Over the past decade, surgery residency programs have adopted structural changes to improve attrition rates, such as work-hour restrictions. Despite these changes, resident attrition continues to be problematic for general surgery programs across the United States. “The modern attrition rates for general surgery residents range between about 3% and 5% per year,” says Christian de Virgilio, MD. “These rates rise to about 19% over the course of a 5-year to 7-year residency program.”
Research has suggested that most residency attrition is voluntary rather than based on poor performance. Studies have looked at residents who leave surgical training, but few have focused on residents who considered quitting their residency. Each year, the Accreditation Council for Graduate Medical Education resident surveys residents to evaluate work hours and gauge the experience of residents. However, the survey does little to address risk factors for quitting residency.
Gaining a Better Understanding
In JAMA Surgery, Dr. de Virgilio and colleagues had a study published to determine how often general surgery residents seriously consider leaving residency. The study aimed to identify factors attributable to an increased desire to leave residency as well as factors that mitigate this desire. The analysis also looked at whether or not the desire to quit was more prevalent among surgery residency programs with historically higher attrition rates. This information could help surgery residency programs develop and adopt changes to improve resident satisfaction and retention.
For the study, an anonymous survey was given to general surgery residents at 13 programs, and 10-year attrition rates were collected for each program. “More than 77% of residents responded to the survey, and 58% of respondents indicated that they considered leaving their training,” Dr. de Virgilio says. The most frequent reasons for wanting to leave were:
♦ Sleep deprivation on a specific rotation.
♦ An undesirable future lifestyle.
♦ Excessive work hours on a specific rotation.
Several factors were significantly associated with the consideration to leave residency, including older age, female sex, postgraduate year, training in a university program, lack of Alpha Omega Alpha status, and the presence of a faculty mentor (Table 1). In addition, residents from high-attrition programs were more likely than others to seriously consider leaving residency. Conversely, factors most often cited that kept residents from leaving their residency program included support from family, significant others, and other residents as well as a perception of being better rested.
Comparing Responses by Gender
The study also made gender comparisons with regard to leaving general surgery residency programs. “Women were more likely than men to continue to have serious thoughts of leaving as their residency progressed,” says Dr. de Virgilio. Women reported thoughts of leaving more often than men in postgraduate years 2 and 3, during research years, and during chief years (Figure). When comparing responses about factors influencing this consideration, women were more likely than men to report sleep deprivation on a specific rotation and difficult interactions with specific faculty as influencing those thoughts. Having the perception of being better rested and beliefs that friends and camaraderie would be lost if they left residency were factors that women associated with decisions to stay in general surgery.
Addressing Important Issues
Published research has shown that practicing surgeons experience high levels of work-home conflicts and burnout, an issue that Dr. de Virgilio says is particularly challenging to address. “Hospital administration and staff should take steps to address the factors that influence residents’ perceptions on leaving surgical residency,” he says. For example, if the workload of a rotation is more stressful than the rigors of the entirety of general surgery, it may be possible to identify high work-hour rotations and modify them accordingly.
“A sobering finding was that many respondents reported that an undesirable future lifestyle was a major factor influencing their feelings about leaving general surgery residency,” Dr. de Virgilio says. “This may be the result of seeing the lifestyle of mentors and other surgeons. It highlights the need for a supportive workplace environment that aims for better work-life balance.”
Dr. de Virgilio notes that issues like sleep deprivation and excessive workloads should be addressed and institutions should strive to ensure that residents have support systems to alleviate the burden of attrition in general surgery residency. “Attrition is a tremendous loss for all parties involved, but we now know that thoughts of leaving training occur before decisions are made to actually leave these programs,” he says. “We should view these findings as an opportunity to address factors that lead to higher attrition rates in general surgery residency.”
Readings & Resources (click to view)
Gifford E, Galante J, Kaji AH, et al. Factors associated with general surgery residents’ desire to leave residency programs: a multi-institutional study. JAMA Surg. 2014;149:948-953. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=1891300.
Kennedy KA, Brennan MC, Rayburn WF, Brotherton SE. Attrition rates between residents in obstetrics and gynecology and other clinical specialties, 2000-2009. J Grad Med Educ. 2013;5:267-271.
Sullivan MC, Yeo H, Roman SA, et al. Surgical residency and attrition: defining the individual and programmatic factors predictive of trainee losses. J AmColl Surg. 2013;216:461-471.
Yaghoubian A, Galante J, Kaji A, et al. General surgery resident remediation and attrition: a multi-institutional study. Arch Surg. 2012;147:829-833.
Sanfey H, Hollands C, Gantt NL. Strategies for building an effective mentoring relationship. Am J Surg. 2013;206:714-718.
Longo WE, Seashore J, Duffy A, Udelsman R. Attrition of categoric general surgery residents: results of a 20-year audit. Am J Surg. 2009;197:774-780.