When rural is no longer rural: Demand for subspecialty trained surgeons increases with increasing population of a non-metropolitan area

Surgery in larger, non-metropolitan, communities may be distinct from rural practice. Understanding these differences may help guide training. We hypothesize that increasing community size is associated with a desire for subspecialty surgeons. We designed a mixed methods study with the ACS Rural Advisory Council. Rural (100,000) communities were compared. Quantitative and qualitative data were analyzed. We received 237 responses, and desire to hire subspecialty-trained surgeons was associated with practice in a large non-metropolitan community, OR 4.5, (1.2–16.5). Qualitative themes demonstrated that rural surgeons limit practices to align with available hospital resources while large non-metropolitan surgeons specialize according to interest and market pressures. Surgery in rural versus large non-metropolitan communities may be more distinct than previously understood. Rural practice requires broad preparation while large non-metropolitan practice favors subspecialty training. [Display omitted] •Rural and small/large non-metropolitan areas have distinct practice environments.•Necessary clinical skills for these different practice environments are unique.•Larger non-metropolitan areas are increasingly looking to hire sub-specialists.•Residency training for rural and non-metropolitan surgeons should reflect this.