Profile and distribution of orthopedic residency graduates in Pará: training and challenges in the Brazilian AmazonABSTRACT
Introduction: Medical residency in Orthopedics and Traumatology is essential for the training of specialists and for strengthening healthcare in Northern Brazil, where there are significant challenges related to the distribution and retention of these professionals.
Objective: To analyze the professional profile of graduates from the Orthopedics and Traumatology medical residency program of a public institution in the state of Pará, considering geographic distribution, healthcare delivery, subspecialization, and academic involvement.
Method: This is an observational, descriptive study with a quantitative and qualitative approach. Data were collected through an electronic questionnaire containing both open and closed questions, sent to all program graduates from 2010 to 2024. Quantitative data were analyzed using descriptive statistics, while open responses underwent thematic content analysis.
Results: A total of 40 graduates participated, of whom 82.5% currently practice in the state of Pará, with 67.5% located in the capital city. Most graduates (95%) pursued at least one subspecialization, primarily in knee surgery (18.8%), hand and wrist (14.6%), foot and ankle (10.4%), and orthopedic trauma (10.4%). Only 18.4% completed subspecialization within the state. The average monthly patient volume was 260.5 consultations per physician, with 35.6% in the public health system (SUS) and 64.4% in the private sector. The average surgical production was 24.7 procedures per month, fairly distributed between the SUS (47.0%) and the private sector (53.0%). Half of the graduates are involved in medical education, working as preceptors or residency supervisors. The main motivations for choosing the program included emotional and geographic ties, recognition of the training quality, and logistical factors.
Conclusion: The residency program contributes significantly to training and retaining orthopedic surgeons in the Amazon region, strengthening the local healthcare network. However, challenges remain, such as the concentration of professionals in the metropolitan area, limited availability of local subspecialty training, and insufficient integration into the public health system (SUS). Public policies promoting the decentralization of medical practice and the expansion of training opportunities are essential to consolidate orthopedic care in the region.
Keywords:
Internship and Residency; Medical Education; Orthopedic Procedures; Health Human Resource Evaluation
RESUMO
Introdução: A residência médica em ortopedia e traumatologia é fundamental para a formação de especialistas e para a consolidação da assistência no Norte do país, onde há desafios relacionados à distribuição e fixação desses profissionais.
Objetivo: Este estudo analisa o perfil dos egressos da residência médica em ortopedia e traumatologia de uma instituição pública do Pará, considerando distribuição geográfica, produção assistencial, subespecialização e inserção acadêmica.
Método: Trata-se de um estudo observacional, descritivo, de abordagem quantiqualitativa. A coleta de dados foi realizada por questionário eletrônico com perguntas abertas e fechadas, enviado a todos os egressos entre 2010 e 2024. Os dados quantitativos foram analisados por estatística descritiva, e as respostas abertas, por análise temática.
Resultado: Participaram 40 egressos, dos quais 82,5% atuam no Pará, sendo 67,5% na capital. A maioria (95%) realizou subespecialização, principalmente em joelho (18,8%), mão e punho (14,6%), pé e tornozelo (10,4%) e trauma ortopédico (10,4%). Apenas 18,4% fizeram subespecialização no estado. A média mensal foi de 260,5 atendimentos, com 35,6% no Sistema Único de Saúde (SUS) e 64,4% no setor privado. A produção cirúrgica foi de 24,7 procedimentos por mês, distribuída entre SUS (47,0%) e setor privado (53,0%). Metade dos egressos atua como preceptores ou supervisores de residência. As principais motivações foram vínculos afetivo-geográficos, qualidade da formação e fatores logísticos.
Conclusão: A residência contribui para formar e fixar ortopedistas na Amazônia Legal, fortalecendo a rede assistencial regional. Contudo, persistem desafios, como a concentração na capital, a baixa oferta de subespecialização local e a necessidade de maior inserção no SUS. Políticas de interiorização e expansão da formação são fundamentais para consolidar a assistência ortopédica na região.
Palavras-chave:
Residência Médica; Educação Médica; Ortopedia; Avaliação de Recursos Humanos em Saúde
INTRODUCTION
Orthopedics and Traumatology is one of the most consolidated medical specialties, essential to hospital and outpatient care, especially in contexts of trauma and musculoskeletal morbidities1. The process of training orthopedists requires technical-surgical mastery and adequate adaptation to regional demands, considering factors such as care structure, epidemiological profile, and population distribution2.
Despite the increase in the absolute number of physicians in Brazil, inequality in territorial distribution remains a structural challenge. According to Medical Demography in Brazil 2025, the national ratio is 2.69 doctors per 1,000 inhabitants, with a strong concentration in the Southeast and South regions. At the opposite extreme, the North region remains with the lowest indicators, and the state of Pará has 1.55 doctors per 1,000 inhabitants, which places it among the worst rates in the country.
In the field of Orthopedics, the discrepancy is even more striking. Pará has 325 records in 2024, which represents a density of 2.55 specialists per 100,000 inhabitants - a value significantly lower than the national average, which ranges between 7 and 9 orthopedists per 100,000 inhabitants4. In addition to the quantitative scarcity, an alarming geographic inequality stands out: 71.9% of orthopedists work exclusively in the capital, Belém, as evidenced by the state’s Capital/Interior Distribution Index (IDCI), which reaches 10.36 - one of the highest in Brazil4.
Consequently, most of the 144 municipalities in Pará remain without specialized orthopedic coverage, whether for emergency procedures, outpatient or surgical ones. This gap forces the population of the interior to seek care in the capital, resulting in delays in diagnosis, aggravation of injuries, and potential permanent sequelae, especially in cases of trauma4),(5),(6.
Orthopedic injuries are among the main reasons for seeking emergency services, corresponding to about 60% of visits to general emergency rooms7. More than 60 million Brazilians are affected by trauma annually, which represents approximately one in six hospital admissions and one of the main causes of mortality in children under 40 years of age8),(9.
In order to mitigate this care gap, the Medical Residency Program in Orthopedics and Traumatology of the Universidade do Estado do Pará (UEPA), was created in 2010, in partnership with the Porto Dias Hospital and the Ministry of Education. The proposal aimed not only to train technically qualified specialists, but also to establish them in the Amazon region, promoting the decentralization of the specialty and the strengthening of the orthopedic care network.
In this context, this study aims to analyze the profile of graduates of the Medical Residency Program in Orthopedics and Traumatology at Universidade do Estado do Pará (UEPA) after ten years of implementation, considering their insertion in the labor market, geographic distribution, subspecialization choices, work in the SUS and participation in academic activities.
METHOD
This is an observational, descriptive and exploratory study, with a quantitative-qualitative approach, developed from the application of semi-structured interviews with physicians who graduated from the Medical Residency Program in Orthopedics and Traumatology of the Universidade do Estado do Pará (UEPA).
The study was conducted in the state of Pará, with the target population being physicians who have graduated from medical residency since its creation in 2010. All professionals who voluntarily agreed to participate in the research and signed the Informed Consent Form (ICF) were included. Participants who did not correctly fill out the questionnaire (Chart 1), who sent it after the stipulated deadline or who refused to participate were excluded.
Data collection and analysis
The graduates were identified through institutional records and invited to participate in the research via e-mail. After acceptance, the questionnaire was sent through the Google Forms platform, containing open and closed questions. The questionnaire addressed sociodemographic aspects, insertion in the labor market, choice of subspecialization, work in the SUS and involvement with teaching.
Statistical treatment
Quantitative data were organized in Microsoft Excel® software and analyzed using descriptive statistics, with calculation of mean, median, and standard deviation. The open answers were submitted to thematic content analysis, allowing the qualitative categorization of the participants’ perceptions. The crossing of the variables allowed the identification of patterns of professional performance, subspecialization and geographic distribution of the graduates.
The data were organized in Microsoft Excel® software and analyzed using descriptive statistics. Qualitative variables were described as simple proportions. Quantitative variables - such as the average monthly number of outpatient visits and surgeries - were self-reported by the participants and expressed as means, medians, and standard deviations.
Ethical Aspects
The study was approved by the Research Ethics Committee of the Porto Dias Hospital, linked to the Universidade do Estado do Pará, in accordance with Resolution N. 466/2012 of the National Health Council (CNS, Conselho Nacional de Saúde). The consolidated Opinion was issued under number 6.952.204, with CAAE 80596424.6.0000.0235. All participants signed the Informed Consent Form (ICF). The data were stored in a secure digital environment, with access restricted to the researchers, and used exclusively for scientific purposes.
RESULTS
Table 1 depicts the sociodemographic characterization of the 40 participants in the research. There was a predominance of males (n = 36; 85.0%), with a mean age of 26.82 years (± 3.31) at the time of entry into medical residency. The mean age of female participants (n = 6; 15.0%) was 24.17 years (± 0.98) at admission.
Regarding the place of birth, 55.0% were born in Belém (PA), and 32.5% came from other municipalities in the state, such as Cametá, Castanhal, Abaetetuba, Altamira, among others. A total of 12.5% of the graduates came from other Brazilian states, including Maranhão, Ceará, Goiás, São Paulo and Acre.
Regarding marital status at the beginning of residency, 80.0% declared themselves single and 20.0% married. Regarding medical education, the majority (n = 33; 82.5%) graduated from public institutions, and 17.5% from private institutions (Table 1).
Motivations for choosing residency in the state of Pará
The thematic analysis of the open responses revealed three main categories that justify the choice to carry out medical residency in Orthopedics and Traumatology in the state of Pará: (1) affective-geographic ties, (2) recognition of the quality of the service offered, and (3) economic and logistical factors. Additional subcategories related to professional motivation and future prospects also emerged.
Most participants reported having chosen to remain in the state for personal and affective reasons, mainly related to proximity to family members and support networks. The institutional prestige of the residency offered in the state, mentioning factors such as the good structure of the service, the preceptors’ reputation and the approval rates in the Board Certification Exams was also pointed out by the research participants. Practical issues such as avoiding travel expenses, maintaining one’s own or family home, and staying in an already known region were also predominant.
Regarding professional qualification, all 40 graduates (100%) obtained the title of specialist by the Brazilian Society of Orthopedics and Traumatology (SBOT). Of these, 39 (97.5%) were approved on the first attempt, shortly after completing medical residency. Only one participant (2.5%) was approved in a subsequent attempt.
Subspecialization after Medical Residency
Of the 40 participants, 38 (95.0%) performed some type of subspecialization after completing their medical residency. Only two graduates (5.0%) did not start complementary training by the time of data collection, both with less than one year of residency completion. Table 2 shows the distribution of the chosen subspecialties. The fields with the highest frequency were knee (18.8%), hand and wrist (14.6%), foot and ankle (10.4%), and orthopedic trauma (10.4%), followed by areas such as pediatric orthopedics, shoulder and elbow, oncological orthopedics, hip, and spine (Table 2).
Regarding the location of the subspecialization centers, there was a predominant concentration in the Southeast region, especially in the state of São Paulo, which absorbed 42.1% of the graduates. Minas Gerais was the second most cited state. Training centers in other states were also mentioned, such as Ceará, the Federal District and São Paulo (interior).
In the North region, seven graduates (18.4%) underwent subspecializations in Belém, with emphasis on programs offered in hand surgery and spine surgery.
Among the 40 graduates analyzed, 33 (82.5%) were working professionally in the state of Pará at the time of collection. The capital Belém concentrated most of the activities, with n = 27 (67.5%), followed by Ananindeua (n = 9; 22.5%) and Barcarena (n = 8; 20.0%). In addition to the Metropolitan Region of Belém, municipalities in the interior were also mentioned, such as Abaetetuba, Breves, Castanhal, Cametá, Tucuruí, Tailândia, Breu Branco, Novo Repartimento and São João de Pirabas.
The color scale represents the absolute number of orthopedists working in each municipality at the time of collection. There is a greater concentration in Belém and municipalities in the Metropolitan Region, with a reduced presence in the interior of the state.
The thematic map was prepared based on data self-reported by the participants at the time of collection. The color scale represents the absolute number of orthopedists working in each municipality, ranging from 1 to 27. The highest concentration was observed in Belém, followed by Ananindeua and Barcarena. The figure shows the trend of retention in the Metropolitan Region of Belém, with less insertion in the municipalities of the interior.
Map of the distribution of medical residency graduates in Orthopedics and Traumatology by municipality of professional activity in the state of Pará.
Care production
Among the 33 orthopedists working in the state of Pará, 8,598 monthly outpatient visits were estimated, of which 3,059.4 (35.6%) were performed in the Unified Health System (SUS) and 5,538.6 (64.4%) in the private sector. The monthly average per graduate was 92.7 consultations in the SUS (± 56.2) and 167.8 in the private sector (± 86.4), totaling an average of 260.5 consultations/month per professional.
Only 10 graduates (30.3%) reported having 200 or more monthly consultations, and 8 of them were mostly linked to the private sector (Table 4).
Of the 33 orthopedists working in the state of Pará, a total of 816 surgical procedures per month were estimated, of which 383.2 (47.0%) were performed in the SUS and 432.8 (53.0%) in the private sector. The monthly average per graduate was 11.6 surgeries in the SUS (± 11.0) and 13.1 in the private sector (± 8.7), totaling an average of 24.7 procedures per professional/month (Table 4). Fourteen professionals (42.4%) reported performing 20 or more surgeries per month, equally distributed between the two sectors (n=7 each).
DISCUSSION
Medical residency is widely recognized as the most effective strategy for the training of specialists and, at the same time, a structuring policy in the territorial redistribution of the health workforce in Brazil and in the world10),(11),(12. However, the country still lives with a marked asymmetry between the supply of vacancies, the concentration of training centers and regional care needs, particularly in the North and Northeast regions. National and international studies show that the location of the residency program has a direct influence on the retention of professionals, functioning as a relevant determinant in the choice of the place of work, especially in areas traditionally underserved10),(13.
In the Orthopedics and Traumatology specialty, this scenario of imbalance becomes even more evident. Recent data indicate that the highest concentration of training programs remains restricted to the large centers of the South-Southeast axis, while states in the Brazilian Amazon, such as Pará, have a limited supply of specialized services and training in the area14. This unequal distribution directly impacts the population’s access to orthopedic care, forcing patients, especially from the interior of the Amazon, to travel long and time-consuming dislocations in search of specialized care15),(16),(17.
Sociodemographic profile
This study revealed a predominance of men (85%) with a mean age of less than 27 years, a characteristic that remains in line with the national orthopedics scenario, which is still marked by low female representation. Although surgical specialties such as general surgery show an upward trend in the participation of women, this advance is still slight in orthopedics 17.
More than half of the participants are from Belém, while the others came from municipalities in the interior of Pará or other states. Training and specialization in peripheral regions, when associated with affective or family ties, favor regional retention, as indicated by previous studies11),(13.
In addition, 82.5% of the graduates attended undergraduate courses in public institutions, which may reflect both the academic tradition of these schools in the North of the country and their consolidated insertion in the public health network. This information suggests not only the historical predominance of public universities in medical education in the North region but also evidences their consolidated capacity to contribute to the public health network, both in the training of human resources and in specialized care itself.
Motivations for choosing a residency
The thematic analysis of the motivations for choosing the specialty in Pará evidenced multiple interconnected factors, including affective-geographical ties, institutional recognition and logistical aspects. Proximity to family members, staying in their hometown, and reducing travel costs were decisive for many graduates, an aspect corroborated by studies that point to local origin as a key variable in the establishment of specialists in peripheral regions12),(13.
In the present study, the graduates also mentioned the recognition of the educational quality of the service, associated with the 97.5% approval rate in the Board Certification Exams of the Brazilian Society of Orthopedics and Traumatology (SBOT), as a decisive factor for choosing to reside in the state. The same was found in another study on vascular surgery in Pará, where 96.6% of surgeons reported interest in continuous qualification, especially in modern techniques, reflecting the importance of programs with the capacity for technological updating and local educational support2.
Another vector identified was career planning oriented towards professional insertion in the state itself, highlighting the desire to remain close to already consolidated professional, social and family networks. This dynamic reiterates a principle widely defended in the international literature: medical residency programs that are territorially linked to local realities fulfill not only a role of technical training, but also of organizing care in structurally underserved regions10)-(14, configuring residency as a powerful tool for regional development, capable of transforming not only individual professional trajectories, but also care and educational networks in the Brazilian Amazon.
Subspecialization
The search for complementary training was significant among the participants: 95% of the graduates completed at least one subspecialization after residency. The most frequent areas included knee, hand and wrist, foot and ankle, as well as orthopedic trauma - reflecting both the epidemiological demand and the concentration of offers in the main training institutions. About 40% chose to subspecialize in the state of São Paulo, followed by Minas Gerais, evidencing the centralization of advanced training in the Southeast and South regions12.
Only 18.4% remained in Belém for this complementary stage, choosing one of the two options currently available in the state: hand surgery - the oldest program - and spine surgery, implemented more recently. This limitation compromises the continuity of decentralization and represents an obstacle to the retention of professionals who seek to deepen their training in areas not contemplated locally.
An example of the infrastructure already installed is the Microsurgery Laboratory (LCE/UEPA), which functions as an official training center in hand surgery and maintains significant scientific production in the area14. The existence of this structure reinforces the technical and institutional potential for the expansion of R4 programs in the state, contributing to consolidate the state as a territory that trains specialists - and not only as a region dependent on traditional training centers in the South and Southeast.
The BMR concentrated 84.2% of the professional contracts informed, with a highlight to Belém (67.5%), Ananindeua (22.5%), Barcarena (20.0%) and Marituba (10.0%). The performance in more distant municipalities, such as Tucuruí, Tailândia, Breves and Cametá, was one-off, maintaining the pattern of metropolitan concentration. This trend is compatible with evidence that the implementation of medical residency programs favors state retention, but does not guarantee, by itself, micro-regional decentralization 2),(15),(17 (Fig 1)
This trend was also observed in a study with vascular surgeons working in Pará, which identified that 71.2% of the professionals were concentrated in the BMR, with a limited presence in the interior of the state2. In both contexts, the pattern of concentration in metropolitan regions seems to reflect not only individual choices, but also the unequal supply of infrastructure, specialized services, and training programs.
Assistance
In terms of assistance, most of the care (64.4%) was concentrated in the private sector, which may reflect both the unequal structure of access to orthopedics in the public network and the dynamism of the supplementary market in large cities. In the context of the state of Pará, in Belém, public coverage of the specialty is concentrated in only two emergency rooms in the capital and three hospitals in the Metropolitan Region, restricting outpatient access to orthopedics within the SUS and also a lack of specific public policies aimed at the insertion of orthopedists in the public service2.
Despite the continuing education of specialists through medical residency, the scarcity of civil service examinations, stable contracts, and outpatient programs makes it difficult to incorporate this workforce into the public network11),(14. As a result, a significant part of the professionals is absorbed by the private sector, which offers greater contractual flexibility and absorption capacity. The misalignment between specialized training and the actual structure of absorption in the SUS reveals a systemic challenge for the effective integration of orthopedics as an accessible specialty in secondary health care in the state of Pará2),(15.
In the regional context, in which the hospital infrastructure of medium complexity is restricted outside the capital, the presence of orthopedists with consolidated surgical training is strategic for the functioning of specialized services. However, the expansion of surgical production in the interior will depend on the expansion of hospitals with functional surgical blocks and the strengthening of inter-municipal agreements, in order to prevent the population of the interior from continuing to overload the tertiary services of the capital.
The analysis of the data reveals that the recent trend of migration of graduates to municipalities in the interior of the state does not occur spontaneously, but rather as a direct response to the saturation of the care market in the Metropolitan Region of Belém. This phenomenon reflects both the limitation of the few public services available, which are unable to absorb the growing number of trained specialists, and the fierce competition in the private sector, which already has a high degree of occupation by older and more consolidated professionals in the market.
The reports of the graduates themselves indicate that the search for insertion in municipalities in the interior is motivated, above all, by the opportunity to occupy market niches that are still little explored, less professional competition and the possibility of establishing more stable care practices, especially in cities with repressed demand for orthopedic services. Therefore, this migration does not necessarily reflect a successful public policy of decentralization, but rather an adaptation of professionals to the structural gaps of the health system, both public and private, in the capital.
Insertion in medical education and training
Half of the graduates interviewed (n = 20) reported actively participating in medical residency programs, acting as preceptors and supervisors (graduates who graduated in the first classes) in educational institutions. This information is particularly relevant, as it shows that the residency implemented in Pará has generated not only care specialists, but also professionals with academic engagement and a multiplying role, contributing to the maturation of the medical training ecosystem in the region. As a result, the professionals who remain in the Metropolitan Region not only continue to work in their training sites, but also start to directly guide new residents, which reinforces the institutional bond and favors the pedagogical continuity of the program.
Together, the data obtained demonstrate that the implementation of medical residency promoted not only quality technical training, but also consistent insertion of graduates in the regional market, with a measurable impact on care production and on the support of the training cycle itself. Such evidence reinforces the strategic relevance of policies that associate the expansion of vacancies with the structuring of the public network and the creation of local subspecializations, promoting the sustainability of orthopedic care in the Legal Amazon12),(14),(15).
Study limitations
This study has methodological limitations inherent to its observational design, such as the use of non-probabilistic convenience sampling and the possibility of recall bias, since the data were self-reported. Although it achieved 100% adherence, the results should be interpreted with caution when considering their generalization to other states or specialties.
Although the findings contribute to understanding the impact of medical residency in the North region, its applicability in other locations depends on factors such as care infrastructure, provision policies, and availability of training centers. Similar studies in different regional contexts can broaden the understanding of the structural effects of residency on the retention and distribution of specialists.
CONCLUSION
The study showed that, after 10 years of implementation, the Medical Residency Program in Orthopedics and Traumatology analyzed has a high rate of regional retention, with a predominance of action in the state of Pará, although concentrated in the capital. There was a wide insertion in the labor market, with a predominance of the private sector and relevant participation in the Unified Health System. Most of the graduates completed subspecialization, mostly outside the state, and half maintain a link with academic activities as preceptors or residency supervisors. These findings demonstrate that the program fulfills its role in the training of specialists and in the consolidation of regional orthopedic care, although challenges related to the decentralization of care and the expansion of the local supply of subspecializations persist.
ACKNOWLEDGMENTS
The authors would like to thank all the graduates of the medical residency program in Orthopedics and Traumatology at the Universidade do Estado do Pará (UEPA) who voluntarily participated in this study. They also thank the logistical support of the Porto Dias Hospital and UEPA, which made this research possible.
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Research data are only available upon request.
Source: prepared by the authors.