Establishing a Rural General Surgery Residency Program: Identifying Community Stakeholder Perception and Obstacles of a de Novo Residency in Rural Appalachia

Introduction

Rural healthcare has become increasing challenging over the past several years. A recent survey indicated that 30% of US counties are without a general surgeon, and surgeon availability is decreasing each year. ¹ It has been suggested that only 10% of current General Surgery training programs are equipped to produce surgeons who are both capable and willing to practice in the rural setting. ² The lack of surgical care in rural areas often leads to surgical patients being transferred to a larger center for their care. These transfers increase the burden on larger hospitals that are already operating with limited resources, while simultaneously moving patients away from their families who often cannot afford to travel long distances or take time away from work.

While it has been suggested that the strongest predictor of future rural practice is growing up in a rural community, ² it also appears that physicians are more likely to practice near their training location. ³ Both rural and urban centers are victims of current and anticipated escalating physician shortages that are predicted in the United States, further limiting resources throughout the healthcare system. In an effort to counter these shortages in medically underserved areas, the Accreditation Council for Graduate Medical Education (ACGME) has recently introduced the Rural Track Program (RTP) to facilitate the training of physicians uniquely equipped to practice in the rural setting. These programs will require greater than 50% of training to take place in the rural setting as opposed to conventional rural tracks which typically involve only a few rural rotations.^4,5

Rural Appalachia has long been considered an underserved area with increasingly limited healthcare resources, further constricted by the recent pandemic. In addition, it has a unique culture and disease pathology that must be understood in order to appropriately care for the population. In collaboration with our existing university-affiliated community-based General Surgery training program in Huntington, WV, we intend to start a rural training program focused on Logan Regional Hospital—a rural 132 bed acute care facility that serves its local community of approximately 2100 residents as well several surrounding areas with even more limited access to healthcare. This will be the first General Surgery program with the ACGME RTP designation and will partially incorporate into the framework of the current Marshall University training program. Residents will spend slightly over 50% of their training with local surgeons in Logan, while the remainder of time will be spent in Huntington working with several surgeons on both General Surgery and sub-specialty rotations with the goal of producing Rural General Surgeons capable of dealing with the wide spectrum of surgical pathology typically encountered in the rural setting.

Objectives

While multiple studies have shown the need for rural surgeons to improve access to care, little to no research has evaluated public perception and potential barriers to rural training. The purpose of this study is to involve the community in its own care and identify any obstacles—with the intention of overcoming these prior to initiation of the training program. After obtaining Institutional Review Board (IRB) approval, we surveyed several community members, hospital staff including both healthcare personnel and administrators as well as the local Chamber of Commerce—obtaining feedback regarding perception of the program and its anticipated strengths and weaknesses while simultaneously raising awareness about the upcoming training program. We believe that by surveying the community and acting on their input, we will improve the healthcare provided by our program while concurrently training general surgeons uniquely qualified to practice in the rural setting.

Methods

430 community stakeholders were surveyed over a 2-month period (January to February 2022) regarding the anticipated impact of a new training program in this acute care facility. Those surveyed included 172 members of the community, 241 healthcare staff and 17 members of the local Chamber of Commerce. Surveys were modified to each group of the community; however, the majority of questions remained the same. Each healthcare staff member surveyed was entered into a drawing to win a $500 gift card, while each community member surveyed was entered into a drawing to win 1 of 5 $100 gift cards, no compensation was offered to the Chamber of Commerce. Questions focused on the awareness/understanding of a Rural Residency Program, the care provided by those involved in the program, impact on availability of local care, current geographical limitation of surgical care and potential benefits and obstacles of the training program.

Results

Only 61% of respondents were aware of the actual role and qualifications of a Surgery Resident (Figure 1), with approximately 68% being aware of the upcoming rural program. Over 90% of all surveyed either approved or strongly approved of training surgeons locally (Figure 2) and 16 of the 17 Chamber of Commerce members believed that the program would be a good investment for the community as a whole. The majority of community members who had previously been treated by a resident were either satisfied or very satisfied with the care they received (Figure 3) and over 75% of healthcare staff reported that they would feel comfortable being cared for by a resident. Among families who have required surgical care, 40% reported that they travel to a larger city at least 4 times per year with 96% of all respondents believing that the program would provide better access to care locally. Greater than 90% of all surveyed believed that the area has a shortage of general surgeons with a similar percentage of respondents believing that local training will improve the residents ability to care for rural communities in the future (Figure 4). Support from the community appeared to be positive, 96% of Chamber of Commerce members expressed at least some interest in assisting residents with local housing. Other potential benefits identified included the ability to get to know the local surgery team and take an active role in patients’ own care, improved physician recruitment and overall improvement in healthcare. The most significant obstacles noted were a possible lack of surgical residents willing to train in Logan and the risk of trainees not staying to practice locally upon graduation.

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Figure 1.

Number of respondents (Hospital staff and Community members, Members of the Chamber of Commerce were not asked this question) and their answers to survey question: “How would you describe a surgery resident?”

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Figure 2.

Number of respondents (separated between Community members, Hospital staff and members of the Chamber of Commerce) and their level of approval regarding training future surgeons in the community.

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Figure 3.

Number of community members who have received care from a Resident Physician elsewhere and their level of satisfaction with care received.

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Figure 4.

Percentage of total respondents (including community members, hospital staff and members of the Chamber of Commerce) who agree with the above statements.

Discussion

The responses of the survey were overwhelmingly positive with a majority of community stakeholders believing that a training program will increase their access to surgical care and limit the need to travel to larger cities. Several patients in Logan frequently travel to Huntington for their healthcare needs where they are treated by resident physicians and appear to be satisfied with their care. From the community perspective, the largest obstacle appears to be retention of surgeons after their graduation from residency. This is a concern shared by our program administration since the goal of our program is to improve access to care for the rural population which will depend on surgeons willing to practice in the area. While no system can guarantee avoiding this, we are working with program administration to focus on recruitment of those intending to practice in the rural setting. We will also collaborate with community leaders to increase retention of graduates. There is limited data available on the impact of rural surgery training on rural practice, however, a survey study conducted in 2009 showed that surgeons practicing in a rural area were twice as likely to have completed a rural clerkship in medical school and more likely to have graduated from a residency program which demonstrated a dedication to rural training. ⁶ This does not show causality, but could indicate that our rural program will improve the number of surgeons wishing to practice rural surgery.

Previous studies have suggested significant benefit from training programs in rural towns including improved physician recruitment and retention as well economic benefits. ⁷ This likely stems from trainees supporting local businesses and increased market security with the ability to depend on local healthcare services as opposed to requiring travel to larger cities for simple care. While the Chamber of Commerce survey involved only 17 individuals (expected in a small town such as Logan), the members do believe that the program will not only improve local healthcare, but also benefit the local economy.

Limitations of this study include the subjective nature of the survey. Those included in the study were predominantly members of the community and local healthcare staff with no specific information regarding the impact of the training program. This study was primarily aimed to involve the community, raise feedback, and identify potential obstacles to the program. While the information regarding impact on healthcare as well as the local economy is certainly valuable and provides insight into the perspective of those likely to be impacted by the program, it cannot serve as fact to predict future outcomes. The complete impact on the health system and economy is beyond the scope of this study. We do, however, intend to conduct a follow up study after training begins in July 2023—to evaluate the impact on the community.

Regardless of the limitations of this particular study, we do believe that we have successfully engaged the community to demonstrate significant positive support from the majority of community stakeholders that will be key to the success of this novel training program.

Conclusion

We expect the program to be well received by the local community while creating an environment dedicated to enhancing local healthcare and simultaneously training general surgeons uniquely equipped to care for rural communities. The community is familiar with healthcare in a training facility and welcoming to a local training program, while believing that trainees will have a positive impact on local surgical care in rural Appalachia. We will continue to work with the local community and healthcare personnel while developing the program and tailor our Residency to the rural setting as able. The largest community concern appears to be retention of rural surgeons after graduation and steps will be taken by program administration and local government to increase retention of graduates.