Do medical schools teach emergency medicine in Brazil?
Medical education in Brazil follows the European model and after the completion of high school, students attend medical school for 6 years. As part of medical school, all programs include a mandatory 2-year internship before graduation. After receiving the medical degree, graduates may apply for residency.
In 2019, Brazil had 342 registered medical schools, including both private and public schools. Based on the available data, EM teaching at medical school level appears to be suboptimal, allowing students’ sparse contact with this specialty during their training. The Brazilian Association of Medical Education has received funding from the Pan American Health Organization to study the impact of national curriculum guidelines on medical school curricula [14]. Within this project, they have developed an initiative to specifically understand the teaching of EM in Brazil. Several themes have emerged from these studies including schools without any curriculum in EM, teaching hospitals without an ED, students working in emergency care units without supervision, lack of EM specialists or other staff capable of teaching EM, and lack of a longitudinal plan where students are exposed to the topics from year 1 through year 6 of medical school [14, 15].
The most recent national guideline from the Ministry of Education (2014) recommends that 30% of the hands-on training during the last 2 years of medical school (i.e., internships) should be held in settings such as the public primary care clinics or emergency care units [15]. Although this recommendation mandates students to rotate in emergency care units or EDs during their internships, exposure to EM is yet irregular and the specialty itself is not widely known within medical schools. Most of the popularity of EM comes from EM interest groups (in Portuguese, “Ligas Acadêmicas”) where students create a parallel curriculum as a strategy to compensate for this educational weakness [16].
Emergency medicine residency training
As previously mentioned, the first Brazilian EM specialty program began in Porto Alegre, Rio Grande do Sul, in 1996. Its initial structure was of a 2-year program with 2 and later 4 spots per year, and, most recently, it changed to a 3-year duration program with 6 spots per year. Currently, all programs in the country have a 3-year curriculum. Before the recognition of the specialty in late 2015, there were only two programs available. Since then, 52 new programs have been listed by the Ministry of Education, totaling 54 programs across 16 federative units. The majority of programs are located in the South and Southeast of Brazil, with almost no programs in the Center-West and North of the country (Fig. 1). As of November 2021, there were 225 residency spots available per year for physicians interested in pursuing formal EM training (Appendix S2).
There is no unified residency application system for medical school graduates in Brazil and every hospital is responsible for structuring their own selection process. Some clusters of hospitals, however, have created unified processes in which medical students take one exam and apply to several different hospitals and programs. In 2019, some EM residency programs had up to 22 candidates per residency spot (data not published). In the Brazilian medical education system, this level of competitiveness is similar to the level experienced by applicants to other classic specialties such as Pediatrics, for example. This highlights how quickly the specialty got the attention of medical students who are now becoming more interested in pursuing a career in EM.
The educational curriculum across residency programs is still very heterogeneous [11]. In a survey of 35 programs, only 5 rotations were mandatory in all programs, including rotations in the ED intermediate acuity unit (“yellow” room), ED high acuity unit (“red” room), ICU, obstetrics and gynecology, and trauma [11]. The North American model is often followed [17], and national guidelines for a competency-based curriculum are being developed by ABRAMEDE leaders. An important aspect of current EM training in Brazil is the predominant focus on skills related to the management of critically ill patients. The high volume of critically ill patients being taken care of by emergency physicians is related to multiple factors including inadequate primary preventive care and lack of hospital and ICU beds [18, 19]. The lack of hospital and ICU beds not only contributes to ED crowding [20], but also leads to prolonged boarding times where patients stay in the ED for days while waiting for a transfer. Even in settings with adequate bed support, ED crowding can still be an issue [20]. For these reasons, the skill of coordinating crowding and optimizing ED patient flow is invaluable for Brazilian emergency physicians in training.
Who practices Emergency medicine in Brazil?
Due to the late recognition of EM as a specialty, EDs are mostly staffed by physicians without formal training in EM. This includes recent medical graduates and physicians with other specialty training (e.g., Internal Medicine, General Surgery). A significant proportion of physicians work in the ED as a way to increase their monthly income while they are specializing in another area [21]. The vision of working in the ED as a temporary job may contribute to make the specialty of EM less attractive. The shortage of formal EM-trained physicians is still significant and at this point it is not feasible to have all Brazilian emergency care units and EDs staffed only with formally trained emergency physicians.
Board certification is being led by ABRAMEDE. In 2017, the first EM board exam occurred and physicians who have been practicing EM for years had the chance to get their official board certification. As of December 2020, 192 physicians [22] have been board certified as emergency physicians in Brazil, and, given the recent spike of new residency programs [11], the expectation is that this number will rapidly increase in the upcoming years.
Emergency physicians trained at the few formal residency programs available are now leading the way, and several have become chairs of EDs, taking important administrative positions. Besides working clinically and teaching at residency programs and universities, important roles include evaluation of appropriate ED patient flow, crowding, and the implementation of evidence-based protocols using EM-tailored clinical research. This scenario is similar to what occurred in the USA in the early 1980s [17].
Emergency care at the pre-hospital setting
Pre-hospital care in Brazil has significant influence from the French model, although it has increasingly acquired its own characteristics. Brazil has ambulance services that use mixed strategies such as the “stay and play” or the “scoop and run.” Both of these approaches are provided by the SAMU (in Portuguese, “Serviço de Atendimento Móvel de Urgência”), which is public and widely available across the country. Private ambulance services are also available. Since 2003, SAMU has been chosen by the government as the standard model for emergency medical services (EMS) [23]. Despite its official national regulations in 2003, there have been reports of regional implementation of SAMU since the 1990s in some Brazilian cities. In 2017, SAMU covered approximately 79% of the Brazilian population [24]. However, its implementation is still unequal across states and regions, with some places fully covered and others with less than 50% coverage [25].
Currently, SAMU operates on a system where citizens may call the toll-free number 192 (same number in any part of the country) and ask for an ambulance. A physician in charge of medical control (unique characteristic of the system) will then decide about dispatching either a basic or an advanced life support unit. A basic ambulance unit will include a driver and a nurse technician. An advanced ambulance unit must include a driver, a physician, and a registered nurse. Some Brazilian states have also adopted a model of ambulance care where the Military Fire Department personnel trained as emergency medical technicians provide pre-hospital care, mostly to trauma patients [26]. For this reason, states such as Rio de Janeiro, for example, relies on both the Fire Department and SAMU for its public pre-hospital care. In contrast to several other countries, Brazil does not follow the concept of “paramedics” but rather have trained nurse technicians and registered nurses occupying this role.
Although certain certifications such as the Pre-Hospital Trauma Life Support course are required in order to work in the pre-hospital setting, there are no formal curricula and there is a low degree of adhesion to continuous educational programs among SAMU medical professionals [27]. As for the role of emergency physicians in this setting, ABRAMEDE currently recommends at least one pre-hospital rotation for EM residents during each of the 3 years of residency, taking into consideration the fact that Brazil remains relying on the presence of physicians in ambulances (advanced units).
Despite progress, pre-hospital EMS are generally under resourced, understaffed, and poorly equipped [26]. These challenges may be the reflection of the late recognition of EM as a specialty. It is possible that with the growth of the specialty and the incorporation of prehospital medicine as a subspecialty of EM, the quality of this service gradually improves.
Emergency care units and emergency departments
There are essentially two types of acute care delivery facilities in Brazil: (1) emergency care units (in Portuguese, “Unidades de Pronto Atendimento” [UPAs]) and EDs. Both are available through the public and private systems, but most emergency care units are part of the SUS (public healthcare system).
In the public system, Brazil had 614 emergency care units (UPAs) spread across the national territory in 2018 [28]. They are classified in three different sizes, according to the population covered, the physical area, the number of available beds, and the capacity to care. These units are defined as facilities of intermediate complexity, between the primary care setting and hospital EDs. The UPA offers a 24/7 simple structure, with ultrasound, X-rays, electrocardiography, basic laboratory, and observation beds. Computerized tomography (CT) or more advanced imaging modalities are not available at these units. If more complex care is needed, patients are then transferred to referral hospitals.
The main purpose of these emergency care units is to provide accessible and rapid acute care in order to avoid the crowding of EDs at large referral hospitals. Although the system is geographically organized to build a comprehensive emergency care network [26], transfers are often difficult due to several issues such as lack of ambulances and lack of beds available at the referral hospital [29]. Importantly, in 2016, there was an estimate of 136 UPAs that were physically built but not properly functioning [29].
Besides resource constraints, one of the biggest challenges is that most UPAs are staffed by physicians who have never had any type of formal EM training. This is an opportunity for future tele-medicine initiatives where trained emergency physicians could support UPAs that are not adequately staffed or are at very distant locations from referral centers. Physicians often “moonlight” in these emergency care units to supplement their income while building their practices and working other jobs. Besides that, there is a high physician turnover and a predominance of recent medical graduates with limited experience [21].
As for EDs at large referral hospitals, there is a highly heterogeneous physician workforce. Some teaching hospitals where EM residency programs are held may have formally trained emergency physicians as part of the ED faculty; however, there is still a significant proportion of staff who have had other types of training such as Internal Medicine or General Surgery. Herpich and colleagues showed that the estimate proportion of faculty with prior EM residency or board certification in EM was less than 20% in 74% of surveyed EM residency programs [11]. The role of the emergency physician is not as clear as it is in other countries. In some EDs, the emergency physician is not responsible for seeing certain chief complaints. For example, patients with gynecological chief complaints may be seen directly by a gynecologist. Patients who come in with abdominal pain may be seen directly by a surgeon. Patients with orthopedic complaints may be seen directly by an orthopedic surgeon.
