Perspectives in Training and Professional Practice of Cardiac Surgery in Latin America

Introduction There is a lack of information about cardiac surgery training and professional practice in Latin American (LATAM) countries. This study is the first comparative analysis of cardiac surgical training and professional practice across LATAM and provides the fundamentals for future academic projects of the Latin American Association of Cardiac and Endovascular Surgery (LACES). Methods International survey-based comparative analysis of the training and professional practice of cardiac surgeons across LATAM. Trainees (residents/fellows) and staf (graduated) surgeons from LATAM countries were included. Results A total of 289 respondents (staf surgeons N=221 [76.5%]; residents/fellows N=68 [23.5%]) from 18 different countries participated in the survey. Most surgeons (N=92 [45.3%]) reported being unsatisfied with their salaries. Most respondents (N=181 [62.6%]) stated that it was difficult to obtain a leadership position, and 149 (73.8%) stated that it was difficult to find a job after completing training. Only half of the trainee respondents (N=32 [47.1%]) reported that their program had all resident spots occupied. Only 22.1% (N=15) of residents/fellows were satisfied with their training programs. The majority (N=205 [70.9%]) of respondents would choose cardiac surgery as their specialty again. Most surgeons (N=129 [63.9%]) and residents/fellows (N=52 [76.5%]) indicated that the establishment of a LATAM cardiac surgery board examination would be beneficial. Conclusion Modernization and standardization of training, as well as greater access to opportunities, may be required in LATAM to increase professional satisfaction of cardiac surgeons and to reduce disparities in the specialty. Such changes may enhance the regional response to the dynamic challenges in the feld.


INTRODUCTION
Training in cardiac surgery varies substantially across the world [1] . These differences are not only evident globally, but also in a regional context [2] . Cardiac surgery training and professional practice differ significantly across Latin American (LATAM) countries. First, there is discordance on how the specialty is named across the continent, using the terms cardiac, cardiothoracic, and cardiovascular surgery interchangeably. Second, the content and duration of the training considerably vary from country to country and even within countries, and the legally attributed roles to the specialty are not homogenous across LATAM countries. Moreover, salaries, workload, surgical volumes, job opportunities, and leadership positions significantly vary within countries and even more across the continent. Finally, there is a lack of officially reported and collected data in LATAM, and therefore, the current professional situation is unknown.
Cardiac surgery is a dynamic and continually evolving specialty. Thus, the challenges that cardiac surgeons must deal with are complex and transcend borders [3] . Hence, constant selfevaluation, improvement, and creative solutions are required to solve these problems. Moreover, LATAM countries have an additional hurdle: the lack of economic resources and limited access to novel technologies. Therefore, the unification of efforts is necessary to recognize the weaknesses and strengths of LATAM as well as to identify our current situation as a continent, thus helping to define a starting point for a common continental improvement pathway.
In response to that imminent need, the Latin American Association of Cardiac and Endovascular Surgery (LACES) works hard to recognize and address the abovementioned disparities and aims to unify and standardize cardiac surgery training programs in LATAM. The current project analyzes the cardiac surgical landscape in LATAM, aiming to have an actual and contemporary overview of the training and professional situation among LATAM cardiac surgeons. This study is a descriptive analysis of 1) cardiac surgical training and 2) professional practice after cardiac surgical training in LATAM countries.

Study Design
We performed a descriptive cross-sectional study. Residents and cardiac surgeons were contacted by email from the LACES database and invited to answer a voluntary survey. Information was anonymous. The survey was conducted in English. Given the small number of surgeons in some countries, demographic information, such as age, could only be answered in the survey as ranges (e.g., 40-50 years), but not with an exact value, thus ensuring the data anonymity. Hence, exact median or mean values cannot be calculated. The questionnaire was constructed considering the following domains: training, research and academic participation, professional satisfaction, financial retribution, and workload. Questions to address each of these domains were constructed. A pilot study was performed among random surgeons and residents to ensure the questionnaire's comprehensiveness and obtain feedback regarding additional or irrelevant questions. Reliability was assessed based on internal consistency evaluation. The survey was divided into three parts: 1) general questions for all participants, 2) questions only for trainees (residents/fellows), and 3) questions only for staff (graduated) surgeons. The survey can be seen in the Supplementary Appendix. Answers were collected from March to April 2021. Participants from the following countries answered the survey ( Figure 1)

Statistical Analysis
The normality of data was assessed using the Shapiro-Wilk test. Normally distributed data were presented as mean ± standard deviation. Non-normally distributed data were presented as median with interquartile ranges. Non-parametric variables were assessed and compared using Student's t-test or chi-squared test, as appropriate. All data were tabulated, and analyses were performed using Microsoft® Excel® (Microsoft, Redmond, Washington, United States of America) and Prism™ (GraphPad LLC, San Diego, California, United States of America). Statistical significance was accepted at P<0.05. To avoid violating confidentiality and ensure the anonymity of the respondents given the small number of surgeons in some participating countries, some results (e.g., age) are limited to ranges rather than expressed as specific numeric values.

Respondents' Demographics
Thirty-seven responses were excluded based on country. After excluding ineligible responses, analyses were performed on the remaining (N=289) responses. Respondents originated from 18 different countries ( Figure 1) with a median age between 40-50 years. Respondents' demographics are summarized in Table 1.
The majority (N=205, 70.9%) of respondents reported choosing cardiac surgery as their specialty of training again if given the option, whereas 23.5% (N=68) were unsure, and 5.5% (N=16) would prefer a different specialty. Among surgeons, 72.4% (N=160) would choose cardiac surgery again, whereas 5.9% (N=13) would not. Among residents and fellows, 66.2% (N=45) reported choosing cardiac surgery again, whereas 4.4% (N=3) would not. Forty-one (14.2%) respondents stated that leadership positions are widely available and accessible in their institution, city, and/ or country. In contrast, 62.6% (N=181) respondents stated that it was difficult to obtain a leadership position in some capacity. The remaining respondents did not consider leadership positions, either due to lack of interest (N=28, 9.7%), lack of time (N=6, 2.1%), or having to take up too many responsibilities with little or no pay (N=27, 9.3%).
Surgeons' training ranged from less than four years (N=51, 25.2%) to more than eight years (N=15, 7.4%), with a median of 5-6 years (Table 2). Also, 18.8% (N=38) reported not having undergone general surgery training, while most conducted either 1-2 years (N=65, 32.2%) or 2-4 years of general surgery training (N=68, 33.7%), with a median of 1-2 years. The median cardiac surgery training surgeons underwent was 3-4 years, ranging from 1-2 years (N=8, 4.0%) to more than four years (N=88, 44.2%). Critical care training varied widely from having received no dedicated training (N=56, 27.8%) to more than two years of training (N=62, 30.8%), with a median of 3-6 months. Most of surgeons (N=129, 63.9%) indicated that establishing a regional cardiac surgery board exam would be beneficial, while 5.9% (N=12) were completely against it. Three-quarters of surgeons (N=149, 73.8%) stated that it was difficult to find a cardiac surgery job after completing training. Surgeons' monthly salaries widely varied, with a median between 2,500-5,000 USD (or United States Dollar). Most surgeons reported being unsatisfied (N=92, 45.3%) or moderately satisfied (N=86, 42.4%) with their salary. Most surgeons (N=165, 82.1%) reported having received a salary during their residency training. Nearly one in five surgeons (N=41, 20.4%) stated they had to pay for residency training, of whom 73.2% (N=30) had to take loans to afford to pay for residency.

Resident/Fellow-Specific Responses
Sixty-eight residents and fellows (23.5%) responded (23.7%, N=15 female vs. 76.3%, N=53 male). Respondents had 14 different countries of origin with a median age between 30-40 years. All residents and fellows completed all or most resident/ fellow-specific questions.
The anticipated median duration of training for residents and fellows is expected to be 5-6 years. Residents and fellows completed a median of less than one year of general surgery training and less than three months of critical care medicine training and are expected to complete a median of more than four years of cardiac surgery training ( Table 2). Most residents and fellows received a salary during training (N=58, 85.3%). One in five (N=13, 19.1%) reported having to pay for residency training.
The comfort levels of residents and fellows in different clinical and surgical tasks varied considerably ( Figure 3). Most (N=41, 60.3%) reported independently performing less than one case per week, on average, whereas contributions to essential parts of operations vary (N=21, 30.9% less than one per week; N=13, 19.1% one per week; N=22, 32.4% 2-5 per week; N=12, 17.6% more than five per week). A third (N=23, 33.8%) of residents and fellows anticipated having performed less than ten procedures independently by the end of their training compared with 30.9% (N=21) expecting to have performed more than 50 independent procedures. Half of the respondents (N=32, 47.1%) reported that their program had all resident spots filled, whereas 11.8% (N=8) had one open spot, 17.6% (N=12) had two open spots, and 23.5% (N=16) had more than two resident spots unfilled. A median of 2-4 night shifts were performed per week, with 8.8% (N=6) reporting 5-7 night shifts per week. Satisfaction with training programs varied, with 22.1% (N=15) being satisfied, 48.5% (N=33) moderately satisfied, and 29.4% (N=20) unsatisfied.

DISCUSSION
The current study represents the first analysis of the current training and professional practice situation in cardiac surgery in LATAM countries. Knowing this information is essential to accelerate continuous improvement and standardize cardiac surgical training and practice in LATAM. It also helps to improve the professional satisfaction of LATAM cardiac surgeons and reduces disparities in the specialty across the continent. The main findings of this study are summarized in Table 3.
Although there is an overall feeling of satisfaction within the specialty, cardiac surgeons in LATAM report difficulties finding job opportunities and are unsatisfied with their salaries. There is a false feeling of "competition" for job opportunities in large cities and a general belief that there is an "over-offering" of surgical training programs in LATAM. However, LATAM is still underperforming cardiac surgical volumes due to an insufficient workforce [4] . Moreover, according to the survey, only around 50% of the available training spots in LATAM are currently occupied. Hence, if the conditions are improved in smaller towns/centers, accurate geographical distribution of LATAM surgeons could be achieved [5] .
To improve the satisfaction with salaries, the implementation of regional "tariff systems", like in Germany [6] , could regulate the wages. The tariff system establishes the minimally legally accepted salary for trainees and surgeons according to their years of experience. Most respondents stated that it is difficult to obtain a leadership position in LATAM. However, most respondents with a leading position also have academic titles such as a master's degree and PhD and/or completed advanced training fellowships. In other countries outside of LATAM [7] , surgeons obtaining leadership positions usually have the most complete surgical and academic profiles. It is the responsibility of associations such as LACES to offer grants and broaden the global network to allow their members access to academic, research, and advanced surgical training programs. This would significantly improve LATAM surgeons' professional profile and increase the opportunities when applying to leadership positions besides considerably increasing the quality of cardiac surgery in LATAM.
The number of weekly work hours for residents in LATAM is comparable to the number of the United States of America [8,9] , but it is considerably higher than in most European countries [10][11][12] . However, except for Brazilian trainees [13] , according to the survey, LATAM residents perform significantly less own "skin-to-skin" cases during their whole training in comparison with European and North American training programs [7,10] . This evident disbalance between surgical learning and work hours must be corrected in LATAM. Moreover, standardized "logbooks" for competencebased learning, where procedures can be rigorously documented, might significantly improve the training [3] . Competency-based training and evaluation offer an option to compensate for inequality among trainees due to patient volume differences in training centers. The opportunities provided by simulation to rehearse procedures and management of challenging situations before encountering them in real life cannot be overemphasized. Different countries have published multiple successful experiences: the United States of America and Canada offer simulation boot camps to learn how to conduct basic skills [14] . The Brazilian Society of Cardiovascular Surgery frequently hosts wet lab courses for trainees [13] . The national cardiac surgery associations in the United Kingdom and Germany offer a broad curriculum of courses covering operative and nonoperative skills [15] . However, surgical simulation is expensive, and access to good quality simulators is, therefore, limited. Hence, LATAM training programs need to find sufficient funding to implement Table 3. Main survey findings.

Positive aspects Negative aspects
Most cardiac surgeons would choose training in cardiac surgery again.
There is a significant gender and racial disparity among cardiac surgeons in LATAM.
A significant number of surgeons completed a clinical fellowship after finishing their initial cardiac surgical training.
Likewise, most residents plan to pursue a fellowship once they finish their training.
According to the respondents, there is a lack of job opportunities and leadership positions in LATAM. Moreover, most surgeons were not satisfied with their salaries.
There is a general agreement on the benefits of a LATAM cardiac surgery board exam, similar to those performed by the European Board of Cardiothoracic Surgery and the American Board of Thoracic Surgery.
Despite good clinical training, academic degrees such as a master's degree or PhD are uncommon amongst the respondents.
There is a high interest of both surgeons and trainees in research activities.
Only one-third of residents/fellows are satisfied with their training programs.
According to the respondents, only half of the training spots in cardiac surgery are occupied.
LATAM=Latin-American a formalized longitudinal simulation curriculum to improve the training of a new generation of cardiac surgeons. Cardiac surgery is going through the so-called endovascular revolution, and surgeons need nowadays to obtain transcatheter expertise [16,17] . However, only a minority of respondents completed advanced fellowship training in minimally invasive surgery and transcatheter interventions. Hence, training programs must respond to the imminent need to update their contents and competencies. In addition, compared to more senior surgeons, younger generations of cardiac surgeons in LATAM have less exposure to critical care and general surgery training. Therefore, including a more comprehensive critical care and basic general surgery training in the current cardiac surgery pensums might significantly improve the training's quality as well as increase the confidence of younger surgeons in the management of perioperative complications. A particular focus in research is of utmost importance to increase innovation in the cardiac surgery field. LATAM countries have plenty of socioeconomic problems, and, therefore, innovation is more than needed to face some of our issues in the treatment of cardiovascular diseases. This is how national and international scientific associations must join forces to increase funding of research projects in LATAM to encourage surgeons to increase research and innovation "made in LATAM". Moreover, a LATAMwide database is required to facilitate the performance of clinical trials and improve quality management and clinical outcomes.
Finally, the generalized acceptance of a LATAM cardiac surgery board examination among the study respondents is a clear sign of the need for standardization of training in LATAM. This exam would not only assure the professional quality of the certified surgeons but would also facilitate international mobility as well as increase the global acknowledgment and acceptance of LATAM cardiac surgeons. Collaborative work with more experienced associations is of utmost importance to achieve this goal.

Limitations
The main limitation of this study is that the survey results might not necessarily represent the complete picture and reality of LATAM since 289 respondents are only a small fraction of the total cardiac surgery trainees and staff surgeons in LATAM. Moreover, other important topics/questions might still be missing and were not included in the survey to increase the survey completion rate since otherwise, the survey might be too long, and respondents would tend to abort the questionnaire. Finally, to avoid violating confidentiality and ensure the anonymity of the respondents, some results are limited to ranges rather than expressed as specific numeric values, thus reducing the specificity of some results.

CONCLUSION
Cardiac surgery is considered a rewarding specialty among LATAM surgeons and trainees. However, significant improvements are required to reduce salary dissatisfaction, increase job and leadership opportunities, and narrow the gender and racial gap. In addition, the modernization and standardization of surgical training programs are also required to improve the training programs' quality and the trainees' satisfaction. All these improvements would reduce significant disparities in the specialty and an enhance regional response to the dynamic challenges in the field.

Supplementary
Supplementary Appendix: Survey Questionnaire.

General questions (for both staff surgeons and residents)
Gender