The surgical workforce is facing shortages, with fewer residency applicants wanting to work in rural communities, as surgery outcomes worsen for patients in rural counties who already face higher rates of smoking, obesity, cancer and cardiovascular diseases.
Over the past 55 years, the burden of cancer mortality has shifted from urban populations to rural communities. From 1969 to 1971, overall cancer mortality was highest in large metropolitan areas and lowest in the smallest nonmetropolitan areas. By 2021 to 2023, that pattern had completely reversed.
Here’s what to know about rural surgery access and outcomes:
Supply and access
Access to affordable healthcare has become the defining concern of leaders in rural America.
Sixty-three percent of rural physicians identify it as the top issue policymakers should address, according to Athenahealth’s 2026 Physician Sentiment Survey; that’s 12 percentage points higher than their urban and suburban counterparts.
Nationally, there are 59.2 surgeons per 100,000 people, but projections show a shortage of 27,940 surgeons, or 15.7%, by 2038. The nation’s supply of surgeons is projected to decline 4.2% from 2023 to 2038, while demand for surgeons will increase 12.8%.
Four specialties face critical shortages: vascular surgery (65.8% of need met), ophthalmology (71.8%), thoracic surgery (73.1%) and plastic surgery (74.1%).
Thirty percent of counties have no identified surgeon. Of 4,532 hospitals and 6,468 ambulatory surgery centers, 4.3%, or 475, were in counties without an identified surgeon.
Only 2.3% of 2026 medical school graduates said they would prefer to practice in a rural area. By comparison, 45% preferred urban or suburban settings and 52.7% had no preference.
Rural physicians also report constant burnout at a rate of 67%, with 69% reporting they have considered leaving the medical profession entirely.
Only 6% of ASCs are in rural areas, compared with 94% in urban areas. Certificate-of-need laws are one barrier to further development of ASCs in rural areas, as some of the most rural states in the U.S. — including Wyoming and Idaho — have CON laws in place.
Outcomes
Rural communities often face worse surgical outcomes. Between 2016 and 2026, Medicare beneficiaries who underwent common general surgery procedures and lived in rural areas had higher 30-day mortality, in-hospital mortality, complications and 30-day readmissions, according to a study published Aug. 6 in JAMA Network Open.
The death rate tied to three common emergency surgical conditions — appendicitis, acute cholecystitis and abdominal wall hernia with obstruction or gangrene — increased about 50% between 1999 and 2020. In that timeframe, the national death rate tied to these conditions grew from 0.4 to 0.6 deaths per 100,000 people.
Death rates associated with the three conditions were 86% higher in rural communities and 49% higher in urban communities during the same time period. Between 2021 and 2024, rural areas saw a 6.1% increase in the number of deaths associated with these conditions, while metropolitan areas saw a 3.2% increase.
What’s being done
Federally, the Rural Health Transformation Program, which directs $50 billion to rural healthcare providers over the next five years, offers some relief for workforce and access challenges. Healthcare organizations have emphasized the importance of federal support efforts to strengthen rural healthcare and streamline technology investments that can help rural hospitals survive and thrive.
At the system and facility level, many health systems are also working to improve rural access and workforce pipelines. For example, Chapel Hill-based University of North Carolina System has awarded more than $6.4 million in state-funded grants to support the growth of its rural hospitals and rural workforce training programs. Of those funds, $1.3 million will support the development of a rural general surgery program partnership with Winston-Salem, N.C.-based Novant Health and the Southeastern Area Health Education Center.
Despite a relatively small presence in the ASC market, rural ASCs may have the benefit of being more connected to their communities and better able to respond to large-scale shifts in healthcare.
Associations are also looking to tackle rural challenges. The American College of Surgeons developed the Commission on Cancer Rural Cancer Program Accreditation to address the approximately 15% higher cancer death rate in rural communities compared with urban areas.
“Previously, some rural hospitals could not pursue accreditation due to resource constraints,” Ronald Weigel, MD, PhD, medical director of the American College of Surgeons Cancer Programs, said in an Aug. 4 news release. “The new category makes accreditation, and the benefits that accompany it, more attainable by tailoring the standards to the needs and resources of rural hospitals.”
