Residents With Realistic Expectations Less Likely to Leave

Laird Harrison

April 19, 2018

General surgery residents are more likely to finish their training if they have a clear picture of the stress involved before they start, researchers report in an article published online April 18 in JAMA Surgery.

Those who expected to work more than 80 hours per week as an attending surgeon, to have a stressful life, and to be the subject of malpractice litigation were significantly less likely to drop out than peers with rosier expectations.

"It's really important for people to set realistic expectations for training," senior author Heather L. Yeo, MD, MHS, from Weill Cornell Medicine in New York City, said in a journal podcast.

Despite efforts to reduce attrition through changes in hours, about one in five residents still drops out before completing surgery residency, Jonathan S. Abelson, MD, from the Department of Surgery at New York-Presbyterian Hospital at Weill Cornell Medicine, and colleagues report. They could not find any study that examined the expectations about a residency and a career as a surgeon as a risk factor for attrition.

To investigate these factors, the researchers interviewed general surgery residents who had dropped out. On the basis of these residents' comments about their expectations and reasons for choosing a particular residency program, the authors crafted questions for a larger survey.

They then surveyed general surgery interns from the class of 2007 to 2008; the survey was administered during the American Board of Surgery In-Service Training Examination in January 2008.

The researchers then followed the interns for 8 years, until December 31, 2016, using linkable identifiers provided by the American Board of Surgery.

Among the 1048 general surgery interns in the 2007 to 2008 academic year, 870 (83.0%) took the survey and 828 had both complete survey data and sufficient linkage data to permit confirmation that they were interns that year. Of these 828 interns, 666 (80.4%) completed their residency training. This group was 63.3% men and 69.1% white. Five hundred (60.4%) interns trained in an academic program, and 247 (29.8%) trained in the Northeast.

The researchers used a statistical method, principal component analysis, to group the 31 survey questions into 9 factors on the basis of their concordance.

After adjusting for demographics and program characteristics, the researchers found that residents who chose their residency programs based on reputation and advice from mentors were more likely to drop out (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.01-1.15). This was true only of those in academic programs, not those in community programs, and it was true only of unmarried interns.

Interns who expected to work more than 80 hours/week, have a very stressful life as an attending, and be the subject of malpractice litigation at some point during their careers were less likely to drop out (OR, 0.90; 95% CI, 0.82-0.98). This was not true of married interns.

In contrast, married interns who chose a program based on geographic location were more likely to drop out (OR, 1.20; 95% CI, 1.03-1.40). This was not true of unmarried interns.

The finding that residents are less likely to drop out if they had expectations of stress, long hours, and lawsuits "suggests that an intervention to reduce attrition could reasonably focus on better preparing medical students and interns for the stress of a surgical career," Abelson and colleagues write.

They also suggest "wellness programs to teach strategies to cope with stress and prevent burnout" and trainings on work–life balance and preparing for a malpractice lawsuit.

However, Yeo noted in the podcast that her team found that the number of hours spent on rotations did not seem to influence residents' expectations about their training.

They speculate that married interns may be "more focused on family," so that choosing programs near their family could influence them to leave their residency.

They recommend that future surgery residents consider focusing on a good fit with the attending, rather than the program's location or reputation.

However, Yeo cautioned that residency programs should not reject applicants based on this research, particularly if this were to interfere with efforts to increase diversity or otherwise improve.

"I don't think all attrition is bad," she said. "I think some people are not meant to be in surgery, and they find that out. I certainly don't want anyone to be here because they don't want to be here. But I think that when you lose a talented individual who has skill, who could move the program forward, who could offer diversity to our patient population, we're losing out."

The researchers cautioned that their findings might not apply to all interns because they were based solely on the responses given by the class of 2007 to 2008. Other factors might loom larger for other classes. Also, the survey was done as the residents were beginning their training; other life events might assume more importance in later years of a residency.

In an accompanying invited commentary, Christiana Shaw, MD, and George A. Sarosi Jr, MD, from the University of Florida College of Medicine in Gainesville, note that attrition rates are higher for general surgery than for other medical specialties, and have not improved since the 1990s.

They interpret the study's findings as a "failure in mentorship." Mentorship should begin in medical school and emphasize realistic expectations, they write.

Yeo reported that her spouse received salary from Bioscrip. Various coauthors reported relationships with drug companies, and one is president of Discourse, a company that creates educational software for healthcare.

JAMA Surg. Published online April 18, 2018. Article abstract, Commentary extract

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