Evolution in Fellowship Selection during General Surgery Residencies Laura R. Vick, MD Karen R. Borman, MD University of Mississippi Medical Center, Jackson, MS

 Increasing numbers of graduating residents are pursuing fellowships  PGY-5 choices are heterogeneous –Individual variables (e.g. - gender) (e.g. - gender) –Residency characteristics (e.g. - program location) (e.g. - program location) –Over time

 PGY-1 fellowship choices unreported  For this study –PGY-1 future fellowship choices from ‘93 - ‘07 –Changes in preferences over timeover time as residents progress during trainingas residents progress during training –Fellowship choices as related to demographic variables GenderGender Program type, size and locationProgram type, size and location

ABSITE examination data – last 15 years Choices for Additional choices for 2006 No Fellowship Minimally Invasive Surgery Undecided Advanced GI Surgery Colon & Rectal Colon & Rectal Hepatobiliary Surgery SCC/Trauma/Burn SCC/Trauma/Burn Breast Surgery Oncology Oncology Pediatric Surgery Pediatric Surgery Additional choices for 2007 Plastic Surgery Plastic Surgery Bariatric Surgery Thoracic Surgery Thoracic Surgery Endocrine Surgery Transplantation TransplantationEndoscopy Vascular Surgery Vascular Surgery SCC split from Trauma/Burn Other Specialty Other Specialty = “Any Fellowship”

All residents Dataset 1 Remove Designated Preliminary / Hand Dataset 3 Paired PGY-1 and PGY-5 responses Residents applying for ABS Qualifying Exam by July 2007 Dataset 2 PGY PGY

Dataset 1: > 80,000 responses > 20,000 PGY-1 responses PGY-1 responses Undecided46%46%55% No Fellowship 8%11%7% Any Fellowship 46%42%38% Undecided Responses 1993, 2000, 2007 all PGY levels PGY-1 PGY-2 PGY-3 PGY-4 PGY-5

Any Fellowship for PGY Thoracic10%7%3% Plastic10%11%9% Vascular5%3%3% SCC/Trauma/ Burn 4%4%5% Pediatric4%3%3% Oncology4%4%4% Other3%5%8% CRS2%2%2% Transplant2%2%1% PGY-1 responses Undecided46%46%55% No Fellowship 8%11%7% Any Fellowship 46%42%38%

Any Fellowship for all PGY years PGY-1 PGY-2 PGY-3 PGY-4 PGY-5

No Fellowship for all PGY years PGY-1 PGY-2/3 PGY-4 PGY-5 PGY-1 responses Undecided46%46%55% No Fellowship 8%11%7% Any Fellowship 46%42%38%

Dataset 2: > 19,000 responses  9,000 PGY-1 responses Responses by Gender for all years Female % Male %

FemaleMale No Fellowship 7%4%5%5%5%5% Undecided55%57%57%46%56%51% Colon & Rectal 4%1%2%3%2%5% SCC/Trauma/Burn3%5%2%6%6%4% Oncology8%12%6%4%5%4% Pediatric Surgery 9%8%4%5%3%3% Plastic Surgery 8%3%15%6%3%10% Thoracic Surgery 2%3%4%16%10%11% Transplantation2%1%1%2%4%2% Vascular Surgery 1%3%2%7%5%4% Other Specialty 2%4%4%1%1%2%

Program Type UniversityIndependent No Fellowship 4%4%5%8%6%5% Undecided49%54%47%47%61%60% Colon & Rectal 2%2%4%4%1%4% SCC/Trauma/Burn2%5%4%8%6%3% Oncology6%7%6%3%6%2% Pediatric Surgery 7%5%5%3%2%1% Plastic Surgery 5%3%10%8%3%11% Thoracic Surgery 16%10%10%10%6%9% Transplantation2%3%2%2%3%1% Vascular Surgery 5%4%4%7%4%2% Other Specialty 1%2%3%1%2%2%

Program Size SmallMediumLarge No Fellowship 10%10%7%5%3%5%7%20%3% Undecided42%58%59%50%57%49%59%46%52% Colon & Rectal 5%1%3%2%2%4%3%2%4% SCC/Trauma/Burn8%8%3%5%6%4%3%3%2% Oncology1%4%3%6%7%3%3%7%8% Pediatric Surgery 3%2%0%6%4%5%0%6%3% Plastic Surgery 10%4%13%6%3%8%13%3%13% Thoracic Surgery 12%8%5%12%10%12%5%6%9% Transplantation2%1%1%2%3%2%1%4%1% Vascular Surgery 6%4%2%6%5%4%2%3%2% Other Specialty 1%3%3%1%1%3%3%2%2%

Program Location over all years

Dataset 3: 12,259 paired responses  6,111 PGY-1 chose Undecided (50%)  Of the Undecided No Fellowship (24%) No Fellowship (24%) Vascular Surgery (12%) Vascular Surgery (12%) Other Fellowship (12%) Other Fellowship (12%) Only 22% of all PGY-1 residents accurately identified their final post-residency plans

 Majority of incoming residents are Undecided  Fellowship choices evolve as PGY level advances  Evolution occurs at variable rates  Uncertainty for PGY-1 residents is desirable, reflecting open-mindedness  Junior residents should experience the full spectrum of potential fellowship areas

 The number of residents choosing fellowships are increasing  Fellowships chosen have changed over time  PGY-1 residents unsure whether to pursue fellowship  Alternative educational pathways are being evaluated and implemented

 Educational models featuring early specialty tracking continue to proliferate  These models should include exposure to all areas of specialization  Examination of PGY-1 fellowship training choices could contribute to the ongoing process of residency redesign  Further studies underway to determine the final plans of the 78% percent of residents who change their mind