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

Ryan J. Ellis, D. Brock Hewitt, Yue Yung Hu, Julie K. Johnson, Ryan P. Merkow, Anthony D. Yang, John R. Potts, David B. Hoyt, Jo Buyske, Karl Y. Bilimoria*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

18 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)585-592
Number of pages8
JournalAnnals of surgery
Issue number4
StatePublished - Oct 1 2019


  • duty hours
  • general surgery
  • residency
  • training environment

ASJC Scopus subject areas

  • Surgery


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