Tuesday, June 27, 2017

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%.

Non-white women, especially those in academic programs, had the highest attrition rate—35%.

The lowest (5%) rates of dropping out were found in the white male group at small nonacademic (community) hospitals located other than in the Northeast.

Two odd findings were that women with a relative in medicine who trained at small community programs left surgery only 6% of the time, and counter-intuitively, “39% of female non-white residents studying in academic programs with family nearby left programs before completion.”

The study, led by Dr. Heather Yeo, an assistant professor of surgery and healthcare policy at Cornell, was reported in General Surgery News. The GSN article featured some comments from leading women surgeons calling for more diversity in the surgical workforce as a way to combat attrition.

Five years ago I blogged about surgical resident attrition and had a different take which was (and still is) that many medical students do not experience what surgery training is really like. They often have brief exposure to general surgery with abbreviated or no night call. Unrealistic expectations may result in disillusionment for some trainees.

Overall, academic programs and those with more than six chief residents per year had higher attrition rates than community hospital and smaller programs. This classification implies that community hospitals are not academic. As I have said before, one definition of academic is “having no practical or useful significance.”

In another 2012 post, I discussed a paper from the Journal of the American College of Surgeons which surveyed almost 4300 surgical residents and found those at community hospitals were “less likely to worry that they will not be confident operating by themselves after they finished training than university trainees.” Community hospital residents “were also happier with the level of didactic teaching than university-based residents.”

The solution to attrition? Maybe small community hospital residency programs are the way to go.

Disclosure: I was a community hospital (non-academic) surgical residency program director for about 24 years.


Anonymous said...

I'd have to agree with the comments above. As a recent residency grad (smaller "hybrid" program), many students wanted to see the "cool" cases but never bothered to read and prep for the daily routine/grind. As a senior resident, I literally had a student walk out of a 2a.m. case because she said she was tired. Unfortunately, in many cases we can't repremand that behavior or a bad evaluation is filed and we apparently want happy medical students more than we want informed residents.
For those students who say they want to be a surgeon to me, I tell them to do what a fellow made me do when I was a 4th year student. Follow around the mid-level resident for a whole month for call, cases, and clinic. There should be a minute during that month that the resident is there when the student isn't. If the student is still interested at the end of the month, they have a chance. It was the best advice I got in med school.

Skeptical Scalpel said...

Anon, thanks for the comments. I agree that reprimanding a student will get you nothing but grief. Your advice about following a mid-level resident around is excellent.

Esther said...

I thought Grey's Anatomy is just a program so there is some truth in it. The numbers are quite low when you compare how many residents start the program and how many get to the finish line. something must be done. great research

Vamsi Aribindi said...

In medical school, I ended up voluntarily doing about 4-5 months worth of Q3-Q4 call. When I got to residency, the grind was about what I expected it to be. It was physically worse, as the alternating weeks of nights were far worse than call, but mentally it hasnt been worse than what I knew I was getting into.

Skeptical Scalpel said...

Esther and Vamsi, thanks for the comments. Vamsi, I like your approach. I don't think you will drop out.

Jack Williams said...

My questions are more serious than they may sound. What happened to the program directors who selected the residents who failed to complete the residency? Did any of them resigned or was fired over that? If not why not? After all they, the directors, claim that they do the right thing by selecting good candidates based on predictability of success. How many candidates they eleminated before selecting those dropped residents? By choosing those dropped residents how much money did those directors waste from the taxpayers? Is there any accountability on the directors' part? I believe that these results render the directors irrelevant and their predictions of success are no better than choosing residents by lottery if not worse.

sirako said...

Very Educative

Skeptical Scalpel said...

Jack, I appreciate your comments. They are thought-provoking. My response may turn into a separate blog post.

As far as I know, no program director has resigned or been fired because of resident attrition. The selection of residents is far from an exact science. For one thing, if a program director identifies several excellent candidates, the NRMP matching algorithm may distribute those candidates to other programs since the way applicants rank programs is factored into the match.

Only about 15% of applicants in general surgery went unmatched in the 2017 match with 1.3% of those being current seniors in US medical schools. There are not hordes of people going unmatched in surgery.

For years we have argued about the best way to identify applicants who would make excellent residents. The fact is no one knows what the best selection criteria are. I have blogged about this in the past. Furthermore, the definition of an excellent resident is also debatable. Is it someone who can pass the boards? Someone everyone likes? Should success be determined by performance as a resident or after an individual has been practicing as an attending surgeon for a few years?

As far as the odds of success in the match being no better than choosing residents by lottery, I disagree. I don't know too many lotteries were you when 80% of the time.

artiger said...

Scalpel, 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. Incidentally, 1992 was when I started residency, and I saw some of this attrition directly. A lot of the people who dropped out were the strongest candidates on paper, but they were often white males, oddly enough. Just my experience, others' mileage may vary.

Skeptical Scalpel said...

I am not aware of such studies. I will research the topic and get back to you if i find any.

Anonymous said...

Anonymous Europe: When I hear from my peers that it is better to be in a university centre, because you "see everything there" I always think, that this thinking is false. Huge centrums get to operate the "big, complicated cases", mostly (not always), at least in Europe....
On the other hand. As a trainee you need the "boot camp" operations to know for sure first, not Whipple's procedure. And the "boot camp" operations tend to pop up in the small, community hospitals mostly, not in the big university centres..... If I had to chose again, I would rather go to a nice small town hospital where I would operate 5 hernias one after the other on a normal day and learn 10 types of operations which I would be able to perform absolutely securely, than go to some university centre where I would assist 2-3 different operations which I would not get to do for the next half year..... Thank God where I am I get to my numbers and teaching is excellent!
Surgery is nice to look at, but way more exciting to actually do it. One other big plus for the small hospitals is (at least for me), that you don't have to do science and you get to spend all your time in the OR, not pipetting some meaningless "academic" experiment (big things that matter come from Elon Musk and co, not from academic research....).

Skeptical Scalpel said...

Yes, I know of a tertiary center where the students and residents rarely see an appendectomy.

Anonymous said...

This problem - breadth of training and level of pre-residency exposure to surgical residency reality is only exacerbated by the fourth year follies - "the only tie I will have to relax before started residency + where is a program with good skiing?", and the stranglehold specialties have on residency slots - really need two residents on transplant team, hand surgery...
- There needs to be a chance to focus on breadth for rural surgery and to live in the rural environment.
- There needs to be chance to practice in the community hospital scenario without all of the bells and whistles.
- The MS 3 and MS4 courses pre-match need rigor, progressive responsibility..
[I was always told the more call I took as a student, the less I was paying per hour of training...YMMV.]

Anonymous said...

Anonymous Europe: Anonymous I strongly agree with you! I started working at the local pediatric surgery unit when I was 19 and got stuck there for the next 9 years( except when living in the US). If you want to get good then you have to start as early as possible. Rigor is important but I guess teaching has to be done in good humor and with care. (Lot of people tend to shout in the OR, which only traumatizes the team).

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