Integrated health system builds collegial network of rural surgeons

July 27, 2017|ACS Surgery News

Two-way relationship with referral center is key

Recruiting and retaining general surgeons is a longstanding problem for rural hospitals. A regional medical system in the Upper Midwest tackles this challenge by integrating small-town general surgeons into the network and emphasizing professional development, fair compensation, and a sustainable call and leave schedule.

The Gundersen Health System (GHS) is a physician-led, nonprofit health care network that operates in 19 rural counties in parts of Wisconsin, Minnesota, and Iowa, with its main campus in La Crosse, Wis. The network, established over a period of almost 40 years, is a mix of larger GHS medical centers, community hospitals, medical clinics, and GHS-managed and independent critical access hospitals (CAHs).

Two surgeons practicing at Gundersen – Thomas H. Cogbill, MD, FACS, and Marilu Bintz, MD, FACS – conducted a seven-question survey of the general surgeons in their regional network to collect data on the demographics of this group, the surgeons’ work profiles, and their reasons for taking and for remaining in their positions. Currently, there are nine GHS-employed general surgeons practicing in the small towns around La Crosse. These general surgeons provide care at critical access hospitals both within and outside the GHS network. The study, published in the Journal of the American College of Surgeons (2017 Jul;225[1]:115-23), provided some lessons on successful strategies based on responses to the survey and the experience of Gundersen over the past 38 years.

A sustainable model

“It is clear that the older paradigm of a single rural surgeon providing care 24/7 to an isolated community is vanishing. Design of a more sustainable model involves small groups of rural surgeons working together to provide general surgery and some subspecialty care locally, but who are also part of a larger network for administrative and clinical support,” said Dr. Cogbill in an interview.

The Gundersen Health System involves a cooperative and collaborative relationship between the surgical services on the main campus in La Crosse and the GHS-employed general surgeons in smaller communities in the surrounding region. The emphasis is on competitive salaries, reasonable call and leave schedules, administrative support, and adequate case variety and volume. The objective is to develop collegial, mutually supportive relationships, not only between GHS and the rural general surgeons it employs but also among the community surgeons.

Lessons learned

Dr. Cogbill said, “Our 38-year experience with rural surgery in our region has taught us many lessons. The strategy of trying to place a solo general surgeon in every small town with a CAH within our service area was not sustainable nor practical. The development of several rural centers of care within our region has allowed us to be more successful in the recruitment and retention of rural general surgeons who are hired to be part of a small group (optimally three) who provide care to their home community as well as outreach surgical care to several outlying CAHs near their home CAH. This has made it possible to offer a reasonable call schedule, mutual assistance, and the chance to build adequate case volumes. Connectivity to the health system should not mean ‘send all the great cases to the main campus,’ but instead should support the rural surgeons in performing appropriate cases locally.”

The survey respondents were aged 36-55 years, five were male, and all were graduates of U.S. medical schools. Eight are board certified and seven are either fellows or associate members of the American College of Surgeons. Their tenure in the GHS system averaged at least 7 years, ranging from 2 years to more than 20. Their surgical logs for a recent 1-year period show a case mix of endoscopy (63.8%), general surgery (26.7%), and obstetrics (6.1%). Mean annual relative value units for the group were 3,627 (range 2,456-5,846).

One goal of the confidential survey was to explore the reasons behind these surgeons’ choice of a rural practice. Their primary motivations were a preference for a rural lifestyle and a desire for a broad scope of practice. Loan forgiveness motivated some (37.5%), and the influence of a mentor was important for others (25%). The opportunity to join an integrated health system such as GHS was deemed extremely important to seven of the respondents.

Retention of rural surgeons

The most important factors mentioned by survey respondents for remaining in their positions were lifestyle (87.5%), family (75.0%), relationship with patients and colleagues, and scope of practice (75.0%), and compensation (62.6%).