What were attrition rates in surgical residency programs 25 years ago?

Last month I blogged about the 20% attrition rate of general surgery resident over the last 25 years, and a recent paper presented at a national meeting that found after following the general surgery resident class of 2007, 20% had dropped out for one reason or another.

A reader who calls himself Artiger commented on that piece asking, “Is there any data on resident attrition prior to 1992? Just curious if this has been a problem for more than the past 25 years.”

I responded that I wasn’t aware of any such studies but I would try to find out.

Most of the few papers written about attrition back in the day focused on one residency program or one medical school’s graduates.

Until the middle of the 1990s, many surgical residency programs were pyramidal—that is, they took more categorical first-year residents than they had chief residency positions. For example, when I began my training in 1971, my program had 12 first-year residents, decreasing to 8 in the second-year and only 4 chiefs.

How to fix the problem of general surgery resident attrition

Over the last 25 years, about 20% of general surgery residents have failed to complete their five years of training. This compares unfavorably to other specialties such as orthopedics, obstetrics-gynecology, and medicine with attrition rates of < 1%, 4.5%, and 5%, respectively.

A paper presented at the American Surgical Association in April looked at the factors associated with attrition in one year’s resident class. In 2007, 1047 residents began their training and after 8 years of follow-up, 80% had become surgeons. How many non-finishers left programs by their own choice is not clear.

Some highlights of the research are as follows:

24% of women and 17% of men left general surgery training.

Size mattered because 23% of men and 25% of women left large programs compared to both sexes leaving smaller programs at a rate of just 11%.

Why is the attrition rate of general surgery residents so high?

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?