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OBJECTIVE: The objective of this study was to investigate the newly graduated physicians' attitudes and perceptions regarding the medical relationship with the pharmaceutical industry and identify the sociodemographic patterns related to such thinking. METHODS: A structured questionnaire was administered to 4,601 participants selected from a pool of 16,323 physicians who were registered with one of the 27 Regional Medical Councils of Brazil in 2015. Answers were analyzed using two stratification variables: type of medical school (public vs. private) and the sex of the respondents. RESULTS: Out of the participants, 61.8% believed that industry funding could support medical conferences and education, and 48.4% felt that small gifts and conference travel funding were acceptable. Conversely, 64.7% disagreed with industry-sponsored social events. Views on whether pharmaceutical representatives' visits influenced prescriptions were divided. Statistically significant differences were observed between genders and medical school types, with men and private school graduates being more accepting of certain industry interactions. CONCLUSION: The study highlights the nuanced attitudes of new doctors toward industry relationships, indicating the need for clearer ethical guidelines and education in medical schools to align practice with evolving societal values.

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OBJECTIVE: The objective of this study was to investigate the newly graduated physicians' attitudes and perceptions regarding the medical relationship with the pharmaceutical industry and identify the sociodemographic patterns related to such thinking. METHODS: A structured questionnaire was administered to 4,601 participants selected from a pool of 16,323 physicians who were registered with one of the 27 Regional Medical Councils of Brazil in 2015. Answers were analyzed using two stratification variables: type of medical school (public vs. private) and the sex of the respondents. RESULTS: Out of the participants, 61.8% believed that industry funding could support medical conferences and education, and 48.4% felt that small gifts and conference travel funding were acceptable. Conversely, 64.7% disagreed with industry-sponsored social events. Views on whether pharmaceutical representatives' visits influenced prescriptions were divided. Statistically significant differences were observed between genders and medical school types, with men and private school graduates being more accepting of certain industry interactions. CONCLUSION: The study highlights the nuanced attitudes of new doctors toward industry relationships, indicating the need for clearer ethical guidelines and education in medical schools to align practice with evolving societal values.

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OBJECTIVES: To examine physicians' perceptions of changing employment opportunities in Brazil, and gain an insight into labour markets in low/middle-income countries (LMICs) during the pandemic. STUDY DESIGN: Descriptive and inferential analysis of a quantitative dataset from a representative cross-sectional survey of physicians of two Brazilian states. SETTINGS: São Paulo and Maranhão states in Brazil. PARTICIPANTS: Representative sample of 1183 physicians. OUTCOME MEASURES: We estimated prevalence and 95% CIs for physicians' perceptions of changes in demand and supply of doctors, as well as changes in prices of medical services for facilities of practice in the two states, stratified by public, private and dual-practice physicians. RESULTS: Most doctors reported increased job opportunities in the public sector (54.9%, 95% CI 52.0% to 57.7%), particularly in Maranhão state (65.0%, 95% CI 60.9% to 68.9%). For the private sector, increased opportunities were reported only in large private hospitals (46.7%, 95% CI 43.9% to 49.6%) but not in smaller clinics. We recorded perceptions of slight increases in availability of doctors in Maranhão, particularly in the public sector (51.4%, 95% CI 43.2% to 59.5%). Younger doctors recounted increased vacancies in the public sector (64%, 95% CI 58.1% to 68.1%), older doctors only in walk-in clinics in Maranhão (47.5%, 95% CI 39.9% to 55.1%). Those working directly with patients with COVID-19 saw opportunities in public hospitals (65%, 95% CI 62.3% to 68.4%) and in large private ones (55%, 95% CI 51.8% to 59.1%). CONCLUSIONS: Our findings hint that health labour markets in LMICs may not necessarily shrink during epidemics, and that impacts will depend on the balance of public and private services in national health systems.

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OBJECTIVE: The objective of this study was to evaluate fresh medical graduates' perceptions regarding the general aspects of ethics teaching in Brazilian medical schools. METHODS: A structured questionnaire was applied to 4,601 participants among the 16,323 physicians who registered in one of the 27 Regional Medical Councils of Brazil in 2015. Answers to four questions regarding general aspects of ethics education in medical school were analyzed. Sampling procedures involved two stratification variables: legal nature (public vs. private) of medical schools and monthly household income higher than 10 minimum wages. RESULTS: A large percentage of the participants had witnessed unethical behaviors during contact with patients (62.0%), toward coworkers (51.5%), and in relationships with patients' families (34.4%) over the course of their medical training. Even though most of the responders (72.0%) totally agreed that patient-physician relationship and humanities education were part of their medical school curriculum, important topics such as conflicts of interest and end-of-life education were not satisfactorily addressed in the participants' medical training. Statistically significant differences were found between the answers of public and private school graduates. CONCLUSION: Despite great efforts to improve medical ethics education, our findings suggest the persistence of deficits and inadequacies in the ethics training currently given in medical schools in Brazil. Further modifications in ethics training must be made to address the deficiencies shown in this study. This process should be accompanied by continuous evaluation.

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BACKGROUND: The short tenure of primary care physicians undermines the continuity of care, compromising health outcomes in low-, middle and in high-income countries. The purpose of this study was to investigate the contextual and individual factors associated with the tenure of physician in Primary Health Care (PHC) services. We consider individual-level sociodemographic variables such as education and work-related variables, as well as the characteristics of employers and services. METHODS: This study is a retrospective cohort study of 2,335 physicians in 284 Primary Health Care Units across the São Paulo, Brazil, public health care system from 2016 to 2020. A multivariate hierarchical model was selected, and an adjusted Cox regression with multilevel analysis was employed. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used to report the findings from the study. RESULTS: The average physician tenure was 14.54 ± 12.89 months, and the median was 10.94 months. Differences between Primary Health Care Units accounted for 10.83% of the variance observed in the outcome, while the employing organizations were responsible for only 2.30%. The physician characteristics associated with higher tenure in PHC were age at hire, i.e., being between 30 and 60 years old, [HR: 0.84, 95% CI: (0.75-0.95)] and professional experience over five years [HR: 0.76, 95% CI: (0.59-0.96)]. Specialties not related to PHC practices were associated with a short tenure [HR: 1.25, 95% CI: (1.02-1.54)]. CONCLUSION: Differences between Primary Health Care Units and in the individual characteristics, such as specializations and experience, are related to the low tenure of professionals, but such characteristics can be changed through investments in PHC infrastructure and changes in work conditions, policies, training, and human resource policies. Finding a remedy for the short tenure of physicians is essential for guaranteeing a robust PHC system that can contribute to universal, resilient, and proactive health care.

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SUMMARY OBJECTIVE: The objective of this study was to evaluate fresh medical graduates' perceptions regarding the general aspects of ethics teaching in Brazilian medical schools. METHODS: A structured questionnaire was applied to 4,601 participants among the 16,323 physicians who registered in one of the 27 Regional Medical Councils of Brazil in 2015. Answers to four questions regarding general aspects of ethics education in medical school were analyzed. Sampling procedures involved two stratification variables: legal nature (public vs. private) of medical schools and monthly household income higher than 10 minimum wages. RESULTS: A large percentage of the participants had witnessed unethical behaviors during contact with patients (62.0%), toward coworkers (51.5%), and in relationships with patients' families (34.4%) over the course of their medical training. Even though most of the responders (72.0%) totally agreed that patient-physician relationship and humanities education were part of their medical school curriculum, important topics such as conflicts of interest and end-of-life education were not satisfactorily addressed in the participants' medical training. Statistically significant differences were found between the answers of public and private school graduates. CONCLUSION: Despite great efforts to improve medical ethics education, our findings suggest the persistence of deficits and inadequacies in the ethics training currently given in medical schools in Brazil. Further modifications in ethics training must be made to address the deficiencies shown in this study. This process should be accompanied by continuous evaluation.

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Aim: In anticipation of the implementation of personalized medicine in Brazil the authors assessed the characteristics of its medical genetics workforce together with the distribution of genetic diseases and services across the country. Materials & methods: The authors used demographic data on medical specialties, and summarized data from the public and private healthcare systems on live births, hospitalization and mortality, for the years 2019 and 2020. Results: The distribution of medical geneticists (MGs) overlapped the country-wide distribution of genetic diseases and services examined, indicating that ∼30% of the patient population has access to a MG specialist. Graduate specialism in medical genetics, registered MGs and suitable workplaces were concentrated in the south and southeast regions, leaving the north and northeast deeply underserved. Conclusion: MGs are concentrated in the wealthiest and most populated areas, while other regions have very limited services. These inequalities should be addressed for a successful transition to personalized medicine.

Personalized, or precision, medicine promotes the incorporation of information on an individual's genetic profile, and environmental and lifestyle exposures in the clinic to prevent and treat diseases. While personalized medicine is closer to being a reality in industrialized countries, it is unclear whether the conditions for its implementation exist in developing nations. The authors assessed the situation in Brazil, a country with a free-at-point-of-care universal health system, and private health insurance coverage for ∼30% of its population. The authors found that a majority of medical geneticists and genetic services were based in the south and southeast regions, which are also the wealthiest and most populated, leaving the other regions largely underserved. In addition, the authors identified a need to curb public­private healthcare asymmetries in medical genetics in order to reduce the observed inequalities.

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BACKGROUND: The use of telemedicine, or the provision of healthcare and communication services through distance-based technologies, has increased substantially since the 2019 novel coronavirus (COVID-19) pandemic. However, it is still unclear what are the innovative features of the widespread use of such modality, its forms of employment and the context in which it is used across pluralist health systems, particularly in low- and middle-income settings. We have sought to provide empirical evidence on the above issues by analysing the responses of medical doctors in a representative cross-sectional survey in two states in Brazil: São Paulo and Maranhão. METHODS: We analysed the responses of 1,183 physicians to a survey on the impact of COVID-19 on their livelihood and working practice. Two independent samples per state were calculated based on a total of 152,511 active medical registries in São Paulo and Maranhão. Proportional stratified sampling was performed and the distributions for gender, age, state and location of address (capital or countryside) were preserved. The survey contained questions on the frequency of physicians' employment of telemedicine services; the specific activities where these were employed, and; the forms in which the pandemic had influenced the adoption or consolidation of this technology. We performed descriptive and univariate analysis based on the chi-square test or Fisher's exact test for the qualitative data, and the Mann-Whitney test in the quantitative cases. Data were shown as absolute frequency and proportion with a 95% confidence interval. RESULTS: In our sample of physicians, telemedicine was employed as a form of clinical collaboration by most doctors (76.0%, 95 CI 73.6-78.5), but only less than a third of them (30.6%, 95 CI 28.0-33.3) used it as a modality to provide healthcare services. During the pandemic, telemedicine was used predominantly in COVID-19-related areas, particularly for hospital-based in-patient services, and in private clinics and ambulatory settings. Male, younger doctors used it the most. Doctors in São Paulo employed telemedicine more frequently than in Maranhão (p < 0.001), in urban settings more than in rural areas (p < 0.001). Approximately three-quarters of doctors in large hospitals reported using telemedicine services (78.3%, 95 CI 75.9-80.6), followed by doctors working for smaller private clinics (66.4%, 95 CI 63.7-69.1), and by a smaller proportion of primary care doctors (58.4%, 95 CI 55.6-61.2). CONCLUSIONS: Our study suggests that telemedicine may have helped ensure and expand the range of communication and healthcare services in low- and middle-income settings during the COVID-19 pandemic. However, the modality appears to lend itself to be disproportionally used by doctors working in specific, priviledged sections of pluralistic health systems, and presumably by patients seeking care there. Regulation and incentives will be required to support the use of the technology across health systems in low- and middle-income countries in order to increase access to services for less disadvantaged populations.

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The study describes the history of legislation, analyzes the trajectory and the amount of foreign capital in the Brazilian health system. The Organic Health Law restricted the participation of foreign capital; sectoral legislation, however, allowed its subsequent entry into supplementary medical care and, in 2015, a new law promoted unrestricted openness, including in hospitals and healthcare services. Our study analyzes documents, legislation, and data obtained from secondary public bases or via the Law on Access to Information. Direct investments and merger and acquisition acts in the private health sector were considered. Five phases were identified: inaugural planning, regulated expansion, legal restriction, sectorized release, and expanded opening. From 2016 to 2020, the amount of foreign resources entering the country's healthcare services was almost ten times more than the previous five-year period. Thirteen companies or funds were identified, most of them from the United States. Regulation allowing for the opening of foreign capital were preceded by business lobbies and public-private interactions that can affect the quality of public policies and the integrity of the legislative process. The invested capital seeks established and profitable companies in various segments of activity. Admission occurs in non-universal private care networks, which serve specific, geographically concentrated clientele. We conclude that foreign capital, an element of health financialization process, is expressed as a possible vector of the expansion of inequalities in the population's access to health services and as an additional obstacle to the consolidation of the Brazilian Unified National Health System.

O estudo descreve o histórico da legislação, analisa a trajetória e dimensiona o capital estrangeiro no sistema de saúde no Brasil. A Lei Orgânica da Saúde restringiu a participação do capital estrangeiro, legislações setoriais permitiram o posterior ingresso na assistência médica suplementar e, em 2015, uma nova lei promoveu a abertura irrestrita, inclusive em hospitais e serviços de saúde. O estudo analisou documentos, legislação e dados de bases secundárias públicas ou obtidos via Lei de Acesso à Informação. Foram considerados investimentos diretos e atos de fusões e aquisições no setor privado da saúde. Foram identificadas cinco fases: ordenamento inaugural, expansão regulada, restrição legal, liberação setorizada e abertura ampliada. De 2016 a 2020, ingressaram no país quase dez vezes mais recursos estrangeiros em serviços de saúde que no quinquênio anterior. Foram identificadas 13 empresas ou fundos, a maioria originária dos Estados Unidos. Normas que permitiram a abertura do capital estrangeiro foram antecedidas por lobbies empresariais e interações público-privadas que podem afetar a qualidade das políticas públicas e a integridade do processo legislativo. O capital aportado busca empresas já constituídas e mais rentáveis, em diversos segmentos de atividade. O ingresso ocorre em redes assistenciais privadas não universais, que atendem clientelas específicas, concentradas geograficamente. Conclui-se que o capital estrangeiro, elemento do processo de financeirização da saúde, se expressa como possível vetor da ampliação de desigualdades de acesso da população aos serviços de saúde e como um obstáculo adicional à consolidação do Sistema Único de Saúde.

Este estudio describe la historia de la legislación, analiza la trayectoria y dimensiona el capital extranjero en el sistema de salud en Brasil. La Ley Orgánica de Salud restringió la participación de capital extranjero, las legislaciones sectoriales permitieron el posterior ingreso a la asistencia médica complementaria y, en el 2015, una nueva ley promovió la apertura sin restricciones, incluso en hospitales y servicios de salud. El estudio analizó documentos, legislación y datos de bases públicas secundarias u obtenidos por medio de la Ley de Acceso a la Información. Se consideraron inversiones directas y actos de fusiones y adquisiciones en el sector privado de la salud. Se identificaron cinco etapas: ordenamiento inaugural, expansión regulada, restricción legal, liberación sectorizada y apertura ampliada. Del 2016 al 2020 ingresaron al país casi diez veces más recursos extranjeros en servicios de salud que en el quinquenio anterior. Se identificaron 13 empresas o fondos, la mayoría con origen en los EE.UU. Las reglas que permitieron la apertura al capital extranjero fueron precedidas por cabildeos empresariales e interacciones público-privadas que pueden afectar la calidad de las políticas públicas y la integridad del proceso legislativo. El capital aportado busca empresas ya consolidadas y más rentables, en diversos segmentos de actividad. El ingreso se da en redes asistenciales privadas no universales, que atienden a una clientela específica y geográficamente concentrada. Se concluye que el capital extranjero, elemento del proceso de financiarización de la salud, se expresa como un posible vector de la ampliación de desigualdades en el acceso de la población a los servicios de salud y como un obstáculo adicional para la consolidación del Sistema Único de Salud.

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