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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., Competing Interests: Declaration of competing interest Dr. Yeo’s spouse receives salary from Bioscrip, Inc. a home infusion company. Dr. Sosa is a member of the Data Monitoring Committee of the Medullary Thyroid Cancer Consortium Registry supported by Novo Nordisk, GlaxoSmithKline, Astra Zeneca, and Eli Lilly. Drs. Dolan and Symer receive support from an NIH AHRQ T-32HS000066 grant. The authors have no other potential conflicts to disclose., (Copyright © 2020. Published by Elsevier Inc.)

On March 1, 2020, the first case of coronavirus disease 2019 (COVID-19) was confirmed in New York, New York. Since then, the city has emerged as an epicenter for the ongoing pandemic in the US. To meet the anticipated demand caused by the predicted surge of patients with COVID-19, the Department of Surgery at NewYork-Presbyterian Hospital/Weill Cornell Medicine developed and executed an emergent restructuring of general surgery resident teams and educational infrastructure. The restructuring of surgical services described in this Special Communication details the methodology used to safely deploy the necessary amount of the resident workforce to support pandemic efforts while maintaining staffing for emergency surgical care, limiting unnecessary exposure of residents to infection risk, effectively placing residents in critical care units, and maintaining surgical education and board eligibility for the training program as a whole.

Background: Medical school experience informs the decision to pursue graduate surgical education. However, it is possible that inadequate preparation in medical school is responsible for the high rate of attrition seen in general surgery residency., Materials and Methods: We performed a national prospective cohort study of all categorical general surgery interns who entered training in the 2007-2008 academic year. Interns answered questions about their medical school experience and reasons for pursuing general surgery residency. Responses were linked with American Board of Surgery residency completion data. Multivariable logistic regression was used to evaluate the association between medical school experiences and residency attrition., Results: Seven hundred and ninety-two surgery interns participated, and the overall attrition rate was 19.3%. Most interns had performed ≤8 wk of third year surgery clerkships (53.2% of those who completed versus 49.7% of those who dropped out, P = 0.08). After multivariable adjustment, shorter duration of third year rotations was protective from attrition (OR: 0.53, 95% CI: 0.29-0.99; P = 0.05). There was no difference in attrition based on whether a surgical subinternship was performed (OR: 0.67, 95% CI: 0.38-1.19; P = 0.18). Residents who perceived that their medical school surgical faculty were happy with their careers were less likely to experience attrition (OR: 0.57, 95% CI: 0.34-0.96; P = 0.03), but those who had gotten along well with attending surgeons had higher odds of attrition (OR: 2.93, 95% CI: 1.34-6.39, P < 0.01)., Conclusions: Increased quality, rather than quantity, of clerkships is associated with improved rates of residency completion. Learner relationships with positive yet demanding role models were associated with a reduced risk of attrition., (Copyright © 2018. Published by Elsevier Inc.)

Importance: Attrition from general surgery training is highest during internship. Whether the expectations and attitudes of new trainees affect their subsequent risk of attrition is unknown., Objective: To identify the expectations of general surgery residency associated with attrition from training., Design, Setting, and Participants: This prospective observational cohort study included categorical general surgery interns entering training in the 2007-2008 academic year. Residents were surveyed regarding their expectations of training and of life as an attending at the start of their intern year (June 1 to August 31, 2007). Expectations were grouped into factors by principal component analysis, and a multivariable model was created using these factors in addition to known demographic and program characteristics associated with attrition. Follow-up was completed on December 31, 2016., Main Outcomes and Measures: Attrition from training was determined by linkage to American Board of Surgery resident files through 2016, allowing 8 additional years of follow-up., Results: Of 1048 categorical surgery interns in the study period, 870 took the survey (83.0% response rate), and 828 had complete information available for analysis (524 men [63.3%], 303 women [36.6%], and 1 missing information [0.1%]). Most were white (569 [69.1%]) and at academic programs (500 [60.4%]). Six hundred sixty-six residents (80.4%) completed training. Principal component analysis generated 6 factors. On adjusted analysis, 2 factors were associated with attrition. Interns who choose their residency based on program reputation (factor 2) were more likely to drop out (odds ratio, 1.08; 95% CI, 1.01-1.15). Interns who expected as an attending to work more than 80 hours per week, to have a stressful life, and to be the subject of malpractice litigation (career life expectation [factor 6]) were less likely to drop out (odds ratio, 0.90; 95% CI, 0.82-0.98)., Conclusions and Relevance: Interns with realistic expectations of the demands of residency and life as an attending may be more likely to complete training. Medical students and residents entering training should be given clear guidance in what to expect as a surgery resident.

Background: The American Board of Surgery In-Training Exam is administered annually to general surgery residents and could provide a way to predict attrition, potentially offering a point of intervention., Methods: In 2007, a national survey of categorical general surgery interns was performed. Resident characteristics were linked to an American Board of Surgery database of American Board of Surgery In-Training Exam scores. Attrition was determined based on completion of training during eight years of follow-up. To identify residents at risk of attrition, American Board of Surgery In-Training Exam scores were analyzed based on average rank and change in American Board of Surgery In-Training Exam score., Results: Of 1,048 residents, 739 (70.5%) participated and 108 (14.6%) did not complete training. Average American Board of Surgery In-Training Exam rank was higher for participants who completed training than those who did not (51.8 vs. 42.7 percentile respectively, P < .001). Ranking below the 25th percentile was less common among those who dropped out (41.7% ranked below 25th percentile and dropped out versus 51.5% ranked below 25th percentile and completed, P = .06), but those whose rank dropped >16.5 percentile points were more likely to leave training (attrition rate 13.0% with a drop versus 6.0% without a drop, P = .003). In adjusted analysis, a one percentile increase in American Board of Surgery In-Training Exam rank was associated with decreased odds of attrition (OR 0.98, P < .01)., Conclusion: Lower American Board of Surgery In-Training Exam scores are associated with attrition, but this difference is small, and some residents complete training with very low scores. A large drop in American Board of Surgery In-Training Exam scores from one year to the next appears to be associated with attrition. Program directors should focus their efforts on these at-risk residents., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Importance: Attrition in general surgery residency remains high, and attrition that occurs in the later years is the most worrisome. Although several studies have retrospectively investigated the timing of attrition, no study to date has prospectively evaluated a national cohort of residents to understand which residents are at risk for attrition and at what point during residency., Objective: To prospectively evaluate individual resident and programmatic factors associated with the timing of attrition during general surgery residency., Design, Setting, and Participants: This longitudinal, national cohort study administered a survey to all categorical general surgery interns from the class of 2007-2008 during their first 30 days of residency and linked the data with 9-year follow-up data assessing program completion. Data were collected from June 1, 2007, through June 30, 2016., Main Outcomes and Measures: Kaplan-Meier curves evaluating time to attrition during the 9 years after the start of residency., Results: Among our sample of 836 residents (306 women [36.6%] and 528 men [63.2%]; gender unknown in 2), cumulative survival analysis demonstrated overall attrition for the cohort of 20.8% (n = 164). Attrition was highest in the first postgraduate year (67.6% [n = 111]; absolute rate, 13.3%) but continued during the next 6 years, albeit at a lower rate. Beginning in the first year, survival analysis demonstrated higher attrition among Hispanic compared with non-Hispanic residents (21.1% vs 12.4%; P = .04) and at military programs compared with academic or community programs after year 1 (32.3% vs 11.0% or 13.5%; P = .01). Beginning in year 4 of residency, higher attrition was encountered among women compared with men (23.3% vs 17.4%; P = .05); at year 5, at large compared with small programs (26.0% vs 18.4%; P = .04). Race and program location were not associated with attrition., Conclusions and Relevance: Although attrition was highest during the internship year, late attrition persists, particularly among women and among residents in large programs. These results provide a framework for timing of interventions in graduate surgical training that target residents most at risk for late attrition.

Background: There is limited understanding of the wide variation in attrition rates among general surgery residencies. We used the validated Behavior Inhibitory System/Behavior Approach System (BIS/BAS) instrument to compare motivational traits among residents who did and not complete surgical training., Study Design: All US general surgery categorical interns in the class of 2007-2008 were surveyed with a validated motivational trait assessment tool. American Board of Surgery records from 2008-2016 were used to determine who completed training. Motivation, an aspect of personality, was assessed with the BIS/BAS, which correlates with an individual's tendency to approach pleasant stimuli (BAS) or avoid negative stimuli (BIS). Subscale mean scores were compared with regard to the primary end point, attrition., Results: Eight hundred and one (76.5%) interns completed the survey and had matching records. Six hundred and forty-five (80.5%) completed training. Men had lower scores than women in the BAS Drive subscale (12.0 vs 12.5; p < 0.002), BAS Reward Response subscale (17.2 vs 17.7; p < 0.01), and BIS scale (19.3 vs 20.9; p < 0.01). The BAS Reward Response scores differed based on program type (academic 17.3 vs community 17.6 vs military 16.6; p < 0.0027). There were no differences based on program size (BIS average, small program 19.9 vs large program 19.7; p = 0.43). There were also no differences in BIS/BAS subscale scores based on residency completion status (BIS mean: completed 19.9 vs dropped out 20.1; p = 0.51)., Conclusions: Surgery residents are characterized by a strong drive and persistence toward their goals. However, residents who drop out do not differ from those who complete training in their motivational personality traits., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: We present 8-year follow-up data from the intern class of 2007 to 2008 using a novel, nonparametric predictive model to identify those residents who are at greatest risk of not completing their training., Background: Nearly 1 in every 4 categorical general surgery residents does not complete training. There has been no study at a national level to identify individual resident and programmatic factors that can be used to accurately anticipate which residents are most at risk of attrition out., Methods: A cross-sectional survey of categorical general surgery interns was conducted between June and August 2007. Intern data including demographics, attendance at US or Canadian medical school, proximity of family members, and presence of family members in medicine were de-identified and linked with American Board of Surgery data to determine residency completion and program characteristics. A Classification and Regression Tree analysis was performed to identify groups at greatest risk for non-completion., Results: Of 1048 interns, 870 completed the initial survey (response rate 83%), 836 of which had linkage data (96%). Also, 672 residents had evidence of completion of residency (noncompletion rate 20%). On Classification and Regression Tree analysis, sex was the independent factor most strongly associated with attrition. The lowest noncompletion rate for men was among interns at small community programs who were White, non-Hispanic, and married (6%). The lowest noncompletion rate for women was among interns training at smaller academic programs (11%)., Conclusions: This is the first longitudinal cohort study to identify factors at the start of training that put residents at risk for not completing training. Data from this study offer a method to identify interns at higher risk for attrition at the start of training, and next steps would be to create and test interventions in a directed fashion.

Background: Women represent half of medical school graduates in the United States. Our aim was to characterize the effects of marriage and childbirth on the experiences of surgery residents., Methods: This was a prospective, longitudinal study of categorical general surgery residents between 2008 and 2010. Outcomes included changes in faculty and peer relationships, work-life balance, financial security, and career goals over time., Results: We included 4,028 residents. Compared with men, women in postgraduate years (PGYs) 1 through 5 were less likely to be married (28.2% to 47.3% vs 49.6% to 67.6%) or have children (4.6% to 18.0% vs 19.0% to 45.8%) (P < .001). Women who married during PGY1 to PGY3 became worried about performing in front of senior residents (P = .005); men who married were more likely to be happy at work (P = .005). Women who had a first child during PGY1 to PGY3 were more likely to feel overwhelmed (P = .008) and worry about financial security (P = .03) than other women. Men who had a child were more likely to feel supported by faculty (P = .004), but they experienced more family strain (P = .008) compared to childless men., Conclusion: Marriage and childbirth are associated with divergent changes in career experiences for women and men. Women lag behind their male peers in these life events from start to finish of residency., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: To determine how race influences US general surgery residents' experiences during residency training., Background: Minorities are underrepresented in medicine, particularly surgery, with no large-scale studies investigating their training experiences., Methods: Cross-sectional national survey administered after the 2008 American Board of Surgery In-Training Examination to all categorical general surgery residents. Demographic characteristics and survey responses with respect to race were evaluated using the χ test and hierarchical logistic regression modeling., Results: A total of 4339 residents were included: 61.9% whites, 18.5% Asians, 8.5% Hispanics, 5.3% Blacks, and 5.8% Others. Minorities differed from whites in sex proportion, marital status, number of children, geographic location, type of residency program, and 24 survey items (all Ps < 0.05). Compared with white residents, Black, Asian, and Other residents were less likely to feel they fit in at their programs (86.2% vs 73.9%, 83.3%, and 81.2%, respectively; P < 0.001). Black and Asian residents were more likely to report that attendings would think worse of them if they asked for help (13.5% vs 20.4% and 18.4%, respectively; P = 0.002), and Black residents were less likely to feel they could count on their peers for help (85.2% vs 77.2%; P = 0.017). On hierarchical logistic regression modeling, Blacks were least likely to fit in at their programs (odds ratio = 0.6; P = 0.004), and all minorities were more likely to feel that there was a need for additional specialty training (odds ratio = 1.4 Blacks and Hispanics, 1.9 Asians, and 2.1 Others; all Ps ≤ 0.05)., Conclusions: Minority residents report less positively on program fit and relationships with faculty and peers. Future studies should focus on examining residency interventions to improve support and integration of minority residents.