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Medicina Hospitalar no Brasil

G
Guilherme Barcellos

This document discusses healthcare in Brazil and the development of hospital medicine (HM) there. Some key points: - Brazil has a large public healthcare system as well as private services, but there is disparity between the two. - HM began emerging in Brazil around 2004, with the founding of hospitalist societies. Early hospitalists often had multiple jobs across settings. - HM is now growing, with more full-time hospitalists and hospital employment. However, some private hospitals still do not fully utilize dedicated hospitalists. - The future of HM in Brazil includes further defining the roles of generalists and specialists and improving certification processes to support different care models.

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Guilherme Brauner Barcellos, MD, SFHM Brazilian Academy of Hospital Medicine (ABMH) Choosing Wisely Brasil National Harbor, 2019 - Society of Hospital Medicine Meeting
* The largest one in South America; * The world's fifth largest country, both by geographical area and by population; * There are private and public healthcare services. They should be complementary, but dysfunctional competition is common. * Public health care universal and free - is provided to all Brazilian permanent residents and foreigners in Brazilian territory as a Constitutional Right through the National Health Care System, known as SUS; * Fee For Service predominates in the private health care, but new payment models are [slowly] coming; * It is still a country of disparities, where overuse and underuse of medical interventions coexist in both private and public practices, even with the underfunding of the public ones.
A country of disparities: * Disparities between private system and pubic system * Disparities between private hospitals * At the public system, some hospitals are islands of excellence
Medicina Hospitalar no Brasil
More developed ones Less developed ones or, at least, less well know Better-quality hospitals (in average)
When an organized movement began around 2004, there were a few doctors working as real hospitalists, some as independent practitioners, other as hospital employees. There were more part-time contracts than part-time hospitalists, because a social agreement in which it was ok for physicians to visit hospitalized patients, prescribe and go for the next job. Transparency and other external forces are determining the execution of the contracts in accordance with the terms. Multiple jobs are still very common here, but theyre decreasing. Hospital employment and medical group participations are increasing. Brazil created two hospitalists independent societies* and a chapter inside the Brazilian Society of Internal Medicine. * I founded both, but Im now entirely dedicated for the ABMH. I would love to say that these organized movements of healthcare professionals were the main drivers (and so my groups efforts), but it was the high pressure environment, crying out for efficiency, that drove forward Brazilian HM, together with new reimbursement models, surgical redesigns, primary care recognition and structuration plus a new way to understand the role of the subspecialist (both unusual yet, at least in practice, but vital for a more strategic role of the Generalism here and for the hospitalist model effective consolidation) and other external factors. HM is in Brazil to stay! The main challenges for the ABMH are to promote hospitalist pride and HM as a sustainable career.
Fancy private hospitals announce hospitalists, but in general they dont have it. Its a physician [usually young, usually woman] that restricts her work to emergent / urgent / bureaucratic needs of inpatients when the owner is not present. And hes absent most of the day (). These hospitals often see themselves as hostages of dysfunctional relationships with physicians recognized as good business partners they bring patients and they order expensive procedures and tests. But efficiency is now part of the equation as well as new value-based reimbursement models are coming. Will these organizations migrate to real hospitalists or keep the current model, a one that a lot of us dont want to work on it, but could be a temporary job while you are in the begging of your career, looking forward to being an illustrious subspecialist? But we do have at ordinary hospitals dozens (considering part-time jobs: hundreds) of physicians doing exactly what my US hospitalist friends do in a typical work day!
Comparing HM across some countries, we could see that the US and Portugal embrace the generalist coordinator. Some European countries have a subespecialist as the inpatient physician of reference, like a pneumologist or a cardiologist (Italy is like this, but the increasing prevalence of the multimorbid complex patient is promoting the "generalist concept). In Brazil, we are at an earlier planning stage: role of generalists and subspecialists is not clear and the same physician could do both at the same period. The role of certifications is not clear also. So its common to see someone that is a certificated arrhythmologist on Wednesdays and works Monday at a Rapid Response Team, Tuesday at an Emergency Department (without the specific certification) and Friday at an ICU (without the specific certification). That's something we need to improve in order to have a sustainable growth and to valorize different medical specialties and teamwork. Brazilian millennials want convenient care - for them! Need of more intelligent regulation while think the system as unique? Need of residency and fellowship supplies and demands better controls? NEED A GENERALIST REVOLUTION?
2004 2007 2008 2010 2011 2012 GEAMH - when everything started First meeting in Brazil about HM National Meeting PASHA First meeting in Brazil about Pediatric HM Transition of Care National Conference 2014/16/18 National Meetings
* Group of Studies and Updates in Hospital Medicine * 2005: First Website in Brazil about Hospitalists
* Porto Alegre, Rio Grande do Sul, Brasil * Participation of Jamie Newman, at that time editor of The Hospitalist * Mayo Clinic support
* Gramado, Rio Grande do Sul, Brasil * Participation of Jamie Newman, Jeanne Huddleston (former president of the SHM) end other Mayo Clinic physicians + Neil Winawer (Emory). * Drove forward the first boom
PASHA2010 * Florian坦polis * A multinational initiative * ~20 non Brazilian speakers * Drew the attention of the mainstream media - article entitled The hospitalists are coming was published in Folha de S達o Paulo, the largest newspaper by daily circulation in Brazil.
Medicina Hospitalar no Brasil
Medicina Hospitalar no Brasil
Medicina Hospitalar no Brasil
* Porto Alegre * Participation of Ricardo Quinonez and Geeta Singhal, Texas Children's Hospital
* First meeting in Brazil (Florian坦polis) on how to promote effective transitions of care at hospital discharge as a multispecialty initiative: * Hospitalists representatives * Brazilian Society of Medicine of Family and Community (SBMFC) * Brazilian Association for Emergency Medicine (ABRAMEDE) * Participation of Sunil Kripalani, Vanderbilt University
Participation of: Neil Winawer (Emory University) Aleta Borrud (Mayo Clinic) John Bulger (Geisinger Medical Center)* * Bulger planted the first seeds of the Choosing Wisely Movement in Brazil.
Participation of: Ron Greeno (Society of Hospital Medicine) Neil Winawer (Emory University) Aleta Borrud (Mayo Clinic) Vandad Yousef (Canadian Society of Hospital Medicine) Jeanne Huddleston (Mayo Clinic) John Nelson (Society of Hospital Medicine)
Participation of: John Nelson (Society of Hospital Medicine) Amit Pahwa (Johns Hopkins) Fernando Rivera (Mayo Clinic) Thomas Kingsley (Mayo Clinic) Adrian Dumitrascu (Mayo Clinic) Neil Winawer (Emory University)
Electronic collection of almost all the presentations
* Partnership between an EBM champion and lots of hospitalists and other generalists around the country.
* Hospital Divina Provid棚ncia * Porto Alegre * 165 beds * Two full-time hospitalists * Two part-time hospitalists Drastically reduction on length of stay extra beds created; Reduction on readmissions compared with traditional internists; Satisfaction of the wards multidisciplinary team.
Medicina Hospitalar no Brasil
And you are invited to visit us! Twitter@brhospitalist gbbarcellos@gmail.com

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Medicina Hospitalar no Brasil

  • 1. Guilherme Brauner Barcellos, MD, SFHM Brazilian Academy of Hospital Medicine (ABMH) Choosing Wisely Brasil National Harbor, 2019 - Society of Hospital Medicine Meeting
  • 2. * The largest one in South America; * The world's fifth largest country, both by geographical area and by population; * There are private and public healthcare services. They should be complementary, but dysfunctional competition is common. * Public health care universal and free - is provided to all Brazilian permanent residents and foreigners in Brazilian territory as a Constitutional Right through the National Health Care System, known as SUS; * Fee For Service predominates in the private health care, but new payment models are [slowly] coming; * It is still a country of disparities, where overuse and underuse of medical interventions coexist in both private and public practices, even with the underfunding of the public ones.
  • 3. A country of disparities: * Disparities between private system and pubic system * Disparities between private hospitals * At the public system, some hospitals are islands of excellence
  • 5. More developed ones Less developed ones or, at least, less well know Better-quality hospitals (in average)
  • 6. When an organized movement began around 2004, there were a few doctors working as real hospitalists, some as independent practitioners, other as hospital employees. There were more part-time contracts than part-time hospitalists, because a social agreement in which it was ok for physicians to visit hospitalized patients, prescribe and go for the next job. Transparency and other external forces are determining the execution of the contracts in accordance with the terms. Multiple jobs are still very common here, but theyre decreasing. Hospital employment and medical group participations are increasing. Brazil created two hospitalists independent societies* and a chapter inside the Brazilian Society of Internal Medicine. * I founded both, but Im now entirely dedicated for the ABMH. I would love to say that these organized movements of healthcare professionals were the main drivers (and so my groups efforts), but it was the high pressure environment, crying out for efficiency, that drove forward Brazilian HM, together with new reimbursement models, surgical redesigns, primary care recognition and structuration plus a new way to understand the role of the subspecialist (both unusual yet, at least in practice, but vital for a more strategic role of the Generalism here and for the hospitalist model effective consolidation) and other external factors. HM is in Brazil to stay! The main challenges for the ABMH are to promote hospitalist pride and HM as a sustainable career.
  • 7. Fancy private hospitals announce hospitalists, but in general they dont have it. Its a physician [usually young, usually woman] that restricts her work to emergent / urgent / bureaucratic needs of inpatients when the owner is not present. And hes absent most of the day (). These hospitals often see themselves as hostages of dysfunctional relationships with physicians recognized as good business partners they bring patients and they order expensive procedures and tests. But efficiency is now part of the equation as well as new value-based reimbursement models are coming. Will these organizations migrate to real hospitalists or keep the current model, a one that a lot of us dont want to work on it, but could be a temporary job while you are in the begging of your career, looking forward to being an illustrious subspecialist? But we do have at ordinary hospitals dozens (considering part-time jobs: hundreds) of physicians doing exactly what my US hospitalist friends do in a typical work day!
  • 8. Comparing HM across some countries, we could see that the US and Portugal embrace the generalist coordinator. Some European countries have a subespecialist as the inpatient physician of reference, like a pneumologist or a cardiologist (Italy is like this, but the increasing prevalence of the multimorbid complex patient is promoting the "generalist concept). In Brazil, we are at an earlier planning stage: role of generalists and subspecialists is not clear and the same physician could do both at the same period. The role of certifications is not clear also. So its common to see someone that is a certificated arrhythmologist on Wednesdays and works Monday at a Rapid Response Team, Tuesday at an Emergency Department (without the specific certification) and Friday at an ICU (without the specific certification). That's something we need to improve in order to have a sustainable growth and to valorize different medical specialties and teamwork. Brazilian millennials want convenient care - for them! Need of more intelligent regulation while think the system as unique? Need of residency and fellowship supplies and demands better controls? NEED A GENERALIST REVOLUTION?
  • 9. 2004 2007 2008 2010 2011 2012 GEAMH - when everything started First meeting in Brazil about HM National Meeting PASHA First meeting in Brazil about Pediatric HM Transition of Care National Conference 2014/16/18 National Meetings
  • 10. * Group of Studies and Updates in Hospital Medicine * 2005: First Website in Brazil about Hospitalists
  • 11. * Porto Alegre, Rio Grande do Sul, Brasil * Participation of Jamie Newman, at that time editor of The Hospitalist * Mayo Clinic support
  • 12. * Gramado, Rio Grande do Sul, Brasil * Participation of Jamie Newman, Jeanne Huddleston (former president of the SHM) end other Mayo Clinic physicians + Neil Winawer (Emory). * Drove forward the first boom
  • 13. PASHA2010 * Florian坦polis * A multinational initiative * ~20 non Brazilian speakers * Drew the attention of the mainstream media - article entitled The hospitalists are coming was published in Folha de S達o Paulo, the largest newspaper by daily circulation in Brazil.
  • 17. * Porto Alegre * Participation of Ricardo Quinonez and Geeta Singhal, Texas Children's Hospital
  • 18. * First meeting in Brazil (Florian坦polis) on how to promote effective transitions of care at hospital discharge as a multispecialty initiative: * Hospitalists representatives * Brazilian Society of Medicine of Family and Community (SBMFC) * Brazilian Association for Emergency Medicine (ABRAMEDE) * Participation of Sunil Kripalani, Vanderbilt University
  • 19. Participation of: Neil Winawer (Emory University) Aleta Borrud (Mayo Clinic) John Bulger (Geisinger Medical Center)* * Bulger planted the first seeds of the Choosing Wisely Movement in Brazil.
  • 20. Participation of: Ron Greeno (Society of Hospital Medicine) Neil Winawer (Emory University) Aleta Borrud (Mayo Clinic) Vandad Yousef (Canadian Society of Hospital Medicine) Jeanne Huddleston (Mayo Clinic) John Nelson (Society of Hospital Medicine)
  • 21. Participation of: John Nelson (Society of Hospital Medicine) Amit Pahwa (Johns Hopkins) Fernando Rivera (Mayo Clinic) Thomas Kingsley (Mayo Clinic) Adrian Dumitrascu (Mayo Clinic) Neil Winawer (Emory University)
  • 22. Electronic collection of almost all the presentations
  • 23. * Partnership between an EBM champion and lots of hospitalists and other generalists around the country.
  • 24. * Hospital Divina Provid棚ncia * Porto Alegre * 165 beds * Two full-time hospitalists * Two part-time hospitalists Drastically reduction on length of stay extra beds created; Reduction on readmissions compared with traditional internists; Satisfaction of the wards multidisciplinary team.
  • 26. And you are invited to visit us! Twitter@brhospitalist gbbarcellos@gmail.com