Impact of Family and Gender on Career Goals: Results of a National Survey of 4586 Surgery Residents

Objective  To determine how marriage, children, and gender influence US categorical general surgery residents' perceptions of their profession and motivations for specialty training.

Design  Cross-sectional national survey administered after the January 2008 American Board of Surgery In-service Training Examination.

Setting  Two hundred forty-eight US general surgery residency programs.

Participants  All US categorical general surgery residents.

Interventions  We evaluated demographic characteristics with respect to survey responses using the χ² test, analysis of variance, and multivariate logistic regression. Interaction terms between variables were assessed.

Main Outcome Measures  Perceptions of respondents regarding the future of general surgery and the role of specialty training in relation to anticipated income and lifestyle.

Results  The survey response rate was 75.0% (4586 respondents). Mean age was 30.6 years; 31.7% were women, 51.3% were married, and 25.4% had children. Of the respondents, 28.7% believed general surgery is becoming obsolete (30.1% of men and 25.9% of women; P = .004), and 55.1% believed specialty training is necessary for success (56.4% of men and 52.7% of women; P = .02). Single residents and residents without children were more likely to plan for fellowship (59.1% single vs 51.9% married, P < .001; 57.0% with no children vs 50.1% with children, P < .001). In our multivariate analyses, male gender was an independent predictor of worry that general surgery is becoming obsolete (P = .003). Female residents who were single or had no children tended to identify lifestyle rather than income as a motivator for specialty training.

Conclusion  Marital status, children, and gender appear to have a powerful effect on general surgery residents' career planning.

Graduate surgical education has changed significantly during the past 2 decades, with elimination of the pyramidal training system (1983) and the institution of the Accreditation Council for Graduate Medical Education (ACGME) core competencies (1999) and the 80-hour workweek (2003). New fast-track residencies and a rapid rise in the number of specialty fellowships, particularly in minimally invasive surgery, reflect growing interest in tailoring traditional general surgery to residents' desire for specialty training. Ultimately, this has created a generation gap between current trainees and experienced surgeons in practice.^1-4

Specialization is a growing trend that might jeopardize the future of general surgery. Research has demonstrated that it likely results from multiple factors, including the changing demographics of medical schools and surgery residency programs, residency type (academic vs community setting), and early exposure through research performed during residency.^5-9 Gender-related studies on specialty training have recently focused on increasing the female surgeon pool and highlight issues surrounding maternity leave, child care, female faculty role models, and shorter training programs.^10-13

There is a paucity of research addressing the influence of external support systems such as family on surgical trainees' plans to specialize during or after their residencies. We conducted a nationwide survey of all US categorical general surgery residents to identify factors that motivate residents to specialize; specifically, we examined the influences of marriage, family, and gender on residents' perception of the need for specialization during and after residency.

We used a national cross-sectional study of all US general surgery residents. All but 1 of the surgical residency training programs in the United States (n = 248) distributed optical scan format surveys to their residents after the American Board of Surgery In-service Training Examination in January 2008. Survey administration procedures and baseline data have been published.¹⁴

The American Board of Surgery resident roster included 7458 general surgery residents reported by all residency program directors to the American Board of Surgery in the academic year 2007-2008. There were 6112 categorical general surgery residents in clinical and research years who were eligible for our study. Results from designated and nondesignated preliminary residents were not included in this research.

The survey sought information on motivations for pursuing surgery as a career, views on specialization, self-assessed performance, ethical dimensions of training, and perceptions of the current and future status of general surgery. Fifty-one questions were structured as statements to which the respondent indicated their level of agreement on a 5-point Likert response scale, ranging from strongly agree to strongly disagree. Demographic items included resident age, gender, race/ethnicity, marital status, and number of children. This report represents data analysis of the questions that focus on concern about the field of general surgery becoming obsolete (question 37), completion of specialty training by the modern general surgeon in order to be successful (question 39), completion of specialty training leading to a better income (question 41), and completion of specialty training leading to a better lifestyle (question 42). Success and lifestyle were not defined in the instrument and were left to the respondents' interpretation. Specific residency program factors also have been incorporated into our analysis; these include the number of chief residents, type of residency setting (academic, community, or US military), geographic region, and affiliation with postresidency training fellowships at the program site.

Data were summarized using descriptive characteristics and univariate analyses for individual- and program-level factors. Categorical variables are presented as column counts and percentages. Age was the only continuous variable and is presented with standard error of the mean. For questions 37, 39, 41, and 42, we divided respondents into those who agreed (strongly agree and agree) and those who disagreed or were neutral (neutral, strongly disagree, and disagree). We performed bivariate comparisons of baseline characteristics between respondents in the agree and neutral/disagree groups using χ² analysis or the Fisher exact test.

To determine whether marital status, number of children, and gender were associated with residents' perceptions of the future of general surgery and pursuit of specialty training, we constructed a series of hierarchical logistic regression models using the GLIMMIX procedure in SAS statistical software (SAS Institute Inc, Cary, North Carolina), which included individual- and program-level factors. Initially, we included all variables significant at the 0.1 level in bivariate analyses and used a backward elimination approach to derive the most parsimonious model. We also examined interactions among marital status, number of children, and gender for questions 41 and 42. All statistical analyses were performed with the SAS statistical software package (version 9.1; SAS Institute Inc).

A total of 4586 categorical general surgery residents participated in our survey, yielding a survey response rate of 75.0% (Table 1). The mean age of respondents was 30.6 years; 31.7% were female. Most of the residents were white (62.0%), with Asians representing the second largest racial group (18.5%). Among the respondents for whom marital status was available, 51.3% were married, 23.6% were in a relationship, and 22.6% were single. Among those who provided the information, 25.4% had children.

Although the Northeast had the largest proportion of residency programs (36.3%), the remaining programs were fairly evenly distributed among the other geographic regions (Table 2). Most of the programs were located in academic settings (54.0%), and most were affiliated with specialty fellowship programs (52.0%). The average number of chief residents per training program was 4.

Of the residents, 28.7% expressed concern that general surgery as a discipline is becoming obsolete (Figure 1). In addition, 55.1% of residents believed that the modern general surgeon must be specialty trained to be successful; 78.1% associated specialty training with a better income, and 62.3% associated it with a better lifestyle.

In our bivariate analysis, respondents' gender, race, residency level, and program satisfaction were associated with the belief that general surgery is becoming obsolete (Table 3). Women were significantly less likely than men to agree with the statements that general surgery is becoming obsolete (25.9% vs 30.1%; P = .004) and that specialty training is necessary for success (52.7% vs 56.4%; P = .02). Single residents, including those within a relationship, were more likely to believe that specialty training is necessary for success (59.1% single vs 51.9% married; P < .001), as well as respondents without children (57.0% with no children vs 50.1% with children; P < .001). The more children a resident had, the less likely the resident was to believe that specialty training is the key to success as a surgeon (P < .001).

Program location, type of program (academic, community, or military), number of chief residents, and affiliation with fellowship programs were associated with the belief that general surgery is becoming obsolete. Most respondents who agreed with this statement were training in academic settings and residencies with affiliated fellowship programs (data not shown). Program location, type, and number of chief residents were associated with the intent to pursue training in a specialty. Of those residents who believed that becoming a specialist is necessary for a successful career, most were training in the northeast and in academic settings (data not shown).

Women were less likely to believe that general surgery is becoming obsolete (odds ratio, 0.79; 95% confidence interval, 0.67-0.92; P = .003), and they were less likely to believe that specialty training is necessary for success (0.75; 0.65-0.87; P < .001) (Table 4). Married residents were less likely to believe that specialty training is needed for success compared with residents who were single, single in a relationship, or divorced or widowed (other); the difference between married and single residents was statistically significant (P = .04). Overall, residents with more children were less likely to view additional training in a specialty as important.

In light of the strong association between gender and the intent to pursue specialty training, we examined potential interactions between gender and marital status and between gender and number of children in evaluating resident perception of the potential income and lifestyle benefits associated with being specialty trained (Figure 2). Married men were least likely to associate specialty training with a higher income. Being unmarried was associated strongly with an increase in this belief among men, but it was associated with a negligible change among women. Men and women with children believed that specialty training is associated with a better income compared with colleagues without children; women with children were the most likely to associate being a specialist with a higher salary.

Unmarried men and married and unmarried women were much more likely to agree that training to be a specialist leads to a better lifestyle compared with married men (Figure 3). Women with children were more than 2 times more likely to believe that specialty training leads to a better lifestyle compared with men without children, who were the least likely to make this association of specialization and quality of life. Overall, women were more likely than men to associate specialization with a better lifestyle.

There has been a paucity of data on the impact of marital status, family, and gender on residents' perceptions of general surgery and specialty training. In our national survey, more than half of surgical trainees believed that specialty training is essential for building a successful career. More than three-quarters associated specialty training with superior income, and approximately two-thirds perceived specialty-trained surgeons as having an improved lifestyle. This would explain published evidence from the American College of Surgeons that 77% of chief residents intended to pursue specialty training in 2005; the study demonstrated a 10% increase in the number of residents pursuing specialty training during a 14-year period.¹ Our estimate of 55.1% of residents planning to specialize is likely lower than that of the American College of Surgeons because it captures the anticipated behavior of residents at all levels of training rather than just chief residents. Overall, residents in our survey who believed that general surgery is becoming obsolete and that specialty training is necessary for success were training at residency programs in academic rather than community settings (74.4% vs 23.5% and 72.0% vs 25.7%, respectively; both P < .001).

In our survey, women were less likely to believe that general surgery is becoming obsolete or that specialty training is necessary for success. Residents further along in training were more likely to believe that general surgery is becoming obsolete; however, they were no more likely to believe that specialty training is necessary for success. Residents with children were less likely to believe that specialty training is necessary for success; in contrast, single residents and residents without children were more likely to believe in the necessity of specialty training. Men and women with children believed that specialty training is associated with a better income compared with colleagues without children. Overall, married women and women with children were twice as likely as their male counterparts to believe that specialty training has a positive effect on lifestyle.

Training in general surgery has undergone a significant transformation during the past decade. The impact of the institution of the 80-hour workweek on surgery residents is unclear. One study demonstrated that 60% of surgery residents have observed a reduction in the number of cases they perform during their training, and more than half believed that they were not participating in as many learning opportunities.¹⁵ A 2005 survey of residency program directors concluded that the rates and patterns of residency attrition have not changed, and the 80-hour workweek does not appear to be associated with improved resident attritition.¹⁶ To date, research on the introduction of new surgical specialty fellowships has focused on minimally invasive fellowship programs, concluding that this specialty has been particularly appealing to surgery residents who feel inadequately prepared after residency training.^8,9

There are new fast-track residencies and early specialization programs that provide alternate pathways to completing a 5-year general surgery residency before entering a specialty track. In cardiothoracic surgery, trainees complete a fast-track residency with 4 years of general surgery plus 3 years of thoracic fellowship; alternatively, they can enroll in an integrated 6-year cardiothoracic surgery residency leading to American Board of Thoracic Surgery certification. In vascular surgery, trainees can specialize early by completing 4 years of general surgery and 2 years of vascular surgery at the same institution. The rapid growth of these programs in the past few years reflects a new trend toward early specialization.

In addition, there has been a proliferation of postresidency fellowship training programs. In the past decade, the ACGME has accredited 13 colon and rectal fellowships, 8 pediatric fellowships, and 24 surgical critical care fellowships. The Society of Surgical Oncology has reported accreditation of 19 surgical oncology and 32 breast oncology fellowships within the past 5 years; 8 surgical oncology and 19 breast oncology fellowship programs are awaiting the society's approval. There are 15 endocrine surgery fellowships in the United States recognized by the American Association of Endocrine Surgeons. According to the Society of American Gastrointestinal and Endoscopic Surgeons, there has been a 53% increase in the number of minimally invasive surgery fellowship positions in the past 5 years, from 113 to 173.

One of the first studies on specialty training, by Kwakwa et al,² studied 8068 general surgery graduates from 1983 through 1990. Results demonstrated that 44% of these surgeons were certified in an ACGME-accredited specialty 10 to 18 years after residency. In the largest cohort study to date, the American Board of Surgery surveyed 11 080 postgraduate fifth-year general surgery residents from 1993 to 2005; the proportion of chief residents planning to pursue specialty training (ACGME-accredited and -nonaccredited programs combined) rose from 55% to 77% during the period.¹

A more general trend toward residents planning to pursue specialty training has been observed outside of surgery, raising the question of whether there are broader generational or societal influences at play. A 2006 study of 2638 internal medicine residents concluded that only 25% of graduating residents intended to pursue a career in general internal medicine.¹⁷ Most of the internal medicine residents rated time with family as the most influential factor in career decision making. A 2009 study of 8290 pediatric residents demonstrated that 47% of graduating respondents planned to pursue specialty training after residency.¹⁸ Residents were less likely to report that lifestyle was the most important factor in career decision making compared with residents who planned to practice general pediatrics.

In a 2009 study by Troppmann et al,¹⁹ female surgeons across all surgical specialties were 5 times less likely to be parents than their male counterparts. The trend toward delaying marriage and children to prioritize career goals makes it ever more relevant to understand the impact of marriage, family, and gender on the intent to pursue surgical residency and specialty training. Beyond additional training time to acquire an appropriate skill set, specialty training may also represent a marketable asset to residents as they attempt to secure postfellowship positions. When deciding whether to pursue a postresidency fellowship, trainees must balance the immediate time and financial burdens of additional training (which can be even more acute if the resident already has children) against future potential salary and lifestyle benefits that stem from becoming a specialty-trained surgeon. It appears that commitment to a spouse, partner, and/or children may dissuade residents from seeking specialty training, possibly because of time constraints of additional training or prioritization of family commitment. In our study, single men and women were more likely than their married colleagues to believe that a fellowship was necessary to be a successful surgeon and, presumably with fewer familial commitments, would be more eager to seek specialty training. Residents with children were more likely to believe that specialty training provides a better income and lifestyle; at the same time, they did not think it was necessary for a successful career.

Research on the role of external support systems and attitudes toward career decision making has been limited in medicine. Literature has focused on recommendations rather than research to promote a balance between profession and family; these reports primarily have been published in pediatric and psychiatry journals.^20,21 One recent study from the American Academy of Otolaryngology examined deterrents to pursuing a clinician-scientist career; residents ranked family as the primary motivation for not choosing an academic path.²² Research fields outside of medicine also have explored the role of marriage and family on career goals. A study examining the motivation of MBA entrepreneurs demonstrated that married women in business were more likely to value lifestyle motivators in choosing and maintaining their career goals; in contrast, men—regardless of their marital status or number of children—were motivated by income and advancement in career status.²³

A recent study examining gender differences in attitudes toward surgery training demonstrated that 75% of women compared with 46% of men would be more willing to enter surgery if maternity leave and child care were made available to female residents and attending physicians.¹³ Women expressed a greater interest in surgery compared with their male colleagues when part-time residency training was possible, acceptable, or could be split with a colleague. They also were more likely to go into surgery if there were more surgical faculty and residents of their same gender (all P < .001).

Limitations of this study include those inherent to any survey-based research. Response bias from residents secondary to sensitive topics addressed in our survey is possible; respondents may offer socially desirable answers or may underreport negative opinions out of fear of reprisal. Several measures were used to minimize potential biases, including confidentiality measures and balanced keying (positive and negative phrasing in question stems). Potential bias associated with training program factors such as geographic region is unlikely because we collected data from 248 programs throughout the country, with a resident response rate of 75.0%.

This study raises interesting questions regarding trainees' beliefs and intent to seek specialty training. Each fellowship experience is unique and provides varying potential for income and lifestyle flexibility. More research is needed to stratify resident characteristics associated with considering postresidency training and the impact of marriage and children on the rigors of residency and fellowship. A pertinent follow-up study could seek to identify specific characteristics and trends of fellows in their designated specialty-training programs, including marital status, family factors, and gender. This additional information may help to guide specialty programs in becoming sensitive to external support structure requirements, while not excluding capable applicants.

Ultimately, all trainees seek a pathway in graduate surgical education that will provide the skill set necessary for optimizing patient care, receiving adequate compensation, and achieving a flexible lifestyle within an appropriate time frame. Understanding how these factors influence this large subgroup of physicians is critical to identifying, recruiting, and retaining the best and brightest candidates in graduate surgical education.

Correspondence: Julie Ann Sosa, MA, MD, Divisions of Endocrine Surgery and Surgical Oncology, Yale University School of Medicine, Tompkins Memorial Pavilion 204, 333 Cedar St, New Haven, CT 06520 (Julie.sosa@yale.edu).

Accepted for Publication: October 22, 2009.

Author Contributions:Study concept and design: Viola, Yeo, Bell, and Sosa. Acquisition of data: Yeo, Piper, and Bell. Analysis and interpretation of data: Viola, Bucholz, and Sosa. Drafting of the manuscript: Viola, Bucholz, Piper, Bell, and Sosa. Critical revision of the manuscript for important intellectual content: Viola, Bucholz, Yeo, and Sosa. Statistical analysis: Viola, Bucholz, and Sosa. Obtained funding: Yeo. Administrative, technical, and material support: Viola, Piper, Bell, and Sosa. Study supervision: Yeo and Sosa.

Financial Disclosure: None reported.

Funding/Support: This study was supported by The Robert Wood Johnson Clinical Scholars Program at the Yale School of Medicine. The American Board of Surgery assisted with survey implementation, study design, and review of the manuscript.

Previous Presentation: This paper was presented at the 90th Annual Meeting of the New England Surgical Society; September 12, 2009; Newport, Rhode Island; and is published after peer review and revision.

This article was corrected for errors on January 20, 2016.