The Performance and Impact of Rural Minimally Invasive Surgery Fellowships

James Patrick Ryan, MD1, Andrew J Borgert, PhD2, Kara J Kallies, MS2, Lea M Carlson, RNC1, Howard McCollister, MD1, Paul A Severson, MD1, Shanu N Kothari, MD3. 1Minnesota Institute for Minimally Invasive Surgery, 2Gundersen Medical Foundation, 3Gundersen Health System

Background: Despite evidence demonstrating similar operative experience in rural and urban residency programs, operative experience in rural fellowship programs is largely unknown. In addition, rural surgical care in the United States has been increasingly challenged by both a shortage of graduating residents remaining in general surgery as well as an urban/rural maldistribution adversely affecting access to surgery for rural populations. Two of the most rural minimally invasive surgery (MIS)/Bariatric fellowships are located in the upper Midwest. We hypothesized that these two programs would offer a similar operative experience to other U.S. programs in more urban locations, and that receiving fellowship training in a rural location would increase the likelihood of entering a rural surgical practice.

Methods: The 2011-2012, 2012-2013, and 2013-2014 fellowship case logs from two rural Midwest programs were compared to case logs from 23 U.S. MIS/Bariatric programs. All 17 rural Midwest fellowship graduates completed a survey describing their fellowship experience and current practice. Statistical analysis included Wilcoxon Rank Sum test.

Results: Mean case volumes for rural Midwest fellows vs. other U.S. programs are reported in Table 1. Case volumes for advanced MIS and bariatric procedures were similar. Mean endoscopy volume was significantly higher among rural Midwest fellows as this is a large component of one of these fellowships. All (100%) rural Midwest fellows reported an adequate number of cases as operating surgeon during fellowship. 94% reported that their fellowship training was extremely beneficial to their career, and 1 (6%) reported it to be somewhat beneficial. 53% of graduated fellows currently practice in a rural area, despite only 6% having an interest in rural practice prior to fellowship. Only one fellow (6%) participated in rural surgery training during residency.

Table 1. Mean case volumes by procedure.
Case type Rural Midwest Programs (N=2) U.S. programs (N=23) P-value
Endoscopy 443.3±351.7 104.9±82.4 0.01
Bariatric 124.0±21.4 150.5±55.2 0.21
Foregut 51.7±19.0 67.2±33.7 0.29
Hepatobiliary 49.5±28.7 47.9±43.0 0.63
Abdominal wall 49.0±22.9 58.2±29.7 0.58
Peritoneum, omentum, mesentery 22.7±5.1 20.0±13.9 0.29
Colorectal 16.8±6.8 16.1±18.1 0.24
Appendix 13.5±6.7 6.5±8.6 0.01
Small intestine 12.8±2.9 11.5±8.1 0.18
Solid organ 3.5±5.2 7.1±6.4 0.08

Conclusions: Rural Midwest MIS/Bariatric fellowship programs offer a similar operative experience to other U.S. programs. A greater volume of endoscopy cases was observed in rural Midwest fellowships, which is particularly needed in rural hospitals. Fellowship training in a rural location results in highly trained specialist surgeons establishing advanced MIS and bariatric practices in rural locations. Rural fellowships can be valuable resources in alleviating the rural manpower shortage while improving access to quality surgical care for rural populations.

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