Profile of plastic surgeons in the state of Goias , Brazil

1 Sociedade Brasileira de Cirurgia Plástica, São Paulo, SP, Brazil. 2 Universidade Federal de Goiás, Goiânia, GO, Brazil. 3 Hospital de Urgências Governador Otávio Lage de Siqueira, Goiânia, GO, Brazil. 4 Hospital de Clínicas Universidade Federal de Goiás, Goiânia, GO, Brazil. Conflicts of interest: none. Introduction: Plastic surgery has become popular in the recent years for the access to procedures and exposure in the media. The current scenario brings difficulties in the job market because of competitiveness and reduced fees. This study describes the profile of the plastic surgeons working in the state of Goias. Methods: The survey was conducted with plastic surgeons who work in the state of Goias and are registered in local chapter of the Brazilian Society of Plastic Surgery in January 2015. Data were divided into socio-economic and demographic profile. Inclusion criteria were residence certified by the Brazilian Ministry of Education or by the Brazilian Society of Plastic Surgery,, practice of plastic surgery in the state of Goias. We excluded residents in plastic surgery, and those who not practice in plastic surgery area. Results: Rate of response was 70%. Most participants were younger than 40 years old, men, married, with 1-2 children, work in Goias, had less than 10 years as a surgeion, had specialization in plastic surgery, work 40-60 hours weekly and main practice was in aesthetic and reconstructive area, the majority of them do not employ assistances in more than 50% of surgeries. Conclusion: The profile of plastic surgeon in state of Goias is composed by young physicians, men, married, with no more than 2 children, and whom practice mainly in the state capital, most of them are specialists, work 40-60 hours per week, and their main practice is with aesthetic and reconstructive surgery. ■ ABSTRACT


INTRODUCTION
Plastic surgery has become popular in the recent years because of the ease access to procedures and exposure in the media 1 .
The diffusion of knowledge by residency programs in plastic surgery allowed that after training, plastic surgeons can practice in regions that was previously had few professionals, however, metropolitan areas 2,3 continue to be preferred location, either because there are better infrastructure and because these areas have more people looking for plastic surgery.
For this reason, early career surgeons and more experienced surgeons have reported increase in the difficulty to enter in the labor market due to decreased fees 2,4,5 , lack of options to work in public hospitals and higher demand from patients 6,7 .

OBJECTIVE
This study reports profile of the plastic surgeon who practice in the state of Goias, Brazil.

METHODS
A survey was conducted using a socioeconomic form with data related to professional activities that was developed specifically for the data collection.The questionnarie included 17 multiple-choice questions.This study was approved by Ethics and Research Committee, and registered in Platform Brazil, CAAE number 37151714.9.000.5078.This paper is based on the final paper of a master degree in health sciences of the Federal University of Gois.
Variables evaluated were: age, marital status, type of graduate program, sex, local of practice of the plastic surgeon, number of children, time as a surgeon, medical office location, membership of Brazilian Society of Plastic Surgery (BSPS), membership category at BSPS, type of medical practice, on-duty shifts, weekly working hours, number of surgeries weekly, type of surgery, employment of an assistant , and monthly income.Data were divided into demographic and professional profile.
Initially, data were collected online using a standard form of Google forms among members of local insurance plans and on private basis, worked 40-60 hours per week, and performed less than 3 surgeries weekly, did work in on-duty shifts, practice in aesthetic and reconstructive surgery area, and more than 50% of them did not employ an assistant in surgeries (Table 2).chapter of BSPS in Goiás registered up to January 2015.The form was sent by e-mail with response deadline of 30 days.In last day of deadline we called participants by phone to confirm if they have responded the questionnaire.After this first approach, more data were collected at regional courses, at physicians' office or in hospitals in which the surgeon worked.
Inclusion criteria were residence certified by the Ministry of Education or by the Brazilian Society of Plastic Surgery, practice as in plastic surgery in the state of Goias.We excluded residents in plastic surgery, and those who did not practice in plastic surgery area.All participants signed the consent form, and confidentiality of information was guaranteed.

RESULTS
The method of sending emails, contact over the phone, and personal approach collected 115 responses of 163 questionaries initially sent.Of participants, 59.5% were younger than 40 years.Most of participants were man, married, with 1-2 children, working in state of Goias and their gross salary was over R$30,000.00(Table 1).The main location of medical office was in Goiania, most of them worked for less than 10 years as surgeons, were specialists certified by the BSPS, did not have graduate degree, worked primarily with health We also compared data related with monthly income with time working as a plastic surgeon (Table 3), weekly working hours (Table 4) and number of surgeries per week (Table 5).

IBOPE (Instituto Brasileiro de Opinião Pública e Estatística-in Portuguese; Brazilian Institute of Public
Opinion and Statistics) investigated plastic surgery market with a response rate of 8% 3 .In 2013, Araújo et al. 2 published a study in State of Parana with 40.5% of responses.Our study was obtained 70% responses of the plastic surgeon population in the State of Goias.We believe that the initial work with a sample calculation previously established as the study objetive, the study previous designed to obtain data enabled the achievement of a representative participation of plastic surgeons in the state of Goias.
Most of this study population was composed by young plastic surgeons, man, specialists members of BSPS and who worked for less than 10 years as a surgeon.Our findings differed from those reported by Araújo et al. 2 and IBOPE (Datafolha) in which sample was composed by surgeons who worked for more years as plastic surgeons.Because most participants were man, this datum clearly suggest the difficult of women to balance of private life and act as surgeons, which normally involves many hours in surgery.
In Datafolha study answers were given by experts were 65%, Paraná 68% and our study 48.7%.Surgeons from Parana carried out 35% of surgeries in SUS, and in our study 14% of surgeons perfomed surgires in public health system.
A study published by Krieger and Lee 10 in 2004 highlights a change in area of actuation of American plastic surgeons who now give priority to aesthetic surgeries compared with reconstructive surgeries because of reduction of the fees paid by the insurances companies [10][11][12][13] .The same change is clearly seen in our country that very low fees are offered by insurances companies and low wages paid by SUS.These facts end up influencing plastic surgeon's decision to finish residence and pursue a career in aesthetic surgery 14,15 .In our study, about 30% of participants worked only with aesthetic surgery and the remaining worked with aesthetic and reconstructive surgery.
Paraná study reported that most surgeons had 10-20 years of experience.In our study, most surgeons had less than 10 years of experience.In Datafolha data 68% surgeons had less than 15 years of experience.Therefore, these data show that many young surgeons are entering in the specialty, and this clarifies the worsening of the market in terms of competitive and price.
Economic stabilization in the beginning of this century led to an increase of demand for aesthetic surgery that is associated with increase of plastic surgeons entering in the market, therefore justifying the competitiveness and reduction in fees 12 , commodification of labor and the invasion of insurance

DISCUSSION
Studies related to plastic surgery, economy and labor market 8,9 are common especially in the United States and Canada.Brazil has few studies comparing this relationship.
In 2009, a study conducted by BSPS reported only 10% of response in survey that addressed overall situation of plastic surgeons in our country.In 2010, that but an assistant surgeon may be necessary if the titular is unable to continue the procedure.
As stated by Araujo et al. 2 , experienced plastic surgeon can help early career plastic surgeon to begin their careers in the right way, and certainly, safer way, so that avoiding preventing them to be seduced by third parties that main objective is to explore medical activity and increase their profits.Indirectly, experience plastic surgeons are putting value to their practice, mainly for all hard work need during their lives to get proper training and become a specialist.
Our study presented data on decrease in medical fees, increase of stressful situations posed by the media, presence of third parties seeking to explore medical workforce, and lack of collaboration among colleagues as factors that can worse the reality of plastic surgeons practice.Further studies are need to confirm these data and to be used as evidence in to seek changes to improve the profession.

CONCLUSIONS
Profile of plastic surgeon in state of Goias is composed by young physicians, man, married, with no more than 2 children, and whom work mainly in the capital of the state.The majority of specialists worked 40-60 hours per week, and worked with aesthetic and reconstructive surgery.

COLABORATIONS
companies.Paraná study evaluated characteristics of the market and payment methods of local surgeons.Our study did not include this aspect.
In our study most surgeons worked 40 to 60 hours weekly, performed up to 10 surgeries a week, both aesthetic and reconstructive surgeries.A similar result was observed by Araujo et al. 2 study in which an significant part of surgeons performed 10-20 surgeries/ monthly followed by those who performed 20-30 surgeries/monthly.Datafolha pool reported average of three cosmetic surgeries a week, therefore, data found are similar to those found in the national literature.
Other studies 5,7,10,11,[16][17][18] report that after 20 years of graduation, the number of surgeries performed monthly decrease because at this stage of the career the surgeon reduces number of surgeries for personal reasons or career circumstances.In our study we did not observe reduction of number of surgeries even after 20-year career.
When monthly income was compared with other variables we seen that after 10 years of professional experience, professionals monthly income improve and there is an increase in the number of surgeries, showing that as time goes by results of the work appear.No significant result was seen in relation to monthly income and weekly working hours.This can be justified because early career surgeon often need to work on-duty shifts and after many years of practice, an increased is seen in number of clients, surgeries and weekly working hours.
Of the sample, only 40% employed an assistant in more than 50% of surgeries.In Parana 52.8% of surgeons did not employ an assistant in surgeries, Except in cases in which of minor surgery and liposuction, larger surgeries should have the presence of another colleague in order to increase patient safety and allow early career physician to gain experience about the market, also learn techniques, as well pricing ethical and prevent these new professionals to put energy on-duty shifts at different areas than plastic surgery.
We observed that 30% of plastic surgeons work as on-duty physicians in other areas of medicine.This finding is a concern because shows that early career surgeons are having trouble to be successfully absorbed by the market, which force them to perform as on-duty to guarantee their family income.Experience surgeons should encourage participation of assistant surgeons to help early career surgeon to not waste energy in onduty shifts in other areas.Such action would help to reduce surgical time, reduce time for anesthesia, and also lower surgical risk.In addition, composition of surgical team is in agreement with resolution 1490/98 of Brazilian Federal Medical Council 19 establishing that surgery is the responsibility of primary surgeon and

FCFA
Contributed to the analysis, interpretation of data, statistical analysis, approval of the final version to be published, conception and design of the study, surgeries and/or experiments, drafting the manuscript and critical review of content of the study.

PRP
Contributed to drafting the manuscript and critical review of content of the study.

CCP
Contributed to the analysis, interpretation of data, statistical analysis, approval of the final version to be published, surgeries and/ or experiments, drafting the manuscript and critical review of content of the study.

Table 1 .
Distribution of sociodemographic data.

Table 2 .
Distribution of frequencies of professional profile.
MBA = Master in Business Administration; BSPS = Brazilian Society of Plastic Surgery; SUS = Brazilian Public Health System.

Table 3 .
Monthly income x Time as surgeon.

Table 4 .
Income x Weekly working hours.

Table 5 .
Income x Number of surgeries weekly.