There is a growing shortage of orthopaedic surgeons in rural areas of the United States. As the general population ages, the need for musculoskeletal care will continue to increase. Without a proportional increase in rural providers, the shortage may become a full-blown healthcare crisis. There are varied reasons why a surgeon may not want to live and/or work in a rural setting, including hospital resources, patient-referral patterns, and geographic/transportation issues.

However, there are many benefits to practicing in a rural area, which include but are not limited to the ability to make a profound impact in the lives of otherwise underserved patients, a slower pace of life, lower cost of living, and better access to nature and recreational activities. For many, these benefits do not overshadow the challenges, so the challenges must be examined and discussed to overcome the critical surgeon shortage in rural America.

Geography and transportation
Rural settings have a wide cross-section of people from all economic backgrounds. For those living below the poverty line, the added restraints of geographical isolation make accessing medical appointments difficult. Many do not own vehicles or have limited funds for gas, and public transportation is often lacking. Even local office visits may be an economic strain, much less referrals to larger cities for subspecialist appointments. Physical therapy visits, postoperative follow-up visits, and other necessary appointments are often not feasible. Moreover, when patients are acutely ill and need to be transported to a higher level of care, there are often a limited number of ambulances available to transport them, and helicopters are highly dependent on weather conditions. Rural areas are often underfunded, further straining services.

Resources
Rural hospitals are typically not as well staffed or well funded as urban hospitals, often offering a smaller variety of services. Many medical subspecialties are simply not available, and if they are, wait lists are months long. Ancillary services such as physical therapy are fewer in number. Advanced imaging is often not available; fewer MRI machines increase wait times for exams, and many areas rely on mobile imaging centers for studies such as positron emission tomography scans. Blood banks are not always present, and blood may take several hours to become available, particularly if a patient needs specially treated or cross-matched blood. There are fewer skilled nursing facilities, long-term acute care facilities, and home health agencies.

Within the hospital itself, rural surgeons may be less likely to have a physician assistant or nurse practitioner and often do not have residents. They shoulder a higher burden of work, including all rounding, orders, notes, implant ordering, and office visits. This workload may contribute to poorer work-life balance and increased burnout. Many rural areas carry a stigma for not providing the same quality of care as urban centers, so retaining patients locally for care can be a challenge. This stigma may add more stress for surgeons whose compensation relies on productivity expectations that are not realistic for the area, resulting in lower compensation and increased surgeon dissatisfaction.

Surgical limitations
Many orthopaedic implant companies are unwilling to keep implants on the shelf for rural surgeons, particularly if they have lower volume in a particular type of case. Each case takes careful planning and anticipation of all possible needs, with implants/trays sometimes being couriered in for individual cases. If there is an issue with sterile processing and a tray is contaminated, there may not be a backup. If a surgical plan changes mid-case and there is no equipment or implant for plan B, the surgeon (and patient) may be out of luck. Even with meticulous planning for each case, if problems arise, the rural surgeon often lacks the resource of a partner to help or provide advice.

Furthermore, rural facilities may not have specialties that may be needed if complications arise, such as vascular surgery, interventional radiology, cardiothoracic surgery, or infectious disease. Room availability, staffing ratios, and room utilization may mean slower turnovers and fewer cases performed in a day. Fewer rooms and limited anesthesia may increase the chance a case is bumped for an emergency. A rural OR is less likely to have a dedicated orthopaedic team; scrub technicians and circulators may be less experienced with orthopaedic cases, increasing challenges for the surgeon. In a rural area with older, sicker, more complex patients, surgeons have less opportunity for subspecialization and need to be more generalists. Surgeons often have to be a jack-(or jill-)of-all-trades; there is less opportunity for a pure hip arthroscopy or hand surgery practice.

Community
Rural communities are often less diverse, and finding a community to call home can be tough for individuals who are not originally from that area. For surgeons who return to the community of their childhood, living around family can be very desirable, particularly if they have children. For single people, rural living can be tough. The dating pool is often smaller and continues to shrink with age. There are often fewer social activities available. An individual may not mesh ideologically with the community. Educational opportunities may be fewer, and if a surgeon or family members have special needs, there are likely fewer resources. Airports and other transportation hubs may be a long distance away, making long-distance travel more time consuming.

These may seem like an innumerable number of challenges for a rural surgeon to face, although practicing in an urban or suburban environment is not challenge-free. However, if you find a rural community where you feel at home, practicing in that setting can be extremely rewarding. Nonetheless, it would be unwise to ignore the challenges, and addressing these issues and improving conditions will help alleviate the growing surgeon shortage in the United States and improve access to care for more Americans.

Leslie Schwindel, MD, FAAOS, is a general orthopaedic surgeon at Lake Cumberland Regional Hospital in Somerset, Kentucky, and a member of the AAOS Now Editorial Board.