Introduction
Since 1999 the Dutch government has controlled the number of medical specialists by regulating the inflow into medical specialty training. Due to the anticipated increase in the demand for healthcare, the annual number of cardiologists in training has risen sharply [
1]. Although the inflow of new cardiologists in training has stabilised in recent years, a mismatch with the outflow of retiring cardiologists remains. As a consequence, the number of cardiologists almost doubled from 654 in 2000 to 1266 in 2020. While this increase in the total number of active cardiologists has in part been essential to meet the growing demand for cardiovascular care, it has also led to a surplus of young cardiologists on the current labour market. Therefore, there is nationwide concern about unemployment among young cardiologists [
1].
In 2016 the Dutch Federation of Young Medical Specialists (
De Jonge Specialist) wrote a report on the short-term career perspectives of young Dutch medical specialists. In addition to an unemployment rate of 2.1%, an increase in temporary contracts was observed, with over 50% of contracts being temporary [
2]. In 2017 Vis et al. observed a low unemployment rate (1.6%) among 189 young cardiologists. Most cardiologists started with a temporary position; however, after 4 years 93% had a permanent contract. Predictors of permanent employment within 1 year were male gender and being trained in an academic teaching hospital [
3]. More recently, in 2019, the number of job vacancies per 100 cardiologists was among the lowest of all medical specialties [
4].
To monitor the current trends in employment among young cardiologists, we as the board of the Junior Association of the Netherlands Society of Cardiology (De Juniorkamer) initiated a new survey. The primary objectives were to investigate the unemployment rate and the time required to find permanent employment. Secondary objectives were to compare career perspectives with regard to gender, professional profile and type of teaching institution attended.
Discussion
The primary objective of this study was to re-evaluate current career perspectives of young cardiologists in the Netherlands. The main results are: (1) there was a very low rate of unemployment between 2015 and 2018 (0.6%, n = 1); (2) the vast majority of young cardiologists start their career as a fellow or attending physician with a relatively high rate (33%) of temporary contracts after 3 years of follow-up; (3) hallmark demographic and career characteristics such as age, gender, PhD degree or type of teaching hospital were not found to have a significant influence on the time required to obtain a permanent position.
When compared to the previously published analysis of young cardiologists in the Netherlands, the unemployment rate tends to be slightly lower (0.6% vs 1.6%), while the percentage of temporary contracts at the start of a career is higher (88% vs 77%). The percentage of temporary contracts after 3 years of follow-up is comparable (33% vs 30–31%).
These data indicate that, although there is hardly any unemployment, the percentage of temporary contracts among starting cardiologists has gradually increased over the last few years and the time between completing training and a first permanent contract is long. In contrast to previous findings, we did not observe gender or teaching hospital to have an influence on the time required to obtain a permanent position.
Multiple aspects could have a significant influence on the high incidence of temporary employment. Firstly, subspecialisation is becoming increasingly important in cardiology. The percentage of cardiologists taking fellowships could therefore increase over time. This is in line with the high percentage of cardiologists with fellowships as a first contract both in the current analysis and previously published results (50% vs 46%). However, the percentage of attending physicians as a first contract increased sharply when compared to previous analyses (38% vs 24%). Therefore, increased subspecialisation only partly explains these results.
Secondly, in parallel with the increase in the demand for cardiovascular healthcare, the number of trained cardiologists has increased strongly over the last few years [
1]. At the same time, a nationwide reorganisation of the financial structure within hospital care has taken place and many reorganisations and hospital mergers have occurred. Furthermore, financial cuts in hospital healthcare costs and the prevention of growth in healthcare expenses by the government have led to an uncertain future for Dutch hospitals [
4]. It could be hypothesised that those financial factors, as well as the increased number of available cardiologists (‘supply/demand mismatch’), may explain the high number of temporary positions.
As mentioned, the previous analysis by Vis et al. revealed an effect of gender as well as of teaching hospital with regard to the time to acquire a permanent position [
3]. In the current study we could not replicate these findings. This may possibly be due to the emancipation of women in the field of cardiology and an increasing general acceptance for men to work part-time, although this interpretation remains speculative. The lack of influence of the type of teaching hospital may suggest a uniform method of education or an improved balance in demand for cardiologists trained in academic and non-academic institutions. However, given the non-significant difference of 14%, it could also be that larger group numbers would indeed reveal a difference.
In the present study we did not analyse the association between fellowships and career perspectives due to the limited follow-up (median 2.3 years) and because most fellowships are coupled with temporary employment contracts, making it difficult to perform an unbiased analysis. Another factor complicating such analyses is the definition of fellowships, which varies greatly between hospitals and subspecialisations. It is not uncommon for temporary positions described as attending physician in the past to be currently referred to as fellowships. This could have biased the current analyses. Uniform description of fellowships for several subspecialties in cardiology may provide clarity on this matter. With this goal in mind, a fellowship working group was recently founded by the Netherlands Society of Cardiology (NVVC).
The number of young cardiologists starting their career as a specialist permanently employed by an independent group practice was found to be low. It is expected that this number will rise as young cardiologists gain more working experience. To adequately assess the incidence of specialists permanently employed by an independent group practice further follow-up is needed.
A significant number of young cardiologists perceive the current job market as problematic. This is mainly due to the financial and geographical insecurity that comes with temporary job positions at a time in life that often involves multiple structural changes in a short timeframe (e.g. marriage, family planning). The lack of true unemployment suggests that there is a strong public need for cardiologists to meet the high demand of cardiovascular care. Therefore, from the perspective of an aging community requiring cardiovascular care, it is of great importance to look after the working climate of our cardiologists.
Job insecurity is not unique to cardiology. As reported in 2016 by the Dutch Federation of Young Specialists (
De Jonge Specialist), there is unemployment (2.1%) and an increase in temporary contracts (over 50% temporary contracts) in many other medical specialties [
2]. However, more recent data on the career perspectives of young medical specialists need to be collected. Moreover, job uncertainty is also not unique to the current younger generations outside the field of medicine (generation X and Y). Young professionals were found to have higher levels of job insecurity and overall career concerns compared to their older counterparts [
5]. However, in contrast to many non-medical professions, cardiologists (and many other medical specialists) are trained for more than a decade for a highly specialised profession, without many other job options. This is not only a time-consuming but also an expensive training programme, which thus emphasises the need for a balance between the inflow of young cardiologists and the demand in the labour market.
Temporary employment comes with less autonomy at the workplace, decreased control over the work environment and possibly less contact with and support from colleagues. These factors induce stress, potentially leading to decreased job satisfaction and even burnout [
6]. Unfortunately, for physicians less job satisfaction can lead to medical errors. For healthcare organisations, high physician job satisfaction is eventually also of economic value, as it reduces absence due to illness and prevents early retirement from medical practice [
7]. The observed high rate of temporary contracts is therefore worrying and highly undesirable.
The ongoing COVID-19 pandemic may potentially lead to a decline in the number of cardiac patients and hence fewer financial healthcare problems. For young cardiologists this may result in more uncertainty concerning the labour market and fewer available permanent positions.
Future perspectives
In order to improve the career perspectives of young cardiologists we believe that it is essential to regulate and match the inflow of (specialised) cardiologists to the actual demands of the labour market. To achieve this goal the following data and measures are vital:
1.
Complete and live data on the number of active cardiologists (number of FTE) and job vacancies. The committee commissie behoefte beraming (Committee for the Estimation of Staffing Needs) has recently been assigned to create a national data acquisition system that will provide these live data.
2.
Accurate estimations of the annual outflow of cardiologists (due to retirement).
3.
Define and make fellowships uniform on a national basis, which is the primary goal of a working group recently initiated by the NVVC.
4.
Align the number of fellowships with the job vacancies for subspecialists (e.g. interventional cardiologists).
In addition, an advisory dashboard, started by the NVVC or the Federation of Medical Specialists (FMS), could help young cardiologists with job application training or in planning their career.
Limitations
Several limitations should be addressed. First, the questionnaire was short to ensure a high response rate. Unfortunately, 21% still did not respond despite several requests, which could have resulted in a selection bias. However, in 65% of non-responders we managed to acquire additional key information, which showed no differences in unemployment rate and the proportion of temporary contracts. Second, our follow-up period is too short to compare the effect of fellowships on the probability of permanent employment for these young cardiologists.
Conclusions
The unemployment rate among young cardiologists in the Netherlands was low between 2015 and 2018. The vast majority of cardiologists start their career on a temporary contract. Three years after starting their career as a cardiologist, 33% still hold temporary positions. Due to the resulting job insecurity, many young cardiologists describe the job market as problematic.