by Justine Broecker, MD
Now that it’s post-match day, a day of celebration for many, I wanted to write a blog post focused on people who may or may not have felt as celebratory—specifically those who didn’t match into categorical surgery programs—as someone who similarly did not match into a categorical position. First of all, even though you may feel like you failed, perhaps for the first time in your life, let me assure you that you are NOT a failure. And, even though challenges are ahead, being a preliminary surgery resident is just the beginning and does not mean you can’t succeed. I wanted to write this post for several reasons—to acknowledge the challenges preliminary surgery residents face, to offer some advice as someone who has now successfully completed general surgery training, and to shed light on how the general surgery community can and should do more to support preliminary surgery residents. As a disclaimer, my experiences are uniquely my own and I do not pretend to entirely represent the wide range of preliminary surgery residents who have had their own unique experiences that may share some similarities with mine, but likely differ in many ways as well. For instance, I know that my friends who are foreign medical graduates (FMG) experienced unique challenges that I myself cannot speak to. However, based on my own experience and conversations with colleagues as well as reading published literature, there are shared experiences that can be improved upon.
Preliminary surgery residency—non-designated surgery residency for 1-2 years without the guarantee of completion of residency for board certification—possesses a controversial reputation within surgical training as it has both been described as a “golden opportunity” and a “dead end.”1 Non-designated preliminary surgery residency developed in response to the end of the previous pyramidal system of surgical training in 1996.2 Non-designated positions became critically important to upholding duty hour restrictions as well as filling open categorical positions secondary to attrition, research and/or other reasons for extended leave of absence among categorical surgery residents.2 As a result, preliminary surgery residents clearly play an important role in helping surgery residency programs function, and although such a relationship has the potential to be mutually beneficial, the power imbalance—which exists for all residents, but is amplified for preliminary surgery residents—creates the potential for inequality, and even abuse. Not surprisingly, perhaps, little is known about the preliminary experience, and more information is needed to address existing challenges.
In the sparse literature that does exist on this topic, one report found that compared to categorical general surgery residents, non-designated preliminary surgery residents are often older, male and international medical graduates (IMG).3 Another single institutional survey suggested that preliminary surgery residents were in need of more support, in particular mentoring.4 Mentors—whether other surgery residents, especially those who had been prior preliminary surgery residents, or attendings I came into contact with—were extremely important in helping me navigate the unique challenges of preliminary surgery residency. There were so many unique concerns I had to consider as a prelim—how do I stand out on service as a junior resident? Should I reapply to the match or apply directly to open PGY-2/PGY-3 categorical positions? There are no easy or right answers to these questions, but it is helpful to get other, often more experienced, insight as you make these difficult decisions. Feedback and mentorship are critical during residency, but even more so as a prelim. As you apply for promotion at your own institution, or others, you will need other people to advocate for and recommend you. I struggled to ask for this direct feedback and support; in hindsight, I was only hurting myself. In particular, my program director was extremely important in helping me eventually achieve a categorical position. Although monitoring and applying through the APDS for positions is necessary, often some positions are word of mouth, and, therefore, maintaining close contact with your program director is necessary. I also recommend being as direct and honest as possible with your program director. This can at times be uncomfortable again given the power imbalance and the possibility you may want to stay or leave your preliminary institution. In my experience, where and when a categorical position may become available is unpredictable and the process of placing preliminary surgery residents in those categorical positions is complex and rarely transparent. It is therefore in your best interest to be as direct as possible, as early as possible, in asking whether you will be offered a position at your institution, and, at the same time, to actively seek out and pursue other options as well, and to remain open-minded and adaptable.
Data regarding the experience of preliminary surgery residents compared to categorical surgery residents is lacking but suggests that disparities exist. One survey reported that preliminary surgery residents were less likely to be satisfied with their operative experience and “the costs of training.”3 At my preliminary institution, preliminary and categorical surgery residents completed the same rotations—which is not always the case everywhere—and I was told we were “the same.” However, there were instances that I did not feel the same. For instance, although it was very common for preliminary surgery residents to pursue research prior to being offered a categorical position, such research often took place in limited, specific labs within our institution. I remember being ecstatic to be accepted to an external fellowship during my second year only to be discouraged from pursuing it and later disappointed when I ultimately could not pursue the fellowship. Residency limits all residents’ freedom, but, as a prelim, I felt even more powerless not only because of the nature of my position but also to advocate for myself for fear of retribution. Perhaps the extent of this fear was unfounded, but without an anonymous mechanism in place, I didn’t feel comfortable, given my vulnerable and unstable position, being honest or entitled to expect or even ask for anything.
Given how little is known about the professional experience of preliminary residents, not unsurprisingly, even less is known about the personal struggles faced. One institutional survey highlighted the “stress” felt.4 As for myself, I experienced a range of emotions the months and even years after I didn’t match into a categorical general surgery residency position: shock, confusion, frustration, anger, resentment, envy, shame, loneliness, powerlessness, anxiety, stress, grief, defeat, self-comparison and self-doubt, burnout. I was certainly fortunate that there were many people who were supportive of me during this time who did their best to try to help me manage these emotions while I also dealt with the very real stresses of pursuing surgical residency while also worrying about where, when and if I might complete it. I sought professional counseling during intern year only to become frustrated and give up after only a couple of sessions were nearly impossible to coordinate with my busy schedule and I felt ultimately unhelpful. I did not feel the few therapists I did manage to find time to see really understood my situation as a surgical resident, let alone the added challenges of a preliminary position, to be able to really help me. Many of these similar emotions, shared amongst many residents, have continued to occasionally trouble me as a categorical resident and surgeon, but I have identified better ways to manage them. Although maintaining positive wellbeing is challenging for any resident, my advice is to as best you can identify ways to protect your self-care and to prepare for, acknowledge and address in particular new mental and emotional stresses that may for the first time present themselves during residency, as residency presents new stresses not previously encountered, especially as a prelim.
In hindsight, there were some perhaps potentially self-inflicted reasons I didn’t match—I didn’t “interview well,” I was choosy about where I wanted to spend five+ years of my life, I wanted to be close to family and friends—but, like much in life, the match is unpredictable and cannot be fully understood or controlled, and there was perhaps an element of “bad luck.” Conversely, I was very fortunate and lucky to obtain my categorical position as many qualified and excellent preliminary surgery residents do not. “Success” following preliminary surgery residency is unclear, potentially debatable and rarely defined in the literature by preliminary surgery residents themselves. Based on available literature, the majority of preliminary surgery residents appear to be able to successfully obtain categorical positions within the US graduate medical system—although success rate differs between institutions—and, roughly one third of preliminary surgery residents eventually obtain a categorical general surgery position.3,5-9 Residents who obtained a categorical general surgery position were more likely to have completed a preliminary PGY-2 year, demonstrate higher ABSITE scores, be US medical graduates, belong to a race other than black or Hispanic, and be younger.3,5
After I obtained my categorical position, I expected life to be much easier. I had “succeeded.” I did not anticipate that the transition was perhaps in some ways even more difficult than my preliminary years. Transitioning programs mid-residency is challenging—you become an outsider who enters a new, strange environment, but at a potentially senior level. Therefore, you are expected to meet the expectations of having completed years you have completed elsewhere that inevitably were different, and, therefore, pose gaps compared to the experience of your peers. Achieving operative autonomy is challenging for any resident; it was especially challenging at a program where no one knew or trusted me. And, again, although I was very fortunate to have extremely supportive mentors at my new institution, I was the first prelim to transfer and succeed at my level at my new institution, and I struggled to navigate these unique challenges. This brings me to my next piece of advice which is I think you have to accept that as a preliminary surgery resident you have to sometimes work harder compared to your categorical counterparts to reach the same goal. But, hard work alone is not enough, and you have to know and be able to ask for help from the right people when you need it. As I reflect on my experience as a preliminary surgery resident and the transitions and adaptations I have had to make in order to succeed, although I would not recommend being a preliminary over a categorical resident to anyone, I do acknowledge the strengths the experience provided me: capacity to work hard, adaptability, resilience, compassion, empathy, self-reflection and awareness. Residency is designed to change people from student to surgeon and we learn many of these and other skills in the process in order to succeed. But, given the nature of preliminary surgery residency, fair or not, more is ultimately required and expected of you to succeed.
There is limited data on what programs can do to improve the wellbeing and/or success of preliminary surgery residents; however, certain program characteristics and interventions appear to enhance preliminary surgery resident success. Larger programs with dedicated faculty researchers, defined mentorship curriculums and an additional PGY-2 year appear to enhance preliminary surgery resident successful placement in particular in categorical surgical positions.2,10,11 From my own experience, I believe additional programs should be offered to support and protect preliminary surgery residents: national standards and expectations that additional support be provided by surgery programs and national organizations for preliminary surgery residents, an anonymous mechanism to provide feedback and advocate for oneself during residency, and a national mentorship program consisting of prior successful preliminary surgery residents to not only offer guidance during the preliminary residency years but also during a potential transition to a categorical position especially at a different institution. More data is needed to define the preliminary experience and to define individual success as it will likely vary individually and potentially evolve over the course of residency. Such knowledge is essential to supporting and empowering preliminary surgery residents. Although the match and obtaining success as a preliminary surgery resident can be—like many things in life—beyond our control even with the best intentions, I believe we can and should explore how to improve the preliminary experience as part of a growing movement to make surgical training more equitable and diverse.
- Christein JD, Cook JK, Enger TM, Farley DR. Preliminary general surgery residents: indentured servitude or golden opportunity? Curr Surg. Jan-Feb 2006;63(1):85-9. doi:10.1016/j.cursur.2005.10.001
- Sarosi GA, Jr., Silver MA, Ben-David K, Behrns KE. Training outcomes of preliminary surgical residents in a university and Veterans Affairs surgical residency. JAMA Surg. Nov 2014;149(11):1127-32. doi:10.1001/jamasurg.2014.2054
- Sullivan MC, Yeo H, Roman SA, Jones AT, Bell RH, Jr., Sosa JA. Discrepancies in training satisfaction and program completion among 2662 categorical and preliminary general surgery residents. Ann Surg. Jun 2013;257(6):1174-80. doi:10.1097/SLA.0b013e3182718ef1
- Rajesh A, Asaad M, Chandra A, et al. What Do Former Residents Say About Their Nondesignated Preliminary Year? A Survey of Prelims’ Experiences in a General Surgery Residency Program. J Surg Educ. Mar – Apr 2020;77(2):281-290. doi:10.1016/j.jsurg.2019.10.003
- Rajesh A, Asaad M, Chandra A, McKenzie TJ, Farley DR. Outcomes of non-designated preliminary general surgery interns: A 25-year Mayo Clinic experience. Surgery. Feb 2020;167(2):314-320. doi:10.1016/j.surg.2019.09.013
- Montero P, Powell R, Travis CM, Nehler MR. Selection, mentorship, and subsequent placement of preliminary residents without a designated categorical position in an academic general surgery residency program. J Surg Educ. Nov-Dec 2012;69(6):785-91. doi:10.1016/j.jsurg.2012.04.009
- Pezzi CM, Leibrandt TJ, Augustine RT, et al. Nondesignated preliminary residents in general surgery: 25-year outcomes. Am J Surg. Aug 2011;202(2):233-6. doi:10.1016/j.amjsurg.2010.06.033
- Yoo PS, Kozol R, Reilly P, et al. AVAS Best Clinical Resident Award (Tied): fate of non-designated preliminary general surgery residents seeking a categorical residency position. Am J Surg. Nov 2009;198(5):593-5. doi:10.1016/j.amjsurg.2009.07.024
- Ahmad R, Mullen JT. Career outcomes of nondesignated preliminary general surgery residents at an academic surgical program. J Surg Educ. Nov-Dec 2013;70(6):690-5. doi:10.1016/j.jsurg.2013.09.004
- Rawlings A, Doty J, Frevert A, Quick J. Finding Them a Spot: A Successful Preliminary Match Curriculum. J Surg Educ. Nov 2018;75(6):e78-e84. doi:10.1016/j.jsurg.2018.09.011
- Ritter KA, Anand RJ, Beard K, et al. Impact of Surgery Program Characteristics on Fate of Non-designated Preliminary Surgery Interns. J Surg Educ. Nov – Dec 2020;77(6):e11-e19. doi:10.1016/j.jsurg.2020.06.001
Justine Broecker is a surgical critical care fellow at UTSW. @jasb805