Book Review

Getting Cut: Failing to Survive Surgical Residency Training

N Engl J Med 2007; 357:948-949August 30, 2007

Article

Getting Cut: Failing to Survive Surgical Residency Training
By Virginia Adams O'Connell. 283 pp. Lanham, MD, University Press of America, 2007. $39.95. ISBN: 978-0-7618-3662-9

This book was written by a sociologist who focuses on a critical but insufficiently studied sociological aspect of residency training programs — why is it that so many residents who start surgical residency programs do not finish them? Getting Cut is based on the concept that given the considerable time and effort that program directors and faculty devote to recruiting residents to their programs and the strong desire of residents who matriculate into programs to finish them, a primary goal of all directors of residency programs should be to retain their residents and have them succeed. Yet many residents leave surgical programs, voluntarily or involuntarily, so commonly that it is almost considered inevitable. Consequently, one value of this book is that the perspective of an outsider like O'Connell can lead those of us who are involved in the training of residents to necessary introspection about the problem.

O'Connell focuses on why residents fail to complete surgical residencies and includes the perspectives of residents who resigned or were terminated. She also includes another important group, the problematic completers. These are residents who ultimately finish their residencies even though faculty members have significant reservations about their success in a clinical setting.

A Surgeon in an Operating Room Instructing Medical Students.

The problem of attrition of residents is not caused solely by the residents, as O'Connell details in the chapter on the effect of program structure on attrition. She stresses that it is necessary to focus on the program as well as on the residents, because the environment or community in which the residents work is an important variable in the rate of attrition. Consequently, she presents options for improving the assimilation of residents into the program as well as strategies to identify and deal with residents who are at risk for leaving it.

One minor limitation of the book is that the data on which O'Connell bases her conclusions are from studies performed in the early 1990s. A second limitation is that generational differences in values between the residents and their older faculty are not considered, although these generational issues have recently been recognized as an important variable in the success of residency programs. These limitations aside, the book's key concepts generally appear valid and relevant, and O'Connell provides sociological insights into the culture of residency that could help program directors and faculty adjust to the inevitable changes that will continue to occur in medicine in general and in surgery in particular.

O'Connell also discusses the environmental and cultural stresses that are faced by women, members of minority groups, and international medical graduates who are entering specialties that historically have been dominated by white men. She justifies her attention to this issue by stating that a self-conscious reevaluation of the education and evaluation of residents that recognizes the potential sociological differences between the sexes and races can be a positive force in reducing the attrition of residents.

In summary, this book is an exploration of associations among the organizational structure of residency programs, the criteria that are used to evaluate the performance of residents, and the unique problems of residents — all factors that contribute to the attrition of residents. The author stresses the critical importance of camaraderie and trust among residents and between faculty and residents in improving the retention of residents. Although the residency process works for most residents, it is a high-stakes game, and attrition rates remain higher than is desirable.

Edwin A. Deitch, M.D.
University of Medicine and Dentistry of New Jersey, Newark, NJ 07103
edeitch@umdnj.edu