OHSU Rural Surgery Training

Evidence-level

Effective (About evidence-level criteria)

Description

Since 2002, Oregon Health & Science University (OHSU) has collaborated with Asante Three Rivers Medical Center in Grants Pass, Oregon, to train general surgery residents in a comprehensive, rural setting. Two residents in their third or fourth years who are interested in practicing in a rural or underserved population are selected by the Program Director to complete a six-month or one-year rotation in this rural community in southern Oregon.

The incentive to develop this rotation came from a needs assessment of rural hospitals in Oregon in 1998. This needs assessment showed that rural surgeons had an average age of 55 and had difficulty recruiting surgeons to step into their role. This is because surgeons in typical urban training programs were never exposed to the broader range of operations that they would need to perform in a rural setting or to the resources available in small, rural hospitals. A collaboration developed with the hospital in Grants Pass due to its interest in being a teaching hospital.

In 2014, the program expanded to a second site in rural Coos Bay, Oregon, which has a hospital similar in size to Grants Pass's hospital. This six-month rotation is open to third-year and fourth-year residents.

Funds to support the residents' salaries and fringe benefits are provided through the hospitals in Grants Pass and Coos Bay, while OHSU provides a stipend that covers their housing.

Services offered

Residents in this program are given diverse and widespread opportunities to become competent in surgical and clinical skills needed for the rural setting as they work alongside:

• General surgeons
• Colorectal surgeons
• Urologists
• Obstetrician-gynecologists
• Orthopedic surgeons
• Otolaryngologists
• Podiatrists

The majority of the residents' work is with the general surgeons in the hospital, including a very large number of gastrointestinal endoscopic procedures, since general surgeons provide the vast majority of endoscopy in most rural settings. Residents also learn the basics of care for emergency conditions in the surgical specialties, which is necessary for surgeons to know if they plan to practice in a rural setting.

Results

29 residents who rotated to Coos Bay have finished residency. Seven of these residents (24%) are now practicing in a rural setting in a town of 50,000 people or fewer. Two additional residents started in a rural practice, but have since moved to a non-rural setting.

There have been 37 graduates of the residency who rotated in Grants Pass. Of these graduates, 12 (32%) are currently practicing in a rural setting. Of these, one is practicing in Grants Pass. One additional resident started in a rural practice, but has since moved to a non-rural setting.

Throughout this same period, only 2% of OHSU general surgery residents who did not take part in the rural program are now practicing in a rural community. This statistic shows the importance and success of rural residency programs for the recruitment and retention of rural physicians.

Residents at Grants Pass log over 500 cases during that year, which is more than twice the caseload of a typical residency year. Residents who rotate for six months in Coos Bay log about 250 cases, with the same case distribution. As a result of their volume of cases and vast amount of experiences, these residents are able to independently, competently, and confidently transition into their chief year of residency.

In summary, residents are more likely to enter general surgery practice and serve in a community of fewer than 50,000 people if they participate in the rural program than residents in the OHSU program who do not participate in the rural program.

For more detailed results:

Deveney, K., Jarman, B.T., & Sticca, R. (2015). Responding to the Need for Rural General Surgery Training Sites: A How-To. American College of Surgeons Bulletin, 100(4), 47-50. Article Citation

Deveney, K., Deatherage, M., Oehling, D., & Hunter, J. (2013). Association between Dedicated Rural Training Year and the Likelihood of Becoming a General Surgeon in a Small Town. JAMA Surgery, 148(9), 817-821. Article Abstract

Challenges

It is critical to choose the rural hospital partner carefully. The surgeons must be dedicated to teaching and mindful of the need to comply with federal residency work-hours restrictions, which were likely not in effect when they were in residency.

The residency program must secure the proper contracts to comply with national Accreditation on Graduate Medical Education requirements (Program Letters of Agreement) and make sure that residents have adequate housing, health insurance, and liability protection.

The rural hospital must provide teaching and Morbidity and Mortality Conferences that are equivalent to those at the residency program. The teaching conference requirement is met by transmitting the conferences from the home institution to the rural hospital. Morbidity and Mortality and Journal Clubs originate in Grants Pass, but the Grand Rounds and Resident Conferences are transmitted from Portland down to Grants Pass.

Funding for the residents' salary and benefits can be a challenge, as it technically needs to be provided by the hospital where the residents are rotating. However, the hospital can obtain teaching hospital status and therefore be eligible for Medicare funding. It is important that a collaborative relationship exists among the surgeons and the hospitals.

During 2020-22, the ongoing COVID-19 pandemic affected all surgical training, and the rural program is no exception. The numbers and variety of cases decreased in all settings, since virtually all hospitals had to eliminate or at least seriously decrease elective surgery. Rural surgeons and residents were pulled into other clinical roles at these times, including medicine hospitalist work, ICU coverage, and public health work. These decreases affected resident experience negatively. Nevertheless, the rural program remains popular with residents, in part because the residents are treated more as colleagues than trainees. Their contributions to their rural communities are highly valued. During the pandemic, the residents at our rural sites experienced what it was truly like to practice surgery under "real world" conditions.

Replication

OHSU has been used as a resource for the formation of similar rural programs through the University of Wisconsin, University of Nebraska, University of New Mexico, and the University of South Dakota in order to address the nationwide shortage of the rural workforce.

The following outline identifies key considerations in developing a new program: Template to Develop a Rural Training Site.

Contact Information

Dr. Estin Yang, MD, MPH, FACS, Clinical Affiliate Professor, Oregon Health & Science University
Asante Health
541.507.2110
yange@ohsu.edu