- Email: [email protected]
Voluntary changes in surgery career paths: a survey of the program directors in surgery
Voluntary Changes in Surgery Career Paths: A Survey of the Program Directors in Surgery Jon B Morris, MD, FACS, Thomas J Leibrandt, MA, Robert S Rhodes, MD, FACS This article attempts to quantify the current scope of attrition, identify the reasons why categorical residents are leaving general surgery residency programs voluntarily, and correlate the program directors’ and residents’ perspectives. STUDY DESIGN: A questionnaire asked the Program Directors of general surgery residency programs how many categorical residents left voluntarily in the 2000–2001 academic year, their postgraduate (PGY) levels, why they left, and where they went. Another questionnaire asked the residents why they entered surgery and why they left. The surveys’ responses were compared. RESULTS: A total of 206 programs (81%) responded. One hundred ten programs (53%) reported voluntarily attrition of 167 categorical residents (mean: 0.8 residents per program for all responders and 1.5 residents per program for programs that reported attrition). Seventy-three programs (66%) lost one resident; 23 programs (21%), 2 residents; 9 programs (8%), 3 residents; 4 programs (4%), 4 residents; and 1 program (⬍1%), 5 residents. Eighty-five PGY-1 residents (51%), 42 PGY-2 residents (25%), 27 PGY-3 residents (16%), and 13 PGY-4 residents (8%) left. The most common reasons for attrition cited by the program directors were personal and work hours/lifestyle in 40% and 35%, respectively. One hundred five residents (63%) entered other fields of medicine; 40 residents transferred to other general surgery programs. Net voluntary attrition, defined as the number of residents who left general surgery voluntarily (127) divided by the resident population at risk, was 3%, indicating that 97% of the residents at risk in the responding programs remained in general surgery. CONCLUSIONS: Most surgery programs that responded were affected by attrition in 2000–2001, with approximately one-third losing more than one resident. Attrition tends to occur early in training. Most residents enter other specialties, primarily for quality-of-life reasons. But many stay in general surgery. ( J Am Coll Surg 2003;196:611–616. © 2003 by the American College of Surgeons) BACKGROUND:
Recent fluctuation in the general surgery resident workforce is a topic of great concern to surgical educators.1 The problem of diminishing interest in general surgery as a career choice for graduating medical students has been substantiated by the 2001 and 2002 National Resident Matching Program (NRMP) results, in which there were 68 unfilled categorical positions in 40 programs and 58 unfilled categorical positions in 34 programs, respectively.2,3
One analysis indicated that the interest in general surgery actually peaked in 1981. Since then, the number of applicants has been declining; only recently has this decline passed the threshold of available positions.4 A second factor of great concern, particularly among program directors (PDs), has been the retention of existing trainees. Such attrition can be defined as voluntary (the resident decides to leave) or involuntary (the program decides not to continue the resident), the sum of which is the total dropout rate. It has been several years since this phenomenon has been systematically analyzed.5-8 Given current concerns by the PDs regarding high attrition rates, we felt that it was appropriate to reexamine this critically important issue.
No competing interests declared.
This study and this article received no ABS approval. Presented at the Joint Meeting of the Association of Program Directors of Surgery and Association for Surgical Education, Baltimore MD, April 4, 2002. Received June 12, 2002; Revised October 24, 2002; Accepted November 11, 2002. From the Department of Surgery, Abington Memorial Hospital, Abington, PA. Correspondence address: Jon B Morris, MD, FACS, Department of Surgery, Abington Memorial Hospital, 1200 Old York Rd, Ste 604, Abington, PA 19001.
© 2003 by the American College of Surgeons Published by Elsevier Science Inc.
PURPOSE The purpose of this study was to quantify the current scope and identify the reasons why categorical residents
611
ISSN 1072-7515/03/$21.00 doi:10.1016/S1072-7515(02)01832-X
612
Morris et al
Surgical Career Changes
leave their general surgery residency training programs voluntarily. In addition, we attempted to examine and correlate the PDs’ and residents’ perspectives of the reasons for such attrition. METHODS A personalized, one-page survey (Fig. 1) was mailed to PDs in all general surgery residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) regarding resident attrition for the 2000–2001 academic year. The survey was accompanied by a self-addressed stamped envelope, although PDs were also encouraged to return the survey via facsimile, if they so preferred. The survey was one page in length and questioned the PD regarding the occurrence of resident attrition, the reason for the attrition, the ultimate destination of the residents who left the program, permission to contact the residents, and a forwarding address when applicable. Each PD was given the option of returning the survey anonymously. If the PD did not respond to the survey, a second survey was sent. When followup information was provided for residents who left voluntarily, attempts were made to contact them by mail, email, facsimile, or telephone. These residents were provided with a one-page survey, which questioned them regarding their principal reasons for entering and exiting their general surgery programs. The survey (Fig. 2) was specifically designed to facilitate correlation of the entry and exit data. Finally, we attempted, when possible, to correlate the individual PD’s response with the resident’s response to their respective surveys. RESULTS Two hundred fifty-five surveys were distributed, to which 167 PDs responded initially. A followup survey yielded an additional 39 responses for a total of 206 responses (81%). One hundred ten programs (53%) reported at least one or more residents who left the program for a total of 167 residents. The mean attrition was 0.8 residents per program for all responders and 1.5 residents per program for programs that reported attrition (range: 1 to 5 residents per program). Most programs lost one (66%) or two (21%) residents and one program lost five (Table 1). Resident attrition tended to occur early with the PGY-1 and PGY-2 years accounting for 51% and 25% of the total attrition, respectively (Ta-
J Am Coll Surg
ble 2). No resident left voluntarily during the chief residency. Only one program chose to remain anonymous. We defined the overall attrition rate as the number of residents who left divided by the at-risk population (number of approved chiefs per program multiplied by five). The trend of early attrition in the PGY-1 and PGY-2 levels was comparable in university programs and nonuniversity programs (76% and 77%, respectively). The overall attrition rate between university programs (4.3%) and nonuniversity programs (3.6%) was also very similar, while the 1.8% attrition rate for military programs was much lower (Table 3). According to the PDs, residents left their programs for a variety of reasons, including personal and unspecified reasons (40% of residents), work hours and lifestyle (35%), medical leave (5%), and financial burden (less than 1%). Other reasons for leaving included changes in specialty interest (35%), relocation to be with a significant other or closer to family (12%), the nature of surgical practice (6%), marginal performance in the surgical program (6%), and desire for an academic upgrade in the training experience (5%). One hundred forty-five residents (87%) stayed in the field of medicine, while 15 (9%) left medicine to start new careers in a variety of disciplines, including law, consulting, travel, Web site development, and setting up a wine business. Seven residents (4%) were unaccounted for. Of those who stayed in medicine, approximately two-thirds (105 residents) entered other specialties, while approximately one-third (40 residents) moved to other general surgery programs. When residents entered disciplines other than surgery, controlled lifestyle programs, including anesthesia, radiology, and emergency medicine, were popular (Table 4). Of the residents who moved to other general surgery programs, the most common reasons indicated by the PDs were an interest in moving closer to a significant other or family (30%), academic performance issues (18%), and an opportunity to obtain an academic upgrade (15%). Tracking down the residents who voluntarily left was challenging. Of the 167 residents who left their programs, we were provided information on approximately half (83). A variety of modalities were used to contact the residents (mail, facsimile, email, and telephone) with a one-page survey (Fig. 2). The survey was designed specifically to assess the reasons these residents entered and exited their general surgery training programs. Thirtyseven residents (22%) responded. Thirty-six of the 37
Morris et al
Vol. 196, No. 4, April 2003
Surgical Career Changes
613
Figure 1. Attrition survey.
confirmed that they had indeed left their previous programs voluntarily; one resident did not answer this question. Most responders (89%) entered surgery because of the nature of surgical practice; most (76%) left because of lifestyle issues (Table 5). Financial concerns or the length of training were very uncommon reasons for leaving, each accounting for 3% of the responses in this group. Other common reasons for leaving a general surgery program according to the residents were concerns
or criticisms of the training program in 11 cases, including problems with the PD, administration, or other residents (n ⫽ 5), unhappiness with the teaching in the training program (n ⫽ 4), and perceived poor prospects for obtaining a fellowship at the end of training in that program (n ⫽ 2). After scrutinizing the PDs’ and residents’ responses, it was possible to correlate them in 25 cases. In 16 of these 25 (64%), the PDs’ and the residents’ responses agreed,
614
Morris et al
Surgical Career Changes
J Am Coll Surg
Figure 2. Resident’s attrition survey.
DISCUSSION The 81% response rate of program directors to the survey probably attests to the brevity of the questionnaire,
the limited timespan examined (2000–2001), and the perceived importance of this issue. As in all surveys, this study is subject to responder bias in that 19% of the PDs chose not to respond. The most significant finding in the study is that the attrition of 167 residents (minus the 40 residents who moved horizontally to another general surgery program) resulted in a net loss to general surgery of 3%. This rate might in fact be an overestimate as we did not include residents outside the 5-year clinical pathway (ie, residents participating in laboratory re-
Table 1. Number of Residents Lost per Program
Table 2. Number of Residents Lost by PGY Level
No. of residents
PGY level
while an apparent discrepancy existed in 9 (36%). In six cases the PDs did not appreciate that the residents left for lifestyle and quality-of-life issues, while in three cases the PD felt that the residents were in academic difficulty while the residents were critical of the training program, the residency experience, or the PD.
1 2 3 4 5 Total number of programs: 110
No. of programs
73 (66%) 23 (21%) 9 (8%) 4 (4%) 1 (⬃1%)
1 2 3 4 5 Total number of residents: 167
No. of residents
85 (51%) 42 (25%) 27 (16%) 13 (8%) 0
Morris et al
Vol. 196, No. 4, April 2003
Table 3. University Versus Nonuniversity Versus Military Programs PGY 4 PGY 3 PGY 2 PGY 1 Total attrition Attrition rate*
Surgical Career Changes
615
Table 4. Other Specialties Entered after Leaving General Surgery (n ⫽ 105)
University
Nonuniversity
Military
9 16 22 57 104 4.3%
4 10 19 27 60 3.6%
0 1 1 1 3 1.8%
*The attrition rate was determined by dividing the total number of residents who left by the total number of residents at risk.
search or other academic or nonacademic leaves of absence) in the calculations; but it might be an underestimate if attrition were higher in nonresponding programs. More than one-half of programs were affected by attrition, with 34% of programs losing more than one resident. When residents did leave, they tended to exit by the end of their junior years, with 76% leaving by the end of their PGY-2 year. But a considerable number of PGY-3 and PGY-4 residents also left. The preference for lifestyle-control specialties with those residents who stayed in medicine but left surgery came as no real surprise, especially because the most common reason cited by residents for leaving a program was lifestyle concerns during the residency training experience. We had expected that workload, financial concerns, and length of training would be more common explanations for leaving programs. Apparently, residents who leave, for the most part, simply do not like the resident lifestyle. This supports the concept that lifestyle and quality-time issues are of paramount importance to members of “Generation X.”1 The 9% of residents who left medicine was somewhat disheartening. In a previous study reporting total resident dropout (including voluntary and involuntary attrition) by O’Leary and Capote,5 the number of residents who ultimately left medicine was only 1%. In the aggregate, the overall attrition rate was fairly low, estimated at approximately 3%. This compared favorably with previous studies, which reported an overall attrition rate in general surgery programs, including voluntary and involuntary attrition, of 10.6%5 and voluntary attrition alone to be as high as 22%.6 It was encouraging that in this study 24% of the residents ultimately entered another general surgery program compared with 14% in a previous study.5 Our data also compared favorably with reports from different disciplines. Overall at-
Residents Specialty
n
%
Anesthesiology Radiology Family practice Emergency medicine Plastic surgery Otolaryngology Orthopedics Urology Research Internal medicine Neurosurgery Pediatrics Flight medicine Obstetrics and gynecology Psychiatry Cardiology Dermatology Ophthalmology Pathology Unspecified
24 11 10 8 6 4 4 4 4 3 3 3 2 2 2 1 1 1 1 11
23 10 10 8 6 4 4 4 4 3 3 3 2 2 2 1 1 1 1 10
trition rates (voluntary and involuntary) in family practice and obstetrics and gynecology residency programs have been reported at 8.6% and 3.47%, respectively.9,10 Although the overall attrition in our study was low, the impact can be substantial on smaller programs that suffer from a high attrition rate. As to whether a 3% rate of attrition is too high or low is a matter of perspective. This phenomenon might simply reflect natural selection or might be indicative of a flawed training model. A further concern is the apparent misperception by medical students of the surgical residency experience. Despite 4 years of medical school, a core rotation in surgery, a subinternship in surgery, followed by the application process, a small number of residents will ultimately leave their programs completely disillusioned Table 5. Principal Reasons for Residents Entering and Leaving General Surgery* (Resident Survey) Reasons
Nature of surgical practice Lifestyle Workload Financial Length of training
Enter (%)
Exit (%)
89 8 3 3 N/A
19 76 35 3 3
*In some responses, more than one reason was given.
616
Morris et al
Surgical Career Changes
with their residency experience. This suggests that they had a poor understanding of what the actual residency experience would be. It has been proposed that this might in part be related to diminishing total time spent on core surgery clerkships,7 but this remains an important unresolved issue. Although the attrition rate was low, the amount of time and effort expended to fill these vacant spots is substantial. It remains to be seen how often the vacancies are filled or if the quality of candidates that are used to fill the vacancies compares favorably with their peers who entered surgery through the NRMP.6 Finally, if the attrition rate is approximately 3%, then one can assume that 97% of residents chose to stay in their training, at least for this limited observation period. Perhaps our focus should be on why the vast majority of residents stay and presumably finish their training, and we should use these positive elements to help attract a new generation of medical students to our specialty. Author contributions
Study conception and design: Morris, Leibrandt, Rhodes Acquisition of data: Morris, Leibrandt Analysis and interpretation of data: Morris, Leibrandt, Rhodes Drafting of manuscript: Morris, Leibrandt, Rhodes Critical revision: Morris, Leibrandt, Rhodes Supervision: Morris
J Am Coll Surg
Acknowledgment: We thank Laura P Morris, MSW, for her technical assistance in contacting the residents.
REFERENCES 1. Ritchie WP. Report of the American Board of Surgery Retreat on “graduate surgical education: current trends, future directions.” Available at http://www.absurgery.org/2002retr.html. Accessed May 13, 2002. 2. Association of American Medical Colleges. National Residency Matching Program: results and data, 2001 match. Washington, DC: National Residency Matching Program; 2001. 3. Association of American Medical Colleges. National Residency Matching Program: results and data, 2002 match. Washington, DC: National Residency Matching Program; 2002. 4. Bland KI, Isaacs G. Contemporary trends in student selection of medical specialties: the potential impact on general surgery. Arch Surg 2002;137:259–267. 5. O’Leary JP, Capote LR. Surgical residency dropout rate. Curr Surg 1997;54:275–278. 6. Aufses AH, Slater GI, Hollier LK. The nature and fate of categorical surgical residents who “drop out.” Am J Surg 1998;175: 236–239. 7. Polk HC. The declining interest in surgical careers, the primary care mirage, and concerns about undergraduate surgical education. Am J Surg 1999;178:177–179. 8. Kwakwa F, Jonasson O. Attrition in graduate surgical education: an analysis of the 1993 entering cohort of surgical residents. J Am Coll Surg 1999;189:602–610. 9. Laufenberg HF, Turkal NW, Baumgardner DJ. Resident attrition from family practice residencies: United States versus international medical graduates. Fam Med 1994;26:614–617. 10. Seltzer VL, Messer RH, Nehra RD. Resident attrition in obstetrics and gynecology. Am J Obstet Gynecol 1992;166:1315– 1317.
Recent fluctuation in the general surgery resident workforce is a topic of great concern to surgical educators.1 The problem of diminishing interest in general surgery as a career choice for graduating medical students has been substantiated by the 2001 and 2002 National Resident Matching Program (NRMP) results, in which there were 68 unfilled categorical positions in 40 programs and 58 unfilled categorical positions in 34 programs, respectively.2,3
One analysis indicated that the interest in general surgery actually peaked in 1981. Since then, the number of applicants has been declining; only recently has this decline passed the threshold of available positions.4 A second factor of great concern, particularly among program directors (PDs), has been the retention of existing trainees. Such attrition can be defined as voluntary (the resident decides to leave) or involuntary (the program decides not to continue the resident), the sum of which is the total dropout rate. It has been several years since this phenomenon has been systematically analyzed.5-8 Given current concerns by the PDs regarding high attrition rates, we felt that it was appropriate to reexamine this critically important issue.
No competing interests declared.
This study and this article received no ABS approval. Presented at the Joint Meeting of the Association of Program Directors of Surgery and Association for Surgical Education, Baltimore MD, April 4, 2002. Received June 12, 2002; Revised October 24, 2002; Accepted November 11, 2002. From the Department of Surgery, Abington Memorial Hospital, Abington, PA. Correspondence address: Jon B Morris, MD, FACS, Department of Surgery, Abington Memorial Hospital, 1200 Old York Rd, Ste 604, Abington, PA 19001.
© 2003 by the American College of Surgeons Published by Elsevier Science Inc.
PURPOSE The purpose of this study was to quantify the current scope and identify the reasons why categorical residents
611
ISSN 1072-7515/03/$21.00 doi:10.1016/S1072-7515(02)01832-X
612
Morris et al
Surgical Career Changes
leave their general surgery residency training programs voluntarily. In addition, we attempted to examine and correlate the PDs’ and residents’ perspectives of the reasons for such attrition. METHODS A personalized, one-page survey (Fig. 1) was mailed to PDs in all general surgery residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) regarding resident attrition for the 2000–2001 academic year. The survey was accompanied by a self-addressed stamped envelope, although PDs were also encouraged to return the survey via facsimile, if they so preferred. The survey was one page in length and questioned the PD regarding the occurrence of resident attrition, the reason for the attrition, the ultimate destination of the residents who left the program, permission to contact the residents, and a forwarding address when applicable. Each PD was given the option of returning the survey anonymously. If the PD did not respond to the survey, a second survey was sent. When followup information was provided for residents who left voluntarily, attempts were made to contact them by mail, email, facsimile, or telephone. These residents were provided with a one-page survey, which questioned them regarding their principal reasons for entering and exiting their general surgery programs. The survey (Fig. 2) was specifically designed to facilitate correlation of the entry and exit data. Finally, we attempted, when possible, to correlate the individual PD’s response with the resident’s response to their respective surveys. RESULTS Two hundred fifty-five surveys were distributed, to which 167 PDs responded initially. A followup survey yielded an additional 39 responses for a total of 206 responses (81%). One hundred ten programs (53%) reported at least one or more residents who left the program for a total of 167 residents. The mean attrition was 0.8 residents per program for all responders and 1.5 residents per program for programs that reported attrition (range: 1 to 5 residents per program). Most programs lost one (66%) or two (21%) residents and one program lost five (Table 1). Resident attrition tended to occur early with the PGY-1 and PGY-2 years accounting for 51% and 25% of the total attrition, respectively (Ta-
J Am Coll Surg
ble 2). No resident left voluntarily during the chief residency. Only one program chose to remain anonymous. We defined the overall attrition rate as the number of residents who left divided by the at-risk population (number of approved chiefs per program multiplied by five). The trend of early attrition in the PGY-1 and PGY-2 levels was comparable in university programs and nonuniversity programs (76% and 77%, respectively). The overall attrition rate between university programs (4.3%) and nonuniversity programs (3.6%) was also very similar, while the 1.8% attrition rate for military programs was much lower (Table 3). According to the PDs, residents left their programs for a variety of reasons, including personal and unspecified reasons (40% of residents), work hours and lifestyle (35%), medical leave (5%), and financial burden (less than 1%). Other reasons for leaving included changes in specialty interest (35%), relocation to be with a significant other or closer to family (12%), the nature of surgical practice (6%), marginal performance in the surgical program (6%), and desire for an academic upgrade in the training experience (5%). One hundred forty-five residents (87%) stayed in the field of medicine, while 15 (9%) left medicine to start new careers in a variety of disciplines, including law, consulting, travel, Web site development, and setting up a wine business. Seven residents (4%) were unaccounted for. Of those who stayed in medicine, approximately two-thirds (105 residents) entered other specialties, while approximately one-third (40 residents) moved to other general surgery programs. When residents entered disciplines other than surgery, controlled lifestyle programs, including anesthesia, radiology, and emergency medicine, were popular (Table 4). Of the residents who moved to other general surgery programs, the most common reasons indicated by the PDs were an interest in moving closer to a significant other or family (30%), academic performance issues (18%), and an opportunity to obtain an academic upgrade (15%). Tracking down the residents who voluntarily left was challenging. Of the 167 residents who left their programs, we were provided information on approximately half (83). A variety of modalities were used to contact the residents (mail, facsimile, email, and telephone) with a one-page survey (Fig. 2). The survey was designed specifically to assess the reasons these residents entered and exited their general surgery training programs. Thirtyseven residents (22%) responded. Thirty-six of the 37
Morris et al
Vol. 196, No. 4, April 2003
Surgical Career Changes
613
Figure 1. Attrition survey.
confirmed that they had indeed left their previous programs voluntarily; one resident did not answer this question. Most responders (89%) entered surgery because of the nature of surgical practice; most (76%) left because of lifestyle issues (Table 5). Financial concerns or the length of training were very uncommon reasons for leaving, each accounting for 3% of the responses in this group. Other common reasons for leaving a general surgery program according to the residents were concerns
or criticisms of the training program in 11 cases, including problems with the PD, administration, or other residents (n ⫽ 5), unhappiness with the teaching in the training program (n ⫽ 4), and perceived poor prospects for obtaining a fellowship at the end of training in that program (n ⫽ 2). After scrutinizing the PDs’ and residents’ responses, it was possible to correlate them in 25 cases. In 16 of these 25 (64%), the PDs’ and the residents’ responses agreed,
614
Morris et al
Surgical Career Changes
J Am Coll Surg
Figure 2. Resident’s attrition survey.
DISCUSSION The 81% response rate of program directors to the survey probably attests to the brevity of the questionnaire,
the limited timespan examined (2000–2001), and the perceived importance of this issue. As in all surveys, this study is subject to responder bias in that 19% of the PDs chose not to respond. The most significant finding in the study is that the attrition of 167 residents (minus the 40 residents who moved horizontally to another general surgery program) resulted in a net loss to general surgery of 3%. This rate might in fact be an overestimate as we did not include residents outside the 5-year clinical pathway (ie, residents participating in laboratory re-
Table 1. Number of Residents Lost per Program
Table 2. Number of Residents Lost by PGY Level
No. of residents
PGY level
while an apparent discrepancy existed in 9 (36%). In six cases the PDs did not appreciate that the residents left for lifestyle and quality-of-life issues, while in three cases the PD felt that the residents were in academic difficulty while the residents were critical of the training program, the residency experience, or the PD.
1 2 3 4 5 Total number of programs: 110
No. of programs
73 (66%) 23 (21%) 9 (8%) 4 (4%) 1 (⬃1%)
1 2 3 4 5 Total number of residents: 167
No. of residents
85 (51%) 42 (25%) 27 (16%) 13 (8%) 0
Morris et al
Vol. 196, No. 4, April 2003
Table 3. University Versus Nonuniversity Versus Military Programs PGY 4 PGY 3 PGY 2 PGY 1 Total attrition Attrition rate*
Surgical Career Changes
615
Table 4. Other Specialties Entered after Leaving General Surgery (n ⫽ 105)
University
Nonuniversity
Military
9 16 22 57 104 4.3%
4 10 19 27 60 3.6%
0 1 1 1 3 1.8%
*The attrition rate was determined by dividing the total number of residents who left by the total number of residents at risk.
search or other academic or nonacademic leaves of absence) in the calculations; but it might be an underestimate if attrition were higher in nonresponding programs. More than one-half of programs were affected by attrition, with 34% of programs losing more than one resident. When residents did leave, they tended to exit by the end of their junior years, with 76% leaving by the end of their PGY-2 year. But a considerable number of PGY-3 and PGY-4 residents also left. The preference for lifestyle-control specialties with those residents who stayed in medicine but left surgery came as no real surprise, especially because the most common reason cited by residents for leaving a program was lifestyle concerns during the residency training experience. We had expected that workload, financial concerns, and length of training would be more common explanations for leaving programs. Apparently, residents who leave, for the most part, simply do not like the resident lifestyle. This supports the concept that lifestyle and quality-time issues are of paramount importance to members of “Generation X.”1 The 9% of residents who left medicine was somewhat disheartening. In a previous study reporting total resident dropout (including voluntary and involuntary attrition) by O’Leary and Capote,5 the number of residents who ultimately left medicine was only 1%. In the aggregate, the overall attrition rate was fairly low, estimated at approximately 3%. This compared favorably with previous studies, which reported an overall attrition rate in general surgery programs, including voluntary and involuntary attrition, of 10.6%5 and voluntary attrition alone to be as high as 22%.6 It was encouraging that in this study 24% of the residents ultimately entered another general surgery program compared with 14% in a previous study.5 Our data also compared favorably with reports from different disciplines. Overall at-
Residents Specialty
n
%
Anesthesiology Radiology Family practice Emergency medicine Plastic surgery Otolaryngology Orthopedics Urology Research Internal medicine Neurosurgery Pediatrics Flight medicine Obstetrics and gynecology Psychiatry Cardiology Dermatology Ophthalmology Pathology Unspecified
24 11 10 8 6 4 4 4 4 3 3 3 2 2 2 1 1 1 1 11
23 10 10 8 6 4 4 4 4 3 3 3 2 2 2 1 1 1 1 10
trition rates (voluntary and involuntary) in family practice and obstetrics and gynecology residency programs have been reported at 8.6% and 3.47%, respectively.9,10 Although the overall attrition in our study was low, the impact can be substantial on smaller programs that suffer from a high attrition rate. As to whether a 3% rate of attrition is too high or low is a matter of perspective. This phenomenon might simply reflect natural selection or might be indicative of a flawed training model. A further concern is the apparent misperception by medical students of the surgical residency experience. Despite 4 years of medical school, a core rotation in surgery, a subinternship in surgery, followed by the application process, a small number of residents will ultimately leave their programs completely disillusioned Table 5. Principal Reasons for Residents Entering and Leaving General Surgery* (Resident Survey) Reasons
Nature of surgical practice Lifestyle Workload Financial Length of training
Enter (%)
Exit (%)
89 8 3 3 N/A
19 76 35 3 3
*In some responses, more than one reason was given.
616
Morris et al
Surgical Career Changes
with their residency experience. This suggests that they had a poor understanding of what the actual residency experience would be. It has been proposed that this might in part be related to diminishing total time spent on core surgery clerkships,7 but this remains an important unresolved issue. Although the attrition rate was low, the amount of time and effort expended to fill these vacant spots is substantial. It remains to be seen how often the vacancies are filled or if the quality of candidates that are used to fill the vacancies compares favorably with their peers who entered surgery through the NRMP.6 Finally, if the attrition rate is approximately 3%, then one can assume that 97% of residents chose to stay in their training, at least for this limited observation period. Perhaps our focus should be on why the vast majority of residents stay and presumably finish their training, and we should use these positive elements to help attract a new generation of medical students to our specialty. Author contributions
Study conception and design: Morris, Leibrandt, Rhodes Acquisition of data: Morris, Leibrandt Analysis and interpretation of data: Morris, Leibrandt, Rhodes Drafting of manuscript: Morris, Leibrandt, Rhodes Critical revision: Morris, Leibrandt, Rhodes Supervision: Morris
J Am Coll Surg
Acknowledgment: We thank Laura P Morris, MSW, for her technical assistance in contacting the residents.
REFERENCES 1. Ritchie WP. Report of the American Board of Surgery Retreat on “graduate surgical education: current trends, future directions.” Available at http://www.absurgery.org/2002retr.html. Accessed May 13, 2002. 2. Association of American Medical Colleges. National Residency Matching Program: results and data, 2001 match. Washington, DC: National Residency Matching Program; 2001. 3. Association of American Medical Colleges. National Residency Matching Program: results and data, 2002 match. Washington, DC: National Residency Matching Program; 2002. 4. Bland KI, Isaacs G. Contemporary trends in student selection of medical specialties: the potential impact on general surgery. Arch Surg 2002;137:259–267. 5. O’Leary JP, Capote LR. Surgical residency dropout rate. Curr Surg 1997;54:275–278. 6. Aufses AH, Slater GI, Hollier LK. The nature and fate of categorical surgical residents who “drop out.” Am J Surg 1998;175: 236–239. 7. Polk HC. The declining interest in surgical careers, the primary care mirage, and concerns about undergraduate surgical education. Am J Surg 1999;178:177–179. 8. Kwakwa F, Jonasson O. Attrition in graduate surgical education: an analysis of the 1993 entering cohort of surgical residents. J Am Coll Surg 1999;189:602–610. 9. Laufenberg HF, Turkal NW, Baumgardner DJ. Resident attrition from family practice residencies: United States versus international medical graduates. Fam Med 1994;26:614–617. 10. Seltzer VL, Messer RH, Nehra RD. Resident attrition in obstetrics and gynecology. Am J Obstet Gynecol 1992;166:1315– 1317.