General Surgery Workforce
in Rural America
Working Paper #77
Matthew J. Thompson, M.B., Ch.B.
Dana Christian Lynge, M.D.
Eric H. Larson, Ph.D.
Pantipa Tachawachira, Ph.C.
L. Gary Hart, Ph.D.
This research was funded by the U.S. Health Resources and Services Administration, Federal Office of Rural Health
Policy. Cooperative Agreement #5 U27 RH 00235-03.
UNIVERSITY OF WASHINGTON • SCHOOL OF MEDICINE • DEPARTMENT OF FAMILY MEDICINE
ABOUT THE CENTER
The WWAMI Rural Health Research Center (RHRC)
is one of six centers supported by the Federal Office of
Rural Health Policy (FORHP), a component of the
Health Resources and Services Administration
(HRSA) of the Public Health Service. The major
focus of the WWAMI RHRC is to perform policy-
oriented research on issues related to rural health care.
Specific interests of the Center include the training and
supply of rural health care providers and the content
and outcomes of the care they provide; the availability
and quality of care for rural women and children,
including obstetric and perinatal care; and access to
high-quality care for vulnerable and minority rural
The WWAMI Rural Health Research Center is based
in the Department of Family Medicine at the
University of Washington School of Medicine, and has
close working relationships with the WWAMI Center
for Health Workforce Studies, Programs for Healthy
Communities (PHC), and the other health science
schools at the University, as well as with other major
universities in the five WWAMI states: Washington,
Wyoming, Alaska, Montana, and Idaho. The
University of Washington has over 30 years of
experience as part of a decentralized educational
research and service consortium involving the
WWAMI states, and the activities of the Rural Health
Research Center are particularly focused on the needs
ABOUT THE AUTHORS
MATTHEW J. THOMPSON, MB, CHB, was an Assistant Professor in the Department of Family Medicine,
University of Washington School of Medicine, at the time of this study.
DANA CHRISTIAN LYNGE, MD, is an Assistant Professor in the Department of Surgery and an Adjunct
Assistant Professor in the Department of Family Medicine, University of Washington School of Medicine.
ERIC H. LARSON, PHD, is Deputy Director at the WWAMI Rural Health Research Center, Department of
Family Medicine, University of Washington School of Medicine.
PANTIPA TACHAWACHIRA, PHC, was a Research Assistant in the Department of Family Medicine,
University of Washington School of Medicine, at the time of this study.
L. GARY HART, PHD, is Director of the WWAMI Rural Health Research Center and Professor in the
Department of Family Medicine, University of Washington School of Medicine.
and challenges in these states. The WWAMI RHRC
also works closely with the associated Area Health
The Rural Health Working Paper Series is a means of
distributing prepublication articles and other working
papers to colleagues in the field. Your comments on
these papers are welcome, and should be addressed
directly to the authors. Questions about the WWAMI
Rural Health Research Center should be addressed to:
L. Gary Hart, PhD, Principal Investigator and Director
Eric H. Larson, PhD, Deputy Director
Roger A. Rosenblatt, MD, MPH, Co-Investigator
Denise Lishner, MSW, Associate Director/Editor
WWAMI Rural Health Research Center
Department of Family Medicine
School of Medicine
University of Washington
Seattle, WA 98195-4982
The WWAMI Rural Health Research Center is
supported by the Federal Office of Rural Health
Policy, Health Resources and Services Administration,
Public Health Service (grant #U1CRH00035-04,
Characterizing the General Surgery
Workforce in Rural America
MATTHEW J. THOMPSON, M.B., CH.B.
DANA CHRISTIAN LYNGE, M.D.
ERIC H. LARSON, PH.D.
PANTIPA TACHAWACHIRA, PH.C
L. GARY HART, PH.D.
General surgeons form a crucial component of the
medical workforce in rural areas of the United
States. Any decline in their numbers could have
profound effects on access to adequate health care
in such areas.
To determine the numbers, characteristics and
distribution of general surgeons currently
practicing in the rural United States.
DESIGN AND SETTING
The American Medical Association’s (AMA)
Physician Masterfile was used to identify all
clinically active general surgeons as well as their
location and characteristics. Their geographic
distribution was examined using the ZIP code
version of the Rural-Urban Commuting Areas
(RUCAs). Surgeons were classified as practicing
in urban areas, “large rural” areas, or “small/
There are currently 17,243 general surgeons
practicing in the United States. Nationally, the
number of general surgeons per 100,000
population varies from 6.53 in urban areas to 7.71
in large rural areas and 4.67 in small/isolated rural
areas. Only 10.6 percent of the nation’s general
surgeons are female. Wide variations in numbers
of general surgeons were found between and
within individual states. General surgeons in the
smallest rural areas are more likely than those in
urban areas to be male (92.7% versus 88.3%,
p < 0.001), 50 years of age or older (51.6% versus
42.1%, p < 0.001), or international medical
graduates (25.2% versus 20.1%, p < 0.001).
The overall size of the rural general surgical
workforce has remained static over the last
decade, but its demographic characteristics
suggest that numbers will decline. Many rural
residents have limited access to surgical services.
Steps to reverse this trend are needed to preserve
the viability of health care in many parts of rural
General surgeons are a crucial component of the health
care workforce in rural America. A 1993 conference
on rural health care, sponsored by the University of
Alabama, concluded that the presence of a general
surgeon was a requirement for adequate health care in
the rural setting. General surgeons provide essential
support for rural family physicians by performing
emergency surgeries and critical care services.
Additionally, where other specialists are unavailable,
they often perform necessary obstetrical,
gynecological, orthopedic, and endoscopic procedures.
The presence of general surgical services has been
shown to be critical to the financial viability of rural
hospitals and the success of rural trauma systems.1-5
Indeed, in many smaller hospitals general surgery is
the second most common specialty after family
practice.6 Given the importance of general surgeons to
rural health care, determining their numbers relative to
the populations they serve and detecting any
significant trends is essential for ensuring an adequate
supply in rural areas.
Although there are few prior estimates of the number
of rural general surgeons per se, workforce studies
from the mid 1990s estimated that there were between
17,000 and 23,000 general surgeons in the United
States, depending on the data sources and definitions
of general surgeons used.7,8 However, it is likely that
both the overall number of general surgeons, and their
number in rural areas has declined. First, the general
surgery workforce, particularly in rural areas, appears
to be aging. A study in rural Missouri, for example,
noted that almost half of the general surgeons were
within a decade of retirement.9 Second, interest of
graduating U.S. medical students in general surgery
careers as reported in graduation questionnaires has
declined since the early 1980s.10 Finally, the
proportion of general surgery residency graduates
selecting rural practice declined from 20 percent in the
late 1970s to 13 percent in the mid-1980s.8,11
Recognizing this decline in rural general surgeons, the
Council on Graduate Medical Education suggested
ameliorative policies,12 including increased attention to
residencies that promote and prepare general surgeons
for rural practice.
General surgeons face mounting challenges in rural
areas as a result of rural hospital closures, changing
referral patterns, increasingly tight reimbursement
policies, difficulties with recruitment because of
“lifestyle issues” and other factors—leading some to
describe rural surgery as facing a “crisis.”13 We report
here on the current state of the general surgery
workforce in the United States, with particular
emphasis on the characteristics and distribution of
surgeons in rural areas.
We used the 2001 American Medical Association
(AMA) Physician Masterfile data set, which contains
information on all 771,491 nonfederal allopathic and
osteopathic physicians in the United States, with
names omitted. We identified general surgeons on the
AMA data set based on primary specialty listed. We
included only surgeons who listed their primary
specialty as general surgery, abdominal surgery,
trauma surgery or critical care. We only included
surgeons if they were clinically active, namely, if they
reported their major professional activity as one of
office-based practice, hospital staff, or locum tenens.
We excluded physicians in residency training because
the purpose of this study is to examine the practice
location of general surgeons who form part of the
permanent physician workforce. Finally, we only
included general surgeons ages 62 years or younger,
based on the average age of retirement of Fellows of
the American College of Surgeons.14 This definition of
clinically-active, nonresident general surgeons was
identical to the “minimum scenario calculation” used
by Jonasson et al.,8 except that they included only
those surgeons less than 62 years of age.
The AMA Masterfile lists a ZIP code, assumed to be a
work address, for each physician. In order to
determine the rural or urban location of a physician’s
reported practice, we used the ZIP code version of the
Rural-Urban Commuting Areas (RUCAs). The
RUCAs were developed in a collaboration between the
Department of Agriculture’s Economic Research
Service and the WWAMI Rural Health Research
Center at the University of Washington, supported by
the Federal Office of Rural Health Policy.15 RUCAs
use Census Tracts (to which ZIP codes are
approximated) rather than counties as building blocks,
to define rurality based on community populations and
work commuting patterns. RUCAs are currently being
used by several federal agencies to define rurality and
determine eligibility for some federal programs
directed at rural areas and residents.
For the purposes of this study, the 30 RUCA categories
were collapsed in three groups—“Urban”
(metropolitan area core with population greater than
50,000), “Large rural” (large town core with a
population between 10,000 and 50,000) and “Small or
isolated rural” (towns with populations of 2,500 to
10,000 or areas without an urban core population of at
least 2,500). ZIP code-based population estimates from
1998 Claritas data were used to determine surgeon/
We examined the demographic characteristics of
general surgeons, including age, gender, medical
school, and board certification, in order to identify
differences in those practicing in rural and urban areas.
International medical graduate (IMG) surgeons were
defined as those who had graduated from a medical
school outside of the United States or Canada.
Bivariate associations between urban/rural site of
practice, and the demographic factors were examined
using the chi-square test.16 Analysis was performed
using SPSS version 6.0.
Using the AMA Masterfile supplemented with county
population data, we calculated the absolute numbers of
clinically-active general surgeons, and the general
surgeon/100,000 population ratios for the nine Census
Bureau Divisions, as well as for each state.
Additionally, we calculated general surgeon/100,000
population ratios for urban, large rural, and small/
isolated rural areas in each of the regions, divisions
and states. This allowed comparisons across divisions,
states, rural and urban areas by taking into account the
wide variations in absolute numbers of general
surgeons in such disparate categories.
GENERAL SURGEON NUMBERS
There were 17,243 clinically-active, nonresident
general surgeons in the United States in 2001, with an
overall general surgeon to population ratio of 6.40
general surgeons per 100,000 population (Table 1).
Nationally, 10.6 percent of general surgeons were
female, and 80.1 percent were graduates of U.S. or
Canadian medical schools. General surgeons in urban
areas were more likely to be female (11.7%) than those
in large rural (6.1%) or small/isolated rural areas
(7.3%) (p < 0.001). General surgeons ages 50 years or
older were significantly more likely to be located in
small/isolated rural areas than in urban areas (51.6%
vs. 42.1%, p < 0. 001), and more likely to be located in
small/isolated rural areas than large rural areas (51.6%
vs. 44.2%, p < 0.001). Board certification information
Table 1: Characteristics of General Surgeons in Urban, Large Rural,
and Small/Isolated Rural Areas of the U.S. in 2001
was not reported for 19 percent of general surgeons.
General surgeons who are IMGs were significantly
more likely to be located in small/isolated rural areas
(25.2%) or urban areas (20.1%), as compared to large
rural areas (14.0%) (p <0.001 for both), and
significantly more likely to be practicing in small/
isolated rural areas than urban areas (25.2% vs, 20.1%,
p < 0.001).
GEOGRAPHIC DISTRIBUTION OF
Nationally, there were 6.40 general surgeons per
100,000 population, however this varied from 6.53 in
urban areas to 7.71 in large rural and 4.67 in small/
isolated rural areas (Table 2). For urban areas, the
lowest number of surgeons per 100,000 population
was found in the Pacific (5.41), West South Central
(6.11), Mountain (6.17), and East North Central (6.22)
census divisions. In large rural areas, the West South
Central (6.20) and Pacific (6.82) divisions again had
the lowest number of general surgeons relative to
population. Finally, in the small/isolated rural areas,
the census divisions with the smallest relative number
of general surgeons included the West South Central
(3.04), West North Central (3.66) and Pacific (4.22)
The numbers of general surgeons per 100,000
population for urban, large rural, and small/isolated
rural areas of all 50 states and the District of Columbia
(Table 3 and Figure 1) demonstrated an even wider
degree of inter- and intra-state variation than was
noted at the more aggregated division level. In some
states, such as Wyoming, there were proportionately
more surgeons in rural and urban areas than the
national average. In others, such as Washington
however, there were proportionately fewer surgeons in
all types of areas than the national average. Finally, in
many states there were proportionately more surgeons
in some types of areas, and fewer in other types of
areas (e.g. North Dakota).
For almost a decade, there have been concerns raised
about the adequacy of the general surgical workforce
serving rural America. Any decline in rural general
surgeons would have profound effects on patient
access to clinical services, the viability of trauma
systems, rural hospital financial viability, and surgical
back up for primary care practitioners in rural areas.
There were 17,243 general surgeons practicing in the
United States in 2001; this is very similar to the
17,289 identified from the AMA Masterfile in 1994
using similar criteria to ours,8 and suggests that the
general surgical workforce has not kept pace with the
rising population. This may be due to a number of
factors, including more general surgeons taking early
retirement, or an increasing tendency for graduating
residents to seek fellowship training rather than
practicing general surgery. Moreover, our study
suggests that the number of general surgeons in the
(n = 13,647)
(n = 1,956)
(n = 1,636)
(n = 17,243)
US or Canadian
Board certified in
* Data on gender, age and country of medical school were missing for 4 individuals.
† Data on Board Certification were missing for 3,278 individuals.
Percentages may not add to 100 owing to rounding.
Table 2: Ratios of General Surgeons per 100,000 Population in Urban, Large Rural,
and Small/Isolated Rural Areas of Census Bureau Divisions in 2001
in Small or
in Small or
Table 3: Ratios of General Surgeons per
100,000 Population in Urban, Large Rural,
and Small/Isolated Rural Areas of All 50
States and the District of Columbia in 2001
most rural areas of the United States, in particular,
will decline further. First, we found that rural
general surgeons are older than those in urban
areas, suggesting that the relative deficit of general
surgeons in more rural areas will only continue to
increase. Second, the preference of female
surgeons for urban practice suggested by our data
may exacerbate the situation in an era when an
increasing number of medical students and thus
surgeons are female. Third, we found that general
surgeons who are IMGs are more likely to be found
in smaller rural areas than in urban areas,
suggesting that IMG general surgeons are filling
positions in what is deemed by U.S. graduates to be
less attractive practice settings, in this case rural
The majority (79.1%, or 13,647) of the 17,243
clinically-active general surgeons in the United
States practice in urban areas, with 11.3 percent
(1,956) in large rural areas and 9.5 percent (1,636)
in small/isolated rural areas. Overall, the 60 million
Americans (22.4% of the total population) living in
rural areas are served by 20.8 percent of the
nation’s general surgeons, suggesting that as a
whole rural areas are adequately served by general
surgeons. This contrasts markedly with previous
studies which estimated that approximately 10
percent of general surgeons were practicing in rural
areas,17 possibly because of less precise definitions
of rurality. However, we did note that there are
relatively more general surgeons (per population) in
large rural areas, compared to urban areas, perhaps
reflecting the fact that many of the clinical services
performed by general surgeons in large rural areas
are undertaken by surgical subspecialists in urban
areas. Alternatively, it is possible that in some
states (e.g., California) managed care organizations
have a greater presence in urban areas than in large
rural areas, and such organizations tend to manage
patients with fewer surgeons. The ratio of general
surgeons is far lower in small/isolated rural areas,
however, with only 4.67 general surgeons per
100,000 population in these areas. Within small/
isolated rural areas we noted wide variation across
the country, with even fewer surgeons in many
states situated in the West North Central, West
South Central, Mountain and East North Central
divisions. This suggests that particular small/
isolated areas in certain states are less attractive
than others. This may be the case in areas that lack
the required threshold population to support a
general surgeon, and may also reflect other factors
such as lifestyle, practice viability, lack of training,
or limited access to clinical facilities in such areas.
The relatively smaller numbers of general surgeons
per unit population located in small rural/isolated
areas compared to urban and large rural areas begs
Figure 1: Comparison of Numbers of General Surgeons per 100,000 Population in
Urban, Large Rural, and Small/Isolated Rural Areas of the United States in 2001
the question of whether there is a baseline shortage of
general surgeons in rural areas at present. There is no
single accepted criterion of an “adequate” general
surgeon to population ratio. The Primary Care Health
Professional Shortage Areas Maps produced by the
U.S. Health Resources and Services Administration
designate areas with shortages of family physicians,
general pediatricians, general internists and
obstetrician/gynecologists—but not general surgeons.
In our study, the average number of general surgeons
per 100,000 population in small rural/isolated areas
nationwide is certainly lower than 2 standard
deviations below the mean number of surgeons per
100,000 population in urban and large rural areas in
our study. It is also markedly lower than the national
average of 7.1 practicing general surgeons per 100,000
population found by Jonasson and Kwakwa in 1996.14
It is also below the HMO benchmark of 5.1 general
surgeons per 100,000 population cited by Goodman et
al. in 1996.18 What exactly constitutes a “shortage” of
general surgeons is beyond the scope of this paper, but
our data suggest that residents of isolated/small rural
areas have less immediate access to general surgical
care than do residents of urban and large rural areas.
This study has several potential limitations. First, we
assumed that a physician’s ZIP code listed in the AMA
Masterfile was his or her practice address—it is
possible however that some surgeons may have listed
their home address. Second, it should be borne in
mind that this study addresses only the supply of
general surgeons available to different populations, not
the utilization of surgical services. For various
reasons, patients from, for example, small/remote
areas may seek care in large rural or urban areas
regardless of the local availability of care. Third, this
study does not take into account any effects of
‘traveling’ or ‘itinerant’ general surgeons, i.e., those
whose ZIP code indicates they work in one (possibly
more urbanized) area, but who travel on a regular basis
to surrounding rural areas to provide consultations and
surgical services.19 Fourth, although the AMA
Masterfile is the most complete nationally-available
source of information on physicians, the criteria for
including general surgeons that we used might exclude
surgeons who perform general surgery as part of a
subspecialty surgical practice, those who have clinical
responsibilities in addition to teaching or research, as
well as the clinical services provided by surgical
residents, federally-employed surgeons, and those who
are still clinically active beyond the retirement age that
Attempts to increase the proportion of general
surgeons choosing rural practice will require a
multifaceted approach. Selection of students at
medical school entry could emphasize those from rural
backgrounds, as they are more likely than their urban
counterparts to eventually practice in rural areas.20
Efforts to promote student interest could include
developing more student rotations with rural general
surgeons.21 Student interest in general surgery
residencies increased in the 2003 National Residency
Matching Program match, with 82.7 percent of
positions filled by U.S. seniors (and 99.0% of
positions filled overall).22 Surgical residencies could
include rural training tracks with structured periods of
rural exposure, more diverse case exposure, or even a
Further research is needed to assess rural surgeons’
ongoing requirements to maintain and update their
clinical skills, and—most importantly—the factors
vital to retaining them in rural practice. There may
also be opportunities to examine alternatives to the
current funding (e.g., changing Medicare fee
schedules) and organization of surgical services in
rural areas (e.g., more favorable reimbursement for
rural training and practice). In Australia a regular
locum tenens service provided by the regional
academic center and flying surgical teams have been
used to provide surgical services in isolated areas.
Finally, telemedicine has shown promise in the areas
of orthopedics and trauma. Once issues of
reimbursement and liability have been resolved,
telemedicine, along with the nascent field of
telesurgery, may contribute to improved surgical care
in isolated rural areas.
General surgeons and family practitioners are core
components of rural medical care. If rural residents
are to achieve health care parity with the urban
populace, medical schools and health care policy
makers need to address the growing crisis in the rural
general surgical workforce.
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FOR HEALTH WORKFORCE
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