What are ESS and OSS?

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 represents a broad skill set, including operative delivery, which is acquired either overseas or through one of the twelve month R3 programs at the University of Alberta or University of Saskatchewan.

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.


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 surgerical 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 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/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.


  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 Iglesias S. Unpublished data