This cross-sectional mixed-methods study assesses preparedness for surgical residency, identifies factors associated with preparedness, examines the association between preparedness and burnout, and explores resident and faculty perspectives on resident preparedness in a national survey of US general surgical residents.
Key Points
Question
What factors are associated with preparation for entering surgical residency, and what is the association between preparation and resident burnout?
Findings
In this cross-sectional study of 3693 surgical residents, those who had opportunities to take call as medical students and those who completed a surgical subinternship reported feeling more prepared for residency. Feeling adequately prepared for residency was associated with a nearly 2-fold lower risk of experiencing burnout symptoms.
Meaning
These findings suggest that adequate exposure to the necessary realities of surgical training and independent practice, particularly overnight call during the medical school clerkship, may contribute to improved preparedness, lower attrition, and lower rates of burnout in general surgery residency.
Abstract
Importance
Differences in medical school experiences may affect how prepared residents feel themselves to be as they enter general surgery residency and may contribute to resident burnout.
Objectives
To assess preparedness for surgical residency, to identify factors associated with preparedness, to examine the association between preparedness and burnout, and to explore resident and faculty perspectives on resident preparedness.
Design, Setting, and Participants
This cross-sectional study used convergent mixed-methods analysis of data from a survey of US general surgery residents delivered at the time of the 2017 American Board of Surgery In-Training Examination (January 26 to 31, 2017) in conjunction with qualitative interviews of residents and program directors conducted as part of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial. A total of 262 Accreditation Council for Graduate Medical Education–approved US general surgery residency programs participated. Survey data were collected from 3693 postgraduate year (PGY) 1 and PGY2 surgical residents (response rate, 99%) and 98 interviews were conducted with residents and faculty from September 1 to December 15, 2018. Data were analyzed from June 1, 2017, to February 15, 2018.
Main Outcomes and Measures
Hierarchical regression models were developed to examine factors associated with preparedness and to assess the association between preparedness and resident burnout. Qualitative interviews were conducted to identify themes associated with preparation for residency.
Results
Of the 3693 PGY1 and PGY2 residents who participated (2258 male [61.1%]), 1775 (48.1%) reported feeling unprepared for residency. Approximately half of surgery residents took overnight call infrequently (≤2 per month) during their core medical student clerkship (1904 [51.6%]) or their subinternship (1600 [43.3%]); 524 (14.2%) took no call during their core clerkship. In multivariable analysis, residents were more likely to report feeling unprepared for residency if they were female (odds ratio [OR], 1.34; 95% CI, 1.15-1.57) or did not take call as a medical student (OR for 0 vs >4 calls, 2.72; 95% CI, 2.10-3.52). Residents who did not complete a subinternship were less likely to report feeling prepared for residency (OR, 0.68; 95% CI, 0.48-0.96). Feeling adequately prepared for residency was associated with a nearly 2-fold lower risk of experiencing burnout symptoms (OR, 0.57; 95% CI, 0.48-0.68). In interviews, the dominant themes associated with preparedness included the following: (1) various regulations limit the medical school experience, (2) overnight call facilitates preparation and selection of a specialty compatible with their preferences, and (3) adequate perceptions of residency improve expectations, resulting in improved preparedness, lower burnout rates, and lower risk of attrition.
Conclusions and Relevance
In this cross-sectional study, the perception of feeling unprepared was associated with inadequate exposure to resident responsibilities while in medical school. These findings suggest that effective preparation of medical students for residency may result in lower rates of subsequent burnout.
Introduction
Applications to surgical residencies have decreased despite an increased need for general surgeons and an overall increase in match participants.1,2,3 In response to heightened attention on medical student wellness, many medical schools have scaled back surgical rotations and student responsibilities. This effectively increases the emphasis on the attractive aspects of surgical careers (eg, operating experience) while minimizing exposure to the less glamorous aspects of surgery (eg, overnight call and rounding).4,5,6,7 However, it remains unclear what effect these curricular changes may have on medical students’ perceptions of surgical careers and ultimately their preparation for surgical residency.
The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial examined the effect of residency work hours on patient safety and resident wellness.8,9,10,11,12,13 During a 2015 pilot study, the FIRST trial investigators learned in interviews with 100 surgical residents and faculty that by restricting experiences during postgraduate year 1 (PGY1), residents reported feeling less prepared to meet residency program expectations during PGY2.14 Moreover, some residents suggested that their medical school experience inadequately prepared them for residency.
In this mixed-methods cross-sectional study, we explored what role certain medical school experiences may play in preparing students for surgical residency training. The objectives of our study were to (1) describe the degree of self-reported preparedness for residency among US surgical trainees, (2) identify factors associated with self-reported preparedness for residency, (3) assess the association between preparedness and burnout; and (4) explore faculty and resident perceptions of preparedness for residency.
Methods
We performed a convergent mixed-methods study using a combination of survey response data from surgery residents and in-depth individual interviews with residents and surgical faculty. The study was approved by the Northwestern University institutional review board and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. All interview participants provided oral or written informed consent. The survey data were determined to be nonhuman subjects research by the institutional review board.
Participants
All clinically active surgery residents from Accreditation Council for Graduate Medical Education (ACGME)–accredited programs taking the American Board of Surgery In-Training Examination (ABSITE) between January 26 and 31, 2017, were eligible to participate in the survey. Residents not engaged in clinical training were excluded. Only PGY1 and PGY2 residents were included in this analysis. For the qualitative investigation, attending surgeons and surgical residents were recruited from programs participating in the FIRST trial for in-depth telephone and/or Skype interviews conducted from September 1 to December 15, 2018.
Survey Instrument
General surgery residents completed a close-ended survey as part of the January 2017 ABSITE.8,9 Questions were developed by a multidisciplinary group of researchers and pretested with research residents not participating in the study.8,9 We asked residents to state whether their medical school experience prepared them adequately for the rigors of general surgery residency on a 5-point Likert scale (ranging from strongly agree to strongly disagree). We dichotomized this outcome into prepared vs not prepared. Participants who replied agree or strongly agree were included in the prepared cohort. In addition, we asked how many call shifts residents had taken while medical students during both their surgical core clerkship and surgery subinternship.
Resident burnout was measured using the modified, abbreviated Maslach Burnout Inventory.15 Overall burnout was defined as being in the top quartile for the Emotional Exhaustion and Depersonalization subscales.
ABSITE performance was grouped into quartiles based on percentile within the respondent’s PGY level. Training programs were characterized as academic, community, and military based on program-reported data. Programs were also grouped into 1 of the following 5 geographic regions as defined by the American Board of Surgery: Northeast, Southeast, Midwest, Southwest, and West. The percentage of international medical graduates (<10%, 10%-25%, and >25%) in the training program and the program size (small [<4 residents per year], medium [4-7 residents per year], and large [>7 residents per year]) were defined according to previous literature.16 Call during the clerkship and subinternship was categorized based on the number of calls taken per month: 0, 1 to 2, 3 to 4, or greater than 4. We also included completion of a surgical subinternship as a dichotomized variable.
Quantitative Analysis
Data were analyzed from June 1, 2017, to February 15, 2018. Baseline demographics are reported with descriptive statistics. To assess the association between resident factors and self-reported preparedness for residency, we developed a hierarchical logistic regression model adjusting for clustering at the program level. We included the following covariates: resident gender, PGY level, ABSITE percentile, number of calls per month taken during clerkship and subinternship, completion of a subinternship, proportion of international medical graduates in the resident’s program, program size, program type, and program location.
To assess the association between resident self-reported preparedness for residency and burnout, we developed a hierarchical logistic regression model accounting for clustering at the program level. We included the following covariates in addition to resident-reported preparedness: resident gender, PGY level, ABSITE percentile, proportion of international medical graduates in the resident’s program, program size, program type, and program location. Two-sided P < .05 was considered significant. All analyses were performed using STATA, version 14 (StataCorp LLC).
Interview Process
Using the quota sampling technique, we recruited 20 participants from each of the following categories: program directors, faculty, interns, and residents (PGY2-PGY5) to participate in individual, semistructured interviews from September 1 to December 31, 2016. An email was sent to program directors participating in the FIRST trial requesting their participation as well as the names of faculty and residents within their program. Simultaneously, an announcement was sent to the American College of Surgeons Resident and Associate Society listserv, and an announcement was posted to social media via Twitter. After the first wave of recruitment, the study team sent an additional email to program directors who failed to respond to the first recruitment email to reach the sampling quota.
The interview guide was designed to query perceptions of quality and patient care, resident education, personal/professional well-being, mentorship, preparation for residency, and gender differences in resident training. We pretested and iteratively revised our interview guide with residents not participating in the FIRST trial to ensure uniform understanding of each question. Interviews were audio recorded and transcribed verbatim.
Qualitative Analysis
An initial codebook was developed based on results of a pilot study completed in 2015.14 Interviews were analyzed deductively, and additional codes were allowed to emerge in an inductive fashion. The codebook was finalized using the constant comparative approach. For each transcript, at least 2 study team members (K.E.E., D.B.H., R.J.E., L.K., R.L., and E.B.) independently coded and then subsequently met with an additional, neutral study team member (J.K.J.) to reconcile differences. The MAXQDA software package, version 12 (VERBI Software GmbH), was used to support data storage, analysis, and retrieval.
Results
Quantitative Analysis
A total of 3693 PGY1 and PGY2 residents from all 262 residency programs participated in the survey (99% response rate) (1413 female [38.3%] and 2258 male [61.1%] of those with data available). Baseline characteristics of the survey respondents are listed in Table 1. Nearly half (1775 [48.1%]) reported feeling unprepared for residency. Approximately half of surgery residents took overnight call infrequently (≤2 per month) during their core medical student clerkship (1904 [51.6%]) or their subinternship (1600 [43.3%]). Moreover, 524 residents (14.2%) took no call during their core clerkship, and 652 (17.7%) did not take call during their surgery subinternship. A small proportion of residents did not complete a subinternship as medical students (267 [7.2%]).
Table 1. Characteristics of PGY1 and PGY2 Residents.
| Characteristic | No. (%) (n = 3693)a |
|---|---|
| PGY level | |
| 1 | 2130 (57.7) |
| 2 | 1563 (42.3) |
| Self-reported gender | |
| Female | 1413 (38.3) |
| Male | 2258 (61.1) |
| ABSITE percentile | |
| <25 | 945 (25.6) |
| 25-49 | 960 (26.0) |
| 50-74 | 899 (24.3) |
| >74 | 889 (24.1) |
| Program type | |
| Academic | 2270 (61.5) |
| Community | 1313 (35.6) |
| Military | 110 (3.0) |
| Geographic region | |
| Northeast | 1250 (33.8) |
| Southeast | 718 (19.4) |
| Midwest | 777 (21.0) |
| Southwest | 428 (11.6) |
| West | 520 (14.1) |
| Program size | |
| Small (<4 residents per y) | 767 (20.8) |
| Medium (4-7 residents per y) | 2175 (58.9) |
| Large (>7 residents per y) | 751 (20.3) |
| International medical graduates, % | |
| <10 | 1404 (38.0) |
| 10-25 | 1168 (31.6) |
| >25 | 928 (25.1) |
| Study arm | |
| Flexible | 900 (24.4) |
| Standard | 971 (26.3) |
| Not enrolled | 1822 (49.3) |
| Calls during clerkship, No. per mo | |
| 0 | 524 (14.2) |
| 1-2 | 1380 (37.4) |
| 3-4 | 1011 (27.4) |
| >4 | 773 (20.9) |
| Calls during subinternship, No. per mo | |
| 0 | 652 (17.7) |
| 1-2 | 948 (25.7) |
| 3-4 | 874 (23.7) |
| >4 | 945 (25.6) |
| Did not complete a subinternship | 267 (7.2) |
| Self-reported preparation for residency | |
| Not prepared | 1775 (48.1) |
| Preparedb | 1918 (51.9) |
Abbreviations: ABSITE, American Board of Surgery In-Training Examination; PGY, postgraduate year.
Response rate was 99%. Data were missing for sex in 22 participants (0.6%), for international medical graduates in 193 (5.2% at 24 programs of 262), for clerkship call data in 5 (0.1%), and subinternship call data for 6 (0.2%).
Defined as responding agree or strongly agree with the statement, “My general surgery exposure during medical school prepared me for the rigors and responsibilities of general surgery residency.”
First, we examined factors associated with preparedness for residency (Table 2). Residents were more likely to report feeling unprepared for residency if they were female (odds ratio [OR], 1.34; 95% CI, 1.15-1.57). Residents who had taken call during the core medical school surgical clerkship were more likely to feel prepared for residency. Further, the more times a resident had taken call, the more likely he or she reported feeling prepared (compared with 0 shifts, OR for 1-2 nights per month, 1.41 [95% CI, 1.12-1.76]; OR for 3-4 nights per month, 1.70 [95% CI, 1.32-2.18]; and OR for >4 nights per month, 2.72 [95% CI, 2.10-3.52]). We found a similar association for call taken during a subinternship, although only those residents who took call more than 4 times per month during their subinternship were significantly more likely to report feeling prepared (OR, 1.71; 95% CI, 1.36-2.15). However, even the experience of a subinternship without call was formative; residents who did not complete a subinternship were significantly less likely to report feeling prepared (OR compared with those who completed a subinternship but took no call, 0.68; 95% CI, 0.48-0.96).
Table 2. Resident-Reported Preparedness for Residencya.
| Characteristic | No. prepared /total No. (%) | OR (95% CI) |
|---|---|---|
| PGY level | ||
| 1 | 1148/2126 (54.0) | 1 [Reference] |
| 2 | 770/1561 (49.3) | 0.77 (0.67-0.89) |
| Self-reported gender | ||
| Male | 1112/2254 (49.3) | 1 [Reference] |
| Female | 797/1411 (56.5) | 1.34 (1.15-1.57) |
| ABSITE percentile | ||
| <25 | 442/942 (46.9) | 1 [Reference] |
| 25-49 | 497/959 (51.8) | 1.18 (0.96-1.44) |
| 50-74 | 477/897 (53.2) | 1.23 (1.01-1.51) |
| >74 | 502/889 (56.5) | 1.42 (1.16-1.74) |
| Program type | ||
| Academic | 1208/2267 (53.3) | 1 [Reference] |
| Community | 649/1310 (49.5) | 0.87 (0.71-1.05) |
| Military | 61/110 (55.5) | 0.95 (0.63-1.45) |
| Location | ||
| Northeast | 643/1249 (51.5) | 1 [Reference] |
| Southeast | 379/717 (52.9) | 1.01 (0.81-1.26) |
| Midwest | 387/777 (49.8) | 0.91 (0.75-1.11) |
| Southwest | 239/426 (56.1) | 1.04 (0.80-1.36) |
| West | 270/518 (52.1) | 1.00 (0.78-1.28) |
| Program size | ||
| Small (<4 residents per y) | 383/766 (50.0) | 1 [Reference] |
| Medium (4-7 residents per y) | 1110/2172 (51.1) | 0.97 (0.78-1.20) |
| Large (>7 residents per y) | 425/749 (56.7) | 1.09 (0.84-1.43) |
| International medical graduates, % | ||
| <10 | 768/1402 (54.8) | 1 [Reference] |
| 10-25 | 591/1166 (50.7) | 0.88 (0.73-1.05) |
| >25 | 469/926 (50.6) | 0.87 (0.71-1.05) |
| Study arm | ||
| Not enrolled | 945/1822 (51.9) | 1 [Reference] |
| Standard | 529/971 (54.5) | 1.05 (0.88-1.26) |
| Flexible | 444/900 (49.3) | 0.85 (0.69-1.04) |
| Calls during clerkship, No. per mo | ||
| 0 | 205/524 (39.1) | 1 [Reference] |
| 1-2 | 652/1379 (47.3) | 1.41 (1.12-1.76) |
| 3-4 | 548/1011 (54.2) | 1.70 (1.32-2.18) |
| >4 | 512/773 (66.2) | 2.72 (2.10-3.52) |
| Calls during subinternship, No. per mo | ||
| 0 | 286/653 (43.8) | 1 [Reference] |
| 1-2 | 455/948 (48.0) | 1.13 (0.91-1.41) |
| 3-4 | 447/874 (51.1) | 1.12 (0.89-1.41) |
| >4 | 624/945 (66.0) | 1.71 (1.36-2.15) |
| Did not complete a subinternship | 106/267 (39.7) | 0.68 (0.48-0.96) |
Abbreviations: ABSITE, American Board of Surgery In-Training Examination; OR, odds ratio; PGY, postgraduate year.
Includes 1918 residents who reported being prepared for residency. Numbers prepared may not total 1918 in each category owing to missing data. Adjusted ORs account for clustering at the program level.
Next, we assessed the association between preparedness and burnout (Table 3). We found that residents who reported feeling prepared for residency were significantly less likely to report burnout symptoms (301 of 1918 [15.7%] vs 442 of 1769 [25.0%]; OR, 0.57; 95% CI, 0.48-0.68). We found similar associations between the perception of feeling prepared for residency and each of the 2 subscales of burnout examined: Emotional Exhaustion (763 of 1918 [39.8%] vs 938 of 1769 [53.0%]; OR, 0.58; 95% CI, 0.51-0.67) and Depersonalization (382 of 1918 [19.9%] vs 481 of 1769 [27.2%]; OR, 0.64; 95% CI, 0.54-0.75).
Table 3. Association Between Preparedness for Residency With Overall Burnout, and the Burnout Subscales of Emotional Exhaustion and Depersonalization.
| Characteristic | OR (95% CI)a | ||
|---|---|---|---|
| Emotional exhaustion | Depersonalization | Overall burnoutb | |
| Prepared for residency | |||
| Not prepared | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Prepared | 0.58 (0.51-0.67) | 0.64 (0.54-0.75) | 0.57 (0.48-0.68) |
| PGY level | |||
| 1 | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| 2 | 1.06 (0.93-1.22) | 1.12 (0.96-1.32) | 1.16 (0.99-1.37) |
| International medical graduates, % | |||
| <10 | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| 10-25 | 1.13 (0.96-1.35) | 1.09 (0.90-1.33) | 1.10 (0.89-1.36) |
| >25 | 1.10 (0.87-1.38) | 0.94 (0.75-1.17) | 1.09 (0.86-1.37) |
| Program size | |||
| Small (<4 residents per year) | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Medium (4-7 residents per year) | 0.82 (0.64-1.06) | 0.92 (0.70-1.20) | 0.97 (0.73-1.29) |
| Large (>7 residents per year) | 0.84 (0.62-1.14) | 0.85 (0.62-1.16) | 0.86 (0.62-1.18) |
| Program type | |||
| Academic | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Community | 0.96 (0.79-1.16) | 0.89 (0.73-1.08) | 0.93 (0.75-1.14) |
| Military | 0.87 (0.59-1.34) | 0.63 (0.27-1.48) | 0.64 (0.26-1.56) |
| Location | |||
| Northeast | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Southeast | 0.93 (0.75-1.15) | 0.99 (0.78-1.27) | 1.09 (0.85-1.40) |
| Midwest | 0.95 (0.77-1.17) | 0.92 (0.74-1.14) | 0.94 (0.73-1.19) |
| Southwest | 0.90 (0.70-1.17) | 0.83 (0.60-1.15) | 0.95 (0.68-1.31) |
| West | 1.16 (0.93-1.46) | 1.50 (1.16-1.94) | 1.61 (1.24-2.08) |
| Self-reported gender | |||
| Male | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Female | 1.34 (1.16-1.53) | 0.79 (0.66-0.95) | 0.84 (0.69-1.01) |
| ABSITE percentile | |||
| <25 | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| 25-49 | 1.13 (0.93-1.38) | 0.86 (0.69-1.06) | 0.80 (0.65-1.00) |
| 50-74 | 0.86 (0.70-1.05) | 0.70 (0.56-0.88) | 0.65 (0.51-0.83) |
| >74 | 0.91 (0.73-1.13) | 0.85 (0.67-1.07) | 0.80 (0.63-1.03) |
| Study arm | |||
| Not enrolled | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Standard | 1.08 (0.90-1.28) | 1.06 (0.86-1.30) | 1.01 (0.81-1.25) |
| Flexible | 0.98 (0.80-1.20) | 0.96 (0.78-1.17) | 0.94 (0.76-1.16) |
Abbreviations: ABSITE, American Board of Surgery In-Training Examination; OR, odds ratio; PGY, postgraduate year.
Adjusted ORs account for clustering at the program level.
Overall burnout is defined as being in the top quartile for emotional exhaustion and depersonalization.
Qualitative Analysis
We conducted 99 semistructured interviews with 57 residents and 42 faculty from 38 programs across 24 US states. We achieved thematic saturation, indicating that it was unlikely we would gain any additional insight from conducting further interviews. We identified 3 themes regarding preparation for residency (Table 4). The primary themes identified included rules and regulations, overnight call, and perceptions of residency.
Table 4. Qualitative Findings From Interviews With Residents and Faculty at Residency Programs Participating in the Flexibility in Duty Hour Requirements for Surgical Trainees Trial.
| Theme | Definition | Quotations |
|---|---|---|
| Rules and regulations | Rules and regulations have altered the medical student experience, making it more difficult to have adequate exposure to the rigors of residency. |
|
| Overnight call | Exposure to overnight call is an important aspect of preparation for surgical residency. However, the experience on call is more important than the mere presence of call. |
|
| Perceptions of residency | Medical students who arbitrate the decision to enter surgery based on an adequate perception of residency may have improved expectations. |
|
Abbreviations: OR, operating room; PGY, postgraduate year.
Rules and Regulations
Faculty reflected that rules and regulations at both the medical school and residency levels have altered the medical school experience, resulting in fewer experiential learning opportunities for medical students entering surgery. In some institutions, medical students are no longer able to document in patient medical records, participate in procedures, or stay the typical shift length of a resident.
Overnight Call
Both residents and faculty stressed the importance of exposure to overnight call as a preparatory experience for surgical residency. Residents who were not active participants in patient care during medical school call shifts reported that overnight call was not formative. Thus, we found that it is not just the act of staying overnight in the hospital but rather the exposure to the unique late-night patient care experiences, such as fielding nursing pages, that interviewees deemed important.
Perceptions of Residency
Many residents and faculty shared the perception that medical students who decide to enter surgery based on a more adequate perception of residency may have more accurate expectations of the field and hence report feeling more prepared. Some interviewees thought that ensuring realistic expectations may affect resident burnout and attrition.
Discussion
Given changes in the experiences of medical students on surgical clerkships and initial findings from a 2015 pilot study,14 we surveyed US general surgery residents and interviewed residents and faculty to explore their perceptions of preparation for residency. Although approximately half of general surgery residents reported that they felt unprepared for residency, those who took overnight call or completed a subinternship during medical school were more likely to report feeling prepared. We saw a dose-dependent association such that the more frequent the overnight call during medical school, the more likely that residents felt prepared once they began residency. We also found that preparedness was associated with a significantly lower likelihood of burnout, emotional exhaustion, and depersonalization. Our qualitative findings indicate that increasing rules and regulations may negatively affect the medical student experience, although some residents retained roles as active participants in patient care during their medical school clerkships. Informants indicated that overnight call facilitated development of accurate perceptions of surgical training and practice that may contribute to preventing resident burnout and attrition. These findings have important implications for clerkship directors.
Preparedness
Approximately half of general surgery residents reported feeling unprepared for residency in our study. Part of this is to be expected with the transition from a mostly observational role as medical student to that of active participant with real responsibility. Our findings are consistent with the European literature that cites preparedness rates ranging from 15% to 66%.17,18 A small study of interns from 11 US residency programs19 evaluated preparedness for specific tasks, with preparedness for individual tasks ranging from 1.3% (for ability to run a code) to 61.0% (for ability to maintain sterile technique). Our findings bring attention to the large proportion of general surgery residents who felt themselves to be unprepared after their undergraduate medical training. However, if approximately half of the residents in our study felt they were prepared, then there may be ways for medical student educators to improve the preparedness of incoming residents.
Overnight Call
Residents in our national cohort who took overnight call as medical students during surgery clerkships and subinternships were significantly more likely to report feeling prepared for residency, and their preparedness increased as they took more call. These findings were further supported in our interviews in which residents shared that medical students overnight were able to carry the intern pager, do minor procedures, and see consults. Overnight call may be particularly beneficial because it typically provides the opportunity for unique experiences, including management of cross-cover issues5 and evaluation of unstable patients unfamiliar to the covering physician.4 Given that 14.2% of residents took no overnight call on their clerkships and 51.6% took limited call, this seems to be a modifiable opportunity to better prepare medical students for residency.
Role of Subinternships
In our cohort, residents who completed a subinternship were significantly more likely to report feeling prepared for residency. This finding is consistent with prior literature showing that on-the-job learning contrasted prepared vs unprepared residents.20 Previous studies have shown that subinternships provide an increased level of responsibility and a forum in which to practice while still under direct supervision.21 However, it should be noted that there are no national standards for content or assessment of subinternships.22 Because of this inconsistency in subinternships, some residency programs have developed intern “boot camps” to provide some consistency to intern preparedness for clinical duties.23 However, clinical reasoning is likely best developed over time, not in a days-long course.24,25
Rules and Regulations
Recent trends in undergraduate medical education are moving away from structured opportunities for experiential learning, such as taking overnight call26 or completing tasks required of an intern (writing orders, answering pages, and initiating a consultation). For example, 86% of medical clerkships involved overnight call in 1994, compared with only 39% in 2015.5 Our interview data suggest that these trends may be associated with stricter rules and regulations on attendings and residents in addition to medical students. These findings are consistent with those of prior literature, which cites an increasing concern for patient safety as the cause for diminished medical student involvement in active patient care and increased dependence on simulation-based education.20 However, transferring skills learned in a simulated environment may prove challenging.27,28
The decrease in overnight call experiences during medical school may also be associated with the pressures surgical educators feel to make surgery more attractive to medical students. Further, many medical schools are particularly focused on medical student responses to the Liaison Committee on Medical Education survey. In some cases, when students voiced displeasure with taking call or their limited roles when on call, medical schools have encouraged surgical clerkships to eliminate their student overnight call requirements. Although intended to protect student well-being, our data suggest that limiting opportunities to participate in call during medical school may actually be detrimental to the longer-term well-being of those students who ultimately become surgical residents.
Implications for Resident Burnout and Attrition
Program directors stated that the perception of feeling unprepared owing to inaccurate perceptions of surgery during medical school may contribute to resident burnout and attrition. These impressions were supported by our survey data, which showed that prepared residents were less likely to report burnout. Although it is difficult to quantify the national trend in general surgery resident attrition,29 recent data suggest that rates of burnout among surgeons are increasing.30 Thus, although some institutions have decreased opportunities for experiential learning in medical school due to a concern for medical student well-being, they may inadvertently be contributing to resident burnout.31 Our findings similarly suggest that experiences such as in-hospital call, which may be viewed negatively in the undergraduate medical education setting, may actually improve well-being and decrease the risk of burnout on entry into residency. Hence, attempts to improve wellness by limiting clinical responsibility in undergraduate medical education may paradoxically harm trainee wellness in the long term. Although certain nonmodifiable features of a surgical career (eg, overnight call, early morning rounding) may deter students and contribute to burnout on clerkships, a systematic review2 suggested that exposure during clerkship to mentors who are able to balance these responsibilities may help dispel the assumption that surgery precludes work-life balance. Further development of alternative approaches to routinely incorporate the beneficial experiences from call into clerkships (eg, mock pages) is also needed to promote learning and provide a more accurate picture of residency for students considering surgical careers.
Limitations
Our study has important limitations. First, as with any retrospective survey, our study is subject to recall bias. To limit this bias, we included only PGY1 and PGY2 residents because they were the closest temporally to their medical school experience. Second, preparation for residency was a self-reported outcome. Objective data are not available to indicate whether a resident was truly prepared for residency. However, self-reported preparedness is associated with burnout and well-being and thus is an important measure to study.32 Third, we were unable to differentiate preliminary and categorical interns in our study cohort. This variability in future career plans may contribute to variation in preparation for a general surgery residency. However, prior analyses of the FIRST trial data have consistently shown no differences between the experiences of preliminary and categorical residents. Moreover, there is no requirement for tracked preliminary residents (eg, radiology, anesthesia) to take the ABSITE. Therefore, our population consists largely of categorical and preliminary residents interested in surgical fields. Fourth, our interview data were obtained only from sites participating in the FIRST trial. Previous work has shown that these sites do not differ substantially from nonparticipating residencies; thus, we expect our findings to be representative of all general surgery residencies.33 Finally, our analysis of preparation is limited to those factors measured in the ABSITE survey. We acknowledge that other unmeasured factors such as experience before medical school, mentorship, and other preparatory courses may also influence preparation for residency.
Conclusions
This study found that approximately half of surgical residents felt unprepared for residency. This self-reported lack of preparedness was primarily associated with inadequate exposure to resident responsibilities while in medical school. Unfortunately, half of residents had not experienced frequent (>2 times per month) overnight call during their medical school surgical clerkship. The perception of feeling unprepared for residency was associated with a higher likelihood of burnout. Adequate exposure to the necessary realities of surgical training and independent practice, particularly overnight call during the medical school clerkship, may contribute to improved preparedness, lower attrition, and lower rates of burnout in general surgery residency.
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