Attrition Rate in Military General Surgery GME and Effect on Quality of Military Programs

Introduction: The attrition rate in civilian general surgery Graduate Medical Education (GME) is estimated at 20%, while estimates of attrition in military general surgery (MGS) GME programs using the same methodology are nearly twice that. We sought to identify the true attrition rate in MGS GME, identify factors influencing attrition, and examine the relationship between attrition and quality of MGS GME. Methods: Deidentified data were collected on categorical general surgery residents matriculating from 2010 to 2013 from all 12 MGS residency programs. Information gathered included gender, medical degree, marital status, location of program, presence of a military-related interruption in training, and age at start of the categorical contract. For those who did not graduate, data on postgraduate year at time of attrition, reasons for attrition, and deficiencies in core competencies were solicited. To assess the effect of true attrition rate on graduate performance, we compared the published 5-year American Board of Surgery qualifying exam/certifying exam first time pass rates between military and civilian programs. Results: One hundred eighty-four categorical residents matriculated from 2010 to 2013. Fifty six (31.5 %) were women, 151 (62.1%) were MD's, 103 (56%) were married, 172 (93.5%) were less than 35 years old, and 33 (17.9%) had a military-related interruption in training. Nineteen individuals left residency prior to graduation (15 resigned, 2 resigned in lieu of termination, 2 terminated) for an overall attrition rate of 10.3%. The most common year for attrition was PGY-3 (31.6%) and most common reason for resignation was changing to a different subspecialty (73.3%). Men and women had equal attrition rates (10.3%), and there was no meaningful difference between MD's and DO's (9.9% vs 12.1%, p = 0.71) or region of training (10.6% East vs 9.1% West, p = 0.73). However, those who were not married, had a militarily mandated interruption in training and started their categorical training over the age of 35 had higher attrition rates (married 5.6%, not married 15%, p = 0.04, interruption 16% vs no interruption 9%, p = 0.1; Age ≥ 35 33.3% vs age < 35 6.7%, p < 0.01). Comparison of American Board of Surgery (ABS) first time pass rates over a similar time period showed that military programs performed statistically discernibly better than civilian programs (82% ± 12 vs 75% ± 13, p = 0.047). Conclusions: Previous used methodology over estimates the attrition rate in MGS GME. The lower rate in MGS programs results in a high level of graduate performance as measured by ABS pass rates. Interruption in training and especially marital status and age ≥ 35 appear to be potential predictors of attrition. Components of MGS GME training and selection processes might inform efforts to reduce attrition and improve performance in civilian surgical GME.