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Revista da Associação Médica Brasileira

Print version ISSN 0104-4230

Rev. Assoc. Med. Bras. vol.59 no.5 São Paulo Sept./Oct. 2013 



Foreign physicians: the language issue



I am not against foreign physicians working in Brazil. Nor could I be. My choice of a profession in medicine is due to a successful story of this kind. On October 9, 1953, my father obtained the revalidation of his diploma at the Faculdade Fluminense de Medicina, in Rio de Janeiro. Born in Italy, he graduated from the School of Medicine of Florence in 1952. A trip to Brazil in the same year changed his destiny and enabled him, with the help of his Brazilian girlfriend, to study Portuguese, Brazilian geography and history, and the disciplines of the fourth, fifth, and sixth years of the Brazilian School of Medicine in order to pass the board examinations. These facts are registered in his diploma, which I kept, and that is what he told us regarding the difficulties with the distinctive and peculiar Portuguese language.

It is still that way. Physicians graduated abroad who wish to work in Brazil must revalidate their diplomas and go through a similar process, equally difficult and somewhat awkward. The many Brazilian doctors who went to work in the United States had similar experiences, and had to undergo English proficiency tests, organized and managed by the Educational Commission for Foreign Medical Graduates (ECFMG - The spoken English proficiency component of the USMLE Step 2 Clinical Skills examination assesses the ability of the candidate to interview and understand the patient.

In 2011, 66.4% of those enrolled in the examination did not declare English as their native language. Nevertheless, the failure rate was 23%, much lower than in the equivalent Brazilian examination for foreign physicians, the REVALIDA, which had a 90% rate of failures in the same year. It should be investigated whether the ECFMG test is easier than the REVALIDA, or if there is an important difference in the level of knowledge of candidates who apply.

Before clarifying these differences, the Brazilian Ministry of Health launched the "More Physicians for Brazil" program (, which is clearly a "shortcut" to the practice of medicine in the country. Aiming to bring more physicians to remote locations, which have lower rates of physicians per capita, the program gives preference to Brazilian professionals, but states that unfilled openings will be assigned to foreign doctors, whom they have called "foreign exchange doctors". Regarding the Portuguese language, the program's website states that "language proficiency will be required in two stages: through a statement by the physician interested in the job during his/her application to the program, stating that he/she has minimal knowledge of the Portuguese language, and after passing the welcoming course."

The first step is a personal statement, with no need of proof, that the doctor reads and/or speaks Portuguese. The second stage, or welcoming course, will be held in various Brazilian cities, with a duration of three weeks (120 hours), divided by program content, according to the website. It will encompass the legislation of the Brazilian Unified Health System (Sistema Único de Saúde - SUS); its operational characteristics and attributions, especially primary healthcare; and the Portuguese language. Will that be enough? Is there any previous experience or any documentation justifying the choice of such a short period of three weeks?

I dare to compare this proposal to that experienced by my father, coming from a Latin country and from one of the best medical schools in Italy. Many months of preparation and study were necessary for him to pass the test.

The program "More Physicians for Brazil" suggests in its website that, in order to guarantee the success of this bypass in the approval of physicians to work in the country, the category of medical supervisors and academic tutors was created. These professionals will be selected by Brazilian health education institutions to supervise, continuously and permanently, the participant physicians. Such supervision, both necessary and arduous, will require time and displacement. Who will play the role of supervisors and tutors in institutions to which they are connected? Can students, researchers, and patients from teaching hospitals relinquish their role, already burdened by the various functions they perform in their institutions?

How important is the question of language in healthcare? Did someone ever need to have a deep insight into the literature of the famous Brazilian author (and physician) Guimarães Rosa to request a blood test or to interpret a chest radiograph? Of course not! But a physician graduated from the most remote medical school in the world provides care following the same steps. It all starts with a history consisting of "main complaint and its duration." After that, the "history of present illness", full of personal interpretations, accompanied by sensations, emotions, exaggerations, and unjustified underestimations of symptoms, all tempered by the patients' emotional status and cultural baggage. And moreover, the consultation is influenced by the emotional status and probably by the different cultural background of the listener, the physician.

There are other scientific studies indicating that the language barrier is associated with receiving 50% less analgesics after fractures in long bones,1with lower adherence to treatment (doing what the physician advised), with three times the number of missed follow-up appointments for patients with asthma,1 with a lower level of patient satisfaction, and with lower rates of explanation regarding possible side effects of medications.2

I recall a young doctor from the state of Minas Gerais, a diehard fan of Guimarães Rosa, who collected different Brazilian expressions to refer to the symptoms of chest pain accompanying myocardial infarction. Some were almost totally incomprehensible and would confound the most attentive doctor. In short, despite the more resources and technological exams that modern medicine has at its disposal, it all starts with a complaint and a history, and both must be well documented and understood. It remains so, and probably will remain as such for the foreseeable future.

That is another point in which the program "More Physicians for Brazil" has chosen the wrong tool to solve the serious problems of public healthcare: medical treatment should be based on experience and scientific evidence. Nothing justifies applying a treatment without scientific proof of its effectiveness. The authorization for physicians to practice medicine without adequate training and without sufficient cultural and linguistic acclimatization is not based on empirical experience or scientific evidence. It is a conjecture. And conjectures do not treat patients.


Bruno Caramelli
Discipline of Cardiology, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brasil

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