Research Article
Why Do Residents Quit General Surgery Residencies? A Study of 789 Graduates from 3 Campuses Who Matched into General Surgery over 40 Years: 1974 to 2015
Daniel M Avery Jr*, Joseph C Wallace, John Burkhardt, John Bell VII, Charles E Geno, Andrew
G Harrell, Garrett Taylor and Melanie Tucker
Department of Obstetrics and Gynecology, College of Community Health Sciences, University of Alabama, USA
*Corresponding author: Daniel M Avery, Department of Obstetrics and Gynecology, College of Community Health Sciences, University of Alabama, USA
Published: 09 Nov, 2017
Cite this article as: Avery DM Jr, Wallace JC, Burkhardt
J, Bell J VII, Geno CE, Harrell AG, et
al. Why Do Residents Quit General
Surgery Residencies? A Study of 789
Graduates from 3 Campuses Who
Matched into General Surgery over 40
Years: 1974 to 2015. Clin Surg. 2017;
2: 1720.
Abstract
Background: General Surgery has the highest rate of attrition of all medical and surgical residencies.
Uncontrollable lifestyle remains the number one reason residents quit general surgery residencies.
Uncontrollable lifestyle means long hours, unpredictable schedules, long operative procedures and
limited personal time. One out of every 6 general surgery residents quits residency training. More
than half of general surgery residents contemplate leaving their surgery residency. Attrition is a
major concern because of the existing shortage of general and rural surgeons in this country and
even greater projected shortage in the near future.
Design, Setting and Participants: A list of 6,271 graduates of the University of Alabama School
of Medicine (UASOM) from the Birmingham, Tuscaloosa and Huntsville campuses from 1974 to
2015 was obtained from the published records of the main campus in Birmingham. The list included
residents who changed from general surgery to another specialty, were dismissed, quit medicine
altogether, specialized early into an integrated program, or completed and practiced a surgical
subspecialty. Graduates from the Tuscaloosa campus between 1974 and 2015 and graduates from
the Birmingham and Huntsville campuses between 2001 and 2011 were interviewed by telephone
or sent surveys by mail.
Results: Ninety residents were identified from the study that changed from general surgery (1
had expired). Fifty-eight graduates (65.2%) responded. Eighteen graduates matched into non-
5 year categorical positions before other surgical specialties like urology, ENT, etc., and were
excluded from the calculations. Nineteen (47.5%) graduates changed to another specialty. Fourteen
(35%) graduates completed general surgery, then subspecialty fellowships and practiced surgical
subspecialties.
Discussion: The most common reason residents quit general surgery residencies is uncontrollable
lifestyle; the second is the physical demands of the presidency itself. Both are amenable to
improvement. The attrition rate of general surgery residents in this study is 44%. Most residents
who quit changed to another specialty or completed general surgery and pursued a subspecialty
fellowship.
Introduction
General surgery has the highest rate of attrition of all medical and surgical residencies [1-4].
Uncontrollable lifestyle remains the number one reason residents quit general surgery residencies
[5]. Uncontrollable lifestyle means long hours, unpredictable schedules, long operative procedures
and limited personal time. One out of every six general surgery residents quits residency training
[1,6]. The national attrition rate for general surgery is 20% [1,3,7]. Attrition in general surgery is
four to five times higher than surgical subspecialties and two to three times higher than internal
medicine. More than half of all general surgery residents contemplate leaving their surgery residency
[8]. Once a resident decides that general surgery will not provide the desired lifestyle, quitting the
residency is inevitable [9]. Attrition usually occurs early in training, typically after the first two years
[10] but can also occur during the research year [11]. All reports suggest that residents do not quit
during their chief residency year. After the PGY1 year, attrition is less likely with progression of the
residency [12]. Programs in the U.S. South have less attrition [12]. Common specialties residents
change to are plastic surgery, anesthesiology and radiology. Attrition is a major concern because of the existing shortage of general and rural surgeons and even greater
projected shortage of general surgeons in the very near future [13].
Currently, 58% of practicing general surgeons is over the age of 55
[14]. We are not keeping up with attrition with those practicing now.
Most general surgery residencies have been affected by attrition and
33% of programs have lost more than one resident. Almost half of
surgery residents consider dropping out of residency and almost half
would not match into surgery again [14,15]. Forty percent of residents
would not choose a medical career again [15]. Resident attrition
continues to increase with some reports of almost 30%. Training
programs classify attrition in several different ways. According to
Dodson and Webb, the most common classifications of reasons for
leaving residency are: 1) lifestyle issues, 2) early specialization into
an integrated program (e.g., plastic surgery), 3) termination, and
4) decision to leave medicine altogether. Other programs have also
used the classifications of voluntary and involuntary withdrawals.
The classifications used by Yeo et al. [11] are: 1) resignation, 2)
termination, and 3) transfer to another program. Attrition that occurs
early in residency suggests that actual residency training was different
from medical school expectations In one study, 20% of those who
quit changed to another general surgery residency which attests to
problems with that particular residency. More women leave surgery
residencies than men. Of particular concern were residents who left
involuntarily for performance or emotional problems. Dismissal or
termination is often a long, hard process that includes documentation
of problems, due process, corrective action, counseling, etc. In one
study, the majority of residents who left a surgery residency left in
good standing [16].
The strenuous lifestyle that accompanies general surgery
residencies remains the most common reason why residents
quit, often leaving to pursue residencies with better quality of life
expectations such as anesthesia or radiology [6,10,12,16,17]. In fact,
83% of males and 63% of females report lifestyle as the primary
factor in their decision against a career in surgery [18,19]. While
previous generations of physicians and surgeons seemed willing to
put medicine all other life priorities, including quality of life, the
current generation appears significantly more committed to finding
balance between their practice and their quality of life [18-21].
Unlike previous generations, today’s medical students are attracted
to specialties that allow for autonomy, flexible schedules, and balance
between work and home life. Current medical students are interested
in students are interested in specialties that allow more control over
their quality of life and are resistant to being on call or otherwise
available all of the time. Nearly half of all medical students’ report
they do not intend to practice medicine full time. Although most
students give favorable evaluations of their surgery clerkship, only
a disparate few ultimately choose to pursue a career in surgery. For
these students, the expectation and frequency of in-house call and oncall
requirements, the length of the residency, and the intensity of the
training are the determining factors in their decision.
The demanding nature of the specialty takes a toll on trainees,
leading to exhaustion due to work and/or stress—also known as
burnout. General surgery residents have the highest burnout rate
in the medical profession. Sixty-nine percent of surgery residents in
one program met the criteria for burnout. What is it about general
surgery that puts residents at such high risk for burnout and attrition?
The volume of work, intensity of technical skills demanded, and
long hours are often overwhelming, especially compared to other
residency programs. Burnout has been associated with working more
than 80 hr per week—the required weekly number of hours expected of general surgery residents. Ninety-nine percent of medical students
rank general surgery as the first or second most stressful specialty.
Bullying has also been associated with attrition and the “surgical
personality.
Resident attrition affects the residency program at multiple
levels. When a resident leaves, the remaining residents must take on
additional responsibilities, increasing their work load and call duties.
This disruption of the resident teams can lead to anger and frustration.
Furthermore, any additional work responsibilities taken on by the
remaining residents do not abrogate their required 80 hr work week.
Program directors, faculty and staff expend additional unplanned
efforts to replace a resident, not to mention costs to the residency.
Attrition is often a net loss to the residency and, subsequently, to
the profession at a time when there is a substantial need for general
surgeons in this country. When a resident leaves, the residency must
utilize more time and resources trying to find a replacement, in
addition to the substantial time that was already spent interviewing
him or her as a prospective resident. Even if a replacement resident
is acquired, the team must consider the possibility that he or she
is available because of a failure to match, dismissal, substandard
performance, etc.
Table 1
Table 1
Expanded Database of the University of Alabama School of Medicine Graduates from the Tuscaloosa, Birmingham and Huntsville Campuses (1974-2015).
Table 2
Design, Setting and Participants
This research was approved by the Institutional Review Board of
The University of Alabama. Financial support was provided by The
University of Alabama Institute of Rural Health Research. A list of
6,271 graduates of the University of Alabama School of Medicine from
the Birmingham, Tuscaloosa, and Huntsville campuses from 1974 to
2015 was obtained from the published records of the main campus
in Birmingham. Graduates assigned to the Montgomery Campus
were not included since this campus opened only recently. This list
contained the years of matriculation and graduation, full names,
specialty choice, name and location of PGY1 institution, and name
and location of residency. This database was expanded to include the
additional information listed in Table 1. Information was obtained
primarily from Google Search Engine. Publicly available data from
internet sources was selected as the primary source of information,
with verification from other sources when feasible. The investigators
recognize the positives as well as the limitations of internet-based
data. Information was obtained for 6,238 (99.5%) graduates assigned
to the three campuses from 1974 to 2015. Physicians were identified
by their practice website. The database was then configured into a
SPSS database so that descriptive statistics could be applied.
This study included graduates who matched into General
or Categorical Surgery but changed into another specialty, were
dismissed, quit medicine altogether, specialized early into an
integrated program or completed general surgery followed by
a subspecialty fellowship and practiced a surgical subspecialty.
Graduates who matched into non-5 year categorical positions (i.e.
one year of surgery before ENT) were not included. Respondents
were not given incentives for participating in the study. Phase 1 of the
study included graduates assigned to the Tuscaloosa Campus from
1974 to 2015 who withdrew from their matched surgery residency.
Responses from Phase 1 were used to prepare survey questions for
Phase 3. Phase 2 of the study included an analysis of the Tuscaloosa
Campus surgery clerkship student evaluations from 2005 to 2015 to
see if improvements could be made in the clerkship to attract more
medical students to surgery residencies and careers (This data is
discussed in another paper). Phase 3 included graduates from the
Birmingham, Tuscaloosa, and Huntsville campuses who changed
from general surgery residencies over the last 10 years of the study
(2001-2011). Study investigators initiated contact with graduates
by telephone to conduct the interviews. Graduates who could not
be reached by telephone were sent surveys through the mail, along
with pre-addressed, postage-paid envelope to return the completed
survey. If a graduate did not return the initial survey, he or she was
sent a second survey.
Table 3
Table 4
Results
In Phase 1, 30 graduates assigned to the Tuscaloosa Regional
Campus from 1974 to 2015 changed from general surgery. Twenty-nine of the graduates were either interviewed by telephone or mailed
surveys and 20 (69.0%) of the 29 graduates responded. One graduate
had died. Phase 2 involved medical student surgery clerkship
evaluations for the past 10 years and these are discussed in a different
publication. In Phase 3, 54 graduates from the Birmingham campus,
four graduates from the Tuscaloosa Campus and six graduates from
the Huntsville campus were identified as having withdrawn from
general surgery from 2001 to 2011. For residents completing a surgery
residency in 2015, they would have matriculated in 2011. Thirtynine
(60.9%) of the 64 graduates responded. Four of the Tuscaloosa
graduates were included in Phase 1. Data were reported together for
Phases 1 and 3 because the numbers were small.M
Ninety residents were identified from the combined study
that changed from general surgery. Fifty-eight residents (65.2%)
responded to the survey. Eighteen residents matched into non-5 year
categorical positions before other surgical specialties like urology,
ENT, etc. and were excluded from the calculations. Nineteen (47.5%)
residents changed to another specialty. Fourteen (35%) residents
changed to surgical subspecialties by completing subspecialty
fellowships after general surgery. Three residents (7.5%) pursued
early specialization into integrated residencies. Two residents (5%)
quit medicine altogether. One resident (2.5%) was dismissed from his
residency program. One resident (2.5%) did not specify a specialty.
Results are shown in Table 2.
Reasons for attrition from general surgery are shown in Table
3. Fifteen residents (37.5%) reported lifestyle issues (e.g., marriage,
children, pregnancy, health, and spouse’s goals) as the reason for
attrition. Eleven residents (27.5%) reported physical demands (work
is too demanding, length of residency is too long, work hours are too
long each day, unable to do the work) as reasons for attrition. Eight
residents (20%) did not like operating. Four residents (10%) reported
that they were unsure about general surgery as a career from the start
of their training. No resident reported difficulty making surgical
decisions as a reason for attrition (Figure 1). Additional participant
comments (e.g., inadequate supervision, unnecessary procedures,
discouragement, and feeling that general surgery is unfulfilling) are
listed in Table 4. Two additional residents notified the medical school
of changes in residency from general surgery to radiology as the study
was begun. One disclosed health reasons as the reason for change;
another did not disclose a reason. Neither was available for telephone
interview and new addresses were not yet available to send surveys.
Neither was included in the calculations.
Figure 1
Discussion
General surgery has the highest rate of attrition of any residency
[1-4]. Attrition of surgery residents is a major concern because of
the existing shortage of general surgeons and even greater projected
shortage in the near future [13]. The attrition rate of general surgery
residents in this study is 44%. Consistent with the literature reviewed,
uncontrollable lifestyle remains the number one reason residents quit
general surgery residencies [6,10,12,17]. The physical demands of
a general surgery residency were the second most common reason
residents quit general surgery. The response rate to the survey was
higher than expected and is probably related to the overall surgical
specialty concern of the shortage of general surgeons and also the
brief amount of time required completing the survey. The written
survey could be completed in less than two minutes.
Lifestyle issues relating to marriage, children, pregnancy, health,
age, spouse’s goals are an opportunity for improvement. Of particular
concern are the reports that the study participants felt the work of
general surgery was too demanding, the training is too long, and/
or there are too many work hours in the day. Also of concern are
the responses that indicate participants did not enjoy operating,
were unable to do the work, or they were undecided about pursuing
general surgery from the start of their training. The graduate who
left medicine altogether, having endured the challenges of medical
school and some residency training, is also concerning. Perhaps these
individuals were inadequately counseled about the expectations of
general surgery residencies and career practices. Nevertheless, this
study offers an opportunity for improved, more comprehensive
medical school career counseling.
This study did not identify residents who completed subspecialty
surgical fellowships after general surgery residencies and went on
to practice primarily general surgery. Residents changing to other
general surgery programs are likewise not identified in this study.
References
- Avery DM, Wallace JC, Avery DM, Harrell AG, Burkhardt J, Henderson C, et al. Attrition of General Surgery Residents during Training. Jacobs J Surg. 2017.
- National Residency Match Program. Residency Match Results by NRMP Year for UAB SOM Graduates by Campus. 2015.
- Fischer JE. The impending disappearance of the general surgeon. JAMA. 2007;298(18):2191-3.
- Newton DA, Grayson MA. Trends in Career Choice by US Medical School Graduates. JAMA. 2003;290(3):1179-82.
- Bachert A. Residents Continue to Quit General Surgery. Journal of Medicine. 2017.
- Dodson TF, Webb ALB. Why Do Residents Leave General Surgery? The Hidden Problem in Today’s Programs. Curr Surg. 2005;62(1):128-31.
- Cogbill TH, Cofer JB, Jarman BT. Contemporary issues in rural surgery. Curr Probl Surg. 2012;49(5):263-318.
- Barone JE. More Than Half of General Surgery Residents Think About Quitting. Healthy Living.
- Foster KN, Neidert GPM, Brubaker-Rimmer R, Artalejo D, Caruso DM. A Psychological Profile of Surgeons and Surgical Residents. J Surg Educ. 2010;67(6):359-70.
- Morris JB, Leibrandt TJ, Rhodes RS. Voluntary Changes in Surgery Career Paths: A Survey of the Program Directors in Surgery. J Am Coll Surg. 2003;196(4):611-6.
- Yeo H, Bucholz E, Sosa JA, Curry L, Lewis FR, Jones AT, et al. A National Study of Attrition in General Surgery Training—Which Residents Leave and Where Do They Go. Ann Surg. 2010;252(3):529-36.
- Sullivan MC, Yeo H, Roman SA, Ciarleglio MM, Cong X, Bell RH, et al. Surgical Residency and Attrition: Defining the Individual and Programmatic Factors Predictive of Trainee Losses. J Am Coll Surg. 2013;216(3):461-71.
- Contessa J, Kyriakides T. Surgical Resident Attrition and the Menninger Morale Curve. Surgical Science. 2011;2:397-401.
- Whellen TV. Training Surgeons for Tomorrow. AAMC. 2006.
- Phillips D. ‘Alarming’ Burnout Rate in General Surgery Residents. Medscape. 2016.
- Longo WE, Seashore J, Duffy A, Udelsman R. Attrition of Categoric General Surgery Residents: Results of a 20-Year Audit. Am J Surg. 2009;197(6):774-8.
- Leibrandt TJ, Pezzi CM, Fassler SA, Reilly EF, Morris JB. Has the 80 Hour Work Week Had an Impact on Voluntary Attrition in General Surgery Residency Programs? J Am Coll Surg. 2006;202(2):340-4.
- Evans S, Sarani B. The Modern Medical School Graduate and General Surgery Training. Arch Surg. 2002;137(3):274-7.
- Barshes NR, Vavra AK, Miller A, Brunicardi FC, Goss JA, Sweeney JF. General Surgery as a Career: A Contemporary Review of Factors Central to Medical Student Specialty Choice. J Am Coll Surg. 2005;199(4):792-9.
- Brooks JV, Bosk CL. Bullying is a Systems Problem. Social Science & Medicine. 2012;77:11-2.
- Berman L, Rosenthal MS, Curry LA, Evans LV, Gusberg RJ. Attracting Surgical Clerks to Surgical Careers: Role Models, Mentoring and Engagement in the Operating Room. J Am Coll Surg. 2008;207(6):793-800.