From the Journals

Remediation for surgical trainees may lower attrition


Key clinical point: Low-attrition programs more likely to be those with remediation, such as mentoring or educational support.

Major finding: Of the 21 programs surveyed, there was an average attrition rate of 8.8% over 5 years.

Data source: Survey of 21 general surgery residency program directors between July 2010 and June 2015.

Disclosures: Investigators report no relevant financial disclosures.



Remediation programs and program director attitudes can make the difference in attrition rates among general surgery residents, according to a survey-based study.

A study by the Association of American Medical Colleges, projects a shortage of 29,000 general surgeons by 2030. Some residency programs are taking steps lower program dropout rates, which has been reported as high as 26% in some programs, according to Alexander Schwed, MD, general surgeon at Harbor–University of California, Los Angeles Medical Center.

Dr. Sharmila Dissanaike

Dr. Sharmila Dissanaike

One approach to addressing the problem of attrition is remediation, where trainees are evaluated to identify areas in which they may be struggling, then offered help through additional formal or informal training sessions.

Dr. Schwed and his colleagues conducted a survey of 21 general surgery residency program directors. In those programs, the overall attrition rate was found to be much lower than expected – 8.8% over a 5-year period (JAMA Surg. 2017 Aug 16. doi: 10.1001/jamasurg.2017.2656).

The survey showed that programs that implemented resident remediation had lower attrition rates, (21.0% vs 6.8%; P less than .001).

“The association between increased use of remediation by residency programs and low rates of resident attrition is novel,” the investigators wrote. “Nevertheless, based on our findings, high-attrition programs could lower their attrition rates through the increased use of resident remediation and increased focus on resident education.”

Both high- and low-attrition programs selected to participate in the study showed relatively similar median numbers of residents, with low-attrition programs reporting a median of 28 participants per year, and high-attrition programs reporting with 35.

Other similarities between low- and high-attrition programs include percentage of female and minority residents, median of 33.3% and 39.8% respectively, and the number of cases performed by first-, second-, and third-year residents.

The other difference between the six low-attrition programs and the five high-attrition programs was the attitude of the program directors regarding their role in the training of residents, according to researchers.

Investigators asked directors a series of questions using a Likert scale with 1 representing “strongly disagree” and 4 representing “strongly agree.”

Program directors from high- and low-attrition programs tended to agree strongly (scoring 3.8 and 3.2, respectively) with the statement that one of their main roles as a program leader was to “redirect residents who should not be surgeons.”

When asked whether “some degree of resident attrition is a necessary phenomenon,” directors from low-attrition programs scored 2.2, while those from high-attrition programs indicated stronger agreement with an overall score of 3.2.

Directors from programs with high dropout rates were also more likely to consider a 6% dropout rate to be too low, compared with directors from low-attrition programs who thought it was too high.

“When we recruit residents, we are very careful to recruit those who seem to buy into our mission, our vision, and our ideals and fit in well with our culture,” said Sharmila Dissanaike, MD, FACS, department of surgery chair at Texas Tech University Health Sciences Center, Lubbock, in an interview. “We emphasize teamwork, collegiality, and an ‘all for one and one for all’ type of mentality.”

This kind of recruitment includes having current residents be a part of the process, Dr. Dissanaike explained, and encouraging current and potential residents to have an informal dinner to get to know one another better.

For the department of surgery at Texas Tech, the collaborative culture combined with a remediation program has resulted in a drop in attrition from 20% down to 7% in recent years, Dr. Dissanaike said. In addition, the current success of her program can be partly attributed to a recent decision to maintain the number of incoming residents at five, she said.*

Larger programs can achieve similar improvement, she noted and the rising demand for surgeons makes it essential to find a solution that incorporates the benefits of both types of programs.

“We need more surgeons, we need more Graduate Medical Education spots, we need more training spots for general surgeons,” said Dr. Dissanaike. “I think within those large programs we need to find ways to structure smaller groups, maybe little pods, to help support residents so they don’t get lost.”

Dr. Schwed and his colleagues expressed concern that institutional barriers, such as the focus on test scores, may impede directors from embracing remediation.

“Greater emphasis on the written and oral General Surgery Qualifying Examination pass rates, which are now publicly posted and used by residency review committees, will likely exert pressure on program directors, who may fear that attempting to remediate a resident with poor medical knowledge may affect their program’s 5-year board pass rates,” the investigators wrote. “Our study suggests that such fears may be unfounded because programs with high levels of remediation and low attrition had similar board pass rates as those with high attrition.”

Dr. Schwed and his coinvestigators acknowledged that the programs studied may not be representative of U.S. residencies and selection bias may have affected the findings.

Researchers reported no relevant financial disclosures.

*Correction, 10/26/17: An earlier version of this article misstated the number of incoming residents in the program.

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