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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.81 no.6 Rio de Janeiro Nov./Dec. 2006
Considerations on the current situation in Brazilian Dermatology
Bernardo GontijoI; Everton Carlos Siviero do ValeII; Sílvio Alencar MarquesIII
Editors of the Anais Brasileiros de Dermatologia
As a counterpoint to Dr. Bruce Thiers' article "Issues facing dermatology in the United States", published in this number, the editors of the Anais Brasileiros de Dermatologia consider it a timely opportunity to offer the dermatological community a brief and succinct view concerning certain topics related to our specialty.
It should be stressed that many of our problems are similar to those faced by American dermatologists. The main purpose of these considerations is to issue an invitation to reflection on the directions our profession and specialty is following and on our ability to make the necessary corrections.
MEDICAL SCHOOLS AND THE CONTINGENT OF PHYSICIANS IN BRAZIL
The problem is complex both in essence and in possible solutions; therefore it is necessary, if we are to solve it, to carry out a historical analysis of the founding of medical schools in Brazil (Table 1).
The first period assessed in Table 1 is characterized by the prevalence of public medical schools, when the State was strongly present in the teaching of medicine. From the 1950s onwards, with the settingup of the first four private courses, the number of private medical schools has progressed steadily and overwhelmingly, until the present day where the situation is a possibly ephemeral balance with public schools.
Medical courses are costly to maintain. Private capital, whose ultimate goal is the bottom line, seeks to provide the greatest number of places, which does not always go hand in hand with quality of teaching. Possibly the most perverse aspect of private courses, owing to their expensive tuition fees, is that entrance examinations have ultimately become an economic rather than knowledge-based selection process.
The last three years of the Fernando Henrique Cardoso administration (2000-2002) show the highest proportional increase in medical schools in Brazil, with the setting-up of 28 new courses. Furthermore, during the first Cardoso administration, the National Health Council (Conselho Nacional de Saúde) was no longer allowed to have the last word about the social need to open new medical schools, a prerogative it had enjoyed up until 1996. Politicians in general, and governing authorities in particular, are usually shortsighted with regard to education. They see teaching as a costly activity bringing little electoral reward- rather, in fact, the fuel of permanent oppositionist manifestations. To dwell on only one example of official neglect, a unique but telling case, one needs only consider that the salary of a full professor, devoting him or herself full time to a federal university department, is equivalent to that of an elevator operator at the Senate.
More than 10,000 physicians graduate in Brazil per year, a figure that may be an under-estimated given that some recently created courses have not yet graduated their students. These figures mean that Brazil shows the average general ratio of 1 physician per 622 inhabitants, above the World Health Organization recommendations of 1 physician per 1,000 inhabitants. Rio de Janeiro and the Federal District are the Brazilian states with the greatest density of physicians with ratios of 1/302 and 1/309 inhabitants, respectively.
The number of physicians is growing at twice the rate of population growth, and a large proportion are professionals coming out of schools that lack minimal conditions to operate. The government spurs the growth of new medical courses under the notalways true, often fallacious, argument that it enhances social inclusion. This is a clear and unwarranted option for quantity over quality. Instead of investing in basic and technical education, acknowledged to be the weak point of the educational system, the government chooses to open courses without complying with fundamental technical requirements, and often aiming to reap political dividends. On the day the present article was written (18 December 2006), the total number of medical schools operating in Brazil was 162 (93 private schools and 69 public schools), offering 14,730 places in the first year. The most recently authorized new opening was on 14 November 2006, the Pará State University Center (Centro Universitário do Estado do Pará).
This plethora of physicians, many of whom lack qualification, leads to inevitable consequences in the job market, with low wages, unfair competition and unfavorable working conditions. The consequences are felt in all segments, but above all hit the individual who ought to be the greatest beneficiary of medicine practiced with knowledge, skill and dedication: the patient.
One particular public authority, notorious for bringing together countless features that are undesirable in a politician, met on one occasion with a group of physicians demanding a salary rise. In order to justify his refusal to grant such a rise, he came out with this pearl of wisdom: "I will not grant you a rise because physicians are like salt: white, cheap and found on every corner". When such words, uttered by someone of that ilk, come dangerously close to being true, then something very wrong must be happening.
One noteworthy aspect is that despite these facts and this evidence, medical courses still attract the greatest number of candidates and demand the highest scores for entrance. The most simplistic explanation might be that our profession, despite coping with underemployment and low wages, does not yet suffer from unemployment.
DERMATOLOGY AND THE JOB MARKET
Simultaneously, the job market has undergone profound changes. The most dramatic of these may have been the drastic fall, virtually to extinction, of the private clinic and the rise of health plans and organizations. Physicians are no longer the archetype of the professional individual, but are rather service providers whose fees are stipulated by the plan-owning organizations. It is a sad fate for the field of health (medicine, dentistry, psychology, physiotherapy, etc.) when it is the only one in which professional activity is mediated and governed by companies, often banks and insurance companies, that take upon themselves the right to fix the value of the work undertaken.
In this nebulous scenario, characterized by an imbalance between work and reward, dermatology has added cosmiatrics to its traditional fields of activity. This is founded on a tripod of incontrovertible evidence: the unbridled pursuit of beauty, raised by some to the major objective in life; the growing demand of an avid public willing to pay high rates for esthetic procedures, as against the always-undervalued clinical reasoning; and the possibility of extra earnings, extracted even from health plan patients, since health plans do not cover cosmetic procedures.
Over the last decade dermatology has become the most fashionable specialty, and as such attracts a growing number of physicians. Some are genuinely interested, while others are only seduced by the glamour and the financial possibilities. And in their wake, a crew of cunning creators of weekend post-graduation courses, whose only aim is to get rich through the use of misleading advertising and the training of pseudo-specialists.
The need for permanent media exposure has given rise to personalities hitherto unknown to medicine: the press relations officer and the marketing professional. Despite the undeniable worth of ethical marketing, there is nothing better for promoting a physician than a patient who has been treated well.
SBD, the Brazilian Dermatology Society currently has 62 accredited services, with an installed capacity to offer specialist instruction to 235 physicians per year. Offering new places ought not to exclusively obey the criteria of economic demand, since demand will grow owing to the above-mentioned reasons. One must bear in mind, among other parameters, the needs of the market as based on the population and the distribution of specialists throughout the several regions of Brazil.
OUR IMAGE WITH THE LAY PUBLIC AND PHYSICIANS
Our dermatology colleagues are often invited by the media to give their opinions on topics concerning our specialty. These issues are sometimes clinical or public health issues, but the overwhelming majority has to do with cosmetic procedures. Regardless of the nature of the topic raised, interviews in any type of media are an inestimable opportunity for the specialist to adopt the stance of a serious professional with a thorough training and sound technical knowledge. If one behaves in this way, one will gain value and above all dignify dermatology as a medical specialty.
Unfortunately, however, many people use such opportunities for self-promotion. What must go through the mind of a lay person who sees a dermatologist posing by the side of his or her new, imported car, or showing of his or her closet full of designer clothes and shoes? Undoubtedly the image of success, since these values are wrongly thought to be the synonym of professional competence. But the worst risk is that we should be reduced in the eyes of the public at large to frivolous physicians, professionals only concerned with the details of beauty treatment. Dermatology cannot, most definitely, allow itself to be stigmatized as a specialty restricted to esthetic procedures. It must retain its clinical and pathological identity, its main reason for existing, as is the case for any other medical specialty.
One of the main factors leading to the sullying of the specialty is that the medical act has been made banal, with patients exposed on television programs to demonstrate new treatment techniques. The idea is conveyed falsely that these are simple procedures that can be carried out in any setting and under any conditions. It cannot therefore be any surprise that some of these therapeutic modalities are being made available even in beauty parlors. If we ourselves do not value our specialty, no one else can be expected to do it for us.
There is a classic overlap in medicine between certain specialties, such as orthopedics and rheumatology, nephrology and urology, otorhinolaryngology and head and neck surgery. Dermatology, since the skin is the largest organ in the body, will naturally present many more points of contact with other specialties than any other medical area. And as a result of our expansion as a specialty, we are beginning to work in segments formerly restricted to plastic surgery or oncological surgery, to name but two examples. Dermatology, which had itself in the not too remote past complained of other specialists encroaching upon it, merely prescribing "creams and ointments", has now been stretching out its own tentacles and extending its own domain.
The reply from other specialties has not been long in coming. Shining like gold in a setting of destruction, dermatology found itself invaded by physicians from other medical specialties. Many of the students graduating from the much-vaunted weekend courses are gynecologists, pediatricians, endocrinologists and anesthetists, among others. What drives them to this? First of all, undoubtedly, the sight of easy earnings and a plentiful clientele. However, there is another reason many are reluctant to admit, but which strikes any attentive observer immediately. If the application of botulinum toxin, a procedure of unquestionable value, backed up by scientific evidence, can be carried out by such differing specialists, such as dermatologists, plastic surgeons, ophthalmologists, otorhinolaryngologists, gynecologists or endocrinologists, one may conclude that its application does not depend on thorough, exclusive, formal training in any one of these areas. This is the major dilemma of many esthetic procedures: the risk of their becoming no-man's-lands, accessible to any outsiders with knowledge gleaned from practical, one-day courses.
Those colleagues who proceed in this way definitely do not change specialty. They simply come into contact with some techniques of esthetic treatment. Dermatology with a capital D is infinitely greater than this.
THE ROLE OF PROFESSIONAL ASSOCIATIONS AND THE SBD
Some of the problems facing us result from decisions taken on the basis of political, rather than technical, aspects, such as the opening of new medical schools, the overall economic situation, low salaries, and the existence of health plans, or even of ineffectual legislation. Combating these inconsistencies is an arduous, sometimes inglorious, struggle, which depends basically on our ability to organize and on our strength as a class.
Young physicians tend to see associative activities as boring and bureaucratic, as well as burdensome, and forget that only effective engagement can bring our profession advantage. They must therefore be encouraged from the outset of their careers to join professional associations and scientific societies, which are the proper stage for the discussion of the problems that concern us.
The Brazilian Medical Association (Associação Médica Brasileira - AMB) and the Federal Medical Council (Conselho Federal de Medicina - CFM) have made considerable efforts trying to persuade public authorities to improve the situation of physicians. All this effort is often lost, however, in bureaucracy, in the slowness of the legal system, or even in the lack of commitment on the part of the authorities. There is nothing more difficult than trying to close down a functioning medical course, even if it is proven to be precarious and lacks the slightest justification for its existence. Many schools take advantage of loopholes in the law or of inconsistencies between the Federal Constitution and State Constitutions to set up courses that are not approved by the Ministry of Education (MEC). The Federal Medical Council therefore brought in Resolution 1808, enacted on 10 November 2006, laying down that Regional Medical Councils can only register the graduation diplomas granted by higher education institutions recognized by the MEC. Since the government will not play its part, the necessary measures have to be taken somehow
MEC accreditation of lato sensu post-graduate level courses provides more fertile ground for illintended actions. Some regularly accredited institutions "transfer" this right to entities set up with the sole purpose of managing such courses and reaping exceptional profits. Since official control is precarious and there is no evaluation, the birth rate of such courses is growing exponentially. What can one expect of a physician who, after taking such courses, is unable to obtain a qualification as a specialist in dermatology? That he or she enter the job market, even without the necessary qualification, or prepare to take another examination, or switch specialty? One does not need a crystal ball to guess the answer.
The Brazilian Medical Association (AMB) and the Federal Medical Council (CFM) recognize 59 specialties, including dermatology and its three main areas of activity: dermatological surgery, hansenology (leprosy studies) and cosmiatrics (cosmetic dermatology). The much-vaunted specialty known as "esthetic medicine" does not, therefore, exist. Despite legal non-existence, however, esthetic medicine is actually practiced by many, both physicians and non-physicians. And in certain cases we hardly know how.
One possibly promising way of overcoming these problems is by the setting-up of the Physician Association Order, along the lines of the Brazilian Bar Association (Ordem dos Advogados do Brasil - OAB). Beset by a plethora of law schools and poorly qualified professionals, and in the absence of any official action to curb this scandalous situation, the OAB created the examination of the association. Upon graduation, a student receives the qualification of Bachelor in Law, which does not entitle him or her to exercise the profession. In order to do so, he or she will have to pass in the Bar exam, and thus earn their qualification as a lawyer. In a recent exam for entering the OAB, the fail rate was over 80%. It would be an exercise of the imagination to predict the fail rate in a medical association examination, but it is reasonable to posit a disappointing figure. Here again the government has failed to play its part, overseeing the quality of education, and therefore it fell to the OAB to play its own part.
Among its multiple roles, the Brazilian Dermatology Society (SBD) has been active in the scientific area, in providing public services, and in policy. It is the only scientific society accredited by the Brazilian Medical Association (AMB) as representative of the specialty and areas of activity, and authorized to apply examinations to qualify specialists. It is of the utmost importance that this role be brought repeatedly to the attention of the public at large, which is bombarded by misleading advertising from other unrepresentative entities that are intensely dedicated to publicizing their events, mini-courses and therapeutic miracles.
Finally it is worth mentioning, albeit briefly, the qualification to become a specialist of the SBD. Initially aiming to certify those who pass, the examination should adapt to the present circumstances and incorporate a new feature: distinguishing between those actually trained in order to exercise the specialty from those opportunists who have received precarious training, who are well-skilled in going to court to contest the questions. While the test remains merely theoretical we run the risk of passing candidates who simply possess enough bytes of memory to rote learn texts. We must demand medical conduct, and assess through practical exams the candidate's performance in clinical cases, their differential diagnoses, the histopathological picture and therapeutic options. Only in this way will we be able to make this distinction.
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4. Machado MHM, Vieira ALS, coords. Perfil dos dermatologistas no Brasil. Relatório final (Brasil e grandes regiões). Rio de Janeiro: Sociedade Brasileira de Dermatologia; 2003.
5. Sodré, CT. Mercado de trabalho dos dermatologistas no Brasil. Conferência no 61º Congresso da Sociedade Brasileira de Dermatologia; 16 Out 2006; Curitiba, PR.
No conflict of interests was declared.