A National Survey of Preliminary versus Categorical General Surgery Residents’ Personal and Professional Experiences

Technical Summary: A National Survey of Preliminary versus Categorical General Surgery Residents' Personal and Professional Experiences

Problem Statement
Preliminary general surgery residents constitute a substantial portion of the surgical training workforce (approximately 1,194 positions in the 2025 Match) yet remain understudied regarding their personal and professional training experiences. While existing literature has documented burnout, mistreatment, and inadequate support among surgical residents generally, and prior work has tracked the career destinations of preliminary residents, there is a lack of contemporary national data characterizing the specific training environment of preliminary residents relative to their categorical peers. The preliminary year is often viewed through opposing lenses: as a "golden opportunity" or as "indentured servitude." Without empirical characterization of their experiences, it remains unclear whether the position serves the trainees or primarily the system, and whether the two preliminary pathways (designated and non-designated) differ in their outcomes.

Methodology
The study employed a cross-sectional, anonymous electronic survey distributed nationally to PGY-1 and PGY-2 general surgery residents over two cycles (2024 and 2025).

• Participants: The analytic sample included 152 respondents: 81 categorical residents and 69 preliminary residents (18 designated, 47 non-designated).
• Framework: The study utilized the learning-environment framework by Gruppen et al., categorizing outcomes into personal (quality of life, burnout), social (mentorship, workplace mistreatment), and organizational (research access, professional trajectory) components.
• Measures: Six co-equal outcomes were assessed:
  1. Quality of life satisfaction (global self-rating).
  2. Burnout (two-item Maslach Burnout Inventory).
  3. Mentorship satisfaction.
  4. Workplace mistreatment (a composite of five items adapted from validated incivility scales, specifically asking if interactions occurred "because of my preliminary vs categorical status").
  5. Perceived research disadvantage.
  6. Professional trajectory satisfaction.
• Statistical Analysis: Comparisons used Pearson chi-square tests and Fisher's exact tests. Multivariable logistic regression adjusted for gender, international medical graduate (IMG) status, citizenship, race, and geographic region. To address multiple comparisons across the six outcomes, the Benjamini-Hochberg false-discovery-rate (FDR) correction was applied. The study was powered to detect a 20-percentage-point difference but was underpowered for burnout and subgroup comparisons (designated vs. non-designated).

Key Results

• Comparative Outcomes: Preliminary residents reported significantly worse experiences than categorical residents across five of the six domains, even after demographic adjustment:
  • Quality of Life: 45% satisfaction (preliminary) vs. 68% (categorical).
  • Professional Trajectory: 58% satisfaction vs. 79%.
  • Mentorship: 25% satisfaction vs. 57%.
  • Workplace Mistreatment: 93% reported mistreatment at least once vs. 47%. This association remained strong after adjustment (Adjusted OR ~15.8).
  • Perceived Research Disadvantage: 53% vs. 35%.
  • Burnout: No statistically significant difference was found (43% vs. 32%), though the study notes this comparison was underpowered (~30% power).
• Preliminary Pathways: When comparing designated versus non-designated preliminary residents, no significant differences were found in any outcome. However, this comparison was underpowered (n=18 for designated) and should be viewed as exploratory.
• Perception Gap: Preliminary residents perceived the negative impact of their status on mentorship, community, and research opportunities more acutely than categorical residents did.
• Trajectory Alignment: Among preliminary residents, 58% of those with a specific categorical goal reported entering that same type of position the following year. Notably, US graduates were significantly more likely to secure a categorical position the following year compared to IMGs (86% vs. 42%), despite entering with comparable aspirations.

Key Contributions

• First Contemporary National Comparison: This study provides the first national, contemporary comparison of personal and professional experiences between preliminary and categorical general surgery residents, extending beyond previous work that focused primarily on professional attitudes or career destinations.
• Identification of Structural Disadvantage: The findings highlight that preliminary status is independently associated with a less supportive training environment, characterized by higher rates of workplace mistreatment, lower mentorship satisfaction, and reduced research opportunities, independent of demographic factors.
• Differentiation of Status vs. Demographics: By adjusting for demographics (including the higher prevalence of IMGs and non-citizens in the preliminary group), the study isolates "preliminary status" itself as a driver of negative experiences, particularly regarding workplace mistreatment.
• Validation of the "Bridge" Concept: The data supports the notion that the preliminary year serves as a bridge for many (approx. 70% entering some categorical position), but reveals that the burden of this role falls disproportionately on marginalized groups (IMGs) who are less likely to successfully transition.

Significance and Claims
The authors claim that the preliminary-categorical disadvantage described in earlier literature (e.g., Sullivan et al., 2009) persists across multiple domains despite a decade of national focus on resident well-being. The study suggests that the preliminary year is not a monolithic experience; while it functions as a bridge for many, it carries real clinical service loads without commensurate support, mentorship, or protection from mistreatment.

The paper posits that these disparities are likely structural rather than merely local, as they were observed across a multi-program national sample. Consequently, the authors argue that addressing these issues requires system-level attention (e.g., by the ACGME or American Board of Surgery) rather than relying solely on local program discretion. The study concludes that while the preliminary role serves an important function for many, the current structure may be inequitable, with the heaviest burdens falling on those already marginalized. The authors explicitly state that their cross-sectional design precludes causal inference and that the lack of difference in burnout may be due to insufficient power rather than a true lack of disparity.