Almost 20% of general surgery residents don't complete their program, and most cite lifestyle-related issues as the reason, a new meta-analysis has found.
Zeyad Khoushhal, MBBS, MPH, from the Division of Vascular Surgery, St. Michael's Hospital in Toronto, Ontario, Canada, and colleagues report their findings online December 14 in JAMA Surgery.
Coauthor Mohammed Al-Omran, MD, MSc, head of the Division of Vascular Surgery at St Michael's Hospital, told Medscape Medical News that without solutions to this problem, talented would-be surgeons will continue to opt out of the field and increasing shortages will affect patients.
Women were much more likely to leave than men (25% vs 15%, respectively; P = .008). Possible reasons for that include lack of role models; perception of sex discrimination or negative attitudes toward women in surgery by colleagues or patients; or perception of lack of support from their programs, the authors write.
Of all residents, 48% who left did so after their first postgraduate year (95% confidence interval [CI], 39% - 57%) and 28% (95% CI, 22% - 33%; P < .001) left after the second year. Only 20% of surgical residents who left relocated to another general surgery program; most switched specialties.
Wide Variations in Programs
The researchers reviewed 22 studies (19,821 residents were included) on general surgery residency programs: 20 on US programs and 1 each in Pakistan and China. Results showed wide variations among surgery programs in numbers leaving and reasons for leaving.
Data are thin for other specialties, the authors note, but attrition in general surgery seems to be on par with that for obstetrics and gynecology (range, 3.6% - 21.6%) and neurosurgery (range, 14% - 42.6%). But general surgery resident attrition is much higher than for ophthalmology (1.15%), otolaryngology (6%), and orthopedics (5.3%).
The top two reasons for leaving were uncontrollable lifestyle during training (range, 12% - 87.5%) and switching specialties (range, 19% - 38.9%). The most popular specialty to switch to was anesthesia. Other reasons for leaving included financial hardship, poor performance or dismissal, family needs, and health issues.
Medscape Medical News previously reported that nearly two thirds of general surgery residents in a national survey met the criteria for burnout.
Dr Al-Omran said a large part of the problem is that residents don't have enough exposure to general surgery before they commit to a program. He suggested an added 6- to 8-week internship like those in some European countries would give residents more responsibilities in general surgery and help them gain more insight into the lifestyle before they enter the program.
Although that adds expense to medical education, he acknowledged, leaving the program has much bigger financial implications.
The institution of duty-hour limits in the United States in 2003 doesn't seem to have had much effect on perception of lifestyle satisfaction for surgeons, the authors point out. In fact, attrition rates before and after implementation of the restrictions were not statistically significant.
"It's not just about the hours, it's about the intensity of the hours," Dr Al-Omran told Medscape Medical News. He likens it to the military: "Not everybody can be a commander or a Navy SEAL," he said.
The authors suggest there may be better ways to support surgical residents than the duty-hour limits.
Assigning mentors during the last 2 years of medical school could help to make sure potential residents are prepared academically, but also psychologically, for the rigors of surgery, Dr Al-Omran said.
The researchers suggest expanding screening to ensure a better fit, including "essay requirements for applicants focusing on stress management, prioritization, and organizational abilities, which are all qualities needed to succeed as a surgical resident."
"You can't judge them on the performance in medical school alone," Dr Al-Omran said.
He also noted that the much higher numbers for women dropping out must be analyzed and addressed. "We have to work harder to find out why that is."
The authors have disclosed no relevant financial relationships.
JAMA Surg. Published online December 14, 2016. Abstract
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Cite this: Nearly 20% of General Surgery Residents Quit Their Program - Medscape - Dec 16, 2016.