Creating a sustainable rural general surgery workforce: what enables fellows to return as rural general surgeons?

Introduction: In the context of shortfalls in rural general surgeon supply, this research aims to explore why rural general surgical fellows returned and remained after fellowship at a single rural centre in Victoria, Australia.  Fellowship positions post achievement of Fellowship of the Australasian College of Surgeons (FRACS) are traditionally not funded by government as they currently fall outside the accredited rural training post funding provided by the federal government.  This paper aims to explore if  fellowship positions can be an important part in sustaining the rural general surgery workforce.
Methods: Semi-structured interviews were conducted with nine former general surgery fellows from a single rural Australian institution. Interviews were recorded, transcribed, coded and themed to undertake analysis according to thematic analysis.
Results: This research demonstrates that consultant rural general surgeons can be recruited from a fellowship year when emphasis is placed on: (1) creating a positive workplace culture with safe working hours, (2) ensuring diversification of the general surgical case mix, (3) facilitating opportunities for schooling and work for the surgeon’s family, and (4) preferentially selecting for those who identify as rural general surgeons. Rural towns can effectively recruit general surgeons where families are supported with career and school opportunities, and the newly qualified surgeon can initially commit to a 12-month position so that opportunities can be assessed by the entire family unit. Fellowship positions (post completion of general surgical training) allow young surgeons to 'try before they buy' prior to moving to a rural area.  
Conclusion: Ensuring a sustainable general surgical workforce in a rural community requires employee and surgical leadership to ensure a collaborative and progressive culture, which offers work diversity, supports the family lifestyle and petitions for selecting those who embody the rural general surgeon identity.  Post fellowship positions can enable young general surgeons to have exposure to the realities of a rural lifestyle which is likely to have a positive effect on recruitment. Due to the return investment of the fellowship program, we propose that the federal government should look at funding post fellowship positions to improve rural recruitment.