Andrew T. Jones

A national study of attrition in general surgery training: which residents leave and where do they go?

Objective(s):Implementation of the 80-hour mandate was expected to reduce attrition from general surgery (GS) residency. This is the first quantitative report from a national prospective study of resident/program characteristics associated with attrition. Methods:Analysis included all categorical GS residents entered on American Board of Surgery residency rosters in 2007 to 2008. Cases of attrition were identified by program report, individually confirmed, and linked to demographic data from the National Study of Expectations and Attitudes of Residents in Surgery administered January 2008. Results:All surgical categorical GS residents active on the 2007–2008 resident rosters (N = 6,303) were analyzed for attrition. Complete National Study of Expectations and Attitudes of Residents in Surgery demographic information was available for 3959; the total and survey groups were similar with regard to important characteristics. About 3% of US categorical residents resigned in 2007 to 2008, and 0.4% had contracts terminated. Across all years (including research), there was a 19.5% cumulative risk of resignation. Attrition was highest in PGY-1 (5.9%), PGY-2 (4.3%), and research year(s) (3.9%). Women were no more likely to leave programs than men (2.1% vs. 1.9%). Of several program/resident variables examined, postgraduate year-level was the only independent predictor of attrition in multivariate analysis. Residents who left GS whose plans were known most often pursued nonsurgical residencies (62%), particularly anesthesiology (21%) and radiology (11%). Only 13% left for surgical specialties. Conclusions:Attrition rates are high despite mandated work hour reductions; 1 in 5 GS categorical residents resigns, and most pursue nonsurgical careers. Demographic factors, aside from postgraduate year do not appear predictive. Residents are at risk for attrition early in training and during research, and this could afford educators a target for intervention.

Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance.

IMPORTANCE In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted resident duty hour requirements beyond those established in 2003, leading to concerns about the effects on patient care and resident training. OBJECTIVE To determine if the 2011 ACGME duty hour reform was associated with a change in general surgery patient outcomes or in resident examination performance. DESIGN, SETTING, AND PARTICIPANTS Quasi-experimental study of general surgery patient outcomes 2 years before (academic years 2009-2010) and after (academic years 2012-2013) the 2011 duty hour reform. Teaching and nonteaching hospitals were compared using a difference-in-differences approach adjusted for procedural mix, patient comorbidities, and time trends. Teaching hospitals were defined based on the proportion of cases at which residents were present intraoperatively. Patients were those undergoing surgery at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). General surgery resident performance on the annual in-training, written board, and oral board examinations was assessed for this same period. EXPOSURES National implementation of revised resident duty hour requirements on July 1, 2011, in all ACGME accredited residency programs. MAIN OUTCOMES AND MEASURES Primary outcome was a composite of death or serious morbidity; secondary outcomes were other postoperative complications and resident examination performance. RESULTS In the main analysis, 204,641 patients were identified from 23 teaching (n = 102,525) and 31 nonteaching (n = 102,116) hospitals. The unadjusted rate of death or serious morbidity improved during the study period in both teaching (11.6% [95% CI, 11.3%-12.0%] to 9.4% [95% CI, 9.1%-9.8%], P < .001) and nonteaching hospitals (8.7% [95% CI, 8.3%-9.0%] to 7.1% [95% CI, 6.8%-7.5%], P < .001). In adjusted analyses, the 2011 ACGME duty hour reform was not associated with a significant change in death or serious morbidity in either postreform year 1 (OR, 1.12; 95% CI, 0.98-1.28) or postreform year 2 (OR, 1.00; 95% CI, 0.86-1.17) or when both postreform years were combined (OR, 1.06; 95% CI, 0.93-1.20). There was no association between duty hour reform and any other postoperative adverse outcome. Mean (SD) in-training examination scores did not significantly change from 2010 to 2013 for first-year residents (499.7 [ 85.2] to 500.5 [84.2], P = .99), for residents from other postgraduate years, or for first-time examinees taking the written or oral board examinations during this period. CONCLUSIONS AND RELEVANCE Implementation of the 2011 ACGME duty hour reform was not associated with a change in general surgery patient outcomes or differences in resident examination performance. The implications of these findings should be considered when evaluating the merit of the 2011 ACGME duty hour reform and revising related policies in the future.

Operative Experience of Surgery Residents: Trends and Challenges

OBJECTIVE To evaluate trends in operative experience and to determine the effect of establishing the Surgical Council on Resident Education (SCORE) operative classification system on changes in operative volume among graduating surgery residents. DESIGN The general surgery operative logs of graduating surgery residents from 2005 were retrospectively compared with residents who completed training in 2010 and 2011. Nonparametric statistical analyses were used (Mann-Whitney and median test) with significance set at p<0.01. PARTICIPANTS A total of 1022 residents completing residency in 2005 were compared with 1923 residents completing training in 2010-2011. RESULTS Total operations reported increased from a median of 1023 to 1238 (21%) between 2005 and 2010-2011 (p<0.001). Cases increased in most SCORE categories. The median numbers of total, basic, and complex laparoscopic operations increased by 49%, 37%, and 82%, respectively, over the 5-year interval (p<0.001). Open cavitary (thoracic + abdominal) operations decreased by 5%, whereas other major operations increased by 35% (both p<0.001). The frequency of discrete operations done at least 10 times during residency did not change. The median number of SCORE essential-common operations performed ranged from 1 to 107, whereas essential-uncommon operations ranged from 0 to 4. Twenty-three of 67 SCORE essential-common operations (34%) had a median of less than 5 and 4 had a median of 0. CONCLUSIONS The operative volume of graduating surgical residents has increased by 21% since 2005; however, the number of operations done 10 times or greater has not changed. Although open cavitary procedures continue to decline, there has been a large increase in endoscopy, complex laparoscopic, and other major operations. Some essential-common operations continue to be performed infrequently. These results suggest that education in the operating room must improve and alternate methods for teaching infrequently performed procedures are needed.

General surgery workloads and practice patterns in the United States, 2007 to 2009: a 10-year update from the American Board of Surgery.

Objective:To assess changes in general surgery workloads and practice patterns in the past decade. Background:Nearly 80% of graduating general surgery residents pursue additional training in a surgical subspecialty. This has resulted in a shortage of general surgeons, especially in rural areas. The purpose of this study is to characterize the workloads and practice patterns of general surgeons versus certified surgical subspecialists and to compare these data with those from a previous decade. Methods:The surgical operative logs of 4968 individuals recertifying in surgery 2007 to 2009 were reviewed. Data from 3362 (68%) certified only in Surgery (GS) were compared with 1606 (32%) with additional American Board of Medical Specialties certificates (GS+). Data from GS surgeons were also compared with data from GS surgeons recertifying 1995 to 1997. Independent variables were compared using factorial ANOVA. Results:GS surgeons performed a mean of 533 ± 365 procedures annually. Women GS performed far more breast operations and fewer abdomen, alimentary tract and laparoscopic procedures compared to men GS (P < 0.001). GS surgeons recertifying at 10 years performed more abdominal, alimentary tract and laparoscopic procedures compared to those recertifying at 20 or 30 years (P < 0.001). Rural GS surgeons performed far more endoscopic procedures and fewer abdominal, alimentary tract, and laparoscopic procedures than urban counterparts (P < 0.001). The United States medical school graduates had similar workloads and distribution of operations to international medical graduates. Compared to 1995 to 1997, GS surgeons from 2007 to 2009 performed more procedures, especially endoscopic and laparoscopic. GS+ surgeons performed 15% to 33% of all general surgery procedures. Conclusions:GS practice patterns are heterogeneous; gender, age, and practice setting significantly affect operative caseloads. A substantial portion of general surgery procedures currently are performed by GS+ surgeons, whereas GS surgeons continue to perform considerable numbers of specialty operations. Reduced general surgery operative experience in GS+ residencies may negatively impact access to general surgical care. Similarly, narrowing GS residency operative experience may impair specialty operation access.

Factors influencing the decision of surgery residency graduates to pursue general surgery practice versus fellowship.

OBJECTIVES Surgery residency serves 2 purposes-prepare graduates for general surgery (GS) practice or postresidency surgical fellowship, leading to specialty surgical practice (SS). This study was undertaken to elucidate factors influencing career choice for these 2 groups. METHODS All US allopathic surgery residency graduates from 2009 to 2013 (n = 5512) were surveyed by the American Board of Surgery regarding confidence, autonomy, and reasons for career selection between GS and SS. Surveys were distributed by mail in November 2013, with follow-up mailings to initial nonrespondents. RESULTS Sixty-one percent (3354) of graduates completed the survey; 26% pursued GS, and 74% SS. GS expressed greater levels of confidence than SS across the common surgical procedures queried. Confidence increased with each year after completion of residency for GS but not SS. The decision to pursue GS or SS was made during residency by 77% and 74%, respectively. Fifty-seven percent of those who chose GS indicated that a GS mentor significantly influenced their decision. GS rated procedural variety, opportunity for practice autonomy, choice of practice location, and influence of a mentor as reasons to pursue GS practice. SS listed control over scope of practice, prestige, salary, and specialty interest as reasons to pursue SF. Both groups expressed a high degree of satisfaction with their career choice (GS, 94%; SS, 90%). CONCLUSIONS Most graduates who pursue GS practice are confident and content. The decision to pursue GS is strongly influenced by a GS mentor. Lack of confidence may be a more significant factor for choosing SS. These findings suggest opportunities for improvements in confidence and mentorship during residency.

Duty Hours, Quality of Care, and Patient Safety: General Surgery Resident Perceptions

BACKGROUND The balance between patient treatment risks and training residents to proficiency is confounded by duty-hour limits. Stricter limits have been recommended to enhance quality and safety, although supporting data are scarce. STUDY DESIGN A previously piloted survey was delivered with the 2010 American Board of Surgery In-Training Examination (ABSITE). First postgraduate year (PGY1) and PGY2 trainees took the Junior examination (IJE); PGY3 and above took the Senior examination (ISE). Residency type, size, and location were linked to examinees using program codes. Five survey items queried all residents about the impact of further hour limits on care quality; online test residents answered 7 more items probing medical error sources. Data were analyzed using factorial ANOVA for association with sex, PGY level, and program demographics. RESULTS There were 6,161 categorical surgery residents who took the ABSITE: 60% men, 60% ISE, and two-thirds in university programs. Paper (n = 5,079) and online (n = 1,082) examinees were similar. Item response rates ranged from 91% to 98%. Few (<25%) perceived that stricter hour limits would improve care quality to a large or maximal extent. IJE plus West and Northeast residents significantly more often favored fewer hours. Factors perceived as contributing to medical errors usually or always by ≥ 15% of residents were incomplete handoffs, inexperience or lack of knowledge, insufficient ancillary personnel, and excessive workload. CONCLUSIONS Most categorical surgery residents do not perceive that reduced duty hours will noticeably improve quality of care. Resident perceptions of causes of medical errors suggest that system changes are more likely to enhance patient safety than further hour limits.

Delay in taking the American Board of Surgery qualifying examination affects examination performance

BACKGROUND The American Board of Surgery (ABS) Qualifying Examination (QE) represents an important step along the pathway to board certification. We investigated whether candidates who delayed taking the QE had worse performance on the examination. METHODS QE pass rates and equated scaled scores for all first-time examinees from 2006 to 2010 (n = 5,193) were reviewed. After eliminating examinees who could not be matched to final ABS In-Training Examination (ABSITE) scores, the remaining cohort (n = 4,909) was analyzed by comparing those who took the exam immediately after residency (Immediate, n = 4,488) to those who delayed for 1 or more years (Delay, n = 421). RESULTS The Immediate group had a mean first-time QE pass rate of 87% compared to 57% for those who delayed 1 year and 48% for those who delayed 2 or more years (P < .001). Regression analysis demonstrated that delay in taking the QE remained a significant determinant of exam failure after controlling for ABSITE scores (odds ratio = 0.35; 95% CI, 0.29-0.43; P = .001). Undergraduate medical education and postresidency training did not affect the results. The Delay group had lower equated scaled scores, a greater ultimate failure rate on the QE, and was more likely to fail the ABS Certifying Examination on the first attempt. CONCLUSION These results demonstrate that candidates who delayed taking the QE immediately are at extremely high risk for exam failure and failure to achieve board certification. These findings presumably are due to deterioration of knowledge over time, but they also may represent characteristics of the Delay group that are currently undefined.

Subscription to the Surgical Council on Resident Education Web Portal and Qualifying Examination Performance

BACKGROUND The Surgical Council on Resident Education (SCORE) curriculum for general surgery was developed to guide surgery residents in the acquisition of knowledge for patient care. We hypothesized that residents in programs that subscribed to the SCORE web portal would perform better on the American Board of Surgery (ABS) Surgery Qualifying Examination (QE). STUDY DESIGN Scaled scores and the percent passing the 2011 ABS Surgery QE for individual residents and programs were compared between programs that subscribed to the SCORE portal in 2010 to 2011 and those that did not subscribe. Regression analyses were performed to control for program QE percent passing from 2004 to 2008 (baseline performance), as well as demographic factors known to affect examination results. RESULTS There were 200 programs and 893 residents that subscribed to the SCORE web portal and 33 programs with 139 residents that did not subscribe. Regression analysis comparing predicted 2011 mean program QE scores based on 2004 to 2008 results showed that subscribing programs had a substantial increase in mean scaled scores of 1.4 points (adjusted means of 81.5 and 80.1, respectively), controlling for the percentage of international medical graduates and program size (p = 0.048). Residents from SCORE portal subscribing programs had a QE percent passing that was 1.6% higher than nonsubscribing residents, and the mean percent passing was higher for subscribing programs (86.4% vs 82.7%), but neither difference was statistically significant. The SCORE subscription status did not correlate with program size, percent of international medical graduates, or baseline scale scores. CONCLUSIONS There was a considerable improvement in mean QE scaled scores for residents in programs that initially subscribed to the SCORE web portal. The percent passing the QE showed a trend toward improvement for subscribing programs and their residents. This association is promising and deserves additional investigation.

The Vulnerable Stage of Dedicated Research Years of General Surgery Residency: Results of a National Survey

OBJECTIVE To characterize the demographics and attitudes of US general surgery residents performing full-time research. DESIGN Cross-sectional national survey administered after the 2008 American Board of Surgery In-Service Training Examination. SETTING Two hundred forty-eight residency programs. PARTICIPANTS General surgery residents. INTERVENTION Survey administration. MAIN OUTCOMES MEASURES A third of categorical general surgery residents interrupt residency to pursue full-time research. To our knowledge, there exist no comprehensive reports on the attitudes of such residents. RESULTS Four hundred fifty residents performing full-time research and 864 postgraduate year 3 (PGY-3) clinical residents completed the survey. Thirty-eight percent of research residents were female, 53% were married, 30% had children, and their mean age was 31 years. Residency programs that were academic, large, and affiliated with fellowships had proportionally more research residents compared with other programs. Research and PGY-3 residents differed (P < .05) on 10 survey items. Compared with PGY-3 residents, research residents were less likely to feel they fit well in their program (86% vs 79%, respectively), that their program had support structures if they struggled (72% vs 64%), or that they could turn to faculty (71% vs 65%). They were more likely to feel training was too long (21% vs 30%) and that surgeons must be specialty trained (55% vs 63%). In multivariate analyses, research residents believed surgical training was too long (odds ratio, 1.36) and they fit in less well at their programs (odds ratio, 0.71) (P < .05). CONCLUSIONS Compared with PGY-3 residents, research residents report less satisfaction with important aspects of training, suggesting this is a vulnerable stage. Interventions could be targeted to facilitate support and better integration into the mainstream of surgical education.

Evolving Patterns of Vascular Surgery Care in the United States: A Report from the American Board of Surgery

BACKGROUND The purpose of this study was to analyze the distribution of major vascular procedures among general and vascular surgeons and to compare the evolution of vascular surgical practice of general and vascular surgeons at specific points in their careers. STUDY DESIGN Case logs of surgeons seeking recertification in surgery from 2007 to 2009 were reviewed. Data from 3,362 physicians certified only in surgery (GS) were compared with 363 additionally certified in vascular surgery (VS). Independent variables were compared using factorial ANOVA. RESULTS The mean numbers of major vascular procedures (±SD) were 10 ± 51 for GS and 192 ± 209 for VS (p < 0.001). Thirty-three percent of the total vascular procedures reported were performed by GS. Compared with VS, GS performed significantly fewer vascular procedures in all major procedure categories, and GS certifying at 10 years performed fewer vascular procedures (6.7 ± 47) than those recertifying at 20 years (11.5 ± 48) and 30 years (13.6 ± 59) (p < 0.01). In contrast, VS certifying at 10 years performed more vascular procedures (235 ± 237) compared with those recertifying at 20 years (157 ± 173) and 30 years (104 ± 115). The mean number of vascular procedures was not different for sex, geographic location, or practice type, after controlling for other variables in the study. CONCLUSIONS The majority of GS currently do not perform any major vascular procedures, and younger GS are performing fewer such procedures than their older counterparts. The opposite is true for VS. These opposing trends indicate that vascular procedures are shifting from GS to VS in modern surgical practice, and this may have important implications for patient access to vascular surgery care, considering the limited capacity for VS to assume the excess case load.