Imagine you are a 59-year-old orthopaedic surgeon who is on call every second night at your rural hospital. In the past week, your case load has included a 4-year-old with a supracondylar elbow fracture, a young man with compartment syndrome from a rattlesnake bite necessitating fasciotomies, a patient with diabetes and a foot infection requiring a transmetatarsal amputation, a patient who is incarcerated and has acromioclavicular joint septic arthritis from IV drug use, a healthy 100-year-old with a subcapital hip fracture, and a 55-year-old woman with a head-splitting proximal humerus fracture for which you performed a reverse total shoulder replacement. You savor the variety and the autonomy. You are rarely bored, but the isolation from your colleagues can be difficult. Your community and hospital are extremely appreciative for the care you provide, and you are treated with great respect. You love your job. You are planning to retire in 6 years, but there is no one in sight to take over care of your patients. Newly graduated orthopaedic surgeons tell you they are very uncomfortable managing this breadth of a caseload and taking so much call.

Rural orthopaedics can be a fulfilling and challenging career choice. There is an immense need for orthopaedic surgeons to choose rural practice. The need is increasing with rural surgeons retiring and an aging population requiring more care. Approximately 71 percent of rural hospital administrators reported they needed more orthopaedic services, and 25 percent of rural hospitals have no orthopaedic services at all. In fact, in 51 percent of U.S. counties, no orthopaedic surgeon can be found, and 93 percent of U.S. orthopaedic surgeons are located in metropolitan counties.

There is a need to create a pipeline of talent interested in rural practice. Ideally, we should recognize rural students interested in medicine early—even in middle school or high school—and start mentoring them. The greatest predictor of having a rural practice is growing up in a rural area or being exposed to rural communities. Mentoring programs can have a huge impact on career choice.

We also should consider rurality or commitment to rural practice in admissions to medical school and residency programs. Currently, only 4 percent of medical students come from rural backgrounds, even though rural communities make up 20 percent of the population. Medical students and residents should have the opportunity to rotate through rural settings so they can consider rural orthopaedics as a possible career choice. The focus on subspecialization after residency needs to be reconsidered, given the country’s workforce needs. Perhaps offering a “generalist” residency or fellowship or tying graduate medical education funding to rural exposure or rural practice could be considered. Loan forgiveness to those starting in rural practice can help facilitate careers. This offering should be expanded to include orthopaedic surgery in all states.

Attracting talent to rural communities
Attracting orthopaedic surgeons to rural areas requires incentives. Competitive salary packages including sign-on bonuses, loan forgiveness, relocation assistance, and performance-based incentives can be helpful. In addition, some states offer tax credits for physicians working in rural areas; this can be a powerful incentive to promote geographic diversity. State and national advocacy efforts can work to expand existing state and federal loan-forgiveness programs for primary care specialists (general surgery, family medicine, internal medicine, obstetrics and gynecology) practicing in underserved rural areas to include orthopaedic surgeons.

Improving work-life balance with lots of vacation and flexible scheduling can add to the appeal of a rural practice. Increasing relative value unit values for surgeries performed in rural settings could be considered, and the Centers for Medicare & Medicaid Services should end the cost-of-living disincentive to rural practice by eliminating the Geographic Practice Cost Indices.

One of the beauties of living in a rural community is easy access to nature and the lack of urban congestion. Rural towns and hospitals often have a very strong sense of community that is friendly and welcoming. The cost of living is significantly lower. Recruiters can highlight these benefits. It is also important to have desirable opportunities available for spouses, partners, and children.

Supporting rural orthopaedic surgeons
When you work with few or no colleagues and have no dedicated orthopaedics team, finding support can be vital. Ideally, partnerships with larger health systems or academic institutions could provide medical education opportunities, referral networks, and colleagues with whom to discuss cases. Creating this type of support and networking could be a goal of institutions committed to healthcare equity. Perhaps 1- to 2-week mini-fellowships for rural orthopaedic surgeons could be developed. Alternatively, specialists could be “deployed” to rural hospitals to provide care and work with rural surgeons.

In rural hospitals, the orthopaedic device companies and representatives play a substantial role in bringing in implants, educating staff, and sponsoring training. Their contributions cannot be overestimated when limited OR staff is stretched thin. They are often the unsung heroes in the rural OR.

Within the hospital itself, policies concerning after-hour calls, availability of hospitalist support, and flexible call solutions can have a huge effect on quality of life. The ability to easily transfer cases that are not appropriate for a rural setting is essential. There are simply not enough resources, specialists, and staff to manage everything at a small hospital. Unfortunately, this is a huge source of aggravation for many rural orthopaedic surgeons and often poorly understood by surgeons at larger facilities.

Advocating for rural orthopaedics
There has recently been a great increase in awareness about rural orthopaedic issues. The opportunities for advocacy are abundant. Creating a special interest group, possibly within AAOS, could be a great place to start. At the state and national levels, access to care in rural communities is a hot topic. The National Institutes of Health are prioritizing issues regarding rural health disparities. The time is ripe to reconsider how we as a profession are providing care for all of our population.

Lisa Ronback, MD, FAAOS, FRCSC, is orthopaedic director at Sutter Amador Hospital in Jackson, California. She is also on the Musculoskeletal Research Assessment Council at Sutter Health.

James Barber, MD, FAAOS, is the owner and solo practitioner at Southeastern Orthopaedics in Douglas, Georgia. In his role as secretary of the AAOS Board of Councilors, he also currently serves on the AAOS Board of Directors.

References

1. Weichel D: Orthopaedic surgery in rural American hospitals: a survey of rural hospital administrators. J Rural Health 2012;28(2):137-41.
2. Ortiz-Babilonia CD, Mo K, Raad M, et al: Orthopaedic surgeon distribution in the United States. J Am Acad Orthop Surg 2022;30(18):e1188-94.
3. Hancock C, Steinbach A, Nesbitt TS, et al: Why doctors choose small towns: a developmental model of rural physician recruitment and retention. Soc Sci Med 2009;69(9):1368-76.
4. Shipman SA, Wendling A, Jones KC, et al: The decline in rural medical students: a growing gap in geographic diversity threatens the rural physician workforce. Health Aff (Millwood) 2019;38(12):2011-8.