ORIGINAL ARTICLE

Expectations about the Future in a Population of argentine Cardiologists

Expectativas acerca del futuro en una población de cardiólogos argentinos

 

ADRIANA I. SALAZAR†, 1, CARLOS BOISONET^{MTSAC, 1}, MARÍA I. SOSA LIPRANDIMTSAC, 2, MARCELO BOSCARO†, 3, ALEJANDRA N. FRANCESIA4, EZEQUIEL BESMALINOVICH5, EZEQUIEL ZAIDEL2

Health Policy Area of the Argentine Society of Cardiology ^MTSAC Full Member of the Argentine Society of Cardiology ^† To apply as Full Member of the Argentine Society of Cardiology

¹ CEMIC (Centro de Educación Médica e Investigaciones Clínicas “Norberto Quirno”) - Health Policy Area of the Argentine Society of Cardiology
² Sanatorio Güemes - Health Policy Area of the Argentine Society of Cardiology
³ Hospital Zonal General de Agudos “Magdalena Villegas de Martínez”, General Pacheco
⁴ Hospital de General de Agudos Dr. Enrique Tornú - Health Policy Area of the Argentine Society of Cardiology
⁵ Hospital Aeronáutico Central - Health Policy Area of the Argentine Society of Cardiology

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ABSTRACT

Background: Studies on the professional status of cardiologists in Argentina demonstrated that worse quality of life was associated with lower incomes and poorer working conditions. Knowledge of cardiologists’ present and future perceptions and expectations is necessary for the individual and proper organization of each professional, as well as for the design of public policies.
Objectives: The aim of this study was to describe the present and future perceptions about the professional and economic situation of cardiologists in Argentina and analyze individual and common characteristics associated with negative perceptions.
Methods: This was an observational, cross-sectional study, based on an electronically delivered survey on the demographics, work-ing characteristics and present, in 10 years and at retirement perceptions of professional situation, defining “Bad” or “Very bad” answers as a negative perception.
Results: A total of 236 cardiologists answered the survey; 26% were women and 57.1% were from CABA and the Buenos Aires subur-ban area. The perceived professional situation was: a) Current: Bad/Very bad 9.7%, Fair 45.1%, Good/Very good 45.1%; b) In 10 years: Bad/Very bad 17.1%, Fair 44.6%, Good/Very good 38.3%; c) At retirement: Bad/Very bad 49.1%, Fair 30.3%, Good/Very good 20.6%. Univariate analysis showed greater negative expectation at retirement in: heart disease (p=0.007), coronary risk factors (p=0.027), anxiety/depression (p=0.016), main breadwinner supporting more than three children/relatives (p=0.034) and having suffered any disease (p=0.03).
The presence of four factors (or hidden variables) was established in the principal component analysis, probingly defined as: vulner-ability, over-adaptation, overt disease and insulated autonomy.
Conclusions: Although cardiologists consider that the present is promising, the near future and retirement impress like a threaten-ing and negative reality. This could then be the opportunity to assume a deep and critical attitude to change the ways of working in order to promote a safer and better future.

Key words: Working Conditions - Socioeconomic Factors - Social Vulnerability - Physicians - Argentina

RESUMEN

Introducción: Estudios sobre la situación profesional de los cardiólogos en la Argentina mostraron peor calidad de vida relacionada con menores ingresos y peores condiciones laborales. Conocer las percepciones y expectativas actuales y alejadas de los cardiólogos resulta una información necesaria para la organización individual y propia de cada profesional, así como para el diseño de políticas públicas.
Objetivos: Describir las percepciones de los cardiólogos en la Argentina sobre su situación profesional y económica actual y futura y analizar las características individuales y comunes asociadas con las percepciones negativas.
Material y métodos: Estudio observacional, de corte transversal, por medio de una encuesta realizada por vía electrónica sobre ca­racterísticas demográficas, laborales y percepciones de situación profesional actual, a 10 años y al retiro, definiendo como percepción negativa las respuestas “Mala” o ”Muy mala”.
Resultados: Contestaron 236 cardiólogos: 26% mujeres, 57,1% de CABA y conurbano. La situación profesional percibida fue: a) Ac­tual: Mala/Muy mala 9,7%, Regular 45,1%, Buena/Muy buena 45,1%; b) A 10 años: Mala/Muy mala 17,1%, Regular 44,6%, Buena/ Muy buena 38,3%; c) Al retiro: Mala/Muy mala 49,1%, Regular 30,3%, Buena/Muy buena 20,6%.
El análisis univariado mostró mayor expectativa negativa al retiro en cardiopatía (p = 0,007), factores de riesgo coronario (p = 0,027), ansiedad/depresión (p = 0,016), principal sostén del hogar con más de tres hijos/familiares a cargo (p = 0,034) y haber pade­cido alguna enfermedad (p = 0,03).
En el análisis de componente principal se estableció la presencia de cuatro factores (o variables ocultas), que definimos exploratoriamente como mayor vulnerabilidad, sobreadaptación, enfermedad manifiesta y autonomía con aislamiento.
Conclusiones: Aunque los cardiólogos ven el presente favorablemente, el futuro cercano y el retiro impresionan como una realidad amenazadora y negativa. Tal vez sea oportunidad de tener un rol crítico y profundo con actitud de cambio de los modos de trabajar para promover un futuro más seguro y mejor.

Palabras clave: Condiciones de trabajo - Factores socioeconómicos - Vulnerabilidad social - Médicos - Argentina

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Abbreviations

CABA GBA Autonomous City Buenos Aires Greater Buenos Aires
saC   Argentine Society of Cardiology
MVaW   Minimum, Vital and Adjustable Wage

 

INTRODUCTION

In the last decade, researches performed by the Bioeth-ics Committee and the Research Area of the Argentine Society of Cardiology (SAC) on the professional situ-ation of cardiologists and their quality of life showed great dissatisfaction and high correlation between in-come level and quality of life perception. (1, 2)

A recent publication by Salazar and Boissonnet (3) suggests that despite this discontent there are few re-search projects on the medical situation in public and private health areas.

In 2012, the Health Policy Area of SAC also re-vealed views on working, union and approaches to “professional issues” matters among cardiologists. The present survey was then designed to update infor-mation on cardiologists, their working methods and near and distant future expectations. After triangula-tion with other information and in a multidisciplinary approach, the data could then be transferred to those who should address the rights of doctors, their welfare and public health. (4-6)

The aim of this study was to describe cardiologists’ perceptions on their current and future professional quality of life in Argentina and to analyze patterns of individual characteristics associated with negative perceptions.

METHODS

The research was based on a survey to all cardiologists in SAC’s database, electronically delivered through the news-letter (e-mail) and available in SAC’s web page to be self-administered and answered anonymously between Sep-tember 2013 and May 2014. The survey consisted in 25 multiple-choice questions focused on the following domains; Demographic: age, gender, location; Curricular: graduation year, subspecialties; Working status: hourly workload, jobs, income, contract forms; Household support status (main breadwinner or not); Health: recreational/sports activities; Opinion on professional risks; Perceptions about their own professional situation: present, in the next decade and at re-tirement.

To compare with other studies, income was defined as multiples of Minimum, Vital and Adjustable Wage (MVAW), which in January 2014 corresponded to $3,600.

The questions about the perceptions of their own pro-fessional situation allowed 5 answer options: Very Good – Good – Fair – Bad – Very Bad, which were dichotomized in association analyses, considering Very Good, Good and Fair as a “favorable” perception and Bad and Very Bad as an “un-favorable” perception.

statistical analysis

This was an observational, cross-sectional study. The sta-tistical analysis was performed in three stages. In the first stage, univariate analysis was done using the chi-square test, considering present and future perceptions as depend-ent variables and age (dichotomized in >40 years), gender, geographical location (dichotomized as CABA and GBA vs. the rest of the country), hourly workload (dichotomized in >40 hours/week), main breadwinner supporting 3 or more persons, living alone (and hence, main breadwinner of his unipersonal home), incomes (dichotomized in >6 MVAW), being both employed and independent versus working in only one of these modalities, coronary risk factors, heart disease, anxiety and/or depression, or presence of any dis-ease as independent variables. The other surveyed variables were not included in this or later analyses because they were scarcely frequent (e.g. cancer), they were nominal variables with multiple categories of difficult statistical analysis (e.g. subspecialty), or because they were considered by research-ers as scarcely related with the objective of this article (e.g. proposed actions).

In a second stage, an exploratory factor analysis was per-formed (main component analysis) as a way of identifying whether there were unifying “hidden variables” of associa-tion between the collected data which could better explain the variability of the sample. (7, 8) This analysis model in-cluded the independent variables mentioned in the previous paragraph.

In a third stage, the association between the factors detected in the main component analysis with present and future perceptions was analyzed with Student’s t test as an initial step to confirm the validity of the theoretical con-structs that might be generated from this exploratory factor analysis.

The statistical analysis was performed using STATA 11.0 software package.

Ethical considerations

The protocol was evaluated and approved by the Health Policy Area of SAC. As the survey was only directed to physi-cians to explore demographic data and perceptions on the professional situation, other assessments were not consid-ered necessary. The answers to the questionnaire were as-sumed as “consent”. No identifying details were requested from the respondents.

One hundred and seventy-five cardiologists (74.2%) answered the questions about current and future perceptions of their situation; a not negligible number of respondents did not answer these questions.

Table 1. Participant description and working situation

To explore other relationships among variables, an exploratory factor analysis was performed in the last stage of the analysis (“main component analysis”). This type of analysis looks for association patterns among variables and attempts to explain this pattern in terms of a (low) number of underlying variables, known as “factors”. These factors may really exist or constitute explicative theoretical constructs encompassing the associated information from different related variables. This is a common methodology in social sciences that helps to elaborate the behavior of sometimes less evident variables. The usual methodology was followed for this analysis. (7, 8)

In the first place, the main component analysis detected the existence of 4 factors (the conventional criterion of considering a factor as real if its Eigenvalue was >1 was used): Factor 1 concentrated 20.8% of sample variability, factor 2: 16.2%, factor 3: 12.8% and factor 4: 9.7% (total among the four factors: 59.5%) (Table 3).

Then, mathematical rotation of the model was performed, and the associations of each variable with each factor (“load”) were estimated, establishing by convention (common criterion) that a variable is associated to a factor when “load” to that factor is >0.5. Table 4 de-tails the variables loading each factor, from 1 to 4.

We could thus establish the presence of four factors (or hidden variables).

-        Factor 1: it basically loaded to variables associated with disease (presence of any type of disease, especially coronary risk factors, anxiety or depression). A priori, the content of this factor is assumed as self-perception of “Physical or psychological vulnerability”.

-        Factor 2: it loaded to male gender, greater hourly workload and higher income variables. This factor was conceived as “Adaptation/over adaptation to demand”.

-        Factor 3: in a certain way, it is similar to factor 1, as it presence of another disease variable (heart disease), in addition to older age. Due to the possibility of perceiving heart disease as more se-vere compared with the other mentioned diseases in the Table (and furthermore, as it is a cardiolo-gist sample) this factor was considered as “Injury perception” or “Presence of greater injury” by the cardiologist.

-        Factor 4: it was the one with lowest weight in factor analysis (lowest eigenvalue), which loaded to two op-posite variables: living alone and not be ing a household breadwinner. It should be expected that this vital situation was common in younger subjects but, as the age variable did not load to this factor, it was interpreted to correspond to another independent personal component, initially termed as “Isolation and autonomy”.

Finally, and to initiate the validity analysis of the generated theoretical constructs, the association of the factors thus established with current and future perceptions was studied (Table 5).

It can be clearly seen that factors detected have an individual conceptual entity (construct validity), as they are associated with perceptions about different moments throughout time.

Thus, at present and at 10 years, professionals Unfavorable expectation: “Bad” or “Very bad” answer to the specifc question. Favorable expectation: “Very good”, “Good” or “Fair” answer to the same question.

disparity in current and future reality perceptions in a sample of Argentine doctors, (9) associated with different demographic, working, health and way of life variables, a significant part of which were detected by this questionnaire. These variables were grouped into four factors, which a priori are called “Perceived vulnerability”, “Adaptation”, “Heart Disease” and “Isolation” based on the variables that statistically load onto these factors. This analysis allows suggesting multiple psychosocial and socioeconomic implications on doctors’ issues in Argentina, opening a possible path for future research. (10-13)

A SAC survey on physician welfare performed in 2007 (1) showed data on cardiologists’ situation indicating the working and personal aspects that had greater correlation with better quality of life perception. (2) Another survey tried to explore the opinion on the role of SAC to treat the issues with favorable responses towards greater membership participation. It was considered essential to continue in this path, so this new survey was organized with the main enquiry focusing on the perceptions of cardiologists concern-ing their current, in the next decade and at retirement situation and in the associated variables.

Although the number of responses does not represent a large sample size and cannot assume popu-lation representativeness, we propose it as an initial approach to the problem. (14, 15) It is worth mention-ing the difficulties of conducting such a research at present, with low interest in participating in this type of voluntary surveys, in the context of professional discontent and skepticism on the subject.

Regarding incomes, although at first glance the average and prevailing values are several times high-er than the MVAW, the high workload and contract styles should be considered. A large percentage of professionals are independent and have no benefits such as holidays, bonus and sick leaves. The report-ed values do not consider structural or tax expenses related to the profession such as property rent/pur-chase, secretary, equipment (others depending on the work style)

Furthermore, although working conditions are clear determinants of perceptions, the workload does not define sense of future. The single working mode (independent or employed) shows correlation with

poorer perception of the future. To work exclusively in an independent way shows poorer perception of the future, whereas the mixed type (both independent and employed) would be better. In contrast, the situ-ation of main household breadwinner with more than 3 persons to support is associated with poorer percep-tion of near and distant future.

Differences are observed when considering heart disease and anxiety/depression: in this case the pro-portion of cardiologists with negative perception about their future is greater.

Factor analysis, a usual methodology in Social Sci-ences, was used to seek obvious or hidden relation-ships among variables. These “factors” express occult variables in the sense that they were not explicitly sought when data collection was made; they could be more powerful than the variables available when explaining what is happening and also because they are deeper elements (actually, the core of an observed phenomenon). These factors are detected by analyzing variable grouping.

We identified four factors: Factor 1 is the grouping of any illness, anxiety or depression/coronary risk fac-tors. Factor 2 is the grouping of male gender, longer working hours (≥40 hours per week) and higher in-comes. Factor 3 is the grouping of age and heart disease. Factor 4 is the grouping of living alone, being economically independent and without persons to support.

Then, we analyzed the associations of these fac-tors with present and future perceptions and we could see that they associate differently according to the factor. Thus, factors 1 and 3 are associated with poor/very poor perception at retirement, while factors 2 and 4 are associated with poor/very poor cur-rent and in next decade perception (an inverse relationship for factor 2).

This mode of analyzing data allows inferring with greater methodological strength that there would be an association between the variables measured and perceptions.

limitations

Limitations are varied but do not undermine the conclusions. First, from the Social Sciences point of view it is acknowledged that the methodology of the studies whose data collection is done through the Web or email makes them difficult to extrapolate to the universe under study since, on the one hand, subjects who frequently use the Internet may not be similar to the general population and, on the other hand, it is not possible to create a reliable sampling frame over which to calculate non-response rates. The European Society for Opinion and Marketing Research (ESOMAR) establishes that one of the principles to consider a subject as potentially eligible for an email-based study (and thus part of the possible sampling universe) is for the individual to have a “reasonable expectation” that he can be invited to participate, (16) a situation that cannot be established precisely in the vast majority of cases. As such, the general opinion is that this type of study cannot under any circumstances assume population representativeness; there-fore no effort was made in our study to estimate non-response rates. (17)

Another significant limitation is the one famil­iar and usual of cross-sectional studies, not allowing cause-effect inferences, given the absence of the temporality premise.

Finally, the questionnaire used was developed ad hoc for this study, and its psychometric characteristics may have been imperfect. However, the strong asso-ciation between the identified factors and professional perspectives provide a first level of questionnaire validation and in addition contribute to the knowledge of the issues which were the objective of the study.

CONCLUSIONS

This survey allows confirming and extending previous data in most of the domains. Although cardiologists in our sample had mostly favorable perceptions of the pre-sent, their perceptions of the future and at retirement were mostly unfavorable. There was some association between variables constituting “patterns” where the profession, subjectivity, modes of individual practice, and personal and family situations show different styles or behaviors that deserve to be studied. These patterns exhibit different associations with current perceptions and future expectations, and their knowl-edge could help to establish prevention behaviors.

From their own responses it is possible to hypoth-esize about the cardiologists’ convenience to have another role and a critical reflection on their work-ing habits and labor identity. The analysis of future negotiations on this subject would be mandatory to promote the construction of a safer and better pro-fessional future and allow this improvement to be re-flected on patient care.

acknowledgements

To Jorge Kamlofsky, MSc, for his collaboration in the prepa-ration, reading and initial analysis of the survey.

To Pablo Balbi, for his collaboration in loading the data and in different stages of this work.

To María Elizalde, for her collaboration in different stages of this work.

To Dr. Raúl A. Borracci and Dr. Hernán C. Doval, for their sustained attitude in support of this long-term research pro-ject.

Conficts of interest

None declared

(See authors’ conflict of interest forms in the web/ Supple-mentary Material).

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