Rural versus urban general surgical practices.

We were delighted to review Van Bibber and colleagues’ recent report on differences between rural and urban general surgical practices as defined through use of the Nationwide Inpatient Sample (NIS). Not surprisingly, these authors reported that rural and urban general surgical case-mixes differ substantially. They concluded that additional competence in a few procedures could result in an increased role for general surgeons in rural areas. Among these procedures, the authors included “vein stripping, arteriovenous fistula creation, venous catheterizations, . . . and amputations.” The authors also describe a report by Ritchie and colleagues who used operative logs from recertifying general surgeons to report differences in surgical practices. Their data confirmed that rural general surgeons performed less vascular surgery than their urban counterparts and substantially less than certified vascular surgeons recertifying in general surgery. We recommended that all general surgeons should know the vascular anatomy associated with general surgical procedures and be competent in the management of vascular trauma, catheter based and operative interventions for angio-access, venous procedures to include vena cava interruption and management of deep vein thrombosis, reconstructive procedures, and amputations. We are disappointed that our recommendations apparently have not been implemented and trainees are increasingly deficient in the vascular procedures identified in Van Bibber’s report. Six years after our recommendations, Van Bibber and colleagues conclude that recognition of these differences will help surgical educators and leaders better understand and meet the needs for training of general surgeons. Finally, we appear to be in agreement on case requirements for general surgeons! These data also confirm the marked differences in the specialty practice of vascular surgery as compared with rural and urban general surgery. We seek to improve the care of vascular disease patients through improved training of general and vascular surgical residents as monitored in the future by the American Board of Surgery and an American Board of Medical Specialities-approved American Board of Vascular Surgery. This latter recommendation should also be reviewed by surgical educators who are influential in decisions about the training of general surgeons. If rural general surgeons need added training, as defined by the authors, vascular surgeons are prepared to participate in a program for correction of these deficiencies.