Why the ACGME Survey Falls Short in Identifying the Truth About Trainee Dissatisfaction

Why the ACGME Survey Falls Short in Identifying the Truth About Trainee Dissatisfaction

Miriam Knoll, MD

May 11, 2016

A recent AMA Wire article highlighted the resident depression endemic and identified some strategies for improvement.1,2 The upshot: Too many trainees are unhappy with their jobs.

The most important tool used to gauge trainees’ satisfaction with their training programs is the ACGME survey. Since the ACGME is the organization that formally accredits training programs, the survey results are taken very seriously by the ACGME itself and by the training programs.

I appreciate ACGME’s commitment to trainee well-being and I recognize that the survey is an important instrument to systematically gather information and identify problems. When issues are recognized via the survey results, the program directors must demonstrate how they will rectify the issues, and sometimes programs get shut down if they are deemed unsatisfactory.

The fact is, though, that the survey is wholly insufficient, because its structure and timing do not encourage honest reporting. Trainees have to weigh the serious professional consequences of identifying problems in their programs against just putting their heads down and quietly finishing their training.

No training program wants their residents to be depressed and miserable, but based on the recent JAMA publications, programs need better tools to identify and fix problems. Here are some suggestions on how to improve the fact-finding process, so that areas for improvement are accurately identified.

Recognize the internal conflict trainees face

Trainees are deeply aware that even while working, they are still students, and their future employment is contingent upon fully completing their training. Otherwise, their prior schooling and incomplete training may leave them with no job prospects at all (and often with hundreds of thousands of dollars in debt).

Residents and fellows also understand that, while their employment is work, they do not operate within the same structure as a typical job. It is extremely difficult to switch residencies, whether to another program in the same field or in a different field (i.e., an anesthesia resident switching to a different anesthesia program or switching to a surgery program). This is in stark contrast to all other employees in the hospital system, wherein an individual with adequate experience can actively search to switch jobs for any reason, whether they are unhappy in their current role or simply because a better opportunity presents itself.

It’s hard to muster the courage to make real complaints when one knows they don’t have an alternate option, no matter the outcome. Trainees know their future job prospects may depend on their current attendings’ and program directors’ opinion of them. Residents and fellows will often tolerate a bad environment so as not to be considered a troublemaker.

In other words, there is an important aspect of self-preservation that always reminds trainees to hold back from raising genuine concerns about their work setting. This realization often leads to trainees encouraging themselves and their peers to tolerate a negative status quo. Common sentiments include, “Everyone goes through this” and “Soon this will be over.”

Make guarantees that training will not be compromised

So if trainees often feel that they can’t report problems with their program to their attending or program director in person, because they’ll be seen as difficult or whiny, why not give extremely candid feedback in the (relative) anonymity of the ACGME survey?

First, trainees in smaller programs have to consider that their feedback could be identified, even if their responses are not associated with their name. In a fishbowl, the nature of the reporting doesn’t truly feel anonymous.

Second, trainees—for whom completing training is paramount—understand full well that a program with many areas of concern may be shut down by the ACGME. There’s no incentive to disclose problems if doing so means that you might lose out on finishing your training.

It is commonly known that if a program is shut down, the trainees may be transferred to another program to complete their training, but the details of this guarantee must be made crystal clear. Trainees need to know: How likely is it that my program will shut down? If it is shut down, how will I complete my training? How far may I have to move? How may this affect my future job prospects or fellowship applications?

The ACGME has a responsibility to disclose the above ramifications, so that trainees feel more assured their careers won’t be negatively impacted by sharing information.

Get the perspective of past residents

Since trainees know their time spent in the training program is limited, they may think, “It’s not worth it to complain, since I’ll be out of here soon.” It’s expedient, but as the JAMA studies show, it may come at a high cost to mental health. It also denies training programs the opportunity to make improvements that would benefit current and future trainees.

A valuable way to circumvent this issue is to administer the survey to trainees who have already graduated from the program. This continuity would encourage more truthful answers and would communicate the programs’ real desire for improvement, independent of stop-gap measures to keep current residents satisfied.

In addition, the benefit of time and reflection would likely lead past trainees to offer suggestions that would otherwise never be conveyed. For example, a graduate may now work with residents in a new program that is more effective and can have suggestions for their old program.

Past trainees now have the perspective to discuss issues that they may not have realized during their training, due to lack of time, reluctance to acknowledge problems, or simply not knowing that there was another way of doing things. Certainly, there may be questions on the survey that are not relevant to graduates anymore, but many of the current survey questions are universal. Program directors would likely be very surprised by the answers, given the benefit of time and distance.

Allow transfers so that trainees have genuine options

The ACGME should loosen the strict system of completing residency programs. If a resident had the option to leave their current program to pursue training at other programs, every training program would have an incentive to investigate areas of improvement and provide the best possible training experience.

Opening up avenues of communication between different programs would also allow sharing of good ideas and effective practices in areas such as call scheduling, conference structure, and benefits.

On this note, I propose adding two new questions to the current ACGME survey:

  1. If you were given the opportunity, would you switch to another program within your field?
  2. If you were given the opportunity, would you switch to another residency program in a different field?

I believe the answers to these questions would be extremely eye-opening to programs and anyone involved in medical education.

Trainees cannot live on grit alone

A supposed marker for trainee happiness is “grit,” a psychological trait for perseverance and focus on long-term goals.3 Certainly, this is a necessary trait to develop when pursuing a challenging, demanding profession.

But, we esteem grit at the risk of implying that trainees should ignore negative experiences and instead focus on finishing their training. Every training program has the potential for improvement. Every training program should have a vested interest in the well-being and satisfaction of its residents.

We should all be concerned when medical residency bears any similarity to fraternity hazing rituals.



  1. Mata D, Ramos M, Bansal N et al. Prevalence of depression and depressive symptoms among resident physicians a systematic review and meta-analysis. JAMA. 2015;314:2373-83.
  2. Schwenk, TL. Resident depression: the tip of a graduate medical education iceberg. JAMA. 2015;314:2357-8.
  3. Salles A, Cohen GL, Mueller CM. The relationship between grit and resident well-being. Am J Surg. 2014;207:251-4.


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