A Systematic Needs Assessment of Rotation-Specific Onboarding Practices in General Surgery Residency Training.

OBJECTIVE: Systems-based practice is an Accreditation Council for Graduate Medical Education competency that requires understanding healthcare delivery systems and rotation-specific workflows. Yet surgical residents frequently transition across surgical subspecialties without adequate orientation, creating gaps that compromise educational quality, delay clinical integration, and threaten patient safety. No systematic assessment has characterized rotation-specific onboarding practices or quantified unmet trainee needs. We conducted a needs assessments hypothesizing that general surgery residents would report limited formalized, rotation-specific onboarding, frequent reliance on peer-led onboarding, and preference for easily accessible digital resources. DESIGN: This was a cross-sectional survey study. SETTING: The study was conducted across two academic level 1 trauma centers with general surgery residencies and surgical critical care fellowships. PARTICIPANTS: General surgery trainees were enrolled at 2 institutions. The survey assessed onboarding exposure, delivery format, timing and consistency, role clarity, feedback mechanisms, and access to essential clinical resources. Statistical analysis employed 1-sample t-test for Likert-scale accessibility ratings and McNemar's test to compare current vs. preferred modalities with significance set at p < 0.05. RESULTS: Among 86 respondents (61.4% response rate, median age 30 years), most were junior residents (postgraduate year 1/2: 58.3%), categorical residents (73.3%), and male (57.0%). Over half (n = 45, 50.6%) of residents received zero rotation-specific onboarding. For those who received onboarding, the most common delivery formats were survival guides (36%), handbooks (19.8%), and in-person lectures (14.0%), typically provided by residents (58.5%) or faculty (41.5%). Material accessibility averaged 3.67 ± 0.98 on a 5-point scale (p < 0.001), but only 32.6% reported materials were up-to-date and 20.9% reported consistent delivery across services. Trainees preferred smartphone app-based onboarding compared to the current receipt (p = 0.035). Less than half (41.9%) of respondents understood their roles and responsibilities at rotation start; of these, only 50% received explicit expectations before the rotation began. There was a significantly higher preference for formal one-on-one feedback than the proportion who received it (27 [31.4%] vs. 12 [14%], Δ = +17.4 pp, p < 0.001). CONCLUSIONS: Substantial gaps exist between current onboarding practices and resident needs in general surgery training. Most residents lack formal, rotation-specific orientation, and existing materials are inconsistently delivered, infrequently updated, and primarily peer-led. These findings establish an urgent imperative for standardized, faculty-supervised, digitally-delivered curricula supporting Accreditation Council for Graduate Medical Education competencies.