Introduction

Mentioning the word “crisis” along with “surgical vocation” may sound rather ostentatious. Economic crisis, social crisis, and political crisis are commonly mentioned, but little is heard of surgical crisis or, even more, of crisis in the surgical vocation. Let us imagine a surgeon in crisis: he/she cannot operate, fails in surgeries, feels overwhelmed in his/her work and permanently worn out. It is something that happens every day in every hospital worldwide.

But what do we mean by crisis when writing this article? The Real Academia Española defines crisis as a: “Deep change with important consequences in a process or situation, or in the way they are appreciated “¹. Crises are times of change; they are times when a paradigm shift must be decided in relation to certain preconceived ideas. A time of crisis can be seen as an opportunity.

In recent years we have witnessed more publications about personal and psychological issues affecting surgeons, such as burn-out syndrome and residents quitting surgery residencies, along with the lack of specialization of young individuals^2-5.

Even during the meetings organized by provincial or national surgical societies in Argentina, the same problem is raised, and the same topics are discussed: there is a shortage of members and surgeons are financially handicapped⁶.

Specialization is also in trouble: according to the Secretariat of Medical Residencies of the Argentine Ministry of Health, only 1009 positions were filled out of the 2888 residency vacancies available in 2015. Only 70 vacancies correspond to General Surgery, and only half of these 70 residents will complete the residency program, as about 50% of them will quit⁷.

The situation of the general surgery residency is even worse worldwide: in the paper published by Yeo et al. in JAMA Surgery (2018), overall attrition was 20.8%; after multivariate Cox regression analysis, attrition was higher in women [odds ratio (OR), 1.40; 95% CI, 1.02-1.94], in Hispanic residents (OR, 1.71; 95% CI, 1.06-2.76) and at military programs compared with academic programs (OR, 2.68; 95% CI, 1.36-5.29)².

But what is the situation in Argentina? Do we think that we are receiving adequate payment for our practice? Do we consider quitting our specialty? How many conflicts do we have with patients each month? What is going on in the province of Santa Fe?

We consider a regional work is necessary to reflect this situation.

The aim of our paper is to determine the relationship between surgeons and the different socioeconomic conditions in the province of Santa Fe.

Material and methods

We performed a cross-sectional study in the province of Santa Fe, Argentina, in May 2019. A survey was conducted using a questionnaire that was handed or completed on-line by surgeons throughout the province. The questionnaire included information about personal, economic, and social data, and type of hospital setting (public or private).

Each surgeon surveyed received an on-line questionnaire or was handed an instrument that was completed anonymously. The survey was elaborated to be completed in less than 5 minutes. The surgeons were not paid to respond.

The population was divided by age, according to E. Erikson’s model⁸, into young adulthood (< 40 years), middle adulthood and older adulthood (> 40 years), and by sex, work setting (private or public) and location (Santa Fe capital city or the inland).

A 95% CI was considered, α = 0.05. The variables were compared using the Fisher’s exact test or the chi square test, as applicable. All the statistical calculations were performed using SPSS Statistics 18.0® software package.

Results

The surveys were sent to 73 surgeons form the province of Santa Fe and 42 answers were received (response rate 57.5%).

The demographic data are shown in Table 1. Some answers that are not specified in the text are shown in Figures 1,2, 3 and 4.

Most respondents were men (87.8%) are practiced their specialty in the capital city of the province (87.8%). Median age was 40 years (SD 9.42, range 31-63); 56.1% were middle/older adults.

Most respondents were general surgeons (66%), followed by cardiovascular surgeons (11.9%).

Eighty-one percent were members of Asociación Santafesina de Cirugía and 52.4% belonged to Asociación Argentina de Cirugía. Of the 19% who were not members of the provincial association, the majority were young people (8 respondents); with a statistically significant association between age groups and participation in the provincial association (P = 0.04).

Most of the members of Asociación Santafesina de Cirugía lived in the capital city (86%) with a statistically significant difference versus surgeons living in inland (P = 0.04).

During the previous month, 61.9% of the surgeons encountered obstacles to carry out surgeries: 41.5% reported issues related to bed availability, 29.3% had problems with anesthesiologists to start surgeries and 26.8% reported lack of supplies. There were no statistically significant differences between age groups and work setting and impossibility to perform surgeries (P > 0.05).

It is noteworthy that 100% of the female surgeons reported problems in performing surgeries due to any of the problems previously mentioned. Yet, this relationship was not statistically significant (P > 0.05).

Almost all surgeons (97.6%) agreed that their income did not reflect the time spent in practice: 92.7% agreed that surgeries should be better paid either in terms of difficulty or time invested. We found no significant differences regarding sex, setting or age.

Up to 26.2% of the survey respondents considered quitting their daily practice in the last year due to economic reasons, which is the main problem for 72.7% of them regardless of age, sex or work setting. Of these 26.2% of professionals, 90% were general surgeons.

Discussion

Despite the limitations of any a cross-sectional study, the results reveal the social situation of surgeons in the province of Santa Fe, where more than half of the specialists did not answer the questionnaire or refused to do so (response rate: 57.5%). We emphasize that the survey was answered anonymously, without exposing the name or surname of the professional.

It should be noted that most professionals belong to the age group > 40 years (56.1%), in line with the current literature that mentions shortage of young surgeons worldwide and that finds a decline in the rates of specialization among physicians, a problem generally associated with generational issues. We believe that Santa Fe is part of the same global scenario^2-4.

The fact that a high percentage (61.9%) of surgeons reported obstacles to perform a surgery indicates that they usually handle situations in which their practice does not depend entirely on them. We consider that the causes should be better analyzed in other type of study.

The female representation in the population studied is very low (12.2%), in contrast to other international studies such as the systematic review by Pulcrano et al. (Jama Surg. 2016) in which they found 29.2% of female surgeons⁴. Keeping on with the difference between sexes, we are concerned because 100% of the female surgeons encountered obstacles to perform surgeries in the previous month. This percentage is totally different from the 58.3% of the male population which reported the same problems. These differences may be due to multiple causes (heteronormative society, the male/female/ transgender wage gap, the lack of female quotas in public or private health care institutions, among others), which exceed the aims of this study. Nevertheless, this issue is frequently addressed by high-impact journals such as The Lancet ⁹. This hypothesis is left open for further research. The number of surgeons who claim that their income does not match the time spent in practice (97.6%) is alarming; most feel that surgeries should be better paid. This problem has become redundant in the most recent congresses and meetings held by Asociación de Cirugía del Litoral⁶. The health system does not include other “costs“ surgeons have, such as: preoperative, intraoperative, and postoperative stress and time spent on patient control before and after surgery⁶. This issue requires a comprehensive approach by national and local surgical associations together with health care providers in order to reach consensus with the rest of the health care system.

Returning to the issue mentioned in the previous paragraph, a quarter (26.2%) of the total surgeons has considered quitting their practice, due to economic reasons. This confirms what was previously explained and the percentage is consistent with what was found in the literature².

If we consider that, according to the Ministry of Health of Argentina⁷, about 35 physicians complete their surgical degree per year and a quarter of professionals will quit their surgical practice over the same period, only 26 certified surgeons will be available per year (without taking into account residency programs not registered by the Ministry of Health).

Conclusions

Surgeons’ discomfort with their salaries (97.6%), the discrepancy in percentages between male and female surgeons (87.8% vs. 12.2%), the lack of young surgeons (43.9%) and the alarming number of surgeons graduated per year (35 per year) are 4 key issues of this research that we believe should be urgently addressed by political bodies and, especially, by local and national surgical associations.