Emergency Medicine in Brazil; in the endeavor for recognition as a unique specialty
Porto Alegre, Brazil, April 2006
Andrés Di Leoni Ferrari, MD, MBA
Significant obstacles still exist in the development of emergency medicine (EM) as a specialty in Brazil. Although emergency care is an important public health issue, the lack of official acceptance stands as the most significant difficulty in the road towards recognition of the specialty and the development of an emergency medicine residency in the country.
Brazil is one of the world's most populated countries, with more than 184 million persons. Porto Alegre, with 1.5 million inhabitants and comprising a total of 3.5 million people in its metropolitan area, is the capital-city of Brazil's southernmost state of Rio Grande do Sul.
Cardiovascular diseases are the main cause of death, and trauma (motor vehicle crashes and interpersonal violence) is a major social issue and source of mortality. In this country alone, more than 100,000 persons die annually due to acute illness or trauma (this is the leading cause of death between the ages of 5 to 50 years). Moreover, another 1.5 million suffer consequences or some kind of disability directly related to external causes.
Located downtown in the city, the publicly-funded Hospital Municipal de Pronto Socorro (HPS) is a 130 bed facility that provides 24/7 free emergency care for Porto Alegre's metropolitan area. This facility would be comparable to a Level I trauma center in the USA3 and has become a referral center for the state and the surrounding states for trauma care.
Our objectives with this article are to characterize the current status of EM in Brazil in order to get a better understanding of why EM remains unrecognized, and to point out the main features of HPS' EM Residency Training Program.
Emergency Medicine in Brazil Today
An Accreditation Committee in 2002, grouping Brazilian Federal Council of Medicine (CFM), Brazilian Medical Association (AMB) and National Residents Committee (CNRM), officially recognized 50 specialties ranging from the traditional internal medicine, surgery, pediatrics, etc., to some new, not-so-traditional ones, such as acupuncture and homeopathy. Residency training is available for almost all such specialties, but not for all medical graduates. That list was revised in 2003 in a new meeting of the Committee (which gathers the bodies in charge of deciding what disciplines would gain the status of specialty), allowing three more disciplines to be part of the recognized group.In neither of those instances, was EM recognized as a unique specialty, posing a major obstacle to the future of EM as a unique, independent specialty. Instead, "Urgency Medicine" was declared as a "Performance Area" within internal medicine as of 2004, and unfortunately, since then other openings towards recognition have not been shown or reported.
An emergency physician in Brazil (understood as a medical graduate professional that performs in an ED) today may be any physician with a valid license to practice medicine.3 There are no statistics about the impact of this issue on the patients' outcomes (detailed reports of emergency care and the facts related to it are often lacking because adequate documentation is quite difficult, if not impossible, to obtain). It was noticed that emergency care was perceived as one of the most critical issues to be faced by the Ministry of Health.
As more physicians are working exclusively in EDs mainly because of the shortness of access to the desired residency training, very few have been specifically trained in necessary ED performance skills (ie, Advanced Trauma Life Support ® or advanced cardiac life support courses). It is not uncommon to see young medical practitioners, just graduated from medical school, making their "first trainings in practice" in the EDs, or residents from other specialties doing overnight shifts.
Most medical schools in the country have placed EM as a discipline in its curricula and most of them have the capability of structuring an EM residency training program.
Besides expanding the number of academic programs focused on EM, the University of São Paulo offers a third-year in internal medicine focused in EM, or a PhD degree for EM and critical care. Emergency care strategies in Brazil definitely need to be rethought and rebuilt.
Patient's rights, safety, and satisfaction along with economics, must be balanced in a way that provides the acutely-ill patient with the best results through access to the best providers.6 For that reason, unified efforts towards unique core content for a unique specialty in EM are necessary.
The Hospital de Pronto Socorro's Emergency Residency Program
The approach to EM in the HPS' Residency Program is to see it as the multidisciplinary specialty for excellence,2 understanding the practice of EM as encompassing a unique body of knowledge.Ross D. Tannebaum, MD, FACEP (American College of Emergency Physicians' Ambassador to Brazil as of 2005), et al, presented the Brazilian EM system to the world in 2001.3 Even though it began in 1996, that was the first time this program appeared in the academic international arena, and fortunately, things have continued evolving and improving, but official recognition has not come yet.
Until 2003, it was a two-year-long program, with the option of a third year for only one resident. At that time, the program accepted four new trainees annually. Since 2004, it was moved forward to become a three year program, entering six new residents in each class.
There are no other requirements to apply for the HPS' residency program other than the previous completion of medical school. The applicants pass through a selection process, which includes a written exam (the same exam that is required to enter other residencies), curriculum vitae analysis, and an interview with the faculty.
The faculty involved in resident training and curriculum design (reviewed annually and largely based on current USA EM residency programs) are all certified in internal medicine, intensive care or surgery, and most have completed other fellowships (ie, cardiology, endocrinology, etc).
The current established curriculum includes approximately six hours per week dedicated to didactic lectures, journal club and article review, case review conferences (morbidity and mortality), besides daily clinical rounds on each of the resident's rotations. Practical activities during the three years include: permanent ED activity (trauma and clinical and shifts overnight), trauma critical care unit, clinical and coronary critical care unit, burn critical care unit, cardiology ward, internal medicine ward, as well as prehospital assistance activities.
There are also rotations in other hospitals in Porto Alegre, searching to broaden the resident's spectrum of training, including clinical adult emergencies in other facilities, pediatric clinical emergency practice and training in gynecological / obstetric emergencies. The second and third years have one month of elective rotation, where the resident chooses where to study according to personal preferences, but always focused on EM topics. There is also one month for vacation per year.
In order to complete the necessary credits for graduation, residents must pass two written exams per year (on a semester basis), attend all courses and shifts (evaluated monthly), compile a complete record of procedures performed, and develop a research project to be concluded and presented at the end of the third year.
HPS' vision is to establish a residency program in EM. These principles set the pillars to provide high-quality emergency care. Quality and safety of EM care stand as the ultimate purpose for the maintenance of this residency program.
Conclusion
Even though efforts for the development of EM are increasing worldwide (Colombia, Argentina, Mexico in Latin America; Turkey, Jordan, Eastern Europe, and many, many other examples), Brazil currently has about the same level of emergency care delivery seen in the United States prior to 1968.5The HPS in Porto Alegre has accepted the challenge with its creation of an EM residency program, an essential step in the development of the specialty as an independent core of knowledge has been taken in Brazil.
Some fundamental changes must occur in order to fulfill this endeavor for recognition of a field of medicine that as demonstrated all around the globe improves the live of millions:
Unify professionals involved in all aspects of emergency medical care to create a strong and functioning Brazilian Association of Emergency Physicians.
Stimulate the development of more new EM residency programs in Brazil and support the existing initiatives.
Establish standardized qualifications and requirements to practice EM, and create a consistent and coherent board certification process, far from personal or political interests.
Shoulder the responsibility for creating a stable and productive workplace for all the new emergency physicians' to motivate them to remain in the field of EM and to work for the development of the specialty in Brazil.
References
IBGE - Instituto Brasileiro de Geografia e Estatística. Available at: http//www.ibge.gov.brTannebaum RD, Arnold JL, de Negri Filho A, Spadoni V. Emergency Medicine in southern Brazil. Ann Emerg Med. February 2001; 37: 223 - 228.
Borges LAA, Di Leoni Ferrari A. Residência em Emergência. Jornal AMRIGS. November 2002. pg 5.
Emergency Medicine: a unique specialty. Available at: http://www.acep.org
Mesquita ET, Duarte AMM, Vaisman M. Emergências Cardiovasculares. Cap. 2: Atendimento Emergencial do Paciente Cardiovascular. Ed. Atheneu 2002; 17- 30.
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