand in rural areas because of smaller populations—and those that do remain in general surgery for the most part are electing to work in or near cities, where the available professional resources are more abundant and comparable to what they had in medical school.

As a result of this lack of interest in working outside of urban regions, more than 900 mostly rural counties in the country have no access to a local surgeon, creating surgical deserts for about 9.5 million Americans, according to an ACS study, “Surgical Deserts in the U.S.: Places without Surgeons.”

“This is not a broken system, but it is a system increasingly facing a crisis,” Sprague says. There are many rural hospitals providing exceptional surgery services, but going forward “it's going to be very difficult,” Sprague says.

It's the falling number of surgeons relative to the population that is driving the problem, and although urban areas also have been hit with a drop in general surgeon coverage, rural areas lack them the most.

A study published in the Archives of Surgery in 2008 found there were 5.69 general surgeons for every 100,000 population in 2005, down 26% from 7.68 in 1981. In rural areas, including counties that are adjacent to urban counties and those that have cities with at least 10,000 to 50,000 residents, the ratio was 5.02 surgeons per 100,000 population, a decrease of 21% from 6.36 in 1981.

The numbers are worse, though, looking at less-populated counties not adjacent to an urban area and without a city of at least 10,000 people, a type of region highly dependent on general surgeons for emergency care, according to the study, titled “A Longitudinal Analysis of the General Surgery Workforce in the United States, 1981-2005.” Such counties had only 4.31 surgeons per 100,000 in 2005, down 16% from 5.15 in 1981. Surgeons are not attracted to the rural lifestyle for a number of reasons. After typically getting trained in a more urban environment, nascent general surgeons have grown accustomed to medical technology that often isn't available in rural settings, says Jess Judy, senior vice president of provider relations at LifePoint Hospitals, a for-profit chain based in Brentwood, Tenn., with a high concentration of rural and sole community hospitals.

LifePoint is working to be creative in attracting surgeons to its rural facilities, trying to employ them directly to remove some of the uncertainty of joining or forming a practice. One approach the company is considering is the creation of a hospitalist-like role for surgeons, possibly to be called a “surgicalist,” though the specifics are far from being definite, says Melissa Waddey, senior director of strategic resource group at LifePoint.

Having access to capital for medical technology is one of the ways 101-bed Natchez (Miss.) Community Hospital, owned by for-profit hospital chain Health Management Associates, Naples, Fla., tries to create an environment that would be more attractive to surgeons considering a rural practice, says Donny Rentfro, the hospital's former CEO. Natchez recently added a surgical robot to its repertoire and also performs community outreach to try to build business for its surgical services, he says.

Indeed, residents in rural communities have become more aware of available technology, but some still seem to prefer metropolitan providers for that care, further hurting prospects for rural surgical-care providers. Healthcare consumers are becoming more educated on healthcare issues and are recognizing that the higher volume of procedures taking place at urban providers generally are associated with better outcomes, says Robert Gift, a director for Chadds Ford, Pa.-based IMA Consulting, which specializes in healthcare. And as larger urban hospitals and systems have affiliated with rural hospitals, the surgical services often end up being performed in the urban hospital, Gift says.

The role of the general surgeon also has changed. Before surgical specialization became so common, a rural surgeon might have performed a lot of vascular surgery, whereas today that type of operation would most likely go to a vascular specialist in a more urban setting, says Arthur Blank, president and CEO of 25-bed Mount Desert Island Hospital, Bar Harbor, Maine, a state with no surgical desert counties. Rural surgeons today might do more endoscopy procedures, something they weren't necessarily trained to do as a general surgeon, but can learn, he says.

Mount Desert is moving toward an employment model for its surgical program, which gets heavy traffic in summer months from nearby Acadia National Park and has most of its C-sections performed by general surgeons, Blank says. Family-practice physicians and nurse midwives handle most of the vaginally delivered babies.

The demand side of the rural surgery equation also has been affected, with proportionately fewer people living in rural areas. The rural population continues to grow, but at a much slower rate than previously.

The rural population grew 4.5%, or about 2.2 million people, between 2000 and 2010, bringing its total population to 51 million, according to a recent analysis of census data conducted by the Carsey Institute, which is part of the University of New Hampshire at Durham. The rural population had grown by 4.1 million in the previous decade, while the urban population growth rate in 2000-2010 was 10.8%, according to the institute.

The slowdown in population growth was driven by shifting trends affecting rural areas, particularly those not close to metropolitan centers.

“The slower population growth in rural America occurred because migration contributed far less to the rural population increase than it had during the 1990s,” wrote the authors of the Carsey Institute analysis titled “Rural Demographic Change in the New Century: Slower Growth, Increased Diversity.”

“Paradoxically, natural increase (more births than deaths) re-emerged as the primary demographic force fueling rural growth, not because of a surge in rural births, but because migration to rural America has sharply diminished,” the authors wrote.

Some regions simply might not be big enough to support a surgeon. A community needs at least 15,000 to 20,000 residents to support a surgeon economically speaking, says Gerald Doeksen, director of the National Center for Rural Health Works, part of Oklahoma State University at Stillwater. But in communities that size there are quality-of-life issues that make it harder to attract surgeons to live and work there.

“The problem is they're often on-call, an awful lot,” says Doeksen, who also is a professor and extension economist for the Oklahoma Cooperative Extension Service at Oklahoma State. The ideal situation can support two surgeons and would therefore have a population of about double that size, Doeksen says. Generally speaking, the areas served by critical-access hospitals are too small to support a general surgeon, he says.

Rural communities are desperate to attract rural surgeons so that surgical services can remain, for economic and quality-of-life reasons. “These hospitals are very passionate about remaining in their community,” says Amy Dore, assistant professor at Metropolitan State College of Denver.

In a survey of executives at “tweener” hospitals conducted by Dore, respondents expressed concern about the dearth of general surgeons in rural areas. Rural hospitals known as tweeners are too large to qualify for critical-access hospital cost-based reimbursement but too small to provide efficient prospective payment system care.

According to Dore's survey, which she conducted for her doctoral dissertation, executives strongly agreed with the statement, “If the surgical services were discontinued at my hospital, the hospital would suffer significantly financially,” as well as the statement, “I consider the shortage of rural general surgeons in the United States to be critical.”

Dore adds that she found a relationship between the success of a rural surgery program and the number of surgical support staffers employed, which may have implications related to the retention and attraction of rural surgeons.

There are broader economic benefits to having a surgery program, according to research from the National Center for Rural Health Works. A rural surgeon generates about $2.7 million in revenue, $1.4 million in wages, salaries and benefits and creates 26 local jobs, according to research published by the center titled “The Economic Impact of a Rural General Surgeon and Model for Forecasting Need,” published in September 2010.

In addition to jobs directly supported by the surgery practice at the hospital and related service, such as diagnostic imaging or pharmacies, some of those jobs are supported by the fact that some patients who go out of the community for general surgery take other services outside their community as well, according to the report.

“The potential risk of losing a general surgeon in a rural hospital represents a substantive economic loss, and a faltering surgical program can represent incremental losses that may ultimately contribute to program failures,” the authors wrote in a report summary. “Conversely, the ability to expand general surgery represents a potential increase in hospital revenues and local health expenditures by recapturing dollars lost when health services are not purchased locally.”

The absence of a general surgeon in a community is also likely to have negative effects on the quality of care, experts say. “If you build in a two- to four-hour delay in getting to a real surgeon, I can't believe it's not going to affect risk-adjusted quality,” says Dr. Tyler Hughes, a surgeon who practices at 41-bed McPherson (Kan.) Hospital and a member of the board of governors for the American College of Surgeons.

“Where you have a low density of surgeons, morbidity and mortality go up,” Hughes says. And some of the solutions being suggested, such as telemedicine, can only do so much, he says. If the physical location is hours away, there are going to be patients who won't or can't get the surgical care they need, he says. Some patients won't want to take a spouse or other relative away from their job to accompany them for a surgical procedure, Hughes says.

Hughes is one of two full-time surgeons in McPherson, a town of 13,000, the seat for McPherson County, which has a population of 29,000. Hughes says he and the other surgeon are on call every other day and every other weekend.

Dr. Philip Caropreso, who manages a solo practice and is the only general surgeon serving Keokuk, Iowa, and Carthage, Ill., communities with a total population of about 40,000, is one of several surgeons joining Hughes on an

advisory committee being formed by the ACS that will tackle the surgeon shortage head on.

“It's going to take some significant and nearly monumental changes,” Caropreso says of the effort. The committee will include members from across the country who will seek to identify the issues and then propose some solutions, he says. The members also will be charged with raising awareness among interested parties and try to gain support for the changes they believe are needed and hope to form this summer.

Caropreso says he has felt the effects of the drought of rural general surgeons directly and now his patients may feel it even more so. He's planning to retire—though not completely—this summer. “In the 14 years since I've been in this area, we've gone from four general surgeons to one,” he says. He says he's tried and failed to recruit qualified surgeons to work there, but he says he may have to become “less persnickety” than he has been in the past in his recruiting.

He wants the role of the rural surgeon to survive, an outcome that he fears is not guaranteed.

“That's the real concern—that there will be an extinction of this kind of practice.”