PEDIATRICIANS AFTER RESIDENCY: A SURVEY OF PERSONAL/PROFESSIONAL DATA AND ISSUES

ABSTRACT Objective: To assess personal, professional, medical, and scientific educational characteristics and issues reported by pediatricians. Methods: Cross-sectional study based on an online survey including 614 pediatricians who graduated in the last 15 years at a University Pediatric Department in Brazil. Results: The response rate was 331/614(54%). The majority were females (82%), the median age was 33 years (27-40) and median years of pediatric practice was 5 (1-13). High workload (>60 hours/week) occurred in 25% and 47% earned ≥15 minimum wages/month. The most work-related issues reported were long working hours, poor social life and a sedentary lifestyle (>50%). Pediatricians were further divided into two groups, according to years of pediatric clinical practice: group 1 (≤5 years) and group 2 (>5 years). The median of overall satisfaction with pediatric residency [8(0-10) vs. 9 (4-10); p=0.002] was significantly reduced in group 1. The frequencies of workload >60 hours, work on pediatric ward and pediatric intensive care were significantly higher in the first group (p<0.05). Regarding main issues related to clinical practice in the last year, long working hours (73 vs. 53%; p<0.001), poor social life (75 vs. 62%; p=0.018) and harassment (23 vs. 4%; p=0.003) were significantly higher in the first group. Conclusions: Very early career pediatricians (≤5 years) reported higher workload, lower income, work-related issues and different location of pediatric practice compared to early career pediatricians (>5 years). The overall satisfaction with pediatric residency was good, however, reduced in very early career pediatricians.


INTRODUCTION
General and pediatric residency programs have been modified worldwide with new curriculums, including a modern approach to teaching, patient care with ethical and humanistic attitudes, and research training. [1][2][3][4][5][6] Increasing technological innovation with new medical procedures, radiology and laboratory exams, translational medicine with drugs development and specific therapeutic targets for each disease are a reality in daily pediatric practice. 2,5,[7][8][9][10][11][12][13] After the conclusion of pediatric residency, pediatricians and pediatric specialists routinely deal with different patient care profiles, including life-threatening, chronic diseases, patients suffering and death. 8,9 In addition, severely compromised patients, harassment, discrimination, low income and disruption in family life may induce high levels of physical/psychological stress and/or professional issues in pediatricians 8,14-17 and may reduce their overall satisfaction, 18 particularly in very early career physicians. 19 To the best of our knowledge, simultaneous analysis of personal, professional, medical, and scientific educational characteristics and issues reported by pediatricians have not been carried out in Latin America.
Therefore, this study aimed to assess pediatricians' reports regarding demographic data, location of clinical practice, pediatric specialties, overall satisfaction rates with residency/clinical practice, income, medical and scientific education, patient care profiles, laboratory exams/medication use and main physical, psychiatric/psychological and professional issues related to clinical practice. In addition, comparisons of personal, professional, educational characteristics and issues according to years of pediatric clinical practice were evaluated.

METHOD
A cross-sectional study involving 614 pediatricians was carried out based on an online survey in terms of personal, professional, medical, and scientific educational characteristics and issues. All physicians had successfully concluded the General Pediatric Residency Program and/ or Pediatric Specialties Residency Program in a Pediatric Department in Brazil, which are teaching-oriented training programs. The General Pediatric Residency Program includes primary and secondary care activities during the first year of training, focusing on care and attention to healthy children and adolescents. In the second and third years, there is a predominance of secondary and tertiary care activities at outpatient and inpatients clinics, including multiple pediatric subspecialties.
The survey was carried out using REDCap tool, which is a secure web application for building, managing, and accessing electronic questionnaires and databases. This survey was sent to all of the pediatricians between November 2018 and January 2019. They had concluded their General Pediatric Residency Program or Pediatric Specialties Residency Program between 2006 and 2018. At least 15 emails were sent to improve the response survey rate. The Ethics Committee of our university hospital approved this study (CAAE: 93564518.5.0000.0068) and an informed consent was obtained from all participants.
Anonymous self-report questionnaire invitations were distributed by email. The online survey comprised 21 questions focused on physician-reported personal, educational, and professional issues. These questions were multiple-choice, dichotomous (yes and no) or horizontal visual analog scale, recollecting events during their practice. Estimated time for completion was nearly 15 minutes The online survey included 21 items related to the following issues: 1. Pediatricians were further subdivided into two groups according to the median years of pediatric clinical practice: group 1 (≤5 years) and group 2 (>5 years).
The Statistical Package for the Social Sciences version 13.0 was used. The results for the continuous variables were presented by median (minimum-maximum values) or mean±standard deviation (SD), and compared by Mann-Whitney test and Student's t-test, respectively. The results for categorical variables were presented as frequency (percentage) and compared by Fisher's exact test or Pearson chi-square test, as appropriated. Pearson or Spearman rank correlation coefficients were used for correlations between overall satisfaction with pediatric residency/pediatrician clinical practice and current age and years of medical practice after residency conclusion. P values less than 0.05 were considered significant.
Most pediatricians (86%) followed-up patients aged between 28 days to 10 years. High workload (>60 hours/week) occurred in one-quarter of pediatricians, and 15% examined more than 100 pediatric patients/week. Almost 50% of pediatricians earned ≥15 minimum wages/month. At least one meeting/congress/course participation was reported in almost 90% of physicians, and approximately 30% reported published research papers in medical literature. Scientific initiation fellowship during medical school was described by 64% of respondents, and 16% reported enrollment in Master and/ or PhD program ( Table 2).
The main patient care profiles described by pediatricians were emergency room, pediatric intensive care, ward, and growth and development monitoring (>40%). The most important physical, psychiatric/psychological and professional issues (>50%)  (11) Results are presented in n (%) and median (range) or mean±standard deviation.
were long working hours, poor social life, physical inactivity and disruption in family life (   (11) Published research papers in medical literature 88 (27) Enrolled in Master's and/or PhD program 54 (16) Results are presented in n (%); PhD: doctor of philosophy.  (Tables 4 and 5).
Regarding Spearman's rank correlations, current age and years of pediatric clinical practice after completing residency were not correlated with overall satisfaction with pediatric residency and overall satisfaction with pediatric clinical practice (p>0.05).  Results are presented in n (%) and median (range); VAS: visual analogy scale (0=no and 10=excellent overall satisfaction).
Further analyses were also carried out comparing two groups according to the duration of pediatric residency program: A (3 years of pediatric residency program, n=82) and B (2 years of pediatric residency program, n=249). The frequencies of infirmary (45 vs. 24%; p<0.001) and emergency room (77 vs. 32%; p<0.001) were significantly higher in group A than in B. The median of overall satisfaction with pediatric residency [8 (0-10) vs. 8 (4-10); p=0.015] and the frequency of pediatricians with ≥15 minimum wages/ month salary (13 vs. 59%; p<0.001) were significantly higher in group B than A, as well as pediatric specialty (68 vs. 96%; p<0.001).

DISCUSSION
This was the first web-based survey to carry out a simultaneous analysis of work-life balance and scientific education of pediatricians after the conclusion of residency in a Latin America Residency Program. Pediatricians were young, reported low income and high workload, particularly in emergency room and pediatric ward. The overall satisfaction with pediatric residency was good, however, reduced in very early career pediatricians (≤5 years).
The advantage of the present study was the moderate response rate (54%) of the online self-reported survey without financial incentive. This response rate observed herein contrasted with a low response in previous studies with neonatologists, members of The American Academy of Pediatrics (15%), 20 with undergraduates in neurology residency (23%) 13 and with medical students, residents and early career physicians listed in Physician Masterfile (35%). 17 The confidentiality of the survey was relevant since there was no disclosure of their identity. Another strength of this study was the assessment of self-report and standardized questionnaire, including measuring instruments to assess overall satisfaction.
Pediatricians in the present study were young, married, and with a low number of children. A predominance of female sex was also observed, similar to other studies. 18,21 Indeed, this finding is related to the increase of women in medical schools and residency programs around the world. 22,23 Nearly 80% of pediatricians worked in both public and private services, known as dual practice. This is a particularity in Brazil, where more than half of medical professionals are engaged in dual practice. 24 Our residents were exposed to all pediatric specialties during the residency training program. However, the most frequent pediatric specialties chosen by our pediatricians were Neonatology, Pediatric Intensive Care and Pediatric Cardiology, as also previously reported. 11 In fact, these specialties are hospital and procedure-based and may have more job opportunities with an improvement of income. 11,25 Of note, the medical profile described in our institution may not represent the Brazilian pediatrician demographic data. In fact, data from the state of Sao Paulo in 2018 showed that the mean age of pediatricians was 47.4±11.6 years, and the most frequent pediatric specialties were Immunology and Allergy, Oncology and Endocrinology. 26 Regarding continuing medical educational, the majority of pediatricians attends medical conferences regularly. This result was important to physicians due to great advances in scientific knowledge in clinical practice in newborn, children and adolescent patients, particularly in those with complex chronic diseases. [2][3][4]12,27 One-quarter of pediatricians reported publishing research papers in medical literature. There has been an increase of this practice in our Medical School and Pediatric Department in the last years, reinforcing the relevance of additional gains in writing a manuscript, 28 such as professional education, financial, social benefits and intellectual pleasure. This is also relevant for those residents that intend to engage in academic medicine.
Importantly, the main location of pediatric practice described by very early career pediatricians was emergency room and pediatric ward, requiring long working hours with poor social life and sedentary lifestyle. The possibility of acute, severely compromised, life-threatening and chronic patients may induce issues and contribute to the decrease in overall satisfaction with pediatric residency reported by our pediatricians with less than 5 years of clinical practice.
In addition, these are issues in medical training programs around the world. The transition from residency training to clinical practice may be challenging for very early career pediatrician, causing work-related stress, fatigue, discomfort and emotional exhaustion, such as burnout, anxiety, depression and susceptibility to harassment. 14, 16,17 Our pediatricians with >5 years of clinical practice became more specialized, worked at private practices and reported high income. Indeed, self-employed pediatricians may choose their workload based on preferences and financial interests. 29,30 The differences between the location of pediatric practices among the pediatricians showed that most physicians started their early career in the emergency rooms and wards and, later on, in pediatric specialties, particularly working in pediatrician private practice. This reinforces the need for the residency programs to cover all areas of practice in pediatrician training.
Of note, the overall satisfaction with clinical practice was high and similar in very early (≤5 years) and early career pediatricians (>5 years). Our study suggests that pediatricians are pleased with their profession, probably due to the strict relationship between patients and family, and the holistic awareness on mental, physical and emotional health. However, general pediatrics is non-procedure based, contrasting with early-career cardiologists training in Japan, where satisfaction was associated with invasive procedures, such as coronary angiography and percutaneous coronary interventions. 19 In 2014, a new 3-year pediatric residency program was instituted in our Pediatric Department, aimed at training pediatricians in the 21 st century. The topics of Adolescent Medicine, Developmental and Behavioral Care, mental health and pediatric chronic diseases care were expanded on. Approximately one third of our 3-year pediatric residents did not study pediatric specialties after the general residency program. Future multicenter studies with a large population will be necessary to clarify this issue.
The limitations of this study included the possibility of memory bias, since respondents were asked to report questions preferable using a 1-year recall period. In addition, the results of this survey must not be generalized beyond the pediatrician population in our country. Other limitations were the cross-sectional study design, and the fact that the survey did not include instruments to evaluate physiological/psychiatric issues. Therefore, longitudinal and qualitative studies are needed to clarify the trajectory of pediatricians and gain more insight into work-life balance and future goals.
In conclusion, very early career pediatricians (≤5 years) reported higher workload, lower income, and work-related issues compared with late career pediatrician (>5 years), but over time they moved on to private practices and specialized care, consequently improving earnings and living conditions. The overall satisfaction with pediatric residency was good, but reduced in very early career pediatricians, possibly due to not being able to encompass all the knowledge they had acquired in their medical residency.