What is ESS?

Enhanced Surgical Skills describe a set of defined competencies of rural family physicians, which generally include one or both of appendectomy and Caesarean section.

As a general rule, with many individual exceptions, the ESS workforce is divided between two distinct skill sets. The first, which we sometimes refer to as ESS Surgery, represents a broad skill set, including operative delivery, which are acquired either overseas or through one of the twelve month R3 programs at the U of A or U of S.

The second, which is sometimes referred to as ESS Operative Delivery (OD), represents a focused skill related to perinatal surgical services. This skill set can be acquired formally (three months or more in a regional hospital or teaching centre) or informally (local mentoring). This second group has a larger number of ESS physicians than the ESS Surgery group.


In 2000 there were 151 ESS rural family physicians sustaining local surgical programs in rural communities in western and northern Canada. Although the number of these programs has shrunk significantly – 80 in 1995; 55 in 2011 – the number of ESS 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 sizable 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 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 physicians, especially for on-call relief (a “mixed” model).


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 Iglesias S. Unpublished data