Introduction

Asociación Argentina de Cirugía (AAC) acknowledges that the residency program in general surgery is not only the most adequate path towards a primary, comprehensive and efficient practice of the specialty in Argentina, but is also the basic educational framework and source of training for all surgical subspecialties¹. However, general surgery appears as a specialty in crisis, with a reduction in the number of applicants for the residency program, high rates of attrition during residency training and significant burnout rates among professionals² due to two reasons. Firstly, as it happens worldwide, the training system seems to be obsolete. Secondly, at least in Argentina, it is associated with poor working conditions of general surgeons³. On the other hand, millennials, the generation currently in training, seek to achieve a balance between profession and work so it is difficult for them to choose specialties as general surgery, which requires long hours in the operating room, great physical demands, long training periods and less autonomy^3,4.

In this scenario, the Commission of Young Surgeons of Cordoba elaborated a survey to describe the perception young surgeons have at the end of their training program, in relation to their job prospects, surgical or academic activity and the need for joining surgical societies. The role of women surgeons in our environment was also considered in a section.

Material and methods

Results

Information about young surgeons

The survey was completed by 53 participants; 58% (n = 31) were mean and median age was 32 years (range: 28-42). Seventy-two percent (n = 38) practiced general surgery and 61% (n = 32) practiced one surgical subspecialty or greater, with a mean number of surgical specialties per young surgeon of 1.3 (range: 1-4) (Table 1). Fifty-five percent (n = 29) worked only in private hospitals and 28% worked in both settings. Semi-senior surgeons had the highest rate of professional practice in both settings (43%) (Table 2). Most young surgeons were junior surgeons (57%, n = 30).

Table 1 Surgical specialties practiced by the participants 

Table 2 Characteristics of the participants by level of seniority 

Professional experience

When asked about the level of complexity of the procedures, 64% (n = 34) and 34% (n = 18) perceived they were capable of performing low or medium complexity procedures and high complexity procedures, respectively. Semi-senior surgeons presented greater competence for highly complex procedures (52% vs. 20%, P = 0.03) ( Table 2). Eightynine percent considered they were capable of solving the postoperative complications of these procedures. However, 57% (n =30) reported that the surgical or academic activities during their training programs were deficient; their causes are detailed in Table 3.

Table 3 Deficiencies during the training program 

Job prospect

Eighty-nine percent (n = 47) considered that young surgeons do not get a job quickly in public or private institutions and 96.2% (n = 51) reported they were not well paid; they all agreed that payment was not equitable across the different institutions. When asked about the current status of their personal and professional quality of life, 57% (n = 30) expressed frustration and economic uncertainty, while 38% reported emotional and economic stability achieved at high personal, family and social costs (Table 4). Furthermore, 89% considered the idea of practicing general surgery or a sub-specialty in another province or country; this idea was more common among semisenior surgeons (55% vs. 34%; P = 0.04) and 42% mentioned that, according to their current work experience, they would not choose the general surgery specialty again.

Table 4 Current status of young surgeons in relation to their personal and professional quality of life 

Surgical societies’ membership

Thirty-four percent (n = 18) belonged to Asociación de Cirugía de Córdoba and 23% (n = 12) to AAC. AAC membership was more common in semisenior surgeons (39% vs. 10%; P = 0.03). Membership rate was higher in men surgeons, for both Asociación de Cirugía de Córdoba (21% vs. 13%) and AAC (15% vs. 8%). The participants who were not members of these societies expressed lack of interest, either because they felt these societies did not represent them or because they found no benefit in belonging to them (Figure 1).

Figure 1 Reasons demonstrating lack of interest or adherence to local and national surgical societies 

Discussion

Our study analyzes the perception of low levels of competency for surgical procedures, the low rate of membership in surgical societies, and feelings of frustration and economic uncertainty among young surgeons, and the current situation of women surgeons. A program focused on training general surgeons for an adequate performance nationwide should consider at least 4 years of intensive and exclusive dedication, in an accredited center with the necessary teaching resources and with sufficient funding to cover trainees’ expenses without being distracted from their objectives⁷. The situation to complete a sub-specialty or a fellowship is as complex, or even more complex, than for the primary specialty.

Once the training program has been successfully completed, the young surgeon faces serious difficulties in attaining hospital positions, which are not available in Cordoba. As a result, surgeons who have recently graduated have few opportunities to fully practice their profession. On the other hand, surgical practice has been concentrated in private centers, and those surgeons who have not matured in experience and professional prestige will find it difficult to attain a job there. Thus, younger surgeons are often trapped in primary or secondary care systems, far from their specialty, or are forced to work under precarious agreements and exposed to medico-legal issues.

In a survey conducted among members of Asociación Argentina de Cirugía³, 52% were employees and self-employed, which would indicate that they have more than one job. In our study, about one third worked in the private and public setting simultaneously. Moonlighting and working long hours adversely affect continuing education of young surgeons and their quality of life. In addition, 84% considered that they were not well paid, so general surgery would not appear to be an attractive specialty to choose nowadays³. In another survey conducted in the province of Santa Fe², 97.6% of surgeons agreed that their income did not correspond to the time invested in practice. Similarly, in our environment 96.2% considered that their practice were not well paid and were not equitable in many institutions.

As for professional experience, when young surgeons enter the workplace, they feel capable of performing the main surgical procedures; however, they perceive that their ability is lower for more complex procedures. This could be explained by the fact that surgeons in training consider that their training program did not provide them with enough number of surgeries, adequate teaching hours or academic activity and, to a lesser extent, they considered that the lack of training to solve more complex procedures resulted from work overload. In addition, only 7.7% (n = 2) of the training centers with a residency program in general surgery are accredited by AAC; therefore, most of them lack supervision which is essential to guide the learning process and finally qualify a specialist, or do not perform periodic evaluations to determine whether the residents are achieving the competencies and performance specified in their training program¹. Furthermore, 12 training centers (46%) have the Specialization in General Surgery course accredited by Comisión Nacional de Evaluación y Acreditación Universitaria (CONEAU).

Regarding job prospects, when young surgeons begin their professional practice they enter a stage of economic and emotional uncertainty they are not prepared for, which generates great frustration and disappointment exacerbated by the limited job opportunities available. This could be probably explained by the stress of completing the training program⁸ which increases when they do not find a satisfactory answer when trying to enter a healthcare institution or, in case they do find an answer, they are not performing the procedures for which they were prepared or are employed in medical areas and not in the field in which they invested effort and 4 years of surgical preparation⁹.

The study carried out in the city of Buenos Aires showed that only 24.7% of those who completed their training program immediately entered the workforce as general surgeons¹⁰. In our environment, 89% of young surgeons do not get a job quickly. On the other hand, most of them considered moving to another province or country, an alarming situation that could be related to the scarce job supply that drives the search for a better income to improve their lifestyle or professional development. A high rate of young surgeons were not members of Asociación de Cirugía de Córdoba or AAC, either because they considered they could not afford the requirements for membership or because they did not find tangible benefits in belonging to surgical societies. Our findings differ from the report carried out in the province of Santa Fe, where 81% belonged to Asociación Santafesina de Cirugía and 52.4% to AAC².

As for women surgeons, the Commission on Young Surgeons of AAC conducted a national census in 2020 to identify residents graduating from training programs over the past 5 years and found that 39% of them were women³. These findings are consistent with ours, with a rate of women surgeons of 42%. Yet, the rate of women surgeons on the province of Santa Fe was lower (12,2%)². Even though the number of women surgeons has experienced an exponential increase in Argentina, men still predominate in surgical residencies. The study by the United Nations Development Programme (UNDP) shows that the proportion of women surgeons is low in surgical specialties such as cardiovascular surgery, general surgery, neurosurgery, thoracic surgery, and head and neck surgery according to statistics from the Federal Registry of Health Professionals of the Ministry of Health¹¹. Traditionally, surgery has been a maledominated specialty but the higher incorporation of women over time has called into question these steps that limit their professional development¹². A study carried out in three of the most important cities in Argentina explores the labor and personal barriers faced by women who choose a surgical specialty^13,14. Sexual comments are common during the residency in surgery, which may result in uncomfortable proposals for those who want to keep their personal life apart¹³. In our setting, 73% of women surgeons experienced discrimination and gender inequalities, and half of them experienced some type of sexual harassment, similar to what has been reported in the literature¹⁵.

A high percentage of managerial positions are held by men despite women accounting for half of the world population¹³. These findings are consistent with ours. The use of data from a self-administered survey is one limitation of this study. A survey conducted in other regions of Argentina could generalize our results. Although we do not have a local registry of young surgeons, we have made an estimated census based on the number of training centers and the number of residents who have graduated in the past 6 years. Nevertheless, this study may be useful as a preliminary analysis for further collaborative work with other regions that are members of the AAC Commission of Young Surgeons.

Conclusion

We can estimate that young surgeons perceive that their level of competency is not appropriate for more complex surgical procedures. In addition, when young surgeons begin their professional practice, they enter a stage of economic and emotional uncertainty that is exacerbated by the limited job opportunities available. Most of them do not belong to surgical societies, ether because then feel these societies do not represent them, and this feeling increases with the economic instability, or because they find no benefit in belonging to them. Abuse and harassment of women surgeons still prevail and persist. The current issues of young surgeons deserve more attention to improve their opportunities to fully practice their profession.

Acknowledgments:

We are grateful to Dr. José Cooke and Dr. Carlos Valenzuela for letting us make this problem known and suggest possible solutions at the 10th Scientific Meeting organized by Asociación de Cirugía de Córdoba. We would also like to thank Dr. Signorini Franco for his cooperation in carrying out this work.