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versão impressa ISSN 1413-8123versão On-line ISSN 1678-4561
Ciênc. saúde coletiva vol.21 no.9 Rio de Janeiro set. 2016
Assessment of the scope of practice of physicians participating in the Mais Médicos (More Doctors) Program, and associated factors
1Observatório de Recursos Humanos em Saúde, Estação de Pesquisa de Sinais de Mercado, Núcleo de Estudos em Saúde Coletiva, Faculdade de Medicina, Universidade Federal de Minas Gerais. Av. Prof. Alfredo Balena 190/7º andar, Santa Efigênia. 30130-100 Belo Horizonte MG Brasil. firstname.lastname@example.org
The purpose of this study was to characterize the scope of practice of physicians working in primary healthcare participating in the Mais Médicos (More Doctors) Program (‘PMM') and investigate the factors associated with execution of a larger number of clinical activities. It is an exploratory study carried over January to March 2016, through a self-applied questionnaire containing a list of 49 procedures, activities and actions carried out in primary healthcare. A total of 1,241 physicians took part in the study, most of them female, between age 40 and 49, and of Cuban nationality. The physicians carried out an average of 22.8 ± 8.2 procedures; they reported knowing how to carry out a larger number of procedures. Factors associated with executing a larger number of procedures were: being male, having graduated more recently, two years or less practicing in their primary healthcare unit, practicing in the North or South geographical regions, in small towns and more distant from the regional health headquarters. The main reason for not carrying out the procedures and activities that they reported knowing how to do was the lack of materials and inadequate infrastructure. The results show that the scope of practice of the physicians of the PMM is lower than their capacities, and that interventions with the intention of widening their scope are necessary.
Key words Mais Médicos Program; Human resources; Primary healthcare
The process of institutionalization of Brazil's Unified Health System (SUS) has now been going on for more than twenty years, and one of the measures of its organization and implementation is the strengthening of Primary Healthcare, seeking to serve the population in accordance with the local realities. In this context, the scope of practice of doctors who work in primary healthcare is crucial for ensuring capacity to provide solutions in meeting the various health demands for the population, because these are the professionals who operate at the frontline of the SUS1,2.
The term ‘scope of practice' is used to describe the group of activities, functions and actions that a professional can exercise with security, according to his training, education and professional competence3. The following key elements are considered for the definition of scope of practice: (i) activities authorized by law; (ii) activities actually realized in the professional practice; (iii) the training and education required; (iv) criteria for exercising the profession; and (v) professional responsibility4.
In the area of health, a professional with limited scope of practice can increase the rates of referral to secondary networks and, consequently, increase the costs of health, as well as restricting users' access to the services5. At the same time, a widened scope of practice can help improve access to health services6. Thus, the way in which the scope of practice is established directly impacts the composition and productivity of the workforce and, thus, the quality and the cost of health services.
Studies point to a wider scope of practice of health professionals principally in rural areas, remote areas and other locations with low availability of doctors and specialists7-9. Among medical professionals, the amplified scope has been associated with factors such as gender, age, time of education, experience, location and access to the secondary network5.
The processes of regulation and qualification of the workforce in health, at the same time as the reforms in the models for provision of health services, principally in primary healthcare, have been indicated as essential to provide equity and quality in the health system6,10, when seeking to face a problem that is chronic for the various countries, including Brazil, which is the scarcity of health professionals, with a highlight for doctors11-13.
Countries that are benchmarks for investigating this problem and proposing strategies for its solution, such as the United States, Canada and Australia, have increasingly been using: (i) widening of the scope of practice of health professionals in primary healthcare; (ii) new professions such as Physician assistants, and nurses with advanced education (Nurse Practitioners); and (iii) transfer of responsibilities to other professional categories or to technical categories – ‘task shifting’14-16.
Recently, based on various evidences that indicated a situation of profound scarcities and unsatisfactory geographical distribution11,17-20, the Brazilian government launched the Mais Médicos (More Doctors) Program, which has as one of its central objectives the reduction of the shortage of doctors in the priority regions of the SUS, so as to reduce inequalities in access to the health services. For this, one of its main thrusts has been emergency provision of Brazilian and/or non-Brazilian doctors at these locations, named the Mais Médicos para o Brasil (‘more doctors for Brazil') Program, or PMMB21.
According to data from the Health Professionals Provision Planning and Regulation Department (DEPREPS), in February 2016 there were 14,913 doctors of the Program operating in Brazil, of which 85% were of foreign origin, the great majority (75%) Cuban, arising from cooperation between Brazil and Cuba. The presence of these doctors in the health teams has been contributing to increase in the supply of services and the capacity of diagnosis in the territory, as well as reducing the user's waiting time for scheduling of consultations22.
In spite of the importance of the doctors of the PMM, little is known about the activities that they have been carrying out, these activities being essential for resolving the population's health problems. In this context, an effort has been made to characterize the scope of practice of doctors working in primary healthcare that are participants of the PMM, and the factors associated with execution of a larger number of clinical activities.
This study presents prior results of the survey ‘Regulation of Work and the Professions in Health', carried out by the Market Signals Research Station (EPSM), of the Collective Health Education Center (NESCON), of the Federal University of Minas Gerais (UFMG), which are part of the Health Human Resources Observatory Network. The project was approved by the Ethics Research Committee of UERJ.
It is an exploratory, cross-sectional study, carried out over the period January-March 2016, through its self-applied questionnaire, sent by email to a sample of doctors participating in the Mais Médicos Program.
The questionnaire, prepared on the basis of the Survey Monkey® tool, covered the following dimensions: socio-democratic profile of the doctors, characteristics of the work, and questions to establish the scope of practice of the professionals, according to a previously prepared list of procedures, activities and actions carried out by doctors in primary healthcare. The construction of the questionnaire involved various stages, including consultation of the Basic Healthcare Protocols of the Health Ministry, interviews with key informants and specialists, and review of international literature on the scope of practice of doctors in primary healthcare5,23-29.
The questionnaire was submitted to a pre-test, carried out on ten doctors who work in Primary Healthcare Units of different geographical regions of Brazil. It was then sent to a prepared list comprising 17,536 records of medical professionals who participated in courses offered by the Open University System of the SUS (UNA-SUS). These included both Specialization in Family Healthcare, which is mandatory for participation in the Primary Healthcare Professional Improvement Program (PROVAB) and the PMM, and also the open online courses of short duration which mostly cover subjects relating to primary healthcare.
A total of 3,568 doctors responded to the questionnaire, of which 1,241 were considered to be eligible to make the sample. The criteria for inclusion used was: all doctors who have operated or who operate in the PMM, and who have responded to the questions relating to procedures, activities and actions carried out in basic healthcare units.
In relation to the socio-demographic profile, data were collected on gender, age, nationality, country and year of conclusion of graduation, specialist qualifications, time of experience in primary healthcare and time of activity in the primary healthcare unit in which the person worked at the time of the application of the questionnaire. As well as these data, questions were asked on the municipality where the unit was located, classified by its geographical region, scale of population and distance, in terms of time, from the headquarter municipality of the health region30. The distance in terms of time was measured from the headquarter municipalities (using the address of the prefectures), by highway, to the location of the prefecture of the municipality in which the doctor worked31.
The socio-demographic data and the data on scopes of practice (procedures, activities and actions in health practiced by the doctors) were described according to the distribution of frequencies and measures of central tendency. For comparison of continuous variables the Mann Whitney non-parametric test was used, since the number of procedures, activities and actions carried out did not show a normal distribution. The level of significance adopted was 5%. The statistical analyses were made using the SPSS 19 software (SPSS Inc., Chicago, United States).
The majority of respondents were female (52.3%), aged 40 to 49 (39.8%), of Cuban nationality (73.8%), with graduation outside Brazil (87.5%), time since graduation greater than 15 years (60.8%) and more than 8 years' experience in primary healthcare (52.9%) (Table 1). Considering only the Brazilians, this profile was different, with younger participants (aged 30-39; 54.0%), shorter time since graduation (≤ 5 years; 47.3%), less time working in primary healthcare (≤ 8 years; 79.6%) and lower proportion of people graduating outside Brazil (35.4%).
|Age group (years)|
|60 or over||39||3.3|
|Country of training|
|Years since graduation|
|26 or more||258||21.3|
|Time in primary health care|
|≤ 8 years||582||47.1|
|> 8 years||653||52.9|
|Time in this primary health unit|
|≤ 2 years||719||58.4|
|> 2 years||513||41.6|
|Location of unit: Region of Brazil|
|Scale of municipality where you work|
|State capital or metropolitan region||292||23.5|
|Population: Over 100,000||166||13.4|
|Population: 50,000 – 100,000||140||11.3|
|Population: 20,000 – 50,000||272||21.9|
|Population: 10,000 – 20,000||221||17.8|
|Population: Up to 10,000||150||12.1|
|Road journey time to health region HQ|
|Up to 15 minutes||448||36.1|
|Over 120 minutes||110||8.9|
Source: Authors, from 2016 Health Professions Regulation survey.
*Excluding missing data.
As to work location, the majority worked in the primary health unit at the time of filling out the questionnaire for two years or less (58.4%), these being allocated in the Northeast (43.5%) and in state capitals and metropolitan regions (23.5%), with distance from the headquarters of the health region of up to 15 minutes (36.1%) (Table 1).
The majority of the participants stated that they had specialist qualification (86.6%), obtained by medical residency, specialization course, recognition of a society of specialists and masters' degree or doctorate (Table 1). These specialties related to primary care – Clinical Practice and Family and Community Medicine, or equivalent – corresponded to more than 90%.
With regard to the population served, a great majority of the doctors (≥ 95%) received demand ranging from nursing mothers to the elderly, and 87% reported also serving newborns. In relation to the conditions and health problems of patients, at least 95% of the interviewees reported receiving demand from patients with diabetes, hypertension, cardiopathies, pregnant women, patients with hypothyroid condition, obesity, cancer, problems with mobility, bedridden or physically disabled, patients with mental suffering and with respiratory problems. More than 75% of the doctors interviewed stated that they also receive demand from patients with chronic kidney deficiency, need to stop smoking, endemic diseases, chemical dependencies and living with HIV/AIDS.
Among situations of vulnerability of the patients served, the situation which the doctors cited most frequently was having among the population of their primary healthcare unit people who live in a situation of poverty (75.5%) – followed by homeless/people living in the street (23.7%), as well as immigrants (20.6%), seasonal populations (10.6%), people deprived of liberty (10.3%), indigenous people (9.8%), residents of river banks (9.2%) and residents of quilombo (former slave) settlements (7.1%).
In relation to the procedures, activities and actions, the average of realization by the doctors of the PMM in the primary healthcare units was 22.8 ± 8.2, of a total of 49, lower than the average of procedures that the doctors reported knowing how to do (39.0 ± 9.1; p < 0.001).
Table 2 presents the list of these procedures, activities and health actions; the percentage of doctors who indicated that they had executed them in the primary healthcare units; and the figures for doctors who reported being able to carry them out. Among those listed, 18 procedures stand out in which replies reporting their realization was greater than 50%, and 12 are cited by more than 90% of the professionals.
|Health procedures, activities and actions||Have executed in the unit||Know how to execute|
|Treatment of anemia||1,215||99.6||1,219||99.9|
|Treatment of skin mycoses||1,219||99.5||1,223||99.8|
|Treatment of dermatitis||1,214||99.3||1,219||99.8|
|Treatment of back pain||1,203||98.8||1,213||99.7|
|Treatment of epigastralgia / peptic ulcer||1,205||98.8||1,215||99.6|
|Treatment of recurrent urinary infection||1,206||98.7||1,217||99.6|
|Treatment of asthma||1,196||98.7||1,209||99.8|
|Treatment of recurrent sinusitis||1,178||97.0||1,200||98.8|
|Low-risk prenatal treatment||1,174||96.2||1,217||99.7|
|Treatment of allergic kidney conditions||1,163||95.5||1,186||97.4|
|Order fecal occult blood test||1,152||95.1||1,204||99.4|
|Treatment of recurrent otitis||1,148||94.9||1,187||98.1|
|Complaints of red eyes||1,045||87.9||1,139||95.8|
|Treatment of superficial wounds||936||79.5||1,168||99.2|
|High-risk prenatal treatment||707||59.9||1,076||91.2|
|Removal of earwax||660||57.7||1,096||95.9|
|Loss of sharp vision (refraction, glaucoma, retinopathy, cataract)||566||49.1||791||68.7|
|Visual acuity screening||530||46.3||895||78.2|
|Infiltration of local anesthetic||506||44.8||1,096||97.1|
|Removal of unwanted body from the ear||478||42.3||1,042||92.2|
|Incision and drainage of abscess||464||40.7||1,112||97.6|
|Removal of unwanted body from legs, arms and extremities||368||32.9||992||88.7|
|Immobilization of wounded extremities||361||32.2||1,054||93.9|
|Drainage of paronychia||346||31.1||964||86.5|
|Insertion of urethral catheter||337||29.7||1,028||90.7|
|Immobilization of fractures||317||28.3||975||87.1|
|Removal of skin lesions||314||28.2||935||84.0|
|Removal of unwanted body from cornea or conjunctiva||313||27.9||851||75.9|
|Removal of unwanted body from air passages||311||27.9||961||86.2|
|Removal of ingrown nail||310||27.8||954||85.6|
|Treatment of subungual bruise||262||23.7||832||75.4|
|Cauterisation of nosebleed||219||19.9||694||63.0|
|Insertion of nasogastric tube / gastric lavage||224||19.6||1,010||88.3|
|Removal of molluscum contagiosum||202||18.3||743||67.3|
|Low risk normal birth||151||13.3||1,084||95.2|
|Removal of painful callus||126||11.5||657||59.9|
|Cryotherapy or chemical therapy for genital wart||121||11.0||686||62.4|
|Removal of cysts, lipoma, nevi||111||10.1||694||63.2|
|Scraping for determination of fungi||58||5.3||573||52.2|
|High risk normal birth||46||4.1||609||54.1|
|Cryotherapy for skin lesions||42||3.8||468||42.4|
Source: Authors, from 2016 Health Professions Regulation survey.
Highlight procedures: more than 90% of the doctors reported knowing how to do them, but less than 50% do them in their primary health unit.
*Excluding missing data.
The procedures, activities and actions which less than 50% of the doctors reported knowing how to do were ‘cryotherapy of skin lesions' and ‘acupuncture'.
Highlights among the procedures which had the highest percentage of positive response on knowing how to do them (> 90%), were ten which had frequency of realization lower than 50% (emphasized in Table 2).
The number of procedures carried out was greater among male individuals, those with less time since graduation, and those with more than two years activity in the primary health unit. Doctors who operated in the North and South geographical regions, in municipalities of smaller scale and remote municipalities, and also in those that are more distant from the regional health headquarters, also presented, on average, a higher number of procedures carried out (Table 3).
|Characteristic||Number of procedures, activities and health actions executed||Number of procedures, activities and health actions that doctor knows how to execute|
|Average ± SD||Median||p-value*||Average ± SD||Median||p-value*|
|Female||22.0 ± 7.5||21.0||0.001||38.4 ± 9.3||41.0||<0.001|
|Male||23.8 ± 8.8||22.0||40.6 ± 8.5||43.0|
|≤ 43||23.0 ± 7.8||22.0||0.139||39.6 ± 8.4||42.0||0.495|
|> 43 years||22.7 ± 8.5||21.0||39.3 ± 9.5||42.0|
|Brazilian||22.4 ± 8.1||21.0||REF||37.3 ± 8||39.0||REF|
|Cuban||22.9 ± 8.2||21.0||0.800||40 ± 9.3||43.0||<0.001|
|Other||22.9 ± 7.9||22.0||0.768||39.4 ± 7.9||41.0||0.005|
|Country of training|
|Brazil||21.7 ± 8.5||20.0||0.061||35.9 ± 8.8||38.0||<0.001|
|Outside Brazil||23.0 ± 8.1||21.0||40 ± 8.9||43.0|
|Years since graduation|
|≤ 17||23.5 ± 8.0||22.0||0.005||39.8 ± 8.1||42.0||0.498|
|> 17 years||22.4 ± 8.3||20.0||39.3 ± 9.6||42.5|
|Yes||22.9 ± 8.4||21.0||0.625||39.6 ± 9.3||43.0||<0.001|
|No||22.2 ± 7.4||21.0||37.8 ± 7.8||39.0|
|Time working in primary care§|
|≤ 8 years||22.5 ± 8.3||21.0||0.349||38.2 ± 9.6||41.0||<0.001|
|> 8 years||23.0 ± 8.2||21.0||40.3 ± 8.6||43.0|
|Time in this primary health unit|
|≤ 2 years||22.3 ± 7.9||21.0||0.026||39.3 ± 9||42.0||0.165|
|> 2 years||23.5 ± 8.6||22.0||39.6 ± 9.2||42.0|
|Location of unit: Region|
|North||24.6 ± 8.1||24.0||<0.001||42.4 ± 6.6||44.0||<0.001|
|Northeast||22 ± 8.3||20.0||REF||39.5 ± 9.1||42.0||REF|
|Southeast||22.3 ± 8.4||20.0||0.666||37.8 ± 9.9||41.0||0.005|
|South||24.6 ± 7.8||24.0||<0.001||39.3 ± 8.9||42.0||0.632|
|Center-West||22.6 ± 7.2||21.0||0.196||39.6 ± 8.7||41.0||0.728|
|Scale of municipality|
|State capital or metropolitan region||20.7 ± 8.0||19.0||REF||37.6 ± 9.8||40.0||REF|
|Population: Over 100,000||21.0 ± 7.1||20.0||0.440||37.6 ± 9.3||40.0||0.835|
|Population: 50,000 – 100,000||21.0 ± 6.4||20.0||0.452||39.5 ± 7.3||40.0||0.256|
|Population: 20,000 – 50,000||23.0 ± 8.3||21.0||0.002||39.6 ± 9.4||42.5||0.001|
|Population: 10,000 – 20,000||25.2 ± 8.7||25.0||<0.001||40.8 ± 9.0||44.0||<0.001|
|Population: up to 10,000||26.6 ± 8.3||27.5||<0.001||42 ± 7.6||44.0||<0.001|
|Journey time to health region HQ|
|Up to 15 minutes||21.2 ± 7.6||20.0||REF||38.5 ± 9.0||41.0||REF|
|16–30 minutes||22.5 ± 8.6||20.0||0.090||38.1 ± 10.5||41.0||0.551|
|31–45 minutes||22.6 ± 8.2||21.0||0.154||39.3 ± 8.7||41.0||0.187|
|45–60 minutes||23.1 ± 7.9||22.5||0.012||39.4 ± 9.9||43.0||0.023|
|61–120 minutes||24.3 ± 8.8||23.0||<0.001||40 ± 9.0||43.0||0.001|
|Over 120 minutes||26.1 ± 7.8||25.0||<0.001||43 ± 7.0||45.0||<0.001|
Source: Authors, from 2016 Health Professions Regulation survey.
*Calculated by Mann Whitney test.
§Data dichotomized by the median. REF = Reference group.
In relation to the procedures that the doctors stated they knew how to do, the pattern observed as to gender, scale and distance of the municipality was similar to that observed for the procedures carried out. However, a larger number of procedures that doctors knew how to do was reported by: doctors of Cuban and other nationalities; those trained outside Brazil; those holding special qualifications; those who had spent more time working in primary healthcare; and those that worked in the North and Southeast regions. There was no difference between them in terms of graduation and time of activity in the Primary Healthcare Unit (Table 3).
Among the reasons presented by the doctors for not carrying out the procedures and activities that they reported that they knew how to do, the outstanding ones were lack of materials and inadequate infrastructure, cited by 87.3% of the participants. In a lower quantity others were cited, including: factors associated with the normative rules of the practice, such as: clinical protocols (34.7%); lack of demand for realization of the procedures (24.5%); and excessive workload (21.7%).
This exploratory study sought to analyze the activities carried out by doctors of the PMM and the distribution of those activities by professional profile and municipality of the activity. In this sample it was also possible to study the factors that influenced the scope of practice of these professionals.
In relation to the social-demographic profile of the participants, it was found that there was a predominance of doctors over the age of 40, of Cuban nationality and of the female gender. This profile is compatible with the data of the DEPREPS of February 2016, in which 75% of the doctors participating in the PMM are of Cuban nationality and the majority are over the age of 40. The participation of Brazilian professionals – predominantly recently qualified and younger, in this sample – increased in the recent tenders, filling up the greater part32 or the totality33 of the vacancies offered by the Program. In spite of this, the number of these professionals is still small to change the overall profile of the doctors who are currently in the PMM. Also, the trend to a higher number of female doctors, observed in this study, is an international trend in the area of health, as shown in a systematic review study by Hedden et al., in 201434.
The doctors of the PMM reported receiving a diversified demand in their health units, both in relation to age group and also in relation to the health problems and conditions, which include chronic diseases, mainly hypertension and diabetes – infectious diseases and endemic diseases. The authors consider that there are elements that affect this profile of demand, such as the availability of a doctor in another health team of the same Unit and the availability of attendance by specialists. It can be noted that a majority of the doctors have worked for two years or less in the Units, which could also influence the perception of the profile of the demand received.
The relationship between an amplified scope of practice and activity in rural and remote areas has been indicated in several international studies8,9,35,36. In this study, doctors who worked in remote municipalities, distant from their regional headquarters, and those of smaller scale, carried out a larger number of procedures compared to those who operated in municipalities up to 15 minutes distant, and in state capitals and metropolitan regions. According to the Primary Health Care Doctors Scarcity Index19, the majority of the municipalities with scarcity were those of smaller scale and, the greater the distance to the regional health headquarters, the greater the degree of scarcity attributed. The Index also reveals that the region with the largest number of municipalities with scarcity is the Northern Region (31%), and in this study this was one of the regions where the doctors carried out a larger number of procedures, activities and actions.
In spite of there being a larger female than male contingent in this study, the results indicate that male doctors carry out and know how to carry out a larger number of procedures, activities and actions. Other studies show a similar influence of gender in the scope of practice of doctors5,37,38. However, the reasons why these scopes differ are not clear, and specific studies are needed on this subject for better comprehension of the findings.
Less time since graduation was associated with the realization of a number of procedures, activities and actions in this study. Recently-graduated doctors tend to seek work locations where they feel challenged and can gain experience9. A recent US study compared the intended scope of practice of family medicine residents to that of doctors already working in this area, at the moment of obtaining professional certification/recertification; these authors observed that the residents interviewed stated a greater intention of practicing with amplified scope, including care in obstetrics, prenatal care, and care for chronic and acute diseases, among others39.
The results show that, in general, respondents reported knowing how to do more procedures, activities and actions than they in fact carried out in the units where they operate, which characterizes a possible reduction of their scope of practice. The phenomenon has been identified in other international studies35,40,41. In the US, for example, low indices of realization of pre-natal and birth care were reported by doctors recently concluding residencies in family medicine who consider themselves to have a high capacity to carry out these activities40.
Among the reasons found in the literature for a reduced scope of practice of primary healthcare doctors the following can be cited: personal factors, such as lifestyle and individual preference; factors related to work, such as lack of training, excessive workload, complexity of the clinical cases, contractual restrictions; and external factors, such as lack of support from the institution and from the community, restriction on reimbursement of procedures executed and the high cost of insurance against malpractice claims39-42.
The main barrier to execution of activities and actions pointed to by the doctors in this study was the lack of materials and the inadequate infrastructure of the primary healthcare units. This limiting factor is likely to be attenuated by 2018, since the Mais Médicos Program Law establishes a period of up to five years for the SUS to provide basic healthcare units with quality of equipment and infrastructure21. To make investment in infrastructure and (re)construction of basic healthcare units even more viable, the Program has made it mandatory for municipalities to join the Requalifica UBS – a program of improvement of infrastructure of the primary healthcare units. This program was launched in 2011 by the federal government and, connected with the PMM, is making it possible for 26,000 basic healthcare units to be refurbished, built and expanded, with an investment of more than R$ 5 billion43.
As well as having an effect on access to health services, the amplified scope of practice is considered an important factor for the choice of working location by the doctor and for the doctor's permanence in the services44,45. It can thus be affirmed that expansion of the scope of practice of primary healthcare helps to attract and fix doctors in the health teams. Although this was not the objective of this paper, mainly in view of the increase of joining of the PMM by Brazilian doctors with medical registry in the country, it becomes essential to study the expansion of scopes of practice as a possible strategy for attracting and fixing doctors in unassisted areas in Brazil.
The process of expansion of scopes of practice of health professionals involves, in countries such as Canada and the United States, among other various stages, research and consultation on public policies, standards of professional regulation and jurisprudence on the subject. The carrying out of public consultations also becomes necessary for there to be alterations in the regulation and the professional legislation that exists at present, further taking into account the competencies necessary for carrying out acts and the establishment of standards of practice4,15,46.
It is also important to recognize and incorporate the superimposition of scopes of practice of different health professionals, as well as proposing mechanisms for carrying out of activities by non-medical professionals6,10,46. On this aspect, a National Committee could be formed to monitor, evaluate and update the standards and patterns of scope of practice of professionals46. These strategies could be applied in professional regulation, with a focus on primary healthcare, for the purpose of maximizing the use of the competencies of the health team.
In Brazil, scales were not found for evaluating the scope of practice of doctors; and the use of international scales is inappropriate to the local health context. Added to this is the scarcity of publications on the subject, which makes comparison of the findings difficult. The study is exploratory and the associations reported need to be studied in future investigations to validate the results. The low level of response found affected its representativeness. However, it was possible to help in the characterization of the clinical practice of the professionals participating in the PMM, and to identify the principal associated factors. Based on the results of the study, construction and validation of a national scale could be proposed.
The study identified various different factors that are associated with a broadened scope of practice of the participants, such as male gender, and lower time since graduation, as well as geographical factors such as location, distance and the scale of the municipalities where the doctors work. It was further highlighted that the doctors working in the Mais Médicos Program carry out a lower number of procedures, activities and actions than they report themselves as knowing how to carry out, mainly due to the lack of materials and the inadequate infrastructure of the basic health units. Thus, the use of the competencies of the professionals could be optimized by structuring of the health units and making materials available. The review of the scopes of practice of health professionals has been highlighted as a tool for expansion of the potential of primary healthcare.
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Received: March 09, 2016; Revised: June 13, 2016; Accepted: June 15, 2016