General surgeon (GS) workforce shortages are predicted to worsen, particularly in rural areas. We report on a sustainable model for delivery of GS services within a large rural region that includes an integrated health system.

We conducted a longitudinal study of a rural GS network from 1978 to 2016. Employment data and rural GS survey results were reviewed to document methods of recruitment, retention, and case-volume development.

During the 38-year study period, 19 rural GSs were employed by the health system. There were 3 practice acquisitions and 16 new hires. The rural GS network grew from 1 in 1978 to 10 in 2016. In 1996, the network consisted of 6 rural GSs at 6 different critical access hospitals (CAHs). Currently, 9 rural GSs practice at 1 of 4 CAHs. They provide outpatient general surgery and endoscopy at an additional 6 CAHs and cesarean section coverage at 4 CAHs. Four (21%) rural GSs have retired, 10 (53%) continue to practice in the network, and only 5 (26%) left before retirement. Six rural GSs have practiced in one location for more than 20 years.

Successful recruitment of rural GSs depends on competitive salary, reasonable call and leave schedules, administrative support, and adequate case variety and volume. Case volume is enhanced by cooperative relationships with CAHs, health system assistance in performing appropriate procedures locally, co-management of complex cases, and development of outreach surgical locations. In addition to the recruitment principles mentioned, rural GS retention is optimized by connectivity with the main campus medical center.