Defining characteristics of categorical general surgery resident lateral transfers

Abstract

Background

Few studies describe rationales for intraspecialty (‘lateral’) general surgery (GS) resident program transfers.

Objective

We aimed to describe the key features of GS residency programs reporting lateral transfers, to characterize reasons behind transfer events, and to compare transferring resident skill sets against their new institutional peers.

Methods

A survey was administered in October 2020 to capture program features and demographic information of residents who transferred into or out of a GS residency program during a 5-year period. This survey was approved and distributed by the Association of Program Directors in Surgery to all participating GS program directors and coordinators. Survey responses were collected, and descriptive analyses were performed.

Results

Of 69 program responses (21.5% survey response rate), 42 (61%) indicated the presence of any type of transfer event (in or out); 19 of 69 (27.5%) programs reported having at least one categorical GS resident transfer out, and 31 of 69 (44.9%) programs reported having at least one transfer in. Most transfer-out events (94.7%) were resident initiated, and the most commonly cited rationale was family obligation (78.9%). Most programs reported that residents who transferred in were on par with the existing resident cohort with respect to their medical knowledge, administrative abilities, and communication skills.

Conclusion

GS transfers were not uncommon and most were resident initiated secondary to family obligations. The majority of transfer resident skill sets met institutional expectations by the time of graduation. Programs surveyed were content with their decision to accept transfer residents.

Level of evidence

III.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• General surgery (GS) residency has one of the highest rates of attrition among medical specialties; however, little is known regarding the incidence and rationales for intraspecialty ‘lateral’ GS transfers.

WHAT THIS STUDY ADDS

• Our results indicate that lateral GS resident transfers are mostly resident initiated and institutions that have accepted lateral transfers report being content with accepting transfer residents. Additionally, programs report that transfer-in resident surgical skills were on par with non-transfer residents by graduation.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY

• Our study highlights that when lateral GS transfers occur they do not necessarily result in lowered GS resident program standards.

Introduction

There is a growing need in the USA for general surgeons, with the predicted future need outgrowing the rate of current residents in training.¹ However, general surgery (GS) attrition rates remain high contributing to a decrease in the supply of surgeons as the US population continues to increase.^{2 3} Despite this need, studies quote attrition rates between 2% and 26% for GS residents in the USA.4,6 Recent data suggest that the majority of GS residents (58%) contemplate leaving residency at least once during training.⁷ These high rates of attrition decrease the available surgeon workforce in the USA and may negatively impact programs by decreasing the appeal to future applicants. Such data have prompted a series of investigations to describe risk factors and way to prevent attrition from GS residency.⁸

One population of GS residents who have remained out of the spotlight are those who transfer to a different GS program during residency (‘lateral transfers’). These residents represent a small percentage of GS residents who leave their home programs for any reason.^{4 9} However, a recent Association of Program Directors in Surgery (APDS) task force survey found that up to 50% of responding program directors (PDs) have had a resident transfer in or out of their program.⁶ Prior work has demonstrated that the most likely reason for these transfers is related to geography and family obligations.⁴ The recent APDS task force survey highlighted the increasing number of lateral transfers and guidelines for PD success in the process.⁶ However, little is known about additional program risk factors that lead to lateral transfers or how these incoming residents impact their new programs. Most importantly, there is a paucity of data regarding how these residents perform clinically.

We sought to describe key features of GS residency programs that experience transfer events and aimed to characterize rationales behind such events. In addition, a major objective of our study was to assess resident performance in their new program after lateral transfer. We hypothesize that lateral GS resident transfers occur across all types of programs and that transfer residents are able to perform on par with institutional peers after transfer.

Methods

Survey construction and database development

A survey study was developed to capture features of GS programs reporting any transfer events in their program during a 5-year period. Using the modified Delphi technique, an interactive process used to obtain group consensus, a novel 49-question survey was generated. This survey was then administered via the Research Electronic Data Capture (REDCap) browser-based software (online supplemental files 1; 2). After approval by the APDS, a link for the REDCap survey was distributed via the APDS Listserv to all participating GS PDs and coordinators over three consecutive weeks in October 2020. Survey responses were recorded, and descriptive analyses were performed.

Resident and program characteristics

At an institutional level, demographic information for transfer residents was collected including age, sex, race, and ethnicity as well as marital status and number of children, if any. Information regarding resident medical school education was also collected. Individual resident-level data were not obtained to preserve resident and institutional anonymity.

Programs provided information on whether a resident transfer-out event was program or resident initiated and rationales for such decisions. Programs were asked to detail the support provided for transfer-out residents. Methodologies used to identify new residents to fill an open position were also characterized. Additionally, programs that reported having at least one resident transfer in provided data on the operative skills, medical knowledge, administrative abilities, and communication skills of those residents via survey response questions. Programs also reported if those residents who had transferred in were, on average, on par with their coresidents by graduation, and if the program was happy or unhappy that they had accepted transfer residents.

Additional variables describing each GS program were captured. These variables included the presence of dedicated research time, resident mentorship, schedule structure (night float system), time available for electives, and presence or absence of an annual resident retreat.

Statistical analysis

Descriptive statistics were performed to characterize programs that reported resident transfer events during a 5-year period. Categorical data were presented as actual number (n) and percentages (%).

Results

Program transfer data

Of 330 GS programs included in the APDS Listserv (as of October 2020), 71 completed the REDCap survey (22%) and 69 of these were complete survey responses. The two incomplete survey responses were not included in this analysis as they did not provide information on transfer events at their respective programs. Figure 1 shows the tree diagram describing survey responses and GS program transfer events. Of the 69 programs, 42 (61%) indicated a transfer and 27 (39%) reported no transfer events. Of the programs participating in this study, 19 of 69 (28%) reported having at least one categorical GS resident transfer out, and 31 of 69 (45%) reported at least one resident transfer-in event. Of the programs reporting a transfer event, there were multiple sites that recorded both a transfer-out and transfer-in event, thus not all sites reported exclusively on residents transferring out or in. The majority of transfer-out events were reported to be resident initiated (95%). The most commonly reported method to fill vacant GS spots after transfer out was via the APDS web page.

Figure 1. Tree diagram characterizing survey response rate and general surgery program resident transfer events. APDS, Association of Program Directors in Surgery; REDCap, Research Electronic Data Capture.

Residency program characteristics

Table 1 reports characteristics of respondent GS programs. The majority of GS programs with transfer events were academic programs (71%) located in urban areas (78.9% of transfer-out residents and 74.2% of transfer-in residents). Across all programs reporting resident transfer status, the most commonly cited resident class size was four to six residents. Characteristics of programs with the highest rate of transfer-in residents included dedicated research time and elective flexibility. The majority of programs reported having a night float system and structured junior resident mentorship.

Table 1. Characterization of respondent general surgery residency programs.

	No transfer (n=27)	Transfer out (n=19)	Transfer in (n=31)
Program type, n (%)
Academic	16 (59.3)	11 (57.9)	22 (71.0)
Community	11 (40.7)	5 (26.3)	7 (22.6)
Other	0	3 (15.8)	2 (6.5)
Program location, n (%)
Urban	18 (66.7)	15 (78.9)	23 (74.2)
Suburban	8 (29.6)	3 (15.8)	8 (25.8)
Rural	1 (3.7)	1 (5.3)	0
Number of residents per year, n (%)
1–3	5 (18.5)	2 (10.5)	4 (12.9)
4–6	16 (59.3)	9 (47.4)	16 (51.6)
7–9	4 (14.8)	5 (26.3)	8 (25.8)
≥10	2 (7.4)	3 (15.8)	3 (9.7)
Allotted protected resident education hours/week, n (%)
3–4	12 (44.4)	7 (36.8)	16 (51.6)
5–6	14 (51.9)	10 (66.7)	15 (48.4)
>6	1 (3.7)	2 (10.5)	0
Dedicated research time (yes)	5 (18.5%)	7 (36.7%)	15 (48.4%)
Annual resident retreat (yes)	6 (22.2%)	6 (31.6)	10 (32.3%)
Night float system (yes)	21 (77.8%)	15 (78.9)	27 (87.1%)
Intern assigned mentors (yes)	15 (55.6%)	16 (84.2%)	19 (61.3%)
Junior residents assigned senior resident mentor (yes)	8 (29.6%)	13 (68.4%)	17 (54.8%)
Elective time availability (yes)	14 (51.9%)	14 (73.7%)	27 (87.1%)
Number of residents requiring remediation during the last 5 years, n (%)
1–3	20 (74.1)	8 (42.1)	20 (64.5)
4–9	3 (11.1)	9 (47.4)	9 (29.0)
≥10	1 (3.7)	2 (10.5)	1 (3.2)
Unknown	3 (11.1)	0	1 (3.2)

Resident characteristics

Programs that reported transfer-out events cited family obligation as the most common reason for resident transfer. With regard to resident performance, the majority of programs reported that residents who transferred in were on par with the existing GS resident cohort with respect to their medical knowledge, operative skills, administrative abilities, and communication skills (table 2). When asked to evaluate transfer residents over time, 84% of programs reported these residents’ cumulative skills met expectations by graduation. The majority of programs (87%) reported that, overall, they were content with accepting a transfer resident.

Table 2. Characterization of resident skills after transfer, n (%).

Skill sets on arrival to new program	Exceeds expectations	Meets expectations	Does not meet expectations	Unanswered
Medical knowledge	3 (9.7%)	18 (58.1%)	9 (29.0%)	1 (3.2%)
Operative skills	0	16 (51.6%)	14 (45.2%)	1 (3.2%)
Administrative abilities	0	23 (74.2%)	7 (22.6%)	1 (3.2%)
Communication skills	0	24 (77.4%)	6 (19.4%)	1 (3.2%)
General Surgery resident cumulative skills, compared with peers, by graduation	1 (3.2%)	26 (83.9%)	3 (9.7%)	1 (3.2%)
Sentiment of program	Content	Not content	Unanswered
General feeling about accepting transfer-in residents	27 (87.1%)	3 (9.7%)	1 (3.2%)

Discussion

In this analysis of 69 unique GS programs, we found that 28% of programs reported at least one categorical GS resident lateral transfer-out event and 45% of programs reported at least one GS transfer-in event. The majority of lateral transfers were resident initiated, with the most commonly reported reason for lateral transfers being lifestyle or family obligations. This aligns with prior studies that identified lifestyle factors as the top reason for attrition from GS residency, including residency non-completion and transferring to a different specialty.^{4 10} We posit that although demanding for both the resident and program-lateral GS resident transfers may prevent overall attrition from GS by supporting resident priorities and providing an alternative route to completion of GS training.

Additional rationales for GS resident lateral transfers include academic goals, geographic considerations, and overall poor program fit. PDs should be aware of these factors when picking applicants to allow for the best alignment between a program and a particular resident overall goals and needs. In addition, medical students should be encouraged to consider both social and academic needs. By optimizing the alignment between resident goals and GS program resources and opportunities, we may be able to eliminate the future need for a resident to undergo a lateral GS program transfer. Having said this, our results also show that in the case that a lateral GS resident transfer does occur, receiving programs are overall satisfied with the new GS resident, and the resident is able to stay on course and advanced through residency with skills on par with their peers.

As briefly mentioned above, the majority of GS programs reported that transfer-in residents met expectations with respect to administrative abilities, communication skills, and medical knowledge on transfer. Although there were some programs that reported transfer residents’ operative skills were not on par initially after transfer, most programs reported these residents’ cumulative skill sets aligned with their resident cohort by graduation. Most importantly, most programs expressed that they were content with their choice to introduce a new resident into their program. Although we present a preliminary survey analysis characterizing ‘lateral’ GS transfers, our results show that GS residents are considered successful by their new programs after transfer. These data may suggest that residents can consider and pursue a lateral GS program transfer without significant disturbance to their training. From the GS program perspective, these results suggest that accepting transfer residents at their program, for the majority of cases, will not lead to a decline in surgical skills and quality of their training cohort. Additionally, our data suggest a potential correlation between higher elective and dedicated research time with higher numbers of GS residents who transferred into their programs. These results may suggest an area of potential growth for those programs experiencing a relatively high rate of lateral GS transfers compared with peer institutions who hope to reduce such losses in the future. These results further highlight the need for overlap between resident needs and program opportunities/resources.

The present study has potential limitations worthy of discussion, the first of which includes low survey response rate (22% of APDS member GS programs). Future studies investigating lateral GS transfers should identify multiple avenues of survey distribution (eg, as a part of the yearly GS resident ACGME (Accreditation Council for Graduate Medical Education) survey, telephone-based survey, etc) over multiple weeks to months to maximize survey response and reduce the risk of sampling bias. A result of this limitation is the introduction of a possible selection bias resulting from a higher rate of survey response from programs that have experienced a transfer event than those that have not experienced a transfer event. By using multiple survey distribution methodologies and extending the time period over which the survey is administered, this may help increase survey response rates, thus reducing selection bias. While the modified Delphi approach was used to generate the APDS distributed survey, this survey did not undergo specific reliability or validation prior to survey distribution. In addition, due to the method of distribution and survey format, there was a possibility of more than one response received per program. Although limited by study design, we believe that the present study is an important first step in characterizing programs reporting lateral GS transfers. Future studies should include large-scale investigation into lateral GS transfers targeted towards GS residents via the ACGME yearly survey. This would provide data directly from residents to better characterize the cohort of residents who have personally laterally transferred between GS programs or who have experienced the result of introducing a new resident into their home program.

Conclusions

More than a quarter of programs that responded to our survey reported at least one transfer-out event during the 5 years prior to the distribution of the survey, and over half were affected by a transferring resident event of any kind. Of these lateral transfers, the majority were resident-initiated lateral transfers, most commonly attributed to family obligations. PDs are content with their decision to accept transferring residents majority of the time. This study highlights that lateral GS resident transfers are not uncommon. Additionally, we encourage our readers to consider that optimal alignment between resident academic and social needs and GS program resources is an important factor to weigh for both the future resident and GS program. Lastly, our study highlights that when lateral GS transfers occur, they do not necessarily result in lowered GS resident program standards. Future studies should focus on surveys directed towards the individual GS resident to better identify reasons for transfer and how residents perceive and are affected by such change.

Data availability statement

No data are available.