- Email: [email protected]
Thoughts of Quitting General Surgery Residency: Factors in Canada
ORIGINAL REPORTS
Thoughts of Quitting General Surgery Residency: Factors in Canada David Nathan Ginther, MD, BSc, Sheev Dattani, MD, BSC, Sarah Miller, MD, and Paul Hayes, MD Department of Surgery, Royal University Hospital, Saskatoon, Saskatchewan, Canada OBJECTIVE: Attrition rates in general surgery training are
higher than other surgical disciplines. We sought to determine the prevalence with which Canadian general surgery residents consider leaving their training and the contributing factors. DESIGN, SETTING, AND PARTICIPANTS: An anony-
mous survey was administered to all general surgery residents in Canada. Responses from residents who considered leaving their training were assessed for importance of contributing factors. The study was conducted at the Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, a tertiary academic center. RESULTS: The response rate was approximately 34.0%.
A minority (32.0%) reported very seriously or somewhat seriously considering leaving their training, whereas 35.2% casually considered doing so. Poor work-life balance in residency (38.9%) was the single-most important factor, whereas concern about future unemployment (16.7%) and poor future quality of life (15.7%) were next. Enjoyment of work (41.7%) was the most frequent mitigating factor. Harassment and intimidation were reported factors in 16.7%. On analysis, only intention to practice in a nonacademic setting approached significant association with thoughts of leaving (odds ratio ¼ 1.92, CI ¼ 0.99-3.74, p ¼ 0.052). There was no association with sex, program, postgraduate year, relationship status, or subspecialty interest. There was a nonsignificant trend toward more thoughts of leaving with older age. CONCLUSION: Canadian general surgery residents appear
less likely to seriously consider quitting than their American counterparts. Poor work-life balance in residency, fear of future unemployment, and anticipated poor future quality of life are significant contributors to thoughts of quitting. Efforts to educate prospective residents about the reality of the surgical lifestyle, and to assist residents in securing employment, may improve completion rates. ( J Surg Ed
Correspondence: Inquiries to David Nathan Ginther, MD, BSc, 103 Hospital Drive, Saskatoon, Canada SK S7N 0W8; e-mail: [email protected]
C 2016 Association of Program Directors in 73:513-517. J Surgery. Published by Elsevier Inc. All rights reserved.)
KEY WORDS: general surgery, education, personnel turn-
over, internship and residency, attrition, completion rate COMPETENCIES: Practice-Based Learning and Improve-
ment, Medical Knowledge, Professionalism
INTRODUCTION Historically, general surgery residency in North America has experienced a high rate of attrition, beginning with the pyramidal training model instituted by Halsted. Despite formal replacement of the pyramidal model with a rectangular structure in 1996, attrition continued, and the United States now accounts for approximately 19% of trainees over a 5- to 7-year residency.1 Our own program at the University of Saskatchewan has a 10-year attrition rate of 20.4%, but pan-Canadian data is not currently available. The rate of attrition within general surgery may be 4 to 5 times higher than for other surgical specialties, and 2 to 3 times higher than for internal medicine.2 The reasons for the disparate rate of attrition in general surgery compared to other fields is not clear. Paradoxically, institution of the 80-hour work week in the United States has not reduced this rate, and may actually be associated with increased attrition.3 Increased personal emphasis on work-life balance and controllable lifestyle is prevalent in all fields of medicine,4-6 and it may be that trainees are less willing to accept the challenging lifestyle of general surgery—the nature of which is not fully recognized until experienced. As a small Canadian survey of 169 surgical residents revealed that most (87%) of the residents had experienced stress in the past year linked to time pressures, working hours and conditions, as well as patient care.7 A recent survey of American programs stated that 58% of general surgery residents have seriously considered leaving training.8 In that study, sleep deprivation and excessive work hours on a specific rotation, along with an undesirable future lifestyle, were the most frequent reasons reported. Other studies have also cited concerns regarding personal
Journal of Surgical Education & 2016 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.2015.11.008
513
wellbeing, the prioritization of clinical duties over education, dissatisfaction with the operative experience, as well as a desire to practice another specialty.9-12 There may be gender variability to attrition with some reports indicating that females are more likely to leave residency than males,13 whereas other investigations contest sex as a predictive factor.14 The current literature is based on American programs and may not be applicable to Canadian trainees. A Medline search did not reveal any publications on attrition rate and factors among Canadian programs. We believe that significant differences in training climate exist between Canada and the United States of America including lack of panCanadian work-hour restrictions, and thus American results may not be generalizable to Canada. We conducted this survey to evaluate factors that influence Canadian general surgery residents to consider quitting or changing their training as well as the factors that support and retain residents.
METHODS An anonymous electronic survey was distributed to all Canadian general surgery residents via and at the discretion of their respective program directors as well as through the Canadian Association of General Surgeons. The study was approved by the University of Saskatchewan Research Ethics Board and was administered to approximately 500 general surgery residents across Canada via online survey software (SurveyMonkey; https://www.surveymonkey.com/). Participation was voluntary and no incentive was provided. A reminder was sent to all programs to encourage participant response but was left up to the discretion of program directors to distribute, thus could not be directly controlled. The survey probed for demographic information, future training, and practice goals, as well as the rate and depth of consideration each resident gave to leaving residency and the factors that influence residents to leave or continue training. Initially, a pilot survey was distributed to a sample population consisting of University of Saskatchewan residents, asking respondents to identify factors that might influence residents to leave their program. The pilot survey response rate was 65% (n ¼ 17), and responses were analyzed for themes which were then used to determine the questions in the final survey. Respondents were asked to identify the top 3 reasons they considered leaving training, as well as to specify the first and second most influential ones. Factors mitigating desire to leave were also evaluated. Statistical analysis was performed with the SAS 9.4 software (SAS Institute Inc., Cary, NC). The Chi-square test was used to examine the association between our binary outcome variable (serious thoughts of leaving residency—yes or no) 514
and other categorical variables. The level of significance was set at 0.05 (2-tailed).
RESULTS A total of 165 responses were received, for an estimated response rate of 34%. No responses were received from residents at the universities of Montreal, Laval, Ottawa, Alberta, or British Columbia. Of the respondents, 52.2% were male and 47.8% were female. Most (53.5%) were between the ages of 25 and 29, and 79.5% reported being in a stable relationship. In regard to future practice, 52.2% plan to practice in a community setting and 47.8% in an academic institution, and with 75.5% of residents overall planning to pursue fellowship training. A minority of residents (32.7%) have never considered leaving their training program. Conversely, 32% of respondents very seriously (18.2%) or somewhat seriously (13.8%) considered leaving, whereas 35.2% have casually considered doing so. Serious thoughts of leaving residency among general surgery trainees were not associated with sex, relationship status, program, postgraduate year, or subspecialty interest. Only intention to practice in a nonacademic setting approached statistical significance, with 39.1% who reported desire to practice community surgery considering leaving, vs. 25% of those who plan to practice in an academic setting (p ¼ 0.052). There was a nonsignificant association with increasing age, with 41.2% of residents older than 34 seriously considering leaving compared to 28.7% of residents less than the age of 30 years doing so (p ¼ 0.50). Poor work-life balance (38.9%) was the single-most reported and significant factor, with concern about future unemployment or underemployment second (16.7%). When asked to indicate the top 3 factors, poor work-life balance was included by 71.3%, concern about future unemployment by 46.3%, and poor future quality of life by 44.4%. Regarding alternative training, family medicine was the most likely transfer destination, at 33.6%. Only 11.5% of respondents would choose another surgical specialty. Radiology, pathology, anesthesia, and medical specialties would be chosen alternatives by less than 5% of respondents. With respect to mitigating factors that retain or support residents, the most frequent reason to continue (41.7%) was enjoyment of work. The second most frequent (34.3%) factor was having invested too much to quit and the third (13.9%) was support of family and friends. Residents from duty-hour restricted provinces (Manitoba, Maritimes, and Quebec), appear more likely (39.3% vs. 28.2%, p ¼ 0.14) to consider leaving than residents from provinces without duty-hour restrictions, although this did
Journal of Surgical Education Volume 73/Number 3 May/June 2016
not reach statistical significance. Furthermore, there were no responses from 2 of the Quebec training programs.
DISCUSSION Based on this survey, a significantly smaller proportion of Canadian general surgery residents seriously consider leaving training than their American counterparts. Reasons for this are unclear, particularly given the lack of pan-Canadian work-hour restrictions. This is somewhat unexpected, as the most commonly cited reason is poor work-life balance that can reasonably be correlated to working hours. However, in our survey, residents from provinces with work-hour restrictions (Newfoundland, Nova Scotia, Quebec, and Manitoba) were more likely (39.3%) to seriously consider leaving their training than residents from nonwork hour restricted provinces (28.2%, p ¼ 0.14), although this did not reach statistical significance. No conclusion about the effect on work-hour restrictions should be drawn from this finding as actual hours worked was not assessed. The most frequently cited reasons for considering leaving training were poor work-life balance as a resident, concern about future unemployment, and anticipated poor future quality of life. Favorably, harassment and intimidation appear to be infrequent, reported as an influential factor by only 16.7% of respondents. Data show that most of the surgical and medical trainees experience mistreatment, harassment, or discrimination.15-17 The comparatively small effect of harassment and intimidation found in our study is encouraging, suggesting that negative interaction with attending surgeons is an infrequent contributor to attrition. Financial stress from deferred income appears to be a minor factor, reflecting appropriate levels of compensation. There is an accurate perception among trainees that jobs in Canada are few and unemployment or underemployment is a realistic possibility. In 2011 and 2012, 28.3% of newly trained general surgeons in Canada were unable to find employment.18 Workforce prediction is challenging, but efforts should be made to match training volume with workforce needs and thus reduce surgeon redundancy. Further resource allocation and collaboration could aid residents in securing employment. In this survey, 44.4% of respondents reported anticipated poor future quality of life among the top 3 reasons they would consider quitting, with 15.7% reporting it as the single most influential factor. This is a challenging issue, as it is not immediately modifiable, but reflects the need to select candidates who understand and accept the lifestyle demanded. Efforts have been directed to identifying predictors of candidate success and this should continue.19-21 Prospective residents may have inadequate experience to be fully aware of the nature of surgeon and trainee lifestyle, but increased medical student exposure to the life of a general surgeon could result in more realistic expectations.
A weakness of our study is the lack of uniform national response, particularly the lack of any response from residents at the universities of Montreal, Laval, Ottawa, Alberta, and British Columbia. This clustering of responses limits generalizability, particularly to the French-language programs (universities of Montreal and Laval). The overall response rate of 34% is suboptimal but compares favorably to published physician and resident survey response rates of 27.9% to 34.1%.22 Due to the response rate, our results may not be truly representative of the entire Canadian resident population and important associations may not be reaching statistical significance. We believe there are several contributing factors to the low response rate. Residents are exposed to a large number of surveys and may have survey fatigue. There may also be fear of being identified by demographic information and potential repercussions. Finally, we depended on program directors to distribute the survey and reminder but are not certain it was actually disseminated to all residents. Despite the current abundance of general surgeons in Canada, attrition ought to be tempered. An anticipated general surgeon shortage in the United States23,24 should raise concern of the same eventual development in Canada. TABLE. Characteristics of Respondents
Training Program Memorial University of Newfoundland Dalhouse University Université Laval Université de Sherbrooke Université de Montreal McGill University University of Ottawa Queen's University Northern Ontario School of Medicine University of Toronto McMaster University Western University University of Manitoba University of Saskatchewan University of Alberta University of Calgary University of British Columbia PGY status 1 2 3 4 5 45 Sex Male Female Age o25 25-29 30-34 434
Percentage
N
5.6 5.6 0.0 4.9 0.0 11.7 0.0 3.1 1.2 16.0 14.8 12.3 4.3 13.0 0.0 7.4 0.0
9 9 0 8 0 19 0 5 2 26 24 20 7 21 0 12 0
17.5 15.0 31.3 18.1 17.5 0.6
28 24 50 29 28 1
52.2 47.8
83 76
5.0 53.5 31.4 10.1
8 85 50 16
PGY, postgraduate year.
Journal of Surgical Education Volume 73/Number 3 May/June 2016
515
Medical education in Canada is subsidized, and thus attrition and transition to other programs lengthens the total length of taxpayer-funded training, ultimately reducing overall contribution to the medical care of society. There is also substantial personal cost to the individual because of loss of practice years, stress of trying to find and transition to a new training program, and dissatisfaction with time lost in training in a field in which they would ultimately not practice (Table).
7. Aminazadeh N, Farrokhyar F, Naeeni A, et al. Is
Canadian surgical residency training stressful? Can J Surg. 2012;55 (4 Suppl 2):S145-S151. 8. Gifford E, Galante J, Kaji AH, et al. Factors associated
with general surgery residents’ desire to leave residency programs: a multi-institutional study. J Am Med Assoc Surg. 2014;149(9):948-953. 9. Longo W, Seashore J, Duffy A, Udelsman R. Attrition
of categoric general surgery residents: results of a 20year audit. Am J Surg. 2009;197(6):774-778.
CONCLUSION
10. Andriole D, Jeffe DB, Klingensmith M. Do general
Based on this survey, it appears that Canadian general surgery residents are less likely to consider leaving their training than their American counterparts, but as of yet there is no comparable data on actual attrition rates. Most of the general surgery residents consider leaving general surgery with varying degrees of seriousness. The highest contributory factors are poor work-life balance, concern about future unemployment, and poor future quality of life as a general surgeon. Conclusions about the effect of work-hour restrictions on resident satisfaction cannot be drawn at this time. To improve completion rates, effort could be directed to enhancing resident quality of life and to collaborative efforts to procure employment and improve optimism about securing a position as a general surgeon.
surgery applicants really want to be general surgeons? Curr Surg. 2006;63(2):145-150. 11. Bongiovanni T, Yeo H, Sosa JA, et al. Attrition from
surgical residency training: perspectives from those who left. Am J Surg. 2015;210(4):648-654. 12. Sullivan M, Yeo H, Sosa J, et al. Surgical residency and
attrition: defining the individual and programmatic factors predictive of trainee losses. J Am Coll Surg. 2013;216(3):461-471. 13. Dodson TF, Webb AL. Why do residents leave general
surgery? The hidden problem in today’s programs Curr Surg. 2005;62(1):128-131. 14. Naylor RA, Reisch JS, Valentine RJ. Factors related to
attrition in surgery residency based on application data. Arch Surg. 2008;143(7):647-651.
REFERENCES
15. Nagata-Kobayashi S, Maeno T, Yoshizu M, Shimbo
1. Kennedy KA, Brennan MC, Rayburn WF, Brotherton
SE. Attrition rates between residents in obstetrics and gynecology and other clinical specialties, 2000-2009. J Grad Med Educ. 2013;5(2):267-271. 2. Schwartz RW, Simpson WG, Strodel WE, et al.
Career change: in quest of a controllable lifestyle. J Surg Res. 1989;47(3):189-192. 3. Everett CB, Helmer SD, Osland JS, Smith RS, et al.
General surgery resident attrition and the 80-hour workweek. Am J Surg. 2007;194(6):751-757. 4. Dorsey ER, Jarjoura D, Rutecki GW. Influence of
controllable lifestyle on recent trends in specialty choice by US medical students. J Am Med Assoc. 2003;290(9):1173-1178. 5. Gelfand D, Podnos Y, Wilson S, Cooke J, Williams R.
T. Universal problems during residency: abuse and harassment. Med Educ. 2009;43(7):628-636. 16. Fnais N, Soobiah C, Tricco A, et al. Harassment
and discrimination in medical training: a systematic review and meta-analysis. Acad Med. 2014;89(5): 817-827. 17. Cook D, Liutkus J, Risdon C, Griffith L, Guyatt G,
Walter S. Residents’ experiences of abuse, discrimination and sexual harassment during residency training. McMaster University Residency Training Programs. Can Med Assoc J. 1996;154(11):1657-1665. 18. Frechette D, et al. Too many, too few doctors? What’s
really behind Canada’s unemployed specialists? Available at: 〈www.royalcollege.ca/common/.../employment_re port_2013_e.pdf〉; Accessed 02.09.15.
Choosing general surgery: insights into career choices of current medical students. Arch Surg. 2002;137 (8):941-945.
19. Bann S, Darzi A. Selection of individuals for training
6. Tambyraja A, McCrea C, Parks R, Garden O.
WH, Jones RS. Can success in the surgical residency be predicted from preresidency evaluation? Ann Surg. 1985;202(6):694-695.
Attitudes of medical students toward careers in general surgery. World J Surg. 2008;32(6):960-963. 516
in surgery. Am J Surg. July 2005;190(1):98-102. 20. Kron IL, Kaiser DL, Nolan SP, Rudolf LE, Muller
Journal of Surgical Education Volume 73/Number 3 May/June 2016
21. Gallagher AG, Neary P, Gillen P, et al. Novel method
for assessment and selection of trainees for higher surgical training in general surgery. ANZ J Surg. 2008;78(4):282-290. 22. Grava-Gubins I, Scott S. Effects of various methodo-
logic strategies: survey response rates among Canadian
physicians and physicians-in-training. Can Fam Physician. 2008;54(10):1424-1430. 23. Powell AC, McAneny D, Hirsch EF. Trends in general
surgery workforce data. Am J Surg. 2004;188(1):1-8. 24. Sheldon GF. Workforce issues in general surgery. Am
Surg. 2007;73(2):100-110.
Journal of Surgical Education Volume 73/Number 3 May/June 2016
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Thoughts of Quitting General Surgery Residency: Factors in Canada David Nathan Ginther, MD, BSc, Sheev Dattani, MD, BSC, Sarah Miller, MD, and Paul Hayes, MD Department of Surgery, Royal University Hospital, Saskatoon, Saskatchewan, Canada OBJECTIVE: Attrition rates in general surgery training are
higher than other surgical disciplines. We sought to determine the prevalence with which Canadian general surgery residents consider leaving their training and the contributing factors. DESIGN, SETTING, AND PARTICIPANTS: An anony-
mous survey was administered to all general surgery residents in Canada. Responses from residents who considered leaving their training were assessed for importance of contributing factors. The study was conducted at the Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, a tertiary academic center. RESULTS: The response rate was approximately 34.0%.
A minority (32.0%) reported very seriously or somewhat seriously considering leaving their training, whereas 35.2% casually considered doing so. Poor work-life balance in residency (38.9%) was the single-most important factor, whereas concern about future unemployment (16.7%) and poor future quality of life (15.7%) were next. Enjoyment of work (41.7%) was the most frequent mitigating factor. Harassment and intimidation were reported factors in 16.7%. On analysis, only intention to practice in a nonacademic setting approached significant association with thoughts of leaving (odds ratio ¼ 1.92, CI ¼ 0.99-3.74, p ¼ 0.052). There was no association with sex, program, postgraduate year, relationship status, or subspecialty interest. There was a nonsignificant trend toward more thoughts of leaving with older age. CONCLUSION: Canadian general surgery residents appear
less likely to seriously consider quitting than their American counterparts. Poor work-life balance in residency, fear of future unemployment, and anticipated poor future quality of life are significant contributors to thoughts of quitting. Efforts to educate prospective residents about the reality of the surgical lifestyle, and to assist residents in securing employment, may improve completion rates. ( J Surg Ed
Correspondence: Inquiries to David Nathan Ginther, MD, BSc, 103 Hospital Drive, Saskatoon, Canada SK S7N 0W8; e-mail: [email protected]
C 2016 Association of Program Directors in 73:513-517. J Surgery. Published by Elsevier Inc. All rights reserved.)
KEY WORDS: general surgery, education, personnel turn-
over, internship and residency, attrition, completion rate COMPETENCIES: Practice-Based Learning and Improve-
ment, Medical Knowledge, Professionalism
INTRODUCTION Historically, general surgery residency in North America has experienced a high rate of attrition, beginning with the pyramidal training model instituted by Halsted. Despite formal replacement of the pyramidal model with a rectangular structure in 1996, attrition continued, and the United States now accounts for approximately 19% of trainees over a 5- to 7-year residency.1 Our own program at the University of Saskatchewan has a 10-year attrition rate of 20.4%, but pan-Canadian data is not currently available. The rate of attrition within general surgery may be 4 to 5 times higher than for other surgical specialties, and 2 to 3 times higher than for internal medicine.2 The reasons for the disparate rate of attrition in general surgery compared to other fields is not clear. Paradoxically, institution of the 80-hour work week in the United States has not reduced this rate, and may actually be associated with increased attrition.3 Increased personal emphasis on work-life balance and controllable lifestyle is prevalent in all fields of medicine,4-6 and it may be that trainees are less willing to accept the challenging lifestyle of general surgery—the nature of which is not fully recognized until experienced. As a small Canadian survey of 169 surgical residents revealed that most (87%) of the residents had experienced stress in the past year linked to time pressures, working hours and conditions, as well as patient care.7 A recent survey of American programs stated that 58% of general surgery residents have seriously considered leaving training.8 In that study, sleep deprivation and excessive work hours on a specific rotation, along with an undesirable future lifestyle, were the most frequent reasons reported. Other studies have also cited concerns regarding personal
Journal of Surgical Education & 2016 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.2015.11.008
513
wellbeing, the prioritization of clinical duties over education, dissatisfaction with the operative experience, as well as a desire to practice another specialty.9-12 There may be gender variability to attrition with some reports indicating that females are more likely to leave residency than males,13 whereas other investigations contest sex as a predictive factor.14 The current literature is based on American programs and may not be applicable to Canadian trainees. A Medline search did not reveal any publications on attrition rate and factors among Canadian programs. We believe that significant differences in training climate exist between Canada and the United States of America including lack of panCanadian work-hour restrictions, and thus American results may not be generalizable to Canada. We conducted this survey to evaluate factors that influence Canadian general surgery residents to consider quitting or changing their training as well as the factors that support and retain residents.
METHODS An anonymous electronic survey was distributed to all Canadian general surgery residents via and at the discretion of their respective program directors as well as through the Canadian Association of General Surgeons. The study was approved by the University of Saskatchewan Research Ethics Board and was administered to approximately 500 general surgery residents across Canada via online survey software (SurveyMonkey; https://www.surveymonkey.com/). Participation was voluntary and no incentive was provided. A reminder was sent to all programs to encourage participant response but was left up to the discretion of program directors to distribute, thus could not be directly controlled. The survey probed for demographic information, future training, and practice goals, as well as the rate and depth of consideration each resident gave to leaving residency and the factors that influence residents to leave or continue training. Initially, a pilot survey was distributed to a sample population consisting of University of Saskatchewan residents, asking respondents to identify factors that might influence residents to leave their program. The pilot survey response rate was 65% (n ¼ 17), and responses were analyzed for themes which were then used to determine the questions in the final survey. Respondents were asked to identify the top 3 reasons they considered leaving training, as well as to specify the first and second most influential ones. Factors mitigating desire to leave were also evaluated. Statistical analysis was performed with the SAS 9.4 software (SAS Institute Inc., Cary, NC). The Chi-square test was used to examine the association between our binary outcome variable (serious thoughts of leaving residency—yes or no) 514
and other categorical variables. The level of significance was set at 0.05 (2-tailed).
RESULTS A total of 165 responses were received, for an estimated response rate of 34%. No responses were received from residents at the universities of Montreal, Laval, Ottawa, Alberta, or British Columbia. Of the respondents, 52.2% were male and 47.8% were female. Most (53.5%) were between the ages of 25 and 29, and 79.5% reported being in a stable relationship. In regard to future practice, 52.2% plan to practice in a community setting and 47.8% in an academic institution, and with 75.5% of residents overall planning to pursue fellowship training. A minority of residents (32.7%) have never considered leaving their training program. Conversely, 32% of respondents very seriously (18.2%) or somewhat seriously (13.8%) considered leaving, whereas 35.2% have casually considered doing so. Serious thoughts of leaving residency among general surgery trainees were not associated with sex, relationship status, program, postgraduate year, or subspecialty interest. Only intention to practice in a nonacademic setting approached statistical significance, with 39.1% who reported desire to practice community surgery considering leaving, vs. 25% of those who plan to practice in an academic setting (p ¼ 0.052). There was a nonsignificant association with increasing age, with 41.2% of residents older than 34 seriously considering leaving compared to 28.7% of residents less than the age of 30 years doing so (p ¼ 0.50). Poor work-life balance (38.9%) was the single-most reported and significant factor, with concern about future unemployment or underemployment second (16.7%). When asked to indicate the top 3 factors, poor work-life balance was included by 71.3%, concern about future unemployment by 46.3%, and poor future quality of life by 44.4%. Regarding alternative training, family medicine was the most likely transfer destination, at 33.6%. Only 11.5% of respondents would choose another surgical specialty. Radiology, pathology, anesthesia, and medical specialties would be chosen alternatives by less than 5% of respondents. With respect to mitigating factors that retain or support residents, the most frequent reason to continue (41.7%) was enjoyment of work. The second most frequent (34.3%) factor was having invested too much to quit and the third (13.9%) was support of family and friends. Residents from duty-hour restricted provinces (Manitoba, Maritimes, and Quebec), appear more likely (39.3% vs. 28.2%, p ¼ 0.14) to consider leaving than residents from provinces without duty-hour restrictions, although this did
Journal of Surgical Education Volume 73/Number 3 May/June 2016
not reach statistical significance. Furthermore, there were no responses from 2 of the Quebec training programs.
DISCUSSION Based on this survey, a significantly smaller proportion of Canadian general surgery residents seriously consider leaving training than their American counterparts. Reasons for this are unclear, particularly given the lack of pan-Canadian work-hour restrictions. This is somewhat unexpected, as the most commonly cited reason is poor work-life balance that can reasonably be correlated to working hours. However, in our survey, residents from provinces with work-hour restrictions (Newfoundland, Nova Scotia, Quebec, and Manitoba) were more likely (39.3%) to seriously consider leaving their training than residents from nonwork hour restricted provinces (28.2%, p ¼ 0.14), although this did not reach statistical significance. No conclusion about the effect on work-hour restrictions should be drawn from this finding as actual hours worked was not assessed. The most frequently cited reasons for considering leaving training were poor work-life balance as a resident, concern about future unemployment, and anticipated poor future quality of life. Favorably, harassment and intimidation appear to be infrequent, reported as an influential factor by only 16.7% of respondents. Data show that most of the surgical and medical trainees experience mistreatment, harassment, or discrimination.15-17 The comparatively small effect of harassment and intimidation found in our study is encouraging, suggesting that negative interaction with attending surgeons is an infrequent contributor to attrition. Financial stress from deferred income appears to be a minor factor, reflecting appropriate levels of compensation. There is an accurate perception among trainees that jobs in Canada are few and unemployment or underemployment is a realistic possibility. In 2011 and 2012, 28.3% of newly trained general surgeons in Canada were unable to find employment.18 Workforce prediction is challenging, but efforts should be made to match training volume with workforce needs and thus reduce surgeon redundancy. Further resource allocation and collaboration could aid residents in securing employment. In this survey, 44.4% of respondents reported anticipated poor future quality of life among the top 3 reasons they would consider quitting, with 15.7% reporting it as the single most influential factor. This is a challenging issue, as it is not immediately modifiable, but reflects the need to select candidates who understand and accept the lifestyle demanded. Efforts have been directed to identifying predictors of candidate success and this should continue.19-21 Prospective residents may have inadequate experience to be fully aware of the nature of surgeon and trainee lifestyle, but increased medical student exposure to the life of a general surgeon could result in more realistic expectations.
A weakness of our study is the lack of uniform national response, particularly the lack of any response from residents at the universities of Montreal, Laval, Ottawa, Alberta, and British Columbia. This clustering of responses limits generalizability, particularly to the French-language programs (universities of Montreal and Laval). The overall response rate of 34% is suboptimal but compares favorably to published physician and resident survey response rates of 27.9% to 34.1%.22 Due to the response rate, our results may not be truly representative of the entire Canadian resident population and important associations may not be reaching statistical significance. We believe there are several contributing factors to the low response rate. Residents are exposed to a large number of surveys and may have survey fatigue. There may also be fear of being identified by demographic information and potential repercussions. Finally, we depended on program directors to distribute the survey and reminder but are not certain it was actually disseminated to all residents. Despite the current abundance of general surgeons in Canada, attrition ought to be tempered. An anticipated general surgeon shortage in the United States23,24 should raise concern of the same eventual development in Canada. TABLE. Characteristics of Respondents
Training Program Memorial University of Newfoundland Dalhouse University Université Laval Université de Sherbrooke Université de Montreal McGill University University of Ottawa Queen's University Northern Ontario School of Medicine University of Toronto McMaster University Western University University of Manitoba University of Saskatchewan University of Alberta University of Calgary University of British Columbia PGY status 1 2 3 4 5 45 Sex Male Female Age o25 25-29 30-34 434
Percentage
N
5.6 5.6 0.0 4.9 0.0 11.7 0.0 3.1 1.2 16.0 14.8 12.3 4.3 13.0 0.0 7.4 0.0
9 9 0 8 0 19 0 5 2 26 24 20 7 21 0 12 0
17.5 15.0 31.3 18.1 17.5 0.6
28 24 50 29 28 1
52.2 47.8
83 76
5.0 53.5 31.4 10.1
8 85 50 16
PGY, postgraduate year.
Journal of Surgical Education Volume 73/Number 3 May/June 2016
515
Medical education in Canada is subsidized, and thus attrition and transition to other programs lengthens the total length of taxpayer-funded training, ultimately reducing overall contribution to the medical care of society. There is also substantial personal cost to the individual because of loss of practice years, stress of trying to find and transition to a new training program, and dissatisfaction with time lost in training in a field in which they would ultimately not practice (Table).
7. Aminazadeh N, Farrokhyar F, Naeeni A, et al. Is
Canadian surgical residency training stressful? Can J Surg. 2012;55 (4 Suppl 2):S145-S151. 8. Gifford E, Galante J, Kaji AH, et al. Factors associated
with general surgery residents’ desire to leave residency programs: a multi-institutional study. J Am Med Assoc Surg. 2014;149(9):948-953. 9. Longo W, Seashore J, Duffy A, Udelsman R. Attrition
of categoric general surgery residents: results of a 20year audit. Am J Surg. 2009;197(6):774-778.
CONCLUSION
10. Andriole D, Jeffe DB, Klingensmith M. Do general
Based on this survey, it appears that Canadian general surgery residents are less likely to consider leaving their training than their American counterparts, but as of yet there is no comparable data on actual attrition rates. Most of the general surgery residents consider leaving general surgery with varying degrees of seriousness. The highest contributory factors are poor work-life balance, concern about future unemployment, and poor future quality of life as a general surgeon. Conclusions about the effect of work-hour restrictions on resident satisfaction cannot be drawn at this time. To improve completion rates, effort could be directed to enhancing resident quality of life and to collaborative efforts to procure employment and improve optimism about securing a position as a general surgeon.
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