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This article originally appeared in the fall 2012 edition of Bridges, the School of Medicine's alumni magazine.

Rural surgeons
Unique residency track helps place general surgeons into rural communities

On a warm summer evening, Mike Munly, M.D., and Libby Windell, D.O., sit outside on their porch enjoying precious moments of free time, listening to music and cataloging what they like about being here.

“Here” is Grants Pass, Ore., population 34,533. The fourth-year residents of OHSU’s general surgery graduate medical education program are living in Grants Pass – weeks into an optional, year-long rotation that has them training in this rural Southern Oregon town. The program embeds two residents each year into the medical community and Asante Three Rivers Medical Center where they become competent in the broad surgical and clinical skills necessary to practice in a rural setting, if they so choose. Equally important, they sample the life of a small town physician.

In turn, Grants Pass benefits with cost-effective surgical help, a recruitment edge and a pipeline into the newest techniques and knowledge circulating at OHSU. As Grants Pass surgeon Mark Deatherage, M.D. ’74, said, “It’s fun. It takes a bunch of old surgeons and makes them young again.”

General surgeons are highly valued in small communities because they provide backup to other physicians and power medical services. Skill-wise, they’re surgical Swiss Army knives, often serving as the crucial operating lead on cases ranging from obstetrics to otolaryngology. These surgeons master a breadth of skills and develop the judgment to know when a patient’s needs have outstripped local expertise.

rural-surgeons2-120712“It’s interesting to see the attendings go through the algorithm, ‘Can I get this patient safely through an operation? Do I have the support staff?’” said Dr. Windell. “It’s a mindset that rural general surgeons need that you don’t always get by training in an academic health center because you’re the main referral center and you always have the staff and expertise.”

Meet the demand

Nationally, across all geographic areas, the number of new general surgeons has essentially remained flat. According to a 2010 report from the American College of Surgeons Health Policy Research Institute, the number of general surgery residents increased by less than 1 percent between 2004 and 2008, while population grew 9 percent.

Professor of Surgery Karen Deveney, M.D., vice chair of education and residency director in the Department of Surgery, hears about Oregon’s rural need all the time. “I frequently get calls from physicians around the state asking to send patients to [OHSU],” she said. “We’re happy to take them, but many patients could have been treated locally if those sites had an adequate surgical workforce.”

It’s not for lack of trying in these communities, she adds. “I get a lot of calls from middle-aged or older surgeons asking, ‘Gee, are you graduating somebody who could come join me in practice?’ It’s hard to find people.”

In response, 10 years ago Dr. Deveney and OHSU launched this first-in-the-nation program to meet the demand, partnering with Dr. Deatherage in Grants Pass.

In the early years, residents didn’t receive credit for their year. They came nonetheless. Then, as now, most love it. They apprentice under small town veteran surgeons and subspecialists, developing relationships and building trust. They practice their skill sets endlessly and lead operations by year’s end. When they leave, they’ve logged about 500 cases, more than twice the caseload of a typical residency year and enter their chief year “independently capable,” according to Dr. Deveney.

“There’s not a lot of structure, just a whole lot of patients who need to be taken care of and operations that need to be done,” explained Dr. Deatherage.

Until a few years ago, Grants Pass was thirsty for general surgeons, according to long-time practitioners there. But now, the workforce benefits of this unique partnership with OHSU are beginning to bear fruit. Of the 15 graduates of the Grants Pass rotation, seven are now practicing in a rural area, and two stayed put in Grants Pass: Alexis Alexandridis, M.D. R ’11, and Mark Jones, M.D. R ’08. (For comparison, of those OHSU general surgery residents who didn’t rotate through Grants Pass in the same time period, just 6 percent practice in rural areas.)

Now, due to the program’s success, other medical schools – University of Utah and University of New Mexico, for example – have used OHSU as a resource for making their own inroads into rural workforce shortages.

And OHSU is also taking the lead in closing the knowledge gap. While anecdotal evidence demonstrates a surgical shortage in rural Oregon, there’s a lack of hard data. This fall, Dr. Deveney is conducting a needs assessment among the state’s rural surgeons in partnership with the American College of Surgeons. When completed, these data from Oregon will be extrapolated to identify national trends, which will inform next steps in other states.

“OHSU has a very unique program”

Dr. Windell offers a visitor some homemade blackberry cobbler. She picked the berries in a pasture just across from where the residents live, a house that is 45 seconds from the hospital. (Not that anyone has timed it.)

Dr. Windell is from Newport, Ore., population 9,989. Dr. Munly grew up in Tillamook, Ore., population 4,935. Both say they want to return to smaller communities to practice. Dr. Windell likes the feel of a small town and enjoys running into patients in the grocery store. Dr. Munly appreciates the friendliness of surgical staff and the relationships he’s developing with local physicians. They both like the case volume and mix.

We get exposure to a whole spectrum, from the standard bread-and-butter surgery such as gall bladders and hernias to the more complex procedures,” said Dr. Munly. “For example, I’ve done a repair on an abdominal aortic aneurism and a difficult resection for recurrent rectal cancer. This gives me confidence about practicing in a rural setting.”

Both say they applied to OHSU’s residency program in large part because of its dedicated year of rural surgery. “Other programs didn’t have that breadth,” said Dr. Munly. “They didn’t rotate at community hospitals. They didn’t have that rural catchment area. OHSU has a very unique program.”

Studies suggest that medical students from rural communities are more likely to practice in those places than suburban or urban students. Dr. Alexandridis, who has just completed her first year in practice in Grants Pass, stands out. She’s from suburban Detroit and went to New York Medical College, just outside New York City.

“There is a decided lack of restaurants and night life in Grants Pass,” said Dr. Alexandridis, smiling. “But all the glitz and glam of a city is replaced by an amazing working environment and an amazing community. This is a great place to practice. And it’s because of the residency program that I am here.”

Pictured: (top) Residents Libby Windell, D.O., and Mike Munly, M.D.; (bottom) Alexis Alexandridis, M.D., R '11


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Published Dec 07, 2012