Surgery in Brazil

Some preliminary data are needed to coherently analyze the present state of surgery in Brazil. Brazil is among the 10 greatest economies of the world, is the most populous South American country, and occupies an area of approximately 8 500 000 km². Its borders make contact with all South American countries, except for Chile and Ecuador. The political administrative organization comprises 26 states, approximately 5500 municipalities, and the Federal District, the seat of the government. The country is divided into 5 great regions, whose characteristics are shown in Table 1.

Most of the Brazilian population is of European (Portugal, Spain, Italy, middle eastern part of Europe, and Germany) and African origin. During recent decades, there has been an increase of Asian immigrants (particularly from Japan and Korea). The official language is Portuguese, and Catholicism is the predominant religion. Native medicine had no significant influence on modern medicine and surgery. According to the Pan American Health Organization, Brazil is one of the countries with the greatest socioeconomic inequalities in the world, a tendency that has been reinforced in recent years despite economic growth. Thus, the average income of the 10% richest is approximately 30 times that of the 40% poorest. In the Northeast, poverty has the typical characteristics of marginal societies, while in the Southeast, it reflects the character of the region as the dynamic center of the national economy. According to the 1991 census, the Brazilian population was 146.8 million inhabitants. There were 17.2 inhabitants per square kilometer, characterizing a low demographic density, and the urban population reached 75.6% of the total. In 1996, with 161 million inhabitants, Brazil occupied the fifth place in the world, preceded by China, India, the United States, and Indonesia. In the last census, completed in 2000, the country's population increased to almost 170 million inhabitants. In recent years, the average demographic growth showed a trend toward reduction; the fertility and gross birth rates have decreased as well.

The Brazilian population, in general, experienced an important process of modification regarding distribution according to age because of a reduction in the proportion of those younger than 15 years and the slow growth of the elderly component, presenting an interesting perspective of a quality leap regarding nutrition, health, and education policies directed to children and young people. Life expectancy increased, reaching more than 64 years for men and more than 71 years for women at the end of the past decade.

Regarding mortality rates, available data are not completely reliable. There is a global underreport (nonreported deaths) of the order of 20%, exceeding 50% in some areas of the North and Northeast. In addition, among the reported deaths, there are approximately 18% due to ill-defined causes, which leads to cautiously analyzing the deaths due to defined causes. However, apparently the demographic data indicate that mortality rates have been significantly declining in recent decades, mainly due to a reduction in the mortality of the population younger than 5 years. Unfortunately, such a global reduction was neutralized in part by an increase in mortality due to external causes among young men. The global analysis of causes of death according to the categories used by the Pan American Health Organization¹ shows that, excluding ill-defined causes, diseases of the circulatory system occupy the first place (circa 34%), followed by external causes (circa 15%), neoplasms (circa 13%), and transmissible diseases (circa 11%). Maternal and infantile mortality rates have been greatly reduced in recent years, mainly in the southeastern and southern regions. In the other regions, they remain high, although lower than in the past.

By analyzing the specific health problems according to age range, the Pan American Health Organization data¹ show that external causes constitute the most important problem up to the age of 60 years, after which circulatory diseases become prominent. Neoplasms are more or less evenly distributed in all age ranges. However, the previously mentioned indicator values tend to hide great disparities that exist between urban and rural areas, between states of the same region, and between municipalities of the same state. The problems resulting from internal migration from the rural to the urban zone, leading to the establishment of shantytowns (favelas) in the megalopoles and to the worsening of sanitary conditions in the great urban centers, should also be emphasized. Such migration has caused modifications in the profile of the nosologic geography of the country. An increasingly important problem of the 10- to 19-year-old population is drug abuse (alcohol, tobacco, solvents, tranquilizers, amphetamines, and marijuana). The profile of the population and the health care system is summarized in Table 2.

The total health cost is approximately 7% of the gross national product. But public expenditure regarding health, as a percentage of the gross national product, is 3.17% (R $24.7 billion) of a total of R $779 billion.² According to data by the Ministry of Health,² the average expenditure for surgical hospitalization is R $575.08 (range, R $253.73 [in Amapá] to R $781.55 [in Paraná]). Most of the Brazilian population is linked to social security and has a right to free medical care. It is estimated that less than 5% have sufficient means to pay for private care. The proportion of Brazilians who have some type of medical care through contracts and health insurance is progressively increasing. These types of medical care have been the subject of increasingly rigorous regulatory measures in view of irregularities that have occurred and are still occurring. The percentage of the population covered by some type of private medical care is calculated to be 25%, reaching higher values in some states. In Table 3, the 30 most frequent surgical procedures, according to estimates or calculations by the Ministry of Health, are presented. The data refer to the procedures covered by public health care, ie, approximately 65% to 70% of the total. Information refers to the year 2000, according to projections based in April 2000, a month that may be regarded as being typical.

By analyzing the medical education system, we see that medical teaching in Brazil started with the arrival of the Portuguese royal family in 1808, when the first medical school was created in Salvador, Bahia. At the end of the past decade, there were 95 medical schools in Brazil, 66 (70%) of which were located in the richest regions of the country, the Southeast and the South.^3,4 This number has increased to more than 100. These medical schools, commonly distributed according to criteria of political representativeness, generated approximately 9500 vacancies per year, of which circa 5000 were public and 4500 were private. Specifically, between 1960 and 1979, there was a significant increase in the number of faculties of medicine. Parallel to this numerical expansion, the existing, particularly the public, schools were induced to increase the number of vacancies in their courses. Thus, the increase in the number of physicians between 1991 and 1996 (3.02%) was more than twice the annual demographic increase during that period (1.38%). This increase in the number of medical schools and vacancies was accomplished with the authorization of the responsible federal bodies, despite the strong opposition of medical entities, such as the Brazilian Medical Association (Associação Médica Brasileira). Although in a less incisive form, these data recall the panorama described by Flexner⁵ in 1910, in his memorable report on medical education in the United States and Canada. In fact, although this increase could be viewed as being beneficial to the country, by offering to the population more professionals, it should be analyzed with caution. Besides promoting a progressive concentration of physicians in the richest regions, the South and the Southeast, the increase in the number of vacancies was not accompanied by an equivalent increase in professional and qualified docents regarding didactical and pedagogical aspects and in residency vacancies in duly equipped hospitals. Consequently, the quantitative increase in the number of health professionals was not accompanied by improvement regarding health care in qualitative terms.

This supposition becomes more incisive if we remember that this numerical growth occurred at a moment characterized by the explosive technological development that made available to the physician sophisticated equipment and extremely expensive procedures that, if not sensibly used, substantially increase the price of health care. In addition, not all medical schools have their own teaching hospitals able to offer residency vacancies in the adequate number for their needs. Such a fact is a particular cause of concern if we consider that instruction offered by graduate courses is not of a terminal character. Regarding the teaching profile, until recently, perhaps until 1950, European medicine was of great influence on the model adopted by the schools. Since then, North American medicine started to have a progressively greater influence. Admission to medical courses is made by a selective examination. The duration of the medical course is 6 years. The minimum curriculum of the medical course is 9000 to 10 000 hours. The first 2 years are dedicated to the basic sciences, and the subsequent 2 years, to doctrinal and cognitive formation in the different fields of medicine. The last 2 years involve internship through training in the hospital. During internship, training in surgery, internal medicine, gynecology, and obstetrics is mandatory, in addition to training in pediatrics. Approximately 20% of working hours are dedicated to the teaching of surgery.

During the curricular course, surgery is taught from the third year on, throughout several disciplines, usually general surgery, surgical technique, vascular surgery, urologic surgery, plastic surgery, head and neck surgery, thoracic surgery, cardiovascular surgery, surgery of the digestive system, and pediatric surgery; there are also internship rotations in the emergency service and in several surgery services. In the more traditional medical schools, the student has the opportunity to work in research laboratories, starting to join research programs during the medical course. There are fellowship programs offered to those students. At the end of the medical course, the physician receives an identification given by the Regional Medical Council. Although most institutions require some postgraduate training to employ a physician, from the legal standpoint, authorization given by the Regional Medical Council automatically gives physicians the right to practice their profession, independently of having completed a program of medical residency. There is no mandatory board examination at the end of the medical course, although, starting in 1998, an open and voluntary evaluation developed and supervised by a committee appointed by the Ministry of Health has been applied. It is possible that this evaluation becomes mandatory for the attainment of the diploma in upcoming years. At the moment, there is no official mechanism of periodical recertification for physicians. Medical residency, created in 1945 to 1946 in Brazil by the "Hospital das Clínicas" of the Faculty of Medicine of the University of São Paulo, progressively spread and is at present offered annually by university, public, and private hospitals.

Approximately 80% of the residents are trained in public and 20% in private institutions. Since 1977, the National Committee of Medical Residency (Comissão Nacional de Residência Médica) has been in charge of the regulation and management of medical residency. This committee consists of representatives of the Brazilian Medical Association (Associação Brasileira de Medician), the National Association of Medical Residents (Associação Nacional de Residentes Médicos), the Brazilian Association of Medical Schools (Associação Brasileiras de Escolas Médicas), the Brazilian Hospital Association (Associação Brasileira de Hospitais), and several interested public organizations.

From the practical standpoint, this committee had and continues to have difficulties in managing a progressively increasing number of programs, requiring the need for the creation of formal legislation for medical residency. In summary, if, on the one hand, it is theoretically of interest to establish nationwide requirements, on the other hand, this is practically unfeasible in a country with the dimensions of Brazil and tends to level off all programs to an acceptable minimum. This fact becomes particularly critical if we recall that, as previously mentioned, one of the greatest obstacles to the professional education of physicians in the country is the limited number of vacancies for residency in the hospitals accredited by the National Committee of Medical Residency. Based on the premise that approximately 9000 physicians graduate per year, only 6500 (72%) will find vacancies in accredited residency programs. In other words, almost 30% of the recently graduated physicians have no access to this step, which is so important for their professional education. Consequently, they end up looking for alternatives for professional improvement that, although possibly contributing to their technical education, are far from offering them the clinical maturity and judgment that are so important in the practice of our profession.

By analyzing the historical development of the opportunity to enter a residency program, the global trend is a progressive increase in the past 15 years. Admission to a residency program in surgery offered by an institution is open to all interested persons, and a selection consisting of several steps is made: (1) a written evaluation of general medical knowledge, (2) a written evaluation referring to knowledge in the area of specific interest to the candidate, and (3) an evaluation of the curriculum and a personal interview with the candidate. The duration of most residency programs is limited to 2 years and rarely exceeds 3 years. These numbers possibly reflect a globally insufficient education or one restricted to a subspecialty. Most surgical specialties imply starting a 2-year residency in general surgery. However, there are several areas in which there is direct access to the specialty. This is the case for gynecology, orthopedics, neurosurgery, ophthalmology, and otorhinolaryngology. Fragmentation of surgery into specialties and subspecialties also affects residency. Indeed, requirement of skill in general surgery in the end is fulfilled by short and sequential rotations in specialized services. In other words, training in general surgery is substituted for a mosaic of training in specialized services that prioritize the care of complex cases that will be attended by and operated on by already qualified surgeons. Residents have a fellowship of US $550 a month granted by the entities, public or not, that offer the programs. According to the present legislation, at the end of the program, the approved resident is granted the title of specialist. However, this title is questioned by the medical societies, which establish their own examinations to issue the title. In the case of surgery, it is the Brazilian College of Surgeons (Colégio Brasileiro de Cirurgiões). Of the total of the offered residency vacancies, including the vacancies from the first to the fifth year, approximately 19% are assigned to the different surgical specialties. More than 65% of these vacancies are offered in the Southeast. The detailed distribution of the surgery program by specialty and year of residency may be seen in Table 4.

Thus, it is evident that the total number of annually offered vacancies for the main surgical specialties is approximately 1100. Of these, circa 750 are for general surgery and usually offer a 2-year training period. Although many recently graduated physicians look for training in other countries at the end of their training programs, the total number of those who improve their training abroad is relatively small and is limited to some specific advanced surgery areas (eg, transplantations).

In analyzing the panorama of practicing physicians, a survey by the Federal Council of Medicine (Conselho Federal de Medicina)⁸ made in August 2000 shows that they number 244 690, ie, approximately 1 physician for each 735 inhabitants. Of these physicians, approximately 55% practice in state capitals and the remaining in the interior. However, it is interesting to analyze detailed information collected in 1994, the year when an agreement was signed between the Oswaldo Cruz Foundation (Fundação Oswaldo Cruz) and the Federal Council of Medicine (Conselho Federal de Medicina),⁹ allowing the start of much more comprehensive research on the profile of Brazilian physicians. The results of this research, performed based on answers to thousands of questionnaires, representing circa 200 000 physicians, were divulged after 2½ years of work. According to the presented information, the distribution of physicians in the different regions of the country was significantly heterogeneous. About 75% were concentrated in the Southeast and the South. The others were distributed among the North (3.1%), Center-West (6.8%), and Northeast (16.0%). Considering distribution in the capitals, the number of physicians per 1000 inhabitants ranged from 1.56 in the North to 4.56 in the South, with a mean of 3.28. In the interior, the number varied from 0.10 in the North to 0.83 in the Southeast, with a mean of 0.53. Of the total, approximately 74% had participated in medical residency. This percentage varied from 56% in the North to 78% in the Southeast. A similar proportion (approximately 70%) used to participate in scientific meetings and updating courses (ie, continuing medical education programs), mostly offered by national medical societies. Also according to this study, data for 1995 showed that of the 183 000 practicing physicians in that year, circa 22 500, ie, approximately 12.5% of the total, practiced surgical specialties (Table 5).

Within this panorama, general surgery, with 10 049 participants, was only below pediatrics (26 650 participants), gynecology and obstetrics (21 575 participants), and internal medicine (14 666 participants).

The distribution of the physicians in the country does not accompany that of the population. Thus, while circa 24% of the population live in the capitals, 65.9% of the physicians are concentrated there, being equivalent to 3.28 physicians per 1000 inhabitants in the capitals, vs 0.53 physicians per 1000 inhabitants in the interior of the states. Most physicians (circa 64%) are young (<45 years), and only 8.6% are older than 60 years.

Concerning the labor market, the global panorama is quite critical. In general, in the private and public institutions, there is a clear tendency to give preference to the specialist to the disadvantage of the general surgeon. The field of activity of the general surgeon is restricted, in most cases, to abdominal surgery (surgery of the abdominal wall and the gastrointestinal tract), regarding elective and emergency surgery. The general surgeon competes with the surgeon of the digestive system and usually is underpaid; the public is reluctant in accepting the general surgeon as a qualified health provider, because they believe a general surgeon is not as competent as a specialist. Thus, the practice of general surgery is not very attractive. This distortion results in fragmentation of surgical assistance and in extremely higher costs and does not take into account that more than 90% of the surgical needs of the population are restricted to procedures of low complexity.

Regarding the labor market, the available data clearly evidence the coexistence of jobs, the "multiemployment" of most physicians. About 70% are somehow linked to the public sector and more than 50% to the private sector. Approximately 75% have liberal activity (ie, engaged in some kind of private practice) and 13.5% get paid by another source. It is estimated that more than 75% of Brazilian physicians have up to 3 professional medical activities and that 24% have 4 or more. Although the activity in the office is the one closer to liberal professional practice, actually 75% to 90% of Brazilian physicians directly depend on health insurance companies (contracts with firms, group medicine, medical cooperative societies, and the like) to maintain their office. The activities of approximately 50% of the physicians are on a "on-call" basis. The monthly income from medical work is as follows (data from 1996)⁹:

This monthly income is about the equivalent of US $1280 vs a desired monthly income equivalent to US $4600.

A similar survey, performed in 1995 by the Brazilian College of Surgeons, with one of us (S.R.) among its members, showed that the income was as follows:

The percentages do not total 100 because of rounding. Also, the data reflect a small sample (about 700 answered questionnaires) of surgeons, most aged 40 to 50 years. Consequently, in general, the physician, and particularly the surgeon, ends up with a lifestyle that is incompatible with a satisfactory level of refresher courses and continuing medical education. In addition, the virtual equality between salaries of those who recently graduated from the medical schools and the more experienced professionals contributes to lessen the interest in professional improvement. Further aggravating the situation, there is no correlation between professional differentiation and remuneration, at least for the younger surgeons. However, the degrading salaries more severely affect the professionals who had inadequate education and, because they are not competitive, who are forced to accept precarious and underpaid jobs. In conclusion, the not always adequately qualified young physician is placed in a position characterized by the following: teaching and medical assistance are compartmentalized into specialties, the labor market and users give preference to specialists, a health system is more centered on treatment than on prevention and basic health care, and there is an inadequate distribution of human and material resources and an increasing impact of technology. Because of all these aspects, there is a social and cultural metamorphosis, which tends to deprive the physician-patient link of its characteristics and to degrade physicians' professional work, making them lose ground to technological sophistication. This unfavorable scenario causes the future of the profession to be seen by most physicians with a strongly negative feeling, reflecting discontentment and lack of professional perspectives.

Although the global panorama is not so good, in Brazil there is no lack of medical centers that offer the most advanced surgical services. The Heart Institute (Instituto do Coração), linked to the Hospital das Clínicas of the University of São Paulo, is an example of a center of excellence, receiving residents and trainees, both national and from several Latin American countries.

The A. C. Camargo Cancer Hospital (Hospital do Câncer A. C. Camargo) and the Ludwig Institute, with their research on the genome, are internationally prominent. There are numerous surgical societies. Among them, the most prominent is the Brazilian College of Surgeons (Colégio Brasileiro de Cirurgiões [CBC]), a national public utility entity, founded on July 30, 1929, with more than 2000 full members and approximately 3000 associate members. The seat of the CBC is in Rio de Janeiro. It consists of a central nucleus and state chapters. The CBC has several committees (trauma, videosurgery, hospital accreditation, nosocomial infection, cancer, organ transplantation, and training in surgery), it regularly organizes regional updating and refresher courses, and it promotes a national congress every 2 years that lasts 6 days and has more than 3000 participants. The CBC issues the title of specialist in general surgery and, since 1974, publishes a bimonthly journal (Revista do Colégio Brasileiro de Cirurgiões) and a trimestrial information bulletin. To be a member of the CBC, in any category, the candidate must fulfill a series of requirements according to the statutes. Further information may be found on the CBC's home page.¹⁰ Brazilian medicine has prominent surgeons among its emeritus members. It would be impossible to name them all, and we would definitely leave out illustrious names. However, there are some who, because of their work, deserve at least one citation. Fernando Paulino, MD, and José Hilário, MD, from Rio de Janeiro; Benedito Montenegro, MD, Alípio Correa Neto, MD, and Edmundo Vasconcelos, MD, from São Paulo; Eurico da Silva Bastos, MD, from Pernambuco; Fernando Carvalho Luz, MD, from Bahia; and João Batista Rezende Alves, MD, from Minas Gerais, are examples of masters who left an indelible mark on Brazilian surgery. Euryclides Zerbini, MD, in thoracic surgery, and Waldemar de Carvalho Pinto, MD, in orthopedics, are other noteworthy examples of surgeons with a great impact on medical education and professional practice.

Thanks to them and those who succeeded them, there are centers of excellence in teaching, research, and assistance in the areas of cardiac surgery, transplantations, oncology, surgery of portal hypertension, and minimally invasive microsurgery. Regarding assistance to trauma, the impact of the advanced trauma life support program, which offers circa 200 courses per year and has already trained more than 13 000 physicians, should be emphasized. In conclusion, the present panorama of Brazilian surgery is not the most favorable. There are difficulties due to the continental dimensions of the country and the regional diversities. There are also serious problems impairing the educational system, and the labor market also is not propitious. The perspectives of the Brazilian surgeon are not stimulating, and many have a pessimistic view of the future. On the other hand, there are nuclei of excellence in several areas and there is increasing concern on the part of physicians and the societies that represent them to modify the previously described panorama.

We thank Ernesto Lima Gonçalves, MD, for his contributions to this article.

Corresponding author and reprints: Dario Birolini, MD, Rua Olegário Mariano, 671, 05612-001 São Paulo SP, Brazil (e-mail: dbmed@attglobal.net).