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OBJECTIVE: Attrition rates among general surgery residents are notoriously high relative to other specialties. The aim of this study was to compare annual resident attrition rates between general surgery and other surgical subspecialties and to examine these trends in recent years.
METHODS: This was a retrospective study performed using Accreditation Council for Graduate Medical Education (ACGME) Data Resource Books from 2012-2022. Annual attrition rate and average ten-year attrition rate were calculated for general surgery and surgical specialties. Differences were assessed by Pearson chi-square test.
METHODS: All ACGME accredited residency programs in the United States were included.
RESULTS: General surgery residencies had a significantly higher average annual attrition rate (3.3%) than all other surgical specialties studied except thoracic surgery. Most attrition among general surgery residents was voluntary and these rates did not appear to be affected by the COVID-19 pandemic.
CONCLUSIONS: Attrition among general surgery residents is higher than in other surgical specialties, suggesting that early specialization may be protective against resident attrition.

BACKGROUND: Is vascular training in paediatric surgical oncology considered desirable ?
METHODS: A voluntary survey of work practice was undertaken with the surgeon membership of The International Society Of Paediatric Surgical Oncology (IPSO) using a structured designed questionnaire.
RESULTS: A total of 149 IPSO surgeon members completed the survey. 57% (N = 84) of surgeons surveyed had no specific training in vascular surgery. 43% surgeons (N = 63) stated they had acquired some skills in residency training and/or with transplantation surgery. 65% (N = 96) of respondent surgeons stated that vascular surgical training must be incorporated into pediatric surgical oncology training and 27% (N = 40) agreed that it was considered desirable. 89% (N = 133) of surgeon respondents had encountered major vascular injury during work practice while operating on pediatric solid tumors. Vascular injury repairs were undertaken and attempted by pediatric surgeons though expert assistance of vascular surgeons proved crucially essential in many instances. Emergent operations included patch repairs, vessel ligation techniques and insertion of vascular graft prostheses. Interventional radiology services to arrest life-threatening hemorrhage were also reportedly utilized by respondents.
CONCLUSIONS: Vascular injuries have significant potential for devastating patient outcomes including never event \'mortality\'. The IPSO surgeon survey highlights that there are visible \'gaps\' in skills training. Training to be a pediatric oncology surgeon must incorporate acquisition of skill sets proficiency in vascular surgery.

BACKGROUND: An enriching learning environment is integral to resident wellness and education. Integrated vascular (VS) and general surgery (GS) residents share 18 months of core GS rotations during the postgraduate years 1-3 (PGY1-3); differences in their experiences may help identify practical levers for change.
METHODS: We used a convergent mixed-methods design. Cross-sectional surveys were administered after the 2020 American Board of Surgery In-Training Examination and Vascular Surgery In-Training Examination, assessing eight domains of the learning environment and resident wellness. Multivariable logistic regression models identified factors associated with thoughts of attrition between categorical PGY1-3 residents at 57 institutions with both GS and VS programs. Resident focus groups were conducted during the 2022 Vascular Annual Meeting to elicit more granular details about the experience of the learning environment. Transcripts were analyzed using inductive and deductive logics until thematic saturation was achieved.
RESULTS: Surveys were completed by 205 VS and 1198 GS PGY1-3 residents (response rates 76.8% for VS and 82.5% for GS). After adjusting for resident demographics, PGY level, and program type, GS residents were more likely than their VS peers to consider leaving their programs (odds ratio [OR]: 2.61, 95% confidence interval [CI]: 1.37-4.99). This finding did not persist after adjusting for differences in perceptions of the learning environment, specifically: GS residents had higher odds of mistreatment (OR: 1.99, 95% CI: 1.36-2.90), poorer work-life integration (OR: 2.88, 95% CI: 1.41-5.87), less resident camaraderie (OR: 3.51, 95% CI: 2.26-5.45), and decreased meaning in work (OR: 2.94, 95% CI: 1.80-4.83). Qualitative data provided insight into how the shared learning environment was perceived differently: (1) vascular trainees expressed that early specialization and a smaller, more invested faculty allow for an apprenticeship model with early operative exposure, hands-on guidance, frequent feedback, and thus early skill acquisition (meaning in work); (2) a smaller program is conducive to closer relationships with co-residents and faculty, increasing familiarity (camaraderie and work-life integration); and (3) due to increased familiarity with program leadership, vascular trainees feel more comfortable reporting mistreatment, allowing for prompt responses (mistreatment).
CONCLUSIONS: Despite sharing a learning environment, VS and GS residents experience training differently, contributing to differential thoughts of attrition. These differences may be attributable to intrinsic features of the integrated training paradigm that are not easily replicated by GS programs, such as smaller program size and higher faculty investment due to early specialization. Alternative strategies to compensate for these inherent differences should be considered (eg, structured operative entrustment programs and faculty incentivization).

BACKGROUND: Applying to general surgery residency is undoubtedly a competitive process. Participation in scholarly activity (SCA) has been cited as a criterion when selecting applicants for interview and in the ranking process. This study aims to evaluate the association between gender of applicants to surgery residency and SCA and to characterize trends in SCAs over time.
METHODS: We analyzed the SCA of applicants interviewed at a general surgery residency program over 6-interview cycles (2016-2021). Eight SCA categories were included: (1) Poster Presentation, (2) Oral Presentation, (3) Peer-Reviewed (PR) Journal Articles/Abstracts, (4) PR Journal Articles/Abstracts (Other than Published), (5) PR Online Publication, (6) PR Book Chapter, (7) Nonpeer reviewed Online Publication, and (8) Other Articles/Scientific Monograph.
RESULTS: Of a total of 335 interviewed applicants, 288 (86%) had at least one count of SCA. Overall, no difference between male and female applicants was noticed (n = 178, 84.8% versus n = 110, 88%, P = 0.409) and no change in percentage of SCA over the six cycles (P = 0.239). The most reported SCAs were poster presentations (n = 242, 72.2%), oral presentations (n = 159, 47.5%), PR journal articles/abstracts (n = 159, 47.5%). Female applicants have marginally higher median (interquartile range) for SCAs compared to male applicants (5 [3, 8] versus 4 [3, 8], P value 0.272).
CONCLUSIONS: No association between gender and SCA among applicants for general surgery residency positions was observed. While more than three-fourths of applicants have at least one SCA, only a small fraction of applicants were published. Students should be made aware of the importance of SCA early in graduate medical education.

Surgery continues to be an increasingly vital component of public health and aspect of patient care in rural communities. An anticipated shortage of surgeons within the next decade in the United States prompts a growing concern for increasing the delivery of essential surgical care to these populations. When considering the existing barriers to surgical healthcare in rural communities, there is a sense of urgency to identify innovative approaches that will promote a sustainable surgeon workforce. A narrative review was conducted to investigate the current state of access to essential surgical care in rural communities. Qualitative and quantitative data were collected to better understand the key issues in rural healthcare and to provide statistical data related to the status of the surgical workforce. With the anticipated shortage of surgeons in both rural and urban areas, this review highlights the importance of enacting immediate measures to address the concern. This review has accomplished the initial objectives of gaining a better understanding of the current state of access to surgical care in rural communities and utilizing this knowledge to provide recommendations to readily attain a sustainable number of rural surgeons. With each approach addressing ways to address the contributory issues to the surgeon shortage, this review reveals a new avenue of integrating valuable aspects from each approach, rather than relying on a single approach. In particular, enhancing the overall pipeline of medical training to attending status may prove to be more beneficial for achieving this goal. Ultimately, this may be accomplished by introducing additional rural surgical mentorship opportunities for medical students, developing a rural surgery fellowship, and incorporating a market-based response that will correspond to attractive incentives that help to retain a sustainable number of surgeons working in rural areas.

To provide a more welcoming environment for LGBTQ residents.
This paper is based upon the authors experience creating a training program welcoming to LGBTQ residents.
University General Surgery Training Program.
Surgical Residents and Surgical Faculty.
Over a 9 year period, our residency has made intentional efforts to welcome LGBTQ applicants and support LGBTQ residents. We now have a residency in which over 25% of our residents identify as LGBTQ.
We see opportunities for other residencies to signal to applicants and trainees that they are welcome and celebrated for who they are.

Resident moral distress rounds were instituted during the COVID-19 pandemic to provide a safe zone for discussion, reflection, and the identification of the ethical challenges contributing to moral distress. The sessions, entitled \"Sip & Share,\" also served to foster connectedness and build resilience.
A baseline needs assessment was performed and only 36% of general surgery residents in the program were satisfied with the current non-technical skills curriculum. Only 62% were comfortable with navigating ethical issues in surgery. About 72% were comfortable with leading a goals-of-care discussion, and 63% of residents were comfortable with offering surgical palliative care options. Case-based discussions over video conferencing were organized monthly. Each session was structured based on the eight-step methodology described by Morley and Shashidhara. Participation was voluntary. The sessions explored moral distress, and the ethical tensions between patient autonomy and beneficence, and beneficence and non-maleficence.
Large general surgery residency in an urban tertiary medical center.
General surgery residents.
A post-intervention survey was performed with improvement in the satisfaction with the non-technical skills curriculum (70% from 36%). The proportion of residents feeling comfortable with navigating ethical issues in surgery increased from 62% to 72%. A survey was performed to assess the efficacy of the moral distress rounds after eight Sip & Share sessions over ten months. All thirteen respondents agreed that the discussions provided them with the vocabulary to discuss ethical dilemmas and define the ethical principles contributing to their moral distress. 93% were able to apply the templates learned to their practice, 77% felt that the discussions helped mitigate stress. All respondents recommended attending the sessions to other residents.
Moral distress rounds provide a structured safe zone for residents to share and process morally distressing experiences. These gatherings mitigate isolation, promote a sense of community, and provide a support network within the residency. In addition, residents are equipped with the vocabulary to identify the ethical principles being challenged and are provided practical take-aways to avoid similar conflicts in the future.

The virtual residency application season posed numerous challenges for the 2021 residency match process. Many residency programs are exploring relationships between this novel format and the match process. The purpose of this study was to compare one of the largest general surgery residency program\'s applications and match data from preCOVID years to the 2021 virtual cycle.
A retrospective review was performed of applicants to a single general surgery residency program from 2017 to 2021. The primary outcome was the number of locally matched applicants. The secondary outcomes were the total number of applications, change in applicant demographics, and variability of the geographic spread during this study period. Chi-square tests of independence, Fisher\'s exact tests, and negative binomial regression were performed.
6819 applicants were included in the study. In 2021, an increase in applications was observed. The distribution of 2021 applications was statistically different from previous years regarding gender and race (P < 0.0001). The 2021 application cycle had a greater proportion of applicants from the United States (P < 0.0001) and southern US medical schools (P = 0.008). While the 2021 cycle had significantly more interviews (P = 0.013), there were no significant differences in the demographic composition of interviewees. During the 2021 application year, all 11 matches were from southern medical schools and there was a trend to more matched female applicants compared to previous years.
During the 2021 COVID-19 virtual match cycle, an increase in both the number of applications and number of interviews for general surgery residency was identified. The characteristics of applicants who interviewed and matched were not different when compared to previous years. As virtual interviews may become more commonplace, it is important to assess all factors that may be involved in the dynamic residency application process.

The resident-attending dyad influences the intraoperative training of surgery residents. To better understand the role of trainees within the dyad, we hypothesized there is a measurable concept of \"teachability,\" a combination of the trainee\'s observed skills and behaviors with their performance. This study aims to define teachability and identify discrete intraoperative behaviors that contribute to this concept. We posit that residents who are active learners as demonstrated by asking questions, proposing next steps, and initiating purposeful actions have higher teachability.
Previously recorded videos from 26 laparoscopic inguinal hernia repairs performed by two PGY-5 general surgery residents at a Midwest tertiary care center were qualitatively reviewed for intraoperative behaviors. A summative content analysis identified behaviors associated with increased teachability and improved operative performance assessment scores.
Average frequencies of intraoperative behaviors for resident 1 and 2 (R1 and R2) were not significantly different, although R2 asked more medical knowledge and technical questions. While the rate of attending feedback was similar for both residents (x=3.82 vs 3.40, p=0.646), R1 consistently incorporated feedback (x=2.27 vs 0.40, p=0.001) whereas R2 needed frequent prompting (x=2.45 vs 1.55, p=0.239). R1 scored higher in all but one operative performance assessment category, including overall performance (x=4.17 vs 2.93, p=0.007), but R2 had a larger magnitude of overall improvement (+1 vs +2).
Teachability is a dynamic component of the resident-attending dyad. While intraoperative active learning behaviors do not appear to be associated with teachability, asking questions may increase the magnitude of improvement in performance. Most importantly, the ability to incorporate intraoperative feedback in real time seems to be a critical aspect of teachability and warrants further research.