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Original Investigation
Pacific Coast Surgical Association
December 2017

Association of General Surgery Resident Remediation and Program Director Attitudes With Resident Attrition

Author Affiliations
  • 1Department of Surgery, Harbor-UCLA (University of California, Los Angeles) Medical Center, Torrance
  • 2Los Angeles BioMedical Research Institute, Torrance, California
  • 3Department of Surgery, University of California–Davis, Sacramento
  • 4Department of Surgery, Loma Linda University, Loma Linda, California
  • 5Department of Surgery, University of Southern California, Los Angeles
  • 6Department of Surgery, Central Iowa Health System, Iowa Methodist Medical Center, Des Moines
  • 7Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
  • 8Department of Surgery, University of Nebraska Medical Center, Omaha
  • 9Department of Surgery, Columbia University, New York, New York
  • 10Department of Surgery, York Hospital, York, Pennsylvania
  • 11Department of Surgery, University of Texas Health Science Center at San Antonio
  • 12Department of Surgery, UCLA, Los Angeles, California
  • 13Department of Surgery, Santa Barbara Cottage Hospital, Santa Barbara, California
  • 14Department of Surgery, Mount Carmel Health System, Columbus, Ohio
  • 15Department of Surgery, University of California, San Diego, San Diego
  • 16Department of Surgery, Gundersen Lutheran Medical Foundation, La Crosse, Wisconsin
  • 17Department of Surgery, Stanford University, Palo Alto, California
  • 18Department of Surgery, Southern Illinois University School of Medicine, Springfield
  • 19Department of Surgery, University of Pennsylvania, Philadelphia
  • 20Department of Surgery, University of Colorado, Denver, Aurora
  • 21Department of Surgery, University of California, Irvine, Irvine
  • 22Department of Surgery, University of San Francisco at Fresno, Fresno, California
  • 23Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
JAMA Surg. 2017;152(12):1134-1140. doi:10.1001/jamasurg.2017.2656
Key Points

Questions  What is the current rate of attrition among categorical general surgery residents, and is it influenced by program director attitudes?

Findings  In this multicenter analysis of 21 US residency programs in general surgery, an 8.8% overall attrition rate was observed among categorical surgical residents. Low-attrition programs had a higher rate of resident remediation than did high-attrition programs, and the difference was statistically significant.

Meaning  Program director attitudes and program characteristics, such as remediation, are associated with overall surgical resident attrition rates, which may be lower than was previously reported.


Importance  Previous studies of resident attrition have variably included preliminary residents and likely overestimated categorical resident attrition. Whether program director attitudes affect attrition has been unclear.

Objectives  To determine whether program director attitudes are associated with resident attrition and to measure the categorical resident attrition rate.

Design, Setting, and Participants  This multicenter study surveyed 21 US program directors in general surgery about their opinions regarding resident education and attrition. Data on total resident complement, demographic information, and annual attrition were collected from the program directors for the study period of July 1, 2010, to June 30, 2015. The general surgery programs were chosen on the basis of their geographic location, previous collaboration with some coauthors, prior work in surgical education and research, or a program director willing to participate. Only categorical surgical residents were included in the study; thus, program directors were specifically instructed to exclude any preliminary residents in their responses.

Main Outcomes and Measures  Five-year attrition rates (2010-2011 to 2014-2015 academic years) as well as first-time pass rates on the General Surgery Qualifying Examination and General Surgery Certifying Examination of the American Board of Surgery (ABS) were collected. High- and low-attrition programs were compared.

Results  The 21 programs represented different geographic locations and 12 university-based, 3 university-affiliated, and 6 independent program types. Programs had a median (interquartile range [IQR]) number of 30 (20-48) categorical residents, and few of those residents were women (median [IQR], 12 [5-17]). Overall, 85 of 966 residents (8.8%) left training during the study period: 15 (17.6%) left after postgraduate year 1, 34 (40.0%) after postgraduate year 2, and 36 (42.4%) after postgraduate year 3 or later. Forty-four residents (51.8%) left general surgery for another surgical discipline, 21 (24.7%) transferred to a different surgery program, and 18 (21.2%) exited graduate medical education altogether. Each program had an annual attrition rate ranging from 0.73% to 6.0% (median [IQR], 2.5% [1.5%-3.4%]). Low-attrition programs were more likely than high-attrition programs to use resident remediation (21.0% vs 6.8%; P < .001). Median (IQR) Qualifying Examination pass rates (93% [90%-98%] vs 92% [86%-100%]; P = .92) and Certifying Examination pass rates (83% [68%-84%] vs 81% [71%-86%]; P = .47) were similar. Program directors at high-attrition programs were more likely than their counterparts at low-attrition programs to agree with this statement: “I feel that it is my responsibility as a program director to redirect residents who should not be surgeons.”

Conclusions and Relevance  The overall 5-year attrition rate of 8.8% was significantly lower than previously reported. Program directors at low-attrition programs were more likely to use resident remediation. Variations in attrition may be explained by program director attitudes, although larger studies are needed to further define program factors affecting attrition.