Association between American Board of Surgery in-training examination score and attrition from general surgery residency

Sculpting the good surgeon or excising the bad one: How clinical teachers could perpetuate attrition in surgical residency programmes

INTRODUCTION

Attrition in surgical residencies remains a significant issue, with traditional research focusing mainly on individual and programme factors. This study explores the role of clinical teachers (CTs) in influencing attrition rates. CTs are essential in moulding residents' training, serving both as enablers of workplace learning and guardians of their medical fields.

METHODS

We employed a hermeneutic phenomenology framework to understand the sociocultural impacts on attrition. Data were collected through semi-structured interviews involving 19 CTs, 3 residents who left the programme and 2 who underwent remediation, following a six-step hermeneutic phenomenological analysis process.

RESULTS

The entrenched 'good surgeon' narrative within the department demanded selflessness and total dedication, which CTs reinforced, thereby normalising a rigorous and challenging environment. This has led to attrition when residents fail to meet these challenges or choose to disengage from the system. We illustrated that CTs were pivotal in perpetuating these expectations, contributing significantly to resident attrition.

CONCLUSIONS

CTs played a crucial role in resident attrition by enforcing a stringent cultural norm within surgical training programmes. Addressing this issue requires a visible change in CTs' role to foster a more supportive educational environment. Emphasising the beneficial aspects of the 'good surgeon' narrative and mitigating its adverse impacts is essential for reducing attrition rates and assisting all residents, including those facing challenges, in successfully completing their training.

A framework to improve retention of Black surgical trainees: A Society of Black Academic Surgeons white paper

Attrition is high among surgical trainees, and six of ten trainees consider leaving their programs, with two ultimately leaving before completion of training. Given known historically and systemically rooted biases, Black surgical trainees are at high risk of attrition during residency training. With only 4.5% of all surgical trainees identifying as Black, underrepresentation among their peers can lend to misclassification of failure to assimilate as clinical incompetence. Furthermore, the disproportionate impact of ongoing socioeconomic crisis (e.g., COVID-19 pandemic, police brutality etc.) on Black trainees and their families confers additional challenges that may exacerbate attrition rates. Thus, attrition is a significant threat to medical workforce diversity and health equity. There is urgent need for surgical programs to develop proactive approaches to address attrition and the threat to the surgical workforce. In this Society of Black Academic Surgeons (SBAS) white paper, we provide a framework that promotes an open and inclusive environment conducive to the retention of Black surgical trainees, and continued progress towards attainment of health equity for racial and ethnic minorities in the United States.

The Potential Application of Mindset Theory to Surgical Education

Mindset theory proposes that individuals hold a range of beliefs regarding the malleability of attributes such as intellect and skill. Within surgery, mindset theory has been discussed as a way of understanding achievement in both the cognitive and technical aspects of learning surgery. A review of the literature reveals a limited body of research that has addressed the mindsets of surgeons or by extension, tied those mindsets to outcomes. Within health professions education, mindset theory has been studied more broadly, but the benefits of mindset theory are largely assumed and drawn from education research regarding children and adolescents. Though mindset theory has gained traction, there has been debate regarding the traits associated with growth and fixed mindsets. The strongest evidence from primary and secondary education shows that low socioeconomic status and academically at-risk students can benefit the most from mindset interventions, and these findings may extend to surgical learning as well. Mindset theory offers an interesting lens to better understand surgical education, but more research is needed to characterize the mindsets of surgeons and understand how these mindsets influence performance and outcomes.

Association of Demographic and Program Factors With American Board of Surgery Qualifying and Certifying Examinations Pass Rates

Importance

American Board of Surgery board certification requires passing both a written qualifying examination and an oral certifying examination. No studies have been conducted assessing the effect of sociodemographic variables on board passage rates.

Objective

To evaluate if trainee sociodemographic factors are associated with board passage rates.

Design, Setting, and Participants

This national and multi-institutional prospective observational cohort study of 1048 categorical general surgery trainees starting in 2007-2008 were surveyed. Data collection began in June 2007, follow-up was completed on December 31, 2016, and analysis began September 2018.

Main Outcomes and Measures

Survey responses were linked to American Board of Surgery board passage data.

Results

Of 662 examinees who had complete survey and follow-up data, 443 (65%) were men and 459 (69%) were white, with an overall board passage rate of 87% (n = 578). In a multinomial regression model, trainees of Hispanic ethnicity were more likely to not attempt the examinations (vs passed both) than non-Hispanic trainees (odds ratio [OR], 4.7; 95% CI, 1.5-14). Compared with examinees who were married with children during internship, examinees who were married without children (OR, 0.3; 95% CI, 0.1-0.8) or were single (OR, 0.4; 95% CI, 0.2-0.9) were less likely to fail the examinations. Logistic regression showed white examinees compared with nonwhite examinees (black individuals, Asian individuals, and individuals of other races) (OR, 1.8; 95% CI, 1.03-3.0) and examinees who performed better on their first American Board of Surgery In-Training Examination (OR, 1.03; 95% CI, 1.02-1.05) were more likely to pass the qualifying examination on the first try. White examinees compared with nonwhite examinees (OR, 1.8; 95% CI, 1.1-2.8), non-Hispanic compared with Hispanic examinees (OR, 2.4; 95% CI, 1.2-4.7), and single women compared with women who were married with children during internship (OR, 10.3; 95% CI, 2.1-51) were more likely to pass the certifying examination on the first try.

Conclusions and Relevance

Resident race, ethnicity, sex, and family status at internship were observed to be associated with board passage rates. There are multiple possible explanations for these worrisome observations that need to be explored. Tracking demographics of trainees to help understand passage rates based on demographics will be important. The American Board of Surgery already has begun addressing the potential for unconscious bias among board examiners by increasing diversity and adding implicit bias training.

National prospective cohort study describing how financial stresses are associated with attrition from surgical residency

BACKGROUND

Attrition from general surgery residency is high with a national rate of 20%. We evaluated potential associations between financial considerations and attrition.

METHODS

National prospective cohort study of categorical general surgery trainees.

RESULTS

Of the 1048 interns who started training in 2007, 681 (65%) had complete survey and follow-up data. In logistic regression, those with higher starting attending salary expectations (>$300K) were more likely to leave training (OR 2.9, 95% CI 1.2-6.9). Women with a partner who earned more (>$50K/year) were more likely to leave training (OR 4.1, 95% CI 1.6-10.5). In a subgroup of interns undecided about their future practice setting (academic, community, private practice, industry), those with less debt (≤$100K) were more likely to leave training (OR 2.4, 95% CI 1.1-5.2).

CONCLUSIONS

Several financial matters were associated with attrition. Addressing these financial concerns may help decrease attrition in surgical training and improve surgical training.