Global EM How the COVID-19 Pandemic Highlighted the Need for More EM Specialists in Brazil

How the COVID-19 Pandemic Highlighted the Need for More EM Specialists in Brazil

By Marcos Campos, MD; Lucas da Matta, MD; and Anjni Joiner, DO, MPH on behalf of the SAEM Global Emergency Medicine Academy A Personal Story

During my first year as an internal medicine resident working in the emergency department in Brazil, I experienced firsthand the emotional and physical toll that the COVID-19 pandemic brought to health care providers. The combination of fear and doubt in caring for patients with respiratory failure coupled with hospital capacity issues, staffing, and resource shortages, and the all-too-frequent deaths followed by the inevitable difficult family conversations, gave me an appreciation for some of the intricacies and challenges involved with emergency medicine. I've witnessed other colleagues working in these settings develop anxiety, depression, and substance use disorders while living through the chaos of providing critical care in the Brazilian health system during the pandemic. The Brazilian public health system, the largest in the world, had its breaking points tested over the last few years. With emergency medicine still in its infancy in Brazil, there are few emergency medicine specialties and specialties such as internal medicine has been forced to fill this gap and become part of the front lines of the pandemic.

The Brazilian Health System and Emergency Medicine as a Specialty

Sistema Único de Saúde (SUS), or the Unified Health System, is the Brazilian government-run health care system. As the largest public health care system in the world, coverage is available to the entire population of Brazil, over 220 million people. SUS provides multiple services, from community-based primary care, to heart transplants, as well as epidemiological surveillance programs and professional training. The system aims to improve the health of

citizens, particularly those with vulnerable backgrounds, but the sheer size and scale of the health care system leads to inherent challenges, particularly with respect to emergency care provision.

The first emergency medicine residency in Brazil was only created in 1996. It was a full 18 years later that the second one was opened. In fact, emergency medicine was only recognized as a medical specialty in Brazil in 2015. Despite a demonstrated need for dedicated emergency medicine physicians, there are still only 11 emergency medicine training centers in a country of over 200 million, highlighting the slow acceptance of this field amongst the greater medical community.

The slow growth of emergency medicine specialists does not reflect the pace of new doctors in the country. In fact, over the last 50 years, the rate of growth of Brazilian doctors has increased almost four times that of the general Brazilian population. New graduates of medical schools are projected to reach 16 per 100,000 inhabitants in the near future, increasing the overall ratio of physicians above the 3.5 physicians per thousand inhabitants of Organization for Economic Co-operation and Development (OECD) countries.

These newly graduated physicians are often placed unsupervised in emergency settings, including emergency departments, where approximately 25% of all doctors are new graduates. These physicians have typically not completed residency training in any area, as residency training is not required to work in primary care or emergency departments. They are also most often the physicians that staff ambulances in the physician-led national ambulance service (Serviço de Atendimento Móvel de Urgência - SAMU).

Despite this influx of new doctors, due to the low proportion of emergency medicine physicians, residents from different specialties across the country, including my internal medicine, were floated over to cover ICU and COVIDdedicated emergency rooms during the pandemic. This change has not only impaired residency training for their specific specialties, but the combination of new graduates and nonemergency medicine residents with little to no oversight greatly impacts the quality of care.

“Organized, direct investments in emergency centers and emergency medicine training programs can help to address the growing gap in emergency care in Brazil.”

A Way Forward

Lack of emergency medicine specialists notwithstanding, emergency departments are ubiquitous throughout Brazil, but remain staffed by nonemergency medicine physicians. Spurred by the pandemic, which highlighted the obvious need for increased emergency medicine specialty training, Brazilian doctors have developed a renewed interest in emergency medicine as a specialty. Recently, many students and doctors have personally invested in extracurricular courses focused on emergency care, including training and optimization of care for patients with COVID-19 in emergency settings. Structured emergency training for nonemergency medicine residents and medical students is a viable shortterm solution. However, in the long term, we need to increase the number of quality emergency medicine residencies and continue to encourage new graduates to enter the field. Organized, direct investments in emergency centers and emergency medicine training programs can help to address the growing gap in emergency care in Brazil.

ABOUT THE AUTHORS

Dr. Campos is a second-year internal medicine resident at State University of São Paulo, Botucatu City, Brazil. He is also a contributor to the Global Emergency Medicine Innovation & Implementation (GEMINI) Research Center from Duke University, NC. Dr. da Matta is a first-year emergency medicine resident at Duke University Medical Center, NC. He earned his MD from the Federal University of Minas Gerais, Brazil.

Dr. Joiner is an assistant professor of emergency medicine at Duke University Medical Center in Durham, NC. She has an interest in improving access to emergency care in low-resource settings.

About GEMA

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