GENERAL SURGERY TRAINING FOR RURAL PRACTICE:

EVOLUTION OVER SIX YEARS

Karen Deveney, M.D.

Oregon Health & Science University

Portland, Oregon

DEMOGRAPHICS OF OREGON

•9th largest geographic area of US states

•3.79 million people

•¾ of population lives in “I-5 corridor”

INITIAL IMPETUS TO DEVELOP PROGRAM-1990’s

• Requests to Program Director and Chair from rural surgeons seeking partners and/or replacements

• OHSU School of Medicine curriculum revision, addition of rural clerkship in family medicine

NEEDS ASSESSMENT

• Survey of all surgeons practicing 10 or more miles from a population center of 30,000 or more

• Age of surgeons

• Future plans

• Spectrum of cases done

• What they wish they’d learned in residency

RESULTS

• Average age 47 (30-71)

• Mean of 15 years in practice

• 78% felt training should be widened for optimal rural practice

• Most needed skills: GYN, endoscopy, trauma; ortho, urology, ENT basics

CHALLENGES TO ESTABLISHING A RURAL SURGERY EXPERIENCE

• “Turf” issues (unwillingness of specialists to train their competition)

• Funding the program

• Finding a setting that is rural, but not so rural that the resident won’t see adequate volume

OHSU ANSWER: THREE RIVERS COMMUNITY HOSPITAL

GRANTS PASS, OR

• In a community of 23,000, 3.5 hours south of Portland, with a “rural feel”; forests, a wild and scenic river, outdoor activities

• A high-quality hospital and ambulatory surgery center

• Seven board-certified general surgeons and specialists in gynecology, orthopedics, urology, and otolaryngology, all eager to mentor a senior surgical resident

• A supportive hospital administration

RURAL SURGERY EXPERIENCE:ADMINISTRATIVE DETAILS

• One year “immersion” experience at PGY-4 level

• Living quarters available, suitable for a small family

• Affiliation agreement with OHSU• Resident has equivalent salary and benefits• Complies with all ACGME policies and

procedures

RURAL SURGERY EXPERIENCE:SCHEDULE

• 6 months general surgery (includes general, vascular, thoracic, endoscopy)

• 1.5 months urology

• 1.5 months gynecology

• 1.5 months otolaryngology

• 1.5 months orthopedics

RURAL SURGERY EXPERIENCE:ANCILLARY BENEFITS

• Models what practice will be like– Working with partners– Interacting with referring MD’s and consultants– Practice and office management– Billing

• Better continuity of care than in most residency programs

HISTORY OF OHSU RURAL PROGRAM-INITIAL YEARS

2003-2004: “Pilot” year-resident who grew up in Grants Pass

2004-2005: Elective year for one resident with interest in rural practice– Initial attempts to obtain RRC approval for year to

“count” as a year of residency

2005-2006: Elective year for two residents– RRC unwilling to approve a “rural track”

– Reapplication for Three Rivers as a site of training

HISTORY OF OHSU RURAL PROGRAM-CURRENT STATUS

2006-2007: Elective year for two residents– RRC approves Three Rivers as site of training for one

resident, subject to review and progress report

October, 2008: First “official” rural resident passes ABS exams

February, 2009: RRC approves progress report and request for the experience of both residents to count as a residency year

RESIDENT EXPERIENCE AT THREE RIVERS

• > 400 major cases

• > 200 minor procedures and endoscopy

• Basic and emergency procedures and rotations in ortho, ob/gyn, ENT, urology

• Teleconferences from OHSU

• Online learning

• Local M&M and Journal Club

SUMMARY OF OHSU RURAL SURGERY EXPERIENCE

• 10 residents have completed the year at Three Rivers from 2003-present

• 4/10 are still in residency

• 3/10 went directly into clinical practice, two in small rural and one in large rural setting

• 3/10 did fellowships, but joined community practices. Two of these have general surgery as part of their practice

LESSONS LEARNED

• In spite of a broad, enriched clinical surgical experience in a rural setting, not all residents will enter rural practice

• The allure of specialist practice and influence of tertiary-care professors may be hard to overcome

FUTURE DIRECTIONS

• Identify site(s) and funding for shorter elective rotations

• Develop debt repayment programs for defined length of practice in rural hospitals

• Improve support by academic centers for rural surgeons: respite through locum tenens programs, advanced training in new procedures