How to Develop Good Strategies to Minimize Attrition in a Diverse Resident Workforce

In his presidential address to the Association of VA Surgeons, Walter Longo reported that up to 40 percent of college freshman never earn their degree, 50 percent of graduate students fail to complete their doctorate degree, and three percent of law students (versus one percent of medical students) never graduate. Approximately 33 percent of military enlistees fail to complete their enlistment terms.¹ These examples show that attrition is common and not unique to surgery. Since close to 20 percent of an incoming surgical class will fail to complete training, the average program director will need to replace one categorical resident every year.² The loss of a resident prior to completion of training is often unexpected, and therefore, problematic for the program director in terms of scheduling and recruitment. In addition, the withdrawal of a resident is demoralizing for the remaining trainees, and there is an academic and financial cost to the individual who has to seek an alternative training path.

Most of us would have predicted that the 2003 Accreditation Council for Graduate Medical Education (ACGME) work hour restrictions would have provided residents with improved life balance and career satisfaction. However, the percentage of programs reporting loss of multiple residents increased from 29 percent to 44 percent after the 80-hour workweek was implemented.³ Before 2003, the most common reason cited for voluntarily leaving a program was personal and family issues, whereas after 2003, work-hour and lifestyle considerations predominated.^3-5 We are all well aware that the current generation of residents is less likely to compromise their personal lifestyle for the sake of their careers. The vulnerability of junior level residents continues, with nearly 70 percent of all reported attrition occurring during the first two years of training.^{1, 3, 6} Of some concern is the finding that, although not statistically significant, there was a suggestion of increased attrition among senior-level residents.

Surveys of medical students demonstrate that students have a more favorable impression of a surgeon's lifestyle and work hours after implementation of the 80-hour workweek.^{7, 8} Perhaps this implementation has been translated into an unrealistic expectation of the rigors of surgical residency. Another possible explanation for the post-2003 increase in attrition is deterioration in job satisfaction. With fewer residents on call at any one time, residents have an increased clinical load and are now subject to the increased documentation and regimentation associated with the duty hour restrictions. These duty hour regulations provide additional stress and adversely impact the professional identity of surgical trainees, who now struggle to make choices between complying with duty hour regulations and providing continuity of care.⁹

Many of the risk factors for failure to complete surgical training are predictable and include poor academic performance, personality mismatch, prior history of personal difficulties, and uncertainty about career goals. All of these factors highlight a need for careful career counseling in medical school and in particular ensuring that medical students are exposed to the realities of surgical residency during the clerkship. The resident who has made a bad career choice should be supported in his or her decision to find alternate training and not coerced into continuing in surgery as a "warm body" on the call schedule. Termination can be positive when a disruptive resident leaves or an unhappy resident finds contentment in another specialty. Postponing a termination or finishing a marginal resident has drawbacks and may negatively impact resident morale.¹

The most effective way to minimize attrition from surgical training will be to focus on developing strategies to deal with the unexpected reasons talented residents decide not to complete training. These reasons include a change in personal health or family demands and dissatisfaction with the current program. Many of the strategies are intuitive and involve creating a supportive environment where diversity and flexibility are supported and encouraged.

Resident demographics have changed over the past decade with the percentage of women in surgical training increasing from 21 percent in 1998 to 32 percent in 2008.¹⁰ In studies that have examined the issue of gender, attrition was equal or just slightly higher for women than men.^{11, 12} In a single institution study, Bergen et al. found that while the most common reason for men to leave was to change specialty, women (and some men) left most commonly for reasons related to the family.¹¹

Much has been written about why men and women are attracted to surgery. Men and women at all levels of surgical training are attracted to a surgical career because it is a hands-on specialty, it is challenging, and the results are immediate.¹³ Both men and women disfavor surgery because of issues surrounding residency lifestyle, practice lifestyle, and length of training.¹⁴ From 1996 to 2003, the percentage of women and men choosing controllable lifestyle specialties increased from 18 percent to 36 percent and from 28 percent to 45 percent, respectively.¹⁵ An earlier study showed that men were actually more likely than women to choose a controllable lifestyle specialty.¹⁶

In one survey of medical students, male and female students both responded that they would be more interested in a surgical field if surgical programs strictly adhered to the 80-hour workweek.¹⁷ In addition, students of both genders agreed that if surgical programs combined residency and fellowship programs into a shorter, joint training program, they would be more interested in surgery.¹⁷ Women more often than men would be more interested in surgery if part-time residency training were an option.^{17, 18} The recent change by the American Board of Surgery to allow surgical training to be extended from five to six years is a positive move. The new policy gives residency programs the option of permitting the five years of general surgery training to be completed over a six-year period and is intended to provide programs with greater flexibility in allowing residents time away from training to pursue other activities or address medical or family issues.¹⁹ It will be interesting to see how many residents choose to avail themselves of this opportunity.

In a series of interviews with female and male surgeons, Ahmadiyeh et al. noted that although both women and men describe with equal frequency having made career tradeoffs for personal and family time (and vice versa), women more frequently than men cite personal time, predictable time, and family relationships as contributing to their career satisfaction.²⁰ When describing strategies used in developing a successful surgical career, women most frequently cite social networks as a key to success (88 percent versus 12 percent), and men more frequently cite reasons related to training (29 percent versus zero percent) and compensation (24 percent versus zero percent).²⁰ A few formal studies have documented the effectiveness of social supports in career satisfaction and success of women and minorities.²¹ Therefore, formally implementing such social support and networks into our training programs would be a worthwhile endeavor. Clearly it is essential to welcome all new residents at a programmatic level, and this should continue beyond the first week of orientation. A number of opportunities are available at low cost to assimilate residents into the surgical family at a national level. These opportunities include offering residents membership in the American College of Surgeons Resident and Associate section²² and membership in the Association of Women Surgeons.²³

The factors that have a selectively adverse impact on women's choice of a surgical career include the perception of surgery as "an old boy's club" and pregnancy and child care concerns.^24-28 Predictably, women intentionally delay having children more often than men until the completion of all surgical training.^29-30 The reasons for this postponement include concerns about childbearing during a stressful surgical residency and maternity leave limitations. In one recent study, Jones and colleagues examined birth rates and changes in parental status of orthopaedic residents before and after work hour restrictions. They found a 40 percent increase in the number of births per year of training and a 60 percent increase in parental status post 2003.³¹ They suggested that this was because residents and their partners believed they would have more time to raise a family together during residency. As more residents (male and female) start their families while in training, the need for affordable child care and flexibility in time off becomes imperative. This is not just a female issue. In one study, 50 percent of men (and 84 percent of women) would be more interested in surgery if maternity or paternity leave were more accepted or supported during residency.¹⁷ Seventy-five percent of women agreed that having child care available on site at one's hospital of employment, either as a resident or attending physician, would increase their interest in surgery, as compared with 46 percent of men.¹⁷ One of the many benefits to having more women in surgical training is that making a program more family friendly to accommodate women residents has also been an advantage to men with the same priorities. Paternity leave became more acceptable for male residents following the introduction of maternity leave for female residents, for instance.

Much has been written in recent years about the generational differences between Baby Boomers (born 1945–1962) and Generation X (born 1963–1981).³² Baby Boomers work hard out of loyalty, expect a long-term job, believe in self-sacrifice, and respect authority. Generation Xers work hard if balance is allowed, expect many job searches, and self-sacrifice is on their terms. They are less likely to put their jobs ahead of friends, family, or outside interests. Although they are committed to their work, they are less willing to sacrifice family time for work than their parents were, and therefore, are occasionally perceived as self-centered. These differences can result in challenges for effective contemporary mentorship across the two generations. Today, an effective mentor must be able to provide guidance in balancing training, commitment, personal growth, wellness, and family. Some helpful approaches include the following:

• Recognize that expecting life balance does not translate into poor work ethic.
• Listen to their side of the story instead of simply telling residents this is the way it is.
• Refrain from talking about the good old days.
• Set clear expectations with regard to outcomes but let residents devise the strategy.
• Aim for immediate gratification by building in short-term rewards.
• Provide frequent feedback.
• Emphasize and model life balance.

In his presidential address, Longo emphasized the need for residents to become assimilated into the surgical family by embracing diversity.¹ This philosophy involves including people who are different from us in informal gatherings and creating a team spirit in which every member feels a part. Many believe that the more social programs that are in place, the lower the attrition. Longo emphasized the importance of identifying a refuge where those of diversity are welcomed.¹

While a detailed discussion of team training is outside the scope of this article, a couple of points need to be highlighted. Phase three of the American College of Surgeons and the Association of Program Directors in Surgery Surgical Skills Curriculum for residents contains a number of team training modules.³³ To work effectively together team members must possess a shared understanding of their own and teammates' responsibilities and abilities and exhibit a shared belief that team members will protect and support the interests of their team. Team leaders should promote an atmosphere of mutual trust in which team members are encouraged to clarify key information or question apparent errors using the three-step closed loop approach, whereby an instruction is articulated, acknowledged, and confirmed as understood. Unfortunately the culture of surgery impedes "speaking up" or volunteering uncertainty. The demands of a busy clinical service can create a sense that calls for help are unwelcome and inexperienced supervisors may not recognize when such calls have been made. The tradition of praising trainees if they can handle a heavy workload with relatively little supervision further increases the possibility that they will not call for help even when they recognize the need to do so. Mutual trust involves developing an atmosphere in which all can ask for help without being viewed as weak. Therefore, team members are willing to admit to mistakes and assert their concerns even to a higher-ranking team member without fear of reprisal.^{34, 35}

Involvement in an emotionally and physically challenging profession is stressful and can lead to changes in behavior commonly known as burnout.³⁶ These changes may manifest as negative work attitudes, unprofessional behavior, and a lack of empathy for the patient. Recognizing that 50 percent of physicians will experience burnout at sometime, the ACGME has mandated that all program directors should monitor residents for signs of stress and fatigue. In a recent paper, Brandt made a number of practical recommendations for stress recognition and prevention.³⁶ Strategies for prevention include promoting regular exercise, developing an interest outside medicine, managing a sleep deficit, and ensuring that all residents have a support system in place.

The attrition rate of surgery residents appears to have increased since the ACGME-mandated work-hour restrictions were implemented. While the reasons are multifactorial, most residents resign because they underestimate the stress associated with surgical work and/or the impact on their personal lives. Programs need to allow flexibility for nonprofessional life events so residents can deal with outside demands and allow balance in their lives. Many of these actions are within the purview of the program director, but others will require a change in the program requirements currently mandated by the ACGME Surgery Residency Review Committee. All members of the teaching faculty should be familiar with early signs of stress and report it appropriately. Finally, providing residents with better information and greater exposure before they choose their specialty during medical school could conceivably reduce attrition and allow more students to make informed choices when they graduate.

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