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Original Investigation
August 12, 2020

A National Mixed-Methods Evaluation of Preparedness for General Surgery Residency and the Association With Resident Burnout

Author Affiliations
  • 1Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 2Department of Surgery, Medical University of South Carolina, Charleston
  • 3Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
  • 4Department of Surgery, Temple University, Philadelphia, Pennsylvania
JAMA Surg. 2020;155(9):851-859. doi:10.1001/jamasurg.2020.2420
Key Points

Question  What factors are associated with preparation for entering surgical residency, and what is the association between preparation and resident burnout?

Findings  In this cross-sectional study of 3693 surgical residents, those who had opportunities to take call as medical students and those who completed a surgical subinternship reported feeling more prepared for residency. Feeling adequately prepared for residency was associated with a nearly 2-fold lower risk of experiencing burnout symptoms.

Meaning  These findings suggest that adequate exposure to the necessary realities of surgical training and independent practice, particularly overnight call during the medical school clerkship, may contribute to improved preparedness, lower attrition, and lower rates of burnout in general surgery residency.


Importance  Differences in medical school experiences may affect how prepared residents feel themselves to be as they enter general surgery residency and may contribute to resident burnout.

Objectives  To assess preparedness for surgical residency, to identify factors associated with preparedness, to examine the association between preparedness and burnout, and to explore resident and faculty perspectives on resident preparedness.

Design, Setting, and Participants  This cross-sectional study used convergent mixed-methods analysis of data from a survey of US general surgery residents delivered at the time of the 2017 American Board of Surgery In-Training Examination (January 26 to 31, 2017) in conjunction with qualitative interviews of residents and program directors conducted as part of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial. A total of 262 Accreditation Council for Graduate Medical Education–approved US general surgery residency programs participated. Survey data were collected from 3693 postgraduate year (PGY) 1 and PGY2 surgical residents (response rate, 99%) and 98 interviews were conducted with residents and faculty from September 1 to December 15, 2018. Data were analyzed from June 1, 2017, to February 15, 2018.

Main Outcomes and Measures  Hierarchical regression models were developed to examine factors associated with preparedness and to assess the association between preparedness and resident burnout. Qualitative interviews were conducted to identify themes associated with preparation for residency.

Results  Of the 3693 PGY1 and PGY2 residents who participated (2258 male [61.1%]), 1775 (48.1%) reported feeling unprepared for residency. Approximately half of surgery residents took overnight call infrequently (≤2 per month) during their core medical student clerkship (1904 [51.6%]) or their subinternship (1600 [43.3%]); 524 (14.2%) took no call during their core clerkship. In multivariable analysis, residents were more likely to report feeling unprepared for residency if they were female (odds ratio [OR], 1.34; 95% CI, 1.15-1.57) or did not take call as a medical student (OR for 0 vs >4 calls, 2.72; 95% CI, 2.10-3.52). Residents who did not complete a subinternship were less likely to report feeling prepared for residency (OR, 0.68; 95% CI, 0.48-0.96). Feeling adequately prepared for residency was associated with a nearly 2-fold lower risk of experiencing burnout symptoms (OR, 0.57; 95% CI, 0.48-0.68). In interviews, the dominant themes associated with preparedness included the following: (1) various regulations limit the medical school experience, (2) overnight call facilitates preparation and selection of a specialty compatible with their preferences, and (3) adequate perceptions of residency improve expectations, resulting in improved preparedness, lower burnout rates, and lower risk of attrition.

Conclusions and Relevance  In this cross-sectional study, the perception of feeling unprepared was associated with inadequate exposure to resident responsibilities while in medical school. These findings suggest that effective preparation of medical students for residency may result in lower rates of subsequent burnout.

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    1 Comment for this article
    Poor Preparedness For Surgical Residency Risks Serious Harm
    Peter Shah, BSc MA FRCOphth FRCP Edin | University Hospitals Birmingham NHS Foundation Trust
    The paper by Kathryn Engelhardt et al highlights the crucial importance of preparedness for surgical residency training. A state of poor preparedness for the quantum step up from medical school to residency training risks serious harm to young doctors, the patients they care for and the institutions in which they work. A work-force that is burning out should worry us all.

    One cannot replace the coal-face learning that comes from medical student apprenticeship with simulation - simulation can only ever go so far. There is no substitute for seeing patients in a real-world setting, at unsociable hours, when systems
    are at their most vulnerable. To think that simulation replaces this type of learning implies a certain lack of understanding of the nature of patient care, and when coupled with misinformed arguments about student wellbeing, produces a dangerous mix.

    Under close supervision, medical students need to work hard, work long hours and work under difficult circumstances. Failure to achieve these first-base objectives will result in young doctors that cannot perform under pressure, and are not fit for purpose. Failure to prepare our young doctors adequately for the gruelling jobs they will perform risks creating a cohort of surgeons and physicians that do not have a strong foundation on which to build long-term resilience.

    The wellbeing of young doctors starts at medical school - shielding medical students from the real-life stresses of delivering 24-hour care will create future problems with far greater potential to harm both doctors and those they care for. The time to debate these important issues is now...