Wednesday, June 13, 2012

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?


Gerard said...

Surely any profession, especially one as important as important as surgery, is institutionally dysfunctional, if 80 hour work weeks are seen as normal. You wouldn't let truck drivers work that long, why surgeons ?

Skeptical Scalpel said...

Gerard, Thanks for commenting. Here's a recent quote about resident work hours from a senior surgeon in England:

“My understanding is that this restriction on hours – a European directive – was designed for Spanish lorry drivers. And in fairness, driving down the motorway is boring. There isn’t much about medicine or surgery that’s boring.”

Here's the link:

qtipp said...

Solution: Find out what is the difference between those that stay and those that leave. I'm not sure how feasible it is to do follow-ups on residents that leave but if there were standardized survey/inventory that went out to programs at the start of residency and then a follow-up survey/inventory at PGY3 and PGY5 I think we would come to some sort of solution.

A former boss in internet advertising (I'm a non-trad starting medical school this summer) told us about his time at a credit card company. When they collected all the data on customers who were the best card holders to target with snail mail offers, they found that 1) rural customers were great (on whatever metric "great" is... i.e. held a balance, paid faithfully but never paid off the card).
2) applications filled out in pencil were great (on the same metric).

#1 makes sense
#2 didn't make sense... and wasn't really something we'd even make a hypothesis on.

Point? If we don't collect the data, we won't know what's happening. If we don't know what's happening we can't come up with a better solution.

Just realized that this isn't really a solution, just a way to arrive at one.

Skeptical Scalpel said...

Qtipp, thanks for the detailed comments. It would be hard to get the departed residents to respond, but your idea has merit. I hope someone can do what you suggest.

Unknown said...

It's probably a lot like med school. Sounds very great going in. Prestigious, worthy of respect. Then you get in knee deep and realize "what the hell have I done?!" I think my clerkship is 4 weeks. You're right, it's really impossible to know what to expect and if you don't have a passion for it it's easy to bail.

Amanda, OMS2

Skeptical Scalpel said...

Amanda, thanks. Good point about the similarity between getting drawn into med school and surgical residency. I agree with you.

Anonymous said...

have them fill out residency applications in pencil.

Anonymous said...
This comment has been removed by a blog administrator.
Anonymous said...

As a medical student considering surgery, I can imagine a number of reasons why people would back out.

1- unrealistic expectations & lack of commitment (as you describe)

2- malignant culture that is hidden from medical students during rotations and interviews: let's face it, not all residency programs are created equal, and to a student without a discerning eye, they may end up in a program that doesn't advocate for it's residents very well. Switching residency programs is interpreted by some as career suicide, so they end up simply changing specialties altogether.

3- The consensus among students is that there's just a greater number of "malignant" general surgery programs than there are in other specialties, which leads to #2.

4- declining rewards for "sticking it out." Surgery ain't what it used to be, and perhaps students discover all the warts once they're in the thick of it. In the old days, becoming a surgeon meant something else and carried different career opportunities. Surgeons today tell me that I'll have to work 3x as hard as they did to make the same amount of money, which doesn't really deter me but could be bothersome to many.

5- other specialties are simply better at recruiting students and watching after their young, so a jaded gen surg intern might think the grass is greener over there in rads/gas/medicine etc...

Skeptical Scalpel said...

And don't sign a two-year lease.

Anonymous said...

In my experience those that wash out (are asked to leave due to poor performance) are a very different group from those who opt out:

Those who perform poorly, I think, are those who discover (or have uncovered) that they don't think and act like surgeons.

Those who opt out chose gen surg as a default (were uncertain about choice) or had two choices in mind and imagined (correctly?) that getting an anesthesia spot after a year of gen surg would be more plausible than securing a categorical surgery spot after a year of anesthesia.

Anecdotally, I've not seen anyone leave gen surg because of hours or anything else 'manipulable'.

Agreeing with Amanda, I think it's hard to envision the life of a surgeon in 6 weeks, 12 or 52 - especially if you're mostly exposed to miserable residents (not attendings) and sleeping through lectures nowhere near the OR, as was my experience as a med student.

Compare radiology or anesthesia - a week on the rotation and you have a fair picture.

Skeptical Scalpel said...

Anonymous and Chris, Thanks for the thoughtful comments.I have had residents drop out because of the hours.

It is likely that there are more "malignant" surgery programs than in other specialties. I agree that it's not always easy for an applicant to pick up on the signs of that.

Anonymous said...

Start paying general surgeons $750,000 a year like your slightly above average spine surgeon or neurosurgeon and the applications will jump significantly. The reward simply isn't there like it used to be, nor is the respect and autonomy. Walk into any community hospital and take a look at the ortho floor, and then go take a look at the general surgery/trauma floor. What's valued is clear. It's a crisis in evolution with nothing being done about it. Eventually, we will all suffer this reimbursement choice.

Anonymous said...

Qtipp has an interesting suggestion, but is only looking at half of the equation. What program factors drive variation among attrition rates? Anonymous suggests a high number of "malignant" programs. What does that actually mean? If it is a real phenomenon, then why does it occur? Is a high attrition rate *actually* a big deal for the programs? I suspect that it is not (and is more like an annoyance) since the problem has remained roughly unchanged for nearly 20yrs AND there appears to be plenty of room for improvement. Sucks for the residents that quit, but they aren't in a good position to change the situation.

Skeptical Scalpel said...

Great comments from both anonymous people. Thanks.

Lisa said...

Perhaps there is lack in positive role models/mentoring in general surgery? There is a formal mentoring program at my med school and I am not aware of any general surgery mentors...
Personally, I am interested in general surgery and as a 3rd year medical student would love to have a surgeon-mentor.

Skeptical Scalpel said...

You are correct. Positive role models are in short supply. I'm not sure how to rectify that. Are the any female general surgeons at your school?

Anonymous said...

The level of "competitiveness" to enter each specialty from the perspective of the medical student also plays a part. General surgery doesn't carry the same allure to medical students that it once did--whether it's the perception of the "lifestyle," salary, whatever. There are definitely students nowadays that may apply into it as a backup for a more competitive surgical subspecialty--i.e. student really wants to do ENT or plastics but applies to general surgery programs too and ranks them low on the list. They don't get the specialty they really wanted and end up in general surg--which of course isn't going to last too long if they're not dedicated.

I still think general surg is one of the most grueling specialties out there, but they just don't get all the top-notch applicants like they once did. During my intern year, there were multiple cases of the general surgery chiefs actually preferring the off-service surgical specialty interns (neurosurg, ent, ortho) to their own categorical interns.

Skeptical Scalpel said...

Thanks for the comments. I think your theory about the reasons people end up in general surgery is quite plausible. It wouldn't be difficult to investigate. Maybe someone will look at it.

Anonymous said...

A few problems:

1. Surgery is far too grueling for the income rewards at the end of residency. In other words, its not worth it from a financial perspective, especially when there are so many other more attractive options.

2. Medical students have to make final decisions about specialization as early as the first year of medical school. These decisions can only be based on the three Rs: rumor, romanticism, and remuneration. Once they get into the thick of residency and have acquired more medical knowledge, these folks who switch out of surgery may have done so because they had inaccurate preconceived notions about it, and the end-game income is not attractive enough for them to slog through it.

The real solution to basically every human resources problem in medicine is to eliminate family medicine as a specialty and give all graduating doctors general licenses.

Skeptical Scalpel said...

Anon, as I said on the other post, it's an interesting idea but it will never happen.

Burnt Orange Scrubs said...

Dear Dr. Skeptical Scalpel,

Thank you for writing such an insightful, honest blog. I think it's also great how active you are in replying to your readers.

Even though I'm just a 3rd medical student, I've come across what you talk about in this entry, and have heard similar things from many upper-level and chief residents.

I fell in love with surgery on my 3-month rotation, but realized how us med students were sheltered from the waves of consults, incoming traumas, and how we didn't have to work nights, or be on the receiving end of harsh criticism from exhausted, jaded superiors.

I've spent days thinking intensely and decided against entering general surgery, but I'm thankful for people like you who sacrificed so much to save the lives of so many patients who needed your help.

Thank you.

Skeptical Scalpel said...

I appreciate your remarks. I hope you've made the right decision for the right reasons. Good luck.

Anonymous said...

Dear Skeptical,

I am a second year surgical resident thinking about leaving my program, despite so far having only excellent evaluations.

The surgical lifestyle in residency and as staff is a factor for me, as I imagine it is at least partly for others. While I feel capable of making the sacrifices needed to succeed in surgery, I find myself feeling less inclined to as time passes.

I think the surgical lifestyle is only tolerable for someone who truly loves the job - and it's hard as a clerk to know if you will. For me back pain has contributed to falling out of love, or perhaps more rightly waking up to the realities always present.

Thank you - I love your blog

Skeptical Scalpel said...

I am sorry to hear about this. I always found that residents were most depressed in the last third of the academic year. It always seemed that they felt there was no end in sight.

I was going to suggest that you speak to a faculty member at your program, but I'm not sure that it would help. Do you have any family that you could talk to? Of course, you must do what is best for yourself.

It's a tough decision to quit something that you worked so hard for. I wish you all the best.

Anonymous said...

I have practiced surgery for many years, and returned to training to change subspecialties. There are many more regulations, but the training is not any better. The nursing staff no longer tries to help you succeed, rather, they are taught that their job is to protect the patient from you. The duty hour restriction is commonly known throughout the United States to create more paperwork with no benefit to house staff. In my training program, any accurate accounting of duty hours will be met with punishment. All evaluations of faculty are artifically inflated to avoid confrontation with those with whom all of the power is vested. The reality is that the academic surgeon able to operate well is execeptional. What one learns in training is, principally, how to survive a hostile environment. General Sugery is a poor choice of specialties. All of the interesting cases are stripped away by subspecialties, leaving the low paying, night emergency room no pay, high lawsuit patient for your practice pleasure. Don't even think obout actually trying to take care of a patient. You are paid to take care of part of a patient. You are expected to learn a few tasks and be able to accomplish them quickly and repeatidly. You are expected to accept the trash from other hospitals. This is called patient care - but another thing to call it would be maximization of profit for the healthcare corporation - a corporation that increasingly sees surgeons specifically and doctors generally as a cost burden that would be eliminated if possible. Surgeons have responded to these pressures by damaging other surgeons - zero sum thinking. Avoid General Surgery. Training is just that, you are being trained to behave in a particular way. Education is what you do yourself. The training is too long, the rewards too small and the quality of life poor. Ignore this post at your peril.

Skeptical Scalpel said...

Anon, thanks for your comments. And I thought I was pessimistic.

"The nursing staff no longer tries to help you succeed, rather, they are taught that their job is to protect the patient from you." It's hard to argue with that.

Your program sounds like a nightmare. I hope it's not that bad everywhere.

Anonymous said...

i am very thankful to my country as it knows how we r working my government run hospital my duty hours iis around 96hrs believe me daily i take nap for just 3hrs it good or bad

Skeptical Scalpel said...

Naps are good.

K said...

I am a surgical intern and agree entirely with what anon said above. The training is not set up in such a way as to help residents learn. You are essentially disposable and are abused by nurses more than by anyone else. Residents are not protected at all. None of the attendings in my program are happy either. Im pretty shocked by the reality of gensurg as a career choice.

Skeptical Scalpel said...

K, I am sorry to hear about your situation. I wish I could help you.

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