Attitudes and factors contributing to attrition in Canadian surgical specialty residency programs

Developing a model describing voluntary residency attrition: a qualitative study

BACKGROUND

Many factors influencing residency attrition are identified in the literature, but what role these factors play and how they influence each other remains unclear. Understanding more about the interaction between these factors can provide background to put the available evidence into perspective and provide tools to reduce attrition. The aim of this study was therefore to develop a model that describes voluntary residency attrition.

METHODS

Semi-structured interviews were held with a convenient sample of orthopaedic surgery residents in the Netherlands who dropped out of training between 2000 and 2018. Transcripts were analysed using a constructivist grounded theory approach. Concepts and themes were identified by iterative constant comparison.

RESULTS

Seventeen interviews with former residents were analysed and showed that reasons for voluntary attrition were different for each individual and often a result of a cumulative effect. Individual expectations and needs determine residents' experiences with the content of the profession, the professional culture and the learning climate. Personal factors like previous clinical experiences, personal circumstances and personal characteristics influence expectations and needs. Specific aspects of the residency programme contributing to attrition were type of patient care, required skills for the profession, work-life balance and interpersonal interaction.

CONCLUSIONS

This study provides a model for voluntary resident attrition showing the factors involved and how they interact. This model places previous research into perspective, gives implications for practice on the (im)possibilities of preventing attrition and opens possibilities for further research into resident attrition.

Female surgical trainee recruitment and attrition - A 10-year national retrospective review

BACKGROUND

Female trainees continue to be underrepresented in surgical specialties. Studies have shown lower enrollment and higher attrition of female trainees in surgery. However, there is no comprehensive data examining trends to determine if positive strides have been made towards greater equity.

METHODS

Retrospective cohort study examining Canadian surgical residents who began training between 2000 and 2010. Enrollment data was compared to how many of those individuals registered for their final surgical certifying examinations by 2018, which indicated completion of residency.

RESULTS

In the 10-year period, overall attrition rates of surgical trainees was 8%. Female residents were twice as likely to leave training compared to their male counterparts (12.4 vs 6.1% p < 0.001). Attrition rates for female residents appeared to trend downwards. Enrollment of female surgical trainees across all surgical specialties increased from 27.3% to 39.2% during this time.

CONCLUSION

Equity in Canadian surgical training enrollment and retention improved for those who began training from 2000 to 2010, but there continued to be differences in female trainee recruitment and attrition rates compared to their male counterparts.

Gender trends in applicants to general surgery residency programs in Canada

BACKGROUND

Surgical disciplines lag behind non-surgical disciplines in attracting female trainees. Female representation of Canadian General Surgeons has not been evaluated in recent years in the literature. The objectives of this study were to assess gender trends in applicants to Canadian General Surgery residency programs and practicing general surgeons and subspecialists.

METHODS

This retrospective cross-sectional study analyzed gender data for residency applicants ranking General Surgery as their first-choice discipline from publicly-available annual Canadian Residency Matching Service (CaRMS) R-1 match reports from 1998 to 2021. Aggregate gender data for practicing female physicians in General Surgery and related subspecialties, including Pediatric Surgery, obtained from annual Canadian Medical Association (CMA) census from 2000 to 2019 was also analysed.

RESULTS

There was a significant increase in the proportion of female applicants from 34% in 1998 to 67% in 2021 (p < 0.001) and of successfully matched candidates from 39% to 68% (p = 0.002) from 1998 to 2021. Success rates between male and female candidates were significantly different in 1998 (p < 0.001), but not in 2021 (p = 0.29). The proportion of practicing female General Surgeons also significantly increased from 10.1% in 2000 to 27.9% in 2019 (p = 0.0013), with variable trends in subspecialties.

CONCLUSION

Gender inequality in General Surgery residency matches has normalized since 1998. Despite females representing more than 40% of applicants and successfully matched candidates to General Surgery since 2008, a gender gap still exists amongst practicing General Surgeons and subspecialists. This suggests the need for further cultural and systemic change to mitigate gender disparities.

TYPE OF STUDY

Original research article, clinical research.

LEVEL OF EVIDENCE

Level III (Retrospective cross-sectional study).

The Relation of Grit and Surgical Specialty Interest Among Medical Students

OBJECTIVE

The assessment of Grit among medical students applying to surgical residency programs may be useful, but the relationship between student Grit and surgical specialty interest is not clear. This study investigated whether medical student Grit differs based on interest in direct-entry surgical specialties.

DESIGN

A literature search informed the development of a cross-sectional study assessing medical student ratings of the validated 6-item Short-Grit scale. Medical students also indicated their career preferences.

SETTING

Faculty of Medicine, Dalhousie University, Halifax, NS, Canada; a tertiary medical center.

PARTICIPANTS

Surgical specialty interest and Grittiness were assessed among 297 (50.4%) pre-clerkship medical students in their first or second year of training. Data was collected from program applicants over 4 years.

RESULTS

Medical students had high levels of Grit (M = 4.029, SD = 0.517). There was a significant difference in Grit level between medical students interested in cardiac surgery ([M = 4.197, SD = 0.471 vs M = 3.919, 0.518]; t(295) = 4.674, p < 0.001; Cohen's D = 0.556), general surgery ([M = 4.178, SD = 0.466 vs M = 3.916, 0.527]; t(295) = 4.434, p < 0.001; Cohen's D = 0.520), neurosurgery ([M = 4.238, SD = 0.457 vs M = 3.950, 0.518]; t(295) = 4.412, p < 0.001; Cohen's D = 0.575), plastic surgery ([M = 4.138, SD = 0.497 vs M = 3.967, 0.520]; t(295) = 2.747, p = 0.006; Cohen's D = 0.333), and vascular surgery (M = 4.248, SD = 0.368 vs M = 3.948, 0.541); t(295) = 4.570, p < 0.001; Cohen's D = 0.501).

CONCLUSIONS

Medical students with a career interest in "poor lifestyle" surgical specialties have higher Grit than their peers. These findings may be noteworthy for surgical residency programs with high rates of attrition and burnout.

Supervisors' transformational leadership style and residents' job crafting in surgical training: the residents' views

OBJECTIVES

This study aims to explore the effects of three supervisors' leadership styles (transformational, transactional, and laissez-faire) on residents' job crafting.

METHODS

Sequential explanatory mixed-methods. First, a purposive sample of residents rated the leadership style of their supervisors and their own job crafting on the Multifactor Leadership Questionnaire and the Dutch Job Crafting Scale. The effects were tested through linear mixed effects regression analysis. Thereafter we conducted semi-structured interviews with residents and conducted a thematic analysis.

RESULTS

A total of 116 residents participated. A transformational style had a positive effect on residents' job crafting (b = .19, t₍₁₁₂₎ =3.76, p=. 009), whereas the transactional and laissez-faire styles did not. This could be explained by the fact that residents felt a positive influence of the supervisors with such style on the atmosphere for training, on the job resources available to them, and on their modelling function for how to handle the demands of the environment.

CONCLUSIONS

A transformational style of the supervisor has a positive effect on residents' job crafting. Future research should explore the supervisors' perspective, as well as the effectiveness of leadership training for supervisors with a focus on resident outcomes, such as job crafting.

Differences in progression by surgical specialty: a national cohort study

The aim of surgical training across the 10 surgical specialties is to produce competent day 1 consultants. Progression through training in the UK is assessed by the Annual Review of Competency Progression (ARCP).

OBJECTIVE

This study aimed to examine variation in ARCP outcomes within surgical training and identify differences in outcomes between specialties.

DESIGN

A national cohort study using data from the UK Medical Education Database was performed. ARCP outcome was the primary outcome measure. Multilevel ordinal regression analyses were performed, with ARCP outcomes nested within trainees.

PARTICIPANTS

Higher surgical trainees (ST3-ST8) from nine UK surgical specialties were included (vascular surgery was excluded due to insufficient data). All surgical trainees across the UK with an ARCP outcome between 2010 and 2017 were included.

RESULTS

Eight thousand two hundred and twenty trainees with an ARCP outcome awarded between 2010 and 2017 were included, comprising 31 788 ARCP outcomes. There was substantial variation in the proportion of non-standard outcomes recorded across specialties with general surgery trainees having the highest proportion of non-standard outcomes (22.5%) and urology trainees the fewest (12.4%). After adjustment, general surgery trainees were 1.3 times more likely to receive a non-standard ARCP outcome compared with trainees in trauma and orthopaedics (T&O) (OR 1.33, 95% CI 1.21 to 1.45, p=0.001). Urology trainees were 36% less likely to receive a non-standard outcome compared with T&O trainees (OR 0.64, 95% CI 0.54 to 0.75, p<0.001). Female trainees and older age were associated with non-standard outcomes (OR 1.11, 95% CI 1.02 to 1.22, p=0.020; OR 1.04, 95% CI 1.03 to 1.05, p<0.001).

CONCLUSION

There is wide variation in the training outcome assessments across surgical specialties. General surgery has higher rates of non-standard outcomes compared with other surgical specialties. Across all specialties, female sex and older age were associated with non-standard outcomes.

Career orientations of medical students: A Q-methodology study

INTRODUCTION

In pursuing optimal health care, an adequate medical workforce is crucial. However, many countries are struggling with a misalignment of students' specialty preferences and societal needs regarding the future medical workforce. In order to bridge this gap, it is relevant to gain a better understanding of the medical career choice processes. We explored career orientations among medical students in the Netherlands and their implications for future career choices.

METHODS

We used Q-methodology, a hybrid qualitative-quantitative method, to explore career orientations of medical students. Medical students from two universities in the Netherlands, varying in year of progression of medical school, ranked 62 statements with regard to importance for their future career choice. Participants explained their ranking in an interview and completed a questionnaire regarding demographics. Using by-person factor analysis we identified groups of individuals with similar orientations.

RESULTS

Twenty-four students participated in this study, resulting in three distinct orientations towards future careers: a first career orientation that highly values lifelong self-development; a second that values work-life balance, and a third that was more concerned with achievement and recognition of their work.

CONCLUSION

Medical students' career orientations differed in the importance of challenge, work-life balance, and need for recognition. This knowledge can help to design interventions to shift career choices of medical students closer towards future needs in society. Offering career coaching to students that challenges them to explore and prioritise their values, needs and motivations, for example using the materials form this study as a tool, and stimulates them to consider specialties accordingly, could be a promising strategy for guiding students to more long-term satisfying careers.

Public Perceptions of General Surgery Residency Training

OBJECTIVE

Patients are integral to surgical training. Understanding our patients' perceptions of surgical training, resident involvement and autonomy is crucial to optimizing surgical education and thus patient care. In the modern, connected world many factors extrinsic to a patient's experience of healthcare may influence their opinion of our training systems (i.e., social media, television shows, and internet searches). The purpose of this article is to contextualize the literature investigating public perceptions of general surgery training to allow us to effect patient education initiatives to optimize both surgical training and patient safety.

DESIGN

This is a perspective including a literature review summarizing the current knowledge of public perceptions of general surgery training.

CONCLUSIONS

Little is published regarding patient and public perceptions of general surgery residency training and the role of residents within this. Current literature demonstrates that the majority of patients are willing to have residents participate in their care. Patients' attitude toward resident involvement in their operation is improved by utilizing educational materials and by ensuring a supervising attending is present within the operating room. These observations, coupled with future work to delve deeper into factors affecting public perceptions of surgical training and resident involvement within this, can guide strategies to improve surgical education.

Burnout and work-life balance in neurosurgery: Current state and opportunities

Background:

Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and reduced sense of personal accomplishment. The syndrome has been recognized as a pandemic among physicians. The demanding nature of neurosurgery makes neurosurgeons, particularly prone to burnout. In recent years, pioneering work has shed light on burnout in the field of neurosurgery.

Methods:

We have reviewed the literature in PUBMED on burnout in physicians, focusing on neurosurgical publications.

Results:

In this manuscript, we explore the topic of burnout in neurosurgery by reviewing definitions, magnitude, etiologies, sequelae, and mitigation strategies.

Conclusion:

Ongoing education, recognition, and targeted interventions for neurosurgeons at different career stages are needed to manage burnout proactively and ensure a resilient neurosurgery workforce.

Factors Associated with Attrition and Performance Throughout Surgical Training: A Systematic Review and Meta-Analysis

Background

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.

Electronic supplementary material

The online version of this article (10.1007/s00268-020-05844-0) contains supplementary material, which is available to authorised users.

The emergence of the physician assistant role in a Canadian acute care surgery setting

BACKGROUND

The role of physician assistants (PAs) in surgical care in Canada is expanding. Similarly, the acute care surgery (ACS) model continues to evolve, and PAs are increasingly being considered as members of ACS teams. However, their exact impact and contribution has not been well studied. Our study describes the contribution of a PA who worked full time on weekdays on an ACS team in a Canadian academic tertiary hospital.

METHODS

To quantify the PA's contributions, an ACS database was created in September 2016. Data on the number of ACS patient encounters, the number of ACS surgical consults, the number of ACS admissions, the PA's involvement in the operating room, the number of PA patient encounters and the number of multidisciplinary meetings were prospectively collected. We report data for 365 consecutive days from Dec. 30, 2016, to Dec. 29, 2017.

RESULTS

The ACS team had 11 651 patient encounters during the year, with a mean of 31.92 per day. The mean number of surgical consults per day was 5.89, and a mean of 2.08 surgical procedures were performed per day. The PA was involved in 53.5% of all patient encounters, despite working only during daytime hours on weekdays. Multidisciplinary meetings were conducted by the PA 94.9% of the time. Alternate level of care patients were seen by the PA 96.2% of the time. The PA was directly involved in 2.0% of the operating room procedures during the study period.

CONCLUSION

Integrating a PA on an ACS team adds value to patient care by providing consistency and efficient management of ward issues and patient care plans, including multidisciplinary discharge planning, timely emergency department consultations and effective organization of the ACS team members.

A survey on the cost of oral surgery dental speciality training

Background Following graduation, training costs for an individual trainee to achieve completion of specialist surgical training has been estimated to be between £20,000 to £71,431, and is expected to rise. Furthermore, there are other non-monetary costs to consider, including poor work-life balance and the burden of training on home life.Methods A 22-question online survey using SurveyGizmo was developed and emailed to all current UK and Ireland oral surgery trainees from 2016-2019. The survey consisted of open free text, binomial and variable scale responses related to the cost of training.Results A total of 43 (96%) oral surgery trainees responded to the survey. Sixty-eight percent had enrolled on a postgraduate degree, or other higher qualification, during their training. Of these, only 4.5% were fully funded and nearly half received no funding at all. Trainees reported vast disparities in financial support across deaneries, with an overall average study budget of £687. Annual obligatory costs of up to £4,142 and a mean average spend of £9,240 on courses and £2,830 on conferences were reported. Childcare, relocating and textbooks were listed as additional costs incurred.Conclusion A standardised, transparent and more substantial financial support system is required for dental specialty trainees.

Burnout of residents: Overview from various medical institutions - A suggested model for improvement

BACKGROUND

Burnout is a common issue among residents across the globe. Although several attempts were made to propose better working hours for residents, burnout is still prevalent as depicted by several studies.

OBJECTIVES

The aim of the paper is to review several worldwide studies related to burnout in residents and propose potential suggestions.

METHODS

The following paper summarizes studies pertinent to burnout in residents from different countries categorized into three main regions: North and South America, Europe, and Middle East. The studies were collected from February 2018 to March 2019.

RESULTS

Numerous studies across the world have revealed high rates of burnout in residents during the last decades.

CONCLUSIONS

Various awareness and wellness programs, as well as professional counseling sessions, are proposed to help residents overcome burnout.

Why do trainees leave hospital-based specialty training? A nationwide survey study investigating factors involved in attrition and subsequent career choices in the Netherlands

OBJECTIVE

To gain insight into factors involved in attrition from hospital-based medical specialty training and future career plans of trainees who prematurely left their specialty training programme.

DESIGN

Nationwide online survey study.

SETTING

Postgraduate education of all hospital-based specialties in the Netherlands.

PARTICIPANTS

174 trainees who prematurely left hospital-based medical specialty training between January 2014 and September 2017.

MAIN OUTCOME MEASURES

Factors involved in trainees' decisions to leave specialty training and their subsequent career plans.

RESULTS

The response rate was 38%. Of the responders, 25% left their programme in the first training year, 50% in year 2-3 and 25% in year 4-6. The most frequently reported factors involved in attrition were: work-life balance, job content, workload and specialty culture. Of the leaving trainees, 66% switched to another specialty training programme, of whom two-thirds chose a non-hospital-based training programme. Twelve per cent continued their career in a non-clinical role and the remainder had no specific plans yet.

CONCLUSIONS

This study provides insight in factors involved in attrition and in future career paths. Based on our findings, possible interventions to reduce attrition are: (1) enable candidates to develop a realistic view on job characteristics and demands, prior to application; (2) provide individual guidance during specialty training, with emphasis on work-life balance and fit with specialty.

Job Crafting to Persist in Surgical Training: A Qualitative Study From the Resident's Perspective

BACKGROUND

Attrition in surgical training, a result of poor well-being at work, continues to rise. Work engagement and persistence, the other side of the coin, depend on the proactivity of residents to optimize the demands and resources in the workplace to achieve a better fit with the environment. This type of proactivity refers to job-crafting. In this study, we sought to explore the specific mechanisms underlying residents' job-crafting to enhance work engagement and persistence, as well as the role of supervisors in this endeavor.

MATERIALS AND METHODS

We used a constructivist-grounded theory design. We conducted semistructured interviews of active residents. During the analysis of verbatim protocols, we developed codes and categories and identified the main themes (job-crafting mechanisms) related to work engagement and persistence. We anticipated procedures to engage in reflexivity.

RESULTS

The residents showed six job-crafting mechanisms (build trust with supervisors, manage proactively, seek help, see errors and frustrations as learning opportunities, find a suitable work-life balance, and seek challenges actively). The supervisors contributed to residents' job-crafting with four mechanisms (earning the trust of the residents, providing guidance and support, allowing residents to fulfill tasks befitting a surgeon in training, and offering increasingly challenging tasks to residents).

CONCLUSIONS

Work engagement and persistence in training are active processes that depend on the ability of residents to take advantage of resources and challenges and to diminish hindering demands at the workplace. Future research should focus on the perspectives of the supervisor, as well as on the effectiveness of job-crafting interventions, to enhance work engagement.

A Critical Appraisal of Emergency Medicine Specialty Training and Resignation among Residents in Emergency Medicine in Turkey

Background and Aim

The nonsatisfaction among emergency medicine specialty trainees is an underrated issue in Turkey. Several previous studies have evaluated the burn-out and its consequences among physicians, but there is no study conducted with specialty trainees. The aim of this study is to evaluate the reasons for resignation among emergency medicine specialty residents in Turkey.

Method

A total of 41 participants, who resigned from emergency medicine residency, were contacted by phone and invited to complete an online survey that included 25 questions about personal characteristics and departmental information.

Results

Most frequent reasons of resignation were violence/security concerns (63.4%), busy work environment (53.7%), and mobbing (26.8%). Participants who reported that they have resigned due to inadequate training were mostly over 30 years old (p=0.02), continued more than 6 months to EMST (p<0.001), reported that there was no regular rotation program (p=0.003) or access to full-text scientific journals (p=0.045) in their department. All participants thought that there were deficits in the training programs, and none of them declared regret for resigning. Twenty-eight participants (68.2%) continued their specialty training at a different discipline after resignation.

Conclusion

Major barriers against a high-quality and sustainable emergency medicine residency are violence in emergency services, mobbing in academic or administrative bodies, and inaccessibility to scientific resources. These obstacles can only be removed by cooperation of multiple institutions in Turkey.

Observational study evaluating obstetric anesthesiologist residents' well-being, anxiety and stress in a North American academic program

BACKGROUND

The obstetric work environment has a unique set of stressors that may be associated with burnout. We investigated how well-being during the obstetric anesthesia (ObA) rotation compared to other rotations; which workplace environment characteristics precipitated the greatest stress; and whether anxiety and stress levels changed in trainees before and after an ObA rotation.

METHODS

Using a survey, anesthesia residents (n=36) ranked their well-being on each anesthesia rotation and answered questions about their work environment. A separate survey measured anxiety and stress before and after an ObA rotation. Friedman's test was used to compare ranking data and Likert responses. T-tests were used to compare stress and anxiety scores.

RESULTS

Residents' ranking of well-being on ObA was higher than that on another high demand rotation (cardiothoracic anesthesia, P=0.007). Work environment stress scores were significantly higher among community and fairness domains than for workload (P=0.002 and P=0.0001, respectively). While stress and anxiety scores did not significantly differ before and after the ObA rotation, they were higher than the reference population scores.

CONCLUSIONS

We provide the first example of tools for assessing work environment stressors in ObA. Our study illustrates that beyond excessive workload, lack of fairness and community values are areas that impact physician well-being. Use of these tools can guide initiatives to address work environment concerns, and presents a need for a validated well-being instrument to gauge physician well-being, in order to create a cultural shift from burnout to one of well-being.

The non-monetary costs of surgical training

Could addressing these issues improve patient outcomes?