Brazil Has Many Physicians, Few Medical Residency Positions

Brazil has never had so many active physicians. The latest survey conducted by the Federal Council of Medicine (CFM) in 2023 revealed 575,930 active physicians, which corresponds to an average of 2.81 physicians per thousand inhabitants, representing the highest ratio ever recorded in the country.

What could seem like a relief and an indication that Brazil is increasingly prepared to deal with challenges in its healthcare sector hides a troubling fact: The number of specialists is not increasing at the same rate.

In practice, this means that fewer professionals are going through the medical residency (MR) program, which could result, according to those directly involved with the issue, in lower quality of care and more risks in patient care.

Dr Ângelo Fajardo Almeida, a member of CFM Young Physicians’ Integration Committee, is a resident in internal medicine at the University Hospital of Canoas, Rio Grande do Sul, Brazil. In conversation with the Medscape Portuguese edition, he highlighted the importance of this type of training. “Residency is today the gold standard in medical education. As I like to say, in college, we learn medicine, but it is in residency that we learn to be a doctor.” 

There are two main paths to becoming a specialist in Brazil, and this has also been the subject of extensive discussion. The more direct path, which is chosen by most professionals, runs through the residency program.

The other possibility is to obtain specialization through a title exam, after a lato sensu postgraduate degree or through recognized practice time. This path is more common in specialties that do not have widely available residency programs or that have more ambulatory characteristics, such as occupational medicine and homeopathy. It is also an option for physicians already in the workforce seeking formal recognition in a specific area without going through the intensive residency process.

The two modes of training may seem equivalent at first glance, and they may even be offered as if they were, but there are fundamental differences.

“The learning you have in a medical residency is unique because you almost live in the hospital, have direct contact with patients, are responsible for making decisions, and all of this under preceptor supervision, that person you can ask questions and who can support you,” said Almeida. “If you don’t do a residency, you may take a shift and have to draw your own conclusions.”

Medical Schools Proliferating

One of the issues with the current scenario is that with the increase in medical schools in Brazil, (the number of which, 389, has nearly quintupled in the past two decades), competition for residency is increasing. In some specialties, there are more than 10 candidates per position, and the number of positions is not growing at the same rate.

In an official statement, the president of CFM, José Hiran Gallo, expressed concern about the rapid opening of these new schools. “We know that a significant number of courses are in municipalities that do not meet the minimum criteria for the proper education of future physicians. In addition, there is a lack of qualified physicians in teaching positions; therefore, we are making Brazilian medicine precarious,” he said.

It is important to distinguish MR from the postgraduate courses offered by these new schools. “These are different types of education, with different objectives and structures, but sometimes they are advertised or presented as if they were the same thing, and this can be dangerous for the patient,” said Dr Daniel Montanini, a psychiatrist and supervisor of the Psychiatry Medical Residency Program of São Bernardo do Campo, São Paulo, Brazil.

The issue even involves legal disputes, including physicians fighting for the right to advertise themselves as specialists after completing a postgraduate course and considerable resistance from CFM.

In June, the Eighth Division of the Federal Regional Court of the First Region accepted an appeal filed by CFM and acknowledged the agency’s authority to issue normative acts related to medical advertising.

The rapporteur of the ruling, Judge Novély Vilanova, validated the regulation issued by the Council, citing an article in the Resolution that expressly prohibits the physician from advertising postgraduate education for pedagogical preparation in medical specialties and his or her areas of practice, even in official institutions.

Measures such as these are important to prevent behaviors that happen informally each day, according to Montanini. “I see this happening a lot on social media. If a doctor presents himself there as ‘providing psychiatric care’ but is not a specialist, this misleads the patient, who cannot differentiate.”

The psychiatrist also emphasized that this question is not a “fight” against postgraduate programs, but an attempt to further value the residency. “Most doctors want to do residency, but not everyone can get a position because there aren’t enough openings for everyone, and then postgraduate programs end up being an option.”

Medical Residency Today

The Medical Demographics in Brazil 2023 study, conducted by the University of São Paulo Medical School in partnership with the Brazilian Medical Association — not to be confused with the CFM study of the same name — analyzed the issue.

In 2022, Brazil had 321,581 specialist physicians, corresponding to 62.5% of professionals active in the country, according to the authors. The remaining 192,634 physicians (37.5%) were general practitioners.

In Brazil, it is not mandatory to enter MR to practice medicine. Some physicians postpone entry or decide not to pursue MR and work as general practitioners or seek another form of specialized training.

“Despite the increase in the number of physicians, residency positions are not growing at the same rate, and many existing positions remain unfilled. It is crucial to investigate the reasons behind these vacancies and understand the factors contributing to this mismatch,” said Almeida.

One reason for this, in his opinion, is linked to an imbalance in the distribution of positions. In 2021, for example, the 41,853 physicians enrolled in MR represented approximately 8% of the total professionals active in Brazil. Although this number is significant, residents, residency programs, and the institutions that maintain them remain unevenly distributed across the country.

The Southeast Region accounted for 56.1% of medical residents in 2021, followed by the Northeast (16.7%) and South (16.1%) Regions. The Central-West (7.5%) and North (3.6%) Regions had the smallest proportions of residents.

Financial considerations may also be an important factor. For newly graduated physicians, the years of residency mean hard work, little free time, and a tight budget, with a scholarship now set at R$4106.09. In major cities, this amount may be insufficient, as reported by Medscape Medical News in the “Residency Survival Guide.” Without time to take shifts or other jobs to supplement income, staying in the residency may become unviable, especially if the candidate has financial dependents.

It is the role of medical students who aspire to pursue residency, as well as the entire medical community, to expand and enhance the MR network and opportunities for new professionals, according to Montanini. “We need to organize ourselves politically, create the necessary conditions to open new positions. That’s what will improve the lives of physicians and, most importantly, of the population,” he concluded.

Potential Contributing Factors

Why is the number of specialists not keeping pace with the growing number of graduated physicians? Potential reasons include the following: 

• Lack of infrastructure and funding. Creating MR positions requires significant investments in teaching hospitals, preceptors (guiding physicians), equipment, and educational resources. Many hospitals and institutions claim to lack the financial resources or sufficient structure for these investments.
• Unequal distribution of positions. Residency positions are concentrated in the more developed regions of the country, especially in the Southeast, while many underserved regions have few opportunities for specialization. This inequality limits the growth of residents in areas with higher demand.
• Bureaucracy and regulation. The creation of new MR positions is regulated by the Ministry of Education and the Ministry of Health, with strict requirements to ensure the quality of education and patient safety. The accreditation process can be lengthy and complex, thus delaying the opening of these positions.
• Disinterest in certain specialties. Some residency areas, such as family and community medicine, face a lack of interest from newly graduated physicians, especially due to the perception of lower status or less competitive salaries. This perception affects the distribution of positions in some specialties.
• Divergence between educational and health policies. While the Ministry of Education encourages the creation of new medical schools and the expansion of positions, public health policies do not always prioritize corresponding increases in residency positions. This discrepancy creates a misalignment between physician training and specialization.
• Low remuneration and suboptimal working conditions. In many cases, the working conditions and remuneration during MR are not attractive, which can limit institutions’ interest in expanding the number of positions.

This story was translated from theMedscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.