DIN White Paper #1

Expanding Access to Specialty Microsurgery in Underserved Areas

A Regional Strategy to Address Workforce Gaps and Underused Operating Rooms in Rural and Underserved Communities

Authored and reviewed by the DIN team, May 2025

Introduction

Access to specialized “microsurgery” – delicate surgical care in fields like ophthalmology (eye surgery), otolaryngology/ENT (ear, nose, and throat), dermatology (skin surgery), and urology (urinary tract and reproductive surgery) – has become a national challenge. Demand for these specialists is rising as the population grows and ages, but the supply of surgeons is not keeping up (Urology Times, 2021). By 2034, the United States may face a shortfall of up to 30,200 surgeons across specialties (Urology Times, 2021). This imbalance is felt most acutely in rural and underserved regions, where patients often struggle to find any local specialist. In many areas, people cannot access an ophthalmologist, dermatologist, ENT, or urologist within a reasonable driving distance (often defined as a two-hour radius). The result is a growing care gap that leaves millions without timely surgical care.

Demand Exceeds Supply: A Widening Gap

Several national statistics highlight how the need for specialty surgeons exceeds the current supply, especially outside urban centers:

  • Ophthalmology: About 61% of U.S. counties have no ophthalmologist at all (AAO, 2022). Nearly 17% of patients needing eye surgery live in rural areas, yet only ~5.6% of ophthalmic surgeons practice in rural communities (Ophthalmology Advisor, 2023).

  • Dermatology: Roughly 69% of U.S. counties lack a dermatologist (Reuters, 2019). Although the number of skin doctors per capita has increased over the years, these gains have mostly benefited cities, not rural towns (Reuters, 2019).

  • ENT (Otolaryngology): An estimated 66–72% of counties have no ENT surgeon available (PMC, 2023). Many states have vast areas without any local ear, nose, and throat specialists, forcing patients to travel long distances for care.

  • Urology: Only 38% of U.S. counties have a practicing urologist, meaning 62% have none (Urology Times, 2021). Nearly half of urologists are over age 55, and few younger doctors are entering rural practice (Urology Times, 2021).

This mismatch between public need and provider availability is most stark in rural America. About 20% of Americans live in rural areas, but only ~10% of physicians practice there (PMC, 2023). For specialists, the gap is even greater: there are only 30 specialists per 100,000 people in rural areas versus 263 per 100,000 in urban areas (NRHA, 2024).

Impact on Rural Patients and Communities

When patients lack access to specialty surgeons within a two-hour drive, the consequences can be serious. A recent study found that the percentage of rural Americans traveling more than an hour for surgical care jumped from about 37% in 2010 to 44% in 2020 (Renal & Urology News, 2020). In one analysis, rural Nebraskans had to travel 5.5 times farther than urban residents to see an ENT specialist (PMC, 2023).

Without local specialists, patients may forgo or postpone care. A shortage of dermatologists leads to later-stage melanoma diagnoses (Reuters, 2019). Dr. Hao Feng noted, “if patients can’t get in to see a dermatologist about a melanoma, it will continue to grow and potentially spread and become fatal” (Reuters, 2019). Similarly, shortages in ENT or ophthalmology mean delays in identifying head and neck cancers or treatable eye disease. General practitioners often step in, but they may lack the training for complex cases (Reuters, 2019).

Beyond health outcomes, these gaps strain communities. Families lose workdays traveling for care. Elderly or immobile patients may simply skip it. Rural hospitals lose revenue to distant centers, eroding the viability of the local health system.

Traditional Care Models Are Leaving Rural Hospitals Behind

Under traditional models, specialty surgeons practice in high-volume urban hospitals. Critical Access Hospitals (CAHs) and rural systems cannot often support full-time microsurgeons. One-third of CAHs offer no surgical services at all (Flex Monitoring Team, 2023). Even those that do typically rely on occasional visiting specialists.

In urology, only 7% of urologists under age 45 practice outside metro areas (Urology Times, 2021). In ophthalmology, younger and female surgeons are less likely to work rurally than their more senior peers (Ophthalmology Advisor, 2023). The pipeline to replenish rural specialists is drying up. Hospitals are left with underused ORs and patients with unmet needs.

Willing Providers, but a Lack of Coordination

Many microsurgeons are open to outreach. Iowa’s Visiting Consultant Network shows how structured coordination can close gaps. Over half of Iowa’s urologists travel to rural clinics. With outreach included, 84% of Iowans live within 30 minutes of a urologist, up from 57% relying on permanent practices alone (Urology, 2018). Monthly, 55 urologists log over 20,000 miles to hold 200 clinic days across the state (Urology, 2018).

However, these models remain rare. Barriers like credentialing, scheduling, and malpractice limits make outreach difficult. Surgeons and hospitals lack infrastructure to match capacity with community need. As a result, resources exist—but remain untapped.

Rethinking Resource Deployment: A Community-Centered Approach

  1. Coordination and Networks: Build rotating specialty care networks. For example, dermatologists could rotate weekly across regional clinics. ENT and ophthalmology teams could serve critical access hospitals on predictable schedules.

  2. Support for Local Hospitals: Provide grants and fast-track credentialing to empower rural hospitals to host rotating surgeons. Local access boosts outcomes and reinforces financial stability.

  3. Extend Specialists' Reach: Encourage flexible practice models and use telehealth for pre/post-op visits. Offer travel stipends, housing, or licensing flexibility to support regional rotations.

  4. Community Partnerships: Maintain trust by integrating visiting surgeons with local care teams. Ensure local providers remain the continuity anchors before and after specialty visits.

Conclusion
This access challenge is solvable—but only if we rethink how surgical care is delivered. While national shortages persist, many microsurgeons are open to broader practice models. Meanwhile, hospital-based ORs in rural areas sit underused. With better coordination, infrastructure, and policy support, we can bridge the gaps between available providers and the patients who need them. By investing in rotating care networks, supporting local systems, and enabling more flexible practice options, we can bring specialty surgical care closer to home for millions.

Works Cited

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