Factors influencing surgical residents attrition: a mixed-methods study from a low-middle-income country

Premature loss of residents prior to completion of training, is common among surgical specialties, negatively impacts other trainees and program leadership, and disrupts the continuity of care. Developing countries face various challanges which may impact this attrition, however, there is a lack of literature on the rate of resident attrition in low-middle-income countries (LMICs). We aimed to identify the rates and predictors of surgical residents' attrition at a single institution.

We conducted a mixed-methods observational study; single center retrospective review and prospective survey including quantitative and qualitative analyses of trainees who left prior to completion of training. Data regarding gender, marital status, locality, year of training, surgical specialty, and reasons for attrition were collected. The trainees were then contacted for a follow-up survey to assess their reasons as well as pathways after leaving, opinions about the program, program director, relationship with peers, and their satisfaction with the decision.

Between 2005 and 2024, 617 surgical residents were enrolled, of whom 51.0% (n=315) completed training, 30.5% (n=188) left before completion (attrition), and 18.5% were still in training. Gender and geographic background (local vs. non-local) were not associated; however, marital status significantly influenced attrition, with singles more likely to drop out (60.5% vs. 34.3% among graduates (p<0.001). Most departures occurred in the first year (54.3%; n=102) particularly in pediatric surgery (62.2%; n=23/37) and general surgery (44.1%; n=57/129). At exit interviews, the most common reasons included family commitments (34.2%), personal reasons (9.6%), and better job opportunities (9.5%). A follow-up survey of 59 former residents revealed that 61% (n=36) switched to another program in the same specialty, while 30.5% (n=18) changed specialties. Despite moderate satisfaction with training (3.07/5) and program leadership (3.14/5), respondents reported high satisfaction with their decision to leave (4.31/5). Main concerns included unprofessional behavior (30.5%), toxic work environments (20.3%), and excessive workload (16.9%).

Surgical resident attrition at our center was high, particularly in the early years of training and in certain specialties, with marital status emerging as a significant predictor. Efforts at reducing reasons for attrition are critical for the future.