Training Outcomes of Preliminary Surgical Residents in a University and Veterans Affairs Surgical Residency

Importance  Nearly 1400 medical students enter preliminary surgical residency each year; placing some of these students into categorical surgical training is an important component of building the future surgical workforce.

Objectives  To examine the training outcomes of preliminary residents in a university and Veterans Affairs surgical residency and to test the hypothesis that characteristics of these residents could be identified that would predict successful placement into categorical general surgical residency.

Design, Setting, and Participants  A retrospective cohort of 66 nondesignated preliminary surgical residents who entered a research-intensive, university-based surgical training program with significant Veterans Affairs hospital experience between 2004 and 2012.

Main Outcomes and Measures  Placement of preliminary residents into a categorical general surgical residency.

Results  Of 66 nondesignated preliminary residents enrolled in our program during the study period, 57 completed a postgraduate year (PGY) 1 and 22 completed a PGY-2. A total of 21 residents (32%) secured categorical general surgical positions, 8 of 57 (14%) after PGY-1 and 13 of 22 (59%) after PGY-2, a significantly different rate (P < .001). Predictors of success in obtaining a categorical position included a PGY-2, United States Medical Licensing Examination step 2 score, year 1 American Board of Surgery In-Training Examination score, class rank, and prior graduate medical education. By multivariable analysis, only the PGY-2 was significant (P < .03). Residents who obtained categorical surgical positions after 1 preliminary year had significantly higher United States Medical Licensing Examination scores (mean [SD] step 1 score, 235.4 [23.5] vs 206.3 [16.2]; P < .02; step 2 score, 239.3 [21.2] vs 218.5 [16.1]; P < .05) but did not have higher year 1 American Board of Surgery In-Training Examination percentiles (mean [SD], 63.3 [33.3] vs 47.3 [30.8]; P < .34).

Conclusions and Relevance  Performing a PGY-2 preliminary year increases the chance for a preliminary surgical resident to obtain a place in a categorical surgical residency. Programs that offer preliminary positions should consider offering both PGY-1 and PGY-2 positions, because the PGY-2 increases the categorical surgical placement rate, especially for residents with lower test scores.

Preliminary surgical residency is a 1- or 2-year period of training without a guarantee of a complete course that leads to board certification. These positions provide basic surgical training before beginning training in another specialty, or they provide training opportunities for medical students who cannot or choose not to initially secure a categorical position. For some students who aspire to a surgical career, a preliminary surgical position can represent an alternative path to enter a categorical surgical residency. Opportunities exist to enter categorical surgical training from preliminary positions because the attrition rate in general surgical residencies is high, approaching 20% during a complete training program.¹

Keeping surgical residency positions full is an important issue for more than just residents and program directors, because there is strong evidence that there is a shortage of general surgeons in the United States. With the aging of the US population, there is a projected increase of 31% in the number of general surgical procedures required to care for these patients by the year 2020.² However, Lynge and colleagues³ found a 25% decrease in the number of general surgeons from 1981 to 2005. A second analysis projects a shortage of 2500 surgeons by 2030, roughly 2.5 times the number of surgeons graduating from residency each year.⁴ The anticipated increase in demand for general surgeons caused by our aging population, combined with a flat number of training positions and shrinking number of practicing surgeons, has been described by many as the “perfect storm” in health care workforce planning. At least 1 recent article proposed that an examination of preliminary surgical training may help provide a mechanism to increase the supply of surgeons who are trained and available for practice.⁵

The purpose of our study was to examine the training placements achieved by preliminary residents in the University of Florida surgical training program. We hypothesized that we could identify characteristics of preliminary residents that would predict successful placement into categorical surgery positions. The ability to identify characteristics that predict success in categorical placement should help guide preliminary residents in achieving their training goals.

A retrospective review was conducted of all nondesignated preliminary residents at the University of Florida over the time period 2004-2012. Institutional review board approval was obtained from the University of Florida. A nondesignated preliminary surgical resident was defined as a trainee who was not matched into a categorical postgraduate year (PGY) 2 position in any field at the time of entry into the preliminary training program. Data on resident demographics, initial specialty choice, test scores, pathway and years of entry and exit from the preliminary training program, and subsequent positions obtained after completion of preliminary training were abstracted from the residents’ training records and entered into a deidentified database. For purposes of this study, residency placement was defined as the next training position entered by the resident after completion of 1 or 2 years of training at our institution.

The primary outcome measure of the study was placement of a resident in a categorical general surgical residency. Statistical analysis for factors predictive of this outcome was performed using χ² analysis for categorical variables, and the t test for comparison of means of continuous variables. Multinomial logistic regression was used to build a multivariable model to predict successful categorical general surgery placement, using all variables identified as significant in univariate analysis. Significance was defined as P ≤ .05. Statistical analysis was performed using STATA, version 13 SE (StataCorp).

During the study period, 66 nondesignated preliminary residents completed at least 1 year in our training program. Fifty-seven residents completed a preliminary PGY-1, and 22 residents completed a PGY-2 and had placement outcomes that could be assessed. Of the 22 residents who completed a PGY-2, 14 had also completed a PGY-1 at our institution. Demographic and test performance information on the residents are presented in Table 1. Of the study population, 49 residents were male (74%), 58 (88%) were US citizens, and 48 (73%) were graduates of Liaison Committee on Medical Education–accredited medical schools. At the time of entry into the program, 89% were interested in entering general surgery or other surgical fields. Most of our study population were PGY-1 residents, with 88% of our residents entering the training program in PGY-1 and 67% placing out of our preliminary training program after PGY-1.

Part A of the Figure shows the training placements achieved by the 57 residents who completed a PGY-1. At the end of 1 preliminary year, 15 residents (26%) had obtained a categorical surgery position, with 8 (14%) of these in general surgery. Seventeen residents (30%) obtained categorical nonsurgical positions, with anesthesia, emergency medicine, and radiology being the most common fields entered. Twenty-two (39%) continued to preliminary surgical positions, and 3 (5%) left graduate medical education (GME) to pursue other careers. Part B of the Figure shows the training placements achieved by the preliminary residents who completed a PGY-2. Of these 22 residents, 13 (59%) obtained a categorical general surgical position, 1 obtained a categorical obstetric and gynecological position, 5 (23%) obtained categorical nonsurgical positions, and 3 (14%) left GME training to pursue other careers. Overall, 51 (77%) obtained categorical positions, 21 (32%) of these obtained categorical general surgical positions, and 8 (12%) obtained other categorical surgical positions. Of the 21 residents who obtained a place in general surgical position, 11 obtained a place in our categorical program and 10 in other training programs. Of the 11 residents who placed into our program, 4 filled positions vacated by attrition, and the other 7 filled positions created by either program expansion or residents taking years out of training to perform full-time research. An additional 33% of residents obtained nonsurgical categorical positions, 14% went to other preliminary opportunities, and 9% left GME at the end of their preliminary training (Table 2).

We next examined variables predictive of placing into a categorical surgical position. By univariate analysis, 9 variables were associated with a categorical placement: entering our program in PGY-2, placement in PGY-2, higher class rank, a desire to train as a general surgeon, prior GME training, obtaining a general surgical position, younger age, and higher United States Medical Licensing Examination (USMLE) step 2 and year 1 American Board of Surgery In-Training Examination (ABSITE) scores. The results of this analysis are presented in Table 3. When we examined factors predictive of obtaining a categorical surgical position by multinomial logistic regression using all variables significant in our univariate analysis, we found only placing from a PGY-2 preliminary position to be significant at P < .03.

Based on our experience that there are differences between residents who find a categorical surgical position after a single preliminary year compared with those who obtain a position after 2 preliminary years, we performed a subgroup analysis in the 21 residents who obtained categorical surgical positions. We found that residents who obtained a place in general surgery after 1 preliminary year had significantly higher USMLE step 1 and 2 scores, ABSITE scores in PGY-1 that were not significantly higher, and much more likelihood of matching into a categorical position than the residents who placed after PGY-2—essentially those who found positions outside of the match (Table 4).

We examined the training placements achieved by 66 preliminary surgical residents in a single surgical training program during a 9-year period. We found that 77% of these residents were able to obtain a categorical training position at the completion of their preliminary training. Two-thirds of these residents obtain their final training disposition after 1 preliminary year, and one-third after a second preliminary year. Nearly one-third of these residents were able to obtain categorical general surgical positions, and almost half obtained surgical positions. We found a significant difference in the rate at which PGY-1 and PGY-2 preliminary residents obtained general surgical categorical positions, at 14% and 59% respectively. We found 9 characteristics of trainees that were associated with obtaining a categorical position, including younger age, higher USMLE step 2 scores, higher PGY-1 ABSITE scores, higher class rank, GME before entering preliminary residency, an original career goal of general surgery, finding a position outside of the match, and completing a PGY-2, but only the PGY-2 preliminary year was associated with obtaining a categorical position on multivariable analysis. Subgroup analysis of the residents who obtained general surgical positions suggested that there are 2 pathways to this outcome: being in a smaller group of trainees with high USMLE scores who match into categorical positions after PGY-1, and being in a larger group with lower test scores who find positions outside of the match after PGY-2.

Six prior studies^5-10 examined the training placement of nondesignated surgical residents during the last decade. Five of these studies^5-9 came from large, academic, university-based training programs,and 1 study¹⁰ came from a medium-sized, independent surgical training program. In many ways, the findings from these studies were similar to ours; 77% to 97% of preliminary residents obtained categorical training positions, and 3% to 17% left GME. These studies also demonstrated similar rates of general surgery placement (29%-48%) and placement into surgical positions overall (38%-66%) as our study. One national-level study,¹¹ an audit of preliminary resident attitudes toward training, reported a 31.5% placement rate of preliminary residents into categorical surgical positions, supporting the finding that one-third of preliminary residents will eventually secure a categorical general surgical training position.

In several ways, our study population is different from those of previous studies. The trainees in the prior studies were mostly PGY-1 residents, while our study included one-third PGY-2 residents. Nearly three-fourths of the residents in our study were graduates of Liaison Committee on Medical Education–accredited medical schools, while most prior studies examined populations of primarily international medical graduates. Nearly 90% of our residents were also US citizens, meaning that these residents did not have visa issues that complicated future employment options. A common perception regarding preliminary residents is that international medical graduates or non-US citizens have more difficulty obtaining a categorical position. That our placement rate was no different than prior studies suggests that this might not be the case.

An important and unique aspect of our study was our ability to identify characteristics of preliminary residents that were associated with the ability of these residents to secure categorical general surgical positions. It seems obvious that a desire to be a general surgeon, higher USMLE scores, higher PGY-1 ABSITE scores, and a higher class rank would be associated with successfully obtaining a categorical general surgical position, because these are many of the characteristics used by program directors to select medical students in the match for categorical general surgical positions. The observation that younger age was associated with obtaining a categorical position is consistent with the work by Sullivan and colleagues,¹¹ the only other study of preliminary residents that reported resident characteristics associated with categorical surgical placement. We believe that our observation that a PGY-2 preliminary year of training is strongly associated with obtaining a categorical general surgery position, and on multivariable analysis is the only variable associated with categorical placement is the most important finding of our study. This finding has not been previously reported, but review of the data from the article by Ahmad and Mullen,⁶ the one other study with a significant number of PGY-2 preliminary residents, shows a general surgical placement rate of 26% after PGY-1 and 47% after PGY-2, consistent with our findings.

Our subgroup analysis of the 21 residents who placed into general surgery helps explain the importance of PGY-2. These 21 residents represent 2 distinct groups: a smaller group of residents with high test scores who are able to match into PGY-1 categorical positions on a second try in the National Resident Mapping Program match, and a larger group of residents with lower test scores who are able to find PGY-2 or PGY-3 positions outside the match following a PGY-2 preliminary year. These PGY-2 residents are an important group because they help to maintain surgical trainee numbers, and therefore the future surgical workforce that would otherwise be reduced by the significant attrition rate noted by others in categorical surgical training programs.^1,12 The difference noted between these 2 groups may prove important in advising preliminary residents; those with higher USMLE scores should consider reentering the match during PGY-1, while those with lower scores should plan on performing 2 preliminary years and finding a position outside the match.

There are several important limitations of this study that must be considered in interpreting our results. First, this is a study of preliminary residents at a single institution, and care must be exercised in generalizing the results to other training programs. Second, although, as a study of 66 preliminary residents, our study is moderately sized compared with others on preliminary residents, this is still a fairly small sample of trainees and limits our ability to generalize our observations to all preliminary residents. Finally, we did not have data on either the clinical performance or clinical evaluations of the residents in this study. During the 9-year duration of the study, our program has changed our evaluation system twice, making it nearly impossible to capture this information in a single variable for all residents. This is likely an important predictor of successful categorical placement by preliminary residents, and our inability to assess the influence of this factor on resident placement has the potential to weaken or change our findings.

Our study of the training outcomes of preliminary residents has allowed us to reach several conclusions. First, medical students who enter preliminary surgical positions, most of whom are students who initially fail to match into the specialty of their choice, have a high likelihood of obtaining a categorical training position after 1 or 2 years of preliminary surgical residency. One-third of these residents will enter categorical general surgery, and up to half will enter other surgical fields. Second, preliminary residents who find categorical positions fall into 2 groups: a group with high USMLE and ABSITE scores who are often able to match on a second try in the main resident match, and a group with lower test scores who find positions outside of the match after 2 preliminary years. Our observations may be of value for program directors who advise preliminary residents. For this second group, a PGY-2 preliminary year provides an important opportunity for residents who wish to enter general surgery to find a categorical training position. We propose that training programs that offer preliminary surgical training should offer both PGY-1 and PGY-2 positions, to maximize the chances of their preliminary residents placing into categorical general surgical positions.

Accepted for Publication: May 16, 2014.

Corresponding Author: George A. Sarosi Jr, MD, Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100109, Gainesville, FL 32610-0109 (george.sarosi@surgery.ufl.edu).

Published Online: September 10, 2014. doi:10.1001/jamasurg.2014.2054.

Author Contributions: Dr Sarosi had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Sarosi, Ben-David, Behrns.

Acquisition, analysis, or interpretation of data: Sarosi, Silver, Behrns.

Drafting of the manuscript: Sarosi, Silver, Behrns.

Critical revision of the manuscript for important intellectual content: Sarosi, Ben-David, Behrns.

Statistical analysis: Sarosi.

Administrative, technical, or material support: All authors.

Study supervision: Behrns.

Conflict of Interest Disclosures: None reported.

Funding Support: This study was supported by funds from the University of Florida Foundation.

Role of Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Previous Presentation: This study was presented at the 38th Annual Surgical Symposium of the Association of VA Surgeons; April 7, 2014; New Haven, Connecticut.