Who's Left to Lead? General Surgery Program Director Attrition Over Time.

OBJECTIVE: To describe trends in general surgery (GS) program director (PD) tenure and attrition over time. DESIGN: Retrospective analysis of PD term duration and reasons for attrition based on a report generated by the Accreditation Council for Graduate Medical Education. We then conducted a Cox proportional hazards regression with PD term duration as the outcome of interest, accounting for institution. Content analysis was performed with regard to the inclusive list of reasons for PD turnover via independent review and coding into distinct categories by 2 separate authors. SETTING: 365 US-based GS programs in existence between 1990 and 2025. PARTICIPANTS: A total of 1112 distinct PDs across 365 programs. RESULTS: The average GS PD term duration in the 1990s was 13.6 years, compared to 6.4 years in the 2000s, and 5.0 years in the 2010s. PD turnover was significantly lower in the 1990s than since the 2000s (p < 0.0001), with no significant differences in PD turnover between the 2000s, 2010s, and 2020s. Programs in the South had significantly more PD turnover (hazard ratio [HR]=1.4 compared to West, 95% confidence interval [CI] = [1.1, 1.9], p = 0.04). Additionally, community-based (HR = 0.7, 95% CI = [0.5, 0.9]) and community-based/university-affiliated programs (HR = 0.7, CI = [0.6, 0.9]) had significantly lower PD turnover rates compared to university programs (p = 0.0002). Formal resignation and/or departure from the institution entirely was the most commonly stated reason for PD turnover (42.6%, n = 120). CONCLUSIONS: We demonstrate significantly more GS PD turnover since the 1990s, with increased turnover appearing stable since 2000. While attrition is not continuing to increase, short PD terms over the past 20 years are concerning for a lack of continuity in leadership for GS trainees nationwide.