This is the first study that evaluates nephrologists' satisfaction in the Eastern Mediterranean Region. Contextual factors, such as workplace-related factors and work environment, can highly influence satisfaction and vary between different healthcare systems . This survey of Lebanese and Jordanian nephrologists revealed low satisfaction rates regarding job opportunities (20%), income (25%), administrative support (32%), research (59%) and the majority of respondents agreed that nephrology is a stressful job. On the other hand, our results highlighted high satisfaction rates regarding relationship with patients (78%) and colleagues (73%). There is a paucity of data in the literature regarding job satisfaction of nephrologists worldwide and most of the studies were conducted in the US. A survey of 6590 American physicians classified nephrology as a "less satisfied" specialty . Several of our satisfaction rates are aligned with those of US nephrologists , like the high satisfaction regarding patients, the low rate of administrative support and high agreement that nephrology is a stressful job. US nephrologists are experiencing stress and burn-out because of poor work-life balance, they are feeling unappreciated, spending a lot of time travelling between dialysis facilities that are owned by large for-profit dialysis companies and there is little of funds provided to research in nephrology [12, 13]. The time of travel to work was also showed in our sample to be significantly associated with stress and burnout. But the satisfaction of US nephrologists is higher regarding job opportunities, income and career trajectory. Another important finding in most surveys is the low rate of regrets of choosing nephrology: 70% in the US sample and 76% in ours would choose nephrology again. A similar percentage was found in a sample of international specialists . Despite the lack of regret, burnout and stress are still highly perceived for many reasons . One of them is that nephrologists globally are often faced with a lot of ethical challenges regarding their chronic disease patients with dilemma regarding end-of-life care and conservative care leading to what some called "moral distress" .
Workload affects the satisfaction of nephrologists differently between a context and another. In Lebanese nephrologists, higher workload was not found to be associated with dissatisfaction although 60% of Lebanese reported to spend more than 40 hours weekly on patient care, a rate similar to the Jordanian group and the US surveyed nephrologists . However, the number of dialysis patients per nephrologist in Lebanon is lower than other countries. And this can explain the higher satisfaction of surveyed nephrologists once the number of hours spent on nephrology practice exceeds the 10 hours weekly. One recent mixed quantitative-qualitative study done in South Africa emphasized the low density of nephrologists in that country and high workload . In Lebanon, the abundance of physicians is an old issue, still not resolved . Therefore, the higher density of nephrologists in Lebanon compared to South Africa, Jordan and the US can be a reason for the lack of significant association between workload and dissatisfaction in Lebanese nephrologists. In the Jordanian group, administrative work was correlated with more stress. The time spent on paperwork and administration is a growing burden for nephrologists worldwide and the Jordanian nephrologists are aligned with the US results . US nephrologists complain of the great amount of time spent on administrative work and filling electronic medical records instead of encouraging patient-centered care .
Dissatisfaction regarding income is an important challenge for physicians globally, even in high-income countries. Income fairness is described as significantly associated with better job satisfaction in Japanese physicians . In Saudi Arabia, a survey of physicians showed a high dissatisfaction rate regarding income . In the Medscape Nephrologist Compensation Report of 2019, US nephrologists' satisfaction with income reached only 66%, despite the fact that they earned 3 times more than our sample, with the same amount of workload and 44% of them were paid fee-for-service. Dissatisfaction with income is more pronounced in low and middle-income countries. In South Africa 39% of nephrologists working in the public sector were dissatisfied with remuneration . In our survey, only 25% felt that they were fairly compensated, a result that is very close to physicians in Mexico . The very high density of nephrologists in Lebanon could be the reason for less income and less remuneration satisfaction. Several reforms to address this issue were suggested 15 years ago but none of them was applied .
Our study revealed a strong correlation between older age and some components of job satisfaction such as work-life balance, career and satisfaction with income. A study done in Norway in 2010 described also higher satisfaction rates in older doctors . Another one that compared German to American physicians showed increase of job satisfaction with age . However, this finding is not consistent in the literature and some authors reported better job satisfaction in younger groups of physicians . Overall, young nephrologists seem to experience less satisfaction with varying degrees. Only 11.8% of our young nephrologists (<40 years old) were satisfied with job opportunities and this is much lower than the 34 % in US young nephrologists .
The gender-based inequities between men and women are very obvious in our study. This imbalance in incomes and opportunities is reported even in developed countries like the US . The higher amount of income in men physicians is emphasized also in the International Physician Compensation Report of 2019 with men specialists earning 30000-70000 $ more than women yearly across countries like US, UK, Germany, France, Spain, Brazil and Mexico . Our study showed significantly less income in women and more academic competencies. Men are those who wanted more patients in dialysis even if the reimbursement fee was increased, despite the fact that they see equal number of outpatients and inpatients. Satisfaction with income is significantly lower in women in our study. Several European studies reported statistically significant better satisfaction of male respondents compared to their female colleagues . Our results highlight as well the high perception of gender discrimination in women.
Our study has one major limitation, the low rate of respondents. This low rate of response to the survey estimated at 27 % with even a lower response from Jordan of around 8%. This could be related to a technical issue because the LimeSurvey appeared in the Junk mail of nephrologists. Despite this limitation, the study is very informative and is the first study to assess factors related to nephrologists' job satisfaction in the Eastern Mediterranean Region.