Brazil Field Report: 2016

Published on April 18, 2016
Just months after its medical and education officials approved EM as an official medical specialty for the first time, planned EM residency training programs already number in the dozens, including pediatric EM programs.

On September 16, 2015, emergency medicine was officially recognized as a specialty in Brazil. At a joint meeting by the Brazilian Medical Association (Associação Médica Brasileira [AMB]), the Federal Council of Medicine (Conselho Federal de Medicina [CFM]) and the National Commission of Medical Residencies (Comissão Nacional de Residência Médica [CNRM]), this triad of organizations formally recognized emergency medicine as an “official,” recognized specialty in Brazil. It was a great year for emergency medicine in Brazil!

The first emergency medicine (EM) residency program in Brazil was begun in Porto Alegre Brazil, in 1996. Porto Alegre is a city of approximately 1.5 million in the southernmost state of Rio Grande do Sul. The residency program began as a two-year program with two residents per year and grew over time to a three-year program with six residents per year. The second EM residency program was started in 2008, in Fortaleza, a city of approximately 2.5 million in the northeastern state of Ceara. The Fortaleza program is also a three-year training program with six residents per year. As of 2015, these were the only two existing EM residency training programs in a country of approximately 200 million people and in an area covering 3.3 million square miles of territory. Prior to 2015, lack of official recognition of the specialty meant both lack of funding and political opposition among academic physicians to formation of EM training programs. The two programs now in existence are the only successful attempts from at least ten serious endeavors known by the authors. Now that the specialty is recognized, there are between 10–20 new EM residency programs throughout the country in the planning stages, with several staged to start with new residents in summer 2016.

These EM training programs are sorely needed. In most of Brazil, emergency departments are staffed by physicians without training in EM. These physicians comprise an eclectic mix of full-time and part-time time emergency physicians, some with essentially no postgraduate training, others with training in various specialties, and still others who “moonlight” in emergency rooms to supplement their income while building their practices and working other jobs.

The quality and availability of medical care in Brazil is widely disparate. Among large regions of the country, and especially among the poor, available medical care would be considered substandard by American standards. At the other end of this spectrum, there is very sophisticated medical care available in many areas, especially in the more developed south, and especially so for patients with private medical insurance. In the latter situation, a person having a STEMI may get an angioplasty and stenting with all care being equivalent to the best hospitals in the US and Europe, but with one exception—the emergency physician first taking care of the STEMI patient may be a physician with no training straight out of medical school!

If the number of applicants for the Hospital de Pronto Socorro (HPS) EM residency program are any indication, very promising trends are emerging for the employment outlook for trained emergency physicians in Brazil. Eighteen years ago, when the HPS EM residency program began, medical school graduates who applied generally could not obtain residency training in other fields, and there were few applicants for each year’s two positions. Now, entry to the program is extremely competitive, with 10–15 applicants for each residency’s six positions. EM resident graduates are highly sought after by local hospitals in the Porto Alegre, especially by the best known private hospitals in the area, and they are often contacted and courted by these hospitals during their last year of residency training. Pay scales for these trained emergency physicians in Porto Alegre have been rising steadily, and their incomes are now roughly on par with other primary care physicians. With predicted dynamic growth in EM training programs, it is anticipated that properly trained emergency physicians will be in great demand, as well as academic emergency physicians.

The future of EM in Brazil now looks bright. Of course, with this great leap forward there will be challenges. One challenge will be to ensure quality and standardization of the curricula among the many new EM residency training programs now being developed. Another will be development of a certification examination. Finally, there needs to be a clear process for recognition of experienced emergency physicians working in Brazil’s emergency departments who have not completed an EM residency. Presumably, there will be some type of grandfather clause for these physicians so that they and EM residency trained physicians may both be able to take a certification exam, similar to the process that occurred in the US in the 1980s. All of these challenges are currently being discussed and debated at meetings of the Brazilian Association of Emergency Medicine (Associação Brasileira de Medicina de Emergência [ABRAMEDE]), and all the more so now that EM is a recognized specialty. For now, we owe our Brazilian EM colleagues a warm “PARABENS!” (Congratulations!) on a great step forward for emergency medical care in Brazil.

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