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JAMA Surg. 2017 Aug 16. doi: 10.1001/jamasurg.2017.2656. [Epub ahead of print]

Association of General Surgery Resident Remediation and Program Director Attitudes With Resident Attrition.

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Department of Surgery, Harbor-UCLA (University of California, Los Angeles) Medical Center, Torrance.
Los Angeles BioMedical Research Institute, Torrance, California.
Department of Surgery, University of California-Davis, Sacramento.
Department of Surgery, Loma Linda University, Loma Linda, California.
Department of Surgery, University of Southern California, Los Angeles.
Department of Surgery, Central Iowa Health System, Iowa Methodist Medical Center, Des Moines.
Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
Department of Surgery, University of Nebraska Medical Center, Omaha.
Department of Surgery, Columbia University, New York, New York.
Department of Surgery, York Hospital, York, Pennsylvania.
Department of Surgery, University of Texas Health Science Center at San Antonio.
Department of Surgery, UCLA, Los Angeles, California.
Department of Surgery, Santa Barbara Cottage Hospital, Santa Barbara, California.
Department of Surgery, Mount Carmel Health System, Columbus, Ohio.
Department of Surgery, University of California, San Diego, San Diego.
Department of Surgery, Gundersen Lutheran Medical Foundation, La Crosse, Wisconsin.
Department of Surgery, Stanford University, Palo Alto, California.
Department of Surgery, Southern Illinois University School of Medicine, Springfield.
Department of Surgery, University of Pennsylvania, Philadelphia.
Department of Surgery, University of Colorado, Denver, Aurora.
Department of Surgery, University of California, Irvine, Irvine.
Department of Surgery, University of San Francisco at Fresno, Fresno, California.
Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California.



Previous studies of resident attrition have variably included preliminary residents and likely overestimated categorical resident attrition. Whether program director attitudes affect attrition has been unclear.


To determine whether program director attitudes are associated with resident attrition and to measure the categorical resident attrition rate.

Design, Setting, and Participants:

This multicenter study surveyed 21 US program directors in general surgery about their opinions regarding resident education and attrition. Data on total resident complement, demographic information, and annual attrition were collected from the program directors for the study period of July 1, 2010, to June 30, 2015. The general surgery programs were chosen on the basis of their geographic location, previous collaboration with some coauthors, prior work in surgical education and research, or a program director willing to participate. Only categorical surgical residents were included in the study; thus, program directors were specifically instructed to exclude any preliminary residents in their responses.

Main Outcomes and Measures:

Five-year attrition rates (2010-2011 to 2014-2015 academic years) as well as first-time pass rates on the General Surgery Qualifying Examination and General Surgery Certifying Examination of the American Board of Surgery (ABS) were collected. High- and low-attrition programs were compared.


The 21 programs represented different geographic locations and 12 university-based, 3 university-affiliated, and 6 independent program types. Programs had a median (interquartile range [IQR]) number of 30 (20-48) categorical residents, and few of those residents were women (median [IQR], 12 [5-17]). Overall, 85 of 966 residents (8.8%) left training during the study period: 15 (17.6%) left after postgraduate year 1, 34 (40.0%) after postgraduate year 2, and 36 (42.4%) after postgraduate year 3 or later. Forty-four residents (51.8%) left general surgery for another surgical discipline, 21 (24.7%) transferred to a different surgery program, and 18 (21.2%) exited graduate medical education altogether. Each program had an annual attrition rate ranging from 0.73% to 6.0% (median [IQR], 2.5% [1.5%-3.4%]). Low-attrition programs were more likely than high-attrition programs to use resident remediation (21.0% vs 6.8%; P < .001). Median (IQR) Qualifying Examination pass rates (93% [90%-98%] vs 92% [86%-100%]; P = .92) and Certifying Examination pass rates (83% [68%-84%] vs 81% [71%-86%]; P = .47) were similar. Program directors at high-attrition programs were more likely than their counterparts at low-attrition programs to agree with this statement: "I feel that it is my responsibility as a program director to redirect residents who should not be surgeons."

Conclusions and Relevance:

The overall 5-year attrition rate of 8.8% was significantly lower than previously reported. Program directors at low-attrition programs were more likely to use resident remediation. Variations in attrition may be explained by program director attitudes, although larger studies are needed to further define program factors affecting attrition.

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