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, and GHS.
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 3 decades.
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 surgeons themselves in their own communities.
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.
The most important factors mentioned by survey respondents for remaining in their positions were lifestyle (87.5%), family (75%), relationship with patients and colleagues, and scope of practice (75%), and compensation (62.6%).
Reasons to consider leaving were call burden (37.5%), relationship with the local hospital (25%), and compensation (25%).
The survey also looked at potential retention of these general surgeons in the coming 5 years: 37.5% said they were somewhat likely to remain, 25% said they were very likely to remain, and 37.5% said they were extremely likely to stay.
The two most successful strategies for developing the network of general surgeons have been promoting a satisfactory case mix and comanagement of patients who are referred to the main campus. This has translated to ensuring the regional surgeons have a satisfactory variety and volume of procedures. The surgeons from the small towns are encouraged to come to La Crosse to assist in procedures on referred patients, to teach in the fellowship program at Gundersen, to participate in clinical research activities, and to engage in a variety of professional activities that strengthen the bonds between GHS and rural surgeons. These interactions help minimize professional isolation, a serious problem for surgeons working on their own in small communities.
Several factors have contributed to recruitment efforts. Fair and competitive compensation and some degree of loan forgiveness have helped recruit new surgeons. Administrative assistance from the main campus eases the clerical burden the surgeons face. Guaranteed free time for vacations and educational meetings, as well as a reasonable call schedule, are all built into contracts; this has had a big impact on recruitment. GHS has concluded that three general surgeons in a community is the optimal number to maintain call coverage and mutual assistance.
“Successful, long-term employment of rural general surgeons within an integrated health system depends on keeping the promises that were made at the time of recruitment,” the investigators wrote.
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