According to research, surgical residents who feel a strong sense of belonging within their programs score significantly higher on high-stakes examinations compared with peers who feel disconnected, and stress levels amplify this relationship
In a cross-sectional survey study of 6,136 general surgery residents, researchers found that those in the lowest decile for sense of belonging scored a mean 476 points on the American Board of Surgery In-Service Training Examination (ABSITE), while those in the highest decile scored 532 points—a 56-point differential that represents a 12-percentile gap. At the extremes, residents at or below the 1st percentile for belonging averaged 465 points compared with 531 points for those at or above the 99th percentile.
After controlling for postgraduate year level, stress, and residency program through mixed-effects multivariable linear regression, the researchers found each 1-point increase in belonging score on the 11-to-55-point validated Belonging in Surgery instrument correlated with a 1-point increase in ABSITE score. This finding suggests residents with weak belonging scores of 15 vs strong scores of 55 might experience a 40-point ABSITE differential that is attributable to belonging alone.
Stress emerged as both an independent negative predictor of performance and an effect modifier. The association between belonging and ABSITE scores proved stronger among residents who reported higher stress levels on a 0 to 10 scale. Residents with weak belonging reported mean stress levels of 7.3 compared with 4.8 among those with strong belonging scores.
The performance gaps appeared across all postgraduate year (PGY) levels. Among PGY-1 residents, those with weak belonging scored a mean 379 points vs 415 for those with strong belonging. For PGY-3 residents, the gap widened to 508 vs 555 points. Even research-year residents showed the pattern: weak-belonging residents averaged 495 points compared with 559 among strong-belonging peers.
The voluntary survey, administered at the completion of the 2025 ABSITE from January 24 to 28, achieved a 57.4% response rate among 10,747 eligible residents. The study design prevented determination of whether belonging influences performance, performance reinforces belonging, or the relationship operates bidirectionally. Still, the findings suggest that programs may improve resident performance by addressing psychological integration alongside traditional structural training interventions. The researchers noted that providing opportunities for residents to socialize with faculty represents one potential mechanism for strengthening belonging.
The study was exempt from institutional review board oversight under educational procedures exemptions. The research team included investigators from the University of Pennsylvania Health System Department of Surgery and the Leonard Davis Institute of Health Economics.
The authors declared having no competing interests.
Source: JAMA Surgery
