A National Survey of Hand Surgeons: Understanding the Rural Landscape

Abstract

Background:

Twenty percent of the US population is described as being rural and may have limited access to hand surgeons, especially on an emergency basis. Little is known about case type, call hours, employment status, and other relevant details of rural hand surgery.

Methods:

We surveyed members of the American Society of Surgery for the Hand to begin to describe the problem.

Results:

There were 471 responses from 2256 members surveyed with 387 completing 100% of questions asked. Ninety (19%) identified themselves as primarily located in a rural population and 381 (81%) in a metropolitan region. In our study, rural hand surgeons were more likely to be employed by a community hospital, followed by independent private practice, multispecialty group, academics, and then locum tenens. Rural surgeons’ practices were 80% solely hand surgery, while metropolitan surgeons’ practices were 89% (P < .01). Metropolitan surgeons felt that of the transfers from rural facilities, 46% did not need emergency hand care and that 60% of the time, there was not actually a need for specialty hand surgery care.

Conclusions:

Our survey begins to shed light on the details of rural hand surgery practice. We found that rural surgeons are more likely to be employed in community hospitals and take more call. When available, hand surgery specialists could prevent unnecessary transfer of patients to metropolitan areas. More work needs to be done to describe the differences between rural and metropolitan hand surgery practices as well as create rural hand surgeons.

Introduction

There are few publications on rural hand surgery. A recent report by Baron et al ¹ showed an unequal distribution of hand surgeons in the United States when analyzing both state and congressional districts. Rios-Diaz et al ² reported inequalities in the United States at a state level and found a correlation with fewer hand surgeons in lower per capita income states. Lacking in both of these articles was the density of hand surgeons in rural populations. The current numbers of hand surgeons working in rural communities and the details of their practices are also unknown. In our experience, these metrics are simply not retained in specialty society registries.

There is inadequate access to emergency hand care in various regions of the United States as a national survey found that 80% of emergency department (ED) directors reported no or inadequate hand surgery coverage. ³ In addition, recent studies on digital replantation identified a lack of availability of local rural hand surgeons. ⁴ In our view, these articles lack the details and demographics of the true current landscape of rural hand surgery. There are approximately 65 million people (correlating to 20% of the US population) living in rural populations^5,6 representing a large swath of America that we simply do not have data for. A better understanding of the local rural community hand surgery care and description of the current state of rural hand surgery is a step forward in that direction.

Current Care of Hand Injuries in Rural Areas

Traumatic wrist, hand, and finger injuries represent 14.4% of all visits to an ED each year. ⁷ In our experience, manual laborers often reside in rural areas and may place these rural populations at even higher rates of hand injuries. Unfortunately, for patients in rural communities, accessing an appropriate level of trauma care can be difficult. In a report on 111 hospitals in Tennessee, only 14% of rural hospitals had a hand specialist, and only 12% had hand surgery call coverage. ⁸

The consequences of these inequalities to patient access in rural areas may be inadequate hand specialist availability, delayed treatment, ED overcrowding, long patient transfer times, and unsustainable pressure on specialist referral center.^9-11 When accessing rural medicine, it is important to remember the long distances and impact that living in rural locations can inflict on patients, their medical care, and their personal health. This results in delayed treatment, increased costs, and additional stressors to rural patients.^12,13 Amazingly, it has been shown that 21% of permanent injuries and disabilities arising from ED visits are caused by delayed specialty care due to inadequate availability of various consultants. ¹⁴

Understanding Rural Hand Surgery

To illuminate difficulties that affect rural patients and describe the differences between rural and metropolitan hand surgery, we surveyed hand surgeons about their practice. By providing a better understanding of how rural communities are cared for by local hand surgeons and by describing the current state of rural hand surgery, we hope to promote access, education, and research of hand surgery in rural populations.

Materials and Methods

To start, we used rural as defined by the US Census Bureau as “all areas outside a metropolitan area.”^5,6 An anonymous survey (surveymonkey.com, Palo Alto, California) was sent to members of the American Society for Surgery of the Hand members using the member directory mailing list that includes active members and candidate members. The survey started with a definition of rural versus metropolitan and then flowed through an initial question asking respondents to categorize their practice location as either rural or metropolitan after which they were sent the same survey. The ensuing survey was generally divided into 2 main sections, first asking about demographics of the surgeon background and practice, followed by questions about actual practice details.

Please see the Supplemental Appendix for the full survey sent to participants.

Results

There was a 21% response rate (471 responses from 2256 members). Of these 471 respondents, 387 completed 100% of questions asked.

Based on the first group of questions, 90 (19%) identified themselves as primarily located in a rural population and 381 (81%) as in a metropolitan region (Table 1). The average practice catchment population size for rural surgeons was 211,015 and the metropolitan catchment population size was 1,746,739. Average distance to nearest hand surgeon for rural practice was 44 miles and for metropolitan was 6 miles.

Table 1.

Response Counts to Survey.

Questions	Answers by type	Metropolitan	Rural	Z score	P value
Responded to survey		381	90
Full respondents		313	74
Type of emergency calls covered	Vascular hemorrhage	70%	65%	0.7983	.4200
	Digital revascularization	57%	38%	2.9508	.0032
	Digital replantation	48%	28%	2.9969	.0027
	Upper extremity compartment syndromes	80%	76%	0.8627	.3883
	Upper extremity burns	45%	38%	1.1246	.2608
	High-pressure injection injuries	81%	73%	1.4335	.1517
Type of practice	Academics	26%	9%	3.0594	.0011
	Community hospital employed	11%	41%	6.2497	.00001
	Locum tenens	0%	1%	2.0474	.0406
	Multispecialty group	12%	11%	0.2424	.8085
	Private practice	51%	36%	2.2521	.0243
Type of coverage call	Coverage by other local hand surgeon (w/in the same city as your practice)	49%	18%	4.8911	.00001
	Coverage by general, orthopedic, or plastic surgeon (w/in the same city as your practice)	22%	35%	2.3748	.0176
	Other	22%	19%	0.5076	.6117
	Transfer to a different hospital	8%	28%	4.9851	.00001
Reimbursed for call	Yes	50%	33%	2.1080	.035

Significant values P < .05 in bold.

Surgeon background demographic questions identified orthopedic surgeons being the majority of specialty trained background (rural and metropolitan), followed by plastic surgeons and then general surgeons. All respondents were hand fellowship trained. Current employment demonstrated rural hand surgeons were more likely to be employed by a community hospital, followed by independent private practice, multispecialty group, academics, and then locum tenens. Metropolitan surgeons were most likely in independent private practice, followed by academics, multispecialty group, and then community hospital. No metropolitan surgeons identified locum tenens employment (Figure 1). There were statistically significant differences in employment type between rural and metropolitan surgeons when comparing private practice, academics, community employment, and locum tenens (Table 1). Specifically, we see metropolitan surgeons tend to be employed in an academic setting (P < .01) or private practice (P < .02), whereas a majority of rural hand surgeons are employed by a community hospital (P < .01). Z score was chosen to analyze our data as we had a large data set with a known standard deviation.

Figure 1.

Type of current employment based on location of hand surgeon in rural or metropolitan area.

There were differences in practice details. Rural surgeons’ practices were 80% solely hand surgery, while metropolitan surgeons’ practices were 89% (P < .01). The percentage of practice made up of elective hand surgery was 67% for rural surgeons and 70% for metropolitan surgeons. Call coverage differed between the 2 groups. Estimated average number of hand calls per month among rural surgeons and metropolitan surgeons was 9.4 and 6.4, respectively. A total of 50% of metropolitan surgeons were reimbursed for call coverage, whereas only 33% of rural hand surgeons were reimbursed (P = .035). Figure 2 illustrates how call coverage differed depending on location: Only 22% of hand call in rural areas was covered by another local hand surgeon versus 62% for metropolitan areas. As well, rural areas were more likely to have a nonhand specialist taking call (43% rural vs 28% metropolitan). Finally, rural areas were more likely to transfer emergency hand patients to a different hospital from the primary hospital (35% vs 10%) (Figure 2). When metropolitan surgeons were asked about those patients transferred from a rural facility for specialized hand care, the impression was that 46% of the time, patients did not actually need emergency hand care and 60% of the time, they did not specifically need specialized hand surgery consultation.

Figure 2.

Specialty of surgeon covering hand surgery call based on location of hand surgeon in rural or metropolitan area.

Figure 3 illustrates how the mix of emergency and trauma cases covered by rural and metropolitan hand surgeons differs by case type. Upper extremity compartment syndromes and high-pressure injection injuries were the most likely emergency call taken in both groups. Digital revascularization (P = .0032) and replantation (P = .0027) were the only emergency with a statistical difference between rural and metropolitan with metropolitan taking more of these complicated and intensive procedures.

Figure 3.

The mix of emergency and trauma cases covered by rural and metropolitan hand surgeons based on self-reported responses.

Discussion

The American College of Surgeons divided the United States into approximately 3500 Federal Hospital Service Areas and found that 18% have no surgical specialist at all and 30% have fewer than 3 surgical specialists. Thus, 48% of hospital districts have a critical shortage of surgeons. ¹⁵ Rural populations suffer the most from this discrepancy. This shortage of surgeons includes a lack of hand surgeons. As already alluded to, fewer rural hand surgeons can result in inadequate access to emergency care in a number of regions in the United States.

Our article attempts to quantify some of the similarities and differences between rural and metropolitan hand surgery practices. While the specialty background of hand surgeons is the same across all practice territories, our survey shows that a rural hand surgeon’s practice will be further from the nearest hand surgeon, more likely to be hospital employed or in locum tenens, tend to have a less hand specialized practice, take more call, and is less likely to be reimbursed for it. When rural hand surgeons are not on call, they are more likely to be covered by nonspecialized surgeons and to transfer patients to another hospital. Interestingly, the patients transferred to metropolitan centers from a rural location, per the opinion of metropolitan surgeons, may not even require a transfer 46% of the time and may not actually need true emergency care 60% of the time. These seemingly inappropriate transfers may result in excessively expensive care and inconvenience to patients. There are many possible explanations but most likely of which is the lack of appropriate decision-making expertise on site and fear of medicolegal reprisals. This nonetheless reiterates the importance of the need for more rural hand surgeons. There may be other ways of dealing with this discrepancy such as telemedicine and improved education of primary providers. Regarding the types of emergency cases, rural hand surgeons are less likely to cover digital revascularization and replantation, but it may be a relatively alarming fact that across the board, both rural and metropolitan hand surgeons routinely cover digital revascularization, replantation, and burn cases less than 50% of the time. This is in line with national trends of hand surgeons performing fewer replantations. ¹⁶

Limitations

We are limited by the response rate of our survey of 21%; however, this is in line with expected email survey results that do not have repeated follow-up. ¹⁷ We were limited by resources for this type of follow-up; however, our aim was to act as a springboard for future investigators to pursue this line of inquiry. Another limitation is that we are unable to draw conclusions about the cause for the differences between our 2 groups as we had to balance a detailed survey versus completion rate. We would also benefit from further subanalysis such as east coast versus west coast or density of surrounding surgeons but we do not have the resources or power for this type of study.

The response to this work should be 2-fold: First, future work should be done to better describe the daily practice and struggles of rural hand surgeons. Specifically, these studies should conduct focus group analysis of rural versus metropolitan to better characterize the differences between these groups as well as factors that lead to creation of a practice in a rural versus metropolitan area. These results could be used to further the second response: There should be active engagement of the academic and surgical community toward recruiting and advancing rural hand surgery. This could include academic advancement for studying health disparities related to access to hand surgery in the United States. As well, recruitment programs engaged in promoting surgical residents to engage with and become exposed to rural hand surgery would be greatly beneficial. ¹⁸

Rural hand surgery is an underdiscussed topic in publications and from the podium at major meetings. Lacking in those few publications on the topic have been the demographic details and practice patterns of the typical rural hand surgeon. With 20% of the US population living in rural communities and suffering the impact of limitations to hand care, our article, together with the data gleaned from our survey, helps to define the actual landscape of rural hand surgery and highlights the practice of rural hand surgeons to hopefully propel the access, education, and research of hand surgery in rural populations.