High Remediation, Attrition Rates Among Surgery Residents

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Retaining Surgical Residents Requires Changes

The surgical residents in this study were intelligent high achievers and the mean USMLE step 1 score of the residents who were remediated was a "quite respectable 225," Dr. Karen Deveney said in an editorial.

"A substantial portion of our very bright residents who have a history of great success in everything they do may have difficulty keeping up with the fast pace and high workload demands," while some may opt for a less stressful career path, and others may need more help from faculty to meet expectations and will "persevere," she said. "It is incumbent on those of us in more senior positions to create educational systems that eliminate nonessential tasks so that residents can devote more attention during the compressed work hours to learning what they need to become competent surgeons," she wrote. "Only then can we have a better chance of training and retaining the best and the brightest" (Arch. Surg. 2012;147; 833).

Dr. Deveney is professor of surgery and vice chair of education and program director, department of surgery, Oregon Health and Science University, Portland. She had no financial disclosures to report.



Almost one-third of general surgery residents required remediation over an 11-year period, most often because of a deficiency in medical knowledge, judging from findings in a retrospective study of remediation and attrition rates among general surgery residents at six academic surgical residency programs in California.

The high remediation rate identified in this study "begs the question of whether we are falling short in the education of surgical residents," said Dr. Arezou Yaghoubian of the department of surgery, Harbor-UCLA Medical Center, Los Angeles, and associates. The study was published in the September issue of Archives of Surgery (2012;147:829-33).

They conducted the study to determine which of the six Accreditation Council for Graduate Medical Education (ACGME) competencies (patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and system-based practice), most often require remediation and to identify predictors of remediation. There is a scarcity of data on how well surgical residency programs have been achieving these competencies, and this information may provide insight into how to modify the surgical curriculum more effectively in this new era of limited hours, they said.

In the study of 348 general surgery residents at the six training programs between 1999 and 2010, the most common reason for remediation was medical knowledge in 74%, followed by interpersonal and communication skills in 24%, patient care in 22%, professionalism in 18%, system-based practice in 14%, and practice-based learning in 8%. Of the 107 residents who required remediation, 27 required remediation more than once. Almost 16% of the residents left their programs, but most (53 of 55 residents) left voluntarily. The other two failed remediation and had to leave the program.

Monthly meetings with faculty was the most common form of remediation, in 79%, followed by specific reading assignments (72%), required attendance at review courses and/or conferences (27%), evaluation by a therapist, psychologist, or psychiatrist (12%), and having to repeat a clinical year (6.5%).

More than half of the remediations were initiated during the first 2 postgraduate years (25% in the first and 35% in the second year), followed by 21% during the third year, 16% during the fourth year, and 4% during the fifth year.

A predictor of remediation was having received honors during the third-year surgery clerkship (58% of those who were subject to remediation vs. 45% of those who were not remediated, a statistically significant difference), which, the authors noted, was counterintuitive.

United States Medical Licensing Examination (USMLE) step 1 and/or step 2 scores and American Board of Surgery In-Training Examination (ABSITE) scores at postgraduate years 1 through 4 were also predictive of remediation. The median USMLE step 1 and step 2 scores were 225 and 223 among the residents subject to remediation, vs. 232 for step 1 and step 2 scores among those who were not remediated, statistically significant differences. The ABSITE scores during postgraduate years 1 through 4 were significantly lower among those who were subject to remediation, but the differences in median scores in years 5 through 7 were not significantly different.

But remediation was not a predictor of attrition. The only predictor of attrition was the ABSITE score at the third postgraduate year, which was a median of 34 among those who left the program and 62 among those who stayed.

Possible explanations for the high remediation rate is that residents are not well prepared for the demands of a surgical residency, they need to be more efficient with their time because of the 80-hour work week, and they may not necessarily be spending their increased time outside of the hospital studying at home, the authors said. Possible reasons for the attrition rate among the residents, an "ongoing concern" in general surgery, may be marital, family, and personal issues and a need for a less stressful environment, they added.

Acknowledging the study’s limitations, including the retrospective design and lack of information on how many residents passed the American Board of Surgery boards, the authors concluded that the high remediation rate "should give surgical educators pause as we should closely examine the potential sources of these deficiencies." They called on surgical societies to "take the initiative to encourage the restructuring of medical school education, such that future surgeons are better prepared to enter surgical residencies," and for residency programs to "determine whether current educational methods are adequate to prepare future surgeons."

The authors had no financial disclosures.

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