Our data show the first complete trainee attrition rate for a surgical specialty in the UK, and the first for vascular surgery. Over 5 years, 15.4% of vascular surgery NTNs appointed between 2013 and 2019 resigned. While this seems significantly higher than the previously published data for surgical trainees in the UK(3), data from the US and Australia are similar(9 )(10)(11), in spite of significant differences between healthcare systems. More UK vascular surgery trainees resigned NTNs at an early stage of training (ST3 or 4), which is consistent with US data, which reports more trainees left US general surgical training during internship (10)(5).
Our 15.4% attrition rate is, however, artificially inflated by the several trainees re-joining vascular surgery training after resigning their NTN. Six trainees in total remained in the specialty, having re-applied through the ST3 application process to gain an NTN in a different deanery or to include academic training, taking on risk to their career in the process. The trainees’ survey responses clearly stated the current IDT system is not working for vascular surgery trainees, and current training programmes are too inflexible to accommodate aspiring academic vascular surgeons. We recommend, therefore, that the difficulties in the IDT system be investigated and the process improved for trainees, enabling them to train in a desired region or academic discipline without having to resign an NTN and reapply, a process fraught with risk to job security and career progression.
Of the gender data for vascular trainees leaving the specialty, equal numbers of male and female leavers were identified. However females only represent 30% of vascular trainees overall(12), making females over-represented among those who left the specialty. This is in agreement with some US and Australian data, which showed a higher proportion of female trainees leaving surgical specialties(13)(11). As the proportion of female trainees entering training increases (female core surgical trainees in all surgical specialties reached 40% in 2018 (12)), it is concerning that if female trainees are more likely to resign, as this may mean in future more surgical trainees resign NTNs. We have not explored whether the factors driving trainees to resign NTNs affect female trainees disproportionately; this clearly merits investigation in future.
A study of US surgical residents considering leaving training cited poor sleep, long hours and an undesirable future lifestyle as factors(6), and these work-life balance or lifestyle related issues were cited by trainees who eventually left(14). Whilst working conditions and hours are markedly different between Europe and the US, a study from the Netherlands of trainee attrition across hospital specialties also found that work-life balance, job content and workload to be the main reasons trainees leave training programmes(7). Again, in Australia and New Zealand poor lifestyle and quality of life were also the main reasons trainees considered discontinuing surgical training(15). It seems that surgery across the world places demands on trainees’ lives outside of work and causes some to reconsider surgery as a career.
Both trainees and TPDs identified work-life balance issues as contributors to the decision to leave vascular surgery. Trainees who left surgical training programmes believed increasing opportunities for LTFT training might also help retain trainees due to improvements in work-life balance, however TPDs did not discuss LTFT training with the trainees who left. A higher proportion of LTFT trainees are female, so increasing access to this may improve retention of female trainees
In the US, dissatisfaction with operative experience contributed to trainees leaving surgery(16) and in the Netherlands, the job content and workload were factors in trainees’ decision to leave (7). These issues are analogous to the system pressures we identified, suggesting that these are not unique to the NHS or UK training system. Conversely, data from the US suggest financial factors contribute to the loss of surgical trainees(17), something not highlighted by either trainees or TPDs in our work. We identified that issues affecting trainees related to system pressures were not known to TPDs. We suggest that conducting formalised exit interviews with trainees deciding to resign would help increase TPDs’ awareness of issues involved locally. Nationally, implementation of the recent GMC-led recommendations within the ‘Caring for Doctors, Caring for Patients’ document(18) attempts to improve the working lives of doctors in training, which may positively impact trainee retention.
Trainees themselves suggested that having a realistic expectation of the workload and lifestyle of surgeons might have helped them to make a more appropriate career decision at an earlier stage, and work from the US suggests that if this is the case, attrition rates from surgical training programmes could be reduced(10). However, trainees leaving the programme had at least 6 months’ experience of vascular surgery at SHO level, far more than afforded to those currently applying to Improving Surgical Training (IST1) programmes or even most higher specialist training applicants. Junior doctors rotating through vascular surgery should therefore be afforded more opportunity to experience the working patterns of consultants and registrars to gain this realistic insight.
We recommend prospective data collection of vascular surgery trainee destinations following exit from the training programme at any stage. To prevent unnecessary resignations at significant personal risk to trainees, we recommend making the IDT system more accessible and flexible. We suggest that increased access to LTFT training, conducting exit interview and ensuring that junior doctors have a realistic insight into the working life of vascular surgeons will help to improve the retention of vascular surgical trainees (Box 1).
Improving vascular surgery trainee retention. Recommendations for improving retention of higher vascular surgery trainees within the training programme, based on suggestions from TPDs’ and trainees’ survey responses.