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Making family medicine a more attractive specialty: strategies to address the shortage of primary care specialists in Brazil

By guest contributors Carmino Antonio De Souza, Clarissa Vasconcellos De Souza, Giuliano Dimarzio, Adail de Almeida Rollo, Aguinaldo Gonçalves, Rubens Bedrikow, and Lair Zambon

Primary Health Care (PHC) is often the first level of the health system and is responsible for the coordination of medical and interdisciplinary care1,2. As the preferred entry point to the Brazilian Unified Health System (SUS), PHC is of fundamental importance and is present in all regions of the country. It aims to enable access to health care and ensures the coordination and completeness of care. This structure can treat approximately 80% of the overall need related to diseases presented in the Basic Health Units3.

Despite its importance, the valorization of PHC and Family Medicine (FM) as a discipline and a public policy has not been prioritized in most Brazilian educational institutions. According to the study on medical demography carried out by the Regional Medical Council of São Paulo (CREMESP), Brazil had 500,000 physicians in 2020, but with unequal distribution among the nation’s five regions, and a concentration of professionals in the capital cities compared to the countryside4.

Although the Family Health Strategy (EFS) is considered a priority by the Ministry of Health5, many regions of Brazil face difficulties in recruiting and, especially, retaining medical professionals for the field. In 2020, Brazil had 7,149 FM physicians, only 2,4% of all specialists in the country3. Ongoing efforts to hire and retain physicians in rural areas remains challenging, and many vacancies remain, leaving residents without access to quality care.

This issue is faced by many countries. In the United States (US) of 8,116 primary care postgraduate training positions (which includes pediatrics, internal medicine, and family doctors), 42 percent were filled by graduates of U.S. medical schools and the American Association of Medical Colleges (AAMC) projects a shortage of 21,100 to 55,200 primary care physicians (PCP) by 2034. In Europe, where PCP was traditionally respected and recognized, the lack of General Practitioners (GP) is also increasing2 and is a matter of concern. Workload and a lack of perceived prestige associated with the PCP track can make primary care less attractive5. These sorts of misconceptions, along with lower salaries, burnout, and difficult career advancement makes primary care a difficult specialty to attract and retain doctors.

For Feuerwerker6, vacancies in Brazilian institutions are the result of several elements: the encouragement of distinctive specialties and institutions, the historical misunderstanding and importance of the practice, and the increased incentive of specialization in medical education. The lack of investments in supplies and infrastructure in primary care, career development concerns, and low salaries, and the valorization of the formation of FM doctors in the work of the EFS also contribute to difficulty in retaining these positions in Brazil.

With the aim to reduce the vacancy rate in the medical residency programs for FM, some Brazilian health departments introduced reforms and additional financing for FM training. In 2020, the region of Campinas, where we work, introduced a program called “More Doctors for the City of Campinas” (PMMC), which established a partnership between public and private higher education institutions, hospitals, and Urgency/Emergency Units with a novel post-graduation proposal for FM. It created a program to support the training of specialists in family medicine, stimulate research, and expand care in Basic Health Units, and has since resulted in a 50% decrease in vacancies.

One of the successful elements of the Campinas program, together with quality of medical training, is that it helps bring medical classroom training closer to the community and everyday social reality. PMMC-trained physicians are aware of their how their work impacts the local community and its particular health needs. The program has resulted in care that is more responsive to community needs, especially from the perspective of adopting a care model that prioritizes health promotion, disease prevention, diagnosis, and treatment in an integrated manner8. However, for the EFS to continue to innovate and improve its response capacity to contemporary health problems, it must invest heavily in professional training, the rational incorporation of information and communication technologies, and the creation of appropriate working conditions for multidisciplinary teams9.

References:

1. Lavras C. Primary health care and the organization of regional health care networks in Brazil. Saúde Soc. [Internet]. 2011Jan.1 [cited 2021Dec.6] 2011;20(4):867-74. Available from: http://doi.org/:10.1590/S0104- 12902011000400005.

2. Garatini L, Martini MB, Mannucci PM. Improving primary care in Europe beyond COVID-19: from telemedicine to organizational reforms. Inter Emerg Med. 2021; 16:225-58. Available from:  http://doi.org/:10.1007/s11739-020-02559-x

3. Santos WD, Comes Y, Pereira LL, Costa AM, Merchan-Hamann E, Santos LMP. Evaluation of the More Doctors Program: an experience report. Saúde Debate. 2019;43(120):256-268; Available from: http://doi.org/:10.1590/0103-1104201912019

4. Scheffer M. et al. Demografia Médica no Brasil 2020. FMUSP, CFM. [Internet]. 2020Dec9. 2020. [cited Dec202.9]. ISBN: 978-65-00-12370-8. Available from: https://www.fm.usp.br/fmusp/conteudo/DemografiaMedica2020_9DEZ.pdf

5. Schimpff SC. Why primary care is in crisis and how to fix it. Medical Economics. [Internet]. 2020Feb.7 [cited Apr2022.9]. Available from: https://www.medicaleconomics.com/view/why-primary-care-crisisand-how-fix-it

6. Feuerwerker LCM. A especialização de médicos e as residências médicas no Brasil. Saúde Debate. 2001;25(57):39-54. Available from: https://pesquisa.bvsalud.org/portal/resource/pt/his-8919

7. Tasca R, Massuda A, Carvalho WM, Buchweitz C, Harzheim E. Recommendations to strengthen primary health care in Brazil. Rev Panam Salud Pública. [Interntet]. 2020Jan6 [cited 2021Dec.6]. 2020;44: e4. Available from:

http://doi.org/:10.26633/RPSP.2020.4.

8. Câmara dos Deputados. MEC afirma que um terço das vagas de Residência médica estão ociosas. Câmara dos Deputados. [Internet]. 2019Aug.20 [cited 2022Jan.6]. Available from: https://www.camara.leg.br/noticias/573483-mec-afirma-que-um-terco-das-vagas-de-residencia-medica-estao-ociosas

9. Gonçalves, MS. The review of internal aspects, external environment, and development of scenarios as a base to define strategies. Santa Maria, RS: Universidade Federal de Santa Maria (UFSM); 2011. Available from: https://repositorio.ufsm.br/handle/1/8218

About the authors:

Carmino Antonio De Souza is a Professor and Head-Chief of the Department of Oncology-Hematology at the University of Campinas – Brazil. He was also Municipal and State Secretary of Health with a vast experience in Public Administration.

Clarissa Vasconcellos De Souza is an MD Specialist in Family Medicine at the Faculty of Medicine São Leopoldo Mandic with a Masters and Doctorate degree in Internal Medicine from the University of Campinas.

Giuliano Dimarzio is a Professor at the Faculty of Medicine São Leopoldo Mandic and Coordinator of the Family Medicine Residency Program, with a Masters in Epidemiology and a Doctorate degree in Medical Education from the University of Campinas.

Adail Rollo is a Professor in the Department of Preventive Medicine at the University of Campinas, and a Specialist in Public Health with vast experience in Health and Public Administration.

Aguinaldo Gonçalves has a post-Doctorate degree in Public Health from the University of São Paulo, with extensive experience in the field. He is currently a Professor at the Pontifical Catholic University of Campinas.

Rubens Bedrikow is a Professor at the Department of Preventive Medicine and Coordinator of the Family Medicine discipline at the University of Campinas with a Masters and Doctorate degree in Public Health from the same university.

Lair Zambon is a Professor and Head-Chief of the Department of Oncology Pulmonology at the University of Campinas. He is the current Secretary of Health for the city of Campinas.

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