There is little published data regarding the caseloads of general surgeons working in rural centres.[1, 2] It remains difficult to attract and retain surgeons in rural areas of Australia, with similar difficulties in the USA and Canada. The aim of this study is to describe the workload of surgeons working in a rural centre with outreach practices, in order to determine the required skills mix for prospective surgeons and trainees. Wangaratta is located in northeastern Victoria, approximately 250 km from Melbourne (the closest metropolitan centre with tertiary services). It is serviced by a public and private hospital, with Northeast Health Wangaratta servicing an area of approximately 43 000 km2, with a catchment population of 90 000 people. There are approximately 14 000 inpatient admissions and 19 000 emergency department attendances per year.
A retrospective review of surgical procedures carried out by two surgeons working from a base in Wangaratta over 5 years from January 2006 to December 2010 was performed. The number, type and location of procedure were recorded. The two surgeons both had public and private practices within Wangaratta, and provided elective outreach services to the neighbouring communities of Benalla, Mansfield and Bright. Data was extracted from surgeon records using Medicare Benefits Schedule (MBS) item numbers. When two MBS items covered a single operation (e.g. cholecystectomy with intraoperative cholangiogram), only one operation was counted. When two separate operations were performed on the same patient (e.g. gastroscopy and colonoscopy), both operations were counted.
Over the last 5 years, a total of 18 029 procedures were performed. Table 1 demonstrates the variety of procedures undertaken, and the distribution of work among the centres visited by the surgeons. The majority of procedures were carried out at Northeast Health Wangaratta and Wangaratta Private Hospital. The majority of procedures undertaken in Benalla, Mansfield and Bright were minor procedures, with only two laparotomies performed at these sites over the 5 years.
Table 1. Caseload of surgeons A and B over 5 years by location and case type
|Thyroid/parathyroid/major head + neck||142||60||0||2||0||204||3||1||0||0||4|
|Axillary/other lymph node dissection||34||32||4||0||0||70||34||13||0||0||47|
|Hand (carpal tunnel/dupuytrens/ganglion)||66||43||88||49||0||246||156||54||52||0||262|
Surgeon A performed a total of 10 322 cases, including 5189 endoscopies, while surgeon B performed 7707 cases, including 540 endoscopies. Surgeon A performed 37% of cases at Northeast Health Wangaratta, 32% at Wangaratta Private, 20% at peripheral hospitals and 11% in outpatient rooms. Surgeon B performed 43% of cases at Northeast Health Wangaratta, 12% at Wangaratta Private, 8% at peripheral hospitals and 37% in outpatient rooms. During the study period, there were four general surgeons working in Wangaratta, with the surgeons sharing a one in four on call roster.
There were four surgeons based in Wangaratta during the study period. We chose to examine the operative experience of two of the four, as these two surgeons had both been working in the area for 15 years with established practices and were therefore in a steady state of practice. The remaining two surgeons were both in the process of building up their practice, so were excluded from the study.
The surgeons in this study had significantly higher caseloads than reported by rural surgeons in Horsham, Hamilton, Echuca and Sale.[1, 2] This is in part due to greater opportunity to develop a private practice, with Wangaratta having its own private hospital, a facility not available in the smaller towns. The surgeons had greater access to theatre lists with their outreach work.
Outreach services were provided to the surrounding towns of Mansfield (103 km from Wangaratta), Bright (77 km from Wangaratta) and Benalla (40 km from Wangaratta). Surgeon A undertook outreach work 5 days a month, while surgeon B was involved in outreach work 2 days a month, with half this time spent consulting and the other half operating. The surgeons were available for telephone advice to general practitioners from outreach towns. A total of 2660 cases were performed in peripheral hospitals. By performing cases in peripheral hospitals, patients can have their procedures undertaken closer to their support networks without having to travel and procedures completed in home towns have been demonstrated to allow significant cost savings.[6, 7]
Surgeons travelling to these areas provide employment for local hospitals, allow local hospitals to remain open and allow nursing staff and general practitioner anaesthetists to maintain skills. If these procedures were not carried out at peripheral hospitals, they would add to the burden of work at an already busy regional centre. Working at multiple sites has several advantages for the surgeon, including increased access to theatre lists and not being at the mercy of a single health service. If complications develop from procedures performed in peripheral hospitals, the patient can be transferred to Wangaratta for ongoing management by the surgeon, so this model of outreach surgery allows for more effective continuity of care compared to fly in/fly out models.
Careful case selection is paramount when choosing patients for outreach surgery, and must be appropriate for the level of care that can be provided within the chosen centre. Patients at high risk of complications or likely to require intensive care support post-operatively are unsuitable for procedures in peripheral hospitals, and are booked for surgery in Wangaratta. American Society of Anaesthesiologists (ASA) classification of physical status 1–2 patients are preferred, with ASA 3 patients only considered if undergoing very minor procedures, usually under local anaesthetic or regional blockade. Patients need to have a body mass index < 35, and the largest cases undertaken are laparoscopic cholecystectomies. All patients are seen by the anaesthetist for preoperative assessment at least a week prior to their procedure. Anaesthetic support in these centres is mostly from older general practitioners who have done some anaesthetic training in the UK, or younger general practitioners who have spent 12 months undertaking anaesthetic training at a local major centre. In our series of patients, there was one patient who returned to theatre for bleeding post-hernia for evacuation of haematoma and one patient transferred to Wangaratta post-hernia for evacuation of haematoma. Equipment available at outreach hospitals is varied and sometimes quite basic, but as only a subset of operations are performed in these centres, limited equipment is usually all that is required.
The practice of the surgeons in this study is less broad when compared with data from rural surgeons working in Horsham, Hamilton, Echuca and Sale, with surgeons in these locations performing orthopaedic, thoracic, gynaecological, obstetric, vascular, ear nose and throat (ENT), urology and neurosurgical procedures in addition to more traditional general surgical procedures.[1, 2] Northeast Health Wangaratta has full-time orthopaedic, urology and obstetric cover, with visiting ENT and paediatric surgeons. The surgeons were supported by two registrars and two interns on rotation. As a result, the surgeons in this study did not perform any thoracic, orthopaedic, ENT or obstetric procedures. The range of skills required by rural surgeons is determined by the existence of surgeons of other specialties, the frequency of visits by surgeons from other specialties and the proximity to other centres with surgical specialty cover. Having a more narrow practice has allowed the two surgeons in this study to develop subspecialty interests in skin cancer, endoscopic retrograde cholangiopancreatiogram and thyroid surgery. Surgeon B has a major interest in skin cancer work, with 70% of cases being classified as skin, minor or plastic, and 37% of cases being performed at his consulting rooms. The UK has traditionally served as a significant contributor to post-fellowship training for rural surgeons, with Surgeon A having completed training in a thyroid and upper gastrointestinal unit. This pathway of post-fellowship training is now more difficult.
Skin, plastics, minor and hand cases accounted for 45% of cases performed during the study period. These cases are suitable to be performed in smaller centres without specialist equipment, anaesthetic, medical or intensive care unit backup. A term in a specialist plastic and reconstructive unit during training or post-fellowship would be helpful for future rural practice. The two surgeons in this study had 3-month registrar terms in plastics, and both came into practice with a soon to retire general surgeon with a lot of plastics experience.
The Rural, Remote and Metropolitan Area classification scale is a measurement of remoteness in Australia, with M1/2 being metropolitan locations, R1/2/3 and Rem 1/2 remote locations. Wangaratta, Horsham, Echuca and Sale are classified as R2 (small rural), while Hamilton is classified as R3 (other rural). Teamwork is exceedingly important in providing rural surgical services. It would be impossible to provide these services without appropriately trained anaesthetists, nursing and paramedical staff.
Doctors are reluctant to work in the country for a multitude of reasons, including partner occupation, access to schools, unwillingness to undertake a broad practice and increased focus on subspecialization, demanding on call commitments, loss of family support, lack of access to religious venues, less opportunity for private practice and academic isolation.[9, 10] The data from this study demonstrate several benefits of working in a larger rural centre compared with a smaller rural centre. These include less on call, greater opportunities for access to theatre with the ability to provide outreach services and greater opportunities to establish a private practice.
In 2010, 31% of Australians were living in rural or remote areas, with 14.5% of surgeons working in rural or remote Australia.[11, 12] The provision of adequate surgical services to rural Australia remains an ongoing issue with rural Australia continuing to struggle to attract and retain appropriately trained surgeons to long-term practice. Trainees should be encouraged to consider rural practice, and those with an interest in rural practice need to consider the needs of the community in which they intend to practice to ensure they undertake adequate training in the range of procedures likely to be required to be undertaken. Surgeons in rural towns should consider outreach to smaller towns to increase service provision to these towns, and in return receive extra theatre time and professional association with local doctors working in these areas. Future studies should examine the caseloads of surgeons working in rural and remote areas of other states of Australia, to allow planning for the future healthcare of rural Australia.