Research

Original Investigation | PACIFIC COAST SURGICAL ASSOCIATION

Pregnancy-Related Attrition in General Surgery

Erin G. Brown, MD; Joseph M. Galante, MD; Benjamin A. Keller, MD; Juanita Braxton, PhD; Diana L. Farmer, MD

Invited Commentary
IMPORTANCE Residency attrition rates remain a great challenge for general surgery training page 898
programs. Despite the increasing acceptance of pregnancy during training, 1 common Supplemental content at
perception is that women who become pregnant are at increased risk of leaving surgery jamasurgery.com
programs.

OBJECTIVE To determine whether child rearing increases the risk of attrition from general
surgery residency.

DESIGN, SETTING, AND PARTICIPANTS Retrospective review of all categorical general surgery
residents in a single academic general surgery residency program over a 10-year period. All
categorical general surgery residents matriculated from July 1, 1999, until July 1, 2009.

MAIN OUTCOMES AND MEASURES Voluntary attrition rate, involuntary attrition rate, and
incidence of child rearing among residents.

RESULTS Eighty-five residents matched into categorical general surgery postgraduate year 1
spots from July 1, 1999, to July 1, 2009. Of the total residents, 49 (58%) were men while 36
(42%) were women. Attrition in the program was 18.8% (16 of 85). Seven (44%) of the
residents who left the program were women; this was 19% of all female residents in the
program. This was not significantly different from the proportion of men who left the
program (P = .90). A higher percentage of women (57%) left after their intern year compared
with men (22%). Furthermore, men had the highest rate of attrition during research (33%)
while no women left during research years. Among the 85 residents, 9 women reported a
total of 10 pregnancies and 16 men reported raising 21 children (1 woman and 1 man left the
program). The proportion of child rearing was higher in those who did not leave the program
but this did not reach significance (P = .10). Neither age (odds ratio, 1.0; 95% CI, 0.8-1.4), sex
(odds ratio, 1.0; 95% CI, 0.2-3.6), nor incidence of child rearing during training (odds ratio, 1.0;
95% CI, 0.1-9.6) were associated with an increased risk of attrition. Residents with children
born during training did not demonstrate fewer total case numbers (men, P = .40; women,
P = .93) or board pass rates (men, P = .76; women, P = .50) compared with residents who did
not have children during training. Women who had children during training were more likely
to pursue fellowship (87.5%) than those who did not (66.7%)(P < .001).

CONCLUSIONS AND RELEVANCE The current study demonstrated there was no association
between female sex and attrition at our institution. Child rearing did not appear to be a risk
factor for attrition in either men or women. Furthermore, child rearing did not negatively
impact the quality of training based on case numbers and board pass rates. Despite prevalent
stereotypes, child rearing did not cause women or men to leave the program.

Author Affiliations: Department of

Surgery, University of California,
Davis, Sacramento.
Corresponding Author: Erin G.
Brown, MD, Department of Surgery,
University of California, Davis, 2315
Stockton Blvd, OP512, Sacramento,
JAMA Surg. 2014;149(9):893-897. doi:10.1001/jamasurg.2014.1227 CA 95817 (erin.brown@ucdmc
Published online July 16, 2014. .ucdavis.edu).

893

Copyright 2014 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ by LEONARDO REZENDE on 09/14/2021

 Research Original Investigation
G
eneral surgery residency is challenging. Despite the in-
troduction of work-hour limitations to 80 hours per
week and new restrictions on hours for postgraduate
year (PGY) 1 residents, attrition from general surgery pro-
grams remains high.1 Some reports estimate that between 14%
to 26% of residents fail to complete their surgical residency.2-6
A consistent finding in research on residency attrition is that
residents leave for lifestyle factors.1-3,5,7 However, these life-
style factors are poorly and variably defined.
Few other causes have been identified as risk factors for
attrition. Several studies have identified a relationship be-
tween female sex and increased risk of attrition3-5,8; how-
ever, not all studies corroborate this relationship.2,6,7,9 De-
spite inconclusive data regarding the risk of attrition among
female residents, the stereotype persists. Furthermore, women
who become pregnant during residency may also be subject
to stigmatization and speculation about their ability or desire
to complete the training program. As many as two-thirds of resi-
dents reported a negative perception of pregnancy during
training.10 To our knowledge, no other studies have investi-
gated a potential link between childbearing and attrition.
Given the growing number of women in medicine, poten-
tial links between sex, pregnancy, and attrition need further in-
vestigation. The objective of this study was to determine whether
child rearing during training increases the risk of attrition from
general surgery residency. We hypothesized that pregnancy does
not have a negative impact on training or attrition.
Methods
We performed a retrospective review of resident files for all cat-
egorical general surgery residents matriculating into a single
academic general surgery residency program over a 10-year pe-
riod (July 1, 1999-July 1, 2009). All categorical general surgery
residents who matriculated to the general surgery residency
program at University of California, Davis, for PGY-1 from 1999
until 2009 were included (men and women). Residents were
excluded if they matched into preliminary positions or other
designated surgery programs (plastic surgery, urology, cardio-
thoracic surgery, or vascular surgery). Residents beginning as
preliminary residents who were later offered categorical po-
sitions and those joining our program after PGY-1 were also ex-
cluded. The study was reviewed by the University of Califor-
nia, Davis, institutional review board and consent was deemed
exempt owing to the retrospective nature of the study.
Main outcome measures were voluntary attrition rate (de-
fined as residents leaving the program by personal choice), in-
voluntary attrition rate (residents leaving at the insistence of
the program), and incidence of child rearing among male and
female residents (all children born to or adopted by residents
or their spouses during residency). No data on abortions or mis-
carriages were available. Secondary outcomes were length of
leave, weeks of training extension, total number of cases at resi-
dency completion, board pass rates, fellowship rate, Ameri-
can Board of Surgery Intraining Exam (ABSITE) scores, age at
the beginning of training, marital status, and residents with
children prior to the start of training.
894 JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ by LEONARDO REZENDE on 09/14/2021
Pregnancy-Related Attrition
Table 1. Cohort Demographicsa
Demographic No. (%)
Residents, total No. 85
Sex
Men 49 (58)
Women 36 (42)
Attrition 16 (18.8)
Child-rearing residents 25 (29)
[31 Children]
Average case No. at graduation 979
Average board pass rate, %
Written 100
Oral, first attempt 93
Fellowship, % 77
a
General characteristics of the cohort of categorical general surgery residents
entering the program between 1999 and 2009.
Statistical analysis was performed with univariate analy-
sis using the χ2 test and t test. A value of P < .05 was consid-
ered significant. Multivariate analysis was performed using ex-
act logistic regression to determine which factors were
statistically associated with an increased risk of attrition. Vari-
ables included were age, incidence of child rearing during train-
ing, sex, and marital status.
Results
A total of 85 residents matched into categorical general sur-
gery PGY-1 positions from 1999 to 2009 (Table 1). Of the total
residents, 49 (58%) were men, and 36 (42%) were women. The
average age on entering residency was 27.7 years; there was no
difference in age between men and women entering the pro-
gram. The overall attrition rate in the program was 18.8% (16
of 85 residents).
Of the 16 residents who left the program, 1 resident left in-
voluntarily while the remaining 15 left voluntarily. Six resi-
dents (38%) left after their first year, 3 (19%) after their sec-
ond, and 4 (25%) after their third (Figure 1A). During their
research years (performed after PGY-3), 3 residents (19%) quit
the program. No residents left during their last 2 years. Three
residents left to join another surgery residency (2 for family
reasons and 1 to pursue research opportunities). Twelve resi-
dents chose to pursue different specialties (family practice
[n = 2], obstetrics and gynecology [n = 1], anesthesia [n = 4],
plastic surgery [n = 1], pediatrics [n = 1], urology [n = 1], radi-
ology [n = 1], and flight medicine [n = 1]). Only 1 resident de-
cided not to practice medicine.
When examining the potential sex difference among resi-
dents leaving the program, 7 of the 16 residents who left were
women (44%); this was 19% (7 of 36) of all female residents in
the program during the period. The remaining 9 residents (56%)
who left the program were men, which was 18% (9 of 49) of
all male residents in the program. There was no statistically
significant difference in the proportion of men vs women leav-
ing the program (P = .90). While there was no difference in over-
all attrition rate by sex, the incidence of attrition per PGY dif-
jamasurgery.com
 Pregnancy-Related Attrition Original Investigation Research

Figure 1. Attrition Rates

A Attrition by PGY B Attrition by PGY and Sex

40 (6) 60 (4)
Men
35
50 Women
Incidence of Attrition, %

Incidence of Attrition, %
30
(4) 40
25
(3)
20 (3) (3) 30 (2)

(2) (2) (2)

15
20
(1)
10
10
5

0 0
PGY-1 PGY-2 PGY-3 Research PGY-4 PGY-5 PGY-1 PGY-2 PGY-3 Research PGY-4 PGY-5
Year Year

A, Rate of attrition per postgraduate year (PGY). Incidence of attrition was highest after PGY-1 but residents continued to leave throughout research years. The
numbers in parentheses indicate the total number of residents leaving. B, Rate of attrition by PGY and sex. Most women left after their intern years while men left at
approximately equal rates from PGY-1 throughout the research years. The numbers in parentheses are the numbers of men or women leaving per PGY.

fered between men and women (Figure 1B). A higher Figure 2. Rates of Child Rearing by PGY and Sex
percentage of women (57%) left after their intern year com-
pared with men (22%). Furthermore, men had the highest rate 45
Men (4)
of attrition during research (33%) while no women left during 40 (8)
Women
research years.
Incidence of Child Rearing, %

35
Rates of child rearing among the entire group of 85 resi- 30
(3)

dents were high, with 29% of residents participating in child (5)

25
rearing during residency (25 of 85). The proportion of child rear-
20 (4)
ing was higher in those who did not leave the program (23 of
15
69 vs 2 of 16) but this did not reach statistical significance
(1) (2) (1) (2) (1)
(P = .10). Six residents had children prior to beginning train- 10

ing; 5 of these 6 residents had additional children during train- 5

ing. Of all residents, 47% were married. Residents leaving the 0

PGY-1 PGY-2 PGY-3 Research PGY-4 PGY-5
program were significantly less likely to be married com- Year
pared with those who did not (12.5% vs 55.1%) (P = .002). Of
all married residents, 55% had children during training; 1 of Twenty-nine percent of residents had children during training. Child rearing
occurred throughout all years for both sexes but was most common during
these residents left the program. Seven percent of unmarried
research years and chief years. The numbers in parentheses indicate the
residents had children during training; 1 of these residents left numbers of children born to men and women during each postgraduate year
the program. (PGY).
Looking specifically at the female residents, 25% of women
had children during training. Nine women reported a total of vs 27.6 years). Evaluation of surrogates for clinical perfor-
10 pregnancies. Only 1 of these women left the program. Chil- mance revealed no significant difference in average case vol-
dren were born throughout residency, with the most com- ume at graduation (1015 vs 1020), written board pass rate (100%
mon years for childbirth being during research (40%) and the for all), or oral board pass rate on first attempt (100% vs 93%)
final year of training (30%) (Figure 2). However, children were between the 2 groups (Table 2). Women who had children dur-
born during the first, third, and fourth clinical years as well; ing training were significantly more likely to pursue fellow-
no women had children during their second year. The aver- ship (87.5%) than those who did not (66.7%) (P < .001). Fi-
age maternity leave was 10.1 weeks for all women. Women hav- nally, average ABSITE score prior to childbirth was compared
ing children during research years took longer maternity leaves with postpregnancy scores and revealed no difference.
(range: 12-16 weeks; average: 13.0) than women taking leave Male residents also demonstrated a high percentage of
during clinical years (range: 5-12 weeks; average: 8.2; P = .01) child rearing during training. Sixteen men (32% of male resi-
(eFigure in the Supplement). One woman extended resi- dents) reported 21 pregnancies. Attrition among this group of
dency training by 2 weeks while the remaining residents com- residents was also low, with only 1 man leaving the program.
pleted residency on schedule. Women taking leave during clini- Men were also most likely to have children born during re-
cal years used vacation time, the American Board of Surgery search years (24%) and their final year of training (38%)
46-week rule, and/or extended training. (Figure 2). However, men also had children throughout train-
Comparing women who had children during training with ing years, with 10% being born during the second year, 19% dur-
those who did not, there was no difference in average age (27.4 ing the third year, and 10% during the fourth clinical year.

jamasurgery.com JAMA Surgery September 2014 Volume 149, Number 9 895

Copyright 2014 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ by LEONARDO REZENDE on 09/14/2021

 Research Original Investigation
Table 2. Female Cohort Demographicsa
Pregnancy
During Training
Variable (n = 9)
Average age, y 27.4
Average total No. of cases at graduation 1015
Board pass rate (oral), % 100.0
Fellowship, % 87.5
Table 3. Male Cohort Demographicsa
Child Rearing No Child Rearing
During Training During Training
Variable (n = 16)
Average age, y 28.5
Average total No. of cases at graduation 921
Board pass rate (oral), % 88.9
Fellowship, % 81.3
When comparing the cohort of men having children dur-
ing residency with the men who did not participate in child
rearing, the average age of men having children was older (28.5
vs 27.3 years); however, this was not significantly different
(P = .07). Average total case number, board pass rates, and rates
of fellowship were no different (Table 3). Childbearing did not
affect ABSITE scores. Paternity leave during clinical years
was 5 days.
Multivariate analysis of the entire cohort revealed that only
marital status was a statistically significant predictor of attri-
tion (odds ratio, 0.2; 95% CI, 0.01-0.9). This correlates with the
univariate analysis that being married predicted a decreased
risk of attrition. Neither age (odds ratio, 1.0; 95% CI, 0.8-1.4),
sex (odds ratio, 1.0; 95% CI, 0.2-3.6), nor incidence of child rear-
ing during training (odds ratio, 1.0; 95% CI, 0.1-9.6) were as-
sociated with an increased risk of attrition.
Discussion
Several institutions have reported an association between fe-
male sex and attrition, with rates of attrition among women
as high as 39%.3-5,8 Dodson and Webb5 noted that 19% of all
residents voluntarily leaving their program had recently had
children and that 22% of the women left the program after re-
cent childbirth. Additionally, numerous studies have demon-
strated the prevalence of negative perceptions regarding preg-
nancy during training.10-12 One study determined that female
residents delay child rearing until after training owing to per-
ceived threats to their careers and that women were more likely
to report these perceptions than men.11 Turner et al10 sur-
veyed female surgeons and demonstrated a persistent nega-
tive stigma regarding pregnancy in training; the study also
found that both male and female surgeons (residents and fac-
ulty) exert negative influences on the decision to pursue child
rearing during training.
To our knowledge, the current study is the first to exam-
ine potential links between pregnancy and attrition. In a co-
hort of residents at our institution, neither sex nor childbear-
ing was a risk factor for attrition by univariate or multivariate
896 JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ by LEONARDO REZENDE on 09/14/2021
Pregnancy-Related Attrition
No Children
During Training
(n = 25) P Value
a
Comparison of women who had
27.6 .79
children during training vs those
1020 .93 who did not. The only statistically
92.9 .50 significant difference was that
women having children were more
66.7 <.001
likely to pursue fellowship.
(n = 33) P Value
27.3 .07 a
Comparison of men who had
959 .40 children during training vs those
92.9 .76 who did not. There were no
statistically significant differences
79.2 .87
between the 2 groups.
analysis. Our attrition rate of 18.8% is comparable with rates
published by other groups.2-6 Rates of attrition among men and
women were equal yet there were differences in the timing of
attrition, with women leaving the program earlier than men.
Although these differences did not reach statistical signifi-
cance, this was likely owing to the small sample size. Women
composed a large overall percentage of the residency and 25%
of these women had children during training. These women
were not more likely to leave the program. Men choosing to
participate in child rearing during training (32%) were not as-
sociated with an increased risk of attrition.
Further examination of the cohort of both male and fe-
male residents having children during residency did not re-
veal any decline in clinical performance compared with resi-
dents not participating in child rearing, based on case volume
and board pass rates. Additionally, child rearing did not have
an effect on ABSITE scores for either sex. Interestingly, women
pursuing child rearing during training were significantly more
likely to pursue fellowship training. Perhaps the additional time
required for fellowship training is a factor in the decision not
to delay pregnancy until after completion of training for some
of these women or they believe that fellowship training may
afford more career flexibility. However, it is also likely that these
are highly motivated women who are unlikely to deviate from
their career goals.
With more women entering the field of surgery than
ever before, any attrition related to sex differences or child
rearing needs to be carefully examined. 12,13 A study by
Arnold et al14 found that female medical students who com-
pleted their surgery rotation after the new work-hour limi-
tations were more likely to believe that surgery could allow
for a positive work-life balance. These students also held
more favorable views of childbearing among female sur-
geons. While these changing perceptions are positive, it
should be acknowledged that female surgeons are more
likely to be childless or to have children later in life com-
pared with male surgeons.12,15 The medical risks of delaying
childbearing are significant. A recent survey revealed that
32% of female surgeons reported fertility struggles com-
pared with 11% of the general population.16
jamasurgery.com
 Pregnancy-Related Attrition Original Investigation Research

With increasing numbers of women entering surgical resi-
dency during prime childbearing years, the acceptance of preg-
nancy during residency is imperative. Furthermore, rates of
child rearing for both male and female residents have been re-
ported and are increasing.17,18 While accommodating mater-
nity and paternity leave may place strain on a residency pro-
gram, these adjustments must be made. By establishing written
policies for leave and encouraging open communication and
advanced notice, burden can be lessened. Furthermore, these
policies may reduce perceived negative attitudes toward child
rearing during training among surgery residents and faculty.
Our surgical residency program is large, with up to 50 cat-
egorical residents at a time and a high percentage of female resi-
dents. The incidence of pregnancy among our female resi-
dents has increased 4-fold, according to a recent study
performed by our institution.18 While many of these women
chose to have children during their research years, 60% of the
women in this cohort had children during clinical years. Given
the Family and Medical Leave Act mandating up to 12 weeks
of leave for any woman after childbirth, residency programs
must devise a way to accommodate this maternity leave.18 Our
institution prioritizes maintenance of education for resi-
dents on service and aims to avoid overburden for covering resi-
dents. Schedule adjustments are based on the need for in-
house coverage, service volume, number of residents on
service, and the length of leave. Existing schedules can be ad-
justed to reallocate call shifts, residents can be redistributed
to different services, and research residents can be used to
cover clinical duties when needed. The aforementioned strat-
egies, or combinations of such, have allowed residents to take
their desired leave for child rearing without undue stress on
their peers.
Our study was limited by the fact that it was a single-
institution study. We have a long tradition of matriculating a
high number of female residents and a high proportion of our
residents choose to participate in child rearing during train-
ing. These factors may preclude wide application of these find-
ings to other programs but they do highlight that neither sex
nor child rearing need to be associated with attrition. Further
investigation with a multicenter study is needed; however, we
believe that programs should be prepared with systems in place
to help support residents who elect to participate in child rear-
ing during pregnancy.
Conclusions
Based on a review of 10 years of data in this single institution,
women do not appear to be at increased risk for attrition. Fur-
thermore, pregnancy and child rearing do not appear to be risk
factors for leaving the program in either men or women. With
the proper institutional support, child rearing during training
can and should be accommodated and should not place resi-
dents at an increased risk for attrition.

ARTICLE INFORMATION
Accepted for Publication: March 21, 2014.
Published Online: July 16, 2014.
doi:10.1001/jamasurg.2014.1227.
Author Contributions: Dr Brown had full access to
all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Brown, Galante, Braxton,
Farmer.
Acquisition, analysis, or interpretation of data:
Brown, Galante, Keller, Braxton.
Drafting of the manuscript: Brown, Braxton.
Critical revision of the manuscript for important
intellectual content: Galante, Keller, Farmer.
Statistical analysis: Brown, Keller, Braxton.
Study supervision: Galante, Farmer.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This paper was presented
at the 85th Annual Meeting of the Pacific Coast
Surgical Association; February 17, 2014; Dana Point,
California.
Additional Contributions: We thank Garth Utter,
MD, University of California, Davis, for assistance
with statistical analysis. He did not receive financial
compensation.
REFERENCES
1. Leibrandt TJ, Pezzi CM, Fassler SA, Reilly EF,
Morris JB. Has the 80-hour work week had an
impact on voluntary attrition in general surgery
residency programs? J Am Coll Surg. 2006;202(2):
340-344.
2. Yeo H, Bucholz E, Ann Sosa J, et al. A national
study of attrition in general surgery training: which
residents leave and where do they go? Ann Surg.
2010;252(3):529-534, discussion 534-536.
3. Aufses AH Jr, Slater GI, Hollier LH. The nature
and fate of categorical surgical residents who “drop
out”. Am J Surg. 1998;175(3):236-239.
4. Bergen PC, Turnage RH, Carrico CJ.
Gender-related attrition in a general surgery
training program. J Surg Res. 1998;77(1):59-62.
5. Dodson TF, Webb AL. Why do residents leave
general surgery? the hidden problem in today’s
programs. Curr Surg. 2005;62(1):128-131.
6. Kwakwa F, Jonasson O. Attrition in graduate
surgical education: an analysis of the 1993 entering
cohort of surgical residents. J Am Coll Surg. 1999;
189(6):602-610.
7. Sullivan MC, Yeo H, Roman SA, et al. Surgical
residency and attrition: defining the individual and
programmatic factors predictive of trainee losses.
J Am Coll Surg. 2013;216(3):461-471.
8. Longo WE, Seashore J, Duffy A, Udelsman R.
Attrition of categoric general surgery residents:
results of a 20-year audit. Am J Surg.
2009;197(6):774-778, discussion 779-780.
9. Naylor RA, Reisch JS, Valentine RJ. Factors
related to attrition in surgery residency based on
application data. Arch Surg. 2008;143(7):647-651,
discussion 651-652.
10. Turner PL, Lumpkins K, Gabre J, Lin MJ, Liu X,
Terrin M. Pregnancy among women surgeons:
trends over time. Arch Surg. 2012;147(5):474-479.
11. Willett LL, Wellons MF, Hartig JR, et al. Do
women residents delay childbearing due to
perceived career threats? Acad Med. 2010;85(4):
640-646.
12. Chen MM, Yeo HL, Roman SA, Bell RH Jr, Sosa
JA. Life events during surgical residency have
different effects on women and men over time.
Surgery. 2013;154(2):162-170.
13. Davis EC, Risucci DA, Blair PG, Sachdeva AK.
Women in surgery residency programs: evolving
trends from a national perspective. J Am Coll Surg.
2011;212(3):320-326.
14. Arnold MW, Patterson AF, Tang AS. Has
implementation of the 80-hour work week made a
career in surgery more appealing to medical
students? Am J Surg. 2005;189(2):129-133.
15. Troppmann KM, Palis BE, Goodnight JE Jr, Ho
HS, Troppmann C. Women surgeons in the new
millennium. Arch Surg. 2009;144(7):635-642.
16. Sullivan M. Women Surgeons Face Childbearing
Challenges. Plainview, NY: ACS Surgery News; 2013.
17. Carty SE, Colson YL, Garvey LS, et al. Maternity
policy and practice during surgery residency: how
we do it. Surgery. 2002;132(4):682-687, discussion
687-688.
18. Smith C, Galante JM, Pierce JL, Scherer LA. The
surgical residency baby boom: changing patterns of
childbearing during residency over a 30-year span.
J Grad Med Educ. 2013;5(4):625-629.

jamasurgery.com JAMA Surgery September 2014 Volume 149, Number 9 897

Copyright 2014 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ by LEONARDO REZENDE on 09/14/2021