Short-term career perspectives of young cardiologists in the Netherlands

Background Since it was anticipated that the need for doctors would increase due to demographic changes, the number of positions for medical specialty training programs has increased from the year 2000 onwards. However, the number of permanent positions for young cardiologists did not follow that trend leading to concerns about future employment. Therefore, the aim of the current study was to assess short-term career perspectives of young cardiologists in the Netherlands. Methods All cardiologists who ended their training between 1 January 2011 and 31 December 2014 were invited to fill in a questionnaire about their first employment status and were followed yearly until the participant had a permanent position. The timespan between the end of training and the moment of permanent employment was assessed. Furthermore, the association between professional profile and short-term career perspectives was investigated. Results The observed unemployment was 1.6% and lasted less than a year in all cases. Of the participants, 77% started their career with a temporary contract; within four years this was 7%. Of young cardiologists, 46% started their career as a fellow and 24% as an attending physician. A total of 29% of male cardiologists started their career with a permanent contract as compared with 12% of females (p = 0.01). Within two years this difference was no longer observed. Conclusions Unemployment is low among young cardiologists. Most cardiologists start their career with a temporary contract. The time to a permanent contract is slightly longer for female cardiologists as compared with males.


Introduction
The Dutch government regulates the number of cardiologists and other medical specialists by controlling the number of positions in medical specialty training. In the past decade, it was anticipated that the need for doctors would increase due to demographic changes such as population ageing. Therefore, the Dutch government decided to gradually increase the number of positions for most medical specialty training programs from the year 2000 onwards [1]. However, partly due to cutbacks in care, cooperative agreements among hospitals and hospital mergers, the number of permanent positions for most medical specialties have not followed that trend so far. This resulted in concerns about unemployment among young medical specialists. In response, the Dutch Federation of Young Medical Specialists issued a survey to investigate the career perspectives of young medical specialists. They reported unemployment rates varying from 5 to 15% depending on the type of medical specialty [2]. A major drawback of this survey was the low response rate (27%). To get a better view on early career perspectives, the Netherlands Society of Cardiology initiated a survey among young cardiologists. The primary goal was to investigate the unemployment rate and the timespan to obtain a permanent position. The secondary goal was to explore the association of professional profiles and shortterm career perspectives.

Methods
Participants were identified by direct contact with the cardiology departments of all training centres. All cardiologists who finished their training between 1 January 2011 and 31 December 2014 were invited to fill in a non-anonymous questionnaire online. The first questionnaire was sent on 1 October 2012. Besides personal characteristics, the questionnaire contained questions about the professional profile of the participant: PhD degree, area of expertise, the type of teaching institution (academic vs. non-academic), preference to work part-time (without defining working hours). Finally, participants were asked about their current employment status: employed vs. unemployed, permanent vs. temporary position, type of temporary position (fellowship, attending physician, locum physician). If participants indicated they had a permanent position, they were excluded from follow-up. If participants indicated they were unemployed, or had a temporary contract, they were included for follow-up. This follow-up questionnaire was sent yearly and contained questions about the current employment status as described above. Follow-up ended when a participant obtained a permanent position. If cardiologists were unavailable, information provided by colleagues or ex-colleagues about employment status was also approved (indirectly received data).

Statistical analysis
Descriptive statistics were used to describe participants' characteristics and type of employment position. Differ-ences between the two groups were analysed by an unpaired Student t test. A multivariate analysis was performed to investigate the association between the baseline variables and the achievement of a permanent contract. Those variables found to be significant by univariate analysis (p < 0.1) were entered in the multivariate model. Statistical analysis was performed with the SPSS software for Windows XP version 16.0.

Results
From 1 January 2011 to 31 December 2014, 193 residents ended their training program. For four young cardiologists, no information could be obtained (2 from 2011, 1 from 2012 and 1 from 2014), thus 189 participants could be included (98%). Of these 189 young cardiologists, information could be obtained from competed questionnaires in 142 cases. Data for the remaining 47 cardiologists was received. Table 1 summarises the baseline characteristics.

First-year employment status
Three cardiologists were unemployed in the first year (all 2012), corresponding to an unemployment rate of 1.6%. In three cases, it was unclear whether or not the contract had a fixed term. All participants who were employed stated they worked as a cardiologist (4 participants worked abroad). Table 2 shows the first-year employment status and the types of positions. Overall, 23% of cardiologists received a permanent contract within 1 year. However, most participants started a fellowship (n = 87, 46%) or worked as an attending physician (n = 46, 24%). Since the first questionnaire was sent on 1 October 2012, participants from 2011 indicated they had a permanent position slightly more frequently (39%) as compared with the participants from 2012-2014 (15%, 21%, 14%, respectively). The participants who had a permanent position were most likely to work in an independent group practice (50%) or in an employed physician practice (36%). A total of 163 participants (86%) indicated having an area of expertise. Table 1 shows a subdivision of the different areas of expertise. As expected, a large proportion (33%) indicated general cardiology as their area of expertise, followed by cardiovascular imaging (23%), interventional cardiology (18%) and electrophysiology (17%).
When analysing indirectly received data versus directly received data, no significant differences were found in gender distribution or proportion of permanent contracts.

Professional profile and first-year career perspectives
Aspects of the professional profile of participants were assessed to analyse influence on first-year career perspectives.

PhD degree
Of the subjects, 41% indicated having a PhD degree and 30% of these had a permanent contract within the first year as compared with 18% of those without a PhD degree (p = 0.07). Subdivision into gender demonstrated that 23% of females with a PhD degree had a permanent contract as compared with 3% of females without a PhD degree (p = 0.046). Of the males with a PhD degree, 32% had a permanent contract within the first year as compared with 27% of males without a PhD degree (p = 0.69).

Type of teaching hospital
Of the participants, 61% were trained in an academic teaching hospital. Of these, 31% had a permanent contract within the first year as compared with 11% of participants trained in a non-academic hospital (p = 0.001). Subdivision by gender demonstrated that 21% of academically trained females have a permanent contract as compared with 0% of nonacademically trained females (p = 0.02). Of academically trained males, 35% had a permanent position, as compared with 17% of non-academically trained males (p = 0.03).

Gender
In total, 68% of the cardiologists were male and 29% of them have a permanent contract within the first year as compared with 12% of the females (p = 0.01). Throughout the years, this tendency remained apparent. From the participants of 2011, 44% of males had a permanent contract

Discussion
The aim of the current study was to investigate short-term career perspectives of young cardiologists. The main findings were: (1) the unemployment rate was low (1.6%) and unemployment was of short duration, (2) most young cardiologists start their career as a fellow or as an attending physician, (3) the period of time between the end of cardiology training and the first permanent contract is slightly longer for females compared with males, (4) a fairly large proportion of young cardiologists have a permanent position within 4 years after the end of training.
To our knowledge, this is the first study on short-term career perspectives of young cardiologists in the Netherlands. As compared with the general population, in which the reported unemployment rate was 5.1% in January 2016, reported unemployment among young cardiologists is lower [3]. In the report of the Dutch Federation of Young Medical Specialists, the unemployment rate among young cardiologists varied between 5-8% [2]. However, the inclusion rate of that survey was lower than the current study (27% vs. 97%), which may lead to selection bias. Furthermore, no follow-up was performed to investigate the period of unemployment.
Most cardiologists start off their careers with a temporary position (77%) and less than 10% have a temporary contract after four years. Several factors may play a role in this observation. First, since subspecialties in cardiology are becoming increasingly important, a significant proportion of young cardiologists do a fellowship directly at the end of cardiology training. And, most of these fellowships are linked to a temporary contract. Second, the number of registered cardiologists has increased by 24% since 2010, [3] while at the same time, large hospital mergers and organisational changes took place on a national level in the medical specialist care sector [4]. The latter may have directed practices towards offering temporary positions in order to ensure organisational flexibility. Third, young cardiologists may also deliberately choose a temporary position to start their career with. It could be questioned if the observations of the current study could have an effect on the number of cardiologists to be trained. Since it takes several years to find a permanent position, one could argue that the number should be reduced. However, this number should mainly be adjusted to the amount of patients demanding cardiovascular care. Since the number of patients has sharply increased in past years and prognoses show that this will continue to increase, it seems reasonable that the number of cardiologists is in agreement with this trend [5,6]. Furthermore, within their human resource policy practices should be balanced, on the one hand offering temporary contracts which increases organisational flexibility and, on the other hand, offering permanent contracts which ensures the career perspectives of young cardiologists. We do believe that the high number of temporary positions is undesirable, especially when this results in a sequence of multiple temporary positions for a cardiologist. However, our study did not show a significant increase in temporary positions during short-term follow-up. Furthermore, we do not know if the number of temporary contracts was lower in the past and we did not investigate the conditions of the temporary contracts and satisfaction level of temporary position holders.
Interestingly, this study shows a gender difference in career perspectives among cardiologists. The time between the end of training and getting a permanent contract is longer for females as compared with males. It could be hypothesised that choices in private life, such as family planning, may have an impact on career development. This may lead to longer fellowship programs and, thus, a longer period with a temporary contract. The higher number of women who preferred to work part-time may lead to an over-representation of women in temporary jobs as permanent jobs may require full time employees. Our data do not provide a clear answer to explain this observed gender difference in the first year. However, the gender difference was only of short duration as the rate of permanent positions was at follow-up.
In this study, the type of training centre appeared to be an independent variable for a permanent job. The national training program is similar across all centres so confounding factors, which we have not included in our study, play a role. Presumably the professional profile is different. However it was out of the scope of this study to investigate the influence of the professional profile on type of contract.

Limitations
There are several limitations in this study. First, a short questionnaire was used to ensure a high inclusion rate. As a consequence, detailed information about participant characteristics and contractual conditions are lacking which hampers interpretation of the observations. Second, in an important number of cases, information was obtained from colleagues or ex-colleagues. However, since the study was focused on objective rather than subjective information, this probably has a limited influence on the study results.

Conclusions
Unemployment is low among young cardiologists and of short duration. A large majority of young cardiologists start off their careers with a temporary contract. However, most cardiologists have a permanent position within four years of completing their cardiology training. The time to a permanent contract is slightly longer for female cardiologists as compared with males.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.