Rural Surgery in Canada

2006 by the Socit Internationale de Chirurgie World J Surg (2006) 30: 16321633 Published Online: 13 March 2006 DOI: 10.1007/s00268-005-0643-3Rural Surgery in CanadaDarrell K. Baker, MDDepartment of Surgery, Haldimand War Memorial Hospital, 207 John Street, Dunnville, Ontario, Canada N1A 2P8Thick snow, blown by a frigid north wind, drifts across the road. A middle-aged surgeon relaxes on hissofa, watching his favorite television program as a steady stream of road closure announcements marches across the bottom of the screen. He reects on a busy Sunday on call: rounds in the morning, Colles fracture after lunch, appendectomy at 4 pm. Just as he slips off to sleep, the loud ring of the telephone brings him back to alertness. A woman with a high-risk pregnancy at 32 weeks was supposed to be delivered in a tertiary care center, but she is now in labor and having fetal decelerations; she wont be able to get to the city because of the snowstorm. Rushing outside carrying his coat, the surgeon revs up his 4wheel drive SUV and hopes that it will get him through the snowdrifts to the local hospital in time.This is not an unusual scenario in rural Canada, and it is one that highlights common problems with the provision of rural surgery. The gradual extinction of the rural surgeon seems to go unnoticed in Canada among the strident headlines about the need for more family physicians, more high-tech diagnostic machinery, shorter surgical waiting lists, and more healthcare funding, all causes worthy of attention, to be sure.Before we can propose solutions to the problems facing rural communities, we must fully grasp the problem. Canada is the second largest country in the world in terms of area, but it is sparsely populated. The United States is only slightly smaller, but has 10 times the population density of Canada. Thus in rural Canada, each person is an average distance of 50 km from a surgeon. During winter snowstorms, that 50 km might as well be 1000 km.A typical general surgery residency in Canada does not prepare young surgeons for the rural setting, where they will spend almost a third of their time working outside the classical realm of general surgery, in gynecology, obstetrics, orthopedics, urology, ENT, and endoscopy.1 Even if residents can get elective rotations in some of those areas, they will not likely get much hands-on experience because they will be competing with sub-specialty residents for cases.There are about 17 solo rural surgeons (the only surgeon on staff at a hospital) in the province of Ontario, and I am one of them. The lack of daily interaction with colleagues is troubling at times. It is often difcult to access consultants at tertiary care centers emergently. The on-call schedule is often onerous, and locum coverage is almost impossible to nd. Lifestyle issues also have a signicant effect on the rural surgeon. The surgeons spouse may have difculty nding work; there is often a lack of educational choices for younger children, and universities and colleges may be far away. Cultural amenities, taken for granted in the big cities, are largely absent.So, why would anyone want to be a rural surgeon in Canada? The rewards far outweigh all of the drawbacks. The sincere gratitude of the patients, the exciting variety of the caseload, nancial incentives, and the camaraderie of the staff of a small hospital are just a few of the things that make it all worthwhile. How can we raise a new generation of true rural surgeons in Canada?The solutions begin with admissions to medical schools and surgical residencies. Medical faculties across Canada must aggressively recruit (and perhaps even favor) applicants who had a rural upbringing, as it has been shown that a higher proportion of this group will return to practice in rural settings. While in medical school and residency programs, the provision of community and rural electives and rotations will signicantly increase the likelihood that those students will set up a rural practice.Optimally, rural surgery in Canada will come to be recognized as a separate specialty, as it is in Australia,Correspondence to: Darrell K. Baker, MD, e-mail: dkbaker@ sympatico.caBaker: Rural Surgery in Canada 1633New Zealand, and South Africa. As such, it would have its own 5-year residency program consisting of rotations in general surgery, Ob/Gyn, endoscopy, orthopedics, plastic surgery, urology, and ENT. Subspecialty rotations would take place in community hospitals to allow the rural surgery resident to learn hands-on without other residents competing for cases. There should be at least a 3-month rotation in a rural setting with a solo surgeon. This type of residency is presently available in Australia, New Zealand, and Cooperstown, New York, at the Mithoefer Center for Rural Surgery.2 McMaster University in Hamilton, Ontario, Canada, has recently started offering a community general surgery program, but 75% of its subspecialty training occurs in academic hospitals, and 90% of the general surgery rotations occur in cities of > 100,000 people, so it is not really a rural surgery residency.Rural surgeons can also be properly trained by doing the usual general surgery residency followed by a rural surgery fellowship. The Mithoefer Center for Rural Surgery offers a exible fellowship for this purpose.2 Noequivalent fellowship is offered in Canada.There will continue to be a role for GP-surgeons in small remote communities in Canada, but we must ensure that they have been properly trained for the limited variety of operations that they can do. Another possible solution for remote communities would be touring surgical teams that could come in and do elective cases, leaving the GP-surgeon to handle many of the emergency operations.A number of actions would make the retention of rural surgeons in small communities much easier. Each provincial medical association should provide readily accessible locum coverage for rural surgeons who want to go on a vacation or take advantage of a continuing medical education opportunity. Traineeships to allow the rural surgeon to acquire additional skills and learn new procedures must be available.Rural surgery in Canada is at a crossroads. We can either allow it to die a slow death or we can revitalize it. We can force patients to travel long distances to reach surgical care (and some will not make it there in time) or we can provide optimal surgical care by allowing the patients to be operated on and recover in their own communities, surrounded by their friends and relatives. Which will it be?REFERENCES1. Landercasper J, Bintz M, Cogbill TH. Spectrum of general surgery in rural America. Arch Surg 1997;132:494.2. Gold MS, Zuckerman R, Dietz P, et al. Cooperstown surgeons throw a pitch for rural surgery. Bull Am Coll Surg 2004;89:16.