Attrition within surgical training is a challenge. In the USA, attrition rates are as high as 20–26%. The factors predicting attrition are not well known. The aim of this systematic review is to identify factors that influence attrition or performance during surgical training.
Method
The review was performed in line with PRISMA guidelines and registered with the Open Science Framework (OSF). Medline, EMBASE, PubMed and the Cochrane Central Register of Controlled Trials were searched for articles. Risk of bias was assessed using the Newcastle–Ottawa scale. Pooled estimates were calculated using random effects meta-analyses in STATA version 15 (Stata Corp Ltd). A sensitivity analysis was performed including only multi-institutional studies.
Results
The searches identified 3486 articles, of which 31 were included, comprising 17,407 residents. Fifteen studies were based on multi-institutional data and 16 on single-institutional data. Twenty-nine of the studies are based on US residents. The pooled estimate for overall attrition was 17% (95% CI 14–20%). Women had a significantly higher pooled attrition than men (24% vs 16%, p < 0.001). Some studies reported Hispanic residents had a higher attrition rate than non-Hispanic residents. There was no increased risk of attrition with age, marital or parental status. Factors reported to affect performance were non-white ethnicity and faculty assessment of clinical performance. Childrearing was not associated with performance.
Conclusion
Female gender is associated with higher attrition in general surgical residency. Longitudinal studies of contemporary surgical cohorts are needed to investigate the complex multi-factorial reasons for failing to complete surgical residency.
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Introduction
Attrition within surgical training is a challenge, in the USA, attrition rates are as high as 20–26% [1, 2]. It is a priority to retain surgical residents to meet the increasing healthcare demand and to reduce the significant costs associated with attrition.
Discrimination in the workplace is protected by US law [3]. Age, sex, disability, race, religion, gender reassignment, sexual orientation, pregnancy and maternity and marriage and civil partnerships are termed ‘protected characteristics’ and relate to personal characteristics or attributes. Differential attainment refers to the differences in performance between groups with and without protected characteristics [4]. The impact of protected characteristics on attrition and performance in general surgery residency is poorly understood.
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The impact of gender on attrition from general surgery residency remains unclear. Two meta-analyses reported conflicting findings regarding differences in attrition between male and female general surgery residents [5, 6]. The focus of these meta-analyses was on attrition prevalence and timing as opposed to the impact of protected characteristics. The need for further studies to clarify the role these characteristics play in attrition and performance in general surgical training was highlighted in the 2019 American College of Surgeons (ACS) statement on Harassment, Bullying and Discrimination [7]. Similarly the UK regulatory body, the General Medical Council (GMC), is working to identify areas of inequality to ensure all doctors are treated fairly regardless of protected characteristics [8].
In recent years, there has been a push to increase the diversity of medical students [9]. Consequently, there is a change in the upcoming surgeons of the future, with women now representing over a third of US surgeons in training [10]. Most studies focus on dated cohorts and do not reflect the change in the demographics of present surgical residents.
In order to reduce attrition and ensure that all trainees are facilitated to meet their maximum potential and maintain a successful surgical career, factors affecting failure to complete training or those that adversely affect performance need to be identified.
Objectives
The aim is to identify factors that influence progression through or completion of surgical training and will address the following:
1.
Are there any factors that predict attrition within postgraduate surgical training?
2.
Are there any factors that predict performance during postgraduate surgical training?
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Methods
Protocol registration
This systematic review was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) [11]. The protocol is available on the Open Science Framework (OFS) at https://osf.io/p5cby.
Eligibility criteria
The review sought to identify papers evaluating factors that affect attrition or progression through surgical training or identify factors affecting performance within surgical training. We included all types of study published as full papers with no restrictions on the language of or date of publication.
Exclusion criteria
1.
Studies not investigating specialty surgical trainees, e.g. consultants/faculty, non-medical staff, undergraduate training.
2.
Studies focused on selection into training.
Information sources, search and study selection
MEDLINE Ovid, Embase Ovid, PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched electronically using a mixture of keywords and MeSH terms. The subject strategies for databases were modelled on the search strategy designed for MEDLINE Ovid (Supplemental Fig. 1). We searched the reference lists of included studies for further eligible studies.
Two review authors (CH and JJR) independently and in duplicate performed the title and abstract screening. The full text of all eligible and potentially eligible studies were further evaluated to identify studies meeting the inclusion criteria. Any disagreement was resolved by discussion or where necessary a third reviewer opinion.
Data collection process
Two review authors (CH and JJR) independently extracted the data. If clarification was needed for any aspect of the included studies, the authors were contacted by email. The primary outcome measures were attrition and performance through training. Attrition was defined as voluntarily or involuntary discontinuation of surgical residency. Protected characteristics (age, sex, ethnicity, and marital and parental status), other factors (personal, workplace/programme, educational/academic) and factors related to performance (examination performance, personality/learning style, operative volume) were extracted from each study. Publication year, country of origin, study size and population, methodology and data source were recorded.
Risk of bias in individual studies
Methodology checklists for both cohort and case–control studies were reviewed and used to critically appraise and grade the evidence of included studies. Quality was assessed using the Newcastle–Ottawa scale [12].
Synthesis of results
The results were divided into studies that investigated factors affecting attrition and studies that focused on factors that affected performance. A random effects meta-analysis was performed to generate a pooled estimate of attrition prevalence. Two sensitivity analyses were performed including only multi-institutional studies and studies published after 2008. Between studies, heterogeneity was measured with the I2 statistic. I2 of greater than 75% was taken as a high level of heterogeneity. Random effects meta-analyses was conducted for sex. In the event of more than one study including the same population of residents, the study with the largest sample was included in the meta-analysis. Subgroup differences were tested using the z test. It was not possible to perform a meta-analysis on any other factors due to variation in outcome measurement and study design. It was also not possible to look at attrition worldwide due to the lack of non-US studies. All analyses were performed in Stata version 15 (Stata Corp LP), with a p < 0.05 significance level.
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Results
Study selection
The searches identified 3486 articles (Fig. 1). The main reason for exclusion on title and abstract screening was wrong outcome or wrong population. Thirty-one studies met the inclusion criteria (Table 1). Twenty-nine of the studies were from the USA, one from Pakistan and one from the UK. In regard to study quality, five studies were at high risk of bias, fifteen moderate risk and eleven low risk (Supplemental Table 1). Twenty-six studies reported attrition prevalence and were included in the meta-analysis, comprising 17,407 residents. The pooled estimate of overall attrition was 17% (95% CI 14–20%) with significant heterogeneity (I2 = 96.84%, p < 0.001) (Fig. 2). The pooled estimate of attrition was 14% (95% CI 10–17%) on sensitivity analysis of only multi-institutional studies with greater heterogeneity (I2 = 98.10%, p = 0.00), and therefore, initial analyses are presented (Supplemental Fig. 2). After only including studies published after 2008, the overall attrition remained 17% (95% CI 13–20%, I2 = 97.06%, p = 0.00) (Supplemental Fig. 3).
Fig. 1
PRISMA flow diagram
Table 1
Summary of all included studies
Author
Title
Year
Country
Study size
Population
Methodology
Source
Attrition rate reported
Alterman
The predictive value of general surgery application data for future resident performance
2011
USA
101
General surgery residents
1990–2008
Single institution
Retrospective review
Resident files
ABSITE
ACGME
Yes
Aufses
The nature and fate of categorical surgical residents who 'drop out'
1998
USA
88
General surgery residents
1982–1995
Single institution
Retrospective review
Resident files
Medical school data
Yes
Bergen
Gender-related attrition in a general surgery training program
1998
USA
132
General surgery residents
1984–1996
Single institution
Retrospective review
National Residency Matching Program
Yes
Brown
Pregnancy-related attrition in general surgery
2014
USA
85
General surgery residents
1999–2009
Single institution
Retrospective review
Resident files
Yes
Burkhart
Grit: A marker of residents at risk for attrition?
2014
USA
180
General surgery residents
2012–2013
Multi-institutional
Survey
Grit survey
Resident files
Yes
Carter
Women in surgery: A longer term follow-up
2018
USA
108
General surgery residents
1996–2009
Single institution
Retrospective review
Resident files
Yes
Dodson
Why do residents leave general surgery? The hidden problem in today's programs
2004
USA
120
General surgery residents
1990–2003
Single institution
Retrospective review
Resident files
Yes
Everett
General surgery resident attrition and the 80 h workweek
2007
USA
2555
General surgery residents
2001–2004
Multi-institutional
Survey to directors of general surgery residency programme
Survey
Yes
Falcone
Home school dropout: a 20 year experience of the matriculation of categorical general surgery residents
2014
USA
104
General surgery residents
1992–2011
Single institution
Retrospective review
Resident files
Yes
Farley
Whatever happened to the General Surgery graduating class of 2001?
2001
USA
53
General surgery residents
1996–2001
Multi-institutional
Cross-sectional
Resident files
Yes
Gifford
Factors associated with general surgery residents' desire to leave residency programs: A multi-institutional study
2014
USA
288
General surgery residents
Multi-institution
2004–2013
Survey across residents
Survey
Resident files
Yes
Hayward
Is there gender bias in the evaluation of surgical residents?
1987
USA
144
General surgery residents
1967–1985
Single institution
Retrospective review of faculty evaluations
Resident files
N/A
Kelz
Prevention of Surgical Resident Attrition by a Novel Selection Strategy
2010
USA
64
General surgery residents
2005–2009
Single institution
Retrospective review
Electronic Resident Application System
Resident interviews
Yes
Kim
The effect of surgical resident learning style preferences on American board of surgery in-training examination scores
2015
USA
53
General surgery residents
2012–2013
Single institution
Retrospective review
Fleming VARK learning styles inventory
ABS in-training examination score
N/A
Leibrant
Has the 80 h work week had an impact on voluntary attrition in general surgery residency programs?
2006
USA
215 programmes
General surgery residents
2003–2004
Multi-institutional
Questionnaire to programme directors
Questionnaire
N/A
Longo
Attrition of categoric general surgery residents: results of a 20 year audit
2009
USA
99
General surgery residents
1986–2006
Single institution
Retrospective review
Resident files
Yes
Nadeem
Attrition in surgical residency programmes: Causes and effects
2014
Pakistan
106
General surgery, orthopaedics, neurosurgery, ENT and urology residents
2005–2011
Single institution
Questionnaire to residents and programme directors
Resident files
Survey
Yes
Naylor
Factors Related to Attrition in Surgery Residency Based on Application Data
2008
USA
111
Surgery doesn’t define
1991–2000
Single institution
Retrospective review
Residency application form
Annual performance evaluations
ABSITE
Yes
Quillin
How residents learn predicts success in surgical residency
2013
USA
130
General surgery residents
1999–2012
Single institution
Retrospective review
ACGME
Operative log data
ABSQE and ABSCE
Resident files
Yes
Salles
Grit as a predictor of risk of attrition in surgical residency
2017
USA
73
General surgery residents
2014–2015
Single institution
Survey to residents
Survey
Short grit scale
Resident files
Yes
Salles
Social Belonging as a Predictor of Surgical Resident Well-being and Attrition
Association of general surgery resident remediation and program director attitudes with resident attrition
2017
USA
966
General surgery residents
2010–2015
Multi-institutional
Survey to programme directors
Survey
General Surgery Qualifying Examination and General Surgery Qualifying Examination of the ABS
Yes
Scrimgeour
Does the Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination predict ‘on-the-job’ performance during UK higher specialty surgical training?
2018
UK
2750
Higher surgical residents
2007–2016
Multi-institutional
Longitudinal cohort study
Membership of Royal College of Surgeons examination
ARCP outcomes
N/A
Sullivan
Surgical residency and attrition: Defining the individual and programmatic factors predictive of trainee losses
2013
USA
2033
General surgery
2008–2009
Multi-institutional
Prospective study
National Study of expectations and Attitudes of Residents in Surgery Survey
ABS resident roster
Yes
Symer
The Surgical Personality: Does Surgery Resident Motivation Predict Attrition?
2018
USA
801
General surgery
2007–2008
Multi-institutional
Survey to residents, data review 2016
Behavioural Inhibition/Behaviour Approach scale
ABS resident roster
Yes
Symer, Wong
Impact of medical school experience on attrition from general surgery residency
2018
USA
792
General surgery
2007–2008
Multi-institutional
Prospective cohort study
ABS
Survey assessing medical school experience
Yes
Wade
Evaluations of surgery resident performance correlate with success in board examinations
1993
USA
48
General surgery
1976–1988
Single institution
Retrospective review
ABSITE
Resident files
N/A
Yaghoubian
General surgery resident remediation and attrition: A multi-institutional study
2012
USA
348
General surgery residents
1999–2010
Multi-institution
Retrospective analysis
USMLE
ABSITE scores
3rd year medical school surgery performance scores
Yes
Yeo
A national study of attrition in general surgery training: Which residents leave and where do they go?
2010
USA
3959
General surgery residents
2007–2008
Multi-institutional
Retrospective analysis
National Study of Expectations and Attitudes of Residents in Surgery survey
Yes
Yeo
Who Makes It to the End?: A novel predictive model for identifying surgical residents at risk for attrition
2017
USA
836
General surgery residents
2007
Multi-institutional
Prospective cohort study with 8-year follow-up
ABS
ABSITE
Yes
Yeo
Association of time to attrition in surgical residency with individual resident and programmatic factors
2018
USA
836
General surgery residents
2007–2008
Multi-institutional
Prospective cohort study With 9-year follow-up data linkage
National Expectations and Attitudes of Residents in Surgery Survey
Yes
ABS American Board of Surgery, ABSITE American Board of Surgery In-Training examination, ACGME Accreditation Council for Graduate Medical Education, ARCP Annual Review of Competency Panel, USMLE United States Medical Licensing Exam
Fig. 2
Pooled attrition by study
×
×
Attrition
Age
Two out of four studies found no association with age and attrition [1, 13] (Table 2). In the studies that found increasing age to be a risk factor for attrition, age was dichotomised to under and over 29 [14] and under and over 35 years [15] in the analysis. The positive finding in the study by Naylor [14] may be due to the outcome measure which combines attrition with failure to pass the board examination.
Table 2
Studies investigating the effect of protected characteristics on attrition (age, sex, race/ethnicity, and marital and parental status)
Age
Author
Year
Study size
Conclusions
Brown
2014
85
Age not associated with attrition (OR 1.0 95% CI 0.8–1.4)
Yeo
2010
3959
Age not associated with attrition (β 0.05 95% CI -0.03–0.13)
Naylor
2008
111
Age > 29 years associated with attrition (OR 0.11 95% CI 0.02–0.47)
Sullivan
2013
2033
Age ≥ 35 years associated with attrition (OR 0.28 95% CI 0.19–0.39)
Sex
Author
Year
Study size
Conclusions
Alterman
2011
101
No association with gender (not reported)
Aufses
1998
88
No association with gender (32% vs 17%, p = 0.12)
Bergen
1998
132
No association with gender (RR 2.26 95% CI 0.96–5.31)
Brown
2014
85
No association with gender (OR 1.0 95% CI 0.2–3.6)
Carter
2018
108
No association with gender (female 22% vs male 19%, p = 0.77)
Dodson
2004
120
No association with gender (female 27% vs male 13%)
Falcone
2014
103
No association with gender (female 23.1% vs male 17.9%, p = 0.57)
Longo
2009
99
No association with gender (female 39% vs 26% male)
Nadeem
2014
106
No association with gender (female 54.5% vs male 34.5%, p = 0.07)
Sullivan
2013
2033
No association with gender (female 7% vs male 6.2%)
Yaghoubian
2012
348
No association with gender (female 47.3% vs male 52.7%, p = 0.08)
Yeo
2010
3959
No association with gender (β -0.23 95% CI -0.72–0.30)
Gifford
2014
371
Significant difference between sexes (Female OR 1.9 CI 1.2–3.0)
Symer, Wong
2018
792
Significant difference between sexes (24% of women vs 16% of men left, p 0.01)
Yeo
2017
836
Significant difference between sexes (24% of women vs 17% of men left, p = 0.02)
Yeo
2018
836
Significant difference between sexes (Female OR 1.40 95% CI 1.02–1.94)
Race/Ethnicity
Author
Year
Study size
Conclusions
Yeo
2010
3959
No association between race/ethnicity (β -0.09 95% CI -0.59–0.41)
Sullivan
2013
2033
Hispanic residents higher risk of attrition (OR 0.50 95% CI 0.38–0.65)
Black residents higher risk of attrition (OR 0.28 95% CI 0.20–0.40)
Symer, Wong
2018
792
Hispanic residents less likely to complete residency (13.1% non-Hispanic vs 7.8% Hispanic completed residency, p = 0.04)
Yeo
2017
836
Hispanic residents less likely to complete residency (29% non-Hispanic vs 19% Hispanic completed residency, p = 0.03)
Yeo
2018
836
Hispanic residents less likely to complete residency (OR 1.71 95% CI 1.06–2.76)
Marital and Parental Status
Author
Year
Study size
Conclusions
Brown
2014
85
No association with child rearing (OR 1.0 95% CI 0.1–9.6)
Association with marital status (Married OR 0.2 95% CI 0.01–0.9)
Sullivan
2013
2033
No association with child rearing (18% with children left vs 15% completed residency, p 0.31)
No association with marital status (46% married left vs 42% completed residency, p 0.34)
Yeo
2010
3959
No association with child rearing (β 0.45 95% CI -0.32–0.98)
No association with marital status (OR 0.23 95% CI -0.32–0.78)
Gender
The pooled attrition prevalence for male residents on random effect meta-analysis was 16% (95% CI 12–20%), with significant between study heterogeneity (I2 = 95.35%, p < 0.01) (Fig. 3). The pooled attrition prevalence for women was significantly higher at 24% (95% CI 18–30%, z = -4.6832 p < 0.001), again with significant heterogeneity (I2 = 94.62%, p < 0.01). On sensitivity analysis, including only multi-intuitional studies or those published after 2008 did not significantly affect the pooled attrition of male or female residents (Supplemental Fig. 4 and 5).
Fig. 3
Pooled attrition by sex
×
Four out of 16 studies found a significantly higher attrition amongst female residents [16‐19] (Table 2). One reported that women were almost twice as likely to leave training as men (OR 1.9 95% CI 1.2–3.0) [16]. A nine-year follow-up study found there were differences in attrition rate for men and women over time, with similar rates in the first year, but at four years into residency women had significantly higher rates of attrition (21.9% vs 16.3%, p = 0.05) [19]. Women also had a higher cumulative attrition (OR 1.40 95% CI 1.02–1.94) [19].
Ethnicity/race
Five studies investigated the association between race or ethnicity and attrition [1, 15, 17‐19] (Table 2). Four studies reported that Hispanic residents were less likely to complete residency; however, 3 of these studies were based on the same population of residents [15, 17‐19]. Therefore, it was not possible to perform a meta-analysis of the data. One study found that while white race was not associated with higher completion rates across both genders (69.7% completion vs 65.8% non-completion, p = 0.34) [18], on subgroup analysis of women, white women had lower non-completion rates than non-white women (20% vs 30% p = 0.08).
Marital and parental status
None of the studies found an association between parental status and attrition [1, 13, 15]; this included two large multi-institutional studies (Table 2). Only one study found those that were married were less likely to leave training, this was a small single-institutional study of 85 residents from 1999 to 2009 [13].
Personal factors
There was no association between attrition and ‘grit’ [20, 21] social belonging [22] or motivational personality traits [23] (Table 3). Grit was defined as perseverance and passion for long-term goals. The number of residents that did not complete training in these studies was small and therefore limits the power of statistical analysis. Quillin et al. reported that residents who learn by observation are more likely to leave the programme and opt for a non-surgical specialty [24].
Table 3
Studies investigating the effect of other factors on attrition (personal, workplace and programme and educational/academic factors)
Personal factors
Author
Year
Study size
Conclusions
Burkhart
2014
180
No significant association with grit (p = 0.246)
Salles
2017
73
No significant association with grit (β 85.83, p = 0.999)
Salles
2015
146
No significant association with lack of belonging (r = 0.15, p = 0.1846)
Symer
2018
801
No significant association with motivational personality traits (p = 0.51)
Quillin
2013
130
Association with learning style (p = 0.0467)
Workplace and programme factors
Author
Year
Study size
Conclusions
Everett
2007
2555
Association with 80 h workweek (0.6 lost/programme/year pre vs 0.8 lost/programme/year post, p = 0.0414)
Leibrant
2006
215
No association with 80 h work week (0.7 lost/programme/year pre vs 0.8 lost/programme/year post)
Sullivan
2013
2033
Association with early postgraduate year (9.4% PGY-1 left vs 4.5% PGY-2, p < 0.001)
Association with regional location (Northeast HR 2.39 vs South, p = 0.006)
Yeo
2010
3959
Association with early postgraduate year (β -0.82 95% CI -1.06- -0.58)
Symer, Wong
2018
792
Association with larger programme size (25.4% from large programme completed vs 34% small programme, p = 0.03)
Yeo
2017
836
Association with larger programme size (24% from large programme left vs 18% small programmes, p = 0.03)
Association with military programmes vs academic programmes vs community programmes (35% vs 20% vs 17%, p = 0.03)
Yeo
2018
836
Association with military programmes vs academic programmes (OR 2.68 95% CI 1.36–5.29)
Yaghoubian
2012
348
No association with remediation (20% vs 15%, p = 40)
Educational and academic factors
Author
Year
Study size
Conclusions
Farley
2001
53
No association with applicant ranking (p = 0.18)
Falcone
2014
103
No association with place of medical degree (p = 0.89)
Yaghoubian
2012
348
No association with place of medical degree (0% vs 5.3% foreign medical graduate,p = 0.09)
Association with PGY-3 ABSITE score (p = 0.04)
Alterman
2011
101
Association with special skill on medical school application (OR 3.59 95% CI 1.035–11.95) and medical school grade point average (p = 0.023)
Association with residency interview score (OR 188.27 95% CI 3.757–9435.405), STEP1 score (p = 0.001) and ABSITE score (p < 0.001)
Naylor
2008
111
Association with residency application—comments in the dean’s letter (OR 4.57 95% CI 2.00–10.43), participation in team sports (OR 4.96 95% CI 1.36–18.05)
Association with merit scholarship (OR 0.25 95% CI 0.08–0.78)
Symer, Wong
2018
792
Association with experience in surgical clerkship—perception that medical school faculty were happy with their careers (OR 0.57 95% CI 0.34–0.96), those that got along well with attending surgeons during medical school (OR 2.93 95% CI 1.34–6.39)
Workplace and programme factors
Eight studies reported the impact of work place factors on failure to complete general surgery residency [1, 15, 17‐19, 25‐27] (Table 3). Early postgraduate year [1, 15], larger programme size [17, 18] and military programmes [18, 19] were found to be associated with higher attrition.
Educational and academic factors
Six studies investigated medical school factors affecting completion of residency [14, 17, 25, 28‐30] (Table 3). Two studies reported an association between ABSITE score and attrition [25, 30]. Residents who felt medical school faculty were happy with their surgical careers were less likely to experience attrition [17], while those who got along well with attending surgeons during medical school had higher odds of attrition. Protective factors on the residency application were comments in the dean’s letter, participation in team sports [14] and residency interview score [30].
Performance
Six studies focused on factors that predicted performance throughout surgical residency [20, 24, 31‐34] (Table 4). Performance included examination scores, operative case volume and in-training evaluations. Childrearing was not associated with operative case volume or examination performance [13]. Factors reported to affect US postgraduate surgical examination performance were learning preference [31] and faculty evaluation of clinical performance [34]. However, these studies are based on small sample sizes. The only UK-based study investigated whether postgraduate examination scores are a predictor of performance throughout UK surgical training [32]. Non-white ethnicity and examination performance were found to be independent predictors of unsatisfactory performance.
Table 4
Studies looking at factors that predict performance
Author
Year
Study size
Conclusions
Brown
2014
85
No association with childrearing and operative case volume (men p = 0.40, women p = −93) or board pass rates (men p = 0.76, women p = 0.50)
Burkhart
2014
180
No association between grit score and ABSITE performance (p = 0.891)
Hayward
1987
144
No association with gender or place of medical degree (not reported)
Quillin
2013
130
No association with learning style and first time pass rate on the ABSQE (p = 0.615) or the ABSCE (p = 0.510)
Association with learning style and operative cases volume (p = 0.0467)
Kim
2015
53
Association with learning preferences and ABSITE performance (p = 0.03)
Scrimgeour
2018
2750
Association with non-white ethnicity (OR 1.36 95% CI 1.08–1.71), MRCS pass score (OR 0.98 95% CI 0.98–1.00) and MRCS attempt number (OR 1.50 95% CI 1.16–1.94) with unsatisfactory ARCP outcome
Wade
1993
48
Association with clinical performances and first time pass rate of ABS (p < 0.005)
Association with ABSITE performance and first time pass rate of the certifying examination (p < 0.001)
Discussion
This is the first study to report the association between protected characteristics and attrition and performance during surgical training. Overall, of the studies included in our systematic review 25 reported factors associated with progression or completion of surgical training and seven focused on factors affecting performance. The pooled attrition rate was high at 17% which causes a burden to residency programmes and existing residents. Efforts should be made to retain residents and to reduce the financial and training implications of attrition. Worryingly given the changing demographic of surgical trainees, rates of attrition were higher in women.
The limitations of this study are related to the included studies, the majority of which are conducted in a single institution which increases bias and reduces generalisability. A significant finding that limits generalisability to current surgical trainees is that fourteen of the studies include cohorts that started training over 20 years ago. During this time, training requirements and assessment processes have changed, as has the population of surgical trainees with an increase in female trainees. However, on sensitivity analysis including only studies published since 2008 did not affect the overall pooled attrition or that of attrition by gender. Nine of the included studies rely on survey data which are subject to response and recall bias. Also, as all but two of the included studies are from the USA, attrition rates and factors affecting this in other countries have not been investigated.
Attrition rates in general surgery residency remain higher than other surgical specialities [35‐37]. In a study of Canadian surgical residents, 26.8% were considering leaving their training programme with poor work–life balance cited as the main reason [38]. This study provides clarity regarding the impact of resident gender on attrition after two previous meta-analyses reported differing findings [5, 6]. We found a significantly higher attrition rate for female residents on pooled meta-analysis. This is consistent with a meta-analysis that found female residents had a 25% pooled attrition rate compared to 15% of men [6]. This finding is not unique to general surgery; higher attrition rates for female residents have also been reported in neurosurgery [39, 40] and orthopaedics [36].
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The findings regarding the impact of Hispanic ethnicity and attrition require further investigation. As three of the four studies reporting higher attrition amongst Hispanic residents are based on the same population, it is not possible to make firm conclusions. However, higher attrition for Hispanic residents has been reported across other specialities. A 2019 study of US emergency medicine residents found that a significantly greater proportion of Hispanic residents left the programme compared to white residents [41]. They also reported a higher rate of dismissal for Hispanic residents compared to Asian and white residents. The fact that Hispanic residents are an underrepresented group in postgraduate medicine may result in less access to role models they can identify with which may impede residency satisfaction [42]. Residents of non-white ethnicity were less likely to feel they fit in their residency programme which may partly explain the higher attrition [43].
Half of the studies found that age is associated with increased attrition; in both of these studies, age was dichotomised to an arbitrary number which may influence the findings [14, 15]. All three of the studies that analysed the effect of parental status find no increased rates [1, 13, 15]. These findings are reassuring given the increasing number of female surgical trainees and increasing acceptance of childrearing during residency. One study found that while the perception of negative attitudes towards pregnancy during training has decreased over time, some stigma persists [44]. It additionally reported that those who had graduated from medical school more recently were more likely to have a pregnancy during training than their older counterparts. The finding that childrearing does not affect attrition or performance should encourage residency programmes to develop clear guidance regarding parental leave, as in a recent study only 3.8% of residents were able to correctly identify the American Board of Surgery policy and felt unsupported [45].
The studies that focused on performance vary greatly in design and outcome measure. As with attrition, there was no association between childrearing or ‘grit’ and performance. The definition of performance is not uniform across studies and this limits interpretation. Four of these studies are based on populations commencing surgical residency more than 20 years ago, in one case from 1967. A 2017 study outlines the different assessment tools used during residency and highlights the lack of effective tools to measure competence [46]. Further studies investigating the relationship between attrition and performance using standardised measures of performance are warranted.
Conclusion
Female residents have higher attrition than male residents in general surgery. Marital and parental status are not associated with increased risk of attrition in general surgery residency. Longitudinal studies of contemporary surgical cohorts are needed to investigate the complex and multi-factorial reasons for failing to complete surgical residency internationally.
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Acknowledgements
None.
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Conflict of interest
The authors declare that they have no conflict of interest.
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