[Skip to Navigation]
December 2016

Confidence Crisis Among General Surgery Residents: A Systematic Review and Qualitative Discourse Analysis

Author Affiliations
  • 1Department of Surgery, University of California–Irvine, Orange
JAMA Surg. 2016;151(12):1166-1175. doi:10.1001/jamasurg.2016.2792
Key Points

Question  What is the quality of evidence supporting the claim that general surgery graduates in the United States are choosing subspecialty fellowship training owing to a lack of confidence?

Findings  This systematic review found 15 studies that have surveyed residents, recent graduates, or practicing surgeons about their confidence as it relates to general surgery training. They found that two-thirds of the studies had negative conclusions; the studies claimed that residents today are less confident than a historic control; and the overall quality of evidence is low, variable, and subject to bias.

Meaning  The worry that residents are experiencing a crisis in confidence may be overstated; subsequent surveys should include social scientists with expertise in social cognitive theory, and we should be cautious about propagating the confidence crisis narrative in future studies.


Importance  In the surgical community, there is concern that general surgery residents are choosing subspecialty training in large numbers because of a crisis in confidence at the end of training. Confidence is an essential quality of surgeons, and recent studies have attempted to quantify and measure it in graduating general surgery residents.

Objectives  To systematically review the quality of evidence provided and to critically analyze the language used to describe the findings using quantitative methods.

Evidence Review  A systematic review of the PubMed indexed literature on general surgery resident confidence was performed in March 2015. A summative table of each study’s hypothesis, definition of confidence, quality using the Medical Education Research Study Quality Instrument, influence using Web of Science citations, results, and conclusions was created, and qualitative coding was applied to identify emerging themes. No date restrictions were used in the search.

Findings  Fifteen survey studies have been performed that measure confidence or readiness to practice. Although 5 studies had neutral or positive conclusions, most studies reported low confidence in general surgery graduates. There are conflicting data about definitions of confidence. The relationships between confidence, autonomy, and competence are varied and complex. Comparisons with the past are frequent.

Conclusions and Relevance  Confidence is difficult to define and measure. Despite limitations, survey studies are used to shape discourse and influence policies. Social and cultural factors influence self-efficacy, and focusing on operative volume and autonomy alone may not address all of the reasons that some residents express concerns about readiness to practice.