Tuesday, December 3, 2013

Surgical training in Brazil

Here is an email I received from a reader in Brazil describing the way surgeons are trained there. You may notice some remarkable similarities and a few differences. My comments are in italics.

After finishing high school, usually at 17 years of age, to enter med school one must pass the tests. At public universities, the tuition is entirely funded by the state. These are the most difficult ones to enter, so the students are generally better. Then there are the private universities, and they are expensive.

Med school is organized into two years of basics, two years of clinics and two years of internship (internal medicine, family medicine, surgery, ob-gyn and pediatrics). Notice—no college. I also have a feeling that students aren't studying that much nowadays, but it's also impossible to fail. Sounds quite familiar. See "Medical school grading and T-ball: Everyone gets a trophy."

As med school goes on and they meet with the awful parts of medicine, they tend to focus on quality of life and moneymaking. Therefore, the most difficult specialties to enter are dermatology, radiology, anesthesia. Also sounds familiar. Although some exams are unified, each hospital establishes its own residency exam and interview. Very different from the US.

General surgery is a two year residency. Different. In the past, general surgery was more general, but each subspecialty grabbed its cases and now what is mostly done are cholecystectomy, appendectomy and hernia. Similar in some ways to the US model. So there is another exam to enter the subspecialty residency: urology, plastic surgery (again, due to quality of life issues, no inpatients, income, status, the most popular Similar), coloproctology, vascular, thoracic surgery, surgical oncology, head and neck surgery. Orthopedics, neurosurgery, ENT don't need general surgery.

I finished general surgery last year, and this year I've been operating by myself. I've done cholecystectomy, appendectomy, hernioplasty, Hartmann procedure, skin lesions, abscesses, etc. Of course, at the beginning, I was not completely confident (which is good in some ways), but I have had nice results.

I can relate with a lot you posted, your blog makes me remember residency and my teachers.

I'm out of time now, in the future I'll catch on some other things. I hope my English isn't too bad, but reading the comments I've seen that even USA citizens have trouble typing. :D

Of course, this is just one doctor's perspective, but it's thought-provoking.

What do you think about the Brazilian system of training surgeons?


Anonymous said...

"What do you think about the Brazilian system of training surgeons?"

Actually our nice and leftist government has found a brilliant way of improving Medicine all over the country: they IMPORT physicians from Cuba without any certification and send Fidel Castro a good amount of money for his kind act of humanity. BTW, Medicine in Brazil is dying. There's nothing more left to discuss after this disaster.

Skeptical Scalpel said...

Anon, I had heard about the importation of doctors from Cuba. Do you have any specific examples of problems with them?

Anonymous said...

I'm not a doctor but I grew up in the family of doctors and currently work in health-care environment.
This description is very very close to the medical training in Russia (where I was born and stay connected after moving out), like no colleges, duration, different exams in hospitals. And certainly they're twin sisters with Cuban med education mentioned by in another comment here.

pamchenko said...

to the original author, could u break down specifically your responsibilities in your 2 year surgical residency to could give you the skill set to perform the tasks of a general surgeon?
my intern year was spent doing paper work, repleting electrolytes, writing the labs in a book for my chief resident. nonetheless, I learned a lot about perioperative care. I started to learn about how complications were managed. I started to learn how to sew and tie knots. My operative experience was minimal.
Half of my second year was spent in the ICU. I learned to predict who could die from surgery. I learned how to identify sick patients. I performed a ton of central lines/arterial lines. I even learned how to float the now outdated Swan Ganz catheter. I spent a good portion of the year also seeing surgical consults. As painful as this was, this was a huge opportunity to learn about how surgical disease presents itself and this was the beginning of "how to think like a surgeon."
If you are performing appendectomies, cholecystectomies, and Hartmann's after 2 years, good for you. Was your residency training less service based? It must have been devoid of a lot of the busy work. Though I'm bitter about how much of a service I provided to the hospital (paperwork, central line slave...etc.), I feel that after 5 years I was a capable general surgeon. To me that means that I can manage trauma, operate in trauma when need be, handle disease of the breast, abdomen...etc. Benign/malignant..etc. Understand their presentation, prognosis, management, complications, alternatives to treatment.
I agree you could train someone to take out a gallbladder, appendix, colon in 2 years. But a surgeon is so much more. Its the decision making that really makes a general surgeon here in the US. Can you train someone to do what I do in 2 years even without the bullsh*t? I dunno, sometimes you just need to see a lot of stuff over time to learn things.
I'm obviously tremendously biased since I'm a product of the US system. However, what I notice is that a lot of people come from overseas to participate in our training programs and are willing to gamble crazy prelim years with no guarantee. I don't see many of our top US medical school graduates leave for foreign residency training. While our US surgical training model is clearly flawed and controversial with work hour limitations...I'm proud of it.

regarding your lack of "college"....there are accelerated programs here in the US that cut down to 6-7 years instead of the 8 years. using the CUNY sophie davis program as a prime example, you get highly qualified 17-18 year old kids. But at that age, its hard to predict who will have the maturity and mettle to finish to become a doctor, much less a surgeon. The attrition rate is very high. I wonder what the attrition rates are in your country?

Anonymous said...

I grew up and did all my college and medical training there before moving here to the U.S. Being the 51st state and all, medical school and residency in Canada were very similar to American ones. In fact, the schools are treated as equivalent by U.S. licensing authorities.

However, a college degree is not required for entry. In my cohort (20 years ago), only half had their bachelor's.

I didn't noticed any difference - except for age - between the non-degreed and the baccalaureates.

Anonymous said...

Sheeesh...I meant "I grew up in Canada and did all my college...."

Skeptical Scalpel said...

Thanks for all the comments. It does seem similar to Russia's system.

I wrote about shortening medical education by requiring fewer years of undergraduate college last month. (http://www.physiciansweekly.com/shorten-medical-school-3-years/) I'm not sure that the attrition rate of those in accelerated programs is any worse than that of traditional students.

I think it's worth a try.

Pamchenko, your residency sounds awful. I bet it was a university program. As I have written before, you get to operate much earlier and more often in community hospital programs.

Skeptical Scalpel said...

Anon, we knew what you meant.

Skeptical Scalpel said...

These are comments from the Brazilian author of the email to me. He was having trouble getting them posted.

I remember WHO setting as ideal one doctor for each 1,000 citizens. Here in Brasil, also was cited England's proportion as 2.5/1,000. We do have enough doctors (I don't recall the exact proportion), unfortunately they are very poorly distributed. There are big extensions of land with few habitants where no one wants to go. Some of these places have very bad statistics, resembling Africa's, no sewage, difficult access to vaccines, etc. But instead of implementing measures to bring our doctors to those who need, the government imported physicians.

If anyone wants to practice medicine in US, they have to do some sort of validation of theirs MD. So is in Brasil, but these imported doctor get to skip the validation - very controversial.

Nevertheless, Brasil's public health system, by law, should provide care for everybody in all the complexities needed. It's not accomplished it. And it's focused in primary/basic care. Since Cuba's health system is also based on primary care, I actually expect these cuban (most imported doctors are cubans or brazilians who graduted in cuba - usually getting their MD thru any left party (there are several, unlike US) to be nice primary care physicians.

Opposed to that, often brazilian med school are linked to some hospital. I did get to see a lot of rare cases, but I wonder if the students shouldn't spend more time learning to manage HTN and diabetes, to diagnose and treat without much resources, and other things that have a greater impact than seeing one case of Tolosa-Hunt Syndrome.

Another issue: the program that imports physicians pays Cuba more than 4,000 USD/month. But cuban doctors receive only 50 USD/month. That is a very interesting question, isn't it?

pamchenko: I never said I was a complete surgeon. Indeed, a lot of procedures belong to the surgical subspecialties. Breast surgery - an extra year of mastology, available to general surgeons and obgyn, generally an ob-gyn wants it. I have very little experience in thoracic surgery, and none in cardiac. As I said, general residence isn't very general nowadays. I agree that decision making certainly is the most important thing to learn. Is 2 years enough? Probably not. One colleague once asked, how long does it take to form a surgeon? A: a lifetime. That's another reason everyone is rushing to subspecialties - I can't imagine how, after 2 years of mainly abdominal experience, anyone would start performing e.g. carotid endarterectomy. We certainly do have very "hands-on" residencies, a lot is learned in practice, and patients do experience some consequences.
It was said here before, surgery is not like airplanes and simulators. To learn how to operate, one has to operate.

I guess attrition rate is low. At the end, a lot of med students are disillusioned, but it's still and solid career with good earnings. The results: a lot of frustration. I saw in a post in Medscape that in US some physicians aren't very happy and do feel burnout too...

Anonymous said...

I'm Brazilian too. Regarding SS's question about problems with the Cuban doctors, I've become aware of language problems--some of the new doctors know very little Portuguese--and some very wrong prescriptions--things like QD cephalexin, 90 IU insulin doses, veterinay drugs (!), &c.

As you might expect, local medical associations are incensed and some medical boards have attempted to deny the Cubans registration because they've bypassed the normal diploma validation channels. However, fighting the federal government on this turf is pretty much mission impossible in Brazil because the judiciary is so painfully slow and statutes explicitly favor the government in court cases.

My pet theory is that the current left-wing government wants to be seen as supporting the poor in the backlands, unlike the moneyed elites who never cared a fig for them, and that complaints against the program help promote this stereotype. My impression is that the Cuba-bashing from the right (Cuba's one of the Latin American right's traditional bête noires) is particularly effective at reinforcing negative perceptions about the well-to-do.

Politically, it seems to be working. Opinion polls show high approval rates for the program and it seems to be propping up the incumbent president's reelection prospects, who seems likely to grab a second term next year.

Skeptical Scalpel said...

Anon, thank you for the insight into this interesting situation. Luckily here in the US, politics and medicine don't mix. :-)

Ganesh Puttu said...

I am from india and here after high school (at 16+ years) we get to join med school....the basic graduation degree- bachelors- took me 5 years (including a year of internship - 2years basics like ant/biochem/path/physio/micro and 2 years of clinical subjects) ...i also did an elective training residency in derma for an year before i decided on surgery for a career- my masters in gen surg training was for 3 years with a masters thesis (original research) as part of the curriculum...followed by a 3 year fellowship in plastic surgery.....so that makes a total of 12 years of education/training before i started practicing...who says med education is easy?

Skeptical Scalpel said...

Ganesh, thanks for commenting. The amount of time it took you to become a plastic surgeon after high school, 12 years, is not that different than a traditional path here in the US--4 years of college, 4 years of med school, 3 years of general surgery and 2 years of plastic surgery. That's 13 years.

João Vitor said...

Please, don't over simplify the cuban situation here in Brazil.

I'm a 2nd year med student in one of those public med schools the doctor in the email talked about, and here I can see first hand the corporatism and straight up narcissism of the "medical class" in my country.

Let me summarize to you guys what's basically happening. As you may know, Brazil is a poor country - not Ethiopia poor, but still poor. We have a very bad distribution of doctors. São Paulo State, the most developed state here (and where I live) has a gigantic concentration of physicians, other states lack even the most basic forms of care.

In a kind of populist action, the federal government - I can't stop laughing of that dude calling our government "far left" - created a program called "Mais Médicos", which translates to "More Doctors". We opened our doors to doctors of all over the world, who would get to practice medicine FOR A LIMITED AMOUNT OF TIME without revalidating their diploma.

The Brazilian doctors guild went berserk right there. They started trowing tantrums about the supposed bad education these doctors received - as if our medical education was any good to begin with.

They totally ignore the fact that people are dieing right now because there isn't doctors in the poor places. In situations like this, half doctor is for sure better than none.

Then, the worst happened. The government made a deal with Cuba. Now, say what you will about the Cuban government, but the know how to train doctors to act in bad situations and - turns out - we're in a bad situation.

Make no mistake, this outrage the doctors here are showing is purely driven by the union. They really couldn't care less about the patients, they just want the foreigners to go away.

Skeptical Scalpel said...

Joao, thanks for your insights into what seems like quite a mess regarding the medical care situation in Brazil.

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