Surgical Resident Attrition and the Menninger Morale Curve

doi:10.4236/ss.2011.27087

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Surgical Science, 2011, 2, 397-401

doi:10.4236/ss.2011.27087 Published Online September 2011 (http://www.SciRP.org/journal/ss)

Surgical Resident Attrition and the Menninger

Morale Curve

Jack Contessa1, Tassos Kyriakides2

1Department of Surgery, Hospital of Saint Raphael, New Haven, USA

2Department of Internal Medicine, Yale University School of Medicine, New Haven, USA

E-mail: [email protected], [email protected]

Received June 23, 2011; revised July 20, 2011; accepted August 11, 2011

Abstract

BACKGROUND: Attrition in surgical residency programs continues to be a significant challenge. Ap-

proximately 20% of residents who begin a categorical surgery residency fail to complete it. A number of

studies speculated reasons for this including work hours, life style, family pressures, and resident feelings of

inadequacy including fear of termination. To date no research has been conducted investigating the relation-

ship between resident morale and attrition. This study sought to determine if this linkage exists in surgery

residents. METHODS: The Morale Assessment in General Practice Index (MAGPI) was a dministered to 21

PGY 1, 2, 3, and 5 surgical residents to assess level of morale. Non-parametric methods were carried out to

assess if there were differences in morale among the four PGY groups. Additionally, analyses of the four

factors comprising the MAGPI were also conducted. RESULTS: Although differences did not reach statis-

tical significance, analysis of the data reveals that residents demonstrate different trends in their levels of

morale based on the amount of time they spend in a residency and in a way that approximates the morale

curve described by W. Walter Menninger, M.D. Additionally, two of the four factors comprising the MAGPI

also indicate trends similar to that described by the Menninger morale curve. CONCLUSIONS: Although

no statistically significant results were achieved, the data reveal trends that approximate shifts in morale

similar to those described by the Menninger morale curve, with residents at the PGY 2 and 3 levels presen t-

ing lower morale levels than at the PGY 1 and 5 levels. This may be due in part to the size of the population

studied. Future research should be continued in this area with a larger sample size.

Keywords: Morale Assessment in General Practice Index (MAGPI), Menninger Morale Curve, Surgery

Resident Attrition

1. Introduction

The attrition rate for general surgery residents continues

to be a significant challenge for programs. Studies done

at the American Board of Surgery suggest that nationally

20 percent or more of residents who begin a categorical

surgery residency fail to complete it [1]. Similar out-

comes were reported in a single institution study of 795

medical graduates, 43 of which entered general surgery

residency programs with 7 discontinuing their training

(16% attrition rate) [2]. In their study of why residents

leave general surgery, Dodson and Webb reported that

although research in this area is limited, there have been

a number of studies that documented a fairly consistent

attrition rate between 14% to 23% [3]. In a research

study investigatin g attrition rates in residents entering US

obstetrics and gynecology residencies, McAlister et al.

quoted an ACGME census data report for the 2004 -

2005 academic year which identified general surgery

attrition rate at 5.8%—higher than obstetrics and gyne-

cology (5.1%), family medicine (4.7%), and internal

medicine (2.1%) [4]. Additionally, Longo et al. reported

an overall annual attrition rate of 6.7% in their residency

program over a 20 year period [5].

Surgery continues to have one of the highest attrition

rates of all graduate medical education programs, which

is of particular concern since it is predicted that there

will be a substantial shortage of general surgeons. Data

reported through 2005 show the population of general

surgeons across the country has already decreased from

398 J. CONTESSA ET AL.

7.68 per 100,000 population in 1981 to 5.69 per 100,000

population in 2005—a decline of almost 26% [6]. Fur-

thermore, it appears implementation of work hour re-

strictions has paradoxically exacerbated the attrition

problem. One national study of general surgery residency

programs reported that the percentage of residents lost

through attrition increased from 29% to 44% since insti-

tution of the 80-hour workweek [7].

A number of studies have speculated reasons for resi-

dent attrition including work hours, lifestyle, pressures

from family, resident feelings of inadequacy along with

the belief that they will be terminated, economic consid-

erations, and possible disconnect by medical students

about the reality of a general surgery work experience.

Additionally, it appears that the highest attrition rate oc-

curs during the first two years of training with 70% or

more taking place during this timeframe [5,7]. This is

confirmed in at least two other studies; one reported resi-

dents who left their program voluntarily often left during

or after the PGY 1 or PGY 2 year [3] and the second

study which indicated that 75% of all attrition occurred

at these levels [8]. In her survey of nearly 4500 general

surgery residents regarding attitudes, training experi-

ences, and professional expectations, Yeo reported over-

all satisfaction varied significantly across training years

with the lowest reported lev el in th e PGY 2 year (82.8%)

and the highest level in the PGY 5 year (89.7%). Also,

reports of having considered leaving training differed

significantly with th e highest in the PGY 2 year (19.2%)

and the lowest in the PGY 5 year (7.2%). Furthermore,

PGY 2 residents reported the lowest level of feeling that

they could turn to faculty when having difficulties in

their program (68.3%) while PGY 5 residents demon-

strated the highest levels (76.1 % ) [9].

Is there anything to explain the predictably high rate of

resident dissatisfaction in the early years, particularly in

the PGY 2 year? One possible explanation can be found

in the work of Dr. Walter Menninger with Peace Corps

volunteers. In order to facilitate volunteers’ readj ustment

to coming home, he held a series of “completion of ser-

vice” conferences just prior to the end of their two year

assignment. From reviewing nearly 1000 questionnaires

and reports of conference discussions, a consistent pat-

tern of psychological adjustment emerged, a pattern sub-

sequently labeled the “morale curve.” See Figure 1. Four

“crisis periods” were identified representing major peri-

ods of psychological difficulty facing the volunteer. The

outcome of the crisis could be positive or negative de-

pending upon the severity of the stress, the individual’s

coping mechanism, and the support received during the

period.

The first crisis period occurs at the beginning of the

experience and is characterized as the Crisis of Arrival.

Individuals demonstrate high levels of morale, but also

apprehension and concern about their ability to meet the

challenges. The second critical period is labeled the Cri-

sis of Engagement; at this point the individual is truly

engaged in the realities of the situation. Morale com-

Figure 1. Menninger morale curve.

J. CONTESSA ET AL.

399

monly is low at this point due to frustrations and limited

support in the new situation. The central feature of this

stage is marked by depression. Individuals take stock of

what they left behind, of unrealized expectations of ac-

complishment, of freedom to express their frustrations.

In the Peace Corps study dropouts peaked during this

stage. The third phase wa s noted approximately half-w ay

through the experience and identified as the Crisis of

Acceptance. This stage is described as one where morale

has been restored as a result of increased knowledge and

mastery of the situation. However, emotionally the tone

is frequently one of anger and activism. Individuals

spoke out more freely and pursued changes to improve

the situation. The final crisis is labeled the Crisis of Re-

entry; morale was generally on an even keel, some satis-

faction associated with what they accomplished and with

completing their commitment, but so me depression asso-

ciated with giving up their identity and ending relation-

ships, and apprehension about an uncertain future.

Menninger indicated that the morale curve is not

unique to the Peace Corps experience, but represents a

process that all individuals undergo as they enter new life

situations. Morale follows a predictable cycle; how an

individual responds is determined by one’s position

within that cycle. He provides support that shows the

model is both universal and scalable (e.g., Stafford-

Clark’s description of the changes in the morale of flight

crew during their 30-sortie tours in World War II) [10].

To date, there has been no research investigating level

of morale of general surgery residents. This study sought

to assess level of resident morale in a general surgery

residency program at the four crisis points to determine if

a cycle similar to the Menninger morale curve is dis-

played and what the implications might be for resident

attrition.

2. Design, Methodology, and

Instrumentation

The instrument used to measure resident morale was the

Morale Assessment in General Practice Index (MAGPI).

This is a 14 question self-scoring instrument designed to

help physicians think about the sources of stress in their

lives and to give them an idea of how they compare with

their colleagues. Respondents are asked to select one of

three statements that “best reflect how you feel about

yourself.” The instrument is scored on the basis of three

points for the most stressed answer, two for intermediate,

and one for least.

MAGPI developers compared their instrument to the

General Health Questionnaire 28 (GHQ 28), which is a

well-validated measure of distress. Both instruments

were sent to 875 physicians in southeast Scotland. Total

scores for the MAGPI were well correlated with total

GHQ 28 scores (r2 = 0.68 p < 0.001). In addition, high

and intermediate scores in all MAGPI parameters (with

one exception) were significantly correlated with GHQ

28 “caseness”—a term used to describe those at risk of

psychological stress. Performing a principal component

analysis revealed four factors comprising the MAGPI:

factor 1—components of control, health, happiness, and

support from friends and worries about family; factor

2—components of being up-to-date, perceptions of value

of patients and colleagues, and career satisfaction; factor

3—components of getting along with colleagues; factor

4—concern over alcohol use. When these factors were

correlated with GHQ 28, all four factors were correlated

highly or moderately, but all demonstrated a p value of

<0.01. In summary, the MAGPI seems to stand up par-

ticularly well when validated against GHQ 28. Also, the

MAGPI was given to 50 General Practitioner trainers.

They found it easy to complete and score, felt the ques-

tions were relevant, and believed that no important pa-

rameters had been missed indicating the MAGPI also has

strong face validity and high acceptability [11].

In this study, the MAGPI was administered to a total

of 21 residents in their PGY 1, 2, 3, and 5 years. Resi-

dents completed th e instru ment in a timeframe during th e

5 year residency cycle congruent with the four crises

identified in the Menninger morale curve—PGY 1 resi-

dents in August, PGY 2 residents in October, PGY 3

residents in March and PGY 5 residents in May.

Setting

The Hospital of Saint Raphael, General Surgery Resi-

dency Program, New Haven, Connecticut. Testing dates

were announced approximately one week prior and resi-

dents reported to a conference room to complete the in-

strument.

Participants

Surgical residents of the Hospital of Saint Raphael

General Surgery Residency Program at the PGY 1, 2, 3,

and 5 levels.

3. Results and Statistical Procedures

Non-parametric methods (Kruskal-Wallis comparisons)

were carried out to assess if there were differences in

MAGPI responses among the four PGY groups. Even

though difference in the MAGPI total means scores did

not achieve statistical significance (p = 0.3229), the

scores for PGY 1 (16.7) and PGY 5 (17.8) residents were

trending lower than PGY 2 (18.0) and PGY 3 (19.5)

scores, indicating an overall higher level of morale for

the PGY 1 and PGY 5 groups (See Table 1). These

findings describe a curve that is similar in shape to the

400 J. CONTESSA ET AL.

Table 1. MAGPI sum scores and factor scores.

MAGPI PGY 1 PGY 2 PGY 3PGY 5

MAGPI Sum Scores 16.7 18.0 19.5 17.8

Factor 1 7.1 7.7 8.3 7.3

Factor 2 5.3 5.0 5.2 5.1

Factor 3 2.3 2.7 3.3 2.9

Factor 4 1.0 1.0 1.0 1.0

Menninger morale curve.

Non-parametric analyses of the four factors compris-

ing the MAGPI were also conducted. Factor 1 (compo-

nents of control, health, happiness, and support from

friends and worries about family) yielded mean scores

respectively for PGY 1 (7.1); PGY 2 (7.7); PGY 3 (8.3)

and PGY 5 (7. 3) r es i dents; (p = 0.50) (See Table 1). Fac-

tor 2 analysis (components of being up-to-date, percep-

tions of value of patients and colleagues, and career sat-

isfaction) revealed mean scores respectively for PGY 1

(5.3); PGY 2 (5.0); PGY 3 (5.2); and PGY 5 (5.1) resi-

dents; (p = 0.91.). Factor 3 analysis (components of get-

ting along with colleagues) yielded the following mean

scores for PGY 1 (2.3); PGY 2 (2.7); PGY 3 (3.3) and

PGY 5 (2.9) residents; (p = 0.20). Factor 4 (concern over

alcohol use) revealed the same mean response (1.0) for

all four PGY groups; (p = 1.0). All analyses were per-

formed usi n g SAS v.9. 1 ( SAS Inc.).

4. Conclusions

In this surgical residency program, analysis of 21 resi-

dents at the PGY 1, 2, 3, and 5 levels who took the

MAGPI appear to exhibit different levels of morale

based on the amount of time they spent in the residency

and in a way that approximates the morale curve de-

scribed by W. Walter Menninger, M.D. These periods of

low morale (PGY 2 and 3 years) also tend to correspond

to times when residents are most at risk for leaving a

surgery program. Additionally, analysis of the four fac-

tors that comprise the MAGPI revealed that factor 1,

which measures components of control, health, happi-

ness, and support from friends and worries about family

also described a curve similar to the Menninger Morale

Curve with residents displaying the highest levels of

morale during the PGY 1 and 5 years and dropping off

during the PGY 2 and 3 years. Factor 2 (components of

being up-to-date, perceptions of value of patients and

colleagues, and career satisfaction ) show little variability

among the four PGY years tested. This may be due in

part to the fact that the question regarding being up to

date is poorly correlated with other parameters and the

overall score during the pilot of the MAGPI instrument

suggested it was not a major cause of stress in doctors’

lives [11]. Factor 3 analysis (components of getting

along with colleagues) indicated that PGY 1 residents

demonstrated higher levels of morale than PGY 2 and

PGY 3 residents while PGY 5 residents demonstrated

higher levels of morale than just PGY 3 residents. Factor

4 analysis (concern over alcohol use) were answered “I

have no problems with alcohol” by 20 of 21 residents in

the study. As a result, there were no differences in mo-

rale between the groups. It may be residents were con-

cerned about test anonymity and confidentiality and did

not want the residency program uncovering a potential

issue. The study by McKinstry, et al., indicates that al-

though the MAGPI is generally a reliable instru ment, the

authors questioned the usefulness of the item related to

alcohol use. This question demonstrated the lowest cor-

relation (0.21) of any of the four factors with the GHQ

and the worst response for this item (“I am worried about

my use of alcohol”) was not significantly associated with

“caseness” [11].

5. Discussion

To date, there are no studies in graduate medical educa-

tion residency programs that have sought to compare

resident level of morale with that described by the Men-

ninger morale curve. Based on the ab ove findings, lower

levels of morale seen in PGY 2 and 3 level residents and

higher levels of morale demonstrated by PGY 1 and

PGY 5 residents are congruent with the four crisis peri-

ods described by Menninger in his morale curve [10].

This tends to reinforce Menninger’s claim that the pat-

tern of morale represents a process applicable to all indi-

viduals as they enter a new life situation like surgical

residency.

These periods of low morale (PGY 2, PGY 3) coincide

with times when residents are at higher risk for leaving

surgical residency. For that reason, programs should pay

particular attention to residents at these stages in their

residency for cues related to severity of stress, coping

mechanisms, and support they receive from colleagues,

faculty and staff.

Studies have demonstrated that people who handle

stress effectively have a greater sense of control over

what occurs in their lives and remain healthier th an those

who feel powerless in the face of external events. Using

cognitive control to incorporate stressful events into a

life plan rather than taking a narrow, focused approach,

mitigates the jarring effects of those events. For residents

at risk who do not demonstrate a h igh level of “cogn itive

control”, a strategy of “anticipatory guidance” can be

used to help these residents. This is using the healthy

defense mechanism of anticipation to improve the resi-

dent’s capacity to adapt to a new life situation or situ-

ational crisis. Making future likelihoods known to these

residents helps them cope with new situations and miti-

J. CONTESSA ET AL.

401

gates the fear and anxiety of upcoming events that are

expected to be stressful. It helps individuals put the

situation in proper perspective and reduce the sense of

isolation and helplessness that they may experience.

Residents who have gone through a similar experience

are helpful. Successful support programs should foster

opportunities for individuals to be in control of their lives,

to be committed to some activity, and to address the

challenge in ways that permit sublimation of the con-

flicted feelings generated by the life change—through

work, play, and personal relations hi p s [10].

6. Recommendations for Further Study

After having completed the research and having corre-

lated findings, conclusions, and implications, the fol-

lowing recommenda tions are made:

1) Continued research should be directed toward de-

termining linkages between resident morale and their

positions in the residency program experience.

2) Attempts should be made to duplicate this study

with larger sample sizes and in programs of different

duration.

3) Longitudinal research should be conducted tracking

the same residents as they progress through a residency

program.

7. References

[1] R. Bell, M. Banker, R. Rhodes, T. Biester and F. Lewis,

“Graduate Medical Education in Surgery in the United

States,” Surgical Clinics of North America, Vol. 87, No.

4, 2007, pp. 811-823. doi:10.1016/j.suc.2007.06.005

[2] D. A. Andriole, et al., “Attrition during Graduate Medical

Education,” Archives of Surgery, Vol. 143, No. 12, 2008,

pp. 1172-1177. doi:10.1001/archsurg.143.12.1172

[3] T. F. Dodson and A. L. Webb, “Why do Residents Leave

General Surgery? The Hidden Problem in Today’s Pro-

grams,” Current Surgery, Vol. 62, No. 1, 2005, pp.

128-131. doi:10.1016/j.cursur.2004.07.009

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B. Jeffe, “Attrition in Residents Entering U.S. Obstetrics

and Gynecology Residencies: Analysis of GME Census

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[8] T. J. Leibrandt, C. M. Pezzi, S. A. Fassler, E. F. Reilly

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