General Surgery versus Fellowship: the Role of the Independent Academic Medical Center Souheil W. Adra, MD Amber W. Trickey, MS Moira E. Crosby, MPH Scott H. Kurtzman, MD * Mark L. Friedell, MD * H. David Reines, MD * * Independent Training Program Committee of the Association of Program Directors in Surgery

Disclosures NONE

Introduction Fellowship training is increasing among graduates of United States surgical residency programs Worsening shortage of general surgeons Reasons leading to fellowship training are not completely understood The impact of the type of surgery program on fellowship training is unknown University Academic Medical Centers (UAMC) vs. Independent Academic Medical Centers (IAMC)

Survey Methods May-August 2011 Electronic survey 14 multiple-choice questions, 1 open-ended question Sent to all 250 general surgery program directors Analyzed the data using Fisher’s exact tests University= university hospital is the prime hospital of the training program

Results Respondents are representative of all 250 programs Any response: N = 91 (36%) Surveys completed: N = 74 (30%)

Program Characteristics IAMC N (%) UAMC p-value Hospital Size 0.36 < 300 beds 1 (3) 5 (12) 300-500 beds 14 (45) 21 (49) > 500 beds 16 (52) 17 (40) Number of Chiefs 0.001 < 3 6 (19) 0 (0) 3 – 5 22 (71) 28 (65) > 5 3 (10) 14 (33) Missing 1 (2) Number of Cases 0.37 750-900 5 (16) 6 (14) 901-1050 10 (32) > 1050 16 (37) Total 31 (100) 43 (100) -

Program Characteristics, cont. IAMC N (%) UAMC p-value Female Chiefs 0.99 < 30% 12 (39) 16 (37) 30 – 50% 15 (48) 21 (49) > 50% 4 (13) 6 (14) City Population 0.13 < 10,000 1 (3) 0 (0) 10,000 – 49,999 7 (23) 4 (9) 50,000 – 499,999 9 (29) ≥ 500,000 17 (40) Region 0.25 Midwest 5 (16) 9 (21) Northeast 13 (42) 10 (23) South 18 (42) West 5 (12) Total 31 (100) 43 (100) -

Distribution of Fellowships UAMC IAMC

Reasons to Pursue Fellowships UAMC IAMC Lifestyle was more commonly listed as a top three reasons for choosing a fellowship by program directors of IAMCs

Reasons to Pursue General Surgery UAMC IAMC

UAMC vs. IAMC Responses There was a trend to more residents going into general surgery from IAMC as compared to UAMC This shows the percentage of program directors that had more than a quarter of their residents go on to become general surgeons

General Surgery by Region

Discussion There is a perception that IAMC graduates do not have the same opportunities for fellowships as UAMC graduates IAMCs tend to graduate proportionately more general surgeons than UAMCs May impact growing general surgeons deficit

Discussion The 80-hour workweek is perceived by Program Directors to increase the interest in fellowships Need tactics to attract fellowship trained surgeons back to general surgery

Limitations Small sample size despite good response rate underpowered for detection of statistically significant differences Using program directors’ perception vs. residents Survey based study: Self-selection bias Respondents’ memory Respondents may be motivated to give answers that present themselves in a favorable light Selection bias unlikely, representative sample Using program directors’ perception vs. residents for our pilot study Representative sample: Our sample had a comparable ratio of IAMCs in the respondants as in the total programs our sample had comparable distribution of programs regionally and by size of city.

Conclusions Residents enter similar types of fellowships in IAMC vs. UAMC Reasons for career choices were similar in IAMC vs. UAMC Geographic location of residency may influence choice of career Trends without statistical significance: More general surgeons from IAMC First choice of fellowships from UAMC

Future Studies Direct surveys of residents Further evaluation of program type in shaping career choices Develop strategies for reducing the general surgeon shortage Further evaluation of program type in shaping career choices should be considered while designing studies as it could be a confounding variable.