Wednesday, July 19, 2017

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.

At that time many more general surgical residency programs existed. A 1985 paper said in 1957 there were 415 approved general surgery residency programs and 352 in 1980. Today there are about 261. Competition for specialties such as orthopedics was not as intense as it is today. Most of my intern class found general surgery positions in other programs or switched to a surgical subspecialty without any interruption in their training.

In the early 80s, many programs voluntarily began to convert to so-called "rectangular" programs where the same number of categorical residents taken in became chief residents. By 1996, the Residency Review Committee for Surgery formally prohibited pyramid programs although some pyramid programs covertly continued the practice for a few years.

A 1999 paper in the Journal of the American College of Surgeons stated that the attrition rate for general surgery residents who entered all programs in 1993 and were followed for five years was 26%. However, the authors combined the attrition rates of categorical and undesignated preliminary residents making it impossible to tell how many of those who dropped out had planned to complete five years of general surgery training.

A total of 590 graduates of Jefferson Medical College who matched in general surgery from 1972 through 1986 were followed for a minimum of five years; 60% of them finished general surgery training; 26% switched to another surgical specialty; 14% went on to train in a non-surgical discipline. These residents were from the pyramid era when leaving a surgical residency program was not necessarily voluntary, and preliminary residents were included in the numbers.

During the years 1982 to 1996, Mount Sinai in New York matched 88 categorical residents, and 19 (22%) dropped out of the program. The male to female ratio of the 19 who left was 11 (17%) to 8 (32%), not a significant difference. “The major reasons for leaving the program were related to the ‘life style’ of the surgeon and the conflict between that life style and the goals and aspirations of the resident.” Specialties chosen by those who left were radiology, 5; orthopedic surgery, 4; dermatology, 3; plastic surgery, 2; urology, anesthesiology, internal medicine, and radiation oncology, 1 each. No one was dismissed for academic or other performance deficiencies.

A paper from the Mayo Clinic traced the career paths of the 57 applicants they ranked in the 1996 match. Eight matched in the Mayo program, and they were able to obtain information on the others from their respective programs. Surprisingly, four applicants did not match in general surgery. Of the 53 who did, 12 (23%) dropped out of general surgery with 4 going into surgical subspecialty training, 3 into anesthesiology and 1 each in family medicine, internal medicine, radiology, and pathology. The other decided to do a PhD.

From 1990 to 2003, Emory University's surgical residency took on 120 categorical residents, and 20 (17%) did not finish for various reasons including lifestyle, opportunity for early specialization, dismissal from the program, and leaving medicine. As other papers have noted, he attrition rate for females was higher at 27% vs. 13% for males.

An issue with the papers mentioned above is that few reported residents being dismissed for cause which certainly must have happened.

Definitive information on the attrition rates of surgical residents from 20-25 years ago is not available due to the combining of categorical and preliminary residents in papers from back then, the prevalence of pyramidal surgical programs, and the lack of comprehensive studies.


Debra Gottsleben said...

Why did they stop the pyramid system? Seemed like if you became the chief resident it was prestigious not just putting in the time. Sounds like if you didn't make it to chief resident it wasn't a problem you could just go to another program. Maybe I'm missing something? And of course when I'm using the word you I'm not referring to you specifically. Thanks

Skeptical Scalpel said...

Debra, thanks for asking. When there were more than 400 surgical residency programs, finding another spot in another surgery program or a subspecialty like ortho or GU was not hard. Now it is extremely difficult.

Also, those who did not find another position in general surgery or a subspecialty were left high and dry.

To be honest, it is not really that different now. There are a lot of undesignated preliminary surgery residents who spend a year or two as general surgery residents and then have to find some non-surgical specialty to go into.

Debra Gottsleben said...

Would seem we need more residency programs not less. Any reason why the number has dropped so dramatically? You'd think hospitals would like having more residents around to do more of the work.

Jack Williams said...

Debra, hospitals have to obtain accreditation from the ACGME which is not neutral. When it evaluates new residency program, say in dermatology, for approval it sends committee of dermatologists. Imagine the conflict of interest in approving program which will produce future rivals for them in the market. Also, the American Medical "Union" (AMA) has conflect of interest. Its main goal is to protect the standards of living for its own members. When you increase the residency positions you increase the practicing doctors in the market. While that would improve the patient care it would lower the salaries of the current members of the AMA and that is what the AMA is reluctant to support. The hospitals, however, succeeded in keeping monopoly on training residents when many hospitals outside the states would willingly meet commonsense national standers for teaching hospitals and for the state licensure so that the unmatched doctors would be able to make their training in them, with lower cost to the medicare, and to meet their state licensure requirements.

Skeptical Scalpel said...

Jack and Debra, Jack's comment is incorrect on many levels.

Here's why. "The Balanced Budget Act of 1997 (BBA) limited the number of allopathic and osteopathic medical residents that would be counted for purposes of calculating Medicare indirect medical education (IME) and direct graduate medical education (DGME) reimbursement to the unweighted number on each hospital's most recent cost report as of December 31, 1996 (BBA Section 4621). Effective October 1, 1997, to the extent the number of allopathic or osteopathic residents being trained at a teaching hospital exceeds the 1996 limit, teaching hospitals receive no additional IME or DGME payments; podiatry and dental residents are excluded from the resident limits." [] While some hospitals have added positions knowing they will not be funded by the federal government, the numbers are small.

If the was a conspiracy to limit the number of doctors, why have 40 new schools open in the last few years and why have most existing schools have increased class sizes?

The AMA can't tell doctors to do anything. In 2013, only 17% of doctors were members []. The figure is probably lower now.

Debra Gottsleben said...

Thanks for the explanation. It must be absolutely gut wrenching for a medical student to not match (and I still don't really understand how that process works) into a residency program after spending all the money they did to go through medical school, let alone the time. Just seems like something in the system needs fixing. Why the govt. has fixed this number on rates from 1996 and not ever increasing the basis is just ridiculous. Hopefully most medical students do find some place in the residency program if not in their top specialty choice.
My own alma mater, Seton Hall, is opening a new medical school next year so I know that new schools are opening. I think it is good we have more schools but just hope these medical school graduates aren't then put into a system where many of them won't be able to move forward if they can't get into a residency program.

Skeptical Scalpel said...

Unfortunately, there will always be graduates who don't match. I've blogged extensively about the risks Caribbean school students take by going to school there. Type "Caribbean" in the search field of my blog and you can read the posts.

Jack Williams said...

Scalpel, with all due respect you are oversimplifying the issue. Congress does not legislate in a vacuum. The AMA, ACGME, AAMC, AACOM, and AHA lobby the congress for their respective interests separately or sometimes collectively. The AMA opposed the Missouri law of assistant physician under pretext of being dangerous for patients while celebrated the match week with NRMP and AAMC when according to the NRMP's stats 30% of the registered applicants did not match and if that was of any indication it would tell their satisfaction with the status quo.
To your rhetorical question about new schools and increased class sizes, the ACGME, AAMC, and AACOM projected there would still be about 4500 more available positions than U.S. graduates in 2023–2024 according to article, why fears of shortage of residency positions may be exaggerated, for Dr. Fitzhugh Mullan in N Engl J Med 12/17/15.
The article talked about convergence between number of us medical graduates and available GME positions and this has been called self-sufficiency. It does not take rocket scientist to know that us graduates would win and displace the IMGs in the competition even if they were us citizens.
The medical establishment, AMA, AHA, ACGME, AAMC, and AACOM should not be allowed to protect socialist medical system in capitalist society by having control on the residency positions.
We live in a capitalist society, and the market should determine the number of doctors in the market. The lobbies of the above organizations should not dictate artificial number of doctors in the market. When the number of doctors exceeds the market needs then the doctors would get lower salaries and the market would adjust itself by attracting fewer people to the profession until the market reaches the equilibrium between the supply and the demand for doctors. Furthermore, the market rewards the good doctor as more patients use him or her and punishes the bad doctor as fewer patients use him or her.

Skeptical Scalpel said...

To your first point, why would the American Hospital Association oppose increasing the number of residency positions when hospitals get reimbursed from the government for each resident they train? Hospitals do not spend as much money as they are paid because if they did, they wouldn’t participate in medical education. Most hospitals do not engage in activities that lose money.

About 7000 IMGs did not match this year. No one is forcing people to go offshore to med school when the prospects for obtaining a residency position are so bleak. I've been blogging about this for years.

The Missouri law allowing medical school graduates who have not done any residency training to practice independently is dangerous. Very few, if any, medical school graduates are ready to practice without additional training. And the “supervision” proposed by the Missouri law is laughable. It says after spending *30 days* with a “physician collaborator,” assistant physicians would be allowed to practice independently as long as they were within 50 miles of their collaborator. 50 miles? I wouldn’t exactly call that supervision. [] Plaintiff’s lawyers in Missouri must be salivating.

Your reference to the New England Journal article by Mullan actually supports my argument that residency positions have not been suppressed by the lobbying that you suggested. As I said before, the feds capped the number of residents. Hospitals can add residency positions if they want to pay for them without government aid.

Your theory that the marketplace weeds out bad doctors is not supported by any evidence.

Jack Williams said...

Scalpel, please be fair to me, I did not say the AHA opposed increasing the residency positions. In my response to Debra I suggested that the ACGME would impede the increase but the AHA succeeded in the lobbying for keeping monopoly on training residents. I can't imagine that Ford Motor Company, GM, and Chrysler say you can't obtain Driver's license unless you buy one of our cars. No doctor can get license to practice medicine unless trains in AHA hospitals.
The convergence and self-sufficiency in Dr. Mullan's article translate to IMGs need not apply even if they were US citizens.

artiger said...

To my knowledge, there is no requirement that a hospital be a member of, or even affiliated with the AHA. I would venture a guess that most, if not all of them are members, but the AHA does not have a "monopoly" on residency training. As for the AMA, sure, they lobby, but as was mentioned above, they represent the interests of fewer than 1 in 5 US physicians.

Jack, I mean no disrespect, but do you even work in a healthcare field? You don't seem to have a good understanding of how US medicine works, at least not the physician training process.

Jack Williams said...

Artiger, just to use Scalpel's words, if you don't like what I have to say, don't read it.
You missed the point on both counts by making distinctions without a difference in your efforts to discredit my comments.
The point is the huge influence that these organizations have on the GME which is the subject matter here.
The AHA is the mainstream representative to the interests of the domestic hospitals whether teaching or not, member or not as opposed to the hospitals outside the states as I differentiated between the two in my response to Debra. It does not matter if the hospital is member or not, when the AHA gets its agenda through that will impact all hospitals members or not, the healthcare system and most importantly the GME per se. Likewise, the AMA is the mainstream representative to the interests of doctors even though it has only about 250,000 members and that is not small number by any means but more importantly when it gets its advocacy through that will impact the member and non member, the healthcare system and the GME which is the subject matter here. In NPR article "Hospitals Fight Proposed Changes In The Training Of Doctors" by JULIE ROVNER on July 31, 2014, you see how the AHA, along with AMA and AAMC, fights to death against shifting some of the GME fund to the community clinics, let alone to hospitals outside the states, and how they collectively fight to keep the status quo in terms of GME.
I like you to take a look at this scenario: A Harvard medical graduate got accepted into residency program in general surgery at Mass. General Hospital, rejected the position because got accepted in general surgery program at a hospital in Singapore, the program accredited by ACGME-I, which is the international branch of the ACGME in case you are not familiar with, she wants to live with her family while doing residency, the father is employee at US embassy in Singapore, forget about DNR, Living Will, Documentation to defend herself in a litigious society that are unique in us medical system and used as pretexts to do the residency in US, she can study 1/2 hour video about them, can she get license to practice medicine in the states after finishing the residency in Singapore?
You know the answer, if that is not monopoly on the residency training by the domestic hospitals I do not know what is. Worse than monopoly for another graduate with otherwise similar qualifications but he wants to do the residency in the states. He did not match after several attempts, technically it may happen even with Harvard graduate. The residency training system basically is telling him, not only you have to do the training with us but also we do not have position for you because the applicants outnumber the positions and you can't get license even if you do residency in Singapore, you are out of business. I wounder how they got this power other than by lobbying and manipulating the GME system.
I think one way congress can solve the problem by using the leverage of GME fund. Congress can distribute the fund as vouchers to at least the qualified US citizens and that would push the hospitals to meet the ACGME requirements so that they can compete for the applicants' vouchers or money and not the other way around.
Anyway, I am not here to convince you about anything, I only expressed my opinion, you expressed yours and let the readers make their own judgments.

artiger said...

Jack, I'm sorry you took offense, which is why I added in my comment "I mean no disrespect".

One thing I responded to was this statement of yours:
"No doctor can get license to practice medicine unless trains in AHA hospitals." Definitely not true, which is what led to my comment about your healthcare experience. Sorry if that came off the wrong way.

I don't disagree that AHA, AMA, as well as many others have influence, but that is not the same thing as a monopoly.

Additionally, your examples are quite specific, not to mention peculiar, but I'll just say that I know lots of people that train outside of the US but manage to practice here. Despite influence, licensure is not determined by the AHA or AMA.

Finally, please know that I read lots of things that I don't like or with which I disagree. That doesn't stop me from reading them.

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