Rural General Surgery: The Last Frontier

As Alaska Native Medical Center celebrates its 25-year anniversary as a Level II Trauma Center, I am compelled to share my personal journey becoming a community surgeon and returning to academia to train the next generation. ?Through my experience, it has become clear to me that the first job of a graduating resident is as important as the choice of medical school and general surgery residency.?

My commitment to underserved communities developed early and was rooted in family.? My parents were the first in their respective families to graduate from college.? My mother’s grandparents were German immigrants that settled in eastern South Dakota in the late 1800s.? Farming was their manifestation of the American dream.

My father’s family is Lakota and struggled to make a living on-and-off the reservations within South Dakota following the Dawes Act of 1887.? The cultural holocaust suffered by the Lakota made reservation life untenable and eventually most of my Lakota family would settle in Rapid City.? As the oldest of 8 siblings, my father navigated life largely on his own, making a name for himself in basketball and using this as a tool to go to college on scholarship.? The effort and transcendence of my father was not lost on me, and for most of my youth, I was preoccupied with athletics as a means to attend college.? There was a distinct separation in my family between the have’s and the have not’s and it was as much cultural as it was circumstance as it was motivational and individual.?

Given my parents’ evolution, the contrast between our immediate family and that of our extended family was stark in many circumstances.? While most of my mother’s siblings, too, went to college and lived classic middle-class lifestyles, my father’s siblings did not have the same academic successes.? They mostly worked odd jobs here and there, struggling to make ends meet.? It was apparent to me as a boy that we were now different.? Some in my family chain-smoked, drank heavily, missed days of work, while others never missed a day of work and lived diligent and thoughtful lives.?

Personal exposure to rural life in America led me to find volunteer and early employment opportunities within underserved communities.? I worked as a student extern at the Indian Health Service in Arizona and South Dakota – being exposed to some of the poorest counties in the Western Hemisphere – and volunteered as a mentor to at-risk youth at the Judge Baker Center in Boston as a medical student.? I had predilections for surgery, but knew I would practice whichever specialty in communities of need upon completing my training.? As a medical student, I accepted IHS scholarships in exchange for a service obligation at a site of my choosing.? Residency was formative at the Brigham and upon graduating my preliminary plans were to work in the Southwest for the Indian Health Service.?

As a resident at Brigham, however, serendipity would connect me with Dr. Kevin Stange, the childhood friend of another residency-affiliated surgeon, and after a phone call and a site visit, I chose to move my family to Anchorage, Alaska.? I would fulfill my service obligation to the Indian Health Service at Alaska Native Tribal Health Consortium and Alaska Native Medical Center.? Unexpectedly, as a Harvard-trained surgeon, Alaska would define general surgery for me and shape my perception of the community general surgeon.?

Unassuming and ordinary, might be the best description of Frank Sacco and Kevin Stange in street clothes (they often wore a fleece and jeans to the American College of Surgeons annual meeting where everyone else was in suits), but in scrubs the OR transformed these surgeons into superheroes.? In my mind, they were the pinnacle of surgery – encompassing the clinical acumen and technical skills of the great surgeons of my residency.? Each having worked at Alaska Native Medical Center for 20-plus years, Dr. Sacco and Dr. Stange were instrumental in development of state of Alaska’s trauma system.? When I arrived in 2012, ANMC had been the only trauma center in the state, receiving patients from all corners of Alaska, including many destinations over 4 hours away by plane.? Their routines included administrative duties of the Trauma Medical Director and Chief of Surgery; they would each take turns in these roles over the years.? ANMC would receive an award from Dr. Berwick at Institute of Healthcare Improvement for their logistics.? Beyond their administrating and leadership abilities, clinically their cases were always the most complex patients – the ones with the most complex diseases or comorbidities – the cases that no one else wanted.? Whether lung cancer, colon cancer, or carotid artery stenosis (we read our own vascular studies), they would manage it.? Pyloromyotomies, gastrectomy, peripheral bypass and pancreas all part of their wheel-house.? They were the most-calm and composed during the worst cases and with the most unstable patients.?

Yet, despite their confidence and competence in the OR, they welcomed me straight out of training.? They encouraged me to treat the breadth of general surgery conditions as I knew them.? They spent the time to help me gain confidence with endoscopy, pediatric surgery, and vascular surgery.? I had a solid core in these areas but needed independence with backup, which they offered and fulfilled routinely during my initial years as a surgeon.? They gave me freedom in breast, colorectal cancer and foregut surgery as these were my immediate strengths.? They scrubbed cases when I needed them – my first open pyloromyotomy, during a difficult LAR, an ED thoracotomy transitioning to the OR with major pulmonary trauma, a difficult polypectomy.? My confidence as a young surgeon was fostered in this environment and I learned that the concept of general surgery in Boston was only a fraction of what actual general surgeons would do in the community.??

Upon fulfilling my service obligation, it was family that led to the difficult decision to leave Alaska.? After three years of continuous post-residency growth as a surgeon, I was confident in my capacity and abilities to manage patients independently. ?Under the mentorship and guidance of these surgeon-mentors, my skills had been nurtured and I could now fly on my own.

My path was not predetermined or planned, but it allowed me to be successful as a community and rural surgeon given contemporary residency training. The case log of my first 1000 cases in Alaska is above. ?My path leaves me wondering: Is it possible to standardize this experience to train more community general surgeons?

Back to the overarching problem that general surgery is not producing enough general surgeons ready for community practice.? It is clear that current training needs to be bolstered – it needs focused rotations and experiences, more hours, and more independence.? Solutions to solving the general surgeon problem are undefined, but the focus of these solutions is likely to be influenced by hypotheses regarding their origin.? For those that believe that residency is lacking clinical focus or rural and community experiences, a solution would be the implementation of rural general surgery tracks with specific community experiences and deliberate clinical rotations.? Another option focused on solving the lack of experience would be general surgery fellowships with increased responsibility and independence.? Concurrent surgery would be permitted at most institutions in this context and give the fellow increased independence and confidence.? There is a certain confidence that one can only achieve as an attending surgeon, however, and in this setting, a post-graduate surgeon position with committed mentorship and facilities whose purpose is to prepare the new surgeon for 3-5 years prior to leaving this institution would be the preferred training plan.? I believe all of the above additions to general surgery training will be required to meet the growing demand for surgeons in rural and community settings.?

In this context, the first job after training is an extension of residency or fellowship and has become increasingly important.? It could be the most important decision for the developing community surgeon.? A poor choice of first job can be detrimental to the young surgeon’s growth.? The first job must be a high-volume experience.? It must give the new surgeon independence to struggle, learn to stay safe, and find confidence in themselves.? It must have experienced surgeon-mentors that are always accessible, but not too accessible, for the new graduate.? These mentors must understand the significant of their role.? This first job should be time-limited, only three to five years, and encourages the surgeon to leave and find their own community practice upon completion.? During this time of true medical and legal independence, surgeons must establish their practice and gain confidence that was historically gained during residency training. ?It is only after a purposeful post-graduate experience that one can succeed as a general surgeon in the community, given the current training model, and we should not leave this up to chance.?