The cumulative attrition rate of general surgery residents has been holding at about 20%, a figure that has been steady for nearly 20 years. This figure is higher than that of most other medical and surgical specialties.
The institution of the 80 hour work week was heralded as a solution to the problem of attrition. Students who in the past wanted to be surgeons but had shied away from surgery were thought to be more likely to enter the field. The presumption was that in the old days, surgery was considered daunting due to the excessive number of hours worked.
If the attrition problem was just about the hours worked, one would expect the attrition rate to be less now; so far, it is not so.
The latest study of this problem points out that attrition occurs early in the course of training and is not related to the gender of the resident or any other specific factor.
So why do so many surgical residents drop out or wash out?
I believe a major cause is that medical students do not understand what surgical residency training is really like. In some schools, third-year clerkships are as short as 4 to 6 weeks, and part of that time may be devoted to clinic or subspecialty rotations.
Many medical schools limit the amount of night call that a student is required to take to one night per week with the proviso that the student is only to be awakened if something interesting is happening on the service. Some schools define night call as ending at 11:00 p.m.
Limited exposure such as this gives the students an unrealistic picture of what a surgical residency is like. This can result in disillusionment when the prospect of 4 years of real general surgery residency hits home. [I am counting only 4 years because the new Accreditation Council for Graduate Medical rule limiting first-year trainees to a maximum of 16 consecutive hours of work will simply postpone the problem for a year.]
An interesting paper from 2006 noted that a significant number of applicants to general surgery residency programs were “relatively uncommitted” to the field of general surgery compared to applicants to other surgical disciplines.
The combination of unrealistic expectations and lack of commitment leads to residents resigning or performing poorly.
This problem has implications for both the program and the departing resident. When a resident leaves a program, a competent replacement may not be easy to find, and the departing resident often finds he has wasted a year or more of his life because he often ends up in a non-surgical specialty.
True to my style, I am good at pointing out problems but not so good at finding solutions.
What do you think?