The continued urbanization of American surgery: A threat to rural hospitals.

BACKGROUND In 2011, we predicted that surgeon shortages for rural hospitals would contribute to closures of rural hospitals. Here, we update population trends, the distribution of rural and urban hospitals, and surgeon supply to estimate surgeon demand for rural and urban hospital settings by 2040. METHODS Surgeon supply was based on new certifications for general surgery, orthopedic surgery, and obstetrics and gynecology adjusted for retirement. Surgeon demand from 2020 to 2040 was projected based on the US Census and published practice ratios: general surgery 10.7/100,000, orthopedic surgery 7.9/100,000, and obstetrics and gynecology 13.0/100,000. RESULTS The US population grew from 309 million in 2011 to 327 million in 2017 with rural populations unchanged at 56 million. By 2040, the US population will be 374 million (urban 85% and rural 15%) creating shortages of general surgery (-31.5%), orthopedic surgery (-34.3%), and obstetrics and gynecology (-25.3). Future hiring needs for urban hospitals will be 5 times greater than rural hospitals. Urban hospitals will likely recruit most newly certified surgeons. CONCLUSION Increases in surgery trainees will not meet the demand. The continued urbanization of American surgery may push rural hospitals into a vicious financial cycle leading to additional closures of rural hospitals and worsening issues of access. An alternative training paradigm for the rural surgeon is recommended to meet the unique demands of rural hospitals.