As a general rule, with many individual exceptions, the ESS workforce is divided between two distinct skill sets. The first represents a broad skill set, including operative delivery, which is acquired either overseas or through the twelve month R3 program at the University of Saskatchewan. In 2017 the University of Saskatchewan convened an Invitational Meeting to reflect on the first 10 years of the program and review the current practice of program graduates.

The second, Obstetrical Surgical Skills (OSS), represents a focused skill set related to perinatal surgical services. This skill set can be acquired formally in programs six months or longer in a regional hospital or teaching centre. There are many more OSS physicians in rural Canada than ESS physicians. 



ESS/OSS practitioners can help provide more equitable access to timely surgical care for people living in rural and remote communities.  In 2000 there were 151 ESS/OSS rural family physicians sustaining local surgical programs in rural communities in western and northern Canada. Although the number of these rural surgical programs has shrunk significantly – 80 in 1995; 55 in 2011 – the number of ESS/OSS has remained stable at 140 (2011). There is some evidence that several of these smaller programs grew larger in volume, absorbing a workforce displaced from programs which closed.

Although there has been a sizeable attrition between 1995 (80 communities) and 2011 (55 communities), these are distributed across all of the western provinces - 11 in BC, 27 in Alberta, 8 in Saskatchewan, 5 in Manitoba, as well as 3 in Northern Ontario and 1 in NWT.  These small volume rural surgical programs can generally be found: 

  • in communities of 5,000‐15,000 where ESS/OSS physicians provide most or all of the local surgical care; and,
  • in communities of 15,000‐25,000 where there is usually a significant local specialist presence that is supported by ESS/OSS physicians, especially for on-call relief (a “mixed” model). In larger rural communities, ESS/OSS physicians often provide the operative delivery services where the local General Surgeons do not have the skill set.


Information about formal surgical skills training for general practitioners is often limited.  Australia has surgical training programs with a curriculum for Advanced Specialist Training Rural Generalist Surgery.  America has the Wayne County Hospital Obstetric Rural Expanded Surgical Skills Track (RREST).   

Canadian ESS/OSS practitioners are also working with communities in less affluent countries to explore options for service delivery and education.  Where up to 20% of health care is delivered by regional or district hospitals in Canada, in less wealthy countries up to 80% of health care may be provided at local hospitals.  Partnerships between overseas surgical practitioners and Canadian  ESS practitioners may help to improve access to essential and emergency surgery and help strengthen local health care services.   


  • Iglesias S, et al. Advanced skills by Canada’s rural physicians, Can J Rural Med, 1999, 4(4); 227-233
  • Iglesias S, Jones L. Rural surgery programs in western Canada. Can J Rural Med, 2002, 7(2)
  • Iglesias S. Unpublished data

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