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  • Open Access

The practice of intensive care in Latin America: a survey of academic intensivists

  • 1, 19Email author,
  • 2, 3,
  • 4,
  • 1,
  • 5,
  • 6,
  • 7,
  • 8,
  • 9,
  • 2, 3,
  • 10,
  • 11,
  • 12,
  • 13, 14,
  • 15, 16,
  • 17,
  • 18,
  • 1, 19 and
Critical Care201822:39

https://doi.org/10.1186/s13054-018-1956-6

  • Received: 13 July 2017
  • Accepted: 16 January 2018
  • Published:

Abstract

Background

Intensive care medicine is a relatively young discipline that has rapidly grown into a full-fledged medical subspecialty. Intensivists are responsible for managing an ever-increasing number of patients with complex, life-threatening diseases. Several factors may influence their performance, including age, training, experience, workload, and socioeconomic context. The aim of this study was to examine individual- and work-related aspects of the Latin American intensivist workforce, mainly with academic appointments, which might influence the quality of care provided. In consequence, we conducted a cross-sectional study of intensivists at public and private academic and nonacademic Latin American intensive care units (ICUs) through a web-based electronic survey submitted by email. Questions about personal aspects, work-related topics, and general clinical workflow were incorporated.

Results

Our study comprised 735 survey respondents (53% return rate) with the following country-specific breakdown: Brazil (29%); Argentina (19%); Chile (17%); Uruguay (12%); Ecuador (9%); Mexico (7%); Colombia (5%); and Bolivia, Peru, Guatemala, and Paraguay combined (2%). Latin American intensivists were predominantly male (68%) young adults (median age, 40 [IQR, 35–48] years) with a median clinical ICU experience of 10 (IQR, 5–20) years. The median weekly workload was 60 (IQR, 47–70) h. ICU formal training was between 2 and 4 years. Only 63% of academic ICUs performed multidisciplinary rounds. Most intensivists (85%) reported adequate conditions to manage patients with septic shock in their units. Unsatisfactory conditions were attributed to insufficient technology (11%), laboratory support (5%), imaging resources (5%), and drug shortages (5%). Seventy percent of intensivists participated in research, and 54% read scientific studies regularly, whereas 32% read no more than one scientific study per month. Research grants and pharmaceutical sponsorship are unusual funding sources in Latin America. Although Latin American intensivists are mostly unsatisfied with their income (81%), only a minority (27%) considered changing to another specialty before retirement.

Conclusions

Latin American intensivists constitute a predominantly young adult workforce, mostly formally trained, have a high workload, and most are interested in research. They are under important limitations owing to resource constraints and overt dissatisfaction. Latin America may be representative of other world areas with similar challenges for intensivists. Specific initiatives aimed at addressing these situations need to be devised to improve the quality of critical care delivery in Latin America.

Keywords

  • Intensive care units
  • Latin American
  • LMIC
  • Critical care
  • Health
  • Manpower

Background

Intensive care medicine (ICM) is a relatively young discipline that has rapidly grown into a full-fledged specialty. Given the aging of the population, the rising burden of chronic comorbidities, and the complexity of modern medicine, the intensive care unit (ICU) turns out to be the very last healthcare venue for many diseases. Intensivists are responsible for managing the ever-increasing number of patients with complex, life-threatening diseases [1]. Several factors could influence the performance of intensivists, including their age, training, experience, workload, and socioeconomic context. Latin America is a region that comprises mainly middle-income countries and deals with challenges such as poverty, low salaries, and low quality of employment [2]. We think it may well represent other world regions in terms of particular contexts and challenges that intensivists must overcome.

Although the commitment to provide high-quality patient care is firmly grounded in the medical profession, several recent publications have addressed noncompliance with best evidence practice by physicians [3]. This is perhaps most relevant for the treatment of patients with sepsis, a key area in critical care medicine in which several diagnostic and therapeutic approaches have been proposed over the years [4, 5]. To address some of these aspects, we developed a survey with the aim of gaining insight into how Latin American intensivists feel about some predetermined issues related to their daily work and expectations, as well as some aspects regarding the management of septic shock.

Methods

This study was designed, coordinated, and executed by the Latin American Intensive Care Network - LIVEN (www.redliven.org) [6], which appointed a steering committee and local coordinators in each country.

Design and setting

We conducted a cross-sectional study of intensivists from 11 Latin American countries (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Guatemala, Mexico, Paraguay, Peru, and Uruguay). The Pontificia Universidad Católica de Chile was the only coordinating center. The local ethics committee (Comité de Etica Clínica de la Facultad de Medicina) waived the need for informed consent because survey participation was voluntary; thus, informed consent is assumed.

In May 2016, Latin American intensivists, identified from lists provided by national critical care medicine societies and networks, social networks, and personal contacts, were invited to participate in the survey. One week later, a web-based electronic questionnaire was submitted. Weekly reminders were emailed to nonrespondents from June through September 2016.

Questionnaire development

The survey was designed by a committee that incorporated questions regarding training, workload, competencies, continuing education, research activities, and experiential aspects. The construct was defined on the basis of studies that demonstrated links between individual characteristics of intensivists with clinical performance [7].

After a draft revision by a group of LIVEN investigators, some questions were reformulated, added, or deleted. Content validity was established by independent reviewers who determined whether each question captured the intended domain. After piloting the survey in 4 centers, the final version included 51 items under the following domains: organizational characteristics of the ICU, human resources, professional development, research participation, competencies and skills, satisfaction, and expectations.

We asked some questions about septic shock management because this condition integrates ICU workflow, resource availability, and diverse aspects of critical care provision. We considered that ICUs with appropriate conditions for septic shock care had availability of antibiotics, vasopressors, laboratory tests (arterial blood gases, serum lactate, general blood and biochemistry tests, blood and fluid cultures and microbiology identification), imaging resources, and the possibility to consult different specialists upon request (see full survey as Additional file 1: File S1).

We defined a long or short morning round on the basis of the duration being longer or shorter than 2 h, respectively. We defined a multidisciplinary round as one that, apart from the intensivists, included at least two other professionals (nurses, respiratory therapists, pharmacists, or other specialists).

Data processing and statistical analysis

Data are expressed as mean ± SD or median (IQR), as appropriate. Categorical variables were compared with the chi-square test; continuous variables were analyzed with t tests, the Kruskal-Wallis test, and the Wilcoxon rank-sum test, according to their distribution. Logistic regression analysis was performed in a stepwise fashion according to individual covariates’ significance. ORs and 95% CIs were reported.

We investigated the association between country-level factors and relevant outcomes, adjusting for individuals’ characteristics using multilevel multivariable logistic regression. A two-level model was fit with intensivist-level fixed effects at the first level and country-level fixed effects at the second level, as well as a country-specific random effect. Individual-level variables of interest included age, sex, years of experience (collinear with age), weekly working time (in hours), and type of ICU (public/private, academic/nonacademic). We selected variables for the multivariable model using forward and backward stepwise regression. We considered variables for the model if they were associated with outcome with a p value less than 0.20 in univariate analysis. Additionally, some variables were introduced to the model because of their clinical relevance, regardless of their p value. We performed subgroup analyses by stratifying intensivists according to their position in the ICU. To choose among the alternative models, we used the likelihood ratio test for testing on the boundary of the parameter space as a measure of the relative predictive ability of a statistical model for a given set of data. Two-tailed p values less than 0.05 were considered statistically significant. We conducted all statistical analyses with the use of Stata 14.2 software (StataCorp, College Station, TX. USA).

Results

General

Of the 1380 surveys sent out, we received 735 responses by intensivists from 11 countries, yielding a global response rate of 53%. (See Fig. 1 for country representation.) Sixty percent of intensivists worked in ICUs located in public hospitals (Table 1, Additional file 2: Table S1A), with no statistically significant difference according to their position (Additional file 2: Table S1B). Sixty percent worked in two or more hospitals (Additional file 2: Table S1C, D), and 67% worked in academic hospitals (Table 1, Additional file 2: Table S1A), without any difference in the public/private status of their primary hospital (Additional file 2: Table S1D).
Fig. 1
Fig. 1

Number of surveys answered, by country

Table 1

General characteristics of study population

Variable

Data

Age, years, median (IQR)

40 (35–48)

Female sex, n (%)

238 (32%)

ICU experience, years, median (IQR)

10 (5–10)

ICU experience, n (%)

  < 10 years

391 (53)

 11–20 years

197 (27)

 21–30 years

123 (17)

  > 30 years

24 (3)

ICU type (public)

440 (60)

ICU type (academic)

494 (67)

Primary specialty, n (%)

 Surgery

15 (2)

 Emergency medicine

25 (3)

 Anesthesia

31 (4)

 Internal medicine only

136 (19)

 Internal medicine

199 (27)

 Intensive care medicine only

411 (56)

 Intensive care medicine

505 (69)

Training, n (%)

 On-the-job training

177 (24)

 2-year program

204 (28)

 3-year program

152 (21)

 4-year program

155 (21)

 Other

45 (6)

 No training

2 (0)

Reading scientific papers, n (%)

 Daily

43 (6)

 1–3/week

346 (50)

 1–2/month

305 (44)

 Other

41 (6)

The surveyed workforce was composed predominantly of males (68%) and young adults (median age, 40 [35–48] years) (Table 1, Fig. 2a). Fifty-three percent of intensivists had less than 10 years of experience in the ICU, and 20% had more than 20 years (Table 1, Fig. 2b). Residents comprised a minority of the respondents (13%).
Fig. 2
Fig. 2

a Distribution of Latin American intensivists according to age. b Distribution of Latin American intensivists according to years of intensive care unit experience

ICU training varied among countries, with three different formal academic programs of variable duration (2–4 years) and a work-based assessment of competences without specific duration (Table 1, Additional file 3: Figure S1).

Workload, clinical rounds, and competencies

The median weekly workload was 60 (IQR, 47–70) h, mostly spent in the ICU (Additional file 4: Figure S2), without differences between academic and nonacademic centers (median 60 [IQR, 46–70] vs. 60 [IQR, 48–68] h; p = 0.7). The duration and characteristics of clinical rounds varied widely across countries, with differences between academic and nonacademic units (Fig. 3).
Fig. 3
Fig. 3

Proportion of intensive care unit rounds according to their academic status and (a) length of morning round, (b) presence of evening round, and (c) number of specialists involved in the morning round

Fifty-two percent of intensivists worked daily and also did night shifts. Twenty-two percent worked only in day shifts, and 22% only in night shifts. The median number of night shifts was 1 (IQR, 1–2) per week. Younger intensivists did more night shifts per week (p < 0.001). According to position, staff intensivists performed the higher number of shifts per week (median, 2 [IQR, 1–3]), followed by residents (median, 2 [IQR, 1–2]) (p < 0.001). The number of beds covered per intensivist varied from 3 to 12 per night shift. Most ICUs (76%) had consultants available during night shifts. Overall, survey respondents considered themselves very competent to perform many common procedures. There were significant differences according to position, age, and years of experience in the ICU (Table 2).
Table 2

Self-reported confidence in competency to perform clinical duties, according to intensivist position, age, and years of experience

Procedure

 

ICU director

Medical coordinator

Staff physicians

Residents

Shift physicians

Other

Overall

p Value

Intensivists by position

 Intubation

Yes

122 (98)

104 (100)

362 (100)

91 (95)

35 (100)

12 (92)

726 (99)

<0.001

No

2 (2)

0 (0)

0 (0)

5 (5)

0 (0)

1 (8)

8 (1)

 

 Central venous catheter insertion

Yes

124 (100)

104 (100)

359 (99)

92 (96)

35 (100)

12 (92)

726 (99)

0.005

No

0 (0)

0 (0)

3 (1)

4 (4)

0 (0)

1 (8)

8 (1)

 

 Arterial line insertion

Yes

120 (97)

103 (99)

350 (97)

89 (93)

35 (100)

10 (77)

707 (96)

0.001

No

4 (3)

1 (1)

12 (3)

7 (7)

0 (0)

3 (23)

27 (4)

 

 PA catheter placement

Yes

111 (90)

90 (87)

290 (80)

66 (69)

26 (74)

7 (54)

590 (80)

<0.001

No

13 (10)

14 (14)

72 (20)

30 (31)

9 (26)

6 (46)

144 (20)

 

 Echocardiography

Yes

53 (43)

43 (41)

149 (41)

42 (44)

11 (31)

3 (23)

301 (41)

0.621

No

71 (57)

61 (59)

213 (59)

54 (56)

24 (69)

10 (77)

433 (59)

 

 End-of-life care issues management

Yes

122 (98)

101 (97)

337 (93)

78 (81)

30 (86)

10 (77)

678 (92)

<0.001

No

2 (2)

3 (3)

25 (7)

18 (19)

5 (14)

3 (23)

56 (8)

 

Intensivists by age

 Intubation

Yes

45 (41–51)

44 (38–52)

39 (35–46)

33 (31–38)

40 (35–53)

39 (37–46)

40 (35–48)

<0.001

No

52 (41–63)

31 (31–33)

31 (31–31)

32 (31–39)

0.202

 Central venous catheter insertion

Yes

45 (41–51)

44 (38–52)

39 (35–46)

33 (31–38)

40 (35–53)

39 (37–46)

40 (35–48)

<0.001

No

34 (29–37)

32 (31–35)

31 (31–31)

32 (31–35)

0.513

 Arterial line insertion

Yes

45 (41–51)

44 (38–52)

39 (35–46)

33 (31–38)

40 (35–53)

38 (37–47)

40 (35–48)

<0.001

No

49 (44–54)

47 (47–47)

36 (33–53)

32 (30–33)

39 (31–42)

35 (32–47)

<0.001

 PA catheter placement

Yes

45 (41–51)

43 (38–51)

40 (35–47)

34 (31–39)

41 (34–53)

44 (37–48)

41 (35–49)

<0.001

No

44 (41–60)

45 (39–52)

36 (33–42)

32 (29–34)

40 (39–45)

35 (32–39)

37 (32–45)

<0.001

 Echocardiography

Yes

46 (40–51)

39 (37–48)

38 (34–44)

34 (31–37)

39 (38–40)

39 (37–39)

39 (34–45)

<0.001

No

45 (42–52)

47 (41–54)

40 (35–49)

33 (31–38)

45 (34–53)

40 (33–47)

42 (35–50)

<0.001

 End-of-life care issues management

Yes

46 (41–51)

45 (38–52)

39 (35–46)

33 (31–38)

42 (38–53)

41 (37–47)

40 (35–49)

<0.001

No

39 (36–41)

38 (37–41)

38 (35–42)

31 (30–37)

37 (33–44)

33 (31–37)

36 (31–41)

0.092

Intensivists by years of experience

 Intubation

Yes

16 (10–23)

15 (10–24)

10 (5–16)

4 (2–6)

12 (7–20)

10 (5–12)

10 (6–20)

<0.0001

No

22 (9–34)

2 (2–4)

2 (2–2)

3 (2–8)

0.1193

 Central venous catheter insertion

Yes

16 (10–23)

15 (10–24)

10 (5–17)

4 (2–6)

12 (7–20)

10 (5–12)

10 (6–20)

<0.0001

No

2 (1–7)

2 (1–4)

2 (2–2)

2 (2–4)

0.9463

 Arterial line insertion

Yes

15 (10–23)

15 (10–24)

10 (6–16)

4 (2–6)

12 (7–20)

10 (5–10)

10 (6–20)

<0.0001

No

21 (18–24)

12 (12–12)

6 (2–19)

2 (1–6)

5 (2–14)

3 (2–16)

0.0315

 PA catheter placement

Yes

16 (10–23)

15 (10–24)

10 (6–20)

5 (2–7)

12 (6–21)

10 (10–14)

11 (6–20)

<0.0001

No

12 (9–27)

12 (11–22)

7 (4–10)

2 (1–5)

12 (9–12)

5 (4–8)

7 (4–12)

<0.0001

 Echocardiography

Yes

15 (10–22)

10 (9–16)

9 (5–15)

4 (2–6)

10 (6–12)

8 (5–14)

10 (5–16)

<0.0001

No

16 (10–24)

20 (12–25)

10 (6–20)

3 (2–5)

14 (8–22)

10 (5–10)

11 (6–20)

<0.0001

 End-of-life care issues management

Yes

16 (10–23)

15 (10–24)

10 (6–18)

4 (2–6)

12 (7–20)

10 (5–14)

16 (10–20)

<0.0001

No

9 (8–10)

10 (8–10)

5 (5–12)

2 (1–6)

10 (8–14)

4 (2–8)

5 (2–10)

0.0106

ICU Intensive care unit, PA Pulmonary artery

p Values for intensivists by position are for yes/no proportions. Age and years of experience are expressed as median (IQR)

Septic shock management

Most intensivists (85%) reported adequate conditions to manage patients with septic shock. However, perception of satisfactory conditions was lower in ICUs located in public hospitals (OR, 0.36 [0.26–0.47]; p < 0.001) and in nonacademic ICUs (OR, 0.48 [0.35–0.65]; p < 0.001). The main reasons for dissatisfaction were attributed to insufficient technology (11%), laboratory support (5%), imaging resources (5%), and limited drug availability (5%). Lactate could be measured by 90% of intensivists, but at a variable time, depending on ICU type (Additional file 5: Table S2A). A computed tomographic (CT) scan was available within < 2 h in 54% of ICUs and within < 6 h in 81% of ICUs, with variations according to ICU type (Additional file 5: Table S2B). In all countries, ICUs located in private hospitals had significantly greater availability of CT scanners compared with ICUs belonging to the public health sector (68% vs 49% in < 2 h; OR, 3.13 [2.02–5.94]; p < 0.001).

Education and research

The Internet was widely accessible (91%). Most Latin American intensivists used online resources to improve their scientific knowledge (96%). More than half of the intensivists surveyed (54%) read scientific studies regularly, daily, or two or three times per week (Table 2), whereas 32% read no more than one scientific study per month. These results were similar for academic and nonacademic ICUs (p = 0.6). Seventy-five percent of respondents had attended at least one scientific meeting in the past year, and 88% had taken a refresher course. Seventy-six percent reported having “some” or “much” institutional support, but 24% responded that they had “minimal” or “no support” from their hospitals to participate in these meetings. Financial and permission restrictions were the main reasons (Table 3).
Table 3

Institutional restrictions on attending scientific meetings in participating countries

Restrictions

No.

%

Some

262

36

Much

299

41

None

72

10

Few

102

14

Total

735

100

Country

Financial restrictions

Permission restrictions

Time restrictions

Other

Total

 Argentina

66 (68)

18 (19)

11 (11)

2 (2)

97 (100)

 Bolivia

4 (36)

6 (55)

1 (9)

0 (0)

11 (100)

 Brazil

49 (36)

58 (44)

0 (0)

26 (20)

133 (100)

 Chile

14 (25)

39 (70)

2 (4)

1 (2)

56 (100)

 Colombia

8 (35)

13 (57)

2 (9)

0 (0)

23 (100)

 Ecuador

23 (40)

33 (57)

1 (2)

1 (2)

58 (100)

 Guatemala

2 (100)

0 (0)

0 (0)

0 (0)

2 (100)

 Mexico

8 (24)

23 (70)

2 (6)

0 (0)

33 (100)

 Paraguay

0 (0)

1 (100)

0 (0)

0 (0)

1 (100)

 Peru

1 (100)

0 (0)

0 (0)

0 (0)

1 (100)

 Uruguay

28 (49)

19 (33)

9 (16)

1 (2)

57 (100)

Overall n (%)

203 (43)

210 (45)

28 (5)

31 (7)

472 (100)

Permission restrictions refer to nonauthorization to attend a meeting owing to managerial reasons

Seventy percent of the respondents participated in research activities, mostly in academic settings (71%). Working in a nonacademic ICU and being a resident were associated with less probability of doing research (OR, 0.50 [0.36–0.73]; and OR, 0.36 [0.23–0.58], respectively; p < 0.001 for both). Conversely, being male was associated with higher probability of doing research (OR, 1.52 [1.08–2.15]; p = 0.017). Most of the funding came from intensivists’ respective institutions (39%) or was self-provided (19%), whereas 14% of intensivists declared no specific research funding. Research grants and pharmaceutical sponsorship were rarely available (9% and 7%, respectively). Most of the research was published in peer-reviewed journals (63%).

Perceptions and expectations

Environmental conditions (private restrooms, comfortable bedrooms for rest or sleep) during night shifts were reported as inappropriate in 62% of the respondents, especially by female intensivists (71% vs. 60%; p < 0.001). A minority of intensivists were satisfied with their personal income (19%). It was higher in male than in female physicians (22% vs 13%; OR, 1.84 [1.17–2.91]; p = 0.009). On the contrary, higher weekly workload (OR, 0.98 [0.97–0.99]; p = 0.017) and a higher number of night shifts (OR, 0.80 [0.67–0.96]; p = 0.007) were associated with lower income satisfaction. Overall, a minority of intensivists (27%) reported having considered quitting their job as intensivists, mostly in Argentina (41%) and Brazil (36%). Fifty-five percent on the Latin American intensivists intended to leave ICU practice before retirement.

Discussion

This is the first study in Latin America involving evaluation of individual- and work-related aspects of the intensivist workforce. Our main findings were that the intensivist workforce of the region, mostly related to academic centers, is predominantly young, has been formally trained, report adequate procedural skills, and operates under high workloads and restrictions owing to resource constraints and local limitations. Although there is no ideal percentage, a higher response rate to our questionnaire would have been desirable. However, our first survey (LIVEN-1) had a similar return rate (52%) [6], which is in line with the declining response rates to surveys over the years [8, 9].

Health systems vary across Latin American countries, and a mix of public and private ICUs do exist, sometimes with uneven resource distribution [10, 11]. In our study, most intensivists worked primarily in public hospitals, but less than half worked in only one hospital. This could have an impact in terms of costs and efficiency because working in more than one hospital might result in higher costs owing to “work dispersion” [12].

Our respondents reported having mostly formal ICM training (70%), mainly under the supraspecialty model, which considers training in a base specialty followed by a common ICM program. This was also the most frequent training mechanism in a 41-country survey published some time ago [13]. Other mechanisms, such as the assessment of competencies, are common in Chile and Brazil, perhaps in response to the shortage of intensivists [14, 15].

With regard to workload, working more than 60 h per week was associated with a high level of burnout in a recent study [16]. Intention to leave is a known predictor of burnout [17, 18], as well. Because 60 h was the median weekly workload of our respondents and more than half of them reported their desire to leave the ICU before retirement, Latin American academic intensivists probably experience high-level burnout. Along the same line, a recent study of ICM training program directors showed that higher workload correlated with negative self-perception about the teaching role, patient care, and job stability [19]. In addition, the number of night shifts has clearly been associated with burnout among pediatric intensivists [20] and critical care nurses [21]. In our survey, staff physicians reported a higher night shift load and higher intention to leave, an association described previously [20, 21]. These findings call for responsible authorities to be concerned about intensivists’ workload and mental health.

Our finding that short and non-multidisciplinary morning rounds occur mainly in academic ICUs, unveiling the tensions that academic intensivists may experience in performing high-quality clinical work in time- and resource-restricted contexts. Conversely, those in many nonacademic ICUs performed long morning rounds, a fact not easily reconciled with the previous one. Academic medical centers share a mission of patient care, teaching, and research [22], but financial pressures might promote the former to the detriment of teaching and research [22] despite the “academic” denomination [23]. This could be happening in Latin America, where financial challenges [2] compete with education at all levels.

Procedural complications are a significant cause of inpatient morbidity and mortality in the ICU [24]. In our surveyed population, self-perception of technical skills was high, especially among older and more experienced doctors. Residents tended to exhibit lower self-confidence in most procedures, but they were a minority. Our results reflect the well-known progression in skill levels after training and years of experience [25].

Regarding septic shock management, some intensivists reported insufficient conditions to treat it adequately, mentioning drug shortages, among other reasons. Increased mortality has been observed during shortages of drugs in low-income [26, 27] and high-income countries [28]. High mortality of sepsis and septic shock reported in Latin America [27, 29] could be partially explained by this.

Additionally, we considered CT scans and lactate measurements as proxies for clinical workflow and resource availability. Lactate measurement availability was acceptable overall, with some differences in public vs private hospitals. On the contrary, in private ICUs, CT scanners were much more accessible. In fact, although we did not study the relationship of these resources with any outcomes, it has been demonstrated that resource inequality is a determinant of quality of care [30] and health outcomes in the ICU [31, 32], especially in resource-poor settings.

Latin American intensivists preferred online resources as the source of scientific information, similar to U.S. physicians [33]. Among our respondents, the rate of reading scientific studies was lower than reported in other studies [34]. Because ICU academic status was not a determinant for scientific reading, knowledge acquisition seems to rely on personal interests. Most intensivists would have attended scientific meetings outside their hospitals, but they were hindered by financial and permission restrictions. This contrasts with a study involving physicians from high-income countries [35], in which researchers reported attendance at a considerable number of meetings each year. The same study showed that congresses and conferences are preferred, which is similar to our results.

Barriers to participation in clinical research in developing countries are widely known [36]. Two-thirds of surveyed physicians showed interest in research and published some work in a peer-reviewed journal. A study on physicians from different specialties, excluding intensivists, yielded similar results, showing that 63% of them had published articles in medical journals [34]. Our reported participation in research is high, probably owing to the academic connections of our respondents.

End-of-life care is an area of increasing prominence in the ICU [37], but studies have shown that, for example, appropriate relief of suffering and pain in dying patients is dissimilar in ICUs [38]. In this field, Latin America presents regional shortcomings related to inadequate legislation, insufficient infrastructure, lack of opportunities for clinical training, unreliable reporting of data, and cultural barriers [39]. Younger intensivists reported lower confidence than their older and more experienced colleagues in addressing these issues. A leveraging agenda must be developed to provide all intensivists with the competencies required to address these patients’ needs properly.

Job satisfaction is a multidomain perception related to many factors [40]. We did not address it specifically but instead asked about income, which has been related to general and emotional well-being as well as job satisfaction [40, 41]. In our study, most respondents considered their income unsatisfactory, especially female and middle-aged physicians. In a recent study in Latin America, being female was associated with lower job satisfaction as well as higher workload [42]. How these issues interact with the expectations, rewards, and drawbacks of working as an intensivist still need to be more completely elucidated.

Our study has several limitations. The results are not generalizable to all Latin American countries. This study was performed with a convenience sample of physicians working in Latin American ICUs, predominantly academic, with respondents probably more prone to read scientific literature and to conduct research. The heading of the survey questions asked that respondents answer thinking about the ICU where they work most hours per week, but undoubtedly this could have introduced bias. We did not interrogate for burnout, moral distress, specific end-of-life care issues, or communication and management skills. In-training physicians were underrepresented in this sample, as were physicians working in ICUs without board certification. Regardless of these considerations, in the absence of previous information, this is the first description of general, individual-, and work-related characteristics of the intensivist workforce in Latin America, mainly at academic ICUs.

Conclusions

Latin American intensivists are still a young adult group of physicians with unique problems that include a high weekly workload, important resource constraints, job dissatisfaction, and financial limitations on and barriers to attending educational opportunities. Many challenges remain unsettled in terms of training and competencies to develop, as well as how to achieve workload balance. Some of the issues described may help to depict the panorama of the delivery of critical care around the world.

Abbreviations

CT: 

Computed tomographic

ICM: 

Intensive care medicine

ICU: 

Intensive care unit

LIVEN: 

Latin American Intensive Care Network

PA: 

Pulmonary artery

Declarations

Acknowledgements

We are fully indebted to all respondents and to the critical care societies of Latin America, as well as to the Brazilian Research in Intensive Care Network (BRICNET) and AMIBNet, which endorsed the study in Brazil.

Funding

This study was performed with no specific funding.

Availability of data and materials

The datasets used and/or analyzed during the present study are available from the corresponding author on reasonable request.

Authors’ contributions

RC was responsible for study design, literature search, data interpretation, tables, figures, statistical and data analysis, and manuscript writing. NNV was responsible for study design, data collection, and data analysis. FR was responsible for study design, data collection, and data analysis. LA was responsible for study design, survey distribution, data collection, and manuscript writing. EE was responsible for data collection, data analysis, and manuscript writing. GM was responsible for data collection. GF was responsible for data collection. MJ was responsible for data collection. GOT was responsible for data collection. JH was responsible for data collection. MM was responsible for data collection. FRM was responsible for data collection. AC was responsible for data collection and data analysis. AD was responsible for data collection. LA was responsible for data collection and data interpretation. MC was responsible for data collection and data interpretation. JB was responsible for data analysis, data interpretation, and manuscript writing. GH was responsible for study design, data interpretation, and manuscript writing. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Pontificia Universidad Católica de Chile was the only coordinating center. For this survey, the local ethics committee (Comité de Etica Clínica de la Facultad de Medicina de la Pontificia Universidad Católica de Chile) approved its content and waived the need for informed consent because physicians’ survey participation was voluntary, informed consent was assumed, and no patients were involved in this study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Authors’ Affiliations

(1)
Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Diagonal Paraguay #362, Santiago Centro, RM, 8330077, Chile
(2)
Hospital Español, Avenida General Garibaldi, 1729 esq., Rocha, Montevideo, Uruguay
(3)
Agencia Nacional de Investigación e Innovación (ANII), Montevideo, Uruguay
(4)
Servicio de Terapia Intensiva. Hospital Alejandro Posadas, Avenida Presidente Arturo U. Illia, El Palomar, Buenos Aires, Argentina
(5)
Servicio de Terapia Intensiva, Hospital Interzonal de Agudos General San Martin de La Plata, Avenida 1 1794, Casco Urbano, La Plata, Buenos Aires, B1904CFU, Argentina
(6)
Clinica Bazterrica and Clinica Santa Isabel, Billinghurst 2072 (esquina Juncal), Ciudad Autónoma de Buenos Aires, Argentina
(7)
Departamento de Medicina Interna - Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350 - Santa Cecilia, Porto Alegre, RS, 90035-903, Brasil
(8)
Escuela de Medicina, Universidad Internacional del Ecuador, Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Avenida Gran Colombia, Quito, 170136, Ecuador
(9)
Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Cali, Carrera 98 No. 18-49, Cali, Valle del Cauca, Colombia
(10)
Unidad de Cuidados Intensivos, Hospital Regional 1 Octubre, ISSSTE, Avenida Instituto Politécnico Nacional 1669. Colonia Lindavista, c.p., Delegación Gustavo A. Madero, Ciudad de México, 07300, México
(11)
Anesthesiology, Pain and Intensive Care Department, Federal University of Sao Paulo, Rua Sena Madureira, 1500 - Clementino, São Paulo, SP, 04021-001, Brasil
(12)
Research Institute HCor, Hospital do Coração, Rua. Desembargador Eliseu Guilherme, 147 - Paraíso, São Paulo, SP, 04004-030, Brasil
(13)
Catedra de Farmacología, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Buenos Aires, Argentina
(14)
Servicio de Terapia Intensiva, Sanatorio Otamendi y Miroli, Azcuénaga 894, CABA, C1115AAB, Argentina
(15)
Anesthesiology, Pain and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, Brazil
(16)
Emergency Medicine Department, University of Sao Paulo, Hospital Sirio-Libanes, Rua Dona Adma Jafet, 91 - Vista, Sao Paulo, SP, 01308-050, Brasil
(17)
St. George’s University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
(18)
Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY 10032, USA
(19)
Unidad de Paciente Critico Adultos, Hospital Clinico UC-CHRISTUS, Marcoleta #367, Santiago Centro, RM, 8330077, Chile

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© The Author(s). 2018

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