It Takes a Village: Building Educational Networks to Sustainably Support Rural Trauma and Surgical Residency Training

Setting and Problem

Urban medical education centers account for most surgical and trauma training locations within the United States. Although 20% of the US population lives in rural areas, only 2% of accredited surgical programs have a rural setting.¹ Successful urban surgical training does not necessarily translate to effectual rural or frontier practice. This context may holistically alter the knowledge, skills, attitudes, and other attributes of core surgical competencies required to be prepared for practice.

To build a surgical workforce equipped to serve rural communities, we need innovative solutions to overcome resource and training limitations. This includes creating more surgical and trauma training programs specifically in rural and frontier areas.

Intervention

Although our institution supports several graduate medical education (GME) programs, partnering with large, established surgical residency programs would bolster the resources needed to support rural surgical training. Leveraging our academic connections, our General Surgery and Trauma team identified 2 prominent urban teaching hospitals (UTHs) that shared our vision for fostering rural surgical training within our health care system, which consists of a rural referral center (RRC) and multiple critical access hospitals (CAHs; Figure). The RRC serves as the surgical training hub, providing a foundation in surgical principles and fostering an understanding of the RRC’s role in supporting patient transfers from CAHs. The trainees also spend time at multiple CAHs developing the surgical competencies needed for austere surgical environments.

View Figure

• Download as Powerpoint
• Download Figure

Planning and logistical considerations have been key challenges. Numerous organizations, despite diverse systems and processes, collaborated to form the educational and logistical foundation for academic success. Strong communication and relationship building across organizations was essential. The surgical site director at the RRC collaborated with surgical program directors at the UTHs to develop curricula that would provide clinical experiences in line with rural practice. Concurrently, GME support staff at the RRC and UTHs collaborated to ensure smooth resident transitions between rotations in multiple varied practice environments. These considerations led to some curriculum adjustments. For example, the number of varied CAH rotations was reduced to focus on fewer core CAH sites with more RRC time. Doing so reduced logistical complexity and enabled the team to focus on contextual considerations and their impact on surgical and trauma clinical practices.

Outcomes to Date

In a little over 2 years, 9 postgraduate year (PGY) 4 surgical resident trainees have participated. The feedback from trainees, supervising surgeons, CAHs, and UTHs has been overwhelmingly positive. Spending time at the RRC and CAHs has provided the opportunity for residents to gain a holistic view of rural health care systems and has addressed rural training challenges. For example, patient volumes could be sporadic at small CAHs, but they offered the opportunity to manage complex patients in low resource environments. Time at the RRC provided higher volumes but also enabled trainees to manage patients initially stabilized at CAHs who would require definitive surgical intervention in a tertiary setting. Residents have averaged a substantial number of surgical procedures per month (mean=68.31; SD=12.81) significantly contributing to their graduation requirements. Because of the initial pilot work successes with PGY-4 residents, we are now exploring options for further development at all learning levels.

This program’s effectiveness has been significantly bolstered by the surgical team’s previously established collaboration network within the regional health care matrix. Five CAHs across the region have hosted residents with several other CAHs expressing interest in participating. Furthermore, a more national surgical network involving educational partnerships with large, urban, academic programs has created opportunities for cross communication. Through those connections, we could successfully address resource issues, communicate essential information, and develop programs with national standards alignment, but also meet rural and frontier surgical and trauma training needs.