- Email: [email protected]
Factors and Influences That Determine the Choices of Surgery Residency Applicants
2015 APDS SPRING MEETING
Factors and Influences That Determine the Choices of Surgery Residency Applicants Benjamin T. Jarman, MD,* Amit R.T. Joshi, MD,† Amber W. Trickey, PhD, MS, CPH,‡ Jonathan M. Dort, MD,§ Kara J. Kallies, MS,║ and Richard A. Sidwell, MD¶ *
Department of General and Vascular Surgery, Gundersen Health System, La Crosse, Wisconsin; Department of Surgery, Einstein Healthcare Network, Philadelphia, Pennsylvania; ‡Advanced Surgical Technology and Education Center, Inova Fairfax Medical Campus, Falls Church, Virginia; §Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia; ║Department of Research, Gundersen Medical Foundation, La Crosse, Wisconsin; and ¶Department of Surgery Education, Iowa Methodist Medical Center, Des Moines, Iowa †
OBJECTIVE: We sought to evaluate characteristics of
residency applicants selected to interview at independent general surgery programs, identify residency information resources, assess if there is perceived bias toward university or independent programs, and determine what types of programs applicants prefer. STUDY DESIGN: An electronic survey was sent to applicants who were selected to interview at a participating independent program. Open-ended responses regarding reasons for program-type bias were submitted. Multivariable logistic regression models were estimated to identify applicant characteristics associated with program-type preference. SETTING: Independent general surgery residency programs.
training and primarily use residency program websites for information gathering. Bias is common toward university programs for a variety of perceived reasons. This information will be useful in applicant evaluation and selection, serve as a stimulus to update program websites, and challenge independent program directors to work to alleC 2015 viate bias against their programs. ( J Surg ]:]]]-]]]. J Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: independent programs, surgery residency,
National Resident Matching Program, applicant characteristics COMPETENCIES: Professionalism, Systems-Based Practice,
Practice-Based Learning and Improvement
PARTICIPANTS: A total, of 1220 applicants were selected
to interview at one of 33 independent programs. RESULTS: In total, 670 surveys were completed (55%
response rate). Demographics of respondents were similar to the full invited population. Median United States Medical Licensing Examination Step 1 and Step 2 scores were between 230 to 239 and 240 to 249, respectively. Most applicants reported receiving general information about surgery residency programs and specific information about independent programs from residency program websites. 34% of respondents perceived an imbalanced representation of program types, with 96% of those reporting bias toward university programs. CONCLUSIONS: Applicants selected to interview at inde-
pendent programs are competitive for general surgery
Correspondence: Inquiries to Benjamin T. Jarman, MD, Department of General and Vascular Surgery, Gundersen Health System, 1900 South Avenue C05-001, La Crosse, WI 54601; E-mail: [email protected], [email protected]
INTRODUCTION Surgery residency training programs broadly fall into 3 categories: university, independent, and military. “University” programs have generally been regarded as those where the primary hospital is also the primary clinical teaching site for an affiliated medical school. “Military” programs are those that are operated by the United States Armed Forces. “Independent” programs are academic centers that are independent of any medical school, or geographically distinct from an affiliated medical school. Educational affiliations between independent programs and medical schools are becoming more common and, depending on the nature of that affiliation, the term “hybrid” is often used to describe them. Independent programs are characterized by high operative volumes, graduates with increased confidence to practice independently, improved program
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.05.017
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support, and successful fellowship and practice opportunities following 5 years of training.1-3 There are several inherent advantages to learning about applicants to surgery residency programs. A better understanding of applicant characteristics and preferences may lead to less resident attrition and improved resident satisfaction with his or her training environment.4 Intuitively, identifying residents with a desire to ultimately practice in a specific location or environment would be better suited by residency programs with a track record consistent with the applicant’s goals. Accordingly, preresidency factors have been identified, which are correlated with a choice to practice general surgery in rural areas.5 Matching applicant objectives with program opportunities is of critical importance to many of the challenges faced by general surgery residency programs. Medical students are challenged with obtaining information about surgery residencies in the midst of studying to become a physician—a remarkable task that is subject to inaccurate resources and time constraints. Clearly, it is in the best interest of medical school advisors and mentors on every level of surgical education to be aware of suitable options for medical students. The type of information available to medical students and advisors, the content of medical student advising, and the preferences of medical students are clearly imperative and are topics where research is needed. Ultimately, a successful program match with a well-informed medical student who has goals consistent with the strengths of the residency program is desirable. We sought to learn more about general surgery residency applicants to independent programs to better understand
residency information sources, assess whether applicants felt bias toward a particular program type, and determine what types of programs applicants prefer.
METHODS AND MATERIALS Program directors of independent surgical residency programs, identified through the Association of Program Directors in Surgery website,6 were contacted electronically. A total of 33 of the 70 program directors elected to participate in the study by providing data (Fig.). The project was approved by the Association of American Medical Colleges (AAMC) and Institutional Review Board approval was obtained. A 30-item survey (Appendix A) was created which included a query for the respondents’ demographic information, United States Medical Licensing Examination (USMLE) scores, prior clinical experience at independent programs, desired characteristics of a surgical residency program, likelihood of pursuing fellowship, and type of guidance received during the application process. Applicants who interviewed with at least one of the 33 participating programs during the 2013-2014 interview season had their e-mail addresses pooled into a common database. All duplicate e-mail addresses were excluded; 1220 unique e-mail addresses remained. On the day after the rank deadline for the 2014 National Resident Matching Program match, an invitation was sent from an e-mail address with no institutional affiliation ([email protected]), asking each applicant to participate in the online survey (via SurveyMonkey). Over the next 2 weeks, 3 additional reminder invitations were sent, and the survey
FIGURE. Map of participating independent academic surgical residency programs. 2
Journal of Surgical Education Volume ]/Number ] ] 2015
A total of 670 responses were received, yielding a participation rate of 55%. Survey respondents were slightly older, but otherwise similar to the full invited participant group. Overall, 61% of the respondents were men, 71% aged between 26 and 30 years, 25% were married, and 7% had children. Applicant preferences for residency type were first analyzed in 3 levels, as recorded in the survey: independent program preference, university program preference, and
no preference. Most respondents preferred university programs (42%), whereas 35% reported no preference, and 23% preferred independent programs. A 2-level comparison of applicant factors by program preference was calculated while excluding the third group. Groups were compared as follows: independent vs university preference, excluding no preference; independent vs no preference, excluding university; and university vs no preference, excluding independent. A total of 20 applicant factors were compared among 2 preference groups, these included sex, age, marital status, parental status, degree type, preliminary application, medical school region, U.S. medical school, USMLE Step 1 and Step 2 clinical knowledge (CK), rotation in an independent program, number of university program interviews, planning a research year, planning a fellowship, ideal number of residents, preferred practice population and region, interest in group practice, academic practice, and hospital practice. Comparison of applicant factors by independent vs university preference yielded the most prominent contrasts: 15 of 20 factors (75%) significantly differed between independent and university preference groups. University vs no preference comparisons produced 14 of 20 factors (70%), which were significantly different. The most similar groups were independent preference and no preference, with only 8 of 20 factors (40%) exhibiting a significant difference between groups. Factors more strongly associated with preference for independent programs over no preference included female sex, completing an independent program rotation, preference for fewer residents, not planning a research year or fellowship, preference for a group practice and against an academic practice, and fewer university interviews. Despite these noted differences, there were considerable similarities between applicants with independent preference and no program-type preference, and these groups were combined for the final analysis. Demographic characteristics varied by program-type preference. Applicants with preferences for university programs were younger, unmarried, and without children (Table 1). Overall, 82% of applicants attended U.S. medical schools. Applicants with no preference or preference for independent programs attended non-U.S. medical schools, and Midwestern medical schools in higher proportions (p ¼ 0.001). Survey data showed self-reported median USMLE Step 1 and Step 2 CK scores to be between 230 to 249 and 240 to 249, respectively. Applicants with no preference or preference for independent programs reported lower USMLE Step 1 (p ¼ 0.002) and Step 2 CK (p ¼ 0.003) scores (Table 2). Applicants who preferred independent programs reported preference for fewer than 7 residents per year. Applicants who preferred university programs had an interest in research year(s) in higher proportions (p o 0.001), and reported planning a fellowship after residency in higher proportions (p o 0.001) (Table 3).
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was closed before the National Resident Matching Program match day. Survey responses were described using frequency statistics and proportions. The primary outcome variable, candidates’ program preference, was categorized as a 3-level variable (independent, no preference, and university). As this was a primary study question, data from 24 applicants (4%) who did not respond to this item were excluded from the analysis. Chi-square tests were used to assess relationships between applicants’ program-type preference and potential predictors (independent variables), including applicants’ demographics, educational background, application history, and future practice preferences. Independent predictors of applicant program-type preference were assessed with a multivariable logistic regression model. Logistic regression is appropriate for categorical outcome variables; we defined a dichotomous outcome of independent or no preference vs university preference. Multivariable regression provides an assessment of all potential predictor variables considered simultaneously, while adjusting for all other variables in the model. Assumptions of logistic regression were evaluated for the data set. Test scores were combined into categories for analysis guided by quartile distributions (i.e., to the extent possible, score cutoffs were chosen to provide an equivalent number of respondents in each group). All potential predictor variables were entered into the full multivariable model; backward stepwise selection was used to remove variables from the model until all remaining variables were statistically significant (at least 1 variable level). Statistical significance was assessed at p o 0.05. McFadden’s pseudo R2 and Hosmer-Lemeshow goodness of fit tests were calculated to assess the model fit to the data; statistical assumptions of logistic regression were upheld.7,8 Calculations were performed in Stata v.12 (College Station, TX). Applicants were asked if they perceived an imbalanced representation of program types (yes/no) and if they responded “yes”, an additional question clarified if the bias was toward university programs or independent programs. Additionally, a free text box was provided to query the reason for the bias. The responses were tabulated and categorized by the authors.
RESULTS
TABLE 1. Demographic Characteristics of Survey Respondents Who Expressed a Program Preference
Demographic Characteristics Total Sex Male Female Age, y o25 26-30 430 Married Yes No Children Yes No
University Preference
Independent or No Preference
N (%) 270 (100)
376 (100)
167 (62) 102 (38)
231 (62) 142 (38)
52 (19) 190 (71) 26 (10)
49 (13) 271 (72) 56 (15)
48 (18) 222 (82)
112 (30) 264 (70)
38 (10) 336 (90)
9 (3) 260 (97)
p Value 0.97 0.025
o0.001 0.001
The number of responses per question may not equal the total number of respondents, as some respondents did not complete all questions.
Applicants who preferred independent programs reported plans to join a group or hospital practice in higher proportions (p o 0.001). Applicants preferring university
programs desired a practice in urban or metropolitan areas (p o 0.001), or in an academic setting. Additionally, they reported a desire to practice outside the Midwest in higher proportions (p ¼ 0.043) (Table 4). Using a multivariable logistic regression model, applicant characteristics positively associated with independent program preference or no preference included: having children (odds ratio [OR] ¼ 2.99; 95% CI: 1.2-7.6, p ¼ 0.021), Midwestern region medical school (OR ¼ 1.81; 95% CI: 1.1-3.0, p ¼ 0.025), ideal number of residents less than 7 (OR ¼ 2.60; 95% CI: 1.6-4.2, p o 0.001), preference for group practice (OR ¼ 3.14; 95% CI: 1.9-5.1, p o 0.001), and preference for hospital practice (OR ¼ 3.35; 95% CI: 1.8-6.2, p o 0.001). Applicant characteristics negatively associated with independent preference or no preference included: more university interviews (referent ¼ 0-2 interviews; 3-5 interviews OR ¼ 0.41; 95% CI: 0.2-0.7, p ¼ 0.003; 45 interviews OR ¼ 0.16; 95% CI: 0.1-0.3, p o 0.001), plans for a research year (OR ¼ 0.45; 95% CI: 0.30.7, p o 0.001), and “very likely” to pursue a fellowship (OR ¼ 0.38; 95% CI: 0.2-0.9, p ¼ 0.039). McFadden’s pseudo R2 for the model was 0.30, and the HosmerLemeshow goodness of fit test resulted in p ¼ 0.14; both tests indicate the model demonstrated a good fit to the data.7,9
TABLE 2. Applicant Medical School Characteristics of Survey Respondents Who Expressed a Program Preference University Preference
N (%)
Academic Characteristics Total U.S. medical school Yes No U.S. medical school region Midwest Northeast South West N/A USMLE Step 1 score o210 210-229 230-249 4249 USMLE Step 2 CK score o230 230-239 240-249 4249 Independent program rotation Yes No Applied to Preliminary Program Yes No
Independent or No Preference p Value
270 (100)
376 (100)
240 (90) 28 (10)
299 (80) 74 (20)
39 61 101 33 36
(14) (23) (37) (12) (13)
90 59 110 39 78
(24) (16) (30) (10) (21)
19 97 111 40
(7) (36) (42) (15)
51 153 138 29
(14) (41) (37) (8)
41 63 71 93
(15) (24) (46) (35)
78 88 108 92
(21) (24) (30) (25)
0.001 0.001
0.002
0.039
0.003 123 (46) 146 (54)
215 (58) 158 (42)
48 (18) 222 (82)
99 (26) 277 (74)
0.011
The number of responses per question may not equal the total number of respondents, as some respondents did not complete all questions. N/A, not applicable. 4
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TABLE 3. Applicants’ Interviews and Preferences for Training From Survey Respondents Who Expressed a Program Preference Interviews and Residency Preference Total Number of university interviews 0-2 3-5 45 Plan research year Yes No Ideal number of residents o4 4-6 7-9 49 Plan fellowship Very or somewhat unlikely Somewhat likely Very likely
University Preference
Independent or No Preference N (%)
p Value
270 (100)
376 (100)
27 (10) 53 (20) 189 (70)
138 (37) 117 (31) 120 (32)
165 (61) 105 (39)
74 (20) 297 (80)
13 149 98 9
44 281 37 8
(5) (55) (36) (3)
7 (3) 45 (17) 218 (81)
(12) (76) (10) (2)
49 (13) 130 (35) 195 (52)
o0.001
o0.001 o0.001
o0.001
The number of responses per question may not equal the total number of respondents, as some respondents did not complete all questions.
We questioned what sources applicants used to obtain information about independent programs. The most common sources they used for all programs and independent programs were websites (86% and 67%, respectively); residents (76% and 59%, respectively), and faculty (73% and 56%, respectively). Few applicants used “So You Want to Be A Surgeon: An Online Guide to Selecting and Matching with the Best Surgery Residency” (commonly known as the “Little Red Book” available on the American College of Surgeons website).10 One-third (34%) of respondents perceived an imbalanced representation of program types with 96% of those
reporting bias towards university programs. The most commonly reported reasons for this bias were: a narrow scope of university mentors (32%), fellowship opportunities (19%), prestige or reputation (15%), academic (9%) or research (7%) opportunities, and lack of information about independent programs (7%) (Table 5).
DISCUSSION The goal of our study was to assess the characteristics, influences, preferences, and demographics of medical student
TABLE 4. Applicants’ Plan for Practice University Preference
N (%)
Preference for Practice Total Setting Small/large rural (r50,000) Urban (variable population)* Metropolitan (450,000) Type Academic Group Hospital Other Geographic area Midwest Northeast South West Other
Independent or No Preference p Value
270 (100)
376 (100)
23 (9) 125 (47) 117 (44)
86 (23) 188 (51) 97 (26)
180 51 25 7
(67) (21) (9) (3)
98 191 74 8
(26) (51) (20) (2)
32 66 82 76 11
(12) (25) (31) (28) (4)
67 65 118 112 8
(18) (18) (32) (30) (2)
o0.001
o0.001
0.043
The number of responses per question may not equal the total number of respondents, as some respondents did not complete all questions. *Urban setting (variable population within 20 miles of a metropolitan center). Journal of Surgical Education Volume ]/Number ] ] 2015
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TABLE 5. Perceived Bias Toward University Programs (OpenEnded Responses)
applicants to independent programs. Program-type preference was significantly associated with family status, medical school region, planning a dedicated research year or a fellowship, preferred number of residents, plans for future practice, and number of university program interviews. Applicants most commonly used individual residency websites to obtain program information. This finding serves as a powerful reminder for Program Directors to assure that their program websites are up to date and that conduits for their residency information, such as Fellowship and Residency Electronic Interactive Database (FREIDA)11 and Association of Program Directors in Surgery websites,6 are current with appropriate internet links to facilitate applicant exploration. In fact, during the process of this study, we identified several internet addresses through FREIDA, which did not link directly to surgery residency program sites and several program sites that were fairly difficult to navigate. Applicants also heavily used surgery residents and teaching faculty for program information although the quality of this guidance or information could not be assessed. We noted that few applicants (6%) used online resources such as “The Little Red Book,”10 which has historically been touted as a “go to guide” for residency information. Independent programs constitute approximately 30% (70/255) of the Accreditation Council for Graduate Medical Education accredited surgery residencies in the United States, yielding approximately 273 graduates per year. Most medical studentsʼ experience occurs in university settings, resulting in less exposure to independent programs. There are increasing numbers of U.S. medical school programs aimed at retaining individuals in their “home” states.12-16 These experiences provide outstanding clinical opportunities, often at independent centers. The increase in “affiliations” between independent programs and medical schools is also an avenue where medical students can gain exposure to these programs, ultimately gaining firsthand experience to enable them to decide for themselves if they desire independent vs university program training environments.
Limited research has been conducted on the differentiating characteristics of independent programs and university programs and “perceptions” seem to be the most common avenue by which medical students obtain information from their mentors. On a broader level, there has been much attention devoted to both surgical trainees’ and practitioners’ views on the current state of American surgery. Particular issues that have recently generated controversy include the level of preparation of graduating chief residents, including the overall trend towards subspecialization within surgery, which has resulted in a population-matched decline of “general surgeons,” and the appropriate length of surgical training given the current Accreditation Council for Graduate Medical Education duty-hour restrictions.17-23 Meanwhile, general surgery is being increasingly considered a threatened specialty with current shortages across our nation, particularly in nonmetropolitan communities.24 Indeed, the current “Fix the Five” initiative by the American Board of Surgery is tasked with addressing these issues to improve surgical training and better meet societal demands.25 Leading the charge for change, a comprehensive analysis of these topics was published in 2012 that was based on the National Study of Expectations and Attitudes of Residents in Surgery survey. This study, administered to all examinees after the 2008 American Board of Surgery In-Service Training Examination, found significant differences in perceptions among trainees in independent programs compared with university programs and military programs.2 Independent program residents (who comprised 28.8% of the 4282 respondents) were most satisfied with their operative experience, most likely to feel their opinions were important, and least likely to believe attending surgeons would think worse of them if they asked for help with patient management. They reported high levels of perceived program support, and felt more confident about their potential for independent practice. They were also less likely to feel that surgical training is too long, when compared with university trainees. Additionally, they were less likely to be women and slightly more likely to be married. Applicants to surgical training programs inherently interact with university surgeons more than independent ones. Although a core surgical rotation may be at an independent hospital, most primary and subspecialty rotations are based at large tertiary hospitals, which are often the flagship university hospital. Applicants are typically assigned advisors who are based in a university setting and who may or may not be familiar with the broad scope of training opportunities that are available to their mentees. This system naturally promotes bias toward university programs that has been identified previously.26-29 Several hypotheses exist about a potential disconnect between qualifications needed for surgical jobs and the surgical trainee perceptions of these qualifications. Friedell
6
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Category Total Narrow scope of university mentors Fellowship options Prestige/reputation Academic opportunities Research opportunities Lack of information about independent programs Other Better teaching Negative comments
N (%) 193 62 37 28 18 13 14
(100) (32) (19) (15) (9) (7) (7)
11 (6) 7 (4) 3 (2)
et al.1 found that lack of confidence was an important issue that prompted trainees to seek fellowship training. Interestingly, they found that independent program trainees felt more confident about entering into surgical practice directly out of residency, when compared with university program graduates. Other factors that have been thought to influence lack of confidence in surgical trainees include less clinical time in the hospital as a result of duty-hour regulations, general underpreparation of graduating medical students for their residency training and an increasing lack of exposure to “general surgeons” during general surgery residency training.19,30 A comprehensive review of the U.S. surgical workforce found that there is a significant shortage of general surgeons throughout the United States, which is more notable in rural and underserved areas.23 There are an estimated 22,486 general surgeons and an additional 6440 general surgeons with subspecialty training in the United States. Between 2005 and 2009, the number of general surgeons has grown 0.2%. Approximately 10% of surgeons are aged 70 years or older. Furthermore, the supply of general surgeons is expected to grow 1% per year between 2014 and 2030. When weighted against the overall growth in population, this results in a static supply of general surgeons per 100,000 persons.31 Paradoxically, 70% to 80% of graduating surgical trainees seek fellowship training, despite the fact that the minority of surgical positions require fellowship training. A recent study in Wisconsin and Oregon estimated that only 34% of available jobs required fellowship training.32 By this calculus, approximately 40% of graduating residents were unnecessarily pursuing further training after residency. These authors also found that 43% of job postings were for rural jobs, whereas 35% were for nonacademic metropolitan, and 17% for metropolitan academic jobs. We observed that medical student applicants to independent programs were less interested in pursuing fellowships and academic surgery. This suggests that independent programs will continue to be a vital source of general surgeons capable of broad spectrum practice—a workforce that is sorely needed across the United States. More than one-third of the surgery residency applicants reported perceived bias in mentorship, which was almost uniformly in favor of university programs. We do not believe that such bias is justified based on successful fellowship match, program attrition rates, overall satisfaction with obtaining career goals, or patient outcome data. We hypothesize that such bias is based on the personal career path of the mentor (likely to be university based), who may be swayed by his/her training experience, personal experience, and area of clinical practice. If our data are extrapolated to current surgical faculty across the country, then one can assume that university faculty were more likely to have trained at university programs, conducted research, and pursued fellowships before their current positions. Regardless, it
is clearly important for members of the surgical education community to be aware of this finding so that they provide accurate and evidence-based guidance regarding the best potential match for their medical students. It would be beneficial for independent program directors to further study and publish the success of their graduates in initiating successful general surgery careers following 5 years of training, obtaining fellowship positions and accomplishing excellent clinical outcomes. In addition, it may be beneficial for independent program directors to meet with Deans of medical schools within their region to reinforce their philosophy and success in training. These steps may aid the attempt to overcome current bias within the surgical education community. In the future, we hope to analyze the career paths of independent program graduates. Specifically, we would be interested to see if the perceptions that medical students have at the beginning of their surgical careers persist through their surgical training. For example, are graduates of independent programs more likely to enter into solo, group, or hospital practice following 5 years of residency with or without fellowship training? How does this differ from surgeons trained in a university setting? Also, can characteristics of medical student applicants be used to streamline the interview process? As applications to surgical residencies increase, and interview slots and residency resources largely stagnate, can program directors analyze medical students’ characteristics to better allocate interviews to candidates who are more likely to prefer to match with them? Our study does have several limitations. Multiple independent program directors were contacted to participate and 47% (33/70) committed to the project. Accordingly, it is possible some of the conclusions drawn about their applicants are subject to selection bias. This could be especially important with regard to some of the geographic preferences that applicants appeared to express. However, we were able to obtain data from institutions across the country from a broad variety of environments (metropolitan and urban settings). Although the surgery residency applicant survey had an excellent response rate, any methodology that relies on a survey is subject to the risk of reporting bias. Additionally, although the results include data about students who have preferences for university programs, it is possible that these results would not be representative of a wider cross-section of students who interviewed only at university programs. Given contemporary concerns related to confidence of graduating residents, a shortage of graduates who are pursuing general surgery practice and an increasing number of graduates who are pursuing fellowship training, changes in residency training are already upon us. Graduates from independent programs have been identified as being more confident in their surgical skill sets and more confident in entering general surgery practice directly following 5 years
Journal of Surgical Education Volume ]/Number ] ] 2015
7
of training.1 It seems that the remedies for graduate surgery education challenges may be present within our current training systems.
4. Alterman DM, Jones TM, Heidel RE, Daley BJ,
IMPLICATIONS
5. Jarman BT, Cogbill TH, Mathiason MA, et al. Factors
A better understanding of the characteristics of applicants who indicate a preference for independent surgery residency programs will help program directors in ranking considerations and may lead to better match outcomes. Information resources about independent programs have been identified as well as a need to assure these resources are updated and distributed to residency applicants. Importantly, many applicants cited a bias towards university programs for several reasons. This bias should be remedied so that information is consistent and accurate for all applicants.
CONCLUSIONS We have identified several demographic variables and applicant characteristics that are associated with a preference for independent programs and university programs. Residency websites are the chief sources of information about programs but faculty and residents play a vital role as well. Bias against independent programs is clearly perceived by medical students and needs to be remedied to provide accurate information about training opportunities for applicants that will match their career interests.
ACKNOWLEDGMENTS The authors gratefully acknowledge the contributions of Residency Program Specialists Colette O’Heron, Lauren Hook, Diann Carreker, and Paula Rasmussen. The authors appreciate and thank the independent program directors and coordinators who facilitated data submission for this study (Appendix B).
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J, Jones DB, Public Policy and Advocacy Committee of the SSAT. Workforce shortage for general surgeons: results from the Society for Surgery of the Alimentary Track (SSAT) surgeon shortage survey. J Gastrointest Surg. 2014;18(12):2061-2073.
H. Clerkship site and duration: do they influence student performance? Surgery. 1986;100(2):306-311. 28. Schwartz GF, Veloski J, Gonnella JS. Evaluation of the
surgical clerkship experience in affiliated hospitals: performance on objective examinations. J Surg Res. 1976;20(3):179-182. 29. Imperato JC, Rand WM, Grable EE, Reines HD. The
role of the community teaching hospital in surgical undergraduate education. Am J Surg. 2000;179(9): 150-153. 30. Bell RH Jr. Why Johnny cannot operate. Surgery.
2009;146(4):533-542. 31. Cecil G. Sheps Center for Health Services Research, The
University of North Carolina at Chapel Hill. FutureDocs Forecasting Tool. Available at: 〈http://www. acshpri.org/documents/ACSHPRI_Surgical_Workfor ce_in_US_apr2010.pdf〉. Accessed 03.04.15. 32. Decker MR, Bronson NW, Greenberg CC, Dolan JP,
Kent KC, Hunter JG. The general surgery job market: analysis of current demand for general surgeons and their specialized skills. J Am Coll Surg. 2013;217(6): 1133-1139.
SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.jsurg. 2015.05.017.
Journal of Surgical Education Volume ]/Number ] ] 2015
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Factors and Influences That Determine the Choices of Surgery Residency Applicants Benjamin T. Jarman, MD,* Amit R.T. Joshi, MD,† Amber W. Trickey, PhD, MS, CPH,‡ Jonathan M. Dort, MD,§ Kara J. Kallies, MS,║ and Richard A. Sidwell, MD¶ *
Department of General and Vascular Surgery, Gundersen Health System, La Crosse, Wisconsin; Department of Surgery, Einstein Healthcare Network, Philadelphia, Pennsylvania; ‡Advanced Surgical Technology and Education Center, Inova Fairfax Medical Campus, Falls Church, Virginia; §Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia; ║Department of Research, Gundersen Medical Foundation, La Crosse, Wisconsin; and ¶Department of Surgery Education, Iowa Methodist Medical Center, Des Moines, Iowa †
OBJECTIVE: We sought to evaluate characteristics of
residency applicants selected to interview at independent general surgery programs, identify residency information resources, assess if there is perceived bias toward university or independent programs, and determine what types of programs applicants prefer. STUDY DESIGN: An electronic survey was sent to applicants who were selected to interview at a participating independent program. Open-ended responses regarding reasons for program-type bias were submitted. Multivariable logistic regression models were estimated to identify applicant characteristics associated with program-type preference. SETTING: Independent general surgery residency programs.
training and primarily use residency program websites for information gathering. Bias is common toward university programs for a variety of perceived reasons. This information will be useful in applicant evaluation and selection, serve as a stimulus to update program websites, and challenge independent program directors to work to alleC 2015 viate bias against their programs. ( J Surg ]:]]]-]]]. J Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: independent programs, surgery residency,
National Resident Matching Program, applicant characteristics COMPETENCIES: Professionalism, Systems-Based Practice,
Practice-Based Learning and Improvement
PARTICIPANTS: A total, of 1220 applicants were selected
to interview at one of 33 independent programs. RESULTS: In total, 670 surveys were completed (55%
response rate). Demographics of respondents were similar to the full invited population. Median United States Medical Licensing Examination Step 1 and Step 2 scores were between 230 to 239 and 240 to 249, respectively. Most applicants reported receiving general information about surgery residency programs and specific information about independent programs from residency program websites. 34% of respondents perceived an imbalanced representation of program types, with 96% of those reporting bias toward university programs. CONCLUSIONS: Applicants selected to interview at inde-
pendent programs are competitive for general surgery
Correspondence: Inquiries to Benjamin T. Jarman, MD, Department of General and Vascular Surgery, Gundersen Health System, 1900 South Avenue C05-001, La Crosse, WI 54601; E-mail: [email protected], [email protected]
INTRODUCTION Surgery residency training programs broadly fall into 3 categories: university, independent, and military. “University” programs have generally been regarded as those where the primary hospital is also the primary clinical teaching site for an affiliated medical school. “Military” programs are those that are operated by the United States Armed Forces. “Independent” programs are academic centers that are independent of any medical school, or geographically distinct from an affiliated medical school. Educational affiliations between independent programs and medical schools are becoming more common and, depending on the nature of that affiliation, the term “hybrid” is often used to describe them. Independent programs are characterized by high operative volumes, graduates with increased confidence to practice independently, improved program
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.05.017
1
support, and successful fellowship and practice opportunities following 5 years of training.1-3 There are several inherent advantages to learning about applicants to surgery residency programs. A better understanding of applicant characteristics and preferences may lead to less resident attrition and improved resident satisfaction with his or her training environment.4 Intuitively, identifying residents with a desire to ultimately practice in a specific location or environment would be better suited by residency programs with a track record consistent with the applicant’s goals. Accordingly, preresidency factors have been identified, which are correlated with a choice to practice general surgery in rural areas.5 Matching applicant objectives with program opportunities is of critical importance to many of the challenges faced by general surgery residency programs. Medical students are challenged with obtaining information about surgery residencies in the midst of studying to become a physician—a remarkable task that is subject to inaccurate resources and time constraints. Clearly, it is in the best interest of medical school advisors and mentors on every level of surgical education to be aware of suitable options for medical students. The type of information available to medical students and advisors, the content of medical student advising, and the preferences of medical students are clearly imperative and are topics where research is needed. Ultimately, a successful program match with a well-informed medical student who has goals consistent with the strengths of the residency program is desirable. We sought to learn more about general surgery residency applicants to independent programs to better understand
residency information sources, assess whether applicants felt bias toward a particular program type, and determine what types of programs applicants prefer.
METHODS AND MATERIALS Program directors of independent surgical residency programs, identified through the Association of Program Directors in Surgery website,6 were contacted electronically. A total of 33 of the 70 program directors elected to participate in the study by providing data (Fig.). The project was approved by the Association of American Medical Colleges (AAMC) and Institutional Review Board approval was obtained. A 30-item survey (Appendix A) was created which included a query for the respondents’ demographic information, United States Medical Licensing Examination (USMLE) scores, prior clinical experience at independent programs, desired characteristics of a surgical residency program, likelihood of pursuing fellowship, and type of guidance received during the application process. Applicants who interviewed with at least one of the 33 participating programs during the 2013-2014 interview season had their e-mail addresses pooled into a common database. All duplicate e-mail addresses were excluded; 1220 unique e-mail addresses remained. On the day after the rank deadline for the 2014 National Resident Matching Program match, an invitation was sent from an e-mail address with no institutional affiliation ([email protected]), asking each applicant to participate in the online survey (via SurveyMonkey). Over the next 2 weeks, 3 additional reminder invitations were sent, and the survey
FIGURE. Map of participating independent academic surgical residency programs. 2
Journal of Surgical Education Volume ]/Number ] ] 2015
A total of 670 responses were received, yielding a participation rate of 55%. Survey respondents were slightly older, but otherwise similar to the full invited participant group. Overall, 61% of the respondents were men, 71% aged between 26 and 30 years, 25% were married, and 7% had children. Applicant preferences for residency type were first analyzed in 3 levels, as recorded in the survey: independent program preference, university program preference, and
no preference. Most respondents preferred university programs (42%), whereas 35% reported no preference, and 23% preferred independent programs. A 2-level comparison of applicant factors by program preference was calculated while excluding the third group. Groups were compared as follows: independent vs university preference, excluding no preference; independent vs no preference, excluding university; and university vs no preference, excluding independent. A total of 20 applicant factors were compared among 2 preference groups, these included sex, age, marital status, parental status, degree type, preliminary application, medical school region, U.S. medical school, USMLE Step 1 and Step 2 clinical knowledge (CK), rotation in an independent program, number of university program interviews, planning a research year, planning a fellowship, ideal number of residents, preferred practice population and region, interest in group practice, academic practice, and hospital practice. Comparison of applicant factors by independent vs university preference yielded the most prominent contrasts: 15 of 20 factors (75%) significantly differed between independent and university preference groups. University vs no preference comparisons produced 14 of 20 factors (70%), which were significantly different. The most similar groups were independent preference and no preference, with only 8 of 20 factors (40%) exhibiting a significant difference between groups. Factors more strongly associated with preference for independent programs over no preference included female sex, completing an independent program rotation, preference for fewer residents, not planning a research year or fellowship, preference for a group practice and against an academic practice, and fewer university interviews. Despite these noted differences, there were considerable similarities between applicants with independent preference and no program-type preference, and these groups were combined for the final analysis. Demographic characteristics varied by program-type preference. Applicants with preferences for university programs were younger, unmarried, and without children (Table 1). Overall, 82% of applicants attended U.S. medical schools. Applicants with no preference or preference for independent programs attended non-U.S. medical schools, and Midwestern medical schools in higher proportions (p ¼ 0.001). Survey data showed self-reported median USMLE Step 1 and Step 2 CK scores to be between 230 to 249 and 240 to 249, respectively. Applicants with no preference or preference for independent programs reported lower USMLE Step 1 (p ¼ 0.002) and Step 2 CK (p ¼ 0.003) scores (Table 2). Applicants who preferred independent programs reported preference for fewer than 7 residents per year. Applicants who preferred university programs had an interest in research year(s) in higher proportions (p o 0.001), and reported planning a fellowship after residency in higher proportions (p o 0.001) (Table 3).
Journal of Surgical Education Volume ]/Number ] ] 2015
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was closed before the National Resident Matching Program match day. Survey responses were described using frequency statistics and proportions. The primary outcome variable, candidates’ program preference, was categorized as a 3-level variable (independent, no preference, and university). As this was a primary study question, data from 24 applicants (4%) who did not respond to this item were excluded from the analysis. Chi-square tests were used to assess relationships between applicants’ program-type preference and potential predictors (independent variables), including applicants’ demographics, educational background, application history, and future practice preferences. Independent predictors of applicant program-type preference were assessed with a multivariable logistic regression model. Logistic regression is appropriate for categorical outcome variables; we defined a dichotomous outcome of independent or no preference vs university preference. Multivariable regression provides an assessment of all potential predictor variables considered simultaneously, while adjusting for all other variables in the model. Assumptions of logistic regression were evaluated for the data set. Test scores were combined into categories for analysis guided by quartile distributions (i.e., to the extent possible, score cutoffs were chosen to provide an equivalent number of respondents in each group). All potential predictor variables were entered into the full multivariable model; backward stepwise selection was used to remove variables from the model until all remaining variables were statistically significant (at least 1 variable level). Statistical significance was assessed at p o 0.05. McFadden’s pseudo R2 and Hosmer-Lemeshow goodness of fit tests were calculated to assess the model fit to the data; statistical assumptions of logistic regression were upheld.7,8 Calculations were performed in Stata v.12 (College Station, TX). Applicants were asked if they perceived an imbalanced representation of program types (yes/no) and if they responded “yes”, an additional question clarified if the bias was toward university programs or independent programs. Additionally, a free text box was provided to query the reason for the bias. The responses were tabulated and categorized by the authors.
RESULTS
TABLE 1. Demographic Characteristics of Survey Respondents Who Expressed a Program Preference
Demographic Characteristics Total Sex Male Female Age, y o25 26-30 430 Married Yes No Children Yes No
University Preference
Independent or No Preference
N (%) 270 (100)
376 (100)
167 (62) 102 (38)
231 (62) 142 (38)
52 (19) 190 (71) 26 (10)
49 (13) 271 (72) 56 (15)
48 (18) 222 (82)
112 (30) 264 (70)
38 (10) 336 (90)
9 (3) 260 (97)
p Value 0.97 0.025
o0.001 0.001
The number of responses per question may not equal the total number of respondents, as some respondents did not complete all questions.
Applicants who preferred independent programs reported plans to join a group or hospital practice in higher proportions (p o 0.001). Applicants preferring university
programs desired a practice in urban or metropolitan areas (p o 0.001), or in an academic setting. Additionally, they reported a desire to practice outside the Midwest in higher proportions (p ¼ 0.043) (Table 4). Using a multivariable logistic regression model, applicant characteristics positively associated with independent program preference or no preference included: having children (odds ratio [OR] ¼ 2.99; 95% CI: 1.2-7.6, p ¼ 0.021), Midwestern region medical school (OR ¼ 1.81; 95% CI: 1.1-3.0, p ¼ 0.025), ideal number of residents less than 7 (OR ¼ 2.60; 95% CI: 1.6-4.2, p o 0.001), preference for group practice (OR ¼ 3.14; 95% CI: 1.9-5.1, p o 0.001), and preference for hospital practice (OR ¼ 3.35; 95% CI: 1.8-6.2, p o 0.001). Applicant characteristics negatively associated with independent preference or no preference included: more university interviews (referent ¼ 0-2 interviews; 3-5 interviews OR ¼ 0.41; 95% CI: 0.2-0.7, p ¼ 0.003; 45 interviews OR ¼ 0.16; 95% CI: 0.1-0.3, p o 0.001), plans for a research year (OR ¼ 0.45; 95% CI: 0.30.7, p o 0.001), and “very likely” to pursue a fellowship (OR ¼ 0.38; 95% CI: 0.2-0.9, p ¼ 0.039). McFadden’s pseudo R2 for the model was 0.30, and the HosmerLemeshow goodness of fit test resulted in p ¼ 0.14; both tests indicate the model demonstrated a good fit to the data.7,9
TABLE 2. Applicant Medical School Characteristics of Survey Respondents Who Expressed a Program Preference University Preference
N (%)
Academic Characteristics Total U.S. medical school Yes No U.S. medical school region Midwest Northeast South West N/A USMLE Step 1 score o210 210-229 230-249 4249 USMLE Step 2 CK score o230 230-239 240-249 4249 Independent program rotation Yes No Applied to Preliminary Program Yes No
Independent or No Preference p Value
270 (100)
376 (100)
240 (90) 28 (10)
299 (80) 74 (20)
39 61 101 33 36
(14) (23) (37) (12) (13)
90 59 110 39 78
(24) (16) (30) (10) (21)
19 97 111 40
(7) (36) (42) (15)
51 153 138 29
(14) (41) (37) (8)
41 63 71 93
(15) (24) (46) (35)
78 88 108 92
(21) (24) (30) (25)
0.001 0.001
0.002
0.039
0.003 123 (46) 146 (54)
215 (58) 158 (42)
48 (18) 222 (82)
99 (26) 277 (74)
0.011
The number of responses per question may not equal the total number of respondents, as some respondents did not complete all questions. N/A, not applicable. 4
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TABLE 3. Applicants’ Interviews and Preferences for Training From Survey Respondents Who Expressed a Program Preference Interviews and Residency Preference Total Number of university interviews 0-2 3-5 45 Plan research year Yes No Ideal number of residents o4 4-6 7-9 49 Plan fellowship Very or somewhat unlikely Somewhat likely Very likely
University Preference
Independent or No Preference N (%)
p Value
270 (100)
376 (100)
27 (10) 53 (20) 189 (70)
138 (37) 117 (31) 120 (32)
165 (61) 105 (39)
74 (20) 297 (80)
13 149 98 9
44 281 37 8
(5) (55) (36) (3)
7 (3) 45 (17) 218 (81)
(12) (76) (10) (2)
49 (13) 130 (35) 195 (52)
o0.001
o0.001 o0.001
o0.001
The number of responses per question may not equal the total number of respondents, as some respondents did not complete all questions.
We questioned what sources applicants used to obtain information about independent programs. The most common sources they used for all programs and independent programs were websites (86% and 67%, respectively); residents (76% and 59%, respectively), and faculty (73% and 56%, respectively). Few applicants used “So You Want to Be A Surgeon: An Online Guide to Selecting and Matching with the Best Surgery Residency” (commonly known as the “Little Red Book” available on the American College of Surgeons website).10 One-third (34%) of respondents perceived an imbalanced representation of program types with 96% of those
reporting bias towards university programs. The most commonly reported reasons for this bias were: a narrow scope of university mentors (32%), fellowship opportunities (19%), prestige or reputation (15%), academic (9%) or research (7%) opportunities, and lack of information about independent programs (7%) (Table 5).
DISCUSSION The goal of our study was to assess the characteristics, influences, preferences, and demographics of medical student
TABLE 4. Applicants’ Plan for Practice University Preference
N (%)
Preference for Practice Total Setting Small/large rural (r50,000) Urban (variable population)* Metropolitan (450,000) Type Academic Group Hospital Other Geographic area Midwest Northeast South West Other
Independent or No Preference p Value
270 (100)
376 (100)
23 (9) 125 (47) 117 (44)
86 (23) 188 (51) 97 (26)
180 51 25 7
(67) (21) (9) (3)
98 191 74 8
(26) (51) (20) (2)
32 66 82 76 11
(12) (25) (31) (28) (4)
67 65 118 112 8
(18) (18) (32) (30) (2)
o0.001
o0.001
0.043
The number of responses per question may not equal the total number of respondents, as some respondents did not complete all questions. *Urban setting (variable population within 20 miles of a metropolitan center). Journal of Surgical Education Volume ]/Number ] ] 2015
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TABLE 5. Perceived Bias Toward University Programs (OpenEnded Responses)
applicants to independent programs. Program-type preference was significantly associated with family status, medical school region, planning a dedicated research year or a fellowship, preferred number of residents, plans for future practice, and number of university program interviews. Applicants most commonly used individual residency websites to obtain program information. This finding serves as a powerful reminder for Program Directors to assure that their program websites are up to date and that conduits for their residency information, such as Fellowship and Residency Electronic Interactive Database (FREIDA)11 and Association of Program Directors in Surgery websites,6 are current with appropriate internet links to facilitate applicant exploration. In fact, during the process of this study, we identified several internet addresses through FREIDA, which did not link directly to surgery residency program sites and several program sites that were fairly difficult to navigate. Applicants also heavily used surgery residents and teaching faculty for program information although the quality of this guidance or information could not be assessed. We noted that few applicants (6%) used online resources such as “The Little Red Book,”10 which has historically been touted as a “go to guide” for residency information. Independent programs constitute approximately 30% (70/255) of the Accreditation Council for Graduate Medical Education accredited surgery residencies in the United States, yielding approximately 273 graduates per year. Most medical studentsʼ experience occurs in university settings, resulting in less exposure to independent programs. There are increasing numbers of U.S. medical school programs aimed at retaining individuals in their “home” states.12-16 These experiences provide outstanding clinical opportunities, often at independent centers. The increase in “affiliations” between independent programs and medical schools is also an avenue where medical students can gain exposure to these programs, ultimately gaining firsthand experience to enable them to decide for themselves if they desire independent vs university program training environments.
Limited research has been conducted on the differentiating characteristics of independent programs and university programs and “perceptions” seem to be the most common avenue by which medical students obtain information from their mentors. On a broader level, there has been much attention devoted to both surgical trainees’ and practitioners’ views on the current state of American surgery. Particular issues that have recently generated controversy include the level of preparation of graduating chief residents, including the overall trend towards subspecialization within surgery, which has resulted in a population-matched decline of “general surgeons,” and the appropriate length of surgical training given the current Accreditation Council for Graduate Medical Education duty-hour restrictions.17-23 Meanwhile, general surgery is being increasingly considered a threatened specialty with current shortages across our nation, particularly in nonmetropolitan communities.24 Indeed, the current “Fix the Five” initiative by the American Board of Surgery is tasked with addressing these issues to improve surgical training and better meet societal demands.25 Leading the charge for change, a comprehensive analysis of these topics was published in 2012 that was based on the National Study of Expectations and Attitudes of Residents in Surgery survey. This study, administered to all examinees after the 2008 American Board of Surgery In-Service Training Examination, found significant differences in perceptions among trainees in independent programs compared with university programs and military programs.2 Independent program residents (who comprised 28.8% of the 4282 respondents) were most satisfied with their operative experience, most likely to feel their opinions were important, and least likely to believe attending surgeons would think worse of them if they asked for help with patient management. They reported high levels of perceived program support, and felt more confident about their potential for independent practice. They were also less likely to feel that surgical training is too long, when compared with university trainees. Additionally, they were less likely to be women and slightly more likely to be married. Applicants to surgical training programs inherently interact with university surgeons more than independent ones. Although a core surgical rotation may be at an independent hospital, most primary and subspecialty rotations are based at large tertiary hospitals, which are often the flagship university hospital. Applicants are typically assigned advisors who are based in a university setting and who may or may not be familiar with the broad scope of training opportunities that are available to their mentees. This system naturally promotes bias toward university programs that has been identified previously.26-29 Several hypotheses exist about a potential disconnect between qualifications needed for surgical jobs and the surgical trainee perceptions of these qualifications. Friedell
6
Journal of Surgical Education Volume ]/Number ] ] 2015
Category Total Narrow scope of university mentors Fellowship options Prestige/reputation Academic opportunities Research opportunities Lack of information about independent programs Other Better teaching Negative comments
N (%) 193 62 37 28 18 13 14
(100) (32) (19) (15) (9) (7) (7)
11 (6) 7 (4) 3 (2)
et al.1 found that lack of confidence was an important issue that prompted trainees to seek fellowship training. Interestingly, they found that independent program trainees felt more confident about entering into surgical practice directly out of residency, when compared with university program graduates. Other factors that have been thought to influence lack of confidence in surgical trainees include less clinical time in the hospital as a result of duty-hour regulations, general underpreparation of graduating medical students for their residency training and an increasing lack of exposure to “general surgeons” during general surgery residency training.19,30 A comprehensive review of the U.S. surgical workforce found that there is a significant shortage of general surgeons throughout the United States, which is more notable in rural and underserved areas.23 There are an estimated 22,486 general surgeons and an additional 6440 general surgeons with subspecialty training in the United States. Between 2005 and 2009, the number of general surgeons has grown 0.2%. Approximately 10% of surgeons are aged 70 years or older. Furthermore, the supply of general surgeons is expected to grow 1% per year between 2014 and 2030. When weighted against the overall growth in population, this results in a static supply of general surgeons per 100,000 persons.31 Paradoxically, 70% to 80% of graduating surgical trainees seek fellowship training, despite the fact that the minority of surgical positions require fellowship training. A recent study in Wisconsin and Oregon estimated that only 34% of available jobs required fellowship training.32 By this calculus, approximately 40% of graduating residents were unnecessarily pursuing further training after residency. These authors also found that 43% of job postings were for rural jobs, whereas 35% were for nonacademic metropolitan, and 17% for metropolitan academic jobs. We observed that medical student applicants to independent programs were less interested in pursuing fellowships and academic surgery. This suggests that independent programs will continue to be a vital source of general surgeons capable of broad spectrum practice—a workforce that is sorely needed across the United States. More than one-third of the surgery residency applicants reported perceived bias in mentorship, which was almost uniformly in favor of university programs. We do not believe that such bias is justified based on successful fellowship match, program attrition rates, overall satisfaction with obtaining career goals, or patient outcome data. We hypothesize that such bias is based on the personal career path of the mentor (likely to be university based), who may be swayed by his/her training experience, personal experience, and area of clinical practice. If our data are extrapolated to current surgical faculty across the country, then one can assume that university faculty were more likely to have trained at university programs, conducted research, and pursued fellowships before their current positions. Regardless, it
is clearly important for members of the surgical education community to be aware of this finding so that they provide accurate and evidence-based guidance regarding the best potential match for their medical students. It would be beneficial for independent program directors to further study and publish the success of their graduates in initiating successful general surgery careers following 5 years of training, obtaining fellowship positions and accomplishing excellent clinical outcomes. In addition, it may be beneficial for independent program directors to meet with Deans of medical schools within their region to reinforce their philosophy and success in training. These steps may aid the attempt to overcome current bias within the surgical education community. In the future, we hope to analyze the career paths of independent program graduates. Specifically, we would be interested to see if the perceptions that medical students have at the beginning of their surgical careers persist through their surgical training. For example, are graduates of independent programs more likely to enter into solo, group, or hospital practice following 5 years of residency with or without fellowship training? How does this differ from surgeons trained in a university setting? Also, can characteristics of medical student applicants be used to streamline the interview process? As applications to surgical residencies increase, and interview slots and residency resources largely stagnate, can program directors analyze medical students’ characteristics to better allocate interviews to candidates who are more likely to prefer to match with them? Our study does have several limitations. Multiple independent program directors were contacted to participate and 47% (33/70) committed to the project. Accordingly, it is possible some of the conclusions drawn about their applicants are subject to selection bias. This could be especially important with regard to some of the geographic preferences that applicants appeared to express. However, we were able to obtain data from institutions across the country from a broad variety of environments (metropolitan and urban settings). Although the surgery residency applicant survey had an excellent response rate, any methodology that relies on a survey is subject to the risk of reporting bias. Additionally, although the results include data about students who have preferences for university programs, it is possible that these results would not be representative of a wider cross-section of students who interviewed only at university programs. Given contemporary concerns related to confidence of graduating residents, a shortage of graduates who are pursuing general surgery practice and an increasing number of graduates who are pursuing fellowship training, changes in residency training are already upon us. Graduates from independent programs have been identified as being more confident in their surgical skill sets and more confident in entering general surgery practice directly following 5 years
Journal of Surgical Education Volume ]/Number ] ] 2015
7
of training.1 It seems that the remedies for graduate surgery education challenges may be present within our current training systems.
4. Alterman DM, Jones TM, Heidel RE, Daley BJ,
IMPLICATIONS
5. Jarman BT, Cogbill TH, Mathiason MA, et al. Factors
A better understanding of the characteristics of applicants who indicate a preference for independent surgery residency programs will help program directors in ranking considerations and may lead to better match outcomes. Information resources about independent programs have been identified as well as a need to assure these resources are updated and distributed to residency applicants. Importantly, many applicants cited a bias towards university programs for several reasons. This bias should be remedied so that information is consistent and accurate for all applicants.
CONCLUSIONS We have identified several demographic variables and applicant characteristics that are associated with a preference for independent programs and university programs. Residency websites are the chief sources of information about programs but faculty and residents play a vital role as well. Bias against independent programs is clearly perceived by medical students and needs to be remedied to provide accurate information about training opportunities for applicants that will match their career interests.
ACKNOWLEDGMENTS The authors gratefully acknowledge the contributions of Residency Program Specialists Colette O’Heron, Lauren Hook, Diann Carreker, and Paula Rasmussen. The authors appreciate and thank the independent program directors and coordinators who facilitated data submission for this study (Appendix B).
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SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.jsurg. 2015.05.017.
Journal of Surgical Education Volume ]/Number ] ] 2015
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