On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.81 no.6 Rio de Janeiro Nov./Dec. 2006
Reflections on present-day dermatology in Brazil
Dermatology, following the general progress of Medicine in the last decades, has had great qualitative and quantitative growth . The knowledge of pathogenic mechanisms of dermatoses has been added to and new therapies have been included which have benefited an ever greater number of dermatosis patients.
Dermatology has not only grown but changed from a purely clinical specialty into a medical-surgical specialty. In addition, a new area of work - Cosmetic Dermatology - has sprouted from within it. It has quickly grown and attracted keen interest from society and the media in the light of current cultural standards that attach great value to youth and physical appearance.
The expansion of the specialty, as with any growth, has brought along with it several positive factors and, in tandem with those, some pre-existing problems have been magnified and new problems have arisen.
Let us initially analyze the consequences of such a growth to professional practice. With the enlargement of the dermatologist's field of action, a growing number of young physicians have been attracted to the specialty, a world-wide phenomenon clearly seen among us. As the number of positions in services able to train true specialists is relatively limited, the result is a significant group of doctors who intend to become dermatologists but who are left out of those services. Such a growing demand led to the appearance of specialization and certificate courses in Dermatology without the necessary conditions to train real specialists. Such makeshift courses end up being the only solution for this group of professionals, thus resulting in the presence, in the labor market, of professionals lacking the mandatory training who compete with the duly trained professionals. This leads to an undervaluing of the dermatologist's working conditions. It is up to our professional representative organizations - which have actually been doing exactly that - to make the competent authorities aware of the consequences of the problem and to remind society that it is being served by professionals without the necessary qualifications.
On the other hand, to increase the number of positions available in accredited services requires conditions which are not always possible, for most institutions struggle with economic difficulties to maintain their level of quality and, besides, the undue increase of positions would harm our trainees' professional education. The overcrowding of the labor market for dermatologists is already noticeable from within the perpetual and habitual distortions in the distribution of physicians throughout Brazil. In large urban areas it may be already seen that health insurance companies no longer accredit new dermatologists, who are left with the option of working for accredited colleagues or even colleagues who lend a business-like character to their professional activity. Not always can such conditions be said to conform to desirable ethical standards of professional relationships among colleagues.
The problem is extremely complex, but studies are necessary aiming at producing a fit between the number of specialists and the market's real needs, for the number of colleagues who receive their title of Specialists after passing the examination conducted by our Society grows by the day and the market insertion of newly certified professionals is increasingly more difficult.
Problems with the labor market for physicians in Brazil are great. The costs of Medicine, considering technological advances, have multiplied in recent years and even in developed countries to pay for health care is problematic. Such a fact is indeed made worse in a developing country such as ours. The remuneration offered by SUS (the Brazilian Unified Health System) is absolutely insufficient. Private health insurance becomes increasingly more important to the people it covers and, mandatorily, it must be managed like any business which is feasible only when profitable. Part of the profit, obviously, comes from the low and unfair payments made to the doctors. Such a situation drives physicians to seek alternative solutions to improve their livelihood, for today, according to existing studies, most physicians have public and private jobs, in general badly paid, or see in their offices patients referred by health insurance companies also at entirely inadequate fees. In order to make enough to live with they are thus forced to see a large number of patients and quality is harmed in the process. Private offices are becoming less and less feasible and they are almost inaccessible to our young colleagues.
In this context, within the domain of Dermatology, Cosmetic Dermatology has acquired much importance, for current cultural practices and the media have given great value to this field of action. This activity is not covered by health insurance plans, thus allowing the physician to draw better pay. This fact explains the powerful attraction this branch of dermatology has exercised over the young dermatologist, together with dermatological surgery, also a generator of better income.
Indeed, Cosmetic Dermatology is one more tool for dermatologists in their professional endeavors and its teaching must be encouraged. However, this must be done within the limitations of what it stands for in the whole of Dermatology and based upon a rigorous scientific foundation, which, to begin with, implies solid knowledge of cutaneous biology, physiology, and pathology. Cosmetic Dermatology techniques may be learned at variable times, from weeks to months, by Dermatologists as well as other physicians. Nevertheless, true dermatological education demands years and it is the mastery of the clinical foundations of dermatology that will differentiate dermatologists in their indications and utilization of cosmetic procedures.
It is a matter of concern how offers to teach these procedures spring outside of hospitals with accredited residence services and even the demand for such training courses during Dermatological conferences. Only the real mastery of Clinical Dermatology will allow us to face the competition of other specialists who, also struggling for better income, are invading this area of action of Dermatology.
It is, therefore, essential to make our young trainees in Dermatology aware that Cosmetic Dermatology is only the tip of the iceberg which represents our specialty. As with Dermatological Surgery, it is not enough to master the technique, because other specialists may compete with us, but they will never be able to do so from within the complete knowledge of the specialty. This is the only element about which no competition with us is possible, once we are adequately trained.
In the case of Dermatological Surgery, which is widely tangential with plastic surgery, even though respecting individual skills, the surgical training of the plastic surgeon is much more extensive, involving also many years of general surgery. We can, therefore, at best have similar technical conditions to those of the plastic surgeon, but the knowledge of skin diseases liable to be treated surgically will doubtlessly differentiate us, making possible better indications, conducts and outcomes for these diseases. At times even opinions on surgical treatments other than plastic surgery may be possible. Hence, in order to be good dermatological surgeons we need, first of all, to be good dermatologists.
Considering that the education of the dermatologist as a whole is essential, the need grows for the basic knowledge of clinical dermatology to irradiate to other fields of action, such as cosmetic procedures and dermatological surgery, always complemented by histopathology and the scientific basis of research. The true education of a dermatologist must be carried out within accredited hospitals, in a planned context which rationally and hierarchically sets out the fields of action of the specialty, also considering basic cosmetic procedures which must fall within the specialist's domain of expertise. Given the very evolution of Dermatology, it is clear that Medical Residence programs need to be continually evaluated so that the educational needs of professionals certified to deal with dermatological problems of communities are constantly adjusted.
By the way, it seems evident that, what with the growth of Dermatology in all its fields of endeavor, and without going into the discussion of the mandatory year in Internal Medicine, the two years Residence in Dermatology seem to be insufficient for the adequate acquisition of the skills required of the Dermatologist. We believe that in the near future, the Brazilian Society of Dermatology should request the National Commission of Medical Residence to add one more year to the residence in Dermatology.
It is essential that the dermatological community define in a precise manner what skills the dermatologist must have so that training programs may design their activities accordingly. For example, particularly I do not consider blepharoplasty as part of Dermatology, but if the dermatological community understands that this procedure falls within our own set of skills, our accredited programs must be geared so that the resident learn the procedure. All residence programs must offer, compulsorily, the learning of everything that the dermatological community considers to fall within the specialty.
Leaving aside purely professional considerations, let us also analyze some problems that our Dermatology faces in the academic sphere. Scientific research in dermatology in Brazil is growing, but it is doing so in the midst of enormous limitations of an economic nature as to equipment, materials, and personnel. Our most likely production possibilities are in the clinical arena, particularly clinical epidemiology, involving significant cohorts of studied cases, especially of diseases of importance in our midst, in which the experience of Brazilian dermatologists is extremely important. The scientific community is ever more rigorous when it comes to paper submission. Great emphasis and priority is given to scientific papers which make use of basic sciences applied to the specialty, such as genetics and molecular biology. It is clear that the economic resources required by research are ever greater and that, with exceptions, we face difficulties in terms both of material and human resources. Such difficulties may be bypassed by joint work with resource maximization through intrainstitutional, interdepartmental, and interinstitutional programs, including institutions abroad. Our thus far predominantly clinical calling must become progressively comprehensive and it must involve clinical and basic research so that we may be recognized by the international scientific community.
About these issues, dermatology demands more representativeness in accreditation agencies, for we have faced great problems in the evaluation of our graduate courses, which not always mirror our reality. It is indispensable that we maintain our Master's and Doctoral programs for the scientific growth of the specialty. This survival is closely linked with our performance, which must improve, and also with the assessment criteria, which must take our specificities into account.
Another fundamental academic issue for which it is necessary to fight in every Medical School is the existence of Departments of Dermatology, and not simply Dermatology courses offered by Internal Medicine Departments. The existence of separate Departments of Dermatology favors the growth of the specialty due to the independence it represents in terms of curriculum, professor selection, and representation in the several faculty and administrative bodies in colleges and universities.
Another major issue is the need to have dermatologists representing our Society participate in Medical Associations and governmental agencies related to Medicine, notably Public Health, because there is a host of sanitary problems involving cutanous medicine.
In sum, it is necessary to consolidate, more and more, the basis of dermatology in the domain of general medicine and dermatological education by recognizing and investing in the essence of the specialty, improving Medical Residence, demanding more participation in accreditation agencies that deal with both undergraduate and graduate levels of medical education, as well as in structures connected with professional regulation and public health. In parallel, we cannot forget that there will be success for dermatologists and for the community they serve only if we work with well-trained, ethically spotless dermatologists.
Full Professor of Dermatology, University of São Paulo