Graduate surgical education has changed significantly during the past 20 years. Several events have changed the landscape considerably, including the elimination of the pyramidal training system in 1983, the institution of the Accreditation Council for Graduate Medical Education core competencies in 1999, and the 80-hour work week mandate in 2003. As a result, there have been many new fast-track residencies and a rapid increase in the number of specialty fellowships, especially in minimally invasive surgery. These changes reflect a growing interest in tailoring traditional general surgery to the desire of residents who want to obtain specialty training. This has created a generation gap between current trainees and experienced surgeons in practice.

In addition, specialization has emerged as a growing trend that might jeopardize the future of general surgery. According to published research, many factors play a role, including the changing demographics of medical schools and surgery residency programs, residency types, and early exposure through research that is performed during residency. “Gender-related studies on specialty training have historically focused on increasing the female surgeon pool,” says Julie Ann Sosa, MD, MA. “These studies highlight issues surrounding maternity leave, child care, female faculty role models, and shorter training programs. Unfortunately, there’s a paucity of research addressing the influence of external support systems, such as family, on surgical trainees’ plans to specialize during or after their residencies.”

New Survey Highlights

In the May 2010 Archives of Surgery, Dr. Sosa and colleagues conducted a nationwide survey of all categorical general surgery residents in the United States to identify factors that motivate residents to specialize. “More specifically, we examined the influences of marriage, family, and gender on residents’ perception of the need for specialization during and after residency,” Dr. Sosa says. The survey asked general surgery residents about their motivations for pursuing surgery as a career, their views on specialization, self-assessments of their performance, and perceptions of the current and future status of general surgery.

“A key finding was that 55.1% of respondents believed that the modern general surgeon must be specialty trained in order to be successful.”

More than half (51.3%) of general surgery residents who were surveyed in the study were married, while 23.6% were in a relationship and 22.6% were single. Another 25.4% of residents had children. More than a quarter (28.7%) of residents expressed concern that general surgery as a discipline was becoming obsolete, but women were less likely than men to agree with this statement. “A key finding was that 55.1% of respondents believed that the modern general surgeon must be specialty trained in order to be successful,” says Dr. Sosa (Figure 1). “This feeling was more common among men than women, single residents than married residents, and residents without children than those with children.” Another 78.1% of respondents associated specialty training with a better income, and 62.3% associated it with a better lifestyle.

“Single residents and those without children were more likely to believe in the necessity of specialty training,” Dr. Sosa notes. “Men and women with children believed that specialty training was associated with a better income, compared with colleagues without children. Overall, married women and women with children were twice as likely as their male counterparts to believe that specialty training has a positive effect on lifestyle [Figure 2].”

Interpreting the Data

The Archives of Surgery study by Dr. Sosa and colleagues raises some interesting questions about the beliefs of trainees and their intent to seek specialty training. “Each fellowship experience is unique,” says Dr. Sosa, “and provides varying potential for greater income and flexibility with lifestyle desires. Studies on the role of external support systems and attitudes toward career decision-making have been limited in medicine. Much of the literature has focused on recommendations rather than research to promote a balance between professional careers in medicine—especially surgery—and family. It would be beneficial to conduct more research in which resident characteristics among those considering post-residency training were stratified with the impact of marriage and children on the rigors of residency and fellowship.”

Dr. Sosa and colleagues note in their study that a pertinent follow-up analysis could seek to identify specific characteristics and trends of fellows in their designated specialty-training programs which include marital status, family factors, and gender. “This additional information may help guide specialty programs in becoming sensitive to balancing surgical careers with lifestyle desires,” Dr. Sosa says. “Ultimately, each trainee will seek a pathway in graduate surgical education that will give them the necessary skill sets for optimizing patient care, receiving adequate compensation, and achieving a flexible lifestyle. Understanding how these factors influence residents is critical to identifying, recruiting, and retaining the best and brightest candidates.”