The establishment of a hospital medicine program in Brazil and the attempt to develop the specialty nationwide is both fascinating and challenging. Brazil has about 7,155 hospitals, with 443,210 beds available (including 2,727 public hospitals with 148,966 beds and 4,428 private facilities with 294,244 beds). 1 (See Table 1, p. 44.)
Historical problems in the public health system—also found in private sectors—have motivated physicians to address and improve inefficient management, insufficient financial support, the high number of frequent unnecessary admissions and re-admissions, extended length of stays, limited access to beds and medical services of high complexity, and overcrowded emergency departments.
SUS—Principles and Problems
The Brazilian public health system, called Sistema Único de Saúde, or SUS, is based on universal care and health as a right of citizenship and a state responsibility. Its main principles are universality, integrality, equity, decentralization, and social control.2 Less than half of the Brazilian population uses the SUS system exclusively. They use private health systems as a complement. This situation reflects the difficulties in the Brazilian public health system. The reasons for this duplicity highlight the challenges of our situation.
At the same time, physicians face serious problems. Most are employed by both the public and private sectors. Average salaries in the public system (by far the largest employer) are extremely low. Medical doctors are forced to work many extra hours, including numerous night shifts, creating a major barrier to the growth of physicians dedicated to horizontal inpatient care.
The government, in an attempt to improve medical—and hospital—assistance in the country with “a new kind of health assistance focused on high quality and efficient services,” has created the following projects: Humaniza SUS and QualiSUS.3,4 Theoretical support, operational contours, extent, and applicability are still not clear, however. For many medical doctors, these are merely abstract ideas. QualiSUS has renovated emergency departments in Brazil, but service quality has not improved enough. In our opinion, there are no public policies capable of providing good hospital services and efficient management in Brazilian hospitals, and—even if they existed—we would need to stop corruption in order to meet public commitments.
In Rio Grande do Sul, the Brazilian state where we work as medical doctors, the inadequate SUS reimbursement points to a calamitous future. Here, most hospital care is provided by philanthropic hospitals, which are more vulnerable in financial terms.5 (See Table 2, p. 44.) Despite being in a pioneer state in terms of hospital administration schools, with more than 2,000 graduates in recent years, these philanthropic hospitals have an estimated reimbursement deficit of more than 80%, an unattainable amount even for the best administrator.
Could Hospitalists Be Part of a Solution?
On top of these growing deficits, we have witnessed the closing of more than 2,000 available beds in the last four years, as well as the loss of 10,000 hospital positions and the complete closing of eight hospitals. Aiming to ensure the survival of this hospital system, physicians, health professionals, and organizations involved with hospitals have joined forces to find a solution. Their logo is best translated as “More Health for the Hospitals,” and our group supports their goals.6
Looking at the situation from a different perspective, we see many opportunities for Brazilian hospitalists. Their potential contribution to the quality and safety of medical care is an obvious advantage for hospital management and patients. We predict that this scenario can be accomplished—even in our state. It is possible to make a profit in public as well as in lucrative private institutions. In public institutions, a profit can be made as long as hospital administrators use adequate policy. We believe that in private institutions, though not in philanthropic ones, the key point is hospital administration cooperation and goodwill. Elucidation of hospitalists’ capabilities will open the necessary doors. We are ready to reduce the hospitalization fee and length of stay—among other costs. In this way, we can work with the administrator to develop tools for systems and quality improvements.
Hospital Medicine’s Emergence in Brazil
The implementation of hospital medicine, especially those aspects that involve more than just having a general medicine physician dealing with inpatient care, is brand new in Brazil. So far, the U.S. hospitalist model of care is unfamiliar to most Brazilian medical doctors and healthcare managers. Some institutions have hired hospitalists to be part of rapid response teams, neglecting the more specialized dimension of this new model of care; they are not aware of this title’s real meaning. There is a long way to go until the hospitalist is seen as a specialist, and we hope all our efforts will earn this new specialty official recognition in Brazil.
Our group is based in the Brazilian state of Rio Grande do Sul, mainly in Porto Alegre, its capital. Most of our time is dedicated to inpatient care, and we started our movement after studying the model of care delineated by Wachter and Lee.7-9 In 2005, we formed a local association called GEAMH (Grupo de Estudos e Atualização em Medicina Hospitalar) to promote the understanding and diffusion of hospitalist principles, integrated by the professors and former and current residents of a large local internal medicine residence program from the Internal Medicine Department of Nossa Senhora da Conceição Hospital (HNSC).
We have created a Web site (www.medicinahospitalar.com.br) where you can find history, news, and information about hospital medicine fellowships in the United States, as well as online hospital medicine continuing education. As you can see, we are spreading SHM’s ideas.
The third year of the HNSC Internal Medicine Residence Program (R3) focused on hospital medicine was developed in 2005. We believe this to be the first initiative of its kind in Brazil. HNSC is part of Conceição Hospital Group, which is composed of four hospital units and is one of the biggest public hospital networks in Brazil.
The Internal Medicine Residence Program started at HNSC in 1968. The department itself has more than 100 hospital beds. Medical residents’ activities all take place in the hospital, and there are nine professors: Eduardo Fernandes, Guilherme Barcellos, Janete Brauner, José Luiz F. Soares, Nelson Roessler, Paulo Almeida, Paulo Ricardo Cardoso, Sergio Dedavid, and Sergio Prezzi. We would like to make special mention of our colleagues Eduardo Fernandes, current head of HNSC Internal Medicine Medical Residence Program, and Sergio Prezzi, the R3 coordinator.
The HNSC Internal Medicine Service is well known for graduating internists skilled in hospital practices, mainly because the program is run by professors who specialize in that area. The R3 is a one-year training program. Our goal is to train physicians to provide outstanding and comprehensive inpatient care. Through supervised training, our residents are able to treat common hospital illnesses; we are also training them in consultative medicine and in the clinical management of surgical patients. Other areas of medical residents’ education include medical ethics, end-of-life care, inpatient nutritional support, risk management, rational use of drugs, and technology and evidence-based medicine.
Our third-year residents have the opportunity to try bone marrow biopsy, pleural biopsy, and thorax draining—all of which are usually handled by other medical specialists. In general, residents also have many opportunities to learn about and practice endotracheal intubations, ventilator management, central vein access, and many other procedures.
Based on HNSC experience, a formal stage in hospital medicine under the supervision of Luciano Bauer Grohs, MD, one of the founders of GEAMH, has also been integrated into internal medicine training at Nossa Senhora de Pompéia Hospital in the city of Caxias do Sul, located 125 kilometers from Porto Alegre.
Our group has developed medical education in the inpatient setting. Because there is no hospital medicine society in Brazil, we have tried to coordinate with the Brazilian Society of Internal Medicine, encouraging discussions about hospital care and promoting workshops about mechanical ventilation, central vein access, and early goal-directed therapy for sepsis. More recently, we have chosen to work independently, believing that hospital medicine is distinct from internal medicine.
When we organized the Brazilian Annual Congress of Medical Residents in 2006, we had the opportunity to bring together medical residents and professors from different medical areas. The Congress’ main focuses were rational use of drugs and technology and the relationship between the young physician and the pharmaceutical industry. The participation of Robert Goodman (of No Free Lunch fame) was an important part of the convention.10
Slow and Steady Growth
We understand that there is a long journey ahead, beyond educational and medical assistance. Our group is still far from promoting research. But hospital medicine specialization has launched in Brazil. Dr. Watcher has said to us, “In the United States, the hospitalist field is the fastest growing specialty in the country—and probably in the history of the country. Hospitalists are transforming the delivery of American hospital care and improving quality, patient safety, education, end-of-life care, and more. We are thrilled to partner with our Brazilian colleagues as, together, we try to improve the quality of care for hospitalized patients everywhere.” We are confident that his vision will become a reality in Brazil in the near future. TH
Note: We are in debt to the professors at the Hospital Conceição Internal Medicine Residency Program, without whom our initiatives would never have blossomed. Special thanks to Eduardo Fernandes, Sergio Prezzi, and Paulo Ricardo Cardoso.
Dr. Barcellos is a specialist in internal medicine, emergency medicine, and critical care. He is professor in Nossa Senhora da Conceição Hospital’s Hospital Medicine Residence Program and president of GEAMH, a local association designed to promote the understanding and diffusion of hospitalist principles.
Dr. Wajner is a specialist in internal medicine and emergency medicine and a Master of Science student at Universidade Federal do Rio Grande do Sul.
Dr. de Waldemar is a specialist in internal medicine and emergency medicine.
- Departamento de População e Indicadores Sociais. Estatísticas da saúde: assistência médico-sanitária 2005/IBGE. Departamento de População e Indicadores Sociais. 2006. Available at: www.ibge.gov.br/home/estatistica/populacao/condicaodevida/ams/2005/ams2005.pdf. Last accessed January 28, 2007.
- Agência Nacional de Vigilância Sanitária. Lei nº 8080. D.O.U. - Diário Oficial da União; Poder Executivo. September 20, 1990. Available at: http://e-legis.bvs.br/leisref/public/showAct.php?id=16619&word=. Last accessed January 28, 2007.
- Brazilian Ministry of Health Web site. Available at: http://portal.saude.gov.br/saude. Last accessed January 28, 2007.
- Deslandes SF. Análise do discurso oficial sobre a humanização da assistência hospitalar. Ciência e saúde coletiva. 2004;9:7-14. Available at: www.scielo.br/pdf/csc/v9n1/19819.pdf. Last ccessed January 28, 2007.
- Portela MC, Lima SML, Barbosa PR, et al. Caracterização assistencial de hospitais filantrópicos no Brasil. Rev Saúde Pública. 2004;38:811-818. Available at: www.scielo.br/pdf/rsp/v38n6/09.pdf. Last accessed January 28, 2007.
- Sindicato Médico do Rio Grande do Sul Web site. Available at: www.simers.org.br/entquerem.php. Last accessed January 28, 2007.
- Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996 Aug 15;335(7):514-517.
- Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002 Feb 16;287:487–494. Review.
- Wachter RM. An introduction to the hospitalist model. Ann Intern Med. 1999 Feb 16;130(4 Pt 2):338–342.
- No Free Lunch Web site. Available at: www.nofreelunch.org. Last accessed January 28, 2007.