The tragedy of medical education in Brazil

EDITORIAL

The tragedy of medical education in Brazil

Paulo Kassab^I,*; Laércio Gomes Lourenço^II; Elias Jirjoss Ilias^I; Carlos Alberto Malheiros^I

^ISurgery Department, Faculdade de Ciências Médicas of Santa Casa de São Paulo, São Paulo, SP, Brazil

^IIDepartment of Surgery of the Stomach and Duodenum, Escola Paulista de Medicina (UNIFESP), São Paulo, SP, Brazil

In Brazil, the education of a Professor of Medicine follows a model that predicts some academic steps. After completing the residency, physicians who want to teach usually start a graduate course. For some years they obtain credits through courses, lectures, and other activities, culminating first in the master's degree thesis and, after a few more years, in the doctoral thesis. During that journey, they need a mentor, who must have at least a Ph.D. The adviser will add to his/ her resume with each advisory activity. Overall, the graduate course is designed to train educators and researchers.

When evaluating universities, one of the quality criteria is the number of Masters and Ph.Ds. among the professors. In addition to the institutional assessment, each professor is evaluated regarding his/her scientific production, according to the old aphorism: “publish or perish”. To become an adviser, you must publish. The production, in general, must be published in high-impact journals, which are rare in Brazil. Getting an article published in such journals is a difficult task. Clinical studies are infrequently accepted, as experimental studies (those involving molecular biology or large prospective series) are preferred. Thus, professors started to request that the supporting agencies provide funding for the construction and purchase of laboratory equipment, reagents, and animals that must be cared for in extremely clean and high-maintenance environments. The objective of all this: improve the curriculum. That gives rise to a “disease” plaguing the Brazilian university: the “curriculitis” which, incidentally, is not restricted to the medical field, but to the entire scientific area.

While this occurs in the clinical arena, the large university hospitals survive with great difficulty. Not rarely, basic supplies such as drugs, gloves, and even sheets are not available. The salaries of physicians and professors are very low, and even though they spend hundreds of hours a month in the hospital corridors teaching students and residents, their efforts will be worthless, as a publication involving a few rats in a laboratory will have much more value when they are evaluated. Nobody wants to treat patients anymore. It is not worth it. Those who dedicate themselves to the activity of caring for patients are often kept away from scientific activities. They are classified as unproductive and incapacitated; however, they will be the first ones to treat researchers and their family members when they become sick.

This aberration has led more and more professors to follow one of two paths: the first is to abandon the academic career to devote themselves exclusively to private medicine; and the second is that, among those who remain, few are interested in teaching, preferring to stay in their laboratories, which will provide data for publications. As a result, students and residents are often left without guidance or teaching, or are taught by residents who, in turn, have learned from a graduate student or have no one to teach them. The recently-graduated physician in Brazil can apply to work as a family physician without any further qualification and with a salary ten times higher than that of a highly-qualified professor in a state or federal university.

It is necessary to understand that excellent professors may not be top researchers and that the opposite also occurs, i.e., great researchers may not know how to teach. This situation leads to the increasing shortage of professors and, in addition, to the proliferation of medical schools aiming solely at commercial gain. Most of them do not have their own hospitals and have no medical residency programs. Flexner's valuable teachings are completely forgotten. Where will the professors to teach in these schools come from?

Another major problem is the funding of researches by private companies. Undoubtedly that can happen, but resolution of the conflict of interest is difficult, especially in some areas of medicine. Then, another problem appears: patients are seen as opportunities, rather than individuals, and are sometimes fought over, not because someone was interested in their health, but because there is a researcher eager to achieve a number of cases in a particular research project. This goes along with the growing interest of private hospitals in becoming centers of education, which is certainly useful, but leads to the question of whether they should do it inside or outside the university environment. Is the interest in teaching and research genuine, or is it just a way to label the institution with the title?

In the surgical area, for instance, it is very common to see the term "laboratory surgeon", ""library surgeon", or "mouse surgeon", referring to those who, for having high scientific production, stay in the laboratories and ignore practical activity. The aim of the graduate courses is then lost: they create researchers only, not educators.

Some measures could be taken to correct these distortions: first, we must promote the equivalence between practical activities and publications when evaluating a curriculum. One option would be as follows: six months of practical activity with students or residents in a medical ward, walk-in clinic, or surgical center, properly verified and controlled, would be equivalent to a national publication; a year of these same activities would have the same weight as an international publication. As the years went by, one could increase the value of the activity. Thus, after one year of practical activity, there would be equivalence to a publication in a QUALIS B2 journal; after two years, a QUALIS B1; after 3 years, a QUALIS A2; and after four years, a QUALIS A1. These suggestions need to be evaluated more thoroughly by the academic community, but this method would provide an option for faculty members who wish to have more teaching activities than research, with encouragement to continue their careers.

These professors should also be required to have a minimum participation in research, but a minimum participation in practical activities should also be required from those who stay only in their laboratories.

It is necessary to create incentives for the teaching profession by improving teaching conditions, with adequate university infrastructure. This means free and easy access to the international literature; well-structured research labs available in all universities; appropriate academic structure that includes available librarians and libraries; sufficient statisticians for the planning of studies in each department or discipline; and financial resources that are exclusively dedicated to funding publications and grants for the purchase of programs for data storage and computers.

This should also include the aspect of remuneration, i.e., paying salaries that allow the teacher to have adequate professional compensation.

Another innovative measure for companies wishing to fund research in Brazil would be the requirement to invest some capital in university entities; thus, a company that wanted to fund a project in a non-university entity would have to invest an equal amount or a percentage thereof in educational institutions.

Finally, it is necessary to more effectively control the creation of medical schools, but also to maintain strict assessments of those that already exist. This control should be carried out by the government, with the mandatory participation of medical entities that have contributed so much to the Brazilian scientific area.

Publication Dates

• Publication in this collection
  09 Sept 2013
• Date of issue
  Aug 2013