Surgical Attrition Rates Impacted by Expectations, Persist in Later Program Years

Heather L. Yeo, MD, MHS

According to new study results, surgical interns with realistic expectations of residency and life as an attending are most likely to complete their training—highlighting the importance of these residents acquiring concise guidance on the demands that residency will require of them.

A prospective cohort study, conducted by Heather L. Yeo, MD, MHS, and Jonathan S. Abelson, MD, MS, from the departments of Surgery and Healthcare Policy and Research at New York-Presbyterian and Weill Cornell Medical Center and colleagues, the analysis surveyed 1048 surgery interns (response rate, 83.0%; n = 870), consisting of 524 men (63.3%) and 303 women (36.6%), with a single survey lacking gender information, with data collection beginning June 1, 2007, and follow-up completion occurring on December 31, 2016.

In total, 666 of the polled residents completed training (80.4%). The analysis included 9 factors: program supportiveness expectation (factor 1), program reputation (factor 2), extracurricular activity expectation (factor 3), program location/benefits (factor 4), gender and sensitivity perception (factor 5), career life expectation (factor 6), operating room expectation (factor 7), the 80-hour rule and career benefits (factor 8), and collegiality (factor 9).

The total variance among these 9 factors was 58.1%. Factors 7 and 8 were excluded from the multivariable analysis, as they were found to have unacceptable internal consistency and thus could not be reliable grouped together. Factor 9 was also excluded, as it was mapped to only 1 variable.

All told, 2 factors were found to be associated with attrition. Those who chose their residency program based on program reputation (factor 2) were more likely to drop out (odds ratio [OR], 1.08; 95% CI, 1.01 to 1.15), while those who expected to work more than 80 hours per week, have a stressful life, and be subject to malpractice litigation (factor 6) were less likely to do so (OR, 0.90; 95% CI, 0.82 to 0.98).

After stratification based on the type of program—academic or community based—only those at academic program who chose their program based on reputation (factor 2) had a higher likelihood of noncompletion (OR, 1.09; 95% CI, 0.99 to 1.19).

Attrition was higher for unmarried interns who chose a program based on reputation (OR, 1.11; 95% CI, 1.02 to 1.21), while reputation had no impact on their married counterparts’ dropout rates. Although, geographic location (factor 4) did impact married interns’ attrition rates (OR, 1.20; 95% CI, 1.03 to 1.40), while the expectation of a stressful life (factor 6) decreased the rate (OR, 0.82; 95% CI, 0.69 to 0.98).

The authors did note that the study was limited in its data collection, as they were only collected at the start of residency. Ultimately, though, Abelson and Yeo, et. al. concluded that better informing residents of the expectation of life in a surgical residency will help better support and prepare them and medical students for their training.

Another recent study conducted earlier this year, also by Abelson and Yeo, et. al., explored the topic of attrition in a way that previous studies had not: prospectively exploring which residents are at risk for dropping out, and at which point that risk is highest, finding that although noncompletion in surgical internships is highest, late erosion from programs persists—mostly among women and residents in larger programs.¹

It examined surveys from all categorical general surgery interns from the class of 2007-2008 during their first 30 days of residency and combined it with data from 9 years of follow-up assessing program completion. Data were collected from June 1, 2007, to June 30, 2016. In total, 836 residents were included, consisting of 306 women (36.6%) and 528 men (63.2%), with 2 surveys displaying unknown genders.

The overall attrition rate for the cohort was 20.8% (n = 164), with the peak rates occurring in the first postgraduate year (67.6%; n = 111; absolute rate, 13.3%). Attrition continued the following 6 years, though the researchers noted it was at a lower rate (absolute rate, 0.6% to 2.7% per year).

Observations of significance were around 4 variables—gender, Hispanic vs. non-Hispanic ethnicity, program size, and program type—though these were found to have an affect on residents at different times.

Rates of attenuation based on gender were similar, at 13.7% for men and 12.7% for women (P = .66), but these rates deviated after Year 1, with the rate for women increasing at a higher rate. By Year 4 of residency, the rates of attrition among women were 21.9%, compared to 16.3% for men (P = .05).

Residents of Hispanic ethnicity were associated with a higher risk of attrition than their non-Hispanic counterparts, becoming statistically significant after 1 year (21.1% compared to 12.4%, respectively; P = .04). There was no difference in rates of noncompletion based on the race of residents.

Those in larger programs (defined as having at least 6 chief residents) experienced significantly higher rates of attenuation after Year 5 (23.6%) than those in smaller programs (17.5%; P = .05). Additionally, those in military programs (32.3%) had higher rates of attrition than those in community (11.0%) and academic (13.5%) programs (P =.01) after the first year, but community and academic programs had no statistically significant differences in rates along the course of the study.

Yeo and colleagues noted that “given the distinct nature of military training, a sensitivity analysis of time to attrition was performed” to determine if its exclusion would reveal a significant difference between the observed variables, although the findings did not change regarding attrition time based on gender, race, or ethnicity.

A Cox multivariable proportional hazards model was utilized to confirm the findings and revealed that cumulative attrition was higher for women (odds ratio [OR], 1.40; 95% CI, 1.02 to 1.94), residents of Hispanic ethnicity (OR, 1.71; 95% CI, 1.06 to 2.76), and those in military training programs compared with academic programs (OR, 2.68; 95% CI, 1.36 to 5.29).

Previous findings, including work from Dodson and Webb, have confirmed that the risk of dropping out is highest during the first and second years, with the rate slowing in the third and fourth years.² The NEARS study, as Yeo and colleagues noted, also demonstrated these findings.

However, Yeo and colleagues noted that “late attrition is more worrisome than early attrition because it implies that significantly more resources were potentially wasted at the program level and by the resident and their family and support structure.” They also pointed to debt as a secondary problem for those that leave programs later, noting that the median debt for a graduate in 2016 was $190,000, though the extent to which debt may contribute to these rates is unclear.

In commentary accompanying Abelson JS, Yeo HL, et. al.'s latest publication, Christina Shaw, MD, MS, and Georeg A. Sarosi Jr, MD, pointed out that “this analysis is a new lends for educators to use to examine an old problem” as data shows that the rates of attrition for general surgery have remained consistent since the 1990s.³

Shaw and Sarosi wrote that “career mentorship should begin earlier, in medical school. Medical students are known to choose a surgical career based on interest in surgery in mentorship; however, the failure of mentorship may be not preparing future surgeons for the rigors of a surgical career.”

The study, “Association of Expectations of Training With Attrition in General Surgery Residents,” was published in JAMA Surgery.

REFERENCES:

1. Yeo HL, Abelson JS, Symer MM, et. al. Association of Time to Attrition in Surgical Residency With Individual Resident and Programmatic Factors. JAMA Surg. 2018. doi:10.1001/jamasurg.2017.6202

2. Dodson TF, Webb AL. Why do residents leave general surgery? The hidden problem in today's programs. Curr Surg. 2005;62(1):128-31. doi: 10.1016/j.cursur.2004.07.009.

3. Shaw C, Sarosi GA. Reducing Surgical Resident Attrition. JAMA Surg. 2018. doi: 10.1001/jamasurg.2018.0619.