It seems to me that non-designated prelim positions only exist as a means either to unofficially continue the now illegal pyramidal program, or to exploit the cheap labor of these ill-fated residents. Yes, there's a hefty attrition rate in surgery. Maybe that would be lower if programs had to do something about the reasons for it. As long as they have this convenient bunch of substitutes hanging around, there isn't really any incentive to do that, is there? As it is, the way surgery programs are organized, it's simply not possible to get all the floor/scut work done without taking in prelims. Or is it? Hell yes. All they have to do is hire some PA's and NP's. The reason they don't is simple. The bottom line. It's just cheaper to keep taking in a fresh batch of young hopefulls each year and working them to the bone before unceremoniously sheding them. Is this situation a disgrace or am I missing something? Are we really so naive as to believe pyramidal programs don't exist while this is going on?