The ongoing decline in the number of general surgeons practicing in rural areas of the United States is concerning. Existing data show that rural surgeons perform a broad spectrum of cases including procedures that are not considered to be in the repertoire of most general surgeons. In particular, rural surgeons seem to be performing a sizeable number of endoscopic procedures. A sixty-item survey was mailed to 1700 rural surgeons while a random sample of 154 urban surgeons were telephoned and administered the same questionnaire. The general surgeons were identified using a list obtained from the American Medical Association Masterfile. The response rate was 25 per cent and 74 per cent among rural and nonrural surgeons respectively. Seventy four per cent of rural surgeons performed more than 50 flexible endoscopies a year in contrast to 33 per cent of nonrural surgeons (P < 0.05). Approximately 42 per cent of rural surgeons reported doing more than 200 procedures annually, whereas only 12 per cent of the nonrural surgeons did so. Additionally, 63 per cent of rural surgeons wished they had further training in endoscopy before starting practice as compared with 46 per cent (P < 0.05) of nonrural surgeons. Rural surgeons perform flexible endoscopy at a much higher rate than their nonrural counterparts. The majority of rural surgeons feel they would have benefited from additional flexible endoscopy training before entering practice.