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Objective: To investigate the current rate of attrition in general surgery residency, assess the risk factors, and identify prevention strategies., Design: A literature review of the PubMed and MEDLINE databases, from January 1, 1980 to February 1, 2016, for relevant articles. The calculated attrition rate and the statistically significant influencing factors were the main measures and outcomes., Selection: All English language articles that described attrition from a general surgery residency were included. Articles that performed an assessment of attrition rates, academic performance, reasons for resident loss, and demographics were identified and data from these studies were collected. Random-effect meta-analysis and meta-regression based on a generalized mixed-effects model was performed., Results: A total of 26 studies were included. Reported attrition rates ranged from 2% to 30% over the course of residency training. Random-effect meta-analysis is indicative of a yearly attrition rate of 2.4% (95% CI: 1.3%-3.5%) and a cumulative 5-year attrition rate of 12.9% (95% CI: 7.9%-17.8%). Most of them leave residency during their first 2 years, and the rate significantly decreases with increasing postgraduate year (p < 0.0001). The Accreditation Council for Graduate Medical Education mandated 80-hour week is associated with a higher rate, though not significantly (3.2% [95% CI: 1.3%-5.1%] vs. 2.2% [0.9%-3.5%], p = 0.37). Pooled analysis demonstrates no statistically significant difference in the rate of attrition between males and females (2.1% [95% CI: 1.1%-3%] vs. 2.9% [95% CI: 1.6%-4.1%], p = 0.73). Most remain in graduate medical education and pursue residency training in other specialties., Conclusion: Attrition in general surgery most commonly occurs within the first 2 years of training and, in contrast to previous findings, is not related to female sex. Restrictions on work hours seem to have increased the rate, whereas remediation practices can prevent it. Training programs should direct efforts towards attrition-prevention strategies., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: Previous studies of resident attrition have variably included preliminary residents and likely overestimated categorical resident attrition. Whether program director attitudes affect attrition has been unclear., Objectives: To determine whether program director attitudes are associated with resident attrition and to measure the categorical resident attrition rate., Design, Setting, and Participants: This multicenter study surveyed 21 US program directors in general surgery about their opinions regarding resident education and attrition. Data on total resident complement, demographic information, and annual attrition were collected from the program directors for the study period of July 1, 2010, to June 30, 2015. The general surgery programs were chosen on the basis of their geographic location, previous collaboration with some coauthors, prior work in surgical education and research, or a program director willing to participate. Only categorical surgical residents were included in the study; thus, program directors were specifically instructed to exclude any preliminary residents in their responses., Main Outcomes and Measures: Five-year attrition rates (2010-2011 to 2014-2015 academic years) as well as first-time pass rates on the General Surgery Qualifying Examination and General Surgery Certifying Examination of the American Board of Surgery (ABS) were collected. High- and low-attrition programs were compared., Results: The 21 programs represented different geographic locations and 12 university-based, 3 university-affiliated, and 6 independent program types. Programs had a median (interquartile range [IQR]) number of 30 (20-48) categorical residents, and few of those residents were women (median [IQR], 12 [5-17]). Overall, 85 of 966 residents (8.8%) left training during the study period: 15 (17.6%) left after postgraduate year 1, 34 (40.0%) after postgraduate year 2, and 36 (42.4%) after postgraduate year 3 or later. Forty-four residents (51.8%) left general surgery for another surgical discipline, 21 (24.7%) transferred to a different surgery program, and 18 (21.2%) exited graduate medical education altogether. Each program had an annual attrition rate ranging from 0.73% to 6.0% (median [IQR], 2.5% [1.5%-3.4%]). Low-attrition programs were more likely than high-attrition programs to use resident remediation (21.0% vs 6.8%; P < .001). Median (IQR) Qualifying Examination pass rates (93% [90%-98%] vs 92% [86%-100%]; P = .92) and Certifying Examination pass rates (83% [68%-84%] vs 81% [71%-86%]; P = .47) were similar. Program directors at high-attrition programs were more likely than their counterparts at low-attrition programs to agree with this statement: "I feel that it is my responsibility as a program director to redirect residents who should not be surgeons.", Conclusions and Relevance: The overall 5-year attrition rate of 8.8% was significantly lower than previously reported. Program directors at low-attrition programs were more likely to use resident remediation. Variations in attrition may be explained by program director attitudes, although larger studies are needed to further define program factors affecting attrition.