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An Empirical National Assessment of the Learning Environment and Factors Associated With Program Culture

Ellis, Ryan J. MD, MS*,†; Hewitt, D. Brock MD, MS, MPH*,‡; Hu, Yue-Yung MD, MPH*; Johnson, Julie K. PhD*; Merkow, Ryan P. MD, MS*,†; Yang, Anthony D. MD, MS*; Potts, John R. III MD§; Hoyt, David B. MD; Buyske, Jo MD; Bilimoria, Karl Y. MD, MS*,†,⊠

doi: 10.1097/SLA.0000000000003545

Objectives: To empirically describe surgical residency program culture and assess program characteristics associated with program culture.

Summary Background Data: Despite concerns about the impact of the learning environment on trainees, empirical data have not been available to examine and compare program-level differences in residency culture.

Methods: Following the 2018 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. Survey items were analyzed using principal component analysis to derive composite measures of program culture. Associations between program characteristics and composite measures of culture were assessed.

Results: Analysis included 7387 residents at 260 training programs (99.3% response rate). Principal component analysis suggested that program culture may be described by 2 components: Wellness and Negative Exposures. Twenty-six programs (10.0%) were in the worst quartile for both Wellness and Negative Exposure components. These programs had significantly higher rates of duty hour violations (23.3% vs 11.1%), verbal/physical abuse (41.6% vs 28.6%), gender discrimination (78.7% vs 64.5%), sexual harassment (30.8% vs 16.7%), burnout (54.9% vs 35.0%), and thoughts of attrition (21.6% vs 10.8%; all P < 0.001). Being in the worst quartile of both components was associated with percentage of female residents in the program (P = 0.011), but not program location, academic affiliation, size, or faculty demographics.

Conclusions: Residency culture was characterized by poor resident wellness and frequent negative exposures and was generally not associated with structural program characteristics. Additional qualitative and quantitative studies are needed to explore unmeasured local social dynamics that may underlie measured differences in program culture.

*Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL

American College of Surgeons, Chicago, IL

Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA

§Accreditation Council for Graduate Medical Education (ACGME), Chicago, IL

American Board of Surgery, Philadelphia, PA.

This study is supported by funding from the American Board of Surgery (ABS), American College of Surgeons (ACS), and Accreditation Council for Graduate Medical Education (ACGME). RJE and DBH were supported by postdoctoral research fellowships (Agency for Healthcare Research and Quality [AHRQ] 5T32HS000078). RPM is supported by the Agency for Healthcare Quality (K12HS023011). ADY is supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (K08HL145139).

The authors report no conflicts of interest.

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