By Alexandria Bachert

Attrition rates in general surgery programs remain high, with many would-be surgeons switching to another program or specialty, according to one meta-analysis.

Reviewing 22 studies on residents from general surgery programs, the authors concluded that overall attrition prevalence among residents was 18% (95% CI 14%-21%), reported Mohammed Al-Omran, MD, MSc, of St. Michael's Hospital in Toronto, and colleagues.

According to Al-Omran and colleagues, the results show that "attrition prevalence is relatively high among general surgery residents and future research should focus on developing strategies to limit resident attrition."

The researchers also found that quit rates were significantly higher among women than men (25% versus 15%, P=0.008). They noted several potential reasons for this difference, including a lack of appropriate role models for female residents, perception of sex discrimination, negative attitudes toward women in surgery, and sexual harassment.

Heather Yeo, MD, MHS, of the Weill Cornell Medicine Department of Surgery in New York City, who was not involved in the research, commented that "overall it is a pretty good study [but] they probably slightly underestimated the risk of attrition."

"Our original 2010 national prospective paper cited a cumulative risk of about 19%, and the range in the literature has been around 18%-33%," said Yeo, whose paper was included in the analysis.

The researchers examined the Medline, EMBASE, Cochrane, PsycINFO, and ERIC databases for studies regarding surgical residents from 1946 to 2015.

Eligibility criteria for the review and analysis included reports from peer-reviewed journals on attrition prevalence or causes, characteristics, and destinations of residents who leave residency programs. The researchers identified 22 reviewable studies on general surgery residency programs, all but two from the U.S., covering a total of 19,821 residents. Significant variation between studies was noted (I2=96.8%, P<0.001).

The most common cause of attrition from general surgery residency cited in the included studies was uncontrollable lifestyle, followed by preference for another specialty.

Of the residents who departed from their residency program, one-fifth relocated to another general surgery program (20%, 95% CI 15%-24%). Another 13% switched to anesthesia (95% CI 11%-16%). "Plastic surgery, radiology, and family medicine were other common specialties that attracted general surgery residents," the researchers indicated.

About half left the program after their first postgraduate year, and 30% left after the second.

Michael E. Shapiro, MD, surgical program director at Rutgers New Jersey Medical School in Newark, believes that the issue of attrition, specifically the distinction between voluntary and involuntary attrition, is more complicated than the paper presents.

"There are likely many residents who left voluntarily because they were told the alternative was having their contract non-renewed. Some might have gone into anesthesia or other specialties because they could see the handwriting on the wall."

"Being a surgeon is hard work, and no one should be a surgeon who doesn't really want to, nor should anyone be a surgeon who isn't really good at it."

Yeo also shared theories on why attrition remains a problem for programs around the country.

"There are multiple reasons for attrition and many of those are unique to individuals. Voluntary attrition is obviously the most concerning. Finding those at risk and being able to support them as they train is important."

Understanding the experiences and expectations of residents before and during training is paramount, she explained.

Although the findings support previous trends for surgical residency attrition rates, Al-Omran and colleagues noted several limitations, including the retrospective nature of nearly all of the studies, as well as the heterogeneity among studies.

They also wrote that there was a wide range in duration of follow-up among studies, and that most of the studies did not adequately control for confounding factors -- including age, sex, medical school attended, and program type.

In an editorial published with the meta-analysis, Julie A. Freischlag, MD, and Michelle M. Silva, both of the University of California Davis, suggested mentorship as a critical retention tool during and after residency, as well as a way to help people cultivate their valuable potential.

"If we've done the right job in recruiting the best candidates for surgical training, it is our duty to be that guiding force for residents to help them see their potential and to encourage them to stay on the path toward a surgical career," they wrote.

"Surgical residency is notoriously arduous and the longer hours compared with other specialties can take a toll on some residents. That's why it's important for mentors to keep a watchful eye on resident mentees. Those who are thinking about leaving may be too overwhelmed to see how their talents have great value."

Shapiro, too, emphasized the benefits of mentorship and support: "Surgical residencies, and GME in general, are working on resident 'wellness' programs, providing opportunities for team building, counselling, mentorship, etc., in order to decrease those leaving."

"We are also teaching residents techniques to deal with fatigue and stress, and providing crisis intervention where indicated," he said of his own department's practices.