Defining the Canadian rural general surgeon
===========================================

* Lyndsay Glass
* Malcolm Davidson
* Emily Friedrich
* Rebecca Afford
* Sarah MacVicar
* Quinn Gentles
* Peter Miles
* Roy Kirkpatrick
* Lauren Smithson
* Mark Walsh
* Stephen Hiscock
* Evan Wong
* Caitlin Champion

## Abstract

**Background** A total of 18%–30% of Canadians live in a rural area and are served by 8% of the country’s general surgeons. The demographic characteristics of Canada’s population and its geography greatly affect the health outcomes and needs of the population living in rural areas, and rural general surgeons hold a unique role in meeting the surgical needs of these communities. Rural general surgery is a distinct area of practice that is not well understood. We aimed to define the Canadian rural general surgeon to inform rural health human resource planning.

**Methods** A scoping review of the literature was undertaken of Ovid, MEDLINE, and Embase using the terms “rural,” “general surgery,” and “workforce.” We limited our review to articles from North America and Australia.

**Results** The search yielded 425 titles, and 110 articles underwent full-text review. A definition of rural general surgery was not identified in the Canadian literature. Rurality was defined by population cut-offs or combining community size and proximity to larger centres. The literature highlighted the unique challenges and broad scope of rural general surgical practice.

**Conclusion** Rural general surgeons in Canada can be defined as specialists who work in a small community with limited metropolitan influence. They apply core general surgery skills and skills from other specialties to serve the unique needs of their community. Surgical training programs and health systems planning must recognize and support the unique skill set required of rural general surgeons and the critical role they play in the health and sustainability of rural communities.

According to the Canadian Institute for Health Information, 8% of general surgeons in Canada work in a rural setting, whereas 18%–30% of the population lives in rural areas, which are dispersed over 95% of the total land mass.1–3 Rural Canadians are a socially diverse and culturally distinct population of Canada, who often face inequities in health care access. Indigenous people are more highly represented within rural Canada, as are people with increased comorbidities, reduced overall income, and a poor level of health compared with urban Canada.4,5 Physicians and surgeons who serve this population face challenges when it comes to meeting the health care needs of rural Canadians. Often having to do more with less, they play a crucial role in their communities.

Rural surgeons positively affect their communities by providing expert-level care close to home. They improve trauma outcomes and provide access to maternity care in their community, which would otherwise be unavailable without surgical back-up.6–11 To better understand the unique role rural general surgeons play in their communities, we aimed to assess the existing surgical literature for definitions and descriptions of rural surgeons and rural surgery practice, particularly in the areas of scope of practice, training, workforce, clinical outcomes, and recruitment and retention. We sought to develop a unifying definition of a Canadian rural general surgeon to guide future health human resource decisions and define training needs to support the sustainability of rural surgical care in Canada.

## Methods

We undertook a scoping review of the literature, searching Ovid, MEDLINE, and Embase databases for primary research studies using the following terms: “general surgery,” “rural,” and “workforce.” These terms were further expanded with appropriate Medical Subject Headings. Two authors (M.D. and E.F.) used Covidence to complete the title and abstract review, and a third author (L.G.) reviewed disagreements.12 Inclusion criteria were general surgeons, Canada, Unites States, and Australia. Australia is frequently compared with Canada, as its population is similarly dispersed and comparable in characteristics, and care provision is equally challenging. The year of publication was not restricted. Studies from other geographic areas and conference proceedings were excluded, as were commentary and grey literature articles.

Full article reviews were undertaken, and searching for a definition of rural surgery was the primary objective. We further assessed articles for the definition of rurality used by authors, as well as data regarding rural scope of practice, workforce, training, clinical outcomes, and barriers to rural surgery. Bibliographies were reviewed to identify any further relevant literature. We used these data to develop a unifying definition of a rural surgeon in Canada.

## Results

### Literature review

The initial literature search identified 426 titles, and 315 were excluded. The remaining 112 articles underwent a full-text review and bibliography review, and 83 were considered relevant (Figure 1). Publications included 9 Canadian, 64 American, and 11 Australian studies (Table 1). Relevant topics identified in rural surgery literature included scope of practice, surgical workforce, surgical training, clinical outcomes, and recruitment and retention (Table 2). Articles regarding rural surgery topics outside of these 5 topics are included in Table 3.

![Fig. 1](http://canjsurg.ca/https://www.canjsurg.ca/content/cjs/67/2/E129/F1.medium.gif)

[Fig. 1](http://canjsurg.ca/content/67/2/E129/F1)

Fig. 1 
Flow chart showing the inclusion and exclusion of articles.

View this table:
[Table 1](http://canjsurg.ca/content/67/2/E129/T1)

Table 1 
Country of publication

View this table:
[Table 2](http://canjsurg.ca/content/67/2/E129/T2)

Table 2 
Literature topics

View this table:
[Table 3](http://canjsurg.ca/content/67/2/E129/T3)

Table 3 
Summary of findings for other topics in rural surgery

### Definition of a rural surgeon

One group put forth a definition; Nealeigh and colleagues18 defined an “isolated surgeon,” which encompassed both rural US and deployed military surgeons. Their definition was derived from strictly American literature based in civilian rural America and the American military. They set out 8 criteria, 5 of which were required for a surgeon to be considered an “isolated surgeon.” The criteria were based on size of community; availability of resources, such as imaging and blood bank capabilities; distance to more complex care; and availability of local and nearby medical and surgical specialties.18

### Defining rurality

A total of 50 studies used a specific definition of rurality; authors defined rurality in many ways. Most frequently used were population cut-off values (< 2500 to < 150 000 people), metropolitan influence, and health authority (Table 4 and Table 5).24,25,27,29,30,34,35,40,41,44,45,47,48,53,57,58,60,61,63,66 An example of metropolitan influence is the American Rural–Urban Commuting Area code used frequently in American studies, whereas Canadian groups more often used census data stratified by metropolitan influence. 18,23,32,36–38,43,46,50,52,55,59,64,65 The third most common definition is based on government or health authority definitions, for example, the Canadian census definition. 17,19,26,28,31,39,49,62 Other authors use a unique definition that is specific to the context of the hospital, region or question that is being answered. For example, a study assessing the use of surgical resources in Manitoba defines rural as any county outside of 2 provincial metropolitan areas.20–22,51,54

View this table:
[Table 4](http://canjsurg.ca/content/67/2/E129/T4)

Table 4 
Definitions of rurality

View this table:
[Table 5](http://canjsurg.ca/content/67/2/E129/T5)

Table 5 
Summary of rurality definitions

### Rural surgery scope of practice

Thirty-two articles assessed the scope of practice of rural surgeons (Table 6). Up to one-third of their scope of practice falls outside of traditional general surgery core competencies, excluding endoscopy.29,41,51,70 Many authors investigated the details of nontraditional procedures that a rural surgeon performs; most frequently identified were urology, orthopedic surgery, and obstetrics and gynecology (Appendix 1, available at [www.canjsurg.ca/lookup/doi/10.1503/cjs.002123/tab-related-content](http://www.canjsurg.ca/lookup/doi/10.1503/cjs.002123/tab-related-content)).23,29,41,46,47,57,60,65,68,70,72,73,77

View this table:
[Table 6](http://canjsurg.ca/content/67/2/E129/T6)

Table 6 
Summary of scope of practice findings

It was found that rural surgeons play an important role in the treatment of trauma. They are routinely the surgical provider of thoracoabdominal trauma, consistent with larger centres but without the support of surgical specialties, such as neurosurgery and vascular surgery.6,11,67,69,71 The scope of rural general surgery practice extends beyond procedural care alone, including workup and management of medical conditions. For example, rural general surgeons are often responsible for endoscopic gastrointestinal workup, as gastroenterologists are not commonly present in rural communities.28 In addition to other specialty procedures, endoscopy typically comprises a significant proportion of a rural general surgeons’ workload, up to 50% of all procedures.19,23,28,29,46,47,49,61,64,66,68,70–72,76

### Rural surgical outcomes

Thirteen studies assessed the clinical outcomes of rural surgeons (Table 7). Additionally, several authors reviewed the outcomes of emergency procedures not usually within general surgery practice, including vascular surgery and neurosurgery.11,67,75,82 These authors focused on rural and remote areas where delays in intervention would likely result in increased morbidity or mortality. In general, these patients had good clinical outcomes regardless of the fact that the specialty procedures were completed by general surgeons. Others assessed clinical outcomes of frequently completed procedures and found the complication rates of rural surgeons to be comparable to those of their higher-volume urban counterparts in both adult and pediatric patient populations.31,42,56,76,80 One study of a Canadian trauma system found the presence of a surgeon in the community improved trauma outcomes and effective transfers to tertiary care, their patients being more likely to arrive hemodynamically stable. These patients also had a high likelihood of requiring multidisciplinary management across several surgical disciplines, suggesting that many trauma patients treated in centres with general surgeons are obtaining appropriate care within the capabilities of their local centre.6

View this table:
[Table 7](http://canjsurg.ca/content/67/2/E129/T7)

Table 7 
Summary of findings for clinical outcomes

One trend identified in the literature is a lower rate of laparoscopic colectomies completed at rural hospitals. Colon and rectal procedures are less likely to be performed by a specialist colorectal surgeon, and patients in rural centres are less likely to receive a laparoscopic procedure. 45,55 Another study identified patients with ulcerative colitis treated by non–colorectal specialists as more frequently experiencing complications.79

### Rural surgical workforce characteristics

Twenty-five papers discussed the characteristics of the rural surgical workforce (Table 8). In the US and Canada, several authors observed that rural surgeons tend to be male, internationally trained, and older than their urban counterparts.23,41,48,52,63 The literature also identified a decrease in the number of general surgery graduates entering rural surgical practice, as well as the loss of rural surgical programs.22,29,39,43,50,85 Studies reviewing advertised surgical position vacancies identified service gaps more frequently in rural positions, often with long-standing vacancies and reliance on locum tenens surgeons as the primary surgical workforce.26,29,38,62 Several studies have been conducted to understand what factors help predict a general surgeon’s decision to practise in a rural setting. The most frequently cited predictor for choosing rural surgical practice is having grown up in a rural area or having a partner who grew up in a rural area.24,36,41,48,66 Rates of rural clerkship and resident rotations were higher among surgeons who chose rural practice settings than those working in urban settings.48

View this table:
[Table 8](http://canjsurg.ca/content/67/2/E129/T8)

Table 8 
Summary of findings for rural surgical workforce characteristics

### Rural surgical training

A total of 22 studies assessed the training of rural surgeons (Table 9). Rural surgical training literature focused on the need for a broad-based general surgery training program to ensure practice-ready surgeons. Multiple studies identified surgical residents graduating with insufficient confidence in performing procedures outside of core general surgery but most often required in rural settings.47,66,90 A Canadian survey of surgery residents in their final year of training found that 37% of residents planned to move directly into practice, and many indicated they did not feel comfortable with orthopedic, plastic surgery, obstetric or gynecologic procedures.90

View this table:
[Table 9](http://canjsurg.ca/content/67/2/E129/T9)

Table 9 
Summary of findings for rural surgical training

The American training literature identified several pilot programs aimed at providing additional rural-oriented training; these included a rural year for fourth-year students, and a rural rotation with an emphasis on endoscopy exposure.34,35 Results of those programs include more analogous caseloads of residents and practising surgeons, increased likelihood of selecting rural surgery as a career, and increased self-reported preparedness for rural practice, including those procedures that fall outside of general surgery. 30,34,35,37,53,54,60,74,88,89,92–94 Canadian literature is lacking regarding general surgery training.

Beyond residency training, continuing education was consistently noted as an important aspect of upgrading and maintaining skills, including laparoscopic colon surgery and others not within core general surgery. Programs were well received by rural surgeons, with participants indicating these programs would broaden the care they would be able to provide to local patients.91 Telementoring was also identified as an educational approach that could benefit rural surgeons in learning new skills or managing unexpected intraoperative findings.44

### Rural surgery recruitment and retention

Six studies examined barriers to selecting rural surgery as a career and rural surgeon retention (Table 10). These studies identified on-call burden and professional isolation as common areas leading to career dissatisfaction. A Canadian study by Ahmed and colleagues27 identified difficulty in accessing resources, with perceived impediments in providing high-quality patient care leading to reduced career satisfaction and negatively affecting rural surgeon retention. Family considerations were also found to affect rural retention, particularly surgeon’s concerns regarding their children’s education and finding spousal employment. Studies also identified positive retention aspects of rural practice, including the sense of community, the ability to establish long-lasting relationships with their patients, and rural settings being noted to provide a positive and preferable environment for raising a family.48,72

View this table:
[Table 10](http://canjsurg.ca/content/67/2/E129/T10)

Table 10 
Summary of findings for rural surgery recruitment and retention

## Discussion

### Defining rurality in a health care context

In Canada, the low population density and distribution of population, with few large metropolitan areas, make the definition of rurality difficult to delineate in the context of health care. For example, a community of 5000 people in southern Ontario is often not more than 1 hour from a tertiary care centre; however, a community of 5000 in Nunavut is thousands of kilometres from a tertiary care centre. Because of the unique features of Canadian geography, numerous institutions have worked to define rurality.

Statistics Canada defines rurality as the area that remains after the delineation of population centres (small towns with a 1000–29 999 population, medium urban centres with a 30 000–99 999 population, and large urban centres with a population > 100 000) with a population density of less than 400 people per square kilometre.96 In a health care context, this definition is unable to capture the nuances and impacts of proximity that larger tertiary care centres have on the delivery of health care. Statistics Canada has worked to develop a “remoteness index” to try to capture this nuance by developing a score based on proximity to other centres.96 Other population cut-offs have been used by provinces to set out criteria for rural retention programs. In Ontario, researchers use the Rural Index for Ontario, which stratifies communities based on their size and distance to secondary and tertiary care.97 The Canadian Institute for Health Information employs a hybrid model that uses a population cut-off of 10 000 and further stratifies communities by metropolitan influence, based on the percentage of residents who commute to and from a metropolitan area for work.98 The literature identified in this review highlights and emphasizes the importance of including metropolitan influence in defining rurality in surgical care.

### Defining the rural general surgeon’s role and scope of practice

Most of the current literature on rural surgery is American, and Canada’s population distribution and physical geography are vastly different. Some of the challenges faced by rural surgeons in Canada are similar to those experienced by their American counterparts; however, it is clear that additional population distribution and geographic factors substantially affect rural Canadian surgeons. This review identified a single pre-existing definition of a rural or isolated surgeon in an American military context. Although this definition was robust and specific, it did not address key elements that are required in a Canadian context, such as the scope of practice and the unique role that a Canadian rural surgeon plays within their community. The definition was further limited by its applicability to Canada, the exclusion of Canadian literature, and the inclusion of deployed military surgeons. The definition of a Canadian rural surgeon must also include the role of the surgeon in the local health care system, the unique scope of practice, and the community characteristics.

Canadian rural surgeons are not only the primary surgeon but also act as an important critical service access point in both emergency and elective practice settings. In the example of trauma care resource access and utilization, Canadian surgeons provided appropriate care in their home community and effectively transferred patients requiring a higher level of care, referring multisystem trauma cases and caring for single-system trauma patients locally.6 Other studies have suggested that general surgeons in rural settings are more likely to perform endoscopy and complete diagnostic workup for gastrointestinal disorders than their urban counterparts.28 In this role, rural surgeons are an important initial access point to subspeciality surgery and medicine, acting as gatekeepers and facilitators of surgical referral to higher-level complex tertiary and quaternary care. Our literature review identified a lower rate of laparoscopic colectomies in the rural setting, which likely represents the older demographic of general surgeons, and this trend may shift as new graduates enter rural practice. Further, our review did identify advanced laparoscopic training as a suggested skill when training rural surgeons, and this can be adequately addressed in rural streams. Within the literature, the most frequently addressed theme of rural surgery is the extended scope of practice, with orthopedics, obstetrics and gynecology, and urology being the most frequently included specialties outside of general surgery. Within Canada, the distribution and diversity of procedures performed by rural surgeons is dependent on the needs of the community and allocation of other local surgical and health care resources as opposed to a one-size-fits-all model. Finally, characteristics of the community that a rural surgeon serves can also affect their extended scope of practice, particularly the influence and access to higher-level care in nearby metropolitan centres. Patient preference also plays a critical role, as rural patients may identify a strong preference for surgery close to home regardless of their knowledge of surgical outcomes. Quality of life issues, including proximity to family and social supports, and capacity and expense for medical travel are critically important and often overlooked aspects of surgical care in rural communities.99,100

### Rural general surgery training, recruitment, and retention considerations

The literature clearly identifies a gap in the surgical care needs of rural patients and the accessibility of trained providers. An aging and shrinking rural surgical workforce combined with decreased confidence of new graduates pursuing rural practice inevitably results in a widening of the access gap among rural surgical patients. Rural general surgeons provide critical services, with improvements in trauma patient outcomes and equivalent surgical care outcomes to those of their high-volume urban counterparts in core general surgery procedural competencies. Recruitment of rural-oriented surgical trainees combined with training opportunities targeted to build rural surgical skill sets with an extended scope of practice may encourage trainees to pursue a career in rural general surgery.

Practice isolation, call burden, and burnout are challenges in rural communities. Communicating these issues in the medical community and the public at large is critical. Authors discussing equitable care distribution and access within the surgical community have called for a shift to group practice and networked care models in rural communities. 101,102 Considering shifts in remuneration models for rural surgeons away from fee-for-service models to salaried or other alternative payment models may also support recruitment to communities with lower practice volumes, as well as a shift to team-based care models. Smaller communities with insufficient case volumes to support multiple general surgeons may also extend the surgical workforce by including Family Physicians with Enhanced Surgical Skills (FP-ESS) training working alongside and in collaboration with general surgeons, ensuring appropriate access to specialist and generalist care in smaller rural and remote communities. 101,103 Supporting healthy multisurgeon rural surgical programs may improve the work–life balance of rural surgeons and build continuing medical education opportunities for surgeons to provide the high-quality care rural communities deserve. Implementing these models of care in rural communities may help overcome practice isolation and burnout challenges affecting retention of rural general surgeons and support the sustainability of rural surgical programs.

## Conclusion

A rural general surgeon in Canada is defined as a surgical specialist who works in smaller (population < 30 000) or remote communities with limited metropolitan influence. Rural general surgeons apply the foundational principles of surgery, combining core general surgery training with additional surgical skills to serve the unique surgical needs of their community. In addition to providing emergent and elective general surgical services, they provide care beyond what is considered the core scope of general surgery practice and optimize care access close to home for rural patients. They act as a surgical care access point for more complex subspecialty surgical presentations. Rural general surgeons provide critical access to emergency and elective surgical expertise to positively affect patient outcomes. Training programs and health systems must support the unique needs and roles of these providers to provide high-quality equitable care access to rural Canadians.

## Acknowledgements

The authors acknowledge the work of Lisa Allen, who assisted with the preparation of the manuscript, and the work of Alla Iansavitchene, who assisted with the literature search.

## Footnotes

*   Competing interests: Lyndsay Glass is a member of the Canadian Association of General Surgeons Rural Surgery Committee. Peter Miles is a member and past chair of the Canadian Association of General Surgeons Rural Committee. Lauren Smithson is chair of the Advisory Council for Rural Surgery, American College of Surgeons. Evan Wong reports a Canadian Association of General Surgeons operating grant. Caitlin Champion reports a Skin Investigation Network of Canada Team Development Grant, and is a member of the Canadian Association of General Surgeons Rural Surgery Committee and co-chair of the Continuing Professional Development Committee. No other competing interests were declared.

*   Contributors: Lyndsay Glass, Rebecca Afford, Quinn Gentles, Sarah MacVicar, Peter Miles, Roy Kirkpatrick, Lauren Smithson, Mark Walsh, Stephen Hiscock, Evan Wong, and Caitlin Champion contributed to the conception and design of the work. Lyndsay Glass, Malcolm Davidson, and Emily Friedrich contributed to the data acquisition and analysis. Lyndsay Glass, Malcolm Davidson, Emily Friedrich, and Caitlin Champion contributed to interpretation of the data and drafting the manuscript. Rebecca Afford, Sarah MacVicar, Quinn Gentles, Peter Miles, Roy Kirkpatrick, Lauren Smithson, Mark Walsh, Stephen Hiscock, and Evan Wong reviewed and revised the manuscript critically. All authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work.

*   Accepted November 24, 2023.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

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