Through a series of exciting initiatives, family medicine is poised to improve primary health care in Brazil. In 1988 the Brazilian Federal Constitution declared that all Brazilian citizens have the right to primary health care services. In 1994, the Brazilian government established the Family Health Program (PSF- Programa de Saúde da Família), to train, distribute and support primary health care teams. Each team is responsible for the health care of 3,000 people. The Brazilian government has allocated resources support to the PSF, funded the establishment of residency programs in family medicine, and has guaranteed jobs with competitive salaries for residents after graduation. Yet many challenges must be addressed for family medicine to fulfill this potential.

The Public Health System (SUS- Sistema Unico de Saúde) is responsible for development and support of the Brazilian primary health care system. Universities and medical schools are responsible for preparing health professionals to deliver such care. However, medical schools continue to focus on preparing students to care for hospitalized patients. Most medical schools and have not yet integrated family medicine into the curriculum.

The expansion of the PSF is now limited by a severe shortage of appropriately trained personnel including family physicians. Without a clear identity, core educational objectives, and a well- defined process for certification, it is difficult to attract young professionals to family medicine careers. While there remains a mismatch between the comprehensive health plans initiated by the government and the type of physicians that are being trained, there are several initiatives in progress to address these challenges.

Specialists and Generalists in Brazil

Currently more than 50% of Brazilian medical school graduates are unable to secure residency training positions. Family medicine is not yet a defined specialty in Brazil and is not incorporated into the curriculum of most medical schools. While a minority of those practicing general medicine do so by choice, the majority of generalist physicians were unable to complete specialty training. Practicing generalists have limited access to continuing medical education and there is no examination or certification process to evaluate the quality of these professionals. As a result generalist physicians are commonly perceived as a second rate health care professionals.

Congress lunch with Joshua Freeman and 10 medical schools reached by Sobramfa.
The traditional Brazilian food named FEIJOADA.

Sobramfa's poster presentation at the 2003 Society of Teachers of Family Medicine (USA)
Annual Meeting

Family Medicine has been a specialty in some countries for more than 40 years, yet many countries and medical schools have not yet incorporated family medicine into medical education. The presence of family medicine in the medical school curriculum allows transmission of the content and values, and provides opportunities for students to participate in delivery of comprehensive primary health carea. Well-trained family physicians can provide services required for robust primary health care programsc.

Students need exposure to family medicine early in the course of training to gain an understanding of the discipline and to consider family medicine as a career choice.
Grumbach describes the importance of generalist family physicians in academic settingsc. All patients, especially patients with chronic illnesses, mutliple co-morbidities and complex family circumstances benefit from working with a heatlh professional who can approach these problems from a broad perspective. A family physician offers more than a simple sum of solutions to the diverse health problems from which the patient suffers. The family physician provides a new perspective in patient care, a different gestalt, and a vision to address patients and their needs in a compehensive fashion. This new paradigm may be presented, experienced, taught and learned in medical education. If family medicine is incorporated into academia, it is better positioned to teach, set standards and provide continuing education for those who practice primary care.

Family Medicine in Brazil: Opportunities and Challenges

There are many opportunities for family medicine to strengthen the primary health care system of Brazil. The Brazilian Government has made a bold commitment to establish the PSF to provide primary health care. Family doctors are needed to join efforts to deliver comprehensive primary health care and improve the health system of Brazil.

Medical schools are beginning to make commitments to prepare well-trained primary care physicians to fill the need created by the PSF. If academic efforts are carefully organized, coordinated and promoted, they will be better able to attract medical students into family medicine.

Residency programs in family medicine are now scattered in diverse departments such as public health, preventive medicine, community medicine, or coordinated by multiple other specialties, resulting in a lack of consistency and identity. While these programs represent a serious effort to respond to community needs and produce physicians for the PSF, uniform standards, core curricula and certification will help these programs gain credibility within the academic community. Universities can fulfill their commitment to society by coordinating these efforts.

Generalist physicians who are practicing primary care may join with their colleagues in academia and professional societies to establish a rigorous process of certification and programs of continuing education. Practicing physicians are well positioned to identify gaps in their training and to design programs to improve their knowledge and skills.

Students can make powerful contributions to the growth of family medicine in Brazil. SOBRAMFA (the Brazilian Society of Family Medicine) has already played an important role in this processd by creating opportunities outside the formal medical school setting for students to experience family medicine by working with practicing generalists.

SOBRAMFA's Delegation at STFM Meeting

SOBRAMFA's 2001 student congress staff

Private health insurers are seeking to improve health care quality, cost effectiveness, coordination and responsiveness. Family physicians are in an excellent position to work with insurers to design and deliver such care.

Towards a Healthy Future for Brazil

Brazil is uniquely poised to strengthen primary health care with family medicine. Representatives of the government, academic institutions, health professionals, students, community members and insurers can each make valuable contributions to address this challenge. Efforts are underway to define the specialty, to establish benchmarks of quality, and to develop and promote Brazilian family medicine.

The Brazilian Medical Association (AMB) has indicated interest in sponsoring a national
conference on family medicine to involve key stakeholders. While there are
many challenges ahead, Brazilian family medicine is planted on fertile ground and ready
for rapid growth. The desire to improve the quality of life and health of the Brazilian
population inspires collective efforts to meet these challenges.

Pablo González Blasco, MD, PhD
Scientific Director, SOBRAMFA- Brazilian Society of Family Medicine.
pablogb@sobramfa.com.br

Marcelo Levites
Director for Residency Programs, SOBRAMFA
marcelolevites@sobramfa.com.br

Joshua Freeman, MD
Professor and Chair, Department of Family Medicine.
University of Kansas School of Medicine
jfreeman3@kumc.edu

Cynthia Haq, MD
Professor and Director of International Health
University of Wisconsin Medical School
chaq@fammed.wisc.edu

a. McWHINNEY, I. (1997) A textbook of Family Medicine. New York. Oxford University Press.
b. Boelen C, Haq C, Hunt V, Rivo M, Shahady E. Improving Health Systems: the Contribution of Family Medicine; a Guidebook.
Singapore: Wonca (World Academy of Family Doctors), Bestprint publications, 2002.
c. Grumbach,K, Chronic Illness, Comorbidities, and the Need for Medical Generalism. Annals of Family Medicine. 1: 1, 4-6, 2003.
d. www.sobramfa.com.br