[snip]What are the prospects of being a subspecialist surgeon practicing in a ruralish area (esp w neurosurg requiring ICU and whatnot). I'm super conflicted because I know gen surg and ent fit rural settings quite well, but my CV is very neuro geared so it looks like it is too late for me to change specialty. Would living semi-rural and working in the city once or twice a week and then spending the rest of my time in a base hospital be feasible.
I am an ICU trainee so have a similar-ish issue in that I like living in rural areas but access to intensive care in those areas (and therefore jobs) is pretty limited.
In short, I think your chances of doing consistent neurosurgery outside of a hospital with a neurosurgical ward and neurosurgically capable ICU are slim to none. It's not enough to have a neurosurgeon to operate and an intensivist to oversee them post-operatively (those things are surprisingly quite available) but the whole rest of the package is where its gets limited -- do the ICU nurses have experience managing an EVD? Do you have enough surgeons in the hospital that can do neurosurgical emergencies when the EVD suddenly starts draining blood at 3am in the morning (if not you will be 24/7 on call)? Do you have capacity to do continuous or at least emergent EEG (machine, tech, neurologist/intensivist to interpret) for when your post-op patient is suddenly unresponsive in non-convulsive status epilepticus? Do you have interventional radiology on hand in case of needing an IR approach instead and if you do then do they have a 24/7 angiogram suite they can use? ... and that's just in the intensive care aspect of it before you even consider the surgical requirements (machines, hybrid theatres, trained scrub nurses) / rehabilitation / post-op non-intensive care nursing requirements etc.
The answer to most of those questions is that they don't exist outside of tertiary centres. There is a reason most general surgeons do some emergency neurosurgery training -- typically there isn't anyone else to do burrholes or a DECRA once you are outside of a capital city and so it falls to them.
I think it's really important to consider these kind of things like you are - my career path means that I can pretty much only work in a base hospital at the absolute minimum and often that comes with the reality of being 1 in 2 on call because the hospital can't justify employing more than 2 intensivists. Similarly, it comes with the reality that you won't be doing ultra-high fidelity intensive care (no cardiothoracics, neurosurgery, severe trauma or burns etc.). This is something that I've come to accept and is also a big motivator in why I'm pushing towards doing adult ICU with enough paediatric ICU to be qualified to work in both.
In terms of "swapping" training pathways I agree that especially for surgery it is difficult -- so much of your pre-SET training determines whether you get a registrar job etc. In saying that if you are willing to move then there is a fair bit of flexibility to get a General Surgery PHO job especially if you are post-GSSE -- Rockhampton for example is currently advertising for a full time general surgery PHO to start ASAP (i.e. tomorrow if possible). Keep in mind as well that doing your general surgery PHO position in a rural area counts towards the scoring for entry to SET training ... and it would be a good test to see whether you actually like working in base hospital areas.
On your last point on working in a tertiary centre a small amount & base hospital the rest -- my non-surgeon understanding is that in general complication rates & outcomes are better when the surgeon does the procedure a lot of times, and so if you are mostly working outside of neurosurgery then it's possible you might not be the best neurosurgeon.
I think despite everyone suggesting that you should go to PagingDr (and you should, there are actual surgical registrars there who will try help you answer the question) your best bet is going to be talking to people you currently work with. Tell them your concerns and ask for their advice - they know you far better than we do!