Impact of Medical School Experience on Attrition From General Surgery Residency
BACKGROUND:Medical school experience informs the decision to pursue graduate surgical education. However, it is possible that inadequate preparation in medical school is responsible for the high rate of attrition seen in general surgery residency. MATERIALS AND METHODS:We performed a national prospective cohort study of all categorical general surgery interns who entered training in the 2007-2008 academic year. Interns answered questions about their medical school experience and reasons for pursuing general surgery residency. Responses were linked with American Board of Surgery residency completion data. Multivariable logistic regression was used to evaluate the association between medical school experiences and residency attrition. RESULTS:Seven hundred and ninety-two surgery interns participated, and the overall attrition rate was 19.3%. Most interns had performed â‰¤8 wk of third year surgery clerkships (53.2% of those who completed versus 49.7% of those who dropped out, PÂ =Â 0.08). After multivariable adjustment, shorter duration of third year rotations was protective from attrition (OR: 0.53, 95% CI: 0.29-0.99; PÂ =Â 0.05). There was no difference in attrition based on whether a surgical subinternship was performed (OR: 0.67, 95% CI: 0.38-1.19; PÂ =Â 0.18). Residents who perceived that their medical school surgical faculty were happy with their careers were less likely to experience attrition (OR: 0.57, 95% CI: 0.34-0.96; PÂ =Â 0.03), but those who had gotten along well with attending surgeons had higher odds of attrition (OR: 2.93, 95% CI: 1.34-6.39, PÂ <Â 0.01). CONCLUSIONS:Increased quality, rather than quantity, of clerkships is associated with improved rates of residency completion. Learner relationships with positive yet demanding role models were associated with a reduced risk of attrition.
Racial and ethnic disparities in promotion and retention of academic surgeons
BACKGROUND:Racial/ethnic diversity remains poor in academic surgery. However, no study has quantified differences in the rates of retention and promotion of underrepresented minority (URM) academic surgeons. METHODS:The American Association of Medical Colleges Faculty Roster was used to track all first-time assistant and associate professors appointed between 1/1/2003 and 12/31/2006. Primary endpoints were percent promotion and retention at ten-year follow-up. RESULTS:Initially, the majority of assistant and associate professors of surgery were White (62%; 75%). Black assistant professors had lower 10-year promotion rates across all specialties (pâ€¯<â€¯0.01). There were no race/ethnicity-based differences in promotion for associate professors. Retention rates were higher for White assistant professors than Asian or Black/Hispanic/Other minority faculty (61.3% vs 52.8% vs. 50.8% respectively; pâ€¯<â€¯0.01). There was no difference in 10-year retention rates among associate professors based on race/ethnicity. CONCLUSIONS:Underrepresented minority surgeons are less likely to remain in academia and Black assistant professors have the lowest rates of promotion. These findings highlight the need to develop institutional programs to better support and develop minority faculty members in academic medicine.
Early operative management of complicated appendicitis is associated with improved surgical outcomes in adults
BACKGROUND:There is no consensus on the ideal management of complicated appendicitis. METHODS:The New York State Planning and Research Cooperative database was used to identify all patients admitted with complicated appendicitis and undergoing appendectomy within 1-year. Primary outcome was any complication. Secondary outcomes included length of stay (LOS), hospital charges, and laparoscopy use. Outcomes were compared in appendectomy before or after 48h from admission. RESULTS:31,167 patients â‰¥18yo were identified for analysis, 28,015(89.9%) underwent early appendectomy. Early appendectomy patients were more likely to be White (69.8% vs. 64.2% pâ€¯<â€¯0.01), and commercially insured (53.1% vs. 45.4%, pâ€¯<â€¯0.01). Of the 3152 undergoing delayed surgery, 1610(51.1%) had surgery later during the index admission, 715(22.7%) were readmitted urgently and underwent appendectomy, and 827(26.2%) had elective appendectomy. Patients undergoing delayed surgery had more complications (OR 1.34 95%CI 1.23-1.45), readmissions (OR 1.55 95%CI 1.42-1.70), high hospital charges (OR 4.79 95%CI 4.35-5.27), and prolonged LOS (OR 6.12 95%CI 5.61-6.68). CONCLUSIONS:In this population-level study of complicated appendicitis we found more complications, longer LOS, and higher charges in patients undergoing delayed surgery.
Association of Expectations of Training With Attrition in General Surgery Residents
Importance:Attrition from general surgery training is highest during internship. Whether the expectations and attitudes of new trainees affect their subsequent risk of attrition is unknown. Objective:To identify the expectations of general surgery residency associated with attrition from training. Design, Setting, and Participants:This prospective observational cohort study included categorical general surgery interns entering training in the 2007-2008 academic year. Residents were surveyed regarding their expectations of training and of life as an attending at the start of their intern year (June 1 to August 31, 2007). Expectations were grouped into factors by principal component analysis, and a multivariable model was created using these factors in addition to known demographic and program characteristics associated with attrition. Follow-up was completed on December 31, 2016. Main Outcomes and Measures:Attrition from training was determined by linkage to American Board of Surgery resident files through 2016, allowing 8 additional years of follow-up. Results:Of 1048 categorical surgery interns in the study period, 870 took the survey (83.0% response rate), and 828 had complete information available for analysis (524 men [63.3%], 303 women [36.6%], and 1 missing information [0.1%]). Most were white (569 [69.1%]) and at academic programs (500 [60.4%]). Six hundred sixty-six residents (80.4%) completed training. Principal component analysis generated 6 factors. On adjusted analysis, 2 factors were associated with attrition. Interns who choose their residency based on program reputation (factor 2) were more likely to drop out (odds ratio, 1.08; 95% CI, 1.01-1.15). Interns who expected as an attending to work more than 80 hours per week, to have a stressful life, and to be the subject of malpractice litigation (career life expectation [factor 6]) were less likely to drop out (odds ratio, 0.90; 95% CI, 0.82-0.98). Conclusions and Relevance:Interns with realistic expectations of the demands of residency and life as an attending may be more likely to complete training. Medical students and residents entering training should be given clear guidance in what to expect as a surgery resident.
Association between American Board of Surgery in-training examination score and attrition from general surgery residency
BACKGROUND:The American Board of Surgery In-Training Exam is administered annually to general surgery residents and could provide a way to predict attrition, potentially offering a point of intervention. METHODS:In 2007, a national survey of categorical general surgery interns was performed. Resident characteristics were linked to an American Board of Surgery database of American Board of Surgery In-Training Exam scores. Attrition was determined based on completion of training during eight years of follow-up. To identify residents at risk of attrition, American Board of Surgery In-Training Exam scores were analyzed based on average rank and change in American Board of Surgery In-Training Exam score. RESULTS:Of 1,048 residents, 739 (70.5%) participated and 108 (14.6%) did not complete training. Average American Board of Surgery In-Training Exam rank was higher for participants who completed training than those who did not (51.8 vs. 42.7 percentile respectively, P < .001). Ranking below the 25th percentile was less common among those who dropped out (41.7% ranked below 25th percentile and dropped out versus 51.5% ranked below 25th percentile and completed, Pâ€¯=â€¯.06), but those whose rank dropped >16.5 percentile points were more likely to leave training (attrition rate 13.0% with a drop versus 6.0% without a drop, Pâ€¯=â€¯.003). In adjusted analysis, a one percentile increase in American Board of Surgery In-Training Exam rank was associated with decreased odds of attrition (OR 0.98, P < .01). CONCLUSION:Lower American Board of Surgery In-Training Exam scores are associated with attrition, but this difference is small, and some residents complete training with very low scores. A large drop in American Board of Surgery In-Training Exam scores from one year to the next appears to be associated with attrition. Program directors should focus their efforts on these at-risk residents.
Association of Time to Attrition in Surgical Residency With Individual Resident and Programmatic Factors
Importance:Attrition in general surgery residency remains high, and attrition that occurs in the later years is the most worrisome. Although several studies have retrospectively investigated the timing of attrition, no study to date has prospectively evaluated a national cohort of residents to understand which residents are at risk for attrition and at what point during residency. Objective:To prospectively evaluate individual resident and programmatic factors associated with the timing of attrition during general surgery residency. Design, Setting, and Participants:This longitudinal, national cohort study administered a survey to all categorical general surgery interns from the class of 2007-2008 during their first 30 days of residency and linked the data with 9-year follow-up data assessing program completion. Data were collected from June 1, 2007, through June 30, 2016. Main Outcomes and Measures:Kaplan-Meier curves evaluating time to attrition during the 9 years after the start of residency. Results:Among our sample of 836 residents (306 women [36.6%] and 528 men [63.2%]; gender unknown in 2), cumulative survival analysis demonstrated overall attrition for the cohort of 20.8% (nâ€‰=â€‰164). Attrition was highest in the first postgraduate year (67.6% [nâ€‰=â€‰111]; absolute rate, 13.3%) but continued during the next 6 years, albeit at a lower rate. Beginning in the first year, survival analysis demonstrated higher attrition among Hispanic compared with non-Hispanic residents (21.1% vs 12.4%; Pâ€‰=â€‰.04) and at military programs compared with academic or community programs after year 1 (32.3% vs 11.0% or 13.5%; Pâ€‰=â€‰.01). Beginning in year 4 of residency, higher attrition was encountered among women compared with men (23.3% vs 17.4%; Pâ€‰=â€‰.05); at year 5, at large compared with small programs (26.0% vs 18.4%; Pâ€‰=â€‰.04). Race and program location were not associated with attrition. Conclusions and Relevance:Although attrition was highest during the internship year, late attrition persists, particularly among women and among residents in large programs. These results provide a framework for timing of interventions in graduate surgical training that target residents most at risk for late attrition.
Hormone Replacement Therapy and Colorectal Cancer Incidence and Mortality in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial
INTRODUCTION:Hormone replacement therapy has been shown to reduce colorectal cancer incidence, but its effect on colorectal cancer mortality is controversial. The objective of this study was to determine the effect of hormone replacement therapy on survival from colorectal cancer. PATIENTS AND METHODS:We performed a secondary analysis of data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, a large multicenter randomized trial run from 1993 to 2001, with follow-up data recently becoming mature. Participants were women aged 55 to 74 years, without recent colonoscopy. Data from the trial were analyzed to evaluate colorectal cancer incidence, disease-specific mortality, and all-cause mortality based on subjects' use of hormone replacement therapy at the time of randomization: never, current, or former users. RESULTS:A total of 75,587 women with 912 (1.21%) incident colorectal cancers and 239 associated deaths were analyzed, with median follow-up of 11.9 years. Overall, 88.6% were non-Hispanic white, andÂ < 10% had not completed high school. The never-user group was slightly older than the current or former user groups (average, 63.8 vs. 61.4 vs. 63.3 years; PÂ < .001). Almost one-half (47.1%) of the current users had undergone hysterectomy, compared with 21.6% of never-users and 34.0% of former users (PÂ < .001). Adjusted colorectal cancer incidence in current users compared to never-users was lower (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.69-0.94; PÂ = .005), as was death from colorectal cancer (HR, 0.63; 95% CI, 0.47-0.85; PÂ = .002) and all-cause mortality (HR, 0.76; 95% CI, 0.72-0.80; PÂ < .001). CONCLUSIONS:Hormone replacement therapy is associated with a reduced risk of colorectal cancer incidence and improved colorectal cancer-specific survival, as well as all-cause mortality.
The Surgical Personality: Does Surgery Resident Motivation Predict Attrition?
BACKGROUND:There is limited understanding of the wide variation in attrition rates among general surgery residencies. We used the validated Behavior Inhibitory System/Behavior Approach System (BIS/BAS) instrument to compare motivational traits among residents who did and not complete surgical training. STUDY DESIGN:All US general surgery categorical interns in the class of 2007-2008 were surveyed with a validated motivational trait assessment tool. American Board of Surgery records from 2008-2016 were used to determine who completed training. Motivation, an aspect of personality, was assessed with the BIS/BAS, which correlates with an individual's tendency to approach pleasant stimuli (BAS) or avoid negative stimuli (BIS). Subscale mean scores were compared with regard to the primary end point, attrition. RESULTS:Eight hundred and one (76.5%) interns completed the survey and had matching records. Six hundred and forty-five (80.5%) completed training. Men had lower scores than women in the BAS Drive subscale (12.0 vs 12.5; p < 0.002), BAS Reward Response subscale (17.2 vs 17.7; p < 0.01), and BIS scale (19.3 vs 20.9; p < 0.01). The BAS Reward Response scores differed based on program type (academic 17.3 vs community 17.6 vs military 16.6; p < 0.0027). There were no differences based on program size (BIS average, small program 19.9 vs large program 19.7; pÂ = 0.43). There were also no differences in BIS/BAS subscale scores based on residency completion status (BIS mean: completed 19.9 vs dropped out 20.1; pÂ = 0.51). CONCLUSIONS:Surgery residents are characterized by a strong drive and persistence toward their goals. However, residents who drop out do not differ from those who complete training in their motivational personality traits.
Surgical time out: Our counts are still short on racial diversity in academic surgery
BACKGROUND:This study provides an updated description of diversity along the academic surgical pipeline to determine what progress has been made. METHODS:Data was extracted from a variety of publically available data sources to determine proportions of minorities in medical school, general surgery training, and academic surgery leadership. RESULTS:In 2014-2015, Blacks represented 12.4% of the U.S. population, but only 5.7% graduating medical students, 6.2% general surgery trainees, 3.8% assistant professors, 2.5% associate professors and 2.0% full professors. From 2005-2015, representation among Black associate professors has gotten worse (-0.07%/year, pÂ <Â 0.01). Similarly, in 2014-2015, Hispanics represented 17.4% of the U.S. population but only 4.5% graduating medical students, 8.5% general surgery trainees, 5.0% assistant professors, 5.0% associate professors and 4.0% full professors. There has been modest improvement in Hispanic representation among general surgery trainees (0.2%/year, pÂ <Â 0.01), associate (0.12%/year, pÂ <Â 0.01) and full professors (0.13%/year, pÂ <Â 0.01). CONCLUSION/CONCLUSIONS:Despite efforts to promote diversity in surgery, Blacks and Hispanics remain underrepresented. A multi-level national focus is imperative to elucidate effective mechanisms to make academic surgery more reflective of the US population.
Recent advances in the management of anal cancer
Anal cancer is a rare condition, although its incidence has been increasing over the past several decades, particularly in women. The majority of anal cancers are squamous cell cancers and are linked with human papilloma virus (HPV) infection. Recent work in HPV basic science has delineated the mechanism by which the virus leads to the development of anal cancer. With widespread availability of an HPV vaccine since 2006, vaccination has become an important strategy for anal cancer prevention. However, in the US, there remain no guidelines for anal cancer screening. Treatment of anal cancer is dictated largely by accurate staging, which is generally accomplished with a combination of physical exam, magnetic resonance imaging, computed tomography, and positron emission tomography. Chemoradiation remains the mainstay of treatment for most patients, with surgery reserved for salvage therapy. Recent trials have identified the optimal use of available chemotherapeutics. Exciting developments in immune therapies targeting HPV oncoproteins as well as therapeutic vaccines may soon dramatically change the way patients with anal cancer are managed.