The surgical profession at a crossroads: recruitment, retention, and resilience in the Netherlands

Abstract

The future of surgery is challenged by two major issues: declining medical students’ interest in a surgical career and increasing burnout numbers among surgical residents. Addressing these issues is vital to maintain a vital and attractive surgical profession. Recruitment of suitable surgical trainees is there for increasingly important. In the Netherlands, the number of applicants for a surgical training position is stable, with a significant increase in female applicants. The applicant-training position is also stable. Nevertheless, as a surgical community, it is our responsibility to ensure that this situation is sustained in the long term in a durable manner. Encouraging medical students, functioning as role models, mentoring surgical trainees and addressing burnout is essential to keep our profession attractive for all.

Introduction

The future of surgery is potentially at risk if we do not act now. Currently, two major issues threaten the sustainability of the surgical profession: a decline in medical students pursuing a surgical career^[1–3] and increasing burnout numbers among junior doctors^[2,4,5]. Regarding the former, a bi-annual survey amongst Dutch medical students revealed a decline in interest; surgery was the most popular career choice in 2012 but fell out of the top five in 2022^[6]. As for the latter issue, rising burnout rates are related to poor work–life balance and unsafe work environments for young surgical doctors^[2,4,5,7]. While not exclusive to surgery, this trend is concerning, as it may contribute to higher attrition rates among surgical trainees^[8], mainly caused by lifestyle-related issues^[9].

These issues raise important questions about the challenges that lie ahead in maintaining the attractiveness and vitality of the surgical profession. Sustained passion and long-term engagement in surgery are clearly essential to create a sustainable workforce and keep meeting the growing healthcare needs and the evolving expectations of new and current generations. However, achieving a balance between these expectations and the preservation of surgery’s core values will require effort and effective intergenerational communication^[10].

Recruitment and retainment of surgical trainees

In Europe, there is a considerable heterogenicity in the selection process of surgical residents^[11], yet challenges in the surgical training appear to be universal^[12]. Recruiting suitable trainees is increasingly important in an era of declining interest in a surgical career^[13,14] in order to maintain a sufficient and sustainable surgical workforce^[15,16].

In the Netherlands surgical training is organized at both national and regional levels. It consists of 4 years of general surgery, followed by 2 years of subspecialty training in (orthopedic) trauma, abdominal, oncological, or vascular surgery^[17]. Each year, 65 applicants are accepted into the training program in one of the seven teaching regions. Data on the number of applicants and surgical trainees were obtained from the Dutch Surgical Society (DSS) and Royal Dutch Medical Association (KNMG).

Table 1 outlines a nonsignificant increase in the number of applicants for the surgical training program in the Netherlands (P = 0.16), alongside a significant increase in the number of female applicants (P = 0.002) and a decrease in the number of male applicants (P = 0.011), using a linear regression analysis. The applicant-to-training position ratio has remained consistent (2:1), with a modest (nonsignificant) increase over the past 3 years (P = 0.153). The number of surgical trainees leaving the training program has remained stable over the past years. Overall, these data suggest that interest in surgical training in the Netherlands remains stable relative to the number of available training positions.

Table 1.

Data on applicants and hired surgical trainees

	Number of applicants						Hired applicants			Quit residents*
Year	Male (%)	P-value	Female (%)	P-value	Total	P-value	Total (%)	Applicant-spot ratio	P-value	Total
2013	85 (66)	0.011	44 (34)	0.002	129	0.16	79 (61)	1.63	0.15	7
2014	72 (54)		62 (46)		134		66 (49)	2.03		9
2015	81 (58)		59 (42)		140		63 (45)	2.22		<5
2016	82 (57)		63 (43)		145		66 (46)	2.2		5
2017	69 (45)		84 (55)		153		65 (42)	2.35		7
2018	79 (52)		73 (48)		152		65 (43)	2.34		7
2019	58 (44)		74 (56)		132		65 (49)	2.03		5
2020	65 (47)		74 (53)		139		64 (46)	2.17		6
2021	70 (47)		78 (53)		148		68 (46)	2.18		<5
2022	57 (39)		91 (61)		148		67 (45)	2.21		<5

In contrast to the Netherlands, surgical training in the UK follows a two-stage structure: Core Surgical Training (CST) for 2 years, followed by Specialty Training (ST) lasting 6 years, depending on the chosen specialty. Entry into CST is competitive and centrally coordinated by Health Education England, after which trainees must reapply for ST based on performance and preference. In the US, surgical training begins with a 5-year general surgery residency, with further subspecialization requiring additional fellowship training of 1–3 years. The application process is centralized through the National Resident Matching Program, and medical graduates must pass the United States Medical Licensing Examination before entering residency. These structural differences reflect national variations in healthcare systems, medical education frameworks, and workforce needs, which should be considered when interpreting interest and attrition trends across countries^[18]. In the UK, a survey among medical students in 2014 also showed that a surgical career was not a top five choice^[3].

Future directions

Even though the decline in medical students’ interest in a surgical career is worrying, this trend is not yet evident in the current Dutch surgical application numbers. Currently, there is still a 2:1 ratio in the number of applicants to the number of available training positions. Nevertheless, these developments deserve serious attention. It seems that the current generation of medical students, often identified as Generation Z (born after 1992), has different work ethics and (work–life) expectations than their predecessors (the Millennials). Interestingly, it was stated that they could be the most productive generation due to a combination of a strong work ethic, technologic capability, and willingness to learn. Compared to Millennials, this generation places less emphasis on work–life balance, but more on other themes such as autonomy, leadership, dedication to a cause, and the chance to be creative^[19]. The first wave of this generation will enter the surgical workforce in the coming years. It is our responsibility to act accordingly in order to prevent a drainage of our profession. Obviously, there are certain challenging factors attributable to this specific generation of young doctors, but also modifiable factors that we – as a surgical community – can influence to keep our profession attractive for all.

To begin, we must actively encourage all medical students interested in a surgical career to pursue it. This is still a point of attention demonstrated in a previous study, as 69% of all students and 75% of those pursuing surgery reported verbal discouragement from pursuing a surgical career. The greatest deterrents for the male and female genders were surgical work hours and time for outside interests. Interestingly, women were significantly more likely to perceive that the verbal discouragement was based on gender, age and family aspirations compared to men^[20].

As shown, a significant increase in female applicants is visible in the Netherlands, leading to an equal distribution of male/female surgical residents in recent years^[21]. This shift in gender balance consequently created specific challenges faced by female surgeons and trainees, such as pregnancy and childbearing barriers^[22]. Unfortunately, these issues are still unresolved, but increasing awareness is seen in the recent literature, also regarding organisational barriers such as organisational cultures and work–family conflict. Resolving these issues should include flexible career and work patterns, increased family-friendly working conditions, and promotion of female mentors and role models in surgical specialties^[23]. Supporting female trainees and surgeons consequently leads to optimalization of the female and overall surgical workforce^[24].

We, as surgeons, carry the responsibility to serve as positive role models. The influence of a positive surgical experience during the internships should not be underestimated^[25]. A positive experience led to a higher percentage of students pursuing a surgical career, even students who were previously not interested in a surgical career. Mentorship, both by consultants and trainees, also plays a critical role in shaping students’ career choices. Some have even advocated for introducing surgical career exposure as early as high school^[26].

Burnout can be defined in various ways and holds three key components “overwhelming emotional exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of personal accomplishment”^[27]. Proposed strategies to reduce burnout include mindfulness, self-care or stress-management programs, duty hour and rotation length restriction, small group curricula, and communication skills training^[5]. As the Generation Z might be more susceptible to mental health issues than other age groups^[19], this issue deserves more attention than in previous years, especially since burnout numbers are rising^[2]. Mentorship and positive role modelling could also play a critical role in managing these current burnout numbers, as well as maintaining the joy in surgery^[28].

Fortunately, we have not yet reached a point where there is a shortage of applicants. Still, the responsibility to preserve interest in surgery lies with us. We must actively engage with students and trainees, listening to their concerns about work–life balance, well-being, and career sustainability. Fostering diversity and inclusivity in surgery is also key to attracting a wide range of talented students.

Conclusion

In the Netherlands, the number of applicants who apply for a position in surgical training, as well as the attrition rate among surgical trainees, has remained stable over recent years. This is encouraging. However, the current cohort of medical students expressing declining interest in a surgical career has not yet reached the application stage. It could well be that a decrease in applicants is imminent in the following years, indicating the urgency of this issue for the surgical workforce. It is our responsibility as a surgical community to transmit the positive aspects of surgery, motivate, encourage, and coach medical students with ambitions for a surgical career. Within this context, it is important we acknowledge that not only taking care of our patients, but also taking care of our own well-being and a better work–life balance, should become one of the core values of our surgical DNA to ensure a durable surgical future.

No AI tools were used to write this paper^[29].

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Author contributions

JJB: concept/writing. MEB, KD and FH: writing. AS: writing/supervision.

Conflicts of interest disclosure

The authors declare no conflict of interest and have no financial support to disclose. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

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