1. GENERAL SURGERY TRAINING FOR RURAL PRACTICE: EVOLUTION OVER SIX YEARS Karen Deveney, M.D. Oregon Health & Science University Portland, Oregon

2. DEMOGRAPHICS OF OREGON 9 th largest geographic area of US states 3.79 million people ¾ of population lives in “I-5 corridor”

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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