Factors Associated With General Surgery Residents’ Desire to Leave Residency Programs A Multi-institutional Study Edward Gifford, MD; Joseph Galante, MD; Amy H. Kaji, MD, PhD; Virginia Nguyen, BS; M. Timothy Nelson, MD; Richard A. Sidwell, MD; Thomas Hartranft, MD; Benjamin Jarman, MD; Marc Melcher, MD, PhD; Mark Reeves, MD, PhD; Christopher Reid, MD; Garth R. Jacobsen, MD; Jonathan Thompson, MD; Chandrakanth Are, MD; Brian Smith, MD; Tracey Arnell, MD; Oscar J. Hines, MD; Christian de Virgilio, MD

IMPORTANCE General surgical residency continues to experience attrition. To date, work hour amendments have not changed the annual rate of attrition.

Invited Commentary page 954 Supplemental content at

OBJECTIVE To determine how often categorical general surgery residents seriously consider leaving residency. DESIGN, SETTING, AND PARTICIPANTS At 13 residency programs, an anonymous survey of 371 categorical general surgery residents and 10-year attrition rates for each program. Responses from those who seriously considered leaving surgical residency were compared with those who did not. MAIN OUTCOMES AND MEASURES Factors associated with the desire to leave residency. RESULTS The survey response rate was 77.6%. Overall, 58.0% seriously considered leaving training. The most frequent reasons for wanting to leave were sleep deprivation on a specific rotation (50.0%), an undesirable future lifestyle (47.0%), and excessive work hours on a specific rotation (41.4%). Factors most often cited that kept residents from leaving were support from family or significant others (65.0%), support from other residents (63.5%), and perception of being better rested (58.9%). On univariate analysis, older age, female sex, postgraduate year, training in a university program, the presence of a faculty mentor, and lack of Alpha Omega Alpha status were associated with serious thoughts of leaving surgical residency. On multivariate analysis, only female sex was significantly associated with serious thoughts of leaving residency (odds ratio, 1.2; 95% CI, 1.1-1.3; P = .003). Eighty-six respondents were from historically high-attrition programs, and 202 respondents were from historically low-attrition programs (27.8% vs 8.4% 10-year attrition rate, P = .04). Residents from high-attrition programs were more likely to seriously consider leaving residency (odds ratio, 1.8; 95% CI, 1.0-3.0; P = .03). CONCLUSIONS AND RELEVANCE A majority of categorical general surgery residents seriously consider leaving residency. Female residents are more likely to consider leaving. Thoughts of leaving seem to be associated with work conditions on specific rotations rather than with overall work hours and are more prevalent among programs with historically high attrition rates.

Author Affiliations: Author affiliations are listed at the end of this article.

JAMA Surg. 2014;149(9):948-953. doi:10.1001/jamasurg.2014.935 Published online July 30, 2014. 948

Corresponding Author: Christian de Virgilio, MD, Department of Surgery, Harbor-UCLA Medical Center, 1000 W Carson St, Campus Box 25, Torrance, CA 90502 (cdevirgilio

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Desire to Leave at High-Attrition Residencies


espite structural changes to residency programs during the past decade, including adoption of the 80hour and then 16-hour rules, resident attrition continues to be a problem facing general surgery programs across the country.1 Modern attrition rates for general surgery residents remain between 3% and 5.1% annually and total 19% during the course of a 5-year to 7-year residency program.2,3 Most of this attrition is voluntary and not secondary to poor resident performance.4 Despite investigations that have examined the cohort of residents that leaves surgical training, little attention has been focused on residents who consider quitting residency but ultimately elect to stay. Although the annual Accreditation Council for Graduate Medical Education resident survey evaluates work hours and attempts to gauge resident experience, it does little to address risk factors for quitting.3 We conducted a multi-institutional survey of categorical general surgery residents to identify how often they seriously consider leaving residency. The objective was to identify what factors are associated with an increased desire to leave residency and which factors mitigate that desire. We also sought to determine whether the desire to quit was more prevalent among programs with historically higher attrition rates. Ultimately, our aim was to better understand the significance of various stressors in the life of a resident so that programs can adopt changes that go beyond broad work hour rules to improve resident satisfaction and retention.

Methods The study was approved by the Human Subjects Committee of the Los Angeles Biomedical Research Institute at HarborUCLA Medical Center. The study was deemed exempt from participant informed consent because the survey was anonymous and voluntary. A 52-question survey was created by the program director (C.d.V.) at Harbor-UCLA Medical Center (eTable 1 in the Supplement) in conjunction with other program directors (including J.G.) in the study and with select surgical residents (E.G. and C.R.). The anonymous survey consisted of demographic information, followed by a question about whether the resident had ever seriously considered leaving the general surgery residency and, if so, how often in each postgraduate (PG) year he or she had completed. Residents who indicated that they had never wanted to quit completed the survey at this point. Those residents who at some point had seriously considered quitting went on to respond to questions using a Likert-type scale (score range, 1-5). They were asked to rate which elements of their program or personal life influenced their thoughts of quitting. Thereafter, they were asked what factors were most helpful in mitigating those thoughts and moving forward with their training. Concurrently, a second survey was sent to the program directors at each of the participating institutions (eTable 2 in the Supplement). The program director was asked to indicate how many categorical general surgery residents were available for survey participation, as well as the attrition rate for the preceding 10 years and whether attrition for each resident was voluntary or involuntary. As a follow-up step, program directors were contacted individually and were asked the

Original Investigation Research

specific attrition and the sex breakdown of the graduating residents from 2004 to 2013. The anonymous survey was sent to 371 categorical general surgery residents at 13 residency programs. Based on prior communication that indicated high interest in study participation, programs were chosen to represent different regions of the United States (West, Southwest, Midwest, and Northeast) and various training models (university program, independent program, or hybrid program [university affiliation without an onsite university or medical school]). Our survey was distributed at the conclusion of the 2013 academic year to capture those residents who had participated in at least 1 year of training. The questionnaire was administered using online survey software (SurveyMonkey; To link the historical attrition rate of each program with the responses from that program, a unique survey link was created for each program. Responses were collected in an anonymous fashion directly from the residents from June 10, 2013, to August 18, 2013. To maintain anonymity, program directors were not given access to the results of their individual program. Statistical analysis of resident and program responses was exported into a native SAS format using a computer program (DBMS/Copy; Dataflux Corporation). Analyses were conducted using statistical software (SAS, version 9.3; SAS Institute Inc). The analysis of the overall study population and the survey results is descriptive and simply uses proportions and medians. For the main objective of the study, the cohort of residents who had never thought of quitting was compared with those who had ever thought of quitting. In addition, a comparison was made between residents who were at programs with a historically high attrition rate vs residents who were at programs with a historically low attrition rate, as defined by a cutoff value of 19%. The numerical determination of highattrition vs low-attrition programs was defined based on a survey by Yeo et al5 that demonstrated a 5-year to 7-year cumulative attrition rate of 19% for a general surgery residency program. For univariate analyses, continuous numerical variables were compared using the nonparametric Wilcoxon rank sum test and were reported as medians (interquartile ranges [IQRs]). Categorical or nominal variables were compared using χ2 test or Fisher exact test, as appropriate. P < .05 was considered statistically significant. Factors that were found to be significantly predictive of a desire to quit on univariate analysis were subjected to a multivariate analysis. Because of the concern that residents from a single program may be more likely to respond similarly to one another, we used the PROC GENMOD (general linear modeling) procedure. Finally, a stratified analysis of sex differences in survey response was also performed to further explore why sex was an independent predictor of the outcome of having ever thought of quitting residency.

Results Survey Response Two hundred eighty-eight residents (77.6%) responded to the survey. Of the respondents, 176 (61.1%) were men, and 112 (38.9%) were women (Table 1). Postgraduate year ranged from JAMA Surgery September 2014 Volume 149, Number 9

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Desire to Leave at High-Attrition Residencies

ciated with serious thoughts of leaving residency training (odds ratio, 1.2; 95% CI, 1.1-1.3; P = .003). The consideration to leave training by women was independent of their specific residency program. A separate analysis of the cohort of 30 respondents who underwent remediation did not demonstrate any significant difference from the respondents as a whole.

Original Investigation Research

Figure. Male vs Female Desire to Leave Residency by Postgraduate (PG) Year Male 60

P =.03

P =.02

P =.04




Female P =.01

Comparing the responses of women and men, women were more likely to continue to have serious thoughts of leaving as residency progressed, with women reporting thoughts of leaving more often than men in PG years 2 and 3, research years, and chief years (Figure). When comparing the responses of men and women about factors influencing this consideration, women were more likely to identify sleep deprivation on a specific rotation (P = .005) and difficult interaction with specific faculty (P = .05) as influencing those thoughts. Factors that women associated with the decision to stay in general surgery were perception of being better rested and loss of friends and camaraderie if they left (Table 3).

Comparison of High-Attrition vs Low-Attrition Programs The 10-year mean attrition rate for the 13 programs was 14.4% (range, 5.0%-29.3%). Three programs had a high (≥19%) median 10-year attrition rate of 27.8% (IQR, 21.6%-29.3%). The remaining 10 programs had a low (

Factors associated with general surgery residents' desire to leave residency programs: a multi-institutional study.

General surgical residency continues to experience attrition. To date, work hour amendments have not changed the annual rate of attrition...
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