“Join the Club”:  Effect of Resident and Attending Social Interactions on Overall Satisfaction Among 4390 General Surgery Residents FREE

General surgery training has undergone a well-documented metamorphosis in recent years. In part, this has been a response to numerous challenges facing residency programs, such as a diminished interest in general surgery among medical students^1- 4 and a prominent attrition rate.^5- 9 Studies have shown general surgery residency attrition to be higher than the dropout rate seen in other medical and surgical subspecialties.^10- 12 This finding has created uncertainty regarding the long-term health of general surgery as a profession^13- 14 and spurred an effort to delineate more clearly the complex and less understood factors associated with surgical residents' satisfaction with their training experience.

Among health care providers, the development of successful professional relationships has wide-ranging implications. Collegial interactions among medical colleagues have been suggested to positively affect continuing professional development and improve overall job satisfaction.^15- 18 Among residents and junior faculty, mentorship is associated with an increase in academic productivity and enhanced feelings of preparedness for clinical practice and can influence the choice of specialization.^19- 21 Our understanding of informal interactions between surgical residents and attending physicians is limited because there is a paucity of research examining their significance.

The goals of this study were to characterize the individual and program factors associated with successful collegial relationships between residents and surgical faculty and to determine the effect of these interactions on overall resident satisfaction. In addition, we sought to identify resident subsets that could benefit from expanded opportunities for social interaction and mentorship with surgical faculty. This study was approved by the Yale University institutional review board.

To examine the factors associated with collegial relationships between residents and attendings, we used data from the National Study of Expectations and Attitudes of Residents in Surgery (NEARS) survey. This national, cross-sectional study of surgical residency programs (n = 248) was administered to all US surgical residents after the American Board of Surgery In-Training Examination in January 2008. Survey administration procedures and baseline data have been reported.⁷

The resident roster for the American Board of Surgery included 7458 general surgery residents for the 2007-2008 academic year. Of these, 5345 were categorical general surgery residents at postgraduate years 1 through 5 (PGY-1 through PGY-5) and therefore eligible for inclusion in our analysis. Designated and nondesignated preliminary residents and residents performing full-time research were excluded from this study.

The NEARS survey consisted of 52 items addressing resident perceptions of their training experience and the current and future status of general surgery. Measures of personal satisfaction, self-assessed performance, and characterizations of resident-to-resident and resident-to-faculty interactions were included. Items were structured as statements, to which respondents indicated their level of agreement on a 5-point Likert response scale. Responses ranged from “strongly agree” to “strongly disagree.” Demographic items included age, race/ethnicity, sex, PGY level, marital status, and number of children. We also analyzed residency program characteristics obtained from the Accreditation Council for Graduate Medical Education database; these characteristics included type of residency (community, academic, or US military), geographic region (Northeast, South, Midwest, and West), number of graduating chief residents, and affiliation with postresidency subspecialty fellowships.

To examine demographic and program characteristics associated with the development of successful interactions between residents and faculty members, we analyzed data regarding the following 2 survey items: “How often do you do things with your attendings on a social level?” and “I feel I can turn to members of the faculty when I am having difficulties in the program.” The terms social level and difficulties in the program were not defined in the survey but rather were left subject to the residents' interpretation. These items were believed to be measures of collegiality. To assess their potential influence on resident satisfaction, both were correlated with the item “Overall, I am very satisfied with my program.”

We performed statistical analysis using commercially available software (SPSS, version 17.0.2 [IBM Corporation] and SAS, version 9.2 [SAS Institute, Inc]). Descriptive statistics were used to characterize individual and program demographics. Consistent with previous NEARS investigations, item responses were dichotomized into those who agreed (strongly agree and agree) and those who did not agree (neutral, disagree, and strongly disagree).⁷ The response scale for the item “How often do you do things with your attendings socially?” had only 4 choices (never, rarely, sometimes, and frequently). Answers were stratified into infrequent (never and rarely) and frequent (sometimes and frequently) categories. We used the Pearson χ² test to execute bivariate analysis of baseline characteristics with the percentage of respondents in agreement with a given item; the t test was used for continuous variables. Tests were 2 sided, with significance set at a probability value of .05 or less. Multivariate analysis was performed using hierarchical logistic regression models (via the GLIMMIX procedure in SAS, version 9.2). All individual and program characteristics were considered; a significance value of less than .1 on bivariate analysis was required for entrance into the model.

Of the 5345 residents eligible for analysis, 4402 returned completed surveys (82.4% response rate). We excluded 12 resident surveys with missing demographic information for a final cohort of 4390 (Table 1). The mean age of all respondents was 30.5 years; 31.7% were female, 62.1% were white, 51.5% were married, and 25.3% had at least 1 child.

The greatest proportion of residents trained in the Northeast (34.1%); 68.6% were in academic programs. Most of the residents were in programs associated with a postgraduate subspecialty fellowship (61.8%). The mean number of chief residents per training program was 5.

Among all residents, 34.9% reported socializing with their attendings. Residents were more likely to interact socially with faculty members if they were older (20-29 years, 32.2%; 30-34 years, 36.2%; ≥35 years, 38.5% [P = .01]) or more advanced in their training based on PGY level (P < .001) (Table 2). Men (36.4% vs 31.7% for women [P = .003]) and residents who were married (36.5% vs 32.9% for unmarried residents [P = .02]) or had children (39.0% vs 33.4% for those with no children [P = .001]) reported more frequent social interactions with faculty. Race of the resident was not associated with the likelihood of social interaction. Among program characteristics, residents in community programs (P < .001), smaller programs (P < .001), and programs without fellowships (P < .001) reported more frequent social interactions with attendings; geographic location of the training program was not associated with the likelihood of resident-faculty interactions.

Nearly three-quarters (72.0%) of all residents reported that they felt comfortable turning to faculty members in a time of hardship. Residents who were male (74.5% vs 66.3% for female residents [P < .001]), married (74.4% vs 69.0% for unmarried residents [P < .001]), and had children (75.8% vs 70.5% for those with no children [P = .001]) were more likely to agree with this statement. Although resident age was not linked with a perceived ability to turn to faculty members with difficulties in the program, PGY level (P = .009) demonstrated a significant association; specifically, interns and senior residents (PGY-4 and PGY-5) reported the highest rates of agreement. Residents in community programs (74.8%) were more likely to believe that they could turn to their attendings with problems than were residents in academic (70.8%) or US military (67.0%) programs (P = .02). The same was true for residents in smaller programs with 1 to 2 graduating chief residents compared with larger programs with at least 7 graduating chief residents (77.7% vs 66.8% [P < .001]).

Resident responses to the 2 survey items were highly associated. Those reporting less frequent social interactions with their attendings were almost 3 times more likely to believe that they could not approach faculty members with difficulties (35.9% vs 13.3% [P < .001]).

Most residents (85.2%) were satisfied with their training experience. Residents who were male (86.6% vs 82.2% for female residents [P < .001]), married (88.0% vs 82.1% for unmarried residents [P < .001]), and had children (87.6% vs 84.5% for those with no children [P = .01]) reported higher rates of satisfaction. Among racial groups, white (86.6%) and Hispanic residents (86.2%) reported the highest rates of satisfaction, whereas Asian residents (82.0%) were least satisfied (P = .02). We found the most satisfaction among PGY-5 (89.7%) and PGY-1 residents (87.1%), whereas PGY-2 residents were the least satisfied with their programs (82.8% [P < .001 across all levels]). Residents training at programs in the South were most likely to report overall program satisfaction (89.0%), while those in the Northeast were least likely to be satisfied (82.2% [P < .001 across all geographic regions]). Program size, type, and association with a fellowship were not associated with resident satisfaction.

On bivariate analysis, social interaction with attendings and the ability to turn to them with difficulties were highly related to overall satisfaction. Residents who did not socialize with their attendings were 3 times more likely to report dissatisfaction with their program (18.9% vs 6.2% [P < .001]). Residents who reported feeling unable to turn to faculty members with problems were 5 times more likely to report feeling dissatisfied with their training program (34.7% vs 7.0% [P < .001]).

Hierarchical regression analyses explored potential independent associations between resident and program factors and the development of successful interactions with attendings (Table 3 and Table 4). After adjustment, PGY-5 status (odds ratio [OR], 1.31 [P = .02]) was the only factor independently associated with increased resident-faculty social interactions. Women and PGY-1 and PGY-2 residents were significantly less likely to have social interactions with surgical faculty. Training programs with a military association, those with at least 7 chief residents, and programs associated with subspecialty fellowships were associated with less frequent social interactions.

After adjustment, residents who were married (OR, 1.41 [P < .001]) and PGY-1 (OR, 1.44 [P < .001]), PGY-4 (OR, 1.42 [P < .001]), and PGY-5 residents (OR, 1.64 [P < .001]) were more likely to report feeling comfortable turning to members of the faculty when faced with program difficulties. Residents in community programs and those in the smallest (1-2 chief residents) and the largest programs (5-6 and ≥7 chief residents) also were more likely to report this belief. Female sex was the only variable that was negatively associated with a resident's ability to seek support from faculty (OR, 0.78 [P < .001]).

To assess the potential influence of collegial relationships between surgical residents and attendings on level of overall resident satisfaction, a hierarchical logistic regression model was constructed. The items regarding social interaction and the ability to turn to faculty were then inserted into the model alongside those personal and program characteristics with a significance value of less than .1 on bivariate analysis (Figure). After adjustment, 3 individual resident characteristics were predictive of overall program satisfaction: being married (OR, 1.55 [P < .001]) and PGY-1 (OR, 1.64 [P < .001]) and PGY-5 levels (OR, 1.71 [P = .002]). Residents who trained in the South also were more likely to report satisfaction with their program (OR, 1.75 [P = .004]). Social interaction (OR, 2.44 [P < .001]) and the ability to turn to attendings with difficulties (OR, 5.59 [P < .001]) were the variables most strongly predictive of resident satisfaction as calculated by ORs.

Little evidence examines the social interactions between surgical residents and their attendings. In our study using a national survey of all US general surgery residents, almost two-thirds of residents reported few to no social interactions with attendings, and more than one-quarter reported an inability to turn to faculty members with their problems. Residents who did not socialize with attendings were 3 times more likely to express dissatisfaction with their residency experience, whereas residents who did not feel they could turn to their attendings were 5 times more likely to express dissatisfaction than their peers. Multivariate analysis demonstrated that collegiality was predictive of overall program satisfaction.

Others have examined the implications of collegial interactions among medical colleagues. Performing a 16-year literature review, Van Ham et al¹⁷ analyzed 24 publications to identify factors predictive of job satisfaction among general practitioners. “Relations and contact with colleagues” were among the 3 themes commonly mentioned. Janus et al¹⁸ performed a cross-national study to examine factors affecting physician motivation and job satisfaction. Participants completed a 28-item survey regarding workplace characteristics, noting their level of satisfaction and the item's importance. Among 675 respondents across medical and surgical specialties, German physicians reported “collegial relationships” as being significantly associated with job satisfaction (r = 0.190 [P < .001]), whereas American physicians cited “interactions with colleagues” (r = 0.351 [P < .001]) and “cooperative working relationships with colleagues and management” (r = 0.329 [P = .001]) as being predictive of happiness. The authors concluded that collegial relationships and collaborative care act as a medium through which peer recognition, communication, and support are fostered.¹⁸

Other investigations have analyzed the effect of mentorship on the development of junior faculty. Wingard et al²² followed up 67 assistant professors in a single-institution, 7-month structured mentorship program. A 36-item survey regarding confidence levels was administered before starting and after completing the program. Participants' self-efficacy scores increased in confidence regarding professional development (53% mean increase [P < .001]) and their abilities in research (19% mean increase [P < .001]), education (34% mean increase [P < .001]), and administrative duties (76% mean increase [P < .001]). Palepu et al¹⁹ used a 177-item survey to examine the prevalence of mentorship for junior faculty at 24 US medical schools. Fifty-four percent of 1302 junior faculty respondents noted recent mentorship relationships; these individuals reported significantly higher mean levels of research preparedness and research skill (P < .001) and a greater level of perceived professional support from their institutions than did their colleagues. On multivariate analysis, the career satisfaction scores of junior faculty with mentors were significantly higher than those without mentors (P < .003).

In the present study, on multivariate analysis, female residents and PGY-1 and PGY-2 residents were less likely to report regular social interactions with attendings. It is possible that this may play a part in the finding by previous studies that female surgical residents^5,23- 24 and junior residents^6,8 are more vulnerable to attrition than their peers. Residents in large programs reported fewer social interactions. This may be attributable to a decrease in the availability or duration of social interactions between individual residents and attendings at these programs, leading to a “lost in the mix” phenomenon. Fellows often are more likely to interact with attendings than residents; this interaction may contribute to the finding that residents at programs with fellowships reported fewer social interactions with attendings than those at programs without fellowships. This fact reinforces the suspicion that residents at programs with multiple fellows sometimes believe that the fellowships interfere with their surgical education.²⁵ This finding is of concern; residency programs need to be mindful and intervene in appropriate ways to counter this trend, particularly in view of the increasing number of fellowship positions across the country.^26- 27 However, our study did not demonstrate an effect of fellowships on residents' degree of overall program satisfaction.

The individual factors independently associated with the ability to turn to attendings in times of need included being married and being at the PGY-1, PGY-4, or PGY-5 level. These findings are consistent with previous studies using data from the NEARS survey, which have demonstrated midlevel residents (PGY-2 and PGY-3 and those performing dedicated research) to have lower levels of overall satisfaction, surgical confidence, and perceived program support and an increased level of disaffection with their program than senior residents or surgical interns.^28- 29

On multivariate analysis, female sex was associated with the inability to turn to faculty members with problems. Previous investigations have sought to understand barriers to the successful recruitment and retention of female surgeons. Gargiulo et al³⁰ surveyed 141 attending physicians, residents, and medical students at a single institution, requesting respondents to select deterrents to a surgical career. The authors found that female respondents were more likely than male respondents to be deterred by their idea of the “surgical personality” (40.0% vs 21.6% [P = .03]) and the perception of surgery as an “old boys' club” (22.2% vs 3.9% [P = .002]). Saalwachter et al³¹ demonstrated that female surgical residents were more likely than men to agree with the statement, “female residents are treated in an inferior manner compared with male residents” (16% women vs 4% men, P < .001). They were less likely than men to agree that multiple dynamics of their residency were balanced, including operative experience (75% vs 91% [P < .001]), availability of mentorship opportunities (55% vs 67% [P = .001]), and overall residency experience (67% vs 82% [P < .001]). In part, these findings are supported by our results, and they strengthen the argument that the successful development of collegial interactions between residents and attendings is important for overall residency satisfaction.

Policy modifications that facilitate collegial professional relationships are encouraged. Examples may include the creation of formalized mentorship programs for junior residents by senior residents and attendings. Pairing residents with a mentor of shared sex, race, or experience may promote an environment of comfort and assist in the identification of residents' professional and personal needs. Establishing this program may be difficult for female or minority residents given the relative paucity of female and minority faculty in surgery. Among junior and senior residents, mentorship may provide an opportunity to receive experience-based advice in a nonthreatening setting. In addition, scheduled social activities are suggested. Such informal events help equalize the power differential among residents and between residents and attendings. Service-specific team events at the conclusion of resident rotations may strengthen professional relationships, foster a cohesive team dynamic, and celebrate trainees' efforts.

Limitations to this study include those of self-report surveys, such as a response bias from respondents fearful of reprisal for voicing discordant attitudes. Explicit confidentiality measures were used to minimize this effect. Individual resident interpretation of the examined items may have biased their answers. However, such interpretation is unlikely to have occurred in a systematic fashion. Data concerning faculty demographics were not collected; therefore, analysis regarding the availability and influence of same-sex role models on resident experiences could not be explored. Finally, the numerous factors affecting happiness during one's surgical residency are poorly understood; causality of the observed association between collegiality and program satisfaction cannot be concluded, but the strong association cannot be ignored.

In summary, our national survey of US categorical general surgery residents highlights the importance of fostering successful working relationships between trainees and their attendings. Surgical residency is physically and emotionally taxing; collegial interactions with faculty may aid in creating a sense of inclusion in the surgical community. Strategies that facilitate the expansion of these interactions to junior residents, female residents, and residents in large academic programs should be considered.